The impact of right ventricular dysfunction on the effectiveness of beta-blockers in heart failure with preserved ejection fraction

Multifaced risk factors and clinical impact of a deep Y descent in patients with heart failure irrespective of RV-PA coupling

Background

A deep Y descent in the jugular venous pulse (JVP) is associated with diseases such as a decrease in right ventricular (RV) preload reserve. The present study investigated the relationship between RV-pulmonary arterial (PA) coupling and a deep Y descent, examined risk factors for a deep Y descent and clarified whether a deep Y descent was an independent risk factor for cardiac events irrespective of RV-PA coupling in patients with heart failure (HF).

Methods

We enrolled 350 patients with HF who underwent echocardiography and JVP examination. A deep Y descent was identified by a deeper 'Y' descent than 'X' descent in the JVP waveform. We defined cardiac events of HF as follows: sudden death, death from HF, the emergent infusion of loop diuretics, or hospitalization for decompensated HF.

Results and Conclusions

A deep Y descent and cardiac events were observed in 129 and 83 patients, respectively. The prevalence of a deep Y descent increased with decreases in the tricuspid annular plane systolic excursion (TAPSE)/systolic pulmonary arterial pressure (SPAP) ratio. Not only the TAPSE/SPAP ratio (odds ratio,0.756 per0.1 mm/mmHg, 95 %confidence interval [CI], 0.660-0.866, p < 0.001), but also age, atrial fibrillation, and the use of beta-blockers were independent factors for a deep Y descent in multivariate logistic model. Multivariate Cox hazard model demonstrated that a deep Y descent was for cardiac events in patients with HF (Hazard ratio,2.682, 95 %CI, 1.599-4.497, p < 0.001) irrespective of the TAPSE/SPAP ratio. The development of therapeutic strategies based on central venous waveform may be needed for patients with HF.

The effect of sustained-release CARvedilol in patients with hypErtension and heart failure with preserved ejection fraction: a study protocol for a pilot randomized controlled trial (CARE-preserved HF)

Background

Although beta-blockers improve clinical outcomes in heart failure with reduced ejection fraction, the benefit of beta-blockers in heart failure with preserved ejection fraction (HFpEF) is uncertain. Global longitudinal strain (GLS) is a robust predictor of heart failure outcomes, and recent studies have shown that beta-blockers are associated with improved survival in those with low GLS (GLS <14%) but not in those with GLS ≥14% among patients with LVEF ≥40%. Therefore, the objective of this trial is to evaluate the effect of sustained-release carvedilol (carvedilol-SR) on the outcome [N-terminal pro-B-natriuretic peptide (NT-proBNP) concentration] in patients with hypertension and HFpEF and will assess the differential effects of these drugs on the outcome, according to the GLS categories.

Methods

This prospective randomized double-blind multicenter trial (CARE-preserved HF) will include 100 patients with HFpEF from three tertiary hospitals in South Korea. Patients with HFpEF and hypertension aged ≥20 years who have evidence of functional and structural heart disease on echocardiography and elevated natriuretic peptide will be enrolled. Eligible participants will be randomized 1:1 to either the carvedilol-SR group (n = 50) or the placebo group (n = 50). Patients in the carvedilol-SR group will receive 8, 16, 32, or 64 mg carvedilol-SR once daily for 6 months, and the dose of carvedilol will be up-titrated at the discretion of the treating physicians. The primary efficacy outcome was the time-averaged proportional change in N-terminal pro-B-natriuretic peptide concentration from baseline to months 3 and 6. We will also evaluate the differential effects of carvedilol-SR on primary outcomes according to GLS, using a cut-off of 14% or the median value.

Discussion

This randomized controlled trial will investigate the efficacy and safety of carvedilol-SR in patients with HFpEF and hypertension.

Clinical Trial Registration

ClinicalTrial.gov, identifier NCT05553314.

Is pulmonary hypertension protective against cardiac tamponade? A systematic review

The presence of pulmonary hypertension (PH) may affect whether cardiac tamponade physiology develops from a pericardial effusion. Specifically, the increased intracardiac pressure and right ventricular hypertrophy associated with PH would seemingly increase the intrapericardial pressure threshold at which the right-sided chambers collapse. In this systematic review, we examined the impact of PH on the incidence, in-hospital and long-term mortality, and echocardiographic findings of patients with cardiac tamponade. Using the PRISMA guideline, a systematic search was conducted in PubMed, Academic Search Premier, Web of Science, Google Scholar, and the Cochrane Database for studies investigating PH and cardiac tamponade. The Newcastle-Ottawa Scale was used to analyze the quality of returned studies. Primary outcomes included the incidence of cardiac tamponade, as well as in-hospital and long-term mortality rates. Secondary outcomes were the presence or absence of echocardiographic findings of cardiac tamponade in patients with PH. Forty-three studies (9 cohort studies and 34 case reports) with 1054 patients were included. The incidence of cardiac tamponade was significantly higher in patients with PH compared to those without PH, 2.0% (95% CI 1.2-3.2%) vs. 0.05% (95% CI 0.05-0.05%), p < 0.0001, OR 40.76 (95% CI 24.8-66.9). The incidence of tamponade in patients with a known pericardial effusion was similar in those with and without PH, 20.3% (95% CI 12.0-32.3%) and 20.9% (95% CI 18.0-24.1%), p = 0.9267, OR 0.97 (95% CI 0.50-1.87). In patients with tamponade, those with PH demonstrated a significantly higher in-hospital mortality than those without PH, 38.8% (95% CI 26.4-52.8%) vs. 14.4% (95% CI 14.2-14.6%), p < 0.0001, OR 3.77 (95% CI 2.12-6.70). Long-term mortality in patients with tamponade was significantly lower in those with PH than in those without PH, 45.5% (95% CI 33.0-58.5%) vs. 59.1% (95% CI 54.7-63.4%), p = 0.0258, OR 0.576 (95% CI 0.33-1.01). However, after stratifying by non-malignant etiologies, the long-term mortality benefit for those with PH disappeared. In the studies that described specific echocardiographic findings of cardiac tamponade, only 10.5% of patients with PH and tamponade showed right atrial and right ventricular collapse. When evaluating patients with pericardial effusions, physicians must recognize the effects of underlying PH on the incidence, in-hospital and long-term mortality rates, and potentially atypical echocardiographic presentation of cardiac tamponade.

Beta-blocker therapy in heart failure with preserved ejection fraction (B-HFpEF): A systematic review and meta-analysis

INTRODUCTION

While beta-blockers are considered the cornerstone of treatment for heart failure with reduced ejection fraction, the same may not apply to patients with heart failure with preserved ejection fraction (HFpEF). To date, the benefit of beta-blockers remains uncertain, and there is no current consensus on their effectiveness. This study sought to evaluate the efficacy of beta-blockers on mortality and rehospitalization among patients with HFpEF.

METHODS

A systematic review and meta-analysis of randomized or observational cohort studies examined the efficacy of beta-blocker therapy in comparison with placebo, control, or standard medical care in patients with HFpEF, defined as left ventricular ejection fraction ≥50 %. The main endpoints were mortality (i.e., all-cause and cardiovascular), rehospitalization (i.e., all-cause and for heart failure) and a composite of the two.

RESULTS

Out of the 13,189 records initially identified, 16 full-text records met the inclusion criteria and were analyzed recruiting a total of 27,188 patients. The mean age range was 62-84 years old, predominantly female, with HFpEF in which 63.4 % of patients received a beta-blocker and 36.6 % did not. The pooled analysis of included cohort studies, of variable follow-up durations, showed a significant reduction in all-cause mortality by 19 % (odds ratio (OR) 0.81; 95 % confidence interval (CI): 0.65-0.99, p = 0.044) whereas rehospitalization for heart failure (OR 1.13; 95 % CI: 0.91-1.41, p = 0.27) or its composite with all-cause mortality (OR 1.01; 95 % CI: 0.78-1.32, p = 0.92) were similar between the beta-blocker and control groups.

CONCLUSION

This meta-analysis showed that beta-blocker therapy has the potential to reduce all-cause mortality in patients with HFpEF based on observational studies. Nevertheless, it did not affect rehospitalization for heart failure or its composite with all-cause mortality. Large scale randomized trials are needed to clarify this uncertainty.

Revisiting Beta-Blocker Therapy in Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a heterogenous disorder and tends to be predominant in elderly, female, and obese patients. HFpEF has been classified using various cut-offs of left ventricular ejection fraction in the published studies with a current cut-off of ≥50%. The evidence of beta-blocker therapy in HFpEF patients showed conflicting findings with variably reported efficacy. This review aims to examine the published studies on the use of beta blockers for the treatment of patients with HFpEF.

Right ventricular diastolic dysfunction worsens clinical outcomes in Japanese patients with heart failure

Background

Heart failure (HF) is a rapidly growing public health issue in super aging societies, such as Japan. Right HF is common in older patients. Therefore, the present study investigated the relationship between right ventricular diastolic function and poor clinical outcomes in patients with HF.

Methods

We retrospectively enrolled 387 Japanese HF patients. All data were obtained from our echocardiographic and jugular venous pulse (JVP) databases and medical records. A less-distensible right ventricle (RV) was identified by a deeper 'Y' descent than 'X' descent in the JVP waveform. We defined cardiac events of HF as follows: sudden death, death from HF, emergent infusion of loop diuretics, or hospitalization for deterioration of HF. Comparisons between patients with and without cardiac events and a multivariate analysis of cardiac events were performed.

Results

Eighty-five patients had cardiac events. Left ventricular ejection fraction (LVEF) was lower, average mitral E/e' and the prevalence of a less-distensible RV were higher, and tricuspid annular plane systolic excursion was shorter in patients with than in those without cardiac events (median55vs65, p < 0.001; median15vs11, p < 0.001; 64 %vs27%, p < 0.001; median17vs20, p < 0.001, respectively). In a multivariate Cox proportional hazard model, LVEF and a less-distensible RV were independent risk factors for cardiac events (hazard ratio [HR]:0.983 per 1 % increase, p = 0.048; HR:3.150, p < 0.001, respectively). The event-free rate was the lowest for patients with LVEF < 50 % and a less-distensible RV (p for trend < 0.001).

Conclusions

When right ventricular diastolic function is impaired and irreversible, Japanese patients with HF may become intractable regardless of LVEF.

Naive Bayes Prediction of the Development of Cardiac Events in Heart Failure With Preserved Ejection Fraction in an Outpatient Clinic - Beyond B-Type Natriuretic Peptide

BACKGROUND

The heterogeneity of B-type natriuretic peptide (BNP) levels among individuals with heart failure and preserved ejection fraction (HFpEF) makes predicting the development of cardiac events difficult. This study aimed at creating high-performance Naive Bayes (NB) classifiers, beyond BNP, to predict the development of cardiac events over a 3-year period in individual outpatients with HFpEF.Methods and Results:We retrospectively enrolled 234 outpatients with HFpEF who were followed up for 3 years. Parameters with a coefficient of association ≥0.1 for cardiac events were applied as features of classifiers. We used the step forward method to find a high-performance model with the maximum area under the receiver operating characteristics curve (AUC). A 10-fold cross-validation method was used to validate the generalization performance of the classifiers. The mean kappa statistics, AUC, sensitivity, specificity, and accuracy were evaluated and compared between classifiers learning multiple factors and only the BNP. Kappa statistics, AUC, and sensitivity were significantly higher for NB classifiers learning 13 features than for those learning only BNP (0.69±0.14 vs. 0.54±0.12 P=0.024, 0.94±0.03 vs. 0.84±0.05 P<0.001, 85±8% vs. 64±20% P=0.006, respectively). The specificity and accuracy were similar.

CONCLUSIONS

We created high-performance NB classifiers for predicting the development of cardiac events in individual outpatients with HFpEF. Our NB classifiers may be useful for providing precision medicine for these patients.

The Impact of Deep Y Descent on Hemodynamics in Patients With Heart Failure and Preserved Left Ventricular Systolic Function

Background: Influence of right ventricular diastolic function on the hemodynamics of heart failure (HF). We aimed to clarify the hemodynamic features of deep Y descent in the right atrial pressure waveform in patients with HF and preserved left ventricular systolic function.

Methods: In total, 114 consecutive inpatients with HF who had preserved left ventricular systolic function (left ventricular ejection fraction ≥ 50%) and right heart catheterization were retrospectively enrolled in this study. The patients were divided into two groups according to right atrial pressure waveform, and those with Y descent deeper than X descent in the right atrial pressure waveform were assigned to the deep Y descent group. We enrolled another seven patients (two men, five women; mean age, 87 ± 6) with HF and preserved ejection fraction, and implanted a pacemaker to validate the results of this study.

Results: The patients with deep Y descent had a higher rate of atrial fibrillation, higher right atrial pressure and mean pulmonary arterial pressure, and lower stroke volume and cardiac index than those with normal Y descent (76 vs. 7% p < 0.001, median 8 vs. 5 mmHg p = 0.001, median 24 vs. 21 mmHg p = 0.036, median 33 vs. 43 ml/m²p < 0.001, median 2.2 vs. 2.7 L/m², p < 0.001). Multiple linear regression revealed a negative correlation between stroke volume index and pulmonary vascular resistance index (wood unit*m²) only in the patients with deep Y descent (estimated regression coefficient: −1.281, p = 0.022). A positive correlation was also observed between cardiac index and heart rate in this group (r = 0.321, p = 0.038). In the other seven patients, increasing the heart rate (from median 60 to 80/min, p = 0.001) significantly reduced the level of BNP (from median 419 to 335 pg/ml, p = 0.005).

Conclusions: The hemodynamics of patients with HF with deep Y descent and preserved left ventricular systolic function resembled right ventricular restrictive physiology. Optimizing the heart rate may improve hemodynamics in these patients.

Prognostic impact of right ventricular function affected by pulmonary hypertension in hospitalized heart failure patients

BACKGROUND

Pulmonary hypertension (PH) may affect right ventricular (RV) function; however, the prognostic implications of RV function in patients with heart failure and PH remain unclear. We aimed to investigate the impact of RV function on the prognosis of hospitalized heart failure patients with and without PH.

METHODS

This observational study initially included 1,349 consecutive hospitalized heart failure patients. After excluding patients who died in hospital, whose left ventricular (LV) function was preserved, and whose echocardiography data were incomplete, 573 patients with heart failure and reduced LV ejection fractions (HFrEF) were analyzed. The patients were grouped according to RV dysfunction that was defined as an RV-tissue Doppler imaging systolic velocity (RV-TDI s') of ≤9.5 cm/s. The primary endpoint was a composite of cardiovascular death and rehospitalization as a consequence of heart failure.

RESULTS

Overall, the patients with reduced RV function had significantly higher event rates than those with preserved RV function (log-rank test p = 0.01). This prognostic impact was observed in the patients with PH (p = 0.001) and was not evident among the patients without PH (p = 0.39). In the patients with PH, reduced RV function independently predicted the prognosis after adjusting for the covariates (adjusted hazard ratio: 3.12; 95% confidence interval: 1.44 to 6.73).

CONCLUSION

RV dysfunction that was estimated during hospitalization using the RV-TDI s', which is a simply determined index, may predict clinical outcomes in hospitalized patients with HFrEF and PH after discharge, but not in those without PH.

Pathophysiological role of right ventricular function and interventricular functional mismatch in the development of pulmonary edema in acute heart failure

BACKGROUND

Parameters of cardiac function related to the development of pulmonary edema (PE) in acute heart failure (AHF), including right ventricular (RV) function and a mismatch of interventricular function, are not fully elucidated. The aim of this study was to verify the hypothesis that a relatively preserved RV function compared with left ventricular function may be associated with the development of PE by using two-dimensional speckle tracking echocardiography (2DSTE).

METHODS

Hospitalized patients with AHF at 11 institutions were enrolled. PE was defined as lung congestion on chest X-ray with hypoxemia. Patients with systolic blood pressure ≥140 mmHg on admission were defined to have hypertensive AHF. Echocardiographic analyses, including 2DSTE, were performed prior to discharge. The index of mismatch between RV and left ventricular systolic function was assessed by interventricular longitudinal strain difference (IVLSD) which was defined as RV free wall longitudinal strain and left ventricular global longitudinal strain.

RESULTS

Of 610 patients with AHF, 422 (69.2%) had PE. In patients with PE, IVLSD (p = 0.007) and RV fractional area change ratio (p<0.001) was significantly higher than those in patients without PE. In patients with non-hypertensive AHF, RV fractional area change ratio, age, ischemic etiology, and serum brain natriuretic peptide (BNP) levels were independent predictors of PE. In patients with hypertensive AHF, IVLSD, age, and serum BNP levels were independent predictors of PE.

CONCLUSIONS

Preserved RV function might be one of the underlying mechanisms of the development of PE in AHF. Furthermore, interventricular functional mismatch might be related to the development of PE in hypertensive AHF.

Kcnk3 dysfunction exaggerates the development of pulmonary hypertension induced by left ventricular pressure overload

AIMS

Pulmonary hypertension (PH) is a common complication of left heart disease (LHD, Group 2 PH) leading to right ventricular (RV) failure and death. Several loss-of-function (LOF) mutations in KCNK3 were identified in pulmonary arterial hypertension (PAH, Group 1 PH). Additionally, we found that KCNK3 dysfunction is a hallmark of PAH at pulmonary vascular and RV levels. However, the role of KCNK3 in the pathobiology of PH due to LHD is unknown.

METHODS AND RESULTS

We evaluated the role of KCNK3 on PH induced by ascending aortic constriction (AAC), in WT and Kcnk3-LOF-mutated rats, by echocardiography, RV catheterization, histology analyses, and molecular biology experiments. We found that Kcnk3-LOF-mutation had no consequence on the development of left ventricular (LV) compensated concentric hypertrophy in AAC, while left atrial emptying fraction was impaired in AAC-Kcnk3-mutated rats. AAC-animals (WT and Kcnk3-mutated rats) developed PH secondary to AAC and Kcnk3-mutated rats developed more severe PH than WT. AAC-Kcnk3-mutated rats developed RV and LV fibrosis in association with an increase of Col1a1 mRNA in right ventricle and left ventricle. AAC-Kcnk3-mutated rats developed severe pulmonary vascular (pulmonary artery as well as pulmonary veins) remodelling with intense peri-vascular and peri-bronchial inflammation, perivascular oedema, alveolar wall thickening, and exaggerated lung vascular cell proliferation compared to AAC-WT-rats. Finally, in lung, right ventricle, left ventricle, and left atrium of AAC-Kcnk3-mutated rats, we found a strong increased expression of Il-6 and periostin expression and a reduction of lung Ctnnd1 mRNA (coding for p120 catenin), contributing to the exaggerated pulmonary and heart remodelling and pulmonary vascular oedema in AAC-Kcnk3-mutated rats.

CONCLUSIONS

Our results indicate that Kcnk3-LOF is a key event in the pathobiology of PH due to AAC, suggesting that Kcnk3 channel dysfunction could play a potential key role in the development of PH due to LHD.

The Efficacy and Safety of Esmolol for Septic Shock: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Purpose: The meta-analysis aims to identify whether septic shock patients can benefit from esmolol.

Materials and Methods: The relevant studies from MEDLINE, Cochrane Library, Embase were searched by two independent investigators using a variety of keywords. Stata software (version 12.0, Stata Corp LP, College Station, TX, United States)was used for statistical analysis.

Results: A total of 14 studies were identified and incorporated into the meta-analysis. For overall analysis, the treatment of esmolol was associated with decreased 28-day mortality (RR = 0.66, 95% CI = 0.56–0.77, p < 0.001). Meanwhile, our analysis found that, esmolol could decrease HR (SMD: −1.70; 95% CI: [−2.24−(−1.17)], cTnI (SMD: −1.61; 95% CI: [−2.06−(−1.16)] compared with standard treatment. No significant differences between the two groups were found in MAP, Lac, CI, and SVI.

Conclusion: The findings of this meta-analysis intend to demonstrate that septic shock patients with high heart beats rate might be benefit from esmolol treatment despite enough fluid resuscitation. While, dependent on the study published, with the further development of septic shock, the positive impact of esmolol varies. The appropriate heart rate change interval cannot be confirmed, further high-quality and large-scale RCTs should be performed to verify it and screening more suitable heart rate levels.

Systematic Review Registration: CRD42021239513

Different Pathophysiology and Outcomes of Heart Failure With Preserved Ejection Fraction Stratified by K-Means Clustering

Background: Stratified medicine may enable the development of effective treatments for particular groups of patients with heart failure with preserved ejection fraction (HFpEF); however, the heterogeneity of this syndrome makes it difficult to group patients together by common disease features. The aim of the present study was to find new subgroups of HFpEF using machine learning. Methods: K-means clustering was used to stratify patients with HFpEF. We retrospectively enrolled 350 outpatients with HFpEF. Their clinical characteristics, blood sample test results and hemodynamic parameters assessed by echocardiography, electrocardiography and jugular venous pulse, and clinical outcomes were applied to k-means clustering. The optimal k was detected using Hartigan's rule. Results: HFpEF was stratified into four groups. The characteristic feature in group 1 was left ventricular relaxation abnormality. Compared with group 1, patients in groups 2, 3, and 4 had a high mean mitral E/e' ratio. The estimated glomerular filtration rate was lower in group 2 than in group 3 (median 51 ml/min/1.73 m² vs. 63 ml/min/1.73 m² p < 0.05). The prevalence of less-distensible right ventricle and atrial fibrillation was higher, and the deceleration time of mitral inflow was shorter in group 3 than in group 2 (93 vs. 22% p < 0.05, 95 vs. 1% p < 0.05, and median 167 vs. 223 ms p < 0.05, respectively). Group 4 was characterized by older age (median 85 years) and had a high systolic pulmonary arterial pressure (median 37 mmHg), less-distensible right ventricle (89%) and renal dysfunction (median 54 ml/min/1.73 m²). Compared with group 1, group 4 exhibited the highest risk of the cardiac events (hazard ratio [HR]: 19; 95% confidence interval [CI] 8.9-41); group 2 and 3 demonstrated similar rates of cardiac events (group 2 HR: 5.1; 95% CI 2.2-12; group 3 HR: 3.7; 95%CI, 1.3-10). The event-free rates were the lowest in group 4 (p for trend < 0.001). Conclusions: K-means clustering divided HFpEF into 4 groups. Older patients with HFpEF may suffer from complication of RV afterload mismatch and renal dysfunction. Our study may be useful for stratified medicine for HFpEF.