Diabetes Is the Strongest Predictor of Limited Exercise Capacity in Chronic Heart Failure and Preserved Ejection Fraction (HFpEF)

Background and Aim

Type 2 diabetes mellitus (T2DM) is a known risk factor in patients with heart failure (HF), but its impact on phenotypic presentations remains unclear. This study aimed to prospectively examine the relationship between T2DM and functional exercise capacity, assessed by the 6-min walk test (6-MWT) in chronic HF.

Methods

We studied 344 chronic patients with HF (mean age 61 ± 10 years, 54% female) in whom clinical, biochemical, and anthropometric data were available and all patients underwent an echo-Doppler study and a 6-MWT on the same day. The 6-MWT distance divided the cohort into; Group I: those who managed ≤ 300 m and Group II: those who managed >300 m. Additionally, left ventricular (LV) ejection fraction (EF), estimated using the modified Simpson's method, classified patients into HF with preserved EF (HFpEF) and HF with reduced EF (HFrEF).

Results

The results showed that 111/344 (32%) patients had T2DM, who had a higher prevalence of arterial hypertension (p = 0.004), higher waist/hips ratio (p = 0.041), higher creatinine (p = 0.008) and urea (p = 0.003), lower hemoglobin (p = 0.001), and they achieved shorter 6-MWT distance (p < 0.001) compared with those with no T2DM. Patients with limited exercise (<300 m) had higher prevalence of T2DM (p < 0.001), arterial hypertension (p = 0.004), and atrial fibrillation (p = 0.001), higher waist/hips ratio (p = 0.041), higher glucose level (p < 0.001), lower hemoglobin (p < 0.001), larger left atrium (LA) (p = 0.002), lower lateral mitral annular plane systolic excursion (MAPSE) (p = 0.032), septal MAPSE (p < 0.001), and tricuspid annular plane systolic excursion (TAPSE) (p < 0.001), compared with those performing >300 m. In the cohort as a whole, multivariate analysis, T2DM (p < 0.001), low hemoglobin (p = 0.008), atrial fibrillation (p = 0.014), and reduced septal MAPSE (p = 0.021) independently predicted the limited 6-MWT distance.

In patients with HFpEF, diabetes [6.083 (2.613–14.160), p < 0.001], atrial fibrillation [6.092 (1.769–20.979), p = 0.002], and septal MAPSE [0.063 (0.027–0.184), p = 0.002], independently predicted the reduced 6-MWT, whereas hemoglobin [0.786 (0.624–0.998), p = 0.049] and TAPSE [0.462 (0.214–0.988), p = 0.041] predicted it in patients with HFrEF.

Conclusion

Predictors of exercise intolerance in patients with chronic HF differ according to LV systolic function, demonstrated as EF. T2DM seems the most powerful predictor of limited exercise capacity in patients with HFpEF.

Left Ventricular Diastolic and Systolic Functions in Patients with Hypothyroidism

Background and objectives: Long standing hypothyroidism may impair myocardial relaxation, but its effect on systolic myocardial function is still controversial. The aim of this study was to investigate left ventricular (LV) systolic and diastolic function in patients with hypothyroidism. Materials and Methods: This study included 81 (age 42 ± 13 years, 92% female) patients with hypothyroidism, and 22 age and gender matched controls. All subjects underwent a detailed clinical examination followed by a complete biochemical blood analysis including thyroid function assessment and anthropometric parameters measurements. LV function was assessed by 2-dimensional, M-mode and Tissue-Doppler Doppler echocardiographic examination performed in the same day. Results: Patients had lower waist/hip ratio (p< 0.001), higher urea level (p = 0.002), and lower white blood cells (p = 0.011), compared with controls. All other clinical, biochemical, and anthropometric data did not differ between the two groups. Patients had impaired LV diastolic function (lower E wave [p< 0.001], higher A wave [p = 0.028], lower E/A ratio [p< 0.001], longer E wave deceleration time [p = 0.01], and higher E/e' ratio [p< 0.001]), compared with controls. Although LV global systolic function did not differ between groups, LV longitudinal systolic function was compromised in patients (lateral mitral annular plane systolic excursion-MAPSE [p = 0.005], as were lateral and septal s' [p< 0.001 for both]). Conclusions: In patients with hypothyroidism, in addition to compromised LV diastolic function, LV longitudinal systolic function is also impaired compared to healthy subjects of the same age and gender. These findings suggest significant subendocardial function impairment, reflecting potentially micro-circulation disease that requires optimum management.

Long-Term Outcomes of Patients with Unprotected Left Main Coronary Artery Disease Treated with Percutaneous Angioplasty versus Bypass Grafting: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND AIM

Treatment of patients with left main coronary artery disease (LMCA) with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) remains controversial. The aim of this meta-analysis was to compare the long-term clinical outcomes of patients with unprotected LMCA treated randomly by PCI or CABG.

METHODS

PubMed, MEDLINE, Embase, Scopus, Google Scholar, CENTRAL and ClinicalTrials.gov database searches identified five randomized trials (RCTs) including 4499 patients with unprotected LMCA comparing PCI (n = 2249) vs. CABG (n = 2250), with a minimum clinical follow-up of five years. Random effect risk ratios were used for efficacy and safety outcomes. The study was registered in PROSPERO. The primary outcome was major adverse cardiac events (MACE), defined as a composite of death from any cause, myocardial infarction or stroke.

RESULTS

Compared to CABG, patients assigned to PCI had a similar rate of MACE (risk ratio (RR): 1.13; 95% CI: 0.94 to 1.36; p = 0.19), myocardial infarction (RR: 1.48; 95% CI: 0.97 to 2.25; p = 0.07) and stroke (RR: 0.87; 95% CI: 0.62 to 1.23; p = 0.42). Additionally, all-cause mortality (RR: 1.07; 95% CI: 0.89 to 1.28; p = 0.48) and cardiovascular (CV) mortality (RR: 1.13; 95% CI: 0.89 to 1.43; p = 0.31) were not different. However, the risk of any repeat revascularization (RR: 1.70; 95% CI: 1.34 to 2.15; p < 0.00001) was higher in patients assigned to PCI.

CONCLUSIONS

The findings of this meta-analysis suggest that the long-term survival and MACE of patients who underwent PCI for unprotected LMCA stenosis were comparable to those receiving CABG, despite a higher rate of repeat revascularization.

P901 Left ventricular diastolic and systolic functions are compromised in patients with hypothyroidism

Background and Aim

Long standing hypothyroidism may impair myocardial relaxation, but its effect on systolic myocardial function is still controversial. The aim of this study was to investigate left ventricular (LV) systolic and diastolic function in patients with hypothyroidism.

Methods

This study included 81 (age 42 ± 13 years, 92% female) patients with hypothyroidism, and 22 age and gender matched controls. All subjects underwent a detailed clinical examination followed by a complete biochemical blood analysis including thyroid function assessment and anthropometric parameters measurements. LV function was assessed by 2 dimensional, M-mode and Tissue-Doppler Doppler echocardiographic examination performed in the same day.

Results

Patients had lower waist/hip ratio (p &lt; 0.001), higher urea level (p = 0.002) and lower white blood cells (p = 0.011), compared to controls. All other clinical, biochemical and anthropometric data did not differ between the two groups. Patients had impaired LV diastolic function (lower E wave [p &lt; 0.001], higher A wave [p = 0.028], lower E/A ratio [p &lt; 0.001], longer E wave deceleration time [p = 0.01], and higher E/e’ ratio [p &lt; 0.001]), compared with controls. Although LV global systolic function did not differ between groups, LV longitudinal systolic function was compromised in patients (lateral mitral annular plane systolic excursion - MAPSE [p = 0.005], as were lateral and septal TDI s’ [p &lt; 0.001 for both]).

Conclusion

In patients with hypothyroidism, in addition to compromised LV diastolic function, LV longitudinal systolic function is also impaired compared to healthy subjects of the same age and gender. These findings suggest significant subendocardial function impairment, reflecting potentially micro-circulation disease, that requires optimum management.

Left atrial compliance index predicts exercise capacity in patients with heart failure and preserved ejection fraction irrespective of right ventricular dysfunction

BACKGROUND AND AIM

Predictors of exercise capacity in heart failure (HF) with preserved ejection fraction (HFpEF) remain of difficult determination. The aim of this study was to identify predictors of exercise capacity in a group of patients with HFpEF and right ventricle (RV) dysfunction METHODS: In 143 consecutive patients with HFpEF (age 62 ± 9 years, LV EF ≥45) and 41 controls, a complete echocardiographic study was performed. In addition to conventional measurements, LA compliance was calculated using the formula: [LAV max - LAV min/LAV min × 100]. Exercise capacity was assessed using the six-minute walking test (6-MWT). Tricuspid annular plane systolic excursion (TAPSE) < 1.7 cm was utilized to categorize patients with RV dysfunction (n = 40) from those with maintained RV function (n = 103).

RESULTS

Patients with RV dysfunction were older (P = 0.002), had higher NYHA class (P = 0.001), higher LV mass index (P = 0.01), reduced septal and lateral MAPSE (all P < 0.001), enlarged LA (P = 0.001) impaired LA compliance index (P < 0.001) and exhibited a more compromised 6-MWT (P = 0.001). LA compliance index correlated more closely with 6-MWT (r = 0.51, P < 0.001) compared with the other LA indices (AP diameter, transverse diameter and volume indexed; r = -0.30, r = -0.35 and r = -0.38, respectively). In multivariate analysis, LA compliance index <60% was 88% sensitive and 61% specific (AUC 0.80, CI = 0.67-0.92 P = 0.001) in predicting exercise capacity.

CONCLUSION

An impairment in LA compliance was profound in patients with HFpEF and RV dysfunction and seems to be most powerful independent predictor of limited exercise capacity.

Adiponectin correlates with body mass index and to a lesser extent with left ventricular mass in dialysis patients

BACKGROUND

Adiponectin is a serum protein produced by adipose tissue which exerts anti-inflammatory, anti-diabetic and anti-atherosclerotic properties, hence is considered a cardio-protective marker. With the current uncertain role of adiponectin in dialysis patients to the aim of this study was to investigate its relationship with left ventricular (LV) structure and function in these patients.

METHODS

This study included 89 (age 56 ± 13 years, 43% male) patients treated with regular dialysis for > 6 months, and 55 control subjects with normal renal function. A complete two-dimensional, M-mode and tissue-Doppler echocardiographic study, and biochemical blood analyses, adiponectin and anthropometric parameters were obtainedon the same day.

RESULTS

Dialysis patients had lower body mass index (BMI) and lower body surface area (BSA) (p < 0.001 for both), lower waist/hips ratio (p = 0.005), higher LV mass index (LVMI, p < 0.001), higher adiponectin level (p < 0.001) and LV end-systolic volume (p = 0.003), lower LV ejection fraction (p = 0.006), longer isovolumic relaxation time (p < 0.001), lower mean LV strain (p = 0.002), larger left atrium volume (p = 0.022) and lower left atrium emptying fraction (p = 0.026), compared to controls. In dialysis patients, adiponectin correlated with waist circumference (r = -0.427, p < 0.001), BMI (r = -0.403, p < 0.001) and BSA (r = -0.480, p < 0.001), and to a lesser extent with LVMI (r = 0.296, p = 0.005), waist/hips ratio (r = -0.222, p = 0.037) and total cholesterol (r = -0.292, p = 0.013). But in controls, it correlated only modestly with age (r = 0.304, p = 0.024), hemoglobin (r = 0.371, p = 0.005), high density lipoprotein cholesterol (r = 0.315, p = 0.019) and LVMI (r = 0.277, p = 0.043).

CONCLUSIONS

It seems that in dialysis patients, adiponectin modest correlation with anthropometric measurements suggests an ongoing catabolic process rather than a change in ventricular function.

Quality of life questionnaire predicts poor exercise capacity only in HFpEF and not in HFrEF

BACKGROUND

The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is the most widely used measure of quality of life (QoL) in HF patients. This prospective study aimed to assess the relationship between QoL and exercise capacity in HF patients.

METHODS

The study subjects were 118 consecutive patients with chronic HF (62 ± 10 years, 57 females, in NYHA I-III). Patients answered a MLHFQ questionnaire in the same day of complete clinical, biochemical and echocardiographic assessment. They also underwent a 5 min walk test (6-MWT), in the same day, which grouped them into; Group I: ≤ 300 m and Group II: >300 m. In addition, left ventricular (LV) ejection fraction (EF), divided them into: Group A, with preserved EF (HFpEF) and Group B with reduced EF (HFrEF).

RESULTS

The mean MLHFQ total scale score was 48 (±17). The total scale, and the physical and emotional functional MLHFQ scores did not differ between HFpEF and HFpEF. Group I patients were older (p = 0.003), had higher NYHA functional class (p = 0.002), faster baseline heart rate (p = 0.006), higher prevalence of smoking (p = 0.015), higher global, physical and emotional MLHFQ scores (p < 0.001, for all), larger left atrial (LA) diameter (p = 0.001), shorter LV filling time (p = 0.027), higher E/e' ratio (0.02), shorter isovolumic relaxation time (p = 0.028), lower septal a' (p = 0.019) and s' (p = 0.023), compared to Group II. Independent predictors of 6-MWT distance for the group as a whole were increased MLHFQ total score (p = 0.005), older age (p = 0.035), and diabetes (p = 0.045), in HFpEF were total MLHFQ (p = 0.007) and diabetes (p = 0.045) but in HFrEF were only LA enlargement (p = 0.005) and age (p = 0.013. A total MLHFQ score of 48.5 had a sensitivity of 67% and specificity of 63% (AUC on ROC analysis of 72%) for limited exercise performance in HF patients.

CONCLUSIONS

Quality of life, assessment by MLHFQ, is the best correlate of exercise capacity measured by 6-MWT, particularly in HFpEF patients. Despite worse ejection fraction in HFrEF, signs of raised LA pressure independently determine exercise capacity in these patients.

Left ventricular markers of global dyssynchrony predict limited exercise capacity in heart failure, but not in patients with preserved ejection fraction

BACKGROUND

The aim of this study was to prospectively examine echocardiographic parameters that correlate and predict functional capacity assessed by 6 min walk test (6-MWT) in patients with heart failure (HF), irrespective of ejection fraction (EF).

METHODS

In 147 HF patients (mean age 61 ± 11 years, 50.3% male), a 6-MWT and an echo-Doppler study were performed in the same day. Global LV dyssynchrony was indirectly assessed by total isovolumic time - t-IVT [in s/min; calculated as: 60 - (total ejection time + total filling time)], and Tei index (t-IVT/ejection time). Patients were divided into two groups based on the 6-MWT distance (Group I: ≤ 300 m and Group II: >300 m), and also in two groups according to EF (Group A: LVEF ≥ 45% and Group B: LVEF < 45%).

RESULTS

In the cohort of patients as a whole, the 6-MWT correlated with t-IVT (r = -0.49, p < 0.001) and Tei index (r = -0.43, p < 0.001) but not with any of the other clinical or echocardiographic parameters. Group I had lower hemoglobin level (p = 0.02), lower EF (p = 0.003), larger left atrium (p = 0.02), thicker interventricular septum (p = 0.02), lower A wave (p = 0.01) and lateral wall late diastolic myocardial velocity a' (p = 0.047), longer isovolumic relaxation time (r = 0.003) and longer t-IVT (p = 0.03), compared with Group II. In the patients cohort as a whole, only t-IVT ratio [1.257 (1.071-1.476), p = 0.005], LV EF [0.947 (0.903-0.993), p = 0.02], and E/A ratio [0.553 (0.315-0.972), p = 0.04] independently predicted poor 6-MWT performance (<300 m) in multivariate analysis. None of the echocardiographic measurements predicted exercise tolerance in HFpEF.

CONCLUSION

In patients with HF, the limited exercise capacity, assessed by 6-MWT, is related mostly to severity of global LV dyssynchrony, more than EF or raised filling pressures. The lack of exercise predictors in HFpEF reflects its multifactorial pathophysiology.

Predictors of exercise capacity in patients with chronic heart failure

BACKGROUND

Heart failure is a major and growing societal problem characterized by high mortality, frequent hospitalization, reduced quality of life and a complex therapeutic regimen. The six-minute walking test (6-MWT) may serve as a useful and reproducible test for assessing exercise capacity in heart failure patients and has been suggested as a simple, well-tolerated and inexpensive alternative to cardiopulmonary exercise testing (CPET). The CPET and 6-MWT are the most broadly used for assessing functional limitation in patients with heart failure. Echocardiography is well qualified to meet the growing need for noninvasive imaging in the expanding heart failure population.

METHODS

This study included 132 consecutive patients (61 ± 10 years, 45% women) with stable heart failure. All patients underwent 6-MWT and Doppler echocardiographic examination on the same day. Clinical, biochemical and echocardiographic predictors were analyzed to assess predictors of exercise capacity. Patients were divided into two groups based on the 6-MWT distance. The first group comprised patients with limited exercise performance (≤ 300 m), and the second group, patients with good exercise performance (>300 m).

RESULTS

In univariate analysis, patients' age [0.931 (0.895-0.968), P < 0.001], arterial hypertension [0.481 (0.239-0.967), P = 0.040], blood urea level [0.860 (0.759-0.975), P = 0.019], New York Heart Association (NYHA) class [0.441 (0.245-0.795), P = 0.006], early diastolic E wave [1.014 (1.000-1.029), P = 0.047], total isovolumic time (t-IVT) [0.868 (0.796-0.947), P = 0.001], Tei index [0.112 (0.028-0.450), P = 0.002], and E' of left-ventricular (LV) lateral wall [1.188 (1.099-1.400), P = 0.039] independently predicted poor 6-MWT performance (<300 m). In multivariate analysis, only patients' age [0.948 (0.902-0.996), P = 0.034], arterial hypertension [0.351 (0.133-0.922), P = 0.034], and t-IVT [0.828 (0.725-0.946), P = 0.005] independently predicted poor 6-MWT performance (<300 m).

CONCLUSION

In chronic stable heart failure patients, in addition to age, systemic hypertension as well as LV asynchrony, as reflected by prolonged t-IVT, are independent predictors of poor exercise capacity.