Obesity and Cardiac Remodeling in Adults: Mechanisms and Clinical Implications

Association of lipids and inflammatory markers with left ventricular wall thickness in patients with bipolar disorder

BACKGROUND

Individuals with bipolar disorder (BD) face a high risk of heart failure and left ventricular (LV) dysfunction. Despite strong evidence that high LV relative wall thickness (RWT) is a risk marker for heart failure, few studies have evaluated LV RWT and aggravating factors in individuals with BD.

METHODS

We recruited 104 participants (52 patients with BD and 52 age- and sex-matched mentally healthy controls) to undergo echocardiographic imaging and biochemistry, high-sensitivity C-reactive protein (hs-CRP), and blood cell count measurements. LV RWT was estimated using the following equation: (2 × LV posterior wall end-diastolic thickness)/LV end-diastolic diameter. Clinical data were obtained through interviews and chart reviews.

RESULTS

The BD group exhibited a significantly greater LV RWT (Cohen's d = 0.53, p = 0.003) and a less favorable mitral valve E/A ratio (Cohen's d = 0.54, p = 0.023) and LV global longitudinal strain (Cohen's d = 0.57, p = 0.047) than did the control group. Multiple linear regression revealed that in the BD group, serum triglyceride levels (β = 0.466, p = 0.001), platelet-to-lymphocyte ratios (β = 0.324, p = 0.022), and hs-CRP levels (β = 0.289, p = 0.043) were all significantly and positively associated with LV RWT.

LIMITATIONS

This study applied a cross-sectional design, meaning that the direction of causation could not be inferred.

CONCLUSIONS

Patients with BD are at a risk of heart failure, as indicated by their relatively high LV RWT. Lipid levels and systemic inflammation may explain this unfavorable association.

Left ventricular systolic dysfunction in obesity: a meta-analysis of speckle tracking echocardiographic studies

BACKGROUND

Obesity is a risk factor for left ventricular hypertrophy (LVH) and diastolic dysfunction. Available evidence on impaired myocardial deformation in obese patients without apparent systolic dysfunction assessed by LV ejection fraction (LVEF) is based on single studies. The aim of the present meta-analysis was to provide a comprehensive and updated information on this issue.

METHODS

The PubMed, OVID-MEDLINE, and Cochrane library databases were analysed to search English-language articles published from the inception up to 31 December 2023. Studies were identified by using MeSH terms and crossing the following search items: ' myocardial strain', 'left ventricular mechanics', 'longitudinal global strain', 'speckle tracking echocardiography', 'systolic dysfunction', 'left ventricular ejection fraction', and 'obesity'.

RESULTS

Twenty-four studies including 5792 obese and 5518 nonobese individuals from different clinical settings were considered for the analysis. LV global longitudinal strain (GLS) was significantly impaired in the obese group [standard means difference (SMD): -0.86 ± 0.08; confidence interval (CI) -1.02 to -0.69, P  < 0.0001] and this was paralleled by a significant difference in pooled LVEF between obese and controls (SMD -0.27 ± 0.06; CI -0.40 to -0.15, P  < 0.0001). Unlike GLS, however, the majority of the selected studies failed to show statistically significant differences in LVEF. Furthermore, in patients with advanced obesity (BMI > 35 kg/m 2 , data from six studies), LV systolic dysfunction was more significantly detected by GLS (SMD -1.24 ± 0.19, CI -1.61/-0.87, P  < 0.0001) than by LVEF (SMD -0.54 ± 0.27, CI -1.07 to -0.01, P  = 0.046).

CONCLUSION

The present meta-analysis suggests that GLS may unmask systolic dysfunction often undetected by conventional LVEF in the obese setting; thus, this parameter should be incorporated into routine work-up aimed to identify obesity-mediated subclinical cardiac damage.

Obesity and Risk of Incident Left Ventricular Hypertrophy in Community-Dwelling Populations With Hypertension: An Observational Study

BACKGROUND

The aim of this study was to evaluate the association between obesity and risk of incident left ventricular hypertrophy (LVH) in community-dwelling populations with hypertension and investigate whether this association would be attenuated by a lower achieved systolic blood pressure (SBP).

METHODS AND RESULTS

We used the EMINCA (Echocardiographic Measurements in Normal Chinese Adults) criteria, which were derived from healthy Chinese populations to define LVH. A total of 2069 participants with hypertension and without LVH (obesity 20.4%) were included. The association between obesity and risk of incident LVH was evaluated using Cox proportional hazard models and stratified by achieved follow-up SBP levels (≥140, 130-139, and <130 mm Hg). These analyses were also assessed using the American Society of Echocardiography/European Association of Cardiovascular Imaging criteria, which were derived from European populations to define LVH. After a median follow-up of 2.90 years, the rates of incident LVH in the normal-weight, overweight, and obese groups were 13.5%, 20.3%, and 27.8%, respectively (P<0.001). In reference to normal weight, obesity was associated with increased risk of incident LVH (adjusted hazard ratio [aHR], 2.51 [95% CI, 1.91-3.29]), which was attenuated when achieved SBP was <130 mm Hg (aHR, 1.78 [95% CI, 0.99-3.19]). This association remained significant when achieved SBP was ≥140 mm Hg (aHR, 3.45 [95% CI, 2.13-5.58]) or at 130 to 139 mm Hg (aHR, 2.32 [95% CI, 1.23-4.36]). Differences in these findings were noted when LVH was defined by the American Society of Echocardiography/European Association of Cardiovascular Imaging criteria.

CONCLUSIONS

Obesity was associated with incident LVH and an SBP target <130 mm Hg might be needed to attenuate this risk in patients with hypertension and obesity.

The effect of bariatric surgery type on cardiac reverse remodelling

INTRODUCTION

Bariatric surgery is effective in reversing adverse cardiac remodelling in obesity. However, it is unclear whether the three commonly performed operations; Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Adjustable Gastric Band (LAGB) are equal in their ability to reverse remodelling.

METHODS

Fifty-eight patients underwent CMR to assess left ventricular mass (LVM), LV mass:volume ratio (LVMVR) and LV eccentricity index (LVei) before and after bariatric surgery (26 RYGB, 22 LSG and 10 LAGB), including 46 with short-term (median 251-273 days) and 43 with longer-term (median 983-1027 days) follow-up. Abdominal visceral adipose tissue (VAT) and epicardial adipose tissue (EAT) were also assessed.

RESULTS

All three procedures resulted in significant decreases in excess body weight (48-70%). Percentage change in VAT and EAT was significantly greater following RYGB and LSG compared to LAGB at both timepoints (VAT:RYGB -47% and -57%, LSG -47% and -54%, LAGB -31% and -25%; EAT:RYGB -13% and -14%, LSG -16% and -19%, LAGB -5% and -5%). Patients undergoing LAGB, whilst having reduced LVM (-1% and -4%), had a smaller decrease at both short (RYGB: -8%, p < 0.005; LSG: -11%, p < 0.0001) and long (RYGB: -12%, p = 0.009; LSG: -13%, p < 0.0001) term timepoints. There was a significant decrease in LVMVR at the long-term timepoint following both RYGB (-7%, p = 0.006) and LSG (-7%, p = 0.021), but not LAGB (-2%, p = 0.912). LVei appeared to decrease at the long-term timepoint in those undergoing RYGB (-3%, p = 0.063) and LSG (-4%, p = 0.015), but not in those undergoing LAGB (1%, p = 0.857). In all patients, the change in LVM correlated with change in VAT (r = 0.338, p = 0.0134), while the change in LVei correlated with change in EAT (r = 0.437, p = 0.001).

CONCLUSIONS

RYGB and LSG appear to result in greater decreases in visceral adiposity, and greater reverse LV remodelling with larger reductions in LVM, concentric remodelling and pericardial restraint than LAGB.

Bariatric surgery partially reverses subclinical proarrhythmic structural, electrophysiological, and autonomic changes in obesity

BACKGROUND

Obesity confers higher risks of cardiac arrhythmias. The extent to which weight loss reverses subclinical proarrhythmic adaptations in arrhythmia-free obese individuals is unknown.

OBJECTIVE

The purpose of this study was to study structural, electrophysiological, and autonomic remodeling in arrhythmia-free obese patients and their reversibility with bariatric surgery using electrocardiographic imaging (ECGi).

METHODS

Sixteen arrhythmia-free obese patients (mean age 43 ± 12 years; 13 (81%) female participants; BMI 46.7 ± 5.5 kg/m2) had ECGi pre-bariatric surgery, of whom 12 (75%) had ECGi postsurgery (BMI 36.8 ± 6.5 kg/m2). Sixteen age- and sex-matched lean healthy individuals (mean age 42 ± 11 years; BMI 22.8 ± 2.6 kg/m2) acted as controls and had ECGi only once.

RESULTS

Obesity was associated with structural (increased epicardial fat volumes and left ventricular mass), autonomic (blunted heart rate variability), and electrophysiological (slower atrial conduction and steeper ventricular repolarization time gradients) remodeling. After bariatric surgery, there was partial structural reverse remodeling, with a reduction in epicardial fat volumes (68.7 cm3 vs 64.5 cm3; P = .0010) and left ventricular mass (33 g/m2.7 vs 25 g/m2.7; P < .0005). There was also partial electrophysiological reverse remodeling with a reduction in mean spatial ventricular repolarization gradients (26 mm/ms vs 19 mm/ms; P = .0009), although atrial activation remained prolonged. Heart rate variability, quantified by standard deviation of successive differences in R-R intervals, was also partially improved after bariatric surgery (18.7 ms vs 25.9 ms; P = .017). Computational modeling showed that presurgical obese hearts had a larger window of vulnerability to unidirectional block and had an earlier spiral-wave breakup with more complex reentry patterns than did postsurgery counterparts.

CONCLUSION

Obesity is associated with adverse electrophysiological, structural, and autonomic remodeling that is partially reversed after bariatric surgery. These data have important implications for bariatric surgery weight thresholds and weight loss strategies.

Cardiac remodelling in non-alcoholic fatty liver disease in the general population

BACKGROUND AND AIMS

Non-alcoholic fatty liver disease (NAFLD) is associated with increased risk for cardiovascular disease. Our study investigates the contribution of NAFLD to changes in cardiac structure and function in a general population.

METHODS

One thousand ninety-six adults (49.3% female) from the Study of Health in Pomerania underwent magnetic resonance imaging including cardiac and liver imaging. The presence of NAFLD by proton density fat fraction was related to left cardiac structure and function. Results were adjusted for clinical confounders using multivariable linear regression model.

RESULTS

The prevalence for NAFLD was 35.9%. In adjusted multivariable linear regression models, NAFLD was positively associated with higher left ventricular mass index (β = 0.95; 95% confidence interval (CI): 0.45; 1.45), left ventricular concentricity (β = 0.043; 95% CI: 0.031; 0.056), left ventricular end-diastolic wall thickness (β = 0.29; 95% CI: 0.20; 0.38), left atrial end-diastolic volume index (β = 0.67; 95% CI: 0.01; 1.32) and inversely associated with left ventricular end-diastolic volume index (β = -0.78; 95% CI: -1.51; -0.05). When stratified by sex, we only found significant positive associations of NAFLD with left ventricular mass index, left atrial end-diastolic volume index, left ventricular cardiac output and an inverse association with global longitudinal strain in women. In contrast, men had an inverse association with left ventricular end-diastolic volume index and left ventricular stroke volume. Higher liver fat content was stronger associated with higher left ventricular mass index, left ventricular concentricity and left ventricular end-diastolic wall thickness.

CONCLUSION

NAFLD is associated with cardiac remodelling in the general population showing sex specific patterns in cardiac structure and function.

ER stress improvement by aerobic training or enalapril differently ameliorates pathological cardiac remodeling in obese mice

Overactivation of the classic arm of the renin-angiotensin system (RAS) is one of the main mechanisms involved in obesity-related cardiac remodeling, and a possible relationship between RAS and ER stress in the cardiovascular system have been described. Thus, the aim of this study is to evaluate if activating the protective arm of the RAS by ACE inhibition or aerobic exercise training could overturn diet-induced pathological cardiac hypertrophy by attenuating ER stress. Male C57BL/6 mice were fed a control (SC) or a high-fat diet (HF) for 16 weeks. In the 8th week, HF-fed animals were randomly divided into HF, enalapril treatment (HF-En), and aerobic exercise training (HF-Ex) groups. Body mass (BM), food and energy intake, plasma analyzes, systolic blood pressure (SBP), physical conditioning, and plasma ACE and ACE2 activity were evaluated. Cardiac morphology, and protein expression of hypertrophy, cardiac metabolism, RAS, and ER stress markers were assessed. Data presented as mean ± standard deviation and analyzed by one-way ANOVA with Holm-Sidak post-hoc. HF group had increased BM and SBP, and developed pathological concentric cardiac hypertrophy, with overactivation of the classic arm of the RAS, and higher ER stress. Both interventions reverted the increase in BM, and SBP, and favored the protective arm of the RAS. Enalapril treatment improved pathological cardiac hypertrophy with partial reversal of the concentric pattern, and slightly attenuated cardiac ER stress. In contrast, aerobic exercise training induced physiological eccentric cardiac hypertrophy, and fully diminished ER stress.

ANMCO (Italian Association of Hospital Cardiologists) scientific statement: obesity in adults-an approach for cardiologists

Obesity is a complex, chronic disease requiring a multidisciplinary approach to its management. In clinical practice, body mass index and waist-related measurements can be used for obesity screening. The estimated prevalence of obesity among adults worldwide is 12%. With the expected further increase in overall obesity prevalence, clinicians will increasingly be managing patients with obesity. Energy balance is regulated by a complex neurohumoral system that involves the central nervous system and circulating mediators, among which leptin is the most studied. The functioning of these systems is influenced by both genetic and environmental factors. Obesity generally occurs when a genetically predisposed individual lives in an obesogenic environment for a long period. Cardiologists are deeply involved in evaluating patients with obesity. Cardiovascular risk profile is one of the most important items to be quantified to understand the health risk due to obesity and the clinical benefit that a single patient can obtain with weight loss. At the individual level, appropriate patient involvement, the detection of potential obesity causes, and a multidisciplinary approach are tools that can improve clinical outcomes. In the near future, we will probably have new pharmacological tools at our disposal that will facilitate achieving and maintaining weight loss. However, pharmacological treatment alone cannot cure such a complex disease. The aim of this paper is to summarize some key points of this field, such as obesity definition and measurement tools, its epidemiology, the main mechanisms underlying energy homeostasis, health consequences of obesity with a focus on cardiovascular diseases and the obesity paradox.Level of evidence V: report of expert committees.

Association of metabolic syndrome and chronic kidney disease

The prevalence of kidney disease is increasing rapidly worldwide, reflecting rising rates of obesity, diabetes, and associated metabolic syndrome (MetS). Chronic kidney disease and related comorbidities such as obesity, diabetes, and hypertension place a significant financial burden on healthcare systems. Despite the widespread use of RAAS inhibitors, intensive blood pressure and glycemic control, and newer therapeutic options consisting of sodium/glucose cotransporter-2 (SGLT-2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists, a significant risk of progression to end-stage renal disease remains in the high-risk obese and diabetic population. The MetS is a cluster of cardiovascular risk factors that adversely affect the development and progression of chronic kidney failure. According to the criteria of the World Health Organization, it is defined by visceral adiposity, impaired glucose tolerance or insulin resistance, atherogenic dyslipidemia, raised blood pressure, and microalbuminuria with a albumin-to-creatinine ratio ≥30 mg/g. At molecular level MetS is marked by a proinflammatory state and increased oxidative stress leading to various pathophysiological changes causing endothelial dysfunction and a hypercoagulable state. Because the kidney is a highly vascularized organ, it is especially susceptible for those microvascular changes. Therefore, the MetS and its individual components are associated with the premature development, acceleration, and progression of chronic kidney disease. Therefore, it is becoming increasingly important to elucidate the underlying mechanisms of MetS-associated chronic kidney disease in order to develop new strategies for preventing and slowing the progression of renal disease. In this review, we will elucidate (i) the renal structural, hemodynamic, and metabolic changes that occur in obesity and obesity-related kidney injury; (ii) the clinicopathological characteristics of obesity-related kidney injury, primarily focusing on obesity-associated glomerulopathy; (iii) the potential additional factors or predisposing factors that may turn patients more susceptible to renal structural or functional compensatory failure and subsequent injury.

The Impact of Comorbidities and Demographic Factors on Ejection Fraction

Heart failure (HF) presents an increasingly significant problem as the population ages. The cause of HF plays a significant role in determining treatment options and outcomes. It is worth noting that several studies have identified gender disparities in both morbidity and mortality, which may suggest differing causes of HF. The purpose of this research is to investigate the influence of various factors, including demographics and comorbidities, on ejection fraction (EF). The objectives of this study involve implementing preventive measures, ensuring timely diagnosis, and implementing interventions that target risk factors and specific comorbidities. These efforts aim to improve the prognosis for individuals affected by heart failure. The main method consists of linear regression. The demographic factors under scrutiny are gender and education, while the comorbidities of interest encompass valvulopathy, ischemia, smoking, obesity, high cholesterol, and diabetes. The main results consist of the fact that high education is associated with a 12.8% better EF on average, while among the factors with a negative role analyzed, ischemia is the most harmful, being 12.8% lower on average. Factors with a smaller impact are smoking, obesity, and high cholesterol. Diabetes does not seem to affect EF.

Exploring the Mechanistic Link Between Obesity and Heart Failure

PURPOSE OF REVIEW

Among subtypes of cardiovascular disease, obesity has a potent and unique association with heart failure (HF) that is unexplained by traditional cardiovascular risk mediators. The concomitant rise in the prevalence of obesity and HF necessitates better understanding of their relationship to develop effective prevention and treatment strategies. The purpose of this review is to provide mechanistic insight regarding the link between obesity and HF by elucidating the direct and indirect pathways linking the two conditions.

RECENT FINDINGS

Several direct pathophysiologic mechanisms contribute to HF risk in individuals with excess weight, including hemodynamic alterations, neurohormonal activation, hormonal effects of dysfunctional adipose tissue, ectopic fat deposition with resulting lipotoxicity and microvascular dysfunction. Obesity further predisposes to HF indirectly through causal associations with hypertension, dyslipidemia, and most importantly, diabetes via insulin resistance. Low levels of physical activity and fitness further influence HF risk in the context of obesity. These various processes lead to myocardial injury and cardiac remodeling that are reflected by abnormalities in cardiac biomarkers and cardiac function on myocardial imaging. Understanding and addressing obesity-associated HF is a pressing clinical and public health challenge which can be informed by a deeper understanding of the complex pathways linking these two conditions together.

Associations of lipid accumulation product, visceral adiposity index, and triglyceride-glucose index with subclinical organ damage in healthy Chinese adults

Background and aims

Obesity is an independent risk factor for cardiovascular disease development. Here, we aimed to examine and compare the predictive values of three novel obesity indices, lipid accumulation product (LAP), visceral adiposity index (VAI), and triglyceride-glucose (TyG) index, for cardiovascular subclinical organ damage.

Methods

A total of 1,773 healthy individuals from the Hanzhong Adolescent Hypertension Study cohort were enrolled. Anthropometric, biochemical, urinary albumin-to-creatinine ratio (uACR), brachial-ankle pulse wave velocity (baPWV), and Cornell voltage-duration product data were collected. Furthermore, the potential risk factors for subclinical organ damage were investigated, with particular emphasis on examining the predictive value of the LAP, VAI, and TyG index for detecting subclinical organ damage.

Results

LAP, VAI, and TyG index exhibited a significant positive association with baPWV and uACR. However, only LAP and VAI were found to have a positive correlation with Cornell product. While the three indices did not show an association with electrocardiographic left ventricular hypertrophy, higher values of LAP and TyG index were significantly associated with an increased risk of arterial stiffness and albuminuria. Furthermore, after dividing the population into quartiles, the fourth quartiles of LAP and TyG index showed a significant association with arterial stiffness and albuminuria when compared with the first quartiles, in both unadjusted and fully adjusted models. Additionally, the concordance index (C-index) values for LAP, VAI, and TyG index were reasonably high for arterial stiffness (0.856, 0.856, and 0.857, respectively) and albuminuria (0.739, 0.737, and 0.746, respectively). Lastly, the analyses of continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI) demonstrated that the TyG index exhibited significantly higher predictive values for arterial stiffness and albuminuria compared with LAP and VAI.

Conclusion

LAP, VAI, and, especially, TyG index demonstrated utility in screening cardiovascular subclinical organ damage among Chinese adults in this community-based sample. These indices have the potential to function as markers for early detection of cardiovascular disease in otherwise healthy individuals.

Multiple anthropometric measures and proarrhythmic 12-lead ECG indices: A mendelian randomization study

BACKGROUND

Observational studies suggest that electrocardiogram (ECG) indices might be influenced by obesity and other anthropometric measures, though it is difficult to infer causal relationships based on observational data due to risk of residual confounding. We utilized mendelian randomization (MR) to explore causal relevance of multiple anthropometric measures on P-wave duration (PWD), PR interval, QRS duration, and corrected QT interval (QTc).

METHODS AND FINDINGS

Uncorrelated (r2 < 0.001) genome-wide significant (p < 5 × 10-8) single nucleotide polymorphisms (SNPs) were extracted from genome-wide association studies (GWAS) on body mass index (BMI, n = 806,834), waist:hip ratio adjusted for BMI (aWHR, n = 697,734), height (n = 709,594), weight (n = 360,116), fat mass (n = 354,224), and fat-free mass (n = 354,808). Genetic association estimates for the outcomes were extracted from GWAS on PR interval and QRS duration (n = 180,574), PWD (n = 44,456), and QTc (n = 84,630). Data source GWAS studies were performed between 2018 and 2022 in predominantly European ancestry individuals. Inverse-variance weighted MR was used for primary analysis; weighted median MR and MR-Egger were used as sensitivity analyses. Higher genetically predicted BMI was associated with longer PWD (β 5.58; 95%CI [3.66,7.50]; p = < 0.001), as was higher fat mass (β 6.62; 95%CI [4.63,8.62]; p < 0.001), fat-free mass (β 9.16; 95%CI [6.85,11.47]; p < 0.001) height (β 4.23; 95%CI [3.16, 5.31]; p < 0.001), and weight (β 8.08; 95%CI [6.19,9.96]; p < 0.001). Finally, genetically predicted BMI was associated with longer QTc (β 3.53; 95%CI [2.63,4.43]; p < 0.001), driven by both fat mass (β 3.65; 95%CI [2.73,4.57]; p < 0.001) and fat-free mass (β 2.08; 95%CI [0.85,3.31]; p = 0.001). Additionally, genetically predicted height (β 0.98; 95%CI [0.46,1.50]; p < 0.001), weight (β 3.45; 95%CI [2.54,4.36]; p < 0.001), and aWHR (β 1.92; 95%CI [0.87,2.97]; p = < 0.001) were all associated with longer QTc. The key limitation is that due to insufficient power, we were not able to explore whether a single anthropometric measure is the primary driver of the associations observed.

CONCLUSIONS

The results of this study support a causal role of BMI on multiple ECG indices that have previously been associated with atrial and ventricular arrhythmic risk. Importantly, the results identify a role of both fat mass, fat-free mass, and height in this association.

Effects of Punica granatum L. peel extract supplementation on body weight, cardiac function, and haematological and biochemical parameters in an animal model of metabolic syndrome

Introduction

Metabolic syndrome (MetS) is a cluster of pathological conditions well described in humans but still investigated insufficiently in animals. A novel approach in its management is the utilisation of nutrients from natural sources. Recent studies suggested that phenolic compounds from pomegranate peel could be a promising dietary intervention for MetS. This study evaluated the potency of polyphenol-rich pomegranate peel extract (EPP) in mitigating some MetS components in an animal model.

Material and Methods

Zucker diabetic fatty rats (with an fa/fa missense mutation in the Lepr leptin receptor gene) and their healthy counterparts (fa/+) as controls were fed a high-calorie diet to induce MetS and supplemented with EPP at two doses: 100 mg/kg body weight (b.w.) and 200 mg/kg b.w. The extract was administered for eight weeks. The rats' body weights were monitored twice per week, and blood samples were taken before EPP administration after four weeks and eight weeks of study. Echocardiography measurement was performed at the beginning and at the end of the study.

Results

The extract restrained the dynamic of weight gain. A cardioprotective effect of the highest dose of EPP supplementation was manifested in a relative decrease in heart rate and improved mid-fractional shortening, representing myocardial contractility. No improvement in fasting blood glucose or lipid profile was observed.

Conclusion

Pomegranate peel extract possesses beneficial health properties that could be useful in dietary intervention in MetS. However, its bioavailability still requires further investigation in clinical trials in humans and animals suffering from endocrine and metabolic disorders.

Heart failure and obesity: The latest pandemic

The marked rise in rates of obesity, which is most prominent among individuals from socio-economically disadvantaged circumstances, has been a powerful contributor to the rising prevalence of heart failure (HF). Obesity has indirect effects on HF through the development of several metabolic risk factors, but also direct adverse effects on the myocardium. Obesity contributes to myocardial dysfunction and HF risk through multiple mechanisms, including hemodynamic changes, neurohormonal activation, endocrine and paracrine effects of adipose tissue, ectopic fat deposition and lipotoxicity. These processes principally result in concentric left ventricular (LV) remodeling and predominant increase in the risk for HF with preserved LV ejection fraction (HFpEF). Despite the excess risk for HF associated with obesity, there is a well described obesity paradox in which individuals with overweight and grade I obesity have better survival than those with normal weight and overweight. Despite the obesity paradox among individuals with prevalent HF, intentional weight loss is associated with improvements in metabolic risk factors, myocardial dysfunction and quality of life, in a dose-response fashion. In matched observational studies of bariatric surgery patients, marked weight loss is associated with decreased risk for developing HF, as well as improved cardiovascular disease (CVD) outcomes in those with existing HF. Ongoing clinical trials using powerful new obesity pharmacotherapies in individuals in with obesity and CVD may provide definitive information regarding the cardiovascular impact of weight loss. Given the powerful contribution of rising obesity prevalence to rates of HF, addressing these intertwined epidemics is a clinical and public health priority.

Correlation between the triglyceride-glucose index and the onset of atrial fibrillation in patients with non-alcoholic fatty liver disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is associated with atrial fibrillation (AF). Insulin resistance (IR) is the main cause of the high prevalence of AF in NAFLD patients. The triglyceride-glucose index (TyG) is a novel IR-related indicator implicated in the incidence and severity of NAFLD. However, the role of TyG in determining the risk for AF in patients with NAFLD remains unclear.

METHODS

A retrospective study was conducted on 912 patients diagnosed with NAFLD via ultrasonography. These patients were divided into two groups: (1) NAFLD+ AF and (2) NAFLD+ non-AF. Least Absolute Shrinkage and Selection Operator (LASSO) regression was used to assess the correlation between the TyG index and the high risk for AF. A receiver operating characteristic (ROC) curve was constructed to evaluate the predictive value for the TyG index for AF. Restricted cubic splines (RCS) were used to test the linear correlation between TyG and the risk for AF.

RESULTS

A total of 204 patients with AF and 708 patients without AF were included in this study. The LASSO logistic regression analysis showed that TyG was an independent risk factor for AF (odds ratio [OR] = 4.84, 95% confidence interval [CI] 2.98-7.88, P < 0.001). The RCS showed that the risk for AF increased linearly with TyG over the entire TyG range; this risk was also evident when the patients were analyzed based on sex (P for nonlinear > 0.05). In addition, the correlation between TyG and AF was a consistent finding in subgroup analysis. Furthermore, ROC curve analysis showed that TyG levels combined with traditional risk factors improved the predictive value for atrial fibrillation.

CONCLUSION

The TyG index is useful in assessing the risk for atrial fibrillation in patients with NAFLD. Patients with NAFLD and increased TyG indices have higher risks for atrial fibrillation. Therefore, TyG indices should be assessed when managing patients with NAFLD.

The role of adiponectin in cardiovascular disease

Cardiovascular disease (CVD) is a common disease that seriously threatens the health of human beings, especially middle-aged and elderly people over 50 years old. It has the characteristics of high prevalence, high disability rate and high mortality rate. Previous studies have shown that adiponectin has therapeutic effects on a variety of CVDs. As a key adipokine, adiponectin, is an abundant peptide-regulated hormone that is mainly released by adipocytes and cardiomyocytes, as well as endothelial and skeletal cells. Adiponectin can protect against CVD by improving lipid metabolism, protecting vascular endothelial cells and inhibiting foam cell formation and vascular smooth muscle cell proliferation. Further investigation of the molecular and cellular mechanisms underlying the adiponectin system may provide new ideas for the treatment of CVD. Herein, this review aims to describe the structure and function of adiponectin and adiponectin receptors, introduce the function of adiponectin in the protection of cardiovascular disease and analyze the potential use and clinical significance of this hormone in the protection and treatment of cardiovascular disease, which shows that adiponectin can be expected to become a new therapeutic target and biomarker for the diagnosis and treatment of CVD.

A Retrospective Evaluation of Changing Health Characteristics Amongst Deceased Organ Donors in the United States

BACKGROUND

The availability of suitable donor organs remains a limiting factor to performing life-saving transplant operations. This study evaluates changes in the health of the donor population and its influence on organ use in the United States.

METHODS

A retrospective analysis was performed using the OPTN STAR data file from 2005 to 2019. Three donor eras were defined: 1) 2005 to 2009, 2) 2010 to 2014, and 3) 2015 to 2019. The primary outcome was donor use, defined as transplantation of at least one solid organ. Descriptive analyses were performed, and associations of donor use were examined with multivariable logistic regression models. P values <.01 were considered significant.

RESULTS

The cohort included 132,783 potential donors of which 124,729 (93.9%) were used for transplantation. Donor median age was 42 years (interquartile range 26-54), 53,566 (40.3%) were female, and 88,209 (66.4%) were White, 21,834 (16.4%) were black, and 18,509 (13.9%) were Hispanic. Compared with donors from Eras 1 and 2, donors in Era 3 were younger (P < .001), had higher body mass index (BMI) (P < .001), increased rates of diabetes mellitus (DM) (P < .001), hepatitis C virus (HCV) positivity (P < .001) and more comorbidities (P < .001). Multivariable modeling found donor BMI, DM, hypertension, and HCV status as health factors significantly associated with donor use. Compared with Era 1, there was increased use in Era 3 of donors with BMI ≥30 kg/m², DM, hypertension, HCV-positive status, and donors with ≥3 comorbidities.

CONCLUSIONS

Despite an increasing prevalence of chronic health problems in the donor population, donors with multiple comorbid conditions are more likely to be used for transplantation in recent years.

Body mass index and atrial fibrillation recurrence post ablation: A systematic review and dose-response meta-analysis

Objectives

The aim of this study was to evaluate the shape of the dose-response relationship between body mass index (BMI) and atrial fibrillation (AF) recurrence in patients who have undergone radiofrequency ablation.

Methods

Studies investigating BMI and AF recurrence in patients with AF after ablation were identified through electronic searches in the PubMed, EMBASE, and Cochrane Library databases. The potential non-linear relationship was fitted using robust error meta-regression. Our study was registered with PROSPERO (CRD42019121373).

Results

Twenty-six cohort studies with 7,878 cases/26,450 individuals were included, and a linear dose-response relationship between BMI and AF recurrence (P _{non-linearity} = 0.12) was found. The risk of AF recurrence in patients with a BMI over 28 was significantly increased. Specifically, for each 5 kg/m² increase in BMI, the risk of AF recurrence increased by 15% (95% CI: 1.08-1.22) with moderate heterogeneity (I ² = 53%). Subgroup analyses showed that the pooled risk ratio was not significantly changed in subgroup analysis adjustment for the following important potential intermediate factors: left atrial diameter and obstructive sleep apnea.

Conclusion

This study showed that there is a borderline positive linear association between BMI and AF recurrence post ablation. Overweight and obesity are significantly associated with AF recurrence.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42019128770.

The relationship between the weight-adjusted-waist index and left ventricular hypertrophy in Chinese hypertension adults

Left ventricular hypertrophy (LVH) is a major cardiac complication of hypertension. Weight-adjusted-waist index (WWI) is a new obesity index that has been found to be positively associated with cardiovascular disease mortality. We aimed to investigate the relationship between the WWI and LVH in Chinese hypertension adults. The study is a community-based cross-sectional study that included 4715 patients with hypertension and integrated clinical and echocardiographic data. LVH was diagnosed by transthoracic echocardiography in these patients based on a criterion of left ventricular mass index (LVMI) over 49.2 g/m^2.7 in men and 46.7 g/m^2.7 in women. The independent association between the WWI quartiles and LVH prevalence was analyzed by logistic regression models. The prevalence of LVH in the first quartile of WWI (Q1: <10.16), second (Q2: 10.16 ~ 10.67), the third (Q3: 10.68~11.19), and the highest quartile (Q4: ≥11.20) was 34.1%, 38.4%, 42.4%, 51.5%, respectively. Logistic regression analysis suggested that the WWI was independently correlated with LVH with adjustment of confounding factors, and increased across the quartile of WWI. Compared to the first quartile of WWI (Q1), the odds ratios (ORs) and their 95% confidence intervals (CIs) for LVH in the increasing quartiles (Q2-Q4) were 1.33(1.08-1.63), 1.50 (1.19-1.89) and 2.28(1.74-2.99), respectively. In stratified analyses, the relationship between WWI and LVH risk persisted. The WWI may be an independent determinant of LVH in Chinese hypertension adults.

The Impact of Bariatric Surgery on Cardiac Structure, and Systolic and Diastolic Function in Patients with Obesity: A Systematic Review and Meta-analysis

The purpose of this study was to provide pooled data from all studies on the impact of bariatric surgery on cardiac structure, and systolic and diastolic function evaluated by either echocardiography or cardiac magnetic resonance. PubMed, Web of Science, Embase, and Scopus databases were searched. Almost all of cardiac left-side structural indices improved significantly after bariatric surgery. However, right-side structural indices did not change significantly. Left ventricular ejection fraction and most of the diastolic function indices improved significantly after the bariatric surgery. The subgroup analysis showed that the left ventricular mass index decreased more in long-term follow-up (≥ 12 months). In addition, subgroup analysis of studies based on surgery type did not reveal any difference in outcomes between gastric bypass and sleeve gastrectomy groups.

Incidence of atrial functional tricuspid regurgitation and its correlation with tricuspid valvular deformation in patients with persistent atrial fibrillation

Background

With the growing prevalence of atrial fibrillation (AF), concomitant atrial functional tricuspid regurgitation (FTR) is increasing. In this study, we aimed to elucidate the incidence of significant atrial FTR and its association with tricuspid valvular (TV) deformation in patients with persistent AF.

Methods

We retrospectively enrolled 344 patients (73.0 ± 9.3 years, 95 female) with persistent AF who underwent 2-dimensional echocardiography. We excluded patients with left-sided heart disease, pulmonary hypertension treated with pulmonary vasodilators, and congenital heart disease. We defined significant TR as having TR ≥ moderate; and tricuspid annulus (TA) diameter, tethering height, and area were measured in all patients.

Results

Among the study population, 80 (23.3%) patients had significant TR. TA diameter, tethering height, and area were significantly greater in the significant TR group (all p < 0.001). In multivariable analysis, TA diameter was independently associated with significant TR (odds ratio 1.1 per mm, p = 0.03), whereas TV tethering height was not. Receiver operating characteristic curve for significant TR exhibited the best predictive value of TA diameter indexed for body surface area [23 mm/m²; area under the curve (AUC) = 0.87] compared with absolute TA diameter (39 mm; AUC = 0.74) and TA diameter indexed for height (0.22 mm/cm; AUC = 0.80).

Conclusion

Approximately 25% of patients with persistent AF had significant TR. The BSA-corrected TA diameter was strongly associated with significant TR, which might be helpful for predicting the development of significant TR and considering its therapeutic strategy in patients with persistent AF.

Energy substrate metabolism and oxidative stress in metabolic cardiomyopathy

Metabolic cardiomyopathy is an emerging cause of heart failure in patients with obesity, insulin resistance, and diabetes. It is characterized by impaired myocardial metabolic flexibility, intramyocardial triglyceride accumulation, and lipotoxic damage in association with structural and functional alterations of the heart, unrelated to hypertension, coronary artery disease, and other cardiovascular diseases. Oxidative stress plays an important role in the development and progression of metabolic cardiomyopathy. Mitochondria are the most significant sources of reactive oxygen species (ROS) in cardiomyocytes. Disturbances in myocardial substrate metabolism induce mitochondrial adaptation and dysfunction, manifested as a mismatch between mitochondrial fatty acid oxidation and the electron transport chain (ETC) activity, which facilitates ROS production within the ETC components. In addition, non-ETC sources of mitochondrial ROS, such as β-oxidation of fatty acids, may also produce a considerable quantity of ROS in metabolic cardiomyopathy. Augmented ROS production in cardiomyocytes can induce a variety of effects, including the programming of myocardial energy substrate metabolism, modulation of metabolic inflammation, redox modification of ion channels and transporters, and cardiomyocyte apoptosis, ultimately leading to the structural and functional alterations of the heart. Based on the above mechanistic views, the present review summarizes the current understanding of the mechanisms underlying metabolic cardiomyopathy, focusing on the role of oxidative stress.

Treatment of HFpEF beyond the SGLT2-Is: Does the Addition of GLP-1 RA Improve Cardiometabolic Risk and Outcomes in Diabetic Patients?

Heart failure with preserved ejection fraction (HFpEF) is a common clinical syndrome frequently seen in elderly patients, the incidence of which is steadily increasing due to an ageing population and the increasing incidence of diseases, such as diabetes, hypertension, obesity, chronic renal failure, and so on. It is a multifactorial disease with different phenotypic aspects that share left ventricular diastolic dysfunction, and is the cause of about 50% of hospitalizations for heart failure in the Western world. Due to the complexity of the disease, no specific therapies have been identified for a long time. Sodium-Glucose Co-Transporter 2 Inhibitors (SGLT2-Is) and Glucagon-Like Peptide Receptor Agonists (GLP-1 RAs) are antidiabetic drugs that have been shown to positively affect heart and kidney diseases. For SGLT2-Is, there are precise data on their potential benefits in heart failure with reduced ejection fraction (HFrEF) as well as in HFpEF; however, insufficient evidence is available for GLP-1 RAs. This review addresses the current knowledge on the cardiac effects and potential benefits of combined therapy with SGLT2-Is and GLP-1RAs in patients with HFpEF.

The importance of caveolin as a target in the prevention and treatment of diabetic cardiomyopathy

The diabetic population has been increasing in the past decades and diabetic cardiomyopathy (DCM), a pathology that is defined by the presence of cardiac remodeling and dysfunction without conventional cardiac risk factors such as hypertension and coronary heart diseases, would eventually lead to fatal heart failure in the absence of effective treatment. Impaired insulin signaling, commonly known as insulin resistance, plays an important role in the development of DCM. A family of integral membrane proteins named caveolins (mainly caveolin-1 and caveolin-3 in the myocardium) and a protein hormone adiponectin (APN) have all been shown to be important for maintaining normal insulin signaling. Abnormalities in caveolins and APN have respectively been demonstrated to cause DCM. This review aims to summarize recent research findings of the roles and mechanisms of caveolins and APN in the development of DCM, and also explore the possible interplay between caveolins and APN.

Cardiac autonomic dysfunction in school age children with overweight and obesity

BACKGROUND AND AIMS

We investigated cardiac autonomic function in overweight and obese school-age children.

METHODS AND RESULTS

Quantitative cross-sectional study conducted with children (n = 110) of both genders. Children were divided by normal weight (NW; n = 54), overweight (OW; n = 24) and obese (OB; n = 32). Systolic (SBP) and diastolic (DBP) blood pressure and electrocardiograms were recorded and analyzed for heart rate and the heart rate variability (HRV) in time (SDRR, RMSSD, PRR50, SD1 and SD2) and frequency domains (HF, LF and LF/HF). The OB group presented higher SBP (p ≤ 0.01) and DBP (p ≤ 0.01). For HRV, the OB group had a lower PRR50 (p ≤ 0.01) and HF (p ≤ 0.01), associated with higher LF (p ≤ 0.01). Moderate negative correlations were found between the HF, BMI (r = -0.37; p ≤ 0.01) and WC (r = -0.38; p ≤ 0.01). Positive moderate correlation were found between LF, LF/HF and BMI (LF: r = 0.32; p ≤ 0.01; LF/HF: r = 0.31; p ≤ 0.01) and WC (LF: r = 0.34; p ≤ 0.01; LF/HF: = 0.34; p ≤ 0.01). Multiple linear regression showed a positive association between body fat and the SDRR (β: 0.48; CI: 0.2-4.2; p = 0.02). No differences were observed in cardiac electrical activity.

CONCLUSION

Children with obesity but not overweight presented higher blood pressure and cardiac autonomic dysfunction, with sympathetic predominance on the heart rate. This fact was positively correlated with BMI and may be considered an important marker for cardiovascular risk in children.

Impact of maternal height, weight at presentation and gestational weight gain on cardiac adaptation in pregnancy

OBJECTIVE

To compare longitudinal maternal hemodynamic changes throughout gestation between different groups stratified according to weight at presentation and assess the relative influence of height, weight at presentation and gestational weight gain on cardiac adaptation.

METHODS

This was a prospective, longitudinal study assessing maternal hemodynamics using bioreactance technology at 11 + 0 to 13 + 6, 19 + 0 to 24 + 0, 30 + 0 to 34 + 0 and 35 + 0 to 37 + 0 weeks' gestation. Women were divided into three groups according to maternal weight at presentation at the first visit at 11 + 0 to 13 + 6 weeks: Group 1, &lt; 60.0 kg (n = 421); Group 2, 60.0-79.7 kg (n = 904); Group 3, &gt; 79.7 kg (n = 427). A multilevel linear mixed-effects model was used to compare the repeated measures of hemodynamic variables, correcting for demographics, medical and obstetric history, pregnancy complications, maternal weight and time of evaluation. The linear mixed-effects model was then repeated using maternal height, weight at presentation and gestational weight gain Z-scores, and the standardized coefficients were used to evaluate the relative impact of each of these demographic parameters on longitudinal changes of maternal hemodynamics.

RESULTS

Compared with Group 1, women in Group 3 demonstrated higher cardiac output (CO), heart rate (HR) and mean arterial pressure (MAP) throughout pregnancy. Groups 2 and 3 had higher stroke volume (SV) than Group 1 at the first visit, but their SV plateaued between the first and second visits and demonstrated an earlier significant decrease from the second visit to the third visit when compared with Group 1. Compared with Groups 1 and 2, there was a higher prevalence of pre-eclampsia, gestational hypertension and gestational diabetes in Group 3. Maternal height was the most important contributor to CO, peripheral vascular resistance (PVR), SV and HR, while weight at presentation was the most important contributor to MAP. Gestational weight gain was the second most important characteristic influencing the longitudinal changes of PVR and SV.

CONCLUSIONS

Women with greater weight at presentation have a pathological hemodynamic profile, with higher CO, HR and MAP compared to women with lower weight at presentation. Height is the main determinant of CO, SV, HR and PVR, weight is the main determinant of MAP, and gestational weight gain is the second most important determinant of SV and PVR. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Obesity-Related High-Output Heart Failure: An Integrative Review

BACKGROUND

High-output heart failure (HF) is a type of HF characterized by signs and symptoms of HF and a cardiac output of 8 L/min or greater or a cardiac index greater than 3.9 L/min/m 2 . High-output HF occurs secondary to an underlying condition that requires high cardiac output due to an increase in oxygen consumption or decreased systemic vascular resistance. Obesity is a major cause of high-output HF, yet there is limited research on obesity-related high-output HF. Thus, the pathophysiologic mechanisms of this syndrome are not fully understood.

OBJECTIVE

The objectives of this integrative review were to describe the current state of the research regarding obesity-related high-output HF and to recommend direction for future research.

METHODS

We conducted an integrative review focusing on the peer-reviewed literature on patients with obesity-related high-output HF using Whittemore and Knafl's methodology. MEDLINE, CINAHL, and EMBASE electronic databases were searched for all publications indexed in the databases as of March 9, 2022. A narrative synthesis of definitions and symptoms, obesity as an underlying condition, pathophysiology, and treatments of obesity-related high-output HF was completed.

RESULTS

A total of 6 articles were included in the integrative review, with 1 nonexperimental, retrospective study and 5 literature reviews. Understanding of obesity-related high-output HF is very limited because of scant empirical evidence in the existing literature. Possible pathophysiologic mechanisms include increased pressure in the upper airways, adipokine dysregulation, increased metabolic activity, and insulin resistance.

CONCLUSION

Additional research is needed on the pathophysiologic mechanisms of obesity-related high-output HF to begin investigations on therapeutic interventions to improve health outcomes.

Obesity, hypertension, and tobacco use associated with left ventricular remodeling and hypertrophy in South African women: Birth to Twenty Plus Cohort

Background

Left ventricular hypertrophy (LVH) is a marker of increased risk in developing future life-threatening cardiovascular disease (CVD), however, it is unclear how CVD risk factors, such as obesity, blood pressure (BP), and tobacco use, are associated with left ventricular (LV) remodeling and LVH in urban African populations. Therefore, we aimed to identify the prevalence of LVH as well as the health factors associated with LV remodeling and LVH, within black South African adult women and their pre-pubescent children.

Methods

Black female adults (n = 123; age: 29–68 years) and their children (n = 64; age: 4–10; 55% female) were recruited from the Birth to Twenty Plus Cohort in Soweto, South Africa. Tobacco and alcohol use, physical activity, presence of diabetes mellitus, heart disease, and medication were self-reported. Height, weight, and blood pressure were measured in triplicate to determine the prevalence of obesity and hypertension respectively. Echocardiography was used to assess LV mass at end-diastole, based on linear measurements, and indexed to body surface area to determine LVH.

Results

Hypertension and obesity prevalences were 35.8% and 59.3% for adults and 45.3% and 6.3% for children. Self-reported tobacco use in adults was 22.8%. LVH prevalence was 35.8% in adults (75% eccentric: 25% concentric), and 6.3% in children. Concentric remodeling was observed in 15.4% of adults, however, concentric remodeling was only found in one child. In adults, obesity [OR: 2.54 (1.07–6.02; p = 0.02)] and hypertension [3.39 (1.08–10.62; p = 0.04)] significantly increased the odds of LVH, specifically eccentric LVH, while concentric LVH was associated with self-reported tobacco use [OR: 4.58 (1.18–17.73; p = 0.03)]. Although no logistic regression was run within children, of the four children LVH, three had elevated blood pressure and the child with normal blood pressure was overweight.

Conclusions

The association between obesity, hypertension, tobacco use, and LVH in adults, and the 6% prevalence of LVH in children, calls for stronger public health efforts to control risk factors and monitor children who are at risk.

Being Overweight Is Related to Neoaortic Sinus Dilatation After Arterial Switch Operation

Background

Neoaortic sinus dilatation is a late comorbidity after an arterial switch operation in patients with dextro-transposition of the great arteries. We aim to explore whether neoaortic sinus dilatation is related to overweight or obesity, as these affect aortic remodeling in such patients.

Methods

We measured neoaortic diameters including those for the annulus, sinus, sinotubular junction, and ascending aorta by echocardiography and studied the relationship between these diameters and body mass index in patients aged 15 years and older after an arterial switch operation.

Results

A total of 45 patients were studied. Median (interquartile range) age, body mass index, and systolic blood pressure at echocardiography were 20 (17–28) years, 21.2 (18.4–24.2) kg/m2, and 120 (112–127) mm Hg, respectively. Echocardiogram revealed the following median values (interquartile ranges): neoaortic annulus diameter, 22.2 (19.8–23.8) mm; sinus diameter, 34.6 (31.8–39.8) mm; sinotubular junction diameter, 27.5 (22.4–30.0) mm; and ascending aortic diameter, 20.4 (19.4–22.7) mm. The neoaortic sinus diameter was significantly correlated with body mass index (r = 0.41, P = .004) and was significantly larger in patients with concomitant ventricular septal defect (P &lt; .001) and those who were over-weight (body mass index ≥25 kg/m2; P = .006).

Conclusion

Neoaortic sinus dilatation after an arterial switch operation is associated with being overweight during adolescence and young adulthood. It is important to prevent obesity in patients after an arterial switch operation and educate them on a healthy lifestyle.

Atrial fibrillation patterns and their cardiovascular risk profiles in the general population: the Rotterdam study

BACKGROUND

Clinical guidelines categorize atrial fibrillation (AF) based on the temporality of AF events. Due to its dependence on event duration, this classification is not applicable to population-based cohort settings. We aimed to develop a simple and standardized method to classify AF patterns at population level. Additionally, we compared the longitudinal trajectories of cardiovascular risk factors preceding the AF patterns, and between men and women.

METHODS

Between 1990 and 2014, participants from the population-based Rotterdam study were followed for AF status, and categorized into 'single-documented AF episode', 'multiple-documented AF episodes', or 'long-standing persistent AF'. Using repeated measurements we created linear mixed-effects models to assess the longitudinal evolution of risk factors prior to AF diagnosis.

RESULTS

We included 14,061 participants (59.1% women, mean age 65.4 ± 10.2 years). After a median follow-up of 9.4 years (interquartile range 8.27), 1,137 (8.1%) participants were categorized as 'single-documented AF episode', 208 (1.5%) as 'multiple-documented AF episodes', and 57 (0.4%) as 'long-standing persistent AF'. In men, we found poorer trajectories of weight and waist circumference preceding 'long-standing persistent AF' as compared to the other patterns. In women, we found worse trajectories of all risk factors between 'long-standing persistent AF' and the other patterns.

CONCLUSION

We developed a standardized method to classify AF patterns in the general population. Participants categorized as 'long-standing persistent AF' showed poorer trajectories of cardiovascular risk factors prior to AF diagnosis, as compared to the other patterns. Our findings highlight sex differences in AF pathophysiology and provide insight into possible risk factors of AF patterns.

Bariatric Surgery and Myocardial Mechanics: A Meta-Analysis of Speckle Tracking Echocardiographic Studies

Aim: Current evidence on the effects of bariatric surgery on cardiac mechanics in patients with obesity is based on a few single studies. We investigated this issue through a meta-analysis of speckle tracking echocardiography (STE) studies that reported data on changes in left ventricular (LV) mechanics as assessed by global longitudinal strain (GLS). Methods: The PubMed, OVID-MEDLINE and Cochrane library databases were systematically analysed to search English-language articles published from inception to 31 May 2022. Studies were identified by using Me-SH terms and crossing the following terms: “obesity”, “bariatric surgery”, “left ventricular mechanics”, “left ventricular hypertrophy”, “systolic dysfunction”, “global longitudinal strain”, “echocardiography” and “STE echocardiography”. Results: The meta-analysis, including a total of 512 patients with obesity from 13 studies (follow-up 1−23 months), showed a significant GLS improvement after bariatric procedures, with standard mean difference (SMD) being 0.50 ± 0.08, CI: 0.34/0.65, p < 0.0001. Corresponding SMD value for LV ejection fraction (LVEF) was 0.15 ± 0.09, CI: −0.04/0.34, p = 0.11. A sensitivity analysis restricted to 11 studies with follow-up ≥ 6 months confirmed that GLS (SMD: 0.47 ± 0.08, CI: 0.30/0.63, p < 0.0001) but not LVEF (SMD: 0.14 ± 0.11, CI: −0.08/0.37, p = 0.21) improved after surgery. Conclusions: Our meta-analysis adds a new piece of information on the beneficial effects of bariatric surgery on LV systolic function and, more importantly, suggests that the assessment of myocardial strain should be routinely implemented for a comprehensive evaluation of cardiac functional changes associated with bariatric procedures.

A lifecourse mendelian randomization study highlights the long-term influence of childhood body size on later life heart structure

Children with obesity typically have larger left ventricular heart dimensions during adulthood. However, whether this is due to a persistent effect of adiposity extending into adulthood is challenging to disentangle due to confounding factors throughout the lifecourse. We conducted a multivariable mendelian randomization (MR) study to separate the independent effects of childhood and adult body size on 4 magnetic resonance imaging (MRI) measures of heart structure and function in the UK Biobank (UKB) study. Strong evidence of a genetically predicted effect of childhood body size on all measures of adulthood heart structure was identified, which remained robust upon accounting for adult body size using a multivariable MR framework (e.g., left ventricular end-diastolic volume (LVEDV), Beta = 0.33, 95% confidence interval (CI) = 0.23 to 0.43, P = 4.6 × 10⁻¹⁰). Sensitivity analyses did not suggest that other lifecourse measures of body composition were responsible for these effects. Conversely, evidence of a genetically predicted effect of childhood body size on various other MRI-based measures, such as fat percentage in the liver (Beta = 0.14, 95% CI = 0.05 to 0.23, P = 0.002) and pancreas (Beta = 0.21, 95% CI = 0.10 to 0.33, P = 3.9 × 10⁻⁴), attenuated upon accounting for adult body size. Our findings suggest that childhood body size has a long-term (and potentially immutable) influence on heart structure in later life. In contrast, effects of childhood body size on other measures of adulthood organ size and fat percentage evaluated in this study are likely explained by the long-term consequence of remaining overweight throughout the lifecourse.

Children with obesity typically have larger left ventricular heart dimensions during adulthood, but this is challenging to disentangle due to confounding factors throughout life. This study uses Mendelian randomization to provide evidence that being overweight in early life may indeed have a long-term influence on cardiac structure.

Increased fatty acid metabolism attenuates cardiac resistance to β-adrenoceptor activation via mitochondrial reactive oxygen species: A potential mechanism of hypoglycemia-induced myocardial injury in diabetes

The mechanism of severe hypoglycemia (SH)-induced cardiovascular disease in diabetes remains unknown. Our previous study found that SH inhibits cardiac function and lipid metabolism in diabetic mice. Conversely, in nondiabetic mice, SH does not induce cardiac dysfunction but promotes cardiac lipid metabolism. This study aims to clarify the effect of increased fatty acid metabolism on the resistance of cardiomyocytes to β-adrenoceptor activation during hypoglycemia in diabetes. Results revealed that cardiomyocytes with enhanced lipid metabolism were more vulnerable to damage due to β-adrenoceptor activation, which presented as decreased cell viability, disorder of mitochondrial structure, dissipation of mitochondrial membrane potential, dysfunction of mitochondrial oxidative phosphorylation, nonapoptotic damage, and accumulation of ROS and calcium from mitochondria to cytoplasm, all of which were partially reversed by mitochondrial antioxidant Mito-TEMPO. The SH-induced cardiac dysfunction, and reduction of myocardial energy metabolism in diabetic mice were rescued by Mito-TEMPO. Our findings indicate that high fatty acid metabolism crippled cardiac resistance to β-adrenoceptor hyperactivation, with mitochondrial ROS playing a pivotal role in this process. Reducing mitochondrial ROS in diabetes could disrupt this synergistic effect and prevent poor cardiac outcomes caused by SH.

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Fatty acid metabolism lowers cardiac resistance to β-adrenoceptor activation via mtROS.

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Pretreatment with mitochondrial antioxidants prevents SH-induced cardiac outcomes.

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This synergistic effect might explicate the progression of other CV diseases.

Gigantomastia as a Cause of Pulmonary Hypertension

Reduction mammaplasty is the gold standard treatment for gigantomastia. We report one female patient with juvenile gigantomastia associated with severe pulmonary hypertension where her pulmonary pressure decreased significantly after the surgery, improving her quality of life. A 22-year-old female patient with gigantomastia since 10 years old, tricuspid regurgitation, and pulmonary thromboembolism antecedent was admitted to the emergency department. Her oxygen saturation was 89%. Acute heart failure management was initiated. An echocardiogram reported left ventricle ejection fraction (LVEF) of 70% with severe right heart dilation, contractile dysfunction, and arterial pulmonary pressure (PASP) of 110 mm Hg. A multidisciplinary team considered gigantomastia could generate a restrictive pattern, so a Thorek reduction mammoplasty with Wise pattern was performed. Presurgical measurements were: sternal notch to nipple-areola complex, right 59 cm, left 56 cm. Three days after surgery, the patient could breathe without oxygen support. In the outpatient follow-up, patient referred reduction of her respiratory symptoms and marked improvement in her quality of life. Six months after surgery, a control echocardiogram showed a LVEF of 62% and PASP of 85 mm Hg. Pulmonary hypertension may be present in patients with gigantomastia. Reduction mammoplasty may be a feasible alternative to improve the cardiac signs and symptoms in patients with medical refractory management.

The Value of Four Anthropometric Indicators for Identifying Left Ventricular Hypertrophy in Chinese Hypertensive Patients

Left ventricular hypertrophy (LVH) has been classified separately as an independent risk factor for hypertension. However, comparisons between different body size indices and left ventricular hypertrophy (LVH) in hypertensive populations have not been reported yet. In this study, we enrolled 4,639 hypertensive patients from rural China. Anthropometric indices and cardiovascular disease risk factor variables were measured and analyzed using Spearman's correlation, logistic regression, and receiver operating characteristic (ROC) curve analyses. Patients in the highest quartile of body size indices were more likely to have left ventricular hypertrophy than those in the lowest quartile; these indices were BMI (adjusted OR: 3.55, 95% CI: 2.90; 4.35), WC (adjusted OR: 2.23, 95% CI: 1.84; 2.70), WHR (adjusted OR: 1.44, 95% CI: 1.18; 1.75), and WHtR (adjusted OR: 3.23, 95% CI: 2.62; 3.99). The areas under the ROC curves of BMI (AUC: 0.628, 95% CI: 0.612; 0.644), WHtR (AUC: 0.628, 95% CI: 0.560; 0.593), WHR (AUC: 0.530, 95% CI: 0.513; 0.547), and WC (AUC: 0.576, 95% CI: 0.513; 0.547) were all above 0.5, which indicated that the four anthropometric indicators may be associated with LVH. The four anthropometric indicators of obesity were identified as risk factors for LVH. Weight control might help reduce the risk of left ventricular hypertrophy.

The Impact of Obesity in Heart Failure

Overweight and obesity adversely impact cardiac structure and function, affecting systolic and diastolic ventricular function. Epidemiologic studies have documented an obesity paradox in large heart failure cohorts, where overweight and obese individuals with established heart failure have a better short- and medium-term prognosis compared with leaner patients; this relationship is strongly impacted by level of cardiorespiratory fitness. There are implications for therapies aimed at increasing lean mass as well as weight loss and improvements in quality of diet for the prevention and treatment of heart failure and concomitant obesity to improve cardiorespiratory fitness.

Changes in body size phenotypes from childhood to adulthood and the associated cardiometabolic outcomes

AIM

To examine the effects of changes in body size phenotypes between childhood and adulthood on risks of diabetes and left ventricular hypertrophy (LVH) in adulthood.

METHODS

We included 3,351 individuals who participated as both children and adults in the Bogalusa Heart Study.

RESULTS

Compared with participants with persistently metabolically healthy normal weight (MHNW) from childhood to adulthood, MHNW children who became metabolically unhealthy in adulthood had increased diabetes burden and LVH risk in adulthood; Metabolically unhealthy normal weight (MUNW) children who became MHNW or metabolically healthy obese (MHO) as adults and individuals with persistent MHO from childhood to adulthood were not at increased risks of diabetes or LVH. The risks were increased if MHO during childhood transitioned to metabolically unhealthy obesity (MUO) by adulthood or MUO stayed from childhood to adulthood. MUO children who became MHO or MHNW as adults had decreased diabetes burden and LVH risk in adulthood.

CONCLUSIONS

Individuals maintained MHO from childhood to adulthood and MUNW children who became MHO as adults had a diabetes burden and LVH risk similar to individuals with persistent MHNW. Progression to metabolically unhealthy status and maintenance of metabolically unhealthy status, regardless of childhood BMI status, were associated with increased cardiometabolic outcomes.

Regional Fat Distributions Are Associated With Subclinical Right Ventricular Dysfunction in Adults With Uncomplicated Obesity

Objective

Obesity is a prominent public health problem that has increased cardiovascular mortality risks. However, the specific effects of obesity, independent of comorbidities, on cardiac structure and function have not been well clarified, especially those effects on the right ventricle (RV). Cardiovascular magnetic resonance (CMR) tissue tracking can assess detailed RV mechanical features. This study aimed to evaluate RV strain using CMR in uncomplicated obese adults and assess its association with fat distributions.

Methods

A total of 49 obese patients and 30 healthy controls were included. The RV global systolic function and strain parameters based on CMR were assessed. Body fat distributions were measured with dual X-ray absorptiometry. RV function indices of obese patients were compared with those of healthy controls. Correlations among related body fat distribution parameters and RV function indices were conducted with multivariable linear regression.

Results

Compared with healthy controls, the obese group had impaired RV strain with lower global longitudinal peak strain (PS), longitudinal peak systolic strain rate (PSSR), circumferential and longitudinal peak diastolic strain rates (PDSR) (all P < 0.05), while LV and RV ejection fractions were not significantly different between the two groups (P > 0.05). Multivariable linear regression analysis demonstrated that android fat% was independently associated with longitudinal PS (β = −0.468, model R² = 0.219), longitudinal PDSR (β = −0.487, model R² = 0.237), and circumferential PSSR (β = −0.293, model R² = 0.086). Trunk fat% was independently associated with longitudinal PSSR (β = −0.457, model R² = 0.209). In addition, the strongest correlations of circumferential PDSR were BMI and gynoid fat% (β = −0.278, β = 0.369, model R² = 0.324).

Conclusions

Extensive subclinical RV dysfunction is found in uncomplicated obese adults. BMI, as an index of overall obesity, is independently associated with subclinical RV dysfunction. In addition, central obesity (android fat and trunk fat distributions) has a negative effect on subclinical RV function, while peripheral obesity (gynoid fat distribution) may have a positive effect on it.

Clinical Trials Registration

Effect of lifestyle intervention on metabolism of obese patients based on smart phone software (ChiCTR1900026476).

The Role of the Adipokine Resistin in the Pathogenesis and Progression of Epithelial Ovarian Cancer

Obesity is a civilization disease associated with an increased risk of developing cardiovascular diseases, diabetes, and some malignancies. The results concerning the relationship between obesity and epithelial ovarian cancer (EOC) are inconclusive. The higher incidence of neoplasms in obese subjects has led to the development of the adipokine hypothesis. Omental adipocyte cells interact with cancer cells, promoting their migration and metastasis via the secretion of adipokines, growth factors, and hormones. One of the adipokines is resistin. It was shown in vitro that resistin stimulates the growth and differentiation of ovarian cancer cells. Moreover, it increases the level of angiogenesis factors, e.g., matrix metalloproteinase 2 (MMP-2) and vascular epithelial growth factor (VEGF). Additionally, resistin induces epithelial–mesenchymal transition (EMT) and stemness in EOC cell lines. A positive correlation has been shown between a higher level of resistin expression and the stage of histological differentiation of EOC or the occurrence of lymph node metastases. In addition, the overexpression of resistin has been found to act as an independent factor determining disease-free survival as well as overall survival in EOC patients. Growing evidence supports the finding that resistin plays an important role in some mechanisms leading to the progression of EOC, though this issue still requires further research.

Remodeling and Fibrosis of the Cardiac Muscle in the Course of Obesity-Pathogenesis and Involvement of the Extracellular Matrix

Obesity is a growing epidemiological problem, as two-thirds of the adult population are carrying excess weight. It is a risk factor for the development of cardiovascular diseases (hypertension, ischemic heart disease, myocardial infarct, and atrial fibrillation). It has also been shown that chronic obesity in people may be a cause for the development of heart failure with preserved ejection fraction (HFpEF), whose components include cellular hypertrophy, left ventricular diastolic dysfunction, and increased extracellular collagen deposition. Several animal models with induced obesity, via the administration of a high-fat diet, also developed increased heart fibrosis as a result of extracellular collagen accumulation. Excessive collagen deposition in the extracellular matrix (ECM) in the course of obesity may increase the stiffness of the myocardium and thereby deteriorate the heart diastolic function and facilitate the occurrence of HFpEF. In this review, we include a rationale for that process, including a discussion about possible putative factors (such as increased renin–angiotensin–aldosterone activity, sympathetic overdrive, hemodynamic alterations, hypoadiponectinemia, hyperleptinemia, and concomitant heart diseases). To address the topic clearly, we include a description of the fundamentals of ECM turnover, as well as a summary of studies assessing collagen deposition in obese individuals.

Strategies for Imaging Metabolic Remodeling of the Heart in Obesity and Heart Failure

PURPOSE OF REVIEW

Define early myocardial metabolic changes among patients with obesity and heart failure, and to describe noninvasive methods and their applications for imaging cardiac metabolic remodeling.

RECENT FINDINGS

Metabolic remodeling precedes, triggers, and sustains functional and structural remodeling in the stressed heart. Alterations in cardiac metabolism can be assessed by using a variety of molecular probes. The glucose tracer analog, 18F-FDG, and the labeled tracer 11C-palmitate are still the most commonly used tracers to assess glucose and fatty acid metabolism, respectively. The development of new tracer analogs and imaging agents, including those targeting the peroxisome proliferator-activated receptor (PPAR), provides new opportunities for imaging metabolic activities at a molecular level. While the use of cardiac magnetic resonance spectroscopy in the clinical setting is limited to the assessment of intramyocardial and epicardial fat, new technical improvements are likely to increase its usage in the setting of heart failure. Noninvasive imaging methods are an effective tool for the serial assessment of alterations in cardiac metabolism, either during disease progression, or in response to treatment.

Subclinical Left Ventricular Systolic Dysfunction in HIV Patients: Prevalence and Associations with Carotid Atherosclerosis and Increased Adiposity

BACKGROUND

Human immunodeficiency virus (HIV) is mainly detected in young, otherwise healthy, individuals. Cardiomyopathy and peripheral artery disease affecting these patients appears to be multifactorial. Prompt and potentially more effective implementation of therapeutic measures could be enabled by pre-symptomatic diagnosis of myocardial dysfunction and peripheral artery damage. However, limited data is available to date on this specific topic. Μethods: We investigated the association between global longitudinal strain (GLS), an established index of subclinical left ventricular systolic dysfunction (LVSD) assessed by two-dimensional speckle-tracking echocardiography, and: (a) patient history; (b) demographic and clinical baseline characteristics; (c) carotid intima-media thickness (IMT) and the presence of carotid atherosclerotic plaque(s), measured by ultrasonography; (d) temperature difference (ΔT) along each carotid artery, measured by microwave radiometry; and (e) basic blood panel measurements, including high-sensitivity troponin-T (hsTnT) and NT-proBNP in people living with HIV (PLWH) and no history of cardiovascular disease.

RESULTS

We prospectively enrolled 103 consecutive PLWH (95% male, age 47 ± 11 years, anti-retroviral therapy 100%) and 52 age- and sex-matched controls. PLWH had a significantly higher relative wall thickness (0.38 ± 0.08 vs. 0.36 ± 0.04, p = 0.048), and higher rate of LVSD (34% vs. 15.4%, p = 0.015), and carotid artery atherosclerosis (28% vs. 6%, p = 0.001) compared with controls. Among PLWH, LVSD was independently associated with the presence of carotid atherosclerosis (adj. OR:3.09; 95%CI:1.10-8.67, p = 0.032) and BMI (1.15; 1.03-1.29, p = 0.017), while a trend for association between LVSD and left ventricular hypertrophy was also noted (3.12; 0.73-13.33, p = 0.124). No differences were seen in microwave radiometry parameters, NT-proBNP, hs-TnT and c-reactive protein between PLWH with and without LVSD.

CONCLUSIONS

Subclinical LVSD and carotid atherosclerosis were significantly more frequent in PLWH compared to a group of healthy individuals, implying a possible link between HIV infection and these two pathological processes. Carotid atherosclerosis and increased adiposity were independently associated with impaired GLS in HIV-infected individuals.

Impact Of Obesity On Cardiac Structural And Functional Changes

The urgency of obesity issue is undeniable. Obesity is now considered the most important risk factor of cardiovascular diseases. Numerous studies have demonstrated the negative effect of excessive adipose tissue on structural and functional changes in the heart that lead to development of left ventricular hypertrophy, arrhythmias and conduction abnormalities, as well as progression of diastolic and systolic heart failure. High prevalence of obesity – so high that it can be called a pandemic – greatly contributes to the increased incidence of cardiovascular diseases. Studying the problem of obesity is a priority area of focus for modern medicine. This article describes hormonal, metabolic and hemodynamic features of obesity impact on cardiovascular system and describes pathogenetic mechanisms of cardiovascular pathology development.

Açaí seed extract (ASE) rich in proanthocyanidins improves cardiovascular remodeling by increasing antioxidant response in obese high-fat diet-fed mice

Obesity is recognized as an independent risk factor for cardiovascular diseases and is an important contributor to cardiac mortality. Açaí seed extract (ASE), rich in proanthocyanidins, has been shown to have potential anti-obesity effects. This study aimed to investigate the therapeutic effect of ASE in cardiovascular remodeling associated with obesity and compare it with that of rosuvastatin. Male C57BL/6 mice were fed a high-fat diet or a standard diet for 12 weeks. The ASE (300 mg/kg/day) and rosuvastatin (20 mg/kg/day) treatments started in the 8th week until the 12th week, totaling 4 weeks of treatment. Our data showed that treatment with ASE and rosuvastatin reduced body weight, ameliorated lipid profile, and improved cardiovascular remodeling. Treatment with ASE but not rosuvastatin reduced hyperglycemia and oxidative stress by reducing immunostaining of 8-isoprostane and increasing SOD-1 and GPx expression in HFD mice. ASE and rosuvastatin reduced NOX4 expression, increased SIRT-1 and Nrf2 expression and catalase and GPx activities, and improved vascular and cardiac remodeling in HFD mice. The therapeutic effect of ASE was similar to that of rosuvastatin in reducing dyslipidemia and cardiovascular remodeling but was superior in reducing oxidative damage and hyperglycemia, suggesting that ASE was a promising natural product for the treatment of cardiovascular alterations associated with obesity.

High-output Cardiac Failure: A Forgotten Phenotype in Clinical Practice

INTRODUCTION

The knowledge on High-Output Cardiac Failure (HOCF) has greatly improved in the last two decades. One of the advances was the identification of a new phenotype of HOCF, characterized by the absence of ventricular dilation, already associated with liver disease, Arteriovenous Fistulas (AVF), lung disease, myelodysplastic syndromes, and obesity. However, it has been noted that any aetiology can present with one of the two phenotypes, depending on the evolution.

OBJECTIVE

The study aims to describe, through an integrative review, the physiopathology and aetiologies of HOCF and to discuss phenotypes associated with this condition.

METHODS

Revisions, guidelines, case-controls, cohort studies and clinical studies were searched in MEDLINE and LILACS, using the connectives in the "cardiac output, high" database (MeSH Terms) OR "high cardiac output" (All Fields).

DISCUSSION

Two distinct phenotypes are currently described in the HOCF, regardless of the aetiology: 1) one with enlarged cardiac chambers; and 2) with normal heart chambers. The mechanisms related to HOCF are vasodilation, arteriovenous shunts that cause increased microvascular density, Reduced Systemic Vascular Resistance (RSVR), and high metabolism. These mechanisms lead to activation of the renin-angiotensin-aldosterone system, sodium and water retention, activation of neprilysin, of the sodium-glucose-2 transporter, which promote interstitial fibrosis, ventricular remodeling and a consequent increase in cardiac output >8L/min.

CONCLUSION

Many aetiologies of HOCF have been described, and some of them are potentially curable. Prompt recognition of this condition and proper treatment may lead to better outcomes.

Beneficial Effects of Psyllium on the Prevention and Treatment of Cardiometabolic Diseases

Cardiometabolic diseases are reaching epidemic proportions worldwide. Nevertheless, current therapeutic strategies are insufficient; thus, studying novel complementary and alternative medicines remains of the upmost importance. Psyllium has been used for...