Dietary therapy in heart failure with preserved ejection fraction and/or left ventricular diastolic dysfunction in patients with metabolic syndrome

Effect of isotretinoin treatment on inflammatory and hematological parameters in patients with acne vulgaris

PURPOSE

Although the inflammatory and anti-inflammatory effects of isotretinoin (ISO) treatment in patients with acne vulgaris have been discussed in the literature in recent years, no sensitive and specific marker has been found in studies so far. Neutrophil/HDL (high-density lipoprotein) (NHR), lymphocyte/HD L(LHR), platelet/HDL (PHR), and lymphocyte/monocyte (LMR) are new biomarkers related to inflammation. Triglyceride/HDL (TG/HDL), LDL/HDL, and total cholesterol/HDL have been shown to be cardiometabolic risk factors predicting both cardiovascular disease risk and metabolic risk, rather than just a simple dyslipidemia scale. To our knowledge, the relationship between these parameters and ISO treatment has never been studied before. We aimed to evaluate the immuno-inflammatory response of ISO treatment in patients with acne vulgaris with NHR, LHR, PHR, LMR, TG/HDL, LDL/HDL, and total cholesterol/HDL parameters.

MATERIALS AND METHODS

In this study, 153 patients who received oral ISO treatment for at least 3 months with a diagnosis of moderate-severe acne vulgaris were evaluated retrospectively. Patients were given oral isotretinoin at a dose of 0.5-1 mg/kg. Pre and post-treatment leukocyte (WBC), neutrophil (NE), lymphocyte (LY), platelet (PLT), red cell distribution width (RDW), plateletcrit (PCT), neutrophil/lymphocyte (NLR), platelet/lymphocyte (PLR), mean platelet volume (MPV), monocyte/lymphocyte (MLR), LMR, total cholesterol, LDL cholesterol, HDL cholesterol, triglyceride, MHR, NHR, LHR, PHR, TG/HDL, total cholesterol/HDL, LDL/HDL parameters were evaluated.

RESULTS

It was found that post-treatment WBC and MPV values increased statistically significantly; NLR, neutrophil, and PCT values, on the other hand, decreased significantly (p < 0.05). No statistically significant change was detected in PLR, MLR, LMR, MHR, NHR, LHR, PHR, lymphocyte, monocyte, platelet, and RDW parameters (p > 0.05). It was determined that post-treatment total cholesterol, triglyceride, VLDL, and LDL levels increased statistically significantly; however, the HDL level decreased significantly (p < 0.05). Levels of total cholesterol/HDL, TG/HDL, and LDL/HDL were also found to increase statistically significantly (p < 0.05).

CONCLUSION

Our study suggests that the MPV and NLR ratio as biomarkers can be used as indicators of atherosclerosis-related inflammation due to ISO treatment, but the MHR, NHR, LHR, PHR, MLR, LMR ratios cannot be used. Moreover, we believe that the ratios of TG/HDL, LDL/HDL, and total cholesterol/HDL offer a new contribution as indicators of cardiovascular risk and systemic inflammation related to ISO treatment.

Long-term dietary n3 fatty acid prevents aging-related cardiac diastolic and vascular dysfunction

AIMS

The prevalence of left ventricular (LV) diastolic and vascular dysfunction increases with age, eventually leading to heart failure with preserved ejection fraction (HFpEF). A preventive strategy is an unmet medical need. We and others reported previously on the beneficial effects of omega-3 fatty acid alpha linolenic acid (ALA) on cardiovascular disorders in animal models and translational studies. We now investigate whether long-term dietary ALA could prevent LV diastolic dysfunction and vascular aging in a murine model.

METHODS AND RESULTS

Wild-type C57BL/6 J mice were fed a chow or ALA diet for 12 months, starting at 6 months of age. Here, we show that aged (~18 months) mice recapitulate major hallmarks of HFpEF, including LV diastolic dysfunction with preserved ejection fraction, impaired vascular function, cardiac fibrosis, arterial stiffening and inflammation, as well as elevated B-type natriuretic peptide (BNP). Long-term ALA supplementation upregulated the mitochondrial tricarboxylic acid enzyme Idh2 and the antioxidant enzymes SOD1 and Gpx1. It also has been associated with reduced inflammation and ECM remodeling, accompanied by a significant downregulation of fibrosis biomarkers MMP-2 and TGF-β in both cardiac and vascular tissues obtained from aged mice. Our data exhibited the preventive effects of dietary ALA against LV diastolic dysfunction, impaired vasorelaxation, cardiac fibrosis, inflammation and arterial stiffening in aged mice.

CONCLUSIONS

We provide evidence and a simplified mechanistic insight on how long-term ALA supplementation is a successful strategy to prevent the development of age-related diastolic and vascular dysfunction.

Reducing Cardiac Steatosis: Interventions to Improve Diastolic Function - A Narrative Review

Heart failure is one of the main causes of morbidity and mortality around the globe. Heart failure with preserved ejection fraction is primarily caused by diastolic dysfunction. Adipose tissue deposition in the heart has been previously explained in the pathogenesis of diastolic dysfunction. In this article, we aim to discuss the potential interventions that can reduce the risk of diastolic dysfunction by reducing cardiac adipose tissue. A healthy diet with reduced dietary fat content can reduce visceral adiposity and improve diastolic function. Aerobic and resistance exercises also reduce visceral and epicardial fat and ameliorate diastolic dysfunction. Some medications, include metformin, glucagon-like peptide-1 analogues, dipeptidyl peptidase-4 inhibitors, thiazolidinediones, sodium-glucose co-transporter-2, inhibitors, statins, ACE-Is, and ARBs, have shown different degrees of effectiveness in improving cardiac steatosis and diastolic function. Bariatric surgery has also shown promising results in this field.

The Interaction of Gut Microbiota and Heart Failure with Preserved Ejection Fraction: From Mechanism to Potential Therapies

Heart failure with preserved ejection fraction (HFpEF) is a disease for which there is no definite and effective treatment, and the number of patients is more than 50% of heart failure (HF) patients. Gut microbiota (GMB) is a general term for a group of microbiota living in humans' intestinal tracts, which has been proved to be related to cardiovascular diseases, including HFpEF. In HFpEF patients, the composition of GMB is significantly changed, and there has been a tendency toward dysbacteriosis. Metabolites of GMB, such as trimethylamine N-oxide (TMAO), short-chain fatty acids (SCFAs) and bile acids (BAs) mediate various pathophysiological mechanisms of HFpEF. GMB is a crucial influential factor in inflammation, which is considered to be one of the main causes of HFpEF. The role of GMB in its important comorbidity-metabolic syndrome-also mediates HFpEF. Moreover, HF would aggravate intestinal barrier impairment and microbial translocation, further promoting the disease progression. In view of these mechanisms, drugs targeting GMB may be one of the effective ways to treat HFpEF. This review focuses on the interaction of GMB and HFpEF and analyzes potential therapies.

Waist-to-height ratio and metabolic phenotype compared to the Matsuda index for the prediction of insulin resistance

Current screening algorithms for type 2 diabetes (T2D) rely on fasting plasma glucose (FPG) and/or HbA1c. This fails to identify a sizeable subgroup of individuals in early stages of metabolic dysregulation who are at high risk for developing diabetes or cardiovascular disease. The Matsuda index, a combination of parameters derived from a fasting and postprandial insulin assay, is an early biomarker for metabolic dysregulation (i.e. insulin resistance/compensatory hyperinsulinemia). The aim of this analysis was to compare four widely available anthropometric and biochemical markers indicative of this condition [waist-to-height ratio (WHtR), hypertriglyceridemic-waist phenotype (HTW), triglycerides-to-HDL-C ratio (TG/HDL-C) and FPG] to the Matsuda index. This cross-sectional analysis included 2231 individuals with normal fasting glucose (NFG, n = 1333), impaired fasting glucose (IFG, n = 599) and T2D (n = 299) from an outpatient diabetes clinic in Germany and thus extended a prior analysis from our group done on the first two subgroups. We analyzed correlations of the Matsuda index with WHtR, HTW, TG/HDL-C and FPG and their predictive accuracies by correlation and logistic regression analyses and receiver operating characteristics. In the entire group and in NFG, IFG and T2D, the best associations were observed between the Matsuda index and the WHtR (r = - 0.458), followed by HTW phenotype (r = - 0.438). As for prediction accuracy, WHtR was superior to HTW, TG/HDL-C and FPG in the entire group (AUC 0.801) and NFG, IFG and T2D. A multivariable risk score for the prediction of insulin resistance was tested and demonstrated an area under the ROC curve of 0.765 for WHtR and its interaction with sex as predictor controlled by age and sex. The predictive power increased to 0.845 when FPG and TG/HDL-C were included. Using as a comparator the Matsuda index, WHtR, compared to HTW, TG/HDL-C and FPG, showed the best predictive value for detecting metabolic dysregulation. We conclude that WHtR, a widely available anthropometric index, could refine phenotypic screening for insulin resistance/hyperinsulinemia. This may ameliorate early identification of individuals who are candidates for appropriate therapeutic interventions aimed at addressing the twin epidemic of metabolic and cardiovascular disease in settings where more extended testing such as insulin assays are not feasible.

Nutritional ketosis to treat pulmonary hypertension associated with obesity and metabolic syndrome: a case report

Metabolic syndrome is characterized by insulin resistance/hyperinsulinemia, atherogenic dyslipidemia (elevated triglycerides, low HDL), and hyperglycemia. The high prevalence of metabolic syndrome in pulmonary hypertension leads to the hypothesis that metabolic syndrome may play a contributing role in pulmonary hypertension and heart failure with preserved ejection fraction pathogenesis. We present a 62-year-old woman with morbid obesity, mild pre-capillary pulmonary hypertension, and metabolic syndrome. Her metabolic syndrome was treated with a medically-supervised ketogenic diet delivered by a telehealth healthcare team via a continuous remote care platform. Following one year of treatment, metabolic syndrome was reversed, leading to successful weight loss concurrent with hemodynamic improvement. This case highlights the feasibility of using a nutritional strategy to treat pulmonary hypertension associated with obesity and metabolic syndrome, common contributors to group 2 and 3 pulmonary hypertension. We bring this case and technique to the pulmonary hypertension community to share a tool in our therapeutic toolkit and highlight the importance of nutritional advice extending beyond telling a patient they should lose weight to invoking a rational strategy. We argue that strategic nutritional intervention through reversal of her metabolic syndrome using a medically-supervised ketogenic diet is a safe and effective treatment strategy in metabolic syndrome-associated pulmonary hypertension.

Mechanisms underlying the pathophysiology of heart failure with preserved ejection fraction: the tip of the iceberg

Heart failure with preserved ejection fraction (HFpEF) is a multifaceted syndrome with a complex aetiology often associated with several comorbidities, such as left ventricle pressure overload, diabetes mellitus, obesity, and kidney disease. Its pathophysiology remains obscure mainly due to the complex phenotype induced by all these associated comorbidities and to the scarcity of animal models that adequately mimic HFpEF. Increased oxidative stress, inflammation, and endothelial dysfunction are currently accepted as key players in HFpEF pathophysiology. However, we have just started to unveil HFpEF complexity and the role of calcium handling, energetic metabolism, and mitochondrial function remain to clarify. Indeed, the enlightenment of such cellular and molecular mechanisms represents an opportunity to develop novel therapeutic approaches and thus to improve HFpEF treatment options. In the last decades, the number of research groups dedicated to studying HFpEF has increased, denoting the importance and the magnitude achieved by this syndrome. In the current technological and web world, the amount of information is overwhelming, driving us not only to compile the most relevant information about the theme but also to explore beyond the tip of the iceberg. Thus, this review aims to encompass the most recent knowledge related to HFpEF or HFpEF-associated comorbidities, focusing mainly on myocardial metabolism, oxidative stress, and energetic pathways.

Consumption of animal and plant foods and risk of left ventricular diastolic dysfunction: the Bogalusa Heart Study

AIMS

Left ventricular diastolic dysfunction (LVDD) is an early heart failure with preserved ejection fraction (HFpEF) phenotype that is reversible. Identifying dietary predictors associated with LVDD in diverse populations may help broadly improve HFpEF primary prevention.

METHODS AND RESULTS

This longitudinal analysis included 456 individuals of the Bogalusa Heart Study (27% Black, 63% women, baseline age = 36.1 ± 4.4 years). Diet was measured at baseline through food frequency questionnaires. LVDD was defined at follow-up (median = 12.9 years) through echocardiographic measurement of the E/A ratio, E/e' ratio, isovolumic relaxation time, and deceleration time. Multivariable-adjusted logistic regression estimated the risk of LVDD according to dietary predictor, adjusting for traditional cardiovascular disease risk factors. Compared with the lowest tertile, participants in the middle tertile of total protein (OR = 3.30, 95% CI: 1.46, 7.45) and animal protein (OR = 2.91, 95% CI: 1.34, 6.34) consumption experienced the highest risk of LVDD. There was a 77% and 56% lower risk of LVDD for persons in the middle vs. lowest tertile of vegetable (OR = 0.23, 95% CI: 0.11, 0.49) and legume consumption (OR = 0.44, 95% CI: 0.22, 0.85), respectively. Total protein, animal protein, processed meat, and egg consumption indicated a quadratic trend towards increased risk of LVDD, while legume and vegetable intake conferred a quadratic trend towards decreased risk of LVDD (all quadratic P < 0.05).

CONCLUSIONS

Diets higher in animal foods and lower in plant foods are associated with an increased risk for LVDD. These findings suggest threshold effects of diet on LVDD, past which more traditional cardiometabolic determinants occupy a larger role in HFpEF risk.

Caloric restriction in heart failure: A systematic review

BACKGROUND AND AIMS

Nutrition exerts a determinant role in maintaining cardiac function, regulating insulin and mitochondrial efficiency, that are essential to support energy production for contractility. In patients with heart failure (HF), myocardial tissue efficiency is reduced because of decreased mitochondrial oxidative capacity. In HF conditions, cardiomyocytes shift toward glucose and a reduction in fatty acid utilization. Calorie restriction induces weight loss in obese patients and can be beneficial in some HF patients, although this has generated some controversy. This study aims to evaluate the impact of the CR diet on myocardial efficiency in HF patients.

METHODS

On Pubmed and Embase, articles related to the keywords: "chronic heart failure" with "diet," "nutrition," "insulin resistance," and "caloric restriction" have been searched, Studies, including exercise or food supplementation, were excluded.

RESULTS

The retrieved articles showed that weight loss, through the activation of insulin and various kinase pathways, regulates the efficiency of myocardial tissue. In contrast, insulin resistance represents a strong cardiovascular risk factor that reduces myocardial function.

CONCLUSION

CR diet represents the first therapy in overweight HF patients, both with preserved ejection fraction (HFpEF) and with reduced ejection fraction (HFrHF) because reducing body fat, the myocardial function increased. Insulin activity is the critical hormone that regulates mitochondrial function and cardiac efficiency. However, a severely restricted diet may represent a severe risk factor correlated with all-cause mortality, particularly in underweight HF patients. Long-term studies conducted on large populations are necessary to evaluate the effects of CR on myocardial function in HF patients.

Western Diet-Fed, Aortic-Banded Ossabaw Swine: A Preclinical Model of Cardio-Metabolic Heart Failure

The development of new treatments for heart failure lack animal models that encompass the increasingly heterogeneous disease profile of this patient population. This report provides evidence supporting the hypothesis that Western Diet-fed, aortic-banded Ossabaw swine display an integrated physiological, morphological, and genetic phenotype evocative of cardio-metabolic heart failure. This new preclinical animal model displays a distinctive constellation of findings that are conceivably useful to extending the understanding of how pre-existing cardio-metabolic syndrome can contribute to developing HF.

Nutritional Interventions in Heart Failure: Challenges and Opportunities

PURPOSE OF REVIEW

There is a growing body of evidence that nutritional factors influence the incidence of heart failure (HF). The current manuscript aims to collate evidence relating to nutritional intervention in the treatment of HF as well as to provide context regarding challenges and opportunities in the field.

RECENT FINDINGS

Despite the accepted importance of nutritional factors relating to cardiovascular disease severity, there is surprisingly little human intervention research regarding dietary intake and HF. Further, existing nutritional interventions in HF were mostly pilot studies with small samples and short follow-up. There is consistent evidence that nutritional factors majorly influence HF. Despite limited research, there is evidence that nutritional modification can rapidly and profoundly influence multiple aspects of HF. There is an urgent need for well-conducted research to ascertain if nutritional modification can alter the long-term course of HF.

Lipid paradox in patients with acute myocardial infarction: Potential impact of malnutrition

BACKGROUND & AIMS

Aggressive lipid reduction is recommended for patients with AMI, but reverse epidemiology, the lipid paradox, has been reported in several clinical studies. The cause of lipid paradox remains uncertain, and nutrition is one possible explanation. In this single-center retrospective study, we investigated the relationships between baseline LDL concentrations and clinical outcomes in patients with AMI, stratified by different nutritional status.

METHODS

Totally 409 patients were enrolled for analysis. The Nutritional Risk Index (NRI) was used to estimate the risk of malnutrition. Subjects were grouped into tertiles according to their NRIs. Clinical outcomes were compared among patients with varying NRIs and LDL levels.

RESULTS

Patients in the lowest NRI tertile had increased incidences of in-hospital mortality, cardiogenic shock, decompensated heart failure, renal failure, and sepsis. This tertile was also associated with increased long-term mortality during the follow-up period of 832 ± 744 days. Mortality was increased among patients with baseline LDL concentrations ≤70 mg/dL in the lowest NRI tertile (log rank test, p = 0.0257), but not in the high or median tertiles. Moreover, baseline LDL level ≤70 mg/dL was an independent risk factor of all-cause mortality (adjusted hazard ratio = 1.73; 95% confidence interval, 1.01-2.94; p = 0.045) in the lowest NRI tertile.

CONCLUSIONS

Lipid paradox was observed in the high-risk of malnutrition population among patients with AMI. Aggressive lipid-lowering therapy is still recommended for patients with AMI and fair nutritional status. However, when treating patients at high risk of malnutrition, the improvement of nutritional status may be more beneficial than strict LDL control.

Impact of Nutrition on Cardiovascular Function

The metabolic sources of energy for myocardial contractility include mainly free fatty acids (FFA) for 95%, and in lesser amounts for 5% from glucose and minimal contributions from other substrates such lactate, ketones, and amino acids. However, myocardial efficiency is influenced by metabolic condition, overload, and ischemia. During cardiac stress, cardiomyocytes increase glucose oxidation and reduce FFA oxidation. In patients with ischemic coronary disease and heart failure, the low oxygen availability limits myocardial reliance on FFA and glucose utilization must increase. Although glucose uptake is fundamental to cardiomyocyte function, an excessive intracellular glucose level is detrimental. Insulin plays a fundamental role in maintaining myocardial efficiency and in reducing glycemia and inflammation; this is particularly evident in obese and type-2 diabetic patients. An excess of F availability increase fat deposition within cardiomyocytes and reduces glucose oxidation. In patients with high body mass index, a restricted diet or starvation have positive effects on cardiac metabolism and function while, in patients with low body mass index, restrictive diets, or starvation have a deleterious effect. Thus, weight loss in obese patients has positive impacts on ventricular mass and function, whereas, in underweight heart failure patients, such weight reduction adds to the risk of heart damage, predisposing to cachexia. Nutrition plays an essential role in the evolution of cardiovascular disease and should be taken into account. An energy-restricted diet improves myocardial efficiency but can represent a potential risk of heart damage, particularly in patients affected by cardiovascular disease. Micronutrient integration has a marginal effect on cardiovascular efficiency.