Diastolic dysfunction and heart failure with a preserved ejection fraction: Relevance in critical illness and anaesthesia

Curcumin Nanoemulsion: Unveiling Cardioprotective Effects via ACE Inhibition and Antioxidant Properties in Hypertensive Rats

Background and Objectives: Curcumin, derived from Curcuma longa, is a well-known traditional medicinal compound recognized for its therapeutic attributes. Nevertheless, its efficacy is hampered by limited bioavailability, prompting researchers to explore the application of nanoemulsion as a potential alternative. Materials and Methods: This study delves into the antihypertensive effects of curcumin nanoemulsion (SNEC) by targeting the renin-angiotensin-aldosterone system (RAAS) and oxidative stress in deoxycorticosterone acetate (DOCA) salt-induced hypertensive rats. To gauge the cardio-protective impact of SNEC in DOCA salt-induced hypertension, molecular docking was undertaken, uncovering curcumin's high affinity and adept binding capabilities to the active site of angiotensin-converting enzyme (ACE). Additionally, the investigation employed uninephrectomized rats to assess hemodynamic parameters via an AD instrument. Serum ACE, angiotensin II, blood urea nitrogen (BUN), and creatinine levels were quantified using ELISA kits, while antioxidant parameters were evaluated through chemical assays. Result: The outcomes of the molecular docking analysis revealed robust binding of curcumin to the ACE active site. Furthermore, oral administration of SNEC significantly mitigated systolic, diastolic, and mean arterial blood pressure in contrast to the DOCA-induced hypertensive group. SNEC administration also led to a reduction in left ventricular end-diastolic pressure (LVEDP) and an elevation in the maximum rate of left ventricular pressure rise (LV (dP/dt) max). Moreover, SNEC administration distinctly lowered serum levels of ACE and angiotensin II compared to the hypertensive DOCA group. Renal markers, including serum creatinine and BUN, displayed a shift toward normalized levels with SNEC treatment. Additionally, SNEC showcased potent antioxidant characteristics by elevating reduced glutathione, catalase, and superoxide dismutase levels, while decreasing the concentration of thiobarbituric acid reactive substances. Conclusions: Collectively, these findings underscore that curcumin nanoemulsion exerts noteworthy cardio-protective effects through ACE activity inhibition and remarkable antioxidant properties.

Dynamic Echocardiographic Assessments Reveal Septal E/e' Ratio as Independent Predictor of Intradialytic Hypotension in Maintenance for Hemodialysis Patients with Preserved Ejection Fraction

BACKGROUND

Intradialytic hypotension (IDH) is a frequent and grave complication of hemodialysis (HD). However, the dynamic hemodynamic changes and cardiac performances during each dialytic session have been rarely explored in patients having IDH.

METHODS

Seventy-six HD patients (IDH = 40, controls = 36) were enrolled. Echocardiography examinations were performed in all patients at the pre-HD, during-HD and post-HD phases of a single HD session. A two-way analysis of variance was applied to compare differences of echocardiographic parameters between IDH and controls over time. The risk association was estimated by using a logistic regression analysis.

RESULTS

The IDH patients had a higher ejection fraction during HD followed by a greater reduction at the post-HD phase than the controls. Significant decreases in septal ratios of transmitral flow velocity to annular velocity (E/e') over times were detected between IDH patients and controls after adjusting for gender, age and ultrafiltration (p = 0.016). A lower septal E/e' ratio was independently associated with IDH (OR = 0.040; 95% CI = 0.003-0.606; p = 0.02). In contrast, significant systolic and diastolic dysfunctions over time were found in diabetic IDH compared to non-diabetic counterparts.

CONCLUSION

The septal E/e' ratio was a significant predictor for IDH.

Pulmonary Edema and Diastolic Heart Failure in the Perioperative Period

Heart failure with preserved ejection fraction (HFPEF) is a diagnosis encountered with increasing frequency in the aging population. We present a case of postoperative pulmonary edema in 63-year-old male with HFPEF. This patient highlights the gap in risk stratification with respect to diastolic heart failure.

[Consensus on Perioperative Transesophageal Echocardiography of the Brazilian Society of Anesthesiology and the Department of Cardiovascular Image of the Brazilian Society of Cardiology]

Through the Life Cycle of Intraoperative Transesophageal Echocardiography (ETTI/SBA) the Brazilian Society of Anesthesiology, together with the Department of Cardiovascular Image of the Brazilian Society of Cardiology (DIC/SBC), createded a task force to standardize the use of intraoperative transesophageal echocardiography by Brazilian anesthesiologists and echocardiographers based on scientific evidence from the Society of Cardiovascular Anesthesiologists/American Society of Echocardiography (SCA/ASE) and the Brazilian Society of Cardiology.

Consensus on Perioperative Transesophageal Echocardiography of the Brazilian Society of Anesthesiology and the Department of Cardiovascular Image of the Brazilian Society of Cardiology

Through the Life Cycle of Intraoperative Transesophageal Echocardiography (ETTI/SBA) the Brazilian Society of Anesthesiology, together with the Department of Cardiovascular Image of the Brazilian Society of Cardiology (DIC/SBC), created a task force to standardize the use of intraoperative transesophageal echocardiography by Brazilian anesthesiologists and echocardiographers based on scientific evidence from the Society of Cardiovascular Anesthesiologists/American Society of Echocardiography (SCA/ASE) and the Brazilian Society of Cardiology.

Chronic Endurance Exercise Impairs Cardiac Structure and Function in Middle-Aged Mice with Impaired Nrf2 Signaling

Nuclear factor erythroid 2 related factor 2 (Nrf2) signaling maintains the redox homeostasis and its activation is shown to suppress cardiac maladaptation. Earlier we reported that acute endurance exercise (2 days) evoked antioxidant cytoprotection in young WT animals but not in aged WT animals. However, the effect of repeated endurance exercise during biologic aging (WT) characterized by an inherent deterioration in Nrf2 signaling and pathological aging (pronounced oxidative susceptibility-Nrf2 absence) in the myocardium remains elusive. Thus, the purpose of our study was to determine the effect of chronic endurance exercise-induced cardiac adaptation in aged mice with and without Nrf2. Age-matched WT and Nrf2-null mice (Nrf2-/-) (>22 months) were subjected to 6 weeks chronic endurance exercise (25 meter/min, 12% grade). The myocardial redox status was assessed by expression of antioxidant defense genes and proteins along with immunochemical detection of DMPO-radical adduct, GSH-NEM, and total ubiquitination. Cardiac functions were assessed by echocardiography and electrocardiogram. At sedentary state, loss of Nrf2 resulted in significant downregulation of antioxidant gene expression (Nqo1, Ho1, Gclm, Cat, and Gst-α) with decreased GSH-NEM immuno-fluorescence signals. While Nrf2-/- mice subjected to CEE showed an either similar or more pronounced reduction in the transcript levels of Gclc, Nqo1, Gsr, and Gst-α in relation to WT littermates. In addition, the hearts of Nrf2-/- on CEE showed a substantial reduction in specific antioxidant proteins, G6PD and CAT along with decreased GSH, a pronounced increase in DMPO-adduct and the total ubiquitination levels. Further, CEE resulted in a significant upregulation of hypertrophy genes (Anf, Bnf, and β-Mhc) (p < 0.05) in the Nrf2-/- hearts in relation to WT mice. Moreover, the aged Nrf2-/- mice exhibited a higher degree of cardiac remodeling in association with a significant decrease in fractional shortening, pronounced ST segment, and J wave elevation upon CEE compared to age-matched WT littermates. In conclusion, our findings indicate that while the aged WT and Nrf2 knockout animals both exhibit hypertrophy after CEE, the older Nrf2 knockouts showed ventricular remodeling coupled with profound cardiac functional abnormalities and diastolic dysfunction.

Perioperative management of left ventricular diastolic dysfunction and heart failure: an anesthesiologist's perspective

Anesthesiologists frequently see asymptomatic patients with diastolic dysfunction or heart failure for various surgeries. These patients typically show normal systolic function but abnormal diastolic parameters in their preoperative echocardiographic evaluations. The symptoms that are sometimes seen are similar to those of chronic obstructive pulmonary disease. Patients with diastolic dysfunction, and even with diastolic heart failure, have the potential to develop a hypertensive crisis or pulmonary congestion. Thus, in addition to conventional perioperative risk quantification, it may be important to consider the results of diastolic assessment for predicting the postoperative outcome and making better decisions. If anesthesiologists see female patients older than 70 years of age who have hypertension, diabetes, chronic renal disease, recent weight gain, or exercise intolerance, they should focus on the patient's diastologic echocardiography indicators such as left atrial enlargement or left ventricular hypertrophy. In addition, there is a need for perioperative strategies to mitigate diastolic dysfunction-related morbidity. Specifically, hypertension should be controlled, keeping pulse pressure below diastolic blood pressure, maintaining a sinus rhythm and normovolemia, and avoiding tachycardia and myocardial ischemia. There is no need to classify these diastolic dysfunction, but it is important to manage this condition to avoid worsening outcomes.

A Randomized Blinded Study of the Left Ventricular Myocardial Performance Index Comparing Epinephrine to Levosimendan following Cardiopulmonary Bypass

BACKGROUND

The objective was to evaluate the effect of epinephrine and levosimendan on the left ventricle myocardial performance index in patients undergoing on-pump coronary artery by-pass grafting (CABG).

METHODS

In a double-blind, randomized clinical trial, 81 patients (age: 45-65 years) of both genders were randomly divided to receive either epinephrine at a dosage of 0.06 mcg.kg(1).min(-1) (epinephrine group, 39 patients) or levosimendan at 0.2 mcg.kg(1).min(-1) (levosimendan group, 42 patients) during the rewarming of cardiopulmonary by-pass (CPB). Hemodynamic data were collected 30 minutes after tracheal intubation, before chest open (pre-CPB) and 10 minutes after termination of protamine (post-CPB). As the primary outcome, we evaluated the left ventricle myocardial performance index by the Doppler echocardiography. The myocardial performance index is the sum of the isovolumetric contraction time and the isovolumetric relaxation time, divided by the ejection time. Secondary outcomes were systolic and diastolic evaluations of the left ventricle and postoperative troponin I and MB-CK levels.

RESULTS

Of the 81 patients allocated to the research, we excluded 2 patients in the epinephrine group and 6 patients in the levosimendan group because they didn't wean from CPB in the first attempt. There was no statistical difference between the groups in terms of patient characteristics, risk factors, or CPB time. The epinephrine group had a lower left ventricle myocardial performance index (p = 0.0013), higher cardiac index (p = 0.03), lower systemic vascular resistance index (p = 0.01), and higher heart rate (p = 0.04) than the levosimendan group at the post-CPB period. There were no differences between the groups in diastolic dysfunction. The epinephrine group showed higher incidence of weaning from CPB in the first attempt (95% vs 85%, p = 0.0001) when compared to the levosimendan group and the norepinephrine requirement was higher in the levosimenandan group than epinephrine group (16% vs. 47%; p = 0.005) in post-CPB period. Twenty-four hours after surgery, the plasma levels of troponin I (epinephrine group: 4.5 ± 5.7 vs. levosimendan group: 2.5 ± 3.2 g/dl; p = 0.09) and MB-CK (epinephrine group: 50.7 ± 31 vs. levosimendan group: 37 ± 17.6 g/dl; p = 0.08) were not significantly different between the two groups.

CONCLUSION

When compared to levosimendan, patients treated with epinephrine had a lower left ventricle myocardial performance index in the immediate post-CPB period, encouraging an efficient weaning from CPB in patients undergoing on-pump CABG.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01616069.

Diastolic dysfunction

Despite the growing number of patients affected, the understanding of diastolic dysfunction and heart failure with preserved ejection fraction (HFpEF) is still poor. Clinical trials, largely based on successful treatments for systolic heart failure, have been disappointing, suggesting that HFpEF has a different pathology to that of systolic dysfunction. In this review, general concepts, epidemiology, diagnosis, and treatment of diastolic dysfunction are summarized, with an emphasis on new experiments suggesting that oxidative stress plays a crucial role in the pathogenesis of at least some forms of the disease. This observation has lead to potential new diagnostics and therapeutics for diastolic dysfunction and heart failure caused by diastolic dysfunction.