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Timóteo AT, Barbas Albuquerque F, Lacerda Teixeira B. Pericardium, epicardial adipose tissue, and heart failure with preserved ejection fraction: Pathophysiology, quantification and treatment target. Int J Cardiol 2024; 412:132303. [PMID: 38944349 DOI: 10.1016/j.ijcard.2024.132303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 05/15/2024] [Accepted: 06/26/2024] [Indexed: 07/01/2024]
Abstract
Heart failure is an important cause of mortality and morbidity worldwide. Heart failure with preserved ejection fraction (HFpEF) incidence and prevalence is increasing, and the phenotype associated with obesity is the most frequent. Epicardial adipose tissue (EAT) is directly associated with systemic obesity and several previous studies have shown a clear link between EAT and HFpEF. Moreover, the restriction induced by the pericardium is also linked to HFpEF. In this review we will describe the epidemiological association between the pericardium, EAT and HFpEF, how to quantify EAT, what are the pathophysiological mechanism to explain theses association and how can the pericardium and EAT be a treatment target in patients with HFpEF.
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Affiliation(s)
- Ana Teresa Timóteo
- Cardiology Department, Santa Marta Hospital, Unidade Local de Saúde São José, Lisbon, Portugal; NOVA Medical School, NOVA Lisbon University, Portugal.
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Subramaniam KG, Sharma D. The bird hunting story: constrictive pericarditis and restrictive cardiomyopathy. Indian J Thorac Cardiovasc Surg 2024; 40:514-515. [PMID: 38919195 PMCID: PMC11194244 DOI: 10.1007/s12055-024-01696-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 01/17/2024] [Indexed: 06/27/2024] Open
Affiliation(s)
- Krishnan Ganapathy Subramaniam
- Department of Cardiothoracic and Vascular Surgery, Sri Padmavathi Children’s Heart Center, Tirupati, Andhra Pradesh India
| | - Dhruva Sharma
- Department of Cardiothoracic and Vascular Surgery, SMS Medical College & Attached Hospitals, JLN Marg, Jaipur, 302001 Rajasthan India
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Borlaug BA, Strong M. Heart Failure Solutions: The PeriCut Device as a Treatment for HFpEF. JACC Basic Transl Sci 2024; 9:448-450. [PMID: 38680967 PMCID: PMC11055196 DOI: 10.1016/j.jacbts.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Affiliation(s)
| | - Mark Strong
- Heart Failure Solutions, Shoreview, Minnesota, USA
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Borlaug BA, Schaff HV, Asirvatham SJ, Koepp KE, Mauermann WJ, Rowse PG. Surgical pericardiotomy to treat heart failure with preserved ejection fraction: a first clinical study. Eur Heart J 2023; 44:4719-4721. [PMID: 37740430 PMCID: PMC10659945 DOI: 10.1093/eurheartj/ehad620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/19/2023] [Accepted: 09/08/2023] [Indexed: 09/24/2023] Open
Affiliation(s)
- Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55906, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Katlyn E Koepp
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | | | - Phillip G Rowse
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55906, USA
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Borlaug BA, Sharma K, Shah SJ, Ho JE. Heart Failure With Preserved Ejection Fraction: JACC Scientific Statement. J Am Coll Cardiol 2023; 81:1810-1834. [PMID: 37137592 DOI: 10.1016/j.jacc.2023.01.049] [Citation(s) in RCA: 88] [Impact Index Per Article: 88.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 05/05/2023]
Abstract
The incidence and prevalence of heart failure with preserved ejection fraction (HFpEF) continue to rise in tandem with the increasing age and burdens of obesity, sedentariness, and cardiometabolic disorders. Despite recent advances in the understanding of its pathophysiological effects on the heart, lungs, and extracardiac tissues, and introduction of new, easily implemented approaches to diagnosis, HFpEF remains under-recognized in everyday practice. This under-recognition presents an even greater concern given the recent identification of highly effective pharmacologic-based and lifestyle-based treatments that can improve clinical status and reduce morbidity and mortality. HFpEF is a heterogenous syndrome and recent studies have suggested an important role for careful, pathophysiological-based phenotyping to improve patient characterization and to better individualize treatment. In this JACC Scientific Statement, we provide an in-depth and updated examination of the epidemiology, pathophysiology, diagnosis, and treatment of HFpEF.
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Affiliation(s)
- Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Kavita Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jennifer E Ho
- CardioVascular Institute and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Popovic D, Alogna A, Omar M, Sorimachi H, Omote K, Reddy YNV, Redfield MM, Burkhoff D, Borlaug BA. Ventricular stiffening and chamber contracture in heart failure with higher ejection fraction. Eur J Heart Fail 2023; 25:657-668. [PMID: 36994635 PMCID: PMC10330082 DOI: 10.1002/ejhf.2843] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/02/2023] [Accepted: 03/26/2023] [Indexed: 03/31/2023] Open
Abstract
AIMS Ancillary analyses from clinical trials have suggested reduced efficacy for neurohormonal antagonists among patients with heart failure and preserved ejection fraction (HFpEF) and higher ranges of ejection fraction (EF). METHODS AND RESULTS A total of 621 patients with HFpEF were grouped into those with low-normal left ventricular EF (LVEF) (HFpEF<65% , n = 319, 50% ≤ LVEF <65%) or HFpEF≥65% (n = 302, LVEF ≥65%), and compared with 149 age-matched controls undergoing comprehensive echocardiography and invasive cardiopulmonary exercise testing. A sensitivity analysis was performed in a second non-invasive community-based cohort of patients with HFpEF (n = 244) and healthy controls without cardiovascular disease (n = 617). Patients with HFpEF≥65% had smaller left ventricular (LV) end-diastolic volume than HFpEF<65% , but LV systolic function assessed by preload recruitable stroke work and stroke work/end-diastolic volume was similarly impaired. Patients with HFpEF≥65% displayed an end-diastolic pressure-volume relationship (EDPVR) that was shifted leftward, with increased LV diastolic stiffness constant β, in both invasive and community-based cohorts. Cardiac filling pressures and pulmonary artery pressures at rest and during exercise were similarly abnormal in all EF subgroups. While patients HFpEF≥57% displayed leftward shifted EDPVR, those with HFpEF<57% had a rightward shifted EDPVR more typical of heart failure with reduced EF. CONCLUSION Most pathophysiologic differences in patients with HFpEF and higher EF are related to smaller heart size, increased LV diastolic stiffness, and leftward shift in the EDPVR. These findings may help to explain the absence of efficacy for neurohormonal antagonists in this group and raise a new hypothesis, that interventions to stimulate eccentric LV remodelling and enhance diastolic capacitance may be beneficial for patients with HFpEF and EF in the higher range.
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Affiliation(s)
- Dejana Popovic
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alessio Alogna
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Massar Omar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Borlaug BA, Larson K. Left Ventricular Volume, Cardiac Reserve, and Aerobic Capacity in Women. JACC Cardiovasc Imaging 2023:S1936-878X(23)00180-8. [PMID: 37178074 DOI: 10.1016/j.jcmg.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Kathryn Larson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Sarma S, MacNamara JP, Balmain BN, Hearon CM, Wakeham DJ, Tomlinson AR, Hynan LS, Babb TG, Levine BD. Challenging the Hemodynamic Hypothesis in Heart Failure With Preserved Ejection Fraction: Is Exercise Capacity Limited by Elevated Pulmonary Capillary Wedge Pressure? Circulation 2023; 147:378-387. [PMID: 36524474 PMCID: PMC9892242 DOI: 10.1161/circulationaha.122.061828] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/31/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Exercise intolerance is a defining characteristic of heart failure with preserved ejection fraction (HFpEF). A marked rise in pulmonary capillary wedge pressure (PCWP) during exertion is pathognomonic for HFpEF and is thought to be a key cause of exercise intolerance. If true, acutely lowering PCWP should improve exercise capacity. To test this hypothesis, we evaluated peak exercise capacity with and without nitroglycerin to acutely lower PCWP during exercise in patients with HFpEF. METHODS Thirty patients with HFpEF (70±6 years of age; 63% female) underwent 2 bouts of upright, seated cycle exercise dosed with sublingual nitroglycerin or placebo control every 15 minutes in a single-blind, randomized, crossover design. PCWP (right heart catheterization), oxygen uptake (breath × breath gas exchange), and cardiac output (direct Fick) were assessed at rest, 20 Watts (W), and peak exercise during both placebo and nitroglycerin conditions. RESULTS PCWP increased from 8±4 to 35±9 mm Hg from rest to peak exercise with placebo. With nitroglycerin, there was a graded decrease in PCWP compared with placebo at rest (-1±2 mm Hg), 20W (-5±5 mm Hg), and peak exercise (-7±6 mm Hg; drug × exercise stage P=0.004). Nitroglycerin did not affect oxygen uptake at rest, 20W, or peak (placebo, 1.34±0.48 versus nitroglycerin, 1.32±0.46 L/min; drug × exercise P=0.984). Compared with placebo, nitroglycerin lowered stroke volume at rest (-8±13 mL) and 20W (-7±11 mL), but not peak exercise (0±10 mL). CONCLUSIONS Sublingual nitroglycerin lowered PCWP during submaximal and maximal exercise. Despite reduction in PCWP, peak oxygen uptake was not changed. These results suggest that acute reductions in PCWP are insufficient to improve exercise capacity, and further argue that high PCWP during exercise is not by itself a limiting factor for exercise performance in patients with HFpEF. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04068844.
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Affiliation(s)
- Satyam Sarma
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
| | - James P MacNamara
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
| | - Bryce N Balmain
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
| | - Christopher M Hearon
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
| | - Denis J Wakeham
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
| | - Andrew R Tomlinson
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
| | - Linda S Hynan
- Peter O'Donnell Jr School of Public Health and Department of Psychiatry (L.S.H.)
| | - Tony G Babb
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
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van Woerden G, van Veldhuisen DJ, Westenbrink BD, de Boer RA, Rienstra M, Gorter TM. Connecting epicardial adipose tissue and heart failure with preserved ejection fraction: mechanisms, management and modern perspectives. Eur J Heart Fail 2022; 24:2238-2250. [PMID: 36394512 PMCID: PMC10100217 DOI: 10.1002/ejhf.2741] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/19/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
Obesity is very common in patients with heart failure with preserved ejection fraction (HFpEF) and it has been suggested that obesity plays an important role in the pathophysiology of this disease. While body mass index defines the presence of obesity, this measure provides limited information on visceral adiposity, which is probably more relevant in the pathophysiology of HFpEF. Epicardial adipose tissue is the visceral fat situated directly adjacent to the heart and recent data demonstrate that accumulation of epicardial adipose tissue is associated with the onset, symptomatology and outcome of HFpEF. However, the mechanisms by which epicardial adipose tissue may be involved in HFpEF remain unclear. It is also questioned whether epicardial adipose tissue may be a specific target for therapy for this disease. In the present review, we describe the physiology of epicardial adipose tissue and the pathophysiological transformation of epicardial adipose tissue in response to chronic inflammatory diseases, and we postulate conceptual mechanisms on how epicardial adipose tissue may be involved in HFpEF pathophysiology. Lastly, we outline potential treatment strategies, knowledge gaps and directions for further research.
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Affiliation(s)
- Gijs van Woerden
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - B Daan Westenbrink
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Thomas M Gorter
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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