Diastolic Dysfunction and Hypertension

Progress in diagnosis and treatment of hypertension combined with left ventricular hypertrophy

BACKGROUND

Hypertension, a worldwide cardiovascular issue, is known to result in significant damage to the left ventricle. Left ventricular hypertrophy refers to an increase in ventricular mass, which is not only the primary independent risk factor for cardiovascular disease onset but also independently related to the risk of death.

OBJECTIVES

We sought to synthesize the existing literature on the occurrence and correlation between hypertension and left ventricular hypertrophy and the progress.

METHODS

A scoping review was performed based on the methodological framework developed by Arksey & O'Malley. Search in the Pubmed database with no language restrictions, as of September 1, 2024.

RESULTS

Of the 8110 articles retrieved, 110 were finally included. The selected articles were published between 1987 and 2024, with 55.5% (61/110) of the studies in the last five years and 14.5% (16/110) of 2024. The studies covered diagnosis, epidemiology, pathophysiology, prognosis, and treatment of hypertension with left ventricular hypertrophy.

CONCLUSION

The literature reviewed suggests that studies on hypertension combined with left ventricular hypertrophy covered a variety of clinical progress, especially the clinical trial results of some new drugs that may bring great hope for treatment.

Diastolic dysfunction in hypertension: a comprehensive review of pathophysiology, diagnosis, and treatment

Diastolic dysfunction refers to impaired relaxation or filling of the ventricles during the diastolic phase of the cardiac cycle. Left ventricular diastolic dysfunction (LVDD) is common in hypertensive individuals and is associated with increased morbidity and mortality. LVDD serves as a critical precursor to heart failure, particularly heart failure with preserved ejection fraction. The pathophysiology of LVDD in hypertension is complex, involving alterations in cardiac structure and function, neurohormonal activation, and vascular stiffness. While the diagnosis of LVDD relies primarily on echocardiography, management remains challenging due to a lack of specific treatment guidelines for LVDD. This review offers an overview of the pathophysiological mechanisms underlying LVDD in hypertension, diagnostic methods, clinical manifestations, strategies for managing LVDD, and prospects for future research.

Left Ventricular Diastolic Dysfunction across Levels of Kidney Function: A Cross-Sectional Study Based on Routine Clinical Practice Data

Left ventricular diastolic dysfunction (LVDD) commonly coexists with kidney dysfunction. In this study, we investigated the presence of abnormalities in echocardiography parameters indicative of LVDD across stages of kidney function. Methods: We selected patients who visited a university hospital and had a serum creatinine and echocardiography reported in their medical records. Participants were categorized based on their kidney function: normal (estimated glomerular filtration rate [eGFR] ≥ 90 mL/min/1.73 m2), mildly decreased (eGFR: 60-90), moderately decreased (eGFR: 30-60), and severely decreased (eGFR < 30). The relationship between kidney function and echocardiography parameters was examined using logistic and linear regressions. Results: Among 4022 patients (age: 66.5 years [SD: 12.1], 41% women), 26%, 50%, 20%, and 4% had a normal, mildly, moderately, and severely decreased kidney function, respectively. Compared to patients with normal kidney function, patients with mildly decreased kidney function had higher odds for an abnormal E/e' ratio (OR: 1.51 [95% CI: 1.13, 2.02]). Patients with moderately decreased kidney function presented a higher risk of abnormal E/e' (OR: 2.90 [95% CI: 2.08, 4.04]), LAVI (OR: 1.62 [95% CI: 1.13, 2.33]), TR velocity (OR: 2.31 [95% CI: 1.49, 3.57]), and LVMI (OR: 1.70 [95% CI: 1.31, 2.20]), while patients with severely decreased kidney function had higher odds for abnormal E/e' (OR: 2.95 [95% CI: 1.68, 5.17]) and LVMI > 95 g/m2 in women or >115 g/m2 in men (OR: 2.07 [95% CI: 1.27, 3.38]). The linear regression showed a significant inverse association between eGFR and echocardiography parameters, meaning that with worse kidney function, the parameters for LVDD worsened as well. Conclusions: Abnormal echocardiography parameters of LVDD were present even in patients with mildly decreased kidney function. As the kidney function worsened, there was a gradual increase in the risk of abnormal parameters of LVDD.

VEGF Polymorphisms (VEGF-936 C/T, VEGF-634 G/C and VEGF-2578 C/A) and Cardiovascular Implications in Long COVID Patients

The COVID-19 pandemic has raised awareness of the virus's long-term non-pulmonary consequences. This study examined the relationship between genetic polymorphisms of VEGF and cardiac dysfunction and subclinical atherosclerosis in patients recovering from COVID-19. This study included 67 patients previously diagnosed with COVID-19. VEGF-936C/T, VEGF-634G/C, and VEGF-2578C/A statuses were determined. Conventional echocardiography and arterial parameters assessments were performed at inclusion and at six months after the first assessment. For VEGF-936C/T, dominant and over-dominant models showed a significant increase in ejection fraction at six months after COVID (p = 0.044 and 0.048) and was also a predictive independent factor for the augmentation index (β = 3.07; p = 0.024). The dominant model showed a rise in RV-RA gradient (3.702 mmHg) (p = 0.028 95% CI: 0.040-7.363), with the over-dominant model indicating a greater difference (4.254 mmHg) (p = 0.025 95% CI: 0.624-7.884). The findings for VEGF-634G/C were not statistically significant, except for a difference in TAPSE during initial evaluation, using the codominant model. For VEGF-2578C/A, a difference in ventricular filling pressure (E/E'ratio) was best described under the recessive model. Our research suggests that the VEG-936C/T genotype may impact the baseline level and subsequent changes in cardiac function and subclinical atherosclerosis. These findings offer valuable insights into the complex correlation between genetic polymorphisms and cardiovascular disfunction in long COVID patients.

Hypertension and Ventilatory Responses During Exercise in the Fitness Registry and the Importance of Exercise National Database (FRIEND)

BACKGROUND

A high minute ventilation/rate of carbon dioxide production (V̇E/V̇co2) slope during exercise is prognostic for cardiovascular death. Recent data indicate that adults with either controlled or untreated primary hypertension, but not those with uncontrolled hypertension, exhibit a higher V̇E/V̇co2 slope during exercise. However, the sample sizes were modest. Therefore, we used the Fitness Registry and the Importance of Exercise National Database to determine whether adults with hypertension, particularly those with controlled or untreated hypertension, exhibit higher V̇E/V̇co2 slopes compared with adults without hypertension.

METHODS AND RESULTS

Using the Fitness Registry and the Importance of Exercise National Database, we isolated primary hypertension by excluding those with any disease other than hypertension or taking any medications other than antihypertension medications. We also excluded current smokers and those with obesity. The V̇E/V̇co2 slope was determined during a peak cycling exercise test. All data are presented as median [interquartile range]. We compared groups using linear regression adjusted for age, male/female, and body mass index. The characteristics of the entire sample (n=4109) were age, 42 [18] years; 48% women; body mass index, 26 [4] kg/m2. The V̇E/V̇co2 slope did not differ between adults with hypertension (n=1940; 24.7 [3.7]) compared with those without hypertension (n=2169; 24.9 [3.8]) (hypertension versus no hypertension, P=0.31; overall model: R2=0.07, F4,4104=73.0; P<0.001). Further, the V̇E/V̇co2 slope did not differ between adults with medication-controlled hypertension (n=107; 24.4 [3.0]), untreated hypertension (n=1626; 24.8 [3.9]), uncontrolled hypertension (n=207; 24.8 [3.0]), or those without hypertension (n=2169; 24.9 [3.8]) (hypertension subgroup versus no hypertension, P≥0.06; overall model: R2=0.07, F6,4102=49.6, P<0.001).

CONCLUSIONS

Primary hypertension is not associated with V̇E/V̇co2 slope in the Fitness Registry and the Importance of Exercise National Database.

Time course of hypertension and myocardial dysfunction following anthracycline chemotherapy in pediatric patients

Background

Anthracyclines are associated with cardiac dysfunction. Little is known about the interplay of pre-existing hypertension and treatment response. We aimed to investigate the relationship between hypertension and the development of cancer therapy-related cardiac dysfunction (CTRCD) in pediatric patients treated with anthracycline chemotherapy.

Methods

Pediatric patients with cancer who received anthracycline chemotherapy from 2013 to 2021 were retrospectively included. Serial cardiac assessments were conducted during and after chemotherapy. The primary outcome was the development of CTRCD, classified as mild, moderate, or severe according to contemporary definitions.

Results

Among 190 patients undergoing anthracycline chemotherapy, 34 patients (17.9 %) had hypertension (24 patients Stage 1, and 10 patients Stage 2) at baseline evaluation. Patients underwent chemotherapy for a median of 234.4 days (interquartile range 127.8-690.3 days) and were subsequently followed up. Hypertension was frequent during follow-up 31.3 % (0-3 months), 15.8 % (3-6 months), 21.9 % (0.5-1 years), 24.7 % (1-2 years), 31.1 % (2-4 years) and 35.8 % (beyond 4 years) (P for trend < 0.001). Freedom from mild CTRCD at 5 years was 45.0 %, freedom from moderate CTRCD was 87.8 % at 5 years. Baseline hypertension did not increase the risk of mild (HR 0.77, 95 % CI: 0.41-1.42, P = 0.385) or moderate CTRCD (HR 0.62, 95 % CI: 0.14-2.72, P = 0.504). Patients with baseline hypertension showed different global longitudinal strain (P < 0.001) and LVEF (P < 0.001) patterns during follow-up.

Conclusions

Pediatric patients often develop CTRCD post-anthracycline chemotherapy. Those with pre-existing hypertension show a unique treatment response, despite no increased CTRCD risk, warranting further investigation.

Mitofilin in cardiovascular diseases: Insights into the pathogenesis and potential pharmacological interventions

The impact of mitochondrial dysfunction on the pathogenesis of cardiovascular disease is increasing. However, the precise underlying mechanism remains unclear. Mitochondria produce cellular energy through oxidative phosphorylation while regulating calcium homeostasis, cellular respiration, and the production of biosynthetic chemicals. Nevertheless, problems related to cardiac energy metabolism, defective mitochondrial proteins, mitophagy, and structural changes in mitochondrial membranes can cause cardiovascular diseases via mitochondrial dysfunction. Mitofilin is a critical inner mitochondrial membrane protein that maintains cristae structure and facilitates protein transport while linking the inner mitochondrial membrane, outer mitochondrial membrane, and mitochondrial DNA transcription. Researchers believe that mitofilin may be a therapeutic target for treating cardiovascular diseases, particularly cardiac mitochondrial dysfunctions. In this review, we highlight current findings regarding the role of mitofilin in the pathogenesis of cardiovascular diseases and potential therapeutic compounds targeting mitofilin.

Types of Septic Cardiomyopathy: Prognosis and Influencing Factors - A Clinical Study

Objective

To explore the prognostic outcomes associated with different types of septic cardiomyopathy and analyze the factors that exert an influence on these outcomes.

Methods

The data collected within 24 hours of ICU admission included cardiac troponin I (cTnI), N-terminal pro-Brain Natriuretic Peptide (NT-proBNP); SOFA (sequential organ failure assessment) scores, and the proportion of vasopressor use. Based on echocardiographic outcomes, septic cardiomyopathy was categorized into left ventricular (LV) systolic dysfunction, LV diastolic dysfunction, and right ventricular (RV) systolic dysfunction. Differences between the mortality and survival groups, as well as between each cardiomyopathy subgroup and the non-cardiomyopathy group were compared, to explore the influencing factors of cardiomyopathy.

Results

A cohort of 184 patients were included in this study, with LV diastolic dysfunction having the highest incidence rate (43.5%). The mortality group had significantly higher SOFA scores, vasopressor use, and cTnI levels compared to the survival group; the survival group had better LV diastolic function than the mortality group (p < 0.05 for all). In contrast to the non-cardiomyopathy group, each subgroup within the cardiomyopathy category exhibited elevated levels of cTnI. The subgroup with left ventricular diastolic dysfunction demonstrated a higher prevalence of advanced age, hypertension, diabetes mellitus, coronary artery disease, and an increased mortality rate; the RV systolic dysfunction subgroup had higher SOFA scores and NT-proBNP levels, and a higher mortality rate (P < 0.05 for all); the LV systolic dysfunction subgroup had a similar mortality rate (P > 0.05).

Conclusion

Patients with advanced age, hypertension, diabetes mellitus, or coronary artery disease are more prone to develop LV diastolic dysfunction type of cardiomyopathy; cardiomyopathy subgroups had higher levels of cTnI. The RV systolic dysfunction cardiomyopathy subgroup had higher SOFA scores and NT-proBNP levels. The occurrence of RV systolic dysfunction in patients with sepsis significantly increased the mortality rate.

The effect of hyperlipidemia and body fat distribution on subclinical left ventricular function in obesity: a cardiovascular magnetic resonance study

BACKGROUND

Obesity is often associated with multiple comorbidities. However, whether obese subjects with hyperlipidemia in the absence of other complications have worse cardiac indices than metabolically healthy obese subjects is unclear. Therefore, we aimed to determine the effect of hyperlipidemia on subclinical left ventricular (LV) function in obesity and to evaluate the association of cardiac parameters with body fat distribution.

MATERIALS AND METHODS

Ninety-two adults were recruited and divided into 3 groups: obesity with hyperlipidemia (n = 24, 14 males), obesity without hyperlipidemia (n = 25, 13 males), and c ntrols (n = 43, 25 males). LV strain parameters (peak strain (PS), peak diastolic strain rate (PDSR), peak systolic strain rate) derived from cardiovascular magnetic resonance tissue tracking were measured and compared. Dual-energy X-ray absorptiometer was used to measure body fat distribution. Correlations of hyperlipidemia and body fat distribution with LV strain were assessed by multivariable linear regression.

RESULTS

Obese individuals with preserved LV ejection fraction showed lower global LV longitudinal, circumferential, and radial PS and longitudinal and circumferential PDSR than controls (all P < 0.05). Among obese patients, those with hyperlipidemia had lower longitudinal PS and PDSR and circumferential PDSR than those without hyperlipidemia (- 12.8 ± 2.9% vs. - 14.2 ± 2.7%, 0.8 ± 0.1 s-1 vs. 0.9 ± 0.3 s-1, 1.2 ± 0.2 s-1 vs. 1.4 ± 0.2 s-1; all P < 0.05). Multivariable linear regression demonstrated that hyperlipidemia was independently associated with circumferential PDSR (β = - 0.477, P < 0.05) in obesity after controlling for growth differences, other cardiovascular risk factors, and central fat distribution. In addition, android fat had an independently negative relationship with longitudinal and radial PS (β = - 0.486 and β = - 0.408, respectively; all P < 0.05); and visceral fat was negatively associated with longitudinal PDSR (β = - 0.563, P < 0.05). Differently, gynoid fat was positively correlated with circumferential PS and PDSR and radial PDSR (β = 0.490, β = 0.481, and β = 0.413, respectively; all P < 0.05).

CONCLUSION

Hyperlipidemia is independently associated with subclinical LV diastolic dysfunction in obesity. Central fat distribution (android and visceral fat) has a negative association, while peripheral fat distribution (gynoid fat) has a positive association on subclinical LV function. These results suggest that appropriate management of hyperlipidemia may be beneficial for obese patients, and that the differentiation of fat distribution in different regions may facilitate the precise management of obese patients. Clinical trials registration Effect of lifestyle intervention on metabolism of obese patients based on smart phone software (ChiCTR1900026476).

Early Renal Denervation Attenuates Cardiac Dysfunction in Heart Failure With Preserved Ejection Fraction

BACKGROUND

The renal sympathetic nervous system modulates systemic blood pressure, cardiac performance, and renal function. Pathological increases in renal sympathetic nerve activity contribute to the pathogenesis of heart failure with preserved ejection fraction (HFpEF). We investigated the effects of renal sympathetic denervation performed at early or late stages of HFpEF progression.

METHODS AND RESULTS

Male ZSF1 obese rats were subjected to radiofrequency renal denervation (RF-RDN) or sham procedure at either 8 weeks or 20 weeks of age and assessed for cardiovascular function, exercise capacity, and cardiorenal fibrosis. Renal norepinephrine and renal nerve tyrosine hydroxylase staining were performed to quantify denervation following RF-RDN. In addition, renal injury, oxidative stress, inflammation, and profibrotic biomarkers were evaluated to determine pathways associated with RDN. RF-RDN significantly reduced renal norepinephrine and tyrosine hydroxylase content in both study cohorts. RF-RDN therapy performed at 8 weeks of age attenuated cardiac dysfunction, reduced cardiorenal fibrosis, and improved endothelial-dependent vascular reactivity. These improvements were associated with reductions in renal injury markers, expression of renal NLR family pyrin domain containing 3/interleukin 1β, and expression of profibrotic mediators. RF-RDN failed to exert beneficial effects when administered in the 20-week-old HFpEF cohort.

CONCLUSIONS

Our data demonstrate that early RF-RDN therapy protects against HFpEF disease progression in part due to the attenuation of renal fibrosis and inflammation. In contrast, the renoprotective and left ventricular functional improvements were lost when RF-RDN was performed in later HFpEF progression. These results suggest that RDN may be a viable treatment option for HFpEF during the early stages of this systemic inflammatory disease.

Phenotyping patients with ischaemic heart disease at risk of developing heart failure: an analysis of the HOMAGE trial

AIMS

We aim to characterize the clinical and proteomic profiles of patients at risk of developing heart failure (HF), with and without coronary artery disease (CAD) or prior myocardial infarction (MI).

METHODS AND RESULTS

HOMAGE evaluated the effect of spironolactone on plasma and serum markers of fibrosis over 9 months of follow-up in participants with (or at risk of having) CAD, and raised natriuretic peptides. In this post hoc analysis, patients were classified as (i) neither CAD nor MI; (ii) CAD; or (iii) MI. Proteomic between-group differences were evaluated through logistic regression and narrowed using backward stepwise selection and bootstrapping. Among the 527 participants, 28% had neither CAD or MI, 31% had CAD, and 41% had prior MI. Compared with people with neither CAD nor MI, those with CAD had higher baseline plasma concentrations of matrix metalloproteinase-7 (MMP-7), galectin-4 (GAL4), plasminogen activator inhibitor 1 (PAI-1), and lower plasma peptidoglycan recognition protein 1 (PGLYRP1), whilst those with a history of MI had higher plasma MMP-7, neurotrophin-3 (NT3), pulmonary surfactant-associated protein D (PSPD), and lower plasma tumour necrosis factor-related activation-induced cytokine (TRANCE). Proteomic signatures were similar for patients with CAD or prior MI. Treatment with spironolactone was associated with an increase of MMP7, NT3, and PGLYRP1 at 9 months.

CONCLUSIONS

In patients at risk of developing HF, those with CAD or MI had a different proteomic profile regarding inflammatory, immunological, and collagen catabolic processes.

Sex-specific differences and predictors of echocardiographic measures of diastolic dysfunction in rhesus macaques (Macaca mulatta)

BACKGROUND

Diastolic dysfunction in humans is an age-related process with an overrepresentation in women. In rhesus macaques (Macaca mulatta), the incidence and predictors of diastolic dysfunction have yet to be reported.

METHODS

Data from routine echocardiographic evaluations on clinically healthy rhesus macaques was obtained and used for univariate, bivariate, hypothesis testing, and linear regression statistical analyses interrogating differences and predictors of diastolic function.

RESULTS

Rhesus macaques fully recapitulate previously reported human hemodynamic studies. Female monkeys display impaired diastology and are at an increased risk for developing diastolic dysfunction. Age, sex, and proxies of exercise activity are confirmed predictors for measures of diastolic dysfunction, regardless of specific pathogen-free status.

CONCLUSIONS

Rhesus macaques share common sex- and age-related echocardiographic findings as humans, therefore, serve as a valuable translational nonhuman primate model for future studies of diastolic dysfunction. These findings confirm the importance of sex- and age-matching within future rhesus macaque cardiovascular research.

Study of left ventricular systolic dysfunction, left ventricular diastolic dysfunction and pulmonary hypertension in CKD 3b-5ND patients-A single centre cross-sectional study

INTRODUCTION

Cardiovascular diseases are associated with increased morbidity and mortality among CKD (chronic kidney disease) population. Recent studies have found increasing prevalence of PH (pulmonary hypertension) in CKD population. Present study was done to determine prevalence and predictors of LV (left ventricular) systolic dysfunction, LVDD (left ventricular diastolic dysfunction) and PH in CKD 3b-5ND (non-dialysis) patients.

METHODS

A cross sectional observational study was done from Jan/2020 to April/2021. CKD 3b-5ND patients aged ≥15 yrs were included. Transthoracic 2D (2 dimensional) echocardiography was done in all patients. PH was defined as if PASP (pulmonary artery systolic pressure) value above 35mm Hg, LV systolic dysfunction was defined as LVEF (left ventricular ejection fraction)≤50% and LVDD as E/e' ratio >14 respectively. Multivariate logistic regression model was done to determine the predictors.

RESULTS

A total of 378 patients were included in the study with 103 in stage 3b, 175 in stage 4 and 100 patients in stage 5ND. Prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%. Predictors of PH were duration of CKD, haemoglobin, serum 25-OH vitamin D, serum iPTH (intact parathyroid hormone) and serum albumin. Predictors of LVDD were duration of CKD and presence of arterial hypertension. Predictors of LV systolic dysfunction were eGFR (estimated glomerular filtration rate), duration of CKD, serum albumin and urine protein.

CONCLUSION

In our study of 378 CKD 3b-5ND patients prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%.

Heartache in a Bottle: Understanding Alcoholic Cardiomyopathy

Alcoholic cardiomyopathy (ACM) is a cardiac ailment marked by impaired contraction and dilation of one or both ventricles of the heart. The extent of daily alcohol intake and duration of alcohol abuse are linked to the development of ACM, although the exact thresholds and timeline for alcohol misuse to induce heart dysfunction remain uncertain. Thus, the objective of this systematic review is to comprehensively evaluate the existing knowledge on the specific disease entity, particularly in light of the ongoing issue of alcohol misuse, with the intention of determining if recent advancements and discoveries have significantly altered the understanding of this condition compared to the past century. This systematic review involved a literature search that was conducted on PubMed to identify suitable and appropriate literature for the study. The inclusion criteria encompassed articles that focused on ACM or the relationship between alcohol abuse and cardiac dysfunction, involved human subjects or relevant animal models, were written in the English language, and were published within the last 10 years. The exclusion criteria included duplicates, case reports, letters, editorials, and reviews not specifically addressing ACM. As a result, a total of 18 articles were included in this systematic review. The risk of bias was assessed through the use of the Cochrane risk-of-bias tool for clinical trials. The findings of this systematic review indicated that the likelihood of ACM occurrence significantly rose when the consumption of over 80 g of alcohol per day occurred for at least five years. The systematic review further revealed that ACM is associated with various detrimental changes in the cellular, structural, and histological aspects of the heart muscles, even though the specific clinical and histological characteristics of ACM have yet to be established. In individuals with an extensive history of excessive alcohol abuse, the diagnosis of ACM was reached through the exclusion of other potential causes of the condition. The fundamental approach to treatment lies in abstaining from alcohol. It is crucial to manage symptoms in individuals with secondary heart failure and address any related complications.

Vortex Formation Time is a Novel Measure for Early Detection of Diastolic Abnormalities in Adolescents with Hypertension

Pediatric hypertension (HTN) has demonstrated an upward trend in recent years. Adolescent HTN has been linked to adult HTN, cardiovascular disease, and other health conditions. Thus, it is essential that HTN and its associated cardiac abnormalities be diagnosed and treated early to minimize lifelong adverse effects. In this study, we evaluated whether vortex formation time (VFT), a validated echocardiogram measure of left ventricular diastolic dysfunction, correlated with ambulatory blood pressure monitoring (ABPM) and HTN in adolescents. Echocardiogram data including systolic and diastolic function indices and ABPM data from 2015 to 2022 in adolescents age 13-21 years were analyzed retrospectively. We found that VFT was significantly lower in adolescents with HTN compared to those without HTN (3.69 ± 1.39 vs. 4.50 ± 1.73, p = 0.02). Standard echocardiographic indices of systolic and diastolic function were similar between the two groups, except indexed left atrial volume. Higher overall systolic blood pressure (SBP) (β = - 0.01, CI - 0.02, - 2.2 × 10^-3, p = 0.02), mean wake SBP (β = - 0.01, CI - 0.02, - 9.4 × 10^-4, p = 0.03), and mean sleep SBP (β = - 0.01, CI - 0.02, - 1.2 × 10^-3, p = 0.03) were significantly associated with lower VFT. This study demonstrates that VFT correlates to ABPM data and can be used a novel diagnostic measure in adolescents with HTN.

Impact of Structural Abnormalities in Left Ventricle and Left Atrium on Clinical Outcomes in Heart Failure with Preserved Ejection Fraction

Two key echocardiographic parameters, left ventricular mass index (LVMI) and left atrial volume index (LAVI), are important in assessing structural myocardial changes in heart failure (HF) with preserved ejection fraction (HFpEF). However, the differences in clinical characteristics and outcomes among groups classified by LVMI and LAVI values are unclear.We examined the data of 960 patients with HFpEF hospitalized due to acute decompensated HF from the PURSUIT-HFpEF registry, a prospective, multicenter observational study. Four groups were classified according to the cut-off values of LVMI and LAVI [LVMI = 95 g/m2 (female), 115 g/m2 (male) and LAVI = 34 mL/m2]. Clinical endpoints were the composite of HF readmission and all-cause death. Study endpoints among the 4 groups were evaluated. The composite endpoint occurred in 364 patients (37.9%). Median follow-up duration was 445 days. Kaplan-Meier analysis revealed significant differences in the composite endpoint among the 4 groups (P < 0.001). Cox proportional hazards analysis demonstrated that patients with increased LAVI alone were at significantly higher risk of HF readmission and the composite endpoints than those with increased LVMI alone (P = 0.030 and P = 0.024, respectively). Age, male gender, systolic blood pressure at discharge, atrial fibrillation (AF) hemoglobin, renal function, and LAVI were significant determinants of LVMI and female gender, AF, hemoglobin, and LVMI were significant determinants of LAVI.In HFpEF patients, increased LAVI alone was more strongly associated with HF readmission and the composite of HF readmission and all-cause death than those with increased LVMI alone.

Cardioprotective potential of lithium and role of fractalkine in euthymic patients with bipolar disorder

OBJECTIVE

Over a half century, lithium has been used as the first-line medication to treat bipolar disorder. Emerging clinical and laboratory studies suggest that lithium may exhibit cardioprotective effects in addition to neuroprotective actions. Fractalkine (CX3CL1) is a unique chemokine associated with the pathogenesis of mood disorders and cardiovascular diseases. Herein we aimed to ascertain whether lithium treatment is associated with favorable cardiac structure and function in relation to the reduced CX3CL1 among patients with bipolar disorder.

METHODS

We recruited 100 euthymic patients with bipolar I disorder aged over 20 years to undergo echocardiographic study and measurement of plasma CX3CL1. Associations between lithium treatment, cardiac structure and function and peripheral CX3CL1 were analyzed according to the cardiovascular risk. The high cardiovascular risk was defined as (1) age ⩾ 45 years in men or ⩾ 55 years in women or (2) presence of concurrent cardiometabolic diseases.

RESULTS

In the high cardiovascular risk group (n = 61), patients who received lithium as the maintenance treatment had significantly lower mean values of left ventricular internal diameters at end-diastole (Cohen's d = 0.65, p = 0.001) and end-systole (Cohen's d = 0.60, p = 0.004), higher mean values of mitral valve E/A ratio (Cohen's d = 0.51, p = 0.019) and superior performance of global longitudinal strain (Cohen's d = 0.51, p = 0.037) than those without lithium treatment. In addition, mean plasma levels of CX3CL1 in the high cardiovascular risk group were significantly lower among patients with lithium therapy compared with those without lithium treatment (p = 0.029). Multiple regression models showed that the association between lithium treatment and mitral value E/A ratio was contributed by CX3CL1.

CONCLUSION

Data from this largest sample size study of the association between lithium treatment and echocardiographic measures suggest that lithium may protect cardiac structure and function in patients with bipolar disorder. Reduction of CX3CL1 may mediate the cardioprotective effects of lithium.

Pathophysiology, Diagnosis, and Management of Hypertension in the Elderly

There is a high prevalence of systemic arterial hypertension in the elderly; 70% of adults >65 years have this disease. A key mechanism in the development of hypertension in the elderly is increased arterial stiffness. This accounts for the increase in systolic blood pressure and pulse pressure and fall in diastolic blood pressure (isolated systolic hypertension) that are commonly seen in the elderly, compared with younger persons. The diagnosis of hypertension is made on the basis of in-office blood pressure measurements together with ambulatory and home blood pressure recordings. Lifestyle changes are the cornerstone of management of hypertension. Comprehensive guidelines regarding blood pressure threshold at which to start pharmacotherapy as well as target blood pressure levels have been issued by both European and American professional bodies. In recent years, there has been considerable interest in intensive lowering of blood pressure in older patients with hypertension. Several large, randomized controlled trials have suggested that a strategy of aiming for a target systolic blood pressure of <120 mm Hg (intensive treatment) rather than a target of <140 mm Hg (standard treatment) results in significant reduction in the incidence of adverse cardiovascular events and total mortality. A systolic blood pressure treatment of <130 mm Hg should be considered favorably in non-institutionalized, ambulatory, free living older patients. In contrast, in the older patient with a high burden of comorbidities and limited life expectancy, an individualized team-based approach, based on clinical judgment and patient preference should be adopted. An increasing body of evidence for older adults with hypertension suggests that intensive blood pressure lowering may prevent or at least partially prevent cognitive decline.

Subclinical HMOD in Hypertension: Left Ventricular Diastolic Dysfunction

Arterial hypertension represents an important risk factor for the development of cardiac, vascular and renal events, predisposing to heart failure, acute coronary syndromes, peripheral artery disease, stroke, and chronic renal disease. Arterial hypertension leads to the development of subclinical hypertension mediated organ damage (HMOD) which has prognostic relevance and may influence the choice of treatment options. Alterations of cardiac structure and function represent the more widely assessed form of HMOD. This manuscript will focus on the diagnostic opportunities, prognostic significance and treatment of diastolic dysfunction alterations.

Automatic quantitative measurement of left atrial pressure using mitral regurgitation spectrum: clinical study on comparison with floating catheter

Introduction

To explore how to measure LAPEq accurately and quantitatively, that is, the left atrial pressure (LAP) measured and calculated by equation method using mitral regurgitation spectrum.

Methods

The mitral regurgitation spectrum, pulmonary arteriolar wedge pressure (PAWP) and invasive arterial systolic pressure of radial artery of 28 patients were collected simultaneously, including 3 patients with rheumatic heart disease, 15 patients with mitral valve prolapse and 10 patients with coronary artery bypass grafting, patients with moderate or above aortic stenosis were excluded. LAPBp (Doppler sphygmomanometer method), LAPEq (Equation method) and LAPC (Catheter method) were measured synchronously, and the measurement results of the three methods were compared and analyzed. A special intelligent Doppler spectrum analysis software was self-designed to accurately measure LAPEq. This study had been approved by the ethics committee of the Northern Theater General Hospital (K-2019-17), and applied for clinical trial (No. Chictr 190023812).

Results

It was found that there was no significant statistical difference between the measurement results of LAPC and LAPEq (t = 0.954, P = 0.348), and significant correlation between the two methods [r = 0.908(0.844, 0.964), P < 0.001]. Although the measurement results of LAPC and LAPBP are consistent in the condition of non-severe eccentric mitral regurgitation, there are significant differences in the overall case and weak correlation between the two methods [r = 0.210, (−0.101, 0.510), P = 0.090]. In MVP patients with P1 or P3 prolapse, the peak pressure difference of MR was underestimated due to the serious eccentricity of MR, which affected the accuracy of LAPBP measurement.

Conclusions

It was shown that there is a good correlation between LAPEq and LAPC, which verifies that the non-invasive and direct quantitative measurement of left atrial pressure based on mitral regurgitation spectrum is feasible and has a good application prospect.

Nomogram based on multimodal echocardiography for assessing the evolution of diabetic cardiomyopathy in diabetic patients with normal cardiac function

Background

Diabetic cardiomyopathy (DCM) remains asymptomatic for many years until progression to asymptomatic left ventricular diastolic dysfunction (ALVDD), a subclinical cardiac abnormality present in early-stage DCM. Because LV function in patients with type 2 diabetes mellitus (T2DM) may be subtly altered long before the onset of ALVDD, quantitative assessment of the risk of progression to early-stage DCM in T2DM patients with normal hearts is critical for delaying or even reversing DCM.

Objective

This study aimed to establish a nomogram with the aid of DCM characteristics revealed by multimodal echocardiography to assess the likelihood of the progression to early-stage DCM in T2DM patients with normal cardiac function.

Methods

Of the 423 T2DM patients enrolled, 302 were included in the training cohort and 121 in the validation cohort. The clinical characteristics, biochemical data, and multimodal echocardiographic parameters were collected. In the training cohort, the screened correlates of ALVDD were utilized to develop a nomogram for estimating the risk coefficient for early-stage DCM. This model was validated both in the training and validation cohorts.

Results

ALVDD was independently correlated with the number of comorbidities [with one comorbidity: odds ratio (OR) = 3.009; with two comorbidities: OR = 4.026], HbA1c (OR = 1.773), myocardial blood flow (OR = 0.841), and global longitudinal strain (OR = 0.856) (all P < 0.05). They constituted a nomogram to visualize the likelihood of DCM development in T2DM patients with normal cardiac function. The model was validated to present strong discrimination and calibration, and obtained clinical net benefits both in the training and validation cohorts.

Conclusion

We constructed and validated a nomogram to estimate the likelihood of developing early-stage DCM in T2DM patients with normal cardiac function. The alteration of the nomogram-predicted risk coefficient is expected to be proposed as a therapeutic target to slow or stop DCM progression.

Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction In Patients With Resistant Hypertension and Type 2 Diabetes Mellitus

Aim      To study the incidence and clinical and pathophysiological features of diastolic dysfunction (DD) and chronic heart failure with preserved ejection fraction (HFpEF) in patients with resistant arterial hypertension (RAH) associated with type 2 diabetes mellitus (DM).Material and methods  A cross-sectional study that included 36 patients with RAH associated with type 2 DM (mean age, 61.4±6.4 years; 14 men) was performed. Measurement of office and 24-h blood pressure (BP), standard echocardiography with assessment of diastolic function (DF) and ventricular-arterial coupling, doppler ultrasound imaging of renal blood flow, and laboratory tests (blood glucose, glycated hemoglobin, blood creatinine, tumor necrosis factor α (TNF-α), brain natriuretic peptide (BNP), type 2 and type 9 matrix metalloproteinases (MMP-2 and MMP-9), tissue inhibitor of MMP 1 (TIMP-1), 24-h urine protein test, and 24-h urine volume test were performed for all patients. HFpEF was diagnosed according to criteria of the American Society of Echocardiography and the European Society of Cardiology 2019, and the Russian Clinical Guidelines on Diagnosis and Treatment of CHF 2017 and 2020.Results All patients had DD. Incidence of HFpEF detection according to the Russian Guidelines 2017 was 100%; according to the Russian Guidelines 2020, that included a required increase in BNP, and according to the criteria of the European Guidelines 2019, this incidence was 89 %. In 55.6 % of patients, DD corresponded to grade 2 (pseudonormal type). According to the correlation analysis, the DF impairment was associated with increases in pulse BP, myocardial mass, arterial and left ventricular elastance (arterial wall and left ventricular elasticity), basal glycemia and DM duration, MMP-2 level, proteinuria, blood creatinine, renal vascular resistance, and also with decreases in 24-h urine volume, MMP-9, TIMP-1, and TIMP-1/MMP-2. Significance of the relations of mean E / e' ratio with nighttime pulse BP, MMP-9, and 24-h urine volume were confirmed by results of multiple linear regression analysis. Increased myocardial and vascular wall stiffness, concentrations of MMP-2 and TNF-α and reduced 24-h urine volume were associated with progressive impairment of DF.Conclusion      The combination of RAH and DM-2 is characterized by an extremely high incidence of DD that determines a great prevalence of HFpEF. The development and progression of DD in such patients are closely related with a complex of metabolic, proinflammatory and profibrotic biomarkers, increased vascular wall stiffness, pronounced left ventricular hypertrophy, and with structural and functional alterations in kidneys.

Echocardiographic markers of early alcoholic cardiomyopathy: Six-month longitudinal study in heavy drinking patients

BACKGROUND

The development of alcoholic cardiomyopathy (ACM) is related to chronic excessive alcohol use. However, features of early-stage ACM are still unclear. We assessed echocardiographic characteristics of patients with alcohol dependence (DSM-IV criteria) during a six-month treatment period.

METHODS

Active drinking patients, heavy alcohol users, without heart disease, referred to our Alcohol Addiction Unit were enrolled in the study. After signing informed consent, patients started outpatient treatment program. Echocardiography was performed at enrollment, then three and six months afterwards, by cardiologists blinded to drinking status.

RESULTS

Forty-three patients (36 males, 7 females) were enrolled. At six months, 20 patients (46.5%) reduced alcohol consumption below heavy drinking levels. Although within normal range, baseline mean IVS thickness and mean LVDD were significantly higher (p < 0.001) and mean EF significantly reduced (p = 0.009), as compared to age-matched mean references. Mean E/A ratio, DcT and LA diameter were significantly different (p < 0.001) from mean references, but within normal range. Baseline mean E/e' ratio was significantly higher than the mean reference (p < 0.001) and out of the normal range. A significant correlation between the number of drinks per drinking days in the 7 days before baseline assessment and E/e' ratio was observed (p = 0.028). After six months, a trend-level reduction of mean E/e' ratio (p = 0.051) was found in the whole sample; this reduction was statistically significant (p = 0.041) among patients reducing drinking, compared to baseline.

CONCLUSIONS

Altered E/e' ratio may characterize early-ACM before the occurrence of relevant echocardiographic alterations. The reduction of alcohol consumption could restore this alteration after six months.

Comparison of Echocardiographic Changes Between Surgery and Medication Treatment in Patients With Primary Aldosteronism

Background

Primary aldosteronism can cause cardiac dysfunction, including left ventricular hypertrophy, left ventricular diastolic dysfunction, and left atrial enlargement. A few studies have compared the cardioprotective effects between surgery and medication for primary aldosteronism, although most have not adjusted for baseline disease status. In this study, we investigated the difference in cardiovascular outcomes between surgery and medication treatment for primary aldosteronism after adjusting for baseline clinical characteristics, including aldosterone level and pretreatment echocardiographic information.

Methods and Results

We retrospectively analyzed 220 patients diagnosed with primary aldosteronism who underwent adrenalectomy (n=144) or medication treatment (n=76) between 2009 and 2019. Echocardiographic changes were evaluated pretreatment and 1 year posttreatment. The surgery group had lower potassium, lower plasma renin activity, and higher plasma aldosterone concentration than the medication group, indicating a severe primary aldosteronism phenotype in the former. The decrease in left ventricular mass index after treatment was significantly greater in the surgery group than in the medication group (P=0.047). However, this relationship was not noted after multivariable regression analysis (standard β=−0.08, P=0.17). Additionally, decreased parameter values related to left ventricular diastolic dysfunction and left atrial enlargement were not different between the groups. Pretreatment echocardiographic values were most associated with changes in all echocardiographic parameters. The findings were consistent in the propensity score‐matched analysis.

Conclusions

This study's findings suggest that there is no difference in cardioprotective efficacy between surgical and medication treatment under similar disease severity; however, it should be considered that several study participants with severe hyperaldosteronism were managed surgically.

Prevalence and prognosis of left ventricular diastolic dysfunction in community hypertension patients

Left ventricular diastolic dysfunction (LVDD) is common in hypertension and is a predictor of increased cardiovascular risk, however the effect of LVDD, detected by new guideline, on major adverse cardiac events (MACE) is unknown in hypertensive patients without known cardiovascular disease. The present study aims to evaluate LVDD in a community hypertension cohort study and assess the effect of LVDD on MACE. we studied 283 asymptomatic nonischemic patients with hypertension who had baseline echocardiogram between 2012 and 2014. Patients were followed for MACE (myocardial infarction, coronary revascularization procedures, heart failure, stroke, all-cause mortality) with mean follow-up of 5.4 years. A Cox proportional hazards model was used to assess the association of LVDD with MACE. At baseline, 35 of the 283 hypertensions were diagnosed with LVDD (12.3%) and 25 patients were women (15.5%). Women had higher frequency of LVDD than men (8%). During follow-up, there were 26.6% patients occurring MACE in the LVDD group at baseline, 9.9% patients occurring MACE in the group with normal diastolic function. In multivariable Cox regression analyses, LVDD was a stronger predictor of MACE (HR: 2.5; 95% CI: 1.20 to 5.25; c- statistics 0.805) than E/e' ratio (HR: 1.13; 95% CI: 1.04 to 1.22). LVDD was strongly associated with MACE in hypertension patients.

Beneficial Effect of Sodium-Glucose Co-transporter 2 Inhibitors on Left Ventricular Function

BACKGROUND

Sodium-glucose cotransporter 2 (SGLT2) inhibitors lowered the risk of cardiovascular events in patients with diabetes or heart failure (HF) with reduced ejection fraction, whether they directly promote cardiac function remains unclear. Therefore, we sought to determine whether SGLT2 inhibitors could improve left ventricular (LV) function in these patients.

METHODS

A literature search was conducted using MEDLINE, EMBASE, and Cochrane Library databases from their inception to July 9, 2021. Randomized clinical trials and cohort studies that reported LV function-related variables were included.

RESULTS

Thirteen studies comprising 1437 patients (830 SGLT2 inhibitor-treated and 607 non-SGLT2 inhibitor-treated patients) and representing 7 randomized controlled trials with 640 individuals and 6 cohort studies with 797 individuals were included in this meta-analysis. LV regression [LV mass (LVM)], LV ejection fractions (LVEF), LV volumes [LV end-diastolic volumes and systolic volumes (LVEDV and LVESV, respectively], and LV diastolic function [mitral inflow E velocity to tissue Doppler e' ratio, E/e' and left atrial volume index (LAVI)] were all significantly improved in patients treated with SGLT2 inhibitors (weighted mean differences, 95% CI, LVM: -6.319 g, -10.850 to -1.789; LVEF: 2.458%, 0.693 to 4.224; LVEDV: -9.134 mL, -15.808 to -2.460; LVESV: -8.440 mL, -15.093 to -1.787; LAVI: -2.791 mL/m2, -.554 to -1.027; E/e': -1.567, -2.440 to -0.698). Subgroup analysis further confirmed the improvement of LV function mainly in patients with HF or those receiving empagliflozin treatment.

CONCLUSIONS

Treatment with SGLT2 inhibitors can significantly improve LV function in patients with or without diabetes (especially those with HF or undergoing empagliflozin treatment).

Challenges in Device Closure of Secundum Atrial Septal Defect in Older Patients in Their Fifth Decade and Beyond

Objective

Transcatheter atrial septal defect (ASD) device closure in the older population presents a greater challenge due to the long-standing effect of atrial left-to-right shunt. This study analyzes the challenges encountered in transcatheter ASD device closure in older patients in their fifth decade and beyond.

Methods

Adults aged 40 years and above with significant secundum ASD who underwent transcatheter ASD device closure between June 2015 and April 2021 were analyzed. Challenges were classified as major and minor challenges based on their impact on the alteration of the treatment protocol. Patients were categorized into three subgroups according to age. Group 1 consisted of patients aged 40-49 years (n = 13), Group 2 consisted of patients aged 50-59 years (n = 16), and Group 3 consisted of patients aged 60 years and above (n = 8).

Results

A total of 37 patients were analyzed. The challenges encountered were arrhythmia, pulmonary hypertension, left ventricular diastolic dysfunction, bleeding, stroke, coronary artery disease (CAD), hypertension, and airway disease. Thirteen percent of challenges were seen in pre-procedure time, whereas 79% of challenges during the procedure and 8% of challenges during post-procedure were seen. Thirty-five patients (94.6%) underwent transcatheter ASD device closure. Two patients (5.4%) did not undergo transcatheter ASD device closure due to severe diastolic dysfunction and associated CAD, respectively. Eleven major challenges were encountered in 10 patients in which one patient had a dual challenge of bleeding and arrhythmia. Thirteen patients (35.1%) had smooth procedures without any challenges encountered. Twenty-seven minor challenges were encountered in 20 patients with some patients having an overlap of multiple major and minor challenges. The patients were doing well at the mean follow-up of 28 months.

Conclusions

Transcatheter ASD device closure in older patients who are 40 years and above is safe and effective. Such high-risk patients are prone to various challenges that can be effectively managed if optimally monitored on the basis of a proper understanding of the altered physiology and anticipation of the deviated course at various stages of the procedure.

Echocardiographic study of cardiac structure and function in people with bipolar disorder after midlife

BACKGROUND

Heart failure is the leading cause of mortality in older people with bipolar disorder (BD). Studies examining cardiac structure and function in middle-aged patients with BD by using echocardiography and cardiac strain imaging are scant.

METHODS

We recruited 48 patients with bipolar I disorder (BD-I) older than 45 years to undergo conventional and tissue speckle tracking echocardiography. Data of 31 mentally healthy adults older than 45 years were randomly retrieved from the echocardiographic dataset and compared with the data of BD patients.

RESULTS

Patients with BD-I had significantly higher mean values of interventricular septal thickness (Cohen's d = 0.83, p = 0.001) and left ventricular internal diameter (Cohen's d = 0.90, p = 0.001) at end-diastole relative to controls. Additionally, BD-I patients exhibited significantly lower mean values of mitral valve E/A ratio (Cohen's d = 0.67, p = 0.007) and a more reduced global longitudinal strain (Cohen's d = 0.72, p = 0.029) than controls. Multiple linear regression revealed that body mass index was negatively correlated with the mitral valve E/A ratio (adjustment R² = 0.363, p = 0.043) in patients with BD-I.

LIMITATIONS

A relatively small sample size may limit generalization.

CONCLUSIONS

After midlife, BD patients exhibit cardiac diastolic (low mitral valve E/A ratio) and systolic (reduced global longitudinal strain) dysfunction. High body mass index may play a role in the unfavorable cardiac function in aging patients with BD.

Development of a Nomogram for Estimating the Risk of Left Ventricular Diastolic Dysfunction in Patients with Non-Alcoholic Fatty Liver Disease

BACKGROUND

Patients with non-alcoholic fatty liver disease (NAFLD) are more likely to develop left ventricular diastolic dysfunction (LVDD). Although lifestyle adjustments contribute to the improvement of NAFLD, thereby delaying or even preventing LVDD progression, it is difficult to maintain a healthy lifestyle, resulting in a higher incidence of LVDD in NAFLD patients.

OBJECTIVE

This study aims to develop a nomogram for assessing the risk of LVDD progression in NAFLD patients to increase their adherence to therapeutic interventions and adjust their treatment regimens timely.

METHODS

A total of 148 medical records of NAFLD patients were retrospectively analyzed. Sixty-three were assigned to the LVDD+ group and 85 were assigned to the LVDD- group. The independent correlates of LVDD, which were screened via least absolute shrinkage and selection operator logistic regression model first, followed by multivariate Logistic regression model, constituted the nomogram to determine the likelihood of LVDD in NAFLD patients.

RESULTS

Number of comorbidities, glycosylated hemoglobin, and epicardial adipose tissue (EAT) volume index were independent correlates of LVDD (all P < 0.05). They served as components in the newly developed nomogram. It obtained significant clinical benefit in detecting NAFLD patients at the risk of LVDD progression, with satisfied discrimination and calibration.

CONCLUSION

We developed a nomogram for identifying NAFLD patients with a normal diastolic function who are at risk of LVDD progression, thus contributing to effective prevention of LVDD progression.

Central Hemodynamic Adjustments during Post-Exercise Hypotension in Hypertensive Patients with Ischemic Heart Disease: Concurrent Circuit Exercise versus High-Intensity Interval Exercise. A Preliminary Study

Concurrent aerobic plus resistance exercise (RAE) and high-intensity interval exercise (HIIE) are both effective at inducing post-exercise hypotension (PEH) in patients with hypertension. However, central hemodynamic changes associated with PEH in hypertensive subjects with underlying ischemic heart disease (IHD) have been poorly investigated. The study aim was to compare the acute effects produced by these two exercise modalities on left ventricular diastolic function and left atrial function. Twenty untrained male patients with a history of hypertension and IHD under stable pharmacological therapy were enrolled. Each patient underwent three exercise sessions: RAE, HIIE and a control session without exercise, each lasting 45 min. An echocardiography examination was performed before and between 30 min and 40 min from the end of the exercise sessions. Following the exercise sessions, BP values decreased in a similar way in RAE and HIIE and were unchanged after the control session. Compared to pre-session, the ratio between early filling velocity (E) and mitral annulus early diastolic velocity (E’). E/E’ increased after HIIE and remained unchanged after both RAE and control sessions (between-sessions p 0.002). Peak atrial longitudinal strain (PALS) increased slightly after RAE (+1.4 ± 1.1%), decreased after HIIE (−4.6 ± 2.4%) and was unchanged after the control session (between-sessions p 0.03). Peak atrial contraction strain (PACS) was mildly increased after RAE, was reduced after HIIE and was unchanged after the control session. Atrial volume was unchanged after both exercise sessions. Left ventricular and left atrial stiffness increased significantly after HIIE, but remained unchanged after the RAE and control sessions. Stroke volume and cardiac output increased after RAE, decreased after HIIE, and were unchanged after the control session. In conclusion, single session of RAE and HIIE brought about similar PEH in hypertensive subjects with IHD, while they evoked different central hemodynamic adjustments. Given its neutral effects on diastolic and atrial functions, RAE seems more suitable for reducing blood pressure in hypertensive patients with IHD.

Aortic wall elasticity and left ventricular function in hypertensive patients with nonsignificant coronary artery disease

PURPOSE

Hypertension is an important cause of nonischemic heart failure. It is important to identify subclinical left ventricular dysfunction in patients with hypertension in an early stage to lower the risk of progression to more severe illness. The aim of our study was to assess the correlation between indices of left ventricular function and aortic stiffness in patients with hypertension.

METHODS

Our study was a case control study of 42 hypertensive and 40 normotensive patients with nonsignificant coronary artery disease. All the patients underwent echocardiography and left ventricular ejection fraction, global longitudinal strain, post systolic index, pulsed Doppler early transmitral peak flow velocity, early diastolic mitral annular velocity (e'), and aortic elasticity measurements were calculated.

RESULTS

The hypertensive patients were older (58.47 ± 9.57 vs. 52.94 ± 10.38 years, p = 0.018) and had a higher body mass index (30.09 ± 5.08 vs. 27.48 ± 4.17 kg/m2, p = 0.013) and E/e' ratio (8.16 ± 1.81 vs. 6.56 ± 1.71, p < 0.001) and a lower e' velocity (8.25 ± 2.28 vs. 9.52 ± 2.34 cm/s, p = 0.015) than normotensives. They also had a lower aortic distensibility (p = 0.008) and a higher aortic stiffness index (p = 0.039) compared with the normotensive group. The hypertensive patients did not show any association between aortic elasticity and stiffness with age or e' velocity despite significant association in normotensives.

CONCLUSION

Hypertension is associated with a high prevalence of diastolic dysfunction, elevated left ventricular filling pressure, and increased arterial stiffness, all of which have significant association with adverse outcomes. The measurements found in the hypertensive patients compared with the normotensive group may be due to several age-independent mechanisms.

Diastolic function assessed with speckle tracking over a decade and its prognostic value: The Copenhagen City Heart Study

BACKGROUND

The ratio of transmitral early filling velocity to early diastolic strain rate (E/e'sr) may be a more accurate measure of LV filling pressure then ratio of early filling pressure to early tissue velocity. The aim of the study was to investigate the impact of age, sex, obesity, smoking, hypertension, hypercholesterolemia, diabetes, physical activity level, socioeconomic, and psychosocial status on E/e'sr over a decade. Additionally, the predictive value of ΔE/e'sr on future major adverse cardiovascular events (MACE) has never been explored.

METHOD

The study included 623 participants from the general population, who participated in the 4th and 5th Copenhagen City Heart Study (CCHS4 and CCHS5). Examinations were median 10 years apart. MACE was the composite endpoint of heart failure, myocardial infarction, and all-cause death.

RESULTS

Follow-up time was median 5.7 years, and 43 (7%) experienced MACE. Mean age was 51 ± 14 years, and 43% were male. Mean ΔE/e'sr was 2.1 ± 23.0 cm. After multivariable adjustment for demographic, clinical, and biochemistry variables, high age (stand. β-coef. = .24, P < .001) and mean arterial blood pressure (MAP) (stand. β-coef. = .17, P < .001) were significantly associated with an accelerated increase in E/e'sr In multivariable Cox regression, E/e'sr at CCHS5 and ΔE/e'sr were independent predictors of MACE (HR = 1.20, 95% CI [1.01; 1.42] per 10 cm increase for both). ΔE/e'sr did only provide incremental prognostic value to change in left atrial volume index of the conventional diastolic measurements.

CONCLUSION

In the general population, age and MAP were predictors of an accelerated increase in E/e'sr over a decade. E/e'sr at CCHS5 and ΔE/e'sr were independent predictors of future MACE.

Effect of Cardiac Rehabilitation on Left Ventricular Diastolic Function in Patients with Acute Myocardial Infarction

Cardiac rehabilitation (CR) improves symptoms and survival in patients with acute myocardial infarction (AMI). We studied the change of diastolic function and its prognostic impact after CR. After reviewing all consecutive AMI patients from January 2012 to October 2015, we analyzed 405 patients (mean, 63.7 ± 11.7 years; 300 males) with baseline and follow-up echocardiographic examinations. We divided them into three groups according to their CR sessions: No-CR group (n = 225), insufficient-CR group (CR < 6 sessions, n = 117) and CR group (CR ≥ 6 sessions, n = 63). We compared echocardiographic parameters of diastolic dysfunction including E/e' ratio > 14, septal e' velocity < 7 cm/s, left atrial volume index (LAVI) > 34 mL/m2, and maximal TR velocity > 2.8 m/s. At baseline, there were no significant differences in all echocardiographic parameters among the three groups. At follow-up echocardiographic examination, mitral annular e' and a' velocities were higher in the CR group (p = 0.024, and p = 0.009, respectively), and mitral E/e' ratio was significantly lower (p = 0.009) in the CR group. The total number of echocardiographic parameters of diastolic dysfunction at the baseline echocardiography was similar (1.29 vs. 1.41 vs. 1.52, p = 0.358). However, the CR group showed the lowest number of diastolic parameters at the follow-up echocardiography (1.05 vs. 1.32 vs. 1.50, p = 0.017). There was a significant difference between the No-CR group and CR group (p = 0.021). The presence of CR was a significant determinant of major adverse cardiovascular events in the univariate analysis (HR = 0.606, p = 0.049). However, the significance disappeared in the multivariate analysis (HR = 0.738, p = 0.249). In conclusion, the CR was significantly associated with favorable diastolic function, with the highest mitral e' and a' velocity, and the lowest mitral E/e' ratio and total number of echocardiographic parameters of diastolic dysfunction at the follow-up echocardiographic examinations in AMI patients.

High density lipoprotein cholesterol / C reactive protein ratio in heart failure with preserved ejection fraction

AIMS

The impacts of high density lipoprotein cholesterol (HDL-C) as an anti-inflammatory and C reactive protein (CRP) as inflammatory properties on the pathogenesis of heart failure were reported. At present, the clinical significance of the HDL-C/CRP ratio in heart failure with preserved ejection fraction (HFpEF) patients remains unknown.

METHODS AND RESULTS

We examined the data on 796 consecutive HFpEF (left ventricular ejection fraction ≥50%) patients hospitalized due to acute decompensated heart failure from the PURSUIT-HFpEF registry, a prospective, multicentre observational study. We calculated the HDL/CRP ratios and evaluated the relationship between the values and clinical outcomes, including degree of cardiac function. The mean follow-up duration was 420 ± 346 days. All-cause death occurred in 118 patients, of which 51 were cardiac deaths. HDL/CRP ≤ 4.05 was independently and significantly associated with all-cause death (odds ratio = 1.84, 95% CI: 1.06-3.20, P = 0.023), and HDL/CRP ≤ 3.14 was associated with cardiac death by multivariate Cox proportional hazard analysis (odds ratio = 2.86, 95% CI: 1.36-6.01, P = 0.003). HDL-C/CRP ratio significantly correlated with the product of the left atrial volume and left ventricular mass index as well as the tricuspid annular plane systolic excursion by multiple regression analysis (standardized beta-coefficient = -0.085, P = 0.034 and standardized beta-coefficient = 0.081, P = 0.044, respectively).

CONCLUSIONS

HDL-C/CRP ratio was a useful marker for predicting all-cause death and cardiac death and correlated with left ventricular diastolic function and right ventricular systolic function in HFpEF patients.

Coronary tortuosity relation with carotid intima-media thickness, coronary artery disease risk factors, and diastolic dysfunction: is it a marker of early atherosclerosis?

Background

Coronary tortuosity (C-Tor) is a common finding in coronary angiography (CAG). There are conflicting data about its link to atherosclerosis: one study found a negative relationship with coronary artery disease (CAD), although it had been linked to age and hypertension (HTN), which are CAD risk factors. Carotid intima-media thickness (C-IMT) is a measure of early atherosclerosis and a surrogate for CAD, diastolic dysfunction is also associated with CAD risk factors. In this retrospective case-control study, we investigated the relationship between C-Tor, C-IMT, diastolic dysfunction, and the other risk factors in patients undergoing CAG in a tertiary hospital between July 2017 and June 2018, after excluding patients with significant CAD. C-Tor was defined as the presence of ≥ 3 bends (≥ 45°) along the trunk of at least one main coronary artery in CAG.

Results

After excluding 663 patients due to exclusion criteria, 30 patients with C-Tor were compared with age and gender-matched controls. HTN was significantly more common in the C-Tor group (86.7% vs. 30%, p < 0.002); other clinical characteristics were similar. The C-IMT was abnormal in the C-Tor group only (p: 0.007). The diastolic dysfunction parameters differed between the two groups: the E/A ratio was < 1 in the C-Tor group and > 1 in the normal group (p: < 0.001); the E velocity and deceleration time were significantly lower in the C-Tor group (p: 0.001 and < 0.001 respectively); the E/E′ ratio, A, and A′ velocities were significantly higher (p: 0.005, < 0.001, < 0.001 respectively); while the S′ velocity was similar in the 2 groups (p: 0.078). The C-Tor group had higher total cholesterol and LDL (p: 0.003 and 0.006 respectively). All C-Tor patients undergoing stress tests had positive results. The only independent C-Tor predictors in a regression analysis were HTN, total cholesterol, A-wave velocity, and deceleration time (DT) (odds ratio: 14.7, 1.03, 1.15, and 0.95, all p: < 0.05). A-wave velocity had the best area under the curve, sensitivity, and specificity for C-Tor prediction (0.88, 73.3%, and 96.7% respectively) followed by DT (0.86, 66.67%, and 96.6% respectively).

Conclusion

C-Tor is associated with increased C-IMT, HTN, hyperlipidemia, and left ventricular diastolic dysfunction; all contributing to an ongoing atherosclerotic process. A-wave velocity and DT were independent predictors of C-Tor. C-Tor may cause microvascular ischemia that merits further investigation.

Cardiovascular Risk Factors in Childhood and Left Ventricular Diastolic Function in Adulthood

BACKGROUND AND OBJECTIVES

Cardiovascular risk factors, such as obesity, blood pressure, and physical inactivity, have been identified as modifiable determinants of left ventricular (LV) diastolic function in adulthood. However, the links between childhood cardiovascular risk factor burden and adulthood LV diastolic function are unknown. To address this lack of knowledge, we aimed to identify childhood risk factors associated with LV diastolic function in the participants of the Cardiovascular Risk in Young Finns Study.

METHODS

Study participants (N = 1871; 45.9% men; aged 34-49 years) were examined repeatedly between the years 1980 and 2011. We determined the cumulative risk exposure in childhood (age 6-18 years) as the area under the curve for systolic blood pressure, adiposity (defined by using skinfold and waist circumference measurements), physical activity, serum insulin, triglycerides, total cholesterol, and high- and low-density lipoprotein cholesterols. Adulthood LV diastolic function was defined by using E/é ratio.

RESULTS

Elevated systolic blood pressure and increased adiposity in childhood were associated with worse adulthood LV diastolic function, whereas higher physical activity level in childhood was associated with better adulthood LV diastolic function (P < .001 for all). The associations of childhood adiposity and physical activity with adulthood LV diastolic function remained significant (both P < .05) but were diluted when the analyses were adjusted for adulthood systolic blood pressure, adiposity, and physical activity. The association between childhood systolic blood pressure and adult LV diastolic function was diluted to nonsignificant (P = .56).

CONCLUSIONS

Adiposity status and the level of physical activity in childhood are independently associated with LV diastolic function in adulthood.

Left-ventricular diastolic dysfunction in Korean children with chronic kidney disease: data from the KNOW-Ped CKD study

Background

Cardiovascular disease (CVD) is the most common cause of mortality in pediatric chronic kidney disease (CKD) patients. Left ventricular (LV) hypertrophy (LVH) is associated with LV diastolic dysfunction (LVDD) development and is used as an early marker of CVD in pediatric CKD. This study aimed to assess the prevalence and risk factors of LVDD and the association between LVH and LVDD in Korean pediatric CKD patients.

Methods

Data were collected using the baseline data of the Korean cohort study for outcome in patients with pediatric chronic kidney disease, a nationwide, 10-year, prospective, observational cohort study of pediatric CKD. A total of 244 patients were included in the final analysis. Two-dimensional echocardiography and tissue Doppler images were used to evaluate LVH and LVDD. LVH was defined as an LV mass index (LVMI) ≥38 g/m^2.7 and LV-wall thickness z-score > 1.64. LVDD was defined as a mitral peak velocity of early filling to early diastolic mitral annular velocity (E/E’) > 14. Univariate and multivariate logistic regression analyses were performed to evaluate risk factors of LVDD.

Results

In this study, the male-to-female ratio was 2.2 (168:76) and median age was 11.2 years. The average estimated glomerular filtration rate was 57.4 ml/min/1.73 m², and no patients received renal replacement therapy. The mean value of LVMI and E/E’ was 37.0 g/m^2.7 and 7.4, respectively. The prevalence of LVH was 40.1 and 17.4% by LVMI ≥38 g/m^2.7 and LV-wall thickness z-score, respectively. The prevalence of LVDD was 4.5%, and patients with LVH showed greater risk of LVDD (odds ratio 7.3, p = 0.012). In the univariate analysis, young age, low hemoglobin level, higher LVMI, and higher LV-wall thickness z-score were associated with LVDD. In the multivariate analysis, young age, low hemoglobin level, and higher LV-wall thickness z-score were independently associated with LVDD.

Conclusion

This study shows that LVH patients have a greater risk of LVDD and that anemia is the only modifiable risk factor for LVDD in Korean pediatric CKD patients.

Heart Failure with Preserved Ejection Fraction-a Concise Review

Purpose of Review

Heart failure with preserved ejection fraction (HFpEF) is a relatively new disease entity used in medical terminology; however, both the number of patients and its clinical significance are growing. HFpEF used to be seen as a mild condition; however, the symptoms and quality of life of the patients are comparable to those with reduced ejection fraction. The disease is much more complex than previously thought. In this article, information surrounding the etiology, diagnosis, prognosis, and possible therapeutic options of HFpEF are reviewed and summarized.

Recent Findings

It has recently been proposed that heart failure (HF) is rather a heterogeneous syndrome with a spectrum of overlapping and distinct characteristics. HFpEF itself can be distilled into different phenotypes based on the underlying biology. The etiological factors of HFpEF are unclear; however, systemic low-grade inflammation and microvascular damage as a consequence of comorbidities associated with endothelial dysfunction, oxidative stress, myocardial remodeling, and fibrosis are considered to play a crucial role in the pathogenesis of a disease. The H₂FPEF score and the HFpEF nomogram are recently validated highly sensitive tools employed for risk assessment of subclinical heart failure.

Summary

Despite numerous studies, there is still no evidence-based pharmacotherapy for HFpEF and the mortality and morbidity associated with HFpEF remain high. A better understanding of the etiological factors, the impact of comorbidities, the phenotypes of the disease, and implementation of machine learning algorithms may play a key role in the development of future therapeutic strategies.

Administration of apo A-I (Milano) nanoparticles reverses pathological remodelling, cardiac dysfunction, and heart failure in a murine model of HFpEF associated with hypertension

Therapeutic interventions with proven efficacy in heart failure with reduced ejection fraction (HFrEF) have been unsuccessful in heart failure with preserved ejection fraction (HFpEF). The modifiable risk factor with the greatest impact on the development of HFpEF is hypertension. The objectives of this study were to establish a murine model of HFpEF associated with hypertension and to evaluate the effect of apo A-I_Milano nanoparticles (MDCO-216) on established HFpEF in this model. Subcutaneous infusion of angiotensin II in combination with 1% NaCl in the drinking water was started at the age of 12 weeks in male C57BL/6 N mice and continued for the entire duration of the experiment. Treatment with MDCO-216 partially reversed established cardiac hypertrophy, cardiomyocyte hypertrophy, capillary rarefaction, and perivascular fibrosis in this model. Pressure-volume loop analysis was consistent with HFpEF in hypertension mice as evidenced by the preserved ejection fraction and a significant reduction of cardiac output (7.78 ± 0.56 ml/min versus 10.5 ± 0.7 ml/min; p < 0.01) and of the peak filling rate (p < 0.05). MDCO-216 completely reversed cardiac dysfunction and abolished heart failure as evidenced by the normal lung weight and normal biomarkers of heart failure. In conclusion, apo A-I_Milano nanoparticles constitute an effective treatment for established hypertension-associated HFpEF.

Association of Arsenic Exposure With Cardiac Geometry and Left Ventricular Function in Young Adults

BACKGROUND

Arsenic exposure has been related to numerous adverse cardiovascular outcomes. The aim of this study was to investigate the cross-sectional and prospective association between arsenic exposure with echocardiographic measures of left ventricular (LV) geometry and functioning.

METHODS

A total of 1337 young adult participants free of diabetes mellitus and cardiovascular disease were recruited from the SHFS (Strong Heart Family Study). The sum of inorganic and methylated arsenic concentrations in urine (ΣAs) at baseline was used as a biomarker of arsenic exposure. LV geometry and functioning were assessed using transthoracic echocardiography at baseline and follow-up.

RESULTS

Mean follow-up was 5.6 years, and median (interquartile range) of ΣAs was 4.2 (2.8-6.9) µg/g creatinine. Increased arsenic exposure was associated with prevalent LV hypertrophy, with an odds ratio (95% CI) per a 2-fold increase in ΣAs of 1.47 (1.05-2.08) in all participants and of 1.58 (1.04-2.41) among prehypertensive or hypertensive individuals. Measures of LV geometry, including LV mass index, left atrial systolic diameter, interventricular septum, and LV posterior wall thickness, were positively and significantly related to arsenic exposure. Among measures of LV functioning, stroke volume, and ejection fraction were associated with arsenic exposure.

CONCLUSIONS

Arsenic exposure was related to an increase in LV wall thickness and LV hypertrophy in young American Indians with a low burden of cardiovascular risk factors. The relationship was stronger in participants with prehypertension or hypertension, suggesting that potential cardiotoxic effects of arsenic might be more pronounced in individuals already undergoing cardiovascular adaptive mechanisms following elevated systemic blood pressure.

Hemodynamic Validation of the E/e' Ratio as a Measure of Left Ventricular Filling Pressure in Patients With Non-ST Elevation Myocardial Infarction

The E/e' ratio has an established role in the assessment of left ventricular filling pressure (LVFP) in stable patients, but its accuracy in acute myocardial ischemia is less well established. The aim of this study was to validate the relation between the E/e' ratio and invasively measured LVFP in patients with non-ST elevation myocardial infarction (NSTEMI). A total of 120 unselected patients with NSTEMI underwent cardiac catheterization with measurement of left ventricular end-diastolic pressure (LVEDP; elevated ≥15 mm Hg) and Doppler echocardiography with either simultaneous (n = 30) or same-day (n = 90) measurement of E/e'. Patients were aged 64.1 ± 11.8 years, 72% were male and mean left ventricular ejection fraction was 48.0 ± 20.9%. Septal, lateral, and average E/e' ratios all showed a significant correlation with LVEDP (Pearson's r: 0.42, 0.43, 0.48, respectively [all p <0.001]). Receiver operating characteristics curves showed an area under the curve of 0.72, 0.72, and 0.75 (all p <0.001) for septal, lateral, and average E/e', respectively. The sensitivity, specificity, positive (PPV), and negative (NPV) predictive values for the guideline-recommended threshold of average E/e' >14 for elevated LVEDP was 27%, 93%, 79%, and 44%, respectively. Utilizing lower E/e' boundaries of 6, 7, and 8 for lateral, average, and medial E/e', respectively, improved the NPV to ≥80% for each parameter. In conclusion, the E/e' ratio is a robust measure of LVFP during acute NSTEMI using upper and lower thresholds to achieve a high PPV and NPV, respectively, with the use of adjunctive guideline-recommend measures required in patients with nonconclusive E/e'.

Comorbidities in chronic heart failure: An update from Italian Society of Cardiology (SIC) Working Group on Heart Failure

The increasing number of patients with heart failure HF and comorbidities is due to aging population and increase of life expectancy of patients with cardiovascular disease. Encouraging results derived by recent trials may suggest some comorbidities as new targets for new drugs, highlighting the need for a better understanding of the comorbidities' effects in HF patients and the need of a multidisciplinary approach for the management of chronic HF with comorbidities. We report a brief review about main cardiovascular and non-cardiovascular comorbidities in HF patients in order to update physicians and researchers engaged in the HF research or in "fight against heart failure."