Heart Failure With Preserved Ejection Fraction In Perspective

Heart failure with preserved ejection fraction: from echocardiographic characteristics to a cardiovascular damage score in a high-risk hypertensive population

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is a high prevalence condition, with high rates of hospitalization and mortality. Arterial hypertension is the main risk factor for HFpEF. Among hypertensive patients, alterations in cardiac and vascular morphology identify hypertension-mediated organ damage (HMOD). Cardiac HMOD in terms of ventricular hypertrophy and diastolic dysfunction is a continuum between the preclinical condition (arterial hypertension) and HFpEF. In hypertensive patients, it is currently unknown what is the prevalence of individuals classifiable as being at high risk of developing HFpEF and whether aortic morphofunctional vascular changes are present.

AIM

This study seeks to retrospectively assess the prevalence of echocardiographic alterations consistent with the diagnosis of HFpEF in a cohort of patients with essential arterial hypertension, and the prevalence of vascular HMOD (V-HMOD) in different risk categories of patients.

METHODS

Hypertensive outpatients referred at the Hypertension Center of Turin from 2003 to 2021 were retrospectively evaluated. Patients with a previous diagnosis of heart failure and known cardiovascular events were excluded. A predictive model associated with the risk of HFpEF development was calculated using echocardiographic variables. V-HMOD morphological and functional parameters were assessed by ascending aorta diameter and arterial stiffness (carotid-femoral pulse wave velocity, cfPWV).

RESULTS

Eight hundred and four patients (34.8% women) were analyzed, age 53.1 ± 14 years; left ventricular mass index (LVMi) and E / e' ratio were impaired in 15.9 and 29.1% of cases, respectively. Dividing them into tertiles according to score: score 1 or less (30.2%); score 2-3 (47.4%); score at least 3 (22.7%). Patients identified at high risk of HFpEF (score ≥3) had higher age, BMI and blood pressure than the other two groups ( P  < 0.05); they showed a significantly higher prevalence of female patients (42.3%), treatment with at least two antihypertensive drugs (40.1%), diabetes (7.1%), and dyslipidemia (28%; P  < 0.05), with a larger ascending aorta diameter (35.5 ± 5.5 mm, P  < 0.05) and higher cfPWV (8.8 ± 2.4 m/s, P  < 0.05).

CONCLUSION

At least one in five hypertensive patients, referred to an outpatient echocardiographic examination, has C-HMOD compatible with a high-risk category of HFpEF and have a significant increase in V-HMOD. This reinforces the notion that arterial hypertension and HFpEF are not two distinctly separate conditions but a continuum of pathophysiologic alterations.

Impact of Multimorbidity on Mortality in Heart Failure With Mildly Reduced and Preserved Ejection Fraction

BACKGROUND

How different combinations of comorbidities influence risk at the patient level and population level in patients with heart failure with mildly reduced ejection fraction/heart failure with preserved ejection fraction is unknown. We aimed to investigate the prevalence of different combinations of cardiovascular and noncardiovascular comorbidities (ie, multimorbidity) and associated risk of death at the patient level and population level.

METHODS

Using patient-level data from the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) and PARAGON-HF trial (Prospective Comparison of ARNI With ARB Global Outcomes in HF With Preserved Ejection Fraction), we investigated the 5 most common cardiovascular and noncardiovascular comorbidities and the resultant 45 comorbidity pairs. Cox proportional hazard models were used to calculate the population-attributable fractions for all-cause mortality and the relative excess risk due to interaction for each comorbidity pair.

RESULTS

Among 6504 participants, 95.2% had at least 2 of the 10 most prevalent comorbidities. The comorbidity pair with the greatest patient-level risk was stroke and peripheral artery disease (adjusted hazard ratio, 1.88 [95% CI, 1.27-2.79]), followed by peripheral artery disease and chronic obstructive pulmonary disease (1.81 [95% CI, 1.31-2.51]), and coronary artery disease and stroke (1.67 [95% CI, 1.33-2.11]). The pair with the highest population-level risk was hypertension and chronic kidney disease (CKD; adjusted population-attributable fraction, 14.8% [95% CI, 9.2%-19.9%]), followed by diabetes and CKD (13.3% [95% CI, 10.6%-16.0%]), and hypertension and diabetes (11.9% [95% CI, 7.1%-16.5%). A synergistic interaction (more than additive risk) was found for the comorbidity pairs of stroke and coronary artery disease (relative excess risk due to interaction, 0.61 [95% CI, 0.13-1.09]), diabetes and CKD (relative excess risk due to interaction, 0.46 [95% CI, -0.15 to 0.77]), and obesity and CKD (relative excess risk due to interaction, 0.24 [95% CI, 0.01-0.46]).

CONCLUSIONS

The risk associated with comorbidity pairs differs at the patient and population levels in heart failure with mildly reduced ejection fraction/heart failure with preserved ejection fraction. At the population level, hypertension, CKD, and diabetes account for the greatest risk, whereas at the patient level, polyvascular disease and chronic obstructive pulmonary disease are the most important.

The effect of long-term administration of green tea catechins on aging-related cardiac diastolic dysfunction and decline of troponin I

Aging is an independent risk factor for cardiovascular diseases. Cardiac diastolic dysfunction (CDD), ultimately leading to heart failure with preserved ejection fraction (HFpEF), is prevalent among older individuals. Although therapeutics have made great progress, preventive strategies remain unmet medical needs. Green tea catechins have been shown to be effective in improving aging-related cardiovascular and cerebral disorders in animal models and patients. However, little attention has been paid to whether long-term administration of epigallocatechin gallate (EGCG), the major bioactive ingredient of green tea catechins, could prevent the onset and progression of CDD. In this study, 12-month-old female mice were orally administered 50, 100 and 200 mg EGCG mixed with drinking water for 6 months. Aged mice (18 months old) exhibited the major features of HFpEF, including CDD with pEF, cardiac fibrosis, increased cardiomyocyte apoptosis, and mitochondrial damages, as well as elevated A/B-type natriuretic peptide. Cardiac troponin I (cTnI) expression was also reduced. Long-term administration of 100 or 200 mg EGCG prevented aging-related CDD and exercise capacity decline, along with alleviating myocardial apoptosis and mitochondria damage. The transcription and protein expression of cTnI were increased, which might be achieved by inhibiting the expression and activity of histone deacetylase 1 (HDAC1), and reducing its binding level near cTnI's promoter, thereby elevating acetylated histone 3 (AcH3) and acetylated lysine 9 on histone H3 (AcH3K9) in the aged mice. We provide a novel insight that long-term administration of EGCG is a potentially effective strategy in preventing aging-related CDD and cTnI expression decline.

Advances of deep Neural Networks (DNNs) in the development of peptide drugs

Peptides are able to bind to difficult disease targets with high potency and specificity, providing great opportunities to meet unmet medical requirements. Nevertheless, the unique features of peptides, such as their small size, high structural flexibility, and scarce data availability, bring extra challenges to the design process. Firstly, this review sums up the application of peptide drugs in treating diseases. Then, the review probes into the advantages of Deep Neural Networks (DNNs) in predicting and designing peptide structures. DNNs have demonstrated remarkable capabilities in structural prediction, enabling accurate three-dimensional modeling of peptide drugs through models like AlphaFold and its successors. Finally, the review deliberates on the challenges and coping strategies of DNNs in the development of peptide drugs, along with future research directions. Future research directions focus on further improving the accuracy and efficiency of DNN-based peptide drug design, exploring novel applications of peptide drugs, and accelerating their clinical translation. With continuous advancements in technology and data accumulation, DNNs are poised to play an increasingly crucial role in the field of peptide drug development.

Correlation between coronary calcification and cardiac structure in non-dialysis patients with chronic kidney disease

AIMS

We aim to explore the correlation between coronary artery calcification (CAC) score (CACS) and cardiac structure and function in chronic kidney disease (CKD) patients, create a clinical prediction model for severe CAC associated with cardiac ultrasound indexes.

METHODS AND RESULTS

The study included 178 non-dialysis CKD patients who underwent CACS testing and collected general information, serological indices, cardiac ultrasound findings and follow-up on renal function, heart failure (HF) manifestations and re-hospitalization. The mean age of participants in the study cohort was 67.4 years; 59% were male, and 66.9% of patients had varying degrees of comorbid CAC. CKD patients with CACS > 100 were older, predominantly male and had a higher proportion of smoking, diabetes and hypertension (P < 0.05) compared with those with CACS = 0 and 0 < CACS ≤ 100, and had higher brain natriuretic peptide, serum magnesium and fibrinogen levels were also higher (P < 0.05). CACS was positively correlated with left atrial inner diameter (LAD), left ventricular end-diastolic inner diameter (LVDd), left ventricular volume at diastole (LVVd), output per beat (SV) and mitral orifice early diastolic blood flow velocity/early mitral annular diastolic myocardial motion velocity (E/e) (P < 0.05). We tested the associations between varying degrees of CAC and HF and heart valve calcification using multivariable-adjusted regression models. The risk of HF in patients with severe CAC was about 1.95 times higher than that in patients without coronary calcification, and the risk of heart valve calcification was 2.46 times higher than that in patients without coronary calcification. Heart valve calcification and HF diagnosis, LAD and LVDd are essential in predicting severe CAC. During a mean follow-up time of 18.26 ± 10.17 months, 65 (36.52%) patients had a composite renal endpoint event, of which 36 (20.22%) were admitted to renal replacement therapy. Patients with severe CAC had a higher risk of progression of renal function, re-admission due to cardiovascular and renal events and more pronounced symptoms of HF (P < 0.05).

CONCLUSIONS

There is a correlation between CACS and cardiac structure and function in non-dialysis CKD patients, which may mainly involve abnormalities in left ventricular structure and cardiac diastolic function. CAC may affect renal prognosis and quality of survival in CKD patients. Based on clinical information, HF, valvular calcification status and indicators related to left ventricular hypertrophy can identify people at risk for severe CAC.

The role of the ER stress sensor IRE1 in cardiovascular diseases

Despite enormous advances in the treatment of cardiovascular diseases, including I/R injury and heart failure, heart diseases remain a leading cause of mortality worldwide. Inositol-requiring enzyme 1 (IRE1) is an evolutionarily conserved sensor endoplasmic reticulum (ER) transmembrane protein that senses ER stress. It manages ER stress induced by the accumulation of unfolded/misfolded proteins via the unfolded protein response (UPR). However, if the stress still persists, the UPR pathways are activated and induce cell death. Emerging evidence shows that, beyond the UPR, IRE1 participates in the progression of cardiovascular diseases by regulating inflammation levels, immunity, and lipid metabolism. Here, we summarize the recent findings and discuss the potential therapeutic effects of IRE1 in the treatment of cardiovascular diseases.

Left Bundle Branch Area Pacing Versus Right Ventricular Pacing in Patients With Atrioventricular Block: A Systematic Review and Meta-Analysis

BACKGROUND

Left bundle branch area pacing (LBBAP) is a new technique for patients with atrioventricular block (AVB) and preserved left ventricular ejection fraction (LVEF), potentially offering better cardiac function than right ventricular pacing (RVP).

METHODS

We searched databases and registries for studies that compared LBBAP with RVP in patients with AVB and preserved LVEF. We extracted data on various outcomes and pooled the effect estimates using random-effects models.

RESULTS

Our meta-analysis included 14 studies (10 observational and 4 RCTs) involving 3062 patients with AVB. The analysis revealed that the QRS duration was significantly shorter in the LBBAP group compared to the RVP group [MD = -35.56 ms; 95% CI: (-39.27, -31.85), p < 0.00001]. Patients in the LBBAP group also exhibited a significant increase in left ventricular ejection fraction (LVEF) [MD = 5.48%; 95% CI: (4.07%, 6.89%), p < 0.00001], and a significant reduction in left ventricular end-diastolic diameter (LVEDD) compared to RVP [MD = -3.98 mm; 95% CI: (-5.88, -2.09 mm), p < 0.0001]. In terms of clinical outcomes, LBBAP was associated with a significantly lower risk of heart failure hospitalizations (HFHs) compared to RVP [OR = 0.26; 95% CI: (0.16, 0.44), p < 0.0001]. However, no significant differences were observed between the two groups in the implant success rate, pacing impedance, or pacing threshold. The RVP group demonstrated a significantly higher R-wave amplitude increase than the LBBAP group [MD = 0.85 mV; 95% CI: (0.23, 1.46), p = .007]. Lastly, there was no significant difference in the incidence of complications between the two groups [OR = 2.12; 95% CI: (0.29, 15.52), p = 0.46].

CONCLUSION

LBBAP outperforms RVP in several cardiac function indicators, suggesting it may be a superior pacing method for AVB patients with preserved LVEF. However, the small sample size in studies and the result in heterogeneity call for more research to validate these findings and assess LBBAP's long-term effects.

Mitochondrial Dysfunction in HFpEF: Potential Interventions Through Exercise

HFpEF is a prevalent and complex type of heart failure. The concurrent presence of conditions such as obesity, hypertension, hyperglycemia, and hyperlipidemia significantly increase the risk of developing HFpEF. Mitochondria, often referred to as the powerhouses of the cell, are crucial in maintaining cellular functions, including ATP production, intracellular Ca2+ regulation, reactive oxygen species generation and clearance, and the regulation of apoptosis. Exercise plays a vital role in preserving mitochondrial homeostasis, thereby protecting the cardiovascular system from acute stress, and is a fundamental component in maintaining cardiovascular health. In this study, we review the mitochondrial dysfunction underlying the development and progression of HFpEF. Given the pivotal role of exercise in modulating cardiovascular diseases, we particularly focus on exercise as a potential therapeutic strategy for improving mitochondrial function. Graphical abstract Note: This picture was created with BioRender.com.

Hydrogen Sulfide Deficiency and Therapeutic Targeting in Cardiometabolic HFpEF: Evidence for Synergistic Benefit with GLP-1/Glucagon Agonism

Background

Heart failure with preserved ejection fraction (HFpEF) is a significant public health concern with limited treatment options. Dysregulated nitric oxide-mediated signaling has been implicated in HFpEF pathophysiology, however, little is known about the role of endogenous hydrogen sulfide (H 2 S) in HFpEF.

Objectives

This study evaluated H 2 S bioavailability in patients and two animal models of cardiometabolic HFpEF and assessed the impact of H 2 S on HFpEF severity through alterations in endogenous H 2 S production and pharmacological supplementation. We also evaluated the effects of the H 2 S donor, diallyl trisulfide (DATS) in combination with the GLP-1/glucagon receptor agonist, survodutide, in HFpEF.

Methods

HFpEF patients and two rodent models of HFpEF ("two-hit" L-NAME + HFD mouse and ZSF1 obese rat) were evaluated for H 2 S bioavailability. Two cohorts of two-hit mice were investigated for changes in HFpEF pathophysiology: (1) endothelial cell cystathionine-γ-lyase (EC-CSE) knockout; (2) H 2 S donor, JK-1, supplementation. DATS and survodutide combination therapy was tested in ZSF1 obese rats.

Results

H 2 S levels were significantly reduced (i.e., 81%) in human HFpEF patients and in both preclinical HFpEF models. This depletion was associated with reduced CSE expression and activity, and increased SQR expression. Genetic knockout of H 2 S -generating enzyme, CSE, worsened HFpEF characteristics, including elevated E/e' ratio and LVEDP, impaired aortic vasorelaxation and increased mortality. Pharmacologic H 2 S supplementation restored H 2 S bioavailability, improved diastolic function and attenuated cardiac fibrosis corroborating an improved HFpEF phenotype. DATS synergized with survodutide to attenuate obesity, improve diastolic function, exercise capacity, and reduce oxidative stress and cardiac fibrosis.

Conclusions

H 2 S deficiency is evident in HFpEF patients and conserved across multiple preclinical HFpEF models. Increasing H 2 S bioavailability improved cardiovascular function, while knockout of endogenous H 2 S production exacerbated HFpEF pathology and mortality. These results suggest H 2 S dysregulation contributes to HFpEF and increasing H 2 S bioavailability may represent a novel therapeutic strategy for HFpEF. Furthermore, our data demonstrate that combining H 2 S supplementation with GLP-1/glucagon receptor agonist may provide synergistic benefits in improving HFpEF outcomes.

Highlights

H 2 S deficiency is evident in both human HFpEF patients and two clinically relevant models. Reduced H 2 S production by CSE and increased metabolism by SQR impair H 2 S bioavailability in HFpEF. Pharmacological H 2 S supplementation improves diastolic function and reduces cardiac fibrosis in HFpEF models. Targeting H 2 S dysregulation presents a novel therapeutic strategy for managing HFpEF. H 2 S synergizes with GLP-1/glucagon agonist and ameliorates HFpEF.

State of precision medicine for heart failure with preserved ejection fraction in a new therapeutic age

Heart failure with preserved ejection fraction (HFpEF) is defined by heart failure (HF) with a left ventricular ejection fraction (LVEF) of at least 50%. HFpEF has a complex and heterogeneous pathophysiology with multiple co-morbidities contributing to its presentation. Establishing the diagnosis of HFpEF can be challenging. Two algorithms, the 'Heavy, 2 or more Hypertensive drugs, atrial Fibrillation, Pulmonary hypertension, Elderly age >60, elevated Filling pressures' (H2FPEF) and the 'Heart Failure Association Pre-test assessment, Echocardiography and natriuretic peptide, Functional testing, Final aetiology' (HFA-PEFF), can help to determine the likelihood of HFpEF in individuals with symptoms of HF. Phenotype clusters defined largely by the total number and types of co-morbidities may delineate groups of patients with HFpEF with different management needs. It is important to recognize alternative diagnoses or HFpEF mimics such as infiltrative cardiomyopathies, coronary artery disease, lung disease, anxiety, depression, anaemia, severe obesity, and physical deconditioning, among others. Treatment with sodium-glucose co-transporter 2 inhibitors (dapagliflozin and empagliflozin) is recommended for all patients with HFpEF unless contraindicated. Future research should consider alternative approaches to guide the initial diagnosis and treatment of HFpEF, including phenotype clustering models and artificial intelligence, and consider whether LVEF is the most useful distinguishing feature for categorizing HF. Ongoing clinical trials are evaluating novel pharmacological and device-based approaches to address the pathophysiological consequences of HFpEF.

Effect of Finerenone on the KCCQ in Patients With HFmrEF/HFpEF: A Prespecified Analysis of FINEARTS-HF

BACKGROUND

Patients with heart failure (HF) are limited by symptoms and have impaired quality of life. The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a patient-reported outcome measure that enables evaluation of the effect of HF and the impact of new therapies on health status in patients with HF.

OBJECTIVES

This prespecified analysis of FINEARTS-HF (Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients With Heart Failure) assessed the efficacy and safety of finerenone according to baseline KCCQ Total Symptom Score (TSS) and the effect of finerenone on KCCQ-TSS.

METHODS

FINEARTS-HF tested the efficacy of the nonsteroidal mineralocorticoid receptor antagonist (MRA) finerenone, compared with placebo, in patients with HF with mildly reduced ejection fraction/preserved ejection fraction. The primary endpoint was the composite of cardiovascular death and total worsening HF events. The KCCQ was completed by patients at randomization and at 6, 9, and 12 months after randomization. Change in KCCQ-TSS was a key secondary endpoint. Patients were stratified by KCCQ-TSS tertiles at baseline. The association between KCCQ tertile and clinical outcomes was evaluated using semiparametric proportional-rates models for total events and Cox models for time-to-first-event data, and the effects of finerenone vs placebo on the primary endpoint were assessed across tertiles of KCCQ-TSS.

RESULTS

Of the 6,001 participants in FINEARTS-HF, 5,986 (99.8%) had baseline KCCQ-TSS recorded (median score 69.8 of a possible 100; higher score = better health status). Lower (worse) KCCQ-TSS was associated with a higher risk of the primary endpoint. Finerenone, compared with placebo, reduced the risk of the primary endpoint across the range of KCCQ-TSS: tertile 1 (score 0-<57): RR: 0.82 (95% CI: 0.68-1.00); tertile 2 (57-<81): 0.88 (95% CI: 0.70-1.11); tertile 3 (81-100): 0.88 (95% CI: 0.69-1.14) (Pinteraction = 0.89). Compared with placebo, finerenone significantly improved KCCQ-TSS from baseline with a mean difference at 12 months of 1.62 points (95% CI: 0.69-2.56 points) (P < 0.001). Numerically fewer finerenone-treated patients experienced clinically meaningful deterioration, and more had improvements in KCCQ-TSS.

CONCLUSIONS

Finerenone significantly reduced HF events and improved health status in patients with HF and mildly reduced ejection fraction/preserved ejection fraction across the spectrum of KCCQ-TSS at baseline. (Study to Evaluate the Efficacy [Effect on Disease] and Safety of Finerenone on Morbidity [Events Indicating Disease Worsening] & Mortality [Death Rate] in Participants With Heart Failure and Left Ventricular Ejection Fraction [Proportion of Blood Expelled Per Heart Stroke] Greater or Equal to 40% [FINEARTS-HF], NCT04435626; Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients with Heart Failure; EudraCT 2020-000306-29).

Left ventricular size and heart failure: A cardiac MRI assessment of 38,129 individuals from the UK Biobank

BACKGROUND

Previous studies suggest that prevalent heart failure (HF) differs based on left ventricular ejection fraction (LVEF) and left ventricular (LV) chamber size. Furthermore, the prevalence of HF with preserved ejection fraction (HFpEF) is often considered approaching, or exceeding that of HF with reduced ejection fraction in the community.

AIM

The aim of this study was to evaluate prevalent and incident HF based on LVEF and CMR-determined LV size within a large community-dwelling cohort.

METHODS

Individuals from the United Kingdom Biobank (UKB) who underwent CMR and had available health record linkage to allow ascertainment of HF diagnosis were included. The cohort was analysed according to LVEF, LV end-diastolic volume (LVEDV) quartiles and LVEDV indexed to body surface area (LVEDVi).

RESULTS

38,129 individuals were included, comprising those with reduced LVEF (LVEF<50 %, n = 5096) and preserved LVEF (LVEF 50-60 %, n = 22,907, LVEF≥60 %, n = 10,126). Prevalent HF was highest in males with LVEF<50 %, and participants with reduced LVEF had higher rates of incident HF (p < 0.001) during the follow-up period (median = 2.46 years from CMR). Mean LVEDV and LVEDVi were largest in individuals with EF < 50 % (146.9 ± 36.2 ml and 76.8 ± 16.4 ml/m2 respectively). Compared to the smallest quartiles, the largest quartiles for LVEDV were associated with increased odds of HF (odds ratio 2.14 [95 % confidence interval 1.47-3.12], p < 0.001).

CONCLUSIONS

Over 50 % of HF cases occur in individuals with LVEF ≥50 %, however HF prevalence is highest in those with reduced LVEF, particularly in males. Larger LV size is associated with increased HF across the LVEF spectrum.

Dietary Inflammatory Score and Incident Heart Failure in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

BACKGROUND

Inflammation plays a key role in the development of heart failure (HF), and diet is a known modifiable factor that modulates systemic inflammation. The dietary inflammatory score (DIS) is a tool that quantifies the inflammatory components of diet. We sought to determine whether the DIS is associated with incident HF events.

METHODS

We examined a total of 17,975 participants without HF at baseline who were in the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. The main exposure variable was the DIS quartile, which was derived from the Food Frequency Questionnaire obtained at baseline study enrollment. The main outcome was an incident HF event, defined as hospitalization due to HF or death. To examine the association between the DIS and incident HF events, we conducted Cox proportional hazard regression modeling, adjusting for total energy intake, sociodemographic factors and pro-inflammatory lifestyle behaviors.

RESULTS

The sample mean age was 64 + 9.2 years, 55.8% were female, and 32.3% were Black. Over a median follow-up of 11.1 years, we observed 900 incident HF events, including 752 hospitalizations and 148 deaths due to HF. In an adjusted model, the highest DIS quartile (Q4) was associated with incident HF (HR 1.26 95% CI 1.03-1.54). Of note, these findings remained, even after adjusting for comorbid conditions and physiological parameters. In an age-stratified analysis, the association was present only in those aged < 65 years (Q4: HR 1.65 95% CI 1.08-2.51). Moreover, the association was present for heart failure with reserved ejection fraction (Q4: HR 1.44 95% CI 1.07-1.94) but not for heart failure with preserved ejection fraction.

CONCLUSION

The highest DIS quartile was associated with incident HF events. These findings indicate the potential value of specific dietary patterns to prevent HF.

Comprehensive exploration of unexplained dyspnoea in subjects with normal ejection fraction and low natriuretic peptides

BACKGROUND

Unexplained exertional dyspnoea without significant elevation of natriuretic peptides is common. One of the causes might be early heart failure with preserved ejection fraction (HFpEF).

AIMS

This study aimed to characterize patients with exertional dyspnoea and normal/near-to-normal N-terminal pro-brain natriuretic peptide (NT-proBNP) levels with regard to early stages of HFpEF and non-cardiac causes.

METHOD AND RESULTS

Sixty-six patients (age 62 ± 7 years old, 85% women) with dyspnoea assessed using the Multidimensional Dyspnea Profile (MDP) questionnaire and NT-proBNP level of <125 pg/mL for patients <75 years old or <300 pg/mL for patients >75 years old were recruited. Patients with known significant heart disease, lung disease (abnormal respiratory function tests) or renal insufficiency stage ≥ 4 were excluded. In 11 patients (16.7%), HFpEF was confirmed according to the European Society of Cardiology Heart Failure Association (ESC HFA) criteria, 31 patients (47%) presented isolated deconditioning and 5 patients (7.6%) had idiopathic hyperventilation. In the remaining 19 patients (28.8%) with normal echocardiography and cardiopulmonary exercise testing (CPX), no objective cause of dyspnoea could be found. Compared with patients without HFpEF, those with HFpEF were older, more often hypertensive and diabetic, with higher NT-proBNP levels. They had higher E/e' ratios during exercise echocardiography and lower volume of oxygen uptake (VO2) peaks and steeper minute ventilation (VE)/volume of carbon dioxide produced (VCO2) slopes during CPX. Psychological impact measured on the Short Form-36 (SF-36) questionnaire was less important in HFpEF patients than in other patients.

CONCLUSIONS

The most common causes of unexplained exertional dyspnoea in patients without significant elevation of natriuretic peptides are peripheral deconditioning, HFpEF and hyperventilation. Studying patients during exercise allows for getting more data about pathophysiology and improving patient phenotyping and management. Early unmasking of HFpEF using exercise echocardiography and/or CPX and initiation of treatment could prevent hospitalizations for acute heart failure. Although using exercise testing, many patients could not be classified according to their diagnosis, and this reinforces the need to better define exercise diagnostic criteria.

Optimal Medical Therapy for Heart Failure and Integrated Care in Patients With Atrial Fibrillation: A Report From the ESC-EHRA EORP Atrial Fibrillation Long-Term General Registry

BACKGROUND

Heart failure (HF) often occurs in patients with atrial fibrillation (AF), with a major impact on prognosis. Few data are available on the effect of integrated treatment strategies to improve prognosis in patients with AF. We aimed to evaluate the association between HF (according to left ventricular ejection fraction [LVEF]), HF optimal medical therapy and adherence to the Atrial Fibrillation Better Care pathway, and major outcomes in patients with AF.

METHODS AND RESULTS

From the ESC-EHRA EORP-AF (European Society of Cardiology-European Heart Rhythm Association EURObservational Research Programme in Atrial Fibrillation) General Long-Term Registry, we evaluated patients with HF, categorized according to LVEF (HF with reduced ejection fraction, HF with mildly reduced ejection fraction, HF with preserved ejection fraction). Optimal medical therapy for HF was guidelines-defined. The primary end point was the composite of all-cause death and major adverse cardiovascular events. From the original cohort, 9373 (84.5%) patients were included in this analysis (median age, 71 [interquartile range, 62-77] years; 39.9% women). Compared with no HF, all HF categories were associated with an increased risk of the primary composite outcome, with highest figures observed for HF with reduced ejection fraction (hazard ratio [HR], 2.36 [95% CI, 2.00-2.78]). The risk was reduced in patients with AF and HF adherent to optimal medical therapy (HR, 0.83 [95% CI, 0.70-0.98]), as well as in those adherents to the Atrial Fibrillation Better Care pathway (HR, 0.65 [95% CI, 0.48-0.88]). The effect of Atrial Fibrillation Better Care pathway was consistent across the spectrum of LVEF.

CONCLUSIONS

Patients with AF and HF have a high risk of major adverse events, and this risk is inversely associated with LVEF. Atrial Fibrillation Better Care pathway adherent management is associated with improved clinical outcomes in patients with HF, across the spectrum of LVEF.

Improving hydraulic performance of the left atrial assist device using computational fluid dynamics

BACKGROUND

The left atrial assist device (LAAD) is a novel continuous-flow pump designed to treat patients with heart failure with preserved ejection fraction, a growing type of heart failure, but with limited device-treatment options. The LAAD is implanted in the mitral plane and pumps blood from the left atrium into the left ventricle. The purpose of this study was to refine the initial design of the LAAD, using results from computational fluid dynamics (CFD) analyses to inform changes that could improve hydraulic performance and flow patterns within the LAAD.

METHODS

The initial design and three variations were simulated, exploring changes to the primary impeller blades, the housing shape, and the number, size, and curvature of the diffuser vanes. Several pump rotational speeds and flow rates spanning the intended range of use were modeled.

RESULTS

Guided by the insight gained from each design iteration, the final design incorporated impeller blades with improved alignment relative to the incoming flow and wider, more curved diffuser vanes that better aligned with the approaching flow from the volute. These design adjustments reduced flow separation within the impeller and diffuser regions. In vitro testing confirmed the CFD predicted improvement in the hydraulic performance of the revised LAAD flow path design.

CONCLUSIONS

The CFD results from this study provided insight into the key pump design-related parameters that can be adjusted to improve the LAAD's hydraulic performance and internal flow patterns. This work also provided a foundation for future studies assessing the LAAD's biocompatibility under clinical conditions.

Unraveling Comorbidities Contribution to Cardiac Diastolic Dysfunction and Heart Failure

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is a major public health problem characterized by multiple simultaneous comorbidities whose specific contribution is challenging to disentangle in humans, leading to a generalized therapeutic approach that may not account for the underlying pathology.

METHODS

We followed distinct mouse models of major HFpEF comorbidities for 2.5 years to unveil their specific contribution to the syndrome.

RESULTS

All comorbidities contributed to HFpEF through partially distinct routes. Aging alone resulted in HFpEF in old age, with delayed left ventricular relaxation and kidney fibrosis. Obesity induced a faster deterioration of relaxation associated with enlarged left ventricle and liver fibrosis. Hypertension caused delayed ventricular relaxation independent from structural changes that preceded left atrial dilatation linked to aortic stiffness and increased fibrosis in myocardium and kidney. Chronic intermittent hypoxia led to HFpEF and relaxation impairment associated with pulmonary hypertension. Hyperglycemia accelerated diastolic dysfunction and HFpEF onset associated with reduced arterial flow and left ventricular remodeling. Therefore, the pathological substrates contributing to HFpEF included cardiac and noncardiac alterations with differential features for each comorbidity. Critically, the characteristics linked to diastolic dysfunction and HFpEF across the various comorbidities agreed with phenogroups observed in human patients.

CONCLUSIONS

The identification of time-dependent pathological features provides a comprehensive picture of HFpEF progression associated with each comorbidity.

Clinical characteristics and prognostic impact of atrial fibrillation among older patients with heart failure with preserved ejection fraction hospitalized for acute heart failure

Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are often coexisting conditions, but their interrelationship has not yet been clarified. This study investigated the clinical characteristics and prognostic impact of AF among older patients with HFpEF hospitalized for acute HF (AHF). The study included patients 65 years of age and older who were admitted to the Emergency Department due to AHF from 1 January 2016 to 31 December 2019. Patients were divided into two groups according to the presence of AF. The primary endpoint was all-cause, in-hospital mortality. Overall, 770 patients with HFpEF were included, mean age 82 years, 53% were females. Nearly, a third (30%) of these patients had a concomitant AF and they were significantly older and had higher N-Terminal pro-B-type natriuretic peptide (NT-proBNP) values. Overall, the in-hospital mortality rate was much higher among HFpEF patients with AF compared to those without AF (11.4% vs 6.9%, respectively; p = 0.037). At multivariate analysis, AF emerged as an independent risk factor for death (OR 1.73 [1.03-2.92]; p = 0.038). Among older patients with HFpEF admitted for AHF, the coexistence of AF was associated with a nearly twofold increased risk of all-cause in-hospital mortality. Patients with HFpEF and AF describe a phenotype of older and more symptomatic patients, with higher NT-proBNP, left atrial enlargement, right ventricular dysfunction, and higher CV mortality.

Lysophosphatidylethanolamine improves diastolic dysfunction by alleviating mitochondrial injury in the aging heart

Diastolic dysfunction in aging mice is linked to mitochondrial abnormalities, including mitochondrial morphology disorders and decreases in membrane potential. Studies also show that aberrant mitochondrial lipid metabolism impairs mitochondrial function in aging cardiomyocytes. Our lipidomic analysis revealed that phosphatidylethanolamine (PE) levels were significantly decreased in aging myocardial mitochondria. Here, we investigated whether a reduction in PE levels in myocardial mitochondria contributes to mitochondrial injury as well as HFpEF pathogenesis and whether modulation of PE levels could ameliorate aging-induced HFpEF. Echocardiography was used to assess cardiac diastolic function in adult and aging mice treated with lysophosphatidylethanolamine (LPE) or saline. Mitochondrial morphologies from tissue samples were evaluated by transmission electron microscopy (TEM), while mitochondrial membrane potential and reactive oxygen species (ROS) levels were assessed using JC-1, MitoSOX, and DCFH-DA detection assays. We performed GO enrichment analysis between adult and aging mice and discovered significant enrichment in transcriptional programs associated with mitochondria and lipid metabolism. Also, mitochondrial PE levels were significantly decreased in aging cardiomyocytes. Treatment with LPE (200 μg/kg) significantly enhanced PE content in aging mice and improved the structure of mitochondria in cardiac cells. Also, LPE treatment protects against aging-induced deterioration of mitochondrial injury, as evidenced by increased mitochondrial membrane potential and decreased mitochondrial ROS. Furthermore, treatment with LPE alleviated severe diastolic dysfunction in aging mice. Taken together, our results suggest that LPE treatment enhances PE levels in mitochondria and ameliorates aging-induced diastolic dysfunction in mice through a mechanism involving improved mitochondrial structure and function.

Prognostic Impact of Right Ventricular Diastolic Dysfunction in Patients Undergoing Isolated Coronary Artery Bypass Grafting

BACKGROUND

Right ventricular diastolic dysfunction (RVDD) increases the volume load on the right ventricle. We aimed to evaluate the association of RVDD with perioperative outcomes in patients undergoing isolated coronary artery bypass graft surgery (CABG).

METHODS

This single-center observational study included all consecutive isolated CABG patients with a left ventricular ejection fraction (LVEF)>40% from May 2022 to May 2023 who were evaluated for RV diastolic function by transthoracic echocardiography. We divided patients into two groups, with and without RVDD, and then compared the two groups in terms of the primary outcomes of the duration of hospitalization, intensive care unit (ICU) stay, and intubation time, and the secondary outcome composed of postoperative in-hospital complications.

RESULTS

Our study found that 49.1% of patients suffered from RVDD, and patients with RVDD had significantly lower systolic blood pressure and were more likely to take angiotensin-converting enzyme inhibitors than those without RVDD. There was no association between RVDD and primary outcomes of hospitalization time (β=-0.01; 95% CI -0.05, 0.04; P value=0.717), ICU stay (β=0.01; 95% CI -0.18, 0.17; P value=0.984) and intubation time ([β=0.06; 95% CI -0.05, 0.17; P value=0.309). However, more postoperative complications occurred in patients with RVDD (90% vs. 85%). After adjustment for confounding factors, RVDD was not independently associated with primary and secondary outcomes.

CONCLUSION

Preexisting RVDD in CABG patients with LVEF>40% increased postoperative complications but not significantly. More extensive studies are needed to evaluate RV diastolic function before cardiac surgery to identify high-risk patients and optimize their perioperative management.

The sympathetic nervous system in heart failure with preserved ejection fraction

The sympathetic nervous system (SNS) is a major mediator of cardiovascular physiology during exercise in healthy people. However, its role in heart failure with preserved ejection fraction (HFpEF), where exercise intolerance is a cardinal symptom, has remained relatively unexplored. The present review summarizes and critically explores the currently limited data on SNS changes in HFpEF patients with a particular emphasis on caveats of the data and the implications for its subsequent interpretation. While direct measurements of SNS activity in HFpEF patients is scarce, modest increases in resting levels of muscle sympathetic nerve activity are apparent, although this may be due to the co-morbidities associated with the syndrome rather than HFpEF per se. In addition, despite some evidence for dysfunctional sympathetic signaling in the heart, there is no clear evidence for elevated cardiac sympathetic nerve activity. The lack of a compelling prognostic benefit with use of β-blockers in HFpEF patients also suggests a lack of sympathetic hyperactivity to the heart. Similarly, while renal and splanchnic denervation studies have been performed in HFpEF patients, there is no concrete evidence that the sympathetic nerves innervating these organs exhibit heightened activity. Taken together, the totality of data suggests limited evidence for elevated sympathetic nerve activity in HFpEF and that any SNS perturbations that do occur are not universal to all HFpEF patients. Finally, how the SNS responds during exertion in HFpEF patients remains unknown and requires urgent investigation.

Prognostic value of the fibrinogen-to-albumin ratio (FAR) in patients with chronic heart failure across the different ejection fraction spectrum

The ratio of fibrinogen to albumin (FAR) is considered a new inflammatory biomarker and a predictor of cardiovascular disease risk. However, its prognostic value for patients with chronic heart failure (CHF) with different ejection fractions (EFs) remains unclear. A total of 916 hospitalized patients with CHF from January 2017 to October 2021 in the First Affiliated Hospital of Kunming Medical University were included in the study. Death occurred in 417 (45.5%) patients out of 916 patients during a median follow-up time of 750 days. Among these patients, 381 patients suffered from HFrEF (LVEF <40%) and 535 patients suffered from HFpEF or HFmrEF (HFpEF plus HFmrEF, LVEF ≥ 40%). Patients were categorized into high-level FAR (FAR-H) and low-level FAR (FAR-L) groups based on the optimal cut-off value of FAR (9.06) obtained from receiver operating characteristic (ROC) curve analysis. Upon analysing the Kaplan - Meier plots, the incidence of death was significantly higher in all patients with FAR-H and patients in both HF subgroups (p < 0.001). The multivariate Cox proportional hazard analyses indicated that the FAR was an independent predictor of all-cause mortality, regardless of heart failure subtype. (HR 1.115, 95% CI 1.089-1.142, p < 0.001; HFpEF plus HFmrEF, HR 1.109, 95% CI 1.074-1.146, p < 0.0001; HFrEF, HR 1.138, 95% CI 1.094-1.183, p < 0.0001) The optimal cut-off value of FAR in predicting all-cause mortality was 9.06 with an area under the curve value of 0.720 (95% CI: 0.687-0.753, p < 0.001), a sensitivity of 68.8% and a specificity of 65.6%. After adjusting for the traditional indicators (LVEF, Lg BNP, etc.), the new model with the FAR had better prediction ability in patients with CHF. Elevated FAR is an independent predictor of death in CHF and is not related to the HF subtype.

Brainstem C1 neurons mediate heart failure decompensation and mortality during acute salt loading

AIMS

Heart failure (HF) is an emerging epidemic worldwide. Despite advances in treatment, the morbidity and mortality rate of HF remain high, and the global prevalence continues to rise. Common clinical features of HF include cardiac sympathoexcitation, disordered breathing, and kidney dysfunction; kidney dysfunction strongly contributes to sodium retention and fluid overload, leading to poor outcomes of HF patients. We have previously shown that brainstem pre-sympathetic neurons (C1) from the rostral ventrolateral medulla (RVLM) play a key role in sympathetic regulation in experimental models of HF. However, the role of RVLM-C1 neurons during salt-loading in the context of HF is unknown. This study tests whether RVLM C1 neurons drive cardiorespiratory decompensation and ultimately lead to sudden death in HF rats.

METHODS AND RESULTS

Adult male Sprague-Dawley rats underwent arteriovenous shunt to induce HF with preserved ejection fraction (HFpEF). Two weeks after HFpEF induction, bilateral selective ablation of RVLM C1 neurons was performed using anti-dopamine β-hydroxylase-saporin toxin. Animals were then fed a high Na+ diet (3% Na+ in food and 2% Na+ in water) for 3 weeks to induce compensated-to-decompensated HF state transition. Echocardiography, cardiac autonomic function, breathing function, and survival were assessed during the progression of HF. Salt loading resulted in marked decompensation in HF rats, as evidenced by a significant decrease in survival rates (survival: 10% vs. 100% HFpEF + Na+ vs. HFpEF). Furthermore, HFpEF + Na+ animals showed a further increase in cardiac sympathetic drive and more severe disordered breathing, including higher hypoxia-related epochs (i.e. apnoeas/hypopnoeas), compared with HF. Ablation of RVLM C1 neurons partly reduced the excessive cardiac sympathoexcitation during salt loading in HF, improved the exaggerated disordered breathing in HFpEF+ Na+ rats, and reduced decompensation-linked mortality. We found that hypoxia, but not high sodium, was the major contributor to impaired calcium handling in isolated adult cardiomyocytes.

CONCLUSION

Our results strongly suggest that RVLM C1 neurons contribute to acute HF decompensation during salt loading by a mechanism encompassing further increases in sympathetic outflow and hypoxia-related breathing disorders. This mechanism may ultimately impact cardiac contractility through cardiomyocyte calcium mishandling, increasing morbidity and mortality.

Incidence and risk factors of heart failure with preserved ejection fraction in elderly patients with hypertension

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) poses a significant clinical challenge, especially in older patients with HT. This study aimed to identify the factors influencing HFpEF occurrence in elderly patients with HT.

METHODS

Elderly patients with HT were categorized into two groups: no HFpEF group and HFpEF group based on HFpEF diagnosis. Demographic, clinical, laboratory and echocardiographic data was conducted. Logistic regression analysis and joint prediction modeling were used to identify predictive factors for HFpEF.

RESULTS

Several factors were associated with HFpEF, including age, body mass index, duration of HT, atrial fibrillation (AF), chronic kidney disease (CKD), stroke, systolic blood pressure (SBP), serum creatinine (SCr), N-terminal pro brain natriuretic peptide (NT-proBNP), heart rate, serum sodium, low density lipoprotein cholesterol (LDL-c), triglyceride, left ventricular ejection fraction (LVEF), E/e' ratio, left atrial diameter, tricuspid regurgitation velocity, mitral regurgitation and C-reactive protein (CRP) levels. The joint prediction model shown high accuracy, with an area under the curve (AUC) of 0.840.

CONCLUSIONS

This study provided insights into the incidence rate and risk factors of HFpEF in elderly patients with HT. Key determinants included age, blood pressure, biomarkers, and echocardiographic parameters.

Exploring the Relationship Between Ejection Fraction, Arterial Stiffness, NT-proBNP, and Hospitalization Risk in Heart Failure Patients

Background/Objectives: Heart failure (HF) remains a leading cause of hospitalization and morbidity. Arterial stiffness, measured by pulse wave velocity (PWV) and the augmentation index (AIx), has been linked to HF severity and prognosis. This study investigates the relationship between clinical parameters, biochemical indicators, and arterial stiffness in hospitalized patients with HF, aiming to identify predictors of hospitalization and improve patient management. Methods: This cross-sectional study included 98 patients admitted with HF: 53 with acutely decompensated HF (sudden worsening of symptoms) and 45 with chronic HF (stable symptoms of HF). Clinical and biochemical parameters, including ejection fraction (EF), N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels, and arterial stiffness indicators (PWV and AIx), were measured at admission. During follow-up, 59 patients required re-hospitalization due to acutely decompensated HF, while 39 remained outpatients without further hospitalization. The relationship between these parameters was analyzed using Pearson correlation coefficients, and multiple Cox regression analysis was conducted to identify independent predictors of re-hospitalization. Results: A significant negative correlation between EF and PWV was found (r = -0.853, 95% CI [-0.910, -0.764]), suggesting an association between improved heart function (higher EF) and reduced arterial stiffness (lower PWV). A moderate positive correlation between EF and AIx (r = 0.626, 95% CI [0.473, 0.805]) suggests that, while higher EF is associated with increased AIx, the relationship is weaker compared to EF and PWV. This may reflect differing contributions of vascular and myocardial factors to HF severity. Hospitalized patients exhibited significantly poorer clinical and biochemical profiles, including higher NT-proBNP levels (p < 0.001) and worse blood pressure (BP) measurements (systolic and diastolic, p < 0.01). Multiple Cox regression analysis identified PWV, Aix, and NT-proBNP as independent predictors of re-hospitalization in HF patients, with significant hazard ratios: PWV (HR = 1.15, p = 0.02), AIx (HR = 1.03, p = 0.02), and NT-proBNP (HR = 1.0001, p < 0.01). Conclusions: Arterial stiffness indices (PWV and AIx), EF, and NT-proBNP were identified as significant predictors of re-hospitalization in HF patients. These findings suggest that integrating arterial stiffness measurements into routine clinical assessments may enhance the risk stratification and inform targeted interventions to reduce hospitalizations and improve outcomes.

Epigenetics of Homocystinuria, Hydrogen Sulfide, and Circadian Clock Ablation in Cardiovascular-Renal Disease

Morning-time heart attacks are associated with an ablation in the sleep-time dip in blood pressure, the mechanism of which is unknown. The epigenetic changes are the hallmark of sleep and circadian clock disruption and homocystinuria (HHcy). The homocystinuria causes ablation in the dip in blood pressure during sleep. Interestingly, HHcy is generated during the epigenetic gene turning off and turning on (i.e., imprinting) by methylation of the DNA promoter. The mitochondrial sulfur metabolism by 3-mercaptopyruvate sulfur transferase (3MST), ATP citrate lyase (ACYL), and epigenetic rhythmic methylation are regulated by folate 1-carbon metabolism (FOCM), i.e., the methionine (M)-SAM-SAH-Hcy, adenosine, and uric acid cycle. Epigenetic gene writer (DNMT), gene eraser (TET/FTO), and editor de-aminase (ADAR) regulate the rhythmic, i.e., reversible methylation/demethylation of H3K4, H3K9, H4K20, m6A, and m5C. The mitochondrial ATP citrate cycle and creatine kinase (CK) regulate chromatin transcription, maturation, and accessibility as well as muscle function. The transcription is regulated by methylation. The maturation and accessibility are controlled by acetylation. However, it is unclear whether a high fat dysbiotic diet (HFD) causes dysrhythmic expression of the gene writer, eraser, and editor, creating hyperuricemia and cardiac and renal dysfunction. We hypothesized that an HFD increases the gene writer (DNMT1) and editor (ADAR), decreases the eraser (TET/FTO), and increases uric acid to cause chronic diseases. This increases the levels of H3K4, H3K9, H4K20, m6A, and m5C. Interestingly, the DNMT1KO mitigates. Further, the DNMT1KO and ADAR inhibition attenuate HFD-induced NGAL/FGF23/TMPRSS2/MMP2, 9, 13, and uric acid levels and improve cardiac and renal remodeling. Although the novel role of nerve endings by the Piezo channels (i.e., the combination of ENaC, VDAC, TRPV, K+, and Mg2+ channels) in the interoception is suggested, interestingly, we and others have shown mechanisms independent of the nerve, by interoception, such as the cargo of the exosome in denervation models of heart failure. If proper and appropriate levels of these enzymes are available to covert homocysteine to hydrogen sulfide (H2S) during homocystinuria, then the H2S can potentially serve as a newer form of treatment for morning heart attacks and renal sulfur transsulfuration transport diseases.

Effects of calcium channel blockers in patients with heart failure with preserved and mildly reduced ejection fraction: A systematic review and meta-analysis

In contrast to beta-blockers and renin-angiotensin system inhibitors, the role of calcium channel blockers (CCBs) in patients with heart failure with preserved ejection fraction (HFpEF) remains uncertain. Despite several randomized controlled trials (RCTs) and cohort studies exploring the effects of CCBs on prognosis and exercise capacity in HFpEF patients, the findings have been inconsistent, likely due to limited statistical power and/or variations in study design. We aimed to conduct a systematic review and meta-analysis of studies on the effects of CCBs in HFpEF patients. The search of electronic databases identified 2 RCTs including 35 patients and 4 cohort studies including 25,078 patients. In cases of significant heterogeneity (I2 > 50 %), data were pooled using a random-effects model; otherwise, a fixed-effects model was used. In pooled analysis of the cohort studies, use of CCBs was not associated with the risk of all-cause death (hazard ratio [95 % CI] = 0.913 [0.732, 1.139], P random  = 0.420) or hospitalization for heart failure (1.050 [0.970, 1.137], P fix  = 0.230). Separate analyses for dihydropyridine and non-dihydropyridine CCBs revealed similar results. In pooled analysis of the RCTs, verapamil increased exercise time (weighted mean difference [95 % CI] = 0.953 [0.109, 1.797] min; P fix  = 0.027) and decreased the congestive heart failure score (2.019 [1.673, 2.365] points; P fix  < 0.001) compared with placebo. In conclusion, in HFpEF patients, verapamil may improve exercise capacity and symptoms but use of CCBs, regardless of subclass, may not be associated with better prognosis. Our meta-analysis is limited by the inclusion of only several studies for each outcome and further research is necessary to confirm our findings.

HeartMate 3 for Heart Failure with Preserved Ejection Fraction: In Vitro Hemodynamic Evaluation and Anatomical Fitting

Heart failure with preserved ejection fraction (HFpEF) constitutes approximately 50% of heart failure (HF) cases, and encompasses different phenotypes. Among these, most patients with HFpEF exhibit structural heart changes, often with smaller left ventricular cavities, which pose challenges for utilizing ventricular assist devices (VADs). A left atrial to aortic (LA-Ao) VAD configuration could address these challenges, potentially enhancing patient quality of life by lowering elevated mean left atrial pressure (MLAP). This study assessed the anatomical compatibility and left atrial unloading capacity using a simulated VAD-supported HFpEF patient. A HeartMate3-supported HFpEF patient in an LA-Ao configuration was simulated using a cardiovascular simulator. Hemodynamic parameters were recorded during rest and exercise at seven pump flow rates. Computed tomography scans of 14 HFpEF (NYHA II-III) and six heart failure with reduced ejection fraction patients were analysed for anatomical comparisons. HFpEF models were independently assessed for virtual anatomical fit with the HM3 in the LA-Ao configuration. Baseline MLAP was reduced from 15 to 11 mmHg with the addition of 1 L/min HM3 support in the rest condition. In an exercise simulation, 6 L/min of HM3 support was required to reduce the MLAP from 29 to 16 mmHg. The HM3 successfully accommodated six HFpEF patients without causing interference with other cardiac structures, whereas it caused impingement ranging from 4 to 14 mm in the remaining patients. This study demonstrated that the HM3 in an LA-Ao configuration may be suitable for unloading the left atrium and relieving pulmonary congestion in some HFpEF patients where size-related limitations can be addressed through pre-surgical anatomical fit analysis.

Automated echocardiographic diastolic function grading: A hybrid multi-task deep learning and machine learning approach

BACKGROUND

Assessing left ventricular diastolic function (LVDF) with echocardiography as per ASE guidelines is tedious and time-consuming. The study aims to develop a fully automatic approach of this procedure by a lightweight hybrid algorithm combining deep learning (DL) and machine learning (ML).

METHODS

The model features multi-modality input and multi-task output, measuring LV ejection fraction (LVEF), left atrial end-systolic volume (LAESV), and Doppler parameters: mitral E wave velocity (E), A wave velocity (A), mitral annulus e' velocity (e'), and tricuspid regurgitation velocity (TRmax). The algorithm was trained and tested on two internal datasets (862 and 239 echocardiograms) and validated using three external datasets, including EchoNet-Dynamic and CAMUS. The ASE diastolic function decision tree and total probability theory were used to provide diastolic grading probabilities.

RESULTS

The algorithm, named MMnet, demonstrated high accuracy in both test and validation datasets, with Dice coefficients for segmentation between 0.922 and 0.932 and classification accuracies between 0.9977 and 1.0. The mean absolute errors (MAEs) for LVEF and LAESV were 3.7 % and 5.8 ml, respectively, and for LVEF in external validation, MAEs ranged from 4.9 % to 5.6 %. The diastolic function grading accuracy was 0.88 with hard criteria and up to 0.98 with soft criteria which account for the top two probability in total probability theory.

CONCLUSIONS

MMnet can automatically grade ASE diastolic function with high accuracy and efficiency by annotating 2D videos and Doppler images.

Characterization of a novel ovine model of hypertensive heart failure with preserved ejection fraction

The lack of animal models that accurately represent heart failure with preserved ejection fraction (HFpEF) has been a major barrier to the mechanistic understanding and development of effective therapies for this prevalent and debilitating syndrome characterized by multisystem impairments. Herein, we describe the development and characterization of a novel large animal model of HFpEF in older, female sheep with chronic 2-kidney, 1-clip hypertension. At 6-wk post unilateral renal artery clipping, hypertensive HFpEF sheep had higher mean arterial pressure compared with similarly aged ewes without unilateral renal artery clipping (mean arterial pressure = 112.7 ± 15.9 vs. 76.0 ± 10.1 mmHg, P < 0.0001). The hypertensive HFpEF sheep were characterized by 1) echocardiographic evidence of diastolic dysfunction (lateral e' = 0.11 ± 0.02 vs. 0.14 ± 0.04 m/s, P = 0.011; lateral E/e' = 4.25 ± 0.77 vs. 3.63 ± 0.54, P = 0.028) and concentric left ventricular hypertrophy without overt systolic impairment, 2) elevated directly measured left ventricular end-diastolic pressure (13 ± 5 vs. 0.5 ± 1 mmHg, P = 2.1 × 10-6), and 3) normal directly measured cardiac output. Crucially, these hypertensive HFpEF sheep had impaired exercise capacity as demonstrated by their 1) attenuated cardiac output (P = 0.001), 2) augmented pulmonary capillary wedge pressure (P = 0.026), and 3) attenuated hindlimb blood flow (P = 3.4 × 10-4) responses, during graded treadmill exercise testing. In addition, exercise renal blood flow responses were also altered. Collectively, our data indicates that this novel ovine model of HFpEF may be a useful translational research tool because it exhibits similar and clinically relevant impairments as that of patients with HFpEF.NEW & NOTEWORTHY We show that older, female sheep with chronic 2-kidney, 1-clip hypertension have similar cardiac and noncardiac exercise hemodynamic abnormalities as patients with HFpEF. This clinically relevant, translatable, and novel large animal model of HFpEF may be useful for elucidating mechanisms and developing treatments for this increasingly common syndrome with few clinically impactful therapies.

Prospective registry of heart failure with preserved ejection fraction in México: EDIFICE-Mx

Background and aims

Heart failure with preserved ejection fraction (HFpEF) is an increasingly common clinical syndrome, estimated to constitute approximately 50 % of all heart failure (HF) cases. Nonetheless, registries from specific geographic areas, as Latin America, are lacking. The present study aims to report the underlying causes, comorbidities, treatment patterns and outcomes of patients with HFpEF in a large cardiovascular center in Mexico City.

Methods

The present is a prospective, longitudinal, observational study, including female and male patients over 18 years of age, who presented to the emergency department, coronary care unit or outpatient department of the National Institute of Cardiology Ignacio Chavez in Mexico City with HFpEF. Patients were classified according to different phenotypes and current literature. The primary outcome was the composite total HFpEF hospitalization and all-cause mortality.

Results

Within a median follow-up of 472 (IQR 425-518) days, total mortality was 14.56 %, with 10.68 % attributed to cardiovascular causes. HF hospitalization was 7.77 %. Atrial fibrillation showed a notable association with outcomes (adjusted HR 2.87, P = 0.028). Beta-blocker showed a non-significant trend towards benefit, while mineralocorticoid receptor antagonists (MRA) significantly influenced outcomes (adjusted HR 3.30, P = 0.018). The primary composite endpoint occurred in 19.42 % of patients, with no significant difference among phenotypes (P = 0.536).

Conclusions

We observed a substantial comorbidity burden impacting quality of life, as indicated by KCCQ scores. There was a high incidence of hard endpoints, including cardiovascular death and hospitalizations, alongside significant variability in treatment utilization. Future research should focus on elucidating individual healthcare trajectories in HFpEF patients and promoting wider adoption of evidence-based therapies.

MRI-Based Circumferential Strain in Boys with Early Duchenne Muscular Dystrophy Cardiomyopathy

Background: In boys with Duchenne muscular dystrophy (DMD), cardiomyopathy has become the primary cause of death. Although both positive late gadolinium enhancement (LGE) and reduced left ventricular ejection fraction (LVEF) are late findings in a DMD cohort, LV end-systolic circumferential strain at middle wall (Ecc) serves as a biomarker for detecting early impairment in cardiac function associated with DMD. However, Ecc derived from cine Displacement Encoding with Stimulated Echoes (DENSE) has not been quantified in boys with DMD. We aim to: (1) use cine DENSE to quantify regional Ecc in LGE negative (-) boys with DMD and healthy controls; and (2) compare Ecc with LVEF in terms of differentiating DMD boys with LGE (-) from healthy boys. Methods: 10 LGE (-) boys with DMD and 12 healthy boys were enrolled prospectively in an IRB-approved study for CMR at 3T. Navigator-gated cine DENSE was used to obtain short-axis mid-ventricular data and estimate global and regional Ecc. Group-wise differences were tested via a Wilcoxon rank-sum test. Within-group differences were tested via a Skillings-Mack test followed by pairwise Wilcoxon signed-rank tests. A binomial logistic regression model was adopted to differentiate between DMD boys with LGE (-) and healthy boys. Results: When compared to healthy boys, LGE (-) boys with DMD demonstrated significantly impaired septal Ecc [-0.13 (0.01) vs. -0.16 (0.03), p = 0.019]. In comparison to the Ecc in other segments, both groups of boys exhibited significantly reduced septal Ecc and significantly elevated lateral Ecc. Septal Ecc outperformed LVEF in distinguishing DMD boys with LGE (-) from healthy boys. Conclusions: Reduced septal Ecc may serve as an early indicator of cardiac involvement in LGE (-) DMD boys prior to reduced LVEF and a positive LGE finding.

Effectiveness and safety of mineralocorticoid receptor antagonists in heart failure patients with and without diabetes: a systematic review and meta-analysis

BACKGROUND

Mineralocorticoid receptor antagonists (MRAs) have been shown to improve outcomes in various populations of heart failure (HF) patients. However, the impact of concomitant diseases, such as diabetes mellitus (DM), on these outcomes remains unclear. This meta-analysis aimed to evaluate the efficacy and safety of MRAs in heart failure patients with and without diabetes mellitus.

METHODS

A systematic search was conducted on PubMed, Scopus, and Google Scholar databases up to April 30, 2024. Data analysis was performed using a random-effects model to account for variability across studies, and statistical analysis was carried out using Review Manager 5.4. Efficacy and safety parameters were evaluated in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines.

RESULTS

The meta-analysis included a total of 21,832 subjects from ten studies. The pooled results demonstrated that MRAs, compared to placebo, significantly reduced all-cause mortality in HF patients with and without DM (RR: 0.85; 95%CI 0.75-0.96; p = 0.009). A similar effect was observed in HF patients without DM (RR: 0.83; 95%CI 0.71-0.97; p = 0.02), while no significant effect was detected in the DM subgroup (RR: 0.87; 95%CI 0.69-1.11; p = 0.27). Both treatments had comparable effects on cardiovascular mortality in HF patients with and without DM (RR: 0.88; 95%CI 0.82-0.94; p = 0.0002), in HF patients with DM (RR: 0.90; 95%CI 0.81-1.01; p = 0.08), and in the non-DM subgroup (RR: 0.86; 95%CI 0.79-0.94; p = 0.0009). MRAs significantly reduced the risk of cardiovascular mortality in HF patients with and without DM (RR: 0.82; 95%CI 0.72-0.94; p = 0.005) and in HF patients with DM (RR: 0.79; 95%CI 0.63-0.98; p = 0.03), but no significant effect was observed in the non-DM subgroup (RR: 0.85; 95%CI 0.69-1.05; p = 0.13). Furthermore, compared to placebo, MRAs were associated with an increased risk of hyperkalemia (> 5.5 mEq/L) in HF patients with and without DM (RR: 1.63; 95%CI 1.18-2.24; p = 0.003), particularly in HF patients with DM (RR: 1.44; 95%CI 0.97-2.13; p = 0.07) and in the non-DM subgroup (RR: 1.87; 95%CI 1.34-2.61; p = 0.0002).

CONCLUSION

MRAs are effective in reducing all-cause mortality, cardiovascular death, and cardiovascular mortality in heart failure patients. However, the use of MRAs is associated with an increased risk of hyperkalemia, necessitating careful monitoring, particularly in patients with diabetes mellitus.

Growth hormone-releasing hormone and its analogues in health and disease

Growth hormone-releasing hormone (GHRH) and its ability to stimulate the production and release of growth hormone from the pituitary were discovered more than four decades ago. Since then, this hormone has been studied extensively and research into its functions is still ongoing. GHRH has multifaceted roles beyond the originally identified functions that encompass a variety of direct extrapituitary effects. In this Review, we illustrate the different biological activities of GHRH, covering the effects of GHRH agonists and antagonists in physiological and pathological contexts, along with the underlying mechanisms. GHRH and GHRH analogues have been implicated in cell growth, wound healing, cell death, inflammation, immune functions, mood disorders, feeding behaviour, neuroprotection, diabetes mellitus and obesity, as well as cardiovascular, lung and neurodegenerative diseases and some cancers. The positive effects observed in preclinical models in vitro and in vivo strongly support the potential use of GHRH agonists and antagonists as clinical therapeutics.

Meta-analysis of the efficacy and impact on cardiac function of sodium-glucose cotransporter 2 inhibitor Empagliflozin in heart failure patients

BACKGROUND

Currently, there is no comprehensive systematic review available to comprehensively assess the efficacy and safety of Empagliflozin and other sodium-glucose cotransporter 2 inhibitors in the treatment of heart failure (HF). This study employed a meta-analysis approach to systematically evaluate the therapeutic effects of Empagliflozin in HF patients and its impact on cardiac function.

METHOD

The keywords including "heart failure," "HF," "cardiac failure," "cardiac disease," "Empagliflozin," and "sodium-glucose cotransporter 2 inhibitors" were utilized to search for relevant clinical studies on Empagliflozin in the treatment of HF in various databases, such as China National Knowledge Infrastructure, Wanfang, VIP Chinese Medical Journal Database, PubMed, MEDLINE, Embase, Cochrane Library, Springer, and Science Direct. The studies included patients with HF who received drug treatment. Data on baseline characteristics and posttreatment outcomes, including HF hospitalization (HHF), cardiovascular mortality, all-cause mortality, estimated glomerular filtration rate changes, Kansas City Cardiomyopathy Questionnaire quality of life (QoL) scores, N-terminal pro-B-type natriuretic peptide, left ventricular ejection fraction, hematocrit, and other relevant indicators were collected. Meta-analysis was conducted using RevMan5.3 to analyze the extracted data.

RESULTS

A total of 15 studies were included in the final analysis, comprising 36,917 patients with HF. Among them, 18,486 patients were in Empagliflozin group, and 18,431 patients were in control (Ctrl) group. The results of the meta-analysis demonstrated that, relative to Ctrl group, Empagliflozin group showed a substantially lower HHF rate, a substantial improvement in estimated glomerular filtration rate changes, a reduced cardiovascular mortality rate, a higher Kansas City Cardiomyopathy Questionnaire QoL score, increased hematocrit values, reduced N-terminal pro-B-type natriuretic peptide changes, and enhanced left ventricular ejection fraction changes. These findings suggest that remarkable improvements in various outcomes compared to the Ctrl group.

CONCLUSION

The sodium-glucose cotransporter 2 inhibitor Empagliflozin markedly reduces the HHF rate and cardiovascular mortality in HF patients. It also improves patients' QoL, enhances renal function, and increases cardiac function while reducing both, the preload and afterload.

Non-invasively measured myocardial torsional modulus: Comparison to invasive evaluation of diastolic function

BACKGROUND

Left ventricular (LV) diastolic function is a key determinant of cardiac output and impairments of diastolic function can lead to heart failure. Assessment of diastolic function is challenging due to several factors, including the load dependence of ventricular filling. We developed a method using cardiovascular magnetic resonance (CMR) imaging to model the untwisting motion of the LV as a viscoelastic damped oscillator to derive myocardial torsional modulus (µ) and frictional damping characteristics, and hypothesized that the torsional modulus would correlate with invasive measures of LV stiffness.

METHODS

Twenty-two participants who underwent invasive left heart catheterization (LHC) and CMR for the evaluation of chest pain were evaluated. µ and damping constants were determined by solving a system of equations using CMR-measured LV geometrical and angular displacement data during diastole. Time constant of pressure decay τ and chamber stiffness β were measured from invasive LHC and CMR-derived volume data as comparison metrics of diastolic function.

RESULTS

µ was correlated with chamber stiffness constant β and time constant of pressure decay τ, derived from invasive measurement (R = 0.78, p < 0.001, and R = 0.51, p = 0.014, respectively). µ was also correlated with pre-A-wave diastolic pressure (0.67, p = 0.001).

CONCLUSION

We propose a new method to objectively evaluate diastolic relaxation properties of the LV. This method may have promise to replace invasive, catheter-based assessment of diastolic function.

Prevalence and significance of pulmonary hypertension among hospitalized patients with left heart disease

BACKGROUND

Pulmonary hypertension associated with left heart disease (PH-LHD) prevalence ranges significantly across studies with limited real-world evidence.

OBJECTIVES

To investigate the prevalence and prognostic influence of PH-LHD in a nationwide sample.

METHODS

Using the 2018 US Nationwide Inpatient Sample we calculated the prevalence of PH across heart failure (HF), cardiomyopathies, aortic, and mitral valve disease. We used logistic regression to assess the impact of PH on LHD and to find significant contributors to in-hospital mortality in the PH-LHD population.

RESULTS

Among 6,270,625 hospitalizations with LHD, 801,535 (12.8 %) had a secondary PH diagnosis. PH-LHD prevalence was 17.2 % in HF with preserved ejection fraction (HFpEF), 11.8 % in HF with reduced ejection fraction (HFrEF), 16.8 % in dilated cardiomyopathy, 12.6 % in hypertrophic cardiomyopathy, 18.7 % in mitral regurgitation, 28.5 % in mitral stenosis, 13.5 % in aortic stenosis, and 13.9 % in aortic regurgitation. PH was associated with increased in-hospital mortality in HFpEF (OR 1.23; 95%CI 1.17-1.28), hypertrophic cardiomyopathy (1.42; 1.06-1.89), mitral regurgitation (1.17; 1.07-1.28), and aortic stenosis (1.14; 1.04-1.26), but not in HFrEF (1.04; 0.99-1.10), or dilated cardiomyopathy (1.13; 0.99-1.29). Among PH-LHD, in-hospital mortality was associated with age, atrial fibrillation/flutter, cancer, and acute cardiac (acute right HF, myocardial infarction, ventricular arrhythmia), or extra-cardiac (stroke, sepsis, pneumonia, acute renal failure, venous thromboembolism) diagnoses.

CONCLUSION

In a nationwide inpatient analysis the prevalence of PH-LHD was lower than previously reported indicating reduced recognition of this disease in real world clinical practice. The diagnosis of PH-LHD was associated with worse fatality rates across all forms of LHD, except for HFrEF.

Hospitalization after hydroxychloroquine initiation in patients with heart failure with preserved ejection fraction and autoimmune disease

BACKGROUND

Hydroxychloroquine (HCQ) reduces cardiovascular events among patients with autoimmune disorders and is being evaluated as a therapeutic option for populations with high-risk cardiovascular disease. However, recent studies have raised concerns about HCQ use and cardiovascular events.

OBJECTIVE

To assess the association of HCQ initiation with heart failure-related and all-cause hospitalizations among patients with heart failure and preserved ejection fraction (HFpEF).

METHODS

We conducted a cohort study of patients aged ≥18 years with diagnosed HFpEF and autoimmune disease using MarketScan Commercial and Medicare Supplemental databases (2007-2019). Patients were required to initiate HCQ after their first HFpEF diagnosis (HCQ users) or not (HCQ nonusers). For the patients in the HCQ users group, the first HCQ prescription date was assigned as the index date. Index date for the HCQ nonuser group was assigned by prescription-time distribution matching HCQ users, by utilizing the number of days from HFpEF diagnosis to the first HCQ prescription. After 1:≥3 propensity score (PS) matching, Cox proportional hazards regression models were used to compare HF-related and all-cause hospitalizations between users and nonusers.

RESULTS

After PS matching, 2229 patients (592 HCQ users and 1637 HCQ nonusers) were included. After controlling for covariates, patients who received HCQ had lower risks of HF-related hospitalization (adjusted hazard ratio, 0.44; 95% CI, 0.24-0.82) and all-cause hospitalization (adjusted hazard ratio, 0.69; 95% CI, 0.57-0.83) compared with patients not using HCQ.

CONCLUSIONS

Among patients with HFpEF and autoimmune disease, initiation of HCQ use was associated with a decreased risk of HF-related and all-cause hospitalizations.

The Distribution of Left Ventricular Ejection Fraction, Characteristics, and Clinical Outcomes of Patients with Newly Diagnosed Heart Failure in Taiwan

Background

Data regarding the distribution of left ventricular ejection fraction among patients with newly diagnosed heart failure (HF) and the outcomes of patients with heart failure with preserved ejection fraction (HFpEF) in Taiwan are limited.

Methods

Patients with newly diagnosed HF were identified from a multi-institutional database between 2016 and 2020. Outcomes were compared between patients with HFpEF and heart failure with reduced ejection fraction (HFrEF) after propensity score matching (PSM).

Results

Of 7,736 newly diagnosed HF patients, 4,393 (56.8%) had HFpEF and 1,977 (25.6%) had HFrEF. The HFpEF group was older (71.5 vs. 64.2 years) and more likely to be female (48.9% vs. 31.1%). Comorbidities were more common in the HFpEF patients. Median follow-up was 2.1 years. Prior to PSM, the HFpEF patients had higher all-cause mortality risk [hazard ratio (HR) 1.21, 95% confidence interval (CI) 1.11-1.33] but lower cardiovascular (CV) death risk (HR 0.84, 95% CI 0.72-0.97) compared to those with HFrEF. The HFpEF group had a trend of higher overall hospitalization risk (HR 1.06, 95% CI 0.99-1.14), but lower HF hospitalization risk (HR 0.61, 95% CI 0.55- 0.67). After PSM, all-cause mortality and overall hospitalization were comparable. The HFpEF group had lower rates of CV death (HR 0.82, 95% CI 0.68-1.0) and HF hospitalization (HR 0.60, 95% CI 0.53-0.69) compared to the HFrEF group.

Conclusions

Among patients with newly diagnosed HF, HFpEF is the predominant phenotype, characterized by older age, higher female prevalence, and increased comorbidities. After adjusting for these factors, all-cause death and hospitalization risks became similar between the HFpEF and HFrEF patients. The HFpEF patients had lower risks of CV death and HF hospitalization.

Navigating the evolving landscape of HFpEF management: A detailed look at key ACC/AHA/ESC guideline updates

Heart failure, a growing concern in the United States, significantly impacts both morbidity and mortality. Classified by ejection fraction, heart failure with preserved ejection fraction (HFpEF) now accounts for half of all cases and is steadily rising. Unlike its counterpart, heart failure with reduced ejection fraction (HFrEF), HFpEF lacks clear management guidelines. Recognizing this critical gap, we aim to review existing recommendations and formulate effective management strategies for HFpEF.

PDE9A Inhibition Improves Coronary Microvascular Rarefaction and Left Ventricular Diastolic Dysfunction in the ZSF1 Rat Model of HFpEF

OBJECTIVE

Heart failure with preserved ejection fraction (HFpEF) commonly arises from comorbid diseases, such as hypertension, obesity, and diabetes mellitus. Selective inhibition of phosphodiesterase 9A (PDE9A) has emerged as a potential therapeutic approach for treating cardiometabolic diseases. Coronary microvascular disease (CMD) is one of the key mechanisms contributing to the development of left ventricular (LV) diastolic dysfunction in HFpEF. Our study aimed to investigate the mechanisms by which PDE9A inhibition could ameliorate CMD and improve LV diastolic function in HFpEF.

METHODS AND RESULTS

The obese diabetic Zucker fatty/spontaneously hypertensive heart failure F1 hybrid (ZSF1) rat model of HFpEF was employed in which it was found that a progressively developing coronary microvascular rarefaction is associated with LV diastolic dysfunction when compared to lean, nondiabetic hypertensive controls. Obese ZSF1 rats had an increased cardiac expression of PDE9A. Treatment of obese ZSF1 rats with the selective PDE9A inhibitor, PF04447943 (3 mg/kg/day, oral gavage for 2 weeks), improved coronary microvascular rarefaction and LV diastolic dysfunction, which was accompanied by reduced levels of oxidative and nitrosative stress markers, hydrogen peroxide, and 3-nitrotyrosine. Liquid chromatography-mass spectrometry (LC-MS) proteomic analysis identified peroxiredoxins (PRDX) as downregulated antioxidants in the heart of obese ZSF1 rats, whereas Western immunoblots showed that the protein level of PRDX5 was significantly increased by the PF04447943 treatment.

CONCLUSIONS

Thus, in the ZSF1 rat model of human HFpEF, PDE9A inhibition improves coronary vascular rarefaction and LV diastolic dysfunction, demonstrating the usefulness of PDE9A inhibitors in ameliorating CMD and LV diastolic dysfunction through augmenting PRDX-dependent antioxidant mechanisms.

Long-term outcomes of patients bridged to recovery with venoarterial extracorporeal life support

OBJECTIVE

Our study examines the long-term outcomes of patients discharged from the hospital without heart replacement therapy (HRT) after recovery from cardiogenic shock using venoarterial extracorporeal life support (VA-ECLS).

METHODS

We retrospectively reviewed 615 cardiogenic shock patients who recovered from VA-ECLS at our institution between January 2015 and July 2021. Of those, 166 patients (27.0%) who recovered from VA-ECLS without HRT were included in this study. Baseline characteristics, discharge labs, vitals, electrocardiograms and echocardiograms were assessed. Patients were contacted to determine vital status. The primary outcome was post-discharge mortality.

RESULTS

Of 166 patients, 158 patients (95.2%) had post-discharge follow-up, with a median time of follow-up of 2 years (IQR: [1 year, 4 years]). At discharge, the median ejection fraction (EF) was 52.5% (IQR: [32.5, 57.5]). At discharge, 92 patients (56%) were prescribed β-blockers, 28 (17%) were prescribed an ACE inhibitor, ARB or ARNI, and 50 (30%) were prescribed loop diuretics. Kaplan-Meier analysis showed a 1-year survival rate of 85.6% (95% CI: [80.1%, 91.2%]) and a 5-year survival rate of 60.6% (95% CI: [49.9%, 71.3%]). A Cox regression model demonstrated that a history of congestive heart failure (CHF) was strongly predictive of increased mortality hazard (HR = 1.929; p = 0.036), while neither discharge EF nor etiology of VA-ECLS were associated with increased post-discharge mortality.

CONCLUSIONS

Patients discharged from the hospital after full myocardial recovery from VA-ECLS support without HRT should have close outpatient follow-up due to the risk of recurrent heart failure and increased mortality in these patients.

Mitochondrial Reactive Oxygen Species Dysregulation in Heart Failure with Preserved Ejection Fraction: A Fraction of the Whole

Heart failure with preserved ejection fraction (HFpEF) is a multifarious syndrome, accounting for over half of heart failure (HF) patients receiving clinical treatment. The prevalence of HFpEF is rapidly increasing in the coming decades as the global population ages. It is becoming clearer that HFpEF has a lot of different causes, which makes it challenging to find effective treatments. Currently, there are no proven treatments for people with deteriorating HF or HFpEF. Although the pathophysiologic foundations of HFpEF are complex, excessive reactive oxygen species (ROS) generation and increased oxidative stress caused by mitochondrial dysfunction seem to play a critical role in the pathogenesis of HFpEF. Emerging evidence from animal models and human myocardial tissues from failed hearts shows that mitochondrial aberrations cause a marked increase in mitochondrial ROS (mtROS) production and oxidative stress. Furthermore, studies have reported that common HF medications like beta blockers, angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and mineralocorticoid receptor antagonists indirectly reduce the production of mtROS. Despite the harmful effects of ROS on cardiac remodeling, maintaining mitochondrial homeostasis and cardiac functions requires small amounts of ROS. In this review, we will provide an overview and discussion of the recent findings on mtROS production, its threshold for imbalance, and the subsequent dysfunction that leads to related cardiac and systemic phenotypes in the context of HFpEF. We will also focus on newly discovered cellular and molecular mechanisms underlying ROS dysregulation, current therapeutic options, and future perspectives for treating HFpEF by targeting mtROS and the associated signal molecules.

Change in left atrial function and volume predicts incident heart failure with preserved and reduced ejection fraction: Multi-Ethnic Study of Atherosclerosis

AIMS

The role of change in left atrial (LA) parameters prior to the onset of heart failure (HF) remains unclear. We used cardiac magnetic resonance (CMR) imaging to investigate the relationship between longitudinal change in LA function and incident HF in a multi-ethnic population with subclinical cardiovascular disease (CVD).

METHODS AND RESULTS

In this prospective multi-ethnic cohort study, 2470 participants (60 ± 9 years, 47% males), free at baseline of clinical CVD, had LA volume and function assessed via multimodality tissue tracking on CMR imaging at baseline (2000-02) and a second study 9.4 ± 0.6 years later. Free of HF, 73 participants developed incident HF [HF with preserved ejection fraction (HFpEF), n = 39; reduced ejection fraction (HFrEF), n = 34] 7.1 ± 2.1 years after the second study. An annual decrease of 1 SD unit in peak LA strain (ΔLASmax) was most strongly associated with the risk of HFpEF [subdistribution hazard ratios (HR) = 2.56, 95% confidence interval (CI) (1.34-4.90), P = 0.004] and improved model reclassification and discrimination in predicting HFpEF [C-statistic = 0.84, 95% CI (0.79-0.90); net reclassification index (NRI) = 0.34, P = 0.01; and integrated discrimination index (IDI) = 0.02, P = 0.02], whilst an annual decrease of 1 mL/m2 of pre-atrial indexed LA volumes (ΔLAVipreA) was most strongly associated with the risk of HFrEF [subdistribution HR = 1.88, 95% CI (1.44-2.45), P < 0.001] and improved model reclassification and discrimination in predicting HFrEF [C-statistic = 0.81, 95% CI (0.72-0.90); NRI = 0.31, P = 0.03; and IDI = 0.01, P = 0.50] after adjusting for event-specific risk factors and baseline LA measures.

CONCLUSION

ΔLASmax and ΔLAVipreA were associated with and incrementally predictive of HFpEF and HFrEF, after adjusting for risk factors and baseline LA measures in this population of subclinical CVD.

Contemporary treatment options in heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) constitutes approximately half of the heart failure population, with its prevalence markedly increasing with older age and the presence of cardio-metabolic comorbidities. Although HFpEF is associated with a high symptom- and mortality burden, historically there have been few evidence-based treatment options for patients with HFpEF. Recent randomized clinical trials have expanded evidence on pharmacological treatment options, introducing new agents for managing HFpEF. Given the complex clinical phenotype with pathophysiological heterogeneity and evolving diagnostic standards, the evidence-based management of HFpEF remains challenging for clinicians. This review summarizes the latest evidence from contemporary randomized clinical trials and recent guideline recommendations to provide guidance for the treatment of patients with HFpEF.

Heart Failure with Preserved Ejection Fraction and Cardiac Amyloidosis in the Aging Heart

Heart Failure with Preserved Ejection Fraction (HFpEF) is one of the most frequent causes of heart failure in the world's population (about 19-55%), and is commonly associated with a high rate of hospitalization (almost 70-80%) and with increased mortality (40-50% in a 5-year timeframe). The elderly are more often affected, with higher rates of hospitalizations than young people, and currently almost 70% of the population aged 65 years old has HFpEF. An increase in cardiomyocyte stiffness, thus resulting in diastolic dysfunction, increased filling pressures and heart failure with preserved ejection fraction are characteristics features of the disease. In addition, among the various causes of HFpEF, cardiac amyloidosis (CA) can provoke diastolic dysfunction and increased wall stiffness directly from intercellular deposition of insoluble proteic substances and their toxic activity. Totally, almost 30 different proteins are able to form deposits, but the most frequently involved are transthyretin and misfolded monoclonal immunoglobulin light chains, which bring to two clinical conditions called transthyretin amyloidosis (ATTR) and light-chain amyloidosis (AL). Although there has been increasing attention on ATTR-CA in recent years, the actual prevalence remains underestimated, especially in people of advanced age, as well as its real impact as a cause of HFpEF, and only data derived from autoptic exams are currently available. Moreover, CA itself often mimics HFpEF, and some conflicting data on the use of predictive scores are described in the literature. The close relationship between HFpEF and CA, especially in older population and the main pathophysiological mechanisms which bond these two conditions are described in this focused review. The need to screen red flags for ATTR-CA in elderly patients with HFpEF is urgently advised, because a prompt recognition of the disease can optimize the approach to the disease with an early therapeutic, life-saving choice.

Daucosterol alleviates heart failure with preserved ejection fraction through activating PPARα pathway

Heart failure with preserved ejection fraction (HFpEF) has been increasing in the population in recent years and is mainly characterized by preserved left ventricle ejection fraction (LVEF), diastolic dysfunction and systemic inflammation. Daucosterol (DAU), a glycoside of β-sitosterol, has good anti-inflammatory and antioxidative properties; however, its effects and mechanisms in HFpEF have not been investigated. To detect whether DAU could alleviate HFpEF, C57BL/6J male mice were fed with N-nitro-l-arginine methyl ester (L-NAME) in drinking water and high fat diet (HFD) and treated with DAU by gavage (i.g.) for 10 weeks. The results showed that DAU treatment significantly alleviated HFpEF in mice. Mechanistically, by controlling PPARα and preventing NF-κB phosphorylation, DAU reduced oxidative stress and the inflammatory response. In conclusion, our study provides a new clue for natural product DAU in alleviating HFpEF.

Hypertrophic Cardiomyopathy as a Form of Heart Failure with Preserved Ejection Fraction: Diagnosis, Drugs, and Procedures

Hypertrophic cardiomyopathy (HCM) is a complex and heterogeneous cardiac disorder characterized by cardiac hypertrophy disproportionate to loading stimuli (e.g. hypertension or aortic stenosis). Diagnosing HCM requires a thorough examination of clinical symptoms, with echocardiography as the key initial imaging tool. Multimodality imaging further supports diagnosis, helps assess left ventricular outflow obstruction, and aids in risk stratification for sudden cardiac death. The cornerstone of HCM management remains pharmacological therapy with β-blockers and calcium channel blockers serving as first-line agents to alleviate symptoms and reduce left ventricular outflow tract obstruction. More recently, cardiac myosin inhibitors have revolutionized the treatment paradigm for obstructive HCM. Procedural interventions such as septal reduction therapy are reserved for refractory cases. Genetic testing and risk stratification for sudden cardiac death play a critical role in treatment decisions, guiding further testing in first-degree relatives and ICD implantation in high-risk individuals. Exercise recommendations have evolved based on recent data, challenging traditional restrictions and emphasizing individualized plans.

Assessing Static Balance, Balance Confidence, and Fall Rate in Patients with Heart Failure and Preserved Ejection Fraction: A Comprehensive Analysis

Chronic heart failure (CHF) is a complex clinical syndrome, associated with frailty, higher fall rates, and frequent hospitalizations. Heart Failure (HF) and preserved ejection fraction (HFpEF) is defined as a condition where a patient with HF have a diagnosis of left ventricular ejection fraction (LVEF) of ≥ 50%. The risk of HFpEF increases with age and is related to higher non-cardiovascular mortality. The aim of this study was to evaluate static balance and examine the effect of task difficulty on the discriminating power of balance control between patients with HFpEF (Patients with HFpEF) and their healthy controls. Moreover, the associations between static balance parameters, balance confidence, falls, lean muscle mass, and strength were assessed. Seventy two patients with HFpEF (mean age: 66.0 ± 11.6 years) and seventy two age- and gender-matched healthy individuals (mean age: 65.3 ± 9.5 years) participated in this study. Participants underwent a 30 s bilateral stance (BS) test and a 20 s Tandem-Romberg stance (TRS) on a force platform, evaluating the Range and Standard Deviation of Center of Pressure (COP) displacement parameters in both axes. Balance confidence was evaluated by the Activities-Specific Balance Confidence (ABC) Scale, and the number of falls during the last year was recorded. Lower limb strength was measured using an isokinetic dynamometer, isometric leg strength, and a Sit-to-Stand test. Bioelectrical impedance analysis was conducted to assess lean fat mass, lean fat mass index, and lean%. Patients with HFpEF presented with lower static balance in BS and TRS compared to healthy controls (p < 0.05), lower balance confidence by 21.5% (p < 0.05), and a higher incidence of falls by 72.9% (p < 0.05). BS was a better descriptor of the between-group difference. Furthermore, static balance, assessed in controlled lab conditions, was found to have little if no relationship to falls, strength, lean muscle mass, and balance confidence. Although no correlation was noted between the static balance parameters and falls, the fall rate was related to balance confidence, age, muscle strength, and lean fat.