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Efremov S, Zagatina A, Filippov A, Ryadinskiy M, Novikov M, Shmatov D. Left Ventricular Diastolic Dysfunction in Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00435-X. [PMID: 39069379 DOI: 10.1053/j.jvca.2024.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 06/19/2024] [Accepted: 06/27/2024] [Indexed: 07/30/2024]
Abstract
Cardiac relaxation is a complex process that involves various interconnected characteristics and, along with contractile properties, determines stroke volume. Perioperative ischemia-reperfusion injury and left ventricular diastolic dysfunction (DD) are characterized by the left ventricle's inability to receive a sufficient blood volume under adequate preload. Baseline DD and perioperative DD have an impact on postoperative complications, length of hospital stay, and major clinical outcomes in a variety of cardiac pathologies. Several baseline and perioperative factors, such as age, female sex, hypertension, left ventricle hypertrophy, diabetes, and perioperative ischemia-reperfusion injury, contribute to the risk of DD. The recommended diagnostic criteria available in guidelines have not been validated in the perioperative settings and still need clarification. Timely diagnosis of DD might be crucial for effectively treating postoperative low cardiac output syndrome. This implies the need for an individualized approach to fluid infusion strategy, cardiac rate and rhythm control, identification of extrinsic causes, and administration of drugs with lusitropic effects. The purpose of this review is to consolidate scattered information on various aspects of diastolic dysfunction in cardiac surgery and provide readers with well-organized and clinically applicable information.
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Affiliation(s)
- Sergey Efremov
- Saint-Petersburg State University Hospital, Saint-Petersburg, Russian Federation.
| | - Angela Zagatina
- Cardiology Department, Research Cardiology Center "Medika", Saint Petersburg, Russian Federation
| | - Alexey Filippov
- Saint-Petersburg State University Hospital, Saint-Petersburg, Russian Federation
| | - Mikhail Ryadinskiy
- Saint-Petersburg State University Hospital, Saint-Petersburg, Russian Federation
| | - Maxim Novikov
- Saint-Petersburg State University Hospital, Saint-Petersburg, Russian Federation
| | - Dmitry Shmatov
- Saint-Petersburg State University Hospital, Saint-Petersburg, Russian Federation
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Kim YI, Ahn MS, Yoo BS, Kim JY, Son JW, Park YJ, Kim SH, Kang DR, Lee HY, Kang SM, Cho MC. Differences in the Effects of Beta-Blockers Depending on Heart Rate at Discharge in Patients With Heart Failure With Preserved Ejection Fraction and Atrial Fibrillation. INTERNATIONAL JOURNAL OF HEART FAILURE 2024; 6:119-126. [PMID: 39081646 PMCID: PMC11284333 DOI: 10.36628/ijhf.2023.0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 06/21/2024] [Accepted: 06/25/2024] [Indexed: 08/02/2024]
Abstract
Background and Objectives Beta-blockers (BBs) improve prognosis in heart failure (HF), which is mediated by lowering heart rate (HR). However, HR has no prognostic implication in atrial fibrillation (AF) and also BBs have not been shown to improve prognosis in heart failure with preserved ejection fraction (HFpEF) with AF. This study assessed the prognostic implication of BB in HFpEF with AF according to discharge HR. Methods From the Korean Acute Heart Failure Registry, 687 patients with HFpEF and AF were selected. Study subjects were divided into 4 groups based on 75 beats per minute (bpm) of HR at discharge and whether or not they were treated with BB at discharge. Results Of the 687 patients with HFpEF and AF, 128 (36.1%) were in low HR group and 121 (36.4%) were in high HR group among those treated with BB at discharge. In high HR group, HR at discharge was significantly faster in BB non-users (85.5±9.1 bpm vs. 89.2±12.5 bpm, p=0.005). In the Cox model, BB did not improve 60-day rehospitalization (hazard ratio, 0.93; 95% confidence interval [95% CI], 0.35-2.47) or mortality (hazard ratio, 0.77; 95% CI, 0.22-2.74) in low HR group. However, in high HR group, BB treatment at discharge was associated with 82% reduced 60-day HF rehospitalization (hazard ratio, 0.18; 95% CI, 0.04-0.81), but not with mortality (hazard ratio, 0.77; 95% CI, 0.20-2.98). Conclusions In HFpEF with AF, in patients with HR over 75 bpm at discharge, BB treatment at discharge was associated with a reduced 60-day rehospitalization rate.
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Affiliation(s)
- Young In Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Min-Soo Ahn
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Byung-Su Yoo
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jang-Young Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jung-Woo Son
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Jun Park
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Hwa Kim
- Center of Biomedical Data Science, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Dae Ryong Kang
- Center of Biomedical Data Science, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seok-Min Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Myeong-Chan Cho
- Chungbuk National University College of Medicine, Cheongju, Korea
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Oraii A, Chaumont C, Marchlinski FE, Hyman MC. Rate-adaptive pacing in heart failure with preserved ejection fraction: Too much of a good thing? Heart Rhythm O2 2024; 5:334-337. [PMID: 38840761 PMCID: PMC11148503 DOI: 10.1016/j.hroo.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Affiliation(s)
- Alireza Oraii
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Corentin Chaumont
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E. Marchlinski
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew C. Hyman
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Infeld M. Accelerated physiologic pacing in patients with heart failure with preserved ejection fraction: An argument in support of therapeutic heart rate modulation. Heart Rhythm O2 2024; 5:327-333. [PMID: 38840759 PMCID: PMC11148487 DOI: 10.1016/j.hroo.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Affiliation(s)
- Margaret Infeld
- Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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Ababei A, Hrib LA, Iancu AC, Hadarag AV, Khebbaiz A, Vătășescu R, Bogdan Ș. Anti-bradycardia pacing-impact on patients with HFpEF: a systematic review. Heart Fail Rev 2024; 29:523-534. [PMID: 38282011 PMCID: PMC10942895 DOI: 10.1007/s10741-024-10382-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 01/30/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) has become an emerging concern. The protective effect of bradycardia in patients with reduced ejection fraction using beta-blockers or ivabradine does not improve symptoms in HFpEF. This review aims to assess current data regarding the impact of anti-bradycardia pacing in patients with HFpEF. A search was conducted on PubMed, ScienceDirect, Springer, and Wiley Online Library, selecting studies from 2013 to 2023. Relevant and eligible prospective studies and randomized controlled trials were included. Functional status, quality of life, and echocardiographic parameters were assessed. Six studies conformed to the selection criteria. Four were prospective studies with a total of 90 patients analyzed. Two were randomized controlled trials with a total of 129 patients assessed. The 6-min walk test (6MWT) and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) score improved in all prospective studies. My-PACE trial showed improvements in MLHFQ score (p < 0.001), significant relative lowering in NT-proBNP levels (p = 0.02), and an increased mean daily activity in the personalized accelerated pacing group compared to usual care. RAPID-HF trial proved that pacemaker implantation to enhance exercise heart rate (HR) did not improve exercise capacity and was associated with increased adverse events. HFpEF requires a more individualized approach and quality of life management. This review demonstrates that higher resting HR by atrial pacing may improve symptoms and even outcomes in HFpEF, while a higher adaptive rate during exertion has not been proven beneficial.
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Affiliation(s)
- Alexandru Ababei
- Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, Sector 5, 050474, Bucharest, Romania
| | - Luciana Andreea Hrib
- Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, Sector 5, 050474, Bucharest, Romania
| | - Adalia Cristiana Iancu
- Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, Sector 5, 050474, Bucharest, Romania.
| | - Andra-Valeria Hadarag
- Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, Sector 5, 050474, Bucharest, Romania
| | - Ahmad Khebbaiz
- Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, Sector 5, 050474, Bucharest, Romania
| | - Radu Vătășescu
- Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, Sector 5, 050474, Bucharest, Romania
- Clinic Emergency Hospital, Bucharest, Romania
| | - Ștefan Bogdan
- Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, Sector 5, 050474, Bucharest, Romania
- Elias Emergency Hospital, Bucharest, Romania
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Sagmeister P, Rosch S, Fengler K, Kresoja KP, Gori T, Thiele H, Lurz P, Burkhoff D, Rommel KP. Running on empty: Factors underpinning impaired cardiac output reserve in heart failure with preserved ejection fraction. Exp Physiol 2024. [PMID: 38421268 DOI: 10.1113/ep091776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/13/2024] [Indexed: 03/02/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is frequently attributed etiologically to an underlying left ventricular (LV) diastolic dysfunction, although its pathophysiology is far more complex and can exhibit significant variations among patients. This review endeavours to systematically unravel the pathophysiological heterogeneity by illustrating diverse mechanisms leading to an impaired cardiac output reserve, a central and prevalent haemodynamic abnormality in HFpEF patients. Drawing on previously published findings from our research group, we propose a pathophysiology-guided phenotyping based on the presence of: (1) LV diastolic dysfunction, (2) LV systolic pathologies, (3) arterial stiffness, (4) atrial impairment, (5) right ventricular dysfunction, (6) tricuspid valve regurgitation, and (7) chronotopic incompetence. Tailored to each specific phenotype, we explore various potential treatment options such as antifibrotic medication, diuretics, renal denervation and more. Our conclusion underscores the pivotal role of cardiac output reserve as a key haemodynamic abnormality in HFpEF, emphasizing that by phenotyping patients according to its individual pathomechanisms, insights into personalized therapeutic approaches can be gleaned.
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Affiliation(s)
- Paula Sagmeister
- Department of Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Sebastian Rosch
- Department of Cardiology, University Hospital Mainz, Mainz, Germany
| | - Karl Fengler
- Department of Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | | | - Tommaso Gori
- Department of Cardiology, University Hospital Mainz, Mainz, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Philipp Lurz
- Department of Cardiology, University Hospital Mainz, Mainz, Germany
| | | | - Karl-Philipp Rommel
- Department of Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
- Cardiovascular Research Foundation, New York, New York, USA
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Wahlberg KJ, Infeld M, Plante TB, Novelli AE, Habel N, Burkhoff D, Barrett T, Lustgarten D, Meyer M. Effects of Continuous Accelerated Pacing on Cardiac Structure and Function in Patients With Heart Failure With Preserved Ejection Fraction: Insights From the myPACE Randomized Clinical Trial. J Am Heart Assoc 2024; 13:e032873. [PMID: 38156545 PMCID: PMC10863817 DOI: 10.1161/jaha.123.032873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/27/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Heart failure with preserved ejection fraction ≥50% is prevalent with few evidence-based therapies. In a trial of patients with heart failure with preserved ejection fraction with specialized pacemakers, treatment with accelerated personalized pacing averaging 75 bpm (myPACE) markedly improved quality of life, NT-proBNP (N-terminal pro-brain natriuretic peptide), physical activity, and atrial fibrillation burden compared with the standard lower rate setting of 60 bpm (usual care). METHODS AND RESULTS In this exploratory study, provider-initiated echocardiographic studies obtained before and after the trial were assessed for changes in left ventricular (LV) structure and function among participants who continued their pacing assignment. The analytic approach aimed to detect differences in standard and advanced echocardiographic parameters within and between study arms. Of the 100 participants, 16 myPACE and 20 usual care arm had a qualifying set of echocardiograms performed a mean (SD) 3 (2.0) years apart. Despite similar baseline echocardiogram measures, sustained exposure to moderately accelerated pacing resulted in reduced septal wall thickness (in cm: myPACE 1.1 [0.2] versus usual care 1.2 [0.2], P=0.008) and lower LV mass to systolic volume ratio (in g/mL: myPACE 4.8 [1.9] versus usual care 6.8 [3.1], P=0.038) accompanied by a minor reduction in LV ejection fraction (in %: myPACE 55 [5] versus usual care 60 [5], P=0.015). These changes were paralleled by improvements in heart failure-related quality of life (myPACE Minnesota Living with Heart Failure Questionnaire improved by 16.1 [13.9] points, whereas usual care worsened by 6.9 [11.6] points, P<0.001). Markers of diastolic function and LV performance were not affected. CONCLUSIONS Exposure to continuous accelerated pacing in heart failure with preserved ejection fraction is associated with a reduced LV wall thickness and a small amount of LV dilation with small reduction in ejection fraction.
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Affiliation(s)
- Kramer J. Wahlberg
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
| | - Margaret Infeld
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
| | - Timothy B. Plante
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
| | - Alexandra E. Novelli
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
| | - Nicole Habel
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
| | | | - Trace Barrett
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
| | - Daniel Lustgarten
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
| | - Markus Meyer
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
- Department of MedicineLillehei Heart Institute, University of Minnesota College of MedicineMinneapolisMN
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de la Espriella R, Wahlberg KJ, Infeld M, Palau P, Núñez E, Sanchis J, Meyer M, Núñez J. Effect of paced heart rate on quality of life and natriuretic peptides for stage B or C heart failure with preserved ejection fraction: A secondary analysis of the myPACE trial. Eur J Heart Fail 2024; 26:167-176. [PMID: 38124404 DOI: 10.1002/ejhf.3107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
AIM Emerging evidence suggests a beneficial effect of higher heart rates in some patients with heart failure with preserved ejection fraction (HFpEF). This study aimed to evaluate the impact of higher backup pacing rates in HFpEF patients with preexisting pacemaker systems that limit pacemaker-mediated dyssynchrony across left ventricular (LV) volumes and LV ejection fraction (LVEF). METHODS AND RESULTS This is a post-hoc analysis of the myPACE clinical trial that evaluated the effects of personalized accelerated pacing setting (myPACE) versus standard of care on changes in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score, N-terminal pro-brain natriuretic peptide (NT-proBNP), pacemaker-detected activity levels, and atrial fibrillation (AF) burden in patients with HFpEF with preexisting pacemakers. Between-treatment comparisons were performed using linear regression models adjusting for the baseline value of the exposure (ANCOVA design). This study included 93 patients with pre-trial transthoracic echocardiograms available (usual care n = 49; myPACE n = 44). NT-proBNP levels and MLHFQ scores improved in a higher magnitude in the myPACE group at lower indexed LV end-diastolic volumes (iLVEDV) (NT-proBNP-iLVEDV interaction p = 0.006; MLHFQ-iLVEDV interaction p = 0.068). In addition, personalized accelerated pacing led to improved changes in activity levels and NT-proBNP, especially at higher LVEF (activity levels-LVEF interaction p = 0.009; NT-proBNP-LVEF interaction p = 0.058). No evidence of heterogeneity was found across LV volumes or LVEF for pacemaker-detected AF burden. CONCLUSIONS In the post-hoc analysis of the myPACE trial, we observed that the benefits of a personalized accelerated backup pacing on MLHFQ score, NT-proBNP, and pacemaker-detected activity levels appear to be more pronounced in patients with smaller iLVEDV and higher LVEF.
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Affiliation(s)
- Rafael de la Espriella
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Kramer J Wahlberg
- University of Vermont, Larner College of Medicine, Department of Medicine, Burlington, VT, USA
| | - Margaret Infeld
- Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | - Patricia Palau
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
| | - Eduardo Núñez
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Juan Sanchis
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Markus Meyer
- Lillehei Heart Institute, Department of Medicine, University of Minnesota College of Medicine, Minneapolis, MN, USA
| | - Julio Núñez
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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Meyer M, Infeld M, Habel N, Lustgarten D. Personalized accelerated physiologic pacing. Eur Heart J Suppl 2023; 25:G33-G43. [PMID: 37970518 PMCID: PMC10637836 DOI: 10.1093/eurheartjsupp/suad117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is increasingly prevalent with a high socioeconomic burden. Pharmacological heart rate lowering was recommended to improve ventricular filling in HFpEF. This article discusses the misperceptions that have resulted in an overprescription of beta-blockers, which in all likelihood have untoward effects on patients with HFpEF, even if they have atrial fibrillation or coronary artery disease as a comorbidity. Directly contradicting the lower heart rate paradigm, faster heart rates provide haemodynamic and structural benefits, amongst which lower cardiac filling pressures and improved ventricular capacitance may be most important. Safe delivery of this therapeutic approach is feasible with atrial and ventricular conduction system pacing that aims to emulate or enhance cardiac excitation to maximize the haemodynamic benefits of accelerated pacing. This conceptual framework was first tested in the myPACE randomized controlled trial of patients with pre-existing pacemakers and preclinical or overt HFpEF. This article provides the background and path towards this treatment approach.
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Affiliation(s)
- Markus Meyer
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, 111 Colchester Avenue, McClure Level 1, Burlington, VT 05401, USA
- Department of Medicine, Lillehei Heart Institute, University of Minnesota College of Medicine, 2231 6th St. SE, 4-165 CCRB, Minneapolis, MN 55455, USA
| | - Margaret Infeld
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, 111 Colchester Avenue, McClure Level 1, Burlington, VT 05401, USA
- Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, 800 Washington Street, Boston, MA 02111, USA
| | - Nicole Habel
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, 111 Colchester Avenue, McClure Level 1, Burlington, VT 05401, USA
| | - Daniel Lustgarten
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, 111 Colchester Avenue, McClure Level 1, Burlington, VT 05401, USA
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Infeld M, Wahlberg K, Cicero J, Plante TB, Meagher S, Novelli A, Habel N, Krishnan AM, Silverman DN, LeWinter MM, Lustgarten DL, Meyer M. Effect of Personalized Accelerated Pacing on Quality of Life, Physical Activity, and Atrial Fibrillation in Patients With Preclinical and Overt Heart Failure With Preserved Ejection Fraction: The myPACE Randomized Clinical Trial. JAMA Cardiol 2023; 8:213-221. [PMID: 36723919 PMCID: PMC9996402 DOI: 10.1001/jamacardio.2022.5320] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 12/02/2022] [Indexed: 02/02/2023]
Abstract
Importance Patients with heart failure with preserved ejection fraction (HFpEF) with a pacemaker may benefit from a higher, more physiologic backup heart rate than the nominal 60 beats per minute (bpm) setting. Objective To assess the effects of a moderately accelerated personalized backup heart rate compared with 60 bpm (usual care) in patients with preexisting pacemaker systems that limit pacemaker-mediated dyssynchrony. Design, Setting, and Participants This blinded randomized clinical trial enrolled patients with stage B and C HFpEF from the University of Vermont Medical Center pacemaker clinic between June 2019 and November 2020. Analysis was modified intention to treat. Interventions Participants were randomly assigned to personalized accelerated pacing or usual care and were followed up for 1 year. The personalized accelerated pacing heart rate was calculated using a resting heart rate algorithm based on height and modified by ejection fraction. Main Outcomes and Measures The primary outcome was the serial change in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score. Secondary end points were changes in N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, pacemaker-detected physical activity, atrial fibrillation from baseline, and adverse clinical events. Results Overall, 107 participants were randomly assigned to the personalized accelerated pacing (n = 50) or usual care (n = 57) groups. The median (IQR) age was 75 (69-81) years, and 48 (48%) were female. Over 1-year follow-up, the median (IQR) pacemaker-detected heart rate was 75 (75-80) bpm in the personalized accelerated pacing arm and 65 (63-68) bpm in usual care. MLHFQ scores improved in the personalized accelerated pacing group (median [IQR] baseline MLHFQ score, 26 [8-45]; at 1 month, 15 [2-25]; at 1 year, 9 [4-21]; P < .001) and worsened with usual care (median [IQR] baseline MLHFQ score, 19 [6-42]; at 1 month, 23 [5-39]; at 1 year, 27 [7-52]; P = .03). In addition, personalized accelerated pacing led to improved changes in NT-proBNP levels (mean [SD] decrease of 109 [498] pg/dL vs increase of 128 [537] pg/dL with usual care; P = .02), activity levels (mean [SD], +47 [67] minutes per day vs -22 [35] minutes per day with usual care; P < .001), and device-detected atrial fibrillation (27% relative risk reduction compared with usual care; P = .04) over 1-year of follow-up. Adverse clinical events occurred in 4 patients in the personalized accelerated pacing group and 11 patients in usual care. Conclusions and Relevance In this study, among patients with HFpEF and pacemakers, treatment with a moderately accelerated, personalized pacing rate was safe and improved quality of life, NT-proBNP levels, physical activity, and atrial fibrillation compared with the usual 60 bpm setting. Trial Registration ClinicalTrials.gov Identifier: NCT04721314.
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Affiliation(s)
- Margaret Infeld
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Kramer Wahlberg
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Jillian Cicero
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Timothy B. Plante
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Sean Meagher
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Alexandra Novelli
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Nicole Habel
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Anand Muthu Krishnan
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Daniel N. Silverman
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston
| | - Martin M. LeWinter
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Daniel L. Lustgarten
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Markus Meyer
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
- Lillehei Heart Institute, Department of Medicine, University of Minnesota College of Medicine, Minneapolis
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Monge García MI, Jian Z, Hatib F, Settles JJ, Cecconi M, Pinsky MR. Relationship between intraventricular mechanical dyssynchrony and left ventricular systolic and diastolic performance: An in vivo experimental study. Physiol Rep 2023; 11:e15607. [PMID: 36808901 PMCID: PMC9937795 DOI: 10.14814/phy2.15607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/13/2023] [Accepted: 01/23/2023] [Indexed: 02/19/2023] Open
Abstract
Left ventricular mechanical dyssynchrony (LVMD) refers to the nonuniformity in mechanical contraction and relaxation timing in different ventricular segments. We aimed to determine the relationship between LVMD and LV performance, as assessed by ventriculo-arterial coupling (VAC), LV mechanical efficiency (LVeff ), left ventricular ejection fraction (LVEF), and diastolic function during sequential experimental changes in loading and contractile conditions. Thirteen Yorkshire pigs submitted to three consecutive stages with two opposite interventions each: changes in afterload (phenylephrine/nitroprusside), preload (bleeding/reinfusion and fluid bolus), and contractility (esmolol/dobutamine). LV pressure-volume data were obtained with a conductance catheter. Segmental mechanical dyssynchrony was assessed by global, systolic, and diastolic dyssynchrony (DYS) and internal flow fraction (IFF). Late systolic LVMD was related to an impaired VAC, LVeff , and LVEF, whereas diastolic LVMD was associated with delayed LV relaxation (logistic tau), decreased LV peak filling rate, and increased atrial contribution to LV filling. The hemodynamic factors related to LVMD were contractility, afterload, and heart rate. However, the relationship between these factors differed throughout the cardiac cycle. LVMD plays a significant role in LV systolic and diastolic performance and is associated with hemodynamic factors and intraventricular conduction.
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Affiliation(s)
| | | | | | | | - Maurizio Cecconi
- Department Anaesthesia and Intensive Care Units, Humanitas Research HospitalHumanitas UniversityMilanItaly
| | - Michael R. Pinsky
- Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
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Asai Y, Yanagawa T, Yamamoto T, Sato Y. Exploratory Study of Pharmacists' Monitoring Methods Based on Left Ventricular Function for Hypermagnesemia by Magnesium Oxide in Heart Failure. J Clin Pharmacol 2023; 63:48-56. [PMID: 35933598 DOI: 10.1002/jcph.2133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022]
Abstract
Serum magnesium (Mg) monitoring in patients with heart failure (HF) receiving magnesium oxide (MgO) is not adequately performed. Furthermore, the relationship between left ventricular function (LVF) and hypermagnesemia in HF is unknown. Here, we investigated the efficacy of serum Mg monitoring by protocol-based pharmaceutical management (PBPM) and the effect of LVF on hypermagnesemia. This protocol is for patients with an estimated glomerular filtration rate of <45 mL/min, receiving MgO, and admitted to the cardiology unit. The pharmacist includes the measurement of Mg when a blood test is ordered for a patient by their physician. Rates of serum Mg measurement and hypermagnesemia detection were compared at 2 years pre-PBPM (n = 88) and at 2 years post-PBPM (n = 55). LVF parameters and reported factors for hypermagnesemia were selected as explanatory factors on multivariate logistic regression. The measurement rate of serum Mg concentration significantly increased from 19.3% pre-PBPM to 80.0% post-PBPM (P < .001). The detection rate of hypermagnesemia also increased from 3.4% to 27.3%, respectively (P < .001). Our results suggest that serum Mg monitoring by PBPM may contribute to the early detection of hypermagnesemia and prevent its progression in HF. According to logistic regression, the adjusted odds ratio for hypermagnesemia with an exacerbation of HF was 9.57 (95% confidence interval: 1.594-57.477, P = .014), and the E/e' > 15, an index of reduced left ventricular diastolic capacity, was 6.46 (95% confidence interval: 1.291-32.364, P = .023). We propose that serum Mg monitoring should be performed during exacerbations of HF in patients with left ventricular diastolic dysfunction, with a pharmacist's assistance.
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Affiliation(s)
- Yuki Asai
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, Tsu, Mie, Japan
| | - Tatsuki Yanagawa
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, Tsu, Mie, Japan
| | - Takanori Yamamoto
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, Tsu, Mie, Japan
| | - Yoshiharu Sato
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, Tsu, Mie, Japan
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13
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Wernhart S, Papathanasiou M, Mahabadi AA, Rassaf T, Luedike P. Betablockers reduce oxygen pulse increase and performance in heart failure patients with preserved ejection fraction. Int J Cardiol 2023; 370:309-318. [PMID: 36220507 DOI: 10.1016/j.ijcard.2022.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/01/2022] [Accepted: 10/04/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Beta blockers (BB) reduce chronotropic response and exercise capacity in heart failure with preserved ejection fraction (HFpEF). To analyze the influence of BB on exercise performance and O 2 pulse increase as a surrogate for stroke volume in HFpEF. METHODS We retrospectively analyzed the influence of BB intake (yes: n = 48/no: n = 51) on peak oxygen uptake (VO 2peak), oxygen uptake efficiency slope (OUES), and increase of O 2 pulse in HFpEF patients undergoing cardiopulmonary exercise testing (CPET). Associations of outcome variables and risk category of the algorithm of the Heart Failure Association of the European Society of Cardiology (HFA-PEFF score) were calculated. RESULTS Patients on BB showed lower VO 2peak (p = .003) and OUES (p = .002), with a dominant effect in the high-risk (p = .020; 0.002), but not in the low risk-group (p = .434; p = .499). In the intermediate group BB showed a trend towards lower VO 2peak (p = .078) and lower values for OUES (p = .020). Patients on BB also demonstrated a lower increase of O 2 pulse during exercise (p = .002), without differences between HFA-PEFF risk groups (low: p = .322, intermediate: p = .269, high: p = .313). CONCLUSIONS BB reduce exercise capacity and O 2 pulse increase in HFpEF patients. Direct quantification of O 2 pulse increase may help to improve the discrimination of HFpEF patients.
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Affiliation(s)
- Simon Wernhart
- University Hospital Essen, University Duisburg-Essen, West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, Hufelandstrasse 55, 45147 Essen, Germany
| | - Maria Papathanasiou
- University Hospital Essen, University Duisburg-Essen, West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, Hufelandstrasse 55, 45147 Essen, Germany
| | - Amir Abbas Mahabadi
- University Hospital Essen, University Duisburg-Essen, West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, Hufelandstrasse 55, 45147 Essen, Germany
| | - Tienush Rassaf
- University Hospital Essen, University Duisburg-Essen, West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, Hufelandstrasse 55, 45147 Essen, Germany
| | - Peter Luedike
- University Hospital Essen, University Duisburg-Essen, West German Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, Hufelandstrasse 55, 45147 Essen, Germany.
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14
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Epidemiology, Diagnosis, Pathophysiology, and Initial Approach to Heart Failure with Preserved Ejection Fraction. Cardiol Clin 2022; 40:397-413. [DOI: 10.1016/j.ccl.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Kagami K, Obokata M, Harada T, Kato T, Wada N, Adachi T, Ishii H. Diastolic Filling Time, Chronotropic Response, and Exercise Capacity in Heart Failure and Preserved Ejection Fraction With Sinus Rhythm. J Am Heart Assoc 2022; 11:e026009. [PMID: 35766289 PMCID: PMC9333393 DOI: 10.1161/jaha.121.026009] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Exercise‐induced high heart rate may impair exercise tolerance by reducing diastolic filling time and ventricular filling in heart failure with preserved ejection fraction (HFpEF). Given the importance of chronotropic response, we hypothesized that reduction in diastolic filling time because of exercise‐induced increased heart rate would not impair cardiac output reserve and exercise capacity. We sought to determine the association between heart rate, diastolic filling time, hemodynamics, and exercise capacity in HFpEF. Methods and Results Patients with HFpEF (n=66) and controls without HF (n=107) underwent bicycle exercise echocardiography with simultaneous expired gas analysis to measure oxygen consumption. Diastolic filling time was assessed by the overlap time between mitral E‐ and A‐waves (longer overlap time indicates shorter diastolic filling duration). Overlap time increased (ie, diastolic filling time shortened) in HFpEF and controls as heart rate increased with exercise, and the relationship was similar between the groups. Greater heart rate response correlated with higher cardiac output (r=0.51, P<0.0001) and oxygen consumption (r=0.50, P<0.0001) during peak exercise. Shorter diastolic filling time, as assessed by longer overlap time, was correlated with higher cardiac output (r=0.47, P<0.0001) and peak oxygen consumption (r=0.38, P=0.007), not with E/e′ or right ventricular‐pulmonary artery uncoupling. Longer overlap time was associated with mitral A velocity (r=0.53, P<0.0001) and left atrial booster pump strain (r=0.42, P<0.0001). Conclusions Shortening of diastolic filling interval in tandem with increased heart rate during exercise does not limit cardiac output reserve or exercise capacity in HFpEF.
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Affiliation(s)
- Kazuki Kagami
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan.,Division of Cardiovascular Medicine National Defense Medical College Tokorozawa, Saitama Japan
| | - Masaru Obokata
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Tomonari Harada
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Naoki Wada
- Department of Rehabilitation Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Takeshi Adachi
- Division of Cardiovascular Medicine National Defense Medical College Tokorozawa, Saitama Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
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Vriz O, Palatini P, Rudski L, Frumento P, Kasprzak JD, Ferrara F, Cocchia R, Gargani L, Wierzbowska-Drabik K, Capone V, Ranieri B, Salzano A, Stanziola AA, Marra AM, Annunziata R, Chianese S, Rega S, Saltalamacchia T, Maramaldi R, Sepe C, Limongelli G, Cademartiri F, D’Andrea A, D’Alto M, Izzo R, Ferrara N, Mauro C, Cittadini A, Ekkehard G, Guazzi M, Bossone E. Right Heart Pulmonary Circulation Unit Response to Exercise in Patients with Controlled Systemic Arterial Hypertension: Insights from the RIGHT Heart International NETwork (RIGHT-NET). J Clin Med 2022; 11:jcm11020451. [PMID: 35054145 PMCID: PMC8778233 DOI: 10.3390/jcm11020451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background. Systemic arterial hypertension (HTN) is the main risk factor for the development of heart failure with preserved ejection fraction (HFpEF). The aim of the study was was to assess the trends in PASP, E/E’ and TAPSE during exercise Doppler echocardiography (EDE) in hypertensive (HTN) patients vs. healthy subjects stratified by age. Methods. EDE was performed in 155 hypertensive patients and in 145 healthy subjects (mean age 62 ± 12.0 vs. 54 ± 14.9 years respectively, p < 0.0001). EDE was undertaken on a semi-recumbent cycle ergometer with load increasing by 25 watts every 2 min. Left ventricular (LV) and right ventricular (RV) dimensions, function and hemodynamics were evaluated. Results. Echo-Doppler parameters of LV and RV function were lower, both at rest and at peak exercise in hypertensives, while pulmonary hemodynamics were higher as compared to healthy subjects. The entire cohort was then divided into tertiles of age: at rest, no significant differences were recorded for each age group between hypertensives and normotensives except for E/E’ that was higher in hypertensives. At peak exercise, hypertensives had higher pulmonary artery systolic pressure (PASP) and E/E’ but lower tricuspid annular plane systolic excursion (TAPSE) as age increased, compared to normotensives. Differences in E/E’ and TAPSE between the 2 groups at peak exercise were explained by the interaction between HTN and age even after adjustment for baseline values (p < 0.001 for E/E’, p = 0.011 for TAPSE). At peak exercise, the oldest group of hypertensive patients had a mean E/E’ of 13.0, suggesting a significant increase in LV diastolic pressure combined with increased PASP. Conclusion. Age and HTN have a synergic negative effect on E/E’ and TAPSE at peak exercise in hypertensive subjects.
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Affiliation(s)
- Olga Vriz
- Cardiac Centre, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia;
- School of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Paolo Palatini
- Department of Medicine, University of Padova, 35122 Padova, Italy;
| | - Lawrence Rudski
- Azrieli Heart Center and Center for Pulmonary Vascular Diseases, Jewish General Hospital, McGill University, Montreal, QC H3A 0G4, Canada;
| | - Paolo Frumento
- Department of Political Sciences, University of Pisa, 56126 Pisa, Italy;
| | - Jarosław D. Kasprzak
- Department of Cardiology, Bieganski Hospital, Medical University, 91-347 Lodz, Poland; (J.D.K.); (K.W.-D.)
| | - Francesco Ferrara
- Heart Department, University Hospital of Salerno, 84131 Salerno, Italy;
| | - Rosangela Cocchia
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (R.C.); (V.C.); (R.A.); (S.C.); (C.S.)
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, 56124 Pisa, Italy; (L.G.); (C.M.)
| | - Karina Wierzbowska-Drabik
- Department of Cardiology, Bieganski Hospital, Medical University, 91-347 Lodz, Poland; (J.D.K.); (K.W.-D.)
| | - Valentina Capone
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (R.C.); (V.C.); (R.A.); (S.C.); (C.S.)
| | - Brigida Ranieri
- IRCCS Synlab SDN, 80143 Naples, Italy; (B.R.); (A.S.); (F.C.)
| | - Andrea Salzano
- IRCCS Synlab SDN, 80143 Naples, Italy; (B.R.); (A.S.); (F.C.)
| | - Anna Agnese Stanziola
- Department of Respiratory Diseases, Monaldi Hospital, University “Federico II”, 80131 Naples, Italy;
| | - Alberto Maria Marra
- Department of Translational Medical Sciences, “Federico II” University of Naples, 80138 Naples, Italy; (A.M.M.); (S.R.); (T.S.); (R.M.); (N.F.); (A.C.)
| | - Roberto Annunziata
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (R.C.); (V.C.); (R.A.); (S.C.); (C.S.)
| | - Salvatore Chianese
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (R.C.); (V.C.); (R.A.); (S.C.); (C.S.)
| | - Salvatore Rega
- Department of Translational Medical Sciences, “Federico II” University of Naples, 80138 Naples, Italy; (A.M.M.); (S.R.); (T.S.); (R.M.); (N.F.); (A.C.)
| | - Teresa Saltalamacchia
- Department of Translational Medical Sciences, “Federico II” University of Naples, 80138 Naples, Italy; (A.M.M.); (S.R.); (T.S.); (R.M.); (N.F.); (A.C.)
| | - Renato Maramaldi
- Department of Translational Medical Sciences, “Federico II” University of Naples, 80138 Naples, Italy; (A.M.M.); (S.R.); (T.S.); (R.M.); (N.F.); (A.C.)
| | - Chiara Sepe
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (R.C.); (V.C.); (R.A.); (S.C.); (C.S.)
| | - Giuseppe Limongelli
- Division of Cardiology, Monaldi Hospital, Second University of Naples, 81100 Naples, Italy; (G.L.); (M.D.)
| | | | - Antonello D’Andrea
- Department of Cardiology and Intensive Coronary Unit, “Umberto I” Hospital, 84014 Nocera Inferiore, Italy;
| | - Michele D’Alto
- Division of Cardiology, Monaldi Hospital, Second University of Naples, 81100 Naples, Italy; (G.L.); (M.D.)
| | - Raffaele Izzo
- Department of Advanced Biomedical Sciences, “Federico II” University of Naples, 80131 Naples, Italy;
| | - Nicola Ferrara
- Department of Translational Medical Sciences, “Federico II” University of Naples, 80138 Naples, Italy; (A.M.M.); (S.R.); (T.S.); (R.M.); (N.F.); (A.C.)
| | - Ciro Mauro
- Institute of Clinical Physiology, National Research Council, 56124 Pisa, Italy; (L.G.); (C.M.)
| | - Antonio Cittadini
- Department of Translational Medical Sciences, “Federico II” University of Naples, 80138 Naples, Italy; (A.M.M.); (S.R.); (T.S.); (R.M.); (N.F.); (A.C.)
| | - Grünig Ekkehard
- Centre for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), 69120 Heidelberg, Germany;
| | - Marco Guazzi
- Heart Failure Unit, Cardiopulmonary Laboratory, University Cardiology Department, IRCCS Policlinico San Donato University Hospital, 20097 Milan, Italy;
| | - Eduardo Bossone
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (R.C.); (V.C.); (R.A.); (S.C.); (C.S.)
- Correspondence:
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Daal MRR, Strijkers GJ, Hautemann DJ, Nederveen AJ, Wüst RCI, Coolen BF. Longitudinal CMR assessment of cardiac global longitudinal strain and hemodynamic forces in a mouse model of heart failure. Int J Cardiovasc Imaging 2022; 38:2385-2394. [PMID: 36434328 PMCID: PMC9700588 DOI: 10.1007/s10554-022-02631-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/22/2022] [Indexed: 12/14/2022]
Abstract
To longitudinally assess left ventricle (LV) global longitudinal strain (GLS) and hemodynamic forces during the early stages of cardiac dysfunction in a mouse model of heart failure with preserved ejection fraction (HFpEF). Cardiac MRI measurements were performed in control mice (n = 6), and db/db mice (n = 7), whereby animals were scanned four times between the age of 11-15 weeks. After the first scan, the db/db animals received a doxycycline intervention to accelerate progression of HFpEF. Systolic function was evaluated based on a series of prospectively ECG-triggered short-axis CINE images acquired from base to apex. Cardiac GLS and hemodynamic forces values were evaluated based on high frame rate retrospectively gated 2-, 3-, and 4-chamber long-axis CINE images. Ejection fraction (EF) was not different between control and db/db animals, despite that cardiac output, as well as end systolic and end diastolic volume were significantly higher in control animals. Whereas GLS parameters were not significantly different between groups, hemodynamic force root mean square (RMS) values, as well as average hemodynamic forces and the ratio between hemodynamic forces in the inferolateral-anteroseptal and apical-basal direction were lower in db/db mice compared to controls. More importantly, hemodynamic forces parameters showed a significant interaction effect between time and group. Our results indicated that hemodynamic forces parameters were the only functional outcome measure that showed distinct temporal differences between groups. As such, changes in hemodynamic forces reflect early alterations in cardiac function which can be of added value in (pre)clinical research on HFpEF.
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Affiliation(s)
- Mariah R. R. Daal
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Gustav J. Strijkers
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | | | - Aart J. Nederveen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Rob C. I. Wüst
- Laboratory for Myology, Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Bram F. Coolen
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Myocardial Tissue Characterization in Heart Failure with Preserved Ejection Fraction: From Histopathology and Cardiac Magnetic Resonance Findings to Therapeutic Targets. Int J Mol Sci 2021; 22:ijms22147650. [PMID: 34299270 PMCID: PMC8304780 DOI: 10.3390/ijms22147650] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/13/2021] [Accepted: 07/16/2021] [Indexed: 12/12/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a complex clinical syndrome responsible for high mortality and morbidity rates. It has an ever growing social and economic impact and a deeper knowledge of molecular and pathophysiological basis is essential for the ideal management of HFpEF patients. The association between HFpEF and traditional cardiovascular risk factors is known. However, myocardial alterations, as well as pathophysiological mechanisms involved are not completely defined. Under the definition of HFpEF there is a wide spectrum of different myocardial structural alterations. Myocardial hypertrophy and fibrosis, coronary microvascular dysfunction, oxidative stress and inflammation are only some of the main pathological detectable processes. Furthermore, there is a lack of effective pharmacological targets to improve HFpEF patients' outcomes and risk factors control is the primary and unique approach to treat those patients. Myocardial tissue characterization, through invasive and non-invasive techniques, such as endomyocardial biopsy and cardiac magnetic resonance respectively, may represent the starting point to understand the genetic, molecular and pathophysiological mechanisms underlying this complex syndrome. The correlation between histopathological findings and imaging aspects may be the future challenge for the earlier and large-scale HFpEF diagnosis, in order to plan a specific and effective treatment able to modify the disease's natural course.
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Izumida T, Imamura T, Fukui T, Koi T, Ueno Y, Hori M, Nakagaito M, Tanaka S, Kataoka N, Ushijima R, Nakamura M, Sobajima M, Fukuda N, Ueno H, Kinugawa K. How to Estimate the Optimal Heart Rate in Patients with Heart Failure with Preserved Ejection Fraction. Int Heart J 2021; 62:816-820. [PMID: 34276013 DOI: 10.1536/ihj.20-788] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Ideal heart rate (HR), particularly for those with heart failure with preserved ejection fraction (HFpEF), remains unknown. We hypothesized that cardiac output would be maximum when the overlap between E-wave and A-wave at the trans-mitral flow is "zero" in the Doppler echocardiography. We retrospectively investigated the association among the overlap length between two waves, actual HR, and other echocardiographic parameters to construct a formula for estimating theoretically ideal HR among those with HFpEF. In total, 48 HFpEF patients were included (70-year-olds, 18 males). Given the results of multivariate linear regression analyses, the overlap length was estimated as follows: -1,050 + 8.4 × (HR [bpm]) + 0.6 × (deceleration time [millisecond]) + 1.7 × (A-width [millisecond]), which had a strong agreement with the actually measured overlap length (r = 0.86, P < 0.001). Theoretically ideal HR was calculated by substituting zero into the estimated overlap length as follows: 125 - 0.07 × (deceleration time [millisecond]) - 0.20 × (A-width [millisecond]). In the validation cohort including another 143 HFpEF patients, the estimated overlap using the formula again had a strong agreement with the actually measured overlap (r = 0.72, P < 0.001). In this study, we proposed a novel formula for calculating theoretically ideal HR, consisting of deceleration time and A-width, in the HFpEF cohort. Clinical implication to optimize the HR targeting the theoretically ideal HR should be investigated in prospective studies.
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Affiliation(s)
| | | | - Takuya Fukui
- Second Department of Internal Medicine, University of Toyama
| | - Takatoshi Koi
- Second Department of Internal Medicine, University of Toyama
| | - Yohei Ueno
- Second Department of Internal Medicine, University of Toyama
| | - Masakazu Hori
- Second Department of Internal Medicine, University of Toyama
| | | | - Shuhei Tanaka
- Second Department of Internal Medicine, University of Toyama
| | - Naoya Kataoka
- Second Department of Internal Medicine, University of Toyama
| | | | - Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama
| | - Mitsuo Sobajima
- Second Department of Internal Medicine, University of Toyama
| | - Nobuyuki Fukuda
- Second Department of Internal Medicine, University of Toyama
| | - Hiroshi Ueno
- Second Department of Internal Medicine, University of Toyama
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20
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Shchendrygina AA, Zhbanov KA, Privalova EV, Yusupova AO, Danilogorskaya YA, Salakheeva EY, Sokolova IY, Tsatsurova SA, Ageeva AA, Belenkov YN. Heart Failure with Perserved Ejection Fraction Current Diagnostic and Therapeutic Approaches. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-05-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a syndrome associated with high morbidity and mortality rates. Little progress has been in the treatment of this condition since its introduction some 30 years ago. It's accepted that HFpEF is heterogeneous in many ways, ethologically and phenotypically. The underlying mechanisms of the syndrome are not clear. Recently, it has been shown that the diagnostic criteria for HFpEF lacks sensitivity and specificity. Novel treatment approaches, which were developed based on current HFpEF pathophysiological concepts, did not show either clinical or prognostic benefit for patients. Therefore, there is an urgent need to revise current diagnostic approaches and to further investigate the underlying mechanisms. Recently, two novel diagnostic score systems were proposed: H2PEF and HFA-PEFF. Recently, a number of phase II and III randomized control trials have been completed. Here, the authors discuss the potential novel diagnostic approaches to HFpEF and treatment perspectives.
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Affiliation(s)
| | - K. A. Zhbanov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - E. V. Privalova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. O. Yusupova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | | | - E. Yu. Salakheeva
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - I. Ya. Sokolova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - S. A. Tsatsurova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. A. Ageeva
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - Yu. N. Belenkov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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Left Ventricular Function Changes Induced by Moderate Hypothermia Are Rapidly Reversed After Rewarming-A Clinical Study. Crit Care Med 2021; 50:e52-e60. [PMID: 34259452 DOI: 10.1097/ccm.0000000000005170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Targeted temperature management (32-36°C) is used for neuroprotection in cardiac arrest survivors. The isolated effects of hypothermia on myocardial function, as used in clinical practice, remain unclear. Based on experimental results, we hypothesized that hypothermia would reversibly impair diastolic function with less tolerance to increased heart rate in patients with uninsulted hearts. DESIGN Prospective clinical study, from June 2015 to May 2018. SETTING Cardiothoracic surgery operation room, Oslo University Hospital. PATIENTS Twenty patients with left ventricular ejection fraction greater than 55%, undergoing ascending aorta graft-replacement connected to cardiopulmonary bypass were included. INTERVENTIONS Left ventricular function was assessed during reduced cardiopulmonary bypass support at 36°C, 32°C prior to graft-replacement, and at 36°C postsurgery. Electrocardiogram, hemodynamic, and echocardiographic recordings were made at spontaneous heart rate and 90 beats per minute at comparable loading conditions. MEASUREMENTS AND MAIN RESULTS Hypothermia decreased spontaneous heart rate, and R-R interval was prolonged (862 ± 170 to 1,156 ± 254 ms, p < 0.001). Although systolic and diastolic fractions of R-R interval were preserved (0.43 ± 0.07 and 0.57 ± 0.07), isovolumic relaxation time increased and diastolic filling time was shortened. Filling pattern changed from early to late filling. Systolic function was preserved with unchanged myocardial strain and stroke volume index, but cardiac index was reduced with maintained mixed venous oxygen saturation. At increased heart rate, systolic fraction exceeded diastolic fraction (0.53 ± 0.05 and 0.47 ± 0.05) with diastolic impairment. Strain and stroke volume index were reduced, the latter to 65% of stroke volume index at spontaneous heart rate. Cardiac index decreased, but mixed venous oxygen saturation was maintained. After rewarming, myocardial function was restored. CONCLUSIONS In patients with normal left ventricular function, hypothermia impaired diastolic function. At increased heart rate, systolic function was subsequently reduced due to impeded filling. Changes in left ventricular function were rapidly reversed after rewarming.
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22
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Bombardini T, Zagatina A, Ciampi Q, Arbucci R, Merlo PM, Haber DML, Morrone D, D’Andrea A, Djordjevic-Dikic A, Beleslin B, Tesic M, Boskovic N, Giga V, de Castro e Silva Pretto JL, Daros CB, Amor M, Mosto H, Salamè M, Monte I, Citro R, Simova I, Samardjieva M, Wierzbowska-Drabik K, Kasprzak JD, Gaibazzi N, Cortigiani L, Scali MC, Pepi M, Antonini-Canterin F, Torres MAR, Nes MD, Ostojic M, Carpeggiani C, Kovačević-Preradović T, Lowenstein J, Arruda-Olson AM, Pellikka PA, Picano E. Hemodynamic Heterogeneity of Reduced Cardiac Reserve Unmasked by Volumetric Exercise Echocardiography. J Clin Med 2021; 10:jcm10132906. [PMID: 34209955 PMCID: PMC8267648 DOI: 10.3390/jcm10132906] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Two-dimensional volumetric exercise stress echocardiography (ESE) provides an integrated view of left ventricular (LV) preload reserve through end-diastolic volume (EDV) and LV contractile reserve (LVCR) through end-systolic volume (ESV) changes. Purpose: To assess the dependence of cardiac reserve upon LVCR, EDV, and heart rate (HR) during ESE. Methods: We prospectively performed semi-supine bicycle or treadmill ESE in 1344 patients (age 59.8 ± 11.4 years; ejection fraction = 63 ± 8%) referred for known or suspected coronary artery disease. All patients had negative ESE by wall motion criteria. EDV and ESV were measured by biplane Simpson rule with 2-dimensional echocardiography. Cardiac index reserve was identified by peak-rest value. LVCR was the stress-rest ratio of force (systolic blood pressure by cuff sphygmomanometer/ESV, abnormal values ≤2.0). Preload reserve was defined by an increase in EDV. Cardiac index was calculated as stroke volume index * HR (by EKG). HR reserve (stress/rest ratio) <1.85 identified chronotropic incompetence. Results: Of the 1344 patients, 448 were in the lowest tertile of cardiac index reserve with stress. Of them, 303 (67.6%) achieved HR reserve <1.85; 252 (56.3%) had an abnormal LVCR and 341 (76.1%) a reduction of preload reserve, with 446 patients (99.6%) showing ≥1 abnormality. At binary logistic regression analysis, reduced preload reserve (odds ratio [OR]: 5.610; 95% confidence intervals [CI]: 4.025 to 7.821), chronotropic incompetence (OR: 3.923, 95% CI: 2.915 to 5.279), and abnormal LVCR (OR: 1.579; 95% CI: 1.105 to 2.259) were independently associated with lowest tertile of cardiac index reserve at peak stress. Conclusions: Heart rate assessment and volumetric echocardiography during ESE identify the heterogeneity of hemodynamic phenotypes of impaired chronotropic, preload or LVCR underlying a reduced cardiac reserve.
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Affiliation(s)
- Tonino Bombardini
- Clinical Center of The Republic of Srpska, Faculty of Medicine, University of Banja-Luka, 78000 Banja-Luka, Bosnia and Herzegovina; (T.B.); (M.O.); (T.K.-P.)
| | - Angela Zagatina
- Cardiology Department, Saint Petersburg University Clinic, Saint Petersburg University, 199034 St Petersburg, Russia;
| | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy
- Correspondence:
| | - Rosina Arbucci
- Cardiodiagnosticos, Investigaciones Medicas, C1082 ACB Buenos Aires, Argentina; (R.A.); (P.M.M.); (D.M.L.H.); (J.L.)
| | - Pablo Martin Merlo
- Cardiodiagnosticos, Investigaciones Medicas, C1082 ACB Buenos Aires, Argentina; (R.A.); (P.M.M.); (D.M.L.H.); (J.L.)
| | - Diego M. Lowenstein Haber
- Cardiodiagnosticos, Investigaciones Medicas, C1082 ACB Buenos Aires, Argentina; (R.A.); (P.M.M.); (D.M.L.H.); (J.L.)
| | - Doralisa Morrone
- Cardiothoracic Department, University of Pisa, 56100 Pisa, Italy;
| | - Antonello D’Andrea
- Department of Cardiology-Umberto I° Hospital Nocera Inferiore (Salerno)-L. Vanvitelli University of Campania, 84014 Nocera Inferiore, Italy;
| | - Ana Djordjevic-Dikic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, 11000 Belgrade, Serbia; (A.D.-D.); (B.B.); (M.T.); (N.B.); (V.G.)
| | - Branko Beleslin
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, 11000 Belgrade, Serbia; (A.D.-D.); (B.B.); (M.T.); (N.B.); (V.G.)
| | - Milorad Tesic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, 11000 Belgrade, Serbia; (A.D.-D.); (B.B.); (M.T.); (N.B.); (V.G.)
| | - Nikola Boskovic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, 11000 Belgrade, Serbia; (A.D.-D.); (B.B.); (M.T.); (N.B.); (V.G.)
| | - Vojislav Giga
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, 11000 Belgrade, Serbia; (A.D.-D.); (B.B.); (M.T.); (N.B.); (V.G.)
| | | | | | - Miguel Amor
- Cardiology Department, Ramos Mejia Hospital, C1221 ADC Buenos Aires, Argentina; (M.A.); (H.M.); (M.S.)
| | - Hugo Mosto
- Cardiology Department, Ramos Mejia Hospital, C1221 ADC Buenos Aires, Argentina; (M.A.); (H.M.); (M.S.)
| | - Michael Salamè
- Cardiology Department, Ramos Mejia Hospital, C1221 ADC Buenos Aires, Argentina; (M.A.); (H.M.); (M.S.)
| | - Ines Monte
- Cardio-Thorax-Vascular Department, Echocardiography Lab, Policlinico Vittorio Emanuele, Catania University, 95124 Catania, Italy;
| | - Rodolfo Citro
- Cardio-Thoracic-Vascular-Department, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84125 Salerno, Italy;
| | - Iana Simova
- Heart and Brain Center of Excellence, University Hospital, 5800 Sofia, Bulgaria; (I.S.); (M.S.)
| | - Martina Samardjieva
- Heart and Brain Center of Excellence, University Hospital, 5800 Sofia, Bulgaria; (I.S.); (M.S.)
| | - Karina Wierzbowska-Drabik
- Department of Cardiology, Bieganski Hospital, Medical University, 93-487 Lodz, Poland; (K.W.-D.); (J.D.K.)
| | - Jaroslaw D. Kasprzak
- Department of Cardiology, Bieganski Hospital, Medical University, 93-487 Lodz, Poland; (K.W.-D.); (J.D.K.)
| | - Nicola Gaibazzi
- Cardiology Department, Parma University Hospital, 43100 Parma, Italy;
| | | | | | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCS, 20138 Milano, Italy;
| | - Francesco Antonini-Canterin
- Highly Specialized Rehabilitation Hospital Motta di Livenza, Cardiac Prevention and Rehabilitation Unit, 31045 Treviso, Italy;
| | - Marco A. R. Torres
- Department of Cardiology, Federal University of Rio Grande do Sul, 90040-060 Porto Alegre, Brazil;
| | - Michele De Nes
- Biomedicine Department, CNR, Institute of Clinical Physiology, 56124 Pisa, Italy; (M.D.N.); (C.C.); (E.P.)
| | - Miodrag Ostojic
- Clinical Center of The Republic of Srpska, Faculty of Medicine, University of Banja-Luka, 78000 Banja-Luka, Bosnia and Herzegovina; (T.B.); (M.O.); (T.K.-P.)
| | - Clara Carpeggiani
- Biomedicine Department, CNR, Institute of Clinical Physiology, 56124 Pisa, Italy; (M.D.N.); (C.C.); (E.P.)
| | - Tamara Kovačević-Preradović
- Clinical Center of The Republic of Srpska, Faculty of Medicine, University of Banja-Luka, 78000 Banja-Luka, Bosnia and Herzegovina; (T.B.); (M.O.); (T.K.-P.)
| | - Jorge Lowenstein
- Cardiodiagnosticos, Investigaciones Medicas, C1082 ACB Buenos Aires, Argentina; (R.A.); (P.M.M.); (D.M.L.H.); (J.L.)
| | - Adelaide M. Arruda-Olson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55901, USA; (A.M.A.-O.); (P.A.P.)
| | - Patricia A. Pellikka
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55901, USA; (A.M.A.-O.); (P.A.P.)
| | - Eugenio Picano
- Biomedicine Department, CNR, Institute of Clinical Physiology, 56124 Pisa, Italy; (M.D.N.); (C.C.); (E.P.)
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23
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Chen MP, Kiduko SA, Saad NS, Canan BD, Kilic A, Mohler PJ, Janssen PML. Stretching single titin molecules from failing human hearts reveals titin's role in blunting cardiac kinetic reserve. Cardiovasc Res 2020; 116:127-137. [PMID: 30778519 DOI: 10.1093/cvr/cvz043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/08/2018] [Accepted: 02/13/2019] [Indexed: 11/15/2022] Open
Abstract
AIMS Heart failure (HF) patients commonly experience symptoms primarily during elevated heart rates, as a result of physical activities or stress. A main determinant of diastolic passive tension, the elastic sarcomeric protein titin, has been shown to be associated with HF, with unresolved involvement regarding its role at different heart rates. To determine whether titin is playing a role in the heart rate (frequency-) dependent acceleration of relaxation (FDAR). W, we studied the FDAR responses in live human left ventricular cardiomyocytes and the corresponding titin-based passive tension (TPT) from failing and non-failing human hearts. METHODS AND RESULTS Using atomic force, we developed a novel single-molecule force spectroscopy approach to detect TPT based on the frequency-modulated cardiac cycle. Mean TPT reduced upon an increased heart rate in non-failing human hearts, while this reduction was significantly blunted in failing human hearts. These mechanical changes in the titin distal Ig domain significantly correlated with the frequency-dependent relaxation kinetics of human cardiomyocytes obtained from the corresponding hearts. Furthermore, the data suggested that the higher the TPT, the faster the cardiomyocytes relaxed, but the lower the potential of myocytes to speed up relaxation at a higher heart rate. Such poorer FDAR response was also associated with a lesser reduction or a bigger increase in TPT upon elevated heart rate. CONCLUSIONS Our study established a novel approach in detecting dynamic heart rate relevant tension changes physiologically on native titin domains. Using this approach, the data suggested that the regulation of kinetic reserve in cardiac relaxation and its pathological changes were associated with the intensity and dynamic changes of passive tension by titin.
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Affiliation(s)
- Mei-Pian Chen
- Department of Physiology and Cell Biology, The Ohio State University, Hamilton Hall 207a, 1645 Neil Avenue, Columbus, OH 43210, USA.,Dorothy M. Davis Heart and Lung Research Institute, 473 W 12th Ave, Columbus, OH 43210 USA
| | - Salome A Kiduko
- Department of Physiology and Cell Biology, The Ohio State University, Hamilton Hall 207a, 1645 Neil Avenue, Columbus, OH 43210, USA.,Dorothy M. Davis Heart and Lung Research Institute, 473 W 12th Ave, Columbus, OH 43210 USA
| | - Nancy S Saad
- Department of Physiology and Cell Biology, The Ohio State University, Hamilton Hall 207a, 1645 Neil Avenue, Columbus, OH 43210, USA.,Dorothy M. Davis Heart and Lung Research Institute, 473 W 12th Ave, Columbus, OH 43210 USA.,Department of Pharmacology and Toxicology, Faculty of Pharmacy, Helwan University, Cairo, Egypt
| | - Benjamin D Canan
- Department of Physiology and Cell Biology, The Ohio State University, Hamilton Hall 207a, 1645 Neil Avenue, Columbus, OH 43210, USA.,Dorothy M. Davis Heart and Lung Research Institute, 473 W 12th Ave, Columbus, OH 43210 USA
| | - Ahmet Kilic
- Division of Cardiothoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, OH 43210, USA
| | - Peter J Mohler
- Department of Physiology and Cell Biology, The Ohio State University, Hamilton Hall 207a, 1645 Neil Avenue, Columbus, OH 43210, USA.,Dorothy M. Davis Heart and Lung Research Institute, 473 W 12th Ave, Columbus, OH 43210 USA.,Department of Internal Medicine, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Columbus, OH 43210, USA
| | - Paul M L Janssen
- Department of Physiology and Cell Biology, The Ohio State University, Hamilton Hall 207a, 1645 Neil Avenue, Columbus, OH 43210, USA.,Dorothy M. Davis Heart and Lung Research Institute, 473 W 12th Ave, Columbus, OH 43210 USA.,Department of Internal Medicine, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Columbus, OH 43210, USA
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24
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Ahn MS, Yoo BS, Son JW, Yu MH, Kang DR, Lee HY, Jeon ES, Kim JJ, Chae SC, Baek SH, Kang SM, Choi DJ, Kim KH, Cho MC, Kim SY. Beta-blocker Therapy at Discharge in Patients with Acute Heart Failure and Atrial Fibrillation. J Korean Med Sci 2020; 35:e278. [PMID: 32830467 PMCID: PMC7445305 DOI: 10.3346/jkms.2020.35.e278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 07/03/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND β-blockers (BBs) are considered primary therapy in stable heart failure (HF) with reduced ejection fraction (HFrEF) without atrial fibrillation (AF); evidence-based benefits of BB on outcome have been documented. However, BBs have not been shown to improve mortality or reduce hospital admissions in HF patients with AF. This study assessed the relationship between BBs at discharge and relevant clinical outcomes in acute heart failure (AHF) patients with AF. METHODS From the Korean Acute Heart Failure Registry, 936 HFrEF and 639 HF patients with preserved ejection fraction (HFpEF) and AF were selected. Propensity score (PS) matching accounted for BB selection bias when assessing associations. RESULTS BB-untreated patients in the overall cohort of HFrEF and HFpEF had greater deteriorated clinical and laboratory characteristics. In the 670 PS-matched cohort of HFrEF patients, incidences of all clinical events at 60 days and 1 year were not different according to use of BBs. In the 470 PS-matched cohort of HFpEF, rehospitalization and composite outcome at 6 months and 1 year more frequently occurred in non-users of BBs. After adjusting for covariates in the multivariable Cox model of matched cohorts, BB was not associated with clinical outcomes at 60 days and 1 year in HFrEF with AF patients. In HFpEF patients with AF, BB use was associated with reduced 6-month (hazard ratio [HR], 0.38; 95% confidence interval [CI], 0.20-0.74) and 1-year rehospitalization (HR, 0.53; 95% CI, 0.34-0.82). CONCLUSION In the HFrEF with AF PS-matched cohort, the use of BBs at discharge was not associated with clinical outcome. However, in HFpEF with AF, the use of BB was associated with reduced rehospitalization during the 6-month and 1-year follow up.
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Affiliation(s)
- Min Soo Ahn
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Byung Su Yoo
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea.
| | - Jung Woo Son
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Min Heui Yu
- Center of Biomedical Data Science, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Dae Ryong Kang
- Center of Biomedical Data Science, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hae Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eun Seok Jeon
- Department of Internal Medicine, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Jae Joong Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shung Chull Chae
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sang Hong Baek
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok Min Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ju Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kye Hun Kim
- Department of Internal Medicine, Heart Research Center of Chonnam National University, Gwangju, Korea
| | - Myeong Chan Cho
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
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25
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Wahlberg K, Arnold ME, Lustgarten D, Meyer M. Effects of a Higher Heart Rate on Quality of Life and Functional Capacity in Patients With Left Ventricular Diastolic Dysfunction. Am J Cardiol 2019; 124:1069-1075. [PMID: 31395299 DOI: 10.1016/j.amjcard.2019.07.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/21/2019] [Accepted: 07/02/2019] [Indexed: 01/23/2023]
Abstract
There is no evidence-based treatment for heart failure with preserved ejection fraction. Although lower heart rates (HRs) provide an unequivocal benefit for patients with HF with reduced ejection fraction, higher HR might convey important hemodynamic and substrate-modifying benefits in patients with diastolic dysfunction. In a prospective study of 20 stable outpatients with diastolic dysfunction and pacemakers, we evaluated the effects of a 4-week increase in the lower pacemaker rate to 80 beats/min followed by reversal to the previous lower HR setting from weeks 4 to 6. We assessed quality of life (Minnesota Living with Heart Failure Questionnaire), 6-minute walk test and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels. Pacing at 80 beats/min significantly improved quality of life and the 6-minute walk test (p ≤0.05). There was a strong positive correlation between the pacing-induced changes in NT-proBNP and baseline QRS intervals (r2 = 0.31, p <0.01). Stratification by QRS duration revealed that pacing at 80 beats/min led to -21 ± 26% reduction in NT-proBNP in patients with QRS ≤150 ms, whereas QRS >150 ms was associated with a 26 ± 35% increase in NT-proBNP (p <0.01). Patients physiologically paced from the conduction system had a -46 ± 26% reduction in NT-proBNP at 80 beats/min as compared with 4 ± 26% and 13 ± 26% change with pacing from the right atrial appendage and right ventricular apical septum (pinteraction = 0.04). In conclusion, increasing the lower rate setting of pacemakers to 80 beats/min in patients with diastolic dysfunction improves quality of life, functional capacity, and NT-proBNP for those patients with a baseline QRS ≤150 ms. These findings suggest that higher HRs may provide meaningful benefits to patients with left ventricular diastolic dysfunction and heart failure with preserved ejection fraction.
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Affiliation(s)
- Kramer Wahlberg
- Cardiology Division, Larner College of Medicine at the University of Vermont, Burlington, Vermont.
| | - Maren E Arnold
- Cardiology Division, Larner College of Medicine at the University of Vermont, Burlington, Vermont
| | - Daniel Lustgarten
- Cardiology Division, Larner College of Medicine at the University of Vermont, Burlington, Vermont
| | - Markus Meyer
- Cardiology Division, Larner College of Medicine at the University of Vermont, Burlington, Vermont
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26
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Meyer M, LeWinter MM. Heart Rate and Heart Failure With Preserved Ejection Fraction: Time to Slow β-Blocker Use? Circ Heart Fail 2019; 12:e006213. [PMID: 31525068 DOI: 10.1161/circheartfailure.119.006213] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Markus Meyer
- Cardiology Unit, Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington
| | - Martin M LeWinter
- Cardiology Unit, Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington
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27
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Bamaiyi AJ, Norton GR, Peterson V, Norman G, Mojiminiyi FB, Woodiwiss AJ. Limited Impact of β-Adrenergic Receptor Activation on Left Ventricular Diastolic Function in Rat Models of Hypertensive Heart Disease. J Cardiovasc Pharmacol 2018; 72:242-251. [PMID: 30403389 DOI: 10.1097/fjc.0000000000000620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hypertension is a major cause of left ventricular (LV) diastolic dysfunction. Although β-adrenergic receptor (β-AR) blockers are often used to manage hypertension, the impact of β-AR activation on LV lusitropic effects and hence filling pressures in the hypertensive heart with LV diastolic dysfunction is uncertain. METHODS Using tissue Doppler imaging and Speckle tracking software, we assessed LV function in isoflurane anesthetised spontaneously hypertensive (SHR) and Dahl salt-sensitive (DSS) rats before and after β-AR activation [isoproterenol (ISO) administration]. RESULTS As compared to normotensive Wistar Kyoto control rats, or DSS rats not receiving NaCl in the drinking water, SHR and DSS rats receiving NaCl in the drinking water had a reduced myocardial relaxation as indexed by lateral wall e' (early diastolic tissue velocity at the level of the mitral annulus) and an increased LV filling pressure as indexed by E/e'. However, LV ejection fraction and deformation and motion were preserved in both SHR and DSS rats. The administration of ISO resulted in a marked increase in ejection fraction and decrease in LV filling volumes in all groups, and an increase in e' in SHR, but not DSS rats. However, after ISO administration, although E/e' decreased in DSS rats in association with a reduced filling volume, E/e' in SHR remained unchanged and SHR retained greater values than Wistar Kyoto control. CONCLUSIONS The hypertensive heart is characterized by reductions in myocardial relaxation and increases in filling pressures, but β-AR activation may fail to improve myocardial relaxation and when this occurs, it does not reduce LV filling pressures.
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Affiliation(s)
- Adamu J Bamaiyi
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gavin R Norton
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Vernice Peterson
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Glenda Norman
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Frank B Mojiminiyi
- Department of Physiology, Faculty of Basic Medical Sciences, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
| | - Angela J Woodiwiss
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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28
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Meyer M, Rambod M, LeWinter M. Pharmacological heart rate lowering in patients with a preserved ejection fraction-review of a failing concept. Heart Fail Rev 2018; 23:499-506. [PMID: 29098508 PMCID: PMC5934348 DOI: 10.1007/s10741-017-9660-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Epidemiological studies have demonstrated that high resting heart rates are associated with increased mortality. Clinical studies in patients with heart failure and reduced ejection fraction have shown that heart rate lowering with beta-blockers and ivabradine improves survival. It is therefore often assumed that heart rate lowering is beneficial in other patients as well. Here, we critically appraise the effects of pharmacological heart rate lowering in patients with both normal and reduced ejection fraction with an emphasis on the effects of pharmacological heart rate lowering in hypertension and heart failure. Emerging evidence from recent clinical trials and meta-analyses suggest that pharmacological heart rate lowering is not beneficial in patients with a normal or preserved ejection fraction. This has just begun to be reflected in some but not all guideline recommendations. The detrimental effects of pharmacological heart rate lowering are due to an increase in central blood pressures, higher left ventricular systolic and diastolic pressures, and increased ventricular wall stress. Therefore, we propose that heart rate lowering per se reproduces the hemodynamic effects of diastolic dysfunction and imposes an increased arterial load on the left ventricle, which combine to increase the risk of heart failure and atrial fibrillation. Pharmacologic heart rate lowering is clearly beneficial in patients with a dilated cardiomyopathy but not in patients with normal chamber dimensions and normal systolic function. These conflicting effects can be explained based on a model that considers the hemodynamic and ventricular structural effects of heart rate changes.
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Affiliation(s)
- Markus Meyer
- Department of Medicine, Cardiology Division, Larner College of Medicine at the University of Vermont, UVMMC, McClure 1, Cardiology, 111 Colchester Avenue, Burlington, VT, 05401, USA.
- Department of Medicine, Cardiology Division, Larner College of Medicine at the University of Vermont, Burlington, VT, 05405, USA.
| | - Mehdi Rambod
- Department of Medicine, Cardiology Division, Larner College of Medicine at the University of Vermont, Burlington, VT, 05405, USA
| | - Martin LeWinter
- Department of Medicine, Cardiology Division, Larner College of Medicine at the University of Vermont, Burlington, VT, 05405, USA
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29
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Høydal MA, Kirkeby-Garstad I, Karevold A, Wiseth R, Haaverstad R, Wahba A, Stølen TL, Contu R, Condorelli G, Ellingsen Ø, Smith GL, Kemi OJ, Wisløff U. Human cardiomyocyte calcium handling and transverse tubules in mid-stage of post-myocardial-infarction heart failure. ESC Heart Fail 2018; 5:332-342. [PMID: 29431258 PMCID: PMC5933953 DOI: 10.1002/ehf2.12271] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 12/06/2017] [Accepted: 01/09/2018] [Indexed: 11/08/2022] Open
Abstract
AIMS Cellular processes in the heart rely mainly on studies from experimental animal models or explanted hearts from patients with terminal end-stage heart failure (HF). To address this limitation, we provide data on excitation contraction coupling, cardiomyocyte contraction and relaxation, and Ca2+ handling in post-myocardial-infarction (MI) patients at mid-stage of HF. METHODS AND RESULTS Nine MI patients and eight control patients without MI (non-MI) were included. Biopsies were taken from the left ventricular myocardium and processed for further measurements with epifluorescence and confocal microscopy. Cardiomyocyte function was progressively impaired in MI cardiomyocytes compared with non-MI cardiomyocytes when increasing electrical stimulation towards frequencies that simulate heart rates during physical activity (2 Hz); at 3 Hz, we observed almost total breakdown of function in MI. Concurrently, we observed impaired Ca2+ handling with more spontaneous Ca2+ release events, increased diastolic Ca2+ , lower Ca2+ amplitude, and prolonged time to diastolic Ca2+ removal in MI (P < 0.01). Significantly reduced transverse-tubule density (-35%, P < 0.01) and sarcoplasmic reticulum Ca2+ adenosine triphosphatase 2a (SERCA2a) function (-26%, P < 0.01) in MI cardiomyocytes may explain the findings. Reduced protein phosphorylation of phospholamban (PLB) serine-16 and threonine-17 in MI provides further mechanisms to the reduced function. CONCLUSIONS Depressed cardiomyocyte contraction and relaxation were associated with impaired intracellular Ca2+ handling due to impaired SERCA2a activity caused by a combination of alteration in the PLB/SERCA2a ratio and chronic dephosphorylation of PLB as well as loss of transverse tubules, which disrupts normal intracellular Ca2+ homeostasis and handling. This is the first study that presents these mechanisms from viable and intact cardiomyocytes isolated from the left ventricle of human hearts at mid-stage of post-MI HF.
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Affiliation(s)
- Morten Andre Høydal
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,St. Olavs University Hospital, Trondheim, Norway
| | - Idar Kirkeby-Garstad
- K.G. Jebsen Center of Exercise in Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,St. Olavs University Hospital, Trondheim, Norway
| | - Asbjørn Karevold
- K.G. Jebsen Center of Exercise in Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,St. Olavs University Hospital, Trondheim, Norway
| | - Rune Wiseth
- K.G. Jebsen Center of Exercise in Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,St. Olavs University Hospital, Trondheim, Norway
| | | | - Alexander Wahba
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,K.G. Jebsen Center of Exercise in Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,St. Olavs University Hospital, Trondheim, Norway
| | - Tomas L Stølen
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,St. Olavs University Hospital, Trondheim, Norway
| | - Riccardo Contu
- Department of Cardiovascular Medicine, Humanitas Research Hospital CNR (National Research Council of Italy), Humanitas University, Milan, Italy
| | - Gianluigi Condorelli
- Department of Cardiovascular Medicine, Humanitas Research Hospital CNR (National Research Council of Italy), Humanitas University, Milan, Italy
| | - Øyvind Ellingsen
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,K.G. Jebsen Center of Exercise in Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,St. Olavs University Hospital, Trondheim, Norway
| | - Godfrey L Smith
- K.G. Jebsen Center of Exercise in Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Institute of Cardiovascular and Medical Sciences and School of Life Sciences, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, UK
| | - Ole J Kemi
- Institute of Cardiovascular and Medical Sciences and School of Life Sciences, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, UK
| | - Ulrik Wisløff
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,K.G. Jebsen Center of Exercise in Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, Australia
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30
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Rommel KP, von Roeder M, Oberueck C, Latuscynski K, Besler C, Blazek S, Stiermaier T, Fengler K, Adams V, Sandri M, Linke A, Schuler G, Thiele H, Lurz P. Load-Independent Systolic and Diastolic Right Ventricular Function in Heart Failure With Preserved Ejection Fraction as Assessed by Resting and Handgrip Exercise Pressure–Volume Loops. Circ Heart Fail 2018; 11:e004121. [DOI: 10.1161/circheartfailure.117.004121] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 01/09/2018] [Indexed: 01/09/2023]
Abstract
Background:
Although systolic right ventricular (RV) dysfunction has been shown to be a potent predictor for adverse outcomes in patients with heart failure with preserved ejection fraction (HFpEF), RV functional abnormalities in the course of the syndrome are not well characterized. We, therefore, sought to assess load-independent and load-dependent systolic and diastolic characteristics of RV function in stable outpatients with HFpEF.
Methods and Results:
We invasively obtained RV and left ventricular pressure–volume loops in 24 HFpEF patients and 9 patients without heart failure symptoms with a conductance catheter during basal conditions and handgrip exercise. Transient preload reduction was used to extrapolate the RV end-systolic elastance and diastolic stiffness constant. HFpEF patients and controls showed similar left ventricular and RV dimensions and ejection fractions with elevated left ventricular filling pressures. In HFpEF patients, invasively determined load-independent RV contractility (
P
=0.04) and load-independent passive RV stiffness constant β (
P
<0.01) were elevated. Although RV relaxation and cardiac output were similar at baseline, HFpEF patients demonstrated a blunted increase in cardiac output under exercise (
P
=0.01) associated with prolonged RV relaxation (
P
=0.01), decrease in stroke volume (
P
<0.01), higher RV-filling pressures (
P
<0.01), and a marked increase in the end-diastolic pressure–volume relationship (
P
<0.01).
Conclusions:
In compensated stages of the HFpEF syndrome, systolic RV function is preserved, but diastolic abnormalities with intrinsic RV stiffness and prolonged RV relaxation are already present. Impaired diastolic RV reserve contributes to a blunted increase in cardiac output during exertion. Because impairments in diastolic function seem to be a biventricular phenomenon, RV diastolic dysfunction warrants further consideration when characterizing HFpEF patients.
Clinical Trial Registration:
https://www.clinicaltrials.gov
. Unique identifier: NCT02459626.
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Affiliation(s)
- Karl-Philipp Rommel
- From the Department of Internal Medicine/Cardiology, Heart Center, Leipzig University, Germany (K.-P.R., M.v.R., C.O., K.L., C.B., S.B., K.F., M.S., G.S., H.T., P.L.); Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Luebeck, Germany (T.S.); and Heart Center Dresden, University Hospital at the Technical University Dresden, Germany (V.A., A.L.)
| | - Maximilian von Roeder
- From the Department of Internal Medicine/Cardiology, Heart Center, Leipzig University, Germany (K.-P.R., M.v.R., C.O., K.L., C.B., S.B., K.F., M.S., G.S., H.T., P.L.); Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Luebeck, Germany (T.S.); and Heart Center Dresden, University Hospital at the Technical University Dresden, Germany (V.A., A.L.)
| | - Christian Oberueck
- From the Department of Internal Medicine/Cardiology, Heart Center, Leipzig University, Germany (K.-P.R., M.v.R., C.O., K.L., C.B., S.B., K.F., M.S., G.S., H.T., P.L.); Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Luebeck, Germany (T.S.); and Heart Center Dresden, University Hospital at the Technical University Dresden, Germany (V.A., A.L.)
| | - Konrad Latuscynski
- From the Department of Internal Medicine/Cardiology, Heart Center, Leipzig University, Germany (K.-P.R., M.v.R., C.O., K.L., C.B., S.B., K.F., M.S., G.S., H.T., P.L.); Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Luebeck, Germany (T.S.); and Heart Center Dresden, University Hospital at the Technical University Dresden, Germany (V.A., A.L.)
| | - Christian Besler
- From the Department of Internal Medicine/Cardiology, Heart Center, Leipzig University, Germany (K.-P.R., M.v.R., C.O., K.L., C.B., S.B., K.F., M.S., G.S., H.T., P.L.); Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Luebeck, Germany (T.S.); and Heart Center Dresden, University Hospital at the Technical University Dresden, Germany (V.A., A.L.)
| | - Stephan Blazek
- From the Department of Internal Medicine/Cardiology, Heart Center, Leipzig University, Germany (K.-P.R., M.v.R., C.O., K.L., C.B., S.B., K.F., M.S., G.S., H.T., P.L.); Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Luebeck, Germany (T.S.); and Heart Center Dresden, University Hospital at the Technical University Dresden, Germany (V.A., A.L.)
| | - Thomas Stiermaier
- From the Department of Internal Medicine/Cardiology, Heart Center, Leipzig University, Germany (K.-P.R., M.v.R., C.O., K.L., C.B., S.B., K.F., M.S., G.S., H.T., P.L.); Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Luebeck, Germany (T.S.); and Heart Center Dresden, University Hospital at the Technical University Dresden, Germany (V.A., A.L.)
| | - Karl Fengler
- From the Department of Internal Medicine/Cardiology, Heart Center, Leipzig University, Germany (K.-P.R., M.v.R., C.O., K.L., C.B., S.B., K.F., M.S., G.S., H.T., P.L.); Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Luebeck, Germany (T.S.); and Heart Center Dresden, University Hospital at the Technical University Dresden, Germany (V.A., A.L.)
| | - Volker Adams
- From the Department of Internal Medicine/Cardiology, Heart Center, Leipzig University, Germany (K.-P.R., M.v.R., C.O., K.L., C.B., S.B., K.F., M.S., G.S., H.T., P.L.); Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Luebeck, Germany (T.S.); and Heart Center Dresden, University Hospital at the Technical University Dresden, Germany (V.A., A.L.)
| | - Marcus Sandri
- From the Department of Internal Medicine/Cardiology, Heart Center, Leipzig University, Germany (K.-P.R., M.v.R., C.O., K.L., C.B., S.B., K.F., M.S., G.S., H.T., P.L.); Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Luebeck, Germany (T.S.); and Heart Center Dresden, University Hospital at the Technical University Dresden, Germany (V.A., A.L.)
| | - Axel Linke
- From the Department of Internal Medicine/Cardiology, Heart Center, Leipzig University, Germany (K.-P.R., M.v.R., C.O., K.L., C.B., S.B., K.F., M.S., G.S., H.T., P.L.); Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Luebeck, Germany (T.S.); and Heart Center Dresden, University Hospital at the Technical University Dresden, Germany (V.A., A.L.)
| | - Gerhard Schuler
- From the Department of Internal Medicine/Cardiology, Heart Center, Leipzig University, Germany (K.-P.R., M.v.R., C.O., K.L., C.B., S.B., K.F., M.S., G.S., H.T., P.L.); Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Luebeck, Germany (T.S.); and Heart Center Dresden, University Hospital at the Technical University Dresden, Germany (V.A., A.L.)
| | - Holger Thiele
- From the Department of Internal Medicine/Cardiology, Heart Center, Leipzig University, Germany (K.-P.R., M.v.R., C.O., K.L., C.B., S.B., K.F., M.S., G.S., H.T., P.L.); Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Luebeck, Germany (T.S.); and Heart Center Dresden, University Hospital at the Technical University Dresden, Germany (V.A., A.L.)
| | - Philipp Lurz
- From the Department of Internal Medicine/Cardiology, Heart Center, Leipzig University, Germany (K.-P.R., M.v.R., C.O., K.L., C.B., S.B., K.F., M.S., G.S., H.T., P.L.); Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Heart Center Luebeck, Germany (T.S.); and Heart Center Dresden, University Hospital at the Technical University Dresden, Germany (V.A., A.L.)
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Pérez del Villar C, Savvatis K, López B, Kasner M, Martinez-Legazpi P, Yotti R, González A, Díez J, Fernández-Avilés F, Tschöpe C, Bermejo J. Impact of acute hypertension transients on diastolic function in patients with heart failure with preserved ejection fraction. Cardiovasc Res 2017; 113:906-914. [DOI: 10.1093/cvr/cvx047] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 03/08/2017] [Indexed: 12/12/2022] Open
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Aikawa T, Naya M, Obara M, Manabe O, Tomiyama Y, Magota K, Yamada S, Katoh C, Tamaki N, Tsutsui H. Impaired Myocardial Sympathetic Innervation Is Associated with Diastolic Dysfunction in Heart Failure with Preserved Ejection Fraction: 11C-Hydroxyephedrine PET Study. J Nucl Med 2016; 58:784-790. [PMID: 27811122 DOI: 10.2967/jnumed.116.178558] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 10/17/2016] [Indexed: 12/20/2022] Open
Abstract
Diastolic dysfunction is important in the pathophysiology of heart failure with preserved ejection fraction (HFpEF). Sympathetic nervous hyperactivity may contribute to the development of diastolic dysfunction. The aim of this study was to determine the relationship between myocardial sympathetic innervation quantified by 11C-hydroxyephedrine PET and diastolic dysfunction in HFpEF patients. Methods: Forty-one HFpEF patients having an echocardiographic left ventricular ejection fraction of 40% or greater and 12 age-matched volunteers without heart failure underwent the echocardiographic examination and 11C-hydroxyephedrine PET. Diastolic dysfunction was classified into grades 0-3 by Doppler echocardiography. Myocardial sympathetic innervation was quantified using the 11C-hydroxyephedrine retention index (RI). The coefficient of variation of 17-segment RIs was derived as a measure of heterogeneity in myocardial 11C-hydroxyephedrine uptake. Results: Grade 2-3 diastolic dysfunction (DD2-3) was found in 19 HFpEF patients (46%). They had a significantly lower global RI (0.075 ± 0.018 min-1) than volunteers (0.123 ± 0.028 min-1, P < 0.001) and HFpEF patients with grade 0-1 diastolic dysfunction (DD0-1) (0.092 ± 0.024 min-1, P = 0.046). HFpEF patients with DD2-3 had the largest coefficient of variation of 17-segment RIs of the 3 groups (18.4% ± 7.7% vs. 14.1% ± 4.7% in HFpEF patients with DD0-1, P = 0.042 for post hoc tests). In multivariate logistic regression analysis, a lower global RI (odds ratio, 0.66 per 0.01 min-1; 95% confidence interval, 0.38-0.99; P = 0.044) was independently associated with the presence of DD2-3 in HFpEF patients. Conclusion: Myocardial sympathetic innervation was impaired in HFpEF patients and was associated with the presence of advanced diastolic dysfunction in HFpEF.
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Affiliation(s)
- Tadao Aikawa
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masanao Naya
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masahiko Obara
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Osamu Manabe
- Department of Nuclear Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yuuki Tomiyama
- Department of Nuclear Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Keiichi Magota
- Department of Medical Imaging, Hokkaido University Hospital, Sapporo, Japan; and
| | - Satoshi Yamada
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Chietsugu Katoh
- Faculty of Health Sciences, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Nagara Tamaki
- Department of Nuclear Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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33
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A Critical Evaluation of the Representation of Black Patients With Heart Failure and Preserved Ejection Fraction in Clinical Trials. J Cardiovasc Nurs 2016; 31:202-8. [DOI: 10.1097/jcn.0000000000000237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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34
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Rammos C, Hendgen-Cotta UB, Totzeck M, Pohl J, Lüdike P, Flögel U, Deenen R, Köhrer K, French BA, Gödecke A, Kelm M, Rassaf T. Impact of dietary nitrate on age-related diastolic dysfunction. Eur J Heart Fail 2016; 18:599-610. [PMID: 27118445 DOI: 10.1002/ejhf.535] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/30/2015] [Accepted: 12/30/2015] [Indexed: 12/28/2022] Open
Abstract
AIMS Diastolic dysfunction is highly prevalent, and ageing is the main contributor due to impairments in active cardiac relaxation, ventriculo-vascular stiffening, and endothelial dysfunction. Nitric oxide (NO) affects cardiovascular functions, and NO bioavailability is critically reduced with ageing. Whether replenishment of NO deficiency with dietary inorganic nitrate would offer a novel approach to reverse age-related cardiovascular alterations was not known. METHODS AND RESULTS A dietary nitrate supplementation was applied to young (6 month) and old (20 month) wild-type mice for 8 weeks and compared with controls. High-resolution ultrasound, pressure-volume catheter techniques, and isolated heart measurements were applied to assess cardiac diastolic and vascular functions. Cardiac manganese-enhanced magnetic resonance imaging was performed to study the effects of dietary nitrate on myocyte calcium handling. In aged mice with preserved systolic function, dietary nitrate supplementation improved LV diastolic function, arterial compliance, and coronary flow reserve. Mechanistically, improved cardiovascular functions were associated with an accelerated cardiomyocyte calcium handling and augmented NO/cyclic guanosine monophosphate/protein kinase G signalling, while enhanced nitrate reduction was related to age-related differences in the oral microbiome. CONCLUSION Dietary inorganic nitrate reverses age-related LV diastolic dysfunction and improves vascular functions. Our results highlight the potential of a dietary approach in the therapy of age-related cardiovascular alterations.
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Affiliation(s)
- Christos Rammos
- West-German Heart and Vascular Center Essen, Department of Medicine, Division of Cardiology, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Ulrike B Hendgen-Cotta
- West-German Heart and Vascular Center Essen, Department of Medicine, Division of Cardiology, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Matthias Totzeck
- West-German Heart and Vascular Center Essen, Department of Medicine, Division of Cardiology, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Julia Pohl
- West-German Heart and Vascular Center Essen, Department of Medicine, Division of Cardiology, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Peter Lüdike
- West-German Heart and Vascular Center Essen, Department of Medicine, Division of Cardiology, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Ulrich Flögel
- Department of Molecular Cardiology, Heinrich-Heine-University, Düsseldorf, Germany
| | - René Deenen
- Biological and Medical Research Center (BMFZ), Genomics and Transcriptomics Laboratory, Heinrich-Heine-University, Düsseldorf, Germany
| | - Karl Köhrer
- Biological and Medical Research Center (BMFZ), Genomics and Transcriptomics Laboratory, Heinrich-Heine-University, Düsseldorf, Germany
| | - Brent A French
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, USA
| | - Axel Gödecke
- Department of Cardiovascular Physiology, Heinrich-Heine-University, Düsseldorf, Germany
| | - Malte Kelm
- Department of Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Tienush Rassaf
- West-German Heart and Vascular Center Essen, Department of Medicine, Division of Cardiology, Medical Faculty, University Hospital Essen, Essen, Germany
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36
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Rosenkranz S, Gibbs JSR, Wachter R, De Marco T, Vonk-Noordegraaf A, Vachiéry JL. Left ventricular heart failure and pulmonary hypertension. Eur Heart J 2016; 37:942-54. [PMID: 26508169 PMCID: PMC4800173 DOI: 10.1093/eurheartj/ehv512] [Citation(s) in RCA: 430] [Impact Index Per Article: 53.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 08/20/2015] [Accepted: 09/07/2015] [Indexed: 12/18/2022] Open
Abstract
In patients with left ventricular heart failure (HF), the development of pulmonary hypertension (PH) and right ventricular (RV) dysfunction are frequent and have important impact on disease progression, morbidity, and mortality, and therefore warrant clinical attention. Pulmonary hypertension related to left heart disease (LHD) by far represents the most common form of PH, accounting for 65-80% of cases. The proper distinction between pulmonary arterial hypertension and PH-LHD may be challenging, yet it has direct therapeutic consequences. Despite recent advances in the pathophysiological understanding and clinical assessment, and adjustments in the haemodynamic definitions and classification of PH-LHD, the haemodynamic interrelations in combined post- and pre-capillary PH are complex, definitions and prognostic significance of haemodynamic variables characterizing the degree of pre-capillary PH in LHD remain suboptimal, and there are currently no evidence-based recommendations for the management of PH-LHD. Here, we highlight the prevalence and significance of PH and RV dysfunction in patients with both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF), and provide insights into the complex pathophysiology of cardiopulmonary interaction in LHD, which may lead to the evolution from a 'left ventricular phenotype' to a 'right ventricular phenotype' across the natural history of HF. Furthermore, we propose to better define the individual phenotype of PH by integrating the clinical context, non-invasive assessment, and invasive haemodynamic variables in a structured diagnostic work-up. Finally, we challenge current definitions and diagnostic short falls, and discuss gaps in evidence, therapeutic options and the necessity for future developments in this context.
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Affiliation(s)
- Stephan Rosenkranz
- Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937 Köln, Germany Cologne Cardiovascular Research Center (CCRC), Universität zu Köln, Köln, Germany
| | - J Simon R Gibbs
- National Heart and Lung Institute (NHLI), Imperial College London, London, UK Department of Cardiology, National Pulmonary Hypertension Service, Hammersmith Hospital London, London, UK
| | - Rolf Wachter
- Klinik für Kardiologie und Pneumologie, Herzzentrum, Georg-August-Universität, Universitätsmedizin Göttingen, Göttingen, Germany German Cardiovascular Research Center (DZHK), Göttingen, Germany
| | - Teresa De Marco
- Division of Cardiology, University of California San Francisco (UCSF), San Francisco, CA, USA
| | | | - Jean-Luc Vachiéry
- Department of Cardiology, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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[Competence Network Heart Failure (CNHF). Together against heart failure]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2016; 59:506-13. [PMID: 26979718 DOI: 10.1007/s00103-016-2322-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Heart failure is one of the most urgent medical and socio-economic challenges of the 21(st) century. Up to three million people are affected in Germany; this means one in ten people over the age of 65 live with heart failure. The current demographic changes will accentuate the importance of this grave health problem. The care of patients with heart failure, as well as the associated research mandates a comprehensive, multidisciplinary approach. The Competence Network Heart Failure (CNHF) pursues this objective. CNHF is a research alliance with 11 sites in Germany and was funded by the Federal Ministry of Research (BMBF) from 2003 through 2014. Since January 2015, the network has been an associate cooperating partner of the German Centre for Cardiovascular Research (DZHK). During the 12-year funding period by the BMBF, scientists in the field of heart failure from 30 university hospitals, 5 research institutes, 7 heart centers, 17 cardiovascular clinics, over 200 general practitioners, 4 rehabilitation clinics, as well as numerous organizations and associations were involved in cooperative CNHF research. In the context of 22 projects, the CNHF covered basic, clinical, and health care research, and generated numerous groundbreaking insights into disease mechanisms, as well as diagnosis and treatment of heart failure, which are documented in more than 350 publications. With its central study database and bank of biomaterials, the network has set up a Europe-wide unique research resource, which can be used in the future for national and international cooperations with the DZHK and other partners. Furthermore, the CNHF strongly promotes nation- and Europe-wide public relations and heart failure awareness activities.
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Kato S, Saito N, Kirigaya H, Gyotoku D, Iinuma N, Kusakawa Y, Iguchi K, Nakachi T, Fukui K, Futaki M, Iwasawa T, Kimura K, Umemura S. Impairment of Coronary Flow Reserve Evaluated by Phase Contrast Cine-Magnetic Resonance Imaging in Patients With Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2016; 5:e002649. [PMID: 26908404 PMCID: PMC4802441 DOI: 10.1161/jaha.115.002649] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 01/12/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Phase contrast (PC) cine-magnetic resonance imaging (MRI) of the coronary sinus allows for noninvasive evaluation of coronary flow reserve (CFR), which is an index of left ventricular microvascular function. The objective of this study was to investigate coronary flow reserve in patients with heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS We studied 25 patients with HFpEF (mean and SD of age: 73±7 years), 13 with hypertensive left ventricular hypertrophy (LVH) (67±10 years), and 18 controls (65±15 years). Breath-hold PC cine-MRI images of the coronary sinus were obtained to assess blood flow at rest and during ATP infusion. CFR was calculated as coronary sinus blood flow during ATP infusion divided by coronary sinus blood flow at rest. Impairment of CFR was defined as CFR <2.5 according to a previous study. The majority (76%) of HFpEF patients had decreased CFR. CFR was significantly decreased in HFpEF patients in comparison to hypertensive LVH patients and control subjects (CFR: 2.21±0.55 in HFpEF vs 3.05±0.74 in hypertensive LVH, 3.83±0.73 in controls; P<0.001 by 1-way ANOVA). According to multivariable linear regression analysis, CFR independently and significantly correlated with serum brain natriuretic peptide level (β=-68.0; 95% CI, -116.2 to -19.7; P=0.007). CONCLUSIONS CFR was significantly lower in patients with HFpEF than in hypertensive LVH patients and controls. These results indicated that impairment of CFR might be a pathophysiological factor for HFpEF and might be related to HFpEF disease severity.
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Affiliation(s)
- Shingo Kato
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center, Boston, MA
| | - Naka Saito
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Hidekuni Kirigaya
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Daiki Gyotoku
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Naoki Iinuma
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Yuka Kusakawa
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Kohei Iguchi
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Tatsuya Nakachi
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Kazuki Fukui
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Masaaki Futaki
- Department of Radiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Tae Iwasawa
- Department of Radiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Kazuo Kimura
- Department of Cardiology, Yokohama City Medical Center, Yokohama, Kanagawa, Japan
| | - Satoshi Umemura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
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Sakamoto K, Hosokawa K, Saku K, Sakamoto T, Tobushi T, Oga Y, Kishi T, Ide T, Sunagawa K. Baroreflex failure increases the risk of pulmonary edema in conscious rats with normal left ventricular function. Am J Physiol Heart Circ Physiol 2015; 310:H199-205. [PMID: 26589328 DOI: 10.1152/ajpheart.00610.2015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 11/17/2015] [Indexed: 11/22/2022]
Abstract
In heart failure with preserved ejection fraction (HFpEF), the complex pathogenesis hinders development of effective therapies. Since HFpEF and arteriosclerosis share common risk factors, it is conceivable that stiffened arterial wall in HFpEF impairs baroreflex function. Previous investigations have indicated that the baroreflex regulates intravascular stressed volume and arterial resistance in addition to cardiac contractility and heart rate. We hypothesized that baroreflex dysfunction impairs regulation of left atrial pressure (LAP) and increases the risk of pulmonary edema in freely moving rats. In 15-wk Sprague-Dawley male rats, we conducted sinoaortic denervation (SAD, n = 6) or sham surgery (Sham, n = 9), and telemetrically monitored ambulatory arterial pressure (AP) and LAP. We compared the mean and SD (lability) of AP and LAP between SAD and Sham under normal-salt diet (NS) or high-salt diet (HS). SAD did not increase mean AP but significantly increased AP lability under both NS (P = 0.001) and HS (P = 0.001). SAD did not change mean LAP but significantly increased LAP lability under both NS (SAD: 2.57 ± 0.43 vs. Sham: 1.73 ± 0.30 mmHg, P = 0.01) and HS (4.13 ± 1.18 vs. 2.45 ± 0.33 mmHg, P = 0.02). SAD markedly increased the frequency of high LAP, and SAD with HS prolonged the duration of LAP > 18 mmHg by nearly 20-fold compared with Sham (SAD + HS: 2,831 ± 2,366 vs. Sham + HS: 148 ± 248 s, P = 0.01). We conclude that baroreflex failure impairs volume tolerance and together with salt loading increases the risk of pulmonary edema even in the absence of left ventricular dysfunction. Baroreflex failure may contribute in part to the pathogenesis of HFpEF.
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Affiliation(s)
- Kazuo Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan;
| | - Kazuya Hosokawa
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Keita Saku
- Department of Therapeutic Regulation of Cardiovascular Homeostasis, Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan; and
| | - Takafumi Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Tomoyuki Tobushi
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yasuhiro Oga
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takuya Kishi
- Collaborative Research Institute of Innovative Therapeutics for Cardiovascular Diseases, Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kenji Sunagawa
- Department of Therapeutic Regulation of Cardiovascular Homeostasis, Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan; and
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Schwarzl M, Hamdani N, Seiler S, Alogna A, Manninger M, Reilly S, Zirngast B, Kirsch A, Steendijk P, Verderber J, Zweiker D, Eller P, Höfler G, Schauer S, Eller K, Maechler H, Pieske BM, Linke WA, Casadei B, Post H. A porcine model of hypertensive cardiomyopathy: implications for heart failure with preserved ejection fraction. Am J Physiol Heart Circ Physiol 2015; 309:H1407-18. [PMID: 26342070 DOI: 10.1152/ajpheart.00542.2015] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 08/25/2015] [Indexed: 01/08/2023]
Abstract
Heart failure with preserved ejection fraction (HFPEF) evolves with the accumulation of risk factors. Relevant animal models to identify potential therapeutic targets and to test novel therapies for HFPEF are missing. We induced hypertension and hyperlipidemia in landrace pigs (n = 8) by deoxycorticosteroneacetate (DOCA, 100 mg/kg, 90-day-release subcutaneous depot) and a Western diet (WD) containing high amounts of salt, fat, cholesterol, and sugar for 12 wk. Compared with weight-matched controls (n = 8), DOCA/WD-treated pigs showed left ventricular (LV) concentric hypertrophy and left atrial dilatation in the absence of significant changes in LV ejection fraction or symptoms of heart failure at rest. The LV end-diastolic pressure-volume relationship was markedly shifted leftward. During simultaneous right atrial pacing and dobutamine infusion, cardiac output reserve and LV peak inflow velocities were lower in DOCA/WD-treated pigs at higher LV end-diastolic pressures. In LV biopsies, we observed myocyte hypertrophy, a shift toward the stiffer titin isoform N2B, and reduced total titin phosphorylation. LV superoxide production was increased, in part attributable to nitric oxide synthase (NOS) uncoupling, whereas AKT and NOS isoform expression and phosphorylation were unchanged. In conclusion, we developed a large-animal model in which loss of LV capacitance was associated with a titin isoform shift and dysfunctional NOS, in the presence of preserved LV ejection fraction. Our findings identify potential targets for the treatment of HFPEF in a relevant large-animal model.
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Affiliation(s)
- Michael Schwarzl
- Department of General and Interventional Cardiology, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nazha Hamdani
- Department of Cardiovascular Physiology, Ruhr University Bochum, Bochum, Germany
| | - Sebastian Seiler
- Division of General Medicine, Klinikum Starnberg, Starnberg, Germany
| | - Alessio Alogna
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Martin Manninger
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Svetlana Reilly
- Division of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Birgit Zirngast
- Department of Cardiothoracic Surgery, Medical University of Graz, Graz, Austria
| | - Alexander Kirsch
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Paul Steendijk
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jochen Verderber
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - David Zweiker
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Philipp Eller
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Gerald Höfler
- Department of Pathology, Medical University of Graz, Graz, Austria
| | - Silvia Schauer
- Department of Pathology, Medical University of Graz, Graz, Austria
| | - Kathrin Eller
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Heinrich Maechler
- Department of Cardiothoracic Surgery, Medical University of Graz, Graz, Austria
| | - Burkert M Pieske
- Division of Cardiology, Medical Department, Charité Berlin Campus Virchow, Berlin, Germany
| | - Wolfgang A Linke
- Department of Cardiovascular Physiology, Ruhr University Bochum, Bochum, Germany
| | - Barbara Casadei
- Division of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Heiner Post
- Division of Cardiology, Medical Department, Charité Berlin Campus Virchow, Berlin, Germany
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Kasner M, Sinning D, Lober J, Post H, Fraser AG, Pieske B, Burkhoff D, Tschöpe C. Heterogeneous responses of systolic and diastolic left ventricular function to exercise in patients with heart failure and preserved ejection fraction. ESC Heart Fail 2015; 2:121-132. [PMID: 27708854 PMCID: PMC5042029 DOI: 10.1002/ehf2.12049] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/10/2015] [Accepted: 06/17/2015] [Indexed: 01/08/2023] Open
Abstract
Aims This study aimed to evaluate ventricular diastolic properties using three‐dimensional echocardiography and tissue Doppler imaging at rest and during exercise in heart failure with preserved ejection fraction (HFpEF) patients with borderline evidence of diastolic dysfunction at rest. Methods and results Results obtained from 52 HFpEF patients (left ventricular ejection fraction ≥ 50%) identified on the basis of heart failure symptoms and E/E′ values between 8 and 15 were compared with those obtained in 26 control patients with no evidence of cardiovascular disease. Mitral flow patterns, tissue Doppler imaging, and volume analysis obtained by three‐dimensional echocardiography were performed at rest and during bicycle exercise. Diastolic compliance was indexed by the E/E′ ratio and left ventricular end‐diastolic volume [(E/E′)/EDV]. There were no significant differences in end‐diastolic volume (EDV), stroke volume (SV), or ejection fraction at rest between groups. In 27 of the 52 patients, E/E′ increased during exercise (11.2 ± 3.7 to 16.8 ± 10.5), driven by a failure to augment early diastole (E′). This correlated with a fall in SV and was associated with an increase in the diastolic index (E/E′)/EDV as a measure for LV stiffness (0.122 ± 0.038 to 0.217 ± 0.14/mL), indicating that impaired diastolic reserve (designated PEF‐IDR) contributed to exercise intolerance. Of the 52 patients, 25 showed no changes in E/E′ during exercise associated with a significant rise in SV and cardiac output, still inappropriate compared with controls. Despite disturbed early diastole (E′), a blunted increase in estimated systolic LV elastance indicated that impaired systolic reserve and chronotropic incompetence rather than primarily diastolic disturbances contributed to exercise intolerance in this group (designated PEF). Conclusion Three‐dimensional stress echocardiography may allow non‐invasive analysis of changes in cardiac output that can differentiate HFpEF patients with an inappropriate increase or a fall in SV during exercise. Impaired systolic or diastolic reserve can contribute to these haemodynamic abnormalities, which may arise from different underlying pathophysiologic mechanisms.
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Affiliation(s)
- Mario Kasner
- Department of Cardiology Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin Hindenburgdamm 30 Berlin Germany
| | - David Sinning
- Department of Cardiology Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin Hindenburgdamm 30 Berlin Germany
| | - Jil Lober
- Department of Cardiology Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin Hindenburgdamm 30 Berlin Germany
| | - Heiner Post
- Department of Cardiology Charité-Universitätsmedizin Berlin, Campus Virchow Berlin Germany
| | - Alan G Fraser
- Wales Heart Research Institute, Cardiff University Cardiff UK
| | - Burkert Pieske
- Department of CardiologyCharité-Universitätsmedizin Berlin, Campus VirchowBerlinGermany; Germany Centre for Cardiovascular Research (DZHK)BerlinGermany
| | | | - Carsten Tschöpe
- Department of CardiologyCharité-Universitätsmedizin Berlin, Campus VirchowBerlinGermany; Germany Centre for Cardiovascular Research (DZHK)BerlinGermany; Berlin-Brandenburg Center for Regenerative TherapiesCharité-Universitätsmedizin Berlin, Campus VirchowBerlinGermany
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42
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Abstract
Recent hemodynamic studies have advanced our understanding of heart failure with preserved ejection fraction (HFpEF). Despite improved pathophysiologic insight, clinical trials have failed to identify an effective treatment for HFpEF. Invasive hemodynamic assessment can diagnose or exclude HFpEF, making it invaluable in understanding the basis of the disease. This article reviews the hemodynamic mechanisms underlying HFpEF and how they manifest clinically, discusses invasive hemodynamic assessment as a diagnostic tool, and explores how invasive hemodynamic profiling may allow understanding of pathophysiological differences and inform the design and entry criteria for future trials.
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43
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Meyer M, McEntee RK, Nyotowidjojo I, Chu G, LeWinter MM. Relationship of exercise capacity and left ventricular dimensions in patients with a normal ejection fraction. An exploratory study. PLoS One 2015; 10:e0119432. [PMID: 25756359 PMCID: PMC4354913 DOI: 10.1371/journal.pone.0119432] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 01/13/2015] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Extreme endurance exercise is known to be associated with an enlargement of the left ventricular (LV) chamber, whereas inactivity results in inverse changes. It is unknown if these dimensional relationships exist in patients. METHODS We analyzed the relationship of exercise capacity and LV dimension in a cohort of sequential patients with a normal ejection fraction undergoing stress echocardiography. In a total of 137 studies the following questions were addressed: (a) is there a difference in LV dimensions of patients with an excellent exercise capacity versus patients with a poor exercise capacity, (b) how is LV dimension and exercise capacity affected by LV wall thickness and (c) how do LV dimensions of patients who are unable to walk on a treadmill compare to the above groups. RESULTS Patients with a poor exercise capacity or who are unable to physically exercise have a 34 percent smaller LV cavity size when compared to patients with an excellent exercise capacity (p<0.001). This reduction in LV chamber size is associated with concentric LV hypertrophy and a reciprocal increase in resting heart rate. In addition, cardiac output reserve is further blunted by chronotropic incompetence and a tachycardia-induced LV volume reduction. In conclusion the relationship of exercise capacity and cardiac dimensions described in extreme athletes also applies to patients. Our exploratory analysis suggests that patients who cannot sufficiently exercise have small LV cavities.
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Affiliation(s)
- Markus Meyer
- Division of Cardiology, University of Vermont College of Medicine, Burlington, Vermont, United States of America
- * E-mail:
| | - Rachel K. McEntee
- Division of Cardiology, University of Vermont College of Medicine, Burlington, Vermont, United States of America
| | - Iwan Nyotowidjojo
- Division of Cardiology, University of Vermont College of Medicine, Burlington, Vermont, United States of America
| | - Guoxiang Chu
- Division of Cardiology, University of Vermont College of Medicine, Burlington, Vermont, United States of America
| | - Martin M. LeWinter
- Division of Cardiology, University of Vermont College of Medicine, Burlington, Vermont, United States of America
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Upadhya B, Taffet GE, Cheng CP, Kitzman DW. Heart failure with preserved ejection fraction in the elderly: scope of the problem. J Mol Cell Cardiol 2015; 83:73-87. [PMID: 25754674 DOI: 10.1016/j.yjmcc.2015.02.025] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 02/25/2015] [Accepted: 02/26/2015] [Indexed: 12/13/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is the most common form of heart failure (HF) in older adults, particularly women, and is increasing in prevalence as the population ages. With morbidity and mortality on par with HF with reduced ejection fraction, it remains a most challenging clinical syndrome for the practicing clinician and basic research scientist. Originally considered to be predominantly caused by diastolic dysfunction, more recent insights indicate that HFpEF in older persons is typified by a broad range of cardiac and non-cardiac abnormalities and reduced reserve capacity in multiple organ systems. The globally reduced reserve capacity is driven by: 1) inherent age-related changes; 2) multiple, concomitant co-morbidities; 3) HFpEF itself, which is likely a systemic disorder. These insights help explain why: 1) co-morbidities are among the strongest predictors of outcomes; 2) approximately 50% of clinical events in HFpEF patients are non-cardiovascular; 3) clinical drug trials in HFpEF have been negative on their primary outcomes. Embracing HFpEF as a true geriatric syndrome, with complex, multi-factorial pathophysiology and clinical heterogeneity could provide new mechanistic insights and opportunities for progress in management. This article is part of a Special Issue entitled CV Aging.
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Affiliation(s)
- Bharathi Upadhya
- Cardiology Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - George E Taffet
- Geriatrics and Cardiovascular Sciences, Baylor College of Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Che Ping Cheng
- Cardiology Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Dalane W Kitzman
- Cardiology Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
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45
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Schwarzl M, Alogna A, Zirngast B, Steendijk P, Verderber J, Zweiker D, Huber S, Maechler H, Pieske BM, Post H. Mild hypothermia induces incomplete left ventricular relaxation despite spontaneous bradycardia in pigs. Acta Physiol (Oxf) 2015; 213:653-63. [PMID: 25515791 DOI: 10.1111/apha.12439] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 08/11/2014] [Accepted: 12/10/2014] [Indexed: 01/08/2023]
Abstract
AIM Mild hypothermia (MH) decreases left ventricular (LV) end-diastolic capacitance. We sought to clarify whether this results from incomplete relaxation. METHODS Ten anaesthetized pigs were cooled from normothermia (NT, 38 °C) to MH (33 °C). LV end-diastolic pressure (LVPed), volume (LVVed) and pressure-volume relationships (EDPVRs) were determined during stepwise right atrial pacing. LV capacitance (i.e. LVVed at LVPed of 10 mmHg, LV VPed10) was derived from the EDPVR. Pacing-induced changes of diastolic indices (LVPed, LVVed and LV VPed10) were analysed as a function of (i) heart rate and (ii) the ratio between diastolic time interval (t-dia) and LV isovolumic relaxation constant τ, which was calculated using a logistic fit (τL ) and monoexponential fit with zero asymptote (τZ ) and nonzero asymptote (τNZ ). RESULTS Mild hypothermia decreased heart rate (85 ± 4 to 68 ± 3 bpm), increased τL (22 ± 1 to 57 ± 4 ms), τZ (26 ± 2 to 56 ± 5 ms) and τNZ (41 ± 1 to 96 ± 5 ms), decreased t-dia/τ ratios, and shifted the EDPVR leftwards compared to NT (all P < 0.05). During NT, pacing at ≥140 bpm shifted the EDPVR progressively leftwards. During MH, relationships between diastolic indices and heart rate were shifted towards lower heart rates compared to NT. However, relationships between diastolic indices and t-dia/τ during NT and MH were superimposable. CONCLUSION We conclude that the loss of LV end-diastolic capacitance during MH can be explained at least in part by slowed LV relaxation. MH thereby is an example of incomplete LV relaxation at a spontaneous low heart rate. Caution may be advised, when heart rate is increased in patients treated with MH.
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Affiliation(s)
- M. Schwarzl
- Department of General and Interventional Cardiology; University Heart Center Hamburg-Eppendorf; Hamburg Germany
| | - A. Alogna
- Department of Cardiology; Medical University of Graz; Graz Austria
| | - B. Zirngast
- Department of Cardiothoracic Surgery; Medical University of Graz; Graz Austria
| | - P. Steendijk
- Department of Cardiology; Leiden University Medical Center; Leiden the Netherlands
| | - J. Verderber
- Department of Cardiology; Medical University of Graz; Graz Austria
| | - D. Zweiker
- Department of Cardiology; Medical University of Graz; Graz Austria
| | - S. Huber
- Department of Cardiothoracic Surgery; Medical University of Graz; Graz Austria
| | - H. Maechler
- Department of Cardiothoracic Surgery; Medical University of Graz; Graz Austria
| | - B. M. Pieske
- Department of Cardiology; Charit e-Universitaetsmedizin Berlin; Campus Virchow-Klinikum; Berlin Germany
| | - H. Post
- Department of Cardiology; Charit e-Universitaetsmedizin Berlin; Campus Virchow-Klinikum; Berlin Germany
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Verloop WL, Beeftink MMA, Santema BT, Bots ML, Blankestijn PJ, Cramer MJ, Doevendans PA, Voskuil M. A systematic review concerning the relation between the sympathetic nervous system and heart failure with preserved left ventricular ejection fraction. PLoS One 2015; 10:e0117332. [PMID: 25658630 PMCID: PMC4319815 DOI: 10.1371/journal.pone.0117332] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 12/20/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Heart failure with preserved left ventricular ejection fraction (HFPEF) affects about half of all patients diagnosed with heart failure. The pathophysiological aspect of this complex disease state has been extensively explored, yet it is still not fully understood. Since the sympathetic nervous system is related to the development of systolic HF, we hypothesized that an increased sympathetic nerve activation (SNA) is also related to the development of HFPEF. This review summarizes the available literature regarding the relation between HFPEF and SNA. METHODS AND RESULTS Electronic databases and reference lists through April 2014 were searched resulting in 7722 unique articles. Three authors independently evaluated citation titles and abstracts, resulting in 77 articles reporting about the role of the sympathetic nervous system and HFPEF. Of these 77 articles, 15 were included for critical appraisal: 6 animal and 9 human studies. Based on the critical appraisal, we selected 9 articles (3 animal, 6 human) for further analysis. In all the animal studies, isoproterenol was administered to mimic an increased sympathetic activity. In human studies, different modalities for assessment of sympathetic activity were used. The studies selected for further evaluation reported a clear relation between HFPEF and SNA. CONCLUSION Current literature confirms a relation between increased SNA and HFPEF. However, current literature is not able to distinguish whether enhanced SNA results in HFPEF, or HFPEF results in enhanced SNA. The most likely setting is a vicious circle in which HFPEF and SNA sustain each other.
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Affiliation(s)
- Willemien L. Verloop
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Bernadet T. Santema
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Michiel L. Bots
- The Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter J. Blankestijn
- Department of Nephrology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maarten J. Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pieter A. Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
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Abstract
Heart failure (HF) is the leading cause of hospitalization among older adults and the prevalence is growing with the aging populations in western countries. Approximately one-half of patients with HF have preserved ejection fraction (HFpEF). In contrast to HF with reduced EF (HFrEF), there is no proven effective treatment for HFpEF. The pathophysiology of HFpEF is complex, and the dominant mechanisms leading to symptoms of HF often vary between afflicted patients, confounding efforts to apply "one-size fits all" types of therapeutic approaches. Current treatment strategies focus on control of volume status and comorbidities, but future research aimed at individualized therapies holds promise to improve outcomes in this increasingly prevalent form of cardiac failure.
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Butler J, Fonarow GC, Zile MR, Lam CS, Roessig L, Schelbert EB, Shah SJ, Ahmed A, Bonow RO, Cleland JGF, Cody RJ, Chioncel O, Collins SP, Dunnmon P, Filippatos G, Lefkowitz MP, Marti CN, McMurray JJ, Misselwitz F, Nodari S, O'Connor C, Pfeffer MA, Pieske B, Pitt B, Rosano G, Sabbah HN, Senni M, Solomon SD, Stockbridge N, Teerlink JR, Georgiopoulou VV, Gheorghiade M. Developing therapies for heart failure with preserved ejection fraction: current state and future directions. JACC-HEART FAILURE 2015; 2:97-112. [PMID: 24720916 DOI: 10.1016/j.jchf.2013.10.006] [Citation(s) in RCA: 237] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 10/01/2013] [Accepted: 10/16/2013] [Indexed: 12/12/2022]
Abstract
The burden of heart failure with preserved ejection fraction (HFpEF) is considerable and is projected to worsen. To date, there are no approved therapies available for reducing mortality or hospitalizations for these patients. The pathophysiology of HFpEF is complex and includes alterations in cardiac structure and function, systemic and pulmonary vascular abnormalities, end-organ involvement, and comorbidities. There remain major gaps in our understanding of HFpEF pathophysiology. To facilitate a discussion of how to proceed effectively in future with development of therapies for HFpEF, a meeting was facilitated by the Food and Drug Administration and included representatives from academia, industry, and regulatory agencies. This document summarizes the proceedings from this meeting.
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Affiliation(s)
- Javed Butler
- Department of Medicine, Emory Cardiovascular Clinical Research Institute, Emory University, Atlanta, Georgia.
| | - Gregg C Fonarow
- Department of Medicine, University of California, Los Angeles, California
| | - Michael R Zile
- Division of Cardiology, Medical University of South Carolina, and RHJ Department of Veterans Affairs Medical Center, Charleston, South Carolina
| | - Carolyn S Lam
- Cardiovascular Research Institute, National University Health System, Singapore
| | - Lothar Roessig
- Global Clinical Development, Bayer HealthCare AG, Wuppertal, Germany
| | - Erik B Schelbert
- Department of Medicine, University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Sanjiv J Shah
- Department of Medicine, Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ali Ahmed
- Division of Gerontology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert O Bonow
- Department of Medicine, Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John G F Cleland
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School, Kingston-Upon-Hull, England
| | - Robert J Cody
- Cardiovascular & Metabolism Division, Janssen Pharmaceuticals, Raritan, New Jersey
| | - Ovidiu Chioncel
- Institute of Emergency for Cardiovascular Diseases, Cardiology, Bucharest, Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee
| | - Preston Dunnmon
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | | | | | - Catherine N Marti
- Department of Medicine, Emory Cardiovascular Clinical Research Institute, Emory University, Atlanta, Georgia
| | - John J McMurray
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland
| | - Frank Misselwitz
- Global Clinical Development, Bayer HealthCare AG, Wuppertal, Germany
| | - Savina Nodari
- Division of Cardiology, University of Brescia, Brescia, Italy
| | - Christopher O'Connor
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Marc A Pfeffer
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Burkert Pieske
- Department of Cardiology, Medical University Graz, Graz, Austria
| | - Bertram Pitt
- Division of Cardiology, Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Giuseppe Rosano
- Centre for Clinical and Basic Science, San Raffaele-Roma, Rome, Italy
| | - Hani N Sabbah
- Department of Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Michele Senni
- Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Scott D Solomon
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Norman Stockbridge
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - John R Teerlink
- University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Vasiliki V Georgiopoulou
- Department of Medicine, Emory Cardiovascular Clinical Research Institute, Emory University, Atlanta, Georgia
| | - Mihai Gheorghiade
- Department of Medicine, Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Hirose A, Khoo NS, Aziz K, Al-Rajaa N, van den Boom J, Savard W, Brooks P, Hornberger LK. Evolution of left ventricular function in the preterm infant. J Am Soc Echocardiogr 2014; 28:302-8. [PMID: 25533193 DOI: 10.1016/j.echo.2014.10.017] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Indexed: 10/24/2022]
Abstract
BACKGROUND The aim of this study was to evaluate left ventricular function in preterm infants from 28 days to near term using echocardiography. METHODS Thirty clinically stable preterm infants delivered at <30 weeks' gestational age were prospectively enrolled. At 28 days, conventional, tissue Doppler, and speckle-tracking echocardiography evaluations of left ventricular function were performed, with comparison made to findings in 30 healthy term infants of similar postnatal age. Sixteen preterm infants underwent repeat examinations near term. RESULTS Compared with controls, preterm infants at 28 days had decreased peak mitral valve (MV) E-wave velocities (P < .01), E/A ratios (P < .0001), annular e' velocities (P < .0001), and e'/a' ratios (P < .0001); increased MV E/e' ratios (P < .01); and lower basal circumferential early diastolic and higher late diastolic strain rates. No significant differences were found in fractional shortening, ejection fraction, and longitudinal or circumferential strain and strain rate between preterm infants and controls. Although preterm infants at 28 days had higher heart rates compared with controls (161 ± 15 vs 142 ± 16 beats/min), no significant correlations existed between heart rate and MV E, E/A ratio, e', e'/a' ratio, and E/e' ratio. Near term, the differences in diastolic function persisted, including decreased MV e'/a' ratio (P < .05), increased E/e' ratio (P < .01), and increased late diastolic strain rate. CONCLUSIONS Clinically stable preterm infants have normal left ventricular systolic function but altered diastolic function, with greater dependence on atrial contraction, the latter of which persists despite nearing term. These findings may be relevant to the management of preterm infants and may relate to the longer term myocardial dysfunction observed in affected adults.
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Affiliation(s)
- Akiko Hirose
- Fetal & Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Nee S Khoo
- Fetal & Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Khalid Aziz
- Department of Pediatrics, Division of Neonatology, University of Alberta, Edmonton, Alberta, Canada
| | - Najlaa Al-Rajaa
- Fetal & Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Jutta van den Boom
- Fetal & Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Winnie Savard
- Fetal & Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Paul Brooks
- Fetal & Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa K Hornberger
- Fetal & Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada; Department of Obstetrics and Gynecology, Women's & Children's Health Research Institute, Mazankowski Alberta Heart Institute, Cardiovascular Research Centre, University of Alberta, Edmonton, Alberta, Canada.
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50
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Erdei T, Smiseth OA, Marino P, Fraser AG. A systematic review of diastolic stress tests in heart failure with preserved ejection fraction, with proposals from the EU-FP7 MEDIA study group. Eur J Heart Fail 2014; 16:1345-61. [PMID: 25393338 DOI: 10.1002/ejhf.184] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 09/22/2014] [Accepted: 09/25/2014] [Indexed: 11/06/2022] Open
Abstract
AIMS Cardiac function should be assessed during stress in patients with suspected heart failure with preserved ejection fraction (HFPEF), but it is unclear how to define impaired diastolic reserve. METHODS AND RESULTS We conducted a systematic review to identify which pathophysiological changes serve as appropriate targets for diagnostic imaging. We identified 38 studies of 1111 patients with HFPEF (mean age 65 years), 744 control patients without HFPEF, and 458 healthy subjects. Qualifying EF was >45-55%; diastolic dysfunction at rest was a required criterion in 45% of studies. The initial workload during bicycle exercise (25 studies) varied from 12.5 to 30 W (mean 23.1 ± 4.6), with increments of 10-25 W (mean 19.9 ± 6) and stage duration 1-5 min (mean 2.5 ± 1); targets were submaximal (n = 8) or maximal (n = 17). Other protocols used treadmill exercise, handgrip, dobutamine, lower body negative pressure, nitroprusside, fluid challenge, leg raising, or atrial pacing. Reproducibility of echocardiographic variables during stress and validation against independent reference criteria were assessed in few studies. Change in E/e' was the most frequent measurement, but there is insufficient evidence to establish this or other tests for routine use when evaluating patients with HFPEF. CONCLUSIONS To meet the clinical requirements of performing stress testing in elderly subjects, we propose a ramped exercise protocol on a semi-supine bicycle, starting at 15 W, with increments of 5 W/min to a submaximal target (heart rate 100-110 b.p.m., or symptoms). Measurements during submaximal and recovery stages should include changes from baseline in LV long-axis function and indirect echocardiographic indices of LV diastolic pressure.
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Affiliation(s)
- Tamás Erdei
- Wales Heart Research Institute, Cardiff University, Cardiff, UK
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