Heart failure with preserved ejection fraction in the elderly: scope of the problem

Endothelial Cell-Specific Prolyl Hydroxylase-2 Deficiency Augments Angiotensin II-Induced Arterial Stiffness and Cardiac Pericyte Recruitment in Mice

BACKGROUND

Endothelial prolyl hydroxylase-2 (PHD2) is essential for pulmonary remodeling and hypertension. In the present study, we investigated the role of endothelial PHD2 in angiotensin II-mediated arterial stiffness, pericyte recruitment, and cardiac fibrosis.

METHODS AND RESULTS

Chondroitin sulfate proteoglycan 4 tracing reporter chondroitin sulfate proteoglycan 4- red fluorescent protein (DsRed) transgenic mice were crossed with PHD2flox/flox (PHD2f/f) mice and endothelial-specific knockout of PHD2 (PHD2ECKO) mice. Transgenic PHD2f/f (TgPHD2f/f) mice and TgPHD2ECKO mice were infused with angiotensin II for 4 weeks. Arterial thickness, stiffness, and histological and immunofluorescence of pericytes and fibrosis were measured. Infusion of TgPHD2f/f mice with angiotensin II resulted in a time-dependent increase in pulse-wave velocity. Angiotensin II-induced pulse-wave velocity was further elevated in the TgPHD2ECKO mice. TgPHD2ECKO also reduced coronary flow reserve compared with TgPHD2f/f mice infused with angiotensin II. Mechanistically, knockout of endothelial PHD2 promoted aortic arginase activity and angiotensin II-induced aortic thickness together with increased transforming growth factor-β1 and ICAM-1/VCAM-1 expression in coronary arteries. TgPHD2f/f mice infused with angiotensin II for 4 weeks exhibited a significant increase in cardiac fibrosis and hypertrophy, which was further developed in the TgPHD2ECKO mice. Chondroitin sulfate proteoglycan 4 pericyte was traced by DsRed+ staining and angiotensin II infusion displayed a significant increase of DsRed+ pericytes in the heart, as well as a deficiency of endothelial PHD2, which further promoted angiotensin II-induced pericyte increase. DsRed+ pericytes were costained with fibroblast-specific protein 1 and α-smooth muscle actin for measuring pericyte-myofibroblast cell transition. The knockout of endothelial PHD2 increased the amount of DsRed+/fibroblast-specific protein 1+ and DsRed+/α-smooth muscle actin+ cells induced by angiotensin II infusion.

CONCLUSIONS

Knockout of endothelial PHD2 enhanced angiotensin II-induced cardiac fibrosis by mechanisms involving increasing arterial stiffness and pericyte-myofibroblast cell transitions.

AMPK, a key molecule regulating aging-related myocardial ischemia-reperfusion injury

Aging leads to the threat of more diseases to the biological anatomical structure and the decline of disease resistance, increasing the incidence and mortality of myocardial ischemia-reperfusion injury (MI/RI). Moreover, MI/RI promotes damage to an aging heart. Notably, 5'-adenosine monophosphate-activated protein kinase (AMPK) regulates cellular energy metabolism, stress response, and protein metabolism, participates in aging-related signaling pathways, and plays an essential role in ischemia-reperfusion (I/R) injury diseases. This study aims to introduce the aging theory, summarize the interaction between aging and MI/RI, and describe the crosstalk of AMPK in aging and MI/RI. We show how AMPK can offer protective effects against age-related stressors, lifestyle factors such as alcohol consumption and smoking, and hypertension. We also review some of the clinical prospects for the development of interventions that harness the effect of AMPK to treat MI/RI and other age-related cardiovascular diseases.

Endurance Exercise Training Mitigates Diastolic Dysfunction in Diabetic Mice Independent of Phosphorylation of Ulk1 at S555

Millions of diabetic patients suffer from cardiovascular complications. One of the earliest signs of diabetic complications in the heart is diastolic dysfunction. Regular exercise is a highly effective preventive/therapeutic intervention against diastolic dysfunction in diabetes, but the underlying mechanism(s) remain poorly understood. Studies have shown that the accumulation of damaged or dysfunctional mitochondria in the myocardium is at the center of this pathology. Here, we employed a mouse model of diabetes to test the hypothesis that endurance exercise training mitigates diastolic dysfunction by promoting cardiac mitophagy (the clearance of mitochondria via autophagy) via S555 phosphorylation of Ulk1. High-fat diet (HFD) feeding and streptozotocin (STZ) injection in mice led to reduced endurance capacity, impaired diastolic function, increased myocardial oxidative stress, and compromised mitochondrial structure and function, which were all ameliorated by 6 weeks of voluntary wheel running. Using CRISPR/Cas9-mediated gene editing, we generated non-phosphorylatable Ulk1 (S555A) mutant mice and showed the requirement of p-Ulk1at S555 for exercise-induced mitophagy in the myocardium. However, diabetic Ulk1 (S555A) mice retained the benefits of exercise intervention. We conclude that endurance exercise training mitigates diabetes-induced diastolic dysfunction independent of Ulk1 phosphorylation at S555.

Status of Research on Sestrin2 and Prospects for its Application in Therapeutic Strategies Targeting Myocardial Aging

Cardiac aging is accompanied by changes in the heart at the cellular and molecular levels, leading to alterations in cardiac structure and function. Given today's increasingly aging population, the decline in cardiac function caused by cardiac aging has a significant impact on quality of life. Antiaging therapies to slow the aging process and attenuate changes in cardiac structure and function have become an important research topic. Treatment with drugs, including metformin, spermidine, rapamycin, resveratrol, astaxanthin, Huolisu oral liquid, and sulforaphane, has been demonstrated be effective in delaying cardiac aging by stimulating autophagy, delaying ventricular remodeling, and reducing oxidative stress and the inflammatory response. Furthermore, caloric restriction has been shown to play an important role in delaying aging of the heart. Many studies in cardiac aging and cardiac aging-related models have demonstrated that Sestrin2 has antioxidant and anti-inflammatory effects, stimulates autophagy, delays aging, regulates mitochondrial function, and inhibits myocardial remodeling by regulation of relevant signaling pathways. Therefore, Sestrin2 is likely to become an important target for antimyocardial aging therapy.

Towards clinical application of GlycA and GlycB for early detection of inflammation associated with (pre)diabetes and cardiovascular disease: recent evidence and updates

Cardiometabolic diseases are associated with low-grade inflammation early in life and persists into old age. The long latency period presents opportunities for early detection, lifestyle modification and intervention. However, the performance of conventional biomarker assays to detect low-grade inflammation has been variable, particularly for early-stage cardiometabolic disorder including prediabetes and subclinical atherosclerotic vascular inflammation. During the last decade, the application of nuclear magnetic resonance (NMR) spectroscopy for metabolic profiling of biofluids in translational and epidemiological research has advanced to a stage approaching clinical application. Proton (1H)-NMR profiling induces no destructible physical changes to specimens, and generates quantitative signals from deconvoluted spectra that are highly repeatable and reproducible. Apart from quantitative analysis of amino acids, lipids/lipoproteins, metabolic intermediates and small proteins, 1H-NMR technology is unique in being able to detect composite signals of acute-phase and low-grade inflammation indicated by glycosylated acetyls (GlycA) and N-acetylneuraminic acid (sialic acid) moieties (GlycB). Different from conventional immunoassays that target epitopes and are susceptible to conformational variation in protein structure and binding, GlycA and GlycB signals are stable over time, and maybe complementary as well as superior to high-sensitivity C-reactive protein and other inflammatory cytokines. Here we review the physicochemical principles behind 1H-NMR profiling of GlycA and GlycB, and the available evidence supporting their potential clinical application for the prediction of incident (pre)diabetes, cardiovascular disease, and adverse outcomes.

Metabolic Syndrome and Cardiac Remodeling Due to Mitochondrial Oxidative Stress Involving Gliflozins and Sirtuins

PURPOSE OF REVIEW

To address the mechanistic pathways focusing on mitochondria dysfunction, oxidative stress, sirtuins imbalance, and other contributors in patient with metabolic syndrome and cardiovascular disease. Sodium glucose co-transporter type 2 (SGLT-2) inhibitors deeply influence these mechanisms. Recent randomized clinical trials have shown impressive results in improving cardiac function and reducing cardiovascular and renal events. These unexpected results generate the need to deepen our understanding of the molecular mechanisms able to generate these effects to help explain such significant clinical outcomes.

RECENT FINDINGS

Cardiovascular disease is highly prevalent among individuals with metabolic syndrome and diabetes. Furthermore, mitochondrial dysfunction is a principal player in its development and persistence, including the consequent cardiac remodeling and events. Another central protagonist is the renin-angiotensin system; the high angiotensin II (Ang II) activity fuel oxidative stress and local inflammatory responses. Additionally, sirtuins decline plays a pivotal role in the process; they enhance oxidative stress by regulating adaptive responses to the cellular environment and interacting with Ang II in many circumstances, including cardiac and vascular remodeling, inflammation, and fibrosis. Fasting and lower mitochondrial energy generation are conditions that substantially reduce most of the mentioned cardiometabolic syndrome disarrangements. In addition, it increases sirtuins levels, and adenosine monophosphate-activated protein kinase (AMPK) signaling stimulates hypoxia-inducible factor-1β (HIF-1 beta) and favors ketosis. All these effects favor autophagy and mitophagy, clean the cardiac cells with damaged organelles, and reduce oxidative stress and inflammatory response, giving cardiac tissue protection. In this sense, SGLT-2 inhibitors enhance the level of at least four sirtuins, some located in the mitochondria. Moreover, late evidence shows that SLGT-2 inhibitors mimic this protective process, improving mitochondria function, oxidative stress, and inflammation. Considering the previously described protection at the cardiovascular level is necessary to go deeper in the knowledge of the effects of SGLT-2 inhibitors on the mitochondria function. Various of the protective effects these drugs clearly had shown in the trials, and we briefly describe it could depend on sirtuins enhance activity, oxidative stress reduction, inflammatory process attenuation, less interstitial fibrosis, and a consequent better cardiac function. This information could encourage investigating new therapeutic strategies for metabolic syndrome, diabetes, heart and renal failure, and other diseases.

Metabolic Changes in Cardiac Aging

Cardiac aging is a natural process accompanied by cardiomyocyte hypertrophy and dysfunction. These changes can lead to adverse organ remodeling and ultimately lead to the development of heart failure. The study of cardiac aging is helpful to explore the mechanism of senescence and is of great significance for preventing cardiac aging. Cardiac aging is accompanied by changes in various metabolic functions. In this process, due to the change of metabolic substrates and enzyme activities, oxidative stress response increases, and reactive oxygen species (ROS) increases, accompanied by mitochondrial dysfunction and gene expression changes, so related protein metabolism also changes. Hormone metabolism and autophagy are also involved in the process of cardiac aging. Based on these findings, changes in diet, caloric restriction, improvement of mitochondrial function and promotion of autophagy have been proven to have positive effects in delaying cardiac aging. This article reviews the metabolic changes involved in the process of cardiac aging from different aspects, and briefly reviews the measures to improve cardiac aging.

Descriptive Epidemiology of Chronic Obstructive Pulmonary Disease in US Nursing Home Residents With Heart Failure

Chronic obstructive pulmonary disease (COPD) is highly prevalent in older adults with heart failure and heart failure is highly prevalent in older adults with COPD. Information is presently lacking about the extent to which COPD and heart failure co-occur among nursing home residents. The objective of this study was to describe the epidemiology of, and factors associated with, COPD among nursing home residents with heart failure. This cross-sectional study included 97,495 long-term stay nursing home residents with heart failure in 2018. The Minimum Data Set 3.0 (MDS) provided information on sociodemographic characteristics, comorbid conditions, and activities of daily living. Heart failure and COPD were defined based on notes at admission, hospitalizations, progress notes, and through physical examination findings. The majority of the study population were ≥75 years old (74.1%), women (67.3%), and Non-Hispanic Whites (77.4%). Nearly 1 in 5 residents had reduced ejection fraction findings, 23.1% had a preserved ejection fraction, and 53.8% of nursing home residents with heart failure had COPD. This pulmonary condition was less frequently noted in women, residents of advanced age, and racial/ethnic minorities and more frequently diagnosed in residents with comorbid conditions such as pneumonia, anxiety, obesity, diabetes mellitus, and coronary artery disease. We found a high prevalence of COPD, and identified several factors associated with COPD, in nursing home residents with heart failure. Our findings highlight challenges in the clinical management of COPD in nursing home residents with heart failure and how best to meet the care needs of this understudied population.

Geriatric Domains in Patients with Heart Failure with Preserved Ejection Fraction

Because heart failure with preserved ejection fraction (HFpEF) is closely linked to aging processes and disproportionately affects older adults, consideration of geriatric domains is paramount to ensure high-quality care to older adults with HFpEF. Multimorbidity, polypharmacy, cognitive impairment, depressive symptoms, frailty, falls, and social isolation each have important implications on quality of life and clinical events including hospitalization and mortality. There are multiple strategies to screen for these conditions. This narrative review underscores the importance of screening for multiple geriatric conditions, integrating these conditions into decision making, and addressing these conditions when caring for older adults with HFpEF.

N-of-1 trials to facilitate evidence-based deprescribing: Rationale and case study

Deprescribing has emerged as an important aspect of patient-centred medication management but is vastly underutilized in clinical practice. The current narrative review will describe an innovative patient-centred approach to deprescribing-N-of-1 trials. N-of-1 trials involve multiple-period crossover design experiments conducted within individual patients. They enable patients to compare the effects of two or more treatments or, in the case of deprescribing N-of-1 trials, continuation with a current treatment versus no treatment or placebo. N-of-1 trials are distinct from traditional between-patient studies such as parallel-group or crossover designs which provide an average effect across a group of patients and obscure differences between individuals. By generating data on the effect of an intervention for the individual rather than the population, N-of-1 trials can promote therapeutic precision. N-of-1 trials are a particularly appealing strategy to inform deprescribing because they can generate individual-level evidence for deprescribing when evidence is uncertain, and can thus allay patient and physician concerns about discontinuing medications. To illustrate the use of deprescribing N-of-1 trials, we share a case example of an ongoing series of N-of-1 trials that compare maintenance versus deprescribing of beta-blockers in patients with heart failure with preserved ejection fraction. By providing quantifiable data on patient-reported outcomes, promoting personalized pharmacotherapy, and facilitating shared decision making, N-of-1 trials represent a potentially transformative strategy to address polypharmacy.

Early Cardiac Rehabilitation to Reduce Heart Failure Readmissions

PURPOSE

This research was conducted to determine whether early participation in cardiac rehabilitation (CR) reduces readmissions following heart failure (HF) hospitalization.

METHODS

A retrospective quasiexperimental comparison group design was used. Electronic medical records were abstracted for HF patients discharged between March 2013 and December 2017. The treatment group was defined as patients with HF who attended ≥1 CR session within 6 wk following discharge. The comparison group was defined as patients with HF without additional HF hospitalizations during the previous year, discharged to home/self-care, and did not attend CR within 6 wk. Readmission rates at 30 d and 6 wk were compared between groups using χ 2 analysis and logistic regression.

RESULTS

Out of 8613 patients with HF, 205 (2.4%) attended ≥1 CR within 6 wk post-discharge. The treatment group had lower, but not statistically significant, readmission rates than the comparison group for 30-d readmissions for HF ( P = .13), and 6-wk readmission rates for HF ( P = .05). The treatment group had lower all-cause readmissions at 30 d (P < .01) and 6 wk ( P < .01) than the comparison group. Multivariable logistic regression revealed that early CR attendance was associated with reduced 30-d all-cause readmissions (adjusted OR = 0.4: 95% CI, 0.2-0.7) and 6-wk all-cause readmissions (adjusted OR = 0.5: 95% CI, 0.3-0.8).

CONCLUSIONS

This study contributes to the existing evidence for allowing early unrestricted CR participation with the aim of improving the health of patients with HF and reducing rehospitalization rates.

Knockout of TIGAR enhances myocardial phosphofructokinase activity and preserves diastolic function in heart failure

Hypertension is an important risk factor in the pathogenesis of diastolic dysfunction. Growing evidence indicates that glucose metabolism plays an essential role in diastolic dysfunction. TP53-induced glycolysis and apoptosis regulator (TIGAR) has been shown to regulate glucose metabolism and heart failure (HF). In the present study, we investigated the role of TIGAR in diastolic function and cardiac fibrosis during pressure overload (PO)-induced HF. WT mice subjected to transverse aortic constriction (TAC), a commonly used method to induce diastolic dysfunction, exhibited diastolic dysfunction as evidenced by increased E/A ratio and E/E' ratio when compared to its sham controls. This was accompanied by increased cardiac interstitial fibrosis. In contrast, the knockout of TIGAR attenuated PO-induced diastolic dysfunction and interstitial fibrosis. Mechanistically, the levels of glucose transporter Glut-1, Glut-4, and key glycolytic enzyme phosphofructokinase 1 (PFK-1) were significantly elevated in TIGAR KO subjected to TAC as compared to that of WT mice. Knockout of TIGAR significantly increased fructose 2,6-bisphosphate levels and phosphofructokinase activity in mouse hearts. In addition, PO resulted in a significant increase in perivascular fibrosis and endothelial activation in the WT mice, but not in the TIGAR KO mice. Our present study suggests a necessary role of TIGAR-mediated glucose metabolism in PO-induced cardiac fibrosis and diastolic dysfunction.

Ageing Increases Cardiac Electrical Remodelling in Rats and Mice via NOX4/ROS/CaMKII-Mediated Calcium Signalling

Objective

Ageing is one of the risk factors associated with cardiovascular diseases including cardiac arrhythmias and heart failure. Ageing-related cardiac dysfunction involves a complicated pathophysiological progress. Abnormal membrane voltage and Ca²⁺ dynamics in aged cardiomyocytes contribute to ageing-related arrhythmias. However, its underlying mechanisms have not been well clarified.

Methods

Young and old rats or mice were included in this study. Cardiac electrophysiological properties and functions were assessed by ECG, echocardiography, and ex vivo heart voltage and Ca²⁺ optical mapping. Proteomics, phosphor-proteomics, Western blotting, Masson staining, and ROS measurement were used to investigate the underlying mechanisms.

Results

Ageing increased the incidence of cardiac hypertrophy and fibrosis in rats. Moreover, ageing increased the occurrence of ventricular tachycardia or ventricular fibrillation induced by rapid pacing and during isoprenaline (ISO) (1 mg/kg i.p.) challenge in mice in vivo. Optical mapping with dual dyes (membrane voltage (V_m) dye and intracellular Ca²⁺ dye) simultaneously recording revealed that ageing increased the action potential duration (APD) and Ca²⁺ transient duration (CaTD) and slowed the ventricular conduction with the Langendorff-perfused mouse heart. More importantly, ageing increased the ISO-induced (1 μM) changes of APD (ΔAPD80) and CaTD (ΔCaTD50). Ageing also delayed the decay of Ca²⁺ transient by extending the decay time constant from 30% to 90% (τ₃₀₋₉₀). In addition, ageing decreased the V_m/Ca²⁺ latency which represented the coupling of V_m/Ca²⁺ including between the midpoint of AP depolarization and Ca²⁺ upstroke, peak transmembrane voltage and peak cytosolic calcium, and time to 50% voltage repolarization and extrusion of cytosolic calcium. Optical mapping also revealed that ageing increased the ISO-induced arrhythmia incidence and occurrence of the excitation rotor. Proteomics and phosphor-proteomics assays from rat hearts demonstrated ageing-induced protein and phosphor-protein changes, suggesting that CaMKII was involved in ageing-induced change. Ageing increased the level of ROS and the expression of NOX4, oxidative CaMKII (ox-CaMKII), phosphorated CaMKII (p-CaMKII), and periostin.

Conclusion

Ageing accelerates cardiac remodelling and increases the susceptibility to ventricular arrhythmias through NOX4/ROS/CaMKII pathway-mediated abnormal membrane voltage and intracellular Ca²⁺ handling and V_m/Ca²⁺ coupling.

Ultrastructural and proteomic profiling of mitochondria-associated endoplasmic reticulum membranes reveal aging signatures in striated muscle

Aging is a major risk for developing cardiac and skeletal muscle dysfunction, yet the underlying mechanism remains elusive. Here we demonstrated that the mitochondria-associated endoplasmic reticulum membranes (MAMs) in the rat heart and skeletal muscle were disrupted during aging. Using quantitative morphological analysis, we showed that the mitochondria-endoplasmic reticulum contacts (MERCs) were reduced by half over the lifespan with an early onset of accelerated thickening in the clefts. The ultrastructural changes were further validated by proteomic profiling of the MAM fractions. A combination of subcellular fractionation and quantitative mass spectrometry identified 1306 MAM-enriched proteins in both heart and skeletal muscle, with a catalog of proteins dysregulated with aging. Functional mapping of the MAM proteome suggested several aging signatures to be closely associated with the ER-mitochondria crosstalk, including local metabolic rewiring, calcium homeostasis imbalance, and impaired organelle dynamics and autophagy. Moreover, we identified a subset of highly interconnected proteins in an ER-mitochondria organization network, which were consistently down-regulated with aging. These decreased proteins, including VDAC1, SAMM50, MTX1 and MIC60, were considered as potential contributors to the age-related MAM dysfunction. This study highlights the perturbation in MAM integrity during the striated muscle aging process, and provides a framework for understanding aging biology from the perspective of organelle interactions.

[Frailty syndrome as an independent predictor of adverse prognosis in patients with chronic heart failure]

This review presents results of clinical studies of senile asthenia ("fragility") syndrome and chronic heart failure (CHF). Recent reports of the "fragility" prevalence in patients with CHF are described. The review presents specific features of pathophysiological pathways underlying the development of both senile asthenia syndrome and CHF; the role of "fragility" in the progression and complications of CHF is addressed. Senile asthenia syndrome associated with CHF is regarded as an independent predictor of unfavorable prognosis and high mortality in this patient category. The authors concluded that methods for "fragility" evaluation in CHF patients followed by risk stratification and selection of individual management tactics should be implemented in clinical practice.

The Role of Oxidative Stress in the Aging Heart

Medical advances and the availability of diagnostic tools have considerably increased life expectancy and, consequently, the elderly segment of the world population. As age is a major risk factor in cardiovascular disease (CVD), it is critical to understand the changes in cardiac structure and function during the aging process. The phenotypes and molecular mechanisms of cardiac aging include several factors. An increase in oxidative stress is a major player in cardiac aging. Reactive oxygen species (ROS) production is an important mechanism for maintaining physiological processes; its generation is regulated by a system of antioxidant enzymes. Oxidative stress occurs from an imbalance between ROS production and antioxidant defenses resulting in the accumulation of free radicals. In the heart, ROS activate signaling pathways involved in myocyte hypertrophy, interstitial fibrosis, contractile dysfunction, and inflammation thereby affecting cell structure and function, and contributing to cardiac damage and remodeling. In this manuscript, we review recent published research on cardiac aging. We summarize the aging heart biology, highlighting key molecular pathways and cellular processes that underlie the redox signaling changes during aging. Main ROS sources, antioxidant defenses, and the role of dysfunctional mitochondria in the aging heart are addressed. As metabolism changes contribute to cardiac aging, we also comment on the most prevalent metabolic alterations. This review will help us to understand the mechanisms involved in the heart aging process and will provide a background for attractive molecular targets to prevent age-driven pathology of the heart. A greater understanding of the processes involved in cardiac aging may facilitate our ability to mitigate the escalating burden of CVD in older individuals and promote healthy cardiac aging.

Clinical Evidence and Proposed Mechanisms of Sodium-Glucose Cotransporter 2 Inhibitors in Heart Failure with Preserved Ejection Fraction: A Class Effect?

Effective treatment for heart failure with preserved ejection fraction (HFpEF) is an unmet need in cardiovascular medicine. The pathophysiological drivers of HFpEF are complex, differing depending on phenotype, making a one-size-fits-all treatment approach unlikely. Remarkably, sodium-glucose cotransporter 2 inhibitors (SGLT2is) may be the first drug class to improve cardiovascular outcomes in HFpEF. Randomised controlled trials suggest a benefit in mortality, and demonstrate decreased hospitalisations and improvement in functional status. Limitations in trials exist, either due to small sample sizes, differing results between trials or decreased efficacy at higher ejection fractions. SGLT2is may provide a class effect by targeting various pathophysiological HFpEF mechanisms. Inhibition of SGLT2 and Na⁺/H⁺ exchanger 3 in the kidney promotes glycosuria, osmotic diuresis and natriuresis. The glucose deprivation activates sirtuins - protecting against oxidation and beneficially regulating metabolism. SGLT2is reduce excess epicardial adipose tissue and its deleterious adipokines. Na⁺/H⁺ exchanger 1 inhibition in the heart and lungs reduces sodium-induced calcium overload and pulmonary hypertension, respectively.

Hemodynamic characteristics and early warnings in very old patients

The hemodynamic characteristics of very old patients (VOPs) are unique. With increasing age, patients may experience reduced diastolic function, increased rates of valvular heart disease and coronary atherosclerosis, stiffer vessels, and a reduced heart response to stimulations. Structural and functional modifications are linked to cardiac aging; echocardiography reveals concentric remodeling of the left ventricle, dilation of the left atrium, thickening and calcification of the valves, modification of the large vessels, and abnormal ventricular relaxation. According to a comprehensive understanding of the insufficient compensatory mechanisms of the aging heart, arrythmia should be avoided to the maximum extent and "conservative" fluid therapy should be provided together with appropriate blood pressure control. Considering these factors will improve the success rate of resuscitation and significantly reduce economic loss. In addition, more attention should be paid to the diastolic blood pressure in VOPs.

Ubiquitin ligase Wwp1 gene deletion attenuates diastolic dysfunction in pressure-overload hypertrophy

Heart failure with a preserved left ventricular (LV) ejection fraction (HFpEF) often arises from a prolonged LV pressure overload (LVPO) and accompanied by abnormal extracellular matrix (ECM) accumulation. The E3 ubiquitin ligase WWP1 is a fundamental determinant ECM turnover. We tested the hypothesis that genetic ablation of Wwp1 would alter the progression of LVPO-induced HFpEF. LV echocardiography in mice with global Wwp1 deletion (n = 23; Wwp1-/-) was performed at 12 wk of age (baseline) and then at 2 and 4 wk following LVPO (transverse aortic banding) or surgery without LVPO induction. Age-matched wild-type mice (Wwp1+/+; n = 23) underwent identical protocols. LV EF remained constant and unchanged with LVPO and LV mass increased in both groups but was lower in the Wwp1-/- mice. With LVPO, the E/A ratio, an index of LV filling, was 3.97 ± 0.46 in Wwp1+/+ but was 1.73 ± 0.19 in the Wwp1-/- group (P < 0.05). At the transcriptional level, mRNA for fibrillar collagens (types I and III) decreased by approximately 50% in Wwp1-/- compared with the Wwp1+/+ group at 4 wk post-LVPO (P < 0.05) and was paralleled by a similar difference in LV fibrillar collagen content as measured by histochemistry. Moreover, mRNA levels for determinants favoring ECM accumulation, such as transforming growth factor (TGF), increased with LVPO, but were lower in the Wwp1-/- group. The absence of Wwp1 reduced the development of left ventricular hypertrophy and subsequent progression to HFpEF. Modulating the WWP1 pathway could be a therapeutic target to alter the natural history of HFpEF.NEW & NOTEWORTHY Heart failure with a preserved left ventricular (LV) ejection fraction (HFpEF) often arises from a prolonged LV pressure overload (LVPO) and is accompanied by abnormal extracellular matrix (ECM) accumulation. It is now recognized that the ECM is a dynamic entity that is regulated at multiple post-transcriptional levels, including the E3 ubiquitin ligases, such as WWP1. In the present study, WWP1 deletion in the context of an LVPO stimulus reduced functional indices of HFpEF progression and determinants of ECM remodeling.

Exercise training for prevention and treatment of older adults with heart failure with preserved ejection fraction

Heart failure (HF) with preserved ejection fraction (HFpEF) is the most rapidly increasing form of HF, occurs primarily in older women, and is associated with high rates of morbidity, mortality, and health care expenditures. In the highest age decile (≥90 years old), nearly all patients with HFpEF. As our understanding of the disease has grown in the last few years, we now know that HFpEF is a systemic disorder influenced by aging processes. The involvement of this broad collection of abnormalities in HFpEF, the recognition of the high frequency and impact of noncardiac comorbidities, and systemic, multiorgan involvement, and its nearly exclusive existence in older persons, has led to the recognition of HFpEF as a true geriatric syndrome. Most of the conventional therapeutics used in other cardiac diseases have failed to improve HFpEF patient outcomes significantly. Several recent studies have evaluated exercise training (ET) as a therapeutic management strategy in patients with HFpEF. Although these studies were not designed to address clinical endpoints, such as HF hospitalizations and mortality, they have shown that ET is a safe and effective intervention to improve peak oxygen consumption, physical function, and quality of life in clinically stable HF patients. Recently, a progressive, multidomain physical rehabilitation study among older adults showed that it is feasible in older patients with acute decompensated HF who have high frailty and comorbidities and showed improvement in physical function. However, the lack of Centers for Medicare and Medicaid Services coverage can be a major barrier to formal cardiac rehabilitation in older HFpEF patients. Unfortunately, insistence upon demonstration of mortality improvement before approving reimbursement overlooks the valuable and demonstrated benefits of physical function and life quality.

The Role of HECT-Type E3 Ligase in the Development of Cardiac Disease

Despite advances in medicine, cardiac disease remains an increasing health problem associated with a high mortality rate. Maladaptive cardiac remodeling, such as cardiac hypertrophy and fibrosis, is a risk factor for heart failure; therefore, it is critical to identify new therapeutic targets. Failing heart is reported to be associated with hyper-ubiquitylation and impairment of the ubiquitin–proteasome system, indicating an importance of ubiquitylation in the development of cardiac disease. Ubiquitylation is a post-translational modification that plays a pivotal role in protein function and degradation. In 1995, homologous to E6AP C-terminus (HECT) type E3 ligases were discovered. E3 ligases are key enzymes in ubiquitylation and are classified into three families: really interesting new genes (RING), HECT, and RING-between-RINGs (RBRs). Moreover, 28 HECT-type E3 ligases have been identified in human beings. It is well conserved in evolution and is characterized by the direct attachment of ubiquitin to substrates. HECT-type E3 ligase is reported to be involved in a wide range of human diseases and health. The role of HECT-type E3 ligases in the development of cardiac diseases has been uncovered in the last decade. There are only a few review articles summarizing recent advancements regarding HECT-type E3 ligase in the field of cardiac disease. This study focused on cardiac remodeling and described the role of HECT-type E3 ligases in the development of cardiac disease. Moreover, this study revealed that the current knowledge could be exploited for the development of new clinical therapies.

Frailty and Post-hospitalization Outcomes in Patients With Heart Failure With Preserved Ejection Fraction

Given the role of comorbid conditions in the pathophysiology of HFpEF, we aimed to identify and rank the importance of comorbid conditions associated with post-hospitalization outcomes of older adults hospitalized for HFpEF. We examined data from 4,605 Medicare beneficiaries hospitalized in 2007-2014 for HFpEF based on ICD-9-CM codes for acute diastolic heart failure (428.31 or 428.33). To identify characteristics with high importance for prediction of mortality, all-cause rehospitalization, rehospitalization for heart failure, and composite outcome of mortality or all-cause rehospitalization up to 1 year, we developed boosted decision tree ensembles for each outcome, separately. For interpretability, we estimated hazard ratios (HRs) and 95% confidence intervals (CI) using Cox proportional hazards models. Age and frailty were the most important characteristics for prediction of mortality. Frailty was the most important characteristic for prediction of rehospitalization, rehospitalization for heart failure, and the composite outcome of mortality or all-cause rehospitalization. In Cox proportional hazards models, a 1-SD higher frailty score (0.1 on theoretical range of 0 to 1) was associated with a HR of 1.27 (1.06 to 1.52) for mortality, 1.16 (1.07 to 1.25) for all-cause rehospitalization, 1.24 (1.14 to 1.35) for HF rehospitalization, and 1.15 (1.07 to 1.25) for the composite outcome of mortality or all-cause rehospitalization. In conclusion, frailty is an important predictor of mortality and rehospitalization in adults aged ≥66 years with HFpEF.

GDF15 Promotes Cardiac Fibrosis and Proliferation of Cardiac Fibroblasts via the MAPK/ERK1/2 Pathway after Irradiation in Rats

Ionizing radiation exposure is associated with a risk of cardiac fibrosis; however, the underlying molecular mechanism remains unclear. Growth/differentiation factor-15 (GDF15), a fibroblast factor, is a divergent member of the transforming growth factor β superfamily. Next-generation sequencing analyses has revealed that Gdf15 is increased in cardiac fibroblasts during radiation-induced fibrosis. However, the role of Gdf15 in cardiac fibrosis remains unclear. In this study, we demonstrated that the upregulated expression of GDF15 in newborn rat cardiac fibroblasts and adult rats after irradiation could induce fibrosis, which was confirmed by the increased cell proliferation rate and the increased expression of fibrosis markers (Col1α and αSMA) in newborn rat cardiac fibroblasts after transfection with Gdf15 in vitro. Conversely, the downregulation of GDF15 inhibited cardiac fibrosis, as confirmed by G2/M-cell cycle arrest, suppression of cell proliferation, and low levels of Col1α and αSMA expression. We also found that suppressing the expression of Gdf15 in cardiac fibroblasts could lead to a decrease in CDK1 and inhibit phosphorylation of ERK1/2. Thus, GDF15 might promote cardiac fibroblast fibrosis through the MAPK/ERK1/2 pathway and thus contribute to the pathogenesis of radiation-induced heart disease.

Proteome analysis demonstrates involvement of endoplasmic reticulum stress response in human myocardium with subclinical left ventricular diastolic dysfunction

AIM

Heart failure is increasing in Japan, in particular that with preserved ejection fraction (HFpEF) prevalent in older-aged patients. The purpose of this study was to investigate the pathophysiology during the early stage of left ventricular (LV) diastolic dysfunction by the quantitative proteome analysis of human myocardium.

METHODS

Among 331 post-mortem autopsy patients, we selected 23 patients (aged 79 ± 9.6 years) with echocardiographic data and without major comorbidities, except hypertension. Cryopreserved autopsy tissue of the LV myocardium was subjected to proteome analysis. LV diastolic function was evaluated by echocardiographic data. Thirteen patients were classified into the impaired diastolic function (IDF) group, and 10 the normal cardiac function group. We performed comparative proteome analysis between the IDF and normal groups by isobaric tags for relative and absolute quantitation (iTRAQ) using nano-liquid chromatography-tandem mass spectrometry.

RESULTS

The iTRAQ-based proteome analysis revealed 57 differentially expressed proteins in the IDF group. Molecular network analysis of differentially expressed proteins indicated that endoplasmic reticulum (ER) stress was a potentially important event. Furthermore, the expressions of proteins associated with the ER stress response, such as glucose-regulated protein 78 kDa, inositol-requiring kinase 1α and spliced X-box binding protein 1, were significantly decreased in the IDF group.

CONCLUSIONS

This study suggested that reduced ER stress responses were involved during the early stage of LV diastolic dysfunction. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2021; 21: 577-583.

Attitudes toward deprescribing among adults with heart failure with preserved ejection fraction

BACKGROUND/OBJECTIVES

Attitudes toward deprescribing could vary among subpopulations. We sought to understand patient attitudes toward deprescribing among patients with heart failure with preserved ejection fraction (HFpEF).

DESIGN

Retrospective cohort study.

SETTING

Academic medical center in New York City.

PARTICIPANTS

Consecutive patients with HFpEF seen in July 2018-December 2019 at a program dedicated to providing care to older adults with HFpEF.

MEASUREMENTS

We assessed the prevalence of vulnerabilities outlined in the domain management approach for caring for patients with heart failure and examined data on patient attitudes toward having their medicines deprescribed via the revised Patient Attitudes Toward Deprescribing (rPATD).

RESULTS

Among 134 patients with HFpEF, median age was 75 (interquartile range 69-82), 60.4% were women, and 35.8% were nonwhite. Almost all patients had polypharmacy (94.0%) and 56.0% had hyperpolypharmacy; multimorbidity (80.6%) and frailty (78.7%) were also common. Overall, 90.3% reported that they would be willing to have one or more of their medicines deprescribed if told it was possible by their doctors; and 26.9% reported that they would like to try stopping one of their medicines to see how they feel without it. Notably, 91.8% of patients reported that they would like to be involved in decisions about their medicines. In bivariate logistic regression, nonwhite participants were less likely to want to try stopping one of their medicines to see how they feel without it (odds ratio 0.25, 95% confidence interval [0.09-0.62], p = 0.005).

CONCLUSIONS

Patients with HFpEF contend with many vulnerabilities that could prompt consideration for deprescribing. Most patients with HFpEF were amenable to deprescribing. Race may be an important factor that impacts patient attitudes toward deprescribing.

The Heart Failure with Preserved Ejection Fraction Conundrum-Redefining the Problem and Finding Common Ground?

PURPOSE OF REVIEW

Heart failure with preserved ejection fraction (HFpEF) or diastolic heart failure (DHF) makes up more than half of all congestive heart failure presentations (CHF). With an ageing population, the case load and the financial burden is projected to increase, even to epidemic proportions. CHF hospitalizations add too much of the financial and infrastructure strain. Unlike systolic heart failure (SHF), much is still either uncertain or unknown. Specifically, in epidemiology, the disease burden is established; however, risk factors and pathophysiological associations are less clear; diagnostic tools are based on rigid parameters without the ability to accurately monitor treatments effects and disease progression; finally, therapeutics are similar to SHF but without prognostic data for efficacy.

RECENT FINDINGS

The last several years have seen guidelines changing to account for greater epidemiological observations. Most of these remain general observation of shortness of breath symptom matched to static echocardiographic parameters. The introduction of exercise diastolic stress test has been welcome and warrants greater focus. HFpEF is likely to see new thinking in the coming decades. This review provides some of perspective on this topic.

The Role of Oxidative Stress in Cardiovascular Aging and Cardiovascular Diseases

Aging can be seen as process characterized by accumulation of oxidative stress induced damage. Oxidative stress derives from different endogenous and exogenous processes, all of which ultimately lead to progressive loss in tissue and organ structure and functions. The oxidative stress theory of aging expresses itself in age-related diseases. Aging is in fact a primary risk factor for many diseases and in particular for cardiovascular diseases and its derived morbidity and mortality. Here we highlight the role of oxidative stress in age-related cardiovascular aging and diseases. We take into consideration the molecular mechanisms, the structural and functional alterations, and the diseases accompanied to the cardiovascular aging process.

A Sex-Specific Role of Endothelial Sirtuin 3 on Blood Pressure and Diastolic Dysfunction in Female Mice

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is characterized by a diastolic dysfunction and is highly prevalent in aged women. Our study showed that ablation of endothelial Sirtuin 3 (SIRT3) led to diastolic dysfunction in male mice. However, the sex-specific role of endothelial SIRT3 deficiency on blood pressure and diastolic function in female mice remains to be investigated.

METHODS AND RESULTS

In this study, we demonstrate that the ablation of endothelial SIRT3 in females elevated blood pressure as compared with control female mice. Diastolic function measurement also showed that the isovolumic relaxation time (IVRT) and myocardial performance index (MPI) were significantly increased, whereas the E' velocity/A' velocity (E'/A') ratio was reduced in the endothelial-specific SIRT3 knockout (SIRT3 ECKO) female mice. To further investigate the regulatory role of endothelial SIRT3 on blood pressure and diastolic dysfunction in metabolic stress, SIRT3 ECKO female mice were fed a normal diet and high-fat diet (HFD) for 20 weeks. The knockout of endothelial SIRT3 resulted in an increased blood pressure in female mice fed with an HFD. Intriguingly, SIRT3 ECKO female mice + HFD exhibited impaired coronary flow reserve (CFR) and more severe diastolic dysfunction as evidenced by an elevated IVRT as compared with control female mice + HFD. In addition, female SIRT3 ECKO mice had higher blood pressure and diastolic dysfunction as compared to male SIRT3 ECKO mice. Moreover, female SIRT3 ECKO mice + HFD had an impaired CFR and diastolic dysfunction as compared to male SIRT3 ECKO mice + HFD.

CONCLUSIONS

These results implicate a sex-specific role of endothelial SIRT3 in regulating blood pressure and diastolic function in mice. Deficiency of endothelial SIRT3 may be responsible for a diastolic dysfunction in aged female.

Bioinformatics analysis of autophagy-lysosomal degradation in cardiac aging

AIM

Cardiac aging, which causes cardiac diastolic dysfunction, frequently occurs in older people. The role of autophagy in cardiac aging is the subject of intensive research. Autophagy comprises steps called the autophagosome formation and autophagosome-lysosome fusion. Caloric restriction (CR) is the gold standard used to induce autophagosome formation, and autophagosome-lysosome fusion is reduced by aging. However, few studies are available that survey and compare signaling during CR (autophagosome formation induced status) and old (potentially autophagosome-lysosome fusion-reduced status). Here we aimed to identify the rate-limiting step of autophagic disorders during cardiac aging.

METHODS

We employed bioinformatics to analyze publicly available DNA microarray datasets. The first dataset compared the hearts of young and old C57BL6 mice (OLD). The second dataset compared the hearts of young C57BL6 mice fed a normal diet with those of young C57BL6 mice subjected to CR.

RESULTS

We analyzed OLD-upregulated genes that were significantly associated with the Gene Ontogeny term "Autophagy," indicating that autophagic genes were upregulated in OLD mice. The autophagy-related gene Atg5 and Atg5-related genes were upregulated in OLD and CR mice. The identified hub and bottleneck genes are autophagic autophagosome formation suppressors such as Sirt2, Ilk and Islr, as well as the autophagosome-lysosome fusion inducer Snapin.

CONCLUSIONS

Autophagosome formation genes were upregulated in aging mice subjected to CR, indicating that an upregulated autophagosome formation is not a change specific to cardiac aging. However, autophagosome-lysosome fusion genes, particularly the lysosome transportation-related gene Snapin, were downregulated in aging, indicating that autophagosome-lysosome fusion may cause autophagic disorders in cardiac aging. Geriatr Gerontol Int 2021; 21: 108-115.

Current Understanding of the Role of Frailty in Cardiovascular Disease

The elderly population is increasing because of increasing life expectancy, and the prevalence of frailty increases with age. Frailty commonly coexists with cardiovascular diseases (CVDs), such as coronary artery disease (CAD), heart failure (HF), aortic stenosis (AS), and atrial fibrillation (AF). Frail patients who undergo revascularization for CAD have higher complication rates; those with HF have a high prevalence of poor outcomes, and those with AF are vulnerable to increased stroke incidence. Moreover, frailty and asymptomatic severe AS were independent factors for mortality. The presence of frailty can lead to poor clinical outcomes, and frailty has been identified as a risk factor for mortality. Thus, the identification of frail patients who are at higher risks of disability and adverse clinical outcomes is important. In this review, the relationship between frailty and CVD is appraised and optimal treatments for frail patients are discussed.

Characteristics of current heart failure patients admitted to internal medicine vs. cardiology hospital units: the VASCO study

The majority of patients hospitalized for heart failure (HF) are admitted to internal medicine (IM) rather than to cardiology (CA) units, but to date few studies have analyzed the characteristics of these two populations. In this snapshot survey, we compared consecutive patients admitted for HF in six IM units vs. one non-intensive CA unit. During the 6-month survey period, 467 patients were enrolled (127 in CA, 27.2% vs. 340 in IM, 72.8%). IM patients were almost 10 years older (CA 75 ± 10, IM 82 ± 8 years; p < 0.001), more frequently female (CA 39%, IM 55%; p = 0.002) and living at home alone (CA 12%, IM 21%; p = 0.017). The leading cause of hospitalization in both groups was acute worsening of HF (CA 42%, IM 53%; p = 0.031), followed by atrial fibrillation (CA 29%, IM 12%; p < 0.001) and infections (CA 24%, IM 27%; p = 0.563). Ischemic (CA 43%, IM 30%; p = 0.008) and dilated cardiomyopathy patients (CA 21%, IM 12%; p < 0.001) were primarily admitted to CA unit, whereas those with hypertensive heart disease to IM (CA 3%, IM 39%; p < 0.001). Left ventricular ejection fraction (LVEF) was available in 96% of CA patients, but only in 60% of IM patients (p = 0.001). Among patients with LVEF measured, those with LVEF < 40% were predominantly admitted to CA (CA 60%, IM 14%; p < 0.001), whereas those with LVEF ≥ 50% were admitted to IM (CA 21%, IM 33%; p = 0.019); 26% of IM patients were discharged without a known LVEF. Medical treatments also significantly differed, according to patients' clinical and instrumental characteristics in each unit. This study demonstrates important differences between HF patients hospitalized in CA vs. IM, and the need for a greater interaction between these two medical specialties for a better care of HF patients.

Tissue Doppler Imaging and strain rate of the left atrial lateral wall: age related variations and comparison with parameters of diastolic function

Background

Strain Rate Imaging (SRI) is one of the most used techniques to study left atrial (LA) and diastolic function. Its availability in low-income countries is diminished since it requires additional expensive software, among other limitations. In contrast, Tissue Doppler Imaging (TDI) is widely available and easy to use. We hypothesize TDI could detect changes in LA and diastolic function associated with age similarly to SRI. The aim of this study is to evaluate the effects of age on LA and diastolic function assessed by LA lateral wall TDI online by spectral pulse, and to compare them with age-related variations of LA SRI and other parameters of diastolic function in a population of healthy adults.

Materials and methods

Ninety-one healthy adults were prospectively evaluated. In apical four - chamber view the LA lateral wall was divided in three portions. Peak velocities of basal and mid portions were measured with TDI online by spectral pulse and with SRI by speckle tracking. A first positive wave (S’la and SRS) and two negative waves (E’la and SRE, and A’la and SRA respectively) were obtained. E’la/A’la ratio and SRE/SRA ratio were analyzed. The distribution of the variables by age subgroups was described and analyzed. Correlation analyses were performed.

Results

The median age was 42 years old and 54.9% were female. E’la/A’la showed a negative good correlation with age. E’la/A’la and SRE/SRA ratios changed from > 1 to < 1 in the age group of 41–50 years old, while this occurred in the group of 51–60 years old for the E/A ratio. Lateral and septal mitral annulus E´ showed decrease with age and prolongation of E-wave deceleration time was observed in the age group over 61 years old.

Conclusion

Normal values​​ according to age group of TDI of the LA lateral wall were obtained. Age-related changes in LA and diastolic function could be detected as early with TDI as with SRI. Future studies are required to explore if this method could be used to address in part LA or diastolic function in other populations with established cardiovascular disease or at risk of presenting it, which could be useful in low-income settings, where SRI is not available.

Treatment with a DC-SIGN ligand reduces macrophage polarization and diastolic dysfunction in the aging female but not male mouse hearts

Cardiac diastolic dysfunction in aging arises from increased ventricular stiffness caused by inflammation and interstitial fibrosis. The diastolic dysfunction contributes to heart failure with preserved ejection fraction (HFpEF), which in the aging population is more common in women. This report examines its progression over 12 weeks in aging C57BL/6J mice and correlates its development with changes in macrophage polarization and collagen deposition.

Aged C57BL/6J mice were injected with dendritic cell–specific intercellular adhesion molecule-3-grabbing nonintegrin (DC-SIGN) ligand 1 (DCSL1, an anti-inflammatory agent) or saline for 12 weeks. Echo and Doppler measurements were performed before and after 4 and 12 weeks of treatment. DCSL1 prevented the worsening of diastolic dysfunction over time in females but not in males. Cardiac single cell suspensions analyzed by flow cytometry revealed changes in the inflammatory infiltrate: (1) in males, there was an increased total number of leukocytes with an increased pro-inflammatory profile compared with females and they did not respond to DCSL1; (2) by contrast, DCSL1 treatment resulted in a shift in macrophage polarization to an anti-inflammatory phenotype in females. Notably, DCSL1 preferentially targeted tumor necrosis factor-α (TNFα⁺) pro-inflammatory macrophages. The reduction in pro-inflammatory macrophage polarization was accompanied by a decrease in collagen content in the heart.

Age-associated diastolic dysfunction in mice is more severe in females and is associated with unique changes in macrophage polarization in cardiac tissue. Treatment with DCSL1 mitigates the changes in inflammation, cardiac function, and fibrosis. The characteristics of diastolic dysfunction in aging female mice mimic similar changes in aging women.

The ubiquitin ligase WWP1 contributes to shifts in matrix proteolytic profiles and a myocardial aging phenotype with diastolic heart

Ubiquitylation is a key event that regulates protein turnover, and induction of the ubiquitin ligase E3 WWP1 has been associated with age. Left ventricular hypertrophy (LVH) commonly occurs as a function of age and can cause heart failure (HF) with a preserved ejection fraction (EF; HFpEF). We hypothesized that overexpression (O/E) of WWP1 in the heart would cause LVH as well as functional and structural changes consistent with the aging HFpEF phenotype. Global WWP1 O/E was achieved in mice (n = 11) and echocardiography (40 MHz) performed to measure LV mass, EF, Doppler velocities (early E, late/atrial A), myocardial relaxation (E'), and isovolumetric relaxation time (IVRT) at 4, 6, and 8 wk. Age-matched wild-type animals (n = 15) were included as referent controls. LV EF was identical (60 ± 1 vs. 60 ± 1%, P > 0.90) with no difference in LV mass (67 ± 3 vs. 75 ± 5, P > 0.25) at 4 wk. However, at 8 wk of age, LV mass increased over twofold, E/A fell (impaired passive filling), and E/E' was lower and IVRT prolonged (impaired LV relaxation) - all P < 0.05. Collagen percent area increased by over twofold and fibrillar collagen expression (RT-PCR) over 1.5-fold (P < 0.05) with WWP1 O/E. WWP1 with an anti-WWP1 antibody could be identified in isolated cardiac fibroblasts, with WWP1 increased over twofold in O/E fibroblasts (P < 0.05). Inducing WWP1 expression caused LVH and preserved systolic function but impaired diastolic dysfunction, consistent with the HFpEF phenotype. Targeting the WWP1 pathway may be a novel therapeutic target for this intractable form of HF associated with aging.NEW & NOTEWORTHY Heart failure (HF) with a preserved ejection fraction (HFpEF) is a growing cause of HF and commonly afflicts the elderly. Milestones for HFpEF include diastolic dysfunction and an abnormal extracelluar matrix (ECM). The ubiquitin ligases, such as WWP1, change with aging and regulate critical protein turnover/stability processes, such as the ECM. The present study demonstrated that induction of WWP1 in mice induced LV hypertrophy, diastolic dysfunction, and ECM accumulation, consistent with the HFpEF phenotype, and thus may identify a new therapeutic pathway.

Assessment of diastolic dysfunction: comparison of different cardiovascular magnetic resonance techniques

Aims

Heart failure with preserved ejection fraction is still a diagnostic and therapeutic challenge, and accurate non‐invasive diagnosis of left ventricular (LV) diastolic dysfunction (DD) remains difficult. The current study aimed at identifying the most informative cardiovascular magnetic resonance (CMR) parameters for the assessment of LVDD.

Methods and results

We prospectively included 50 patients and classified them into three groups: with DD (DD+, n = 15), without (DD−, n = 26), and uncertain (DD±, n = 9). Diagnosis of DD was based on echocardiographic E/E′, invasive LV end‐diastolic pressure, and N‐terminal pro‐brain natriuretic peptide. CMR was performed at 1.5 T to assess LV and left atrial (LA) morphology, LV diastolic strain rate (SR) by tissue tracking and tagging, myocardial peak velocities by tissue phase mapping, and transmitral inflow profile using phase contrast techniques. Statistics were performed only on definitive DD+ and DD− (total number 41). DD+ showed enlarged LA with LA end‐diastolic volume/height performing best to identify DD+ with a cut‐off value of ≥0.52 mL/cm (sensitivity = 0.71, specificity = 0.84, and area under the receiver operating characteristic curve = 0.75). DD+ showed significantly reduced radial (inferolateral E peak: DD−: −14.5 ± 6.5%/s vs. DD+: −10.9 ± 5.9%/s, P = 0.04; anterolateral A peak: DD−: −4.2 ± 1.6%/s vs. DD+: −3.1 ± 1.4%/s, P = 0.04) and circumferential (inferolateral A peak: DD−: 3.8 ± 1.2%/s vs. DD+: 2.8 ± 0.8%/s, P = 0.007; anterolateral A peak: DD−: 3.5 ± 1.2%/s vs. DD+: 2.5 ± 0.8%/s, P = 0.048) SR in the basal lateral wall assessed by tissue tracking. In the same segments, DD+ showed lower peak myocardial velocity by tissue phase mapping (inferolateral radial peak: DD−: −3.6 ± 0.7 ms vs. DD+: −2.8 ± 1.0 ms, P = 0.017; anterolateral longitudinal peak: DD−: −5.0 ± 1.8 ms vs. DD+: −3.4 ± 1.4 ms, P = 0.006). Tagging revealed reduced global longitudinal SR in DD+ (DD−: 45.8 ± 12.0%/s vs. DD+: 34.8 ± 9.2%/s, P = 0.022). Global circumferential and radial SR by tissue tracking and tagging, LV morphology, and transmitral flow did not differ between DD+ and DD−.

Conclusions

Left atrial size and regional quantitative myocardial deformation applying CMR identified best patients with DD.

Sirtuin 3, Endothelial Metabolic Reprogramming, and Heart Failure With Preserved Ejection Fraction

The incidences of heart failure with preserved ejection fraction (HFpEF) are increased in aged populations as well as diabetes and hypertension. Coronary microvascular dysfunction has contributed to the development of HFpEF. Endothelial cells (ECs) depend on glycolysis rather than oxidative phosphorylation for generating adenosine triphosphate to maintain vascular homeostasis. Glycolytic metabolism has a critical role in the process of angiogenesis, because ECs rely on the energy produced predominantly from glycolysis for migration and proliferation. Sirtuin 3 (SIRT3) is found predominantly in mitochondria and its expression declines progressively with aging, diabetes, obesity, and hypertension. Emerging evidence indicates that endothelial SIRT3 regulates a metabolic switch between glycolysis and mitochondrial respiration. SIRT3 deficiency in EC resulted in a significant decrease in glycolysis, whereas, it exhibited higher mitochondrial respiration and more prominent production of reactive oxygen species. SIRT3 deficiency also displayed striking increases in acetylation of p53, EC apoptosis, and senescence. Impairment of SIRT3-mediated EC metabolism may lead to a disruption of EC/pericyte/cardiomyocyte communications and coronary microvascular rarefaction, which promotes cardiomyocyte hypoxia, Titin-based cardiomyocyte stiffness, and myocardial fibrosis, thus leading to a diastolic dysfunction and HFpEF. This review summarizes current knowledge of SIRT3 in EC metabolic reprograming, EC/pericyte interactions, coronary microvascular dysfunction, and HFpEF.

Exercise training reverses cardiac aging phenotypes associated with heart failure with preserved ejection fraction in male mice

Heart failure with preserved ejection fraction (HFpEF) is the most common type of HF in older adults. Although no pharmacological therapy has yet improved survival in HFpEF, exercise training (ExT) has emerged as the most effective intervention to improving functional outcomes in this age‐related disease. The molecular mechanisms by which ExT induces its beneficial effects in HFpEF, however, remain largely unknown. Given the strong association between aging and HFpEF, we hypothesized that ExT might reverse cardiac aging phenotypes that contribute to HFpEF pathophysiology and additionally provide a platform for novel mechanistic and therapeutic discovery. Here, we show that aged (24–30 months) C57BL/6 male mice recapitulate many of the hallmark features of HFpEF, including preserved left ventricular ejection fraction, subclinical systolic dysfunction, diastolic dysfunction, impaired cardiac reserves, exercise intolerance, and pathologic cardiac hypertrophy. Similar to older humans, ExT in old mice improved exercise capacity, diastolic function, and contractile reserves, while reducing pulmonary congestion. Interestingly, RNAseq of explanted hearts showed that ExT did not significantly modulate biological pathways targeted by conventional HF medications. However, it reversed multiple age‐related pathways, including the global downregulation of cell cycle pathways seen in aged hearts, which was associated with increased capillary density, but no effects on cardiac mass or fibrosis. Taken together, these data demonstrate that the aged C57BL/6 male mouse is a valuable model for studying the role of aging biology in HFpEF pathophysiology, and provide a molecular framework for how ExT potentially reverses cardiac aging phenotypes in HFpEF.

Differential Gender-Dependent Patterns of Cardiac Fibrosis and Fibroblast Phenotypes in Aging Mice

Aging is characterized by physiological changes within the heart leading to fibrosis and dysfunction even in individuals without underlying pathologies. Gender has been shown to influence the characteristics of cardiac aging; however, gender-dependent cardiac fibrosis occurring with age remains largely not elucidated. Thus, broadening our understanding of this phenomenon proves necessary in order to develop novel anti-fibrotic strategies in the elderly. In this study, we aim to characterize cardiac fibrosis and cardiac fibroblast (CF) populations in aged male and female mice. Echocardiography revealed eccentric hypertrophy with left ventricular dilatation in the aged male versus concentric hypertrophy with left posterior wall thickening in the female, with preserved cardiac function in both groups. Reactive fibrosis was evidenced in the myocardium and epicardium of the aged female mice hearts whereas perivascular and replacement ones where present in the male heart. Collagen I was predominant in the aged male heart whereas collagen III was the main component in the female heart. CFs in the aged male heart were mainly recruited from resident PDGFRα⁺ populations but not derived from epicardium as evidenced by the absence of epicardial progenitor transcription factors Tcf21, Tbx18 and Wt1. Our results present a paradigm for gender-dependent cardiac fibrosis and the origins of CFs with age. This sets forth to revisit cardiac anti-fibrotic management according to the gender in the elderly and to explore novel therapeutic targets.

Cardiomyocyte ageing and cardioprotection: consensus document from the ESC working groups cell biology of the heart and myocardial function

Advanced age is a major predisposing risk factor for the incidence of coronary syndromes and comorbid conditions which impact the heart response to cardioprotective interventions. Advanced age also significantly increases the risk of developing post-ischaemic adverse remodelling and heart failure after ischaemia/reperfusion (IR) injury. Some of the signalling pathways become defective or attenuated during ageing, whereas others with well-known detrimental consequences, such as glycoxidation or proinflammatory pathways, are exacerbated. The causative mechanisms responsible for all these changes are yet to be elucidated and are a matter of active research. Here, we review the current knowledge about the pathophysiology of cardiac ageing that eventually impacts on the increased susceptibility of cells to IR injury and can affect the efficiency of cardioprotective strategies.

SMN-deficiency disrupts SERCA2 expression and intracellular Ca2+ signaling in cardiomyocytes from SMA mice and patient-derived iPSCs

Spinal muscular atrophy (SMA) is a neurodegenerative disease characterized by loss of alpha motor neurons and skeletal muscle atrophy. The disease is caused by mutations of the SMN1 gene that result in reduced functional expression of survival motor neuron (SMN) protein. SMN is ubiquitously expressed, and there have been reports of cardiovascular dysfunction in the most severe SMA patients and animal models of the disease. In this study, we directly assessed the function of cardiomyocytes isolated from a severe SMA model mouse and cardiomyocytes generated from patient-derived IPSCs. Consistent with impaired cardiovascular function at the very early disease stages in mice, heart failure markers such as brain natriuretic peptide were significantly elevated. Functionally, cardiomyocyte relaxation kinetics were markedly slowed and the T₅₀ for Ca²⁺ sequestration increased to 146 ± 4 ms in SMN-deficient cardiomyocytes from 126 ± 4 ms in wild type cells. Reducing SMN levels in cardiomyocytes from control patient IPSCs slowed calcium reuptake similar to SMA patent-derived cardiac cells. Importantly, restoring SMN increased calcium reuptake rate. Taken together, these results indicate that SMN deficiency impairs cardiomyocyte function at least partially through intracellular Ca²⁺ cycling dysregulation.

Heart failure and chronic obstructive pulmonary disease: a review

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are important causes of morbidity and mortality worldwide. The association between the two conditions have significant systemic effects and a chronic, progressive evolution, affecting exercise tolerance and quality of life. The diseases share common risk factors, such as smoking, advanced age, and low-grade systemic inflammation. The majority of symptoms and physical signs, such as dyspnoea, orthopnea, nocturnal cough, exercise intolerance, muscle weakness may coexist in both pathologies. Thus, the differential clinical diagnosis between exacerbation of COPD and HF decompensation may be difficult. Natriuretic peptides are sensitive biomarkers of HF, used mostly to exclude HF if their values are less than 100 pg/mL for Brain Natriuretic Peptide (BNP), respectively less than 300 pg/mL for N-terminal-pro Brain Natriuretic Peptide (NT-proBNP). Natriuretic peptides are very useful in emergency, for the differential diagnosis of acute dyspnoea. Echocardiography is the standard imaging technique of HF diagnosis and should be performed in all patients with potential HF. Treatment of patients with both HF and COPD should include drugs that prolong survival in HF, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, cardioselective beta1-blockers, aldosterone antagonists, and long-acting bronchodilators (an antimuscarinic rather than a beta2-agonist). The prognosis of patients with both diseases is worse than in patients with only one of the two conditions. These patients represent a continuous challenge of diagnosis and treatment for the clinicians and require a close monitoring of cardiopulmonary function.

Heart Failure and Adipose Mesenchymal Stem Cells

Mesenchymal stem cells (MSCs) are considered a promising cell type for the treatment of heart failure (HF). In particular, MSCs in adipose tissue are being evaluated as an effective therapeutic tool. However, adipose MSCs are a major source of adipocyte generation and linked to obesity, which is an independent risk factor for HF. MSCs express all of the components of the renin-angiotensin system (RAS), which plays a pivotal role in the pathophysiology of HF. The local RAS also regulates MSC adipogenesis, indicating a connection between MSC-adipogenesis-obesity and HF. This review examines evidence of the complex relationship between HF and adipose MSCs and discusses how to explore this association for favorable therapeutic outcomes for HF.

Cardiac Manifestations of Sarcopenia

OBJECTIVES

Screening questions for sarcopenia used in the community (SARC-F) may be regarded as indicators of exercise tolerance.

DESIGN

Observational study.

SETTING

We tested the hypothesis that community-living older people who are screened positive for sarcopenia using the SARC-F tool but without a history of heart failure (HF) have a higher prevalence of cardiac abnormalities compared with those who are SARC-F negative.

PARTICIPANTS

Participants were recruited from a territory-wide primary care needs assessment for older people based in community centres, and from non-acute hospitals in the same region as the study centre.

MEASUREMENTS

Participants with a total score of >=4 and who did not have any history of HF were invited to attend for further cardiac assessment. Grip strength, walking speed, and the 6-minute walk test and echocardiography were carried out. Patients with frailty and at least Grade II diastolic dysfunction were considered to have heart failure with preserved ejection fraction (HFpEF) if they also had concomitant elevated N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) of at least 300 pg/ml.

RESULTS

Diastolic dysfunction (DD) was significantly associated with SARC-F score >=4 and higher circulating NT-proBNP levels. ROC curves evaluating the predictive values of SARC-F, HGS and gait speed for DD showed that a combination of SARC-F and HGS or gait speed provided significant incremental value in predicting DD.

CONCLUSIONS

Community living older people with sarcopenia detected using a simple questionnaire have a higher prevalence of DD accompanied by elevated NT proBNP. Addition of hand grip strength or walking speed improve the magnitude of the association. SARC-F may be used as a tool to detect early cardiac dysfunction in the community.

Improved Cardiovascular Function in Old Mice After N-Acetyl Cysteine and Glycine Supplemented Diet: Inflammation and Mitochondrial Factors

Metabolic, inflammatory, and functional changes occur in cardiovascular aging which may stem from oxidative stress and be remediable with antioxidants. Glutathione, an intracellular antioxidant, declines with aging, and supplementation with glutathione precursors, N-acetyl cysteine (NAC) and glycine (Gly), increases tissue glutathione. Thirty-month old mice were fed diets supplemented with NAC or NAC+Gly and, after 7 weeks, cardiac function and molecular studies were performed. The NAC+Gly supplementation improved diastolic function, increasing peak early filling velocity, and reducing relaxation time, left atrial volume, and left ventricle end diastolic pressure. By contrast, cardiac function did not improve with NAC alone. Both diet supplementations decreased cardiac levels of inflammatory mediators; only NAC+Gly reduced leukocyte infiltration. Several mitochondrial genes reduced with aging were upregulated in hearts by NAC+Gly diet supplementation. These Krebs cycle and oxidative phosphorylation enzymes, suggesting improved mitochondrial function, and permeabilized cardiac fibers from NAC+Gly-fed mice produced ATP from carbohydrate and fatty acid sources, whereas fibers from control old mice were less able to utilize fatty acids. Our data indicate that NAC+Gly supplementation can improve diastolic function in the old mouse and may have potential to prevent important morbidities for older people.

Coexisting Frailty With Heart Failure

People over 65 years of age constitute over 80% of patients with heart failure (HF) and the incidence of HF is 10 per 1,000 in people aged above 65 years. Approximately 25% of older patients with HF exhibit evidence of frailty. Frail patients with cardiovascular disease (CVD) have a worse prognosis than non-frail patients, and frailty is an independent risk factor for incident HF among older people. Planning the treatment of individuals with HF and concomitant frailty, one should consider not only the limitations imposed by frailty syndrome (FS) but also those associated with the underlying heart disease. It needs to be emphasized that all patients with HF and concomitant FS require individualized treatment.

Younger- vs Older-Old Patients with Heart Failure with Preserved Ejection Fraction

OBJECTIVES

Heart failure with preserved ejection fraction (HFpEF) is now recognized as a geriatric syndrome with multifactorial pathophysiology and clinical heterogeneity rather than a solely left ventricular diastolic dysfunction. Because the pathophysiology of HFpEF is suggested to differ by age, this study compared the clinical characteristics and prognostic factors between HFpEF patients aged 65 to 84 years and those aged 85 years or older.

DESIGN

Retrospective cohort study.

SETTING

The Tokyo CCU Network including 73 hospitals in Tokyo, Japan.

PARTICIPANTS

Individuals aged 65 years or older with HFpEF (N = 4305).

MEASUREMENTS

Very old patients were defined as those aged 85 years or older. Potential risk factors for in-hospital mortality were selected by univariate analyses, and those with a P value <.10 were used in multivariate Cox regression analysis with forward selection (likelihood ratio) to identify significant factors.

RESULTS

Prevalence of hypertension was significantly higher in very old patients, whereas prevalence of coronary artery disease, diabetes mellitus, hyperlipidemia, and smoking was significantly higher in patients aged 65 to 84 years. In very old patients, low systolic blood pressure (hazard ratio [HR] = .988), high serum creatinine level (HR = 1.34), and coexisting chronic obstructive pulmonary disease (COPD; HR = 2.01) were identified as independent risk factors for in-hospital mortality. In contrast, low systolic blood pressure (HR = .987) and low body mass index (HR = .935) were identified as independent risk factors in patients aged 65 to 84 years.

CONCLUSION

Significant differences were observed in the clinical characteristics and prognostic factors for in-hospital mortality between HFpEF patients aged 65 to 84 and those 85 years and older. Of note, coexisting COPD was associated with significantly lower survival rate only in patients aged 85 years and older, suggesting the prognostic impact of concomitant pulmonary disease in HFpEF may increase with age. These results have implications for future research and management of older HFpEF patients. J Am Geriatr Soc 00:1-6, 2019. J Am Geriatr Soc 67:2123-2128, 2019.