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Shen Z, Zhang Y, Bu G, Fang L. Renal denervation improves mitochondrial oxidative stress and cardiac hypertrophy through inactivating SP1/BACH1-PACS2 signaling. Int Immunopharmacol 2024; 141:112778. [PMID: 39173402 DOI: 10.1016/j.intimp.2024.112778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/13/2024] [Accepted: 07/23/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Renal denervation (RDN) has been proved to relieve cardiac hypertrophy; however, its detailed mechanisms remain obscure. This study investigated the detailed protective mechanisms of RDN against cardiac hypertrophy during hypertensive heart failure (HF). METHODS Male 5-month-old spontaneously hypertension (SHR) rats were used in a HF rat model, and male Wistar-Kyoto (WKY) rats of the same age were used as the baseline control. Myocardial hypertrophy and fibrosis were evaluated by hematoxylin-eosin (HE) staining and Masson staining. The expression of target molecule was analyzed by reverse transcription-quantitative polymerase chain reaction (RT-qPCR), Western blot, immunohistochemical and immunofluorescence, respectively. Cardiomyocyte hypertrophy was induced by norepinephrine (NE) in H9c2 cells in vitro and evaluated by brain natriuretic peptide (BNP), atrial natriuretic peptide (ANP), β-myosin heavy chain (β-MHC), and α-myosin heavy chain (α-MHC) levels. Oxidative stress was determined by malondialdehyde (MDA) level, superoxide dismutase (SOD), and glutathione peroxidase (GSH-Px) enzyme activities. Mitochondrial function was measured by mitochondrial membrane potential, adenosine triphosphate (ATP) production, mitochondrial DNA (mtDNA) number, and mitochondrial complex I-IV activities. Molecular mechanism was assessed by dual luciferase reporter and chromatin immunoprecipitation (ChIP) assays. RESULTS RDN decreased sympathetic nerve activity, attenuated myocardial hypertrophy and fibrosis, and improved cardiac function in the rat model of HF. In addition, RDN ameliorated mitochondrial oxidative stress in myocardial tissues as evidenced by reducing MDA and mitochondrial reactive oxygen species (ROS) levels, and enhancing SOD and GSH-Px activities. Moreover, phosphofurin acid cluster sorting protein 2 (PACS-2) and broad-complex, tramtrak and bric à brac (BTB) domain and cap'n'collar (CNC) homolog 1 (BACH1) were down-regulated by RDN. In NE-stimulated H9c2 cells, PACS-2 and BACH1 levels were markedly elevated, and knockdown of them could suppress NE-induced oxidative stress, cardiomyocyte hypertrophy, fibrosis, as well as mitochondrial dysfunction. Transforming growth factor beta1(TGFβ1)/SMADs signaling pathway was inactivated by RDN in the HF rats, which sequentially inhibited specificity protein 1 (SP1)-mediated transcription of PACS2 and BACH1. CONCLUSION Collectively, these data demonstrated that RDN improved cardiac hypertrophy and sympathetic nerve activity of HF rats via repressing BACH1 and PACS-2-mediated mitochondrial oxidative stress by inactivating TGF-β1/SMADs/SP1 pathway, which shed lights on the cardioprotective mechanism of RDN in HF.
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Affiliation(s)
- Zhijie Shen
- Department of Cardiology, The First Hospital of Changsha (The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University), Changsha 410005, Hunan Province, PR China
| | - Yinzhuang Zhang
- Department of Cardiology, The First Hospital of Changsha (The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University), Changsha 410005, Hunan Province, PR China
| | - Guangkui Bu
- Department of Gastroenterology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha 410024, Hunan Province, PR China
| | - Li Fang
- Department of Cardiology, The First Hospital of Changsha (The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University), Changsha 410005, Hunan Province, PR China.
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Doiron JE, Xia H, Yu X, Nevins AR, LaPenna KB, Sharp TE, Goodchild TT, Allerton TD, Elgazzaz M, Lazartigues E, Shah SJ, Li Z, Lefer DJ. Adjunctive therapy with an oral H 2S donor provides additional therapeutic benefit beyond SGLT2 inhibition in cardiometabolic heart failure with preserved ejection fraction. Br J Pharmacol 2024; 181:4294-4310. [PMID: 38982742 DOI: 10.1111/bph.16493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 05/20/2024] [Accepted: 05/26/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND AND PURPOSE Sodium glucose cotransporter 2 inhibitors (SGLT2i) have emerged as a potent therapy for heart failure with preserved ejection fraction (HFpEF). Hydrogen sulphide (H2S), a well-studied cardioprotective agent, could be beneficial in HFpEF. SGLT2i monotherapy and combination therapy involving an SGLT2i and H2S donor in two preclinical models of cardiometabolic HFpEF was investigated. EXPERIMENTAL APPROACH Nine-week-old C57BL/6N mice received L-NAME and a 60% high fat diet for five weeks. Mice were then randomized to either control, SGLT2i monotherapy or SGLT2i and H2S donor, SG1002, for five additional weeks. Ten-week-old ZSF1 obese rats were randomized to control, SGLT2i or SGLT2i and SG1002 for 8 weeks. SG1002 monotherapy was investigated in additional animals. Cardiac function (echocardiography and haemodynamics), exercise capacity, glucose handling and multiorgan pathology were monitored during experimental protocols. KEY RESULTS SGLT2i treatment improved E/e' ratio and treadmill exercise in both models. Combination therapy afforded increases in cardiovascular sulphur bioavailability that coincided with improved left end-diastolic function (E/e' ratio), exercise capacity, metabolic state, cardiorenal fibrosis, and hepatic steatosis. Follow-up studies with SG1002 monotherapy revealed improvements in diastolic function, exercise capacity and multiorgan histopathology. CONCLUSIONS AND IMPLICATIONS SGLT2i monotherapy remediated pathological complications exhibited by two well-established HFpEF models. Adjunctive H2S therapy resulted in further improvements of cardiometabolic perturbations beyond SGLT2i monotherapy. Follow-up SG1002 monotherapy studies inferred an improved phenotype with combination therapy beyond either monotherapy. These data demonstrate the differing effects of SGLT2i and H2S therapy while also revealing the superior efficacy of the combination therapy in cardiometabolic HFpEF.
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Affiliation(s)
- Jake E Doiron
- Department of Pharmacology and Experimental Therapeutics, LSU Health Sciences Center, New Orleans, Louisiana, USA
| | - Huijing Xia
- Department of Pharmacology and Experimental Therapeutics, LSU Health Sciences Center, New Orleans, Louisiana, USA
- Cardiovascular Center of Excellence, LSU Health Sciences Center, New Orleans, Louisiana, USA
| | - Xiaoman Yu
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Alexandra R Nevins
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Kyle B LaPenna
- Department of Pharmacology and Experimental Therapeutics, LSU Health Sciences Center, New Orleans, Louisiana, USA
| | - Thomas E Sharp
- Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida, USA
| | - Traci T Goodchild
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Mona Elgazzaz
- Department of Pharmacology and Experimental Therapeutics, LSU Health Sciences Center, New Orleans, Louisiana, USA
- Cardiovascular Center of Excellence, LSU Health Sciences Center, New Orleans, Louisiana, USA
| | - Eric Lazartigues
- Department of Pharmacology and Experimental Therapeutics, LSU Health Sciences Center, New Orleans, Louisiana, USA
- Cardiovascular Center of Excellence, LSU Health Sciences Center, New Orleans, Louisiana, USA
| | - Sanjiv J Shah
- Feinberg School of Medicine, Northwestern University Medicine, Chicago, Illinois, USA
| | - Zhen Li
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - David J Lefer
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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3
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Abdin A, Böhm M, Shahim B, Karlström P, Kulenthiran S, Skouri H, Lund LH. Heart failure with preserved ejection fraction epidemiology, pathophysiology, diagnosis and treatment strategies. Int J Cardiol 2024; 412:132304. [PMID: 38944348 DOI: 10.1016/j.ijcard.2024.132304] [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: 12/31/2023] [Revised: 06/11/2024] [Accepted: 06/26/2024] [Indexed: 07/01/2024]
Abstract
The prevalence of HF with preserved ejection raction (HFpEF, with EF ≥50%) is increasing across all populations with high rates of hospitalization and mortality, reaching up to 80% and 50%, respectively, within a 5-year timeframe. Comorbidity-driven systemic inflammation is thought to cause coronary microvascular dysfunction and increased epicardial adipose tissue, leading to downstream friborsis and molecular changes in the cardiomyocyte, leading to increased stiffness and diastolic dynsfunction. HFpEF poses unique challenges in terms of diagnosis due to its complex and diverse nature. The diagnosis of HFpEF relies on a combination of clinical assessment, imaging studies, and biomarkers. An additional important step in diagnosing HFpEF involves excluding certain cardiac diagnoses that may be specific underlying causes of HFpEF or may be masquerading as HFpEF and require specific alternative treatment approaches. In addition to administering sodium-glucose cotransporter 2 inhibitors to all patients, the most effective approach to enhance clinical outcomes may involve tailored therapy based on each patient's unique clinical profile. Exercise should be recommended for all patients to improve the quality of life. Glucagon-like peptide-1 1 agonists are a promising treatment option in obese HFpEF patients. Novel approaches targeting inflammation are also in early phase trials.
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Affiliation(s)
- Amr Abdin
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Bahira Shahim
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Patric Karlström
- Department of Internal Medicine, Ryhov County Hospital, Jönköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Saarraaken Kulenthiran
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hadi Skouri
- Division of Cardiology, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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D'Amario D, Laborante R, Bianchini E, Ciliberti G, Paglianiti DA, Galli M, Restivo A, Stolfo D, Vergallo R, Rosano GM, Crea F, Lam CS, Lund LH, Metra M, Patti G, Savarese G. Impact of coronary microvascular dysfunction in heart failure with preserved ejection fraction: a meta-analysis. ESC Heart Fail 2024; 11:2063-2075. [PMID: 38549197 PMCID: PMC11287310 DOI: 10.1002/ehf2.14626] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/20/2023] [Indexed: 07/31/2024] Open
Abstract
AIMS Several mechanisms have been identified in the aetiopathogenesis of heart failure with preserved ejection fraction (HFpEF). Among these, coronary microvascular dysfunction (CMD) may play a key pathophysiological role. We performed a systematic review and meta-analysis to investigate the prevalence, echocardiographic correlates, and prognostic implications of CMD in patients with HFpEF. METHODS AND RESULTS A systematic search for articles up to 1 May 2023 was performed. The primary aim was to assess the prevalence of CMD. Secondary aims were to compare key echocardiographic parameters (E/e' ratio, left atrial volume index [LAVi], and left ventricular mass index [LVMi]), clinical outcomes [death and hospitalization for heart failure (HF)], and prevalence of atrial fibrillation (AF) between patients with and without CMD. Meta-regressions according to baseline patient characteristics and study features were performed to explore potential heterogeneity sources. We identified 14 observational studies, enrolling 1138 patients with HFpEF. The overall prevalence of CMD was 58%. Compared with patients without CMD, patients with HFpEF and CMD had larger LAVi [mean difference (MD) 3.85 confidence interval (CI) 1.19-6.5, P < 0.01)], higher E/e' ratio (MD 2.76 CI 1.54-3.97; P < 0.01), higher prevalence of AF (odds ratio 1.61 CI 1.04-2.48, P = 0.03) and higher risk of death or hospitalization for HF [hazard ratio 3.19, CI 1.04-9.57, P = 0.04]. CONCLUSIONS CMD is present in little more than half of the patients with HFpEF and is associated with echocardiographic evidence of more severe diastolic dysfunction and a higher prevalence of AF, doubling the risk of death or HF hospitalization.
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Affiliation(s)
- Domenico D'Amario
- Department of Translational MedicineUniversità del Piemonte OrientaleNovaraItaly
- Division of CardiologyAOU Maggiore della CaritàNovaraItaly
| | | | | | | | | | - Mattia Galli
- Maria Cecilia Hospital, GVM Care & ResearchCotignolaItaly
| | | | - Davide Stolfo
- Department of CardiothoracovascularAzienda Sanitaria Universitaria Giuliano IsontinaTriesteItaly
- Department of Medicine, Division of CardiologyKarolinska InstitutetStockholmSweden
| | - Rocco Vergallo
- Cardiology UnitIRCCS Ospedale Policlinico San MartinoGenoaItaly
| | - Giuseppe M.C. Rosano
- Centre for Clinical & Basic Research, IRCCS San Raffaele PisanaRomeItaly
- St George's Hospital Medical SchoolLondonUK
| | - Filippo Crea
- Catholic University of the Sacred HeartRomeItaly
| | - Carolyn S.P. Lam
- National Heart Centre SingaporeCentral SingaporeSingapore
- Duke‐National University of Singapore Medical SchoolCentral SingaporeSingapore
| | - Lars H. Lund
- Department of Medicine, Division of CardiologyKarolinska InstitutetStockholmSweden
- Heart and Vascular ThemeKarolinska University HospitalStockholmSweden
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Giuseppe Patti
- Department of Translational MedicineUniversità del Piemonte OrientaleNovaraItaly
- Division of CardiologyAOU Maggiore della CaritàNovaraItaly
| | - Gianluigi Savarese
- Department of Medicine, Division of CardiologyKarolinska InstitutetStockholmSweden
- Heart and Vascular ThemeKarolinska University HospitalStockholmSweden
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Smereka Y, Ezekowitz JA. HFpEF and sex: understanding the role of sex differences. Can J Physiol Pharmacol 2024; 102:465-475. [PMID: 38447124 DOI: 10.1139/cjpp-2023-0403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Heart failure is a complex clinical syndrome with many etiological factors and complex pathophysiology affecting millions worldwide. Males and females can have distinct clinical presentation and prognosis, and there is an emerging understanding of the factors that highlight the similarities and differences to synthesize and present available data for sex-specific differences in heart failure with preserved ejection fraction (HFpEF). While the majority of data demonstrate more similarities than differences between females and males in terms of heart failure, there are key differences. Data showed that females have a higher risk of developing HFpEF, but a lower risk of mortality and hospitalization. This can be conditioned by different profiles of comorbidities, postmenopausal changes in sex hormone levels, higher levels of inflammation and chronic microvascular dysfunction in females. These factors, combined with different left ventricular dimensions and function, which are more pronounced with age, lead to a higher prevalence of LV diastolic dysfunction at rest and exercise. As a result, females have lower exercise capacity and quality of life when compared to males. Females also have different activities of systems responsible for drug transformation, leading to different efficacy of drugs as well as higher risk of adverse drug reactions. These data prove the necessity for creating sex-specific risk stratification scales and treatment plans.
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Affiliation(s)
- Yuliia Smereka
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Justin A Ezekowitz
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Canadian VIGOUR Centre, Edmonton, AB, Canada
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Wolsk E, Jürgens M, Schou M, Ersbøll M, Hasbak P, Kjaer A, Zerahn B, Høgh Brandt N, Haulund Gæde P, Rossing P, Faber J, Kistorp CM, Gustafsson F. Coronary microvascular dysfunction and left heart filling pressures in patients with type 2 diabetes. ESC Heart Fail 2024. [PMID: 39073008 DOI: 10.1002/ehf2.14929] [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: 10/10/2023] [Revised: 05/11/2024] [Accepted: 06/14/2024] [Indexed: 07/30/2024] Open
Abstract
AIMS Patients with type 2 diabetes (T2D) have a high prevalence of diastolic dysfunction and heart failure with preserved ejection fraction (HFpEF), which in turn leads to an increased risk of hospitalization and death. However, the factors of risk and their relative importance in leading to higher left ventricular filling pressures are still disputed. We sought to clarify the associations of a wide range of invasive and non-invasive risk factors with cardiac filling pressures in high-risk T2D patients. METHODS AND RESULTS Patients with T2D at high risk of cardiovascular events were prospectively enrolled in this study. Participants were thoroughly phenotyped including right heart catheterization at rest and during exercise, echocardiography, urinary excretion of albumin (UACR), and quantification of their myocardial blood flow rate (MFR) using cardiac 82Rb-PET/CT. Of the 37 patients included in the study, 22 (59%) patients met invasive criteria for HFpEF. Only 2 out of 39 variables emerged as independent factors associated with left ventricular filling pressure as assessed by pulmonary capillary wedge pressure (PCWP) at rest; history of hypertension (coefficient: 2.6 mmHg [0.3; 5.0], P = 0.030) and MFR (P = 0.026). We found a significant inverse association between MFR and PCWP with a coefficient of -2.3 mmHg (-4.3; -0.3) in PCWP per integer change of MFR. The MFR ranged from 1.18 to 3.68 in our study, which corresponds to a difference in PCWP of approximately 6 mmHg between patients with the lowest compared to the highest MFR. During exercise, only 2 variables emerged as borderline independent factors associated with PCWP: myocardial flow reserve (coefficient: -4.4 [-9.6; 0.8], P = 0.091) and beta-blockers use (coefficient: 6.1 [-0.1; 12.4], P = 0.053). CONCLUSIONS In patients with type 2 diabetes without known HFpEF but risk factors for cardiovascular disease, myocardial blood flow rate was independently associated with PCWP at rest across the range from normal to abnormal left heart filling pressures. A clinically significant difference of 6 mmHg in PWCP was attributable to differences in MFR in patients with the lowest compared with the highest MFR values. This suggests that strategies than attenuate microvascular dysfunction could slow progression of increased left ventricular left heart filling pressures in patients at increased risk.
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Affiliation(s)
- Emil Wolsk
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Mikkel Jürgens
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
- Department of Clinical Physiology and Nuclear Medicine & Cluster for Molecular Imaging, Copenhagen University Hospital, Rigshospitalet & Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mads Ersbøll
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Philip Hasbak
- Department of Clinical Physiology and Nuclear Medicine & Cluster for Molecular Imaging, Copenhagen University Hospital, Rigshospitalet & Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Kjaer
- Department of Clinical Physiology and Nuclear Medicine & Cluster for Molecular Imaging, Copenhagen University Hospital, Rigshospitalet & Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bo Zerahn
- Department of Clinical Physiology and Nuclear Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Niels Høgh Brandt
- Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Peter Haulund Gæde
- Department of Cardiology and Endocrinology, Slagelse Hospital, Slagelse, Denmark
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens Faber
- Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Caroline Michaela Kistorp
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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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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8
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Hyun J. Heart Failure With Preserved Ejection Fraction and Atrial Fibrillation: Are Beta-Blockers Still Relevant? INTERNATIONAL JOURNAL OF HEART FAILURE 2024; 6:127-128. [PMID: 39081647 PMCID: PMC11284336 DOI: 10.36628/ijhf.2024.0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Accepted: 07/16/2024] [Indexed: 08/02/2024]
Affiliation(s)
- Junho Hyun
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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9
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Hiraiwa H, Okumura T, Murohara T. Drug Therapy for Acute and Chronic Heart Failure with Preserved Ejection Fraction with Hypertension: A State-of-the-Art Review. Am J Cardiovasc Drugs 2024; 24:343-369. [PMID: 38575813 PMCID: PMC11093799 DOI: 10.1007/s40256-024-00641-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 04/06/2024]
Abstract
In this comprehensive state-of-the-art review, we provide an evidence-based analysis of current drug therapies for patients with heart failure with preserved ejection fraction (HFpEF) in the acute and chronic phases with concurrent hypertension. Additionally, we explore the latest developments and emerging evidence on the efficacy, safety, and clinical outcomes of common and novel drug treatments in the management of HFpEF with concurrent hypertension. During the acute phase of HFpEF, intravenous diuretics, mineralocorticoid receptor antagonists (MRAs), and vasodilators are pivotal, while in the chronic phase, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have proven effective in enhancing clinical outcomes. However, the use of calcium channel blockers in HFpEF with hypertension should be approached with caution, owing to their potential negative inotropic effects. We also explored emerging drug therapies for HFpEF, such as sodium-glucose co-transporter 2 (SGLT2) inhibitors, angiotensin receptor-neprilysin inhibitor (ARNI), soluble guanylate cyclase (sGC) stimulators, novel MRAs, and ivabradine. Notably, SGLT2 inhibitors have shown promise in reducing heart failure hospitalizations and cardiovascular mortality in patients with HFpEF, regardless of their diabetic status. Additionally, ARNI and sGC stimulators have demonstrated potential in improving symptoms, functional capacity, and quality of life. Nonetheless, additional research is necessary to pinpoint optimal treatment strategies for HFpEF with concurrent hypertension. Furthermore, long-term studies are essential to assess the durability and sustained benefits of emerging drug therapies. Identification of novel targets and mechanisms underlying HFpEF pathophysiology will pave the way for innovative drug development approaches in the management of HFpEF with concurrent hypertension.
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Affiliation(s)
- Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Patel L, Segar MW, Keshvani N, Subramanian V, Pandey A, Chandra A. Association of Beta-Blocker Use With Exercise Capacity in Participants With Heart Failure With Preserved Ejection Fraction: A Post Hoc Analysis of the RELAX Trial. Am J Cardiol 2024; 216:48-53. [PMID: 38336082 DOI: 10.1016/j.amjcard.2024.01.023] [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: 06/15/2023] [Revised: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024]
Abstract
Patients with heart failure with preserved ejection fraction (HFpEF) often receive β-blocker (BB) therapy for management of co-morbidities. However, the association of BB therapy with exercise capacity and health-related quality of life (HRQL) in HFpEF is not well-studied. In this post hoc analysis of the Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in HFpEF (RELAX) trial, which included patients with chronic stable HFpEF with peak exercise capacity assessment at baseline and at 12 and 24 weeks of follow-up, we evaluated the association of BB use with the measures of exercise capacity (peak exercise oxygen uptake), anaerobic threshold, and HRQL (Minnesota living with heart failure questionnaire). Separate linear mixed-effect models were constructed for each outcome with adjustment for treatment arm, demographics, medical history, left ventricular ejection fraction, and duration of heart failure. Of the 216 study participants (median age 69 years, 48.2% women), 76% reported BB use at baseline. Participants with (vs without) BB therapy were older (70 vs 63.5 years, p = 0.001) and had a higher prevalence of ischemic heart disease (44% vs 23%, p = 0.01). In the adjusted linear mixed model, BB use over time was not associated with peak exercise oxygen uptake (β 95% confidence interval [CI] 0.2 (-0.31 to 0.7), p = 0.5) and 6-minute walk distance (β 95% CI 14.69 [-14.25 to 43.63], p = 0.3). However, BB use was associated with a higher anaerobic threshold (β 95% CI 0.32 (0.02 to 0.62), p = 0.036) and better HRQL (lower quality of life as assessed by Minnesota living with heart failure questionnaire score) (β 95% CI -6.68 [-10.96 to -2.4], p = 0.002). Future trials are needed to better evaluate the effects of BB on exercise capacity in patients with chronic stable HFpEF.
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Affiliation(s)
- Lajjaben Patel
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | | | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Vinayak Subramanian
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Alvin Chandra
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas.
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11
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Lin X, Wu G, Wang S, Huang J. The prevalence of coronary microvascular dysfunction (CMD) in heart failure with preserved ejection fraction (HFpEF): a systematic review and meta-analysis. Heart Fail Rev 2024; 29:405-416. [PMID: 37870703 DOI: 10.1007/s10741-023-10362-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
To date, studies on the prevalence of coronary microvascular dysfunction (CMD) in heart failure with preserved ejection fraction (HFpEF) have not been summarized and analyzed as a whole. We conducted this systematic review and meta-analysis to assess the prevalence of CMD in patients with HFpEF. The PubMed, Cochrane, and Embase databases were searched from dates of inception until May 1, 2023. The primary outcome was the prevalence of CMD in patients with HFpEF, and values of CMD prevalence were pooled using a random-effects model. In total, 10 studies involving 1267 patients, including 822 with HFpEF and 445 without HFpEF, were included. The pooled prevalence of CMD in patients with HFpEF was 71% (95% CI, 0.63-0.79). In the subgroup analysis, the prevalence of CMD was 79% (95% CI, 0.71-0.87) by invasive measurement and 66% (95% CI, 0.54-0.77) by noninvasive measurement and 67% (95% CI, 0.52-0.82) with CFR < 2.0 and 75.0% (95% CI, 0.71-0.79) with CFR < 2.5. The prevalence of endothelium-independent CMD and endothelium-dependent CMD was 62% (95% CI, 0.53-0.72) and 50% (95% CI, 0.19-0.81), respectively. The prevalence of CMD was 74% (95% CI = 0.69-0.79) and 66% (95% CI = 0.41-0.90) in prospective and retrospective studies, respectively. Compared with the control group, patients with HFpEF had a significantly lower CFR (MD = - 1.28, 95% CI = - 1.82 to - 0.74, P < 0.01) and a higher prevalence of CMD (RR = 2.21, 95% CI = 1.52 to 3.20, P < 0.01). Qualitative analysis demonstrated that CMD might be associated with poor clinical outcomes in patients with HFpEF. In conclusion, this is the first systematic review and meta-analysis of all studies reporting the prevalence of CMD in patients with HFpEF. Our study demonstrates that CMD is common in patients with HFpEF and might be associated with poor clinical outcomes in these patients. Clinicians should attach importance to CMD in the diagnosis and treatment of HFpEF. The number of studies in this field is relatively small. Therefore, more high-quality studies are needed to explore the diagnostic and prognostic value of CMD and the potential role of CMD as a therapeutic target in patients with HFpEF.
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Affiliation(s)
- Xiaoxiao Lin
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310030, China
| | - Guomin Wu
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310030, China
| | - Shuai Wang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310030, China.
| | - Jinyu Huang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310030, China.
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12
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Doiron JE, Li Z, Yu X, LaPenna KB, Quiriarte H, Allerton TD, Koul K, Malek A, Shah SJ, Sharp TE, Goodchild TT, Kapusta DR, Lefer DJ. Early Renal Denervation Attenuates Cardiac Dysfunction in Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2024; 13:e032646. [PMID: 38353216 PMCID: PMC11010115 DOI: 10.1161/jaha.123.032646] [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] [Received: 09/12/2023] [Accepted: 12/08/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND The renal sympathetic nervous system modulates systemic blood pressure, cardiac performance, and renal function. Pathological increases in renal sympathetic nerve activity contribute to the pathogenesis of heart failure with preserved ejection fraction (HFpEF). We investigated the effects of renal sympathetic denervation performed at early or late stages of HFpEF progression. METHODS AND RESULTS Male ZSF1 obese rats were subjected to radiofrequency renal denervation (RF-RDN) or sham procedure at either 8 weeks or 20 weeks of age and assessed for cardiovascular function, exercise capacity, and cardiorenal fibrosis. Renal norepinephrine and renal nerve tyrosine hydroxylase staining were performed to quantify denervation following RF-RDN. In addition, renal injury, oxidative stress, inflammation, and profibrotic biomarkers were evaluated to determine pathways associated with RDN. RF-RDN significantly reduced renal norepinephrine and tyrosine hydroxylase content in both study cohorts. RF-RDN therapy performed at 8 weeks of age attenuated cardiac dysfunction, reduced cardiorenal fibrosis, and improved endothelial-dependent vascular reactivity. These improvements were associated with reductions in renal injury markers, expression of renal NLR family pyrin domain containing 3/interleukin 1β, and expression of profibrotic mediators. RF-RDN failed to exert beneficial effects when administered in the 20-week-old HFpEF cohort. CONCLUSIONS Our data demonstrate that early RF-RDN therapy protects against HFpEF disease progression in part due to the attenuation of renal fibrosis and inflammation. In contrast, the renoprotective and left ventricular functional improvements were lost when RF-RDN was performed in later HFpEF progression. These results suggest that RDN may be a viable treatment option for HFpEF during the early stages of this systemic inflammatory disease.
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Affiliation(s)
- Jake E. Doiron
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLAUSA
| | - Zhen Li
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Xiaoman Yu
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Kyle B. LaPenna
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLAUSA
| | - Heather Quiriarte
- Department of Vascular MetabolismPennington Biomedical Research CenterBaton RougeLAUSA
| | - Timothy D. Allerton
- Department of Vascular MetabolismPennington Biomedical Research CenterBaton RougeLAUSA
| | - Kashyap Koul
- School of MedicineLouisiana State University Health Sciences Center New OrleansNew OrleansLAUSA
| | - Andrew Malek
- School of MedicineLouisiana State University Health Sciences Center New OrleansNew OrleansLAUSA
| | - Sanjiv J. Shah
- Division of Cardiology, Department of Medicine and Bluhm Cardiovascular InstituteNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Thomas E. Sharp
- Department of Molecular Pharmacology and Physiology, Morsani College of MedicineUniversity of South FloridaTampaFLUSA
- USF Health Heart InstituteTampaFLUSA
| | - Traci T. Goodchild
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Daniel R. Kapusta
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLAUSA
| | - David J. Lefer
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCAUSA
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13
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Kaddoura R, Patel A. Revisiting Beta-Blocker Therapy in Heart Failure with Preserved Ejection Fraction. Curr Probl Cardiol 2023; 48:102015. [PMID: 37544622 DOI: 10.1016/j.cpcardiol.2023.102015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a heterogenous disorder and tends to be predominant in elderly, female, and obese patients. HFpEF has been classified using various cut-offs of left ventricular ejection fraction in the published studies with a current cut-off of ≥50%. The evidence of beta-blocker therapy in HFpEF patients showed conflicting findings with variably reported efficacy. This review aims to examine the published studies on the use of beta blockers for the treatment of patients with HFpEF.
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Affiliation(s)
- Rasha Kaddoura
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar.
| | - Ashfaq Patel
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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14
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Sotomi Y, Hikoso S, Nakatani D, Okada K, Dohi T, Sunaga A, Kida H, Sato T, Matsuoka Y, Kitamura T, Komukai S, Seo M, Yano M, Hayashi T, Nakagawa A, Nakagawa Y, Tamaki S, Ohtani T, Yasumura Y, Yamada T, Sakata Y. Medications for specific phenotypes of heart failure with preserved ejection fraction classified by a machine learning-based clustering model. Heart 2023; 109:1231-1240. [PMID: 36822821 PMCID: PMC10423528 DOI: 10.1136/heartjnl-2022-322181] [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] [Received: 11/24/2022] [Accepted: 02/07/2023] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVE Our previously established machine learning-based clustering model classified heart failure with preserved ejection fraction (HFpEF) into four distinct phenotypes. Given the heterogeneous pathophysiology of HFpEF, specific medications may have favourable effects in specific phenotypes of HFpEF. We aimed to assess effectiveness of medications on clinical outcomes of the four phenotypes using a real-world HFpEF registry dataset. METHODS This study is a posthoc analysis of the PURSUIT-HFpEF registry, a prospective, multicentre, observational study. We evaluated the clinical effectiveness of the following four types of postdischarge medication in the four different phenotypes: angiotensin-converting enzyme inhibitors (ACEi) or angiotensin-receptor blockers (ARB), beta blockers, mineralocorticoid-receptor antagonists (MRA) and statins. The primary endpoint of this study was a composite of all-cause death and heart failure hospitalisation. RESULTS Of 1231 patients, 1100 (83 (IQR 77, 87) years, 604 females) were eligible for analysis. Median follow-up duration was 734 (398, 1108) days. The primary endpoint occurred in 528 patients (48.0%). Cox proportional hazard models with inverse-probability-of-treatment weighting showed the following significant effectiveness of medication on the primary endpoint: MRA for phenotype 2 (weighted HR (wHR) 0.40, 95% CI 0.21 to 0.75, p=0.005); ACEi or ARB for phenotype 3 (wHR 0.66 0.48 to 0.92, p=0.014) and statin therapy for phenotype 3 (wHR 0.43 (0.21 to 0.88), p=0.020). No other medications had significant treatment effects in the four phenotypes. CONCLUSIONS Machine learning-based clustering may have the potential to identify populations in which specific medications may be effective. This study suggests the effectiveness of MRA, ACEi or ARB and statin for specific phenotypes of HFpEF. TRIAL REGISTRATION NUMBER UMIN000021831.
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Affiliation(s)
- Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Medical Informatics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomoharu Dohi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Akihiro Sunaga
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hirota Kida
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Taiki Sato
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuki Matsuoka
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masahiro Seo
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Masamichi Yano
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Japan
| | | | - Akito Nakagawa
- Division of Cardiology, Amagasaki Chuo Hospital, Amagasaki, Japan
| | - Yusuke Nakagawa
- Division of Cardiology, Kawanishi City Medical Center, Kawanishi, Japan
| | - Shunsuke Tamaki
- Department of Cardiovascular Medicine, Rinku General Medical Center, Izumisano, Japan
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoshio Yasumura
- Division of Cardiology, Amagasaki Chuo Hospital, Amagasaki, Japan
| | - Takahisa Yamada
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
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15
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Anker SD, Usman MS, Anker MS, Butler J, Böhm M, Abraham WT, Adamo M, Chopra VK, Cicoira M, Cosentino F, Filippatos G, Jankowska EA, Lund LH, Moura B, Mullens W, Pieske B, Ponikowski P, Gonzalez-Juanatey JR, Rakisheva A, Savarese G, Seferovic P, Teerlink JR, Tschöpe C, Volterrani M, von Haehling S, Zhang J, Zhang Y, Bauersachs J, Landmesser U, Zieroth S, Tsioufis K, Bayes-Genis A, Chioncel O, Andreotti F, Agabiti-Rosei E, Merino JL, Metra M, Coats AJS, Rosano GMC. Patient phenotype profiling in heart failure with preserved ejection fraction to guide therapeutic decision making. A scientific statement of the Heart Failure Association, the European Heart Rhythm Association of the European Society of Cardiology, and the European Society of Hypertension. Eur J Heart Fail 2023; 25:936-955. [PMID: 37461163 DOI: 10.1002/ejhf.2894] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 07/26/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) represents a highly heterogeneous clinical syndrome affected in its development and progression by many comorbidities. The left ventricular diastolic dysfunction may be a manifestation of various combinations of cardiovascular, metabolic, pulmonary, renal, and geriatric conditions. Thus, in addition to treatment with sodium-glucose cotransporter 2 inhibitors in all patients, the most effective method of improving clinical outcomes may be therapy tailored to each patient's clinical profile. To better outline a phenotype-based approach for the treatment of HFpEF, in this joint position paper, the Heart Failure Association of the European Society of Cardiology, the European Heart Rhythm Association and the European Hypertension Society, have developed an algorithm to identify the most common HFpEF phenotypes and identify the evidence-based treatment strategy for each, while taking into account the complexities of multiple comorbidities and polypharmacy.
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Affiliation(s)
- Stefan D Anker
- Department of Cardiology, Deutsches Herzzentrum der Charité (Campus CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | | | - Markus S Anker
- Deutsches Herzzentrum der Charité, Klinik fär Kardiologie, Angiologie und Intensivmedizin (Campus CBF), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | | | - Marianna Adamo
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | | | - Francesco Cosentino
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ewa A Jankowska
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Brenda Moura
- Centro de Investigação em Tecnologias e Serviços de Saúde, Porto, Portugal; Serviço de Cardiologia, Hospital das Forças Armadas-Pólo do Porto, Porto, Portugal
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk and Faculty of Medicine and Life Sciences, University Hasselt, Belgium
| | - Burkert Pieske
- Berlin-Brandenburgische Gesellschaft für Herz-Kreislauferkrankungen (BBGK), Berlin, Germany
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Cardiology Department, Wroclaw Medical University, Wroclaw, Poland
| | - Jose R Gonzalez-Juanatey
- Cardiology Department, Hospital Clínico Universitario, Santiago de Compostela, IDIS, CIBERCV, Santiago de Compostela, Spain
| | - Amina Rakisheva
- Department of Cardiology, Scientific Institution of Cardiology and Internal Diseases, Almaty, Kazakhstan
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Petar Seferovic
- Department Faculty of Medicine, University of Belgrade, Belgrade & Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, CA, USA
| | - Carsten Tschöpe
- Department of Cardiology, Deutsches Herzzentrum der Charité (Campus CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine (CVK), Charité Universitätsmedizin, Berlin, Germany
| | - Maurizio Volterrani
- Cardio-Pulmonary Department, San Raffaele Open University of Rome; Exercise Science and Medicine, IRCCS San Raffaele - Rome, Italy
| | | | - Jian Zhang
- Fuwai Hospital Chinese Academic of Medical Science, Beijing, China
| | - Yuhui Zhang
- Fuwai Hospital Chinese Academic of Medical Science, Beijing, China
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Ulf Landmesser
- Deutsches Herzzentrum der Charité, Klinik fär Kardiologie, Angiologie und Intensivmedizin (Campus CBF), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité, Berlin, Germany
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba Winnipeg, Winnipeg, Manitoba, Canada
| | - Konstantinos Tsioufis
- 1st Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, CIBERCV, Barcelona, Spain
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Felicita Andreotti
- Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
- Catholic University Medical School, Rome, Italy
| | - Enrico Agabiti-Rosei
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Jose L Merino
- Department of Cardiology, La Paz University Hospital, IdiPaz, Universidad Autonoma, Madrid, Spain
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Giuseppe M C Rosano
- Cardio-Pulmonary Department, San Raffaele Open University of Rome; Exercise Science and Medicine, IRCCS San Raffaele - Rome, Italy
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Wernhart S, Papathanasiou M, Rassaf T, Luedike P. The controversial role of beta-blockers in heart failure with preserved ejection fraction. Pharmacol Ther 2023; 243:108356. [PMID: 36750166 DOI: 10.1016/j.pharmthera.2023.108356] [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: 12/09/2022] [Revised: 01/22/2023] [Accepted: 02/01/2023] [Indexed: 02/07/2023]
Abstract
Beta-blocker (BB) therapy is a main pillar in treating patients with heart failure and reduced ejection fraction and has shown a prognostic benefit. However, evidence for application of BB in heart failure with preserved ejection fraction (HFpEF), especially in the absence of coronary artery disease, atrial fibrillation or arterial hypertension, is scarce. HFpEF is characterized by elevations in left atrial pressure and reduced compliance of the left ventricle leading to a hampered increase of cardiac output (CO) during exercise, which results in exertional dyspnea. This may be due to either a limited increase in stroke volume or reduced chronotropy during physical activity. We critically discuss the pathophysiological background of HFpEF, current data on BB in heart failure therapy, as well as the potential benefits and harms of BB therapy in HFpEF. Furthermore, we argue that non-cardio selective BB with peripheral activity to reduce afterload may be more suitable in this population than cardio-selective BB. Although preliminary data on BB in HFpEF are available, multicenter prospective trials to assess a reduction of cardiovascular morbidity are warranted. Future trials need to focus on phenotyping HFpEF patients and assess who may benefit most from tailored BB therapy.
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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
| | - 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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17
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Fuertes-Kenneally L, Manresa-Rocamora A, Blasco-Peris C, Ribeiro F, Sempere-Ruiz N, Sarabia JM, Climent-Paya V. Effects and Optimal Dose of Exercise on Endothelial Function in Patients with Heart Failure: A Systematic Review and Meta-Analysis. SPORTS MEDICINE - OPEN 2023; 9:8. [PMID: 36739344 PMCID: PMC9899305 DOI: 10.1186/s40798-023-00553-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Exercise-based cardiac rehabilitation (CR) is considered an effective treatment for enhancing endothelial function in patients with heart failure (HF). However, recent studies have been published and the optimal "dose" of exercise required to increase the benefits of exercise-based CR programmes on endothelial function is still unknown. OBJECTIVES (a) To estimate the effect of exercise-based CR on endothelial function, assessed by flow-mediated dilation (FMD), in patients with HF; (b) to determine whether high-intensity interval training (HIIT) is better than moderate-intensity training (MIT) for improving FMD; and (c) to investigate the influence of exercise modality (i.e. resistance exercise vs. aerobic exercise and combined exercise vs. aerobic exercise) on the improvement of endothelial function. METHODS Electronic searches were carried out in PubMed, Embase, and Scopus up to February 2022. Random-effects models of between-group mean differences were estimated. Heterogeneity analyses were performed by means of the chi-square test and I2 index. Subgroup analyses and meta-regressions were used to test the influence of potential moderator variables on the effect of exercise. RESULTS We found a FMD increase of 3.09% (95% confidence interval [CI] = 2.01, 4.17) in favour of aerobic-based CR programmes compared with control groups in patients with HF and reduced ejection fraction (HFrEF). However, the results of included studies were inconsistent (p < .001; I2 = 95.2%). Higher FMD improvement was found in studies which were randomised, reported radial FMD, or performed higher number of training sessions a week. Moreover, HIIT enhanced FMD to a greater extent than MIT (2.35% [95% CI = 0.49, 4.22]) in patients with HFrEF. Insufficient data prevented pooled analyses for the effect of exercise in patients with HF and preserved ejection fraction and the influence of exercise modality on the improvement of endothelial function. CONCLUSION Aerobic-based CR is a non-pharmacological treatment for enhancing endothelial function in patients with HFrEF. However, higher training frequency and HIIT induce greater adaptation of endothelial function in these patients, which should betaken into consideration when designing exercise-based CR programmes. Trial registration The protocol was prospectively registered on the PROSPERO database (CRD42022304687).
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Affiliation(s)
- Laura Fuertes-Kenneally
- grid.513062.30000 0004 8516 8274Institute for Health and Biomedical Research of Alicante (ISABIAL), 03010 Alicante, Spain ,Cardiology Department, Alicante General University Hospital (HGUA), 03010 Alicante, Spain
| | - Agustín Manresa-Rocamora
- grid.513062.30000 0004 8516 8274Institute for Health and Biomedical Research of Alicante (ISABIAL), 03010 Alicante, Spain ,grid.26811.3c0000 0001 0586 4893Department of Sport Sciences, Sports Research Centre, Miguel Hernández University of Elche, 03202 Elche, Spain
| | - Carles Blasco-Peris
- grid.513062.30000 0004 8516 8274Institute for Health and Biomedical Research of Alicante (ISABIAL), 03010 Alicante, Spain ,grid.5338.d0000 0001 2173 938XDepartment of Physical Education and Sport, University of Valencia, 46010 Valencia, Spain
| | - Fernando Ribeiro
- grid.7311.40000000123236065Institute of Biomedicine‑iBiMED and School of Health Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
| | - Noemí Sempere-Ruiz
- grid.513062.30000 0004 8516 8274Institute for Health and Biomedical Research of Alicante (ISABIAL), 03010 Alicante, Spain ,grid.26811.3c0000 0001 0586 4893Department of Sport Sciences, Sports Research Centre, Miguel Hernández University of Elche, 03202 Elche, Spain
| | - José Manuel Sarabia
- grid.513062.30000 0004 8516 8274Institute for Health and Biomedical Research of Alicante (ISABIAL), 03010 Alicante, Spain ,grid.26811.3c0000 0001 0586 4893Department of Sport Sciences, Sports Research Centre, Miguel Hernández University of Elche, 03202 Elche, Spain
| | - Vicente Climent-Paya
- grid.513062.30000 0004 8516 8274Institute for Health and Biomedical Research of Alicante (ISABIAL), 03010 Alicante, Spain ,Cardiology Department, Alicante General University Hospital (HGUA), 03010 Alicante, Spain
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Elkammash A, Tam SSC, Yogarajah G, You J. Management of Heart Failure With Preserved Ejection Fraction in Elderly Patients: Effectiveness and Safety. Cureus 2023; 15:e35030. [PMID: 36938226 PMCID: PMC10023169 DOI: 10.7759/cureus.35030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/17/2023] Open
Abstract
The proportion of the elderly population continues to increase due to the global increase in longevity. Heart failure with preserved ejection fraction (HFpEF) is common in the elderly due to cellular aging, myocardial stiffness, and multiple comorbidities. This age group is often under-represented in clinical trials. In this narrative review, we looked into the latest evidence-based lines of management of HFpEF in this vulnerable cohort. In this narrative review, we brought the latest evidence on the treatment of HFpEf in the elderly. We searched the largest three scientific databases (Pubmed, Google Scholar, and EMBASE) using the search words (elderly, HFpEF, heart failure with preserved ejection fraction, guidelines, treatment, and management) in different combinations. To date, screening for and treatment of the causes of HFpEF (such as hypertension, coronary artery disease [CAD], valvular heart disease, and cardiac amyloidosis) and associated comorbidities (such as diabetes mellitus [DM], iron deficiency, obesity, and thyroid dysfunction) are the main line of management of HFpEF. A multidisciplinary team, including an HF specialist cardiologist, an HF nurse, a geriatrician, a dietician, a psychologist, a physiotherapist, and an occupational therapist, should manage HFpEF elderly patients. Other specialist input may be needed according to the patient's requirements. The evidence on the effective management of HFpEF in the elderly age group is scarce and controversial. Some studied non-pharmacological approaches include supervised exercise training, pulmonary artery pressure monitoring, and the interatrial shunt device (an emerging modality that includes a small percutaneously inserted interatrial left to right valve aiming to reduce the left atrial and pulmonary wedge pressures). These modalities can only improve the symptoms and HF hospitalizations without robustly impacting cardiovascular (CV) death. Among the pharmacological approaches to treat HFpEF, only the sodium-glucose cotransporter 2 (SGLT-2) inhibitors proved efficacy in reducing the hard outcomes of CV death, HF hospitalizations, and urgent visits for HF when used in elderly HFpEF patients, irrespective of the presence of diabetes mellitus. Diuretics are only beneficial to alleviate the symptoms of fluid overload, with a risk of renal impairment in volume-depleted patients. The evidence on the effectiveness of other HF-specific disease-modifying agents in elderly HFpEF patients is controversial. Elderly patients have a higher risk of having side effects from HF medications due to the higher prevalence of polypharmacy, cognitive decline, and impairment of kidney and liver functions. Therefore, cautious initiation of HF treatment with a close follow-up of the blood pressure, liver functions, kidney functions, and electrolytes are of utmost importance.
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Affiliation(s)
- Amr Elkammash
- Department of Cardiology, The Royal Papworth Hospital NHS Foundation Trust, Cambridge, GBR
| | | | | | - Jianing You
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
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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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20
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Lin X, Wu G, Gao B, Wang S, Huang J. Bibliometric and visual analysis of coronary microvascular dysfunction. Front Cardiovasc Med 2022; 9:1021346. [PMID: 36457808 PMCID: PMC9705352 DOI: 10.3389/fcvm.2022.1021346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/31/2022] [Indexed: 11/05/2023] Open
Abstract
Background Coronary microvascular dysfunction (CMD) may play an important role in various cardiovascular diseases, including HFpEF and both obstructive and non-obstructive coronary artery disease (CAD). To date, there has been no bibliometric analysis to summarize this field. Here, we aim to conduct a bibliometric analysis of CMD to determine the current status and frontiers in this field. Materials and methods Publications about CMD were taken from the Web of Science Core Collection database (WOSCC). WOSCC's literature analysis wire, the VOSviewer 1.6.16, and CiteSpace 5.1.3 were used to conduct the analysis. Results A total of 785 publications containing 206 reviews and 579 articles are included in the sample. The leading authors are Iacopo Olivotto, Paolo G. Camici, and Carl J. Pepine. The most productive institutions are the University of Florence, Cedars Sinai Medical Center, and Harvard University. The most productive countries are the USA, Italy, and England. There are a total of 237 journals that contribute to this field, and the leading journals in our study were the International Journal of Cardiology, the European Heart Journal and the JACC. From 2012 to 2021, the top three most-cited articles focused on the association between HFpEF and CMD. The important keywords are heart failure, hypertrophic cardiomyopathy, chest pain, women, coronary flow reserve (CFR), endothelial dysfunction and prognostic value. "Positron emission tomography" shows the strongest burst strength, followed by "blow flow" and "artery." The keywords that started to burst from 2015 are particularly emphasized, including "heart failure," "coronary flow reserve," and "management." Conclusion Studies about CMD are relatively limited, and the largest contribution comes from the USA, Italy and England. More studies are needed, and publications from other countries should be enhanced. The main research hotspots in the CMD field include CMD in patients with HFpEF, sex differences, the new methods of diagnosis for CMD, and the effective treatment of CMD. Attention should be given to CMD in patients with HFpEF, and untangling the association between CMD and HFpEF could be helpful in the development of physiology-stratified treatment for patients with CMD and HFpEF.
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Affiliation(s)
- Xiaoxiao Lin
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Guomin Wu
- Department of Cardiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Beibei Gao
- Department of Cardiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shuai Wang
- Department of Translation Medicine Center, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jinyu Huang
- Department of Cardiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Szklarz M, Gontarz-Nowak K, Matuszewski W, Bandurska-Stankiewicz E. Can Iron Play a Crucial Role in Maintaining Cardiovascular Health in the 21st Century? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11990. [PMID: 36231287 PMCID: PMC9565681 DOI: 10.3390/ijerph191911990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/01/2022] [Accepted: 09/08/2022] [Indexed: 06/16/2023]
Abstract
In the 21st century the heart is facing more and more challenges so it should be brave and iron to meet these challenges. We are living in the era of the COVID-19 pandemic, population aging, prevalent obesity, diabetes and autoimmune diseases, environmental pollution, mass migrations and new potential pandemic threats. In our article we showed sophisticated and complex regulations of iron metabolism. We discussed the impact of iron metabolism on heart diseases, treatment of heart failure, diabetes and obesity. We faced the problems of constant stress, climate change, environmental pollution, migrations and epidemics and showed that iron is really essential for heart metabolism in the 21st century.
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22
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Jia R, Ji Y, Sun D. Progress and prospects of Sacubitril/Valsartan: Based on heart failure with preserved ejection fraction. Biomed Pharmacother 2022; 155:113701. [PMID: 36116249 DOI: 10.1016/j.biopha.2022.113701] [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: 08/13/2022] [Revised: 09/09/2022] [Accepted: 09/13/2022] [Indexed: 12/20/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is present in nearly half of patients with heart failure. The prevalence of heart failure with normal or near-normal ejection fractions increases more rapidly than in patients with reduced ejection fractions. Angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), aldosterone antagonist, β-blocker, and calcium channel blocker have not shown significant efficacy in HFpEF clinical trials. Sacubitril/Valsartan, combined angiotensin receptor blocker (Valsartan) with neprilysin inhibitor (Sacubitril), was the first-of-its-kind angiotensin receptor-neprilysin inhibitor (ARNI) to be developed. It has shown significant efficacy on HFpEF in recent studies. It is considered that most of the current Sacubitril/Valsartan studies are still concentrated in the field of heart failure, especially heart failure with reduced ejection fraction (HFrEF). This review discusses the latest advances in cardiovascular, renal, and metabolic aspects of Sacubitril/Valsartan, mainly in HFpEF, providing more evidence for further future research on Sacubitril/Valsartan and raising issues that should be paid attention. At the same time, this review will introduce the academic consensus on Sacubitril/Valsartan in treating HFpEF in China.
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Affiliation(s)
- Ruoyu Jia
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China; Graduate School, Xuzhou Medical University, Xuzhou 221002, China
| | - Ying Ji
- Graduate School, Xuzhou Medical University, Xuzhou 221002, China
| | - Dong Sun
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221002, China; Institute of Nephrology, Xuzhou Medical University, Xuzhou 221002, China.
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23
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Voorrips SN, Saucedo-Orozco H, Sánchez-Aguilera PI, De Boer RA, Van der Meer P, Westenbrink BD. Could SGLT2 Inhibitors Improve Exercise Intolerance in Chronic Heart Failure? Int J Mol Sci 2022; 23:8631. [PMID: 35955784 PMCID: PMC9369142 DOI: 10.3390/ijms23158631] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 12/04/2022] Open
Abstract
Despite the constant improvement of therapeutical options, heart failure (HF) remains associated with high mortality and morbidity. While new developments in guideline-recommended therapies can prolong survival and postpone HF hospitalizations, impaired exercise capacity remains one of the most debilitating symptoms of HF. Exercise intolerance in HF is multifactorial in origin, as the underlying cardiovascular pathology and reactive changes in skeletal muscle composition and metabolism both contribute. Recently, sodium-related glucose transporter 2 (SGLT2) inhibitors were found to improve cardiovascular outcomes significantly. Whilst much effort has been devoted to untangling the mechanisms responsible for these cardiovascular benefits of SGLT2 inhibitors, little is known about the effect of SGLT2 inhibitors on exercise performance in HF. This review provides an overview of the pathophysiological mechanisms that are responsible for exercise intolerance in HF, elaborates on the potential SGLT2-inhibitor-mediated effects on these phenomena, and provides an up-to-date overview of existing studies on the effect of SGLT2 inhibitors on clinical outcome parameters that are relevant to the assessment of exercise capacity. Finally, current gaps in the evidence and potential future perspectives on the effects of SGLT2 inhibitors on exercise intolerance in chronic HF are discussed.
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Affiliation(s)
- Suzanne N. Voorrips
- Department of Cardiology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (H.S.-O.); (P.I.S.-A.); (R.A.D.B.); (P.V.d.M.)
| | | | | | | | | | - B. Daan Westenbrink
- Department of Cardiology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (H.S.-O.); (P.I.S.-A.); (R.A.D.B.); (P.V.d.M.)
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Abstract
Chronic heart failure is one of the most common causes of hospitalization and death in industrialized countries. Demographic changes with an aging population are expected to further increase the prevalence of chronic heart failure. The associated increase in comorbidities in patients with chronic heart failure leads to a less favorable prognosis for survival. A selection of the major comorbidities discussed in this review—along with prevalence, impact on prognosis, treatment approaches, and current study status—include atrial fibrillation, arterial hypertension, coronary artery disease, coronary microvascular dysfunction, renal dysfunction, type 2 diabetes, sleep apnea, reduced lymphatic reserve, and the effects on oxygen utilization and physical activity. The complex clinical picture of heart failure with preserved ejection fraction (HFpEF) remains challenging in the nearly absence of evidence-based therapy. Except for comorbidity-specific guidelines, no HFpEF-specific treatment of comorbidities can be recommended at this time. Optimized care is becoming increasingly relevant to reducing hospitalizations through a seamless inpatient and outpatient care structure. Current treatment is focused on symptom relief and management of associated comorbidities. Therefore, prevention through early minimization of risk factors currently remains the best approach.
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25
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Zhou X, Jeong E, Liu H, Kaseer B, Liu M, Shrestha S, Imran H, Kavanagh K, Jiang N, Desimone L, Feng F, Shi G, Jeong GE, Zhou A, Stockwell P, Dudley SC. Circulating S-Glutathionylated cMyBP-C as a Biomarker for Cardiac Diastolic Dysfunction. J Am Heart Assoc 2022; 11:e025295. [PMID: 35656993 PMCID: PMC9238749 DOI: 10.1161/jaha.122.025295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background cMyBP-C (Cardiac myosin binding protein-C) regulates cardiac contraction and relaxation. Previously, we demonstrated that elevated myocardial S-glutathionylation of cMyBP-C correlates with diastolic dysfunction (DD) in animal models. In this study, we tested whether circulating S-glutathionylated cMyBP-C would be a biomarker for DD. Methods and Results Humans, African Green monkeys, and mice had DD determined by echocardiography. Blood samples were acquired and analyzed for S-glutathionylated cMyBP-C by immunoprecipitation. Circulating S-glutathionylated cMyBP-C in human participants with DD (n=24) was elevated (1.46±0.13-fold, P=0.014) when compared with the non-DD controls (n=13). Similarly, circulating S-glutathionylated cMyBP-C was upregulated by 2.13±0.47-fold (P=0.047) in DD monkeys (n=6), and by 1.49 (1.22-2.06)-fold (P=0.031) in DD mice (n=5) compared with the respective non-DD controls. Circulating S-glutathionylated cMyBP-C was positively correlated with DD in humans. Conclusions Circulating S-glutathionylated cMyBP-C was elevated in humans, monkeys, and mice with DD. S-glutathionylated cMyBP-C may represent a novel biomarker for the presence of DD.
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Affiliation(s)
- Xiaoxu Zhou
- Division of CardiologyDepartment of MedicineThe Lillehei Heart InstituteUniversity of MinnesotaMinneapolisMN
| | - Euy‐Myoung Jeong
- Lifespan Cardiovascular Research CenterBrown UniversityProvidenceRI
| | - Hong Liu
- Division of CardiologyDepartment of MedicineThe Lillehei Heart InstituteUniversity of MinnesotaMinneapolisMN
| | - Bahaa Kaseer
- Lifespan Cardiovascular Research CenterBrown UniversityProvidenceRI
| | - Man Liu
- Division of CardiologyDepartment of MedicineThe Lillehei Heart InstituteUniversity of MinnesotaMinneapolisMN
| | - Suvash Shrestha
- Lifespan Cardiovascular Research CenterBrown UniversityProvidenceRI
| | - Hafiz Imran
- Lifespan Cardiovascular Research CenterBrown UniversityProvidenceRI
| | - Kylie Kavanagh
- Department of PathologyWake Forest Baptist Medical CenterWinston‐SalemNC
| | - Ning Jiang
- Lifespan Cardiovascular Research CenterBrown UniversityProvidenceRI
| | | | - Feng Feng
- Division of CardiologyDepartment of MedicineThe Lillehei Heart InstituteUniversity of MinnesotaMinneapolisMN
| | - Guangbin Shi
- Lifespan Cardiovascular Research CenterBrown UniversityProvidenceRI
| | - Go Eun Jeong
- Department of Biology and MedicineBrown UniversityProvidenceRI
| | - Anyu Zhou
- Lifespan Cardiovascular Research CenterBrown UniversityProvidenceRI
| | - Philip Stockwell
- Lifespan Cardiovascular Research CenterBrown UniversityProvidenceRI
| | - Samuel C. Dudley
- Division of CardiologyDepartment of MedicineThe Lillehei Heart InstituteUniversity of MinnesotaMinneapolisMN
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26
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Priel E, Wahab M, Mondal T, Freitag A, O'Byrne PM, Killian KJ, Satia I. The Impact of beta blockade on the cardio-respiratory system and symptoms during exercise. Curr Res Physiol 2022; 4:235-242. [PMID: 34988470 PMCID: PMC8710988 DOI: 10.1016/j.crphys.2021.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 09/22/2021] [Accepted: 10/25/2021] [Indexed: 12/03/2022] Open
Abstract
Background Beta blockers prolong life in patients with cardiovascular diseases. Negative chronotropic and inotropic effects carry the potential to adversely effect peripheral skeletal and airway smooth muscle contributing to further fatigue, dyspnea and exercise intolerance. Research questions Do beta-blockers reduce maximal power output (MPO), VO2 max, cardiorespiratory responses, increase the perceived effort required to cycle and breath during cardiopulmonary exercise tests (CPET) and limit the capacity to exercise? Methods Retrospective observational study of subjects performing CPET to capacity from 1988 to 2012. Subjects with and without beta-blockers were compared: baseline physiological characteristics, MPO, VO2 max, heart rate max, ventilation responses and perceived exertion required to cycle and breathe (modified Borg scale). Forward stepwise linear additive regression was performed with MPO as the dependent factor with height, age, gender, muscle strength, FEV1 and DLCO as independent contributors. Results 42,771 subjects were included 7,787 were receiving beta-blocker [mean age 61 yrs, BMI 28.40 kg/m2, 9% airflow obstruction (FEV1/FVC<0.7)] and 34,984 were not [mean age 51yrs, BMI 27.40 kg/m2, 11% airflow obstruction]. Heart rate was lower by 18.2% (95% C.I. 18.15–18.38) (p<0.0001) while Oxygen pulse (VO2/HR) was higher by 19.5% (95% C.I. 19.3–19.7) in those receiving beta blockers. Maximum power output (MPO) was 3.3% lower in those taking beta-blockers. The perceived effort required to cycle and breathe (mBorg) was 8% lower in those taking beta-blockers. Interpretation Increases in oxygen pulse minimize the reduction in exercise intolerance and symptom handicap associated with beta-blockers. Comprehensive set of exercise physiology measurements in a large cohort, to delineate any hazardous effects of beta blockade. Beta-blockers attenuate the heart rate at rest and during exercise. Beta-blockade has no meaningful effects on muscle strength, breathing capacity or exercise induced bronchoconstriction. Beta Blockers were not associated with a reduction in Maximal power output. Increases in Oxygen pulse minimize the reduction in exercise intolerance and symptom handicap associated with beta-blockers.
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Affiliation(s)
- Eldar Priel
- McMaster University Department of Medicine, Hamilton, Canada.,Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, Canada
| | - Mustafaa Wahab
- McMaster University Department of Medicine, Hamilton, Canada
| | - Tapas Mondal
- McMaster University Department of Medicine, Hamilton, Canada
| | - Andy Freitag
- McMaster University Department of Medicine, Hamilton, Canada
| | - Paul M O'Byrne
- McMaster University Department of Medicine, Hamilton, Canada.,Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, Canada
| | | | - Imran Satia
- McMaster University Department of Medicine, Hamilton, Canada.,Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, Canada
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Cho JH. Sudden Death and Ventricular Arrhythmias in Heart Failure With Preserved Ejection Fraction. Korean Circ J 2022; 52:251-264. [PMID: 35388994 PMCID: PMC8989786 DOI: 10.4070/kcj.2021.0420] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/27/2022] [Accepted: 02/22/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jae Hyung Cho
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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28
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Palau P, Seller J, Domínguez E, Sastre C, Ramón JM, de La Espriella R, Santas E, Miñana G, Bodí V, Sanchis J, Valle A, Chorro FJ, Llácer P, Bayés-Genís A, Núñez J. Effect of β-Blocker Withdrawal on Functional Capacity in Heart Failure and Preserved Ejection Fraction. J Am Coll Cardiol 2021; 78:2042-2056. [PMID: 34794685 DOI: 10.1016/j.jacc.2021.08.073] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Chronotropic incompetence has shown to be associated with a decrease in exercise capacity in heart failure with preserved ejection fraction (HFpEF), yet β-blockers are commonly used in HFpEF despite the lack of robust evidence. OBJECTIVES This study aimed to evaluate the effect of β-blocker withdrawal on peak oxygen consumption (peak Vo2) in patients with HFpEF and chronotropic incompetence. METHODS This is a multicenter, randomized, investigator-blinded, crossover clinical trial consisting of 2 treatment periods of 2 weeks separated by a washout period of 2 weeks. Patients with stable HFpEF, New York Heart Association functional classes II and III, previous treatment with β-blockers, and chronotropic incompetence were first randomized to withdrawing from (arm A: n = 26) versus continuing (arm B: n = 26) β-blocker treatment and were then crossed over to receive the opposite intervention. Changes in peak Vo2 and percentage of predicted peak Vo2 (peak Vo2%) measured at the end of the trial were the primary outcome measures. To account for the paired-data nature of this crossover trial, linear mixed regression analysis was used. RESULTS The mean age was 72.6 ± 13.1 years, and most of the patients were women (59.6%) in New York Heart Association functional class II (66.7%). The mean peakVo2 and peak Vo2% were 12.4 ± 2.9 mL/kg/min, and 72.4 ± 17.8%, respectively. No significant baseline differences were found across treatment arms. Peak Vo2 and peak Vo2% increased significantly after β-blocker withdrawal (14.3 vs 12.2 mL/kg/min [Δ +2.1 mL/kg/min]; P < 0.001 and 81.1 vs 69.4% [Δ +11.7%]; P < 0.001, respectively). CONCLUSIONS β-blocker withdrawal improved maximal functional capacity in patients with HFpEF and chronotropic incompetence. β-blocker use in HFpEF deserves profound re-evaluation. (β-blockers Withdrawal in Patients With HFpEF and Chronotropic Incompetence: Effect on Functional Capacity [PRESERVE-HR]; NCT03871803; 2017-005077-39).
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Affiliation(s)
- Patricia Palau
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Julia Seller
- Cardiology Department, Hospital de Denia, Alicante, Spain
| | | | - Clara Sastre
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Jose María Ramón
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Rafael de La Espriella
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Enrique Santas
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Gema Miñana
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain
| | - Vicent Bodí
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain
| | - Alfonso Valle
- Cardiology Department, Hospital de Denia, Alicante, Spain
| | - F Javier Chorro
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain
| | - Pau Llácer
- Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain; Internal Medicine Department, Hospital Ramón y Cajal, Madrid, Spain
| | - Antoni Bayés-Genís
- Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain; Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain.
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Guazzi M. The Link Between Heart Rate, Exercise, and β-Blocker in HFpEF: Time to Untie the Knot. J Am Coll Cardiol 2021; 78:2057-2059. [PMID: 34794686 DOI: 10.1016/j.jacc.2021.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Marco Guazzi
- Cardiology Division, University of Milano School of Medicine, Department of Health Sciences, San Paolo Hospital, Milano, Italy.
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Longhi S, Saturi G, Caponetti AG, Gagliardi C, Biagini E. Advanced Heart Failure in a Special Population: Heart Failure with Preserved Ejection Fraction. Heart Fail Clin 2021; 17:685-695. [PMID: 34511215 DOI: 10.1016/j.hfc.2021.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a complex clinical syndrome that has become a global health issue, with mortality ranging from 53% to 74% at 5 years. It is defined as the presence of signs and symptoms of heart failure associated with left ventricular ejection fraction greater than or equal to 50%. The definition and diagnosis of HFpEF in patients with unexplained dyspnea remain a clinical challenge in the absence of a unique diagnostic algorithm universally recognized. Clinical trials conducted so far did not show a significant improvement of prognosis, but forthcoming therapies could provide innovative solutions.
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Affiliation(s)
- Simone Longhi
- Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, Bologna 40138, Italy.
| | - Giulia Saturi
- Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, Bologna 40138, Italy; Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Italy
| | - Angelo Giuseppe Caponetti
- Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, Bologna 40138, Italy; Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Italy
| | - Christian Gagliardi
- Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Elena Biagini
- Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, Bologna 40138, Italy
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31
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Impact of β-Blockers on Heart Rate and Oxygen Uptake During Exercise and Recovery in Older Patients With Heart Failure With Preserved Ejection Fraction. J Cardiopulm Rehabil Prev 2021; 40:174-177. [PMID: 31899703 DOI: 10.1097/hcr.0000000000000459] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE The study aimed to investigate the differences in oxygen uptake ((Equation is included in full-text article.)O2) and heart rate (HR) (at rest, submaximal exercise, peak exercise, and recovery) in patients with heart failure with preserved ejection fraction (HFpEF) with β-blockers (BB) or without BB treatment (NBB) and to analyze the relationship between HR reserve (HRresv) and peak (Equation is included in full-text article.)O2 ((Equation is included in full-text article.)O2peak) in BB and NBB. METHODS A total of 174 HFpEF patients (>65 yr; BB, n = 59; NBB, n = 115) were assessed with a cardiopulmonary exercise test to peak exertion using an incremental protocol. After 5 min of supine rest, HR and (Equation is included in full-text article.)O2 (HRrest, (Equation is included in full-text article.)O2rest) at submaximal exercise (HRsubmax, (Equation is included in full-text article.)O2submax), at peak exercise (HRpeak, (Equation is included in full-text article.)O2peak), at 1 min of passive recovery (HRrec1), HRresv (HRpeak- HRrest), and HR recovery (HRrecov = HRpeak- HRrec1) were evaluated. RESULTS Analysis showed that HRrest (66.0 ± 12.2 vs 69.7 ± 10.6 bpm), HRsubmax (91.7 ± 16.2 vs 98.6 ± 15.2 bpm), and HRrec1 (102.9 ± 18.9 vs 109.4 ± 16.9 bpm) were significantly lower (P ≤ .05) in BB than in NBB, respectively. However, there were no significant differences (P > .05) between the BB and the NBB for HRpeak, HRresv, HRrecov, (Equation is included in full-text article.)O2rest, (Equation is included in full-text article.)O2submax, and (Equation is included in full-text article.)O2peak. A significant relationship was found between HRresv and (Equation is included in full-text article.)O2peak values in both groups (BB, r = 0.52; NBB, r = 0.49, P < .001). CONCLUSIONS The nonsignificant differences in HRpeak, HRresv, HRrecov, or (Equation is included in full-text article.)O2 values between BB and NBB HFpEF patients, along with significant correlation between HRresv and (Equation is included in full-text article.)O2peak, suggest that these measures may have equal utility in prognostic and functional assessment as well as clinical applications, including the prescription of exercise, in elderly HFpEF patients.
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Yoshida Y, Nakanishi K, Daimon M, Ishiwata J, Sawada N, Hirokawa M, Kaneko H, Nakao T, Mizuno Y, Morita H, Di Tullio MR, Homma S, Komuro I. Sex-specific difference in the association between arterial stiffness and subclinical left ventricular dysfunction. Eur Heart J Cardiovasc Imaging 2021; 22:817-823. [PMID: 32594106 DOI: 10.1093/ehjci/jeaa156] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/22/2020] [Accepted: 05/12/2020] [Indexed: 01/01/2023] Open
Abstract
AIMS Increased arterial stiffness is one of the key mechanisms of heart failure with preserved ejection fraction (HFpEF). However, the possible association between arterial stiffness and subclinical left ventricular (LV) dysfunction and its sex-specific difference remains unclarified. LV strain is emerging as a highly sensitive tool to unmask early LV abnormalities. METHODS AND RESULTS We examined 1155 participants free of overt cardiovascular disease who underwent extensive cardiovascular examination. Speckle-tracking echocardiography was employed to assess LV global longitudinal strain (LVGLS) and circumferential strain (GCS), and arterial stiffness was assessed by cardio-ankle vascular index (CAVI). Mean age was 62 ± 12 years, and 56% were men. CAVI as continuous variable was associated with abnormal LVGLS (>-18.6%) independent of cardiovascular risk factors and echocardiographic parameters [adjusted odds ratio (OR) 1.23, P = 0.027] but not with LVGCS. In sex-stratified analysis, more pronounced association between quartiles of CAVI and abnormal LVGLS was observed in women than in men (unadjusted OR = 6.43 in women and 2.46 in men for upper quartile vs. lower quartile; both P < 0.01). CAVI was significantly associated with abnormal LVGLS independent of cardiovascular risk factors in both sexes. However, after further adjustment for LV mass index and diastolic parameters, the independent association persisted only in women (adjusted OR 1.67, P = 0.007), but not in men (adjusted OR 1.14, P = 0.227). CONCLUSION Increased arterial stiffness was independently associated with decreased LVGLS even without overt cardiovascular disease; a sex-specific pattern exists in the alteration of vascular-ventricular coupling, which might partially explain the greater susceptibility to HFpEF in women.
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Affiliation(s)
- Yuriko Yoshida
- Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Koki Nakanishi
- Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Masao Daimon
- Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.,Department of Clinical Laboratory, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Jumpei Ishiwata
- Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Naoko Sawada
- Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Megumi Hirokawa
- Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Hidehiro Kaneko
- Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Tomoko Nakao
- Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Yoshiko Mizuno
- Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Hiroyuki Morita
- Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Marco R Di Tullio
- Department of Medicine, Columbia University, 622 West 168th Street, New York, NY 10032, USA
| | - Shunichi Homma
- Department of Medicine, Columbia University, 622 West 168th Street, New York, NY 10032, USA
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Ambrosino P, Papa A, Buonauro A, Mosella M, Calcaterra I, Spedicato GA, Maniscalco M, Di Minno MND. Clinical assessment of endothelial function in heart failure with preserved ejection fraction: A meta-analysis with meta-regressions. Eur J Clin Invest 2021; 51:e13552. [PMID: 33749828 DOI: 10.1111/eci.13552] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endothelial dysfunction is a key mechanism in the development of cardiac remodelling and diastolic dysfunction in heart failure with preserved ejection fraction (HFpEF). Flow-mediated (FMD) and nitrate-mediated dilation (NMD) are noninvasive methods to assess endothelial function. We performed a meta-analysis evaluating the impact of HFpEF on FMD and NMD. METHODS PubMed, Web of Science, Scopus and EMBASE databases were systematically searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Differences were expressed as mean difference (MD) with 95% confidence intervals (95%CI). The random effects method was used. RESULTS A total of seven studies were included in the final analysis, 7 with data on FMD (326 HFpEF patients and 417 controls) and 3 on NMD (185 HFpEF patients and 271 controls). Compared to controls, HFpEF patients showed significantly lower FMD (MD: -1.929; 95%CI: -2.770, -1.088; P < .0001) and NMD values (MD: -2.795; 95%CI: -3.876, -1.715; P < .0001). Sensitivity analyses substantially confirmed results. Meta-regression models showed that increasing differences in E/A ratio (Z-score: -2.002; P = .045), E/E' ratio (Z-score: -2.181; P = .029) and left atrial diameter (Z-score: -1.951; P = .050) were linked to higher differences in FMD values between cases and controls. CONCLUSIONS Impaired endothelial function can be documented in HFpEF, with the possibility of a direct association between the severity of diastolic and endothelial dysfunction. Targeting endothelial dysfunction through pharmacological and rehabilitation strategies may represent an attractive therapeutic option.
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Affiliation(s)
| | - Antimo Papa
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | | | - Marco Mosella
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Ilenia Calcaterra
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
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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: 6] [Impact Index Per Article: 2.0] [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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Hypertension and heart failure with preserved ejection fraction: position paper by the European Society of Hypertension. J Hypertens 2021; 39:1522-1545. [PMID: 34102660 DOI: 10.1097/hjh.0000000000002910] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Hypertension constitutes a major risk factor for heart failure with preserved ejection fraction (HFpEF). HFpEF is a prevalent clinical syndrome with increased cardiovascular morbidity and mortality. Specific guideline-directed medical therapy (GDMT) for HFpEF is not established due to lack of positive outcome data from randomized controlled trials (RCTs) and limitations of available studies. Although available evidence is limited, control of blood pressure (BP) is widely regarded as central to the prevention and clinical care in HFpEF. Thus, in current guidelines including the 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) Guidelines, blockade of the renin-angiotensin system (RAS) with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers provides the backbone of BP-lowering therapy in hypertensive patients. Although superiority of RAS blockers has not been clearly shown in dedicated RCTs designed for HFpEF, we propose that this core drug treatment strategy is also applicable for hypertensive patients with HFpEF with the addition of some modifications. The latter apply to the use of spironolactone apart from the treatment of resistant hypertension and the use of the angiotensin receptor neprilysin inhibitor. In addition, novel agents such as sodium-glucose co-transporter-2 inhibitors, currently already indicated for high-risk patients with diabetes to reduce heart failure hospitalizations, and finerenone represent promising therapies and results from ongoing RCTs are eagerly awaited. The development of an effective and practical classification of HFpEF phenotypes and GDMT through dedicated high-quality RCTs are major unmet needs in hypertension research and calls for action.
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Kim IC. Atrial Fibrillation and Heart Failure with Preserved Ejection Fraction: Two Chronic Troublemakers. Heart Fail Clin 2021; 17:377-386. [PMID: 34051970 DOI: 10.1016/j.hfc.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this article, the definition; mechanisms; diagnostic strategies, including scoring systems; treatments; prognosis; and future perspectives in heart failure with preserved ejection fraction with atrial fibrillation, which are common comorbid conditions, are reviewed thoroughly.
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Affiliation(s)
- In-Cheol Kim
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1035, Dalgubeol-daero, Dalseo-gu, Daegu 42601, Republic of Korea.
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Martin N, Manoharan K, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2021; 5:CD012721. [PMID: 34022072 PMCID: PMC8140651 DOI: 10.1002/14651858.cd012721.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin-aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction (LVEF); a review of the evidence is required to determine whether these treatments are beneficial for people with heart failure with preserved ejection fraction (HFpEF). OBJECTIVES To assess the effects of beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with HFpEF. SEARCH METHODS We updated searches of CENTRAL, MEDLINE, Embase, and one clinical trial register on 14 May 2020 to identify eligible studies, with no language or date restrictions. We checked references from trial reports and review articles for additional studies. SELECTION CRITERIA: We included randomised controlled trials with a parallel group design, enrolling adults with HFpEF, defined by LVEF greater than 40%. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 41 randomised controlled trials (231 reports), totalling 23,492 participants across all comparisons. The risk of bias was frequently unclear and only five studies had a low risk of bias in all domains. Beta-blockers (BBs) We included 10 studies (3087 participants) investigating BBs. Five studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 30 years to 81 years. A possible reduction in cardiovascular mortality was observed (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; number needed to treat for an additional benefit (NNTB) 25; 1046 participants; three studies), however, the certainty of evidence was low. There may be little to no effect on all-cause mortality (RR 0.82, 95% CI 0.67 to 1.00; 1105 participants; four studies; low-certainty evidence). The effects on heart failure hospitalisation, hyperkalaemia, and quality of life remain uncertain. Mineralocorticoid receptor antagonists (MRAs) We included 13 studies (4459 participants) investigating MRA. Eight studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 54.5 to 80 years. Pooled analysis indicated that MRA treatment probably reduces heart failure hospitalisation (RR 0.82, 95% CI 0.69 to 0.98; NNTB = 41; 3714 participants; three studies; moderate-certainty evidence). However, MRA treatment probably has little or no effect on all-cause mortality (RR 0.91, 95% CI 0.78 to 1.06; 4207 participants; five studies; moderate-certainty evidence) and cardiovascular mortality (RR 0.90, 95% CI 0.74 to 1.11; 4070 participants; three studies; moderate-certainty evidence). MRA treatment may have little or no effect on quality of life measures (mean difference (MD) 0.84, 95% CI -2.30 to 3.98; 511 participants; three studies; low-certainty evidence). MRA treatment was associated with a higher risk of hyperkalaemia (RR 2.11, 95% CI 1.77 to 2.51; number needed to treat for an additional harmful outcome (NNTH) = 11; 4291 participants; six studies; high-certainty evidence). Angiotensin-converting enzyme inhibitors (ACEIs) We included eight studies (2061 participants) investigating ACEIs. Three studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 70 to 82 years. Pooled analyses with moderate-certainty evidence suggest that ACEI treatment likely has little or no effect on cardiovascular mortality (RR 0.93, 95% CI 0.61 to 1.42; 945 participants; two studies), all-cause mortality (RR 1.04, 95% CI 0.75 to 1.45; 1187 participants; five studies) and heart failure hospitalisation (RR 0.86, 95% CI 0.64 to 1.15; 1019 participants; three studies), and may result in little or no effect on the quality of life (MD -0.09, 95% CI -3.66 to 3.48; 154 participants; two studies; low-certainty evidence). The effects on hyperkalaemia remain uncertain. Angiotensin receptor blockers (ARBs) Eight studies (8755 participants) investigating ARBs were included. Five studies used a placebo comparator and in three the comparator was usual care. The mean age of participants ranged from 61 to 75 years. Pooled analyses with high certainty of evidence suggest that ARB treatment has little or no effect on cardiovascular mortality (RR 1.02, 95% 0.90 to 1.14; 7254 participants; three studies), all-cause mortality (RR 1.01, 95% CI 0.92 to 1.11; 7964 participants; four studies), heart failure hospitalisation (RR 0.92, 95% CI 0.83 to 1.02; 7254 participants; three studies), and quality of life (MD 0.41, 95% CI -0.86 to 1.67; 3117 participants; three studies). ARB was associated with a higher risk of hyperkalaemia (RR 1.88, 95% CI 1.07 to 3.33; 7148 participants; two studies; high-certainty evidence). Angiotensin receptor neprilysin inhibitors (ARNIs) Three studies (7702 participants) investigating ARNIs were included. Two studies used ARBs as the comparator and one used standardised medical therapy, based on participants' established treatments at enrolment. The mean age of participants ranged from 71 to 73 years. Results suggest that ARNIs may have little or no effect on cardiovascular mortality (RR 0.96, 95% CI 0.79 to 1.15; 4796 participants; one study; moderate-certainty evidence), all-cause mortality (RR 0.97, 95% CI 0.84 to 1.11; 7663 participants; three studies; high-certainty evidence), or quality of life (high-certainty evidence). However, ARNI treatment may result in a slight reduction in heart failure hospitalisation, compared to usual care (RR 0.89, 95% CI 0.80 to 1.00; 7362 participants; two studies; moderate-certainty evidence). ARNI treatment was associated with a reduced risk of hyperkalaemia compared with valsartan (RR 0.88, 95% CI 0.77 to 1.01; 5054 participants; two studies; moderate-certainty evidence). AUTHORS' CONCLUSIONS There is evidence that MRA and ARNI treatment in HFpEF probably reduces heart failure hospitalisation but probably has little or no effect on cardiovascular mortality and quality of life. BB treatment may reduce the risk of cardiovascular mortality, however, further trials are needed. The current evidence for BBs, ACEIs, and ARBs is limited and does not support their use in HFpEF in the absence of an alternative indication. Although MRAs and ARNIs are probably effective at reducing the risk of heart failure hospitalisation, the treatment effect sizes are modest. There is a need for improved approaches to patient stratification to identify the subgroup of patients who are most likely to benefit from MRAs and ARNIs, as well as for an improved understanding of disease biology, and for new therapeutic approaches.
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Affiliation(s)
- Nicole Martin
- Institute of Health Informatics Research, University College London, London, UK
| | | | - Ceri Davies
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - R Thomas Lumbers
- Institute of Health Informatics, University College London, London, UK
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Graziani F, Lillo R, Crea F. Rationale for the Use of Pirfenidone in Heart Failure With Preserved Ejection Fraction. Front Cardiovasc Med 2021; 8:678530. [PMID: 33969025 PMCID: PMC8100203 DOI: 10.3389/fcvm.2021.678530] [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: 03/09/2021] [Accepted: 03/29/2021] [Indexed: 12/28/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a major public health problem with growing prevalence and poor outcomes, mainly due to the lack of an effective treatment. HFpEF pathophysiology is heterogeneous and complex. Recently a “new paradigm” has been proposed, suggesting that cardiovascular and non-cardiovascular coexisting comorbidities lead to a systemic inflammatory state, perturbing the physiology of the endothelium and the perivascular environment and engaging molecular pathways that ultimately converge to myocardial fibrosis. If inflammation and fibrosis are the “fil rouge” in the heterogeneous spectrum of HFpEF, anti-fibrotic and anti-inflammatory drugs may have a role in its treatment. Pirfenidone is an orally bioavailable drug with antifibrotic and anti-inflammatory properties already approved for the treatment of idiopathic pulmonary fibrosis. Pirfenidone has been recently tested in animal models of myocardial fibrosis with promising results. Here we will review the rationale underlying the potential therapeutic effect of Pirfenidone in HFpEF.
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Affiliation(s)
- Francesca Graziani
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Rosa Lillo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Catholic University of the Sacred Heart, Rome, Italy
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Wolsk E, Kaye DM, Komtebedde J, Shah SJ, Borlaug BA, Burkhoff D, Kitzman DW, Cleland JG, Hasenfuß G, Hassager C, Møller JE, Gustafsson F. Determinants and consequences of heart rate and stroke volume response to exercise in patients with heart failure and preserved ejection fraction. Eur J Heart Fail 2021; 23:754-764. [PMID: 33686716 DOI: 10.1002/ejhf.2146] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 02/26/2021] [Accepted: 03/03/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS A hallmark of heart failure with preserved ejection fraction (HFpEF) is impaired exercise capacity of varying severity. The main determinant of exercise capacity is cardiac output (CO), however little information is available about the relation between the constituents of CO - heart rate and stroke volume - and exercise capacity in HFpEF. We sought to determine if a heterogeneity in heart rate and stroke volume response to exercise exists in patients with HFpEF and describe possible clinical phenotypes associated with differences in these responses. METHODS AND RESULTS Data from two prospective trials of HFpEF (n = 108) and a study of healthy participants (n = 42) with invasive haemodynamic measurements during exercise were utilized. Differences in central haemodynamic responses were analysed with regression models. Chronotropic incompetence was present in 39-56% of patients with HFpEF and 3-56% of healthy participants depending on the definition used, but some (n = 47, 44%) had an increase in heart rate similar to that of healthy controls. Patients with HFpEF had a smaller increase in their stroke volume index (SVI) (HFpEF: +4 ± 10 mL/m2 , healthy participants: +24 ± 12 mL/m2 , P < 0.0001), indeed, SVI fell in 28% of patients at peak exercise. Higher body mass index and lower SVI at rest were associated with smaller increases in heart rate during exercise, whereas higher resting heart rate, and angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use were associated with a greater increase in SVI in patients with HFpEF. CONCLUSION The haemodynamic response to exercise was very heterogeneous among patients with HFpEF, with chronotropic incompetence observed in up to 56%, and 28% had impaired increase in SVI. This suggests that haemodynamic exercise testing may be useful to identify which HFpEF patients may benefit from interventions targeting stroke volume and chronotropic response.
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Affiliation(s)
- Emil Wolsk
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - David M Kaye
- Department of Cardiology, Alfred Hospital, Baker IDI Heart and Diabetes Research Institute, Melbourne, Australia
| | | | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Barry A Borlaug
- Division of Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, MN, USA
| | | | - Dalane W Kitzman
- Department of Internal Medicine, School of Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - John G Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow and National Heart & Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, UK
| | - Gerd Hasenfuß
- Clinic for Cardiology and Pneumology, Georg August University Goettingen, Goettingen, Germany
| | | | - Jacob E Møller
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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Paz PA, Mantilla BD, Argueta EE, Mukherjee D. Narrative review: the holy grail: update on pharmacotherapy for heart failure with preserved ejection fraction. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:523. [PMID: 33850920 PMCID: PMC8039660 DOI: 10.21037/atm-20-4602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is the presence of clinical signs and/or symptoms of heart failure with a left ventricular ejection fraction (LVEF) ≥50%. Risk factors associated with this disease include hypertension, hyperlipidemia, atrial fibrillation (AF), obesity, diabetes and coronary artery disease (CAD). Despite the multiple risk factors identified for this condition, treatment and management remain challenging and a subject of ongoing research. Since a treatment approach that alters the natural course or lowers mortality for this disease has not been found, treating co-morbidities and symptom management is essential. From the comorbidities, hypertension is identified as the main risk factor for disease development. Thus, after congestive symptom control with diuretics, blood pressure (BP) management is considered one of the most important preventive measures and also a target for treatment. Amongst antihypertensives, angiotensin receptor blockers (ARBs) and aldosterone antagonists are the therapeutic agents used that have a role in reducing hospitalizations. Implantable monitoring devices have also been shown to reduce hospitalizations in comparison to standard heart failure therapies by allowing to tailor diuretic therapy based on ongoing hemodynamic data. In this manuscript we discuss pharmacologic strategies for HFpEF patients by risk factors, including those with and without a potential role.
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Affiliation(s)
- Pablo Alejandro Paz
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | | | - Erwin E Argueta
- Division of Cardiovascular medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
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Wang M, Shan Y, Wu C, Cao P, Sun W, Han J, Shen L, Chen J, Yu P, Chen X. Efficacy and Safety of Qishen Yiqi Dripping Pill for Heart Failure With Preserved Ejection Fraction: A Systematic Review and Meta-Analysis. Front Pharmacol 2021; 11:626375. [PMID: 33633570 PMCID: PMC7900630 DOI: 10.3389/fphar.2020.626375] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/15/2020] [Indexed: 12/11/2022] Open
Abstract
Background: The number of heart failure with preserved ejection fraction (HFpEF) patients is increasing year by year, yet all western medicines currently used for heart failure have been shown to be ineffective for HFpEF. Qishen Yiqi Dripping Pill is one of the commonly drugs for the treatment of heart failure in China. In recent years, some clinical studies found that it has curative effect on HFpEF. Objective: To evaluate the efficacy and safety of Qishen Yiqi Dripping Pill in treatment of HFpEF. Methods: Databases including CNKI, Wanfang, VIP, CBM, PubMed, Web of Science, The Cochrane Library and EMbase were searched from their inception to May 2020 to screen relevant randomized controlled trials. The "risk of bias" evaluation tool in the Cochrane Handbook was used to evaluate the quality of the included studies. RevMan 5.3 software was used for meta-analysis. Results: Eight studies meeting the criteria were included, with a total of 895 patients. The results of meta-analysis showed that compared with western medicine alone, combination of western medicine and Qishen Yiqi Dripping Pill can further increase the quotient of early diastolic mitral inflow velocity and late diastolic mitral inflow velocity (E/A) in patients with HFpEF [mean difference (MD) = 0.20, 95% CI (0.14, 0.26), p < 0.000 01], decrease the quotient of early diastolic mitral inflow velocity and mitral annular tissue velocity (E/e') [MD = -2.50, 95% CI (-3.18, -1.82), p < 0.000 01], decrease brain natriuretic peptide (BNP) [MD = -151.83, 95% CI (-245.78, -57.89), p = 0.002], increase cardiac function improvement rate [relative risk (RR) = 1.30, 95% CI (1.11, 1.52), p = 0.001], and increase six-minutes walking distance (6-MWD) [MD = 64.75, 95% CI (22.65, 106.85), p = 0.003]. Four studies reported the occurrence of adverse reactions, among which three studies reported no adverse reactions and one study reported three patients with mild adverse reactions in the intervention group. Conclusion: Current evidence suggests that Qishen Yiqi Dripping Pill may be effective in the treatment of HFpEF. However, due to the low quality of the included studies, lack of placebo control, large heterogeneity among different studies, and great possibility of publication bias, the results of our review should be evaluated with more prudence, more high-quality clinical studies are needed to verify the conclusion in the future. In addition, the safety of Qishen Yiqi Dripping Pill remains uncertain, further assessment is required in the future.
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Affiliation(s)
- Mengxi Wang
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
- First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yiwen Shan
- First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Chenjie Wu
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
- First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Peihua Cao
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
- First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Weixin Sun
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
- First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jie Han
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Le Shen
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Jiandong Chen
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Peng Yu
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Xiaohu Chen
- Department of Cardiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- Department of Cardiology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
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Shibata MC, Curl-Roper J, Van Veldhuisen DJ, Roughton M, Coats AJS, Flather M. Six-minute walk test: prognostic value and effects of nebivolol versus placebo in elderly patients with heart failure from the SENIORS trial. Clin Res Cardiol 2020; 110:1193-1201. [PMID: 33136223 DOI: 10.1007/s00392-020-01768-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 10/20/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is limited information about the 6-min walk test (6MWT) in elderly patients with heart failure. We evaluated 6MWT and the effect of nebivolol on 6MWT from the SENIORS trial. METHODS AND RESULTS The SENIORS trial evaluated nebivolol versus placebo on death and hospitalisation in patients aged ≥ 70 years with heart failure. A total of 1982 patients undertook a 6MWT at baseline and 1716 patients at 6 months. Patients were divided into tertiles (≤ 200 m, 201 to ≤ 300 m and > 300 m) and to change in distance walked between baseline and 6 months (< 0 m, 0 to < 30 m and ≥ 30 m). The primary outcome was all-cause mortality and cardiovascular hospital admission. Secondary endpoint was all-cause mortality. Baseline walk distance of ≤ 200 m incurred a greater risk of the primary and secondary outcomes (HR 1.41, CI 95% 1.17-1.69, p < 0.001) and (HR 1.37, CI 95% 1.05-1.78, p = 0.019). A decline in walk distance over 6 months was associated with increased risk of clinical events. Nebivolol had no influence on change in walk distance over 6 months. CONCLUSIONS The 6MWT has prognostic utility in elderly patients. Those who walked less than 200 m were at highest risk. Nebivolol had no effect on 6MWT.
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Affiliation(s)
- Marcelo C Shibata
- University of Alberta, and Covenant Health, Misericordia Hospital, Suite 362, Heritage Medical Research Centre, Edmonton, AB, T6G 2C8, Canada.
| | - Jordan Curl-Roper
- University of East Anglia and Norfolk and Norwich University Hospital, Norwich, UK
| | - Dirk J Van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - Marcus Flather
- University of East Anglia and Norfolk and Norwich University Hospital, Norwich, UK
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Suzuki S, Motoki H, Kanzaki Y, Maruyama T, Hashizume N, Kozuka A, Yahikozawa K, Kuwahara K. Prognostic impact of mineralocorticoid receptor antagonist in patients with heart failure with preserved ejection fraction. ESC Heart Fail 2020; 7:2752-2761. [PMID: 32592265 PMCID: PMC7524222 DOI: 10.1002/ehf2.12867] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 06/01/2020] [Accepted: 06/09/2020] [Indexed: 01/05/2023] Open
Abstract
AIMS This study aims to investigate the prognostic impact of mineralocorticoid receptor antagonists (MRAs) on cardiovascular events in patients hospitalized for acute decompensated heart failure with preserved ejection fraction (HFpEF; defined as left ventricular ejection fraction ≥45%). METHODS AND RESULTS A prospective multicentre cohort study was conducted in Nagano prefecture, Japan, between July 2014 and December 2018 that contained 518 consecutive HFpEF patients hospitalized for acute decompensated heart failure (HF). The primary outcome was a composite of cardiovascular death and HF readmission. We compared the incidence of cardiovascular events between patients who were prescribed with MRAs and those who were not in a propensity score matched cohort using a Cox proportional hazards regression model with a propensity score derived from 23 baseline variables. For sensitivity analysis, we conducted Cox proportional hazards regression models for the primary outcome adjusting for 16 clinically relevant variables in the crude cohort. The median age was 83 years, and 53% were female. The median left ventricular ejection fraction was 61%. During a median follow-up of 553 days, the primary outcome occurred in 192 (37%) patients. MRAs were used in 255 (49%) patients. After analysis, a matched cohort consisting of 370 patients was created. After propensity score matching, the baseline characteristics were well balanced between the two groups. The incidence of the primary outcome was significantly lower in MRA users than in non-users [32% (59/185) vs. 49% (90/185); hazard ratio (HR) 0.669, 95% confidence interval (CI) 0.482-0.929, P = 0.016]. The incidence of cardiovascular death was also significantly lower in the MRA users [11% (21/185) vs. 22% (41/185); HR, 0.563; 95% CI, 0.333-0.953; P = 0.032]. The risk of HF readmission tended to be lower in the MRA users [29% (54/185) vs. 41% (75/185); HR, 0.738; 95% CI, 0.520-1.048; P = 0.089]. MRA use was also associated with a lower risk of the primary outcome after Cox proportional hazards analysis adjusting for 16 clinically relevant variables in the crude cohort (HR, 0.710; 95% CI 0.507-0.995; P = 0.047). CONCLUSIONS Mineralocorticoid receptor antagonist use was significantly associated with a lower risk of the primary composite outcome of cardiovascular death and HF readmission in patients hospitalized for acute decompensated HFpEF. The incidence of cardiovascular mortality was also significantly lower in these patients.
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Affiliation(s)
- Sho Suzuki
- Department of Cardiovascular Medicine, Minaminagano Medical CenterShinonoi General HospitalNaganoJapan
| | - Hirohiko Motoki
- Department of Cardiovascular MedicineShinshu University School of MedicineAsahi 3‐1‐1, MatsumotoNagano390‐8621Japan
| | - Yusuke Kanzaki
- Department of Cardiovascular Medicine, Minaminagano Medical CenterShinonoi General HospitalNaganoJapan
| | - Takuya Maruyama
- Department of Cardiovascular Medicine, Minaminagano Medical CenterShinonoi General HospitalNaganoJapan
| | - Naoto Hashizume
- Department of Cardiovascular Medicine, Minaminagano Medical CenterShinonoi General HospitalNaganoJapan
| | - Ayako Kozuka
- Department of Cardiovascular Medicine, Minaminagano Medical CenterShinonoi General HospitalNaganoJapan
| | - Kumiko Yahikozawa
- Department of Cardiovascular Medicine, Minaminagano Medical CenterShinonoi General HospitalNaganoJapan
| | - Koichiro Kuwahara
- Department of Cardiovascular MedicineShinshu University School of MedicineAsahi 3‐1‐1, MatsumotoNagano390‐8621Japan
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Hicklin HE, Gilbert ON, Ye F, Brooks JE, Upadhya B. Hypertension as a Road to Treatment of Heart Failure with Preserved Ejection Fraction. Curr Hypertens Rep 2020; 22:82. [PMID: 32880741 DOI: 10.1007/s11906-020-01093-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Hypertension heralds the diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF) in 75-85% of cases and shares many of its adverse outcomes as well as its acute and chronic symptoms. This review provides important new data about the pathophysiology and mechanisms that connect hypertension and HFpEF as well as therapy used in both conditions. RECENT FINDINGS The traditional model of HFpEF pathophysiology emphasizes the role of hypertension causing increased afterload on the left ventricle (LV), leading to LV hypertrophy (LVH) and subsequent LV diastolic dysfunction. Recent work has provided valuable insights into the mechanisms underlying the transition from hypertension to HFpEF, showing that the pathophysiology extends beyond LVH and diastolic dysfunction. An evolving paradigm suggests that HFpEF is inflammatory in nature with multifactorial pathophysiology, affected by age-related changes and comorbidities. Hypertension shares many of the proinflammatory mechanisms of HFpEF. Furthermore, hypertension precedes HFpEF in the majority of cases. Because of its clinically heterogeneous nature, development of standardized therapies for HFpEF has been challenging. As there are standardized approaches to hypertension, we suggest that similar approaches be used for the treatment of HFpEF, including medical and non-medical therapies. With medical therapies, a treat-to-target blood pressure (BP) strategy could be employed, such as systolic BP < 130 mmHg. With non-medical therapies, approaches to deal with physical inactivity, obesity, and sleep apnea could be used. Due to its heterogeneity, delineation of standardized therapies for HFpEF has been challenging. Focusing on the tremendous overlap of hypertensive heart disease with HFpEF, it is proposed that approaches currently used to guide therapies for hypertension be applied to the treatment of HFpEF.
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Affiliation(s)
- Harry E Hicklin
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Olivia N Gilbert
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Fan Ye
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Jeremy E Brooks
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Bharathi Upadhya
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA.
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Del Buono MG, Iannaccone G, Scacciavillani R, Carbone S, Camilli M, Niccoli G, Borlaug BA, Lavie CJ, Arena R, Crea F, Abbate A. Heart failure with preserved ejection fraction diagnosis and treatment: An updated review of the evidence. Prog Cardiovasc Dis 2020; 63:570-584. [DOI: 10.1016/j.pcad.2020.04.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 04/19/2020] [Indexed: 12/20/2022]
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Wintrich J, Kindermann I, Ukena C, Selejan S, Werner C, Maack C, Laufs U, Tschöpe C, Anker SD, Lam CSP, Voors AA, Böhm M. Therapeutic approaches in heart failure with preserved ejection fraction: past, present, and future. Clin Res Cardiol 2020; 109:1079-1098. [PMID: 32236720 PMCID: PMC7449942 DOI: 10.1007/s00392-020-01633-w] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/11/2020] [Indexed: 02/07/2023]
Abstract
In contrast to the wealth of proven therapies for heart failure with reduced ejection fraction (HFrEF), therapeutic efforts in the past have failed to improve outcomes in heart failure with preserved ejection fraction (HFpEF). Moreover, to this day, diagnosis of HFpEF remains controversial. However, there is growing appreciation that HFpEF represents a heterogeneous syndrome with various phenotypes and comorbidities which are hardly to differentiate solely by LVEF and might benefit from individually tailored approaches. These hypotheses are supported by the recently presented PARAGON-HF trial. Although treatment with LCZ696 did not result in a significantly lower rate of total hospitalizations for heart failure and death from cardiovascular causes among HFpEF patients, subanalyses suggest beneficial effects in female patients and those with an LVEF between 45 and 57%. In the future, prospective randomized trials should focus on dedicated, well-defined subgroups based on various information such as clinical characteristics, biomarker levels, and imaging modalities. These could clarify the role of LCZ696 in selected individuals. Furthermore, sodium-glucose cotransporter-2 inhibitors have just proven efficient in HFrEF patients and are currently also studied in large prospective clinical trials enrolling HFpEF patients. In addition, several novel disease-modifying drugs that pursue different strategies such as targeting cardiac inflammation and fibrosis have delivered preliminary optimistic results and are subject of further research. Moreover, innovative device therapies may enhance management of HFpEF, but need prospective adequately powered clinical trials to confirm safety and efficacy regarding clinical outcomes. This review highlights the past, present, and future therapeutic approaches in HFpEF.
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Affiliation(s)
- Jan Wintrich
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Germany.
| | - Ingrid Kindermann
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Germany
| | - Christian Ukena
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Germany
| | - Simina Selejan
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Germany
| | - Christian Werner
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Germany
| | - Christoph Maack
- Comprehensive Heart Failure Center (CHFC), University Clinic Würzburg, Würzburg, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie im Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Carsten Tschöpe
- Department of Cardiology, Universitätsmedizin Berlin, Charite, Campus Rudolf Virchow Clinic (CVK), Augustenburger Platz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
- Berlin-Brandenburg Institute of Health/Center for Regenerative Therapies (BIHCRT), Berlin, Germany
| | - Stefan D Anker
- Department of Cardiology, Universitätsmedizin Berlin, Charite, Campus Rudolf Virchow Clinic (CVK), Augustenburger Platz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
- Berlin-Brandenburg Institute of Health/Center for Regenerative Therapies (BIHCRT), Berlin, Germany
| | - Carolyn S P Lam
- National Heart Centre, Singapore and Duke-National University of Singapore, Singapore, Singapore
- University Medical Centre Groningen, Groningen, The Netherlands
- The George Institute for Global Health, Sydney, Australia
| | - Adriaan A Voors
- University Medical Centre Groningen, Groningen, The Netherlands
| | - Michael Böhm
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Germany
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Fukuta H, Goto T, Wakami K, Kamiya T, Ohte N. Effect of beta-blockers on heart failure severity in patients with heart failure with preserved ejection fraction: a meta-analysis of randomized controlled trials. Heart Fail Rev 2020; 26:165-171. [PMID: 32743714 DOI: 10.1007/s10741-020-10013-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients with heart failure with preserved ejection fraction (HFpEF) are often elderly and likely to have cardiac comorbidities such as coronary artery disease (CAD) and atrial fibrillation (AF). The primary chronic symptom of HFpEF patients is severe exercise intolerance. The inability to adequately increase heart rate during exercise is commonly present in HFpEF patients and contributes to their exercise intolerance. Although beta-blockers are frequently used for the treatment of myocardial ischemia and tachycardia in HFpEF patients, there is a concern that slowing heart rate by beta-blockers may worsen chronotropic incompetence and further exacerbate their symptoms. Although the effect of beta-blockers on heart failure severity in HFpEF patients has been examined in randomized controlled trials (RCTs), results are inconsistent due partly to limited power. We aimed to conduct a meta-analysis of RCTs on the effect of beta-blockers on heart failure severity in HFpEF patients. The search of electronic databases identified 5 RCTs including 538 patients. In pooled analyses, beta-blockers did not significantly change the New York Heart Association (NYHA) class, exercise capacity expressed as metabolic equivalents, or plasma B-type natriuretic peptide (BNP) levels compared with control but with substantial heterogeneity across trials. In meta-regression analyses, the higher proportion of CAD or AF in the included trials was associated with a decrease in NYHA class and BNP levels and with an increase in exercise capacity. Thus, we found no clear beneficial effect of beta-blockers on heart failure severity in HFpEF patients. However, beta-blockers may be beneficial in HFpEF patients with CAD or AF.
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Affiliation(s)
- Hidekatsu Fukuta
- Core Laboratory, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-cho Mizuho-ku, Nagoya, 467-8601, Japan.
| | - Toshihiko Goto
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kazuaki Wakami
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takeshi Kamiya
- Department of Medical Innovation, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Nobuyuki Ohte
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Pagel PS, Tawil JN, Boettcher BT, Izquierdo DA, Lazicki TJ, Crystal GJ, Freed JK. Heart Failure With Preserved Ejection Fraction: A Comprehensive Review and Update of Diagnosis, Pathophysiology, Treatment, and Perioperative Implications. J Cardiothorac Vasc Anesth 2020; 35:1839-1859. [PMID: 32747202 DOI: 10.1053/j.jvca.2020.07.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/15/2020] [Accepted: 07/02/2020] [Indexed: 02/07/2023]
Abstract
Almost three-quarters of all heart failure patients who are older than 65 have heart failure with preserved ejection fraction (HFpEF). The proportion and hospitalization rate of patients with HFpEF are increasing steadily relative to patients in whom heart failure occurs as result of reduced ejection fraction. The predominance of the HFpEF phenotype most likely is explained by the prevalence of medical conditions associated with an aging population. A multitude of age-related, medical, and lifestyle risk factors for HFpEF have been identified as potential causes for the sustained low-grade proinflammatory state that accelerates disease progression. Profound left ventricular (LV) systolic and diastolic stiffening, elevated LV filling pressures, reduced arterial compliance, left atrial hypertension, pulmonary venous congestion, and microvascular dysfunction characterize HFpEF, but pulmonary arterial hypertension, right ventricular dilation and dysfunction, and atrial fibrillation also frequently occur. These cardiovascular features make patients with HFpEF exquisitely sensitive to the development of hypotension in response to acute declines in LV preload or afterload that may occur during or after surgery. With the exception of symptom mitigation, lifestyle modifications, and rigorous control of comorbid conditions, few long-term treatment options exist for these unfortunate individuals. Patients with HFpEF present for surgery on a regular basis, and anesthesiologists need to be familiar with this heterogeneous and complex clinical syndrome to provide successful care. In this article, the authors review the diagnosis, pathophysiology, and treatment of HFpEF and also discuss its perioperative implications.
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Affiliation(s)
- Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
| | - Justin N Tawil
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Brent T Boettcher
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - David A Izquierdo
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Timothy J Lazicki
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - George J Crystal
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, IL
| | - Julie K Freed
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
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49
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Kokhan EV, Kiyakbaev GK, Kobalava ZD. [Frequency of use and Indications for Beta-Blockers in Heart Failure with Preserved Ejection Fraction]. KARDIOLOGIIA 2020; 60:30-40. [PMID: 32720613 DOI: 10.18087/cardio.2020.6.n1062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/20/2020] [Indexed: 06/11/2023]
Abstract
Aim To evaluate trends in beta-blocker prescribing and incidence of possible reasons for beta-blocker administration, including arterial hypertension (AH), atrial fibrillation (AF), ischemic heart disease (IHD), and myocardial infarction, in participants of clinical studies enrolling patients with chronic heart failure with preserved ejection fraction (CHF-PEF).Material and methods A systematic literature search was performed in the PubMed and EMBASE databases. The study included RCSs of pharmacological therapies for patients with CHF-PEF conducted from 1993 through 2019. Studies of beta-blocker efficacy or those including a specific population (CHF-PEF+IHD or CHF-PEF+AH, etc.) were excluded from the analysis. Baseline characteristics of patients, incidence rate of beta-blocker prescribing, and prevalence of AH, AF, IHD, and MI were recorded. Trends in prevalence of concomitant diseases and the proportion of patients using beta-blockers by the year of enrollment to the study were analyzed with the Mann-Kendall test.Results 14 RCSs of 718 selected publications completely met the inclusion and exclusion criteria. Beta-blocker prescribing significantly increased between 1993 and 2019 (tau=0.51; p=0.014) and reached 80 % in recent studies. Furthermore, prevalence of IHD, MI, AH, and AF did not significantly change among the RCS participants (p>0.05 for all). However, while for AH and AF, a tendency toward an increasing prevalence (tau=0.4; p=0.055 and tau=0.043; p=0.063, respectively) could be considered and became statistically significant for AF when the ALDO-DHF study was excluded from the analysis (tau=0.5; p=0.042), the MI prevalence tended to decrease (tau= -0.73; p=0.06).Conclusion Beta-blocker prescribing to patients upon inclusion into RCSs for CHF-PEF has significantly increased for the recent 20 years while the incidence of formal reasons for beta-blocker administration (AF, AH, MI, IHD) did not significantly change.
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Affiliation(s)
- E V Kokhan
- Peoples' Friendship University of Russia (RUDN University), Russia, Moscow
| | - G K Kiyakbaev
- Peoples' Friendship University of Russia (RUDN University), Russia, Moscow
| | - Zh D Kobalava
- Peoples' Friendship University of Russia (RUDN University), Russia, Moscow
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50
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Russak AJ, Chaudhry F, De Freitas JK, Baron G, Chaudhry FF, Bienstock S, Paranjpe I, Vaid A, Ali M, Zhao S, Somani S, Richter F, Bawa T, Levy PD, Miotto R, Nadkarni GN, Johnson KW, Glicksberg BS. Machine Learning in Cardiology-Ensuring Clinical Impact Lives Up to the Hype. J Cardiovasc Pharmacol Ther 2020; 25:379-390. [PMID: 32495652 DOI: 10.1177/1074248420928651] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Despite substantial advances in the study, treatment, and prevention of cardiovascular disease, numerous challenges relating to optimally screening, diagnosing, and managing patients remain. Simultaneous improvements in computing power, data storage, and data analytics have led to the development of new techniques to address these challenges. One powerful tool to this end is machine learning (ML), which aims to algorithmically identify and represent structure within data. Machine learning's ability to efficiently analyze large and highly complex data sets make it a desirable investigative approach in modern biomedical research. Despite this potential and enormous public and private sector investment, few prospective studies have demonstrated improved clinical outcomes from this technology. This is particularly true in cardiology, despite its emphasis on objective, data-driven results. This threatens to stifle ML's growth and use in mainstream medicine. We outline the current state of ML in cardiology and outline methods through which impactful and sustainable ML research can occur. Following these steps can ensure ML reaches its potential as a transformative technology in medicine.
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Affiliation(s)
- Adam J Russak
- Department of Internal Medicine, Mount Sinai Hospital, New York, NY, USA.,Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Farhan Chaudhry
- Department of Emergency Medicine and Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
| | - Jessica K De Freitas
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Garrett Baron
- Department of Emergency Medicine and Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
| | - Fayzan F Chaudhry
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Solomon Bienstock
- Department of Internal Medicine, Mount Sinai Hospital, New York, NY, USA
| | - Ishan Paranjpe
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Akhil Vaid
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mohsin Ali
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shan Zhao
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sulaiman Somani
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Felix Richter
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tejeshwar Bawa
- Department of Emergency Medicine and Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
| | - Phillip D Levy
- Department of Emergency Medicine and Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
| | - Riccardo Miotto
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Girish N Nadkarni
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Nephrology, Mount Sinai Hospital, New York, NY, USA.,Division of Cardiology, Mount Sinai Hospital, New York, NY, USA.,Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kipp W Johnson
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Benjamin S Glicksberg
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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