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Hiraiwa H, Okumura T, Murohara T. Drug Therapy for Acute and Chronic Heart Failure with Preserved Ejection Fraction with Hypertension: A State-of-the-Art Review. Am J Cardiovasc Drugs 2024; 24:343-369. [PMID: 38575813 PMCID: PMC11093799 DOI: 10.1007/s40256-024-00641-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 04/06/2024]
Abstract
In this comprehensive state-of-the-art review, we provide an evidence-based analysis of current drug therapies for patients with heart failure with preserved ejection fraction (HFpEF) in the acute and chronic phases with concurrent hypertension. Additionally, we explore the latest developments and emerging evidence on the efficacy, safety, and clinical outcomes of common and novel drug treatments in the management of HFpEF with concurrent hypertension. During the acute phase of HFpEF, intravenous diuretics, mineralocorticoid receptor antagonists (MRAs), and vasodilators are pivotal, while in the chronic phase, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have proven effective in enhancing clinical outcomes. However, the use of calcium channel blockers in HFpEF with hypertension should be approached with caution, owing to their potential negative inotropic effects. We also explored emerging drug therapies for HFpEF, such as sodium-glucose co-transporter 2 (SGLT2) inhibitors, angiotensin receptor-neprilysin inhibitor (ARNI), soluble guanylate cyclase (sGC) stimulators, novel MRAs, and ivabradine. Notably, SGLT2 inhibitors have shown promise in reducing heart failure hospitalizations and cardiovascular mortality in patients with HFpEF, regardless of their diabetic status. Additionally, ARNI and sGC stimulators have demonstrated potential in improving symptoms, functional capacity, and quality of life. Nonetheless, additional research is necessary to pinpoint optimal treatment strategies for HFpEF with concurrent hypertension. Furthermore, long-term studies are essential to assess the durability and sustained benefits of emerging drug therapies. Identification of novel targets and mechanisms underlying HFpEF pathophysiology will pave the way for innovative drug development approaches in the management of HFpEF with concurrent hypertension.
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Affiliation(s)
- Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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2
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Tumelty E, Chung I, Hussain S, Ali MA, Addada H, Banerjee D. An Updated Review of the Management of Chronic Heart Failure in Patients with Chronic Kidney Disease. Rev Cardiovasc Med 2024; 25:144. [PMID: 39076544 PMCID: PMC11264008 DOI: 10.31083/j.rcm2504144] [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: 10/10/2023] [Revised: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 07/31/2024] Open
Abstract
Chronic kidney disease (CKD) is common in patients with heart failure (HF) and is associated with high morbidity and mortality. There has been remarkable progress in the treatment of HF over recent years with the establishment of guideline-directed medical therapies including: (1) Beta-blockers, (2) renal angiotensin aldosterone system (RAAS) inhibition (i.e., angiotensin-converting enzyme inhibitor [ACEi], aldosterone receptor blocker [ARB] or angiotensin receptor-neprilysin inhibitor [ARNI]); (3) mineralocorticoid receptor antagonists (MRA), and (4) sodium-glucose cotransporter-2 inhibitors (SGLT2i). However, there are challenges to the implementation of these medications in patients with concomitant CKD due to increased vulnerability to common side-effects (including worsening renal function, hyperkalaemia, hypotension), and most of the pivotal trials which provide evidence of the efficacy of these medications excluded patients with severe CKD. Patients with CKD and HF often have regular healthcare encounters with multiple professionals and can receive conflicting guidance regarding their medication. Thus, despite being at higher risk of adverse cardiovascular events, patients who have both HF and CKD are more likely to be under-optimised on evidence-based therapies. This review is an updated summary of the evidence available for the management of HF (including reduced, mildly reduced and preserved left ventricular ejection fraction) in patients with various stages of CKD. The review covers the evidence for recommended medications, devices such as implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy (CRT), intravenous (IV) iron, and discusses how frailty affects the management of these patients. It also considers emerging evidence for the prevention of HF in the cohort of patients with CKD. It synthesises the available evidence regarding when to temporarily stop, continue or rechallenge medications in this cohort. Chronic HF in context of CKD remains a challenging scenario for clinicians to manage, which is usually complicated by frailty, multimorbidity and polypharmacy. Treatment should be tailored to a patients individual needs and management in specialised cardio-renal clinics with a multi-disciplinary team approach has been recommended. This review offers a concise summary on this expansive topic.
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Affiliation(s)
- Ella Tumelty
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Isaac Chung
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Sabba Hussain
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Mahrukh Ayesha Ali
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Harshavardhani Addada
- Cardiovascular and Genetics Research Institute St George’s University of London, SW17 0QT London, UK
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
- Cardiovascular and Genetics Research Institute St George’s University of London, SW17 0QT London, UK
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3
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Rabkin SW, Wong CN. Epigenetics in Heart Failure: Role of DNA Methylation in Potential Pathways Leading to Heart Failure with Preserved Ejection Fraction. Biomedicines 2023; 11:2815. [PMID: 37893188 PMCID: PMC10604152 DOI: 10.3390/biomedicines11102815] [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: 08/23/2023] [Revised: 09/21/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
This review will focus on epigenetic modifications utilizing the DNA methylation mechanism, which is potentially involved in the pathogenesis of heart failure with preserved ejection fraction (HFpEF). The putative pathways of HFpEF will be discussed, specifically myocardial fibrosis, myocardial inflammation, sarcoplasmic reticulum Ca2+-ATPase, oxidative-nitrosative stress, mitochondrial and metabolic defects, as well as obesity. The relationship of HFpEF to aging and atrial fibrillation will be examined from the perspective of DNA methylation.
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Affiliation(s)
- Simon W. Rabkin
- Department of Medicine, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Division of Cardiology, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | - Chenille N. Wong
- Department of Medicine, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
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Ravassa S, López B, Treibel TA, San José G, Losada-Fuentenebro B, Tapia L, Bayés-Genís A, Díez J, González A. Cardiac Fibrosis in heart failure: Focus on non-invasive diagnosis and emerging therapeutic strategies. Mol Aspects Med 2023; 93:101194. [PMID: 37384998 DOI: 10.1016/j.mam.2023.101194] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/09/2023] [Accepted: 06/14/2023] [Indexed: 07/01/2023]
Abstract
Heart failure is a leading cause of mortality and hospitalization worldwide. Cardiac fibrosis, resulting from the excessive deposition of collagen fibers, is a common feature across the spectrum of conditions converging in heart failure. Eventually, either reparative or reactive in nature, in the long-term cardiac fibrosis contributes to heart failure development and progression and is associated with poor clinical outcomes. Despite this, specific cardiac antifibrotic therapies are lacking, making cardiac fibrosis an urgent unmet medical need. In this context, a better patient phenotyping is needed to characterize the heterogenous features of cardiac fibrosis to advance toward its personalized management. In this review, we will describe the different phenotypes associated with cardiac fibrosis in heart failure and we will focus on the potential usefulness of imaging techniques and circulating biomarkers for the non-invasive characterization and phenotyping of this condition and for tracking its clinical impact. We will also recapitulate the cardiac antifibrotic effects of existing heart failure and non-heart failure drugs and we will discuss potential strategies under preclinical development targeting the activation of cardiac fibroblasts at different levels, as well as targeting additional extracardiac processes.
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Affiliation(s)
- Susana Ravassa
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Begoña López
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, UK; Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Gorka San José
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Blanca Losada-Fuentenebro
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Leire Tapia
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Antoni Bayés-Genís
- CIBERCV, Carlos III Institute of Health, Madrid, Spain; Servei de Cardiologia i Unitat d'Insuficiència Cardíaca, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; ICREC Research Program, Germans Trias i Pujol Health Science Research Institute, Badalona, Spain
| | - Javier Díez
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain.
| | - Arantxa González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain.
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Wołowiec A, Wołowiec Ł, Grześk G, Jaśniak A, Osiak J, Husejko J, Kozakiewicz M. The Role of Selected Epigenetic Pathways in Cardiovascular Diseases as a Potential Therapeutic Target. Int J Mol Sci 2023; 24:13723. [PMID: 37762023 PMCID: PMC10531432 DOI: 10.3390/ijms241813723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
Epigenetics is a rapidly developing science that has gained a lot of interest in recent years due to the correlation between characteristic epigenetic marks and cardiovascular diseases (CVDs). Epigenetic modifications contribute to a change in gene expression while maintaining the DNA sequence. The analysis of these modifications provides a thorough insight into the cardiovascular system from its development to its further functioning. Epigenetics is strongly influenced by environmental factors, including known cardiovascular risk factors such as smoking, obesity, and low physical activity. Similarly, conditions affecting the local microenvironment of cells, such as chronic inflammation, worsen the prognosis in cardiovascular diseases and additionally induce further epigenetic modifications leading to the consolidation of unfavorable cardiovascular changes. A deeper understanding of epigenetics may provide an answer to the continuing strong clinical impact of cardiovascular diseases by improving diagnostic capabilities, personalized medical approaches and the development of targeted therapeutic interventions. The aim of the study was to present selected epigenetic pathways, their significance in cardiovascular diseases, and their potential as a therapeutic target in specific medical conditions.
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Affiliation(s)
- Anna Wołowiec
- Department of Geriatrics, Division of Biochemistry and Biogerontology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Torun, Poland
| | - Łukasz Wołowiec
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Torun, Poland
| | - Grzegorz Grześk
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Torun, Poland
| | - Albert Jaśniak
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Torun, Poland
| | - Joanna Osiak
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Torun, Poland
| | - Jakub Husejko
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Torun, Poland
| | - Mariusz Kozakiewicz
- Department of Geriatrics, Division of Biochemistry and Biogerontology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Torun, Poland
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Vaz-Salvador P, Adão R, Vasconcelos I, Leite-Moreira AF, Brás-Silva C. Heart Failure with Preserved Ejection Fraction: a Pharmacotherapeutic Update. Cardiovasc Drugs Ther 2023; 37:815-832. [PMID: 35098432 PMCID: PMC8801287 DOI: 10.1007/s10557-021-07306-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 02/06/2023]
Abstract
While guidelines for management of heart failure with reduced ejection fraction (HFrEF) are consensual and have led to improved survival, treatment options for heart failure with preserved ejection fraction (HFpEF) remain limited and aim primarily for symptom relief and improvement of quality of life. Due to the shortage of therapeutic options, several drugs have been investigated in multiple clinical trials. The majority of these trials have reported disappointing results and have suggested that HFpEF might not be as simply described by ejection fraction as previously though. In fact, HFpEF is a complex clinical syndrome with various comorbidities and overlapping distinct phenotypes that could benefit from personalized therapeutic approaches. This review summarizes the results from the most recent phase III clinical trials for HFpEF and the most promising drugs arising from phase II trials as well as the various challenges that are currently holding back the development of new pharmacotherapeutic options for these patients.
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Affiliation(s)
- Pedro Vaz-Salvador
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Rui Adão
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Inês Vasconcelos
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Adelino F. Leite-Moreira
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Carmen Brás-Silva
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
- Faculty of Nutrition and Food Sciences, University of Porto, Rua Do Campo Alegre, 823 4150-180 Porto, Portugal
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LaPenna KB, Li Z, Doiron JE, Sharp TE, Xia H, Moles K, Koul K, Wang JS, Polhemus DJ, Goodchild TT, Patel RB, Shah SJ, Lefer DJ. Combination Sodium Nitrite and Hydralazine Therapy Attenuates Heart Failure With Preserved Ejection Fraction Severity in a "2-Hit" Murine Model. J Am Heart Assoc 2023; 12:e028480. [PMID: 36752224 PMCID: PMC10111505 DOI: 10.1161/jaha.122.028480] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/04/2023] [Indexed: 02/09/2023]
Abstract
Background Recent studies have suggested that cardiac nitrosative stress mediated by pathological overproduction of nitric oxide (NO) via inducible NO synthase (iNOS) contributes to the pathogenesis of heart failure with preserved ejection fraction (HFpEF). Other studies have suggested that endothelial NO synthase (eNOS) dysfunction and attenuated NO bioavailability contribute to HFpEF morbidity and mortality. We sought to further investigate dysregulated NO signaling and to examine the effects of a NO-based dual therapy (sodium nitrite+hydralazine) following the onset of HFpEF using a "2-hit" murine model. Methods and Results Nine-week-old male C57BL/6 N mice (n=15 per group) were treated concurrently with high-fat diet and N(ω)-nitro-L-arginine methyl ester (L-NAME) (0.5 g/L per day) via drinking water for 10 weeks. At week 5, mice were randomized into either vehicle (normal saline) or combination treatment with sodium nitrite (75 mg/L in the drinking water) and hydralazine (2.0 mg/kg IP, BID). Cardiac structure and function were monitored with echocardiography and invasive hemodynamic measurements. Cardiac mitochondrial respiration, aortic vascular function, and exercise performance were also evaluated. Circulating and myocardial nitrite were measured to determine the bioavailability of NO. Circulating markers of oxidative or nitrosative stress as well as systemic inflammation were also determined. Severe HFpEF was evident by significantly elevated E/E', LVEDP, and Tau in mice treated with L-NAME and HFD, which was associated with impaired NO bioavailability, mitochondrial respiration, aortic vascular function, and exercise capacity. Treatment with sodium nitrite and hydralazine restored NO bioavailability, reduced oxidative and nitrosative stress, preserved endothelial function and mitochondrial respiration, limited the fibrotic response, and improved exercise capacity, ultimately attenuating the severity of "two-hit" HFpEF. Conclusions Our data demonstrate that nitrite, a well-established biomarker of NO bioavailability and a physiological source of NO, is significantly reduced in the heart and circulation in the "2-hit" mouse HFpEF model. Furthermore, sodium nitrite+hydralazine combined therapy significantly attenuated the severity of HFpEF in the "2-hit" cardiometabolic HFpEF. These data suggest that supplementing NO-based therapeutics with a potent antioxidant and vasodilator agent may result in synergistic benefits for the treatment of HFpEF.
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Affiliation(s)
- Kyle B. LaPenna
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLA
| | - Zhen Li
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCA
| | - Jake E. Doiron
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLA
| | - Thomas E. Sharp
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
- Department of Medicine, Section of CardiologyLouisiana State University Health Sciences CenterNew OrleansLA
| | - Huijing Xia
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
| | - Karl Moles
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
| | - Kashyap Koul
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
| | - John S. Wang
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
| | | | - Traci T. Goodchild
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCA
| | - Ravi B. Patel
- Division of Cardiology, Department of Medicine and Bluhm Cardiovascular InstituteNorthwestern University Feinberg School of MedicineChicagoIL
| | - Sanjiv J. Shah
- Division of Cardiology, Department of Medicine and Bluhm Cardiovascular InstituteNorthwestern University Feinberg School of MedicineChicagoIL
| | - David J. Lefer
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCA
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Parra-Lucares A, Romero-Hernández E, Villa E, Weitz-Muñoz S, Vizcarra G, Reyes M, Vergara D, Bustamante S, Llancaqueo M, Toro L. New Opportunities in Heart Failure with Preserved Ejection Fraction: From Bench to Bedside… and Back. Biomedicines 2022; 11:70. [PMID: 36672578 PMCID: PMC9856156 DOI: 10.3390/biomedicines11010070] [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: 11/10/2022] [Revised: 12/07/2022] [Accepted: 12/13/2022] [Indexed: 12/29/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a growing public health problem in nearly 50% of patients with heart failure. Therefore, research on new strategies for its diagnosis and management has become imperative in recent years. Few drugs have successfully improved clinical outcomes in this population. Therefore, numerous attempts are being made to find new pharmacological interventions that target the main mechanisms responsible for this disease. In recent years, pathological mechanisms such as cardiac fibrosis and inflammation, alterations in calcium handling, NO pathway disturbance, and neurohumoral or mechanic impairment have been evaluated as new pharmacological targets showing promising results in preliminary studies. This review aims to analyze the new strategies and mechanical devices, along with their initial results in pre-clinical and different phases of ongoing clinical trials for HFpEF patients. Understanding new mechanisms to generate interventions will allow us to create methods to prevent the adverse outcomes of this silent pandemic.
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Affiliation(s)
- Alfredo Parra-Lucares
- Critical Care Unit, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
- MD PhD Program, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
| | - Esteban Romero-Hernández
- MD PhD Program, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
- Division of Internal Medicine, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
| | - Eduardo Villa
- School of Medicine, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
| | - Sebastián Weitz-Muñoz
- Division of Internal Medicine, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
| | - Geovana Vizcarra
- Division of Internal Medicine, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
| | - Martín Reyes
- School of Medicine, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
| | - Diego Vergara
- School of Medicine, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
| | - Sergio Bustamante
- Coronary Care Unit, Cardiovascular Department, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
| | - Marcelo Llancaqueo
- Coronary Care Unit, Cardiovascular Department, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
| | - Luis Toro
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
- Centro de Investigación Clínica Avanzada, Hospital Clínico, Universidad de Chile, Santiago 8380420, Chile
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Chirinos JA, Zhao L, Reese-Petersen AL, Cohen JB, Genovese F, Richards AM, Doughty RN, Díez J, González A, Querejeta R, Zamani P, Nuñez J, Wang Z, Ebert C, Kammerhoff K, Maranville J, Basso M, Qian C, Rasmussen DGK, Schafer PH, SeifFert D, Karsdal MA, Gordon DA, Ramirez-Valle F, Cappola TP. Endotrophin, a Collagen VI Formation-Derived Peptide, in Heart Failure. NEJM EVIDENCE 2022; 1:10.1056/evidoa2200091. [PMID: 37645406 PMCID: PMC10465122 DOI: 10.1056/evidoa2200091] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Endotrophin, a collagen type VI-derived peptide, mediates metabolic dysregulation, inflammation, and fibrosis in animal models, but has not been studied in human heart failure (HF). METHODS We examined the association between circulating endotrophin and outcomes in participants suffering from HF with preserved ejection fraction (HFpEF) enrolled in the TOPCAT trial (n=205). Associations were validated in a participant-level meta-analysis (n=810) that included participants with HFpEF from the PHFS study (United States; n=174), PEOPLE cohort (New Zealand; n=168), a randomized trial of vasodilator therapy (United States; n=45), a cohort from Donostia University Hospital and University of Navarra (Spain; n=171), and the TRAINING-HF trial (Spain; n=47). We also assessed associations in HF with reduced ejection fraction in PHFS (n=1,642). RESULTS Plasma endotrophin levels at baseline were associated with risk of future death (standardized hazard ratio [HR] = 1.74; 95% confidence interval [CI]=1.36-2.24; P<0.001) and death or HF-related hospital admission (DHFA; standardized HR=2.11; 95% CI= 1.67-2.67; P<0.001) in TOPCAT. Endotrophin improved reclassification and discrimination for these outcomes beyond the MAGGIC risk score and NT-proBNP (N-terminal pro b-type natriuretic peptide). Findings were confirmed in the participant-level meta-analysis. In participants with HF with reduced ejection fraction in PHFS, endotrophin levels were associated with death (standardized HR=1.82; 95% CI=1.66-2.00; P<0.001) and DHFA (standardized HR=1.40; 95% CI=1.31-1.50; P<0.001), but the strength of the latter association was substantially lower than for the MAGGIC risk score (standardized HR=1.93; 95% CI=1.76-2.12) and BNP (standardized HR=1.78; 95% CI=1.66-1.92). CONCLUSIONS Circulating endotrophin levels are independently associated with future poor outcomes in patients with HF, particularly in HFpEF. (Funded by Bristol Myers Squibb; Instituto de Salud Carlos III [Spain] and European Regional Development Fund; European Commission CRUCIAL project; and the U.S. National Institutes of Health National Heart, Lung, and Blood Institute.).
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Affiliation(s)
- Julio A Chirinos
- Hospital of the University of Pennsylvania, Philadelphia
- University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | - Lei Zhao
- Bristol Myers Squibb Company, Princeton, NJ
| | | | | | | | - A Mark Richards
- Cardiovascular Research Institute, National University of Singapore, Singapore
- Christchurch Heart Institute, University of Otago, Dunedin, New Zealand
| | | | - Javier Díez
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra, IdiSNA and CIBERCV, Pamplona, Navarra, Spain
- Departments of Cardiology and Nephrology, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - Arantxa González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra, IdiSNA and CIBERCV, Pamplona, Navarra, Spain
| | - Ramón Querejeta
- Department of Cardiology, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain
| | - Payman Zamani
- Hospital of the University of Pennsylvania, Philadelphia
- University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | - Julio Nuñez
- Hospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVA, CIBER Cardiovascular, Valencia, Spain
| | | | | | | | | | | | - Chenao Qian
- University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | | | | | | | | | | | | | - Thomas P Cappola
- Hospital of the University of Pennsylvania, Philadelphia
- University of Pennsylvania, Perelman School of Medicine, Philadelphia
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10
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Semerdzhieva NE, Denchev SV, Gospodinova MV. Left Ventricular Diastolic Function: Comparison of Slow Coronary Flow Phenomenon and Left Ventricular Hypertrophy in the Absence of Obstructive Coronary Disease. Cureus 2022; 14:e24789. [PMID: 35673304 PMCID: PMC9165915 DOI: 10.7759/cureus.24789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/05/2022] Open
Abstract
Background An interplay of myocardial structural abnormalities and coronary arterial dysfunction underlies the worsening left ventricular compliance. The conventionally used angina drugs have demonstrated a beneficial effect on both angina and coronary flow in cases with microvascular dysfunction and non-obstructive coronary disease. Despite that, vasoactive therapy only partially affects diastolic function in this patient population. Purpose This retrospective study was planned to evaluate the association of myocardial mass, delayed epicardial coronary flow, and vasoactive drugs with parameters of diastolic function in two cohorts with preserved left ventricular function and non-obstructive coronary disease in patients with slow coronary flow phenomenon (SCFP) and patients with the hypertensive disease and left ventricular hypertrophy. Material and methods The epicardial coronary flow was evaluated in 48 patients with unstable angina in the absence of coronary stenosis >50%, by applying the methods of corrected thrombolysis in myocardial infraction frame count (cTFC). The abnormalities in the left ventricular function were assessed by echocardiography using PW-Doppler of the diastolic mitral inflow and tissue Doppler imaging. Twenty-one (43.8%) patients were diagnosed with SCFP, and twelve patients (25%) had slow epicardial coronary flow, hypertensive disease, and ventricular hypertrophy (SFLVH). The remaining 15 (31.3%) were patients with ventricular hypertrophy, hypertension, and non-delayed epicardial coronary flow (NFLVH). Results The patients with SFLVH showed reduced peak early diastolic lateral mitral annular velocity (e'L) when compared to SCFP (7.1±1.9cm/s vs 8.6±2.1 cm/s, p=0.045) and NFLVH (7.1±1.9 cm/s vs 8.7±1.8 cm/s, p=0.018). A borderline significant difference was observed for the peak early diastolic septal mitral annular velocity (e'S) between the patients with SFLVH and SCFP ( 7.0±1.3 cm/s vs 8.3±2.1 cm/s, p=0.057). The ratio of mitral diastolic inflow velocity to early diastolic velocity of the mitral annulus (E/e') in the SFLVH group was a tendency higher than E/e' of the patients with SCFP (9.8±3.1 vs. 8.2±2.1, p=0.084) and NFLVH (9.8±3.1 vs. 7.8±1.5, p=0.051) .In the group with left ventricular hypertrophy, E/e' >10 was more frequently observed in patients with a marked delay in the epicardial flow (33.1 ± 13.1 frames vs. 25.4 ± 11.8 frames, p=0.011) and higher left ventricular mass (146.9 ± 17.7 g/m2 vs. 126.1 ± 121.5 g/m2, p=0.027). Conclusions Patients with microvascular angina represent a diverse population. The echocardiographic parameters of left ventricular relaxation (e') and end-diastolic pressure (E/e') are abnormally altered in the population with left ventricular hypertrophy compared to SCFP. The delayed epicardial flow further impairs diastolic function in hypertensive patients with hypertrophy and non-obstructive coronary disease.
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11
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Weerts J, Mourmans SGJ, Barandiarán Aizpurua A, Schroen BLM, Knackstedt C, Eringa E, Houben AJHM, van Empel VPM. The Role of Systemic Microvascular Dysfunction in Heart Failure with Preserved Ejection Fraction. Biomolecules 2022; 12:biom12020278. [PMID: 35204779 PMCID: PMC8961612 DOI: 10.3390/biom12020278] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/01/2022] [Accepted: 02/05/2022] [Indexed: 02/06/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a condition with increasing incidence, leading to a health care problem of epidemic proportions for which no curative treatments exist. Consequently, an urge exists to better understand the pathophysiology of HFpEF. Accumulating evidence suggests a key pathophysiological role for coronary microvascular dysfunction (MVD), with an underlying mechanism of low-grade pro-inflammatory state caused by systemic comorbidities. The systemic entity of comorbidities and inflammation in HFpEF imply that patients develop HFpEF due to systemic mechanisms causing coronary MVD, or systemic MVD. The absence or presence of peripheral MVD in HFpEF would reflect HFpEF being predominantly a cardiac or a systemic disease. Here, we will review the current state of the art of cardiac and systemic microvascular dysfunction in HFpEF (Graphical Abstract), resulting in future perspectives on new diagnostic modalities and therapeutic strategies.
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Affiliation(s)
- Jerremy Weerts
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; (S.G.J.M.); (A.B.A.); (B.L.M.S.); (C.K.); (V.P.M.v.E.)
- Correspondence: ; Tel.: +31-43-387-7097
| | - Sanne G. J. Mourmans
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; (S.G.J.M.); (A.B.A.); (B.L.M.S.); (C.K.); (V.P.M.v.E.)
| | - Arantxa Barandiarán Aizpurua
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; (S.G.J.M.); (A.B.A.); (B.L.M.S.); (C.K.); (V.P.M.v.E.)
| | - Blanche L. M. Schroen
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; (S.G.J.M.); (A.B.A.); (B.L.M.S.); (C.K.); (V.P.M.v.E.)
| | - Christian Knackstedt
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; (S.G.J.M.); (A.B.A.); (B.L.M.S.); (C.K.); (V.P.M.v.E.)
| | - Etto Eringa
- Department of Physiology, CARIM School for Cardiovascular Diseases, Maastricht University, 6211 LK Maastricht, The Netherlands;
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands
| | - Alfons J. H. M. Houben
- Department of Internal Medicine, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands;
| | - Vanessa P. M. van Empel
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; (S.G.J.M.); (A.B.A.); (B.L.M.S.); (C.K.); (V.P.M.v.E.)
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12
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Napoli C, Bontempo P, Palmieri V, Coscioni E, Maiello C, Donatelli F, Benincasa G. Epigenetic Therapies for Heart Failure: Current Insights and Future Potential. Vasc Health Risk Manag 2021; 17:247-254. [PMID: 34079271 PMCID: PMC8164213 DOI: 10.2147/vhrm.s287082] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/29/2021] [Indexed: 12/20/2022] Open
Abstract
Despite the current reductionist approach providing an optimal indication for diagnosis and treatment of patients with heart failure with reduced ejection fraction (HFrEF), there are no standard pharmacological therapies for heart failure with preserved ejection fraction (HFpEF). Although in its infancy in cardiovascular diseases, the epigenetic-based therapy ("epidrugs") is capturing the interest of physician community. In fact, an increasing number of controlled clinical trials is evaluating the putative beneficial effects of: 1) direct epigenetic-oriented drugs, eg, apabetalone, and 2) repurposed drugs with a possible indirect epigenetic interference, eg, metformin, statins, sodium glucose transporter inhibitors 2 (SGLT2i), and omega 3 polyunsaturated fatty acids (PUFAs) in both HFrEF and HFpEF, separately. Apabetalone is the first and unique direct epidrug tested in cardiovascular patients to date, and the BETonMACE trial has reported a reduction in first HF hospitalization (any EF value) and cardiovascular death in patients with type 2 diabetes and recent acute coronary syndrome, suggesting a possible role in secondary prevention. Patients with HFpEF seem to benefit from supplementation to the standard therapy with statins, metformin, and SGLT2i owing to their ability in reducing mortality. In contrast, the vasodilator hydralazine, with or without isosorbide dinitrate, did not provide beneficial effects. In HFrEF, metformin and SGLT2i could reduce the risk of incident HF and mortality in affected patients whereas clinical trials based on statins provided mixed results. Furthermore, PUFAs diet supplementation was significantly associated with reduced cardiovascular risk in both HFpEF and HFrEF. Future large trials will reveal whether direct and indirect epitherapy will remain a work in progress or become a useful way to customize the therapy in the real-world management of HFpEF and HFrEF. Our goal is to discuss the recent advancement in the epitherapy as a possible way to improve personalized therapy of HF.
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Affiliation(s)
- Claudio Napoli
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Naples, 80138, Italy
| | - Paola Bontempo
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, 80138, Italy
| | - Vittorio Palmieri
- Department of Cardiac Surgery and Transplantation, Heart Transplantation Unit in Adults of the 'Ospedali dei Colli Monaldi-Cotugno-CTO', Naples, Italy
| | - Enrico Coscioni
- Department of Cardiac Surgery, Azienda Ospedaliera Universitaria San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Ciro Maiello
- Department of Cardiovascular Surgery and Transplants, Monaldi Hospital, Azienda dei Colli, Naples, Italy
| | - Francesco Donatelli
- Chair of Cardiac Surgery, Department of Cardiothoracic Center, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Giuditta Benincasa
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Naples, 80138, Italy
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13
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Zhang Y, Mui D, Chirinos JA, Zamani P, Ferrari VA, Chen Y, Han Y. Comparing cardiovascular magnetic resonance strain software packages by their abilities to discriminate outcomes in patients with heart failure with preserved ejection fraction. J Cardiovasc Magn Reson 2021; 23:55. [PMID: 34011382 PMCID: PMC8136221 DOI: 10.1186/s12968-021-00747-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 03/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cardiovascular magnetic resonance (CMR) myocardial strain analysis using feature tracking (FT) is an increasingly popular method to assess cardiac function. However, different software packages produce different strain values from the same images and there is little guidance regarding which software package would be the best to use. We explored a framework under which different software packages could be compared and used based on their abilities to differentiate disease from health and differentiate disease severity based on outcome. METHOD To illustrate this concept, we compared 4-chamber left ventricular (LV) peak longitudinal strain (GLS) analyzed from retrospective electrocardiogram gated cine imaging performed on 1.5 T CMR scanners using three CMR post-processing software packages in their abilities to discriminate a group of 45 patients with heart failure with preserved ejection fraction (HFpEF) from 26 controls without cardiovascular disease and to discriminate disease severity based on outcomes. The three different post-processing software used were SuiteHeart, cvi42, and DRA-Trufistrain. RESULTS All three software packages were able to distinguish HFpEF patients from controls. 4-chamber peak GLS by SuiteHeart was shown to be a better discriminator of adverse outcomes in HFpEF patients than 4-chamber GLS derived from cvi42 or DRA-Trufistrain. CONCLUSION We illustrated a framework to compare feature tracking GLS derived from different post-processing software packages. Publicly available imaging data sets with outcomes would be important to validate the growing number of CMR-FT software packages.
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Affiliation(s)
- Ying Zhang
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104 USA
- PLA General Hospital, Beijing, China
| | - David Mui
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Julio A. Chirinos
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104 USA
| | - Payman Zamani
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104 USA
| | - Victor A. Ferrari
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104 USA
| | - Yucheng Chen
- Department of Cardiology, West China Hospital, Chengdu, China
| | - Yuchi Han
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104 USA
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14
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Harrison N, Pang P, Collins S, Levy P. Blood Pressure Reduction in Hypertensive Acute Heart Failure. Curr Hypertens Rep 2021; 23:11. [PMID: 33611627 DOI: 10.1007/s11906-021-01127-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW To review the key clinical and research questions regarding blood pressure (BP) reduction with vasodilators in the early management of hypertensive acute heart failure (H-AHF). RECENT FINDINGS Despite numerous AHF vasodilator clinical trials in the past two decades, virtually none has studied a population where vasoconstriction is the predominant physiology, and with the agents and doses most commonly used in contemporary practice. AHF patients are remarkably heterogenous by vascular tone, and this heterogeneity is not always discernible through BP or clinical exam. Emerging data suggest that diastolic BP may be a stronger correlate of vascular tone in AHF than systolic BP, despite the latter historically serving as a key inclusion criterion for vasodilator clinical trials. Existing data are limited. A clinical trial that evaluates vasodilators in a manner of use consistent with contemporary practice, specifically within the subpopulation of patients with true H-AHF, is greatly needed. Until then, observational data supports long-standing vasodilators such as nitroglycerin, administered by IV bolus, and with goal reduction of SBP ≤25% as a safe first-line approach for patients with severe H-AHF presentations.
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Affiliation(s)
| | - Peter Pang
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sean Collins
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Phillip Levy
- Wayne State University School of Medicine, Detroit, MI, USA
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15
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Lim SL, Gandhi M, Woo KL, Chua HR, Lim YC, Sim DKL, Lee SSG, Teoh YL, Richards AM, Lam CSP. Nitrates in combination with hydralazine in cardiorenal syndrome: a randomized controlled proof-of-concept study. ESC Heart Fail 2020; 7:4267-4276. [PMID: 33150715 PMCID: PMC7754984 DOI: 10.1002/ehf2.13076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/09/2020] [Accepted: 10/05/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS Cardiorenal syndrome (CRS) is a common problem of great morbidity and mortality. Hydralazine-isosorbide dinitrate (H-ISDN) may be used in renal failure and may improve exercise capacity in heart failure (HF). Our proof-of-concept study aimed to evaluate early evidence of efficacy, safety, and feasibility of H-ISDN compared with standard of care in CRS. METHODS AND RESULTS This multi-centre, single-blind, randomized trial in Singapore enrolled CRS patients, defined as chronic HF with concomitant renal failure [estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2 ]. The primary outcome was 6 min walk test (6MWT) distance measured at 6 months. Secondary outcomes included study feasibility; efficacy outcomes which included renal, cardiac, and endothelial functions, health-related quality of life using Short Form-36, clinical outcomes; and adverse events. Forty-four patients [71 ± 10 years; 75% male; median (inter-quartile range) N-terminal prohormone brain natriuretic peptide 1346 (481-2272) pg/mL] with CRS (left ventricular ejection fraction 42 ± 12% and eGFR 46 ± 15 ml/min/1.73 m2 ) were randomized into two equal groups. Of these, 39 (89%) had hypertension, 27 (61%) had diabetes mellitus, and 17 (39%) had atrial fibrillation. Six (27%) discontinued H-ISDN owing to intolerance and poor compliance. There was a trend towards improved 6MWT distance with H-ISDN compared with standard of care at 6 months (mean difference 27 m; 95% CI, -12 to 66), with little differences in secondary efficacy outcomes. Giddiness and hypotension occurred more frequently with H-ISDN, but HF hospitalizations and mortality were less. CONCLUSIONS Our pilot study does not support the addition of H-ISDN on top of standard medical therapy to improve exercise capacity in patients with CRS.
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Affiliation(s)
- Shir Lynn Lim
- Department of Cardiology, National University Heart Center, 1E Kent Ridge Road, 119228, Singapore
| | - Mihir Gandhi
- Singapore Clinical Research Institute, Singapore.,Duke-NUS Medical School, Singapore.,Global Health Group, Center for Child Health Research, Tampere University, Tampere, Finland
| | - Kai Lee Woo
- Department of Cardiology, National University Heart Center, 1E Kent Ridge Road, 119228, Singapore
| | - Horng Ruey Chua
- Division of Nephrology, National University Hospital, Singapore
| | - Yoke Ching Lim
- Department of Cardiology, National University Heart Center, 1E Kent Ridge Road, 119228, Singapore
| | - David K L Sim
- Department of Cardiology, National Heart Center, Singapore
| | - Sheldon S G Lee
- Department of Cardiology, Changi General Hospital, Singapore
| | - Yee Leong Teoh
- Singapore Clinical Research Institute, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Arthur Mark Richards
- Department of Medicine, Yong Loo Lin School of Medicine, Singapore.,Cardiovascular Research Institute, National University Heart Center, Singapore.,Christchurch Heart Institute, University of Otago, Dunedin, New Zealand
| | - Carolyn S P Lam
- Duke-NUS Medical School, Singapore.,Department of Cardiology, National Heart Center, Singapore
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16
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Napoli C, Benincasa G, Donatelli F, Ambrosio G. Precision medicine in distinct heart failure phenotypes: Focus on clinical epigenetics. Am Heart J 2020; 224:113-128. [PMID: 32361531 DOI: 10.1016/j.ahj.2020.03.007] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 03/07/2020] [Indexed: 12/31/2022]
Abstract
Heart failure (HF) management is challenging due to high clinical heterogeneity of this disease which makes patients responding differently to evidence-based standard therapy established by the current reductionist approach. Better understanding of the genetic and epigenetic interactions may clarify molecular signatures underlying maladaptive responses in HF, including metabolic shift, myocardial injury, fibrosis, and mitochondrial dysfunction. DNA methylation, histone modifications and micro-RNA (miRNAs) may be major epigenetic players in the pathogenesis of HF. DNA hypermethylation of the kruppel-like factor 15 (KLF15) gene plays a key role in switching the failing heart from oxidative to glycolytic metabolism. Moreover, hypomethylation at H3K9 promoter level of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) genes also leads to reactivation of fetal genes in man. The role of miRNAs has been investigated in HF patients undergoing heart transplantation, for whom miR-10a, miR-155, miR-31, and miR-92 may be putative useful prognostic biomarkers. Recently, higher RNA methylation levels have been observed in ischemic human hearts, opening the era of "epitranscriptome" in the pathogenesis of HF. Currently, hydralazine, statins, apabetalone, and omega-3 polyunsatured fatty acids (PUFA) are being tested in clinical trials to provide epigenetic-driven therapeutic interventions. Moreover, network-oriented analysis could advance current medical practice by focusing on protein-protein interactions (PPIs) perturbing the "cardiac" interactome. In this review, we provide an epigenetic map of maladaptive responses in HF patients. Furthermore, we propose the "EPi-transgeneratIonal network mOdeling for STratificatiOn of heaRt Morbidity" (EPIKO-STORM), a clinical research strategy offering novel opportunities to stratify the natural history of HF.
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17
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Non-Invasive Quantification of Ventricular Contractility, Arterial Elastic Function and Ventriculo-Arterial Coupling from a Single Diagnostic Encounter Using Simultaneous Arterial Tonometry and Magnetic Resonance Imaging. Cardiovasc Eng Technol 2020; 11:283-294. [DOI: 10.1007/s13239-020-00462-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 04/07/2020] [Indexed: 12/31/2022]
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18
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The Role of Arterial Stiffness and Central Hemodynamics in Heart Failure. ACTA ACUST UNITED AC 2020; 2:209-230. [PMID: 36262174 PMCID: PMC9536727 DOI: 10.36628/ijhf.2020.0029] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/01/2020] [Accepted: 09/03/2020] [Indexed: 02/06/2023]
Abstract
Whereas traditional understanding of left ventricular afterload was focused on a steady-state circulation model with continuous pressures and flow, a more realistic concept is emerging, taking the pulsatile nature of the heart and the arterial system into account. The most simple measure of pulsatility is brachial pulse pressure, representing the pulsatility fluctuating around the mean blood pressure level. Brachial pulse pressure is widely available, fundamentally associated with the development and treatment of heart failure (HF), but its analysis is often confounded in patients with established HF. The next step of analysis consists of arterial stiffness, central (rather than brachial) pressures, and of wave reflections. The latter are closely related to left ventricular late systolic afterload, ventricular remodeling, diastolic dysfunction, exercise capacity, and, in the long term, the risk of new-onset HF. Wave reflection may also evolve as a suitable therapeutic target for HF with preserved and reduced ejection fraction. A full understanding of ventricular-arterial coupling, however, requires dedicated analysis of time-resolved pressure and flow signals. This review provides a summary of current understanding of pulsatile hemodynamics in HF.
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19
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Weber T, Chirinos JA. Pulsatile arterial haemodynamics in heart failure. Eur Heart J 2019; 39:3847-3854. [PMID: 29947746 DOI: 10.1093/eurheartj/ehy346] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/29/2018] [Indexed: 12/15/2022] Open
Abstract
Due to the cyclic function of the human heart, pressure and flow in the circulation are pulsatile rather than continuous. Addressing pulsatile haemodynamics starts with the most convenient measurement, brachial pulse pressure, which is widely available, related to development and treatment of heart failure (HF), but often confounded in patients with established HF. The next level of analysis consists of central (rather than brachial) pressures and, more importantly, of wave reflections. The latter are closely related to left ventricular late systolic afterload, ventricular remodelling, diastolic dysfunction, exercise capacity, and, in the long-term, the risk of new-onset HF. Wave reflection may also represent a suitable therapeutic target. Treatments for HF with preserved and reduced ejection fraction, based on a reduction of wave reflection, are emerging. A full understanding of ventricular-arterial coupling, however, requires dedicated analysis of time-resolved pressure and flow signals, which can be readily accomplished with contemporary non-invasive imaging and modelling techniques. This review provides a summary of our current understanding of pulsatile haemodynamics in HF.
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Affiliation(s)
- Thomas Weber
- Department of Cardiology, Klinikum Wels-Grieskirchen, Austria
| | - Julio A Chirinos
- University of Pennsylvania School of Medicine/Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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20
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Upadhya B, Haykowsky MJ, Kitzman DW. Therapy for heart failure with preserved ejection fraction: current status, unique challenges, and future directions. Heart Fail Rev 2019; 23:609-629. [PMID: 29876843 DOI: 10.1007/s10741-018-9714-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is the most common form of HF. Among elderly women, HFpEF comprises more than 80% of incident HF cases. Adverse outcomes-exercise intolerance, poor quality of life, frequent hospitalizations, and reduced survival-approach those of classic HF with reduced EF (HFrEF). However, despite its importance, our understanding of the pathophysiology of HFpEF is incomplete, and despite intensive efforts, optimal therapy remains uncertain, as most trials to date have been negative. This is in stark contrast to management of HFrEF, where dozens of positive trials have established a broad array of effective, guidelines-based therapies that definitively improve a range of clinically meaningful outcomes. In addition to providing an overview of current management status, we examine evolving data that may help explain this paradox, overcome past challenges, provide a roadmap for future success, and that underpin a wave of new trials that will test novel approaches based on these insights.
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Affiliation(s)
- Bharathi Upadhya
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1045, USA
| | - Mark J Haykowsky
- College of Nursing and Health Innovation, University of Texas Arlington, Arlington, TX, USA
| | - Dalane W Kitzman
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1045, USA.
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Abstract
Heart failure (HF) is a clinical syndrome of diverse etiologies and can be associated with preserved, reduced, or mid-range ejection fraction (EF). In the community, heart failure with preserved ejection fraction (HFpEF) is emerging as the most common form of HF. There remains considerable uncertainty regarding its pathogenesis, diagnosis, and optimal therapeutic approach. Hypotheses have been advanced to explain the underlying pathophysiology responsible for HFpEF, but to date, no specific therapy based on these hypotheses has been proven to improve outcomes in HFpEF. We provide a clinically focused review of the epidemiology, clinical presentation, diagnostic approach, pathophysiology, and treatment of HFpEF.
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Affiliation(s)
- James D Gladden
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota 55905; , ,
| | - Antoine H Chaanine
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota 55905; , ,
| | - Margaret M Redfield
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota 55905; , ,
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22
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Schiattarella GG, Altamirano F, Tong D, French KM, Villalobos E, Kim SY, Luo X, Jiang N, May HI, Wang ZV, Hill TM, Mammen PPA, Huang J, Lee DI, Hahn VS, Sharma K, Kass DA, Lavandero S, Gillette TG, Hill JA. Nitrosative stress drives heart failure with preserved ejection fraction. Nature 2019; 568:351-356. [PMID: 30971818 PMCID: PMC6635957 DOI: 10.1038/s41586-019-1100-z] [Citation(s) in RCA: 493] [Impact Index Per Article: 98.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/07/2019] [Indexed: 12/21/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a common syndrome with high morbidity and mortality for which there are no evidence-based therapies. Here we report that concomitant metabolic and hypertensive stress in mice-elicited by a combination of high-fat diet and inhibition of constitutive nitric oxide synthase using Nω-nitro-L-arginine methyl ester (L-NAME)-recapitulates the numerous systemic and cardiovascular features of HFpEF in humans. Expression of one of the unfolded protein response effectors, the spliced form of X-box-binding protein 1 (XBP1s), was reduced in the myocardium of our rodent model and in humans with HFpEF. Mechanistically, the decrease in XBP1s resulted from increased activity of inducible nitric oxide synthase (iNOS) and S-nitrosylation of the endonuclease inositol-requiring protein 1α (IRE1α), culminating in defective XBP1 splicing. Pharmacological or genetic suppression of iNOS, or cardiomyocyte-restricted overexpression of XBP1s, each ameliorated the HFpEF phenotype. We report that iNOS-driven dysregulation of the IRE1α-XBP1 pathway is a crucial mechanism of cardiomyocyte dysfunction in HFpEF.
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Affiliation(s)
- Gabriele G Schiattarella
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Francisco Altamirano
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dan Tong
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kristin M French
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Elisa Villalobos
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Soo Young Kim
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Xiang Luo
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nan Jiang
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Herman I May
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Zhao V Wang
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Theodore M Hill
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Pradeep P A Mammen
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jian Huang
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dong I Lee
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Virginia S Hahn
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kavita Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - David A Kass
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sergio Lavandero
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Chemical & Pharmaceutical Sciences and Faculty of Medicine, University of Chile, Santiago, Chile
- Center for Molecular Studies of the Cell (CEMC), Institute of Biomedical Sciences (ICBM), Faculty of Medicine, University of Chile, Santiago, Chile
| | - Thomas G Gillette
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Joseph A Hill
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
- Department of Molecular Biology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Chirinos JA, Bhattacharya P, Kumar A, Proto E, Konda P, Segers P, Akers SR, Townsend RR, Zamani P. Impact of Diabetes Mellitus on Ventricular Structure, Arterial Stiffness, and Pulsatile Hemodynamics in Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2019; 8:e011457. [PMID: 30764699 PMCID: PMC6405670 DOI: 10.1161/jaha.118.011457] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/22/2019] [Indexed: 01/05/2023]
Abstract
Background Heterogeneity in the underlying processes that contribute to heart failure with preserved ejection fraction ( HF p EF ) is increasingly recognized. Diabetes mellitus is a frequent comorbidity in HF p EF , but its impact on left ventricular and arterial structure and function in HF p EF is unknown. Methods and Results We assessed the impact of diabetes mellitus on left ventricular cellular and interstitial hypertrophy (assessed with cardiac magnetic resonance imaging, including T1 mapping pregadolinium and postgadolinium administration), arterial stiffness (assessed with arterial tonometry), and pulsatile arterial hemodynamics (assessed with in-office pressure-flow analyses and 24-hour ambulatory monitoring) among 53 subjects with HF p EF (32 diabetic and 21 nondiabetic subjects). Despite few differences in clinical characteristics, diabetic subjects with HFpEF exhibited a markedly greater left ventricular mass index (78.1 [95% CI , 70.4-85.9] g versus 63.6 [95% CI , 55.8-71.3] g; P=0.0093) and indexed extracellular volume (23.6 [95% CI , 21.2-26.1] mL/m2 versus 16.2 [95% CI , 13.1-19.4] mL/m2; P=0.0008). Pronounced aortic stiffening was also observed in the diabetic group (carotid-femoral pulse wave velocity, 11.86 [95% CI , 10.4-13.1] m/s versus 8.8 [95% CI , 7.5-10.1] m/s; P=0.0027), with an adverse pulsatile hemodynamic profile characterized by increased oscillatory power (315 [95% CI , 258-373] mW versus 190 [95% CI , 144-236] mW; P=0.0007), aortic characteristic impedance (0.154 [95% CI , 0.124-0.183] mm Hg/mL per second versus 0.096 [95% CI , 0.072-0.121] mm Hg/mL per second; P=0.0024), and forward (59.5 [95% CI , 52.8-66.1] mm Hg versus 40.1 [95% CI , 31.6-48.6] mm Hg; P=0.0010) and backward (19.6 [95% CI , 16.2-22.9] mm Hg versus 14.1 [95% CI , 10.9-17.3] mm Hg; P=0.0169) wave amplitude. Abnormal pulsatile hemodynamics were also evident in 24-hour ambulatory monitoring, despite the absence of significant differences in 24-hour systolic blood pressure between the groups. Conclusions Diabetes mellitus is a key determinant of left ventricular remodeling, arterial stiffness, adverse pulsatile hemodynamics, and ventricular-arterial interactions in HF p EF . Clinical Trial Registration URL : https://www.clinicaltrials.gov . Unique identifier: NCT 01516346.
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Affiliation(s)
- Julio A. Chirinos
- Division of Cardiovascular MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
- Department of RadiologyCorporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
| | - Priyanka Bhattacharya
- Division of Cardiovascular MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Anupam Kumar
- Division of Cardiovascular MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Elizabeth Proto
- Division of Cardiovascular MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Prasad Konda
- Division of Cardiovascular MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Patrick Segers
- Biofluid, Tissue and Solid Mechanics for Medical ApplicationsGhent UniversityGhentBelgium
| | - Scott R. Akers
- Department of RadiologyCorporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
| | - Raymond R. Townsend
- Division of Cardiovascular MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Payman Zamani
- Division of Cardiovascular MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
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24
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Tamargo J, Caballero R, Delpón E. New drugs in preclinical and early stage clinical development in the treatment of heart failure. Expert Opin Investig Drugs 2018; 28:51-71. [DOI: 10.1080/13543784.2019.1551357] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, CIBERCV, Madrid,
Spain
| | - Ricardo Caballero
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, CIBERCV, Madrid,
Spain
| | - Eva Delpón
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, CIBERCV, Madrid,
Spain
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25
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Londono-Hoyos F, Zamani P, Beraun M, Vasim I, Segers P, Chirinos JA. Effect of organic and inorganic nitrates on cerebrovascular pulsatile power transmission in patients with heart failure and preserved ejection fraction. Physiol Meas 2018; 39:044001. [PMID: 29488900 DOI: 10.1088/1361-6579/aab2ef] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Increased penetration of pulsatile power to the brain has been implicated in the pathogenesis of age-related cognitive dysfunction and dementia, a common comorbidity in patients with heart failure and preserved ejection fraction (HFpEF). However, there is a lack of knowledge on the effects of organic and inorganic nitrates administration in this population on the power carried by pressure and flow waves traveling through the proximal aorta and penetrating the carotid artery into the brain microvasculature. APPROACH We assessed aortic and carotid hemodynamics non-invasively in two sub-studies: (1) at baseline and after administration of 0.4 mg of sublingual nitroglycerine (an organic nitrate; n = 26); and (2) in a randomized controlled trial of placebo (PB) versus inorganic nitrate administration (beetroot-juice (BR), 12.9 mmol NO3; n = 16). MAIN RESULTS Wave and hydraulic power analysis demonstrated that NTG increased total hydraulic power (from 5.68% at baseline to 8.62%, P = 0.001) and energy penetration (from 8.69% to 11.63%; P = 0.01) from the aorta to the carotid, while inorganic nitrate administration did not induce significant changes in aortic and carotid wave power (power: 5.49%PB versus 6.25%BR, P = 0.49; energy: 8.89%PB versus 10.65%BR, P = 0.27). SIGNIFICANCE Organic nitrates, but not inorganic nitrates, increase the amount of hydraulic energy transmitted into the carotid artery in subjects with HFpEF. These findings may have implications for the adverse effect profiles of these agents (such as the differential incidence of headaches) and for the pulsatile hemodynamic stress of the brain microvasculature in this patient population.
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Affiliation(s)
- Francisco Londono-Hoyos
- University of Pennsylvania Perelman School of Medicine Hospital of the University of Pennsylvania, Philadelphia, PA, United States of America. Institute Biomedical Technology (IBiTech)-bioMMeda Research Group-Ghent University, Ghent, Belgium. FLH and PZ contributed equally to this manuscript
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26
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Chirinos JA. The Nitrate-Nitrite-NO Pathway as a Novel Therapeutic Target in Heart Failure with Reduced Ejection Fraction. J Card Fail 2018; 24:74-77. [DOI: 10.1016/j.cardfail.2017.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 12/06/2017] [Accepted: 12/06/2017] [Indexed: 11/26/2022]
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27
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Snipelisky D, Kelly J, Levine JA, Koepp GA, Anstrom KJ, McNulty SE, Zakeri R, Felker GM, Hernandez AF, Braunwald E, Redfield MM. Accelerometer-Measured Daily Activity in Heart Failure With Preserved Ejection Fraction: Clinical Correlates and Association With Standard Heart Failure Severity Indices. Circ Heart Fail 2017; 10:e003878. [PMID: 28588021 DOI: 10.1161/circheartfailure.117.003878] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/26/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Daily physical activity assessed by accelerometers represents a novel method to assess the impact of interventions on heart failure (HF) patients' functional status. We hypothesized that daily activity varies by patient characteristics and correlates with established measures of HF severity in HF with preserved ejection fraction. METHODS AND RESULTS In this ancillary study of the NEAT-HFpEF trial (Nitrate's Effects on Activity Tolerance in HF With Preserved Ejection Fraction), average daily accelerometer units (ADAU) and hours active per day were assessed during a 14-day period before starting isosorbide mononitrate or placebo (n=110). Baseline ADAU was negatively associated with age, female sex, height, and body mass index, and these variables accounted for 28% of the variability in ADAU (P<0.007 for all). Adjusting for these factors, patients with lower ADAU were more likely to have had an HF hospitalization, orthopnea, diabetes mellitus and anemia, be treated with β-blockers, have higher ejection fraction, relative wall thickness and left atrial volume, and worse New York Heart Association class, HF-specific quality of life scores, 6-minute walk distance, and NT-proBNP (N-terminal pro-B-type natriuretic peptide; P<0.05 for all). Associations between hours active per day and clinical characteristics were similar. Relative to baseline, there were no significant associations between changes in ADAU or hours active per day and changes in standard functional assessments (New York Heart Association, quality of life, 6-minute walk distance, and NT-proBNP) with isosorbide mononitrate. CONCLUSIONS Daily activity is a measure of HF-related and global functional status in HF with preserved ejection fraction. As compared with intermittently assessed standard HF assessments, change in daily activity may provide unique information about the impact of HF interventions on functional status. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02053493.
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Affiliation(s)
- David Snipelisky
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (D.S., R.Z., M.M.R.); Duke Clinical Research Institution, Duke University, Durham, NC (J.K., K.J.A., S.E.M., G.M.F., A.F.H.); Endocrine Research Unit, Mayo Clinic, Phoenix, AZ (J.A.L., G.A.K.); and Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Jacob Kelly
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (D.S., R.Z., M.M.R.); Duke Clinical Research Institution, Duke University, Durham, NC (J.K., K.J.A., S.E.M., G.M.F., A.F.H.); Endocrine Research Unit, Mayo Clinic, Phoenix, AZ (J.A.L., G.A.K.); and Brigham and Women's Hospital, Boston, MA (E.B.)
| | - James A Levine
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (D.S., R.Z., M.M.R.); Duke Clinical Research Institution, Duke University, Durham, NC (J.K., K.J.A., S.E.M., G.M.F., A.F.H.); Endocrine Research Unit, Mayo Clinic, Phoenix, AZ (J.A.L., G.A.K.); and Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Gabriel A Koepp
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (D.S., R.Z., M.M.R.); Duke Clinical Research Institution, Duke University, Durham, NC (J.K., K.J.A., S.E.M., G.M.F., A.F.H.); Endocrine Research Unit, Mayo Clinic, Phoenix, AZ (J.A.L., G.A.K.); and Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Kevin J Anstrom
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (D.S., R.Z., M.M.R.); Duke Clinical Research Institution, Duke University, Durham, NC (J.K., K.J.A., S.E.M., G.M.F., A.F.H.); Endocrine Research Unit, Mayo Clinic, Phoenix, AZ (J.A.L., G.A.K.); and Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Steven E McNulty
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (D.S., R.Z., M.M.R.); Duke Clinical Research Institution, Duke University, Durham, NC (J.K., K.J.A., S.E.M., G.M.F., A.F.H.); Endocrine Research Unit, Mayo Clinic, Phoenix, AZ (J.A.L., G.A.K.); and Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Rosita Zakeri
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (D.S., R.Z., M.M.R.); Duke Clinical Research Institution, Duke University, Durham, NC (J.K., K.J.A., S.E.M., G.M.F., A.F.H.); Endocrine Research Unit, Mayo Clinic, Phoenix, AZ (J.A.L., G.A.K.); and Brigham and Women's Hospital, Boston, MA (E.B.)
| | - G Michael Felker
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (D.S., R.Z., M.M.R.); Duke Clinical Research Institution, Duke University, Durham, NC (J.K., K.J.A., S.E.M., G.M.F., A.F.H.); Endocrine Research Unit, Mayo Clinic, Phoenix, AZ (J.A.L., G.A.K.); and Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Adrian F Hernandez
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (D.S., R.Z., M.M.R.); Duke Clinical Research Institution, Duke University, Durham, NC (J.K., K.J.A., S.E.M., G.M.F., A.F.H.); Endocrine Research Unit, Mayo Clinic, Phoenix, AZ (J.A.L., G.A.K.); and Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Eugene Braunwald
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (D.S., R.Z., M.M.R.); Duke Clinical Research Institution, Duke University, Durham, NC (J.K., K.J.A., S.E.M., G.M.F., A.F.H.); Endocrine Research Unit, Mayo Clinic, Phoenix, AZ (J.A.L., G.A.K.); and Brigham and Women's Hospital, Boston, MA (E.B.)
| | - Margaret M Redfield
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (D.S., R.Z., M.M.R.); Duke Clinical Research Institution, Duke University, Durham, NC (J.K., K.J.A., S.E.M., G.M.F., A.F.H.); Endocrine Research Unit, Mayo Clinic, Phoenix, AZ (J.A.L., G.A.K.); and Brigham and Women's Hospital, Boston, MA (E.B.).
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Ofili E, Anand I, Williams RA, Akinboboye O, Xu L, Puckrein G. Fixed-Dose Versus Off-Label Combination of Isosorbide Dinitrate Plus Hydralazine Hydrochloride: Retrospective Propensity-Matched Analysis in Black Medicare Patients with Heart Failure. Adv Ther 2017; 34:1976-1988. [PMID: 28707284 PMCID: PMC5565652 DOI: 10.1007/s12325-017-0584-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Based upon the findings of the African-American Heart Failure Trial, the US Food and Drug Administration approved the fixed-dose combination of isosorbide dinitrate (ISDN) and hydralazine hydrochloride (HYD) (FDC-ISDN/HYD) as a new drug for treatment of heart failure (HF) in self-identified African Americans. According to the FDA, FDC-ISDN/HYD has no therapeutic equivalent. However, off-label combinations of the separate generic drugs ISDN and HYD (OLC-ISDN+HYD) or isosorbide mononitrate (ISMN) and HYD (OLC-ISMN+HYD) are routinely substituted without any supporting outcome data. We conducted an exploratory retrospective propensity-matched cohort study using Medicare data to determine whether a survival difference exists between these treatments in medication-adherent patients. METHODS Black Medicare beneficiaries with HF were matched with Medicare Part D data to identify patients with prescriptions to FDC-ISDN/HYD or the off-label combinations. Only patients with 1-year adherence levels ≥80% were included in the analysis. Propensity-matched scoring created two sets of matched cohort pairs on a 1:1 basis, each set comparing FDC-ISDN/HYD with one of the off-label combinations. Kaplan-Meier (KM) survival curves with the log-rank test were then calculated for each pair for the year of medication adherence. RESULTS The analysis population was relatively older (77 years) and mainly female (66.7%), with a high burden of comorbid disease. The KM estimates of 1-year survival were 87.9% (95% CI 85.6-89.9%) and 83.0% (95% CI 80.3-85.3%) (log rank p = 0.0024), respectively, for the matched cohorts FDC-ISDN/HYD and OLC-ISDN+HYD (n = 886 in each group) and 88.2% (95% CI 85.9-90.2%) and 84.8% (95% CI 82.2-87.0%) (log rank p = 0.0320), respectively, for the matched cohorts FDC-ISDN/HYD and OLC-ISMN+HYD (n = 868 in each group). CONCLUSION The 1-year survival advantage for FDC-ISDN/HYD compared with off-label combinations in adherent black Medicare beneficiaries with HF suggests a genuine difference between these medications and warrants prospective investigation.
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Chirinos JA, Londono-Hoyos F, Zamani P, Beraun M, Haines P, Vasim I, Varakantam S, Phan TS, Cappola TP, Margulies KB, Townsend RR, Segers P. Effects of organic and inorganic nitrate on aortic and carotid haemodynamics in heart failure with preserved ejection fraction. Eur J Heart Fail 2017; 19:1507-1515. [PMID: 28547861 DOI: 10.1002/ejhf.885] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 04/04/2017] [Accepted: 04/10/2017] [Indexed: 01/23/2023] Open
Abstract
AIMS To assess the haemodynamic effects of organic vs. inorganic nitrate administration among patients with heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS We assessed carotid and aortic pressure-flow relations non-invasively before and after the administration of 0.4 mg of sublingual nitroglycerin (n = 26), and in a separate sub-study, in response to 12.9 mmoL of inorganic nitrate (n = 16). Nitroglycerin did not consistently reduce wave reflections arriving at the proximal aorta (change in real part of reflection coefficient, 1st harmonic: -0.09; P = 0.01; 2nd harmonic: -0.045, P = 0.16; 3rd harmonic: +0.087; P = 0.05), but produced profound vasodilatation in the carotid territory, with a significant reduction in systolic blood pressure (133.6 vs. 120.5 mmHg; P = 0.011) and a marked reduction in carotid bed vascular resistance (19 580 vs. 13 078 dynes · s/cm5 ; P = 0.001) and carotid characteristic impedance (3440 vs. 1923 dynes · s/cm5 ; P = 0.002). Inorganic nitrate, in contrast, consistently reduced wave reflections across the first three harmonics (change in real part of reflection coefficient, 1st harmonic: -0.12; P = 0.03; 2nd harmonic: -0.11, P = 0.01; 3rd harmonic: -0.087; P = 0.09) and did not reduce blood pressure, carotid bed vascular resistance, or carotid characteristic impedance (P = NS). CONCLUSIONS Nitroglycerin produces marked vasodilatation in the carotid circulation, with a pronounced reduction in blood pressure and inconsistent effects on central wave reflections. Inorganic nitrate, in contrast, produces consistent reductions in wave reflections, and unlike nitroglycerin, it does so without significant hypotension or cerebrovascular dilatation. These haemodynamic differences may underlie the different effects on exercise capacity and side effect profile of inorganic vs. organic nitrate in HFpEF.
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Affiliation(s)
- Julio A Chirinos
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Francisco Londono-Hoyos
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Institute of Biomedical Technology, Ghent University, Ghent, Belgium
| | - Payman Zamani
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Melissa Beraun
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Philip Haines
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Izzah Vasim
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Swapna Varakantam
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Timothy S Phan
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas P Cappola
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kenneth B Margulies
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Raymond R Townsend
- University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick Segers
- Institute of Biomedical Technology, Ghent University, Ghent, Belgium
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30
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Deep Phenotyping of Systemic Arterial Hemodynamics in HFpEF (Part 2): Clinical and Therapeutic Considerations. J Cardiovasc Transl Res 2017; 10:261-274. [PMID: 28401511 DOI: 10.1007/s12265-017-9736-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 01/30/2017] [Indexed: 01/09/2023]
Abstract
Multiple phase III trials over the last few decades have failed to demonstrate a clear benefit of various pharmacologic interventions in heart failure with a preserved left ventricular (LV) ejection fraction (HFpEF). Therefore, a better understanding of its pathophysiology is important. An accompanying review describes key technical and physiologic aspects regarding the deep phenotyping of arterial hemodynamics in HFpEF. This review deals with the potential of this approach to enhance our clinical, translational, and therapeutic approach to HFpEF. Specifically, the role of arterial hemodynamics is discussed in relation to (1) the pathophysiology of left ventricular diastolic dysfunction, remodeling, and fibrosis, (2) impaired oxygen delivery to peripheral skeletal muscle, which affects peripheral oxygen extraction, (3) the frequent presence of comorbidities, such as renal failure and dementia in this population, and (4) the potential to enhance precision medicine approaches. A therapeutic approach to target arterial hemodynamic abnormalities that are prevalent in this population (particularly, with inorganic nitrate/nitrite) is also discussed.
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31
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Affiliation(s)
- Deepak K Gupta
- Division of Cardiovascular Medicine, Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University School of Medicine, Nashville, TN
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32
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Abstract
Measures of interaction between the left ventricle (LV) and arterial system (ventricular-arterial coupling) are important but under-recognised cardiovascular phenotypes in heart failure. Ventriculo-arterial coupling is commonly assessed in the pressure-volume plane, using the ratio of effective arterial elastance (EA) to LV end-systolic elastance (EES) to provide information on ventricular-arterial system mechanical efficiency and performance when LV ejection fraction is abnormal. These analyses have significant limitations, such as neglecting systolic loading sequence, and are less informative in heart failure with preserved ejection fraction (HFpEF). EA is almost entirely dependent on vascular resistance and heart rate. Assessment of pulsatile arterial haemodynamics and time-resolved myocardial wall stress provide critical incremental physiological information and should be more widely utilised. Pulsatile arterial load represents a promising therapeutic target in HFpEF. Here, we review various approaches to assess ventricular-arterial interactions, and their pathophysiological and clinical implications in heart failure.
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Affiliation(s)
- Julio A Chirinos
- University of Pennsylvania Perelman School of Medicine and Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nancy Sweitzer
- Tucson and Arizona Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ, USA
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