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Chen QF, Lu Y, Katsouras CS, Peng Y, Sun J, Li M, Liu C, Yao H, Lian L, Feng X, Lin WH, Zhou XD. Characteristics, outcomes and the necessity of continued guideline-directed medical therapy in patients with heart failure with improved ejection fraction. Ann Med 2025; 57:2442535. [PMID: 39687932 DOI: 10.1080/07853890.2024.2442535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 09/12/2024] [Accepted: 11/14/2024] [Indexed: 12/18/2024] Open
Abstract
BACKGROUND Much remains to be learned about patients with heart failure with improved ejection fraction (HFimpEF). OBJECTIVE This study sheds light on the characteristics and clinical outcomes of HFimpEF patients, including the consequences of halting guideline-directed medical therapy (GDMT). METHODS This retrospective study was conducted on patients diagnosed with heart failure with reduced ejection fraction (HFrEF) who underwent a second echocardiogram at least 6 months apart between January 2009 and February 2023. The primary outcomes were major adverse cardiovascular events (MACEs), including all-cause mortality and heart failure hospitalization. The second outcome was recurrent HFrEF. RESULTS Of 4,560 HFrEF patients were included, 3,289 (72.1%) achieved HFimpEF within a median follow-up period of 3.4 years (IQR: 1.8 - 5.9 years). Among these HFimpEF patients, recurrent HFrEF was observed in 941 (28.6%) patients during a median follow-up period of 2.3 years (IQR: 0.8-4.6 years). The proportion of patients who halted GDMT was 70.4%, 53.2%, 59.8% and 63.8% for MRA, beta-blockers, ACEI/ARB/ARNI and SGLT-2 inhibitors. Multivariable Cox analysis revealed ischemic heart disease, chronic kidney disease, coronary heart disease, lower left ventricular ejection fraction, larger left ventricular diastolic dimension and non-use GDMT are associated with recurrent HFrEF. Individuals without GDMT use exhibited lower chances of persistently recovering ejection fraction and high risks of MACEs compared to those who continue use. CONCLUSIONS HFimpEF is a common condition across all clinical follow-ups. Prevalent discontinuation of GDMT medications may contribute significantly to recurrent HFrEF, placing patients at a higher risk for poor prognosis.
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Affiliation(s)
- Qin-Fen Chen
- Medical Care Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Institute of Aging, Key Laboratory of Alzheimer's Disease of Zhejiang Province, Zhejiang Provincial Clinical Research Center for Mental Disorders, Wenzhou Medical University, Wenzhou, China
| | - Yindan Lu
- Department of Cardiovascular Medicine, the Heart Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Christos S Katsouras
- Second Department of Cardiology, University Hospital of Ioannina Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Yangdi Peng
- Department of Respiratory Medicine, Yongjia County Traditional Chinese Medicine Hospital, Wenzhou, China
| | - Junfang Sun
- Department of Cardiovascular Medicine, the Heart Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Mingming Li
- Department of Cardiovascular Medicine, the Heart Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chenyang Liu
- Department of Cardiovascular Medicine, the Heart Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hongxia Yao
- Department of Cardiovascular Medicine, the Heart Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Liyou Lian
- Department of Cardiovascular Medicine, the Heart Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaofang Feng
- Department of Cardiovascular Medicine, the Heart Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wei-Hong Lin
- Medical Care Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiao-Dong Zhou
- Department of Cardiovascular Medicine, the Heart Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Fayyaz AU, Eltony M, Prokop LJ, Koepp KE, Borlaug BA, Dasari S, Bois MC, Margulies KB, Maleszewski JJ, Wang Y, Redfield MM. Pathophysiological insights into HFpEF from studies of human cardiac tissue. Nat Rev Cardiol 2025; 22:90-104. [PMID: 39198624 PMCID: PMC11750620 DOI: 10.1038/s41569-024-01067-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2024] [Indexed: 09/01/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a major, worldwide health-care problem. Few therapies for HFpEF exist because the pathophysiology of this condition is poorly defined and, increasingly, postulated to be diverse. Although perturbations in other organs contribute to the clinical profile in HFpEF, altered cardiac structure, function or both are the primary causes of this heart failure syndrome. Therefore, studying myocardial tissue is fundamental to improve pathophysiological insights and therapeutic discovery in HFpEF. Most studies of myocardial changes in HFpEF have relied on cardiac tissue from animal models without (or with limited) confirmatory studies in human cardiac tissue. Animal models of HFpEF have evolved based on theoretical HFpEF aetiologies, but these models might not reflect the complex pathophysiology of human HFpEF. The focus of this Review is the pathophysiological insights gained from studies of human HFpEF myocardium. We outline the rationale for these studies, the challenges and opportunities in obtaining myocardial tissue from patients with HFpEF and relevant comparator groups, the analytical approaches, the pathophysiological insights gained to date and the remaining knowledge gaps. Our objective is to provide a roadmap for future studies of cardiac tissue from diverse cohorts of patients with HFpEF, coupling discovery biology with measures to account for pathophysiological diversity.
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Affiliation(s)
- Ahmed U Fayyaz
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Muhammad Eltony
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, MN, USA
| | - Larry J Prokop
- Mayo Clinic College of Medicine and Science, Library Reference Service, Rochester, MN, USA
| | - Katlyn E Koepp
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, MN, USA
| | - Barry A Borlaug
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, MN, USA
| | - Surendra Dasari
- Mayo Clinic College of Medicine and Science, Computational Biology, Rochester, MN, USA
| | - Melanie C Bois
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Kenneth B Margulies
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joesph J Maleszewski
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ying Wang
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, MN, USA
| | - Margaret M Redfield
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, MN, USA.
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Kamiya K, Tanaka S, Saito H, Yamashita M, Yonezawa R, Hamazaki N, Matsuzawa R, Nozaki K, Endo Y, Wakaume K, Uchida S, Maekawa E, Matsue Y, Suzuki M, Inomata T, Ako J. Effects of Acute Phase Intensive Exercise Training in Patients With Acute Decompensated Heart Failure. JACC. HEART FAILURE 2025:S2213-1779(24)00869-2. [PMID: 39846909 DOI: 10.1016/j.jchf.2024.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 10/29/2024] [Accepted: 11/06/2024] [Indexed: 01/24/2025]
Abstract
BACKGROUND Acute decompensated heart failure (ADHF) leads to hospitalizations and functional decline in older adults. Although cardiac rehabilitation (CR) is effective for stable heart failure, its impact on ADHF patients, particularly those without frailty, is unclear. OBJECTIVES The goal of this study was to evaluate the efficacy and safety of early in-hospital CR for patients hospitalized with ADHF who are not frail. METHODS In this multicenter trial (ACTIVE-ADHF [Effects of Acute Phase Intensive Exercise Training in Patients with Acute Decompensated Heart Failure]), ADHF patients without physical frailty were randomized 2:1 to undergo either exercise-based CR or standard care. The intervention included early mobilization and structured exercise training. The primary outcome was the change in 6-minute walk distance (6MWD) from baseline to discharge. Secondary outcomes assessed physical and cognitive function, quality of life, and safety. RESULTS A total of 91 patients were randomized to treatment, with 59 allocated to the intervention group and 32 to the control group. The primary outcome, 6MWD, improved significantly more in the intervention group, with a mean increase of 75.0 ± 7.8 m vs 44.1 ± 10.2 m in the control group, with an effect size of 30.9 ± 13.1 m (95% CI: 4.8-57.0; P = 0.021). The intervention group showed favorable results in secondary efficacy outcomes, including physical and cognitive function, physical activity, and quality of life. Safety outcomes were similar between groups, except for a greater reduction in B-type natriuretic peptide levels at 90 days' postdischarge in the intervention group. CONCLUSIONS In patients with ADHF without physical frailty, in-hospital exercise-based CR led to significant improvements in 6MWD at 2 weeks after randomization without compromising safety. (ACTIVE-ADHF [Effects of Acute Phase Intensive Exercise Training in Patients with Acute Decompensated Heart Failure]; UMIN000020919).
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Affiliation(s)
- Kentaro Kamiya
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, Kanagawa, Japan; Department of Rehabilitation Sciences, Graduate School of Medical Sciences, Kitasato University, Sagamihara, Japan.
| | - Shinya Tanaka
- Department of Rehabilitation, Nagoya University Hospital, Aichi, Japan
| | - Hiroshi Saito
- Department of Rehabilitation, Kamede Medical Center, Chiba, Japan
| | - Masashi Yamashita
- Department of Rehabilitation Sciences, Graduate School of Medical Sciences, Kitasato University, Sagamihara, Japan; Division of Research, ARCE Inc, Sagamihara, Japan
| | - Ryusuke Yonezawa
- Department of Rehabilitation, Kitasato University Medical Center, Saitama, Japan
| | - Nobuaki Hamazaki
- Department of Rehabilitation, Kitasato University Hospital, Kanagawa, Japan
| | - Ryota Matsuzawa
- Department of Physical Therapy, School of Rehabilitation, Hyogo Medical University, Kobe, Japan
| | - Kohei Nozaki
- Department of Rehabilitation, Kitasato University Hospital, Kanagawa, Japan
| | - Yoshiko Endo
- Department of Rehabilitation, Kamede Medical Center, Chiba, Japan
| | - Kazuki Wakaume
- Department of Rehabilitation, Kitasato University Medical Center, Saitama, Japan
| | - Shota Uchida
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, Kanagawa, Japan
| | - Emi Maekawa
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Makoto Suzuki
- Department of Cardiology, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan
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4
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Chen M, Li W, Ran Q. Incidence and risk factors of heart failure with preserved ejection fraction in elderly patients with hypertension. BMC Cardiovasc Disord 2024; 24:742. [PMID: 39716088 DOI: 10.1186/s12872-024-04419-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2024] [Accepted: 12/12/2024] [Indexed: 12/25/2024] Open
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) poses a significant clinical challenge, especially in older patients with HT. This study aimed to identify the factors influencing HFpEF occurrence in elderly patients with HT. METHODS Elderly patients with HT were categorized into two groups: no HFpEF group and HFpEF group based on HFpEF diagnosis. Demographic, clinical, laboratory and echocardiographic data was conducted. Logistic regression analysis and joint prediction modeling were used to identify predictive factors for HFpEF. RESULTS Several factors were associated with HFpEF, including age, body mass index, duration of HT, atrial fibrillation (AF), chronic kidney disease (CKD), stroke, systolic blood pressure (SBP), serum creatinine (SCr), N-terminal pro brain natriuretic peptide (NT-proBNP), heart rate, serum sodium, low density lipoprotein cholesterol (LDL-c), triglyceride, left ventricular ejection fraction (LVEF), E/e' ratio, left atrial diameter, tricuspid regurgitation velocity, mitral regurgitation and C-reactive protein (CRP) levels. The joint prediction model shown high accuracy, with an area under the curve (AUC) of 0.840. CONCLUSIONS This study provided insights into the incidence rate and risk factors of HFpEF in elderly patients with HT. Key determinants included age, blood pressure, biomarkers, and echocardiographic parameters.
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Affiliation(s)
- Min Chen
- Department of cardiovascular medicine, Chengdu Seventh People's Hospital, No.1188 Shuangxing Avenue, Chengdu city, 610200, Sichuan Province, China.
| | - Wentao Li
- Department of Internal Medicine, West China Second Hospital, Sichuan University, No. 1416 Chenglong Avenue, Chengdu city, 610041, Sichuan Province, China
| | - Qin Ran
- Department of cardiovascular medicine, Chengdu Seventh People's Hospital, No.1188 Shuangxing Avenue, Chengdu city, 610200, Sichuan Province, China
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5
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Lin TT, Juang JMJ. Personalized Heart Failure Management: Bridging Technology and Care. J Am Heart Assoc 2024; 13:e037648. [PMID: 39392162 DOI: 10.1161/jaha.124.037648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
- Ting-Tse Lin
- Division of Cardiology, Department of Internal Medicine National Taiwan University College of Medicine and Hospital Taipei Taiwan
- Department of Internal Medicine, College of Medicine National Taiwan University Taipei Taiwan
- Cardiovascular Center, Heart Failure Center, and Center of Genetic Heart Diseases National Taiwan University Hospital Taipei Taiwan
| | - Jyh-Ming Jimmy Juang
- Division of Cardiology, Department of Internal Medicine National Taiwan University College of Medicine and Hospital Taipei Taiwan
- Department of Internal Medicine, College of Medicine National Taiwan University Taipei Taiwan
- Cardiovascular Center, Heart Failure Center, and Center of Genetic Heart Diseases National Taiwan University Hospital Taipei Taiwan
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6
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Liang S, Wan K, Li J, Chen J, Chen Y. Patients With Cardiac Amyloidosis Are More Prone to Hypotension. J Am Coll Cardiol 2024; 84:e233. [PMID: 39357945 DOI: 10.1016/j.jacc.2024.04.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 10/04/2024]
Affiliation(s)
- Shichu Liang
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ke Wan
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jialin Li
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiaxin Chen
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yucheng Chen
- West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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7
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Abdin A, Böhm M, Shahim B, Karlström P, Kulenthiran S, Skouri H, Lund LH. Heart failure with preserved ejection fraction epidemiology, pathophysiology, diagnosis and treatment strategies. Int J Cardiol 2024; 412:132304. [PMID: 38944348 DOI: 10.1016/j.ijcard.2024.132304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 06/11/2024] [Accepted: 06/26/2024] [Indexed: 07/01/2024]
Abstract
The prevalence of HF with preserved ejection raction (HFpEF, with EF ≥50%) is increasing across all populations with high rates of hospitalization and mortality, reaching up to 80% and 50%, respectively, within a 5-year timeframe. Comorbidity-driven systemic inflammation is thought to cause coronary microvascular dysfunction and increased epicardial adipose tissue, leading to downstream friborsis and molecular changes in the cardiomyocyte, leading to increased stiffness and diastolic dynsfunction. HFpEF poses unique challenges in terms of diagnosis due to its complex and diverse nature. The diagnosis of HFpEF relies on a combination of clinical assessment, imaging studies, and biomarkers. An additional important step in diagnosing HFpEF involves excluding certain cardiac diagnoses that may be specific underlying causes of HFpEF or may be masquerading as HFpEF and require specific alternative treatment approaches. In addition to administering sodium-glucose cotransporter 2 inhibitors to all patients, the most effective approach to enhance clinical outcomes may involve tailored therapy based on each patient's unique clinical profile. Exercise should be recommended for all patients to improve the quality of life. Glucagon-like peptide-1 1 agonists are a promising treatment option in obese HFpEF patients. Novel approaches targeting inflammation are also in early phase trials.
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Affiliation(s)
- Amr Abdin
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Bahira Shahim
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Patric Karlström
- Department of Internal Medicine, Ryhov County Hospital, Jönköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Saarraaken Kulenthiran
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hadi Skouri
- Division of Cardiology, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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8
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Makino T, Ishihara Y, Harada M, Sobue Y, Watanabe E, Ozaki Y, Izawa H. Phenogroups and Their Prognosis of Acute Decompensated Heart Failure with Preserved Ejection Fraction. Int Heart J 2024; 65:841-848. [PMID: 39261030 DOI: 10.1536/ihj.24-080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Abstract
Acute heart failure is an important cause of unplanned hospitalizations and poses a significant burden through increased mortality and frequent hospitalizations. Heart failure with preserved ejection fraction (HFpEF) presents as a diverse condition characterized by complex cardiovascular and non-cardiovascular pathology. This study aimed to identify distinct clinical phenotypes in acute decompensated HFpEF (ADHF) using cluster analysis and assess their prognostic significance. We applied a latent class analysis to 1,281 ADHF patients admitted to a single cardiac intensive care unit between 2008 and 2022 with a left ventricular ejection fraction ≥ 50%. We used 83 factors obtained at hospitalization. We evaluated the association between phenogroups and clinical outcomes using either Cox regression model or Fine-Gray competing risk model. We identified 4 phenogroups: Phenogroup 1 (n = 133, 10%) included younger patients with metabolic disorders and a low level of B-type natriuretic peptide (BNP); Phenogroup 2 (n = 346, 27%) had systemic congestion and high BNP levels; Phenogroup 3 (n = 514, 40%) had multiple comorbidities and vascular disorders; Phenogroup 4 (n = 288, 22%) included older patients with bradyarrhythmia and atrial fibrillation. After adjusting for age, sex, and Get with the Guidelines-Heart Failure risk score, Phenogroup 2 had the highest risk of all-cause death and cardiac death. In conclusion, we identified 4 clinically relevant phenogroups of ADHF patients, each associated with different adverse outcomes. Phenotyping may provide a better understanding of the underlying mechanisms involved in the heterogeneity of ADHF and decompensation. Furthermore, it may facilitate the search for phenotype-specific therapeutic strategies.
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Affiliation(s)
- Taro Makino
- Department of Cardiology, Hekinan City Hospital
| | - Yuya Ishihara
- Department of Laboratory Medicine, Fujita Health University Hospital
| | | | - Yoshihiro Sobue
- Division of Cardiology, Department of Internal Medicine, Fujita Health University Bantane Hospital
| | - Eiichi Watanabe
- Division of Cardiology, Department of Internal Medicine, Fujita Health University Bantane Hospital
| | - Yukio Ozaki
- Division of Cardiology, Department of Internal Medicine, Fujita Health University Okazaki Medical Center
| | - Hideo Izawa
- Department of Cardiology, Fujita Health University Hospital
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9
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Gelfman DM. Chlorthalidone as Secondary Treatment in HFpEF? Am J Med 2024:S0002-9343(24)00619-3. [PMID: 39341526 DOI: 10.1016/j.amjmed.2024.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2024] [Revised: 09/18/2024] [Accepted: 09/19/2024] [Indexed: 10/01/2024]
Abstract
This review addresses important issues that face practitioners today concerning the treatment of heart failure with preserved ejection fraction (HFpEF). It points out how the accepted efficacy of HFpEF medication treatment has changed. Medications are now recommended for use in HFpEF that have diuretic properties and are significant because of a reduction in the frequency of the development of heart failure (not mortality). This heart failure incidence reduction appears predictable and is valuable, but it raises the question of the use of chlorthalidone in the treatment of HFpEF. Chlorthalidone has previously been demonstrated to reduce heart failure incidence in the treatment of hypertensive patients, which is a similar patient population. Chlorthalidone, possibly with a generic mineralocorticoid antagonist, could be an acceptable low-cost alternate therapy as secondary treatment for HFpEF. Of course, chlorthalidone does not have the other theoretic benefits of the sodium-glucose cotransporter 2 (SGLT2) inhibitors or finerenone. It would be helpful if this was discussed in the upcoming HFpEF guidelines, especially for use in patients who cannot afford or tolerate the new HFpEF medications.
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Affiliation(s)
- Daniel M Gelfman
- Division of Cardiovascular Medicine, Indiana University School of Medicine, Indianapolis.
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10
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Hamo CE, DeJong C, Hartshorne-Evans N, Lund LH, Shah SJ, Solomon S, Lam CSP. Heart failure with preserved ejection fraction. Nat Rev Dis Primers 2024; 10:55. [PMID: 39143132 DOI: 10.1038/s41572-024-00540-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2024] [Indexed: 08/16/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) accounts for nearly half of all heart failure cases and has a prevalence that is expected to rise with the growing ageing population. HFpEF is associated with significant morbidity and mortality. Specific HFpEF risk factors include age, diabetes, hypertension, obesity and atrial fibrillation. Haemodynamic contributions to HFpEF include changes in left ventricular structure, diastolic and systolic dysfunction, left atrial myopathy, pulmonary hypertension, right ventricular dysfunction, chronotropic incompetence, and vascular dysfunction. Inflammation, fibrosis, impaired nitric oxide signalling, sarcomere dysfunction, and mitochondrial and metabolic defects contribute to the cellular and molecular changes observed in HFpEF. HFpEF impacts multiple organ systems beyond the heart, including the skeletal muscle, peripheral vasculature, lungs, kidneys and brain. The diagnosis of HFpEF can be made in individuals with signs and symptoms of heart failure with abnormality in natriuretic peptide levels or evidence of cardiopulmonary congestion, facilitated by the use of HFpEF risk scores and additional imaging and testing with the exclusion of HFpEF mimics. Management includes initiation of guideline-directed medical therapy and management of comorbidities. Given the significant impact of HFpEF on quality of life, future research efforts should include a particular focus on how patients can live better with this disease.
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Affiliation(s)
- Carine E Hamo
- New York University School of Medicine, Leon H. Charney Division of Cardiology, New York University Langone Health, New York, NY, USA
| | - Colette DeJong
- Division of Cardiology, University of California San Francisco, San Francisco, CA, USA
| | - Nick Hartshorne-Evans
- CEO and Founder of the Pumping Marvellous Foundation (Patient-Led Heart Failure Charity), Preston, UK
| | - Lars H Lund
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine and Bluhm Cardiovascular Institute Northwestern University Feinberg School of Medicine Chicago, Chicago, IL, USA
| | - Scott Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore, Singapore.
- Baim Institute for Clinical Research, Boston, MA, USA.
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11
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Bozkurt B. Contemporary pharmacological treatment and management of heart failure. Nat Rev Cardiol 2024; 21:545-555. [PMID: 38532020 DOI: 10.1038/s41569-024-00997-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 03/28/2024]
Abstract
The prevention and treatment strategies for heart failure (HF) have evolved in the past two decades. The stages of HF have been redefined, with recognition of the pre-HF state, which encompasses asymptomatic patients who have developed either structural or functional cardiac abnormalities or have elevated plasma levels of natriuretic peptides or cardiac troponin. The first-line treatment of patients with HF with reduced ejection fraction includes foundational therapies with angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, mineralocorticoid receptor antagonists, sodium-glucose cotransporter 2 (SGLT2) inhibitors and diuretics. The first-line treatment of patients with HF with mildly reduced ejection fraction or with HF with preserved ejection fraction includes SGLT2 inhibitors and diuretics. The timely initiation of these disease-modifying therapies and the optimization of treatment are crucial in all patients with HF. Reassessment after initiation of these therapies is recommended to evaluate patient symptoms, health status and left ventricular function, and timely referral to a HF specialist is necessary if a patient has persistent advanced HF symptoms or worsening HF. Lifestyle modification and treatment of comorbidities such as diabetes mellitus, ischaemic heart disease and atrial fibrillation are crucial through each stage of HF. This Review provides an overview of the management strategies for HF according to disease stages that are derived from the recommendations in the latest US and European HF guidelines.
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Affiliation(s)
- Biykem Bozkurt
- Winters Center for Heart Failure Research, Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX, USA.
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12
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Li L, Chang Y, Li F, Yin Y. Relationship between serum uric acid levels and uric acid lowering therapy with the prognosis of patients with heart failure with preserved ejection fraction: a meta-analysis. Front Cardiovasc Med 2024; 11:1403242. [PMID: 38938653 PMCID: PMC11210376 DOI: 10.3389/fcvm.2024.1403242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 05/29/2024] [Indexed: 06/29/2024] Open
Abstract
Aims This meta-analysis aimed to explore the association between serum uric acid levels and the efficacy of uric acid-lowering therapies on clinical outcomes among patients with heart failure with preserved ejection fraction (HFpEF). Methods A comprehensive literature search was conducted through October 21, 2023, across PubMed, Embase, Cochrane Library, and Web of Science databases. The pooled effect sizes were estimated and presented with their respective 95% confidence intervals (CI). Subgroup analyses were conducted based on various factors, including sample size (<1,000 vs. ≥1,000), follow-up duration (<2 years vs. ≥2 years), study quality (assessed by a score of <7 vs. ≥7), ethnicity (Non-Asian vs. Asian), study design (prospective vs. retrospective), type of heart failure (HF) (acute vs. chronic), presence of hyperuricemia (yes or no), left ventricular ejection fraction (LVEF) thresholds (≥45% vs. ≥50%), and the type of uric acid-lowering therapy (traditional vs. novel). Results The analysis included a total of 12 studies. Elevated serum uric acid levels were significantly linked to an increased risk of all-cause mortality [relative risk (RR): 1.21, 95% CI: 1.06-1.37, P = 0.004] and cardiovascular (CV) mortality (RR: 1.71, 95% CI: 1.42-2.04, P < 0.001) in HFpEF patients. Subgroup analyses confirmed this association, particularly in non-Asian populations, those with chronic HFpEF, and studies with a follow-up duration of two years or more. Additionally, higher uric acid levels were associated with an increased risk of HF-related hospitalization [hazard ratio (HR): 1.61, 95% CI: 1.12-2.34, P = 0.011]. Regarding treatment, uric acid-lowering therapy did not show a significant effect on reducing mortality in HFpEF patients. However, it was associated with a decreased risk of hospitalization due to HF (RR: 0.85, 95% CI: 0.79-0.91, P < 0.001). Conclusion The findings of this study highlight the prognostic significance of serum uric acid levels in HFpEF and suggest that uric acid-lowering therapy may be beneficial in reducing the incidence of HF hospitalizations. Further research is warranted to elucidate the mechanisms by which uric acid-lowering therapy confers its potential benefits.
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Affiliation(s)
- Linzhi Li
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Geriatrics, Chongqing General Hospital, Chongqing, China
| | - Ying Chang
- Department of Geriatrics, Chongqing General Hospital, Chongqing, China
| | - Fei Li
- Department of Geriatrics, Chongqing General Hospital, Chongqing, China
| | - Yuehui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Huang X, Li Y, Zheng H, Xu Y. Sudden Cardiac Death Risk Stratification in Heart Failure With Preserved Ejection Fraction. Cardiol Rev 2024:00045415-990000000-00279. [PMID: 38814094 DOI: 10.1097/crd.0000000000000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) poses a significant clinical challenge, with sudden cardiac death (SCD) emerging as one of the leading causes of mortality. Despite advancements in cardiovascular medicine, predicting and preventing SCD in HFpEF remains complex due to multifactorial pathophysiological mechanisms and patient heterogeneity. Unlike heart failure with reduced ejection fraction, where impaired contractility and ventricular remodeling predominate, HFpEF pathophysiology involves heavy burden of comorbidities such as hypertension, obesity, and diabetes. Diverse mechanisms, including diastolic dysfunction, microvascular abnormalities, and inflammation, also contribute to distinct disease and SCD risk profiles. Various parameters such as clinical factors and electrocardiogram features have been proposed in SCD risk assessment. Advanced imaging modalities and biomarkers offer promise in risk prediction, yet comprehensive risk stratification models specific to HFpEF ar0e lacking. This review offers recent evidence on SCD risk factors and discusses current therapeutic strategies aimed at reducing SCD risk in HFpEF.
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Affiliation(s)
- Xu Huang
- From the Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
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14
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Pai RG, Varadarajan P. Diastolic Heart Failure Mechanisms and Assessment Revisited. J Clin Med 2024; 13:3043. [PMID: 38892754 PMCID: PMC11172756 DOI: 10.3390/jcm13113043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/22/2024] [Accepted: 05/19/2024] [Indexed: 06/21/2024] Open
Abstract
The syndrome of heart failure (HF) with preserved ejection fraction (HFpEF) makes up about half of the HF population. The HF mechanisms in these patients are varied and not fully understood. In addition, the term "diastolic HF" was switched to HFpEF because of difficulties in measuring the left ventricular (LV) diastolic performance. In the late stages, HFpEF carries a prognosis that is as bad as or worse than that of HFrEF. Hence, it is important to recognize LV diastolic impairment at an earlier stage so that the causal mechanisms, if any, can be treated to retard its progression. Despite the availability of numerous disease-modifying agents for HFrEF, there are hardly any available treatments for HFpEF. With our aging population, there will be an epidemic of HFpEF and hence this entity needs attention and respect. In this paper, we review the fundamental mechanisms of HFpEF, the physiology of LV filling and how LV diastolic function can be comprehensively measured. We also speculate how this may help with the early recognition of diastolic HF and its treatment.
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Affiliation(s)
- Ramdas G. Pai
- Department of Medicine, University of California Riverside School of Medicine, Riverside, CA 92521, USA;
- Department of Medicine, California University of Science and Medicine, Colton, CA 92324, USA
| | - Padmini Varadarajan
- Department of Medicine, University of California Riverside School of Medicine, Riverside, CA 92521, USA;
- Department of Medicine, California University of Science and Medicine, Colton, CA 92324, USA
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15
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Zhao Z, Qi D, Zhang Z, Du X, Zhang F, Ma R, Liang Y, Zhao Y, Gao Y, Yang Y. Prognostic Value of Inflammatory Cytokines in Predicting Hospital Readmissions in Heart Failure with Preserved Ejection Fraction. J Inflamm Res 2024; 17:3003-3012. [PMID: 38764501 PMCID: PMC11102073 DOI: 10.2147/jir.s459989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/02/2024] [Indexed: 05/21/2024] Open
Abstract
Purpose The aim of this study was to explore the relationship between inflammatory cytokines and the risk of heart failure (HF) readmission in patients with heart failure with preserved ejection fraction (HFpEF). Patients and Methods We enrolled 429 patients with HFpEF admitted to the cardiology department in our hospital from January 2020 to July 2022. The patients were divided into the readmission or non-readmission groups according to whether they were readmitted for heart failure within 1 year of discharge. The clinical features and laboratory date of the subjects were collected and analyzed. Multivariate cox regression analysis was used to identify predictors of HF readmission. In addition, receiver operating characteristic (ROC) curves were used to determine the prognostic value of each factor. Results The levels of IL-1β, IL-6, IL-10, IL-17, TNF-α, NT-proBNP, heart rate, total cholesterol and NYHA class were significantly higher in the readmission group than in the non-readmission group (p < 0.05). IL-1β, IL-6, IL-17, TNF-α, NT-proBNP, heart rate and NYHA class were identified as independent predictors of HF readmission. Conclusion Inflammatory markers, including IL-1β, IL-6, IL-17 and TNF-α were related to the HF readmission in patients with HFpEF.
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Affiliation(s)
- Zhihao Zhao
- Department of Cardiology, the Affiliated Xuzhou Municipal Hospital of Xuzhou Medical University, Xuzhou First People’s Hospital, Xuzhou, People’s Republic of China
| | - Diya Qi
- Department of Cardiology, the Affiliated Xuzhou Municipal Hospital of Xuzhou Medical University, Xuzhou First People’s Hospital, Xuzhou, People’s Republic of China
| | - Zeqing Zhang
- Department of Cardiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, People’s Republic of China
| | - Xin Du
- Department of Neurology, the Affiliated Xuzhou Municipal Hospital of Xuzhou Medical University, Xuzhou First People’s Hospital, Xuzhou, People’s Republic of China
| | - Fengyun Zhang
- Department of Cardiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, People’s Republic of China
| | - Ruicong Ma
- Graduate School, Dalian Medical University, Dalian, People’s Republic of China
| | - Yi Liang
- Department of Cardiology, the Affiliated Xuzhou Municipal Hospital of Xuzhou Medical University, Xuzhou First People’s Hospital, Xuzhou, People’s Republic of China
| | - Yuewu Zhao
- Department of Cardiology, the Affiliated Xuzhou Municipal Hospital of Xuzhou Medical University, Xuzhou First People’s Hospital, Xuzhou, People’s Republic of China
| | - Ying Gao
- Department of Cardiology, the Affiliated Xuzhou Municipal Hospital of Xuzhou Medical University, Xuzhou First People’s Hospital, Xuzhou, People’s Republic of China
| | - Yu Yang
- Department of Cardiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, People’s Republic of China
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Lava SAG, Laurence C, Di Deo A, Sekarski N, Burch M, Della Pasqua O. Dapagliflozin and Empagliflozin in Paediatric Indications: A Systematic Review. Paediatr Drugs 2024; 26:229-243. [PMID: 38635113 DOI: 10.1007/s40272-024-00623-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION In adults, sodium-glucose cotransporter type 2 inhibitors have revolutionised the treatment of type 2 diabetes mellitus, heart failure, and chronic kidney disease. OBJECTIVE We aimed to review information on compassionate use, clinical pharmacology, efficacy, and safety of dapagliflozin and empagliflozin in children. METHODS We conducted a systematic review of published clinical trials, case reports, and observational studies in Medline, Excerpta Medica, and Web of Science databases from inception to September 2023. For the two randomised controlled trials on type 2 diabetes mellitus (T2DM), we implemented a meta-analysis on the primary outcome (mean difference in glycosylated haemoglobin [HbA1c] between intervention and placebo groups). Review Manager (RevMan), version 5.4.1, was used for this purpose. RESULTS Thirty-five articles (nine case reports, ten case series, one prospective non-controlled trial, four controlled randomised trials, two surveys, six pharmacokinetic studies, and three pharmacovigilance studies) were selected, in which 415 children were exposed to either dapagliflozin or empagliflozin: 189 diabetic patients (mean age 14.7 ± 2.9 years), 32 children with glycogen storage disease type Ib (GSD Ib), glucose-6-phosphatase catalytic subunit 3 (G6PC3) deficiency, or severe congenital neutropenia type 4 (8.5 ± 5.1 years), 47 children with kidney disease or heart failure (11.2 ± 6.1 years), 84 patients in pharmacokinetic studies (15.1 ± 2.3 years), and 63 patients in toxicological series. The effect of dapagliflozin and empagliflozin in T2DM was demonstrated by HbA1c reduction in two randomised trials among a total of 177 adolescents, with a mean HbA1c difference of -0.82% (95% confidence interval -1.34 to -0.29) as compared to placebo (no heterogeneity, I2 = 0%). Dosage ranged between 5 and 20 mg (mean 11.4 ± 3.7) once daily for dapagliflozin and between 5 and 25 mg (mean 15.4 ± 7.4) once daily for empagliflozin. Among the paediatric cases of GSD Ib, empagliflozin 0.1-1.3 mg/kg/day improved neutropenia, infections, and gastrointestinal health. Dapagliflozin (mean dosage 6.9 ± 5.2 mg once daily) was well-tolerated in children with chronic kidney disease and heart failure. Side effects were generally mild, the most frequent being hypoglycaemia in children with GSD Ib (33% of patients) or T2DM (14% of patients) on concomitant hypoglycaemic drugs. Diabetic ketoacidosis is rare in children. CONCLUSION Early evidence suggests that dapagliflozin and empagliflozin are well tolerated in children. A clinical pharmacology rationale currently exists only for adolescents with diabetes mellitus. PROSPERO REGISTRATION NUMBER CRD42023438162.
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Affiliation(s)
- Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
- Heart Failure and Transplantation, Department of Paediatric Cardiology, Great Ormond Street Hospital, London, UK.
- Clinical Pharmacology and Therapeutics Group, University College London, London, UK.
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.
| | - Craig Laurence
- Heart Failure and Transplantation, Department of Paediatric Cardiology, Great Ormond Street Hospital, London, UK
| | - Alessandro Di Deo
- Clinical Pharmacology and Therapeutics Group, University College London, London, UK
| | - Nicole Sekarski
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Michael Burch
- Heart Failure and Transplantation, Department of Paediatric Cardiology, Great Ormond Street Hospital, London, UK
| | - Oscar Della Pasqua
- Clinical Pharmacology and Therapeutics Group, University College London, London, UK
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Shah A, Sabharwal N, Day J. Heart failure with preserved ejection fraction: implications for anaesthesia. BJA Educ 2024; 24:155-163. [PMID: 38646450 PMCID: PMC11026937 DOI: 10.1016/j.bjae.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2024] [Indexed: 04/23/2024] Open
Affiliation(s)
- A. Shah
- Nuffield Division of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - N. Sabharwal
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - J.R. Day
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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18
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Bansal N, Zelnick L, Scherzer R, Estrella M, Shlipak M. Risk Factors and Outcomes Associated With Heart Failure With Preserved and Reduced Ejection Fraction in People With Chronic Kidney Disease. Circ Heart Fail 2024; 17:e011173. [PMID: 38742428 PMCID: PMC11108746 DOI: 10.1161/circheartfailure.123.011173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 02/12/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Heart failure (HF) is associated with poor outcomes in people with chronic kidney disease, yet it is unknown whether outcomes differ by HF subtype. This study aimed to examine associations of incident HF with preserved ejection fraction (HFpEF) versus HF with reduced ejection fraction (HFrEF) with progression to end-stage kidney disease (ESKD) and mortality. METHODS We studied individuals with chronic kidney disease in the CRIC study (Chronic Renal Insufficiency Cohort) who were free of HF at cohort entry. Incident HF hospitalizations were adjudicated and classified into HFpEF (ejection fraction, ≥50%) or HFrEF (ejection fraction, <50%) based on echocardiograms performed during the hospitalization or at a research study visit. ESKD was defined as need for chronic dialysis or kidney transplant. Cox proportional hazards were used to evaluate the association of time-updated HF subtype with risk of ESKD and mortality, adjusting for demographics, comorbidities, and medication use. RESULTS Among the 3557 study participants without HF at cohort entry, mean age was 57 years and mean estimated glomerular filtration rate was 45 mL/min per 1.73 m2. A total of 682 participants had incident HF. Incidence rates for HFpEF and HFrEF were 0.9 (95% CI, 0.8-1.0) and 0.7 (95% CI, 0.6-0.8) per 100 person-years, respectively (Pdifference=0.005). Associations of incident HF with progression to ESKD were not statistically different for HFpEF (hazard ratio, 2.06 [95% CI, 1.66-2.56]) and HFrEF (hazard ratio, 1.80 [95% CI, 1.36-2.38]; P=0.42). The associations with mortality were stronger for HFrEF (hazard ratio, 2.73 [95% CI, 2.24-3.33]) compared with HFpEF (hazard ratio, 1.99 [95% CI, 1.65-2.40]; P=0.0002). CONCLUSIONS In a chronic kidney disease population, the rates of HFpEF hospitalizations were greater than that of HFrEF. Risk of ESKD was high but not statically different across HF subtypes. There was a stronger association of HFrEF with mortality. Prevention and treatment of both HFpEF and HFrEF should be central priorities to improve outcomes in chronic kidney disease.
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Affiliation(s)
- Nisha Bansal
- Division of Nephrology, University of Washington
| | | | - Rebecca Scherzer
- Kidney Health Research Collaborative, University of California, San Francisco
| | - Michelle Estrella
- Kidney Health Research Collaborative, University of California, San Francisco
| | - Michael Shlipak
- Kidney Health Research Collaborative, University of California, San Francisco
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Chen L, Xie W, Hong X, Hong H. Association of pulse pressure and aortic root diameter in elderly Chinese patients with chronic heart failure. Front Cardiovasc Med 2024; 11:1366282. [PMID: 38495938 PMCID: PMC10940542 DOI: 10.3389/fcvm.2024.1366282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 02/20/2024] [Indexed: 03/19/2024] Open
Abstract
Background High pulse pressure (PP) and aortic root diameter (AoD) are hallmarks of arterial stiffness or vascular aging and they are considered as risk factors for age-related cardiovascular disease, including heart failure (HF). However, the relationship between PP and AoD in patients with heart failure (HF) is uncertain. This study aimed to evaluate the relationship between PP and AoD in the middle-aged and the elderly with HF. Methods A total of 1,027 Chinese middle-aged and elderly patients with HF, including HF with reduced ejection fraction (HFrEF), HF with mid-range EF (HFmrEF), and HF with preserved EF (HFpEF) were included in this study. Pearson correlation analysis was used to evaluate the relationship between PP and AoD in the three types of HF. Multiple linear regression analysis was performed to assess the factors that affected AoD. Multivariate logistic regression was performed to determine the association between the PP level quartiles and AoD. The results were validated in an independent dataset included a total of 378 consecutive patients with HFrEF hospitalized at the Pingtan Branch of Fujian Medical University Union Hospital (Fujian, China). Results There was a positive correlation between PP and AoD in the middle-aged and the elderly with HFrEF. Multiple linear regression analysis revealed that PP, age, and body mass index (BMI) were independently correlated with AoD in HFrEF patients. In multivariate logistic regression analysis, an increased risk of aortic root dilation was observed in the highest quartile of the PP level compared with the lowest quartile. Age significantly interacted with PP (p = 0.047). A significant association between PP levels and AoD was only observed in patients ≥ 65 years old, but not in patients < 65 years old. In the validation dataset, PP was independently related to AoD in patients with HFrEF (β = 0.205, p = 0.001). Conclusions PP level was independently and positively associated with AoD, especially in the elderly with HFrEF, but not in patients with HFmrEF and HFpEF. Arterial stiffening or vascular aging may play a certain role in the elderly HFrEF patients.
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Lucà F, Oliva F, Abrignani MG, Di Fusco SA, Gori M, Giubilato S, Ceravolo R, Temporelli PL, Cornara S, Rao CM, Caretta G, Pozzi A, Binaghi G, Maloberti A, Di Nora C, Di Matteo I, Pilleri A, Gelsomino S, Riccio C, Grimaldi M, Colivicchi F, Gulizia MM. Heart Failure with Preserved Ejection Fraction: How to Deal with This Chameleon. J Clin Med 2024; 13:1375. [PMID: 38592244 PMCID: PMC10933980 DOI: 10.3390/jcm13051375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/11/2024] [Accepted: 02/14/2024] [Indexed: 04/10/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is characterized by a notable heterogeneity in both phenotypic and pathophysiological features, with a growing incidence due to the increase in median age and comorbidities such as obesity, arterial hypertension, and cardiometabolic disease. In recent decades, the development of new pharmacological and non-pharmacological options has significantly impacted outcomes, improving clinical status and reducing mortality. Moreover, a more personalized and accurate therapeutic management has been demonstrated to enhance the quality of life, diminish hospitalizations, and improve overall survival. Therefore, assessing the peculiarities of patients with HFpEF is crucial in order to obtain a better understanding of this disorder. Importantly, comorbidities have been shown to influence symptoms and prognosis, and, consequently, they should be carefully addressed. In this sense, it is mandatory to join forces with a multidisciplinary team in order to achieve high-quality care. However, HFpEF remains largely under-recognized and under-treated in clinical practice, and the diagnostic and therapeutic management of these patients remains challenging. The aim of this paper is to articulate a pragmatic approach for patients with HFpEF focusing on the etiology, diagnosis, and treatment of HFpEF.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, 89129 Reggio Calabria, Italy
| | - Fabrizio Oliva
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (A.M.)
| | | | | | - Mauro Gori
- Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Simona Giubilato
- Cardiology Department, Ospedale Lamezia Terme, 88046 Catanzaro, Italy
| | - Roberto Ceravolo
- Cardiac Rehabilitation Unitof Maugeri, IRCCS, 28010 Gattico-Veruno, Italy
| | | | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy;
| | | | - Giorgio Caretta
- Levante Ligure Sant’Andrea Hospital, ASL 5 Liguria, 19121 La Spezia, Italy
| | - Andrea Pozzi
- Cardiology Division, Valduce Hospital, 22100 Como, Italy
| | - Giulio Binaghi
- Department of Cardiology, Azienda Ospedaliera Brotzu, 09134 Cagliari, Italy
| | - Alessandro Maloberti
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (A.M.)
| | - Concetta Di Nora
- Department of Cardiothoracic Science, Azienda Sanitaria UniversitariaIntegrata di Udine, 33100 Udine, Italy
| | - Irene Di Matteo
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (A.M.)
| | - Anna Pilleri
- Department of Cardiology, Azienda Ospedaliera Brotzu, 09134 Cagliari, Italy
| | - Sandro Gelsomino
- Cardiovascular Research Institute, Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy
| | - Furio Colivicchi
- Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Rome, Italy
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Pagano M, Corallo F, D’Aleo P, Duca A, Bramanti P, Bramanti A, Cappadona I. A Set of Possible Markers for Monitoring Heart Failure and Cognitive Impairment Associated: A Review of Literature from the Past 5 Years. Biomolecules 2024; 14:185. [PMID: 38397422 PMCID: PMC10886491 DOI: 10.3390/biom14020185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Heart failure is an epidemiologically relevant disease because of the aging population and widespread lifestyles that promote it. In addition to the acute event, it is possible for the disease to become chronic with periodic flare-ups. It is essential to study pathology from a diagnostic and prognostic point of view and to identify parameters for effective monitoring. In addition, heart failure is associated with multiple comorbidities, including cognitive impairment, which is monitored clinically but not through specific biomarkers in these patients. The purpose of this review is to gather the most recent scientific evidence on a few possible biomarkers previously identified for monitoring heart failure and associated cognitive impairment. METHODS We surveyed studies inherent to a set of previously identified markers, evaluating English-language articles from the past five years conducted in adult heart failure patient populations. We used the databases PubMed, Web of Sciences, and Cochrane Library for search studies, and we considered articles published in journals with an impact factor greater than five in the publication year. RESULTS Among the biomarkers evaluated, a concordant indication for serial measurements for heart failure monitoring emerged only for interleukin-6. For the other markers, there is still little evidence available, which is interesting but sometimes conflicting. Interesting studies have also emerged for biomarkers of cognitive decline assessed in patients with heart failure, confirming the hypotheses of the increasingly studied heart-brain correlation. CONCLUSION Certainly, further studies in large populations are needed to identify effective biomarkers for monitoring heart failure and associated cognitive impairment.
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Affiliation(s)
- Maria Pagano
- IRCCS Centro Neurolesi Bonino-Pulejo, Via Palermo, S.S. 113, C.da Casazza, 98124 Messina, Italy; (M.P.); (P.D.); (A.D.); (P.B.); (I.C.)
| | - Francesco Corallo
- IRCCS Centro Neurolesi Bonino-Pulejo, Via Palermo, S.S. 113, C.da Casazza, 98124 Messina, Italy; (M.P.); (P.D.); (A.D.); (P.B.); (I.C.)
| | - Piercataldo D’Aleo
- IRCCS Centro Neurolesi Bonino-Pulejo, Via Palermo, S.S. 113, C.da Casazza, 98124 Messina, Italy; (M.P.); (P.D.); (A.D.); (P.B.); (I.C.)
| | - Antonio Duca
- IRCCS Centro Neurolesi Bonino-Pulejo, Via Palermo, S.S. 113, C.da Casazza, 98124 Messina, Italy; (M.P.); (P.D.); (A.D.); (P.B.); (I.C.)
| | - Placido Bramanti
- IRCCS Centro Neurolesi Bonino-Pulejo, Via Palermo, S.S. 113, C.da Casazza, 98124 Messina, Italy; (M.P.); (P.D.); (A.D.); (P.B.); (I.C.)
- Faculty of Psychology, Università degli Studi eCampus, Via Isimbardi 10, 22060 Novedrate, Italy
| | - Alessia Bramanti
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, Italy;
| | - Irene Cappadona
- IRCCS Centro Neurolesi Bonino-Pulejo, Via Palermo, S.S. 113, C.da Casazza, 98124 Messina, Italy; (M.P.); (P.D.); (A.D.); (P.B.); (I.C.)
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Abstract
PURPOSE OF REVIEW Pulmonary hypertension associated with left heart disease (PHLHD) is common and associated with adverse prognosis. Proper diagnosis is critical to avoid inappropriate treatment. Practical approaches to noninvasive diagnosis are available, though invasive hemodynamics including volume loading or exercise are often necessary for definitive diagnosis. Treatment strategies and research in the field is rapidly evolving. RECENT FINDINGS Combined pre and post capillary pulmonary hypertension is associated with remodeling of the pulmonary vasculature that is proportional to the severity of the pulmonary hypertension. Even quite mild elevation of pulmonary vascular resistance (PVR), (greater than 2.0 Wood units (WU)) is associated with adverse outcome. Guideline-directed medical therapy (GDMT) for left heart failure has rapidly evolved, including approval of SGLT2 inhibitors for treatment of heart failure with preserved ejection fraction (HFpEF). However, full implementation of GDMT is lagging. Utilization of implanted pulmonary artery pressure monitoring can facilitate patient management in selected patient phenotypes and has been utilized to demonstrate improvement in pulmonary pressures with emerging therapies in HFpEF including SGLT2 inhibitors and sacubitril/valsartan. A variety of shunt devices to create a left-to-right shunt in order to decompress the left heart are available or undergoing clinical trials. There is concern that there could be adverse response to such devices in patients who have even mild elevation of pulmonary vascular resistance. Sleep disordered breathing is common in PHLHD and should be aggressively sought out and treated. SUMMARY Even mild elevation in pulmonary vascular resistance is associated with adverse outcome. A systematic approach to diagnosis of PHLHD is essential. Guideline-directed medical therapy for PHLHD prioritizes optimal management of the left heart disease. Pulmonary artery pressure sensors are useful in selected patients.
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Affiliation(s)
- Robert P Frantz
- Department of Cardiovascular Medicine, Rochester, Minnesota, USA
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23
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Akao K, Imamura T, Tanaka S, Onoda H, Ushijima R, Sobajima M, Fukuda N, Ueno H, Kinugawa K. Prognostic Impact of Modified H2FPEF Score in Patients Receiving Trans-Catheter Aortic Valve Replacement. J Clin Med 2023; 12:5396. [PMID: 37629434 PMCID: PMC10455783 DOI: 10.3390/jcm12165396] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND H2FPEF is a recently introduced score for the diagnosis of heart failure with preserved ejection fraction (HFpEF). Many patients with severe aortic stenosis have clinical/subclinical HFpEF and have worsening heart failure even after trans-catheter aortic valve replacement (TAVR). We investigated the prognostic impact of the H2FPEF score in TAVR candidates. METHODS Patients undergoing TAVR procedures at a single academic center between 2015 and 2022 were included. The H2FPEF score was calculated using baseline characteristics before TAVR. The prognostic impact of the score on the post-TAVR composite endpoint, consisting of all-cause death and heart failure readmissions during the 2-year observation period, was evaluated. RESULTS A total of 244 patients (median age 86 years, 70 males) were included. The median value of H2FPEF score was 3 (2, 4). The score was significantly associated with the primary outcome with a hazard ratio of 1.33 (95% confidence interval 1.02-1.74, p = 0.036). We constructed a modified H2FPEF score by adjusting cutoffs of several items for better prognostic stratification (i.e., age and body mass index). A modified score had a higher area under the curve than the original one (0.65 vs. 0.59, p = 0.028) and was independently associated with the primary outcome with an adjusted hazard ratio of 1.22 (95% confidence interval 1.01-1.49, p = 0.047). CONCLUSIONS A modified H2FPEF score, which was originally developed to diagnose the presence of HFpEF, could be used to risk-stratify elderly patients receiving TAVR. The clinical utility of this score should be validated in future studies.
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24
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Moscucci F, Sciomer S, Maffei S, Meloni A, Lospinuso I, Carnovale M, Corrao A, Di Diego I, Caltabiano C, Mezzadri M, Mattioli AV, Gallina S, Rossi P, Magrì D, Piccirillo G. Sex Differences in Repolarization Markers: Telemonitoring for Chronic Heart Failure Patients. J Clin Med 2023; 12:4714. [PMID: 37510828 PMCID: PMC10381165 DOI: 10.3390/jcm12144714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
Aging and chronic heart failure (CHF) are responsible for the temporal inhomogeneity of the electrocardiogram (ECG) repolarization phase. Recently, some short period repolarization-dispersion parameters have been proposed as markers of acute decompensation and of mortality risk in CHF patients. Some important differences in repolarization between sexes are known, but their impact on ECG markers remains unstudied. The aim of this study was to evaluate possible differences between men and women in ECG repolarization markers for the telemonitoring of CHF patients. METHOD 5 min ECG recordings were collected to assess the mean and standard deviation (SD) of the following variables: QT end (QTe), QT peak (QTp), and T peak to T end (Te) in 215 decompensated CHF (age range: from 49 to 103 years). Thirty-day mortality and high levels of NT-pro BNP (<75 percentile) were considered markers of decompensated CHF. RESULTS A total of 34 patients (16%) died during the 30-day follow-up, without differences between sexes. Women showed a more preserved ejection fraction and higher LDL and total cholesterol levels. Among female patients, implantable cardioverter devices, statins, and antiplatelet agents were less used. Data for Te mean showed increased values among deceased men and women compared to survival, but TeSD was shown to be the most reliable marker for CHF reacutization in both sexes. CONCLUSION TeSD could be considered a risk factor for CHF worsening and complications for female and male patients, but different cut offs should be taken into account. (ClinicalTrials.gov number, NCT04127162.).
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Affiliation(s)
- Federica Moscucci
- Department of Internal Medicine and Medical Specialties, Policlinico Umberto I, Viale del Policlinico n. 155, 00161 Rome, Italy
| | - Susanna Sciomer
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche, Cardiovascolari, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Silvia Maffei
- Endocrinologia Cardiovascolare Ginecologica ed Osteoporosi, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Ilaria Lospinuso
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche, Cardiovascolari, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Myriam Carnovale
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche, Cardiovascolari, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Andrea Corrao
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche, Cardiovascolari, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Ilaria Di Diego
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche, Cardiovascolari, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Cristina Caltabiano
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche, Cardiovascolari, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Martina Mezzadri
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche, Cardiovascolari, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Anna Vittoria Mattioli
- Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, 42121 Modena, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies, "G. D'Annunzio" University, 66100 Chieti, Italy
| | - Pietro Rossi
- Arrhythmology Unit, Fatebenefratelli Hospital Isola Tiberina-Gemelli Isola, 00186 Rome, Italy
| | - Damiano Magrì
- Dipartimento di Medicina Clinica e Molecolare, S. Andrea Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Gianfranco Piccirillo
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche, Cardiovascolari, "Sapienza" University of Rome, 00185 Rome, Italy
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25
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Guazzi M. The biventricular paths to exercise dyspnoea in heart failure with preserved ejection fraction: the future is now. Eur J Heart Fail 2023; 25:967-969. [PMID: 37199380 DOI: 10.1002/ejhf.2914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/14/2023] [Indexed: 05/19/2023] Open
Affiliation(s)
- Marco Guazzi
- University of Milan School of Medicine, Cardiology Division, San Paolo University Hospital, Milan, Italy
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