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Hikoso S, Kida H, Sunaga A, Nakatani D, Okada K, Dohi T, Sotomi Y, Oeun B, Sato T, Matsuoka Y, Kitamura T, Yamada T, Kurakami H, Tamaki S, Seo M, Yano M, Hayashi T, Nakagawa A, Nakagawa Y, Yamada T, Yasumura Y, Sakata Y. β-blockers may be detrimental in frail patients with heart failure with preserved ejection fraction. Clin Res Cardiol 2024; 113:842-855. [PMID: 38019285 DOI: 10.1007/s00392-023-02301-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 09/01/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND The effectiveness of β-blocker in patients with heart failure with preserved ejection fraction (HFpEF) remains to be determined. We aimed to clarify the association between the use of β-blocker and prognosis according to the status of frailty. METHODS We compared prognosis between HFpEF patients with and without β-blockers stratified with the Clinical Frailty Scale (CFS), using data from the PURSUIT-HFpEF registry (UMIN000021831). RESULTS Among 1159 patients enrolled in the analysis (median age, 81.4 years; male, 44.7%), 580 patients were CFS ≤ 3, while 579 were CFS ≥ 4. Use of β-blockers was associated with a worse composite endpoint of all-cause death and heart failure readmission in patients with CFS ≥ 4 (adjusted hazard ratio (HR) 1.43, 95% CI 1.10-1.85, p = 0.007), but was not significantly associated with this endpoint in those with CFS ≤ 3 (adjusted HR 0.95, 95% CI 0.71-1.26, p = 0.719) in multivariable Cox proportional hazard models. These results were confirmed in a propensity-matched analysis (HR in those with CFS ≥ 4: 1.42, 95% CI 1.05-1.90, p = 0.020; that in those with CFS ≤ 3: 0.83, 95% CI 0.60-1.14, p = 0.249), and in an analysis in which patients were divided into CFS ≤ 4 and CFS ≥ 5. CONCLUSIONS Use of β-blockers was significantly associated with worse prognosis specifically in patients with HFpEF and high CFS, but not in those with low CFS. Use of β-blockers in HFpEF patients with frailty may need careful attention.
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Affiliation(s)
- Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan.
| | - Hirota Kida
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Akihiro Sunaga
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
- Department of Medical Informatics, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Tomoharu Dohi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Bolrathanak Oeun
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Taiki Sato
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Yuki Matsuoka
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Tomomi Yamada
- Department of Medical Innovation, Osaka University Hospital, 2-15 Yamadaoka, Suita, 565-0871, Japan
| | - Hiroyuki Kurakami
- Department of Medical Innovation, Osaka University Hospital, 2-15 Yamadaoka, Suita, 565-0871, Japan
| | - Shunsuke Tamaki
- Department of Cardiology, Rinku General Medical Center, 2-23 Ourai-kita, Rinku, Izumisano, Osaka, 598-8577, Japan
| | - Masahiro Seo
- Division of Cardiology, Osaka General Medical Center, 3-1-56 Bandaihigashi, Osaka, 558-8558, Japan
| | - Masamichi Yano
- Division of Cardiology, Osaka Rosai Hospital, 3-1179 Nagasonecho, Kita-ku, Sakai, Osaka, 591-8025, Japan
| | - Takaharu Hayashi
- Cardiovascular Division, Osaka Police Hospital, 10-31 Kitayamacho, Tennojiku, Osaka, 543-0035, Japan
| | - Akito Nakagawa
- Department of Medical Informatics, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
- Division of Cardiology, Amagasaki Chuo Hospital, 1-12-1 Shioe, Amagasaki, Hyogo, 661-0976, Japan
| | - Yusuke Nakagawa
- Division of Cardiology, Kawanishi City Medical Center, 1-4-1 Hiuchi, Kawanishi, 666-0017, Japan
| | - Takahisa Yamada
- Division of Cardiology, Osaka General Medical Center, 3-1-56 Bandaihigashi, Osaka, 558-8558, Japan
| | - Yoshio Yasumura
- Division of Cardiology, Amagasaki Chuo Hospital, 1-12-1 Shioe, Amagasaki, Hyogo, 661-0976, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
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Murray KR, Poirier JA, Au JS, Hedge ET, Robertson AD, Heckman GA, Hughson RL. Ambulatory Monitoring of Cerebrovascular Responses to Upright Posture and Walking in Older Adults With Heart Failure. CJC Open 2023; 5:870-880. [PMID: 38204855 PMCID: PMC10774084 DOI: 10.1016/j.cjco.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/23/2023] [Indexed: 01/12/2024] Open
Abstract
Background Insufficient cardiac output in individuals with heart failure (HF) limits daily functioning and reduces quality of life. Although lower cerebral perfusion, secondary to limitations in cardiac output, has been observed during moderate-intensity efforts, individuals with HF also may be at risk for lower perfusion during even low-intensity ambulatory activities. Methods We determined whether HF is associated with an altered cerebrovascular response to low-intensity activities representative of typical challenges of daily living. In this study, we monitored central hemodynamics and middle cerebral artery blood velocity (MCAv) and cerebral tissue oxygenation (near-infrared spectroscopy) in 10 individuals with HF (aged 78 ± 4 years; left ventricular ejection fraction 20%-61%) and 13 similar-aged controls (79 ± 8 years; 52%-73%) during 3 randomized transitions, as follows: (i) supine-to-standing; (ii) sitting-to-slow-paced over-ground walking; and (iii) sitting-to-normal-paced over-ground walking. Results Throughout supine, sitting, standing, and both walking conditions, individuals with HF had lower cardiac index and cerebral tissue oxygenation than controls (P < 0.05), and MCAv was lower across the range of blood pressure in HF patients (P = 0.051) and during walking only (P = 0.011). Individuals with HF had an attenuated increase in stroke volume index and cardiac index during normal-paced walking, compared to controls (P < 0.01). Conclusions The indices of cerebral perfusion from MCAv and cerebral oxygenation were lower during ambulatory activities in individuals with HF; however, relationships between MCAv and blood pressure were not different between those with HF and controls, indicating no difference in static cerebral autoregulation.
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Affiliation(s)
- Kevin R. Murray
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Jessica A. Poirier
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Jason S. Au
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Eric T. Hedge
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - Andrew D. Robertson
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
| | - George A. Heckman
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Richard L. Hughson
- Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada
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3
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Bunsawat K, Skow RJ, Kaur J, Wray DW. Neural control of the circulation during exercise in heart failure with reduced and preserved ejection fraction. Am J Physiol Heart Circ Physiol 2023; 325:H998-H1011. [PMID: 37682236 PMCID: PMC10907034 DOI: 10.1152/ajpheart.00214.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/23/2023] [Accepted: 09/06/2023] [Indexed: 09/09/2023]
Abstract
Patients with heart failure with reduced (HFrEF) and preserved ejection fraction (HFpEF) exhibit severe exercise intolerance that may be due, in part, to inappropriate cardiovascular and hemodynamic adjustments to exercise. Several neural mechanisms and locally released vasoactive substances work in concert through complex interactions to ensure proper adjustments to meet the metabolic demands of the contracting skeletal muscle. Specifically, accumulating evidence suggests that disease-related alterations in neural mechanisms (e.g., central command, exercise pressor reflex, arterial baroreflex, and cardiopulmonary baroreflex) contribute to heightened sympathetic activation and impaired ability to attenuate sympathetic vasoconstrictor responsiveness that may contribute to reduced skeletal muscle blood flow and severe exercise intolerance in patients with HFrEF. In contrast, little is known regarding these important aspects of physiology in patients with HFpEF, though emerging data reveal heightened sympathetic activation and attenuated skeletal muscle blood flow during exercise in this patient population that may be attributable to dysregulated neural control of the circulation. The overall goal of this review is to provide a brief overview of the current understanding of disease-related alterations in the integrative neural cardiovascular responses to exercise in both HFrEF and HFpEF phenotypes, with a focus on sympathetic nervous system regulation during exercise.
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Affiliation(s)
- Kanokwan Bunsawat
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Rachel J Skow
- Department of Kinesiology, The University of Texas at Arlington, Arlington, Texas, United States
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Jasdeep Kaur
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, Texas, United States
| | - D Walter Wray
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
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4
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Bunsawat K, Clifton HL, Ratchford SM, Vranish JR, Alpenglow JK, Haykowsky MJ, Trinity JD, Ryan JJ, Fadel PJ, Wray DW. Cardiovascular responses to static handgrip exercise and postexercise ischemia in heart failure with preserved ejection fraction. J Appl Physiol (1985) 2023; 134:1508-1519. [PMID: 37167264 PMCID: PMC10259865 DOI: 10.1152/japplphysiol.00045.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/13/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is characterized by reduced ability to sustain physical activity that may be due partly to disease-related changes in autonomic function that contribute to dysregulated cardiovascular control during muscular contraction. Thus, we used a combination of static handgrip exercise (HG) and postexercise ischemia (PEI) to examine the pressor response to exercise and isolate the skeletal muscle metaboreflex, respectively. Mean arterial pressure (MAP), heart rate (HR), cardiac output (CO), and total peripheral resistance (TPR) were assessed during 2-min of static HG at 30 and 40% of maximum voluntary contraction (MVC) and subsequent PEI in 16 patients with HFpEF and 17 healthy, similarly aged controls. Changes in MAP were lower in patients with HFpEF compared with controls during both 30%MVC (Δ11 ± 7 vs. Δ15 ± 8 mmHg) and 40%MVC (Δ19 ± 14 vs. Δ30 ± 8 mmHg), and a similar pattern of response was evident during PEI (30%MVC: Δ8 ± 5 vs. Δ12 ± 8 mmHg; 40%MVC: Δ13 ± 10 vs. Δ18 ± 9 mmHg) (group effect: P = 0.078 and P = 0.017 at 30% and 40% MVC, respectively). Changes in HR, CO, and TPR did not differ between groups during HG or PEI (P > 0.05). Taken together, these data suggest a reduced pressor response to static muscle contractions in patients with HFpEF compared with similarly aged controls that may be mediated partly by a blunted muscle metaboreflex. These findings support a disease-related dysregulation in neural cardiovascular control that may reduce an ability to sustain physical activity in HFpEF.NEW & NOTEWORTHY The current investigation has identified a diminution in the exercise-induced rise in arterial blood pressure (BP) that persisted during postexercise ischemia (PEI) in an intensity-dependent manner in patients with heart failure with preserved ejection fraction (HFpEF) compared with older, healthy controls. These findings suggest that the pressor response to exercise is reduced in patients with HFpEF, and this deficit may be mediated, in part, by a blunted muscle metaboreflex, highlighting the consequences of impaired neural cardiovascular control during exercise in this patient group.
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Affiliation(s)
- Kanokwan Bunsawat
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Heather L Clifton
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Stephen M Ratchford
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Jennifer R Vranish
- Department of Kinesiology, College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas, United States
- Department of Integrative Physiology and Health Science, Alma College, Alma, Michigan, United States
| | - Jeremy K Alpenglow
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
| | - Mark J Haykowsky
- Department of Kinesiology, College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas, United States
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Joel D Trinity
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Paul J Fadel
- Department of Kinesiology, College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas, United States
| | - D Walter Wray
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
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5
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Reddy YNV, Koepp KE, Carter R, Win S, Jain CC, Olson TP, Johnson BD, Rea R, Redfield MM, Borlaug BA. Rate-Adaptive Atrial Pacing for Heart Failure With Preserved Ejection Fraction: The RAPID-HF Randomized Clinical Trial. JAMA 2023; 329:801-809. [PMID: 36871285 PMCID: PMC9986839 DOI: 10.1001/jama.2023.0675] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/18/2023] [Indexed: 03/06/2023]
Abstract
Importance Reduced heart rate during exercise is common and associated with impaired aerobic capacity in heart failure with preserved ejection fraction (HFpEF), but it remains unknown if restoring exertional heart rate through atrial pacing would be beneficial. Objective To determine if implanting and programming a pacemaker for rate-adaptive atrial pacing would improve exercise performance in patients with HFpEF and chronotropic incompetence. Design, Setting, and Participants Single-center, double-blind, randomized, crossover trial testing the effects of rate-adaptive atrial pacing in patients with symptomatic HFpEF and chronotropic incompetence at a tertiary referral center (Mayo Clinic) in Rochester, Minnesota. Patients were recruited between 2014 and 2022 with 16-week follow-up (last date of follow-up, May 9, 2022). Cardiac output during exercise was measured by the acetylene rebreathe technique. Interventions A total of 32 patients were recruited; of these, 29 underwent pacemaker implantation and were randomized to atrial rate responsive pacing or no pacing first for 4 weeks, followed by a 4-week washout period and then crossover for an additional 4 weeks. Main Outcomes and Measures The primary end point was oxygen consumption (V̇o2) at anaerobic threshold (V̇o2,AT); secondary end points were peak V̇o2, ventilatory efficiency (V̇e/V̇co2 slope), patient-reported health status by the Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OSS), and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels. Results Of the 29 patients randomized, the mean age was 66 years (SD, 9.7) and 13 (45%) were women. In the absence of pacing, peak V̇o2 and V̇o2 at anaerobic threshold (V̇o2,AT) were both correlated with peak exercise heart rate (r = 0.46-0.51, P < .02 for both). Pacing increased heart rate during low-level and peak exercise (16/min [95% CI, 10 to 23], P < .001; 14/min [95% CI, 7 to 21], P < .001), but there was no significant change in V̇o2,AT (pacing off, 10.4 [SD, 2.9] mL/kg/min; pacing on, 10.7 [SD, 2.6] mL/kg/min; absolute difference, 0.3 [95% CI, -0.5 to 1.0] mL/kg/min; P = .46), peak V̇o2, minute ventilation (V̇e)/carbon dioxide production (V̇co2) slope, KCCQ-OSS, or NT-proBNP level. Despite the increase in heart rate, atrial pacing had no significant effect on cardiac output with exercise, owing to a decrease in stroke volume (-24 mL [95% CI, -43 to -5 mL]; P = .02). Adverse events judged to be related to the pacemaker device were observed in 6 of 29 participants (21%). Conclusions and Relevance In patients with HFpEF and chronotropic incompetence, implantation of a pacemaker to enhance exercise heart rate did not result in an improvement in exercise capacity and was associated with increased adverse events. Trial Registration ClinicalTrials.gov Identifier: NCT02145351.
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Affiliation(s)
- Yogesh N. V. Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Katlyn E. Koepp
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rickey Carter
- Department of Biostatistics and Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida
| | - Sithu Win
- Department of Medicine, University of California, San Francisco
| | | | - Thomas P. Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bruce D. Johnson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert Rea
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Manabe K, D’Souza AW, Washio T, Takeda R, Hissen SL, Akins JD, Fu Q. Sympathetic and hemodynamic responses to exercise in heart failure with preserved ejection fraction. Front Cardiovasc Med 2023; 10:1148324. [PMID: 37139124 PMCID: PMC10150451 DOI: 10.3389/fcvm.2023.1148324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/27/2023] [Indexed: 05/05/2023] Open
Abstract
Excessive sympathetic activity during exercise causes heightened peripheral vasoconstriction, which can reduce oxygen delivery to active muscles, resulting in exercise intolerance. Although both patients suffering from heart failure with preserved and reduced ejection fraction (HFpEF and HFrEF, respectively) exhibit reduced exercise capacity, accumulating evidence suggests that the underlying pathophysiology may be different between these two conditions. Unlike HFrEF, which is characterized by cardiac dysfunction with lower peak oxygen uptake, exercise intolerance in HFpEF appears to be predominantly attributed to peripheral limitations involving inadequate vasoconstriction rather than cardiac limitations. However, the relationship between systemic hemodynamics and the sympathetic neural response during exercise in HFpEF is less clear. This mini review summarizes the current knowledge on the sympathetic (i.e., muscle sympathetic nerve activity, plasma norepinephrine concentration) and hemodynamic (i.e., blood pressure, limb blood flow) responses to dynamic and static exercise in HFpEF compared to HFrEF, as well as non-HF controls. We also discuss the potential of a relationship between sympathetic over-activation and vasoconstriction leading to exercise intolerance in HFpEF. The limited body of literature indicates that higher peripheral vascular resistance, perhaps secondary to excessive sympathetically mediated vasoconstrictor discharge compared to non-HF and HFrEF, drives exercise in HFpEF. Excessive vasoconstriction also may primarily account for over elevations in blood pressure and concomitant limitations in skeletal muscle blood flow during dynamic exercise, resulting in exercise intolerance. Conversely, during static exercise, HFpEF exhibit relatively normal sympathetic neural reactivity compared to non-HF, suggesting that other mechanisms beyond sympathetic vasoconstriction dictate exercise intolerance in HFpEF.
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Affiliation(s)
- Kazumasa Manabe
- Women’s Heart Health Laboratory, Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital, Dallas, TX, United States
- Cardiology Division, Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Andrew W. D’Souza
- Women’s Heart Health Laboratory, Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital, Dallas, TX, United States
- Cardiology Division, Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, United States
- Neurovascular Research Laboratory, School of Kinesiology, Western University, London, ON, Canada
| | - Takuro Washio
- Women’s Heart Health Laboratory, Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital, Dallas, TX, United States
- Cardiology Division, Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ryosuke Takeda
- Women’s Heart Health Laboratory, Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital, Dallas, TX, United States
- Cardiology Division, Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Sarah L. Hissen
- Women’s Heart Health Laboratory, Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital, Dallas, TX, United States
- Cardiology Division, Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - John D. Akins
- Women’s Heart Health Laboratory, Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital, Dallas, TX, United States
- Cardiology Division, Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Qi Fu
- Women’s Heart Health Laboratory, Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital, Dallas, TX, United States
- Cardiology Division, Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, United States
- Correspondence: Qi Fu
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7
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Zhou Y, Zhu Y, Zeng J. Research Update on the Pathophysiological Mechanisms of Heart Failure with Preserved Ejection Fraction. Curr Mol Med 2023; 23:54-62. [PMID: 34844539 DOI: 10.2174/1566524021666211129111202] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 09/21/2021] [Accepted: 10/06/2021] [Indexed: 12/16/2022]
Abstract
Heart failure (HF) is a serious clinical syndrome, usually occurs at the advanced stage of various cardiovascular diseases, featured by high mortality and rehospitalization rate. According to left ventricular (LV) ejection fraction (LVEF), HF has been categorized as HF with reduced EF (HFrEF; LVEF<40%), HF with mid-range EF (HFmrEF; LVEF 40-49%), and HF with preserved EF (HFpEF; LVEF ≥50%). HFpEF accounts for about 50% of cases of heart failure and has become the dominant form of heart failure. The mortality of HFpEF is similar to that of HFrEF. There are no welldocumented treatment options that can reduce the morbidity and mortality of HFpEF now. Understanding the underlying pathological mechanisms is essential for the development of novel effective therapy options for HFpEF. In recent years, significant research progress has been achieved on the pathophysiological mechanism of HFpEF. This review aimed to update the research progress on the pathophysiological mechanism of HFpEF.
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Affiliation(s)
- Yuying Zhou
- Center of Cooperative Postgraduate Cultivation in Xiangtan Central Hospital, University of South China Xiangtan 411100, China
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan 411100, China
| | - Yunlong Zhu
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan 411100, China
| | - Jianping Zeng
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan 411100, China
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Saw EL, Werner LD, Zamani P, Chirinos JA, Valero-Muñoz M, Sam F. Skeletal muscle phenotypic switching in heart failure with preserved ejection fraction. Front Cardiovasc Med 2022; 9:1016452. [PMID: 36531739 PMCID: PMC9753550 DOI: 10.3389/fcvm.2022.1016452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022] Open
Abstract
Background Skeletal muscle (SkM) phenotypic switching is associated with exercise intolerance in heart failure with preserved ejection fraction (HFpEF). Patients with HFpEF have decreased type-1 oxidative fibers and mitochondrial dysfunction, indicative of impaired oxidative capacity. The SAUNA (SAlty drinking water/Unilateral Nephrectomy/Aldosterone) mice are commonly used in HFpEF pre-clinical studies and demonstrate cardiac, lung, kidney, and white adipose tissue impairments. However, the SkM (specifically the oxidative-predominant, soleus muscle) has not been described in this preclinical HFpEF model. We sought to characterize the soleus skeletal muscle in the HFpEF SAUNA mice and investigate its translational potential. Methods HFpEF was induced in mice by uninephrectomy, d-aldosterone or saline (Sham) infusion by osmotic pump implantation, and 1% NaCl drinking water was given for 4 weeks. Mice were euthanized, and the oxidative-predominant soleus muscle was collected. We examined fiber composition, fiber cross-sectional area, capillary density, and fibrosis. Molecular analyses were also performed. To investigate the clinical relevance of this model, the oxidative-predominant, vastus lateralis muscle from patients with HFpEF was biopsied and examined for molecular changes in mitochondrial oxidative phosphorylation, vasculature, fibrosis, and inflammation. Results Histological analyses demonstrated a reduction in the abundance of oxidative fibers, type-2A fiber atrophy, decreased capillary density, and increased fibrotic area in the soleus muscle of HFpEF mice compared to Sham. Expression of targets of interest such as a reduction in mitochondrial oxidative-phosphorylation genes, increased VEGF-α and an elevated inflammatory response was also seen. The histological and molecular changes in HFpEF mice are consistent and comparable with changes seen in the oxidative-predominant SkM of patients with HFpEF. Conclusion The HFpEF SAUNA model recapitulates the SkM phenotypic switching seen in HFpEF patients. This model is suitable and relevant to study SkM phenotypic switching in HFpEF.
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Affiliation(s)
- Eng Leng Saw
- Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, United States
| | - Louis Dominic Werner
- Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, United States
| | - Payman Zamani
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Julio A. Chirinos
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - María Valero-Muñoz
- Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, United States
| | - Flora Sam
- Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, United States,Eli Lilly and Co, Indianapolis, IND, United States,*Correspondence: Flora Sam,
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9
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Hammer SM, Bruhn EJ, Bissen TG, Muer JD, Villarraga N, Borlaug BA, Olson TP, Smith JR. Inspiratory and leg muscle blood flows during inspiratory muscle metaboreflex activation in heart failure with preserved ejection fraction. J Appl Physiol (1985) 2022; 133:1202-1211. [PMID: 36227167 PMCID: PMC9639766 DOI: 10.1152/japplphysiol.00141.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 09/29/2022] [Accepted: 10/07/2022] [Indexed: 11/22/2022] Open
Abstract
The purpose of this study was to determine the cardiovascular consequences elicited by activation of the inspiratory muscle metaboreflex in patients with heart failure with preserved ejection fraction (HFpEF) and controls. Patients with HFpEF (n = 15; 69 ± 10 yr; 33 ± 4 kg/m2) and controls (n = 14; 70 ± 8 yr; 28 ± 4 kg/m2) performed an inspiratory loading trial at 60% maximal inspiratory pressure (PIMAX) until task failure. Mean arterial pressure (MAP) was measured continuously. Near-infrared spectroscopy and bolus injections of indocyanine green dye were used to determine the percent change in blood flow index (%ΔBFI) from baseline to the final minute of inspiratory loading in the vastus lateralis and sternocleidomastoid muscles. Vascular resistance index (VRI) was calculated. Time to task failure was shorter in HFpEF than in controls (339 ± 197 s vs. 626 ± 403 s; P = 0.02). Compared with controls, patients with HFpEF had a greater increase from baseline in MAP (16 ± 7 vs. 10 ± 6 mmHg) and vastus lateralis VRI (76 ± 45 vs. 32 ± 19%) as well as a greater decrease in vastus lateralis %ΔBFI (-32 ± 14 vs. -17 ± 9%) (all, P < 0.05). Sternocleidomastoid %ΔBFI normalized to absolute inspiratory pressure was higher in HFpEF compared with controls (8.0 ± 5.0 vs. 4.0 ± 1.9% per cmH2O·s; P = 0.03). These data indicate that patients with HFpEF exhibit exaggerated cardiovascular responses with inspiratory muscle metaboreflex activation compared with controls.NEW & NOTEWORTHY Respiratory muscle dysfunction is thought to contribute to exercise intolerance in heart failure with preserved ejection fraction (HFpEF); however, the underlying mechanisms are unknown. In the present study, patients with HFpEF had greater increases in leg muscle vascular resistance index and greater decreases in leg muscle blood flow index compared with controls during inspiratory resistive breathing (to activate the metaboreflex). Furthermore, respiratory muscle blood flow index responses normalized to pressure generation during inspiratory resistive breathing were exaggerated in HFpEF compared with controls.
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Affiliation(s)
- Shane M Hammer
- Department of Cardiovascular Medicine, https://ror.org/03zzw1w08Mayo Clinic, Rochester, Minnesota
- School of Kinesiology, Applied Health and Recreation, Oklahoma State University, Stillwater, Oklahoma
| | - Eric J Bruhn
- Department of Cardiovascular Medicine, https://ror.org/03zzw1w08Mayo Clinic, Rochester, Minnesota
| | - Thomas G Bissen
- Department of Cardiovascular Medicine, https://ror.org/03zzw1w08Mayo Clinic, Rochester, Minnesota
| | - Jessica D Muer
- Department of Cardiovascular Medicine, https://ror.org/03zzw1w08Mayo Clinic, Rochester, Minnesota
| | - Nicolas Villarraga
- Department of Cardiovascular Medicine, https://ror.org/03zzw1w08Mayo Clinic, Rochester, Minnesota
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, https://ror.org/03zzw1w08Mayo Clinic, Rochester, Minnesota
| | - Thomas P Olson
- Department of Cardiovascular Medicine, https://ror.org/03zzw1w08Mayo Clinic, Rochester, Minnesota
| | - Joshua R Smith
- Department of Cardiovascular Medicine, https://ror.org/03zzw1w08Mayo Clinic, Rochester, Minnesota
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10
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Marco Guazzi M, Wilhelm M, Halle M, Van Craenenbroeck E, Kemps H, de Boer RA, Coats AJ, Lund L, Mancini D, Borlaug B, Filippatos G, Pieske B. Exercise Testing in HFpEF: an Appraisal Through Diagnosis, Pathophysiology and Therapy A Clinical Consensus Statement of the Heart Failure Association (HFA) and European Association of Preventive Cardiology (EAPC) of the European Society of Cardiology (ESC). Eur J Heart Fail 2022; 24:1327-1345. [PMID: 35775383 PMCID: PMC9542249 DOI: 10.1002/ejhf.2601] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 06/10/2022] [Accepted: 06/26/2022] [Indexed: 11/09/2022] Open
Abstract
Patients with heart failure with preserved ejection fraction (HFpEF) universally complain of exercise intolerance and dyspnoea as key clinical correlates. Cardiac as well as extracardiac components play a role for the limited exercise capacity, including an impaired cardiac and peripheral vascular reserve, a limitation in mechanical ventilation and/or gas exchange with reduced pulmonary vascular reserve, skeletal muscle dysfunction and iron deficiency/anaemia. Although most of these components can be differentiated and quantified through gas exchange analysis by cardiopulmonary exercise testing (CPET), the information provided by objective measures of exercise performance have not been systematically considered in the recent algorithms/scores for HFpEF diagnosis, neither by European nor US groups. The current Clinical Consensus Statement by the HFA and EAPC Association of the ESC aims at outlining the role of exercise testing and its pathophysiological, clinical and prognostic insights, addressing the implication of a thorough functional evaluation from the diagnostic algorithm to the pathophysiology and treatment perspectives of HFpEF. Along with these goals, we provide a specific analysis on the evidence that CPET is the standard for assessing, quantifying, and differentiating the origin of dyspnoea and exercise impairment and even more so when combined with echo and/or invasive hemodynamic evaluation is here provided. This will lead to improved quality of diagnosis when applying the proposed scores and may also help useful to implement the progressive characterization of the specific HFpEF phenotypes, a critical step toward the delivery of phenotype-specific treatments.
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Affiliation(s)
- M Marco Guazzi
- Division of Cardiology, University of Milano School of Medicine, San Paolo Hospital, Milano
| | - Matthias Wilhelm
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Martin Halle
- Department of Prevention and Sports Medicine, Faculty of Medicine, University Hospital 'Klinikum rechts der Isar', Technical University Munich, Munich, Germany; DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), partner site Munich, Munich Heart Alliance, Munich, Germany
| | - Emeline Van Craenenbroeck
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, Belgium; Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Hareld Kemps
- Department of Cardiology, Máxima Medical Center, Eindhoven, Netherlands; Department of Industrial Design, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Rudolph A de Boer
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
| | | | - Lars Lund
- Solna, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Donna Mancini
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Barry Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, 55902, United States
| | | | - Burkert Pieske
- Department of Cardiology, Charité University Medicine, Campus Virchow Klinikum, Berlin, Germany, German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany, German Heart Center, Berlin, Germany
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11
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Omote K, Verbrugge FH, Borlaug BA. Heart Failure with Preserved Ejection Fraction: Mechanisms and Treatment Strategies. Annu Rev Med 2022; 73:321-337. [PMID: 34379445 PMCID: PMC9002335 DOI: 10.1146/annurev-med-042220-022745] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Approximately half of all patients with heart failure (HF) have a preserved ejection fraction, and the prevalence is growing rapidly given the aging population in many countries and the rising prevalence of obesity, diabetes, and hypertension. Functional capacity and quality of life are severely impaired in heart failure with preserved ejection fraction (HFpEF), and morbidity and mortality are high. In striking contrast to HF with reduced ejection fraction, there are few effective treatments currently identified for HFpEF, and these are limited to decongestion by diuretics, promotion of a healthy active lifestyle, and management of comorbidities. Improved phenotyping of subgroups within the overall HFpEF population might enhance individualization of treatment. This review focuses on the current understanding of the pathophysiologic mechanisms underlying HFpEF and treatment strategies for this complex syndrome.
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Affiliation(s)
- Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Frederik H. Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States;,Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium;,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
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12
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Guazzi M. The Link Between Heart Rate, Exercise, and β-Blocker in HFpEF: Time to Untie the Knot. J Am Coll Cardiol 2021; 78:2057-2059. [PMID: 34794686 DOI: 10.1016/j.jacc.2021.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Marco Guazzi
- Cardiology Division, University of Milano School of Medicine, Department of Health Sciences, San Paolo Hospital, Milano, Italy.
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13
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Moriwaki K, Fujimoto N, Omori T, Miyahara S, Kameda I, Ishiyama M, Sugiura E, Nakamori S, Dohi K. Comparison of haemodynamic response to muscle reflex in heart failure with reduced vs. preserved ejection fraction. ESC Heart Fail 2021; 8:4882-4892. [PMID: 34725954 PMCID: PMC8712776 DOI: 10.1002/ehf2.13682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/13/2021] [Accepted: 10/05/2021] [Indexed: 12/04/2022] Open
Abstract
Aims Isometric handgrip (IHG) training reduces the blood pressure in patients with hypertension. It is unclear how IHG exercise affects the haemodynamics and cardiovascular function through the muscle reflex in patients with heart failure (HF) with reduced (HFrEF) and preserved ejection fraction (HFpEF). Methods and results Twenty patients (HFrEF: n = 10, HFpEF: n = 10) underwent left ventricular (LV) pressure–volume assessments using a conductance catheter and microtip manometer to evaluate haemodynamics, LV and arterial function, and LV‐arterial coupling during 3 min of IHG at 30% of maximal voluntary contraction (MVC), followed by 3 min of post‐exercise circulatory arrest (PECA). Three minutes of IHG exercise produced significant and modest increases in the heart rate (HR) and LV end‐systolic pressure (LVESP), respectively, in both HFpEF and HFrEF groups. In HFrEF, the increase in LVESP was caused by the variable increase in effective arterial elastance (Ea), which was counterbalanced by the increase in LV end‐systolic elastance (Ees), resulting in a maintained Ees/Ea. In HFpEF, the increase in LVESP was not accompanied by changes in Ea, Ees, Ees/Ea, or LV end‐diastolic pressure. LVESP during PECA was not maintained in HFpEF, suggesting smaller metabo‐reflex activity in HFpEF. Conclusions The IHG exercise used in this study may increase the LVESP and LVEDP without detrimental effects on cardiac function or ventricular‐arterial coupling, especially in HFpEF patients. The effects of IHG exercise on haemodynamics and ventricular‐arterial coupling may be affected by the patient background and the type and intensity of the exercise.
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Affiliation(s)
- Keishi Moriwaki
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Naoki Fujimoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Taku Omori
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - So Miyahara
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Issei Kameda
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Masaki Ishiyama
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Emiyo Sugiura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Shiro Nakamori
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, 514-8507, Japan
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