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Gharagozloo K, Mehdizadeh M, Heckman G, Rose RA, Howlett J, Howlett SE, Nattel S. Heart Failure With Preserved Ejection Fraction in the Elderly Population: Basic Mechanisms and Clinical Considerations. Can J Cardiol 2024; 40:1424-1444. [PMID: 38604339 DOI: 10.1016/j.cjca.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/04/2024] [Accepted: 04/06/2024] [Indexed: 04/13/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) refers to a clinical condition in which the signs of heart failure, such as pulmonary congestion, peripheral edema, and increased natriuretic peptide levels, are present despite normal ejection fractions and the absence of other causes (eg, pericardial disease). The ejection fraction cutoff for the definition of HFpEF has varied in the past, but recent society guidelines have settled on a consensus of 50%. HFpEF is particularly common in the elderly population. The aim of this narrative review is to summarize the available literature regarding HFpEF in elderly patients in terms of evidence for the age dependence, specific clinical features, and underlying mechanisms. In the clinical arena, we review the epidemiology, discuss distinct clinical phenotypes typically seen in elderly patients, the importance of frailty, the role of biomarkers, and the role of medical therapies (including sodium-glucose cotransport protein 2 inhibitors, renin-angiotensin-aldosterone system blockers, angiotensin receptor/neprilysin inhibitors, diuretics, and β-adrenergic receptor blockers). We then go on to discuss the basic mechanisms implicated in HFpEF, including cellular senescence, fibrosis, inflammation, mitochondrial dysfunction, enhanced production of reactive oxygen species, abnormal cellular calcium handling, changes in microRNA signalling, insulin resistance, and sex hormone changes. Finally, we review knowledge gaps and promising areas of future investigation. Improved understanding of the specific clinical manifestations of HFpEF in elderly individuals and of the fundamental mechanisms that contribute to the age-related risk of HFpEF promises to lead to novel diagnostic and treatment approaches that will improve outcomes for this common cardiac disorder in a vulnerable population.
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Affiliation(s)
- Kimia Gharagozloo
- Montreal Heart Institute Research Center and Université de Montréal, Montréal, Quebec, Canada; McGill University Departments of Pharmacology and Therapeutics, Montréal, Quebec, Canada
| | - Mozhdeh Mehdizadeh
- Montreal Heart Institute Research Center and Université de Montréal, Montréal, Quebec, Canada; McGill University Departments of Pharmacology and Therapeutics, Montréal, Quebec, Canada
| | - George Heckman
- Schlegel Research Institute for Aging and University of Waterloo, Waterloo, Ontario, Canada
| | - Robert A Rose
- Department of Cardiac Sciences, Department of Physiology and Pharmacology, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan Howlett
- Libin Cardiovascular Institute and Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Susan E Howlett
- Departments of Pharmacology and Medicine (Geriatric Medicine), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Stanley Nattel
- Montreal Heart Institute Research Center and Université de Montréal, Montréal, Quebec, Canada; McGill University Departments of Pharmacology and Therapeutics, Montréal, Quebec, Canada; Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany.
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Núñez-Marín G, Iraola D, Lorenzo M, de la Espriella R, Villar S, Santas E, Miñana G, Sanchis J, Carratalá A, Miró Ò, Bayés-Genís A, Núñez J. An update on utilising brain natriuretic peptide for risk stratification, monitoring and guiding therapy in heart failure. Expert Rev Mol Diagn 2023:1-13. [PMID: 37216616 DOI: 10.1080/14737159.2023.2216386] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/04/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Heart failure (HF) is a dominant health problem with an overall poor prognosis. Natriuretic peptides (NPs) are upregulated in HF as a compensatory mechanism. They have extensively been used for diagnosis and risk stratification. AREAS COVERED This review addresses the history and physiology of NPs in order to understand their current role in clinical practice. It further provides a detailed and updated narrative review on the utility of those biomarkers for risk stratification, monitoring, and guiding therapy in HF. EXPERT OPINION NPs show excellent predictive ability in heart failure patients, both in acute and chronic settings. Understanding their pathophysiology and their modifications in specific situations is key for an adequate interpretation in specific clinical scenarios in which their prognostic value may be weaker or less well evaluated. To better promote risk stratification in HF, NPs should be integrated with other predictive tools to develop multiparametric risk models. Both inequalities of access to NPs and evidence caveats and limitations will need to be addressed by future research in the coming years.
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Affiliation(s)
- Gonzalo Núñez-Marín
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Diego Iraola
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Miguel Lorenzo
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Rafael de la Espriella
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Sandra Villar
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Enrique Santas
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Gema Miñana
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Arturo Carratalá
- Clinical Chemistry Department, Hospital Clínico Universitario, INCLIVA
| | - Òscar Miró
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Antoni Bayés-Genís
- Cardiology Department, Hospital Universitari Germas Trias i Pujol. Badalona, Spain
- CIBER Cardiovascular, Madrid, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
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B-Type Natriuretic Peptide at Admission Is a Predictor of All-Cause Mortality at One Year after the First Acute Episode of New-Onset Heart Failure with Preserved Ejection Fraction. J Pers Med 2022; 12:jpm12060890. [PMID: 35743676 PMCID: PMC9225135 DOI: 10.3390/jpm12060890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/11/2022] [Accepted: 05/23/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Heart failure with preserved ejection fraction (HFpEF) has been assessed extensively, but few studies analysed the predictive value of the NT-proBNP in patients with de novo and acute HFpEF. We sought to identify NT-proBNP at admission as a predictor for all-cause mortality and rehospitalisation at 12 months in patients with new-onset HFpEF. Methods: We analysed 91 patients (73 ± 11 years, 68% females) admitted for de novo and acute HFpEF, using the Cox proportional hazard risk model. Results: An admission NT-proBNP level above the threshold of 2910 pg/mL identified increased all-cause mortality at 12 months (AUC = 0.72, sensitivity = 92%, specificity = 53%, p < 0.001). All-cause mortality adjusted for age, gender, medical history, and medication in the augmented NT-proBNP group was 16-fold higher (p = 0.018), but with no difference in rehospitalisation rates (p = 0.391). The predictors of increased NT-proBNP ≥ 2910 pg/mL were: age (p = 0.016), estimated glomerular filtration rate (p = 0.006), left atrial volume index (p = 0.001), history of atrial fibrillation (p = 0.006), and TAPSE (p = 0.009). Conclusions: NT-proBNP above 2910 pg/mL at admission for de novo and acute HFpEF predicted a 16-fold increased mortality at 12 months, whereas values less than 2910 pg/mL forecast a high likelihood of survival (99.3%) in the next 12 months, and should be considered as a useful prognostic tool, in addition to its utility in diagnosing heart failure.
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Abudureyimu M, Luo X, Wang X, Sowers JR, Wang W, Ge J, Ren J, Zhang Y. OUP accepted manuscript. J Mol Cell Biol 2022; 14:6577125. [PMID: 35511596 PMCID: PMC9465638 DOI: 10.1093/jmcb/mjac028] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 11/30/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM or T2D) is a devastating metabolic abnormality featured by insulin resistance, hyperglycemia, and hyperlipidemia. T2D provokes unique metabolic changes and compromises cardiovascular geometry and function. Meanwhile, T2D increases the overall risk for heart failure (HF) and acts independent of classical risk factors including coronary artery disease, hypertension, and valvular heart diseases. The incidence of HF is extremely high in patients with T2D and is manifested as HF with preserved, reduced, and midrange ejection fraction (HFpEF, HFrEF, and HFmrEF, respectively), all of which significantly worsen the prognosis for T2D. HFpEF is seen in approximately half of the HF cases and is defined as a heterogenous syndrome with discrete phenotypes, particularly in close association with metabolic syndrome. Nonetheless, management of HFpEF in T2D remains unclear, largely due to the poorly defined pathophysiology behind HFpEF. Here, in this review, we will summarize findings from multiple preclinical and clinical studies as well as recent clinical trials, mainly focusing on the pathophysiology, potential mechanisms, and therapies of HFpEF in T2D.
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Affiliation(s)
| | | | - Xiang Wang
- Cardiovascular Department, Shanghai Xuhui Central Hospital, Fudan University, Shanghai 200031, China
| | - James R Sowers
- Diabetes and Cardiovascular Research Center, University of Missouri Columbia, Columbia, MO 65212, USA
| | - Wenshuo Wang
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jun Ren
- Correspondence to: Jun Ren, E-mail:
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De Luca M, Crisci G, Giardino F, Valente V, Amaranto I, Iacono O, D'Assante R, Giallauria F, Marra AM. Anabolic hormones and heart failure with preserved ejection fraction: looking for Ariadne's thread. Monaldi Arch Chest Dis 2021; 92. [PMID: 34351104 DOI: 10.4081/monaldi.2021.1743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 06/29/2021] [Indexed: 11/23/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a complex clinical syndrome that accounts for more than half of all heart failure patients. Identification, early diagnosis and management of patients are still complex, and no targeted treatment is available, since all tested drugs were not able to lower hard clinical outcomes. A multi-hormonal deficiency syndrome has been described in HFpEF patients suggesting that different hormones may represent new biomarkers of the disease, but their clinical utility is still debated. The natriuretic peptides are the cornerstone biomarker in heart failure, predicting cardiovascular death and heart failure hospitalization. Testosterone and DHEA-S deficiencies have been reported in HFpEF and associated with right ventricular impairment and diastolic dysfunction. IGFBP-1/IGF-1 axis correlates with echocardiographic parameters of HFpEF patients and with several prognostic biomarkers including NT-proBNP and C reactive protein. Low triiodothyronine syndrome is frequently found in HFpEF and thyroid hormones should represent a potential biomarker of risk stratification and prognosis.
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Affiliation(s)
| | - Giulia Crisci
- Department of Translational Medical Sciences, "Federico II" University, Naples.
| | - Federica Giardino
- Department of Translational Medical Sciences, "Federico II" University, Naples.
| | - Valeria Valente
- Department of Translational Medical Sciences, "Federico II" University, Naples.
| | - Ilaria Amaranto
- Department of Translational Medical Sciences, "Federico II" University, Naples.
| | - Olimpia Iacono
- Department of Translational Medical Sciences, "Federico II" University, Naples.
| | - Roberta D'Assante
- Department of Translational Medical Sciences, "Federico II" University, Naples.
| | | | - Alberto M Marra
- Department of Translational Medical Sciences, "Federico II" University, Naples.
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Schmitt W, Rühs H, Burghaus R, Diedrich C, Duwal S, Eissing T, Garmann D, Meyer M, Ploeger B, Lippert J. NT-proBNP Qualifies as a Surrogate for Clinical End Points in Heart Failure. Clin Pharmacol Ther 2021; 110:498-507. [PMID: 33630302 PMCID: PMC8360001 DOI: 10.1002/cpt.2222] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 01/27/2021] [Indexed: 12/11/2022]
Abstract
N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a well-established biomarker in heart failure (HF) but controversially discussed as a potential surrogate marker in HF trials. We analyzed the NT-proBNP/mortality relationship in real-world data (RWD) of 108,330 HF patients from the IBM Watson Health Explorys database and compared it with the NT-proBNP / clinical event end-point relationship in 20 clinical HF studies. With a hierarchical statistical model, we quantified the functional relationship and interstudy variability. To independently qualify the model, we predicted outcome hazard ratios in five phase III HF studies solely based on NT-proBNP measured early in the respective study. In RWD and clinical studies, the relationship between NT-proBNP and clinical outcome is well described by an Emax model. The NT-proBNP independent baseline risk (R0 , RWD/studies median (interstudy interquartile range): 5.5%/3.0% (1.7-4.9%)) is very low compared with the potential NT-proBNP-associated maximum risk (Rmax : 55.2%/79.4% (61.5-89.0%)). The NT-proBNP concentration associated with the half-maximal risk is comparable in RWD and across clinical studies (EC50 : 3,880/2,414 pg/mL (1,460-4,355 pg/mL)). Model-based predictions of phase III outcomes, relying on short-term NT-proBNP data only, match final trial results with comparable confidence intervals. Our analysis qualifies NT-proBNP as a surrogate for clinical outcome in HF trials. NT-proBNP levels after short treatment durations of less than 10 weeks quantitatively predict hazard ratios with confidence levels comparable to final trial readout. Early NT-proBNP measurement can therefore enable shorter and smaller but still reliable HF trials.
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Affiliation(s)
- Walter Schmitt
- PharmacometricsBayer AG ‐ PharmaceuticalsWuppertalGermany
| | - Hauke Rühs
- Quantitative PharmacologyBayer AG ‐ PharmaceuticalsWuppertalGermany
| | - Rolf Burghaus
- Systems Pharmacology & MedicineBayer AG ‐ PharmaceuticalsWuppertalGermany
| | - Christian Diedrich
- Systems Pharmacology & MedicineBayer AG ‐ PharmaceuticalsWuppertalGermany
| | - Sulav Duwal
- Systems Pharmacology & MedicineBayer AG ‐ PharmaceuticalsWuppertalGermany
| | - Thomas Eissing
- PharmacometricsBayer AG ‐ PharmaceuticalsWuppertalGermany
| | - Dirk Garmann
- Quantitative PharmacologyBayer AG ‐ PharmaceuticalsWuppertalGermany
| | - Michaela Meyer
- PharmacometricsBayer AG ‐ PharmaceuticalsWuppertalGermany
| | - Bart Ploeger
- PharmacometricsBayer AG ‐ PharmaceuticalsWuppertalGermany
| | - Jörg Lippert
- PharmacometricsBayer AG ‐ PharmaceuticalsWuppertalGermany
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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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Wang D, He Z, Chen S, Du J. The Relationship between Abnormal Circadian Blood Pressure Rhythm and Risk of Readmission in Patients with Heart Failure with Preserved Ejection Fraction. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2021. [DOI: 10.15212/cvia.2021.0014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Objective: Abnormal circadian blood pressure rhythm has been revealed to be associated with hypertensive target organ damage and cardiovascular events, but its association with readmission risk in patients with heart failure with preserved ejection fraction (HFpEF) remains unknown.
We conducted a retrospective study to explore the relationship between circadian blood pressure rhythm and readmission risk in HFpEF patients.Methods: We retrospectively collected baseline and follow-up data on HFpEF patients who underwent ambulatory blood pressure monitoring (ABPM)
from May 2015 to October 2019. Patient circadian blood pressure rhythms defined by ABPM were grouped as dipper, nondipper, or riser patterns. Univariate and multivariate linear regression analyses were performed to assess the association between circadian blood pressure rhythm and readmission
risk.Results: A total of 122 patients were enrolled in this study. The mean age and ejection fraction were 69.87 years and 61.44%, respectively, with mean the N-terminal pro-B-type natriuretic peptide (NT-proBNP) level being 1048.15 pg/mL. There were significant differences in the
24-hour systolic blood pressure (SBP), sleep SBP, and sleep diastolic blood pressure (DBP) among the three groups, where the 24-hour SBP, sleep SBP, and sleep DBP in the riser pattern group were markedly higher than in the dipper pattern group. Notably, serum NT-proBNP levels, the proportion
of patients readmitted for heart failure and the mean number of admissions differed markedly among three groups. Instructively, multivariate linear regression analysis showed that the riser pattern was a significant and independent risk factor for increased serum NT-proBNP level (β
= 929.16, 95% confidence interval 178.79‐1679.53, P = 0.016). In multivariate logistic regression analysis, the riser pattern was demonstrated to be a significant risk factor for readmission (odds ratio 11.23, 95% confidence interval 2.01‐62.67, P = 0.006) in HFpEF patients.Conclusion:
The riser blood pressure pattern is a potential risk factor for elevated serum NT-proBNP level and readmission in HFpEF patients.
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Affiliation(s)
- Diqing Wang
- Department of Cardiology, the First People’s Hospital of Fuyang District in Hangzhou, Hangzhou, 311400, China
| | - Zhengfei He
- Department of Cardiology, the First People’s Hospital of Fuyang District in Hangzhou, Hangzhou, 311400, China
| | - Sihua Chen
- Department of Cardiology, the First People’s Hospital of Fuyang District in Hangzhou, Hangzhou, 311400, China
| | - Jianlin Du
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
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Caprnda M, Zulli A, Shiwani HA, Kubatka P, Filipova S, Valentova V, Gazdikova K, Mozos I, Berukstis A, Laucevicius A, Rihacek I, Dragasek J, Prosecky R, Egom EE, Staffa R, Kruzliak P, Krasnik V. The therapeutic effect of B-type natriuretic peptides in acute decompensated heart failure. Clin Exp Pharmacol Physiol 2020; 47:1120-1133. [PMID: 32083749 DOI: 10.1111/1440-1681.13290] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/03/2020] [Accepted: 02/19/2020] [Indexed: 12/23/2022]
Abstract
B-type natriuretic peptide (BNP) exhibits roles in natriuresis and diuresis, making it an ideal drug that may aid in diuresing a fluid-overloaded patient with poor or worsening renal function. Several randomized clinical trials have tested the hypothesis that infusions of pharmacological doses of BNP to acute heart failure (HF) patients may enhance decongestion and preserve renal function in this clinical setting. Unfortunately, none of these have demonstrated beneficial outcomes. The current challenge for BNP research in acute HF lies in addressing a failure of concept and a reluctance to abandon an ineffective research model. Future success will necessitate a detailed understanding of the mechanism of action of BNP, as well as better integration of basic and clinical science.
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Affiliation(s)
- Martin Caprnda
- First Department of Internal Medicine, Faculty of Medicine, Comenius University and University Hospital, Bratislava, Slovakia
| | - Anthony Zulli
- Institute for Health and Sport, Victoria University, Melbourne, VIC, Australia
| | - Haaris A Shiwani
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Trust, Lancaster, UK
| | - Peter Kubatka
- Department of Medical Biology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
- Division of Oncology, Department of Experimental Carcinogenesis, Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Slavomira Filipova
- Department of Cardiology, National Institute of Cardiovascular Diseases and Slovak Medical University, Bratislava, Slovakia
| | - Vanda Valentova
- Division of Oncology, Department of Experimental Carcinogenesis, Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
- Independent Researcher, Mosjøen, Norway
| | - Katarina Gazdikova
- Department of Nutrition, Faculty of Nursing and Professional Health Studies, Slovak Medical University, Bratislava, Slovakia
- Department of General Medicine, Faculty of Medicine, Slovak Medical University, Bratislava, Slovakia
| | - Ioana Mozos
- Department of Functional Sciences, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
- Center for Translational Research and Systems Medicine, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Andrius Berukstis
- Clinic of Heart and Vessel Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Aleksandras Laucevicius
- Clinic of Heart and Vessel Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ivan Rihacek
- Second Department of Internal Medicine, Faculty of Medicine, Masaryk University and St, Anne´s University Hospital, Brno, Czech Republic
| | - Jozef Dragasek
- First Department of Psychiatry, Faculty of Medicine, Luis Pasteur University Hospital, Pavol Jozef Safarik University, Kosice, Slovakia
| | - Robert Prosecky
- Department of Internal Medicine, Brothers of Mercy Hospital, Brno, Czech Republic
| | - Emmanuel E Egom
- Egom Clinical & Translational Research Services Ltd, Dartmouth, NS, Canada
- Jewish General Hospital and Lady Davis Research Institute, Montreal, QC, Canada
| | - Robert Staffa
- Second Department of Surgery, Faculty of Medicine, St. Anne´s University Hospital, Masaryk University, Brno, Czech Republic
| | - Peter Kruzliak
- Department of Internal Medicine, Brothers of Mercy Hospital, Brno, Czech Republic
- Second Department of Surgery, Faculty of Medicine, St. Anne´s University Hospital, Masaryk University, Brno, Czech Republic
| | - Vladimir Krasnik
- Department of Ophthalmology, Faculty of Medicine, Comenius University and University Hospital, Bratislava, Slovakia
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10
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Mendez Fernandez AB, Ferrero-Gregori A, Garcia-Osuna A, Mirabet-Perez S, Pirla-Buxo MJ, Cinca-Cuscullola J, Ordonez-Llanos J, Roig Minguell E. Growth differentiation factor 15 as mortality predictor in heart failure patients with non-reduced ejection fraction. ESC Heart Fail 2020; 7:2223-2229. [PMID: 32589369 PMCID: PMC7524215 DOI: 10.1002/ehf2.12621] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 12/04/2019] [Accepted: 01/03/2020] [Indexed: 12/28/2022] Open
Abstract
Aims The prognostic value of biomarkers in patients with heart failure (HF) and mid‐range (HFmrEF) or preserved ejection fraction (HFpEF) has not been widely addressed. The aim of this study was to assess whether the prognostic value of growth differentiation factor 15 (GDF‐15) is superior to that of N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) in patients with HFmrEF or HFpEF. Methods and results Heart failure patients with either HFpEF or HFmrEF were included in the study. During their first visit to the HF unit, serum samples were obtained and stored for later assessment of GDF‐15 and NT‐proBNP concentrations. Patients were followed up by the HF unit. The main endpoint was all‐cause mortality. A total of 311 patients, 90 (29%) HFmrEF and 221 (71%) HFpEF, were included. Mean age was 72 ± 13 years, and 136 (44%) were women. No differences were found in GDF‐15 or NT‐proBNP concentrations between both HF groups. During a median follow‐up of 15 months (Q1–Q3: 9–30 months), 98 patients (32%) died, most (71%) of cardiovascular causes. Patients who died had higher median concentrations of GDF‐15 (4085 vs. 2270 ng/L, P < 0.0001) and NT‐proBNP (1984 vs. 1095 ng/L, P < 0.0001). A Cox multivariable model identified New York Heart Association Functional Class III (P = 0.04), systolic blood pressure (P = 0.01), left atrial diameter (P = 0.03), age >65 years (P < 0.0001), and GDF‐15 concentrations (P = 0.01) but not NT‐proBNP as independent predictors of all‐cause mortality. The area under the curve was 0.797 for the basic model including NT‐proBNP, and the area under the curve comparing the overall model was 0.819, P = 0.016 (DeLong's test). Integrated discrimination improvement index after the inclusion of GDF‐15 in the model with the mortality risk factors was 0.033; that is, the ability to predict death increased by 3.3% (P = 0.004). Net reclassification improvement was 0.548 (P < 0.001); that is, the capacity to improve the classification of the event (mortality) was 54.8%. GDF‐15 concentrations were divided in tertiles (<1625, 1625–4330, and >4330 ng/L), and survival curves were evaluated using the Kaplan–Meier technique. Patients in the highest tertile had the poorest 5 year survival, at 16%, whereas the lowest tertile had the best survival, of 78% (P < 0.001). Conclusions Growth differentiation factor 15 was superior to NT‐proBNP for assessing prognosis in patients with HFpEF and HFmrEF. GDF‐15 emerges as a strong, independent biomarker for identifying HFmrEF and HFpEF patients with worse prognosis.
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Affiliation(s)
| | | | | | - Sonia Mirabet-Perez
- Department of Cardiology, CIBERCV, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - Jordi Ordonez-Llanos
- Department of Biochemistry, IIB-Sant Pau, Barcelona, Spain.,Department of Biochemistry and Molecular Biology, Universitat Autònoma, Barcelona, Spain
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11
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Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GFM, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
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Affiliation(s)
- Meaghan Lunney
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Marinella Ruospo
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Patrizia Natale
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Robert R Quinn
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Paul E Ronksley
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical CenterDepartment of Medicine3459 Fifth AvenuePittsburghPAUSA15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of OtagoDepartment of Medicine, NephrologistChristchurchNew Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Pietro Ravani
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
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12
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Pellicori P, Ferreira JP, Mariottoni B, Brunner-La Rocca HP, Ahmed FZ, Verdonschot J, Collier T, Cuthbert JJ, Petutschnigg J, Mujaj B, Girerd N, González A, Clark AL, Cosmi F, Staessen JA, Heymans S, Latini R, Rossignol P, Zannad F, Cleland JGF. Effects of spironolactone on serum markers of fibrosis in people at high risk of developing heart failure: rationale, design and baseline characteristics of a proof-of-concept, randomised, precision-medicine, prevention trial. The Heart OMics in AGing (HOMAGE) trial. Eur J Heart Fail 2020; 22:1711-1723. [PMID: 31950604 DOI: 10.1002/ejhf.1716] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 11/18/2019] [Accepted: 11/21/2019] [Indexed: 12/12/2022] Open
Abstract
AIMS Asymptomatic patients with coronary artery disease (CAD), hypertension and/or type 2 diabetes mellitus (T2DM) are at greater risk of developing heart failure (HF). Fibrosis, leading to myocardial and vascular dysfunction, might be an important pathway of progression. The Heart OMics in AGing (HOMAGE) trial aims to investigate the effects of spironolactone on serum markers of collagen metabolism and on cardiovascular structure and function in people at risk of developing HF and potential interactions with a marker of fibrogenic activity, galectin-3. METHODS AND RESULTS The HOMAGE trial is a prospective, randomised, open-label, blinded endpoint (PROBE) study comparing spironolactone (up to 50 mg/day) and standard care over 9 months in people with clinical risk factors for developing HF, including hypertension, CAD and T2DM, and elevated plasma concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP, 125 to 1000 ng/L) or B-type natriuretic peptide (BNP, 35 to 280 ng/L). Exclusion criteria included left ventricular ejection fraction < 45%, atrial fibrillation, severe renal dysfunction, or treatment with loop diuretics. The primary endpoint was the interaction between change in serum concentrations of procollagen type III N-terminal propeptide (PIIINP) and treatment with spironolactone according to median plasma concentrations of galectin-3 at baseline. For the 527 participants enrolled, median (interquartile range) age was 73 (69-79) years, 135 (26%) were women, 412 (78%) had hypertension, 377 (72%) CAD, and 212 (40%) T2DM. At baseline, medians (interquartile ranges) were for left ventricular ejection fraction 63 (58-67) %, for left atrial volume index 31 (26-37) mL/m2 , for plasma NT-proBNP 214 (137-356) ng/L, for serum PIIINP 3.9 (3.1-5.0) ng/mL, and for galectin-3 16.1 (13.5-19.7) ng/mL. CONCLUSIONS The HOMAGE trial will provide insights on the effect of spironolactone on pathways that might drive progression to HF. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT02556450.
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Affiliation(s)
- Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - João Pedro Ferreira
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy,Institut Lorrain du Coeur et des Vaisseaux, FCRIN INI-CRCT, Nancy, France
| | | | | | - Fozia Z Ahmed
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Job Verdonschot
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Tim Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Joe J Cuthbert
- Department of Academic Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - Johannes Petutschnigg
- Department of Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Center of Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Blerim Mujaj
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy,Institut Lorrain du Coeur et des Vaisseaux, FCRIN INI-CRCT, Nancy, France
| | - Arantxa González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain.,CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Andrew L Clark
- Department of Academic Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - Franco Cosmi
- Department of Cardiology, Cortona Hospital, Arezzo, Italy
| | - Jan A Staessen
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Stephane Heymans
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, KU Leuven, Leuven, Belgium.,The Netherlands Heart Institute, Utrecht, The Netherlands
| | - Roberto Latini
- Department of Cardiovascular Medicine, Istituto di Ricerche Farmacologiche Mario Negri, IRCCS, Milan, Italy
| | - Patrick Rossignol
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy,Institut Lorrain du Coeur et des Vaisseaux, FCRIN INI-CRCT, Nancy, France
| | - Faiez Zannad
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy,Institut Lorrain du Coeur et des Vaisseaux, FCRIN INI-CRCT, Nancy, France
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK
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13
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Litwin SE, Zile MR. Should We Test for Diastolic Dysfunction? How and How Often? JACC Cardiovasc Imaging 2020; 13:297-309. [DOI: 10.1016/j.jcmg.2019.02.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 02/14/2019] [Accepted: 02/20/2019] [Indexed: 01/24/2023]
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14
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Lam CSP, Gamble GD, Ling LH, Sim D, Leong KTG, Yeo PSD, Ong HY, Jaufeerally F, Ng TP, Cameron VA, Poppe K, Lund M, Devlin G, Troughton R, Richards AM, Doughty RN. Mortality associated with heart failure with preserved vs. reduced ejection fraction in a prospective international multi-ethnic cohort study. Eur Heart J 2019; 39:1770-1780. [PMID: 29390051 DOI: 10.1093/eurheartj/ehy005] [Citation(s) in RCA: 182] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 01/11/2018] [Indexed: 11/13/2022] Open
Abstract
Aims Whether prevalence and mortality of patients with heart failure with preserved or mid-range (40-49%) ejection fraction (HFpEF and HFmREF) are similar to those of heart failure with reduced ejection fraction (HFrEF), as reported in some epidemiologic studies, remains highly controversial. We determined and compared characteristics and outcomes for patients with HFpEF, HFmREF, and HFrEF in a prospective, international, multi-ethnic population. Methods and results Prospective multi-centre longitudinal study in New Zealand (NZ) and Singapore. Patients with HF were assessed at baseline and followed over 2 years. The primary outcome was death from any cause. Secondary outcome was death and HF hospitalization. Cox proportional hazards models were used to compare outcomes for patients with HFpEF, HFmrEF, and HFrEF. Of 2039 patients enrolled, 28% had HFpEF, 13% HFmrEF, and 59% HFrEF. Compared with HFrEF, patients with HFpEF were older (62 vs. 72 years), more commonly female (17% vs. 48%), and more likely to have a history of hypertension (61% vs. 78%) but less likely to have coronary artery disease (55% vs. 41%). During 2 years of follow-up, 343 (17%) patients died. Adjusting for age, sex, and clinical risk factors, patients with HFpEF had a lower risk of death compared with those with HFrEF (hazard ratio 0.62, 95% confidence interval 0.46-0.85). Plasma (NT-proBNP) was similarly related to mortality in both HFpEF, HFmrEF, and HFrEF independent of the co-variates listed and of ejection fraction. Results were similar for the composite endpoint of death or HF and were consistent between Singapore and NZ. Conclusion These prospective multinational data showed that the prevalence of HFpEF within the HF population was lower than HFrEF. Death rate was comparable in HFpEF and HFmrEF and lower than in HFrEF. Plasma levels of NT-proBNP were independently and similarly predictive of death in the three HF phenotypes. Trial Registration Australian New Zealand Clinical Trial Registry (ACTRN12610000374066).
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Affiliation(s)
- Carolyn S P Lam
- Cardiovascular Research Institute, National University Health System, 1E Kent Ridge Road, Singapore 119228.,National Heart Centre Singapore and Duke-National University of Singapore, 5 Hospital Drive, Singapore 169609
| | - Greg D Gamble
- Heart Health Research Group, University of Auckland, Park Road, Grafton, Auckland 1023, New Zealand
| | - Lieng H Ling
- Cardiovascular Research Institute, National University Health System, 1E Kent Ridge Road, Singapore 119228.,National Heart Centre Singapore and Duke-National University of Singapore, 5 Hospital Drive, Singapore 169609
| | - David Sim
- National Heart Centre Singapore and Duke-National University of Singapore, 5 Hospital Drive, Singapore 169609
| | | | | | - Hean Yee Ong
- Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828
| | | | - Tze P Ng
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road Singapore, Singapore 119228
| | - Vicky A Cameron
- Christchurch Heart Institute, University of Otago, 2 Riccarton Avenue, Christchurch 8011, New Zealand
| | - Katrina Poppe
- Heart Health Research Group, University of Auckland, Park Road, Grafton, Auckland 1023, New Zealand
| | - Mayanna Lund
- Middlemore Hospital, 100 Hospital Road, Otahuhu, Auckland 2025, NZ
| | - Gerry Devlin
- Waikato Hospital, Pembroke Street, Hamilton 3204, New Zealand
| | - Richard Troughton
- Christchurch Heart Institute, University of Otago, 2 Riccarton Avenue, Christchurch 8011, New Zealand
| | - A Mark Richards
- Cardiovascular Research Institute, National University Health System, 1E Kent Ridge Road, Singapore 119228.,Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road Singapore, Singapore 119228.,Christchurch Heart Institute, University of Otago, 2 Riccarton Avenue, Christchurch 8011, New Zealand
| | - Robert N Doughty
- Heart Health Research Group, University of Auckland, Park Road, Grafton, Auckland 1023, New Zealand
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15
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Vinnakota S, Scott CG, Rodeheffer RJ, Chen HH. Estimated Glomerular Filtration Rate, Activation of Cardiac Biomarkers and Long-Term Cardiovascular Outcomes: A Population-Based Cohort. Mayo Clin Proc 2019; 94:2189-2198. [PMID: 31668448 PMCID: PMC6959123 DOI: 10.1016/j.mayocp.2019.03.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 02/28/2019] [Accepted: 03/18/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To classify subjects in a general population per their renal function and characterize the cardiac biomarker levels, left ventricular function and cardiovascular outcomes over a 10.2 year follow-up period (interquartile range, 5.1-11.4 years). METHODS This was a retrospective review of a population-based random sample of residents aged ≥45 years. Data were collected between January 1, 1997, and December 31, 2000. One thousand nine hundred eighty-one individuals were classified based on estimated glomerular filtration rate (eGFR) into group I (>90 mL/min/1.73 m2), group II (60 to 89 mL/min/1.73 m2) and group III (<60 mL/min/1.73 m2; chronic kidney disease [CKD]). Age/sex-adjusted baseline characteristics, tertiles of N-terminal pro B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (hs-TnT) and their interactions with eGFR were examined. Outcomes measured included incident myocardial infarction (MI), congestive heart failure, stroke, and all-cause mortality. RESULTS Eight hundred nineteen patients were classified as group I, 1036 as group II, and 126 of 1981 (6.4%) as group III or CKD. Subjects in group III were older and had a higher incidence of hypertension, diabetes, and MI at baseline. Over a 10.2-year follow-up period, CKD was associated with an increased risk of MI (hazard ratio, 1.95; 95% CI, 1.2-3.14; P=.006) and composite cardiovascular outcomes including MI, congestive heart failure, stroke, and all-cause mortality (hazard ratio, 1.38; 95% CI, 1.05-1.83 ;P=.02). Subjects with NT-proBNP or hs-TnT in the third tertile were at greater risk of cardiovascular events without significant interactions between eGFR and levels of NT-proBNP and hs-TnT. CONCLUSION Subjects with CKD had significantly elevated cardiac biomarkers and were at an increased risk of MI and adverse cardiovascular events. This warrants future studies to investigate whether these cardiac biomarkers could identify high-risk CKD patients for aggressive management of cardiovascular risk factors.
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Affiliation(s)
| | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Horng H Chen
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
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16
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Vergaro G, Ghionzoli N, Innocenti L, Taddei C, Giannoni A, Valleggi A, Borrelli C, Senni M, Passino C, Emdin M. Noncardiac Versus Cardiac Mortality in Heart Failure With Preserved, Midrange, and Reduced Ejection Fraction. J Am Heart Assoc 2019; 8:e013441. [PMID: 31587602 PMCID: PMC6818034 DOI: 10.1161/jaha.119.013441] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background A thorough analysis of noncardiac determinants of mortality in heart failure (HF) is missing. Furthermore, evidence conflicts on the outcome of patients with HF and no or mild systolic dysfunction. We aimed to investigate the prevalence of noncardiac and cardiac causes of death in a cohort of chronic HF patients, covering the whole spectrum of systolic function. Methods and Results We enrolled 2791 stable HF patients, classified into HF with reduced ejection fraction (HFrEF; left ventricular ejection fraction [EF] <40%), HR with midrange EF (HFmrEF; left ventricular EF 41–49%), or HF with preserved EF (HFpEF; left ventricular EF ≥50%), and followed up for all‐cause, cardiac, and noncardiac mortality (adjudicated as due to cancer, sepsis, respiratory disease, renal disease, or other causes). Over follow‐up of 39 months, adjusted mortality was lower in HFpEF and HFmrEF versus HFrEF (hazard ratio: 0.75 [95% CI, 0.67–0.84], P<0.001 for HFpEF; hazard ratio: 0.78 [95% CI, 0.63–0.96], P=0.017 for HFmrEF). HFrEF had the highest rates of cardiac death, whereas noncardiac mortality was similar across left ventricular EF categories. Noncardiac causes accounted for 62% of deaths in HFpEF, 54% in HFmrEF and 35% in HFrEF; cancer was twice as frequent as a cause of death in HFpEF and HFmrEF versus HFrEF. Yearly rates of noncardiac death exceeded those of cardiac death since the beginning of follow‐up in HFpEF and HFmrEF. Conclusions Noncardiac death is a major determinant of outcome in stable HF, exceeding cardiac‐related mortality in HFpEF and HFmrHF. Comorbidities should be regarded as main therapeutic targets and objects of dedicated quality improvement initiatives, especially in patients with no or mild systolic dysfunction.
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Affiliation(s)
- Giuseppe Vergaro
- Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy.,Division of Cardiology and Cardiovascular Medicine Fondazione Toscana Gabriele Monasterio Pisa Italy
| | - Nicolò Ghionzoli
- Division of Cardiology and Cardiovascular Medicine Fondazione Toscana Gabriele Monasterio Pisa Italy
| | - Lisa Innocenti
- Division of Cardiology and Cardiovascular Medicine Fondazione Toscana Gabriele Monasterio Pisa Italy
| | - Claudia Taddei
- Division of Cardiology and Cardiovascular Medicine Fondazione Toscana Gabriele Monasterio Pisa Italy
| | - Alberto Giannoni
- Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy.,Division of Cardiology and Cardiovascular Medicine Fondazione Toscana Gabriele Monasterio Pisa Italy
| | - Alessandro Valleggi
- Division of Cardiology and Cardiovascular Medicine Fondazione Toscana Gabriele Monasterio Pisa Italy
| | - Chiara Borrelli
- Division of Cardiology and Cardiovascular Medicine Fondazione Toscana Gabriele Monasterio Pisa Italy
| | - Michele Senni
- Cardiology Division Cardiovascular Department Papa Giovanni XXIII Hospital Bergamo Italy
| | - Claudio Passino
- Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy.,Division of Cardiology and Cardiovascular Medicine Fondazione Toscana Gabriele Monasterio Pisa Italy
| | - Michele Emdin
- Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy.,Division of Cardiology and Cardiovascular Medicine Fondazione Toscana Gabriele Monasterio Pisa Italy
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Lin KY, Wu ZY, You ZB, Zheng WP, Lin CJ, Jiang H, Ruan JM, Guo YS, Zhu PL. Pre-Procedural N-Terminal Pro-B Type Natriuretic Peptide Predicts Contrast-Induced Acute Kidney Injury and Long-Term Outcome in Elderly Patients After Elective Percutaneous Coronary Intervention. Int Heart J 2018; 59:926-934. [PMID: 30158378 DOI: 10.1536/ihj.17-573] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of the study is to evaluate the association of pre-procedural N-terminal pro-B type natriuretic peptide (NT-proBNP) with contrast-induced acute kidney injury (CI-AKI) and long-term outcomes in elderly patients undergoing elective percutaneous coronary intervention (PCI).A total of 540 patients aged ≥ 75 years who had undergone elective PCI between January 2012 and December 2015 were enrolled in this study. Admission NT-proBNP levels were measured before PCI. CI-AKI was defined as a relative increase in serum creatinine (SCr) of ≥50%, or an absolute increase of ≥ 0.3 mg/dL, occurring within 48 hours after contrast medium exposure. The predictive value of NT-proBNP for predicting CI-AKI was assessed by receiver operating characteristic (ROC) and multivariable logistic regression analysis.A total of 54 (10.0%) patients developed CI-AKI. The best cutoff value of NT-pro-BNP for detecting CI-AKI was 1133 pg/mL with 66.7% sensitivity and 70.8% specificity according to the ROC analysis (C statistic = 0.719; 95% CI, 0.679-0.756). Multivariable analysis demonstrated that Lg-NT-proBNP is significantly related to CI-AKI (odds ratio [OR] = 3.892; 95% CI, 1.996-7.590; P < 0.001). Cox regression analysis showed that Lg-NT-proBNP is associated with long-term mortality (adjusted hazard ratio [HR] = 2.158; 95% CI, 1.246-3.740; P = 0.006) during follow-up.Pre-procedural NT-proBNP is a significant and independent predictor of CI-AKI and long-term mortality in elderly patients following elective PCI, and the best cutoff point for predicting CI-AKI was 1133 pg/mL.
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Affiliation(s)
- Kai-Yang Lin
- Department of Cardiology, Fujian Provincial Hospital, Fujian Medical University, Fujian Cardiovascular Institute
| | - Zhi-Yong Wu
- Department of Cardiology, Fujian Provincial Hospital, Fujian Medical University, Fujian Cardiovascular Institute
| | - Zhe-Bin You
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Provincial Institute of Clinical Geriatrics, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University
| | - Wei-Ping Zheng
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Provincial Institute of Clinical Geriatrics, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University
| | - Chun-Jin Lin
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Provincial Institute of Clinical Geriatrics, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University
| | - Hui Jiang
- Department of Cardiology, Fujian Provincial Hospital, Fujian Medical University, Fujian Cardiovascular Institute
| | - Jing-Ming Ruan
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Provincial Institute of Clinical Geriatrics, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University
| | - Yan-Song Guo
- Department of Cardiology, Fujian Provincial Hospital, Fujian Medical University, Fujian Cardiovascular Institute
| | - Peng-Li Zhu
- Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Provincial Institute of Clinical Geriatrics, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics, Fujian Medical University
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Martin N, Manoharan K, Thomas J, 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 2018; 6:CD012721. [PMID: 29952095 PMCID: PMC6513293 DOI: 10.1002/14651858.cd012721.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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. There is uncertainty whether these treatments are beneficial for people with heart failure with preserved ejection fraction and a comprehensive review of the evidence is required. 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 heart failure with preserved ejection fraction. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two clinical trial registries on 25 July 2017 to identify eligible studies. Reference lists from primary studies and review articles were checked for additional studies. There were no language or date restrictions. SELECTION CRITERIA We included randomised controlled trials with a parallel group design enrolling adult participants with heart failure with preserved ejection fraction, defined by a left ventricular ejection fraction of greater than 40 percent. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion and extracted data. The outcomes assessed included cardiovascular mortality, heart failure hospitalisation, hyperkalaemia, all-cause mortality and quality of life. Risk ratios (RR) and, where possible, hazard ratios (HR) were calculated for dichotomous outcomes. For continuous data, mean difference (MD) or standardised mean difference (SMD) were calculated. We contacted trialists where neccessary to obtain missing data. MAIN RESULTS 37 randomised controlled trials (207 reports) were included across all comparisons with a total of 18,311 participants.Ten studies (3087 participants) investigating beta-blockers (BB) were included. A pooled analysis indicated a reduction in cardiovascular mortality (15% of participants in the intervention arm versus 19% in the control arm; RR 0.78; 95% confidence interval (CI) 0.62 to 0.99; number needed to treat to benefit (NNTB) 25; 1046 participants; 3 studies). However, the quality of evidence was low and no effect on cardiovascular mortality was observed when the analysis was limited to studies with a low risk of bias (RR 0.81; 95% CI 0.50 to 1.29; 643 participants; 1 study). There was no effect on all-cause mortality, heart failure hospitalisation or quality of life measures, however there is uncertainty about these effects given the limited evidence available.12 studies (4408 participants) investigating mineralocorticoid receptor antagonists (MRA) were included with the quality of evidence assessed as moderate. MRA treatment reduced heart failure hospitalisation (11% of participants in the intervention arm versus 14% in the control arm; RR 0.82; 95% CI 0.69 to 0.98; NNTB 41; 3714 participants; 3 studies; moderate-quality evidence) however, little or no effect on all-cause and cardiovascular mortality and quality of life measures was observed. MRA treatment was associated with a greater risk of hyperkalaemia (16% of participants in the intervention group versus 8% in the control group; RR 2.11; 95% CI 1.77 to 2.51; 4291 participants; 6 studies; high-quality evidence).Eight studies (2061 participants) investigating angiotensin converting enzyme inhibitors (ACEI) were included with the overall quality of evidence assessed as moderate. The evidence suggested that ACEI treatment likely has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. Data for the effect of ACEI on hyperkalaemia were only available from one of the included studies.Eight studies (8755 participants) investigating angiotensin receptor blockers (ARB) were included with the overall quality of evidence assessed as high. The evidence suggested that treatment with ARB has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. ARB was associated with an increased risk of hyperkalaemia (0.9% of participants in the intervention group versus 0.5% in the control group; RR 1.88; 95% CI 1.07 to 3.33; 7148 participants; 2 studies; high-quality evidence).We identified a single ongoing placebo-controlled study investigating the effect of angiotensin receptor neprilysin inhibitors (ARNI) in people with heart failure with preserved ejection fraction. AUTHORS' CONCLUSIONS There is evidence that MRA treatment reduces heart failure hospitalisation in heart failure with preserverd ejection fraction, however the effects on mortality related outcomes and quality of life remain unclear. The available evidence for beta-blockers, ACEI, ARB and ARNI is limited and it remains uncertain whether these treatments have a role in the treatment of HFpEF in the absence of an alternative indication for their use. This comprehensive review highlights a persistent gap in the evidence that is currently being addressed through several large ongoing clinical trials.
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Affiliation(s)
- Nicole Martin
- University College LondonFarr Institute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Karthick Manoharan
- John Radcliffe HospitalEmergency Department3 Sherwood AvenueLondonMiddlesexUKUb6 0pg
| | - James Thomas
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of EducationLondonUK
| | - Ceri Davies
- Barts Heart Centre, St Bartholomew's HospitalDepartment of CardiologyWest SmithfieldLondonUKEC1A 7BE
| | - R Thomas Lumbers
- University College LondonInstitute of Health InformaticsLondonUK
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19
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Savarese G, Orsini N, Hage C, Dahlström U, Vedin O, Rosano GM, Lund LH. Associations With and Prognostic and Discriminatory Role of N-Terminal Pro–B-Type Natriuretic Peptide in Heart Failure With Preserved Versus Mid-range Versus Reduced Ejection Fraction. J Card Fail 2018; 24:365-374. [DOI: 10.1016/j.cardfail.2018.03.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 01/22/2018] [Accepted: 03/20/2018] [Indexed: 11/26/2022]
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20
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Kasahara S, Sakata Y, Nochioka K, Yamauchi T, Onose T, Tsuji K, Abe R, Oikawa T, Sato M, Aoyanagi H, Miura M, Shiroto T, Takahashi J, Miyata S, Shimokawa H. Comparable prognostic impact of BNP levels among HFpEF, Borderline HFpEF and HFrEF: a report from the CHART-2 Study. Heart Vessels 2018; 33:997-1007. [DOI: 10.1007/s00380-018-1150-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 03/09/2018] [Indexed: 10/17/2022]
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21
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Ezekowitz JA, O'Meara E, McDonald MA, Abrams H, Chan M, Ducharme A, Giannetti N, Grzeslo A, Hamilton PG, Heckman GA, Howlett JG, Koshman SL, Lepage S, McKelvie RS, Moe GW, Rajda M, Swiggum E, Virani SA, Zieroth S, Al-Hesayen A, Cohen-Solal A, D'Astous M, De S, Estrella-Holder E, Fremes S, Green L, Haddad H, Harkness K, Hernandez AF, Kouz S, LeBlanc MH, Masoudi FA, Ross HJ, Roussin A, Sussex B. 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure. Can J Cardiol 2017; 33:1342-1433. [PMID: 29111106 DOI: 10.1016/j.cjca.2017.08.022] [Citation(s) in RCA: 435] [Impact Index Per Article: 62.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 08/28/2017] [Accepted: 08/28/2017] [Indexed: 02/06/2023] Open
Abstract
Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.
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Affiliation(s)
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | - Michael Chan
- Edmonton Cardiology Consultants, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Adam Grzeslo
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Serge Lepage
- Université de Sherbrooke, Sherbrooke, Québec, Canada
| | | | | | - Miroslaw Rajda
- QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Sean A Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Sabe De
- London Health Sciences, Western University, London, Ontario, Canada
| | | | - Stephen Fremes
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lee Green
- University of Alberta, Edmonton, Alberta, Canada
| | - Haissam Haddad
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Karen Harkness
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Simon Kouz
- Centre Hospitalier Régional de Lanaudière, Joliette, Québec, Canada
| | | | | | | | - Andre Roussin
- Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Bruce Sussex
- Memorial University, St John's, Newfoundland, Canada
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22
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Oskouie SK, Prenner SB, Shah SJ, Sauer AJ. Differences in Repolarization Heterogeneity Among Heart Failure With Preserved Ejection Fraction Phenotypic Subgroups. Am J Cardiol 2017; 120:601-606. [PMID: 28651852 DOI: 10.1016/j.amjcard.2017.05.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 05/04/2017] [Accepted: 05/04/2017] [Indexed: 12/22/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a highly heterogeneous syndrome associated with multiple medical comorbidities and pathophysiologic pathways or phenotypes. We recently developed a phenomapping method combining deep phenotyping with machine learning analysis to classify HFpEF patients into 3 clinically distinct phenotypic subgroups (phenogroups) with different clinical outcomes. Phenogroup #1 was younger with lower B-type natriuretic peptide levels, phenogroup #2 had the highest prevalence of obesity and diabetes mellitus, and phenogroup #3 was the oldest with the most factors for chronic kidney disease, the most dysfunctional myocardial mechanics, and the highest adverse outcomes. The pathophysiological differences between these phenogroups, however, remain incompletely described. We sought to evaluate whether these 3 groups differ on the basis of repolarization heterogeneity, which has previously been linked to adverse outcomes in HFpEF. The T-peak to T-end (TpTe) interval, a well-validated index of repolarization heterogeneity, was measured by 2 readers blinded to each other and all other clinical data on the electrocardiograms of 201 HFpEF patients enrolled in a systematic observational study. TpTe duration was associated with higher B-type natriuretic peptide level (p = 0.006), increased QRS-T angle (p = 0.008), and lower septal e' velocity (p = 0.007). TpTe duration was greatest in phenogroup #3 (100.4 ± 24.5 ms) compared with phenogroups #1 (91.2 ± 17.3 ms) and #2 (90.2 ± 17.0 ms) (p = 0.0098). On multivariable analyses, increased TpTe was independently associated with the high-risk phenogroup #3 classification. In conclusion, repolarization heterogeneity is a marker of a specific subset of HFpEF patients identified using unsupervised machine learning analysis and therefore may be a key pathophysiologic marker in this subset of HFpEF patients.
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23
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Dovancescu S, Pellicori P, Mabote T, Torabi A, Clark AL, Cleland JGF. The effects of short-term omission of daily medication on the pathophysiology of heart failure. Eur J Heart Fail 2017; 19:643-649. [PMID: 28295907 PMCID: PMC5434940 DOI: 10.1002/ejhf.748] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 12/13/2022] Open
Abstract
Aims Pharmacological therapies for heart failure (HF) aim to improve congestion, symptoms, and prognosis. Failing to take medication is a potential cause of worsening HF. Characterizing the effects of short‐term medication omission could inform the development of better technologies and strategies to detect and interpret the reasons for worsening HF. We examined the effect of planned HF medication omission for 48 h on weight, echocardiograms, transthoracic bio‐impedance, and plasma concentrations of NT‐proBNP. Methods and results Outpatients with stable HF and an LVEF <45% were assigned to take or omit their HF medication for 48 h in a randomized, crossover trial. Twenty patients (16 men, LVEF 32 ± 9%, median NT‐proBNP 962 ng/L) were included. Compared with regular medication, omission led to an increase in NT‐proBNP by 99% (from 962 to 1883 ng/L, P < 0.001), systolic blood pressure by 16% (from 131 to 152 mmHg, P < 0.001), and left atrial volume by 21% (from 69 to 80 mL, P = 0.001), and reductions in transthoracic bio‐impedance by 10% (from 33 to 30 Σ, P = 0.001) and serum creatinine by 8% (from 135 to 118 µmol/L, P = 0.012). No significant changes in body weight, heart rate, or LVEF were observed. Conclusions The characteristic pattern of response to short‐term medication omission is of increasing congestion but, in contrast to the pattern reported for disease progression, with a rise in blood pressure and improved renal function. In stable HF, weight is not a sensitive marker of short‐term diuretic omission.
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Affiliation(s)
- Silviu Dovancescu
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, UK.,Philips Research, Eindhoven, The Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Pierpaolo Pellicori
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, UK
| | - Thato Mabote
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, UK
| | - Azam Torabi
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, UK
| | - Andrew L Clark
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, UK
| | - John G F Cleland
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, UK.,National Heart & Lung Institute and National Institute of Health Research, Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield Hospitals, Imperial College, London, UK
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24
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Cardiac Dysfunction, Congestion and Loop Diuretics: their Relationship to Prognosis in Heart Failure. Cardiovasc Drugs Ther 2017; 30:599-609. [PMID: 27819111 DOI: 10.1007/s10557-016-6697-7] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Diuretics are the mainstay of treatment for congestion but concerns exist that they adversely affect prognosis. We explored whether the relationship between loop diuretic use and outcome is explained by the underlying severity of congestion amongst patients referred with suspected heart failure. METHOD AND RESULTS Of 1190 patients, 712 had a left ventricular ejection fraction (LVEF) ≤50 %, 267 had LVEF >50 % with raised plasma NTproBNP (>400 ng/L) and 211 had LVEF >50 % with NTproBNP ≤400 ng/L; respectively, 72 %, 68 % and 37 % of these groups were treated with loop diuretics including 28 %, 29 % and 10 % in doses ≥80 mg furosemide equivalent/day. Compared to patients with cardiac dysfunction (either LVEF ≤50 % or NT-proBNP >400 ng/L) but not taking a loop diuretic, those taking a loop diuretic were older and had more clinical evidence of congestion, renal dysfunction, anaemia and hyponatraemia. During a median follow-up of 934 (IQR: 513-1425) days, 450 patients were hospitalized for HF or died. Patients prescribed loop diuretics had a worse outcome. However, in multi-variable models, clinical, echocardiographic (inferior vena cava diameter), and biochemical (NTproBNP) measures of congestion were strongly associated with an adverse outcome but not the use, or dose, of loop diuretics. CONCLUSIONS Prescription of loop diuretics identifies patients with more advanced features of heart failure and congestion, which may account for their worse prognosis. Further research is needed to clarify the relationship between loop diuretic agents and outcome; imaging and biochemical measures of congestion might be better guides to diuretic dose than symptoms or clinical signs.
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25
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DeVore AD, McNulty S, Alenezi F, Ersboll M, Vader JM, Oh JK, Lin G, Redfield MM, Lewis G, Semigran MJ, Anstrom KJ, Hernandez AF, Velazquez EJ. Impaired left ventricular global longitudinal strain in patients with heart failure with preserved ejection fraction: insights from the RELAX trial. Eur J Heart Fail 2017; 19:893-900. [PMID: 28194841 DOI: 10.1002/ejhf.754] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 11/23/2016] [Accepted: 11/24/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND While abnormal left ventricular (LV) global longitudinal strain (GLS) has been described in patients with heart failure with preserved ejection fraction (HFpEF), its prevalence and clinical significance are poorly understood. METHODS AND RESULTS Patients enrolled in the RELAX trial of sildenafil in HFpEF (LV ejection fraction ≥50%) in whom two-dimensional, speckle-tracking LV GLS was possible (n = 187) were analysed. The distribution of LV GLS and its associations with clinical characteristics, LV structure and function, biomarkers, exercise capacity and quality of life were assessed. Baseline median LV GLS was -14.6% (25th and 75th percentile, -17.0% and -11.9%, respectively) and abnormal (≥ - 16%) in 122/187 (65%) patients. Patients in the tertile with the best LV GLS had lower N-terminal pro-brain natriuretic peptide (NT-proBNP) [median 505 pg/mL (161, 1065) vs. 875 pg/mL (488, 1802), P = 0.008) and lower collagen III N-terminal propeptide (PIIINP) levels [median 6.7 µg/L (5.1, 8.1) vs. 8.1 µg/L (6.5, 10.5), P = 0.001] compared with the tertile with the worst LV GLS. There was also a modest linear relationship with LV GLS and log-transformed NT-proBNP and PIIINP (r = 0.29, P < 0.001 and r = 0.19, P = 0.009, respectively). We observed no linear association of LV GLS with Minnesota Living with Heart Failure scores, 6-min walk distance, peak oxygen consumption, or expiratory minute ventilation/carbon dioxide excretion slope. CONCLUSIONS Impaired LV GLS is common among HFpEF patients, indicating the presence of covert systolic dysfunction despite normal LV ejection fraction. Impaired LV GLS was associated with biomarkers of wall stress and collagen synthesis and diastolic dysfunction but not with quality of life or exercise capacity, suggesting other processes may be more responsible for these aspects of the HFpEF syndrome.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, 2400 Pratt Street, NP-8064, Durham, NC, 27705, USA
| | | | - Fawaz Alenezi
- Department of Medicine, Duke University School of Medicine, 2400 Pratt Street, NP-8064, Durham, NC, 27705, USA
| | - Mads Ersboll
- Department of Cardiology, The Heart Centre, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Justin M Vader
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jae K Oh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Grace Lin
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | - Gregory Lewis
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marc J Semigran
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin J Anstrom
- Duke Clinical Research Institute, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, 2400 Pratt Street, NP-8064, Durham, NC, 27705, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, 2400 Pratt Street, NP-8064, Durham, NC, 27705, USA
| | - Eric J Velazquez
- Duke Clinical Research Institute, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, 2400 Pratt Street, NP-8064, Durham, NC, 27705, USA
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26
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Khalid U, Wruck LM, Quibrera PM, Bozkurt B, Nambi V, Virani SS, Jneid H, Agarwal S, Chang PP, Loehr L, Basra SS, Rosamond W, Ballantyne CM, Deswal A. BNP and obesity in acute decompensated heart failure with preserved vs. reduced ejection fraction: The Atherosclerosis Risk in Communities Surveillance Study. Int J Cardiol 2017; 233:61-66. [PMID: 28185703 DOI: 10.1016/j.ijcard.2017.01.130] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 12/01/2016] [Accepted: 01/28/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Levels of B-type natriuretic peptide (BNP), a prognostic marker in patients with heart failure (HF), are lower among HF patients with obesity or preserved Left Ventricular Ejection Fraction (LVEF). We examined the distribution and prognostic value of BNP across BMI categories in acute decompensated heart failure (ADHF) patients with preserved vs. reduced LVEF. METHODS We analyzed data from the Atherosclerosis Risk in Communities (ARIC) HF surveillance study which sampled and adjudicated ADHF hospitalizations in patients aged ≥55years from 4 US communities (2005-2009). We examined 5 BMI categories: underweight (<18.5kg/m2), normal weight (18.5-<25), overweight (25-<30), obese (30-<40) and morbidly obese (≥40) in HF with preserved LVEF (HFpEF) and reduced LVEF (HFrEF). The outcome was 1-year mortality from admission. We used ANCOVA to model log BNP and logistic regression for 1-year mortality, both adjusted for demographics and clinical characteristics. RESULTS The cohort included 9820 weighted ADHF hospitalizations (58% HFrEF; 42% HFpEF). BNP levels were lower in HFpEF compared to HFrEF (p<0.001) and decreased as BMI increased within the LVEF groups (p<0.001). After adjustment for covariates, log10 BNP independently predicted 1-year mortality (adjusted OR 1.62 (95% CI 1.17-2.24)) with no significant interaction by BMI or LVEF groups. CONCLUSIONS BNP levels correlated inversely with BMI, and were higher in HFrEF compared to HFpEF. Obese patients with HFpEF and ADHF had a significant proportion with BNP levels below clinically accepted thresholds. Nevertheless, BNP was a predictor of mortality in ADHF across groups of BMI in HFpEF and HFrEF.
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Affiliation(s)
- Umair Khalid
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Lisa Miller Wruck
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, United States
| | - Pedro Miguel Quibrera
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, United States
| | - Biykem Bozkurt
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States; Section of Cardiology, Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Vijay Nambi
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States; Section of Cardiology, Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Salim S Virani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States; Section of Cardiology, Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Hani Jneid
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States; Section of Cardiology, Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Sunil Agarwal
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Patricia P Chang
- Department of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Laura Loehr
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, United States
| | - Sukhdeep Singh Basra
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Wayne Rosamond
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, United States
| | - Christie M Ballantyne
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Anita Deswal
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States; Section of Cardiology, Michael E. DeBakey VA Medical Center, Houston, TX, United States.
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Savarese G, Hage C, Orsini N, Dahlström U, Perrone-Filardi P, Rosano GM, Lund LH. Reductions in N-Terminal Pro-Brain Natriuretic Peptide Levels Are Associated With Lower Mortality and Heart Failure Hospitalization Rates in Patients With Heart Failure With Mid-Range and Preserved Ejection Fraction. Circ Heart Fail 2016; 9:CIRCHEARTFAILURE.116.003105. [DOI: 10.1161/circheartfailure.116.003105] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 10/13/2016] [Indexed: 01/15/2023]
Abstract
Background—
In heart failure with mid-range ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF), feasible surrogate end points are needed for phase II trials. The aim was to assess whether a reduction in N-terminal pro–B-type natriuretic peptide (NT-proBNP) is associated with improved mortality/morbidity in an unselected population of HFmrEF and HFpEF patients.
Methods and Results—
In the Swedish Heart Failure Registry, HFmrEF (EF=40%–49%) and HFpEF (EF≥50%) patients reporting at least 2 consecutive outpatient NT-proBNP assessments were prospectively studied. Associations between reduction in NT-proBNP and overall mortality, HF hospitalization, and their composite were assessed by multivariable Cox regressions, with NT-proBNP changes modeled as binary (decrease/increase) or quantitative predictor by restricted cubic splines. In 650 patients, at a median of 7 months between the 2 measurements of NT-proBNP and over a median follow-up of 1.65 years, 361 patients (55%) showed a reduction and 289 patients (45%) an increase in NT-proBNP. Change in NT-proBNP was associated with risk of outcomes. Fifty-seven patients (16%) who decreased their NT-proBNP versus 78 patients (27%) who increased it died from any cause (adjusted hazard ratio=0.53; 95% confidence interval=0.36–0.77), 61 (17%) versus 86 (30%) were hospitalized for HF (hazard ratio=0.41; 95% confidence interval=0.29–0.60), and 96 (27%) versus 125 (43%) reported the composite outcome (hazard ratio=0.46; 95% confidence interval=0.34–0.62). These findings were replicated in HFmrEF and HFpEF separately.
Conclusions—
In HFmrEF and HFpEF during routine care, decreases in NT-proBNP were associated with improved mortality and morbidity. Studies to determine whether NT-proBNP changes in response to therapy predict drug efficacy are needed.
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Affiliation(s)
- Gianluigi Savarese
- From the Department of Medicine (G.S., C.H., L.H.L.) and Department of Public Health Sciences (N.O.), Karolinska Institutet, Stockholm, Sweden; Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden; Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (P.P.-F.); Cardiovascular and Cell Sciences Research Institute, St George’s University, London, UK (G.M.C.R.); and IRCCS San Raffaele Pisana, Rome, Italy (G.M.C.R.)
| | - Camilla Hage
- From the Department of Medicine (G.S., C.H., L.H.L.) and Department of Public Health Sciences (N.O.), Karolinska Institutet, Stockholm, Sweden; Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden; Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (P.P.-F.); Cardiovascular and Cell Sciences Research Institute, St George’s University, London, UK (G.M.C.R.); and IRCCS San Raffaele Pisana, Rome, Italy (G.M.C.R.)
| | - Nicola Orsini
- From the Department of Medicine (G.S., C.H., L.H.L.) and Department of Public Health Sciences (N.O.), Karolinska Institutet, Stockholm, Sweden; Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden; Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (P.P.-F.); Cardiovascular and Cell Sciences Research Institute, St George’s University, London, UK (G.M.C.R.); and IRCCS San Raffaele Pisana, Rome, Italy (G.M.C.R.)
| | - Ulf Dahlström
- From the Department of Medicine (G.S., C.H., L.H.L.) and Department of Public Health Sciences (N.O.), Karolinska Institutet, Stockholm, Sweden; Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden; Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (P.P.-F.); Cardiovascular and Cell Sciences Research Institute, St George’s University, London, UK (G.M.C.R.); and IRCCS San Raffaele Pisana, Rome, Italy (G.M.C.R.)
| | - Pasquale Perrone-Filardi
- From the Department of Medicine (G.S., C.H., L.H.L.) and Department of Public Health Sciences (N.O.), Karolinska Institutet, Stockholm, Sweden; Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden; Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (P.P.-F.); Cardiovascular and Cell Sciences Research Institute, St George’s University, London, UK (G.M.C.R.); and IRCCS San Raffaele Pisana, Rome, Italy (G.M.C.R.)
| | - Giuseppe M.C. Rosano
- From the Department of Medicine (G.S., C.H., L.H.L.) and Department of Public Health Sciences (N.O.), Karolinska Institutet, Stockholm, Sweden; Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden; Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (P.P.-F.); Cardiovascular and Cell Sciences Research Institute, St George’s University, London, UK (G.M.C.R.); and IRCCS San Raffaele Pisana, Rome, Italy (G.M.C.R.)
| | - Lars H. Lund
- From the Department of Medicine (G.S., C.H., L.H.L.) and Department of Public Health Sciences (N.O.), Karolinska Institutet, Stockholm, Sweden; Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden; Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (P.P.-F.); Cardiovascular and Cell Sciences Research Institute, St George’s University, London, UK (G.M.C.R.); and IRCCS San Raffaele Pisana, Rome, Italy (G.M.C.R.)
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Pellicori P, Goode KM, Nicholls R, Ahmed D, Clark AL, Cleland JG. Regional circulatory distribution of novel cardiac bio-markers and their relationships with haemodynamic measurements. Int J Cardiol 2016; 210:149-55. [DOI: 10.1016/j.ijcard.2016.02.081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/30/2015] [Accepted: 02/02/2016] [Indexed: 01/19/2023]
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29
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Kramer F, Dinh W. Molecular and Digital Biomarker Supported Decision Making in Clinical Studies in Cardiovascular Indications. Arch Pharm (Weinheim) 2016; 349:399-409. [DOI: 10.1002/ardp.201600055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 03/21/2016] [Accepted: 03/23/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Frank Kramer
- Clinical Sciences - Experimental Medicine; BAYER Pharma AG; Wuppertal Germany
| | - Wilfried Dinh
- Clinical Sciences - Experimental Medicine; BAYER Pharma AG; Wuppertal Germany
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30
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Rodrigues PG, Leite-Moreira AF, Falcão-Pires I. Myocardial reverse remodeling: how far can we rewind? Am J Physiol Heart Circ Physiol 2016; 310:H1402-22. [PMID: 26993225 DOI: 10.1152/ajpheart.00696.2015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 03/04/2016] [Indexed: 12/19/2022]
Abstract
Heart failure (HF) is a systemic disease that can be divided into HF with reduced ejection fraction (HFrEF) and with preserved ejection fraction (HFpEF). HFpEF accounts for over 50% of all HF patients and is typically associated with high prevalence of several comorbidities, including hypertension, diabetes mellitus, pulmonary hypertension, obesity, and atrial fibrillation. Myocardial remodeling occurs both in HFrEF and HFpEF and it involves changes in cardiac structure, myocardial composition, and myocyte deformation and multiple biochemical and molecular alterations that impact heart function and its reserve capacity. Understanding the features of myocardial remodeling has become a major objective for limiting or reversing its progression, the latter known as reverse remodeling (RR). Research on HFrEF RR process is broader and has delivered effective therapeutic strategies, which have been employed for some decades. However, the RR process in HFpEF is less clear partly due to the lack of information on HFpEF pathophysiology and to the long list of failed standard HF therapeutics strategies in these patient's outcomes. Nevertheless, new proteins, protein-protein interactions, and signaling pathways are being explored as potential new targets for HFpEF remodeling and RR. Here, we review recent translational and clinical research in HFpEF myocardial remodeling to provide an overview on the most important features of RR, comparing HFpEF with HFrEF conditions.
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Affiliation(s)
- Patrícia G Rodrigues
- Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, Universidade do Porto, Porto, Portugal
| | - Adelino F Leite-Moreira
- Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, Universidade do Porto, Porto, Portugal
| | - Inês Falcão-Pires
- Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, Universidade do Porto, Porto, Portugal
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Brunner-La Rocca HP, Eurlings L, Richards AM, Januzzi JL, Pfisterer ME, Dahlström U, Pinto YM, Karlström P, Erntell H, Berger R, Persson H, O'Connor CM, Moertl D, Gaggin HK, Frampton CM, Nicholls MG, Troughton RW. Which heart failure patients profit from natriuretic peptide guided therapy? A meta-analysis from individual patient data of randomized trials. Eur J Heart Fail 2015; 17:1252-61. [PMID: 26419999 DOI: 10.1002/ejhf.401] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 06/26/2015] [Accepted: 06/10/2015] [Indexed: 12/17/2022] Open
Abstract
AIMS Previous analyses suggest that heart failure (HF) therapy guided by (N-terminal pro-)brain natriuretic peptide (NT-proBNP) might be dependent on left ventricular ejection fraction, age and co-morbidities, but the reasons remain unclear. METHODS AND RESULTS To determine interactions between (NT-pro)BNP-guided therapy and HF with reduced [ejection fraction (EF) ≤45%; HF with reduced EF (HFrEF), n = 1731] vs. preserved EF [EF > 45%; HF with preserved EF (HFpEF), n = 301] and co-morbidities (hypertension, renal failure, chronic obstructive pulmonary disease, diabetes, cerebrovascular insult, peripheral vascular disease) on outcome, individual patient data (n = 2137) from eight NT-proBNP guidance trials were analysed using Cox-regression with multiplicative interaction terms. Endpoints were mortality and admission because of HF. Whereas in HFrEF patients (NT-pro)BNP-guided compared with symptom-guided therapy resulted in lower mortality [hazard ratio (HR) = 0.78, 95% confidence interval (CI) 0.62-0.97, P = 0.03] and fewer HF admissions (HR = 0.80, 95% CI 0.67-0.97, P = 0.02), no such effect was seen in HFpEF (mortality: HR = 1.22, 95% CI 0.76-1.96, P = 0.41; HF admissions HR = 1.01, 95% CI 0.67-1.53, P = 0.97; interactions P < 0.02). Age (74 ± 11 years) interacted with treatment strategy allocation independently of EF regarding mortality (P = 0.02), but not HF admission (P = 0.54). The interaction of age and mortality was explained by the interaction of treatment strategy allocation with co-morbidities. In HFpEF, renal failure provided strongest interaction (P < 0.01; increased risk of (NT-pro)BNP-guided therapy if renal failure present), whereas in HFrEF patients, the presence of at least two of the following co-morbidities provided strongest interaction (P < 0.01; (NT-pro)BNP-guided therapy beneficial only if none or one of chronic obstructive pulmonary disease, diabetes, cardiovascular insult, or peripheral vascular disease present). (NT-pro)BNP-guided therapy was harmful in HFpEF patients without hypertension (P = 0.02). CONCLUSION The benefits of therapy guided by (NT-pro)BNP were present in HFrEF only. Co-morbidities seem to influence the response to (NT-pro)BNP-guided therapy and may explain the lower efficacy of this approach in elderly patients.
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Affiliation(s)
- Hans-Peter Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Centre, PO Box 5800, NL-6202AZ, Maastricht, the Netherlands
| | - Luc Eurlings
- Department of Cardiology, Maastricht University Medical Centre, PO Box 5800, NL-6202AZ, Maastricht, the Netherlands
| | - A Mark Richards
- Department of Medicine, University of Otago Christchurch, Christchurch Hospital, Christchurch, New Zealand.,National University Heart Centre Singapore, Singapore
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Boston, MA, USA
| | | | - Ulf Dahlström
- Department of Cardiology and Department of Medical and Health Sciences, Linkoping University, Department of Cardiology, Linkoping, Sweden
| | | | - Patric Karlström
- Division of Cardiology, Department of Medicine, County Hospital Ryhov, Jonkoping, Sweden
| | - Hans Erntell
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Rudolf Berger
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Hans Persson
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | | | - Deddo Moertl
- Department of Cardiology, LKH, St Poelten, Austria
| | - Hanna K Gaggin
- Cardiology Division, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher M Frampton
- Department of Medicine, University of Otago Christchurch, Christchurch Hospital, Christchurch, New Zealand
| | - M Gary Nicholls
- Department of Medicine, University of Otago Christchurch, Christchurch Hospital, Christchurch, New Zealand
| | - Richard W Troughton
- Department of Medicine, University of Otago Christchurch, Christchurch Hospital, Christchurch, New Zealand
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32
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Binoun-A-Egom C, Andreas A, Klimas J, Valentova V, Kruzliak P, Egom EE. B-type natriuretic peptide and heart failure: what can we learn from clinical trials? Clin Exp Pharmacol Physiol 2015; 42:881-887. [PMID: 25969125 DOI: 10.1111/1440-1681.12418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 04/24/2015] [Accepted: 05/07/2015] [Indexed: 11/26/2022]
Abstract
The B-type natriuretic peptide (BNP) may favour natriuresis and diuresis, making it an ideal drug to aid in diuresing a fluid-overloaded patient with poor or worsening renal function. Several randomized clinical trials have tested the hypothesis that infusions of pharmacological doses of BNP to acute heart failure (HF) patients may enhance decongestion and preserve renal function in this clinical setting. Unfortunately, none of these has resulted in a better outcome. The current challenge for BNP research in acute HF lies in a failure of concept and reluctance to abandon a demonstrably ineffectual research model. Future success will necessitate a detailed understanding of the mechanism of action of BNP as well as a better integration of basic and clinical science.
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Affiliation(s)
| | - Angelo Andreas
- University of Toronto Scarborough Campus, Toronto, ON, Canada
| | - Jan Klimas
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University, Bratislava, Slovak Republic
| | - Vanda Valentova
- Department of Medical Biology, Jessenius Medical Faculty in Martin, Comenius University, Martin, Slovak Republic
| | - Peter Kruzliak
- International Clinical Research Center, St. Anne's University Hospital and Masaryk University, Brno, Czech Republic
| | - Emmanuel E Egom
- EGOM Clinical and Translational Research Services (ECTRS) Ltd, Halifax, NS, Canada
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33
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Pellicori P, Kallvikbacka-Bennett A, Dierckx R, Zhang J, Putzu P, Cuthbert J, Boyalla V, Shoaib A, Clark AL, Cleland JGF. Prognostic significance of ultrasound-assessed jugular vein distensibility in heart failure. Heart 2015; 101:1149-58. [PMID: 26006717 DOI: 10.1136/heartjnl-2015-307558] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 04/29/2015] [Indexed: 11/03/2022] Open
Abstract
AIMS Jugular venous distension is a classical sign of heart failure (HF) but it can be difficult to assess clinically. METHODS AND RESULTS Outpatients with HF and control subjects were assessed. Internal jugular vein diameter (JVD) was measured using a linear high-frequency ultrasound probe (10 MHz) at rest, after a Valsalva manoeuvre and during deep inspiration. JVD ratio was calculated as the maximum diameter during Valsalva to that measured at rest. 311 patients (mean age 71 years, mean left ventricular EF 42%, median (IQR) amino-terminal pro-brain natriuretic peptide 979 (441-2007) ng/L) and 66 controls were included. JVD (median and IQR range) at rest was smaller in controls (0.16 (0.14-0.20) cm) than in patients with HF (0.23 (0.17-0.33) cm; p<0.001) but similar during Valsalva (1.03 (0.90-1.16) cm vs 1.08 (0.90-1.25) cm; p=0.28). Consequently, JVD ratio was greater in controls (6.3 (4.9-7.6)) than in patients (4.5 (2.9-6.1); p<0.001). During a median follow-up of 516 (IQR 335-622) days, 48 patients (15%) with HF died or were hospitalised for HF. In multivariable models, among clinical, echocardiographic or biochemical variables, only increasing NT-proBNP and ultrasound assessment of internal jugular vein were independently associated with prognosis. Comparing top and bottom tertiles of JVD ratio (2.3 (IQR 1.7-2.9) versus 6.8 (6.1-7.7)), the tertile with lower values had a 10-fold greater risk of an adverse event (HR 10.05, 95% CI 3.07 to 32.93). CONCLUSIONS Ultrasound assessment of the internal jugular vein identifies outpatients with HF who have a higher risk of an adverse outcome. CLINICAL TRIAL REGISTRATION NCT01872299.
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Affiliation(s)
- Pierpaolo Pellicori
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Anna Kallvikbacka-Bennett
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Riet Dierckx
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Jufen Zhang
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Paola Putzu
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Joe Cuthbert
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Vennela Boyalla
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Ahmed Shoaib
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Andrew L Clark
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - John G F Cleland
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK National Heart & Lung Institute and National Institute of Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield Hospitals, Imperial College, London, UK
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Cleland JGF, Pellicori P, Dierckx R. Clinical trials in patients with heart failure and preserved left ventricular ejection fraction. Heart Fail Clin 2015; 10:511-23. [PMID: 24975913 DOI: 10.1016/j.hfc.2014.04.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There is no robust evidence that any treatment can modify the natural history of patients with heart failure and preserved left ventricular ejection fraction (HFpEF), although most agree that diuretics can control congestion and improve symptoms. HFpEF is often complicated by systemic and pulmonary hypertension, atrial fibrillation, obesity, chronic lung and kidney disease, lack of physical fitness, and old age that can complicate both diagnosis and management. Further trials should phenotype patients precisely and create better definitions of HFpEF based on biomarkers.
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Affiliation(s)
- John G F Cleland
- National Heart & Lung Institute, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield Hospitals NHS Trust, Imperial College, London, UK.
| | - Pierpaolo Pellicori
- Department of Cardiology, Castle Hill Hospital, Hull and York Medical School, University of Hull, Kingston-upon-Hull, UK
| | - Riet Dierckx
- Department of Cardiology, Castle Hill Hospital, Hull and York Medical School, University of Hull, Kingston-upon-Hull, UK
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35
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Egom EE. BNP and Heart Failure: Preclinical and Clinical Trial Data. J Cardiovasc Transl Res 2015; 8:149-57. [PMID: 25771949 DOI: 10.1007/s12265-015-9619-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/05/2015] [Indexed: 12/11/2022]
Abstract
The B-type natriuretic peptide (BNP), a member of the family of vasoactive peptides, has emerged as an important diagnostic, prognostic, and therapeutic tool in patients with heart failure (HF). The rapid incorporation into clinical practice of bioassays to BNP concentrations and pharmacological agents that augment the biological actions of this peptide such as nesiritide or vasopeptidase inhibitors has shown the potential for translational research to improve patient care. Despite the indirect evidence in support of a potential benefit from raising BNP, accumulating evidence suggests that simply increasing the amount of circulating BNP does not necessarily confer cardiovascular benefits in patient with HF. Moreover, in experimental HF, the response to treatments targeting specific natriuretic peptide receptors (NPRs) signaling seems to be attenuated. A better understanding of the NPRs signaling in HF would be clinically relevant and thus required, in order to devise strategies to develop novel agents and technologies that directly target this signaling pathway.
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Affiliation(s)
- Emmanuel E Egom
- EGOM Clinical and Translational Research Services (ECTRS) Ltd, 5991 Spring garden Road, Halifax, Nova Scotia, Canada, B3H 4R7,
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36
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37
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Does speckle tracking really improve diagnosis and risk stratification in patients with HF with normal EF? J Am Coll Cardiol 2015; 64:1535. [PMID: 25277623 DOI: 10.1016/j.jacc.2014.02.616] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 02/18/2014] [Accepted: 02/20/2014] [Indexed: 11/23/2022]
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Abstract
Many patients with heart failure (HF) have a normal left ventricular ejection fraction, and are labelled as having HF with preserved left ventricular ejection fraction (HFPEF). Hypertension, atrial fibrillation and age are important contributors to the development of HFPEF and, therefore, its prevalence is likely to increase in the next few decades. The pathophysiology of HFPEF is heterogeneous but with a final common pathway leading to congestion. HF remains a clinical diagnosis but the plasma concentration of B-type natriuretic peptide (eg BNP/N-terminal prohormone BNP (NT-proBNP)), a marker of congestion, is an essential component. Imaging, usually by echocardiography, is required to determine the cardiac phenotype (ie valve disease, left ventricular ejection fraction) underlying HF. A superficially normal echocardiogram does not exclude a diagnosis of HF. No treatment has been shown conclusively to alter the prognosis of HFPEF. However, treatments directed at congestion and hypertension, such as diuretics, mineralocorticoid receptor antagonists (MRAs) and angiotensin converting-enzyme inhibitors, may improve symptoms and probably do improve outcomes. No treatment has yet been shown to reverse the underlying myocardial pathology of HFPEF, although there is some hope that MRAs might.
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Affiliation(s)
| | - John G F Cleland
- Cardiovascular Biomedical Research Unit Royal Brompton and Harefield Hospitals, Imperial College, London, UK
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39
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Lelli D, Pedone C, Rossi FF, Incalzi RA. Clinical and echocardiographic characteristics of elderly hospitalized patients with high levels of NT-proBNP without clinical diagnosis of heart failure. Aging Clin Exp Res 2014; 26:607-13. [PMID: 24781829 DOI: 10.1007/s40520-014-0226-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 04/08/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with high NT-proBNP levels but without heart failure (HF) diagnosis have a higher risk of cardiovascular events and mortality; however, there are few data about their characteristic, especially in the elderly. AIMS To compare the clinical and echocardiographic characteristics of elderly hospitalized patients with and without increased NT-proBNP and with and without a diagnosis of HF. METHODS We reviewed 209 charts of patients admitted to an acute care ward (mean age 78.9 years, SD 10.2, 62% women). We classified the patients into four groups: no HF with or without increased (>900 pg/mL) NT-proBNP (HF-/BNP-, N = 89 and HF-/BNP+, N = 41), and HF with or without increased NT-proBNP (HF+/BNP-, N = 4 and HF+/BNP+, N = 75). The groups were compared with respect to demographic and clinical characteristics, symptoms at admission, comorbidities, echocardiographic parameters, and cardiovascular events at 180 days. RESULTS Patients in the groups HF+/BNP+ and HF-/BNP+ were older, with higher serum creatinine, blood urea nitrogen, and lower serum hemoglobin compared to patients in the HF-/BNP- group. The prevalence of ischemic heart disease, pulmonary hypertension, and atrial fibrillation progressively decreased across the HF+/BNP+, HF-/BNP+, and HF-/BNP- groups. The prevalence of abnormal echocardiographic findings in the HF-/BNP+ group was intermediate compared to the other two groups for severe aortic or mitralic regurgitation, monophasic transmitralic pattern, biatrial atriomegaly, ejection fraction, akinesia extension, and PAPs. The same pattern was observed for cardiovascular events at follow-up. DISCUSSION Elderly patients without a diagnosis of HF, but with high NT-proBNP serum concentration have intermediate clinical characteristics compared to the other two groups. CONCLUSION NT-proBNP may be a useful marker of silent cardiac damage.
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Affiliation(s)
- D Lelli
- Unit of Geriatrics, Area di Geriatria, Università Campus Biomedico di Roma, via Alvaro del Portillo 200, 00128, Rome, Italy,
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Bansal N, Hyre Anderson A, Yang W, Christenson RH, deFilippi CR, Deo R, Dries DL, Go AS, He J, Kusek JW, Lash JP, Raj D, Rosas S, Wolf M, Zhang X, Shlipak MG, Feldman HI. High-sensitivity troponin T and N-terminal pro-B-type natriuretic peptide (NT-proBNP) and risk of incident heart failure in patients with CKD: the Chronic Renal Insufficiency Cohort (CRIC) Study. J Am Soc Nephrol 2014; 26:946-56. [PMID: 25278510 DOI: 10.1681/asn.2014010108] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
High-sensitivity troponin T (hsTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) strongly predict heart failure (HF) in the general population. However, the interpretation of levels of these biomarkers as predictors of HF is uncertain among patients with CKD. Here, we investigated whether hsTnT and NT-proBNP are associated with incident HF among patients with CKD. In a prospective cohort analysis, we studied 3483 people with CKD in the Chronic Renal Insufficiency Cohort (CRIC) Study recruited from June of 2003 to August of 2008 who were free of HF at baseline. We used Cox regression to examine the association of baseline levels of hsTnT and NT-proBNP with incident HF after adjustment for demographic factors, traditional cardiovascular risk factors, markers of kidney disease, pertinent medication use, and mineral metabolism markers. At baseline, hsTnT levels ranged from ≤5.0 to 738.7 pg/ml, and NT-proBNP levels ranged from ≤5 to 35,000 pg/ml. Compared with those who had undetectable hsTnT, participants in the highest quartile (>26.5 pg/ml) had a significantly higher rate of HF (hazard ratio, 4.77; 95% confidence interval, 2.49 to 9.14). Similarly, compared with those in the lowest NT-proBNP quintile (<47.6 pg/ml), participants in the highest quintile (>433.0 pg/ml) experienced a substantially higher rate of HF (hazard ratio, 9.57; 95% confidence interval, 4.40 to 20.83) [corrected]. In conclusion, hsTnT and NT-proBNP were strongly associated with incident HF among a diverse cohort of individuals with mild to severe CKD. Elevations in these biomarkers may indicate subclinical changes in volume and myocardial stress that subsequently contribute to clinical HF.
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Affiliation(s)
| | | | - Wei Yang
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Rajat Deo
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Alan S Go
- Kaiser Permanente Northern California, Oakland, California
| | - Jiang He
- Tulane University, New Orleans, Louisiana
| | - John W Kusek
- National Institutes of Health, Bethesda, Maryland
| | | | - Dominic Raj
- The George Washington University, Washington, DC
| | - Sylvia Rosas
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Myles Wolf
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois; and
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Kimura Y, Izumiya Y, Hanatani S, Yamamoto E, Kusaka H, Tokitsu T, Takashio S, Sakamoto K, Tsujita K, Tanaka T, Yamamuro M, Kojima S, Tayama S, Kaikita K, Hokimoto S, Ogawa H. High serum levels of thrombospondin-2 correlate with poor prognosis of patients with heart failure with preserved ejection fraction. Heart Vessels 2014; 31:52-9. [PMID: 25150586 DOI: 10.1007/s00380-014-0571-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 08/15/2014] [Indexed: 12/22/2022]
Abstract
Thrombospondin-2 (TSP-2) is highly expressed in hypertensive heart. Interstitial fibrosis is frequently observed in hypertensive heart, and it is a characteristic feature of heart failure with preserved ejection fraction (HFpEF). We tested here the hypothesis that high TSP-2 serum levels reflect disease severity and can predict poor prognosis of patients with HFpEF. Serum TSP-2 levels were measured by ELISA in 150 patients with HFpEF. HFpEF was defined as left ventricular ejection fraction ≥ 50%, B-type natriuretic peptide (BNP) ≥ 100 pg/ml or E/e' ≥ 15. The endpoints were mortality rate, HF-related hospitalization, stroke and non-fatal myocardial infarction. The median serum TSP-2 level was 19.2 (14.4-26.0) ng/ml. Serum TSP-2 levels were associated with the New York Heart Association (NYHA) functional class. Circulating levels of BNP and high-sensitivity troponin T were positively correlated with serum TSP-2 levels. Kaplan-Meier survival curve showed high risk of adverse cardiovascular events in the high TSP-2 group (>median value), and that the combination of high TSP-2 and high BNP (≥ 100 pg/ml) was associated with the worst event-free survival rate. Multivariate Cox proportional hazard analysis identified TSP-2 as independent predictor of risk of death and cardiovascular events. Circulating TSP-2 correlates with disease severity in patients with HFpEF. TSP-2 is a potentially useful predictor of future adverse cardiovascular events in patients with HFpEF.
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Affiliation(s)
- Yuichi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan.
| | - Shinsuke Hanatani
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
| | - Hiroaki Kusaka
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
| | - Takanori Tokitsu
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
| | - Kenji Sakamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
| | - Tomoko Tanaka
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
| | - Megumi Yamamuro
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
| | - Sunao Kojima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
| | - Shinji Tayama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
| | - Seiji Hokimoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, Kumamoto, 860-8556, Japan
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42
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Jiang H, Zhang L, Yu Y, Liu M, Jin X, Zhang P, Yu P, Zhang S, Zhu H, Chen R, Zou Y, Ge J. A pilot study of angiogenin in heart failure with preserved ejection fraction: a novel potential biomarker for diagnosis and prognosis? J Cell Mol Med 2014; 18:2189-97. [PMID: 25124701 PMCID: PMC4224553 DOI: 10.1111/jcmm.12344] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 04/28/2014] [Indexed: 01/06/2023] Open
Abstract
Characteristics of heart failure with preserved ejection fraction (HFPEF) have not yet been fully understood. The objectives of this pilot study are to detect protein expression profile in the sera of HFPEF patients, and to identify potential biomarkers for the disease. Five hundred and seven proteins were detected in the sera of healthy volunteers and patients with either HFPEF or hypertension using antibody microarrays (three in each group). The results showed that the serum concentrations of 17 proteins (e.g. angiogenin, activin A and artemin) differed considerably between HFPEF and non-HFPEF patients (hypertensive patients and healthy controls), while a protein expression pattern distinct from that in non-HFPEF patients was associated with HFPEF patients. The up-regulation of angiogenin in both HFPEF patients with LVEF ≥50% (P = 0.004) and a subset of HFPEF patients with LVEF = 41–49% (P < 0.001) was further validated in 16 HFPEF patients and 16 healthy controls. Meanwhile, angiogenin distinguished HFPEF patients from controls with a mean area under the receiver operating characteristic curve of 0.88 (P < 0.001) and a diagnostic cut-off point of 426 ng/ml. Moreover, the angiogenin levels in HFPEF patients were positively correlated with Lg(N-terminal pro-B-type natriuretic peptide, NT-proBNP) (P < 0.001). In addition, high angiogenin level (≥426 ng/ml) was a predictor of all-cause death within a short-term follow-up duration, but not in the longer term of 36 months. This pilot study indicates that the aforementioned 17 potential biomarkers, such as angiogenin, may hold great promise for both diagnosis and prognosis assessment of HFPEF.
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Affiliation(s)
- Hong Jiang
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Shanghai Medical College of Fudan University, Shanghai, China
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Sherwi N, Pellicori P, Joseph AC, Buga L. Old and newer biomarkers in heart failure: from pathophysiology to clinical significance. J Cardiovasc Med (Hagerstown) 2014; 14:690-7. [PMID: 23846675 DOI: 10.2459/jcm.0b013e328361d1ef] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Heart failure is a complex disease in which a careful clinical examination and the measurement of cardiac function may not always be sufficient for making a correct diagnosis. Measuring plasma levels of natriuretic peptides may assist in this process, also offering a good tool for accurate risk stratification. Other alternative biomarkers may give insight into the different pathways of heart failure genesis and pathophysiology, and may help to identify those patients with overt heart failure and a more adverse outcome, or distinguish between those at risk of developing heart failure. Despite a high number of potentially useful biomarkers, only a few will likely be introduced routinely into clinical practice. However, a multi-marker approach might increase the diagnostic accuracy and it might identify different phenotypes of heart failure patients who might benefit from individualized therapy in the future.
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Affiliation(s)
- Nasser Sherwi
- Department of Academic Cardiology, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, UK
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44
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Pieske B, Butler J, Filippatos G, Lam C, Maggioni AP, Ponikowski P, Shah S, Solomon S, Kraigher-Krainer E, Samano ET, Scalise AV, Müller K, Roessig L, Gheorghiade M. Rationale and design of the SOluble guanylate Cyclase stimulatoR in heArT failurE Studies (SOCRATES). Eur J Heart Fail 2014; 16:1026-38. [DOI: 10.1002/ejhf.135] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 06/06/2014] [Accepted: 06/13/2014] [Indexed: 12/24/2022] Open
Affiliation(s)
- Burkert Pieske
- Department of Cardiology; Medical University Graz; Graz Austria
| | - Javed Butler
- Division of Cardiology; Emory University School of Medicine; Atlanta GA USA
| | | | - Carolyn Lam
- Cardiovascular Research Institute; Singapore
| | - Aldo Pietro Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri Research Center; Florence Italy
| | - Piotr Ponikowski
- Department of Heart Diseases; Medical University; Military Hospital Wroclaw Poland
| | - Sanjiv Shah
- Division of Cardiology, Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - Scott Solomon
- Cardiovascular Division; Brigham and Women's Hospital; Boston MA USA
| | | | | | | | | | | | - Mihai Gheorghiade
- Division of Cardiology, Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
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45
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Patel HC, Hayward C, di Mario C, Cowie MR, Lyon AR, Rosen SD. Heart failure with preserved ejection fraction: the impact of stricter definitions. Eur J Heart Fail 2014; 16:767-71. [PMID: 24806550 DOI: 10.1002/ejhf.106] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 04/09/2014] [Accepted: 04/11/2014] [Indexed: 01/15/2023] Open
Abstract
AIMS To determine the impact of internationally recognized criteria for the diagnosis of heart failure with preserved ejection fraction (HF-PEF) on the feasibility of recruitment into a HF-PEF trial. METHODS AND RESULTS We reviewed the medical records of 5883 consecutive patients admitted with heart failure across eight hospitals in the U.K. From those who had an EF ≥50% (filter 1), patients who had an alternative cardiac cause of symptoms or an over-riding co-morbidity were excluded (filter 2). The remaining patients had to satisfy the following selection criteria (filter 3): the presence of a non-dilated left ventricle; structural remodelling (LV hypertrophy or dilated left atrium); and evidence of impaired diastolic function or raised BNP. Overall, 20.5% (n = 1203) of patients admitted with heart failure had an EF ≥50%. There was significant heterogeneity between the hospitals as this proportion varied from 42.4% in the teaching hospitals to 13.8% in the district general hospitals (P < 0.0001). Applying filter 2, the cohort size was reduced from 1203 to 122 patients. Of the latter 122, only 45 people had evidence of structural cardiac remodelling and evidence of either raised cardiac filling pressures on echocardiography or raised BNP consistent with HF-PEF. CONCLUSION Applying our filters, only 0.8% of all patients admitted with heart failure would be eligible for a HF-PEF trial. These data have important implications for the feasibility of clinical trials for HF-PEF and for the generalizability of the results of such studies.
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Affiliation(s)
- Hitesh C Patel
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
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46
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Izumiya Y, Hanatani S, Kimura Y, Takashio S, Yamamoto E, Kusaka H, Tokitsu T, Rokutanda T, Araki S, Tsujita K, Tanaka T, Yamamuro M, Kojima S, Tayama S, Kaikita K, Hokimoto S, Ogawa H. Growth differentiation factor-15 is a useful prognostic marker in patients with heart failure with preserved ejection fraction. Can J Cardiol 2013; 30:338-44. [PMID: 24484911 DOI: 10.1016/j.cjca.2013.12.010] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 12/16/2013] [Accepted: 12/16/2013] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Circulating growth differentiation factor 15 (GDF-15) levels correlate with heart mass and fibrosis; however, little is known about its value in predicting the prognosis of patients with heart failure with preserved ejection fraction (HFpEF). METHODS We measured serum GDF-15 levels in 149 consecutive patients with left ventricular diastolic dysfunction (LVDD) and normal LV ejection fraction (>50%) and followed them for cardiovascular events. LVDD was defined according to the European Society of Cardiology guidelines. RESULTS The New York Heart Association functional class and circulating B-type natriuretic peptide (BNP) levels were significantly higher in the high-GDF-15 group (n = 75; greater than or equal to the median value [3694 pg/mL]) than in the low-GDF-15 group (n = 74). Patients were divided into HFpEF and LVDD groups according to the presence or absence of HF. Serum GDF-15 levels were significantly higher in the HFpEF group (n = 73) than in the LVDD group (n = 76) (median, 4215 [interquartile range, 3382-5287] vs 3091 [interquartile range, 2487-4217 pg/mL]; P < 0.0001). Kaplan-Meier curve analysis showed a significantly higher probability of cardiovascular events in the high-GDF-15 group than in the low-GDF-15 group for data of all patients (log-rank test P = 0.006) and data of patients in the HFpEF group only (P = 0.014). Multivariate Cox hazard analysis identified age (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.87-0.98; P = 0.008), atrial fibrillation (HR, 7.95; 95% CI, 1.98-31.85, P = 0.003), lnBNP (HR, 3.37; 95% CI, 1.73-6.55; P < 0.0001), and GDF-15 (ln[GDF-15]) (HR, 4.74; 95% CI, 1.26-17.88, P = 0.022) as independent predictors of primary end points. CONCLUSIONS GDF-15 is a potentially useful prognostic biomarker in patients with HFpEF.
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Affiliation(s)
- Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Shinsuke Hanatani
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuichi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroaki Kusaka
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takanori Tokitsu
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Taku Rokutanda
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoshi Araki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Tomoko Tanaka
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Megumi Yamamuro
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Sunao Kojima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shinji Tayama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Seiji Hokimoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Toma M, Ezekowitz JA, Bakal JA, O'Connor CM, Hernandez AF, Sardar MR, Zolty R, Massie BM, Swedberg K, Armstrong PW, Starling RC. The relationship between left ventricular ejection fraction and mortality in patients with acute heart failure: insights from the ASCEND-HF Trial. Eur J Heart Fail 2013; 16:334-41. [PMID: 24464687 DOI: 10.1002/ejhf.19] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 09/09/2013] [Accepted: 09/27/2013] [Indexed: 01/11/2023] Open
Abstract
AIM Acute decompensated heart failure (ADHF) is associated with significant morbidity and mortality but the relationship between LVEF and outcomes is unclear. We explored the association between LVEF and 30 and 180 day mortality in 7007 ADHF patients enrolled in the Acute Studies of Nesiritide in Decompensated Heart Failure (ASCEND-HF) trial. METHODS AND RESULTS We explored the association between LVEF and 30 and 180 day mortality in 7007 ADHF patients enrolled in the Acute Studies of Nesiritide in Decompensated Heart Failure (ASCEND-HF) trial. LVEF was analysed both as a continuous variable and according to three categories: < 40% (LowEF), 40-50% [intermediate EF (IntEF)], and > 50% [preserved ejection fraction (PresEF)]. Of the patients in the trial, 4474 (78.7%) had LowEF, 674 (11.9%) had IntEF, and 539 (9.5%) had PresEF. The unadjusted 30 and 180 day mortality was similar for LowEF (3.7%, 12.3%), IntEF (3.4%, 13.1%), and PresEF (4.3%, 14.1%), respectively (P > 0.05). After multivariable adjustment, the hazard ratio (HR) for 180 day mortality remained similar for the LowEF [HR 0.96, 95% confidence interval (CI) 0.75-1.24; P = 0.77] and IntEF (0.91, 95% CI 0.66-1.3; P = 0.58) compared to PresEF patients. By contrast, when LVEF was evaluated as a continuous measure, it exhibited a U-shaped pattern with mortality. After matching for age and sex, the mortality risk attributed to LVEF was attenuated, as the LVEF increased as a continuous variable over 35%. However, in patients with EF < 35%, the mortality risk continue to increase as the LVEF declined. CONCLUSIONS Among patients with ADHF, the unadjusted mortality rates are similar across LVEF strata. However, after accounting for key patient variables, the mortality risk increases as EF falls below 35%. These data will be useful in planning future studies of ADHF. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov identifier: NCT00475852.
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Affiliation(s)
- Mustafa Toma
- Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
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48
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Relation of risk factors with response to carvedilol in heart failure with preserved ejection fraction - a report from the Japanese Diastolic Heart Failure Study (J-DHF). J Cardiol 2013; 63:424-31. [PMID: 24286855 DOI: 10.1016/j.jjcc.2013.10.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 10/10/2013] [Accepted: 10/25/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND The Japanese Diastolic Heart Failure Study (J-DHF) has suggested beneficial effects of the standard-dose prescription of carvedilol in heart failure with preserved ejection fraction (HFPEF). However, it is unclear whether any risk factors modulate the effects of the standard-dose carvedilol. METHODS AND RESULTS Data from 245 patients with HFPEF in J-DHF were evaluated. Decreased body mass index, diabetes mellitus, and left atrial (LA) dilatation were independent risk factors for both of the primary outcomes (cardiovascular death and unplanned hospitalization for heart failure) and another major composite outcome (cardiovascular death and unplanned hospitalization for any cardiovascular causes) in multivariable analysis. In patients with LA diameter≥the median value (43.2mm), standard-dose carvedilol was associated with unadjusted hazard ratio (HR) 0.263 [95% confidence interval (CI): 0.080-0.859] and covariate adjusted 0.264 (0.080-0.876) for the primary outcome. In those with LA diameter<43.2mm, unadjusted and adjusted HRs were 1.123 (0.501-2.514) and 1.067 (0.472-2.412). A p-value for interaction was 0.046 (unadjusted) and 0.058 (adjusted). The similar effects of LA diameter were observed regarding another major composite outcome. The other risk factors in univariate or multivariable analyses did not influence the response to the standard-dose carvedilol. CONCLUSIONS The standard-dose carvedilol may exert greater reduction of the incidence of clinical outcomes in the patients with HFPEF and advanced rather than mild diastolic dysfunction.
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49
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Global longitudinal strain in patients with suspected heart failure and a normal ejection fraction: does it improve diagnosis and risk stratification? Int J Cardiovasc Imaging 2013; 30:69-79. [DOI: 10.1007/s10554-013-0310-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 10/09/2013] [Indexed: 10/26/2022]
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