Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial

Pathophysiology of heart failure with preserved ejection fraction in overweight and obesity - Clinical and treatment implications

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome with vast prevalence worldwide. Despite recent advances in understanding its pathophysiology, HFpEF remains under-diagnosed in clinical practice. Obesity-related HFpEF is a distinct and frequent phenotype with an additionally challenging diagnosis. We address the importance of overweight and obesity in HFpEF, focusing on the influence of adipose tissue in inflammation and neurohormonal activity. We also discuss atrial and ventricular remodelling in obesity-related HFpEF and potential clinical implications. Obesity is an independent risk factor for HFpEF. Adipose tissue synthesizes aldosterone, causing lower levels of natriuretic peptide. Adipocytes dysfunction promotes a pro-inflammatory state and leads to extracellular matrix remodelling and consequently stiffening of the heart and vessels. Thus, the quantity, distribution and quality of the excess fat influences cardiovascular risk. Visceral and epicardial adipose tissue are often associated with an increased likelihood of developing HFpEF. Obesity-related HFpEF presents higher risk of left ventricular concentric remodelling and inadequate accommodation of the expanded volume due to the obesity, resulting in higher left ventricular filling pressure. Nevertheless, microvascular endothelium inflammation modifies cardiomyocyte elasticity and increases collagen deposition, which enhances myocardial fibrosis and results in HFpEF. Furthermore, neurohormonal activation may also contribute to cardiac remodelling by inducing plasma volume expansion. In turn, leptin also stimulates aldosterone synthesis and enhances renin-angiotensin-aldosterone system. Obesity-related HFpEF presents worse overall prognosis, with increased risk of heart failure hospitalization and all-cause mortality. Intentional weight loss through caloric restriction, physical activity, pharmacological intervention and/or bariatric surgery are promising strategies.

Timing of acute decompensated heart failure in patients with heart failure and mildly reduced ejection fraction

This study investigates the prognosis of acute decompensated heart failure (ADHF) on admission (i.e., primary ADHF) as compared to ADHF onset during course of hospitalization (i.e., secondary ADHF) in patients hospitalized with heart failure with mildly reduced ejection fraction (HFmrEF). Limited data regarding the prognostic impact of the timing of onset of ADHF is available. Consecutive patients with HFmrEF and ADHF were retrospectively included at one institution from 2016 to 2022. Patients with primary ADHF were compared to patients with secondary ADHF with regard to the primary endpoint all-cause mortality at 30 months. Kaplan-Meier, uni- and multivariable Cox proportional regression analyses were applied for statistics. From a total of 484 patients hospitalized with HFmrEF and ADHF, 67.98% (n = 329) were admitted with primary ADHF. Patients with secondary ADHF had higher rates of concomitant acute myocardial infarction, alongside with a higher extend of coronary artery disease. The risk of all-cause mortality at 30 months was not affected by the timing of ADHF (hazard ratio (HR) = 0.853; 95% confidence interval (CI) 0.653-1.115; p = 0.246). However, patients with primary ADHF were associated with a higher risk of HF-related rehospitalization at 30 months (HR = 2.513; 95% CI 1.555-4.065; p = 0.001), which was still evident after multivariable adjustment (HR = 2.347; 95% CI 1.418-3.883; p = 0.001). The timing of onset of ADHF was not associated with long-term mortality in HFmrEF, however primary ADHF was associated with a higher risk of HF-related rehospitalization.

Systolic blood pressure lower than 130 mmHg in heart failure with preserved ejection fraction: a systematic review and meta-analysis of clinical outcomes

The optimal blood pressure (BP) management level for patients with heart failure (HF) with preserved ejection fraction (HFpEF) remains unclear. In conjunction with the upcoming the Japanese Society of Hypertension Guidelines for the Management of Hypertension 2025 (JSH2025), we conducted a systematic review and meta-analysis to evaluate whether managing systolic BP (SBP) < 130 mmHg improves outcomes in HFpEF patients. We searched PubMed, Cochrane and Ichishi for randomized controlled trials (RCTs) published since 2012 that targeted HFpEF patients; used strict BP control, antihypertensive medications, or intensive HF management as interventions; demonstrated significant BP reduction with achieved SBP < 130 mmHg in intervention groups; and had follow-up periods ≥6 months. Six studies were included, evaluating mineralocorticoid receptor antagonists (n = 2), angiotensin receptor-neprilysin inhibitors (n = 2), intensive BP control (n = 1), and intensive HF management (n = 1). Meta-analysis showed that achieving SBP < 130 mmHg significantly reduced HF hospitalizations (relative risk [RR] [95% confidence interval (CI)] 0.80 [0.69-0.93], p = 0.005) and demonstrated a trend toward reduced all-cause mortality (RR [95% CI] 0.74 [0.53-1.04], p = 0.083). While hypotension increased (RR [95% CI] 1.35 [1.03-1.79], p = 0.03), there was no significant increase in renal dysfunction or serious adverse events. Despite limitations from indirectness (no RCTs specifically targeted SBP < 130 mmHg as primary intervention), our findings suggest that achieving SBP < 130 mmHg in HFpEF patients may improve clinical outcomes. We recommend managing HFpEF patients to achieve SBP < 130 mmHg, while carefully monitoring for hypotension.

Renal-Cardiac Crosstalk in the Pathogenesis and Progression of Heart Failure

Chronic kidney disease (CKD) represents a global health issue with a high socioeconomic impact. Beyond a progressive decline of kidney function, patients with CKD are at increased risk of cardiovascular diseases, including heart failure (HF) and sudden cardiac death. HF in CKD can manifest both as HF with reduced ejection fraction and HF with preserved ejection fraction, with the latter further increasing in relative importance in the more advanced stages of CKD. Typical cardiac remodeling characteristics in uremic cardiomyopathy include left ventricular hypertrophy, myocardial fibrosis, cardiac electrical dysregulation, capillary rarefaction, and microvascular dysfunction, which are triggered by increased cardiac preload, cardiac afterload, and preload and afterload-independent factors. The pathophysiological mechanisms underlying cardiac remodeling in CKD are multifactorial and include neurohormonal activation (with increased activation of the renin-angiotensin-aldosterone system, the sympathetic nervous system, and mineralocorticoid receptor signaling), cardiac steroid activation, mitochondrial dysfunction, inflammation, innate immune activation, and oxidative stress. Furthermore, disturbances in cardiac metabolism and calcium homeostasis, macrovascular and microvascular dysfunction, increased cellular profibrotic responses, the accumulation of uremic retention solutes, and mineral and bone disorders also contribute to cardiovascular disease and HF in CKD. Here, we review the current knowledge of HF in CKD, including the clinical characteristics and pathophysiological mechanisms revealed in animal studies. We also elaborate on the detrimental impact of comorbidities of CKD on HF using hypertension as an example and discuss the clinical characteristics of hypertensive heart disease and the genetic predisposition. Overall, this review aims to increase the understanding of HF in CKD to support future research and clinical translational approaches for improved diagnosis and therapy of this vulnerable patient population.

Heart failure with preserved ejection fraction therapeutics: in search of the pillars

Heart failure (HF) affects nearly 8 million individuals in the USA, with approximately half diagnosed with heart failure with preserved ejection fraction (HFpEF). HFpEF is associated with high morbidity and mortality, with fewer than 25% of patients surviving beyond 5 years after diagnosis. Historically, poor outcomes have been largely attributed to a lack of effective disease-modifying therapies. However, the past 5 years have marked a transformative era in HFpEF management, with multiple landmark clinical trials demonstrating benefits for novel therapeutic classes. These include sodium-glucose cotransporter 2 inhibitors (SGLT2i), non-steroidal mineralocorticoid receptor antagonists (Ns-MRAs), and glucagon-like peptide-1 (GLP-1) receptor agonists, particularly for the obesity-related HFpEF phenotype. In this review, we summarize the evolution of HFpEF therapeutics, from traditional heart failure treatments with limited efficacy to emerging targeted therapies, highlighting the latest evidence shaping a modern, comprehensive approach to HFpEF management.

Diagnosis of Diastolic Dysfunction in Adults With Failing Fontan Circulation

Since the initial Fontan procedure introduced in 1968 for tricuspid atresia, significant advancements have expanded its application to various congenital cardiac anomalies where a biventricular circulation is unattainable. Despite improved survival rates, Fontan circulation tends to fail over time leading to late morbidity and mortality. Diastolic dysfunction is increasingly recognized as a significant contributor to circulatory insufficiency and failure in Fontan patients. This review aims to assess the current evidence for diagnosing diastolic dysfunction in adults with failing Fontan circulation, including biomarkers, echocardiography, cardiac magnetic resonance imaging, and catheterization. While advancements have been made in understanding diastolic dysfunction in single ventricles, challenges remain due to the unique anatomy and physiology of Fontan patients. Future research should focus on refining diagnostic parameters and exploring potential therapies tailored to the distinct needs of this population.

The effects of SGLT2i on cardiac metabolism in patients with HFpEF: Fact or fiction?

The rising prevalence of Type 2 diabetes (T2D) has been closely associated with an increased incidence of cardiovascular diseases, particularly heart failure with preserved ejection fraction (HFpEF). Cardiometabolic disturbances in T2D, such as insulin resistance, hyperglycemia, and dyslipidemia, contribute to both microvascular and macrovascular complications, thereby intensifying the risk of heart failure. Sodium-glucose cotransporter-2 inhibitors (SGLT2i), initially developed as glucose-lowering agents for T2D, have demonstrated promising cardiovascular benefits in patients with heart failure, including those with preserved ejection fraction (HFpEF), regardless of T2D status. These benefits include reduced heart failure hospitalization rates and improvements in various metabolic parameters. This review aims to critically examine the effects of SGLT2i on cardiac metabolism in HFpEF, evaluating whether the observed benefits can truly be attributed to their impact on myocardial energy regulation or whether they represent other, potentially confounding, mechanisms. We will focus on the key metabolic processes possibly modulated by SGLT2i, including myocardial glucose utilization, fatty acid oxidation, and mitochondrial function, and explore their effects on heart failure pathophysiology. Additionally, we will address the role of SGLT2i in other pathogenetic factors involved in HFpEF, such as sodium and fluid balance, inflammation, and fibrosis, and question the extent to which these mechanisms contribute to the observed clinical benefits. By synthesizing the current evidence, this review will provide an in-depth analysis of the mechanisms through which SGLT2i may influence cardiac metabolism in HFpEF, assessing whether their effects are supported by robust scientific data or remain speculative. We will also discuss the potential for personalized treatment strategies, based on individual patient characteristics, to optimize the therapeutic benefits of SGLT2i in managing both T2D and cardiovascular risk. This review seeks to clarify the true clinical utility of SGLT2i in the management of cardiometabolic diseases and HFpEF, offering insights into their role in improving long-term cardiovascular outcomes.

Renin Angiotensin Inhibition and Lower Risk of Kidney Failure in Patients with Heart Failure: Subtitle: RAS inhibition and kidney failure in heart failure

BACKGROUND

Renin-angiotensin system (RAS) inhibitors reduce risk of kidney failure in patients with chronic kidney disease, but worsen kidney function in heart failure patients, especially in those with chronic kidney disease. Less is known about risk of kidney failure in heart failure patients receiving RAS inhibitors.

METHODS

We used propensity score matching for outcome-blinded assembly of 168,860 Veterans with heart failure phenotyped by artificial intelligence who were balanced on 77 baseline characteristics and initiated on RAS inhibitors. Hazard ratio (95% CI) for 5-year kidney failure in high-dose (versus low-dose) RAS inhibitor group was estimated, accounting for competing risk of death. Kidney failure was defined as kidney replacement therapy or estimated glomerular filtration rate (eGFR) <15 mL/min/1.73m2.

RESULTS

New-onset kidney failure occurred in 4.1% (3455/84,430) and 3.5% (2966/84,430) of patients in low-dose and high-dose RAS inhibitor groups, respectively (HR, 0.85; 95%CI, 0.81-0.89). Respective HRs (95%CIs) in eGFR subgroups ≥60, 45-59 and 15-44 mL/min/1.73m2 were 1.21 (1.08-1.36), 0.93 (0.82-1.05) and 0.82 (0.77-0.87). The association was similar across ejection fraction subgroups. There was a lower risk of death in the subgroup with ejection fraction ≤40%.

CONCLUSIONS

Patients with heart failure receiving high-dose (versus low-dose) RAS inhibitors had a lower associated risk of kidney failure, which was driven by the subgroup with chronic kidney disease. This new information may help to inform future guideline recommendations and clinical practice regarding RAS inhibitor use in these patients. Future studies need to examine this association in those with normal kidney function.

Left Atrial Unloading in Heart Failure With Preserved Ejection Fraction: In-Vitro Study of Interatrial Shunting and Continuous Flow Pumping

Heart failure with preserved ejection fraction (HFpEF) often presents with elevated left atrial (LA) pressure. Interatrial shunt devices (IASD) were developed and rotary blood pumps implanted off-label to reduce LA pressure in HFpEF patients. This study modeled an HFpEF patient in a mock circulation loop, comparing pulmonary decompression using an IASD (2-12 mm diameter) and a continuous flow (CF) centrifugal rotary blood pump (HeartMate 3; Abbott Laboratories, Abbott Park, IL) in LA to aortic configuration (1-6 L/min support). Left atrial pressure, pulmonary artery pressure (PAP), and cardiac output (CO) at 12 mm shunt diameter and 6 L/min pump support were primarily used to quantify pulmonary decompression. The IASD reduced LA pressure by 28% and 45%, while the CF reduced LA pressure by 135% and 51% at rest and exercise, respectively. Both devices reduced mean PAP by 13% (IASD) and 57% (CF) at rest and by 21% (IASD) and 32% (HM3) at exercise. The IASD resulted in reduced CO (rest: 14%, exercise 8%), but the CF increased CO (rest: 63%, exercise: 28%) and ventricular loading due to the LA to aortic configuration. Automated changes to rotary blood pump speed or IASD diameter may assist with unloading as physiologic conditions change.

Prognostic impact of prior LVEF in patients with heart failure with mildly reduced ejection fraction

AIMS

As there is limited evidence regarding the prognostic impact of prior left ventricular ejection fraction (LVEF) in patients with heart failure with mildly reduced ejection fraction (HFmrEF), this study investigates the prognostic impact of longitudinal changes in LVEF in patients with HFmrEF.

METHODS

Consecutive patients with HFmrEF (i.e. LVEF 41-49% with signs and/or symptoms of HF) were included retrospectively in a monocentric registry from 2016 to 2022. Based on prior LVEF, patients were categorized into three groups: stable LVEF, improved LVEF, and deteriorated LVEF. The primary endpoint was 30-months all-cause mortality (median follow-up). Secondary endpoints included in-hospital and 12-months all-cause mortality, as well as HF-related rehospitalization at 12 and 30 months. Kaplan-Meier and multivariable Cox proportional regression analyses were applied for statistics.

RESULTS

Six hundred eighty-nine patients with HFmrEF were included. Compared to their prior LVEF, 24%, 12%, and 64% had stable, improved, and deteriorated LVEF, respectively. None of the three LVEF groups was associated with all-cause mortality at 12 (p ≥ 0.583) and 30 months (31% vs. 37% vs. 34%; log rank p ≥ 0.376). In addition, similar rates of 12- (p ≥ 0.533) and 30-months HF-related rehospitalization (21% vs. 23% vs. 21%; log rank p ≥ 0.749) were observed. These findings were confirmed in multivariable regression analyses in the entire study cohort.

CONCLUSION

The transition from HFrEF and HFpEF towards HFmrEF is very common. However, prior LVEF was not associated with prognosis, likely due to the persistently high dynamic nature of LVEF in the follow-up period.

ANMCO position paper: diagnosis and treatment of heart failure with preserved systolic function

Heart failure is the leading cardiovascular cause of hospitalization with an increasing prevalence, especially in older patients. About 50% of patients with heart failure have preserved ventricular function, a form of heart failure that, until a few years ago, was orphaned by pharmacological treatments effective in reducing hospitalization and mortality. New trials, which have tested the use of gliflozins in patients with heart failure with preserved ejection fraction (HFpEF), have for the first time demonstrated their effectiveness in changing the natural history of this insidious and frequent form of heart failure. Therefore, diagnosing those patients early is crucial to provide the best treatment. Moreover, the diagnosis is influenced by the patient's comorbidities, and some HFpEF patients have symptoms common to other rare diseases that, if unrecognized, develop an unfavourable prognosis. This position paper aims to provide the clinician with a useful tool for diagnosing and treating patients with HFpEF, guiding the clinician towards the most appropriate diagnostic and therapeutic pathway.

Comparison of Investigator-Reported and Centrally Adjudicated Heart Failure Outcomes in the EMPEROR-Preserved Trial

BACKGROUND

There is limited published information on outcome adjudication in heart failure (HF) trials, particularly in heart failure with preserved ejection fraction (HFpEF).

OBJECTIVES

The study sought to compare investigator reports with clinical events committee (CEC) adjudication and assess the impact of the SCTI (Standardized Data Collection for Cardiovascular Trials) criteria.

METHODS

In the EMPEROR-Preserved (EMPagliflozin outcome tRial in Patients with chronic heart Failure With Preserved Ejection Fraction) trial, we compared investigator reports with CEC for concordance, treatment effect on primary composite outcome events and components (first event primary heart failure hospitalization [HHF] or cardiovascular [CV] mortality), prognosis after first HHF, total HHF, and trial duration with and without SCTI criteria.

RESULTS

The CEC confirmed 67.4% investigator-reported events for the primary outcome (CV mortality 82.7%, HHF 66.3%). The HR for treatment effect did not differ between adjudication methods for the primary outcome: investigator reports (HR: 0.77; 95% CI: 0.69-0.87), CEC (HR: 0.79; 95% CI: 0.69-0.90), its components, or total HHFs. The prognosis after the first HHF for all-cause mortality and CV mortality also did not differ between investigator reports and the CEC, nor did investigator reports and HHFs with a different CEC cause. SCTI criteria were present in 92% of CEC HHFs with a similar treatment effect to non-SCTI criteria. The investigator-reported primary events reached the protocol target number 6 months earlier than the CEC (7 months with full SCTI criteria).

CONCLUSIONS

Investigator adjudication is an alternative to a CEC with similar accuracy and faster event accumulation in HFpEF. The use of granular (SCTI) criteria did not improve trial performance. Our data suggest that a broader definition of an HHF event could be particularly beneficial in HFpEF clinical trials. (EMPagliflozin outcome tRial in Patients with chronic heart Failure With Preserved Ejection Fraction; NCT03057951).

Initiation and sequencing of guideline-directed medical therapy for heart failure across the ejection fraction spectrum

Strong evidence supports the importance of rapid sequence or simultaneous initiation of quadruple guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) for substantially reducing risk of mortality and hospitalization. Barring absolute contraindications for each individual medication, employing the strategy of rapid sequence, simultaneous, and/or in-hospital initiation at the time of HF diagnosis best ensures patients with HFrEF have the opportunity to benefit from proven medications and achieve large absolute risk reductions for adverse clinical outcomes. However, despite guideline recommendations supporting this approach, implementation in clinical practice remains persistently low, with less than one-fifth of eligible patients being prescribed the quadruple GDMT regimen. Additionally, for heart failure with mildly reduced or preserved ejection fraction (HFpEF), sodium-glucose co-transporter 2 inhibitors (SGLT2i) and non-steroidal mineralocorticoid receptor antagonists (MRA) constitute foundational therapy for all eligible patients with significant clinical benefits within just weeks of medication initiation. Nonetheless, the burden of symptoms, functional limitations, and hospitalizations remains substantial for many of these patients, even with SGLT2i and non-steroidal MRA therapy. Additional evidence supports consideration of adjunctive therapies for HF with EF > 40% that can be tailored to the patient phenotype, including glucagon-like peptide-1 receptor agonists (GLP-1 RA) for patients with obesity, as well as angiotensin receptor-neprilysin inhibitors (ARNI) for patients with EF below normal. This article reviews the evidence-based sequencing of GDMT for HF across the spectrum of EF, emphasizing the rationale and benefits of early up-front initiation of quadruple medical therapy for HFrEF, rapid initiation of SGLT2i for HF regardless of EF, and prompt phenotype-specific tailored approach to adjunctive therapies for HF with EF > 40%.

A multi-center, randomized, double-blind, placebo-controlled trial to evaluate the efficacy and safety of Fuzheng Yangxin Granule in treating heart failure with preserved ejection fraction (Qi-Yin deficiency and blood stasis syndrome): study protocol

Introduction

Heart failure with preserved ejection fraction (HFpEF) is a widespread public health issue worldwide. Despite recent advances in pharmacologic treatments and the introduction of new diagnostic approaches, HFpEF remains underdiagnosed and under-recognized in clinical practice. Traditional Chinese medicine (TCM) may offer a potentially effective treatment for HFpEF. Nevertheless, few clinical trials employ rigorous research methodologies to evaluate the efficacy and safety of TCM in treating HFpEF. Consequently, we propose to assess the hypothesis that patients with HFpEF may benefit from Fuzheng Yangxin Granule (FZYX) and evaluate its safety in a rigorously designed clinical trial.

Methods

This multicenter, double-blind, randomized controlled trial will be conducted across seven tertiary hospitals in China. We will enroll 150 participants aged 18-80 years with confirmed HFpEF (Qi-Yin deficiency and blood stasis syndrome) meeting inclusion criteria. Participants will be randomly assigned (1:1) to the FZYX group or the placebo group, ​with both groups receiving standardized Western medical therapy according to the National Heart Failure Guideline 2023. The 12-week intervention phase will be followed by 40-week safety follow-up. The primary outcome will be maximal peak oxygen uptake (peak VO2). Secondary outcomes will include composite endpoint events, all-cause mortality, 6-minute walking distance (6MWD), New York Heart Association (NYHA) functional class, serum N-terminal pro-B-type natriuretic peptide (NT-proBNP), echocardiographic variables, Minnesota Living with Heart Failure Questionnaire (MLHFQ) score, TCM syndrome scores, and the FRAIL scale.

Discussion

The objective of this study is to evaluate the efficacy and safety of FZYX in treating HFpEF (Qi-Yin deficiency and blood stasis syndrome), thereby providing a high-quality, reliable evidence-based foundation for clinical practice.

Clinical Trial Registration

China Clinical Trial Registry (ChiCTR2400087293), Registered on July 24, 2024.

Evolving role of myocardial fibrosis in heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is a complex clinical diagnosis with a heterogeneous pathophysiology and clinical presentation. The hallmark of HFpEF is diastolic dysfunction associated with left ventricular remodeling and fibrosis. Myocardial interstitial fibrosis (MIF) occurs as the result of collagen deposition and is dependent on the underlying etiology of heart failure. Detection of MIF can be done by invasive histopathologic sampling or by imaging. More recently, novel biomarkers have been investigated as an alternative tool for not only the detection of MIF but also for the prognostication of patients with HFpEF which may in turn alleviate the need for invasive and expensive imaging in the future.

Optimizing renin-angiotensin-aldosterone inhibition in advanced chronic kidney disease: balancing benefits and risks

PURPOSE OF REVIEW

Renin-angiotensin-aldosterone system inhibitors (RAASi), including angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs), are fundamental in chronic kidney disease (CKD) management, particularly in proteinuric conditions. However, their use in advanced CKD (eGFR <30 ml/min/1.73 m 2 ) remains debated because of risks of hyperkalaemia, acute kidney injury (AKI), and hypotension. This review evaluates the latest evidence, including the STOP-ACEi trial, to inform the risks and benefits of RAASi in advanced CKD.

RECENT FINDINGS

The STOP-ACEi trial, a multicentre randomized controlled trial (RCT), investigated RAASi discontinuation in 411 patients with advanced CKD. After 3 years, discontinuation did not slow eGFR decline or reduce mortality, while continuation was associated with a numerical trend towards lower end-stage kidney disease (ESKD) rates. Meta-analyses also indicate that ACEi may offer superior kidney protection compared to ARBs, though both lower cardiovascular risk and this difference may not be clinically significant. Combination ACEi/ARB therapy provides no additional benefits and increases adverse events, such as hyperkalaemia and hypotension. Adjunct therapies like potassium binders and sodium-glucose cotransporter-2 (SGLT2) inhibitors may enable safer RAASi use in high-risk patients.

SUMMARY

Current evidence supports RAASi continuation in most CKD patients, including those with advanced disease, unless contraindicated. Future studies should refine patient selection criteria and optimize adjunctive strategies to mitigate adverse effects.

Type 2 diabetes increases the risk of mortality and cardiovascular events in ischemic HFmrEF patients: a retrospective cohort study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is known to worsen the prognosis of heart failure (HF), but its specific impact on patients with ischemic versus non-ischemic heart failure with mildly reduced ejection fraction (HFmrEF) remains unclear due to limited research and conflicting evidence.

METHODS

We conducted a retrospective study of 1,691 HFmrEF patients at Xiangtan Central Hospital. Participants were divided into four groups: ischemic with T2DM (467 patients), ischemic without T2DM (856 patients), non-ischemic with T2DM (87 patients), and non-ischemic without T2DM (281 patients). We utilized the Cox proportional hazards model to analyze differences in all-cause mortality and cardiovascular events among the groups.

RESULTS

After adjusting for multiple confounding factors using the Cox proportional hazards model, the ischemic heart disease and T2DM group had a significantly higher risk of all-cause mortality compared to the ischemic group without T2DM (HR = 1.5, 95% CI = 1.2-1.9, P = 0.001). The risk of cardiovascular events was also significantly increased (HR = 1.3, 95% CI = 1.1-1.5, P = 0.001). In non-ischemic HFmrEF patients, T2DM was not associated with a significantly increased risk of all-cause mortality (HR = 1.0, 95% CI = 0.6-1.7, P = 0.957) or cardiovascular events (HR = 1.3, 95% CI = 0.9-1.9, P = 0.113).

CONCLUSION

T2DM significantly increases the risk of all-cause mortality and cardiovascular events in ischemic HFmrEF patients, while its impact on non-ischemic HFmrEF patients is limited. These findings underscore the importance of managing T2DM in patients with ischemic HFmrEF.

Obesity and heart failure-the role of GLP-1 receptor agonists

Patients with obesity-driven heart failure with preserved ejection fraction (HFpEF) often suffer from symptoms despite guideline-recommended treatment with diuretics, sodium glucose cotransporter 2 (SGLT2) inhibition, and mineralocorticoid antagonists. Obesity by itself drives heart failure via multiple pathophysiological mechanisms. This review summarizes current data on glucagon-like peptide‑1 (GLP-1) receptor agonists and the dual GIP/GLP‑1 agonist tirzepatide, including symptoms and outcomes in patients with obesity-driven HFpEF with or without diabetes.

Renal macro- and microcirculatory perturbations in acute kidney injury and chronic kidney disease associated with heart failure and cardiac surgery

Chronic kidney disease (CKD) affects 50% of patients with heart failure. The pathophysiology of CKD in heart failure is proposed to be driven by macrocirculatory hemodynamic changes, including reduced cardiac output and elevated central venous pressure. However, our understanding of renal microcirculation in heart failure and CKD remains limited. This is largely due to the lack of noninvasive techniques to assess renal microcirculation in patients. Moreover, there is a lack of clinically relevant animal models of heart failure and CKD to advance our understanding of the timing and magnitude of renal microcirculatory dysfunction. Patients with heart failure and CKD commonly require cardiac surgery with cardiopulmonary bypass (CPB) to improve their prognosis. However, acute kidney injury (AKI) is a frequent unresolved clinical complication in these patients. There is emerging evidence that renal microcirculatory dysfunction, characterized by renal medullary hypoperfusion and hypoxia, plays a critical role in the pathogenesis of cardiac surgery-associated AKI. In this review, we consolidate the preclinical and clinical evidence of renal macro- and microcirculatory perturbations in heart failure and cardiac surgery requiring CPB. We also examine emerging biomarkers and therapies that may improve health outcomes for this vulnerable patient population by targeting the renal microcirculation.

A Portuguese expert panel position paper on the management of heart failure with preserved ejection fraction - Part I: Pathophysiology, diagnosis and treatment

Heart failure (HF) with preserved ejection fraction (HFpEF) affects more than 50% of HF patients worldwide, and more than 70% of HF patients aged over 65. This is a complex syndrome with a clinically heterogeneous presentation and a multifactorial pathophysiology, both of which make its diagnosis and treatment challenging. A Portuguese HF expert panel convened to address HFpEF pathophysiology and therapy, as well as appropriate management within the Portuguese context. This initiative resulted in two position papers that examine the most recently published literature in the field. The present Part I includes a review of the HFpEF literature covering pathophysiology, clinical presentation, diagnosis and treatment, including pharmacological and non-pharmacological strategies. Part II, the second paper, addresses the development of a holistic and integrated HFPEF clinical care system within the Portuguese context that is capable of reducing morbidity and mortality and improving patients' functional capacity and quality of life.

Guidelines for treating heart failure

Optimal guideline-directed medical therapy for heart failure with reduced ejection fraction comprises the angiotensin receptor-neprilysin inhibitor (sacubitril/valsartan), an evidence-based beta-blocker (bisoprolol, carvedilol, or sustained-release metoprolol), a mineralocorticoid antagonist (spironolactone or eplerenone), and a sodium-glucose cotransporter-2 inhibitor (dapagliflozin or empagliflozin). Optimal guideline-directed medical therapy for heart failure with preserved ejection fraction comprises a sodium-glucose cotransporter-2 inhibitor with emerging evidence to support the use of a mineralocorticoid antagonist and glucagon-like peptide-1 receptor agonists. This review will summarize the evidence behind the guideline recommendations, the impact of newer trials on management of patients with HF, and strategies for implementation into clinical practice.

Chinese Guidelines for the Diagnosis and Treatment of Heart Failure 2024

In the past 6 years, significant breakthroughs have been achieved in the treatment of heart failure (HF), especially in drug therapy. The classification of chronic HF and the treatment methods for HF and its complications are also constantly being updated. In order to apply these results to the diagnosis and treatment of patients with HF in China and further improve the level of diagnosis and treatment of HF in China, the HF Group of Chinese Society of Cardiology, Chinese Medical Association, Chinese College of Cardiovascular Physician, Chinese HF Association of Chinese Medical Doctor Association, and Editorial Board of Chinese Journal of Cardiology have organized an expert group and update the consensus and evidence-based treatment methods in the field of HF based on the latest clinical research findings at home and abroad, combined with the national conditions and clinical practice in China, and referring to the latest foreign HF guidelines while maintaining the basic framework of the 2018 Chinese Guidelines for Diagnosis and Treatment of HF.

Personalized app-based coaching for improving physical activity in heart failure with preserved ejection fraction patients compared with standard care: rationale and design of the MyoMobile Study

Aims

Patients suffering from heart failure with preserved ejection fraction (HFpEF) often exhibit a sedentary lifestyle, contributing to the worsening of their condition. Although there is an inverse relationship between physical activity (PA) and adverse cardiovascular outcomes, the implementation of Class Ia PA guidelines is hindered by low participation in supervised and structured programmes, which are not suitable for a diverse population of HFpEF patients. The MyoMobile study has been designed to assess the effect of a 12-week, app-based coaching programme on promoting PA in patients with HFpEF.

Methods and results

The MyoMobile study was a single-centre, randomized, controlled three-armed parallel group clinical trial with prospective data collection to investigate the effect of a personalized mobile app health intervention compared with usual care on PA levels in patients with HFpEF. Major inclusion criteria were age ≥ 45 years, a diagnosis of HFpEF, LVEF > 40%, and current HF symptoms (NYHA Class I-III). Major exclusion criteria included acute decompensated HF, non-ambulatory status, recent acute coronary syndrome or cardiac surgery, alternative diagnoses for HF symptoms, active cancer treatment, and physical or medical conditions affecting mobility. Participants were recruited from hospitals, general practices, and practices specialized in internal medicine and cardiology in the Rhine-Main area, Germany. Participants underwent an objective 7-day PA measurement with a 3D accelerometer (Dynaport, McRoberts) at screening and after the 12-week intervention period. Following the screening, eligible participants were randomized into one of three groups: standard care (PA consulting), the intervention arm with app-based PA tracking and coaching, or the intervention arm with tracking but without coaching. The primary efficacy endpoint was the change in average daily step count between the average step count at baseline and at the end of the intervention, comparing standard care to a 12-week app-based PA coaching intervention.

Conclusion

Exercise intolerance is a primary symptom in HFpEF patients, leading to poor quality of life and HF-related adverse outcomes due to physical inactivity. The MyoMobile study was designed to investigate the use of app-based coaching to improve PA in patients with HFpEF with a personalized, home-based intervention, focusing on simple step counts for flexibility and ease of integration into daily routines.

Clinical trial registration

URL: https://clinicaltrials.gov/ct2/show/NCT04940312.

Unique identifier

NCT04940312.

Have SGLT-2 inhibitors DELIVERed an EMPhatic win in heart failure and chronic kidney disease?

INTRODUCTION

Major global guidelines currently recommend sodium-glucose co-transporter-2 inhibitors (SGLT-2i) as the first-line agent in people with type 2 diabetes (T2D) who have either established cardiovascular disease (eCVD), heart failure (HF), or chronic kidney disease (CKD), regardless of baseline glycated hemoglobin (HbA1c). Moreover, SGLT-2i are currently included in guideline-directed medical therapy as one of the pillars for people with HF and CKD, regardless of T2D. These recommendations are based on positive cardio-renal outcomes from several randomized controlled trials (RCTs).

AREAS COVERED

Following an extensive search in electronic databases of PubMed, Google Scholar, and clinicaltrials.gov, we critically analyzed the RCTs that assessed cardio-renal outcome trials of SGLT-2i and put a perspective on how SGLT-2i delivered an emphatic win for people with HF and CKD, with or without T2D.

EXPERT OPINION

From thirteen high-quality RCTs, including five cardiovascular outcome trials, five HF outcome trials, three renal outcome trials, and a pooled meta-analysis, it is evident that SGLT-2i has delivered an emphatic win in people with HF and CKD, with or without T2D, with an acceptable safety profile. Ongoing RCTs shall further enlighten whether SGLT-2i will be effective in polycystic kidney disease, lupus nephritis, vasculitis, end-stage CKD with or without hemodialysis, and renal transplant.

Comparative efficacy of different antihypertensive drug classes for stroke prevention: A network meta-analysis of randomized controlled trials

OBJECTIVE

The study aimed to compare the effectiveness of various antihypertensive drugs in preventing strokes in hypertensive patients.

METHODS

We conducted a comprehensive search of PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov to identify randomized controlled trials (RCTs) investigating the efficacy of antihypertensive drugs in stroke prevention from inception until April 2023. A network meta-analysis in a Bayesian framework was performed using the random-effects model.

RESULTS

This study included 88 RCTs involving 487,076 patients to investigate the effects of antihypertensive drugs in preventing stroke. Among these trials, 58 RCTs specifically focused on comparing the impact of such drugs on hypertensive subjects. In overall population, Angiotensin-converting enzyme inhibitor (ACEIs), Angiotensin receptor blockers (ARBs), Calcium channel blockers (CCBs), and Diuretics (DIs) demonstrated superiority over placebo in in reducing stroke, all-cause mortality, and cardiovascular mortality. CCBs and DIs outperformed β adrenergic receptor blockers (BBs), ACEIs, and ARBs in stroke reduction. However, when focusing on hypertensive patients, ACEIs, CCBs, and DIs proved superior to placebo in reducing stroke, all-cause mortality, and cardiovascular mortality. ARBs reduced stroke and all-cause mortality but lacked efficacy in reducing cardiovascular mortality. Of the various CCB subclasses, only the Dihydropyridines displayed efficacy in preventing stroke, all-cause mortality, and cardiovascular mortality. Among diuretic subclasses, thiazide-type DIs exhibited no efficacy in preventing all-cause mortality. ACEIs+CCBs were more effective than ACEIs or ARBs monotherapy in reducing stroke, more effective than ACEIs, ARBs, CCBs, or DIs monotherapy in reducing all-cause mortality, and more effective than ARBs in reducing cardiovascular mortality.

CONCLUSION

These findings suggest that ACEIs, dihydropyridine CCBs, and thiazide-like diuretics may provide superior prevention against stroke, all-cause mortality, and cardiovascular mortality in hypertensive patients. Combinations of ACEIs and CCBs may provide enhanced protection of stroke than ACEIs or ARBs monotherapy.

Sex-based differences in left ventricular mass reduction across angiotensin II receptor blockers in patients with heart failure with preserved or mildly reduced ejection fraction

Although angiotensin II receptor blockers (ARBs) are more effective in women for either reduction of blood pressure or heart failure (HF), the gender disparities and the impact of class/drug effects on ARBs in relation to cardiac hypertrophy and HF remain unclear. We aimed to investigate the sex-based and drug-specific differences in left ventricular (LV) mass reduction with ARBs. We employed the cohort of 193 hypertensive patients with HF and an LV ejection fraction of ≥ 45% treated with azilsartan or candesartan once daily for 48 weeks as a sub-analysis of the J-TASTE trial. After exclusion of patients without LV mass data nor the drugs, 170 patients were finally enrolled (azilsartan: male, n = 43, female, n = 39 and candesartan: male, n = 52; female, n = 36). We investigated the sex-based differences of the primary endpoint of the change in LV mass as assessed by echocardiography from baseline to the end of the study (48 weeks), and the secondary endpoint of the incidence of the composite cardiovascular endpoint (death from cardiovascular disease or hospitalization for heart failure). In the male stratum, the ratio of patients with > 10% LV mass reduction at 48 weeks was higher in the azilsartan group than candesartan group (40 vs. 19%, p = 0.029). There was no significant difference in LV mass reduction between two groups in the female stratum. There were no differences of the onset of the secondary endpoints between male and female groups, and azilsartan and candesartan groups. The event-free survival rate of the composite cardiovascular endpoints tended to be lower in patients with ≤ 10% than > 10% LV mass reduction (95.3 vs. 100% at 48 weeks, log-rank p = 0.11). In patients with HF, the effectiveness of either azilsartan or candesartan in achieving > 10% LV mass reduction depends on sex. Male is more sensitive to azilsartan than candesartan to achieve cardiac hypertrophy in HF patients.

Pharmacologic Management of Heart Failure with Preserved Ejection Fraction (HFpEF) in Older Adults

There are several pharmacologic agents that have been touted as guideline-directed medical therapy for heart failure with preserved ejection fraction (HFpEF). However, it is important to recognize that older adults with HFpEF also contend with an increased risk for adverse effects from medications due to age-related changes in pharmacokinetics and pharmacodynamics of medications, as well as the concurrence of geriatric conditions such as polypharmacy and frailty. With this review, we discuss the underlying evidence for the benefits of various treatments in HFpEF and incorporate key considerations for older adults, a subpopulation that may be at higher risk for adverse drug events. Key considerations for older adults include: the use of loop diuretics, mineralocorticoid receptor antagonists (MRAs), and sodium glucose co-transporter-2 (SGLT2) inhibitors for most; angiotensin receptor blockers/ angiotensin receptor-neprilysin inhibitors (ARB/ARNIs) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) as add-on therapies for some, though risk of geriatric conditions such as falls, malnutrition, and/or sarcopenia must be considered; and beta blockers for a smaller subset of patients (with consideration of deprescribing for some, though data are lacking on this approach). Naturally, when making clinical decisions for older adults with cardiovascular disease, it is critical to consider the complexity of their conditions, including cognitive and physical function and social and environmental factors, and ensure alignment of care plans with the patient's health goals and priorities.

Efficacy and Safety of Finerenone Across the Ejection Fraction Spectrum in Heart Failure With Mildly Reduced or Preserved Ejection Fraction: A Prespecified Analysis of the FINEARTS-HF Trial

BACKGROUND

The effects of treatments for heart failure (HF) may vary among patients according to left ventricular ejection fraction (LVEF). In FINEARTS-HF (Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients With Heart Failure), the nonsteroidal mineralocorticoid receptor antagonist finerenone reduced the risk of cardiovascular death and total worsening HF events in patients with HF with mildly reduced or preserved ejection fraction. We examined the effect of finerenone according to LVEF in FINEARTS-HF.

METHODS

FINEARTS-HF was a randomized, placebo-controlled trial examining the efficacy and safety of finerenone in patients with HF and LVEF ≥40%. The treatment effect of finerenone was examined in prespecified analyses according to LVEF categories (<50%, ≥50% to <60%, and ≥60%) and with LVEF as a continuous variable. The primary outcome was a composite of total (first and recurrent) worsening HF events and cardiovascular death.

RESULTS

Baseline LVEF data were available for 5993 of the 6001 participants in FINEARTS-HF. Mean and median LVEF were 53±8% and 53% (interquartile range, 46%-58%), respectively. LVEF was <50% in 2172 (36%), between 50% and <60% in 2674 (45%), and ≥60% in 1147 (19%). Patients with higher LVEF were older, were more commonly female, were less likely to have a history of coronary artery disease, and more frequently had a history of hypertension and chronic kidney disease compared with those with a lower LVEF. Finerenone reduced the risk of cardiovascular death and total HF events consistently across LVEF categories (LVEF <50% rate ratio, 0.84 [95% CI, 0.68-1.03]; LVEF ≥50% to <60% rate ratio, 0.80 [0.66-0.97]; and LVEF ≥60% rate ratio, 0.94 [0.70-1.25]; Pinteraction=0.70). There was no modification of the benefit of finerenone across the range of LVEF when analyzed as a continuous variable (Pinteraction=0.28). There was a similar consistent effect of finerenone on reducing the total number of worsening HF events (continuous Pinteraction=0.26).

CONCLUSIONS

In patients with HF with mildly reduced or preserved ejection fraction, finerenone reduced the risk of cardiovascular death and worsening HF events, irrespective of LVEF.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04435626. URL: https://eudract.ema.europa.eu; Unique identifier: 2020-000306-29.

Two-hit mouse model of heart failure with preserved ejection fraction combining diet-induced obesity and renin-mediated hypertension

Heart failure with preserved ejection fraction (HFpEF) is increasingly common but its pathogenesis is poorly understood. The ability to assess genetic and pharmacologic interventions is hampered by the lack of robust preclinical mouse models of HFpEF. We developed a novel "two-hit" model, which combines obesity and insulin resistance with chronic pressure overload to recapitulate clinical features of HFpEF. C57Bl6/NJ mice fed a high-fat diet (HFD) for > 10 weeks were administered an AAV8-driven vector resulting in constitutive overexpression of mouse Renin1d. HFD-Renin (aka "HFpEF") mice demonstrated obesity and insulin resistance, moderate left ventricular hypertrophy, preserved systolic function, and diastolic dysfunction indicated by echocardiographic measurements; increased left atrial mass; elevated natriuretic peptides; and exercise intolerance. Transcriptomic and metabolomic profiling of HFD-Renin myocardium demonstrated upregulation of pro-fibrotic pathways and downregulation of metabolic pathways, in particular branched chain amino acid catabolism, similar to human HFpEF. Treatment with empagliflozin, an effective but incompletely understood HFpEF therapy, improved multiple endpoints. The HFD-Renin mouse model recapitulates key features of human HFpEF and will enable studies dissecting the contribution of individual pathogenic drivers to this complex syndrome. Additional preclinical HFpEF models allow for orthogonal studies to increase validity in assessment of interventions.

Angiotensin Receptor Neprilysin Inhibition and Cardiovascular Outcomes Across the Kidney Function Spectrum: The PARAGON-HF Trial

BACKGROUND

Lower estimated glomerular filtration rate (eGFR) may be one of the major reasons for hesitation or failure to initiate potentially beneficial therapies in patients with heart failure (HF).

OBJECTIVES

This study sought to assess if the effects of sacubitril/valsartan (vs valsartan) on cardiovascular outcomes differ according to baseline kidney function in patients with HF with preserved ejection fraction.

METHODS

The PARAGON-HF (Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction) trial was global clinical trial of 4,796 patients with chronic HF and left ventricular ejection fraction (LVEF) ≥45% randomly assigned to sacubitril/valsartan or valsartan. We examined the effect of treatment on cardiovascular outcomes using Cox regression models, stratified by region, and assessed for differential treatment effects according to the baseline eGFR and ejection fraction.

RESULTS

At randomization, mean eGFR was 67 ± 19 mL/min/1.73 m2; 1,955 (41%) participants had an eGFR <60 mL/min/1.73 m2. Compared with valsartan, sacubitril/valsartan reduced the primary cardiovascular outcome (cardiovascular death and total HF hospitalizations) to a greater extent among those with lower baseline eGFR (P interaction = 0.07 for continuous eGFR), and was most pronounced for those with eGFR ≤45 mL/min/1.73 m2 (RR: 0.69; 95% CI: 0.51-0.94). The influence of eGFR on the treatment effect for cardiovascular death was nonlinear, with the most pronounced treatment effect for those with baseline eGFR <45 mL/min/1.73 m2 (HR: 0.65; 95% CI: 0.43-0.97). In further subgroup analyses according to LVEF and eGFR, the treatment effect for the primary outcome was most pronounced among those with LVEF ≤57% and eGFR ≤45 mL/min/1.73 m2 (HR: 0.66; 95% CI: 0.45-0.97).

CONCLUSIONS

In the PARAGON-HF trial, the benefits of sacubitril/valsartan to reduce the frequency of HF hospitalizations and cardiovascular death were most apparent in patients with lower baseline eGFR and lower ejection fraction. (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).

Comorbidities, pharmacologic interventions, and mechanical interventions associated with mortality in isolated diastolic left heart failure: lessons from a national database

BACKGROUND

Diastolic heart failure may be noted in paediatric patients with CHD, cardiomyopathy, or malignancies requiring chemotherapy, but the available data are scarce, and often derived from adult trials or based on theoretic or anecdotal evidence.

METHODS

Data between 2016 and 2021 were obtained from Pediatric Health Information System database. Patients <18 years of age with isolated diastolic heart failure admitted to ICU at some point during admission were included. They were divided into patients with and without inpatient mortality. Patients' demographics, comorbidities using ICD-10 codes, and pharmacologic interventions were also recorded. Univariate analysis was done in demographics, comorbidities, pharmacologic interventions, and mechanical interventions between admissions with and without mortality. Multivariable logistic regression was done for inpatient mortality and multivariable linear regression was done for total hospital length of stay in survivors.

RESULTS

Isolated diastolic heart failure comprised 0.5% of critically ill paediatric patients. A total of 121 (5%) experienced mortality among the 2,273 admissions in the final analyses. Milrinone and angiotensin converting enzyme inhibitor were found to be associated with decreased mortality. Increasing age and diuretics were associated with decreased total hospital length of stay in survivors.

CONCLUSION

In the cohort studied, isolated diastolic left heart failure has a 5% mortality. Several comorbidities and interventions are associated with increased mortality with milrinone and angiotensin converting enzyme inhibitors being associated with decreased risk of mortality. When only admissions with survival to discharge are considered, older age and diuretics are associated with lower total hospital length of stay.

Diagnostic and therapeutic practice for Heart Failure with preserved ejection fraction around the world: An international survey

BACKGROUND AND AIMS

There is a gap in knowledge about implementing diagnostic tools and therapy for heart failure with preserved ejection fraction (HFpEF) in clinical practice. This survey aimed to assess real-world practice in HFpEF diagnosis and treatment in the international medical community.

METHODS

An independent academic web-based 29-question survey was designed by a group of heart failure specialists and posted by email and through scientific societies and social networks to a broad community of physicians worldwide.

RESULTS

1.460 physicians from 95 countries answered the survey, with a mean age of 42.2±10.4 years, 39.4 % females, and 85.1 % were cardiologists. The left ventricular ejection fraction cut-off value selected for HFpEF diagnosis was 50 % for 89 % of participants. The scores for the probability of diagnosis of HFpEF were used only by 47.2 %, and H2FPEF was the most used score (31 %). Natriuretic peptides were used by 87.4 % of participants for the diagnostic workup, while the diastolic stress test was only used by 26.2 %. 54.4 % of participants chose SGLT2 inhibitors as their first drug treatment, followed by diuretics (18.6 %) and ACE inhibitors (8.4 %).

CONCLUSIONS

In an international academic survey on HFpEF management, the criteria for screening and diagnosis of HFpEF patients remain aligned with classic international guidelines with a low use of diagnostic scores. SGLT2i is the leading therapeutic drug class used for this heterogeneous patient population. These results raise the need to improve education and awareness on diagnosing and managing HFpEF patients.

Angiotensin II Exposure In Vitro Reduces High Salt-Induced Reactive Oxygen Species Production and Modulates Cell Adhesion Molecules' Expression in Human Aortic Endothelial Cell Line

Background/Objectives: Increased sodium chloride (NaCl) intake led to leukocyte activation and impaired vasodilatation via increased oxidative stress in human/animal models. Interestingly, subpressor doses of angiotensin II (AngII) restored endothelium-dependent vascular reactivity, which was impaired in a high-salt (HS) diet in animal models. Therefore, the present study aimed to assess the effects of AngII exposure following high salt (HS) loading on endothelial cells' (ECs') viability, activation, and reactive oxygen species (ROS) production. Methods: The fifth passage of human aortic endothelial cells (HAECs) was cultured for 24, 48, and 72 h with NaCl, namely, the control (270 mOsmol/kg), HS320 (320 mOsmol/kg), and HS350 (350 mOsmol/kg). AngII was administered at the half-time of the NaCl incubation (10-4-10-7 mol/L). Results: The cell viability was significantly reduced after 24 h in the HS350 group and in all groups after longer incubation. AngII partly preserved the viability in the HAECs with shorter exposure and lower concentrations of NaCl. Intracellular hydrogen peroxide (H2O2) and peroxynitrite (ONOO-) significantly increased in the HS320 group following AngII exposure compared to the control, while it decreased in the HS350 group compared to the HS control. A significant decrease in superoxide anion (O2.-) formation was observed following AngII exposure at 10-5, 10-6, and 10-7 mol/L for both HS groups. There was a significant decrease in intracellular adhesion molecule 1 (ICAM-1) and endoglin expression in both groups following treatment with 10-4 and 10-5 mol/L of AngII. Conclusions: The results demonstrated that AngII significantly reduced ROS production at HS350 concentrations and modulated the viability, proliferation, and activation states in ECs.

Why Have We Not Been Able to Demonstrate Reduced Mortality in Patients With HFmrEF/HFpEF?

No randomized controlled trial has yet demonstrated a statistically significant reduction in mortality in patients with heart failure and mildly reduced ejection (HFmrEF) or heart failure and preserved ejection fraction (HFpEF), in contrast to the benefits observed in heart failure with reduced ejection fraction (HFrEF). However, this probably reflects the statistical power of trials to date to show an effect on mortality rather than mechanistic differences between HFmEF/HFpEF and HFrEF or differences in treatment efficacy. Compared to patients with HFrEF, those with HFmrEF/HFpEF have lower mortality rates and a smaller proportion of potentially modifiable cardiovascular deaths (as opposed to unmodifiable noncardiovascular deaths). In addition, some causes of cardiovascular deaths may not be reduced by treatments for HF. Therefore, the low rate of potentially modifiable deaths in patients with HFmrEF/HFpEF, compared with HFrEF, has made it challenging to demonstrate a reduction in death (or cardiovascular death) in trials to date.

Heart failure with preserved ejection fraction management: a systematic review of clinical practice guidelines and recommendations

Multiple guidelines exist for the diagnosis and management of heart failure with preserved ejection fraction (HFpEF). We systematically reviewed current guidelines and recommendations, developed by national and international medical organizations, on the management of HFpEF in adults to aid clinical decision-making. We searched MEDLINE and EMBASE on 28 February 2024 for publications over the last 10 years as well as websites of organizations relevant to guideline development. Of the 10 guidelines and recommendations retrieved, 7 showed considerable rigour of development and were subsequently retained for analysis. There was consensus on the definition of HFpEF and the diagnostic role of serum natriuretic peptides and resting transthoracic echocardiography. Discrepancies were identified in the thresholds of serum natriuretic peptides and transthoracic echocardiography parameters used to diagnose HFpEF. There was agreement on the general pharmacological and supportive management of acute and chronic HFpEF. However, differences exist in strategies to identify and address specific phenotypes. Contemporary guidelines for HFpEF management agree on measures to avoid its development and the consideration of cardiac transplantation in advanced diseases. There were discrepancies in recommended frequency of surveillance for patients with HFpEF and sparse recommendations on screening for HFpEF in the general population, use of diagnostic scoring systems, and the role of newly emerging therapies.

Heart Failure and All-Cause Hospitalizations in Patients With Heart Failure: A Meta-Analysis

Importance

Heart failure (HF) hospitalization is a common end point in HF trials; however, how HF hospitalization is associated with all-cause hospitalization in terms of proportionality, correlation of treatment effects, and concomitant reporting has not been studied.

Objective

To determine the ratio of HF to all-cause hospitalizations, whether reported treatment effects on HF hospitalization are associated with treatment effects on all-cause hospitalization, and how often all-cause hospitalization is reported alongside HF hospitalization.

Data Sources

PubMed was searched from inception to September 2, 2024, for randomized clinical trials (RCTs) of HF treatments using MeSH (medical subject heading) terms and keywords associated with heart failure, ventricular failure, ventricular dysfunction, and cardiac failure, as well as the names of specific journals.

Study Selection

RCTs of HF treatments and reporting on HF hospitalization published in 1 of 3 leading medical journals (New England Journal of Medicine, The Lancet, or JAMA).

Data Extraction and Synthesis

The PRISMA guidelines were followed. Data extraction was performed by 2 reviewers, and disagreements were resolved by consensus. Trial baseline characteristics and outcome data on HF and all-cause hospitalizations were extracted. The ratio of HF to all-cause hospitalizations was calculated. The association of HF hospitalization effects with all-cause hospitalization effects was evaluated using hierarchical bayesian models with weak priors. The posterior distribution was used to calculate the HF hospitalization treatment effects that would need to be observed before a high probability (97.5%) of a reduction in all-cause hospitalization could be achieved. The proportion of trials reporting all-cause hospitalization was calculated.

Main Outcomes and Measures

HF and all-cause hospitalizations.

Results

Of 113 trials enrolling 261 068 patients (median proportion of female participants, 25.4% [IQR, 21.3%-34.2%]; median age, 66.2 [IQR, 62.8-70.0] years), 60 (53.1%) reported on all-cause hospitalization. The weighted median ratio of HF to all-cause hospitalizations was 45.9% (IQR, 30.7%-51.7%). This ratio was higher in trials with greater proportions of New York Heart Association class III or IV HF, with lower left ventricular ejection fractions, investigating nonpharmaceutical interventions, and that restricted recruitment to patients with HF and reduced ejection fraction. Reported effects on HF and all-cause hospitalizations were well-correlated (R2 = 90.1%; 95% credible interval, 62.3%-99.8%). In a large trial, the intervention would have to decrease the odds of HF hospitalization by 16% to ensure any reduction, 36% to ensure a 10% reduction, and 56% to ensure a 20% reduction in the odds of all-cause hospitalization with 97.5% probability.

Conclusions and Relevance

In this meta-analysis of HF trials, all-cause hospitalization was underreported despite a large burden of non-HF hospitalizations. Large reductions in HF hospitalization must be observed before clinically relevant reductions in all-cause hospitalization can be inferred.

Navigating the evolving landscape of HFpEF management: A detailed look at key ACC/AHA/ESC guideline updates

Heart failure, a growing concern in the United States, significantly impacts both morbidity and mortality. Classified by ejection fraction, heart failure with preserved ejection fraction (HFpEF) now accounts for half of all cases and is steadily rising. Unlike its counterpart, heart failure with reduced ejection fraction (HFrEF), HFpEF lacks clear management guidelines. Recognizing this critical gap, we aim to review existing recommendations and formulate effective management strategies for HFpEF.

Pharmacological management of heart failure: a patient-centred approach

INTRODUCTION

Heart failure (HF) is a global health challenge that requires a multidisciplinary approach. Despite recent advances in pharmacological and interventional therapy, morbidity and mortality in these patients remain high. For this reason, and because of its interplay with other cardiovascular and non-cardiovascular diseases, HF represents a major area of research, with new trials being published every year and international guidelines constantly updated.

AREAS COVERED

The authors review the current status and possible future developments in HF pharmacotherapy.

EXPERT OPINION

The treatment of HF has made significant advances in recent years, and the current recommendations are based on large outcome trials. This has led to significant reductions in both mortality and morbidity, but the death rate remains unacceptably high. In this context, a patient-centered approach that considers comorbidities and specific clinical scenarios when dosing HF medication is essential. Prevention of hospital admissions for cardiac decompensation is of utmost importance in patients with HF as is the enablement of activities of daily living, an endpoint which has only recently been incorporated into major HF trials.

Mitochondrial Reactive Oxygen Species Dysregulation in Heart Failure with Preserved Ejection Fraction: A Fraction of the Whole

Heart failure with preserved ejection fraction (HFpEF) is a multifarious syndrome, accounting for over half of heart failure (HF) patients receiving clinical treatment. The prevalence of HFpEF is rapidly increasing in the coming decades as the global population ages. It is becoming clearer that HFpEF has a lot of different causes, which makes it challenging to find effective treatments. Currently, there are no proven treatments for people with deteriorating HF or HFpEF. Although the pathophysiologic foundations of HFpEF are complex, excessive reactive oxygen species (ROS) generation and increased oxidative stress caused by mitochondrial dysfunction seem to play a critical role in the pathogenesis of HFpEF. Emerging evidence from animal models and human myocardial tissues from failed hearts shows that mitochondrial aberrations cause a marked increase in mitochondrial ROS (mtROS) production and oxidative stress. Furthermore, studies have reported that common HF medications like beta blockers, angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and mineralocorticoid receptor antagonists indirectly reduce the production of mtROS. Despite the harmful effects of ROS on cardiac remodeling, maintaining mitochondrial homeostasis and cardiac functions requires small amounts of ROS. In this review, we will provide an overview and discussion of the recent findings on mtROS production, its threshold for imbalance, and the subsequent dysfunction that leads to related cardiac and systemic phenotypes in the context of HFpEF. We will also focus on newly discovered cellular and molecular mechanisms underlying ROS dysregulation, current therapeutic options, and future perspectives for treating HFpEF by targeting mtROS and the associated signal molecules.

Contemporary treatment options in heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) constitutes approximately half of the heart failure population, with its prevalence markedly increasing with older age and the presence of cardio-metabolic comorbidities. Although HFpEF is associated with a high symptom- and mortality burden, historically there have been few evidence-based treatment options for patients with HFpEF. Recent randomized clinical trials have expanded evidence on pharmacological treatment options, introducing new agents for managing HFpEF. Given the complex clinical phenotype with pathophysiological heterogeneity and evolving diagnostic standards, the evidence-based management of HFpEF remains challenging for clinicians. This review summarizes the latest evidence from contemporary randomized clinical trials and recent guideline recommendations to provide guidance for the treatment of patients with HFpEF.

Emerging Role of Natriuretic Peptides in Diabetes Care: A Brief Review of Pertinent Recent Literature

Diabetes markedly increases susceptibility to adverse cardiovascular events, including heart failure (HF), leading to heightened morbidity and mortality rates. Elevated levels of natriuretic peptides (NPs), notably B-type natriuretic peptide (BNP) and N-terminal-proBNP (NT-proBNP), correlate with cardiac structural and functional abnormalities, aiding in risk stratification and treatment strategies in individuals with diabetes. This article reviews the intricate relationship between diabetes and HF, emphasizing the role of NPs in risk assessment and guiding therapeutic strategies, particularly in individuals with type 2 diabetes mellitus (T2DM). We also explore the analytical and clinical considerations in the use of natriuretic peptide testing and the challenges and prospects of natriuretic-peptide-guided therapy in managing cardiovascular risk in patients with diabetes. We conclude with some reflections on future prospects for NPs.

Heart failure with preserved ejection fraction: The role of inflammation

Heart failure (HF) is a debilitating clinical syndrome affecting 64.3 million patients worldwide. More than 50% of HF cases are attributed to HF with preserved ejection fraction (HFpEF), an entity growing in prevalence and mortality. Although recent breakthroughs reveal the prognostic benefits of sodium-glucose co-transporter 2 inhibitors (SGLT2i) in HFpEF, there is still a lack of effective pharmacological therapy available. This highlights a major gap in medical knowledge that must be addressed. Current evidence attributes HFpEF pathogenesis to an interplay between cardiometabolic comorbidities, inflammation, and renin-angiotensin-aldosterone-system (RAAS) activation, leading to cardiac remodelling and diastolic dysfunction. However, conventional RAAS blockade has demonstrated limited benefits in HFpEF, which emphasises that alternative therapeutic targets should be explored. Presently, there is limited literature examining the use of anti-inflammatory HFpEF therapies despite growing evidence supporting its importance in disease progression. Hence, this review aims to explore current perspectives on HFpEF pathogenesis, including the importance of inflammation-driven cardiac remodelling and the therapeutic potential of anti-inflammatory therapies.

Clinical Update in Heart Failure with Preserved Ejection Fraction

PURPOSE OF REVIEW

To review the most recent clinical trials and data regarding epidemiology, pathophysiology, diagnosis, and treatment of heart failure with preserved ejection fraction with an emphasis on the recent trends in cardiometabolic interventions.

RECENT FINDINGS

Heart failure with preserved ejection fraction makes up approximately half of overall heart failure and is associated with significant morbidity, mortality, and overall burden on the healthcare system. It is a complex, heterogenous syndrome and clinical trials, to this point, have not revealed quite as many effective treatment options when compared to heart failure with reduced ejection fraction. Nevertheless, there is an expanding amount of data insight into the pathogenesis of this disease and the potential for newer therapies and management strategies. Heart failure with preserved ejection fraction pathology has been found to be linked to abnormal energetics, myocyte hypertrophy, cell signaling, inflammation, ischemia, and fibrosis. These mechanisms also intricately overlap with the significant comorbidities often associated with heart failure with preserved ejection fraction including, but not limited to, atrial fibrillation, chronic kidney disease, hypertension, obesity and coronary artery disease. Treatment of this disease, therefore, should focus on the management and strict regulation of these comorbidities by pharmacologic and nonpharmacologic means. In this review, a clinical update is provided reviewing the most recent clinical trials and data regarding epidemiology, pathophysiology, diagnosis, and treatment of heart failure with preserved ejection fraction with an emphasis on the recent trend in cardiometabolic interventions.

Managing hypertension in African Americans with heart failure: A guide for the primary care clinician

Hypertension is the predominant risk factor for cardiovascular disease related morbidity and mortality among Black adults in the United States. It contributes significantly to the development of heart failure and increases the risk of death following heart failure diagnosis. It is also a leading predisposing factor for hypertensive disorders of pregnancy and peripartum cardiomyopathy in Black women. As such, all stakeholders including health care providers, particularly primary care clinicians (including physicians and advanced practice providers), patients, and communities must be aware of the consequences of uncontrolled hypertension among Black adults. Appropriate treatment strategies should be identified and implemented to ensure timely and effective blood pressure management among Black individuals, particularly those with, and at risk for heart failure.

Two-year clinical outcome of patients with mildly reduced ejection fraction after acute myocardial infarction: insights from the prospective KAMIR-NIH Registry

Background

Left ventricular ejection fraction (LVEF) is a crucial prognostic indicator of acute myocardial infarction (AMI). However, there is a lack of studies on the clinical characteristics and prognosis of patients with mildly reduced ejection fraction (EF) after AMI.

Methods

We categorized 6,553 patients with AMI from the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH) between November 2011 and December 2015 into three groups based on their EF, as assessed by echocardiography during index hospitalization: reduced EF (LVEF ≤40%), mildly reduced EF (LVEF 41%-49%), and preserved EF (LVEF ≥50%). The primary outcome was all-cause death within 2 years. The secondary outcomes included myocardial infarction (MI), revascularization, and patient-oriented composite endpoint (POCE), which was defined as a composite of all-cause death, any MI, or revascularization.

Results

Of the total 6,553 patients, 884 (13.5%) were classified into the reduced EF group, 1,749 (26.7%) into the mildly reduced EF group, and 3,920 (59.8%) into the preserved EF group. Patients with mildly reduced EF exhibited intermediate mortality (reduced EF, 24.7%; mildly reduced EF, 8.3%; preserved EF, 4.6%; p < 0.0001), MI (3.9% vs. 2.7% vs. 2.6%; p < 0.0046), and POCE (33.0% vs. 15.6% vs. 12.4%; p < 0.0001) rates, albeit closer to those of the preserved EF. After adjustment for demographics, risk factors, admission status, and discharge medications, patients with mildly reduced EF showed a lower risk of all-cause death than those with reduced EF (mildly reduced EF group as a reference: HR, 1.74; 95% CI, 1.40-2.18; p < 0.001), but it did not differ significantly from those with preserved EF (HR, 0.94; 95% CI, 0.75-1.18; p = 0.999).

Conclusions

Over a 2-year follow-up period, patients with AMI and mildly reduced EF demonstrated better prognoses than those with reduced EF, but did not differ significantly from those with preserved EF.

Clinical Trial Registration

cris.nih.go.kr, identifier: KCT-0000863.