The epidemiology and pathophysiology of heart failure

Raman spectroscopy in chronic heart failure diagnosis based on human skin analysis

This work aims at studying Raman spectroscopy in combination with chemometrics as an alternative fast noninvasive method to detect chronic heart failure (CHF) cases. Optical analysis is focused on the changes in the spectral features associated with the biochemical composition changes of skin tissues. A portable spectroscopy setup with the 785 nm excitation wavelength was used to record skin Raman features. In this in vivo study, 127 patients and 57 healthy volunteers were involved in measuring skin spectral features by Raman spectroscopy. The spectral data were analyzed with a projection on the latent structures and discriminant analysis. 202 skin spectra of patients with CHF and 90 skin spectra of healthy volunteers were classified with 0.888 ROC AUC for the 10-fold cross validated algorithm. To identify CHF cases, the performance of the proposed classifier was verified by means of a new test set that is equal to 0.917 ROC AUC.

The Role of Sodium-Glucose Cotransporter-2 Inhibitors in Heart Failure Management: The Continuing Challenge of Clinical Outcome Endpoints in Heart Failure Trials

The introduction of sodium-glucose cotransporter-2 (SGLT2) inhibitors in the management of heart failure with preserved ejection fraction (HFpEF) may be regarded as the first effective treatment in these patients. However, this proposition must be evaluated from the perspective of the complexity of clinical outcome endpoints in heart failure. The major goals of heart failure treatment have been categorized as: (1) reduction in (cardiovascular) mortality, (2) prevention of recurrent hospitalizations due to worsening heart failure, and (3) improvement in clinical status, functional capacity, and quality of life. The use of the composite primary endpoint of cardiovascular death and hospitalization for heart failure in SGLT2 inhibitor HFpEF trials flowed from the assumption that hospitalization for heart failure is a proxy for subsequent cardiovascular death. The use of this composite endpoint was not justified since the effect of the intervention on both components was clearly distinct. Moreover, the lack of convincing and clinically meaningful effects of SGLT2 inhibitors on metrics of heart failure-related health status indicates that the effect of this class of drugs in HFpEF patients is essentially restricted to an effect on hospitalization for heart failure. In conclusion, SGLT2 inhibitors do not represent a substantial breakthrough in the management of HFpEF.

LEAP Virtual Visit Assessment (VIVA): a structured protocol for virtual visits for patients with heart failure

AIMS

Telemedicine may be of benefit in patients with heart failure (HF), although virtual visits are often carried out on an ad hoc basis. Herein, we discuss a structured protocol that defines all the steps needed for virtual visits, LEAP Virtual Visit, which includes guides and support kits for clinicians and patients.

METHODS

A working group of clinicians was established to develop a protocol for virtual visits. The virtual model for monitoring HF patients was based on measurement and sizing of patient flows, type of services, and critical organizational points. The process of virtual visits was broken down to identify the specific activities, players, roles, and support tools needed for implementation in daily practice.

RESULTS

In the protocol developed, sections were included on patient eligibility, exams, supportive tools, and practical organizational aspects. IT requirements were also considered and the most widely used teleconference platforms were compared according to features that were considered to be priority for virtual visits. Protocols and support kits were developed, including guides for clinicians and patients, two questionnaires to assess the level of satisfaction, patient diary, disease awareness brochure, and template to monitor key performance indicators. The phases include an enrolment phase, document sharing phase, pre-evaluation phase, the virtual visit itself, and the post-visit phase. The protocol for the virtual visit was divided into 8 sequential steps to be carried out between the clinic and patient/caregiver.

CONCLUSION

The protocol described can be expected to have a number of benefits for the patient, clinic, and healthcare structure.

Multispecialty multidisciplinary input into comorbidities along with treatment optimisation in heart failure reduces hospitalisation and clinic attendance

Aims

Heart failure (HF) is associated with comorbidities which independently influence treatment response and outcomes. This retrospective observational study (January 2020–June 2021) analysed the impact of monthly HF multispecialty multidisciplinary team (MDT) meetings to address management of HF comorbidities and thereby on provision, cost of care and HF outcomes.

Methods

Patients acted as their own controls, with outcomes compared for equal periods (for each patient) pre (HF MDT) versus post-MDT (multispecialty) meeting. The multispecialty MDT comprised HF cardiologists (primary, secondary, tertiary care), HF nurses, nephrologist, endocrinologist, palliative care, chest physician, pharmacist, clinical pharmacologist and geriatrician. Outcome measures were (1) all-cause hospitalisations, (2) outpatient clinic attendances and (3) cost.

Results

334 patients (mean age 72.5±11 years) were discussed virtually through MDT meetings and follow-up duration was 13.9±4 months. Mean age-adjusted Charlson Comorbidity Index was 7.6±2.1 and Rockwood Frailty Score 5.5±1.6. Multispecialty interventions included optimising diabetes therapy (haemoglobin A1c-HbA1c pre-MDT 68±11 mmol/mol vs post-MDT 61±9 mmol/mol; p<0.001), deprescribing to reduce anticholinergic burden (pre-MDT 1.85±0.4 vs 1.5±0.3 post-MDT; p<0.001), initiation of renin–angiotensin aldosterone system inhibitors in HF with reduced ejection fraction (HFrEF) with advanced chronic kidney disease (9% pre vs 71% post-MDT; p<0.001). Other interventions included potassium binders, treatment of anaemia, falls assessment, management of chest conditions, day-case ascitic, pleural drains and palliative support. Total cost of funding monthly multispecialty meetings was £32 400 and resultant 64 clinic appointments cost £9600. The post-MDT study period was associated with reduction in 481 clinic appointments (cost saving £72150) and reduced all-cause hospitalisations (pre-MDT 1.1±0.4 vs 0.6±0.1 post-MDT; p<0.001), reduction of 1586 hospital bed-days and cost savings of £634 400. Total cost saving to the healthcare system was £664 550.

Conclusion

HF multispecialty virtual MDT model provides integrated, holistic care across all healthcare tiers for management of HF and associated comorbidities. This approach is associated with reduced clinic attendances and all-cause hospitalisations, leading to significant cost savings.

Effectiveness of telemedicine systems for adults with heart failure: a meta-analysis of randomized controlled trials

Despite favorable effects from telemedicine (TM) on cardiovascular diseases, outcome and comparative impact of TM on heart failure (HF) adults remain controversial. A meta-analysis was conducted to summarize the evidence from existing randomized controlled trials (RCTs) which compared potential impact of TM on HF with conventional healthcare. TM mainly included structure telephone support (STS), involving interactive vocal response monitoring and telemonitoring. PubMed, MEDLINE, EMBASE, and the Cochrane Library were searched to identify RCTs to fit our analysis (1999 to 2018). Odds ratio (OR) with its 95% confidence interval (CI) was used. Sensitivity analysis, subgroup analysis, and tests for publication bias were conducted. Heterogeneities were also evaluated by I² tests. A total of 29 RCTs consisting of 10,981 HF adults were selected for meta-level synthesis, with follow-up range of 1-36 months. Telemonitoring is associated with the reduction in total number of all-cause hospitalization (OR 0.82, 95% CI 0.73-0.91, P = 0.0004) and cardiac hospitalization (OR 0.83, 95% CI 0.72-0.95, P = 0.007). Telemonitoring resulted in statistically significant risk reduction of all-cause mortality (OR 0.75, 95% CI 0.62-0.90, P = 0.003). However, the OR of HF-related mortality (OR 0.84, 95% CI 0.61-1.16, P = 0.28) is not significantly distinguishable from that of conventional healthcare. Receiving STS interventions is likely to reduce the hospitalization for all causes (OR 0.86, 95% CI 0.78-0.96, P = 0.006, I² = 6%) and the hospitalization due to HF (OR 0.74, 95% CI 0.65-0.85, P < 0.0001, I² = 0%), compared with interventions from conventional healthcare. OR of all-cause STS mortality (OR 0.96, 95% CI 0.83-1.11, P = 0.55) was identified in meta-analyses of eight cases. OR of STS cardiac mortality (OR 0.54, 95% CI 0.34-0.86, P = 0.009) was identified in meta-analyses of three cases. This work represents the comprehensive application of network meta-analysis to examine the comparative effectiveness of telemedicine interventions in improving HF patient outcomes. Compared with conventional healthcare, telemedicine systems with medical support prove to be more effective for HF adults, particularly in reducing all-cause hospitalization, cardiac hospitalization, all-cause mortality, cardiac mortality, and length of stay. While further research is required to confirm these observational findings and identify optimal telemedicine strategies and the duration of follow-up for which it confers benefits.

Efficacy and Mode of Action of Mesenchymal Stem Cells in Non-Ischemic Dilated Cardiomyopathy: A Systematic Review

Non-ischemic dilated cardiomyopathy (NIDCM) constitutes one of the most common causes to non-ischemic heart failure. Despite treatment, the disease often progresses, causing severe morbidity and mortality, making novel treatment strategies necessary. Due to the regenerative actions of mesenchymal stem cells (MSCs), they have been proposed as a treatment for NIDCM. This systematic review aims to evaluate efficacy and mode of action (MoA) of MSC-based therapies in NIDCM. A systematic literature search was conducted in Medline (Pubmed) and Embase. A total of 27 studies were included (3 clinical trials and 24 preclinical studies). MSCs from different tissues and routes of delivery were reported, with bone marrow-derived MSCs and direct intramyocardial injections being the most frequent. All included clinical trials and 22 preclinical trials reported an improvement in cardiac function following MSC treatment. Furthermore, preclinical studies demonstrated alterations in tissue structure, gene, and protein expression patterns, primarily related to fibrosis and angiogenesis. Consequently, MSC treatment can improve cardiac function in NIDCM patients. The MoA underlying this effect involves anti-fibrosis, angiogenesis, immunomodulation, and anti-apoptosis, though these processes seem to be interdependent. These encouraging results calls for larger confirmatory clinical studies, as well as preclinical studies utilizing unbiased investigation of the potential MoA.

Decompensation in Critical Care: Early Prediction of Acute Heart Failure Onset

BACKGROUND

Heart failure is a leading cause of mortality and morbidity worldwide. Acute heart failure, broadly defined as rapid onset of new or worsening signs and symptoms of heart failure, often requires hospitalization and admission to the intensive care unit (ICU). This acute condition is highly heterogeneous and less well-understood as compared to chronic heart failure. The ICU, through detailed and continuously monitored patient data, provides an opportunity to retrospectively analyze decompensation and heart failure to evaluate physiological states and patient outcomes.

OBJECTIVE

The goal of this study is to examine the prevalence of cardiovascular risk factors among those admitted to ICUs and to evaluate combinations of clinical features that are predictive of decompensation events, such as the onset of acute heart failure, using machine learning techniques. To accomplish this objective, we leveraged tele-ICU data from over 200 hospitals across the United States.

METHODS

We evaluated the feasibility of predicting decompensation soon after ICU admission for 26,534 patients admitted without a history of heart failure with specific heart failure risk factors (ie, coronary artery disease, hypertension, and myocardial infarction) and 96,350 patients admitted without risk factors using remotely monitored laboratory, vital signs, and discrete physiological measurements. Multivariate logistic regression and random forest models were applied to predict decompensation and highlight important features from combinations of model inputs from dissimilar data.

RESULTS

The most prevalent risk factor in our data set was hypertension, although most patients diagnosed with heart failure were admitted to the ICU without a risk factor. The highest heart failure prediction accuracy was 0.951, and the highest area under the receiver operating characteristic curve was 0.9503 with random forest and combined vital signs, laboratory values, and discrete physiological measurements. Random forest feature importance also highlighted combinations of several discrete physiological features and laboratory measures as most indicative of decompensation. Timeline analysis of aggregate vital signs revealed a point of diminishing returns where additional vital signs data did not continue to improve results.

CONCLUSIONS

Heart failure risk factors are common in tele-ICU data, although most patients that are diagnosed with heart failure later in an ICU stay presented without risk factors making a prediction of decompensation critical. Decompensation was predicted with reasonable accuracy using tele-ICU data, and optimal data extraction for time series vital signs data was identified near a 200-minute window size. Overall, results suggest combinations of laboratory measurements and vital signs are viable for early and continuous prediction of patient decompensation.

Cost-effectiveness of B-type natriuretic peptide-guided care in patients with heart failure: a systematic review

Measuring the level of B-type natriuretic peptide (BNP), as a guide to pharmacotherapy, can increase the survival of patients with heart failure. This study is aimed at systematically reviewing the studies conducted on the cost-effectiveness of BNP-guided care in patients with heart failure. Using the systematic review method, we reviewed the published studies on the cost-effectiveness of BNP-guided care in patients with heart failure during the years 2004 to 2017. The results showed that all studies clearly stated the time horizon of the study and included direct medical costs in their analysis. In addition, most of the studies used the Markov model. The quality-adjusted life years (QALYs) were the main outcome used for measuring the effectiveness. The studies reported various ranges of the incremental cost-effectiveness ratio (ICER); accordingly, the highest ratio was observed in the USA ($32,748) and the lowest ratio was observed in Canada ($6251). Although the results of the studies were different in terms of a number of aspects, such as the viewpoint of the study, the study horizons, and the costs of expenditure items, they reached similar results. Based on the results of the present study, it seems that the use of BNP or N-terminal pro-BNP (NT-pro-BNP) in patients with heart failure may reduce cost compared to the symptom-based clinical care and increase QALY. In this regard, these studies were designed and conducted in high-income countries; thus, the application of these results in low- and middle-income countries will be limited.

Reconstituted HDL (Milano) Treatment Efficaciously Reverses Heart Failure with Preserved Ejection Fraction in Mice

Heart failure with preserved ejection fraction (HFpEF) represents a major unmet therapeutic need. This study investigated whether feeding coconut oil (CC diet) for 26 weeks in female C57BL/6N mice induces HFpEF and evaluated the effect of reconstituted high-density lipoprotein (HDL)_Milano (MDCO-216) administration on established HFpEF. Eight intraperitoneal injections of MDCO-216 (100 mg/kg protein concentration) or of an equivalent volume of control buffer were executed with a 48-h interval starting at 26 weeks after the initiation of the diet. Feeding the CC diet for 26 weeks induced pathological left ventricular hypertrophy characterized by a 17.1% (p < 0.0001) lower myocardial capillary density and markedly (p < 0.0001) increased interstitial fibrosis compared to standard chow (SC) diet mice. Parameters of systolic and diastolic function were significantly impaired in CC diet mice resulting in a reduced stroke volume, decreased cardiac output, and impaired ventriculo-arterial coupling. However, ejection fraction was preserved. Administration of MDCO-216 in CC diet mice reduced cardiac hypertrophy, increased capillary density (p < 0.01), and reduced interstitial fibrosis (p < 0.01). MDCO-216 treatment completely normalized cardiac function, lowered myocardial acetyl-coenzyme A carboxylase levels, and decreased myocardial transforming growth factor-β1 in CC diet mice. In conclusion, the CC diet induced HFpEF. Reconstituted HDL_Milano reversed pathological remodeling and functional cardiac abnormalities.

Telemonitoring in subjects with newly diagnosed heart failure with reduced ejection fraction: From clinical research to everyday practice

INTRODUCTION

Heart failure is increasingly common, and characterised by frequent admissions to hospital. To try and reduce the risk of hospitalisation, techniques such as telemonitoring (TM) may have a role. We wanted to determine if TM in patients with newly diagnosed heart failure and ejection fraction <40% reduces the risk of readmission or death from any cause in a 'real-world' setting.

METHODS

This is a retrospective study of 124 patients (78.2% male; 68.6 ± 12.6 years) who underwent TM and 345 patients (68.5% male; 70.2 ± 10.7 years) who underwent the usual care (UC). The TM group were assessed daily by body weight, blood pressure and heart rate using electronic devices with automatic transfer of data to an online database. Follow-up was 12 months.

RESULTS

Death from any cause occurred in 8.1% of the TM group and 19% of the UC group ( p = 0.002). There was no difference between the two groups in all-cause hospitalisation, either in the number of subjects hospitalised ( p = 0.7) or in the number of admissions per patient ( p = 0.6). There was no difference in the number of heart-failure-related readmissions per person between the two groups ( p = 0.5), but the number of days in hospital per person was higher in the UC group ( p = 0.03). Also, there were a significantly greater number of days alive and out of hospital for the patients in the TM group compared with the UC group ( p = 0.0001).

DISCUSSION

TM is associated with lower any-cause mortality and also has the potential to reduce the number of days lost to hospitalisation and death.

Cardiac replacement therapies: outcomes and costs for heart transplantation versus circulatory assist

OBJECTIVES

Growing number of patients with terminal heart failure and a shortage of heart donors have increased use of short- and long-term mechanical circulatory support (MCS). Few studies have analyzed survival rates and healthcare costs for heart transplantation (HTx), with or without extracorporeal membrane oxygenation (ECMO) and left ventricular assist device (LVAD).

DESIGN

In a retrospective, single-center study, data were analyzed from patients listed for HTx who died on the waiting list (DWL, n = 12), underwent HTx (n = 206), had ECMO as bridge to HTx (ECHTx, n = 15), or received LVAD treatment, either isolated (LVAD, n = 19) or bridging to HTx (LVADHTx, n = 26) during 2005-2012. Survival and hospital costs were assessed.

RESULTS

One- and five-year survival rates were 96% and 83% for the LVADHTx group, 92% and 81% for HTx, 70% and 70% for ECHTx, 48% and 36% for LVAD and 0% for the DWL group (overall survival, p < 0.001). Total hospital cost at one year was $102,101 ± 202,604 for DWL, $151,685 ± 86,892 for HTx, $292,078 ± 101,915 for ECHTx, $427,337 ± 365,154 for LVAD, and $600,897 ± 198,109 for LVADHTx.

CONCLUSION

The LVADHTx and HTx groups showed excellent one- and five-year survival. The combined group of DWL and HTx patients had similar survival to the combined groups of MCS, but use of LVAD pre-transplant quadrupled the cost.

Influence of diabetes on natriuretic peptide thresholds in screening for Stage B heart failure

CONTEXT

Natriuretic peptide (NP) has been shown to be an effective screening tool to identify patients with Stage B heart failure and to have clinical value in preventing heart failure progression. The impact of associated metabolic confounders on the screening utility of NP needs clarification.

OBJECTIVE

To assess the impact of diabetes mellitus (DM) on NP screening for asymptomatic Stage B heart failure.

MATERIALS AND METHODS

The study population consisted of 1368 asymptomatic patients with cardiovascular risk factors recruited from general practice as part of the STOP-HF trial. B-type NP (BNP) was quantified at point-of-care.

RESULTS

BNP was found to be as accurate for detecting Stage B heart failure in DM patients compared to non-DM patients (AUC 0.75 [0.71,0.78] and 0.77 [0.72,0.82], respectively). However, different BNP thresholds are required to achieve the same level of diagnostic sensitivity in DM compared with non-DM patients. To achieve 80% sensitivity a difference of 5-ng/L lower is required for patients with DM.

CONCLUSION

Although a significantly different BNP threshold is detected for patients with DM, the BNP concentration difference is small and unlikely to warrant a clinically different diagnostic threshold.

Influence of bilevel positive airway pressure on autonomic tone in hospitalized patients with decompensated heart failure

[Purpose] This study evaluated the effect of Bilevel Positive Airway (BiPAP) on the autonomic control of heart rate, assessed by heart rate variability (HRV), in patients hospitalized with decompensated heart failure. [Subjects and Methods] This prospective cross-sectional study included 20 subjects (age: 69±8 years, 12 male, left ventricular ejection fraction: 36 ±8%) diagnosed with heart failure who were admitted to a semi-intensive care unit with acute decompensation. Date was collected for HRV analysis during: 10 minutes spontaneous breathing in the resting supine position; 30 minutes breathing with BiPAP application (inspiratory pressure = 20 cmH2O and expiratory pressure = 10 cmH2O); and 10 minutes immediately after removal of BiPAP, during the return to spontaneous breathing. [Results] Significantly higher values for indices representative of increased parasympathetic activity were found in the time and frequency domains as well as in nonlinear Poincaré analysis during and after BiPAP in comparison to baseline. Linear HRV analysis: standard deviation of the average of all R-R intervals in milliseconds = 30.99±4.4 pre, 40.3±6.2 during, and 53.3±12.5 post BiPAP. Non-linear HRV analysis: standard deviations parallel in milliseconds = 8.31±4.3 pre, 12.9±5.8 during, and 22.8 ±6.3 post BiPAP. [Conclusion] The present findings demonstrate that BiPAP enhances vagal tone in patients with heart failure, which is beneficial for patients suffering from acute decompensation.

Association between plasma ADAMTS-7 levels and ventricular remodeling in patients with acute myocardial infarction

Background

The metalloproteinase family of a disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS) degrades extracellular matrix. However, the relevance of the ADAMTS family to cardiovascular diseases remains largely unknown. The study aimed to examine plasma ADAMTS-7 levels in patients with acute myocardial infarction (AMI) and the relationship between plasma ADAMTS-7 levels and heart function.

Methods

This was a prospective study performed in 84 patients with ST-elevation myocardial infarction (STEMI), 70 patients with non-STEMI (NSTEMI), and 38 controls. Enzyme-linked immunosorbent assay (ELISA) was used to measure plasma ADAMTS-7 levels. Cardiac structure and function were assessed using two-dimensional transthoracic echocardiography. Patients were stratified according to left ventricular ejection fraction (LVEF) ≤35% or >35%.

Results

Plasma ADAMTS-7 levels were higher in patients with LVEF ≤35% compared with those with LVEF >35% (6.73 ± 2.47 vs. 3.22 ± 2.05 ng/ml, P < 0.05). Plasma ADAMTS-7 levels were positively correlated with brain natriuretic peptide (BNP), left ventricular mass index (LVMI), left ventricular end-diastolic diameter (LVEDD), and left ventricular end-systolic diameter (LVESD) and negatively correlated with the 6-min walk test (P < 0.05). According to the receiver operating characteristic (ROC) curve, using a cutoff value of plasma ADAMTS-7 of 5.69 ng/ml was associated with a specificity of 61.0% and a sensitivity of 87.6% for the diagnosis of heart failure after AMI. Logistic regression analysis indicated that the association between ADAMTS-7 and heart failure after AMI was independent from traditional cardiovascular risk factors and other biomarkers (odds ratio = 1.236, 95% confidence interval: 1.023 to 1.378, P = 0.021).

Conclusions

Elevated ADAMTS-7 level may be involved in ventricular remodeling after AMI.

Therapeutic potential of HDL in cardioprotection and tissue repair

Epidemiological studies support a strong association between high-density lipoprotein (HDL) cholesterol levels and heart failure incidence. Experimental evidence from different angles supports the view that low HDL is unlikely an innocent bystander in the development of heart failure. HDL exerts direct cardioprotective effects, which are mediated via its interactions with the myocardium and more specifically with cardiomyocytes. HDL may improve cardiac function in several ways. Firstly, HDL may protect the heart against ischaemia/reperfusion injury resulting in a reduction of infarct size and thus in myocardial salvage. Secondly, HDL can improve cardiac function in the absence of ischaemic heart disease as illustrated by beneficial effects conferred by these lipoproteins in diabetic cardiomyopathy. Thirdly, HDL may improve cardiac function by reducing infarct expansion and by attenuating ventricular remodelling post-myocardial infarction. These different mechanisms are substantiated by in vitro, ex vivo, and in vivo intervention studies that applied treatment with native HDL, treatment with reconstituted HDL, or human apo A-I gene transfer. The effect of human apo A-I gene transfer on infarct expansion and ventricular remodelling post-myocardial infarction illustrates the beneficial effects of HDL on tissue repair. The role of HDL in tissue repair is further underpinned by the potent effects of these lipoproteins on endothelial progenitor cell number, function, and incorporation, which may in particular be relevant under conditions of high endothelial cell turnover. Furthermore, topical HDL therapy enhances cutaneous wound healing in different models. In conclusion, the development of HDL-targeted interventions in these strategically chosen therapeutic areas is supported by a strong clinical rationale and significant preclinical data.

The empirical foundations of telemedicine interventions for chronic disease management

The telemedicine intervention in chronic disease management promises to involve patients in their own care, provides continuous monitoring by their healthcare providers, identifies early symptoms, and responds promptly to exacerbations in their illnesses. This review set out to establish the evidence from the available literature on the impact of telemedicine for the management of three chronic diseases: congestive heart failure, stroke, and chronic obstructive pulmonary disease. By design, the review focuses on a limited set of representative chronic diseases because of their current and increasing importance relative to their prevalence, associated morbidity, mortality, and cost. Furthermore, these three diseases are amenable to timely interventions and secondary prevention through telemonitoring. The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations, albeit with a few exceptions. Generally, the benefits include reductions in use of service: hospital admissions/re-admissions, length of hospital stay, and emergency department visits typically declined. It is important that there often were reductions in mortality. Few studies reported neutral or mixed findings.

Probiotic administration attenuates myocardial hypertrophy and heart failure after myocardial infarction in the rat

BACKGROUND

Probiotics are extensively used to promote gastrointestinal health, and emerging evidence suggests that their beneficial properties can extend beyond the local environment of the gut. Here, we determined whether oral probiotic administration can alter the progression of postinfarction heart failure.

METHODS AND RESULTS

Rats were subjected to 6 weeks of sustained coronary artery occlusion and administered the probiotic Lactobacillus rhamnosus GR-1 or placebo in the drinking water ad libitum. Culture and 16s rRNA sequencing showed no evidence of GR-1 colonization or a significant shift in the composition of the cecal microbiome. However, animals administered GR-1 exhibited a significant attenuation of left ventricular hypertrophy based on tissue weight assessment and gene expression of atrial natriuretic peptide. Moreover, these animals demonstrated improved hemodynamic parameters reflecting both improved systolic and diastolic left ventricular function. Serial echocardiography revealed significantly improved left ventricular parameters throughout the 6-week follow-up period including a marked preservation of left ventricular ejection fraction and fractional shortening. Beneficial effects of GR-1 were still evident in those animals in which GR-1 was withdrawn at 4 weeks, suggesting persistence of the GR-1 effects after cessation of therapy. Investigation of mechanisms showed a significant increase in the leptin:adiponectin plasma concentration ratio in rats subjected to coronary ligation, which was abrogated by GR-1. Metabonomic analysis showed differences between sham control and coronary artery ligated hearts particularly with respect to preservation of myocardial taurine levels.

CONCLUSIONS

The study suggests that probiotics offer promise as a potential therapy for the attenuation of heart failure.

CD34+ stem cell therapy in nonischemic dilated cardiomyopathy patients

Recent trends indicate that patients with nonischemic dilated cardiomyopathy represent the largest subpopulation of heart failure patients with a significant need for alternative treatment modalities. Similar to patients with ischemic cardiomyopathy, patients with nonischemic dilated cardiomyopathy have been found to have myocardial regions with flow abnormalities, which may represent targets for neoangiogenic therapies. CD34(+) stem cells might contribute to the formation of new blood vessels from existing vascular structures in ischemic tissues by the direct incorporation of injected cells into the newly developing vasculature or by the production and secretion of angiogenic cytokines. This review summarizes the long-term clinical effects and potential underlying mechanisms of CD34(+) cell therapy in patients with nonischemic dilated cardiomyopathy.

The epidemiology of heart failure, based on data for 2.1 million inhabitants in Sweden

AIMS

The epidemiology of congestive heart failure (CHF) is likely to have changed due to changes in demography, risk factors, diagnostic procedures, and medical care. Prevailing information is in part old, incomplete, and to some extent contradictory. We determined the current prevalence, incidence, mortality, and 5-year survival rate of CHF, and possible temporal changes in Sweden.

METHODS AND RESULTS

This was a cross-sectional study on individual patient data from an administrative health data register in the Stockholm region, Sweden, comprising 2.1 million inhabitants. This contained all recorded diagnoses on all consultations in primary and secondary care (defined as specialist outpatient care), and on all hospitalizations. Prevalence, incidence, and mortality were estimated for the entire Swedish population, adjusted for demographic composition in 2010. The study population consisted of 88 038 patients (51% women). The prevalence was 2.2% (both women and men), the incidence was 3.8/1000 person-years (both women and men), and mortality was 3.2/1000 person-years in women and 3.0/1000 person-years in men (P < 0.001); the 5-year survival rate was 48%. Mortality (age adjusted; hazard ratio and 95% confidence intervals) was higher in men, 1.29, 1.24-1.34; P < 0.001. Prevalence remained essentially unchanged from 2006 to 2010, while incidence decreased by 24% (P < 0.001) and mortality by 19% (both women and men; P < 0.001).

CONCLUSIONS

The estimated prevalence of CHF in Sweden is 2.2%, incidence 3.8/1000 person-years, and mortality 3.1/1000 person-years. There has been a decrease in incidence and mortality from 2006 to 2010 in both women and men, with no major change in prevalence over time.

Cost-effectiveness of heart failure therapies

Heart failure (HF) is a leading cause of morbidity and mortality worldwide. Management of HF involves accurate diagnosis and implementation of evidence-based treatment strategies. Costs related to the care of patients with HF have increased substantially over the past 2 decades, partly owing to new medications and diagnostic tests, increased rates of hospitalization, implantation of costly novel devices and, as the disease progresses, consideration for heart transplantation, mechanical circulatory support, and end-of-life care. Not surprisingly, HF places a huge burden on health-care systems, and widespread implementation of all potentially beneficial therapies for HF could prove unrealistic for many, if not all, nations. Cost-effectiveness analyses can help to quantify the relationship between clinical outcomes and the economic implications of available therapies. This Review is a critical overview of cost-effectiveness studies on key areas of HF management, involving pharmacological and nonpharmacological clinical therapies, including device-based and surgical therapeutic strategies.

Pharmacological approaches to the treatment of oxidative stress-induced cardiovascular dysfunctions

Cardiovascular diseases are a growing major global health problem. Our understanding of the mechanisms of pathophysiology of cardiovascular diseases has been gaining significant advances and a wealth of knowledge implicates oxidative stress as a key causative agent. However, to date, most efforts to treat heart failure using conventional antioxidant therapies have been less than encouraging. With increasing incidences of cardiovascular disease in young as well as in aging populations, and the problem of long-term diminishing efficacy of conventional therapeutics, the need for new treatments has never been greater. In this review, a variety of therapeutic targets and compounds applied to treat cardiovascular diseases via inhibition of oxidative stress are presented.