Sympathetic nervous system activation and heart failure: Current state of evidence and the pathophysiology in the light of novel biomarkers

The effects of SGLT2i on cardiac metabolism in patients with HFpEF: Fact or fiction?

The rising prevalence of Type 2 diabetes (T2D) has been closely associated with an increased incidence of cardiovascular diseases, particularly heart failure with preserved ejection fraction (HFpEF). Cardiometabolic disturbances in T2D, such as insulin resistance, hyperglycemia, and dyslipidemia, contribute to both microvascular and macrovascular complications, thereby intensifying the risk of heart failure. Sodium-glucose cotransporter-2 inhibitors (SGLT2i), initially developed as glucose-lowering agents for T2D, have demonstrated promising cardiovascular benefits in patients with heart failure, including those with preserved ejection fraction (HFpEF), regardless of T2D status. These benefits include reduced heart failure hospitalization rates and improvements in various metabolic parameters. This review aims to critically examine the effects of SGLT2i on cardiac metabolism in HFpEF, evaluating whether the observed benefits can truly be attributed to their impact on myocardial energy regulation or whether they represent other, potentially confounding, mechanisms. We will focus on the key metabolic processes possibly modulated by SGLT2i, including myocardial glucose utilization, fatty acid oxidation, and mitochondrial function, and explore their effects on heart failure pathophysiology. Additionally, we will address the role of SGLT2i in other pathogenetic factors involved in HFpEF, such as sodium and fluid balance, inflammation, and fibrosis, and question the extent to which these mechanisms contribute to the observed clinical benefits. By synthesizing the current evidence, this review will provide an in-depth analysis of the mechanisms through which SGLT2i may influence cardiac metabolism in HFpEF, assessing whether their effects are supported by robust scientific data or remain speculative. We will also discuss the potential for personalized treatment strategies, based on individual patient characteristics, to optimize the therapeutic benefits of SGLT2i in managing both T2D and cardiovascular risk. This review seeks to clarify the true clinical utility of SGLT2i in the management of cardiometabolic diseases and HFpEF, offering insights into their role in improving long-term cardiovascular outcomes.

Gut Microbiota and Cardiovascular Diseases: Unraveling the Role of Dysbiosis and Microbial Metabolites

Cardiovascular diseases (CVDs), including heart failure (HF), hypertension, myocardial infarction (MI), and atherosclerosis, are increasingly linked to gut microbiota dysbiosis and its metabolic byproducts. HF, affecting over 64 million individuals globally, is associated with systemic inflammation and gut barrier dysfunction, exacerbating disease progression. Similarly, hypertension and MI correlate with reduced microbial diversity and an abundance of pro-inflammatory bacteria, contributing to vascular inflammation and increased cardiovascular risk. Atherosclerosis is also influenced by gut dysbiosis, with key microbial metabolites such as trimethylamine-N-oxide (TMAO) and short-chain fatty acids (SCFAs) playing crucial roles in disease pathogenesis. Emerging evidence highlights the therapeutic potential of natural compounds, including flavonoids, omega-3 fatty acids, resveratrol, curcumin, and marine-derived bioactives, which modulate the gut microbiota and confer cardioprotective effects. These insights underscore the gut microbiota as a critical regulator of cardiovascular health, suggesting that targeting dysbiosis may offer novel preventive and therapeutic strategies. Further research is needed to elucidate underlying mechanisms and optimize microbiome-based interventions for improved cardiovascular outcomes.

Stellate Ganglia: A Key Therapeutic Target for Malignant Ventricular Arrhythmia in Heart Disease

Malignant ventricular arrhythmias (VAs), such as ventricular tachycardia and ventricular fibrillation, are the cause of approximately half a million deaths per year in the United States, which is a common lethal event in heart disease, such as hypertension, catecholaminergic polymorphic ventricular tachycardia, takotsubo cardiomyopathy, long-QT syndrome, and progressing into advanced heart failure. A common characteristic of these heart diseases, and the subsequent development of VAs, is the overactivation of the sympathetic nervous system. Current treatments for VAs in these heart diseases, such as β-adrenergic receptor blockers and cardiac sympathetic ablation, aim at inhibiting cardiac sympathetic overactivation. However, these treatments do not translate into becoming efficacious as long-term suppressors of ventricular tachycardia/ventricular fibrillation events. As a key regulatory component in the heart, cardiac postganglionic sympathetic neurons residing in the stellate ganglia (SGs) release neurotransmitters (such as norepinephrine and NPY [neuropeptide Y]) to perform their regulatory role in dictating cardiac function. Growing evidence from animal experiments and clinical studies has demonstrated that the remodeling of the SG may be intimately involved in malignant arrhythmogenesis. This identifies the SG as a key potential therapeutic target for the treatment of malignant VAs in heart disease. Therefore, this review summarizes the role of SG in ventricular arrhythmogenesis and updates the novel targeting of SG for clinical treatment of VAs in heart disease.

Elevated serum amylase concentrations are associated with worse in-hospital outcomes among patients with acute myocardial infarction

BACKGROUND

In light of the well-established connection between sympathetic overactivity and early adverse events in myocardial infarction (MI) patients, this study aims to explore the potential association between serum amylase levels and in-hospital outcomes in patients with acute MI.

METHODS

Patients aged ≥ 18 years that were hospitalized due to acute MI were prospectively included in the present study. All patients underwent clinical and laboratory examination, transthoracic echocardiography and were referred for invasive cardiology work-up as needed. Blood sample for serum amylase measurement were obtained at the time of admission, using the spectrophotometric method. A composite outcome, comprising death, ventricular tachycardia, 3rd degree atrioventricular block, instances requiring cardiopulmonary resuscitation, and transfer for cardiac surgery, was formulated for the present analysis and was the principal outcome of interest.

RESULTS

A total of 202 patients were included in the present analysis. Patients who met the composite outcome exhibited significantly higher serum amylase levels than the counterparts who have not (55 (41-75) U/L vs. 87 (53-122) U/L, p < 0.001). Multivariate analysis revealed that amylase levels predicted the composite outcome independent of age, sex, acute MI type, serum creatinine, and cardiac troponin (adjusted odds ratio [aOR] 1.021, 95% confidence interval [CI] 1.008-1.034, p = 0.001). Additionally, a weak but significant association was observed between serum amylase levels and GRACE score (r = 0.25, p < 0.001).

CONCLUSION

The findings suggest that serum amylase concentration at admission might be used as a simple, non-invasive indicator of increased sympathetic activity and adverse in-hospital outcomes in patients with acute MI.

Multi-Organ Denervation: The Past, Present and Future

The sympathetic division of the autonomic nervous system plays a crucial role in maintaining homeostasis, but its overactivity is implicated in various pathological conditions, including hypertension, hyperglycaemia, heart failure, and rheumatoid arthritis. Traditional pharmacotherapies often face limitations such as side effects and poor patient adherence, thus prompting the exploration of device-based multi-organ denervation as a therapeutic strategy. Crucially, this procedure can potentially offer therapeutic benefits throughout the 24 h circadian cycle, described as an "always-on" effect independent of medication compliance and pharmacokinetics. In this comprehensive review, we evaluate the evidence behind targeted multi-organ sympathetic denervation by considering the anatomy and function of the autonomic nervous system, examining the evidence linking sympathetic nervous system overactivity to various cardiometabolic and inflammatory conditions and exploring denervation studies within the literature. So far, renal denervation, developed in 2010, has shown promise in reducing blood pressure and may have broader applications for conditions including arrhythmias, glucose metabolism disorders, heart failure, chronic kidney disease and obstructive sleep apnoea. We review the existing literature surrounding the denervation of other organ systems including the hepatic and splenic arteries, as well as the pulmonary artery and carotid body, which may provide additional physiological benefits and enhance therapeutic effects if carried out simultaneously. Furthermore, we highlight the challenges and future directions for implementing multi-organ sympathetic ablation, emphasising the need for further clinical trials to establish optimal procedural technique, efficacy and safety.

Network meta-analysis on efficacy of nerve stimulation or modulation in patients with heart failure

BACKGROUND

Dysfunction of the autonomic nervous system (characterized by excessive sympathetic activation and reduced parasympathetic activity) is regarded as 1 of the primary mechanisms of heart failure. Theoretically, nerve stimulation or modulation targeting this autonomic imbalance could improve outcomes in heart failure, but current evidence is inconclusive.

OBJECTIVE

This systematic review and network meta-analysis (NMA) aimed to compare the efficacy of various nerve stimulation/modulation approaches in patients with heart failure.

METHODS

We conducted a frequentist-based NMA of randomized controlled trials (RCTs) investigating nerve stimulation or modulation techniques for heart failure management. The primary outcomes included objective measures (such as brain natriuretic peptide [BNP] serum levels) and subjective measures (such as psychosocial functioning and quality of life).

RESULTS

Interventions targeting both arms of the autonomic nervous system, including sympathetic and parasympathetic nervous systems, and the vasculature (carotid or renal arteries) demonstrated preferable results. Interventions dealing only with the autonomic nervous system did not provide significant results. Specifically, only renal sympathetic denervation was significantly associated with a more significant reduction in BNP levels than in the control group. Additionally, baroreflex activation therapy was the only treatment significantly associated with improving quality of life.

CONCLUSION

This study provides comparative evidence supporting the use of specific nerve stimulation/modulation techniques in treating heart failure. Further well-designed RCTs, incorporating appropriate blinding, are recommended to minimize potential biases.

Undiagnosed Insulinoma in a Young Patient With Idiopathic Dilated Cardiomyopathy: A Case Report

Insulinomas are rare pancreatic tumors that present with symptoms of hypoglycemia secondary to unregulated high levels of insulin. Literature has described that recurrent hypoglycemic events induce a sympathetic drive that could compromise cardiac function. Tumor resection eliminates the hypoglycemia source, halting the cycle of sympathetic overdrive and improving cardiac function. We present the case of a 43-year-old patient who was hospitalized after a recent gastric bypass for recurrent episodes of confusion, mumbling, night terrors, and low glucose levels. She also had a chronic diagnosis of idiopathic dilated cardiomyopathy and heart failure with an ejection fraction of 30%. Imaging and laboratory studies demonstrated the presence of insulinoma. She underwent tumor resection with improvement in her exercise tolerance. Her ejection fraction improved from 30% to 35-40% eight months post-resection. This case is intended to review current data on the possible association between insulinomas and heart disease. To the best of our knowledge, our report stands out as one of the few case studies available that explores this potential association. It is crucial to recognize that tumor resection can significantly enhance cardiac function, making it imperative to thoroughly investigate the diverse cardiovascular effects linked to insulinomas.

Influence of Primary Neurologic Disease on Cardiovascular Health in Females

Neurocardiology is an interdisciplinary field that examines the complex interactions between the nervous and the cardiovascular systems, exploring how neurological processes, such as autonomic nervous system regulation and brain-heart communication impact heart function and contribute to cardiovascular health and disease. Although much of the focus on cardiovascular health has centered on traditional risk factors, the influence of the nervous system, especially in females, is increasingly recognized as a key determinant of cardiovascular outcomes. This article reviews existing literature on the neurological mechanisms that impact cardiovascular function in females. Specifically, we analyze how primary neurological disorders including cerebrovascular disease, headache disorders, and multiple sclerosis have specific downstream effects on cardiac function. By understanding the complex relationship between neurological and cardiovascular health, this review highlights the need for sex-specific approaches to prevention, diagnosis, and treatment of cardiovascular disease in females, ultimately encouraging the discovery of more effective care strategies and improving health outcomes.

Acute mental stress-induced alpha or beta-adrenergic reactivity patterns linked to unique cardiometabolic risk profiles

Cardiometabolic risk may differ based on a stress-induced alpha(α)-adrenergic response versus a predominant beta(β)-adrenergic response. Whether these responses might serve as significant markers of distinct cardiometabolic risk profiles based on hemodynamic reactivity remain unknown. We (1) characterized predominant α-and β-adrenergic hemodynamic response patterns to acute mental stress; and (2) determined the cardiometabolic risk profile within predominant α-or β-adrenergic responders, irrespective of age, sex, or ethnicity. We included 117 South African teachers (aged 20-65 years) and administered an acute mental stress task (Color-Word-Conflict test) for one-minute. Participants' hemodynamic response profiles were characterized as predominant α-adrenergic (decreases in cardiac output (CO) and Windkessel arterial compliance (Cwk) (lowest quartile)) (n = 48) and β-adrenergic (increases in CO, Cwk (highest quartile)) responses (n = 69) via Finometer beat-to-beat hemodynamic monitoring. Ambulatory-BP was measured and the number of 24 H-ischemic events determined by ECG. Cardiometabolic markers were analyzed using fasting blood samples, and abnormal glucose tolerance (Abnl-GT), combining prediabetes and diabetes, was defined as glycated hemoglobin (HbA1c) ≥ 5.7% and/or fasting glucose > 100 mg/dL and/or diabetes medication usage. Predominant α-adrenergic responders presented with an overall poorer cardiometabolic profile, with higher levels of HbA1c, insulin, greater insulin resistance and higher total cholesterol and lower HDL-cholesterol. Adjusted analyses indicated that a predominant α-adrenergic profile had higher odds of central obesity (P = 0.031), low HDL-cholesterol (P = 0.042), 24-H-hypertension (P < 0.001), cardiac stress (P = 0.025), ischemic events (P = 0.048) and medium-to-high 10-year stroke probability (P < 0.001), compared to β-adrenergic responders. In the β-adrenergic responders, higher odds for ischemic events, stroke probability and Abnl-GT were found (all P ≤ 0.022), compared to α-adrenergic responders. Independent of age, sex or ethnicity, the risk profile identified in predominant α-adrenergic responders mainly involved the effects of a high-pressure system, cardiac stress, and ischemia. Whereas in predominant β-adrenergic responders, the risk profile pointed to a more metabolic and hyperperfusion injury-related cardiometabolic risk.

Impact of early CVP monitoring on 1-year mortality in patients with congestive heart failure in the ICU: a retrospective analysis based on the MIMIC-IV2.2 database

BACKGROUND

Central venous pressure (CVP) monitoring is critical for fluid management in critically ill patients. This study evaluated the impact of CVP monitoring on 1-year mortality in intensive care unit (ICU) patients with congestive heart failure (CHF).

METHODS

Data from the Medical Information for Critical Care IV (MIMIC-IV) database were analyzed for ICU patients admitted for the first time with a stay > 24 h. Patients were categorized into CVP and no-CVP groups based on CVP measurement. Logistic regression analyses were performed, with propensity score matching (PSM) and overlap weighting (OW) to minimize confounding. Inflection point analysis using logistic regression was conducted in the CVP group. Patients were further stratified into early (≤ 24 h) and late (> 24 h) CVP monitoring groups for additional analysis.

RESULTS

Among 4,479 patients, 919 were in the CVP group and 3,560 in the no-CVP group. CVP monitoring was associated with lower 1-year mortality (odds ratio [OR] = 0.75, 95% confidence interval [CI] = 0.62-0.91, p = 0.003). Early CVP monitoring (≤ 24 h) independently reduced 1-year mortality (OR = 0.68, 95% CI = 0.47-0.97, p = 0.032). Predictors of mortality included the lowest diastolic blood pressure, lowest blood glucose, highest blood chloride, and Acute Physiology Score III (APSIII) score within 24 h of admission.

CONCLUSION

Early CVP monitoring significantly improves 1-year survival in ICU patients with congestive heart failure. These findings underscore the value of timely hemodynamic assessments in critical care and warrant further prospective validation in diverse settings.

Echocardiographic Evaluation of the Effect of Long-Term Methylphenidate Use on Cardiovascular Functions

OBJECTIVE

ADHD is one of the most common neurodevelopmental disorders, seen in children and adolescents, and is often treated with various pharmacological agents, especially methylphenidate. There are differing opinions in the literature regarding the cardiovascular safety of long-term methylphenidate use. Studies suggest that the drug may increase the risk of hypertension, myocardial infarction, ventricular arrhythmia, sudden cardiac death, cardiomyopathy, heart failure (HF), pulmonary hypertension, and stroke. This study aimed to compare the clinical and echocardiographic characteristics of patients diagnosed with ADHD who have been using long-acting methylphenidate for an extended period with age-gender matched healthy volunteers.

MATERIALS AND METHODS

A total of 70 patients diagnosed with ADHD, who had been using long-acting methylphenidate for 2 years or more, and 51 healthy volunteers, who were referred to our clinic, were included in our study. Patients were evaluated with basic and advanced techniques such as Motion Mode (M-mode), two-dimensional (2D), Doppler, and 2D-Speckle Tracking (STE) using transthoracic echocardiography. All other data were evaluated instantly after the processing with the strain images analysis program.

RESULTS

Statistically significant differences were observed between the case and control groups in terms of body mass index (BMI) and systolic blood pressure (SBP), with BMI negatively correlated and SBP positively correlated with methylphenidate use duration. There was no significant difference between the groups in apical four-chamber, three-chamber, two-chamber, and global longitudinal strain (GLS) values obtained by 2D-STE technique indicating early deterioration. The Left Ventricular (LV) lateral E' value, which indicates diastolic dysfunction, was lower in the drug group, but still within normal limits. The lateral LV E', Right Ventricular (RV) E', and RV A' values showed a significant negative correlation with the duration of drug use and remained within normal limits. Other parameters evaluating systolic/diastolic function such as E/E', left ventricular ejection fraction (LVEF), myocardial performance index (MPI), and tricuspid/mitral annular plane systolic excursion (TAPSE/MAPSE) did not differ significantly between the groups and were within normal limits. Valve structures and regurgitations were also not significantly different between the two groups.

CONCLUSION

Considering all parameters, we conclude that long-term use of long-acting methylphenidate does not cause cardiovascular dysfunction in late adolescent and early adult individuals. The observed differences in the E' lateral value between the case and control groups, as well as the slight correlation of lateral LV E', RV E', and RV A' values with the duration of use, do not directly indicate cardiac dysfunction.

Effect of early application of a sodium-glucose cotransporter-2 inhibitor on ventricular remodelling and prognosis in patients with anterior wall acute myocardial infarction

BACKGROUND

The role of sodium-glucose cotransporter-2 inhibitors in patients with acute myocardial infarction remains elusive.

AIM

To evaluate the effect of early application of a sodium-glucose cotransporter-2 inhibitor on ventricular remodelling and prognosis in patients with anterior wall acute myocardial infarction.

METHODS

In this prospective study, 102 patients diagnosed with anterior wall acute myocardial infarction were enrolled and divided into intervention and control groups according to the use of dapagliflozin within 24hours after admission. Demographic and clinical data, including age, sex, associated co-morbidities, number of lesions, length of hospital stay, N-terminal prohormone of brain natriuretic peptide, left ventricular ejection fraction, left ventricular end-systolic and end-diastolic diameters and drug-related adverse reactions, were collected and analysed between the two groups. All patients were followed up 1, 3 and 6 months after discharge.

RESULTS

At 6 months, left ventricular ejection fraction was higher (55.98±7.17% vs. 52.71±7.78%; P=0.03) and N-terminal prohormone of brain natriuretic peptide was lower (141.52±83.18 vs. 203.69±152.13pg/mL; P=0.01) in the intervention group versus the control group. Left ventricular end-systolic diameter (35.68±4.32 vs. 38.00±5.01mm; P=0.01) and left ventricular end-diastolic diameter (50.48±4.90 vs. 52.67±4.91mm; P=0.03) were smaller in the intervention group versus the control group. Event-free survival rates were better in the intervention group than in the control group (90% vs. 74.5%; P=0.03). The cumulative incidence of drug-related adverse reactions was similar in the two groups (14% vs. 4.0%; P=0.15).

CONCLUSIONS

Use of dapagliflozin within 24hours after admission can improve cardiac function, inhibit ventricular remodelling, improve clinical prognosis and have high safety in patients with anterior wall acute myocardial infarction during 6-month follow-up.

Mental Illness Strikes at the Heart: Impact of Psychiatric Diseases on Ventricular Ejection Fraction in Patients with Acute Coronary Syndromes

Mental illnesses can have a significant impact on individuals experiencing acute coronary syndromes (ACS). Mental illnesses are associated with an increased cardiovascular risk profile and early onset of cardiovascular disease. A critical aspect of this interplay is the effect of psychiatric conditions on left ventricular ejection fraction (LVEF), a key parameter in evaluating cardiac function and predicting long-term outcomes in ACS patients. The present single-center, retrospective study investigated the associations between psychiatric conditions and cardiac function, with a focus on LVEF in ACS patients. The inclusion criteria were Italian nationality and 30 years or older. One hundred and sixty-four patients without (Mage = 68.8 ± 10.6, 62 females) and 161 patients with a psychiatric diagnosis (Mage = 68.4 ± 13.7, 63 females) were enrolled. The data collected included sociodemographic variables, psychiatric diagnoses, LVEF, ACS type (STEMI/NSTEMI), smoking status, previous interventions, and pharmacological treatments. Statistical analyses included chi-square, t-tests, ANOVAs, and ANCOVA to assess differences across groups. Findings revealed lower LVEF in patients with a psychiatric diagnosis compared to patients without a psychiatric diagnosis (p = 0.004, d = 0.36). Patients without a psychiatric diagnosis were associated with NSTEMI (p = 0.047, φ = 0.11), hypertension (p = 0.003, φ = -0.16), and dyslipidemia (p = 0.022, φ = -0.13). In contrast, patients with a psychiatric diagnosis were associated with STEMI (p = 0.047, φ = 0.11), neurological dysfunction (p = 0.014, φ = 0.14), and chronic obstructive pulmonary disease (p = 0.010, φ = 0.14). Among psychiatric diagnoses, anxiety disorders were associated with lower LVEF compared to substance abuse disorders (p = 0.012, d = -0.81). The findings underscore the complex relationship between mental illness and cardiac function, emphasising the need to integrate psychiatric evaluations into cardiology care to optimise the management of both mental and cardiovascular health. This study has several limitations, including its design, which prevents causal conclusions, and the use of convenience sampling, which limits the generalizability of the findings.

Stellate Ganglionectomy Attenuates Pressure Overload-Induced Cardiac Hypertrophy and Dysfunction

BACKGROUND

Enhanced cardiac sympathetic activity contributes to chronic heart failure (CHF). Interventions targeting the stellate ganglion (SG) can reduce this activity, potentially slowing the progression of cardiovascular diseases. This study examined the effects and mechanisms of stellate ganglionectomy on myocardial hypertrophy and cardiac dysfunction caused by pressure overload.

METHODS

A rat model of pressure overload was created using abdominal aortic constriction. Four groups were studied: the sham surgery, abdominal aortic coarctation (AB), aortic constriction plus left stellate ganglionectomy (LSG), and aortic constriction plus right stellate ganglionectomy (RSG) groups. Cardiac function was assessed via echocardiography, and myocardial hypertrophy and fibrosis were evaluated using hematoxylin-eosin staining (H&E) and Masson staining. Serum atrial natriuretic peptides (ANP) and norepinephrine (NE) levels were measured using enzyme linked immunosorbent assay (ELISA), and the levels of the molecular markers tyrosine hydroxylase (TH) and growth-associated protein-43 (GAP43) were analyzed using Western blotting and PCR. Calcium calmodulin dependent protein kinase II (CaMKII) and phosphorylated Ryanodine Receptor 2 (p-RyR2) expression were also investigated.

RESULTS

Stellate ganglionectomy significantly reduced myocardial hypertrophy and improved cardiac function, as indicated by decreased left ventricular posterior wall thickness (LVPWD) (p < 0.01), left ventricular end-diastolic diameter (LVEDD) and volume (p < 0.001), left ventricular end-diastolic volume (LVEDV) (p < 0.001), increased left ventricular ejection fraction (LVEF) (p < 0.001) and left ventricular fractional shortening (LVFS) (p < 0.001). Histological analysis confirmed reduced myocardial dilation. Molecular analysis revealed decreased CaMKII/RyR2 signaling (p < 0.001) and lower NE levels (p < 0.01), suggesting reduced neurohormonal stress.

CONCLUSIONS

Stellate ganglionectomy alleviates hypertrophy and cardiac dysfunction caused by pressure overload, likely through inhibition of the CaMKII/RyR2 pathway, underscoring its potential as a therapeutic approach.

A Nerve-Fibroblast Axis in Mammalian Lung Fibrosis

Fibrosis contributes to incurable pathologies in vital organs including the lung. Myofibroblasts are fibrogenic effector cells that accumulate via incompletely understood mechanisms. We discovered that α1-adrenoreceptor expressing myofibroblasts receive sympathetic nerve-derived noradrenergic inputs in fibrotic mouse and human lungs. We combined optical clearing, whole lung imaging, cell-specific gene deletion in sympathetic nerves and myofibroblasts, pharmacologic interventions, sympathetic nerve co-culture and precision-cut lung slices, with analysis of bronchoalveolar lavage fluid, lung tissues, single-cell RNA sequencing datasets, and isolated lung fibroblasts from patients with diverse forms of pulmonary fibrosis to characterize a fibrogenic unit comprised of aberrantly patterned sympathetic nerves and α1-adrenoreceptor subtype D expressing myofibroblasts. The discovery of this previously undefined nerve-fibroblast axis that is conserved across species demonstrates the pivotal contribution of nerves to tissue remodeling and heralds a novel paradigm in fibrosis research.

High-intensity interval training attenuates renal injury induced by myocardial ischemia-reperfusion in rats

BACKGROUND

High-intensity interval training (HIIT) has been recognized as an effective form of short-duration exercise. The purpose of this study was to assess whether HIIT could reduce renal injury induced by myocardial ischemia-reperfusion (MIR) in rats.

METHODS

Male Sprague-Dawley rats were randomly assigned to the Sham (SHAM), coronary artery occlusion (CAO), HIIT, and ischemic precondition (IPC) groups. Rats underwent 40 minutes of left anterior descending CAO under anesthesia, followed by 3 hours of reperfusion, to induce MIR. Postsurgery, rats were sacrificed, and their blood, heart, and kidney tissues were examined. The HIIT group underwent 4 weeks of HIIT training before surgery.

RESULTS

HIIT intervention significantly reduced renal injury after MIR and the concentrations of blood urea nitrogen (BUN) and creatinine (CRE) in the serum. Moreover, proinflammatory cytokines, including tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and IL-6, were significantly decreased, while the anti-inflammatory cytokine IL-10 was significantly increased in the serum. Additionally, HIIT intervention suppressed the expression of FoxO1, Bax/Bcl-2 ratio, TNF-α, and cleaved-caspase-3/caspase-3 ratio in kidney tissues, ultimately reducing renal cell apoptosis.

CONCLUSION

This study is the first to demonstrate that HIIT has effects similar to IPC, significantly reducing renal injury after MIR. HIIT regulates the production of proinflammatory and anti-inflammatory cytokines and inhibits renal cell apoptosis, thereby reducing the occurrence of cardiorenal syndrome.

Exploring the Link Between Cheese Consumption and Heart Failure Risk: A Mendelian Randomization Approach with Biomarker Analysis

The study investigates the association between cheese consumption and heart failure risk, employing Mendelian randomization (MR) analysis. Heart failure, influenced by various factors including diet, remains a major global health concern. Cheese, a nutrient-rich dairy product, has shown potential in reducing heart failure risk, though the mechanisms are not fully understood. This study clarifies the association by examining 45 biomarkers that could mediate this effect. This analysis revealed a significant reduction in heart failure risk with cheese consumption (OR = 0.771, P = 0.00588). Of the 45 biomarkers analyzed, 24 showed a significant relationship with cheese intake. Six biomarkers-neutrophil count (mediating effect ratio: 3.37%), apolipoprotein B (2.73%), glucose (4.16%), triglycerides (5.82%), diastolic blood pressure (14.78%), and serum uric acid (8.45%)-were identified as mediators in the cheese consumption-heart failure relationship. This study underscores the role of biomarkers in understanding heart failure mechanisms and highlights the potential of dietary interventions, like cheese consumption, to reduce heart failure risk. While these findings are promising, their generalizability may be limited, and further research across diverse populations is needed.

Diagnosis and Management of Hypertensive Heart Disease: Incorporating 2023 European Society of Hypertension and 2024 European Society of Cardiology Guideline Updates

Hypertensive heart disease (HHD) continues to be a leading cause of cardiovascular morbidity and mortality worldwide, necessitating the evolution of evidence-based management strategies. This literature review examines the most recent updates from the 2023 and 2024 hypertension guidelines issued by the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC). These guidelines are compared with previous key recommendations, such as the 2017 American College of Cardiology/American Heart Association guidelines and the 2018 ESC/ESH guidelines. The updated recommendations reflect a paradigm shift in the approach to hypertension diagnosis and management, including a stricter systolic blood pressure (BP) target of 120-129 mmHg, which underscores the importance of early and precise BP control. The difference between the classification of "elevated BP" and hypertension in the ESC versus ESH guidelines, particularly, regarding their implications for early detection and prevention of HHD, are critically examined, highlighting areas of clinical and academic debate. The introduction of a new "elevated BP" category (120-139/70-89 mmHg) highlights a proactive strategy aimed at identifying at-risk individuals earlier in the disease course to prevent progression to HHD. Additionally, the divergent roles of hypertension-mediated organ damage (HMOD), including HHD, in risk stratification as recommended by the ESC and ESH are discussed, emphasising their significance in tailoring management approaches. For patients with resistant hypertension, the 2023 and 2024 updates also endorse innovative therapies, such as renal denervation, an interventional procedure that has demonstrated significant promise in managing treatment-resistant cases. This review synthesises these updates, focusing on their implications for clinical practice in diagnosing and managing HHD. By emphasising aggressive intervention and the integration of novel treatment modalities, the review aims to bridge existing gaps in earlier approaches to hypertension management. The critical evaluation of guideline discrepancies and evolving evidence seeks to provide clinicians with a nuanced understanding to optimise outcomes for patients with HHD, particularly considering emerging therapeutic possibilities and more stringent BP control targets.

Modulating Sympathetic Nervous System With the Use of SGLT2 Inhibitors: Where There Is Smoke, There Is Fire?

Heart failure (HF) has become even more prevalent in recent years, because of improved diagnostics and an increase in the risk factors predisposing to its pathology. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) emerged as one of the key pharmacotherapy options for both reduced and preserved ejection fraction, providing cardio- and renoprotection and improving mortality and cardiovascular (CV) outcomes. The pleiotropism of SGLT2i has led to multiple efforts to understand their distinct pathophysiologic interactions with various pathways, including microcirculation, endothelial dysfunction, and inflammation. More recently, the role of SGLT2i on the sympathetic nervous system (SNS) is starting to be recognized, especially because observations of retained or reduced heart rate despite volume contraction have been noted by investigators in the large clinical trials testing the safety and efficacy of these agents. Both preclinical and clinical studies have been performed, with conflicting results. Interestingly, in both settings, although there are indications of SNS modulation by SGLT2i, other studies contradict such findings, without showing, however, worsening of the autonomic homeostasis. Given the importance of neuromodulation in HF, in both pharmacologic and interventional therapies, in this review, we aim to describe the role of SNS in CV disease, focusing on HF, analyze preclinical and clinical data regarding the efficacy of SGLT2i in modulating autonomic dysfunction by examining various markers of SNS activation, and provide the most plausible theoretical backgrounds on the mechanism of benefit of SNS from the inhibition of SGLT2 receptors.

Renal nerves in physiology, pathophysiology and interoception

Sympathetic efferent renal nerves have key roles in the regulation of kidney function and blood pressure. Increased renal sympathetic nerve activity is thought to contribute to hypertension by promoting renal sodium retention, renin release and renal vasoconstriction. This hypothesis led to the development of catheter-based renal denervation (RDN) for the treatment of hypertension. Two RDN devices that ablate both efferent and afferent renal nerves received FDA approval for this indication in 2023. However, in animal models, selective ablation of afferent renal nerves resulted in comparable anti-hypertensive effects to ablation of efferent and afferent renal nerves and was associated with a reduction in sympathetic nerve activity. Selective afferent RDN also improved kidney function in a chronic kidney disease model. Notably, the beneficial effects of RDN extend beyond hypertension and chronic kidney disease to other clinical conditions that are associated with elevated sympathetic nerve activity, including heart failure and arrhythmia. These findings suggest that the kidney is an interoceptive organ, as increased renal sensory nerve activity modulates sympathetic activity to other organs. Future studies are needed to translate this knowledge into novel therapies for the treatment of hypertension and other cardiorenal diseases.

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

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

Renal interoception in health and disease

Catheter based renal denervation has recently been FDA approved for the treatment of hypertension. Traditionally, the anti-hypertensive effects of renal denervation have been attributed to the ablation of the efferent sympathetic renal nerves. In recent years the role of the afferent sensory renal nerves in the regulation of blood pressure has received increased attention. In addition, afferent renal denervation is associated with reductions in sympathetic nervous system activity. This suggests that reductions in sympathetic drive to organs other than the kidney may contribute to the non-renal beneficial effects observed in clinical trials of catheter based renal denervation. In this review we will provide an overview of the role of the afferent renal nerves in the regulation of renal function and the development of pathophysiologies, both renal and non-renal. We will also describe the central projections of the afferent renal nerves, to give context to the responses seen following their ablation and activation. Finally, we will discuss the emerging role of the kidney as an interoceptive organ. We will describe the potential role of the kidney in the regulation of interoceptive sensitivity and in this context, speculate on the possible pathological consequences of altered renal function.

m6A RNA methylation modification is involved in the disease course of heart failure

We explored N6-methyladenosine (m6A) RNA methylation as one of the gene regulatory mechanisms in heart failure (HF) biology. Understanding the different physiological mechanisms will facilitate the prevention and individualized treatment of HF. The Gene Expression Omnibus (GEO) database served as the source of the data. In GSE116250, differential analysis between ischemic cardiomyopathy (ICM), dilated cardiomyopathy (DCM) and controls yielded differentially expressed m6A regulators. Differential analysis between HF and controls in GSE131296 identifies m6A-modified genes and then performs enrichment analysis. Protein-protein interaction (PPI) network analysis was performed for the differentially expressed ICM- or DCM-associated genes in GSE116250 and GSE55296, respectively. Finally, the diagnostic genes for ICM and DCM were predicted using receiver operating characteristic (ROC) curve. YTHDC1, HNRNPC and HNRNPA2B1 were significantly downregulated in GSE116250 in DCM and ICM compared with controls. A total of 195 genes were identified in GSE131296 as subject to m6A alteration. These genes may play a role in HF through the MAPK signaling pathway and p53 signaling pathway. PPI network analysis identified CCL5, CXCR4 and CCL2 as key genes for ICM and IL-6 as a key gene for DCM. Through ROC curves, we identified m6A-modified APLP1, KLF2 as potential diagnostic genes for ICM, and m6A-modified FGF7, FREM1 and C14orf132 as potential diagnostic genes for DCM. Our findings support m6A modifying mechanisms in HF etiology that contribute to the treatment of HF. Thus, our data suggest that m6A methylation may be an interesting target for therapeutic intervention.

Pathophysiology of Congestion in Heart Failure: A Contemporary Review

Acutely decompensated heart failure is one of the leading causes of hospitalisation worldwide, with a significant majority of these cases attributed to congestion. Although congestion is commonly mistaken for volume overload, evidence suggests that decompensation can occur without significant water accumulation, being attributed to volume redistribution. Yet, the distinction between intravascular and extravascular congestion in heart failure often blurs, as patients frequently exhibit overlapping features of both, and as patients may transition between phenotypes over time. Considering that differentiation between intravascular and extravascular congestion can lead to different management strategies, the aim of this review was to delineate the pathophysiological nuances between the two, as well as their correlation with clinical, biochemical and imaging indices.

Advances in the Insulin-Heart Axis: Current Therapies and Future Directions

The insulin-heart axis plays a pivotal role in the pathophysiology of cardiovascular disease (CVD) in insulin-resistant states, including type 2 diabetes mellitus. Insulin resistance disrupts glucose and lipid metabolism, leading to systemic inflammation, oxidative stress, and atherogenesis, which contribute to heart failure (HF) and other CVDs. This review was conducted by systematically searching PubMed, Scopus, and Web of Science databases for peer-reviewed studies published in the past decade, focusing on therapeutic interventions targeting the insulin-heart axis. Studies were selected based on their relevance to insulin resistance, cardiovascular outcomes, and the efficacy of pharmacologic treatments. Key findings from the review highlight the efficacy of lifestyle modifications, such as dietary changes and physical activity, which remain the cornerstone of managing insulin resistance and improving cardiovascular outcomes. Moreover, pharmacologic interventions, such as metformin, sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and dipeptidyl peptidase-4 inhibitors, have shown efficacy in reducing cardiovascular risk by addressing metabolic dysfunction, reducing inflammation, and improving endothelial function. Furthermore, emerging treatments, such as angiotensin receptor-neprilysin inhibitors, and mechanical interventions like ventricular assist devices offer new avenues for managing HF in insulin-resistant patients. The potential of these therapies to improve left ventricular ejection fraction and reverse pathological cardiac remodeling highlights the importance of early intervention. However, challenges remain in optimizing treatment regimens and understanding the long-term cardiovascular effects of these agents. Future research should focus on personalized approaches that integrate lifestyle and pharmacologic therapies to effectively target the insulin-heart axis and mitigate the burden of cardiovascular complications in insulin-resistant populations.

Cardiomegaly: Navigating the uncharted territories of heart failure - A multimodal radiological journey through advanced imaging, pathophysiological landscapes, and innovative therapeutic frontiers

Cardiomegaly is among the disorders categorized by a structural enlargement of the heart by any of the situations including pregnancy, resulting in damage to heart muscles and causing trouble in normal heart functioning. Cardiomegaly can be defined in terms of dilatation with an enlarged heart and decreased left or biventricular contraction. The genetic origin of cardiomegaly is becoming more evident due to extensive genomic research opening up new avenues to ensure the use of precision medicine. Cardiomegaly is usually assessed by using an array of radiological modalities, including computed tomography (CT) scans, chest X-rays, and MRIs. These imaging techniques have provided an important opportunity for the physiology and anatomy of the heart. This review aims to highlight the complexity of cardiomegaly, highlighting the contribution of both ecological and genetic variables to its progression. Moreover, we further highlight the worth of precise clinical diagnosis, which comprises blood biomarkers and electrocardiograms (EKG ECG), demonstrating the significance of distinguishing between numerous basic causes. Finally, the analysis highlights the extensive variation of treatment lines, such as lifestyle modifications, prescription drugs, surgery, and implantable devices, although highlighting the critical need for individualized and personalized care.

Management of patients with heart failure and chronic kidney disease

Chronic kidney disease (CKD) and heart failure are often co-existing conditions due to a shared pathophysiological process involving neurohormonal activation and hemodynamic maladaptation. A wide range of pharmaceutical and interventional tools are available to patients with CKD, consisting of traditional ones with decades of experience and newer emerging therapies that are rapidly reshaping the landscape of medical care for this population. Management of patients with heart failure and CKD requires a stepwise approach based on renal function and the clinical phenotype of heart failure. This is often challenging due to altered drug pharmacokinetics interactions with various degrees of kidney function and frequent adverse effects from the therapy that lead to poor patient tolerance. Despite a great body of clinical evidence and guidelines that have offered various treatment options for patients with heart failure and CKD, respectively, patients with CKD are still underrepresented in heart failure clinical trials, especially for those with advanced CKD and end-stage renal disease (ESRD). Future studies are needed to better understand the generalizability of these therapeutic options among heart failures with different stages of CKD.

Nrf2-Keap1 in Cardiovascular Disease: Which Is the Cart and Which the Horse?

High levels of oxidant stress in the form of reactive oxidant species are prevalent in the circulation and tissues in various types of cardiovascular disease including heart failure, hypertension, peripheral arterial disease, and stroke. Here we review the role of nuclear factor erythroid 2-related factor 2 (Nrf2), an important and widespread antioxidant and anti-inflammatory transcription factor that may contribute to the pathogenesis and maintenance of cardiovascular diseases. We review studies showing that downregulation of Nrf2 exacerbates heart failure, hypertension, and autonomic function. Finally, we discuss the potential for using Nrf2 modulation as a therapeutic strategy for cardiovascular diseases and autonomic dysfunction.

X-ray Radiotherapy Impacts Cardiac Dysfunction by Modulating the Sympathetic Nervous System and Calcium Transients

Recent epidemiological studies have shown that patients with right-sided breast cancer (RBC) treated with X-ray irradiation (IR) are more susceptible to developing cardiovascular diseases, such as arrhythmias, atrial fibrillation, and conduction disturbances after radiotherapy (RT). Our aim was to investigate the mechanisms induced by low to moderate doses of IR and to evaluate changes in the cardiac sympathetic nervous system (CSNS), atrial remodeling, and calcium homeostasis involved in cardiac rhythm. To mimic the RT of the RBC, female C57Bl/6J mice were exposed to X-ray doses ranging from 0.25 to 2 Gy targeting 40% of the top of the heart. At 60 weeks after RI, Doppler ultrasound showed a significant reduction in myocardial strain, ejection fraction, and atrial function, with a significant accumulation of fibrosis in the epicardial layer and apoptosis at 0.5 mGy. Calcium transient protein expression levels, such as RYR2, NAK, Kir2.1, and SERCA2a, increased in the atrium only at 0.5 Gy and 2 Gy at 24 h, and persisted over time. Interestingly, 3D imaging of the cleaned hearts showed an early reduction of CSNS spines and dendrites in the ventricles and a late reorientation of nerve fibers, combined with a decrease in SEMA3a expression levels. Our results showed that local heart IR from 0.25 Gy induced late cardiac and atrial dysfunction and fibrosis development. After IR, ventricular CSNS and calcium transient protein expression levels were rearranged, which affected cardiac contractility. The results are very promising in terms of identifying pro-arrhythmic mechanisms and preventing arrhythmias during RT treatment in patients with RBC.

Electrophysiological Mechanism of Catestatin Antiarrhythmia: Enhancement of Ito, IK, and IK1 and Inhibition of ICa-L in Rat Ventricular Myocytes

BACKGROUND

Cardiovascular disease remains one of the leading causes of death globally. Myocardial ischemia and infarction, in particular, frequently cause disturbances in cardiac electrical activity that can trigger ventricular arrhythmias. We aimed to investigate whether catestatin, an endogenous catecholamine-inhibiting peptide, ameliorates myocardial ischemia-induced ventricular arrhythmias in rats and the underlying ionic mechanisms.

METHODS AND RESULTS

Adult male Sprague-Dawley rats were randomly divided into control and catestatin groups. Ventricular arrhythmias were induced by ligation of the left anterior descending coronary artery and electrical stimulation. Action potential, transient outward potassium current, delayed rectifier potassium current, inward rectifying potassium current, and L-type calcium current (ICa-L) of rat ventricular myocytes were recorded using a patch-clamp technique. Catestatin notably reduced ventricular arrhythmia caused by myocardial ischemia/reperfusion and electrical stimulation of rats. In ventricular myocytes, catestatin markedly shortened the action potential duration of ventricular myocytes, which was counteracted by potassium channel antagonists TEACl and 4-AP, and ICa-L current channel agonist Bay K8644. In addition, catestatin significantly increased transient outward potassium current, delayed rectifier potassium current, and inward rectifying potassium current density in a concentration-dependent manner. Catestatin accelerated the activation and decelerated the inactivation of the transient outward potassium current channel. Furthermore, catestatin decreased ICa-L current density in a concentration-dependent manner. Catestatin also accelerated the inactivation of the ICa-L channel and slowed down the recovery of ICa-L from inactivation.

CONCLUSIONS

Catestatin enhances the activity of transient outward potassium current, delayed rectifier potassium current, and inward rectifying potassium current, while suppressing the ICa-L in ventricular myocytes, leading to shortened action potential duration and ultimately reducing the ventricular arrhythmia in rats.

Compound 3K attenuates isoproterenol-induced cardiac hypertrophy by inhibiting pyruvate kinase M2 (PKM2) pathway

AIM

Chronic sympathetic stimulation has been identified as a primary factor in the pathogenesis of cardiac hypertrophy (CH). However, there is no appropriate treatment available for the management of CH. Recently, it has been revealed that pyruvate kinase M2 (PKM2) plays a significant role in cardiac remodeling, fibrosis, and hypertrophy. However, the therapeutic potential of selective PKM2 inhibitor has not yet been explored in cardiac hypertrophy. Thus, in the current study, we have studied the cardioprotective potential of Compound 3K, a selective PKM2 inhibitor in isoproterenol-induced CH model.

METHODS

To induce cardiac hypertrophy, male Wistar rats were subcutaneously administered isoproterenol (ISO, 5 mg/kg/day) for 14 days. Compound 3K at dosages of 2 and 4 mg/kg orally was administered to ISO-treated rats for 14 days to explore its effects on various parameters like ECG, ventricular functions, hypertrophic markers, histology, inflammation, and protein expression were performed.

RESULTS

Fourteen days administration of ISO resulted in the induction of CH, which was evidenced by alterations in ECG, ventricular dysfunctions, increase in hypertrophy markers, and fibrosis. The immunoblotting of hypertrophy heart revealed the significant rise in PKM2 and reduction in PKM1 protein expression. Treatment with Compound 3K led to downregulation of PKM2 and upregulation of PKM1 protein expression. Compound 3K showed cardioprotective effects by improving ECG, cardiac functions, hypertrophy markers, inflammation, and fibrosis. Further, it also reduced cardiac expression of PKM2-associated splicing protein, HIF-1α, and caspase-3.

CONCLUSION

Our findings suggest that Compound 3K has a potential cardioprotective effect via PKM2 inhibition in isoproterenol-induced CH.

Percutaneous left stellate ganglion block for refractory ventricular tachycardia in structural heart disease: our single-centre experience

INTRODUCTION

When electrical storm (ES) is amenable to neither antiarrhythmic drugs, nor deep sedation or catheter ablation, autonomic modulation may be considered. We report our experience with percutaneous left stellate ganglion block (PSGB) to temporarily suppress refractory ventricular arrhythmia (VA) in patients with structural heart disease.

METHODS

A retrospective analysis was performed at our institution of patients with structural heart disease and an implantable cardioverter defibrillator (ICD) who had undergone PSGB for refractory VA between January 2018 and October 2021. The number of times antitachycardia pacing (ATP) was delivered and the number of ICD shocks/external cardioversions performed in the week before and after PSGB were evaluated. Charts were checked for potential complications.

RESULTS

Twelve patients were identified who underwent a combined total of 15 PSGB and 5 surgical left cardiac sympathetic denervation procedures. Mean age was 73 ± 5.8 years and all patients were male. Nine of 12 (75%) had ischaemic cardiomyopathy, with the remainder having non-ischaemic dilated cardiomyopathy. Mean left ventricular ejection fraction was 35% (± 12.2%). Eight of 12 (66.7%) patients were already being treated with both amiodarone and beta-blockers. The reduction in ATP did not reach statistical significance (p = 0.066); however, ICD shocks (p = 0.028) and ATP/shocks combined were significantly reduced (p = 0.04). At our follow-up electrophysiology meetings PSGB was deemed ineffective in 4 of 12 patients (33%). Temporary anisocoria was seen in 2 of 12 (17%) patients, and temporary hypotension and hoarseness were reported in a single patient.

DISCUSSION

In this limited series, PSGB showed promise as a method for temporarily stabilising refractory VA and ES in a cohort of male patients with structural heart disease. The side effects observed were mild and temporary.

Insulin-Heart Axis: Bridging Physiology to Insulin Resistance

Insulin signaling is vital for regulating cellular metabolism, growth, and survival pathways, particularly in tissues such as adipose, skeletal muscle, liver, and brain. Its role in the heart, however, is less well-explored. The heart, requiring significant ATP to fuel its contractile machinery, relies on insulin signaling to manage myocardial substrate supply and directly affect cardiac muscle metabolism. This review investigates the insulin-heart axis, focusing on insulin's multifaceted influence on cardiac function, from metabolic regulation to the development of physiological cardiac hypertrophy. A central theme of this review is the pathophysiology of insulin resistance and its profound implications for cardiac health. We discuss the intricate molecular mechanisms by which insulin signaling modulates glucose and fatty acid metabolism in cardiomyocytes, emphasizing its pivotal role in maintaining cardiac energy homeostasis. Insulin resistance disrupts these processes, leading to significant cardiac metabolic disturbances, autonomic dysfunction, subcellular signaling abnormalities, and activation of the renin-angiotensin-aldosterone system. These factors collectively contribute to the progression of diabetic cardiomyopathy and other cardiovascular diseases. Insulin resistance is linked to hypertrophy, fibrosis, diastolic dysfunction, and systolic heart failure, exacerbating the risk of coronary artery disease and heart failure. Understanding the insulin-heart axis is crucial for developing therapeutic strategies to mitigate the cardiovascular complications associated with insulin resistance and diabetes.

Sympathetic dysfunction is associated with worse fatigue and early and subtle symptoms in heart failure: an exploratory sex-stratified analysis

AIMS

Physical symptoms impact patients with heart failure (HF) despite treatment advancements; however, our understanding of the pathogenic mechanisms underlying HF symptoms remains limited, including sex differences therein. The objective of this study was to quantify associations between sympathetic markers [norepinephrine (NE) and 3,4-dihydroxyphenylglycol (DHPG)] and physical symptoms in patients with HF and to explore sex differences in these associations.

METHODS AND RESULTS

We performed a secondary analysis of combined data from two studies: outpatients with HF (n = 111), and patients prior to left ventricular assist device implantation (n = 38). Physical symptoms were measured with the Heart Failure Somatic Perception Scale (HFSPS) dyspnoea and early/subtle symptom subscales and the Functional Assessment in Chronic Illness Therapy Fatigue Scale (FACIT-F) to capture dyspnoea, early symptoms of decompensation, and fatigue. Norepinephrine and DHPG were measured with high-performance liquid chromatography with electrochemical detection. Multivariate linear regression was used to quantify associations between symptoms and sympathetic markers. The sample (n = 149) was 60.8 ± 15.7 years, 41% women, and 71% non-ischaemic aetiology. Increased plasma NE and NE:DHPG ratio were associated with worse FACIT-F scores (P = 0.043 and P = 0.013, respectively). Increased plasma NE:DHPG ratio was associated with worse HFSPS early/subtle symptoms (P = 0.025). In sex-stratified analyses, increased NE:DHPG ratio was associated with worse FACIT-F scores (P = 0.011) and HFSPS early/subtle scores (P = 0.022) among women but not men.

CONCLUSION

In patients with HF, sympathetic dysfunction is associated with worse fatigue and early/subtle physical symptoms with associations stronger in women than men.

The Role of Muscarinic Acetylcholine Receptor M3 in Cardiovascular Diseases

The muscarinic acetylcholine receptor M3 (M3-mAChR) is involved in various physiological and pathological processes. Owing to specific cardioprotective effects, M3-mAChR is an ideal diagnostic and therapeutic biomarker for cardiovascular diseases (CVDs). Growing evidence has linked M3-mAChR to the development of multiple CVDs, in which it plays a role in cardiac protection such as anti-arrhythmia, anti-hypertrophy, and anti-fibrosis. This review summarizes M3-mAChR's expression patterns, functions, and underlying mechanisms of action in CVDs, especially in ischemia/reperfusion injury, cardiac hypertrophy, and heart failure, opening up a new research direction for the treatment of CVDs.

Cardiac Myosin Activator Omecamtiv Mecarbil: Novel Treatment for Systolic Heart Failure

Systolic Heart failure is a complex clinical syndrome characterized by a decrease in cardiac contractility and a reduction in organ perfusion. Current pharmacologic inotropes attempt to improve contractility via indirect mechanisms but are limited in terms of safety and effectiveness. Omecamtiv mecarbil is a novel agent in a new class of drugs known as cardiac myosin activators; their unique mechanism of action involves directly activating the enzymatic pathway in the cardiac myocyte as a way to improve ventricular contraction. Preclinical and clinical trials have found that omecamtiv mecarbil improves cardiac contractility without increasing the risk of any of the harmful effects that are associated with the currently available inotropic agents. Omecamtiv mecarbil is a worthwhile advance and patients with systolic heart failure would benefit from pharmacological use of this drug.

Mechanisms of myocardial reverse remodelling and its clinical significance: A scientific statement of the ESC Working Group on Myocardial Function

Cardiovascular disease (CVD) is the leading cause of morbimortality in Europe and worldwide. CVD imposes a heterogeneous spectrum of cardiac remodelling, depending on the insult nature, that is, pressure or volume overload, ischaemia, arrhythmias, infection, pathogenic gene variant, or cardiotoxicity. Moreover, the progression of CVD-induced remodelling is influenced by sex, age, genetic background and comorbidities, impacting patients' outcomes and prognosis. Cardiac reverse remodelling (RR) is defined as any normative improvement in cardiac geometry and function, driven by therapeutic interventions and rarely occurring spontaneously. While RR is the outcome desired for most CVD treatments, they often only slow/halt its progression or modify risk factors, calling for novel and more timely RR approaches. Interventions triggering RR depend on the myocardial insult and include drugs (renin-angiotensin-aldosterone system inhibitors, beta-blockers, diuretics and sodium-glucose cotransporter 2 inhibitors), devices (cardiac resynchronization therapy, ventricular assist devices), surgeries (valve replacement, coronary artery bypass graft), or physiological responses (deconditioning, postpartum). Subsequently, cardiac RR is inferred from the degree of normalization of left ventricular mass, ejection fraction and end-diastolic/end-systolic volumes, whose extent often correlates with patients' prognosis. However, strategies aimed at achieving sustained cardiac improvement, predictive models assessing the extent of RR, or even clinical endpoints that allow for distinguishing complete from incomplete RR or adverse remodelling objectively, remain limited and controversial. This scientific statement aims to define RR, clarify its underlying (patho)physiologic mechanisms and address (non)pharmacological options and promising strategies to promote RR, focusing on the left heart. We highlight the predictors of the extent of RR and review the prognostic significance/impact of incomplete RR/adverse remodelling. Lastly, we present an overview of RR animal models and potential future strategies under pre-clinical evaluation.

The Impact of Cardiovascular Antecedents on the Prognosis of COVID-19 Critically Ill Patients

Background/Objectives: The objective of the study is to analyze the impact of cardiovascular history on mortality in COVID-19 patients, hospitalized in the intensive care unit with indications for continuous positive airway pressure (CPAP) and subsequently mechanical ventilation, without oncological disease. Methods: A retrospective observational study was carried out on a group of 108 critical COVID-19 patients. We compared demographic data, paraclinical and clinical parameters, days of hospitalization, and mortality rate between two groups of patients, one group with a history of cardiovascular disease (81 patients) and a group without a history of cardiovascular disease (27 patients). Results: Patients with cardiovascular antecedents had a higher mortality rate than those without cardiovascular antecedents, presenting severe forms with shorter survival time in the intensive care unit and increased inflammatory evidence. Compared to patients without a history of cardiovascular illness, those with cardiovascular disease had a lower average age, and developed a severe form of COVID-19. Conclusions: Cardiovascular antecedents can worsen the prognosis of patients with COVID-19, requiring a careful screening and multidisciplinary approach.

Heart Rate Recovery: Up to Date in Heart Failure-A Literature Review

The rising prevalence of cardiovascular disease underscores the growing significance of heart failure (HF). Pathophysiological insights into HF highlight the dysregulation of the autonomic nervous system (ANS), characterized by sympathetic overactivity and diminished vagal tone, impacting cardiovascular function. Heart rate recovery (HRR), a metric measuring the heart's ability to return to its baseline rate post-exertion, plays a crucial role in assessing cardiovascular health. Widely applied across various cardiovascular conditions including HF, coronary artery disease (CAD), and arterial hypertension (HTN), HRR quantifies the difference between peak and recovery heart rates. Given its association with elevated sympathetic tone and exercise, HRR provides valuable insights into the perspective of HF, beyond effort tolerance, reaching toward prognostic and mortality indicators. Incorporating HRR into cardiovascular evaluations enhances our understanding of autonomic regulation in HF, offering potential implications for prognostication and patient management. This review addresses the significance of HRR in HF assessment, analyzing recently conducted studies, and providing a foundation for further research and clinical application.

Association between baseline hemodynamic indices, cardiotoxicity risk, and survival in women with breast cancer

BACKGROUND

The outcome of breast cancer (BrCa) women monitored by low-dose equilibrium radionuclide angiography (ERNA) remains challenging to predict.

AIM

This study aims to determine whether heart rate (HR)/blood pressure (BP) ratio-based indexes, previously confirmed to predict outcomes of various diseases, also predict BrCa-therapy-related cardiotoxicity and survival.

METHODS

Predictors of cardiotoxicity and survival were determined among pre-therapy variables, including shock index ([SI HR/systolic BP) and age-adjusted SI (ASI), in a female BrCa cohort with normal baseline ERNA-left ventricular ejection fraction (LVEF).

RESULTS

We included 274 women with a median age of 54.8 (interquartile range: 45.5-65.4) years, 271 treated with anthracyclines and 96 with trastuzumab. During a median follow-up of 25.9 (18.6-33.5) months, 31 women developed cardiotoxicity (LVEF: <50% and ≥10% drop from baseline), and 25 died. Baseline ASI was a multivariate predictor (p < 0.001) of (i) cardiotoxicity, in association with trastuzumab treatment (p = 0.010), and LV end-diastolic volume (p = 0.001) and (ii) survival, in association with metastasis (p < 0.001) and estimated glomerular filtration rate (p = 0.008). Cardiotoxicity poorly impacted survival (p = 0.064). The 36-month cardiotoxicity and mortality rates were markedly higher for patients in the upper half of baseline ASI values (ASI: >30 years min-1.mmHg-1, 16.5% and 20.7%, respectively) than in the lower half (7.6% and 4.5%, respectively, both p < 0.05).

CONCLUSIONS

In BrCa women with normal baseline ERNA-LVEF, HR/BP ratio-based indexes unmask hemodynamic profiles associated with increased cardiotoxicity risk and decreased survival, highlighting the need for a comprehensive assessment of cardiac- and vascular-related risks in BrCa women monitored by ERNA.

CONDENSED ABSTRACT

In a cohort of 274 women BrCa women who were monitored by ERNA for potentially cardiotoxic drugs (anthracyclines or trastuzumab) and who had no history of cardiac disease and a normal left ventricular ejection fraction before treatment, baseline indexes based on HR/BP ratios unmask hemodynamic profiles strongly associated with an increased risk of cardiotoxicity and subsequently decreased survival. Although further validations in other cohorts are needed, these findings highlight the need for a more comprehensive assessment of the cardiac- and vascular-related risk in BrCa women monitored by ERNA.

P2X7 receptor is essential for ST36-attenuated cardiac fibrosis upon beta-adrenergic insult

P2X7 receptor (P2X7R) plays an important role in modulating inflammation and fibrosis, but information is limited whether Zusanli (ST36) can inhibit inflammation and fibrosis by regulating P2X7R. Isoprenaline at 5 mg/kg was subcutaneously injected to wild-type and P2X7R knockout mice for 7 days, while treatment groups received electroacupuncture (EA) stimulation at ST36 for 7 sessions. Following 7-session treatment, Masson's trichrome staining was performed to assess the fibrosis. Morphology, electrocardiogram, and echocardiography were carried out to evaluate the cardiac function and structure. Western blotting, hematoxylin and eosin staining, immunohistochemistry, and biochemical analysis of inflammatory cytokine and transmission electron microscopy were carried out to characterize the effect of ST36 on inflammation. P2X7R was overexpressed in ISO-treated mice. EA at ST36, but not at non-points, reduced ISO-induced cardiac fibrosis, increases in HW/BW, R+S wave relative to mice in ISO groups. In addition, EA at ST36 downregulated ISO-upregulated P2X7R and NLRP3 in ventricle. Moreover, EA reduced cytokines of IL-1β, IL-6, and IL-18 in serum, and inhibited foam cell gathering, inflammatory cell infiltration, and autophagy. However, EA at ST36 failed to attenuate the cardiac fibrosis and hypertrophy in P2X7R knockout mice. In conclusion, EA at ST36 attenuated ISO-induced fibrosis possibly via P2X7R.

Role of vericiguat in management of patients with heart failure with reduced ejection fraction after worsening episode

Worsening heart failure (HF) is a vulnerable period in which the patient has a markedly high risk of death or HF hospitalization (up to 10% and 30%, respectively, within the first weeks after episode). The prognosis of HF patients can be improved through a comprehensive approach that considers the different neurohormonal systems, with the early introduction and optimization of the quadruple therapy with sacubitril-valsartan, beta-blockers, mineralocorticoid receptor antagonists, and inhibitors. Despite that, there is a residual risk that is not targeted with these therapies. Currently, it is recognized that the cyclic guanosine monophosphate deficiency has a negative direct impact on the pathogenesis of HF, and vericiguat, an oral stimulator of soluble guanylate cyclase, can restore this pathway. The effect of vericiguat has been explored in the VICTORIA study, the largest chronic HF clinical trial that has mainly focused on patients with recent worsening HF, evidencing a significant 10% risk reduction of the primary composite endpoint of cardiovascular death or HF hospitalization (number needed to treat 24), after adding vericiguat to standard therapy. This benefit was independent of background HF therapy. Therefore, optimization of treatment should be performed as earlier as possible, particularly within vulnerable periods, considering also the use of vericiguat.

Unraveling the complex pathophysiology of heart failure: insights into the role of renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system (SNS)

Heart failure (HF) is a widespread disease with significantly elevated mortality, morbidity, and hospitalization rates. Dysregulation of the sympathetic nervous system (SNS) and renin-angiotensin-aldosterone system (RAAS) are both postulated to be significant regulators of cardiovascular function, thereby playing a pivotal role in its pathophysiology. The RAAS is a sophisticated hormonal system that controls electrolyte homeostasis, fluid balance, and blood pressure. Angiotensin II, which operates to constrict blood vessels and raise blood pressure, is its principal effector molecule. The RAAS is frequently hyperactive in HF, which increases fluid retention and worsens cardiac function. The SNS is frequently hyperactive in heart failure, which increases the workload on the heart and worsens symptoms. This review will discuss what is currently known about the pathophysiology of heart failure, specifically in the context of RAAS and the SNS, in-depth to emphasize the knowledge gap that necessitates more research.

Autonomic brain functioning and age-related health concerns

The autonomic nervous system (ANS) regulates involuntary bodily functions such as blood pressure, heart rate, breathing, and digestion, in addition to controlling motivation and behavior. In older adults, the ANS is dysregulated, which changes the ability of the ANS to respond to physiological signals, regulate cardiovascular autonomic functionality, diminish gastric motility, and exacerbate sleep problems. For example, a decrease in heart rate variability, or the variation in the interval between heartbeats, is one of the most well-known alterations in the ANS associated with health issues, including cardiovascular diseases and cognitive decline. The inability to perform fundamental activities of daily living and compromising the physiological reactivity or motivational responses of older adults to moving toward or away from specific environmental stimuli are significant negative consequences of chronic and geriatric conditions that pose grave threats to autonomy, health, and well-being. The most updated research has investigated the associations between the action responsiveness of older adults and the maintenance of their physiological and physical health or the development of mental and physical health problems. Once autonomic dysfunction may significantly influence the development of different age-related diseases, including ischemic stroke, cardiovascular disease, and autoimmune diseases, this review aimed to assess the relationship between aging and autonomic functions. The review explored how motivational responses, physiological reactivity, cognitive processes, and lifelong developmental changes associated with aging impact the ANS and contribute to the emergence of health problems.

Clinical Review of Hypertensive Acute Heart Failure

Although acute heart failure (AHF) is a common disease associated with significant symptoms, morbidity and mortality, the diagnosis, risk stratification and treatment of patients with hypertensive acute heart failure (H-AHF) still remain a challenge in modern medicine. Despite great progress in diagnostic and therapeutic modalities, this disease is still accompanied by a high rate of both in-hospital (from 3.8% to 11%) and one-year (from 20% to 36%) mortality. Considering the high rate of rehospitalization (22% to 30% in the first three months), the treatment of this disease represents a major financial blow to the health system of each country. This disease is characterized by heterogeneity in precipitating factors, clinical presentation, therapeutic modalities and prognosis. Since heart decompensation usually occurs quickly (within a few hours) in patients with H-AHF, establishing a rapid diagnosis is of vital importance. In addition to establishing the diagnosis of heart failure itself, it is necessary to see the underlying cause that led to it, especially if it is de novo heart failure. Given that hypertension is a precipitating factor of AHF and in up to 11% of AHF patients, strict control of arterial blood pressure is necessary until target values are reached in order to prevent the occurrence of H-AHF, which is still accompanied by a high rate of both early and long-term mortality.

Basic science of cardiac contractility modulation therapy: Molecular and electrophysiological mechanisms

In heart failure with reduced ejection fraction and heart failure with preserved ejection fraction, profound cellular and molecular changes have recently been documented in the failing myocardium. These changes include altered calcium handling and metabolic efficiency of the cardiac myocyte, reactivation of the fetal gene program, changes in the electrophysiological properties of the heart, and accumulation of collagen (fibrosis) at the interstitial level. Cardiac contractility modulation therapy is an innovative device-based therapy currently approved for heart failure with reduced ejection fraction in patients with narrow QRS complex and under investigation for the treatment of heart failure with preserved ejection fraction. This therapy is based on the delivery of high-voltage biphasic electrical signals to the septal wall of the right ventricle during the absolute refractory period of the myocardium. At the cellular level, in patients with heart failure with reduced ejection fraction, cardiac contractility modulation therapy has been shown to restore calcium handling and improve the metabolic status of cardiac myocytes, reverse the heart failure-associated fetal gene program, and reduce the extent of interstitial fibrosis. This review summarizes the preclinical literature on the use of cardiac contractility modulation therapy in heart failure with reduced and preserved ejection fraction, correlating the molecular and electrophysiological effects with the clinical benefits demonstrated by this therapy.

Unveiling Wide Spectrum Therapeutic Implications and Signaling Mechanisms of Valsartan in Diverse Disorders: A Comprehensive Review

Valsartan is an orally active non-peptide angiotensin receptor antagonist, an effective and well-tolerated anti-hypertensive drug. Besides its antihypertensive action, it has clinical implications in many other disorders, like heart failure (HF), arrhythmia, chronic kidney disease (CKD), diabetic complications (DM), atherosclerosis, etc. Besides angiotensin receptor blocking activity, valsartan reduces circulating levels of biochemical markers, such as hs-CRP, which is responsible for its anti-inflammatory and anti-oxidant activity. Moreover, valsartan also acts by inhibiting or inducing various signalling pathways, such as inducing autophagy via the AKT/mTOR/S6K pathway or inhibiting the TLR/NF-kB pathway. The current review exhaustively discusses the therapeutic implications of valsartan with specific emphasis on the mechanism of action in various disorders. The article provides a detailed spectrum of the therapeutic profile of valsartan and will likely be very useful to researchers working in the relevant research areas.

Heart Rate Variability and Coronary Artery Bypass Grafting: A Systematic Review

Background

Coronary artery bypass grafting (CABG) is a well-established surgical procedure used to treat significant coronary artery disease. Nevertheless, unfavorable cardiovascular events and complications, including cardiac arrhythmias may be observed in patients after CABG. Previous studies have revealed a relationship between risk of cardiac arrhythmias and abnormal heart rate variability (HRV), which reflects adverse alterations in cardiac autonomic functioning, that may occur in patients after a CABG procedure. The aim of this article was to provide a systematic review of the major research findings in this area.

Methods

A literature search was carried out using PubMed, Cochrane, and Embase databases and relevant articles, published in English, were analyzed in detail.

Results

Studies performed so far have shown time depending changes in HRV after CABG. Time and frequency domain HRV decrease acutely after CABG but recover almost completely to pre-operative values by 6 months after surgery. Some preoperative clinical states such as: heart failure, type 2 diabetes mellitus and depression adversely affect post-CABG HRV. Finally, post-CABG cardiac rehabilitation appears to improve exercise capacity and speed up recovery of HRV.

Conclusions

Generally, traditional time and frequency domain HRV parameters fail to predict complications post-CABG. Altered non-linear measures of HRV may identify subgroups of subjects at increased risk of potential complications, including atrial fibrillation post-CABG. However, data available currently does not appear to unequivocally support the hypothesis that early HRV assessment in post-CABG patients predicts long-term mortality.

Cross Talks between CNS and CVS Diseases: An Alliance to Annihilate

Cardiovascular and neurological diseases cause substantial morbidity and mortality globally. Moreover, cardiovascular diseases are the leading cause of death globally. About 17.9 million people are affected by cardiovascular diseases and 6.8 million people die every year due to neurological diseases. The common neurologic manifestations of cardiovascular illness include stroke syndrome which is responsible for unconsciousness and several other morbidities significantly diminished the quality of life of patients. Therefore, it is prudent need to explore the mechanistic and molecular connection between cardiovascular disorders and neurological disorders. The present review emphasizes the association between cardiovascular and neurological diseases specifically Parkinson's disease, Alzheimer's disease, and Huntington's disease.

Clinical value of the low-grade inflammation score in aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Multiple inflammatory biomarkers have been shown to predict symptomatic cerebral vasospasm (SCVS) and poor functional outcome in patients with aneurysmal subarachnoid hemorrhage. However, the impact of the low-grade inflammation (LGI) score, which can reflect the synergistic effects of five individual inflammatory biomarkers on SCVS and poor functional outcome on aneurysmal subarachnoid hemorrhage (aSAH), has not yet been well established. The aim of this study was to evaluate the impact of the LGI score on SCVS and poor functional outcome in aSAH patients.

METHODS

The LGI score was calculated as the sum of 10 quantiles of each individual inflammatory biomarker. The association of the LGI score with the risk of SCVS and poor functional outcome was analyzed with multivariate logistical regression.

RESULTS

A total of 270 eligible aSAH patients were included in this study: 74 (27.4%) had SCVS, and 79 (29.3%) had poor functional outcomes. After adjusting for confounders, a higher LGI score was revealed to independently predict SCVS (OR, 1.083; 95% CI, 1.011-1.161; P = 0.024) and poor functional outcome (OR, 1.132; 95% CI, 1.023-1.252; P = 0.016), and the second and third tertile group had higher risk of SCVS than lowest tertile group (OR, 2.826; 95% CI, 1.090-7.327; P = 0.033) (OR, 3.243; 95% CI, 1.258-8.358; P = 0.015). The receiver operating characteristic (ROC) curve uncovered the ability of the LGI score to distinguish patients with and without SCVS (area under the curve [AUC] = 0.746; 95% CI, 0.690-0.797; P < 0.001) and poor functional outcomes (area under the curve [AUC] = 0.799; 95% CI, 0.746-0.845; P < 0.001), the predictive value of LGI on SCVS and poor functional outcome is superior than PLT, NLR and WBC, but there was no statistical difference between LGI and CRP for predicting SCVS (P = 0.567) and poor functional outcome (P = 0.171).

CONCLUSIONS

A higher LGI which represents severe low grade inflammation status is associated with SCVS and poor functional outcome at 3 months after aSAH.