Beta-blockers and reverse remodeling: what are the implications?

The Use of Angiotensin-Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers Is Associated with the Recovered Ejection Fraction in Patients with Dilated Cardiomyopathy

Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB) have been shown to prevent left ventricular remodeling and improve outcomes of patients with heart failure (HF). This study aimed to investigate whether the use of ACEi/ARB could be associated with HF with recovered ejection fraction (HFrecEF) in patients with dilated cardiomyopathy (DCM).We collected individual patient data regarding demographics, echocardiogram, and treatment in DCM between 2003 and 2014 from the clinical personal record, a national database of the Japanese Ministry of Health, Labour and Welfare. Patients with left ventricular ejection fraction (LVEF) < 40% were included. Eligible patients were divided into two groups according to the use of ACEi/ARB. A propensity score matching analysis was employed. The primary outcome was defined as LVEF ≥ 40% at 3 years of follow-up.Out of 5,955 patients with DCM and LVEF < 40%, propensity score matching yielded 830 pairs. The mean age was 58.8 years, and 1,184 (71.3%) of the patients were male. The primary outcome was observed more frequently in the ACEi/ARB group than in the no ACEi/ARB group (57.0% versus 49.3%; odds ratio 1.36; 95% confidence interval (CI) 1.12-1.65; P = 0.002). Subgroup analysis revealed that the use of ACEi and ARB was associated with recovery of LVEF regardless of atrial fibrillation. The change in LVEF from baseline to 3 years of follow-up was greater in the ACEi-ARB group (14.9% ± 0.6% versus 12.3% ± 0.5%; P = 0.001).The use of ACEi/ARB is associated with HFrecEF in patients with DCM and reduced LVEF.

Clinical significance of ischemia-like electrocardiographic finding during heart failure treatment on left ventricular recovery in patients with non-ischemic dilated cardiomyopathy

BACKGROUND

Patients with non-ischemic dilated cardiomyopathy (DCM) often show ischemia-like electrocardiographic findings. We aimed to elucidate the clinical impact of ischemia-like electrocardiographic findings in DCM, focusing on left ventricular reverse remodeling (LVRR).

METHODS

We evaluated 195 patients hospitalized with heart failure (HF) and diagnosed with DCM. All patients underwent twelve-lead electrocardiography (ECG) and echocardiography during hospitalization and at the 2-year follow-up.

RESULTS

During hospitalization, 152 (78%) patients experienced ischemia-like ECG findings (Minnesota codes I3, IV1-3, V1-3, or VII1); 43 patients (22%, non-ischemia-like group) did not experience these findings. Ischemia-like ECG findings were normalized during hospitalization in 64 patients (33%, transient-ischemia-like group) but were unchanged in 88 patients (45%, persistent-ischemia-like group). The highest rates of LVRR, defined as an increase in LV ejection fraction from ≥10% to a final value of ≥35%, along with decreased LV end-diastolic dimension of ≥10% during 2 years of follow-up, were shown in the transient-ischemia-like group (transient-ischemia-like group, 91%; persistent-ischemia-like group, 40%; non-ischemia-like-group, 51%; p < 0.001). The transient-ischemia-like group had lowest composite event rates, including readmission for HF, the detection of major ventricular arrhythmia, and sudden cardiac death.

CONCLUSIONS

Normalization of ischemia-like ECG findings during the first HF treatments was associated with a higher occurrence of mid-term LVRR and favorable long-term outcome in patients with DCM.

Baseline cardiac magnetic resonance imaging versus baseline endomyocardial biopsy for the prediction of left ventricular reverse remodeling and prognosis in response to therapy in patients with idiopathic dilated cardiomyopathy

Endomyocardial biopsy (EMB) and late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) imaging performed at baseline are both used to evaluate the extent of myocardial fibrosis. However, no study has directly compared the effectiveness of these diagnostic tools in the prediction of left ventricular reverse remodeling (LVRR) and prognosis in response to therapy in patients with idiopathic dilated cardiomyopathy (IDCM). Seventy-five patients with newly diagnosed IDCM who were undergoing optimal therapy were assessed at baseline using LGE-CMR imaging and EMB; the former measured LGE area and the latter measured collagen volume fraction (CVF) as possible predictive indices of LVRR and cardiac event-free survival. Among all the baseline primary candidate factors with P < 0.2 as per univariate analysis, multivariate analysis indicated that only LGE area was an independent predictor of subsequent LVRR (β = 0.44; 95 % confidence interval (CI) 0.87–2.53; P < 0.001), as indicated by decreasing left ventricular end-systolic volume index over the 1-year follow-up. Kaplan–Meier curves indicated significantly lower cardiac event-free survival rates in patients with LGE at baseline than in patients without (P < 0.01). By contrast, there was no significant difference in prognosis between patients with CVF values above (severe fibrosis) and below (mild fibrosis) the median of 4.9 %. Cox proportional hazard analysis showed that LGE area was an independent predictor of subsequent cardiac events (hazard ratio 1.06; 95 % CI 1.02–1.10; P ≤ 0.01). The degree of myocardial fibrosis estimated by baseline LGE-CMR imaging, but not that estimated by baseline EMB, can predict LVRR and cardiac event-free survival in response to therapy in patients with newly diagnosed IDCM.

β1 adrenergic receptor polymorphisms and heart failure: a meta-analysis on susceptibility, response to β-blocker therapy and prognosis

Aims

The risk stratification of patients for heart failure (HF) remains a challenge, as well as the anticipation of the response to β-blocker therapy. Since the pivotal role of β1 adrenergic receptor (β1-AR) in HF, many publications have studied the associations between the β1-AR polymorphisms (Ser49Gly and Arg389Gly) and HF, with inconsistent results. Thus, we performed a meta-analysis of studies to evaluate the impact of β1-AR polymorphisms on susceptibility to HF, the response to β-blocker therapy and the prognosis of HF.

Methods and Results

Electronic databases were systematically searched before August 2011. We extracted data sets and performed meta-analysis with standardized methods. A total of 27 studies met our inclusion criteria. It was found that in East Asians, the Gly389 allele and Gly389 homozygotes significantly increased the HF risk, while the Gly389 allele and Gly389 homozygotes trended to decrease the risk of HF in whites. With the similar reduction of heart rate, overall, the Arg389 homozygotes showed a better response to β-blocker therapy. Furthermore, the Arg389 homozygotes were significantly associated with better LVEF improvement in East Asians and a mixed population. And in white people, the Arg389 homozygotes made a greater LVESd/v improvement and trended to be associated with better LVEDd/v improvement. However, the prognosis of Arg389 homozygotes HF patients was similar to those with Gly389 carriers. The Ser49Gly polymorphism did not impact the risk or prognosis of HF.

Conclusion

Based on our meta-analysis, the Gly389 allele and Gly389 homozygotes were risk factors in East Asians while trending to protect whites against HF. Furthermore, Arg389 homozygote is significantly associated with a favorable response to β-blocker treatment in HF patients. However, neither of the two polymorphisms is an independent predictor of the prognosis of HF.

Effect of left ventricular reverse remodeling on long-term prognosis after therapy with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers and β blockers in patients with idiopathic dilated cardiomyopathy

It remains unknown whether left ventricular (LV) reverse remodeling (LVRR) after therapy with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers and β blockers is correlated with prognosis in patients with idiopathic dilated cardiomyopathy. Forty-two patients with idiopathic dilated cardiomyopathy treated with the therapy were studied. Complete left ventricular reverse remodeling was defined as LV end-diastolic dimension ≤ 55 mm and fractional shortening ≥ 25% at the last echocardiographic assessment. The incidence of complete LVRR was significantly higher in patients who survived than in those who died or underwent heart transplantation. Patients were divided into 3 groups: death or transplantation, alive with complete LVRR, and alive without complete LVRR. Although patients who died or underwent transplantation did not show any LV improvements, those with complete LVRR showed significant improvements at 1 to 6 months after starting the therapy. Patients without complete LVRR also showed small but significant improvements at 1 to 6 months. The decrease in LV end-systolic dimension from the initial value to that at 1 to 6 months was an independent determinant of future cardiac death or transplantation. In conclusion, complete LVRR is related to favorable prognosis in patients with idiopathic dilated cardiomyopathy. The extent of left ventricular reverse remodeling at 1 to 6 months after starting the therapy is predictive of long-term prognosis.

Role of beta-adrenergic receptor gene polymorphisms in the long-term effects of beta-blockade with carvedilol in patients with chronic heart failure

BACKGROUND

Beta-blockers are mainstay of current treatment of heart failure (HF). Beta-adrenergic receptors (AR) single nucleotide gene polymorphisms (SNPs) may influence the sensitivity and density of beta-AR. We assessed the relation between three common beta-AR SNPs and the response to carvedilol administration.

METHODS AND RESULTS

We studied 183 consecutive patients with chronic HF due to ischemic or nonischemic cardiomyopathy, a LV ejection fraction (LVEF) < or = 0.35, not previously treated with beta-blockers. Each patient underwent gated-SPECT radionuclide ventriculography, cardiopulmonary exercise testing and invasive hemodynamic monitoring at baseline and after 12 months of carvedilol administration at maintenance dosages. The beta1-AR gene Arg389Gly and the beta2-AR gene Arg16Gly SNPs were not related to the response to carvedilol administration. Homozygotes for the Glu27Glu allele showed a greater increase in the LVEF, compared to the other patients (+13.0 +/- 12.2% versus +7.1 +/- 8.1% in the Gln27Gln homozygotes, and 8.3 +/- 11.4% units in the Gln27Glu heterozygotes; p = 0.022 by ANOVA). Glu27Glu homozygotes also showed a greater decline in the pulmonary wedge pressure both at rest and at peak exercise. Gln27Glu SNP was selected amongst the determinants of the LVEF response to carvedilol at multivariable analysis, in addition to the cause of cardiomyopathy, baseline systolic blood pressure and the dose of carvedilol administered.

CONCLUSION

Beta1-AR Arg389Gly and beta2-AR Arg16Gly SNPs are not related to the response to carvedilol therapy. In contrast, the Gln27Glu SNP is a determinant of the LVEF response to this agent in patients with chronic HF.