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van Ruiten CC, Smits MM, Kok MD, Serné EH, van Raalte DH, Kramer MHH, Nieuwdorp M, IJzerman RG. Mechanisms underlying the blood pressure lowering effects of dapagliflozin, exenatide, and their combination in people with type 2 diabetes: a secondary analysis of a randomized trial. Cardiovasc Diabetol 2022; 21:63. [PMID: 35484607 PMCID: PMC9052512 DOI: 10.1186/s12933-022-01492-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/08/2022] [Indexed: 02/06/2023] Open
Abstract
Background Sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) lower blood pressure (BP). When SGLT2i and GLP-1RA are combined, synergistic effects on BP have been observed. The mechanisms underlying these BP reductions are incompletely understood. The aim of this study was to assess the mechanisms underlying the BP reduction with the SGLT2i dapagliflozin, GLP-1RA exenatide, and dapagliflozin-exenatide compared with placebo in people with obesity and type 2 diabetes. Methods Sixty-six people with type 2 diabetes were randomized to 16 weeks of dapagliflozin 10 mg/day, exenatide 10 µg twice daily, dapagliflozin-exenatide, or placebo treatment. The effect of treatments on estimates of: (1) plasma volume (calculated by Strauss formula, bioimpedance spectroscopy, hematocrit, (2) autonomic nervous system activity (heart rate variability), (3) arterial stiffness (pulse wave applanometry), (4) systemic hemodynamic parameters including peripheral vascular resistance, cardiac output and stroke volume (all derived from non-invasively systemic hemodynamic monitoring), and (5) natriuresis (24-hour urine collection) were assessed after 10 days and 16 weeks of treatment. Results After 10 days, dapagliflozin reduced systolic BP (SBP) by − 4.7 mmHg, and reduced plasma volume. After 16 weeks, dapagliflozin reduced SBP by − 4.4 mmHg, and reduced sympathetic nervous system (SNS) activity. Exenatide had no effect on SBP, but reduced parasympathetic nervous system activity after 10 days and 16 weeks. After 10 days, dapagliflozin-exenatide reduced SBP by − 4.2 mmHg, and reduced plasma volume. After 16 weeks, dapagliflozin-exenatide reduced SBP by − 6.8 mmHg, and the reduction in plasma volume was still observed, but SNS activity was unaffected. Conclusions The dapagliflozin-induced plasma volume contraction may contribute to the initial SBP reduction, while a reduction in SNS activity may contribute to the persistent SBP reduction. Dapagliflozin-exenatide resulted in the largest decrease in SBP. The effect on plasma volume was comparable to dapagliflozin monotherapy, and SNS activity was not reduced, therefore other mechanisms are likely to contribute to the blood pressure lowering effect of this combination, which need further investigation. Trial registration Clinicaltrials.gov, NCT03361098.
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Affiliation(s)
- Charlotte C van Ruiten
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands. .,Department of Internal Medicine, Amsterdam Diabetes Center, Amsterdam University Medical Centers (Amsterdam UMC), Location VU University Medical Center (VUMC), De Boelelaan 1117 (room ZH 4A63), 1081 HV, Amsterdam, The Netherlands.
| | - Mark M Smits
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands
| | - Megan D Kok
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands
| | - Erik H Serné
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands.,Department of Vascular Medicine, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands
| | - Daniël H van Raalte
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands
| | - Mark H H Kramer
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands
| | - Max Nieuwdorp
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands.,Department of Vascular Medicine, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Richard G IJzerman
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, Location VU University Medical Center, Amsterdam, The Netherlands
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Delnoy PPHM, Gutleben KJ, Bruun NE, Maier SKG, Oswald H, Stellbrink C, Johansen JB, Paule S, Søgaard P. Hemodynamic monitoring by intracardiac impedance measured by cardiac resynchronization defibrillators: Evaluation in a controlled clinical setting (BIO.Detect HF II study). Indian Pacing Electrophysiol J 2021; 21:209-218. [PMID: 33866018 PMCID: PMC8263311 DOI: 10.1016/j.ipej.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/31/2021] [Accepted: 04/12/2021] [Indexed: 12/28/2022] Open
Abstract
Background In patients with cardiac resynchronization therapy defibrillators (CRT-Ds), intracardiac impedance measured by dedicated CRT-D software may be used to monitor hemodynamic changes. We investigated the relationship of hemodynamic parameters assessed by intracardiac impedance and by echocardiography in a controlled clinical setting. Methods The study enrolled 68 patients (mean age, 66 ± 9 years; 74% males) at 12 investigational sites. The patients had an indication for CRT-D implantation, New York Heart Association class II/III symptoms, left ventricular ejection fraction 15%–35%, and a QRS duration ≥150 ms. Two months after a CRT-D implantation, hemodynamic changes were provoked by overdrive pacing. Intracardiac impedance was recorded at rest and at four pacing rates ranging from 10 to 40 beats/min above the resting rate. In parallel, echocardiography measurements were performed. We hypothesized that a mean intra-individual correlation coefficient (rmean) between stroke impedance (difference between end-systolic and end-diastolic intracardiac impedance) measured by CRT-D and the aortic velocity time integral (i.e., stroke volume) determined by echocardiography would be significantly larger than 0.65. Results The hypothesis was evaluated in 40 patients with complete data sets. The rmean was 0.797, with a lower confidence interval bound of 0.709. The study hypothesis was met (p = 0.007). A stepwise reduction of stroke impedance and stroke volume was observed with increasing heart rate. Conclusions Intracardiac impedance measured by implanted CRT-Ds correlated well with the aortic velocity time integral (stroke volume) determined by echocardiography. The impedance measurements bear potential and are readily available technically, not requiring implantation of additional material beyond standard CRT-D system. Intracardiac impedance measurement feature (ICI-MF) is integrated in some CRT-Ds. We studied relationship between echo hemodynamic parameters and ICI-MF of CRT-Ds. Stroke volume by echo correlated well with stroke impedance by ICI-MF of CRT-Ds. Stepwise reduction in stroke impedance and stroke volume with increasing heart rate. The ICI-MF bears potential and requires only a ‘standard’ CRT-D system implantation.
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Affiliation(s)
| | | | - Niels Eske Bruun
- Clinical Institute, Copenhagen and Aalborg Universities, Dept. Cardiology, Zealand University Hospital, Roskilde, Denmark
| | | | - Hanno Oswald
- Medizinische Hochschule Hannover, Hannover, Germany
| | | | | | | | - Peter Søgaard
- Heart Center and Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
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Kirchner J, Arnold M, Fischer G. Analysis of the Movement of ICD Leads During Cardiac Contraction as Determinant of Intracardiac Impedance. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2018; 2018:3449-3452. [PMID: 30441126 DOI: 10.1109/embc.2018.8512960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Intracardiac impedance (ICI) has been proposed as an indicator of cardiac status in heart failure patients. We introduce a biophysical model of the measurement setup and apply it to the movement of ICD leads reconstructed from clinical-routine X-ray recordings in a study population of 12 patients. Tilting of the right ventricular lead is found to be a major determinant of ICI changes during cardiac contraction with a mean contribution of 42±23%. The relative position between right and left ventricular lead is the second major contributor (40±22%). However, the contributions of the components of movement strongly differ between the patients. The proposed method provides means for a better interpretation of ICI measurements and for an improvement of its performance for monitoring heart failure status.
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Smits MM, Tonneijck L, Muskiet MHA, Hoekstra T, Kramer MHH, Diamant M, van Raalte DH. Heart rate acceleration with GLP-1 receptor agonists in type 2 diabetes patients: an acute and 12-week randomised, double-blind, placebo-controlled trial. Eur J Endocrinol 2017; 176:77-86. [PMID: 27777261 DOI: 10.1530/eje-16-0507] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 10/04/2016] [Accepted: 10/24/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To examine mechanisms underlying resting heart rate (RHR) increments of GLP-1 receptor agonists in type 2 diabetes patients. DESIGN Acute and 12-week randomised, placebo-controlled, double-blind, single-centre, parallel-group trial. METHODS In total, 57 type 2 diabetes patients (mean ± s.d. age: 62.8 ± 6.9 years; BMI: 31.8 ± 4.1 kg/m2; HbA1c: 7.3 ± 0.6%), treated with metformin and/or sulfonylureas, were included between July 2013 and August 2015. In the acute study, the GLP-1 receptor agonist exenatide (n = 29) or placebo (saline 0.9%; n = 28) was infused intravenously. Subsequently, patients were again randomised to receive the GLP-1 receptor agonist liraglutide (n = 19) or matching placebo (n = 17) for 12 weeks. RHR and blood pressure (BP) were measured by oscillometric technique, systemic haemodynamics by finger photoplethysmography, sympathetic nervous system (SNS) activity by heart rate variability and arterial stiffness by applanation tonometry. This trial was registered at ClinicalTrials.gov (Nbib1744236). RESULTS Exenatide-infusion increased RHR (mean ± s.e.m. +7.5 ± 0.9 BPM, P < 0.001), and systolic and diastolic BP (both P < 0.05), compared with placebo. Vascular resistance increased during exenatide-infusion, whereas stroke volume and arterial stiffness decreased (P < 0.05). SNS activity and cardiac output were unaffected. Twelve-week treatment with liraglutide increased RHR (+6.6 ± 2.1 BPM), while reducing systolic BP (-12.6 ± 4.7 mmHg) and stroke volume (all P < 0.01). Cardiac output, vascular resistance, arterial stiffness and SNS activity remained unchanged (all P > 0.05). CONCLUSIONS RHR acceleration with acute and 12-week GLP-1 receptor agonist treatment in type 2 diabetes patients is not explained by changes in SNS activity, and our data argue against vasodilation. In line with pre-clinical data, direct sino-atrial stimulation may be involved.
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Affiliation(s)
- Mark M Smits
- Department of Internal MedicineDiabetes Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Lennart Tonneijck
- Department of Internal MedicineDiabetes Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Marcel H A Muskiet
- Department of Internal MedicineDiabetes Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Trynke Hoekstra
- Department of Health Sciences and the EMGO Institute for Health and Care ResearchVU University, Amsterdam, The Netherlands and Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Mark H H Kramer
- Department of Internal MedicineDiabetes Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Michaela Diamant
- Department of Internal MedicineDiabetes Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Daniël H van Raalte
- Department of Internal MedicineDiabetes Center, VU University Medical Center, Amsterdam, The Netherlands
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Padeletti L, Botto GL, Curnis A, De Ruvo E, D’Onofrio A, Gronda E, Ricci RP, Vado A, Zanotto G, Zecchin M, Antoniou X, Gargaro A. Selection of potential predictors of worsening heart failure. J Cardiovasc Med (Hagerstown) 2015; 16:782-9. [DOI: 10.2459/jcm.0000000000000171] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Herrera MC, Olivera JM, Gomez Lopez MDLA. Implantable hemodynamic monitors: Can be conductance catheter system successfully implemented? ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2011; 2010:3549-52. [PMID: 21096825 DOI: 10.1109/iembs.2010.5627487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Successful management of cardiac heart failure requires a multifactorial approaching. It has been suggested that implantable hemodynamic long-term monitoring can improve patient care. This paper presents an analysis of the hemodynamic parameters commonly recorded, the most used implantable devices and their associated clinical trials. Newly implantable miniaturized sensors and devices are revisited. Finally, a newly implantable conductance-catheter based system is presented. The feasibility to realise volume and pressure measurements in the human left ventricular cavity using an implantable conductance-catheter based system is evaluated. It has the advantage to obtain LV signals continuously. In addition, it allows to realise maneuvers such as calibration and LV function by telemetry being avoiding patient hospitalizations. The rapid advances in device monitoring capabilities could change the new paradigm of the heart disease management.
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Affiliation(s)
- Myriam C Herrera
- Bioengineering Department, National University of Tucumán, Argentina.
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Bocchiardo M, Meyer zu Vilsendorf D, Militello C, Lippert M, Czygan G, Schauerte P, Gaita F, Stellbrink C. Resynchronization therapy optimization by intracardiac impedance. Europace 2010; 12:1589-95. [DOI: 10.1093/europace/euq273] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Taborsky M, Kupec J, Vopalka R, Barbetta A, Di Gregorio F. Left ventricular mechanical activity detected by impedance recording. Europace 2010; 12:534-9. [PMID: 20338989 PMCID: PMC2845509 DOI: 10.1093/europace/euq052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aims Recording and analysing impedance fluctuation along the cardiac cycle in the right (RV) and left ventricles (LV). Methods and results During a biventricular (BiV) implantation procedure, impedance was sequentially derived between the atrial ring electrode and either electrode (tip or ring) of the RV lead [transvalvular impedance (TVI)], and between the atrial ring and either the tip or ring electrode of a coronary sinus lead, positioned in a cardiac vein [left ventricle impedance (LVI)]. The LVI signal was also recorded by the implanted pacemaker at the 1 day and 3 months follow-ups. With intrinsic conduction, TVI showed an average increase of 53 ± 29 Ω during ventricular systole, whereas at the same time, LVI decreased by 45 ± 21 Ω (25 and 23 patients, respectively, out of 28 tested cases). Transvalvular impedance and LVI displayed a similar time course, which appeared to be related to the systolic timing in the RV and LV. Both LVI amplitude and duration decreased as a function of the cardiac rate. The LVI deflection started immediately after LV stimulation, and often anticipated the R-wave sensing after contralateral pacing. At the 3-month follow-up, LVI amplitude was decreased in 70% of cases and increased in the remainder, with a non-significant average change of −5 ± 85% with respect to the acute recordings. Conclusion Transvalvular impedance properties are consistent with the assumption of an inverse relationship with RV volume. Though LVI requires a different physical interpretation, the waveform duration might reflect the timing of LV myocardial contraction. In this hypothesis, the relationship between TVI and LVI could provide insight into the effects of BiV pacing on mechanical synchronization.
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Affiliation(s)
- Milos Taborsky
- 1st Internal-Cardiology Clinic, University Hospital, Olomouc, Czech Republic.
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Kroll MW. Four-terminal impedance monitoring of cardiac output: an elegant clinical application of a classical engineering trick. Europace 2010; 12:616-7. [DOI: 10.1093/europace/euq100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bocchiardo M, Meyer zu Vilsendorf D, Militello C, Lippert M, Czygan G, Gaita F, Schauerte P, Stellbrink C. Intracardiac impedance monitors stroke volume in resynchronization therapy patients. Europace 2010; 12:702-7. [DOI: 10.1093/europace/euq045] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Stahl C, Walker T, Straub A, Kettering K, Knubben K, Greiner TO, Paule S, Lippert M, Czygan G, Schweika O, Kühlkamp V. Assessing acute ventricular volume changes by intracardiac impedance in a chronic heart failure animal model. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:1395-401. [PMID: 19694969 DOI: 10.1111/j.1540-8159.2009.02477.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Implantable device diagnostics may play an essential role in simplifying the care of heart failure patients by providing fundamental insights into their complex clinical patterns. Early recognition of heart failure progression by a continuous hemodynamic monitoring would allow for timely therapeutic interventions to prevent decompensation and hospitalization. In this study, the feasibility of assessing ventricular volume changes by implant-based measurements of intracardiac impedance was tested in a heart failure animal model. METHODS Heart failure was induced in five minipigs by high-rate pacing over 3 weeks. During a final open-chest examination a graded dobutamine stress test was performed. Stroke volume (SV) was measured by an ultrasonic flow probe at the ascending aorta. End diastolic pressure (EDP) and maximum pressure slope (dP/dtmax) were calculated from a left ventricular microtip catheter signal. Impedance was measured by an implanted pacemaker between biventricular leads. Stroke impedance (SZ) was calculated as the difference between end-systolic and end-diastolic impedance (EDZ). RESULTS Administration of dobutamine led to an increase in SV (55+/-16%), dP/dtmax (107+/-89%), and SZ (56+/-30%). EDP changed by 37+/-21% whereas EDZ changed by 7.4+/-4%. Significant correlations were found between SZ and SV (r=0.88), and between EDZ and EDP (r=-0.82). CONCLUSION The strong correlation with SV allows the application of intracardiac impedance measurements for an implant-based continuous monitoring of cardiac function. Impedance may also be used for hemodynamic optimization of cardiac resynchronization therapy.
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Affiliation(s)
- Carsten Stahl
- Department of Cardiology, University of Tübingen, Tübingen, Germany.
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Jung W, Rillig A, Birkemeyer R, Miljak T, Meyerfeldt U. Advances in remote monitoring of implantable pacemakers, cardioverter defibrillators and cardiac resynchronization therapy systems. J Interv Card Electrophysiol 2008; 23:73-85. [DOI: 10.1007/s10840-008-9311-5] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2008] [Accepted: 08/11/2008] [Indexed: 11/24/2022]
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Kaye G, Edgar D, Mudawi T, Lippert M, Czygan G. Can transventricular intracardiac impedance measurement discriminate haemodynamically unstable ventricular arrhythmias in human? ACTA ACUST UNITED AC 2007; 9:122-6. [PMID: 17272334 DOI: 10.1093/europace/eul150] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIMS To measure changes in transventricular impedance during arrhythmias. METHODS AND RESULTS Patients were studied during electrophysiological studies. A quadrapolar catheter was positioned at the right ventricular apex (RVA) and a decapolar catheter within the coronary sinus (CS). Transventricular impedance was measured by injecting a subthreshold biphasic rectangular pulse of 600 micro A between poles 1 of the CS catheter and pole 1 of the RVA catheter and the voltage measured between CS pole 10 and RVA catheter pole 4. Stroke impedance (SZ), surface ECG, intracardiac electrogram (IEGM), and invasive femoral artery blood pressure (FAP) were recorded. Twenty-eight patients were analysed, 5 with inducible, haemodynamically unstable ventricular tachycardia (VT) (HUSVT), 5 with stable VT (HSVT). During HUSVT, the SZ value reduced to 22% (range 0.15-0.32 P < 0.001) in comparison with sinus rhythm. For HSVT, the SZ value reduced to 58% (range 0.33-0.88) P < 0.01, significantly different from HUSVT (P < 0.01). There was a good correlation between reduction of SZ and arterial pulse pressure (PP) during arrhythmias (r = 0.95). CONCLUSION Changes in SZ strongly correlated with PP amplitude. Transventricular impedance fell significantly during unstable arrhythmias and may be useful as a sensor capable of haemodynamic discrimination.
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Affiliation(s)
- Gerry Kaye
- Department of Cardiology, Castle Hill Hospital, East Yorkshire, UK.
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