The Polymorphonuclear Leukocyte and the Abdominal Aortic Aneurysm

The rejection that defies antirejection drugs-chronic vascular rejection (allograft vasculopathy): The role of terminology and linguistic relativity

While allograft loss due to acute rejection has been dramatically reduced due to the introduction of immunophilins, this therapy has little effect on allografts lost due to chronic vascular rejection. This situation may be due to a misnomer of the pathology. Specifically, its designation as 'chronic rejection' has given the wrong impression that the cause of the disease has been identified. Analyzing this phenomenon under the rubric of linguistic relativity suggests that the words chosen to name the disease may have restricted our cognitive ability to solve the problem. Thus, we have to step out of the 'alloimmunity/rejection box'. Let's pause between our words, Speak and fall silent again, So that the meaning of the word just spoken, Sounds a clearer echo in our heads. Let's pause between our words. Andrey Makarevich.

The molecular mechanism of obesity: The science behind natural exercise yoga and healthy diets in the treatment of obesity

The review centers on the scientific evidence underlying obesity, providing a detailed examination of the role of perilipin in this condition. It explores potential causes of obesity and delves into therapeutic approaches involving exercise, yoga, and herbal treatments. The paper discusses natural sources that can contribute to combating obesity and underscores the importance of exercise in a scientific context for overcoming obesity. Additionally, it includes information on herbal ingredients that aid in reducing obesity. The review also examines the impact of exercise type and intensity at various time intervals on muscle development. It elucidates triglyceride hydrolysis through different enzymes and the deposition of fatty acids in adipose tissue. The mechanisms by which alpha/beta hydrolase domain-containing protein 5 (ABHD5) and hormone-sensitive lipase (HSL) target and activate their functions are detailed. The inflammatory response in obesity is explored, encompassing inflammatory markers, lipid storage diseases, and their classification with molecular mechanisms. Furthermore, the hormonal regulation of lipolysis is elaborated upon in the review.

Relationship between stress hyperglycemia ratio and acute kidney injury in patients with congestive heart failure

BACKGROUND

The stress hyperglycemia ratio (SHR) has been demonstrated as an independent risk factor for acute kidney injury (AKI) in certain populations. However, this relationship in patients with congestive heart failure (CHF) remains unclear. Our study sought to elucidate the relationship between SHR and AKI in patients with CHF.

METHODS

A total of 8268 patients with CHF were included in this study. We categorized SHR into distinct groups and evaluated its association with mortality through logistic or Cox regression analyses. Additionally, we applied the restricted cubic spline (RCS) analysis to explore the relationship between SHR as a continuous variable and the occurrence of AKI. The primary outcome of interest in this investigation was the incidence of AKI during hospitalization.

RESULTS

Within this patient cohort, a total of 5,221 (63.1%) patients experienced AKI during their hospital stay. Upon adjusting for potential confounding variables, we identified a U-shaped correlation between SHR and the occurrence of AKI, with an inflection point at 0.98. When the SHR exceeded 0.98, for each standard deviation (SD) increase, the risk of AKI was augmented by 1.32-fold (odds ratio [OR]: 1.32, 95% CI: 1.22 to 1.46). Conversely, when SHR was below 0.98, each SD decrease was associated with a pronounced increase in the risk of AKI.

CONCLUSION

Our study reveals a U-shaped relationship between SHR and AKI in patients with CHF. Notably, we identified an inflection point at an SHR value of 0.98, signifying a critical threshold for evaluating AKI in this population.

Effects of Continuous Accelerated Pacing on Cardiac Structure and Function in Patients With Heart Failure With Preserved Ejection Fraction: Insights From the myPACE Randomized Clinical Trial

BACKGROUND

Heart failure with preserved ejection fraction ≥50% is prevalent with few evidence-based therapies. In a trial of patients with heart failure with preserved ejection fraction with specialized pacemakers, treatment with accelerated personalized pacing averaging 75 bpm (myPACE) markedly improved quality of life, NT-proBNP (N-terminal pro-brain natriuretic peptide), physical activity, and atrial fibrillation burden compared with the standard lower rate setting of 60 bpm (usual care).

METHODS AND RESULTS

In this exploratory study, provider-initiated echocardiographic studies obtained before and after the trial were assessed for changes in left ventricular (LV) structure and function among participants who continued their pacing assignment. The analytic approach aimed to detect differences in standard and advanced echocardiographic parameters within and between study arms. Of the 100 participants, 16 myPACE and 20 usual care arm had a qualifying set of echocardiograms performed a mean (SD) 3 (2.0) years apart. Despite similar baseline echocardiogram measures, sustained exposure to moderately accelerated pacing resulted in reduced septal wall thickness (in cm: myPACE 1.1 [0.2] versus usual care 1.2 [0.2], P=0.008) and lower LV mass to systolic volume ratio (in g/mL: myPACE 4.8 [1.9] versus usual care 6.8 [3.1], P=0.038) accompanied by a minor reduction in LV ejection fraction (in %: myPACE 55 [5] versus usual care 60 [5], P=0.015). These changes were paralleled by improvements in heart failure-related quality of life (myPACE Minnesota Living with Heart Failure Questionnaire improved by 16.1 [13.9] points, whereas usual care worsened by 6.9 [11.6] points, P<0.001). Markers of diastolic function and LV performance were not affected.

CONCLUSIONS

Exposure to continuous accelerated pacing in heart failure with preserved ejection fraction is associated with a reduced LV wall thickness and a small amount of LV dilation with small reduction in ejection fraction.

Mitochondrial dysfunction and skeletal muscle atrophy: Causes, mechanisms, and treatment strategies

Skeletal muscle, which accounts for approximately 40% of total body weight, is one of the most dynamic and plastic tissues in the human body and plays a vital role in movement, posture and force production. More than just a component of the locomotor system, skeletal muscle functions as an endocrine organ capable of producing and secreting hundreds of bioactive molecules. Therefore, maintaining healthy skeletal muscles is crucial for supporting overall body health. Various pathological conditions, such as prolonged immobilization, cachexia, aging, drug-induced toxicity, and cardiovascular diseases (CVDs), can disrupt the balance between muscle protein synthesis and degradation, leading to skeletal muscle atrophy. Mitochondrial dysfunction is a major contributing mechanism to skeletal muscle atrophy, as it plays crucial roles in various biological processes, including energy production, metabolic flexibility, maintenance of redox homeostasis, and regulation of apoptosis. In this review, we critically examine recent knowledge regarding the causes of muscle atrophy (disuse, cachexia, aging, etc.) and its contribution to CVDs. Additionally, we highlight the mitochondrial signaling pathways involvement to skeletal muscle atrophy, such as the ubiquitin-proteasome system, autophagy and mitophagy, mitochondrial fission-fusion, and mitochondrial biogenesis. Furthermore, we discuss current strategies, including exercise, mitochondria-targeted antioxidants, in vivo transfection of PGC-1α, and the potential use of mitochondrial transplantation as a possible therapeutic approach.

From mid-range to mildly reduced ejection fraction heart failure: A call to treat

The historical classification of heart failure (HF) has considered two distinct subgroups, HF with reduced ejection fraction (HFrEF), generally classified as EF below 40%, and HF with preserved ejection fraction (HFpEF) variably classified as EF above 40%, 45% or 50%. One of the principal reasons behind this distinction was related to presence of effective therapy in HFrEF, but not in HFpEF. Recently the expanding knowledge in the specific subgroup of patient with a LVEF between 41% and 49% and the potential benefit of new therapies and of those used in patients with LVEF below 40%, has led to rename this group as HF with mildly reduced EF (HFmrEF). In this review we discuss the reasons behind this modification, we summarize the main characteristics of HFmrEF the similarities and differences with the two other EF categories, and finally we provide a comprehensive overview of the current available evidence supporting the treatment of patients with HFmrEF.

Human abdominal aortic aneurysm (AAA): Evidence for an autoimmune antigen-driven disease

Abdominal aortic aneurism (AAA) is a complex immunological disease with a strong genetic component, and one of the ten leading causes of death of individuals 55-74 years old worldwide. Strong evidence has been accumulated suggesting that AAA is an autoimmune specific antigen-driven disease. Mononuclear cells infiltrating AAA lesions comprised of T and B lymphocytes and other cells expressing early-, intermediate- and late-activation antigens, and the presence of antigen-presenting cells have been documented, demonstrating an ongoing immune response. The three components of the trimolecular complex, T-cell receptor (TCR)/peptide (antigen)/HLA have been identified in AAA, and specifically: (i) clonal expansions of T-cell clones in AAA lesions; (ii) the association of AAA with particular HLA Class I and Class II; and (iii) self or nonself putative AAA-associated antigens. IgG autoantibodies recognizing proteins present in normal aortic tissue have been reported in patients with AAA. Molecular mimicry, defined as the sharing of antigenic epitopes between microorganisms (bacteria, viruses) and self antigens, maybe is responsible for T-cell responses and antibody production in AAA. Also, the frequency and the suppressor activity of CD4 + CD25 + FOXP3+ Tregs and the expression of FOXP3 transcripts and protein have been reported to be significantly impaired in AAA patients vs normal donors.

A systematic review on the role of MSC-derived exosomal miRNAs in the treatment of heart failure

BACKGROUND

This systematic review summarizes results of studies that evaluated the expression of microRNAs (miRs) in pre-diabetes or type 2 diabetes.

METHODS

The information was obtained in PubMed, EMBL-EBI, Wanfang, Trip Database, Lilacs, CINAHL and Google. A qualitative synthesis of the results was performed and miRs frequency was graphically. From 1880 we identified studies, only 53 fulfilled the inclusion criteria. The 53 studies analyzed miRs in T2D; and of them, thirteen also described data in pre-diabetes.

RESULTS

In diabetics, 122 miRs were reported and 35 miRs for pre-diabetics. However, we identified that 5 miRs (-122-5p, 144-3p, 210, 375, -126b) were reported more often in diabetics, and 4 (144-3p, -192, 29a and -30d) in pre-diabetics.

CONCLUSIONS

Circulating miRs could be used as biomarkers of type 2 diabetes. However, it is necessary to validate these microRNAs in prospective and multi-center studies, where different population subgroups, considering the age, gender, and risk factors.

A Randomized Controlled Trial of Heart Failure Disease Management in Skilled Nursing Facilities

OBJECTIVE

Patients discharged from the hospital to a skilled nursing facility (SNF) are not typically part of a heart failure disease management program (HF-DMP). The objective of this study is to determine if an HF-DMP in SNF improves outcomes for patients with HF.

DESIGN

Cluster-randomized controlled trial.

PARTICIPANTS

The trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care).

METHODS

The HF-DMP included documentation of ejection fraction, symptoms, weights, diet, medication optimization, education, and 7-day visit post SNF discharge. The composite outcome was all-cause hospitalization, emergency department visits, or mortality at 60 days. Secondary outcomes included the composite endpoint at 30 days, change in the Kansas City Cardiomyopathy Questionnaire and the Self-care of HF Index at 60 days. Rehospitalization and mortality rates were calculated as an exploratory outcome.

RESULTS

Mean age of the patients was 79 ± 10 years, 58% were women, and the mean ejection fraction was 51% ± 16%. At 30 and 60 days post SNF admission, the composite endpoint was not significant between DMP (29%) and usual care (32%) at 30 days and 60 days (43% vs 47%, respectively). The Kansas City Cardiomyopathy Questionnaire significantly improved in the HF-DMP vs usual care for the Physical Limitation (11.3 ± 2.9 vs 20.8 ± 3.6; P = .039) and Social Limitation subscales (6.0 ± 3.1 vs 17.9 ± 3.8; P = .016). Self-care of HF Index was not significant. The total number of events (composite endpoint) totaled 517 (231 in HF-DMP and 286 in usual care). Differences in the 60-day hospitalization rate [mean HF-DMP rate 0.43 (SE 0.03) vs usual care 0.54 (SE 0.05), P = .04] and mortality rate (HF-DMP 5.2% vs usual care 10.8%, P < .001) were significant.

CONCLUSIONS AND IMPLICATIONS

The composite endpoint was high for patients with HF in SNF regardless of group. Rehospitalization and mortality rates were reduced by the HF-DMP. HF-DMPs in SNFs may be beneficial to the outcomes of patients with HF. SNFs should consider structured HF-DMPs for their patients.

Dry-reagent microfluidic biosensor for simple detection of NT-proBNP via Ag nanoparticles

The diagnosis of many diseases requires monitoring of biomarker levels over a period of time instead of assessing their concentration only once. For example, in case of heart failure determination, the levels of N-terminal prohormone brain natriuretic peptide (NT-proBNP) in blood vary so strongly amongst individuals, that the current procedure of one-time measurement in combination with clinical examination does not allow for accurate assessment of disease severity and progression. Our microfluidic biosensor addresses key characteristics of desirable home-tests which include low limits of detection, small sample volume (less than 10 μL), simple detection strategies, and ready-to-go all-dried long-term stable reagents. Here, electrochemically superior silver nanoparticles (AgNP) were dried directly within the microfluidic channel in a matrix of trehalose sugar doped with Na₂SO₃ as oxygen scavenger. This successfully prevented AgNP oxidation and enabled dry and ready-to-use storage for at least 18 weeks. Based on this, laser-cut flow chips were developed containing all bioassay reagents needed in a ready-to-go dry format. An oxidation-reduction stripping voltammetry strategy was used for highly sensitive quantification of the AgNPs as electrochemical label. This microfluidic biosensor demonstrated limits of detection for NT-proBNP of 0.57 ng mL^-1 with a mean error of 6% (n ≥ 3) in undiluted human serum, which is below the clinically relevant cut-off of 1 ng mL^-1. This practical approach has the potential to substitute commonly used lateral-flow assays for various biomarkers, as it offers low patient sample volumes hence supporting simple finger-prick strategies well-known also for other electrochemical biosensors, and independence from the notorious variability in fleece fabrication.

Validation of a deep-learning semantic segmentation approach to fully automate MRI-based left-ventricular deformation analysis in cardiotoxicity

OBJECTIVE

Left-ventricular (LV) strain measurements with the Displacement Encoding with Stimulated Echoes (DENSE) MRI sequence provide accurate estimates of cardiotoxicity damage related to chemotherapy for breast cancer. This study investigated an automated and supervised deep convolutional neural network (DCNN) model for LV chamber quantification before strain analysis in DENSE images.

METHODS

The DeepLabV3 +DCNN with three versions of ResNet-50 backbone was designed to conduct chamber quantification on 42 female breast cancer data sets. The convolutional layers in the three ResNet-50 backbones were varied as non-atrous, atrous and modified, atrous with accuracy improvements like using Laplacian of Gaussian filters. Parameters such as LV end-diastolic diameter (LVEDD) and ejection fraction (LVEF) were quantified, and myocardial strains analyzed with the Radial Point Interpolation Method (RPIM). Myocardial classification was validated with the performance metrics of accuracy, Dice, average perpendicular distance (APD) and others. Repeated measures ANOVA and intraclass correlation (ICC) with Cronbach's α (C-Alpha) tests were conducted between the three DCNNs and a vendor tool on chamber quantification and myocardial strain analysis.

RESULTS

Validation results in the same test-set for myocardial classification were accuracy = 97%, Dice = 0.92, APD = 1.2 mm with the modified ResNet-50, and accuracy = 95%, Dice = 0.90, APD = 1.7 mm with the atrous ResNet-50. The ICC results between the modified ResNet-50, atrous ResNet-50 and vendor-tool were C-Alpha = 0.97 for LVEF (55±7%, 54±7%, 54±7%, p = 0.6), and C-Alpha = 0.87 for LVEDD (4.6 ± 0.3 cm, 4.6 ± 0.3 cm, 4.6 ± 0.4 cm, p = 0.7).

CONCLUSION

Similar performance metrics and equivalent parameters obtained from comparisons between the atrous networks and vendor tool show that segmentation with the modified, atrous DCNN is applicable for automated LV chamber quantification and subsequent strain analysis in cardiotoxicity.

ADVANCES IN KNOWLEDGE

A novel deep-learning technique for segmenting DENSE images was developed and validated for LV chamber quantification and strain analysis in cardiotoxicity detection.

A randomized ablation-based atrial fibrillation rhythm control versus rate control trial in patients with heart failure and high burden atrial fibrillation: The RAFT-AF trial rationale and design

Heart failure (HF) and atrial fibrillation (AF) are 2 cardiac conditions that are increasing in prevalence and incidence. The 2 conditions frequently coexist, and are associated with increased morbidity and mortality. Catheter ablation of AF has been successfully performed in patients with HF, with an improvement in HF and AF, when compared to amiodarone, but further data is required to compare this to rate control. OBJECTIVES: The primary objective is to determine whether AF treated by catheter ablation, with or without antiarrhythmic drugs reduces all-cause mortality and hospitalizations for HF as compared with rate control in patients with HF and a high burden AF. METHODS: This is a multi-center prospective randomized open blinded endpoint (PROBE) study. Patients with NYHA class II-III HF (HF with reduced ejection fraction (<35%) or HF with preserved ejection fraction), and high burden AF are included in the trial. Patients are randomized to either rate control or catheter ablation-based AF rhythm control in a 1:1 ratio. Patients in the rate control group receive optimal HF therapy and rate control measures to achieve a resting hazard ratio (HR) < 80 bpm and 6-minute walk HR < 110 bpm. Patients randomized to catheter ablation-based AF rhythm control group receive optimal HF therapy and one or more aggressive catheter ablation, which include PV antral ablation and LA substrate ablation with or without adjunctive antiarrhythmic drug. The primary outcome is a composite of all-cause mortality and hospitalization for heart failure defined as an admission to a health care facility. The sample size is 600. Enrolment has been completed.

Artificial Intelligence-Powered Measurement of Left Ventricular Ejection Fraction Using a Handheld Ultrasound Device

The aim of this study was to assess the accuracy of an algorithm for automated measurement of left ventricular ejection fraction (LVEF) available on handheld ultrasound devices (HUDs). One hundred twelve patients admitted to the cardiology department underwent assessment performed with an HUD. In each case, the four-chamber apical view was obtained, and LVEF was calculated with LVivo software. Subsequently, during the examination performed with the use of the stationary echocardiograph, the 3-D measurement of LVEF was recorded. The average LVEFs measured with LVivo and the 3-D reference method were 46 ± 14% and 48 ± 14%, respectively. The correlation between the measurements obtained with the HUD and 3-D evaluation was high (r = 0.92, 95% confidence interval: 0.87-0.95, p < 0.0001). The mean difference between the LVEF obtained with LVivo and the 3-D LVEF was not significant (mean difference: -0.61%, 95% confidence interval: -1.89 to 0.68, p = 0.31). The LVivo software despite its limitations is capable of the accurate LVEF measurement when the acquired views are of at least good imaging quality.

Asymptomatic Left Ventricular Dysfunction: Is There a Role for Screening in General Population?

Stage A and B heart failure (HF) include asymptomatic patients without and with structural cardiac disorder, respectively. Asymptomatic left ventricular (LV) dysfunction represents an early stage of HF that should be recognized to prevent overt HF development. Echocardiography plays a pivotal role in assessment of cardiac structure and function and represents the ideal imaging technique for screening in the general population, thanks to its availability, feasibility, and low cost. Traditional echocardiography, with LV systolic and diastolic function and cardiac remodeling assessment, is usually performed. Development of new technologies may offer additional information and insights in detection of early LV dysfunction.

Patient Characteristics Are Not Associated With Documentation of Weight and Heart Failure Related Sign and Symptom Assessment in Skilled Nursing Facilities

OBJECTIVE

Monitoring body weight and signs and symptoms related to heart failure (HF) can alert clinicians to a patient's worsening condition but the degree to which these practices are performed in skilled nursing facilities (SNFs) is unknown. This study analyzed the frequency of these monitoring practices in SNFs and explored associated factors at both the patient and SNF level.

DESIGN

An observational study of data from the usual care arm of the SNF Connect Trial, a randomized cluster trial of a HF disease management intervention. The data extracted from charts were combined with publicly available facility data. A linear regression model was estimated to evaluate the frequency of HF disease management conditional on patient and facility covariates.

SETTING

Data from 28 SNFs in Colorado.

PARTICIPANTS

Patients discharged from hospital to SNFs with a primary or secondary diagnosis of HF.

MEASUREMENTS

Patient-level covariates included demographics, New York Heart Association class, type of HF, and Charlson comorbidity index. Facility-level covariates were from Nursing Home Compare.

RESULTS

The sample (n = 320) was majority female (66%), white (93%), with mean age 80 ± 10 years and a Charlson comorbidity index of 3.2 ± 1.5. Seventy percent had HF with preserved ejection fraction, mean ejection fraction of 50 ± 16% and 40% with a New York Heart Association class III-IV. On average, patients were weighed 40% of their days in the SNF and had documentation of at least 1 HF-related sign or symptom 70% of their days in the SNF. Patient-level factors were not associated with frequency of documenting weight and assessments of HF-related signs/symptoms. Health Inspection Star Rating was positively associated with weight monitoring (P < .05) but not associated with symptom assessment.

CONCLUSIONS AND IMPLICATIONS

Patient-level factors are not meaningfully associated with the documentation of weight tracking or sign/symptom assessment. Monitoring weight was instead associated with the Health Inspection Star Rating.

The Role of Antithrombotic Therapy in Heart Failure

Heart failure is a major contributor to global morbidity and mortality burden affecting approximately 1-2% of adults in developed countries, mounting to over 10% in individuals aged >70 years old. Heart failure is characterized by a prothrombotic state and increased rates of stroke and thromboembolism have been reported in heart failure patients compared with the general population. However, the impact of antithrombotic therapy on heart failure remains controversial. Administration of antiplatelet or anticoagulant therapy is the obvious (and well-established) choice in heart failure patients with cardiovascular comorbidity that necessitates their use, such as coronary artery disease or atrial fibrillation. In contrast, antithrombotic therapy has not demonstrated any clear benefit when administered for heart failure per se, i.e. with heart failure being the sole indication. Randomized studies have reported decreased stroke rates with warfarin use in patients with heart failure with reduced left ventricular ejection fraction, but at the expense of excessive bleeding. Non-vitamin K oral anticoagulants have shown a better safety profile in heart failure patients with atrial fibrillation compared with warfarin, however, current evidence about their role in heart failure with sinus rhythm is inconclusive and further research is needed. In the present review, we discuss the role of antithrombotic therapy in heart failure (beyond coronary artery disease), aiming to summarize evidence regarding the thrombotic risk and the role of antiplatelet and anticoagulant agents in patients with heart failure.

Temporal changes in left ventricular ejection fraction and their prognostic impacts in patients with Stage B heart failure

BACKGROUND

We have recently demonstrated that left ventricular ejection fraction (LVEF) dynamically changes over time with prognostic impacts in Stage C/D patients, namely, those who have a current or past history of heart failure (HF). However, it is unknown whether this is also the case in asymptomatic Stage B patients, namely, those who have a risk of HF, but do not have a history of HF.

METHODS

In our CHART-2 Study (N = 10,219), we enrolled 4005 Stage B patients and divided them into 3 groups by LVEF; preserved EF (pEF, LVEF ≥50%, N = 3526), mid-range EF (mrEF, LVEF 41-49%, N = 302), and reduced EF (rEF, LVEF ≤40%, N = 177). We examined the prognostic impacts of LVEF transitions among the 3 groups in comparison with 4477 patients with Stage C/D HF.

RESULTS

Stage B were characterized by less severe clinical status and better prognosis compared with Stage C/D. Stage B in mrEF and rEF at baseline dynamically transitioned to other groups at 1-year, whereas those in pEF unchanged; at 1-year, mrEF transitioned to pEF/rEF by 50/16%, and rEF transitioned to pEF/mrEF by 25/31%, respectively, whereas pEF transitioned to mrEF/rEF by only 3.6/0.7%, respectively, which were consistent with findings in findings with Stage C/D. Although LVEF decrease was directly associated with all-cause mortality in both the Stage B and Stage C/D with pEF, factors related to LVEF changes were different between the 2 groups.

CONCLUSIONS

In Stage B, LVEF dynamically changes with prognostic impacts as in Stage C/D, whereas different determination factors may be involved in the 2 stages.

CLINICAL TRIAL REGISTRATION

Chronic Heart Failure Analysis and Registry in the Tohoku District (CHART)-2 (NCT00418041).

Hyperkalemia in heart failure patients in Spain and its impact on guidelines and recommendations: ESC-EORP-HFA Heart Failure Long-Term Registry

INTRODUCTION AND OBJECTIVES

Hyperkalemia is a growing concern in the treatment of patients with heart failure and reduced ejection fraction because it limits the use of effective drugs. We report estimates of the magnitude of this problem in routine clinical practice in Spain, as well as changes in potassium levels during follow-up and associated factors.

METHODS

This study included patients with acute (n=881) or chronic (n=3587) heart failure recruited in 28 Spanish hospitals of the European heart failure registry of the European Society of Cardiology and followed up for 1 year. Various outcomes were analyzed, including changes in serum potassium levels and their impact on treatment.

RESULTS

Hyperkalemia (K⁺> 5.4 mEq/L) was identified in 4.3% (95%CI, 3.7%-5.0%) and 8.2% (6.5%-10.2%) of patients with chronic and acute heart failure, respectively, and was responsible for 28.9% of all cases of contraindication to mineralocorticoid receptor antagonist use and for 10.8% of all cases of failure to reach the target dose. Serum potassium levels were not recorded in 291 (10.8%) of the 2693 chronic heart failure patients with reduced ejection fraction. During follow-up, potassium levels increased in 179 of 1431 patients (12.5%, 95%CI, 10.8%-14.3%). This increase was directly related to age, diabetes, and history of stroke and was inversely related to history of hyperkalemia.

CONCLUSIONS

This study highlights the magnitude of the problem of hyperkalemia in patients with heart failure in everyday clinical practice and the need to improve monitoring of this factor in these patients due to its interference with the possibility of receiving optimal treatment.

Fully automated and comprehensive MRI-based left-ventricular contractility analysis in post-chemotherapy breast cancer patients

OBJECTIVE

This study investigated the occurrence of cardiotoxicity-related left-ventricular (LV) contractile dysfunction in breast cancer patients following treatment with antineoplastic chemotherapy agents.

METHODS

A validated and automated MRI-based LV contractility analysis tool consisting of quantization-based boundary detection, unwrapping of image phases and the meshfree Radial Point Interpolation Method was used toward measuring LV chamber quantifications (LVCQ), three-dimensional strains and torsions in patients and healthy subjects. Data were acquired with the Displacement Encoding with Stimulated Echoes (DENSE) sequence on 21 female patients and 21 age-matched healthy females. Estimates of patient LVCQs from DENSE acquisitions were validated in comparison to similar steady-state free precession measurements and their strain results validated via Bland-Altman interobserver agreements. The occurrence of LV abnormalities was investigated via significant differences in contractility measurements (LVCQs, strains and torsions) between patients and healthy subjects.

RESULTS

Repeated measures analysis showed similarities between LVCQ measurements from DENSE and steady-state free precession, including cardiac output (4.7 ± 0.4 L, 4.6 ± 0.4 L, p = 0.8), and LV ejection fractions (59±6%, 58±5%, p = 0.2). Differences found between patients and healthy subjects included enlarged basal diameter (5.0 ± 0.5 cm vs 4.4 ± 0.5 cm, p < 0.01), apical torsion (6.0 ± 1.1° vs 9.7 ± 1.4°, p < 0.001) and global longitudinal strain (-0.15 ± 0.02 vs. -0.21 ± 0.04, p < 0.001), but not LV ejection fraction (59±6% vs. 63±6%, p = 0.1).

CONCLUSION

The results from the statistical analysis reveal the possibility of LV abnormalities in the post-chemotherapy patients via enlarged basal diameter and reduced longitudinal strain and torsion, in comparison to healthy subjects.

ADVANCES IN KNOWLEDGE

This study shows that subclinical LV abnormalities in post-chemotherapy breast cancer patients can be detected with an automated technique for the comprehensive analysis of contractile parameters.

Heart failure drug treatment

Heart failure is the most common cardiovascular reason for hospital admission for people older than 60 years of age. Few areas in medicine have progressed as remarkably as heart failure treatment over the past three decades. However, progress has been consistent only for chronic heart failure with reduced ejection fraction. In acutely decompensated heart failure and heart failure with preserved ejection fraction, none of the treatments tested to date have been definitively proven to improve survival. Delaying or preventing heart failure has become increasingly important in patients who are prone to heart failure. The prevention of worsening chronic heart failure and hospitalisations for acute decompensation is also of great importance. The objective of this Series paper is to provide a concise and practical summary of the available drug treatments for heart failure. We support the implementation of the international guidelines. We offer views on the basis of our personal experience in research areas that have insufficient evidence. The best possible evidence-based drug treatment (including inhibitors of the renin-angiotensin-aldosterone system and β blockers) is useful only when optimally implemented. However, implementation might be challenging. We believe that disease management programmes can be helpful in providing a multidisciplinary, holistic approach to the delivery of optimal medical care.

Circulating Long Non-coding RNA ENST00000507296 Is a Prognostic Indicator in Patients with Dilated Cardiomyopathy

Background: Long non-coding RNAs (lncRNAs) participate in the pathogenesis of cardiovascular diseases. However, whether circulating lncRNAs serve as dilated cardiomyopathy (DCM) biomarkers remains unclear. Methods: Totally, 266 controls and 818 patients were enrolled. First, microarray-based circulating lncRNA profiling was performed in 10 normal controls and 10 patients with DCM. Second, the top 20 differentially expressed lncRNAs were validated by real-time qPCR in 64 controls and 64 DCM patients. Moreover, lncRNA sequencing was performed in three human heart-derived cell types, and the correlation between circulating lncRNA levels and the severity of heart failure was evaluated in the validated population. The validated two lncRNAs were assessed in 198 DCM patients and 198 matched controls. Finally, the sensitivity and specificity of circulating lncRNA expression in DCM diagnosis were evaluated using receiver-operating characteristic curve analysis, while Cox regression and Kaplan-Meier curve analysis were further performed in 552 DCM patients. Results: Eight candidate lncRNA biomarkers were obtained after microarray screening and real-time PCR validation. Among them, five were validated in the second cohort. However, only the levels of circulating lncRNA ENST00000507296 and ENST00000532365 were significantly correlated with the cardiac function, as well as detectable in at least one of the human heart-derived cell types by lncRNA-seq. Importantly, low circulating ENST00000507296 level was associated with high event-free survival in patients with DCM. Conclusions: Circulating lncRNA ENST00000507296 was a prognostic biomarker in patients with DCM.

The role of nuclear medicine in assessments of cardiac dyssynchrony

Radionuclide imaging has an advantage for quantitative analyses of the tracer concentration and its temporal changes. Myocardial perfusion and function have been adapted for synchrony analyses. Extracted parameters have been demonstrated to measure ventricular synchrony and even to predict CRT outcomes. ERNA has the advantages of higher temporal resolution, greater reproducibility, and the volumetric analysis of both ventricles that can be applied for analyses of intraventricular synchrony and interventricular synchrony. Several software packages such as Quantitative Gated SPECT, the Emory Cardiac Toolbox, cardioREPO, and Heart Function View are available to assess the LV dyssynchrony parameters from GSPECT. A count-based method is applied to extract the amplitude and phase from each of the reconstructed GSPECT short-axis datasets throughout the cardiac cycle and then subjected to a Fourier analysis, the results of which are displayed on a polar map and histogram. Some of the parameters such as the bandwidth (expressed as the 95% width of the phase histogram) and the standard deviation of the phase are obtained by the phase histogram to assess the intraventricular synchrony. This review paper focuses on the application of the LV dyssynchrony parameters estimated by cardiac SPECT in patients with a heart disease.

Variations in cardiovascular risk factors in people with and without migration background in Germany - Results from the STAAB cohort study

BACKGROUND

About 20% of the German population have a migration background which might influence prevalence of preventable cardiovascular risk factors (CVRF).

METHODS

We report data of the prospective Characteristics and Course of Heart Failure Stages A-B and Determinants of Progression (STAAB) cohort study investigating a representative sample of inhabitants of the City of Würzburg, Germany, aged 30 to 79 years. Individuals without migration background were defined as follows: German as native language, no other native language, and/or born in Germany. All other participants were defined as individuals with migration background.

RESULTS

Of 2473 subjects (51% female, mean age 54 ± 12 years), 291 (12%) reported a migration background: n = 107 (37%) from a country within the EU, n = 117 (40%) from Russia, and n = 67 (23%) from other countries. Prevalence of hypertension, atherosclerotic disease, and diabetes mellitus was similar in individuals with and without migration background. By contrast, prevalence of obesity and metabolic syndrome was significantly higher in individuals with migration background, with the least favourable profile apparent in individuals from Russia (individuals without vs. with migration background: obesity 19 vs. 24%, p < 0.05; odds ratio: EU: 1.6, Russia: 2.2*, other countries: 0.6; metabolic syndrome 18 vs. 21%, p < 0.05; odds ratio: EU: 1.2, Russia: 1.7*, other countries: 1.5; *p < 0.05).

CONCLUSION

Individuals with migration background in Germany might exhibit a higher CVRF burden due to a higher prevalence of obesity and metabolic syndrome. Strategies for primary prevention of heart failure may benefit from deliberately considering the migration background.

The 3A3B score: The simple risk score for heart failure with preserved ejection fraction - A report from the CHART-2 Study

BACKGROUND

Few simple risk models, without echocardiography have been developed for patients with heart failure (HF) and preserved left ventricular ejection fraction (LVEF) (HFpEF).

METHODS

To develop a risk score to predict all-cause death for HFpEF patients, we examined 1277 HF patients with LVEF ≥50% and BNP ≥100 pg/ml in the CHART-2 Study, a large-scale prospective cohort study for HF in Japan. We selected the optimal subset of covariates for the score with Cox proportional hazard models and random survival forests (RSF).

RESULTS

During the median 5.7-year follow-up, 576 deaths occurred. Cox models and RSF analyses consistently indicated age ≥75 years, albumin <3.7 g/dl, anemia, BMI <22 kg/m², BNP ≥300 pg/ml (or NT-proBNP ≥1400 pg/ml), and BUN ≥25 mg/dl, as the important 6 prognostic variables. Incorporating these 6 variables, we developed a scoring system (3A3B score, with 2 points given to age ≥75 years and 1 point to the others based on the hazard ratios. The discrimination ability of the risk score was excellent (c-index 0.708). Regarding model goodness-of-fit, the overall gradient in 5-year risk was well captured by the score. The predictive accuracy of the 3A3B score was confirmed in the external validation cohorts from the TOPCAT trial (N = 835, c-index 0.652) and the ASIAN-HF registry (N = 170, c-index 0.741).

CONCLUSIONS

We developed a simple risk score to predict long-term prognosis of HFpEF patients. The 3A3B score, comprising 6 commonly available parameters in daily practice, has potential utility in the risk stratification and management of HFpEF patients.

Impact of "increased-risk" donor hearts on transplant outcomes: A propensity-matched analysis

OBJECTIVES

Orthotopic heart transplantation (OHT) remains the gold standard for advanced heart failure. Increased risk (IR) donors were categorized by the United Network for Organ Sharing Database (UNOS) according to the Centers for Disease Control and Prevention (CDC) criteria. However, the impact of CDC IR donor hearts on the outcome of adult OHT recipients remains unclear. The aim of this study was to compare the outcome of adult OHT recipients between CDC IR and non-CDC IR donor grafts.

METHODS

Data were obtained from the United Network for Organ Sharing Databas. All adult patients (age ≥18 years) undergoing OHT from 2004 through 2016 were included (n = 24,751). Propensity scores for CDC IR donors were calculated by estimating probabilities of CDC IR donor graft use using a nonparsimonious multivariable logistic regression model. Patients were matched 1:1 using a greedy matching algorithm based on the propensity score of each patient. The impact of CDC IR donors on the post-transplant outcomes, such as 30-day and overall mortalities, was investigated using Cox-proportional hazards. Overall survival probability analyses were performed.

RESULTS

Of 24,751 primary heart transplants from 2004 to 2016 with 3584 (14.5%) as IR donors, 6304 transplants were successfully matched (n = 3152 in CDC IR group and non-IR group). There were no significant differences in baseline characteristics in recipients and donors. In the Cox-proportional hazards model for matched subjects, the use of CDC IR grafts was not associated with 30-day (hazard ratio of IR group vs non-IR group 0.97; 95% confidence interval, 0.87-1.08; P = .57) and overall mortalities (hazard ratio, 0.94; 95% confidence interval, 0.73-1.21; P = .62). Interestingly, post-transplant acute myocardial rejection episodes during hospital stays were found more often in the CDC-IR group, compared with the non-CDC IR group (CDC IR, n = 358 [11.4%]; non-CDC IR, n = 304 [9.6%] P = .03), whereas post-transplant pacemaker placements were performed less frequently in the CDC IR group (CDC IR, n = 80 [2.6%]; non-CDC IR, n = 111 [3.5%] P = .020). Importantly, there was no significant difference in the overall survival probability between CDC IR and non-IR groups in both unadjusted and adjusted survival analyses.

CONCLUSIONS

CDC IR status does not have a significant impact on adult OHT recipient survival probability. Increased use of CDC IR donor grafts can potentially alleviate the persistent and worsening shortage of available donor organs and shorten the waitlist time for heart transplantation.

Is Heart Failure Associated With Risk of Suicide?

BACKGROUND

The high prevalence of heart failure (HF) in developed countries imposes a substantial burden on health care resources. Depression is widely recognized as a risk factor associated with HF. This study examined the relationship between suicide and HF after controlling for depression and other comorbidities.

METHODS AND RESULTS

The population comprised 52,749 adult patients who died from suicide from 2000 to 2012 and 210,996 living control subjects matched by age, sex, and residence area. Data were obtained from the Health and Welfare Data Science Center, Taiwan. Multivariable models were constructed to evaluate the relationship between HF and suicide. In the case and control groups 1624 (3.08%) and 4053 (1.92%) patients had HF, respectively, indicating that HF was associated with an increased risk of suicide (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.59-1.79). The risk of suicide was highest during the initial 6 months after HF (adjusted OR 7.04, 95% CI 5.37-9.22) and subsequently declined gradually. Among psychiatric disorders, mood disorders (adjusted OR 7.42, 95% CI 7.06-7.79) yielded the highest odds of suicide.

CONCLUSIONS

The risk of suicide is higher for patients with HF than for healthy individuals without HF. This risk is particularly high during the first 6 months after HF diagnosis. This study provides strong evidence that depression is a negative prognostic factor for patients with HF and increases the risk of suicide. The results suggest that early screening and treatment for depression and suicide risk should be conducted for patients with HF.

Regional Cardiac Sympathetic Nervous System Evaluation Using 123I-mIBG SPECT in Patients with Heart Failure

BACKGROUND

Heart failure (HF) involves both mechanical and autonomic nervous system dysfunction that can lead to sudden cardiac death. In the failing human heart, there is increased release of norepinephrine from neurons and reduced uptake. Iodine-123-labeled metaiodobenzylguanidine (123I-mIBG) demonstrates reduced global uptake and increased washout associated with increased mortality in HF. This research examined the potential benefits of single-photon emission computed tomography (SPECT) regional quantitation in risk stratification of HF patients and its role in prediction of cardiac morbidity and mortality.

METHODS

Twenty-two clinically diagnosed HF patients were recruited into this study. The subjects underwent myocardial perfusion SPECT and cardiac sympathetic imaging with 123I-mIBG. Early (at 15 min after injection) and delayed (four hours after injection) planar and SPECT were performed. Visual and semiquantitative analysis was conducted, and global (from planar imaging) and regional (from SPECT imaging) uptake and washout indices determined. The patients were clinically followed for up to two years, and the cardiac events (CEs) in these patients were recorded and correlated with the various parameters.

RESULTS

The occurrence of a CE in HF was independent of the patients' demographics or the cause of HF. Genetic biomarkers were unable to reliably predict CEs. Global or regional uptake had limited ability to predict a CE, whereas regional washout from the inferior wall (P = .005) was a statistically significant predictor of CEs. Similarly, a high washout of 40% or more from the peri-infarcted and noninfarcted segments on myocardial perfusion scintigraphy was also a significant predictor of CEs (P = .035).

CONCLUSION

HF is a complex, multifactorial, progressive disease that appears to begin regionally. 123I-mIBG provides a valuable tool in imaging the global and regional sympathetic nervous system innervation of the heart. This may allow early identification and stratification of patients at risk of sudden cardiac death.

Palliative Care and Health Care Utilization for Patients With End-Stage Liver Disease at the End of Life

BACKGROUND & AIMS

There has been increased attention on ways to improve the quality of end-of-life care for patients with end-stage liver disease; however, there have been few reports of care experiences for patients during terminal hospitalizations. We analyzed data from a large national database to increase our understanding of palliative care for and health care utilization by patients with end-stage liver disease.

METHODS

We performed a cross-sectional, observational study to examine terminal hospitalizations of adults with decompensated cirrhosis using data from the National Inpatient Sample from 2009 through 2013. We collected data on palliative care consultation and total hospital costs, and performed multivariate regression analyses to identify factors associated with palliative care consultation. We also investigated whether consultation was associated with lower costs.

RESULTS

Among hospitalized adults with terminal decompensated cirrhosis, 30.3% received palliative care; the mean cost per hospitalization was $48,551 ± $1142. Palliative care consultation increased annually, and was provided to 18.0% of patients in 2009 and to 36.6% of patients in 2013 (P < .05). The mean cost for the terminal hospitalization did not increase significantly ($47,969 in 2009 to $48,956 in 2013, P = .77). African Americans, Hispanics, Asians, and liver transplant candidates were less likely to receive palliative care, whereas care in large urban teaching hospitals was associated with a higher odds of receiving consultation. Palliative care was associated with lower procedure burden-after adjusting for other factors, palliative care was associated with a cost reduction of $10,062.

CONCLUSIONS

Palliative care consultation for patients with end-stage liver disease increased from 2009 through 2013. Palliative care consultation during terminal hospitalizations is associated with lower costs and procedure burden. Future research should evaluate timing and effects of palliative care on quality of end-of-life care in this population.

Ambulatory blood pressure monitoring in heart failure and serum sodium levels

AIMS

To determine whether there are differences in blood pressure profile on dynamic assessment by ambulatory blood pressure monitoring (ABPM) according to serum sodium levels in stable heart failure patients.

METHODS

Data were collected from the Spanish National Registry on Ambulatory Blood Pressure Monitoring in Heart Failure (DICUMAP). Patients underwent ABPM by the oscillometric principle using a Spacelabs 90121 monitor. The sample was divided into three groups according to sodium levels and their clinical and laboratory data and echocardiographic findings were analyzed. Robust statistical methods were used to compare the groups in univariate and multivariate models.

RESULTS

A total of 175 patients (44.57% male) were analyzed. We found a predominance of anomalous circadian blood pressure profiles in all three groups, with a significantly higher percentage of risers in the lowest serum sodium group (p=0.05). In addition, in this group there were significant differences in mean 24-hour systolic blood pressure (SBP) (24-h SBP, p=0.05) and in mean daytime SBP (dSBP, p=0.008), with significant differences in nocturnal fall in SBP (p=0.05) and in diastolic blood pressure (p=0.005). In multivariate analysis a significant relationship was found between sodium levels and 24-h SBP (OR 0.97, 95% CI 0.95-0.99, p=0.01) and dSBP (OR 0.96, 95% CI 0.94-0.99, p=0.004).

CONCLUSION

A relationship was found between lower sodium levels and lower systolic blood pressure, especially during waking hours, with a lower decline between daytime and night-time blood pressure.

Expert consensus document: Mitochondrial function as a therapeutic target in heart failure

Heart failure is a pressing worldwide public-health problem with millions of patients having worsening heart failure. Despite all the available therapies, the condition carries a very poor prognosis. Existing therapies provide symptomatic and clinical benefit, but do not fully address molecular abnormalities that occur in cardiomyocytes. This shortcoming is particularly important given that most patients with heart failure have viable dysfunctional myocardium, in which an improvement or normalization of function might be possible. Although the pathophysiology of heart failure is complex, mitochondrial dysfunction seems to be an important target for therapy to improve cardiac function directly. Mitochondrial abnormalities include impaired mitochondrial electron transport chain activity, increased formation of reactive oxygen species, shifted metabolic substrate utilization, aberrant mitochondrial dynamics, and altered ion homeostasis. In this Consensus Statement, insights into the mechanisms of mitochondrial dysfunction in heart failure are presented, along with an overview of emerging treatments with the potential to improve the function of the failing heart by targeting mitochondria.

The Safety of Metformin in Heart Failure

Objective:

To examine the evidence regarding the safety of metformin in heart failure.

Data Sources:

Searches in MEDLINE and International Pharmaceutical Abstracts were performed (1966–February 2007). Search terms included metformin, heart failure, lactic acidosis, clinical trials, and insulin resistance.

Study Selection and Data Extraction:

Published studies and case reports that evaluated the causal link between metformin and lactic acidosis in patients with heart failure were selected for review.

Data Synthesis:

There were no case reports of patients who had metformin-associated lactic acidosis when heart failure was the only contraindication, Two large retrospective studies showed that metformin does not increase the risk of lactic acidosis in patients with heart failure. However, these retrospective analyses did not account for many important confounding variables. A reduction in mortality rates in metformin users with New York Heart Association Class III and IV heart failure was observed in one small (N = 94) prospective trial.

Conclusions:

Results from 3 trials suggest that metformin may be safe to use in heart failure. Large prospective trials are needed to provide conclusive evidence regarding metformin's safety. Until then, use of metformin in heart failure patients should not be recommended routinely. If it is used in patients with heart failure, they should be monitored closely for signs of lactic acidosis.

Engineered heart tissues and induced pluripotent stem cells: Macro- and microstructures for disease modeling, drug screening, and translational studies

Engineered heart tissue has emerged as a personalized platform for drug screening. With the advent of induced pluripotent stem cell (iPSC) technology, patient-specific stem cells can be developed and expanded into an indefinite source of cells. Subsequent developments in cardiovascular biology have led to efficient differentiation of cardiomyocytes, the force-producing cells of the heart. iPSC-derived cardiomyocytes (iPSC-CMs) have provided potentially limitless quantities of well-characterized, healthy, and disease-specific CMs, which in turn has enabled and driven the generation and scale-up of human physiological and disease-relevant engineered heart tissues. The combined technologies of engineered heart tissue and iPSC-CMs are being used to study diseases and to test drugs, and in the process, have advanced the field of cardiovascular tissue engineering into the field of precision medicine. In this review, we will discuss current developments in engineered heart tissue, including iPSC-CMs as a novel cell source. We examine new research directions that have improved the function of engineered heart tissue by using mechanical or electrical conditioning or the incorporation of non-cardiomyocyte stromal cells. Finally, we discuss how engineered heart tissue can evolve into a powerful tool for therapeutic drug testing.