Heart failure

The Discovery of C7-Substituted Norbornyl Bisamides as RXFP1 Small Molecule Agonists

Human relaxin-2 (relaxin, H2-RLX, RLN2), an endogenous hormone associated with mammalian pregnancy, and its cognate receptor relaxin family peptide receptor 1 (RXFP1) have been implicated as important modulators of cardiovascular function and agonism of RXFP1 may potentially be utilized for the treatment of heart failure. Exploration of chemical space around previously reported anthranilamide 2 led to the discovery of lead compound 39 with significantly improved agonist activities toward human and rodent RXFP1. Compound 39 induced a dose-dependent heart rate increase in isoflurane-anesthetized naïve rats, which is consistent with the hemodynamic profile of relaxin in rat. Compound 39 also elicited significant interpubic ligament (IPL) expansion in C57BL/6 mouse, measured with microCT imaging, which recapitulated the effect of relaxin.

Global trends and disparities in the burden of heart failure caused by chronic kidney disease: an analysis of the global burden of disease study 2021

Background

Heart failure (HF) is a major public health concern, and chronic kidney disease (CKD) plays a significant role in its pathogenesis. Understanding the trends and disparities in the burden of HF caused by CKD can provide valuable insights into health policymaking.

Methods

This study was a secondary analysis based on previously published data. We obtained global, regional, national, and age- and sex-specific data on the prevalence and years lived with disability (YLDs) of HF caused by CKD from the Global Burden of Disease Study 2021 (GBD 2021) and performed a secondary comparative analysis by age, sex, time, location, sociodemographic index (SDI), and health system level.

Results

In 2021, there were 1,936.9 (95%UI: 1,600.2-2,343.5) thousand cases of HF caused by CKD globally, with an age-standardized rate of YLDs of 3.1 (95%UI: 1.9-4.4) per 100,000 population. The global burden of HF caused by CKD has continuously increased from 1990 to 2021 and is expected to keep growing through 2045 according to predictions. Significant disparities were found across different locations, genders, and ages. Higher burdens were noted among males, older individuals, and regions with lower SDI or less advanced health systems.

Conclusion

The burden of HF caused by CKD has increased significantly since 1990 and varies widely across regions. More significant efforts are needed in the prevention and treatment of CKD and HF, especially among older individuals and males in regions with lower SDI or less advanced health systems.

Cardiac dysfunction is associated with indices of brain atrophy and cognitive impairment in heart failure with reduced ejection fraction

Cardiac dysfunction in heart failure with reduced ejection fraction (HFrEF) may contribute to brain atrophy and cognitive decline beyond that which is typical of healthy aging. This study tested the hypothesis that HFrEF would be associated with regionally unique brain remodeling and impaired cognitive performance independent of age. Furthermore, that cardiac index and clinical markers of HFrEF severity would predict brain remodeling and cognition with age and HFrEF, respectively. Cardiac function and brain morphology were assessed using magnetic resonance imaging in young healthy adults (24 ± 6 yr), older healthy adults (60 ± 6 yr), and patients living with HFrEF (59 ± 6 yr). The Montreal Cognitive Assessment was administered to assess cognition. Gray matter volume (GMV) (young: 492 ± 24, old: 456 ± 24, HFrEF: 433 ± 32 cm3, P ≤ 0.05) and cortical thickness (young: 2.44 ± 0.07, old: 2.33 ± 0.08, HFrEF: 2.22 ± 0.10 mm, P < 0.01) were lower with age and lowered further with HFrEF. Regional analysis revealed a unique pattern of atrophy with HFrEF. Whereas age had little effect on cortical curvature (P = 0.60), it was greater in HFrEF (young: 0.127 ± 0.003, old: 0.128 ± 0.003, HFrEF: 0.136 ± 0.005 mm-1, P < 0.01). Cardiac index was the best correlate of brain atrophy and cognitive performance with age (R = 0.33-0.47; P < 0.05). However, EF and end systolic volume index were better correlates of brain atrophy and cognitive performance in HFrEF (R = -0.50-0.49; P ≤ 0.05). These data indicate that lower GMV and cortical thickness in HFrEF are not merely an acceleration of age-related declines but reflect a unique pattern of brain atrophy and remodeling. In addition, classic markers of HF severity may be better predictors of pathological brain remodeling than reduced cardiac index.NEW & NOTEWORTHY Lower gray matter volume, and cortical thinning in heart failure are regionally dependent, and independent of age. Patients living with heart failure had higher cortical curvature, but older adults did not. Lower gray matter volume, cortical thinning, and cognitive impairment were associated with markers of cardiac dysfunction, with ejection fraction, and end systolic volume index being better predictors among the older and heart failure cohort than cardiac index.

The role of estrogen in the sex difference for the risk factors of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is a major subtype of heart failure, primarily characterized by a normal or mildly reduced left ventricular ejection fraction along with left ventricular diastolic dysfunction. Recent studies have shown that the prevalence of HFpEF is higher in women than that in men, particularly in postmenopausal women. Concurrently, it has been observed that the incidence of risk factors contributing to HFpEF (such as obesity, hypertension, diabetes, and atrial fibrillation) also notably increases post-menopause, affecting the incidence of HFpEF. This review aimed to examine the relationship between estrogen and risk factors associated with HFpEF, clarifying the underlying mechanisms through which estrogen affects these risk factors from epidemiological and pathophysiological perspectives. This review also provides a comprehensive understanding of the association between estrogen and the risk factors for HFpEF, thus helping explore potential targets for HFpEF treatment.

Therapeutic Potential of Gasdermin D-Mediated Myocardial Pyroptosis in Ischaemic Heart Disease: Expanding the Paradigm From Bench to Clinical Insights

Ischaemic heart disease (IHD) remains a leading cause of global morbidity and mortality. One significant contributor to the pathology of IHD is the excessive release of inflammatory mediators during the disease progression. Pyroptosis is a form of programmed cell death (PCD) triggered by the activation of inflammasomes and caspase 1. The activation of inflammatory caspase 1 proteolytically cleaves gasdermin D (GSDMD) to the activated form amino acid terminus (GSDMD-NT), leading to disruption of the plasma membrane. This cascade of events is considered the canonical pathway of pyroptosis. IHD also caused oxidative stress, thereby triggering noncanonical pyroptosis via the activation of caspases 4/5/11. Previous studies have provided compelling evidence of the close relationship between pyroptosis and the aetiology of IHD (e.g., acute myocardial infarction, myocardial ischaemia and reperfusion injury and chronic myocardial infarction), as well as the association of pyroptosis with unfavourable clinical outcomes. Several interventions aimed at targeting pyroptosis have demonstrated promising therapeutic benefits against IHD-related pathologies. This review provides mechanistic insights into the roles of pyroptosis in IHD from in vitro, in vivo and clinical perspectives. In-depth understanding into this area could also pave the way for the future development of novel therapeutic strategies targeting pyroptosis in IHD.

Microtubules Sequester Acetylated YAP in the Cytoplasm and Inhibit Heart Regeneration

BACKGROUND

The Hippo pathway effector YAP (Yes-associated protein) plays an essential role in cardiomyocyte proliferation and heart regeneration. In response to physiological changes, YAP moves in and out of the nucleus. The pathophysiological mechanisms regulating YAP subcellular localization after myocardial infarction remain poorly defined.

METHODS

We identified YAP acetylation at site K265 by in vitro acetylation followed by mass spectrometry analysis. We used adeno-associated virus to express YAP-containing mutations that either abolished acetylation (YAP-K265R) or mimicked acetylation (YAP-K265Q) and studied how acetylation regulates YAP subcellular localization in mouse hearts. We generated a cell line with YAP-K265R mutation and investigated the protein-protein interactors by YAP immunoprecipitation followed by mass spectrometry, then validated the YAP interaction in neonatal rat ventricular myocytes. We examined colocalization of YAP and TUBA4A (tubulin α 4A) by superresolution imaging. Furthermore, we developed YAP-K265R and αMHC-MerCreMer (MCM); Yap-loxP/K265R mutant mice to examine the pathophysiological role of YAP acetylation in cardiomyocytes during cardiac regeneration.

RESULTS

We found that YAP is acetylated at K265 by CBP (CREB-binding protein)/P300 (E1A-binding protein P300) and is deacetylated by nicotinamide phosphoribosyltransferase/nicotinamide adenine dinucleotide/sirtuins axis in cardiomyocytes. After myocardial infarction, YAP acetylation is increased, which promotes YAP cytoplasmic localization. Compared with controls, mice that were genetically engineered to express a K265R mutation that prevents YAP K265 acetylation showed improved cardiac regenerative ability and increased YAP nuclear localization. Mechanistically, YAP acetylation facilitates its interaction with TUBA4A, a component of the microtubule network that sequesters acetylated YAP in the cytoplasm. After myocardial infarction, the microtubule network increased in cardiomyocytes, resulting in the accumulation of YAP in the cytoplasm.

CONCLUSIONS

After myocardial infarction, decreased sirtuin activity enriches YAP acetylation at K265. The growing TUBA4A network sequesters acetylated YAP within the cytoplasm, which is detrimental to cardiac regeneration.

A Novel non-invasive optical framework for simultaneous analysis of contractility and calcium in single-cell cardiomyocytes

The use of a video method based on the Digital Image Correlation (DIC) algorithm from experimental mechanics to estimate the displacements, strain field, and sarcolemma length in a beating single-cell cardiomyocyte is proposed in this work. The obtained deformation is then correlated with the calcium signal, from calcium imaging where fluorescent dyes sensitive to calcium Ca2+ are used. Our proposed video-based method for simultaneous contraction and intracellular calcium analysis results in a low-cost, non-invasive, and label-free method. This technique has shown great advantages in long-term observations because this type of intervention-free measurement neutralizes the possible alteration in the beating cardiomyocyte introduced by other techniques for measuring cell contractility (e.g., Traction Force Microscopy, Atomic Force Microscopy, Microfabrication or Optical tweezers). Three tests were performed with synthetically augmented data from cardiomyocyte images to validate the robustness of the algorithm. First, a simulated rigid translation of a referenced image is applied, then a rotation, and finally a controlled longitudinal deformation of the referenced image, thus simulating a native realistic deformation. Finally, the proposed framework is evaluated with real experimental data. To validate contraction induced by intracellular calcium concentration, this signal is correlated with a new deformation measure proposed in this article, which is independent of cell orientation in the imaging setup. Finally, based on the displacements obtained by the DIC algorithm, the change in sarcolemma length in a contracting cardiomyocyte is calculated and its temporal correlation with the calcium signal is obtained.

Animal Models for Mechanical Circulatory Support: A Research Review

Heart failure is a clinical syndrome that has become a leading public health problem worldwide. Globally, nearly 64 million individuals are currently affected by heart failure, causing considerable medical, financial, and social challenges. One therapeutic option for patients with advanced heart failure is mechanical circulatory support (MCS) which is widely used for short-term or long-term management. MCS with various ventricular assist devices (VADs) has gained traction in end-stage heart failure treatment as a bridge-to-recovery, -decision, -transplant or -destination therapy. Due to limitations in studying VADs in humans, animal studies have substantially contributed to the development and advancement of MCS devices. Large animals have provided an avenue for developing and testing new VADs and improving surgical strategies for VAD implantation and for evaluating the effects and complications of MCS on hemodynamics and organ function. VAD modeling by utilizing rodents and small animals has been successfully implemented for investigating molecular mechanisms of cardiac unloading after the implantation of MCS. This review will cover the animal research that has resulted in significant advances in the development of MCS devices and the therapeutic care of advanced heart failure.

The effects of digoxin on heart failure mortality and re-admission in a single center cross-sectional study

Introduction

Mortality benefit of digoxin prescription in patients suffering from heart failure has been questioned many time. We evaluated these effects among admitted symptomatic heart failure patients.

Methods

We retrospectively divided our patients into two groups: group A (n=205) were digoxin prescribed, and group B (n=96) were digoxin naïve patients. Both groups' medical records were gathered for one year, and the study endpoints were compared between the two groups.

Results

The mean age was 62.3±12.1 years and 54.8 % were male. All-cause mortality and readmission occurred in 26.7% and 31.7% of individuals, respectively, without significant differences between the two groups. However, in subgroup analysis, there was a significant relationship between in-hospital mortality and the presence of cardiovascular risk factors.

Conclusion

Digoxin might increase in-hospital mortality in patients with underlying cardiovascular risk factors.

The effect of management of older patients with heart failure by general physicians on mortality and hospitalization rates: a retrospective cohort study

BACKGROUND

The prevalence of heart failure is increasing owing to the aging of the population, resulting in growing medical costs and an increasing number of patients with multimorbidity. The optimal management of heart failure by general physicians in addition to internal medicine physicians, such as cardiologists, is essential, although the specifics are unclear. In this study, we aimed to determine the differences in heart failure management outcomes among older patients between those managed by general physicians and those managed by internal medicine physicians, especially in terms of hospitalization and mortality rates.

METHODS

This was a retrospective cohort study of patients with heart failure who visited a community hospital in Japan. Patients with heart failure were selected based on International Classification of Diseases codes from electronic medical record data over 9 years, from September 2015 to August 2023. The independent variables were whether a general physician treated the patient; the primary outcome was death; the secondary outcome was hospitalization; and the covariates were patient background, including comorbidities. Multiple logistic regression analysis was used to evaluate the association between being managed by a general physician and death and hospitalization, after adjusting for confounding factors.

RESULTS

A total of 1032 patients with heart failure were identified, with a mean age of 82.4 years, and 48.9% were men. Patients treated by general physicians were older, were more likely to have dementia and were more likely to need care than those treated by internal medicine physicians. Being treated by a general physician was significantly negatively associated with death (odds ratio [OR], 0.62) and hospitalization (OR, 0.73).

CONCLUSIONS

In Japan, where medical specialties are increasingly differentiated, the comprehensive management of older patients with heart failure and multiple comorbidities by general physicians may reduce hospitalization and mortality rates. Appropriate education of general physicians and an increase in their numbers may prove essential for the successful management of patients with heart failure in aging communities.

Physiological effects of ivabradine in heart failure and beyond

Ivabradine is a pharmacologic agent that inhibits the funny current responsible for determining heart rate in the sinoatrial node. Ivabradine's clinical potential has been investigated in the context of heart failure since it is associated with reduced myocardial oxygen demand, enhanced diastolic filling, stroke volume, and coronary perfusion time; however, it is yet to demonstrate definitive mortality benefit. Alternative effects of ivabradine include modulation of the renin-angiotensin-aldosterone system, sympathetic activation, and endothelial function. Here, we review key clinical trials informing the clinical use of ivabradine and explore opportunities for leveraging its potential pleiotropic effects in other diseases, including treatment of hyperadrenergic states and mitigating complications of COVID-19 infection.

Prognostically Optimal Heart Rate at Discharge in Hospitalized Patients With Heart Failure and Atrial Fibrillation

Background

Managing heart rate (HR) is crucial for enhancing clinical prognosis in patients with heart failure (HF) and atrial fibrillation (AF). Nevertheless, the prognostic impact of HR at discharge in hospitalized HF patients remains unclear.

Objectives

This study aimed to determine the HR associated with the lowest risk of death and HF in patients hospitalized with HF and AF.

Methods

In this observational study, 334 persistent AF patients were analyzed from a database of 1,930 consecutive HF hospitalizations. Exclusion criteria included sinus rhythm or paroxysmal AF, cardiac pacemakers, or unrecorded HR at discharge. Participants were divided into four groups based on HR at discharge in 10 beats/min increments. The primary endpoint was a composite of death from any cause and rehospitalization due to HF. The association between resting HR and the primary endpoint was determined using Kaplan-Meier analysis and Cox proportional hazards models.

Results

The median follow-up period was 389 days, with 133 patients (39.8%) reaching the primary endpoint. Kaplan-Meier analysis revealed a significantly higher primary endpoint incidence in patients with HR >81 beats/min at discharge compared to those with HR <60 beats/min (log-rank test for trend: P = 0.039). Multivariable Cox regression analysis showed that HR >81 beats/min at discharge was associated with the primary endpoint, with a hazard ratio of 1.79 (95% CI: 1.04-3.07), compared to HR <60 beats/min.

Conclusions

The findings suggest that controlling HR to less than 80 beats/min at discharge may lead to better clinical outcomes in patients with HF and persistent AF.

Prediction of new-onset heart failure in patients with type 2 diabetes derived from ALTITUDE and CANVAS

AIM

To create and validate a prediction model to identify patients with type 2 diabetes (T2D) at high risk of new-onset heart failure (HF), including those treated with a sodium-glucose cotransporter-2 (SGLT2) inhibitor.

METHODS

A prediction model was developed from the Aliskiren Trial in Type 2 Diabetes Using Cardiorenal Endpoints (ALTITUDE), a trial in T2D patients with albuminuria or cardiovascular disease. We included 5081 patients with baseline N-terminal pro B-type natriuretic peptide (NT-proBNP) measurement and no history of HF. The model was developed using Cox regression and validated externally in the placebo arm of the Canagliflozin Cardiovascular Assessment Study (CANVAS), which included 996 participants with T2D and established cardiovascular disease or high cardiovascular risk, and in patients treated with canagliflozin.

RESULTS

ALTITUDE participants (mean age 64 ± 9.8 years) had a median serum NT-proBNP level of 157 (25th-75th percentile 70-359) pg/mL. Higher NT-proBNP level, troponin T (TnT) level and body mass index (BMI) emerged as significant and independent predictors of new-onset HF in both cohorts. The model further contained urinary albumin-to-creatinine ratio, glycated haemoglobin, age, haematocrit, and use of calcium channel blockers. A prediction model including these variables had a C-statistic of 0.828 (95% confidence interval [CI] 0.801-0.855) in ALTITUDE and 0.800 (95% CI 0.720-0.880) in CANVAS. The C-statistic of this model increased to 0.847 (95% CI 0.792-0.902) in patients after 1 year of canagliflozin treatment.

CONCLUSION

In patients with T2D, higher NT-proBNP level, TnT level and BMI are independent and externally validated predictors of new-onset HF, including patients using an SGLT2 inhibitor. This newly developed model may identify patients at high risk of new-onset HF, contributing to early recognition and possibly prevention.

Left and Right Ventricular Hemodynamic Response After Transcatheter Mitral Valve Replacement

Background

Transcatheter mitral valve replacement (TMVR) represents a novel treatment option for patients with mitral regurgitation (MR), but little is known about the hemodynamic impact of MR elimination following TMVR. We sought to investigate the hemodynamic impact of TMVR on left ventricular (LV) and right ventricular (RV) function using noninvasive pressure-volume loops.

Methods

All consecutive patients undergoing TMVR with dedicated devices between May 2016 and August 2022 were enrolled. The end-diastolic and end-systolic pressure-volume relationships were estimated from 26 patients using single-beat echocardiographic measurements at baseline and after TMVR at discharge. RV function was assessed by RV-pulmonary artery (PA) coupling and RV fractional area change. One-year follow-up was available for 19 patients. The prognostic impact of calculated end-diastolic volume at an end-diastolic pressure of 20 mmHg (VPed20) reduction was assessed by Cox regression.

Results

A total of 26 patients (77.0 years [interquartile range 73.9-80.1], N = 17 [65.4%] male) with successful TMVR were included (secondary MR [N = 21, 80.8%]; median LV ejection fraction was 37.0% [interquartile range 30.7-50.7]). At discharge, a decrease in VPed20 (p < 0.001) indicating leftward shift of end-diastolic pressure-volume relationship, and an increase of the end-systolic elastance slope (p = 0.007) were observed after TMVR. No changes were observed for RV-PA coupling (p = 0.19) and RV fractional area change (p = 0.22). At 1-year follow-up, LV contractility (end-systolic elastance) and RV-PA coupling remained stable. Vped20 reduction at discharge was significantly associated with 1-year all-cause mortality or heart failure hospitalization (hazard ratio 0.16, 95% CI 0.04-0.71, p = 0.016).

Conclusions

Noninvasive assessment of pressure-volume loops demonstrated early LV reverse remodeling and improved LV contractility, while RV performance was preserved. These results indicate the potential prognostic impact of complete MR elimination after TMVR.

Patients' UX Impact on Medication Adherence in Czech Pilot Study for Chronically Ill

This article presents a comprehensive and multistage approach to the development of the user experience (UX) for an mHealth application targeting older adult patients with chronic diseases, specifically chronic heart failure and chronic obstructive pulmonary disease. The study adopts a mixed methods approach, incorporating both quantitative and qualitative components. The underlying hypothesis posits that baseline medicine adherence knowledge (measured by the MARS questionnaire), beliefs about medicines (measured by the BMQ questionnaire), and level of user experience (measured by the SUS and UEQ questionnaires) act as predictors of adherence change after a period of usage of the mHealth application. However, contrary to our expectations, the results did not demonstrate the anticipated relationship between the variables examined. Nevertheless, the qualitative component of the research revealed that patients, in general, expressed satisfaction with the application. It is important to note that the pilot testing phase revealed a notable prevalence of technical issues, which may have influenced participants' perception of the overall UX. These findings contribute to the understanding of UX development in the context of mHealth applications for older adults with chronic diseases and emphasise the importance of addressing technical challenges to enhance user satisfaction and engagement.

Regenerative medicine in cardiovascular disease

Owing to the rapid increase in the number of people with severe heart failure, regenerative medicine is anticipated to play a role in overcoming the limitations inherent in existing surgical interventions. There are essentially two types of cardiac regenerative therapies for a failing heart. Cellular regenerative therapies using various stem cells improve the functional recovery of the heart mainly by cytokine paracrine effects. The implantation of induced pluripotent stem cell-derived cardiomyocytes can contribute not only to the inhibition of adverse heart remodeling by paracrine effects but also to the supply of newly born functional myocytes with the recipient myocardium as "mechanically working cells." Cell transplantation, including autologous myoblast transplantation, reduces heart failure exacerbations and benefits patients without the need for other treatment options. Although cellular therapy is currently the mainstream approach, it requires an in-house cell-processing center with an aseptic environment. In addition, these stem cells are usually introduced via several invasive delivery methods, including intracoronary administration, and cellular sheet implantation. Simplifying the culture methods for these cells is a crucial problem that needs to be resolved. Drug-induced regenerative therapy is another option that enhances self-endogenous regenerative systems in the human body and does not require invasive methods or cell cultures. Therefore, drug-induced regenerative therapies may overcome the disadvantages of these cellular therapies. The purpose of this report is to summarize cell transplantation therapy in the cardiovascular system and regenerative therapy for heart failure using an autologous endogenous regenerative system.

Ultrasound-targeted microbubble destruction rapidly improves left ventricular function in rats with ischemic cardiac dysfunction

BACKGROUND

Previous studies have demonstrated the efficacy of ultrasound-targeted microbubble destruction (UTMD) in the treatment of ischemic heart failure (HF). The purpose of this study was to explore the mechanism by which UTMD improves ischemic HF.

METHODS

An ischemic heart failure model was established using Sprague-Dawley rats. Rats were randomly divided into 7 groups: sham group, HF group, HF + MB group, HF + ultrasound (US) group, HF + UTMD group, HF + UTMD+LY294002 group, and HF + LY294002 group. Serum BNP level and echocardiographic parameters were measured to evaluate cardiac function. PI3K/Akt/eNOS signaling pathway protein levels were detected by immunohistochemistry (IHC) and western blotting. The concentrations of nitrous oxide (NO) and ATP were detected by ELISA, and hematoxylin and eosin (HE) staining was used to evaluate myocardial tissue.

RESULTS

UTMD rapidly improved ejection fraction (EF) (HF: 37.16 ± 1.21% vs. HF + UTMD: 46.31 ± 3.00%, P < 0.01) and fractional shortening (FS) (HF: 18.53 ± 0.58% vs. HF + UTMD: 24.05 ± 1.84%, P < 0.01) in rats with ischemic HF. UTMD activated the PI3K/AKT/eNOS signaling pathway (HF vs. HF + UTMD, P < 0.01) and promoted the release of NO and ATP (HF vs. HF + UTMD, both, P < 0.05). Inhibition of the PI3K/AKT/eNOS signaling pathway by LY294002 worsened EF (HF: 37.16 ± 1.21% vs. HF + LY294002: 32.73 ± 3.05%, P < 0.05), and the release of NO and ATP by UTMD (HF + UTMD vs. HF + UTMD+LY294002, P < 0.05).

CONCLUSIONS

UTMD can rapidly improve cardiac function in ischemic HF by activating the PI3K/Akt/eNOS signaling pathway and promoting the release of NO and ATP.

Blood pressure and heart failure: focused on treatment

Heart failure (HF) remains a significant global health burden, and hypertension is known to be the primary contributor to its development. Although aggressive hypertension treatment can prevent heart changes in at-risk patients, determining the optimal blood pressure (BP) targets in cases diagnosed with HF is challenging owing to insufficient evidence. Notably, hypertension is more strongly associated with HF with preserved ejection fraction than with HF with reduced ejection fraction. Patients with acute hypertensive HF exhibit sudden symptoms of acute HF, especially those manifested with severely high BP; however, no specific vasodilator therapy has proven beneficial for this type of acute HF. Since the majority of medications used to treat HF contribute to lowering BP, and BP remains one of the most important hemodynamic markers, targeted BP management is very concerned in treatment strategies. However, no concrete guidelines exist, prompting a trend towards optimizing therapies to within tolerable ranges, rather than setting explicit BP goals. This review discusses the connection between BP and HF, explores its pathophysiology through clinical studies, and addresses its clinical significance and treatment targets.

Role of Vasoactive Hormone-Induced Signal Transduction in Cardiac Hypertrophy and Heart Failure

Heart failure is the common concluding pathway for a majority of cardiovascular diseases and is associated with cardiac dysfunction. Since heart failure is invariably preceded by adaptive or maladaptive cardiac hypertrophy, several biochemical mechanisms have been proposed to explain the development of cardiac hypertrophy and progression to heart failure. One of these includes the activation of different neuroendocrine systems for elevating the circulating levels of different vasoactive hormones such as catecholamines, angiotensin II, vasopressin, serotonin and endothelins. All these hormones are released in the circulation and stimulate different signal transduction systems by acting on their respective receptors on the cell membrane to promote protein synthesis in cardiomyocytes and induce cardiac hypertrophy. The elevated levels of these vasoactive hormones induce hemodynamic overload, increase ventricular wall tension, increase protein synthesis and the occurrence of cardiac remodeling. In addition, there occurs an increase in proinflammatory cytokines and collagen synthesis for the induction of myocardial fibrosis and the transition of adaptive to maladaptive hypertrophy. The prolonged exposure of the hypertrophied heart to these vasoactive hormones has been reported to result in the oxidation of catecholamines and serotonin via monoamine oxidase as well as the activation of NADPH oxidase via angiotensin II and endothelins to promote oxidative stress. The development of oxidative stress produces subcellular defects, Ca2+-handling abnormalities, mitochondrial Ca2+-overload and cardiac dysfunction by activating different proteases and depressing cardiac gene expression, in addition to destabilizing the extracellular matrix upon activating some metalloproteinases. These observations support the view that elevated levels of various vasoactive hormones, by producing hemodynamic overload and activating their respective receptor-mediated signal transduction mechanisms, induce cardiac hypertrophy. Furthermore, the occurrence of oxidative stress due to the prolonged exposure of the hypertrophied heart to these hormones plays a critical role in the progression of heart failure.

Postmyocardial Infarction Ventricular Aneurysm: JACC Focus Seminar 5/5

Ventricular aneurysm represents a rare complication of transmural acute myocardial infarction, although other cardiac, congenital, or metabolic diseases may also predispose to such condition. Ventricular expansion includes all the cardiac layers, usually with a large segment involved. Adverse events include recurrent angina, reduced ventricular stroke volume with congestive heart failure, mitral regurgitation, thromboembolism, and ventricular arrhythmias. Multimodality imaging is paramount to provide comprehensive assessment, allowing for appropriate therapeutic decision-making. When indicated, surgical intervention remains the gold standard, although additional therapy (heart failure, anticoagulation, and advanced antiarrhythmic treatment) might be required. However, the STICH (Surgical Treatment for Ischemic Heart Failure) trial did not show any advantage from adding surgical ventricular reconstruction to coronary artery bypass surgery in terms of survival, rehospitalization or symptoms, compared with revascularization alone. Finally, implantable cardiac defibrillator may reduce the risk of fatal arrhythmias.

α-Melanocyte-stimulating hormone alleviates pathological cardiac remodeling via melanocortin 5 receptor

α-Melanocyte-stimulating hormone (α-MSH) regulates diverse physiological functions by activating melanocortin receptors (MC-R). However, the role of α-MSH and its possible target receptors in the heart remain completely unknown. Here we investigate whether α-MSH could be involved in pathological cardiac remodeling. We found that α-MSH was highly expressed in the mouse heart with reduced ventricular levels after transverse aortic constriction (TAC). Administration of a stable α-MSH analog protected mice against TAC-induced cardiac hypertrophy and systolic dysfunction. In vitro experiments revealed that MC5-R in cardiomyocytes mediates the anti-hypertrophic signaling of α-MSH. Silencing of MC5-R in cardiomyocytes induced hypertrophy and fibrosis markers in vitro and aggravated TAC-induced cardiac hypertrophy and fibrosis in vivo. Conversely, pharmacological activation of MC5-R improved systolic function and reduced cardiac fibrosis in TAC-operated mice. In conclusion, α-MSH is expressed in the heart and protects against pathological cardiac remodeling by activating MC5-R in cardiomyocytes. These results suggest that analogs of naturally occurring α-MSH, that have been recently approved for clinical use and have agonistic activity at MC5-R, may be of benefit in treating heart failure.

Neutrophils facilitate the epicardial regenerative response after zebrafish heart injury

Despite extensive studies on endogenous heart regeneration within the past 20 years, the players involved in initiating early regeneration events are far from clear. Here, we assessed the function of neutrophils, the first-responder cells to tissue damage, during zebrafish heart regeneration. We detected rapid neutrophil mobilization to the injury site after ventricular amputation, peaking at 1-day post-amputation (dpa) and resolving by 3 dpa. Further analyses indicated neutrophil mobilization coincides with peak epicardial cell proliferation, and recruited neutrophils associated with activated, expanding epicardial cells at 1 dpa. Neutrophil depletion inhibited myocardial regeneration and significantly reduced epicardial cell expansion, proliferation, and activation. To explore the molecular mechanism of neutrophils on the epicardial regenerative response, we performed scRNA-seq analysis of 1 dpa neutrophils and identified enrichment of the FGF and MAPK/ERK signaling pathways. Pharmacological inhibition of FGF signaling indicated its' requirement for epicardial expansion, while neutrophil depletion blocked MAPK/ERK signaling activation in epicardial cells. Ligand-receptor analysis indicated the EGF ligand, hbegfa, is released from neutrophils and synergizes with other FGF and MAPK/ERK factors for induction of epicardial regeneration. Altogether, our studies revealed that neutrophils quickly motivate epicardial cells, which later accumulate at the injury site and contribute to heart regeneration.

The Eye as the Window to the Heart: Optical Coherence Tomography Angiography Biomarkers as Indicators of Cardiovascular Disease

Alterations in microvasculature represent some of the earliest pathological processes across a wide variety of human diseases. In many organs, however, inaccessibility and difficulty in directly imaging tissues prevent the assessment of microvascular changes, thereby significantly limiting their translation into improved patient care. The eye provides a unique solution by allowing for the non-invasive and direct visualization and quantification of many aspects of the human microvasculature, including biomarkers for structure, function, hemodynamics, and metabolism. Optical coherence tomography angiography (OCTA) studies have specifically identified reduced capillary densities at the level of the retina in several eye diseases including glaucoma. This narrative review examines the published data related to OCTA-assessed microvasculature biomarkers and major systemic cardiovascular disease. While loss of capillaries is being established in various ocular disease, pilot data suggest that changes in the retinal microvasculature, especially within the macula, may also reflect small vessel damage occurring in other organs resulting from cardiovascular disease. Current evidence suggests retinal microvascular biomarkers as potential indicators of major systemic cardiovascular diseases, including systemic arterial hypertension, atherosclerotic disease, and congestive heart failure.

Oral Cardiac Drug-Gut Microbiota Interaction in Chronic Heart Failure Patients: An Emerging Association

Regardless of the currently proposed best medical treatment for heart failure patients, the morbidity and mortality rates remain high. This is due to several reasons, including the interaction between oral cardiac drug administration and gut microbiota. The relation between drugs (especially antibiotics) and gut microbiota is well established, but it is also known that more than 24% of non-antibiotic drugs affect gut microbiota, altering the microbe's environment and its metabolic products. Heart failure treatment lies mainly in the blockage of neuro-humoral hyper-activation. There is debate as to whether the administration of heart-failure-specific drugs can totally block this hyper-activation, or whether the so-called intestinal dysbiosis that is commonly observed in this group of patients can affect their action. Although there are several reports indicating a strong relation between drug-gut microbiota interplay, little is known about this relation to oral cardiac drugs in chronic heart failure. In this review, we review the contemporary data on a topic that is in its infancy. We aim to produce scientific thoughts and questions and provide reasoning for further clinical investigation.

Could admission level of uric acid predict total diuretic dose in acute heart failure?

BACKGROUND

Recent studies have shown that increases in serum UA levels are associated with adverse clinical outcomes in patients with chronic heart failure (CHF); the aim of this study was to determine the relationship between serum uric acid and total diuretic dose received during hospitalization in hospitalized patients with acute exacerbation of heart failure. The main purpose of this study is to determine the role of uric acid as a biomarker that can be a substitute for pro-BNP in clinical evaluation and the need for diuretics in hospitalized patients with acute heart failure.

METHODS

After approving the plan in the Research Council of the Heart Department and obtaining an ethical code from the Regional Committee on Research Ethics (Human Subjects Studies), the researcher referred to the archives of our center, the case of 100 patients diagnosed with acute heart failure. Cardiac patients were selected, and the information required for the study was collected using a pre-prepared data collection form, and the information was entered into SPSS software after categorization and appropriate analysis and statistical tests were performed on it. Were performed and in all statistical tests the statistical significance level was considered 0.05: RESULTS: 100 patients with acute heart failure were included in this study with a mean age of 63.43 ± 14.78 years. 66% of them were men. The mean dose of furosemide in these patients was 680.92 ± 377.47 mg and the mean serum uric acid level in these patients was 8.55 ± 2.50 mg / dL. In the study of the relationship between the variables, there was a significant relationship between the dose of furosemide received with the serum level of serum uric acid (P = 0.017, r = 0.248 and P = 0.009, r = -0.267, respectively). There is also a significant relationship between serum uric acid level and patient mortality (P = 0.013, r = 0.247). However this relationship lost its significance after multivariate analysis.

CONCLUSION

There is a significant relationship between serum uric acid level and diuretic use. However, in-hospital mortality is not related to uric acid levels at admission.

Swine Model of Myocardial Infarction Induced by Ischemia-Reperfusion and Embolization

Acute myocardial infarction continues to account for a growing burden of heart failure worldwide. Despite existing therapies, new approaches for reducing the extent of damage and better managing heart failure progression are urgently needed. Preclinical large animal models are a critical step in the translation of scientific discoveries toward clinical trials and therapeutic application. In this chapter, we detail methods to induce swine models of myocardial infarction through catheter-mediated approaches involving either temporary (ischemia-reperfusion) or permanent (thrombus injection or embolic coil) occlusions. These techniques are relatively low in invasiveness, while infarct size with corresponding cardiac dysfunction can be controlled by adjusting the location of coronary occlusion. We also describe methods for cardiac angiography and echocardiography in pigs. This is the second edition of a previously published chapter with modifications.

Cardiac magnetic resonance for the early prediction of reverse left ventricular remodeling in patients with ST-segment elevation myocardial infarction

OBJECTIVES

To evaluate the changes in cardiac magnetic resonance (CMR) characteristics and investigate the predictors of reverse left ventricular remodeling (r-LVR) in ST-segment elevation myocardial infarction (STEMI) patients.

MATERIALS AND METHODS

Eighty-six STEMI patients (median 56 years) were retrospectively studied. The patients were divided into r-LVR and without r-LVR groups. CMR analysis included LV volume, infarct characteristics, and global and regional myocardial function. The strain and displacement were assessed by CMR-feature tracking. The predictors of r-LVR were analyzed by the logistic regression method.

RESULTS

There were 37 patients in the r-LVR group and 49 patients in the without r-LVR group. At initial CMR, there was no difference in LV volume and global cardiac function between the two groups. However, the infarct zone radial and longitudinal displacements were higher in the r-LVR group (p < 0.05, respectively). At the second CMR, the r-LVR group showed higher LVEF, lower LV volume, and total enhanced mass (all p < 0.05). The infarct zone radial and circumferential strains and radial displacement were higher in the r-LVR group (all p < 0.05). The r-LVR group had better recovery of myocardial injury and function. Of note, microvascular obstruction (MVO) mass (odds ratio: 0.779 (0.613-0.989), p = 0.041) and infarct zone peak longitudinal displacement (PLD) (odds ratio: 1.448 (1.044-2.008), p = 0.026) were independent predictors of r-LVR.

CONCLUSIONS

At initial CMR, there were no differences in global cardiac function between the two groups, but infarct zone displacements were higher in the r-LVR group. The r-LVR group had better recovery of cardiac function. In addition, MVO mass and infarct zone PLD were independent predictors of r-LVR.

CLINICAL RELEVANCE STATEMENT

Our study assessed changes in cardiac structure, function, and tissue characteristics after STEMI by CMR, investigated the best predictors of r-LVR in STEMI patients, and laid the foundation for the development of new parameter-guided treatment strategies for STEMI patients.

KEY POINTS

• At initial CMR, the reverse left ventricular remodeling (r-LVR) group had less myocardial damage and higher infarct zone displacement, but there were no differences in global function between the two groups. • Both groups showed recovery of myocardial injury and cardiac function over time, but the r-LVR group had less enhanced mass and better cardiac function compared to the without r-LVR group at the second CMR. • Microvascular obstruction mass and infarct zone peak longitudinal displacement by cardiac magnetic resonance feature-tracking were significant predictors of r-LVR in STEMI patients.

The characteristic large-scale annual analysis by gender and age in heart failure patients: cohort for 10 years in Korea

AIMS

The prevalence and incidence rate of heart failure (HF) continues to increase along with the aging of the population and the increase of ischaemic heart disease. The morbidity and mortality of HF are also on the rise in the industrialized countries; it can be a great public health problem. A detailed and accurate analysis of the demographical incidence and prevalence of HF is an important first step in predicting the occurrence of the disease in the future and proper preparing for prevention. Here, we aimed to analyse the annual prevalence and incidence of HF by gender and age using long-term national health insurance service data in the Republic of Korea.

METHODS AND RESULTS

A total of 47 243 patients newly diagnosed with HF between 2006 and 2015 among nationally representative random subjects of 1 000 000 were included. The data of age and gender were analysed by year, and the total population information of the Ministry of Land, Infrastructure, and Transport of Korea was referred to compare the data of HF patients with the total population (2008-15). Over the decade from 2006 to 2015, the prevalence of HF patients showed tendency of increase (P < 0.001). The overall incidence rate was also gradually increasing (P < 0.001), but in women, it tended to decrease gradually. Women significantly accounted higher than the male group in incidence of HF over the period (54.6% vs. 45.4%, P < 0.001). The mean age at the time of diagnosis gradually increased (P = 0.002 for total, P = 0.001 for each gender). Total incidence was highest in 70s (27.22%), but males were the most in their 60s and females were in their 70s. Analysis of annual trend by age and gender distribution of HF incidence in men presented highest in the 50s-70s with a similar pattern annually, and the incidence is increasing more recently. Different from that of men, in the case of women, the incidence gradually increased with age in a similar annual pattern, peaking in their 70s and gradually decreasing in recent years.

CONCLUSIONS

The prevalence and incidence of HF are gradually increasing. It increased rapidly in their 50s and older. It showed an increased incidence of HF especially in men between their 50s and 70s, and more observation and caution for the management of the risk factors may be needed to prevent HF in the male group.

Effects of pirfenidone on scar size and ventricular remodeling after myocardial infarction: a preclinical study

BACKGROUND

An intense fibrotic response after myocardial infarction (MI) may lead to scar expansion and left ventricular (LV) remodeling. We investigated the effects of the antifibrotic drug pirfenidone in this setting.

METHODS

Male Wistar rats were randomized to: sham procedure (n = 13), reperfused MI-induced by ligating the left anterior descending artery (LAD) for 45 min (n = 17), reperfused MI plus standard therapy (aspirin, angiotensin-converting enzyme inhibitor, beta blocker, and mineralocorticoid receptor antagonist) (n = 17), reperfused MI plus pirfenidone alone (n = 17), or reperfused MI plus standard therapy and pirfenidone (n = 17). Rats surviving MI induction underwent cardiac magnetic resonance scans after 72 h and 30 days from MI, and were sacrificed on day 31.

RESULTS

Rats completing the whole protocol numbered 11 in the sham group, 9 in the untreated MI group, 8 in the standard treatment group, 9 in the pirfenidone alone group, and 9 in the standard treatment plus pirfenidone group. No significant differences emerged between LV volumes, ejection fraction or mass at 30 days or the differences from 72 h to 30 days. Small, nonsignificant differences between rats on pirfenidone alone vs. those on standard therapy emerged. The total extent of LV fibrosis, quantified as area and percentage of the tissue sample, did not differ significantly between rats on pirfenidone alone vs. those on standard therapy alone.

CONCLUSION

Pirfenidone does not have additional effects on LV remodeling or fibrosis compared with standard therapy, but its effects are similar to standard therapy alone.

Systolic heart failure induced by butylparaben in zebrafish is caused through oxidative stress and immunosuppression

Due to Butylparaben (BuP) widespread application in cosmetics, food, pharmaceuticals, and its presence as an environmental residue, human and animal exposure to BuP is common, potentially posing hazards to both human and animal health. Congenital heart disease is already a serious problem. However, the effects of BuP on the developing heart and its underlying mechanisms remain unclear. Here, zebrafish embryos were exposed to environmentally and human-relevant concentrations of BuP (0.6 mg/L, 1.2 mg/L, and 1.8 mg/L, calculated but not measured) at 6 h post-fertilization (hpf) and were treated until 72 hpf. Exposure to BuP led to cardiac morphological defects and cardiac dysfunction in zebrafish embryos, manifesting symptoms similar to systolic heart failure. The etiology of BuP-induced systolic heart failure in zebrafish embryos is multifactorial, including cardiomyocyte apoptosis, endocardial and atrioventricular valve damage, insufficient myocardial energy, impaired Ca2+ homeostasis, depletion of cardiac-resident macrophages, cardiac immune non-responsiveness, and cardiac oxidative stress. However, excessive accumulation of reactive oxygen species (ROS) in the cardiac region and cardiac immunosuppression (depletion of cardiac-resident macrophages and cardiac immune non-responsiveness) may be the predominant factors. In conclusion, this study indicates that BuP is a potential hazardous substance that can cause adverse effects on the developing heart and provides evidence and insights into the pathological mechanisms by which BuP leads to cardiac dysfunction. It may help to prevent the BuP-based congenital heart disease heart failure in human through ameliorating strategies and BuP discharge policies, while raising awareness to prevent the misuse of preservatives.

Circulating thyroid hormones and clinical parameters of heart failure in men

Heart failure (HF) is a multiple hormonal deficiency syndrome which includes alterations in the serum concentration of thyroid hormones (TH). This cross-sectional study enrolled 215 male patients hospitalised for acute HF. Data on cardiovascular risk factors, chronic medications, cardiac function assessed by echocardiography, and clinical parameters of HF were prospectively collected. The independent predictive association of TH with all investigated parameters of the HF severity were assessed. The patient's mean age was 74.4 years, 57.2% had arterial hypertension, 54.0% were consuming alcohol, and 42.3% were diabetics. Multivariate analysis revealed that total triiodothyronine (TT3) was an independent predictor of greater left ventricular ejection fraction (LVEF; β = 0.223, p = 0.008), less progressed left ventricular diastolic dysfunction (LVDD; β = - 0.271, p = 0.001) and lower N-terminal pro-brain natriuretic peptide (NT-proBNP; β = - 0.365, p < 0.001). None of the TH other than TT3 was associated with LVDD or NT-proBNP, whereas free triiodothyronine (β = - 0.197, p = 0.004), free thyroxine (β = - 0.223, p = 0.001) and total thyroxine (β = - 0.140, p = 0.041) were inversely associated with LVEF. The present study suggests that, among TH, serum TT3 level is most closely associated with echocardiographic, laboratory and clinical parameters of the severity of HF in men.

Colchicine added to standard therapy further reduces fibrosis in pigs with myocardial infarction

BACKGROUND

The anti-inflammatory drug colchicine improves the outcome of patients with myocardial infarction (MI). As an intense inflammatory and fibrotic response after MI may lead to scar expansion and left ventricular (LV) remodeling, the clinical benefit of colchicine could be related to a positive effect on the infarct scar and LV remodeling.

METHODS

Pigs underwent left anterior descending artery occlusion through an angioplasty balloon for 90 min and were then randomized into two groups: standard therapy [ACE inhibitor, beta blocker, mineralocorticoid receptor antagonist (MRA), aspirin] plus colchicine (n = 14) or standard therapy alone (n = 13). The pigs were treated for 30 days and underwent two cardiac magnetic resonance (CMR) scans at 72 h and 30 days. The pigs were then sacrificed the day after the second CMR. The primary efficacy end point was the extent of fibrosis in the infarct zone (calculated on eight samples from this zone and averaged).

RESULTS

In the hearts explanted after 31 days, pigs in the colchicine group had less fibrosis in the infarct zone than the other animals [41.6% (20.4-51.0) vs. 57.4% (42.9-66.5); P = 0.022]. There was a trend toward a higher myocardial salvage index (MSI; an index of the efficacy of revascularization) in pigs on colchicine (P = 0.054). Conversely, changes in LV volumes, ejection fraction and mass did not differ between groups.

CONCLUSION

Colchicine therapy for 1 month after reperfused MI further reduces myocardial fibrosis when added to standard therapy, while it does not have additional effects on LV remodeling.

Peritoneal ultrafiltration in older adult patients with advanced heart failure

Advanced heart failure (HF) with congestive symptoms refractory to diuretic treatment worsens the patient's prognosis and quality of life. Peritoneal ultrafiltration (PUF) attempts to improve symptoms and reduce HF-related events. This study analyzes the impact of PUF on older adult patients with significant comorbidity and advanced HF. Eighteen patients with advanced HF attended to in the Internal Medicine HF Unit of the Lucus Augusti University Hospital of Lugo, Spain, who started PUF between 2014 and 2021 were analyzed. The number of admissions and instances in which diuretic rescue treatment was used in the year before and after starting PUF were compared. The evolution of renal function, complications secondary to the technique, and survival were also analyzed. The median age was 80 (SD 5.8) years and 72.2% were men. Comparing the year after starting PUF to the year before starting PUF, hospital admissions due to HF (4 vs 20, p = 0.01) and the use of intravenous diuretic rescue treatment declined (4 vs 118, p < 0.001). There was no significant deterioration in renal function during the first year of follow-up or major complications associated with the technique. Survival was 72% at 1 year. In older adult patients with comorbidity, advanced HF, and refractory congestive symptoms, PUF reduced hospital admissions and the use of intravenous diuretic rescue treatment, without major complications.

Heart Failure With Preserved Ejection Fraction: An Evolving Understanding

Heart failure (HF) with preserved ejection fraction (HFpEF) is a clinical syndrome in which patients have signs and symptoms of HF due to high left ventricular (LV) filling pressure despite normal or near normal LV ejection fraction. It is more common than HF with reduced ejection fraction (HFrEF), and its diagnosis and treatment are more challenging than HFrEF. Although hypertension is the primary risk factor, coronary artery disease and other comorbidities, such as atrial fibrillation (AF), diabetes, chronic kidney disease (CKD), and obesity, also play an essential role in its formation. This review summarizes current knowledge about HFpEF, its pathophysiology, clinical presentation, diagnostic challenges, current treatments, and promising novel treatments. It is essential to continue to be updated on the latest treatments for HFpEF so that patients always receive the most therapeutic treatments. The use of GnRH agonists in the management of HFpEF, infusion of Apo a-I nanoparticle, low-level transcutaneous vagal stimulation (LLTS), and estrogen only in post-menopausal women are promising strategies to prevent diastolic dysfunction and HFpEF; however, there is still no proven curative treatment for HFpEF yet.

Pharmacological Therapy Optimization for Heart Failure: A Practical Guide for the Internist

Heart failure carries significant morbidity and mortality and affects a large population of patients cared for predominantly by primary care physicians. The complexity of managing heart failure patients is increasing as new therapies continue to emerge. This review outlines important clinical pearls and proposes strategies for optimization of medical therapy.

Plant-Derived Biomaterials and Their Potential in Cardiac Tissue Repair

Cardiovascular disease remains the leading cause of mortality worldwide. The inability of cardiac tissue to regenerate after an infarction results in scar tissue formation, leading to cardiac dysfunction. Therefore, cardiac repair has always been a popular research topic. Recent advances in tissue engineering and regenerative medicine offer promising solutions combining stem cells and biomaterials to construct tissue substitutes that could have functions similar to healthy cardiac tissue. Among these biomaterials, plant-derived biomaterials show great promise in supporting cell growth due to their inherent biocompatibility, biodegradability, and mechanical stability. More importantly, plant-derived materials have reduced immunogenic properties compared to popular animal-derived materials (e.g., collagen and gelatin). In addition, they also offer improved wettability compared to synthetic materials. To date, limited literature is available to systemically summarize the progression of plant-derived biomaterials in cardiac tissue repair. Herein, this paper highlights the most common plant-derived biomaterials from both land and marine plants. The beneficial properties of these materials for tissue repair are further discussed. More importantly, the applications of plant-derived biomaterials in cardiac tissue engineering, including tissue-engineered scaffolds, bioink in 3D biofabrication, delivery vehicles, and bioactive molecules, are also summarized using the latest preclinical and clinical examples.

Effects of Angiotensin 1-7 and Mas Receptor Agonist on Renal System in a Rat Model of Heart Failure

Congestive heart failure (CHF) is often associated with impaired kidney function. Over- activation of the renin-angiotensin-aldosterone system (RAAS) contributes to avid salt/water retention and cardiac hypertrophy in CHF. While the deleterious effects of angiotensin II (Ang II) in CHF are well established, the biological actions of angiotensin 1-7 (Ang 1-7) are not fully characterized. In this study, we assessed the acute effects of Ang 1-7 (0.3, 3, 30 and 300 ng/kg/min, IV) on urinary flow (UF), urinary Na⁺ excretion (UNaV), glomerular filtration rate (GFR) and renal plasma flow )RPF) in rats with CHF induced by the placement of aortocaval fistula. Additionally, the chronic effects of Ang 1-7 (24 µg/kg/h, via intra-peritoneally implanted osmotic minipumps) on kidney function, cardiac hypertrophy and neurohormonal status were studied. Acute infusion of either Ang 1-7 or its agonist, AVE 0991, into sham controls, but not CHF rats, increased UF, UNaV, GFR, RPF and urinary cGMP. In the chronic protocols, untreated CHF rats displayed lower cumulative UF and UNaV than their sham controls. Chronic administration of Ang 1-7 and AVE 0991 exerted significant diuretic, natriuretic and kaliuretic effects in CHF rats, but not in sham controls. Serum creatinine and aldosterone levels were significantly higher in vehicle-treated CHF rats as compared with controls. Treatment with Ang 1-7 and AVE 0991 reduced these parameters to comparable levels observed in sham controls. Notably, chronic administration of Ang 1-7 to CHF rats reduced cardiac hypertrophy. In conclusion, Ang 1-7 exerts beneficial renal and cardiac effects in rats with CHF. Thus, we postulate that ACE2/Ang 1-7 axis represents a compensatory response to over-activity of ACE/AngII/AT1R system characterizing CHF and suggest that Ang 1-7 may be a potential therapeutic agent in this disease state.

Control of the post-infarct immune microenvironment through biotherapeutic and biomaterial-based approaches

Ischemic heart failure (IHF) is a leading cause of morbidity and mortality worldwide, for which heart transplantation remains the only definitive treatment. IHF manifests from myocardial infarction (MI) that initiates tissue remodeling processes, mediated by mechanical changes in the tissue (loss of contractility, softening of the myocardium) that are interdependent with cellular mechanisms (cardiomyocyte death, inflammatory response). The early remodeling phase is characterized by robust inflammation that is necessary for tissue debridement and the initiation of repair processes. While later transition toward an immunoregenerative function is desirable, functional reorientation from an inflammatory to reparatory environment is often lacking, trapping the heart in a chronically inflamed state that perpetuates cardiomyocyte death, ventricular dilatation, excess fibrosis, and progressive IHF. Therapies can redirect the immune microenvironment, including biotherapeutic and biomaterial-based approaches. In this review, we outline these existing approaches, with a particular focus on the immunomodulatory effects of therapeutics (small molecule drugs, biomolecules, and cell or cell-derived products). Cardioprotective strategies, often focusing on immunosuppression, have shown promise in pre-clinical and clinical trials. However, immunoregenerative therapies are emerging that often benefit from exacerbating early inflammation. Biomaterials can be used to enhance these therapies as a result of their intrinsic immunomodulatory properties, parallel mechanisms of action (e.g., mechanical restraint), or by enabling cell or tissue-targeted delivery. We further discuss translatability and the continued progress of technologies and procedures that contribute to the bench-to-bedside development of these critically needed treatments.

Positive Airway Pressure Adherence and Health Care Resource Utilization in Patients With Obstructive Sleep Apnea and Heart Failure With Reduced Ejection Fraction

Background Obstructive sleep apnea (OSA) is a common comorbidity in patients with heart failure, although current evidence is equivocal regarding the potential benefits of treating OSA with positive airway pressure (PAP) therapy in patients with heart failure. This study assessed the impact of adherence to PAP therapy on health care resource utilization in patients with OSA and heart failure with reduced ejection fraction. Methods and Results Administrative insurance claims data linked with objective PAP therapy use data from patients with OSA and heart failure with reduced ejection fraction were used to determine associations between PAP adherence and a composite outcome of hospitalizations and emergency room visits. One-year PAP adherence was based on an adapted US Medicare definition. Propensity score methods were used to create groups with similar characteristics across PAP adherence levels. The study cohort included 3182 patients (69.9% male, mean age 59.7 years); 39% were considered adherent to PAP therapy (29% intermediate adherent, 31% nonadherent). One year after PAP initiation, adherent patients had fewer composite visits than matched nonadherent patients, driven by a 24% reduction in emergency room visits for adherent patients. Composite visit costs were lower in adherent versus nonadherent patients ($3500 versus $5879, P=0.031), although total health care costs were not statistically different ($13 028 versus $14 729, P=0.889). Conclusions PAP therapy adherence in patients with OSA with heart failure with reduced ejection fraction was associated with a reduction in health care resource utilization. This suggests that greater emphasis should be placed on diagnosing and effectively treating OSA with PAP in patients with heart failure with reduced ejection fraction.

Coronary Artery Spasm-Related Heart Failure Syndrome: Literature Review

Although heart failure (HF) is a clinical syndrome that becomes worse over time, certain cases can be reversed with appropriate treatments. While coronary artery spasm (CAS) is still underappreciated and may be misdiagnosed, ischemia due to coronary artery disease and CAS is becoming the single most frequent cause of HF worldwide. CAS could lead to syncope, HF, arrhythmias, and myocardial ischemic syndromes such as asymptomatic ischemia, rest and/or effort angina, myocardial infarction, and sudden death. Albeit the clinical significance of asymptomatic CAS has been undervalued, affected individuals compared with those with classic Heberden's angina pectoris are at higher risk of syncope, life-threatening arrhythmias, and sudden death. As a result, a prompt diagnosis implements appropriate treatment strategies, which have significant life-changing consequences to prevent CAS-related complications, such as HF. Although an accurate diagnosis depends mainly on coronary angiography and provocative testing, clinical characteristics may help decision-making. Because the majority of CAS-related HF (CASHF) patients present with less severe phenotypes than overt HF, it underscores the importance of understanding risk factors correlated with CAS to prevent the future burden of HF. This narrative literature review summarises and discusses separately the epidemiology, clinical features, pathophysiology, and management of patients with CASHF.

MicroRNA-19 upregulation attenuates cardiac fibrosis via targeting connective tissue growth factor

BACKGROUND

Previous studies have shown the role of microRNA (miR)-19 in aging-related heart failure. The present study aimed to verify the effects of miR-19 on cardiac fibrosis and its target.

METHODS

Cardiac fibrosis was induced by myocardial infarction (MI)-induced heart failure and angiotensin (Ang) II-treated rats in vivo, and was induced in Ang II-treated cardiac fibroblasts (CFs) in vitro.

RESULTS

The expression of miR-19 was reduced in the heart tissue of MI and Ang II-treated rats, and Ang II-treated CFs. The impaired cardiac function in rats was repaired after miR-19 administration. The levels of collagen I, collagen III and transforming growth factor-beta (TGF-β) increased in the heart tissue of MI and Ang II-treated rats, and Ang II-treated CFs. These increases were reversed by miR-19 agomiR. Moreover, the bioinformatic analysis and luciferase reporter assays demonstrated that connective tissue growth factor (CTGF) was a direct target of miR-19. MiR-19 treatment inhibited CTGF expression in CFs, while CTGF overexpression inhibited miR-19 agomiR to attenuate the Ang II-induced increases of collagen I and collagen III in CFs. The increases of p-ERK, p-JNK and p-p38 in the CFs induced by Ang II were repressed by miR-19 agomiR.

CONCLUSIONS

Upregulating miR-19 can improve cardiac function and attenuate cardiac fibrosis by inhibiting the CTGF and MAPK pathways.

Defining cardiac functional recovery in end-stage heart failure at single-cell resolution

Recovery of cardiac function is the holy grail of heart failure therapy yet is infrequently observed and remains poorly understood. In this study, we performed single-nucleus RNA sequencing from patients with heart failure who recovered left ventricular systolic function after left ventricular assist device implantation, patients who did not recover and non-diseased donors. We identified cell-specific transcriptional signatures of recovery, most prominently in macrophages and fibroblasts. Within these cell types, inflammatory signatures were negative predictors of recovery, and downregulation of RUNX1 was associated with recovery. In silico perturbation of RUNX1 in macrophages and fibroblasts recapitulated the transcriptional state of recovery. Cardiac recovery mediated by BET inhibition in mice led to decreased macrophage and fibroblast Runx1 expression and diminished chromatin accessibility within a Runx1 intronic peak and acquisition of human recovery signatures. These findings suggest that cardiac recovery is a unique biological state and identify RUNX1 as a possible therapeutic target to facilitate cardiac recovery.

Sacubitril/Valsartan for Heart Failure with Preserved Ejection Fraction: A Cost-Effectiveness Analysis from the Perspective of the Chinese Healthcare System

BACKGROUND AND OBJECTIVES

Sacubitril/valsartan has shown effectiveness in reducing hospitalization compared with valsartan in HFpEF patients with heart failure with preserved ejection fraction (HFpEF). We aimed to investigate the cost effectiveness of sacubitril/valsartan as an alternative to valsartan in Chinese patients with heart failure with HFpEF.

METHODS

A Markov model was built to investigate the cost effectiveness of sacubitril/valsartan as an alternative to valsartan in Chinese patients with HFpEF, from the healthcare system perspective. The time horizon was a lifetime, with a cycle length of 1 month. Costs were obtained from local information or published papers, discounted at a rate of 0.05 for future costs. The transition probability and utility were based on other studies. The primary outcome of the study was the incremental cost-effectiveness ratio (ICER). Sacubitril/valsartan was considered cost effective if the ICER obtained was lower than the willingness-to-pay threshold of US dollars (US$) 12,551.5 per quality-adjusted life-year (QALY). One-way and probabilistic sensitivity analyses, as well as scenario analysis, were performed to test robustness.

RESULTS

Over a lifetime simulation, a 73-year-old Chinese patient with HFpEF could gain 6.44 QALYs (9.15 life-years) if sacubitril/valsartan plus standard treatment was administered, and 6.37 QALYs (9.07 life-years) if valsartan plus standard treatment was prescribed. The corresponding costs in both groups were US$12,471 and US$8663, respectively. The ICER was US$49,019/QALY (US$46,610/life-year), higher than the willingness-to-pay threshold. Sensitivity analyses and scenario analysis showed that our results were robust.

CONCLUSION

Adding sacubitril/valsartan to standard treatment as an alternative to valsartan for the treatment of HFpEF resulted in more effectiveness but higher costs. Sacubitril/valsartan was likely to not be cost effective in Chinese patients with HFpEF. The cost of sacubitril/valsartan needs to reduce to 34% of its current price to be cost effective in this population. Studies based on real-world data are needed to confirm our conclusions.

Large animal models for cardiac remuscularization studies: A methodological review

Myocardial infarction is the most common cause of heart failure, one of the most fatal non-communicable diseases worldwide. The disease could potentially be treated if the dead, ischemic heart tissues are regenerated and replaced with viable and functional cardiomyocytes. Pluripotent stem cells have proven the ability to derive specific and functional cardiomyocytes in large quantities for therapy. To test the remuscularization hypothesis, the strategy to model the disease in animals must resemble the pathophysiological conditions of myocardial infarction as in humans, to enable thorough testing of the safety and efficacy of the cardiomyocyte therapy before embarking on human trials. Rigorous experiments and in vivo findings using large mammals are increasingly important to simulate clinical reality and increase translatability into clinical practice. Hence, this review focus on large animal models which have been used in cardiac remuscularization studies using cardiomyocytes derived from human pluripotent stem cells. The commonly used methodologies in developing the myocardial infarction model, the choice of animal species, the pre-operative antiarrhythmics prophylaxis, the choice of perioperative sedative, anaesthesia and analgesia, the immunosuppressive strategies in allowing xenotransplantation, the source of cells, number and delivery method are discussed.

Low-carbohydrate diets containing plant-derived fat but not animal-derived fat ameliorate heart failure

Cardiovascular disease (CVD) is a global health burden in the world. Although low-carbohydrate diets (LCDs) have beneficial effects on CVD risk, their preventive effects remain elusive. We investigated whether LCDs ameliorate heart failure (HF) using a murine model of pressure overload. LCD with plant-derived fat (LCD-P) ameliorated HF progression, whereas LCD with animal-derived fat (LCD-A) aggravated inflammation and cardiac dysfunction. In the hearts of LCD-P-fed mice but not LCD-A, fatty acid oxidation-related genes were highly expressed, and peroxisome proliferator-activated receptor α (PPARα), which regulates lipid metabolism and inflammation, was activated. Loss- and gain-of-function experiments indicated the critical roles of PPARα in preventing HF progression. Stearic acid, which was more abundant in the serum and heart of LCD-P-fed mice, activated PPARα in cultured cardiomyocytes. We highlight the importance of fat sources substituted for reduced carbohydrates in LCDs and suggest that the LCD-P-stearic acid-PPARα pathway as a therapeutic target for HF.

Effectiveness of exhaled nitric oxide for the prediction of non-invasive left atrial pressure in older people: a cross-sectional cohort study

BACKGROUND

During left-sided heart failure (HF), left atrial and pulmonary venous pressure increase, which may lead to pulmonary congestion. Previous cohort studies, examining participants with symptomatic HF or rheumatic heart disease, suggest a relationship between increased left atrial pressure (LAP) and fractional exhaled nitric oxide (FeNO).

AIM

To examine the strength of association between FeNO and echocardiographic assessment of LAP by the E/e' ratio, to determine if FeNO could be used to identify those with elevated LAP.

DESIGN & SETTING

This cross-sectional cohort study examined a subset of the OxVALVE cohort aged ≥65 years. Data collection was undertaken in primary care practices in central England.

METHOD

Each participant underwent a focused cardiovascular history and clinical examination. Standard transthoracic echocardiographic (TTE) assessment was performed on all participants, with the E/e' ratio calculated to obtain a validated surrogate of LAP. FeNO was measured in 227 participants.

RESULTS

FeNO was higher in males compared with females and no different in participants with asthma, chronic obstructive pulmonary disease (COPD), or those using inhaled steroids. Participants with a high E/e' (>14) were older, with a higher proportion of females than males. There was no relationship between E/e' and FeNO, either when measured as a continuous variable or in the group with high E/e'.

CONCLUSION

FeNO was not found to be an accurate predictor of elevated LAP in a primary care setting.

Knockout of ACE-N facilitates improved cardiac function after myocardial infarction

Angiotensin-converting enzyme (ACE) hydrolyzes N-acetyl-seryl-aspartyl-lysyl-proline (Ac-SDKP) into inactive fragments through its N-terminal site (ACE-N). We previously showed that Ac-SDKP mediates ACE inhibitors' cardiac effects. Whether increased bioavailability of endogenous Ac-SDKP caused by knocking out ACE-N also improves cardiac function in myocardial infarction (MI)-induced heart failure (HF) is unknown. Wild-type (WT) and ACE-N knockout (ACE-NKO) mice were subjected to MI by ligating the left anterior descending artery and treated with vehicle or Ac-SDKP (1.6 mg/kg/day, s.c.) for 5 weeks, after which echocardiography was performed and left ventricles (LV) were harvested for histology and molecular biology studies. ACE-NKO mice showed increased plasma Ac-SDKP concentrations in both sham and MI group compared to WT. Exogenous Ac-SDKP further increased its circulating concentrations in WT and ACE-NKO. Shortening (SF) and ejection (EF) fractions were significantly decreased in both WT and ACE-NKO mice post-MI, but ACE-NKO mice exhibited significantly lesser decrease. Exogenous Ac-SDKP ameliorated cardiac function post-MI only in WT but failed to show any additive improvement in ACE-NKO mice. Sarcoendoplasmic reticulum calcium transport ATPase (SERCA2), a marker of cardiac function and calcium homeostasis, was significantly decreased in WT post-MI but rescued with Ac-SDKP, whereas ACE-NKO mice displayed less loss of SERCA2 expression. Our study demonstrates that gene deletion of ACE-N resulted in improved LV cardiac function in mice post-MI, which is likely mediated by increased circulating Ac-SDKP and minimally reduced expression of SERCA2. Thus, future development of specific and selective inhibitors for ACE-N could represent a novel approach to increase endogenous Ac-SDKP toward protecting the heart from post-MI remodeling.

Echo Doppler Parameters of Diastolic Function

PURPOSE OF REVIEW

The purpose of this review is to highlight the echo Doppler parameters that form the cornerstone for the evaluation of diastolic function as per the guideline documents of the American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACVI). In addition, the individual Doppler-based parameters will be explored, with commentary on the rationale behind their use and the multi-parametric approach to the assessment of diastolic dysfunction (DD) using echocardiography.

RECENT FINDINGS

Previous guidelines for assessment of diastolic function are complex with modest diagnostic performance and significant inter-observer variability. The most recent guidelines have made the evaluation of DD more streamlined with excellent correlation with invasive measures of LV filling pressures. This is a review of the echo-derived Doppler parameters that are integral in the diagnosis and gradation of DD. A brief description of the physiological principles that govern changes in echocardiographic parameters during normal and abnormal diastolic function is also discussed for the appropriate diagnosis of DD using non-invasive Doppler echocardiography techniques.

Shenmai Injection Improves Hypertensive Heart Failure by Inhibiting Myocardial Fibrosis via TGF-β 1/Smad Pathway Regulation

OBJECTIVE

To study effects of Shenmai Injection on hypertensive heart failure and its mechanism for inhibiting myocardial fibrosis.

METHODS

Salt-sensitive (Dahl/SS) rats were fed with normal diet (0.3% NaCl) and the high-salt diet (8% NaCl) to observe the changes in blood pressure and heart function, as the control group and the model group. Salt-insensitive rats (SS-13BN) were fed with the high-salt diet (8% NaCl) as the negative control group. After modeling, the model rats were randomly divided into heart failure (HF) group, Shenmai Injection (SMI) group and pirfenidone (PFD) group by a random number table, with 6 rats in each group. They were given sterilized water, SMI and pirfenidone, respectively. Blood pressure, cardiac function, fibrosis and related molecular expression were detected by sphygmomanometer, echocardiogram, enzyme linked immunosorbent assay (ELISA), hematoxylin-eosin staining, Masson staining, immunofluorescence and qPCR analysis.

RESULTS

After high-salt feeding, compared with the control and negative control group, in the model group the blood pressure increased significantly, the left ventricular ejection fraction (LVEF) and left ventricular fraction shortening (LVFS) were significantly reduced, and the serum NT-proBNP concentration increased significantly (all P<0.05); furthermore, the arrangement of myocardial cells was disordered, the edema was severe, and the degree of myocardial fibrosis was also significantly increased (P<0.05); the protein and mRNA expressions of collagen type I (Col I) were up-regulated (P<0.05), and the mRNA expressions of transforming growth factor β 1 (TGF- β 1), Smad2 and Smad3 were significantly up-regulated (P<0.05). Compared with HF group, after intervention of Shenmai Injection, LVEF and LVFS increased, myocardial morphology was improved, collagen volume fraction decreased significantly (P<0.05), and the mRNA expressions of Col I, TGF- β 1, Smad2 and Smad3, as well as Col I protein expression, were all significantly down-regulated (all P<0.05).

CONCLUSION

Myocardial fibrosis is the main pathological manifestation of hypertensive heart failure, and Shenmai Injection could inhibit myocardial fibrosis and effectively improve heart failure by regulating TGF-β 1/Smad signaling pathway.