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Meyer M. Personalized Pacing for HFpEF: myPACE. J Card Fail 2024; 30:860-862. [PMID: 38447634 DOI: 10.1016/j.cardfail.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Markus Meyer
- Lillehei Heart Institute, University of Minnesota Medical School, Department of Medicine, Minneapolis, MN.
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2
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Preisendörfer S, Singla V, Bhonsale A, Kancharla K, Thoma F, Mulukutla S, Voigt A, Shalaby A, Estes NAM, Jain S, Saba S. Heart Rate at Rest and Incident Atrial Fibrillation in Patients With Diastolic Dysfunction. Am J Cardiol 2024; 218:72-76. [PMID: 38461926 DOI: 10.1016/j.amjcard.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 01/28/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024]
Abstract
Diastolic dysfunction (DD) is associated with incident atrial fibrillation (AF). The influence of heart rate at rest (RHR) on incident AF in patients with DD has not been investigated. The goal of this study is to assess the influence of RHR on incident AF in patients with DD. Patients from a large health system with no previous history of AF, a left ventricular ejection fraction ≥50%, and documented DD on echocardiography were divided into quartiles (<66, 66 to 76, 77 to 91, >91 beats per minute) based on RHR. Incident AF was estimated using AF hospitalization during follow-up. Hazard ratios (HR) for AF hospitalization and all-cause death were calculated with a Cox proportional hazards model. A total of 19,046 patients were analyzed. Over a median follow-up of 42.2 months, 742 (3.9%) patients were hospitalized for AF. Both slower and faster RHR were associated with increased risk of AF hospitalization (HR 1.40, confidence interval [CI] 1.14 to 1.71, p = 0.001, HR 1.23, CI 0.99 to 1.53, p = 0.06 and HR 1.72, CI 1.38 to 2.14, p <0.001, for quartiles 1, 2, and 4, respectively), suggesting a J-shaped relation. Progressive increase in all-cause death was noted with faster RHR (HR1.19 per quartile increase, CI 1.16 to 1.22, p <0.001). These results persisted after adjustment for age, cardiovascular co-morbidities, grade of DD, and β-blocker use. In conclusion, this large, real-world analysis indicates increased risk of incident AF with slower and faster RHR in patients with DD. Randomized trials are needed to evaluate the potential of RHR modification to mitigate the risk of incident AF.
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Affiliation(s)
- Stefan Preisendörfer
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Virginia Singla
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Aditya Bhonsale
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Krishna Kancharla
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Suresh Mulukutla
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew Voigt
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alaa Shalaby
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - N A Mark Estes
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sandeep Jain
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Samir Saba
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Oraii A, Chaumont C, Marchlinski FE, Hyman MC. Rate-adaptive pacing in heart failure with preserved ejection fraction: Too much of a good thing? Heart Rhythm O2 2024; 5:334-337. [PMID: 38840761 PMCID: PMC11148503 DOI: 10.1016/j.hroo.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Affiliation(s)
- Alireza Oraii
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Corentin Chaumont
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E. Marchlinski
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew C. Hyman
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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4
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Infeld M. Accelerated physiologic pacing in patients with heart failure with preserved ejection fraction: An argument in support of therapeutic heart rate modulation. Heart Rhythm O2 2024; 5:327-333. [PMID: 38840759 PMCID: PMC11148487 DOI: 10.1016/j.hroo.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Affiliation(s)
- Margaret Infeld
- Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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Ababei A, Hrib LA, Iancu AC, Hadarag AV, Khebbaiz A, Vătășescu R, Bogdan Ș. Anti-bradycardia pacing-impact on patients with HFpEF: a systematic review. Heart Fail Rev 2024; 29:523-534. [PMID: 38282011 PMCID: PMC10942895 DOI: 10.1007/s10741-024-10382-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 01/30/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) has become an emerging concern. The protective effect of bradycardia in patients with reduced ejection fraction using beta-blockers or ivabradine does not improve symptoms in HFpEF. This review aims to assess current data regarding the impact of anti-bradycardia pacing in patients with HFpEF. A search was conducted on PubMed, ScienceDirect, Springer, and Wiley Online Library, selecting studies from 2013 to 2023. Relevant and eligible prospective studies and randomized controlled trials were included. Functional status, quality of life, and echocardiographic parameters were assessed. Six studies conformed to the selection criteria. Four were prospective studies with a total of 90 patients analyzed. Two were randomized controlled trials with a total of 129 patients assessed. The 6-min walk test (6MWT) and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) score improved in all prospective studies. My-PACE trial showed improvements in MLHFQ score (p < 0.001), significant relative lowering in NT-proBNP levels (p = 0.02), and an increased mean daily activity in the personalized accelerated pacing group compared to usual care. RAPID-HF trial proved that pacemaker implantation to enhance exercise heart rate (HR) did not improve exercise capacity and was associated with increased adverse events. HFpEF requires a more individualized approach and quality of life management. This review demonstrates that higher resting HR by atrial pacing may improve symptoms and even outcomes in HFpEF, while a higher adaptive rate during exertion has not been proven beneficial.
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Affiliation(s)
- Alexandru Ababei
- Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, Sector 5, 050474, Bucharest, Romania
| | - Luciana Andreea Hrib
- Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, Sector 5, 050474, Bucharest, Romania
| | - Adalia Cristiana Iancu
- Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, Sector 5, 050474, Bucharest, Romania.
| | - Andra-Valeria Hadarag
- Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, Sector 5, 050474, Bucharest, Romania
| | - Ahmad Khebbaiz
- Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, Sector 5, 050474, Bucharest, Romania
| | - Radu Vătășescu
- Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, Sector 5, 050474, Bucharest, Romania
- Clinic Emergency Hospital, Bucharest, Romania
| | - Ștefan Bogdan
- Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, Sector 5, 050474, Bucharest, Romania
- Elias Emergency Hospital, Bucharest, Romania
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6
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Wu Y, Song M, Wu M, Lin L. Advances in device-based treatment of heart failure with preserved ejection fraction: evidence from clinical trials. ESC Heart Fail 2024; 11:13-27. [PMID: 37986663 PMCID: PMC10804156 DOI: 10.1002/ehf2.14562] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/10/2023] [Accepted: 10/02/2023] [Indexed: 11/22/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a group of clinical syndromes that exhibit a remarkably heterogeneous phenotype, characterized by symptoms and signs of heart failure, left ventricular diastolic dysfunction, elevated levels of natriuretic peptides, and an ejection fraction greater than or equal to 50%. With the aging of the population and the escalating prevalence of hypertension, obesity, and diabetes, the incidence of HFpEF is progressively rising. Drug therapy options for HFpEF are currently limited, and the associated high risk of cardiovascular mortality and heart failure rehospitalization significantly impact patients' quality of life and longevity while imposing a substantial economic burden on society. Recent research indicates that certain device-based therapies may serve as valuable adjuncts to drug therapy in patients with specific phenotypes of HFpEF, effectively improving symptoms and quality of life while reducing the risk of readmission for heart failure. These include inter-atrial shunt and greater splanchnic nerve ablation to reduce left ventricular filling pressure, implantable heart failure monitor to guide diuresis, left atrial pacing to correct interatrial dyssynchrony, cardiac contractility modulation to enhance cardiac calcium handling, as well as renal denervation, baroreflex activation therapy, and vagus nerve stimulation to restore the autonomic imbalance. In this review, we provide a comprehensive overview of the mechanisms and clinical evidence pertaining to these devices, with the aim of enhancing therapeutic strategies for HFpEF.
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Affiliation(s)
- Ying Wu
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
| | - Meiyan Song
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
| | - Meifang Wu
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
| | - Liming Lin
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
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Wahlberg KJ, Infeld M, Plante TB, Novelli AE, Habel N, Burkhoff D, Barrett T, Lustgarten D, Meyer M. Effects of Continuous Accelerated Pacing on Cardiac Structure and Function in Patients With Heart Failure With Preserved Ejection Fraction: Insights From the myPACE Randomized Clinical Trial. J Am Heart Assoc 2024; 13:e032873. [PMID: 38156545 PMCID: PMC10863817 DOI: 10.1161/jaha.123.032873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/27/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Heart failure with preserved ejection fraction ≥50% is prevalent with few evidence-based therapies. In a trial of patients with heart failure with preserved ejection fraction with specialized pacemakers, treatment with accelerated personalized pacing averaging 75 bpm (myPACE) markedly improved quality of life, NT-proBNP (N-terminal pro-brain natriuretic peptide), physical activity, and atrial fibrillation burden compared with the standard lower rate setting of 60 bpm (usual care). METHODS AND RESULTS In this exploratory study, provider-initiated echocardiographic studies obtained before and after the trial were assessed for changes in left ventricular (LV) structure and function among participants who continued their pacing assignment. The analytic approach aimed to detect differences in standard and advanced echocardiographic parameters within and between study arms. Of the 100 participants, 16 myPACE and 20 usual care arm had a qualifying set of echocardiograms performed a mean (SD) 3 (2.0) years apart. Despite similar baseline echocardiogram measures, sustained exposure to moderately accelerated pacing resulted in reduced septal wall thickness (in cm: myPACE 1.1 [0.2] versus usual care 1.2 [0.2], P=0.008) and lower LV mass to systolic volume ratio (in g/mL: myPACE 4.8 [1.9] versus usual care 6.8 [3.1], P=0.038) accompanied by a minor reduction in LV ejection fraction (in %: myPACE 55 [5] versus usual care 60 [5], P=0.015). These changes were paralleled by improvements in heart failure-related quality of life (myPACE Minnesota Living with Heart Failure Questionnaire improved by 16.1 [13.9] points, whereas usual care worsened by 6.9 [11.6] points, P<0.001). Markers of diastolic function and LV performance were not affected. CONCLUSIONS Exposure to continuous accelerated pacing in heart failure with preserved ejection fraction is associated with a reduced LV wall thickness and a small amount of LV dilation with small reduction in ejection fraction.
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Affiliation(s)
- Kramer J. Wahlberg
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
| | - Margaret Infeld
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
| | - Timothy B. Plante
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
| | - Alexandra E. Novelli
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
| | - Nicole Habel
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
| | | | - Trace Barrett
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
| | - Daniel Lustgarten
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
| | - Markus Meyer
- Department of MedicineUniversity of Vermont Larner College of MedicineBurlingtonVT
- Department of MedicineLillehei Heart Institute, University of Minnesota College of MedicineMinneapolisMN
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Habel N, Infeld M, Bernknopf J, Meyer M, Lustgarten D. Rationale and design of the PACE HFpEF trial: Physiologic accelerated pacing as a holistic treatment of heart failure with preserved ejection fraction. Heart Rhythm O2 2024; 5:41-49. [PMID: 38312209 PMCID: PMC10837182 DOI: 10.1016/j.hroo.2023.12.001] [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] [Indexed: 02/06/2024] Open
Abstract
Background In heart failure with preserved ejection fraction (HFpEF), it has been assumed that pharmacologic heart rate suppression should provide clinical benefits through an increase in diastolic filling time. Contrary to this assumption, heart rate lowering in patients with preserved left ventricular ejection fraction and hypertension or coronary artery disease results in adverse outcomes and suggests that the opposite may be beneficial. Namely, shortening the diastolic filling time with a higher heart rate might normalize the elevated filling pressures that are the sine qua non of HFpEF. Initial clinical studies that assessed the effects of accelerated heart rates in pacemaker patients with preclinical and overt HFpEF provide support for this latter hypothesis, having shown improvements in quality of life, natriuretic peptide and activity levels, and atrial fibrillation burden. Objective The study sought to determine the effects of continued resting heart rate elevation with and without superimposed nocturnal pacing in HFpEF patients without standard pacing indication. Methods The physiologic accelerated pacing as treatment for heart failure with preserved ejection fraction (PACE HFpEF) trial is an investigator-initiated, prospective, patient-blinded multiple crossover pilot study that assesses the impact of accelerated pacing on quality of life, physical activity, N-terminal pro-B-type natriuretic peptide, and echocardiographic measures of cardiac structure and function. Results Twenty patients were enrolled and underwent dual-chamber pacemaker implantation under U.S. Food and Drug Administration investigational device exemption with both atrial and ventricular physiologic lead placement targeting the Bachmann bundle and the His bundle. Conclusion This manuscript describes the rationale and design of the PACE HFpEF trial, which tests the safety and feasibility of continuous accelerated physiological pacing as a treatment strategy in HFpEF.
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Affiliation(s)
- Nicole Habel
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Margaret Infeld
- Cardiovascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Jacob Bernknopf
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Markus Meyer
- Lillehei Heart Institute, Department of Medicine, University of Minnesota College of Medicine, Minneapolis, Minnesota
| | - Daniel Lustgarten
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
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de la Espriella R, Wahlberg KJ, Infeld M, Palau P, Núñez E, Sanchis J, Meyer M, Núñez J. Effect of paced heart rate on quality of life and natriuretic peptides for stage B or C heart failure with preserved ejection fraction: A secondary analysis of the myPACE trial. Eur J Heart Fail 2024; 26:167-176. [PMID: 38124404 DOI: 10.1002/ejhf.3107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
AIM Emerging evidence suggests a beneficial effect of higher heart rates in some patients with heart failure with preserved ejection fraction (HFpEF). This study aimed to evaluate the impact of higher backup pacing rates in HFpEF patients with preexisting pacemaker systems that limit pacemaker-mediated dyssynchrony across left ventricular (LV) volumes and LV ejection fraction (LVEF). METHODS AND RESULTS This is a post-hoc analysis of the myPACE clinical trial that evaluated the effects of personalized accelerated pacing setting (myPACE) versus standard of care on changes in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score, N-terminal pro-brain natriuretic peptide (NT-proBNP), pacemaker-detected activity levels, and atrial fibrillation (AF) burden in patients with HFpEF with preexisting pacemakers. Between-treatment comparisons were performed using linear regression models adjusting for the baseline value of the exposure (ANCOVA design). This study included 93 patients with pre-trial transthoracic echocardiograms available (usual care n = 49; myPACE n = 44). NT-proBNP levels and MLHFQ scores improved in a higher magnitude in the myPACE group at lower indexed LV end-diastolic volumes (iLVEDV) (NT-proBNP-iLVEDV interaction p = 0.006; MLHFQ-iLVEDV interaction p = 0.068). In addition, personalized accelerated pacing led to improved changes in activity levels and NT-proBNP, especially at higher LVEF (activity levels-LVEF interaction p = 0.009; NT-proBNP-LVEF interaction p = 0.058). No evidence of heterogeneity was found across LV volumes or LVEF for pacemaker-detected AF burden. CONCLUSIONS In the post-hoc analysis of the myPACE trial, we observed that the benefits of a personalized accelerated backup pacing on MLHFQ score, NT-proBNP, and pacemaker-detected activity levels appear to be more pronounced in patients with smaller iLVEDV and higher LVEF.
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Affiliation(s)
- Rafael de la Espriella
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Kramer J Wahlberg
- University of Vermont, Larner College of Medicine, Department of Medicine, Burlington, VT, USA
| | - Margaret Infeld
- Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | - Patricia Palau
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
| | - Eduardo Núñez
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Juan Sanchis
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Markus Meyer
- Lillehei Heart Institute, Department of Medicine, University of Minnesota College of Medicine, Minneapolis, MN, USA
| | - Julio Núñez
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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Meyer M. Diastolic Tone-Friend and Foe of Cardiac Performance. Circ Heart Fail 2023; 16:e011307. [PMID: 38113299 DOI: 10.1161/circheartfailure.123.011307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Affiliation(s)
- Markus Meyer
- Department of Medicine, Lillehei Heart Institute, University of Minnesota College of Medicine, Minneapolis
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11
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Meyer M, Infeld M, Habel N, Lustgarten D. Personalized accelerated physiologic pacing. Eur Heart J Suppl 2023; 25:G33-G43. [PMID: 37970518 PMCID: PMC10637836 DOI: 10.1093/eurheartjsupp/suad117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is increasingly prevalent with a high socioeconomic burden. Pharmacological heart rate lowering was recommended to improve ventricular filling in HFpEF. This article discusses the misperceptions that have resulted in an overprescription of beta-blockers, which in all likelihood have untoward effects on patients with HFpEF, even if they have atrial fibrillation or coronary artery disease as a comorbidity. Directly contradicting the lower heart rate paradigm, faster heart rates provide haemodynamic and structural benefits, amongst which lower cardiac filling pressures and improved ventricular capacitance may be most important. Safe delivery of this therapeutic approach is feasible with atrial and ventricular conduction system pacing that aims to emulate or enhance cardiac excitation to maximize the haemodynamic benefits of accelerated pacing. This conceptual framework was first tested in the myPACE randomized controlled trial of patients with pre-existing pacemakers and preclinical or overt HFpEF. This article provides the background and path towards this treatment approach.
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Affiliation(s)
- Markus Meyer
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, 111 Colchester Avenue, McClure Level 1, Burlington, VT 05401, USA
- Department of Medicine, Lillehei Heart Institute, University of Minnesota College of Medicine, 2231 6th St. SE, 4-165 CCRB, Minneapolis, MN 55455, USA
| | - Margaret Infeld
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, 111 Colchester Avenue, McClure Level 1, Burlington, VT 05401, USA
- Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, 800 Washington Street, Boston, MA 02111, USA
| | - Nicole Habel
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, 111 Colchester Avenue, McClure Level 1, Burlington, VT 05401, USA
| | - Daniel Lustgarten
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, 111 Colchester Avenue, McClure Level 1, Burlington, VT 05401, USA
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12
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Infeld M, Lustgarten DL, Meyer M. Comments on the myPACE Randomized Clinical Trial-Reply. JAMA Cardiol 2023; 8:795. [PMID: 37378996 DOI: 10.1001/jamacardio.2023.1746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Affiliation(s)
- Margaret Infeld
- Division of Cardiology, Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Daniel L Lustgarten
- Division of Cardiology, Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Markus Meyer
- Division of Cardiology, Department of Medicine, University of Vermont Larner College of Medicine, Burlington
- Lillehei Heart Institute, Department of Medicine, University of Minnesota College of Medicine, Minneapolis
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13
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Habel N, du Fay de Lavallaz J, Infeld M, Koehler JL, Ziegler PD, Lustgarten DL, Meyer M. Lower heart rates and beta-blockers are associated with new-onset atrial fibrillation. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2023; 17:200182. [PMID: 36911071 PMCID: PMC9996284 DOI: 10.1016/j.ijcrp.2023.200182] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/07/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023]
Abstract
Background Lower heart rates (HRs) prolong diastole, which increases filling pressures and wall stress. As a result, lower HRs may be associated with higher brain natriuretic peptide (BNP) levels and incident atrial fibrillation (AF). Beta-blockers may increase the risk for AF due to suppression of resting HRs. Objective Examine the relationships of HR, BNP, beta-blockers and new-onset AF in the REVEAL-AF and SPRINT cohort of subjects at risk for developing AF. Methods In REVEAL-AF, 383 subjects without a history of AF and a mean CHA2DS2VASC score of 4.4 ± 1.3 received an insertable cardiac monitor and were followed up to 30 months. In SPRINT, 7595 patients without prior history of AF and a mean CHA2DS2VASC score of 2.3 ± 1.2 were followed up to 60 months. Results The median daytime HR in the REVEAL-AF cohort was 75bpm [IQR 68-83]. Subjects with below-median HRs had 2.4-fold higher BNP levels compared to subjects with above-median HRs (median BNP [IQR]: 62 pg/dl [37-112] vs. 26 pg/dl [13-53], p < 0.001). HRs <75bpm were associated with a higher incidence of AF: 37% vs. 27%, p < 0.05. This was validated in the SPRINT cohort after adjusting for AF risk factors. Both a HR < 75bpm and beta-blocker use were associated with a higher rate of AF: 1.9 vs 0.7% (p < 0.001) and 2.5% vs. 0.6% (p < 0.001), respectively. The hazard ratio for patients on beta-blockers to develop AF was 3.72 [CI 2.32, 5.96], p < 0.001. Conclusions Lower HRs are associated with higher BNP levels and incident AF, mimicking the hemodynamic effects of diastolic dysfunction. Suppression of resting HR by beta-blockers could explain their association with incident AF.
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Affiliation(s)
- Nicole Habel
- University of Vermont Larner College of Medicine, Department of Medicine, Division of Cardiology, Burlington, VT, 05401, USA
| | | | - Margaret Infeld
- University of Vermont Larner College of Medicine, Department of Medicine, Division of Cardiology, Burlington, VT, 05401, USA
| | - Jodi L Koehler
- Medtronic, Diagnostics and Monitoring Research, Mounds View, MN, 55112, USA
| | - Paul D Ziegler
- Medtronic, Diagnostics and Monitoring Research, Mounds View, MN, 55112, USA
| | - Daniel L Lustgarten
- University of Vermont Larner College of Medicine, Department of Medicine, Division of Cardiology, Burlington, VT, 05401, USA
| | - Markus Meyer
- Lillehei Heart Institute, University of Minnesota College of Medicine, Department of Medicine, Minneapolis, MN, 55455, USA
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14
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Affiliation(s)
- Dalane W Kitzman
- Sections on Cardiovascular Medicine and Geriatrics, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Bharathi Upadhya
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
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Infeld M, Wahlberg K, Cicero J, Plante TB, Meagher S, Novelli A, Habel N, Krishnan AM, Silverman DN, LeWinter MM, Lustgarten DL, Meyer M. Effect of Personalized Accelerated Pacing on Quality of Life, Physical Activity, and Atrial Fibrillation in Patients With Preclinical and Overt Heart Failure With Preserved Ejection Fraction: The myPACE Randomized Clinical Trial. JAMA Cardiol 2023; 8:213-221. [PMID: 36723919 PMCID: PMC9996402 DOI: 10.1001/jamacardio.2022.5320] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 12/02/2022] [Indexed: 02/02/2023]
Abstract
Importance Patients with heart failure with preserved ejection fraction (HFpEF) with a pacemaker may benefit from a higher, more physiologic backup heart rate than the nominal 60 beats per minute (bpm) setting. Objective To assess the effects of a moderately accelerated personalized backup heart rate compared with 60 bpm (usual care) in patients with preexisting pacemaker systems that limit pacemaker-mediated dyssynchrony. Design, Setting, and Participants This blinded randomized clinical trial enrolled patients with stage B and C HFpEF from the University of Vermont Medical Center pacemaker clinic between June 2019 and November 2020. Analysis was modified intention to treat. Interventions Participants were randomly assigned to personalized accelerated pacing or usual care and were followed up for 1 year. The personalized accelerated pacing heart rate was calculated using a resting heart rate algorithm based on height and modified by ejection fraction. Main Outcomes and Measures The primary outcome was the serial change in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score. Secondary end points were changes in N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, pacemaker-detected physical activity, atrial fibrillation from baseline, and adverse clinical events. Results Overall, 107 participants were randomly assigned to the personalized accelerated pacing (n = 50) or usual care (n = 57) groups. The median (IQR) age was 75 (69-81) years, and 48 (48%) were female. Over 1-year follow-up, the median (IQR) pacemaker-detected heart rate was 75 (75-80) bpm in the personalized accelerated pacing arm and 65 (63-68) bpm in usual care. MLHFQ scores improved in the personalized accelerated pacing group (median [IQR] baseline MLHFQ score, 26 [8-45]; at 1 month, 15 [2-25]; at 1 year, 9 [4-21]; P < .001) and worsened with usual care (median [IQR] baseline MLHFQ score, 19 [6-42]; at 1 month, 23 [5-39]; at 1 year, 27 [7-52]; P = .03). In addition, personalized accelerated pacing led to improved changes in NT-proBNP levels (mean [SD] decrease of 109 [498] pg/dL vs increase of 128 [537] pg/dL with usual care; P = .02), activity levels (mean [SD], +47 [67] minutes per day vs -22 [35] minutes per day with usual care; P < .001), and device-detected atrial fibrillation (27% relative risk reduction compared with usual care; P = .04) over 1-year of follow-up. Adverse clinical events occurred in 4 patients in the personalized accelerated pacing group and 11 patients in usual care. Conclusions and Relevance In this study, among patients with HFpEF and pacemakers, treatment with a moderately accelerated, personalized pacing rate was safe and improved quality of life, NT-proBNP levels, physical activity, and atrial fibrillation compared with the usual 60 bpm setting. Trial Registration ClinicalTrials.gov Identifier: NCT04721314.
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Affiliation(s)
- Margaret Infeld
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Kramer Wahlberg
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Jillian Cicero
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Timothy B. Plante
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Sean Meagher
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Alexandra Novelli
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Nicole Habel
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Anand Muthu Krishnan
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Daniel N. Silverman
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston
| | - Martin M. LeWinter
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Daniel L. Lustgarten
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Markus Meyer
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington
- Lillehei Heart Institute, Department of Medicine, University of Minnesota College of Medicine, Minneapolis
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Tanaka H, Yamauchi Y, Imanishi J, Hatani Y, Odajima S, Okamoto H, Hayashi T, Hirata KI. Effect of Ivabradine on Left Ventricular Diastolic Function of Patients With Preserved Ejection Fraction ― Results of the IVA-PEF Study ―. Circ Rep 2022; 4:499-504. [PMID: 36304432 PMCID: PMC9535126 DOI: 10.1253/circrep.cr-22-0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/21/2022] [Accepted: 09/02/2022] [Indexed: 11/14/2022] Open
Abstract
Background: The association between heart rate (HR) reductions caused by ivabradine and left ventricular (LV) diastolic function in heart failure with preserved ejection fraction (HFpEF) remains uncertain because of off-label use. Thus, the present study investigated the effect of HR reductions by ivabradine on LV diastolic function in HFpEF patients. Methods and Results: This study enrolled 16 HFpEF patients with HR ≥75 beats/min. After 3 months administration of ivabradine, no significant changes were observed in mitral inflow E and mitral e’ annular velocities, B-type natriuretic peptide, or left atrial volume index, but there were significant improvements in global longitudinal strain. Conclusions: Ivabradine did not improve LV diastolic function for HFpEF patients with HR ≥75 beats/min. Because this may be due to some study limitations, further studies should be conducted.
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Affiliation(s)
- Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Yuki Yamauchi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Junichi Imanishi
- Department of Cardiology, Hyogo Prefectural Awaji Medical Center
| | - Yutaka Hatani
- Department of Cardiology, Hyogo Prefectural Awaji Medical Center
| | - Susumu Odajima
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | | | | | - Ken-ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
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17
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Nelson G, Ye B, Schock M, Lustgarten DL, Mayhew EK, Palmer BM, Meyer M. Heart rate changes and myocardial sodium. Physiol Rep 2022; 10:e15446. [PMID: 36065860 PMCID: PMC9446395 DOI: 10.14814/phy2.15446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/14/2022] [Accepted: 08/14/2022] [Indexed: 06/15/2023] Open
Abstract
Historic studies with sodium ion (Na+ ) micropipettes and first-generation fluorescent probes suggested that an increase in heart rate results in higher intracellular Na+ -levels. Using a dual fluorescence indicator approach, we simultaneously assessed the dynamic changes in intracellular Na+ and calcium (Ca2+ ) with measures of force development in isolated excitable myocardial strip preparations from rat and human left ventricular myocardium at different stimulation rates and modeled the Na+ -effects on the sodium-calcium exchanger (NCX). To gain further insight into the effects of heart rate on intracellular Na+ -regulation and sodium/potassium ATPase (NKA) function, Na+ , and potassium ion (K+ ) levels were assessed in the coronary effluent (CE) of paced human subjects. Increasing the stimulation rate from 60/min to 180/min led to a transient Na+ -peak followed by a lower Na+ -level, whereas the return to 60/min had the opposite effect leading to a transient Na+ -trough followed by a higher Na+ -level. The presence of the Na+ -peak and trough suggests a delayed regulation of NKA activity in response to changes in heart rate. This was clinically confirmed in the pacing study where CE-K+ levels were raised above steady-state levels with rapid pacing and reduced after pacing cessation. Despite an initial Na+ peak that is due to a delayed increase in NKA activity, an increase in heart rate was associated with lower, and not higher, Na+ -levels in the myocardium. The dynamic changes in Na+ unveil the adaptive role of NKA to maintain Na+ and K+ -gradients that preserve membrane potential and cellular Ca2+ -hemostasis.
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Affiliation(s)
- Gabrielle Nelson
- Department of MedicineLillehei Heart Institute, University of Minnesota College of MedicineMinneapolisMinnesotaUSA
| | - Bo Ye
- Department of MedicineLillehei Heart Institute, University of Minnesota College of MedicineMinneapolisMinnesotaUSA
| | - Morgan Schock
- Department of MedicineLillehei Heart Institute, University of Minnesota College of MedicineMinneapolisMinnesotaUSA
| | - Daniel L. Lustgarten
- Department of Medicine and PhysiologyUniversity of Vermont Larner College of MedicineBurlingtonVermontUSA
| | - Elisabeth K. Mayhew
- Department of Medicine and PhysiologyUniversity of Vermont Larner College of MedicineBurlingtonVermontUSA
| | - Bradley M. Palmer
- Department of Medicine and PhysiologyUniversity of Vermont Larner College of MedicineBurlingtonVermontUSA
| | - Markus Meyer
- Department of MedicineLillehei Heart Institute, University of Minnesota College of MedicineMinneapolisMinnesotaUSA
- Department of Medicine and PhysiologyUniversity of Vermont Larner College of MedicineBurlingtonVermontUSA
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18
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Kagami K, Harada T, Ishii H, Obokata M. Key Phenotypes of Heart Failure with Preserved Ejection Fraction. Cardiol Clin 2022; 40:415-429. [DOI: 10.1016/j.ccl.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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19
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Kagami K, Obokata M, Harada T, Kato T, Wada N, Adachi T, Ishii H. Diastolic Filling Time, Chronotropic Response, and Exercise Capacity in Heart Failure and Preserved Ejection Fraction With Sinus Rhythm. J Am Heart Assoc 2022; 11:e026009. [PMID: 35766289 PMCID: PMC9333393 DOI: 10.1161/jaha.121.026009] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Exercise‐induced high heart rate may impair exercise tolerance by reducing diastolic filling time and ventricular filling in heart failure with preserved ejection fraction (HFpEF). Given the importance of chronotropic response, we hypothesized that reduction in diastolic filling time because of exercise‐induced increased heart rate would not impair cardiac output reserve and exercise capacity. We sought to determine the association between heart rate, diastolic filling time, hemodynamics, and exercise capacity in HFpEF. Methods and Results Patients with HFpEF (n=66) and controls without HF (n=107) underwent bicycle exercise echocardiography with simultaneous expired gas analysis to measure oxygen consumption. Diastolic filling time was assessed by the overlap time between mitral E‐ and A‐waves (longer overlap time indicates shorter diastolic filling duration). Overlap time increased (ie, diastolic filling time shortened) in HFpEF and controls as heart rate increased with exercise, and the relationship was similar between the groups. Greater heart rate response correlated with higher cardiac output (r=0.51, P<0.0001) and oxygen consumption (r=0.50, P<0.0001) during peak exercise. Shorter diastolic filling time, as assessed by longer overlap time, was correlated with higher cardiac output (r=0.47, P<0.0001) and peak oxygen consumption (r=0.38, P=0.007), not with E/e′ or right ventricular‐pulmonary artery uncoupling. Longer overlap time was associated with mitral A velocity (r=0.53, P<0.0001) and left atrial booster pump strain (r=0.42, P<0.0001). Conclusions Shortening of diastolic filling interval in tandem with increased heart rate during exercise does not limit cardiac output reserve or exercise capacity in HFpEF.
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Affiliation(s)
- Kazuki Kagami
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan.,Division of Cardiovascular Medicine National Defense Medical College Tokorozawa, Saitama Japan
| | - Masaru Obokata
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Tomonari Harada
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Naoki Wada
- Department of Rehabilitation Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Takeshi Adachi
- Division of Cardiovascular Medicine National Defense Medical College Tokorozawa, Saitama Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
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20
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Li H, Xia YY, Xia CL, Li Z, Shi Y, Li XB, Zhang JX. Mimicking Metabolic Disturbance in Establishing Animal Models of Heart Failure With Preserved Ejection Fraction. Front Physiol 2022; 13:879214. [PMID: 35592030 PMCID: PMC9110887 DOI: 10.3389/fphys.2022.879214] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 03/30/2022] [Indexed: 01/10/2023] Open
Abstract
Heart failure (HF), the terminal state of different heart diseases, imposed a significant health care burden worldwide. It is the last battlefield in dealing with cardiovascular diseases. HF with preserved ejection fraction (HFpEF) is a type of HF in which the symptoms and signs of HF are mainly ascribed to diastolic dysfunction of left ventricle, whereas systolic function is normal or near-normal. Compared to HF with reduced ejection fraction (HFrEF), the diagnosis and treatment of HFpEF have made limited progress, partly due to the lack of suitable animal models for translational studies in the past. Given metabolic disturbance and inflammatory burden contribute to HFpEF pathogenesis, recent years have witnessed emerging studies focusing on construction of animal models with HFpEF phenotype by mimicking metabolic disorders. These models prefer to recapitulate the metabolic disorders and endothelial dysfunction, leading to the more detailed understanding of the entity. In this review, we summarize the currently available animal models of HFpEF with metabolic disorders, as well as their advantages and disadvantages as tools for translational studies.
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Affiliation(s)
- Hui Li
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yi-Yuan Xia
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chun-Lei Xia
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Intensive Medicine, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Zheng Li
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yi Shi
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiao-Bo Li
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- *Correspondence: Xiao-Bo Li, ; Jun-Xia Zhang,
| | - Jun-Xia Zhang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- *Correspondence: Xiao-Bo Li, ; Jun-Xia Zhang,
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21
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Infeld M, Wahlberg K, Cicero J, Meagher S, Habel N, Muthu Krishnan A, Silverman DN, Lustgarten DL, Meyer M. Personalized pacing for diastolic dysfunction and heart failure with preserved ejection fraction: Design and rationale for the myPACE randomized controlled trial. Heart Rhythm O2 2021; 3:109-116. [PMID: 35243443 PMCID: PMC8859799 DOI: 10.1016/j.hroo.2021.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Patients with pacemakers and heart failure with preserved ejection fraction (HFpEF) or isolated diastolic dysfunction (DD) may benefit from a higher backup heart rate (HR) setting compared with the standard setting of 60 bpm. Objective The purpose of this study was to assess the effects of a personalized backup HR setting (myPACE group) compared with 60 bpm (control group). Methods In this prospective, blinded, randomized controlled study, pacemaker patients with DD or HFpEF and atrial pacing with intrinsic ventricular conduction or conduction system or biventricular pacing are randomized to the myPACE group or control group for 1 year. The primary outcome is the change in Minnesota Living with Heart Failure Questionnaire (MLHFQ) scores. Secondary endpoints include changes in N-terminal pro–brain natriuretic peptide levels, physical and emotional MLHFQ subscores, and pacemaker-detected atrial arrhythmia burden, patient activity levels, and thoracic impedance; hospitalization for heart failure, atrial fibrillation, cerebrovascular accident, or myocardial infarction; and loop diuretic or antiarrhythmic medication initiation or up-titration. A sample size of 118 subjects is expected to allow detection of a 5-point change in MLHFQ score in an intention-to-treat analysis and allow initial assessment of clinical outcomes and subgroup analyses. Results Enrollment began in July 2019. As of November 2020, 107 subjects have been enrolled. It is projected that the 1-year follow-up will be completed by December 2021. Conclusion Atrial pacing with intrinsic ventricular conduction or advanced ventricular pacing at a higher, personalized backup HR may be a therapeutic target for patients with isolated DD or HFpEF. The myPACE trial is designed to test this hypothesis.
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22
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Echocardiography in the diagnostic evaluation and phenotyping of heart failure with preserved ejection fraction. J Cardiol 2021; 79:679-690. [PMID: 34857430 DOI: 10.1016/j.jjcc.2021.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/05/2021] [Indexed: 12/19/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) represents one of the greatest unmet needs in modern cardiology given its diagnostic difficulty and limited therapeutic options. Echocardiography provides valuable information on cardiac structure, function, and hemodynamics and plays a central role in the evaluation of HFpEF. Echocardiography is crucial in identifying HFpEF among patients with dyspnea, especially when overt congestion is absent. The combination of echocardiographic indices of diastolic function, clinical characteristics, and natriuretic peptide tests has been proposed in the diagnostic evaluation of patients with suspected HFpEF. Echocardiography also provides valuable insight into the pathophysiology and underlying phenotypes of HFpEF. Exercise stress echocardiography can also detect abnormalities that develop only during exercise. This may enhance the diagnosis of HFpEF by demonstrating elevation in the left ventricular filling pressure and may have potential for better pathophysiological characterization. This review focuses on the role of echocardiography in the diagnostic evaluation and phenotyping of HFpEF. We also discuss the potential role of exercise stress echocardiography for the diagnosis and disease phenotyping of HFpEF.
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23
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Averin AS, Zakharova NM, Tarlachkov SV. Effect of Cooling on Force-Frequency Relationship, Rest Potentiation, and Frequency-Dependent Acceleration of Relaxation in the Guinea Pig Myocardium. J EVOL BIOCHEM PHYS+ 2021. [DOI: 10.1134/s0022093021040025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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24
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Silverman DN, Rambod M, Lustgarten DL, Lobel R, LeWinter MM, Meyer M. Heart Rate-Induced Myocardial Ca 2+ Retention and Left Ventricular Volume Loss in Patients With Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2020; 9:e017215. [PMID: 32856526 PMCID: PMC7660766 DOI: 10.1161/jaha.120.017215] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Increases in heart rate are thought to result in incomplete left ventricular (LV) relaxation and elevated filling pressures in patients with heart failure with preserved ejection fraction (HFpEF). Experimental studies in isolated human myocardium have suggested that incomplete relaxation is a result of cellular Ca2+ overload caused by increased myocardial Na+ levels. We tested these heart rate paradigms in patients with HFpEF and referent controls without hypertension. Methods and Results In 22 fully sedated and instrumented patients (12 controls and 10 patients with HFpEF) in sinus rhythm with a preserved ejection fraction (≥50%) we assessed left‐sided filling pressures and volumes in sinus rhythm and with atrial pacing (95 beats per minute and 125 beats per minute) before atrial fibrillation ablation. Coronary sinus blood samples and flow measurements were also obtained. Seven women and 15 men were studied (aged 59±10 years, ejection fraction 61%±4%). Patients with HFpEF had a history of hypertension, dyspnea on exertion, concentric LV remodeling and a dilated left atrium, whereas controls did not. Pacing at 125 beats per minute lowered the mean LV end‐diastolic pressure in both groups (controls −4.3±4.1 mm Hg versus patients with HFpEF −8.5±6.0 mm Hg, P=0.08). Pacing also reduced LV end‐diastolic volumes. The volume loss was about twice as much in the HFpEF group (controls −15%±14% versus patients with HFpEF −32%±11%, P=0.009). Coronary venous [Ca2+] increased after pacing at 125 beats per minute in patients with HFpEF but not in controls. [Na+] did not change. Conclusions Higher resting heart rates are associated with lower filling pressures in patients with and without HFpEF. Incomplete relaxation and LV filling at high heart rates lead to a reduction in LV volumes that is more pronounced in patients with HFpEF and may be associated with myocardial Ca2+ retention.
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Affiliation(s)
- Daniel N Silverman
- Division of Cardiology Department of Medicine Medical University of South Carolina Charleston SC
| | - Mehdi Rambod
- Cardiology Division Department of Medicine Larner College of Medicine at the University of Vermont Burlington VT
| | - Daniel L Lustgarten
- Cardiology Division Department of Medicine Larner College of Medicine at the University of Vermont Burlington VT
| | - Robert Lobel
- Cardiology Division Department of Medicine Larner College of Medicine at the University of Vermont Burlington VT
| | - Martin M LeWinter
- Cardiology Division Department of Medicine Larner College of Medicine at the University of Vermont Burlington VT
| | - Markus Meyer
- Cardiology Division Department of Medicine Larner College of Medicine at the University of Vermont Burlington VT.,Cardiology Division Department of Medicine University of Minnesota College of Medicine Minneapolis MN
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