Methods to predict heart failure in diabetes patients

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is one of the leading causes of cardiovascular disease and powerful predictor for new-onset heart failure (HF).

AREAS COVERED

We focus on the relevant literature covering evidence of risk stratification based on imaging predictors and circulating biomarkers to optimize approaches to preventing HF in DM patients.

EXPERT OPINION

Multiple diagnostic algorithms based on echocardiographic parameters of cardiac remodeling including global longitudinal strain/strain rate are likely to be promising approach to justify individuals at higher risk of incident HF. Signature of cardiometabolic status may justify HF risk among T2DM individuals with low levels of natriuretic peptides, which preserve their significance in HF with clinical presentation. However, diagnostic and predictive values of conventional guideline-directed biomarker HF strategy may be non-optimal in patients with obesity and T2DM. Alternative biomarkers affecting cardiac fibrosis, inflammation, myopathy, and adipose tissue dysfunction are plausible tools for improving accuracy natriuretic peptides among T2DM patients at higher HF risk. In summary, risk identification and management of the patients with T2DM with established HF require conventional biomarkers monitoring, while the role of alternative biomarker approach among patients with multiple CV and metabolic risk factors appears to be plausible tool for improving clinical outcomes.

Extracellular vesicles in heart failure

Physiologically, extracellular vesicles (EVs) have been implicated as crucial mediators of immune response, cell homeostasis, angiogenesis, cell differentiation and growth, and tissue repair. In heart failure (HF) they may act as regulators of cardiac remodeling, microvascular inflammation, micro environmental changes, tissue fibrosis, atherosclerosis, neovascularization of plaques, endothelial dysfunction, thrombosis, and reciprocal heart-remote organ interaction. The chapter summaries the nomenclature, isolation, detection of EVs, their biologic role and function physiologically as well as in the pathogenesis of HF. Current challenges to the utilization of EVs as diagnostic and predictive biomarkers in HF are also discussed.

Predictors of Kidney Function Outcomes and Their Relation to SGLT2 Inhibitor Dapagliflozin in Patients with Type 2 Diabetes Mellitus Who Had Chronic Heart Failure

INTRODUCTION

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have a favorable impact on the kidney function in patients with heart failure (HF), while there is no clear evidence of what factors predict this effect. The aim of the study was to identify plausible predictors for kidney function outcome among patients with HF and investigate their association with SGLT2i.

METHODS

We prospectively enrolled 480 patients with type 2 diabetes mellitus (T2DM) treated with diet and metformin and concomitant chronic HF and followed them for 52 weeks. In the study, we determined kidney outcome as a composite of ≥ 40% reduced estimated glomerular filtration rate from baseline, newly diagnosed end-stage kidney disease or kidney replacement therapy. The relevant medical information and measurement of the biomarkers (N-terminal natriuretic pro-peptide, irisin, apelin, adropin, C-reactive protein, tumor necrosis factor-alpha) were collected at baseline and at the end of the study.

RESULTS

The composite kidney outcome was detected in 88 (18.3%) patients of the entire population. All patients received guideline-recommended optimal therapy, which was adjusted to phenotype/severity of HF, cardiovascular risk and comorbidity profiles, and fasting glycemia. Levels of irisin, adropin and apelin significantly increased in patients without clinical endpoint, whereas in those with composite endpoint the biomarker levels exhibited a decrease with borderline statistical significance (p = 0.05). We noticed that irisin ≤ 4.50 ng/ml at baseline and a ≤ 15% increase in irisin serum levels added more valuable predictive information than the reference variable. However, the combination of irisin ≤ 4.50 ng/ml at baseline and ≤ 15% increase in irisin serum levels (area under curve = 0.91; 95% confidence interval = 0.87-0.95) improved the discriminative value of each biomarker alone.

CONCLUSION

We suggest that low levels of irisin and its inadequate increase during administration of SGLT2i are promising predictors for unfavorable kidney outcome among patients with T2DM and concomitant HF.

Biomarkers in Heart Failure: From Research to Clinical Practice

The aim of this narrative review is to summarize contemporary evidence on the use of circulating cardiac biomarkers of heart failure (HF) and to identify a promising biomarker model for clinical use in personalized point-of-care HF management. We discuss the reported biomarkers of HF classified into clusters, including myocardial stretch and biomechanical stress; cardiac myocyte injury; systemic, adipocyte tissue, and microvascular inflammation; cardiac fibrosis and matrix remodeling; neurohumoral activation and oxidative stress; impaired endothelial function and integrity; and renal and skeletal muscle dysfunction. We focus on the benefits and drawbacks of biomarker-guided assistance in daily clinical management of patients with HF. In addition, we provide clear information on the role of alternative biomarkers and future directions with the aim of improving the predictive ability and reproducibility of multiple biomarker models and advancing genomic, transcriptomic, proteomic, and metabolomic evaluations.

Low Plasma Levels of Irisin Predict Acutely Decompensated Heart Failure in Type 2 Diabetes Mellitus Patients with Chronic Heart Failure

The aim of this study was to determine the discriminative value of irisin for acutely decompensated heart failure (ADHF) in type 2 diabetes mellitus (T2DM) patients with chronic HF. We included 480 T2DM patients with any phenotype of HF and followed them for 52 weeks. Hemodynamic performances and the serum levels of biomarkers were detected at the study entry. The primary clinical end-point was ADHF that led to urgent hospitalization. We found that the serum levels of N-terminal natriuretic pro-peptide (NT-proBNP) were higher (1719 [980-2457] pmol/mL vs. 1057 [570-2607] pmol/mL, respectively) and the levels of irisin were lower (4.96 [3.14-6.85] ng/mL vs. 7.95 [5.73-9.16] ng/mL) in ADHF patients than in those without ADHF. The ROC curve analysis showed that the estimated cut-off point for serum irisin levels (ADHF versus non-ADHF) was 7.85 ng/mL (area under curve [AUC] = 0.869 (95% CI = 0.800-0.937), sensitivity = 82.7%, specificity = 73.5%; p = 0.0001). The multivariate logistic regression yielded that the serum levels of irisin < 7.85 ng/mL (OR = 1.20; p = 0.001) and NT-proBNP > 1215 pmol/mL (OR = 1.18; p = 0.001) retained the predictors for ADHF. Kaplan-Meier plots showed a significant difference of clinical end-point accumulations in patients with HF depending on irisin levels (<7.85 ng/mL versus ≥7.85 ng/mL). In conclusion, we established that decreased levels of irisin were associated with ADHF presentation in chronic HF patients with T2DM independently from NT-proBNP.

Adropin Predicts Chronic Kidney Disease in Type 2 Diabetes Mellitus Patients with Chronic Heart Failure

Adropin is a multifunctional secreted protein, which is involved in the metabolic modulation of the heart-brain-kidney axis in heart failure (HF). The aim of the study was to detect the plausible predictive value of serum levels of adropin for chronic kidney disease (CKD) grades 1-3 in type 2 diabetes mellitus (T2DM) patients with chronic HF. We enrolled 417 T2DM individuals with chronic HF and subdivided them into two groups depending on the presence of CKD. The control group was composed of 25 healthy individuals and 30 T2DM patients without HF and CKD. All eligible patients underwent an ultrasound examination. Adropin was detected by ELISA in blood samples at the study baseline. We found that adropin levels in T2DM patients without HF and CKD were significantly lower than in healthy volunteers, but they were higher than in T2DM patients with known HF. The optimal cut-off point for adropin levels was 2.3 ng/mL (area under the curve [AUC] = 0.86; 95% CI = 0.78-0.95; sensitivity = 81.3%, specificity = 77.4%). The multivariate logistic regression adjusted for albuminuria/proteinuria showed that serum levels of adropin <2.30 ng/mL (OR = 1.55; p = 0.001) independently predicted CKD. Conclusions: Low levels of adropin in T2DM patients with chronic CH seem to be an independent predictor of CKD at stages 1-3.

Cardiac Hepatopathy: New Perspectives on Old Problems through a Prism of Endogenous Metabolic Regulations by Hepatokines

Cardiac hepatopathy refers to acute or chronic liver damage caused by cardiac dysfunction in the absence of any other possible causative reasons of liver injury. There is a large number of evidence of the fact that cardiac hepatopathy is associated with poor clinical outcomes in patients with acute or actually decompensated heart failure (HF). However, the currently dominated pathophysiological background does not explain a role of metabolic regulative proteins secreted by hepatocytes in progression of HF, including adverse cardiac remodeling, kidney injury, skeletal muscle dysfunction, osteopenia, sarcopenia and cardiac cachexia. The aim of this narrative review was to accumulate knowledge of hepatokines (adropin; fetuin-A, selenoprotein P, fibroblast growth factor-21, and alpha-1-microglobulin) as adaptive regulators of metabolic homeostasis in patients with HF. It is suggested that hepatokines play a crucial, causative role in inter-organ interactions and mediate tissue protective effects counteracting oxidative stress, inflammation, mitochondrial dysfunction, apoptosis and necrosis. The discriminative potencies of hepatokines for HF and damage of target organs in patients with known HF is under on-going scientific discussion and requires more investigations in the future.

The Association of Glucose Control with Circulating Levels of Red Blood Cell-Derived Vesicles in Type 2 Diabetes Mellitus Patients with Atrial Fibrillation

Hyperglycemia is a trigger for structural alteration of red blood cells (RBCs) and their ability to release extracellular vesicles (EVs). The aim of the study was to elucidate whether glucose control in T2DM patients with concomitant HF and AF affects a circulating number of RBC-derived EVs. We prospectively included 417 T2DM patients with HF, 51 of them had atrial fibrillation and 25 healthy volunteers and 30 T2DM non-HF individuals. Clinical assessment, echocardiography examination and biomarker measures were performed at the baseline of the study. RBC-derived EVs were determined as CD235a+ PS+ particles by flow cytometry. NT-proBNP levels were measured by ELISA. AF patients with glycosylated hemoglobin (HbA1c) < 6.9% had lower levels of CD235a+ PS+ RBC-derived vesicles than those with HbA1c ≥ 7.0%. There were no significant differences in number of CD235a+ PS+ RBC-derived vesicles between patients in entire cohort and in non-AF sub-cohort with HbA1c < 6.9% and HbA1c ≥ 7.0%, respectively. Multivariate linear regression yielded that CD235a+ PS+ RBC-derived vesicles ≥ 545 particles in µL (OR = 1.06; 95% CI = 1.01−1.11, p = 0.044) independently predicted HbA1c ≥ 7.0%. Elevated levels of CD235a+ PS+ RBC-derived EVs independently predicted poor glycaemia control in T2DM patients with HF and AF.

Interplay between Myokine Profile and Glycemic Control in Type 2 Diabetes Mellitus Patients with Heart Failure

Type 2 diabetes mellitus (T2DM) remains a powerful predictor of progressive heart failure (HF), but it is not clear whether altered glycemic control interferes with HF progression via an impaired profile of circulating myokines. The aim was to investigate plausible effects of glucose control on a myokine signature in T2DM patients affected by chronic HF. We selected 372 T2DM patients from the local database and finally included 314 individuals suffering from chronic HF and subdivided them into two groups according to glycosylated hemoglobin (HbA1c) levels (<6.9% and ≥7.0%). Echocardiography and Doppler examinations along with biomarker measurements were performed at the baseline of the study. The results showed that irisin levels were significantly lower in patients with HbA1c ≥ 7.0% than in those with HbAc1 < 6.9%, whereas concentrations of apelin, myostatin and adropin did not significantly differ between these two groups. We also identified numerous predictors of poor glycemic control, but only N-terminal brain natriuretic propeptide (odds ratio [OR] = 1.07; 95% confidence interval [CI] = 1.02−1.10, p = 0.04) and irisin (OR = 1.09; 95% CI = 1.04−1.17, p = 0.001) remained independent predictors of the dependent variable. In conclusion, we found that decreased levels of irisin were associated with poor glycemic control in T2DM patients with HF regardless of clinical conditions and other biomarkers.

Predictive value of serum irisin for chronic heart failure in patients with type 2 diabetes mellitus

We hypothesize that serum irisin can have additional discriminative potency for heart failure (HF) in individuals with type 2 diabetes mellitus (T2DM). The study group comprised 226 consecutive T2DM patients (153 patients with any HF phenotypes and 30 patients without HF) aged 41 to 65 years. The plasma levels N-terminal brain natriuretic pro-peptide (NT-proBNP) and irisin were detected by ELISA at the baseline of the study. We found that the most appropriate cut-off value of irisin (HF versus non-HF) were 10.4 ng/mL (area under curve [AUC] = 0.96, sensitivity = 81.0%, specificity = 88.0%; P = 0.0001). Cutoff point of NT-proBNP that distinguished patients with HF and without it was 750 pmol/L (AUC = 0.78; sensitivity = 72.7%, specificity 76.5%, p = 0.0001). Using multivariate comparative analysis we established that concentrations of irisin < 10.4 ng/mL (odds ration [OR] = 1.30; P = 0.001) and NT-proBNP > 750 pmol/mL (OR = 1.17; P = 0.042), left atrial volume index (LAVI) > 34 mL/m² (OR = 1.06; P = 0.042) independently predicted HF. Irisin being added to NT-proBNP improved predictive modality for HF, whereas combination of NT-proBNP and LAVI > 34 mL/m² did not. In conclusion, we established that irisin had independent predicted potency for HF in patients with established T2DM.

Discriminative Value of Serum Irisin in Prediction of Heart Failure with Different Phenotypes among Patients with Type 2 Diabetes Mellitus

Recent studies have shown that circulating levels of irisin are prognostic factors in heart failure (HF), but no data are available on the predictive role of irisin in patients with type 2 diabetes mellitus (T2DM) and different phenotypes of HF. The aim of the study was to investigate whether serum levels of irisin predict HF in T2DM patients. We prospectively included 183 participants with T2DM aged 41 to 62 years (30 non-HF patients and 153 HF patients) and 25 healthy volunteers in the study and evaluated clinical data, hemodynamics and biomarkers (N-terminal pro-brain natriuretic peptide (NT-proBNP) and irisin). Serum levels of irisin < 8.30 ng/mL were found to be a better indicator of HF with reduced ejection fraction (HFrEF) than irisin ≥ 8.30 ng/mL, but the predictive cut-off point for NT-proBNP remained the same as for HF with mildly reduced ejection fraction (HFmrEF). Serum levels of irisin < 10.4 ng/mL significantly improved the predictive ability of NT-proBNP for HF with preserved ejection fraction (HFpEF). In conclusion, we found that decreased serum levels of irisin significantly predicted HFpEF, rather than HFmrEF and HFrEF, in T2DM patients. This finding may open a new approach to HF risk stratification in T2DM patients.

Circulating levels of irisin and apelin predict heart failure with preserved ejection fraction in type 2 diabetes mellitus patients

Funding Acknowledgements

Type of funding sources: None.

Background

Irisin is skeletal muscle-derived peptide that produced by a proteolytic cleavage of fibronectin type III domain-containing-5 transmembrane protein, the expression of which is under close control of peroxisome proliferator-activated receptor-γ co-activator 1α. Apelin is a powerful regulatory peptide having positive inotrope ability and acting as an autocrine regulator of cardiac and vascular reparation. The aim of the study was to investigate whether serum levels of both irisin and apelin predict HF with preserved ejection fraction (HFpEF) in patients with T2DM.

Methods

One hundred and eight HF patients with T2DM having HFpEF (EF&gt;50%; n=58), HF with mildly reduced ejection fraction (HFmrEF, EF&lt;40%; n=22), HF with reduced ejection fraction (HFrEF, EF&lt;40%; n=28) aged from 41 to 62 years and 20 non-HF patients with T2DM. Healthy control group was consisted of 25 individuals matched with age and sex. We collected demographic and anthropometric information, data for hemodynamic performances by B-mode echocardiography, Doppler and TDI, and the levels of biomarkers including irisin, apelin, N-terminal pro-brain natriuretic peptide (NT-proBNP) by ELISA at the study entry.

Results

We found that the levels of irisin were significantly higher in HFpEF patients than in HFrEF individuals, whereas healthy volunteers and T2DM non-HF patients demonstrated lower concentrations of these peptides. On contrary, apelin levels were significantly increased in HF patients mainly with HFrEF. There were not significant differences between the levels of these biomarkers in HFrEF and HFmrEF (P=0.42 for all cases). Using ROC curve we revealed that cut-off points for irisin and apelin that distinguished HFpEF from HFrEF/HFmrEF were (6.50 ng/mL; AUC=0.78; 95% confidence interval [CI] = 6.85 - 10.66 ng/mL and 4.12 ng/mL, AUC=0.72; 95% CI=3.90-5.75 ng/mL, respectively). Then we divided all patients with HF having elevation of NT-proBNP &gt; 750 pmol/mL into three subgroups depending on the biomarkers’ levels. Patients from subgroup A had both irisin and apelin levels higher cut-off points, individuals from group B had higher concentration of one of two biomarkers, and patients from subgroup C demonstrated levels of both peptides lower cut-off points. Multivariate logistic regression analysis revealed that discriminative value of irisin and apelin to predict HFpEF in subgroup B (Odds Ratio [OR]= 2.18; 95% CI=1.26-3.14; P=0.001) were substantially higher compared with subgroups A and C (OR = 1.03; 95% CI=1.00-1.05; P=0.64 and OR = 0.92; 95% CI=0.89-1.01; P=0.62, respectively). Adding irisin and apelin to NT-proBNP as independent variables to the predictive model sufficiently improved discriminative ability of whole model for HFpEF.

In conclusion

We found that multidirectional changes in the levels of irisin and apelin in T2DM patients had better predictive value for HFpEF that simultaneous increase and decrease in the circulating levels of these peptides.

Sodium-Glucose Co-transporter-2 Inhibitors in Heart Failure with Preserved Ejection Fraction: A Breakthrough in Improvement of Clinical Outcomes?

The conventional conception of the therapy of heart failure (HF) with reduced ejection fraction has been recently modified by adding sodium-glucose co-transporter-2 (SGLT2) inhibitors to the combination consisting of beta blockers, mineralocorticoid receptor antagonists, and angiotensin receptor-neprilysin inhibitors, with the aim of improving clinical outcomes. It remains unclear whether other sub-populations of patients with HF, having either HF with preserved ejection fraction (HFpEF) or HF with mildly reduced ejection fraction, are relevant candidates for the effective therapeutic intervention that includes SGLT2 inhibitors. The purpose of the narrative review is to elucidate plausible perspectives for the clinical implementation of SGLT2 inhibitors into optimal medical therapy in patients with HFpEF. The authors searched the bibliographic databases (Embase, Medline, and the Web of Science) and the Cochrane Central to find English-written publications satisfying the purpose of this study. The authors included eight studies and two meta-analyses that have been reported as completed and found that there were high heterogeneous data regarding the fact that SGLT2 inhibitors had strict resemblance in their efficacy among patients with HFpEF with and without Type 2 diabetes. Due to the use of unpublished data and findings from the trials ended early, there is a lack of upper left ventricular ejection fraction threshold levels to identify inclusion criteria and no agreement in heart failure with reduced ejection fraction determination. However, the results of the meta-analysis, especially come from subgroups’ analysis, appeared to be relevantly optimistic for use of SGLT2 inhibitors in HFpEF therapy.

Point-of-care heart failure platform: where are we now and where are we going to?

INTRODUCTION

Heart failure (HF) remains a leading cause of cardiovascular (CV) mortality in patients with CV disease. The point-of-care (POC) HF platform seems to be an ideal non-invasive workflow-adapted system for personally adjusted management of patients with HF.

AREAS COVERED

In the present manuscript, we reviewed the literature covering some relevant studies regarding the role of point-of care heart failure platform in the risk stratification, earlier diagnosis and prognostically beneficial treatment of patients with different phenotypes of HF.

EXPERT OPINION

POC HF platform including personal consultation, optimization of the comorbidity treatment, step-by-step HF diagnostic algorithm, single biomarker measurements, has also partially been provided in the current guidelines. Although there are several obstacles to implement POC in routine practice, such as education level, aging, affordability of health care, even partial implementation of POC can also improve clinical outcomes. POC seems to be an evolving model, more research studies are required to clearly see whether it helps to make better decisions with diagnosis and care of HF, as well helps to achieve better clinical outcomes.In summary, the POC HF platform is considered to be a more effective tool than conventional algorithm of HF management.

Serum Levels of Irisin Predict Cumulative Clinical Outcomes in Heart Failure Patients With Type 2 Diabetes Mellitus

Background: The aim of this study was to investigate the role of serum irisin level in predicting clinical outcome in heart failure (HF) patients with type 2 diabetes mellitus (T2DM).

Methods: 153 T2DM patients with HF aged 41–62 years were prospectively recruited for the study. Serum levels of irisin and NT-proBNP were measured by ELISA. Laboratory tests including HbA1c, fasting glucose, blood creatinine, insulin, lipids and creatinine with estimation of GFR were performed along with echocardiography at baseline. The observation period was 56 weeks.

Results: We identified 76 composite cardiovascular (CV) outcomes, which included CV death and death from all causes, resuscitated cardiac death, non-fatal/fatal acute myocardial infarction or stroke, and HF hospitalization. Therefore, the entire patient cohort was divided into 2 groups with (n = 76) and without (n = 77) composite CV outcomes. We found that the concentrations of NT-proBNP were higher in HF patients with T2DM who had a CV composite outcome than in patients without CV composite outcome (p = 0.001). In contrast, the relationship was exactly reversed for irisin, as HF and T2DM patients with CV composite outcome had significantly lower irisin levels (p = 0.001). Unadjusted multivariate Cox regression analyses showed that LVEF &lt; 40%, LAVI &gt; 39 ml/m2, NT-proBNP &gt; 2,250 pmol/ml, and irisin &lt; 6.50 ng/ml were the strongest predictors of CV outcomes in HF patients with T2DM. After adjustment for LVEF, serum levels of NT-proBNP and irisin remained independent predictors of end points. Furthermore, divergence of Kaplan-Meier curves pointed out that patients with NT-proBNP &gt; 2,250 pmol/ml and irisin &lt; 6.50 ng/ml had worse prognosis than those with any other compartment of the bomarkers’ levels.

Conclusion: Adding irisin to NT-proBNP significantly improved discriminative value of the whole model. HF patients with T2DM had significantly worse clinical outcomes when showing the constellation NT-proBNP &gt; 2,250 pmol/ml and irisin &lt; 6.50 ng/ml, respectively, in comparison to patients with opposite trends for both biomarkers.

Predictive value of both irisin and apelin for heart failure with preserved ejection fraction in type 2 diabetes mellitus patients

Funding Acknowledgements

Type of funding sources: None.

Background

Irisin is skeletal muscle-derived peptide, the expression of which is under close control of peroxisome proliferator-activated receptor-γ co-activator 1α. Apelin is a peptide having positive inotrope ability and acting as an autocrine regulator of cardiac and vascular reparation. Type 2 diabetes mellitus (T2DM). The aim of the study was to investigate whether serum levels of both irisin and apelin predict HF with preserved ejection fraction (HFpEF) in patients with T2DM.

Methods

One hundred and eight HF patients with T2DM having HFpEF (EF&gt;50%; n=58), HF with mildly reduced ejection fraction (HFmrEF, EF&lt;40%; n=22), HF with reduced ejection fraction (HFrEF, EF&lt;40%; n=28) aged from 41 to 62 years and 20 non-HF patients with T2DM. Healthy control group was consisted of 25 individuals matched with age and sex. All patients gave voluntary written informed consent to participate in the study. We polled at baseline demographic and anthropometric information, data for hemodynamic performances by B-mode echocardiography, Doppler and TDI, and the levels of biomarkers including irisin, apelin, N-terminal pro-brain natriuretic peptide (NT-proBNP) by ELISA.

Results

We found that the levels of irisin were significantly higher in HFpEF patients than in HFrEF individuals, whereas healthy volunteers and T2DM non-HF patients demonstrated lower concentrations of these peptides. On contrary, apelin levels were significantly increased in HF patients mainly with HFrEF. There were not significant differences between the levels of these biomarkers in HFrEF and HFmrEF (P=0.42 for all cases). Using ROC curve we revealed that cut-off points for irisin and apelin that distinguished HFpEF from HFrEF/HFmrEF were (6.50 ng/mL; AUC=0.78; 95% confidence interval [CI] = 6.85 - 10.66 ng/mL and 4.12 ng/mL, AUC=0.72; 95% CI=3.90-5.75 ng/mL, respectively). Then we divided all patients with HF having elevation of NT-proBNP &gt; 750 pmol/mL into three subgroups depending on the biomarkers’ levels. Patients from subgroup A had both irisin and apelin levels higher cut-off points, individuals from group B had higher concentration of one of two biomarkers, and patients from subgroup C demonstrated levels of both peptides lower cut-off points. Multivariate logistic regression analysis revealed that discriminative value of irisin and apelin to predict HFpEF in subgroup B (Hazard Ratio [HR]= 2.18; 95% CI=1.26-3.14; P=0.001) were substantially higher compared with subgroups A and C (HR = 1.03; 95% CI=1.00-1.05; P=0.64 and HR = 0.92; 95% CI=0.89-1.01; P=0.62, respectively). Adding irisin and apelin to NT-proBNP as independent variables to the predictive model sufficiently improved discriminative ability of whole model for HFpEF.

In conclusion: We found that multidirectional changes in the levels of irisin and apelin in T2DM patients had better predictive value for HFpEF that simultaneous increase and decrease in the circulating levels of these peptides.

Elevated levels of apelin predict favorable clinical course of heart failure in type 2 diabetes mellitus patients

Funding Acknowledgements

Type of funding sources: None.

Background

Apelin is a regulatory peptide having positive inotrope and reparative abilities. Type 2 diabetes mellitus (T2DM) is common comorbidity that is associated to occurrence of HF mainly HF with preserved ejection fraction (HFpEF). The discriminative potency of conventional cardiac biomarkers such as natriuretic peptides in HFpEF was found to be sufficiently lower compared to HF with reduced / mildly reduced ejection fraction (HFrEF / HFmrEF). The aim of the study was to investigate whether serum levels of apelin predict HF in patients with T2DM.

Methods

A total of 108 HF patients (left ventricular ejection fraction [LVEF] &lt;60%) with T2DM were prospectively involved in the study. Entire HF population consisted of 58 HFpEF patients and 50 HFmrEF / HFrEF aged from 41 to 62 years. Cardiac hemodynamic performances were obtained by B-mode echocardiography, Doppler and TDI. The levels of apelin, N-terminal pro-brain natriuretic peptide (NT-proBNP), high sensitive troponin T (hs-TnT) were measured by ELISA. Combined end-point for the study were defined as all-cause death and any non-fatal cardiovascular event or HF hospitalization during 52 weeks.

Results

The combined end-point occurred in 37 patients (34.3%) from entire population. The levels of apelin in patients who had the combined end-point were significantly lower (3.55 ng/mL, 95% confidence interval [CI]=3.12-3.95 ng/mL) compared with those who did not meet it (5.60 ng/mL; 95% CI = 4.10-7.10 ng/mL; P=0.001). ROC curve revealed that the best-balanced cut-off point for apelin levels, which predicted combined end-point occurrence, was 3.88 ng/mL (AUC=0.82; P=0.001). Cox regression showed that apelin levels &gt; 3.55 ng/mL (Odds Ratio [OR]= 2.02; 95% CI=1.14-3.25; P=0.001), LVEF&lt; 49% (OR=1.48; 95% CI=1.22-1.68, P = 0.001), NT-proBNP &gt; 785 ng/mL (OR =2.08; 95% CI = 1.03–4.12; P = 0.001), global longitudinal strain &lt; -8.6% (OR =2.02; 95% CI = 1.09–3.10; P = 0.001), hs-TnT &gt; 0.4 ng/mL (OR=1.98; 95% CI=1.10-2.93; P=0.001), estimated glomerular filtration rate &lt;60 mL/min/1.73 m2 (OR=1.46; 95% CI=1.09-2.55; P=0.001) and history of atrial fibrillation (OR=1.14; 95% CI=1.02-1.80; P=0.001) predicted the combined end-point. After adjustment for HFpEF, apelin levels &gt; 3.55 ng/mL (OR=2.03; 95% CI=1.10-3.20; P=0.001) and NT-proBNP &gt; 785 ng/mL (OR =2.10; 95% CI = 1.05–3.80; P = 0.001) remain independent predictors for the combined end-point. The addition of apelin to the ABC model (NT-proBNP &gt; 785 ng/mL) improved the relative integrated discrimination indices by 10.5% and net-reclassification improvement for 11.5% for combined end-point. Kaplan – Meier curve showed that patients having the levels of apelin &gt;3.55 ng/mL demonstrated better clinical course of HF compared with those who had lower apelin levels (log rank test p=0.001).

In conclusion: We found that apelin levels &gt;3.55 ng/mL regardless of NT-proBNP had positive discriminative ability for clinical course of HF in T2DM patients.

Discriminative Utility of Apelin-to-NT-Pro-Brain Natriuretic Peptide Ratio for Heart Failure with Preserved Ejection Fraction among Type 2 Diabetes Mellitus Patients

Background: Apelin is a regulatory vasoactive peptide, which plays a pivotal role in adverse cardiac remodeling and heart failure (HF) with reduced ejection fraction. The purpose of the study was to investigate whether serum levels of apelin is associated with HF with preserved election fraction (HFpEF) in patients with T2DM. Methods: The study retrospectively involved 101 T2DM patients aged 41 to 62 years (48 patients with HFpEF and 28 non-HFpEF patients). The healthy control group consisted of 25 individuals with matched age and sex. Data collection included demographic and anthropometric information, hemodynamic performances and biomarkers of the disease. Transthoracic B-mode echocardiography, Doppler and TDI were performed at baseline. Serum levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and apelin were measured by ELISA in all patients at the study entry. Results: Unadjusted multivariate logistic model yielded the only apelin to NT-proBNP ratio (OR = 1.44; p = 0.001), BMI > 34 кг/м2 (OR = 1.07; p = 0.036), NT-proBNP > 458 pmol/mL (OR = 1.17; p = 0.042), LAVI > 34 mL/m2 (OR = 1.06; p = 0.042) and E/e’ > 11 (OR = 1.04; p = 0.044) remained to be strong predictors for HFpEF. After obesity adjustment, multivariate logistic regression showed that the apelin to NT-proBNP ratio < 0.82 × 10−2 units remained sole independent predictor for HFpEF (OR = 1.44; 95% CI: 1.18–2.77; p = 0.001) HFpEF in T2DM patients. In conclusion, we found that apelin to NT-proBNP ratio < 0.82 × 10−2 units better predicted HFpEF in T2DM patients than apelin and NT-proBNP alone. This finding could open new approach for CV risk stratification of T2DM at higher risk of HF.

Antigen-presenting cell-derived extracellular vesicles in accelerating atherosclerosis

Extracellular vesicles (EVs) are a population of heterogeneous particles that originate from the endosomal system or plasma membrane. Antigen-presenting cells (APCs) produce and release a broad spectrum of EVs involved in the pathogenesis of atherosclerosis. APC-derived EVs contain several bioactive molecules, such as non-coding RNAs, cytokines, chemokines, active proteins, immunomodulatory factors, and growth factors. The review focuses on the role of APC-derived EVs in regulating the transformation of macrophage phenotype, shaping foam cells, driving autophagy and/or inhibiting apoptosis of Th4+ cells, T regulatory cells, endothelial and smooth muscle cells (SMCs), as well as in facilitating oxidative stress in vasculature. APC-derived EVs act as triggers of angiogenesis, neovascularization and inflammation through their participation in microvascular inflammation, angiogenesis, development of atherosclerotic plaques, and modulation of their instability.

Shift of conventional paradigm of heart failure treatment: from angiotensin receptor neprilysin inhibitor to sodium-glucose co-transporter 2 inhibitors?

Current clinical guidelines for heart failure (HF) contain a brand new therapeutic strategy for HF with reduced ejection fraction (HFrEF), which is based on neurohumoral modulation through the use of angiotensin receptor neprilysin inhibitors. There is a large body of evidence for the fact that sodium-glucose co-transporter 2 inhibitors may significantly improve all-cause mortality, cardiovascular mortality and hospitalization for HF in patients with HFrEF who received renin-angiotensin system blockers including angiotensin receptor neprilysin inhibitors, β-blockers and mineralocorticoid receptor antagonists. The review discusses that sodium-glucose co-transporter 2 inhibitors have a wide spectrum of favorable molecular effects and contribute to tissue protection, improving survival in HFrEF patients.

Emerging Role of Adipocyte Dysfunction in Inducing Heart Failure Among Obese Patients With Prediabetes and Known Diabetes Mellitus

Adipose tissue dysfunction is a predictor for cardiovascular (CV) events and heart failure (HF) in patient population with obesity, metabolic syndrome, and known type 2 diabetes mellitus. Previous preclinical and clinical studies have yielded controversial findings regarding the role of accumulation of adipose tissue various types in CV risk and HF-related clinical outcomes in obese patients. There is evidence for direct impact of infiltration of epicardial adipocytes into the underlying myocardium to induce adverse cardiac remodeling and mediate HF development and atrial fibrillation. Additionally, perivascular adipocytes accumulation is responsible for release of proinflammatory adipocytokines (adiponectin, leptin, resistin), stimulation of oxidative stress, macrophage phenotype switching, and worsening vascular reparation, which all lead to microvascular inflammation, endothelial dysfunction, atherosclerosis acceleration, and finally to increase in CV mortality. However, systemic effects of white and brown adipose tissue can be different, and adipogenesis including browning of adipose tissue and deficiency of anti-inflammatory adipocytokines (visfatin, omentin, zinc-α2-glycoprotein, glypican-4) was frequently associated with adipose triglyceride lipase augmentation, altered glucose homeostasis, resistance to insulin of skeletal muscles, increased cardiomyocyte apoptosis, lowered survival, and weak function of progenitor endothelial cells, which could significantly influence on HF development, as well as end-organ fibrosis and multiple comorbidities. The exact underlying mechanisms for these effects are not fully understood, while they are essential to help develop improved treatment strategies. The aim of the review is to summarize the evidence showing that adipocyte dysfunction may induce the onset of HF and support advance of HF through different biological mechanisms involving inflammation, pericardial, and perivascular adipose tissue accumulation, adverse and electrical cardiac remodeling, and skeletal muscle dysfunction. The unbalancing effects of natriuretic peptides, neprilysin, and components of renin–angiotensin system, as exacerbating cause of altered adipocytokine signaling on myocardium and vasculature, in obesity patients at high risk of HF are disputed. The profile of proinflammatory and anti-inflammatory adipocytokines as promising biomarker for HF risk stratification is discussed in the review.

Circulating Cardiac Biomarkers in Diabetes Mellitus: A New Dawn for Risk Stratification-A Narrative Review

The aim of this narrative review is to update the current knowledge on the differential choice of circulating cardiac biomarkers in patients with prediabetes and established type 2 diabetes mellitus (T2DM). There are numerous circulating biomarkers with unconfirmed abilities to predict clinical outcomes in pre-DM and DM individuals; the prognostication ability of the cardiac biomarkers reported here has been established, and they are still being studied. The conventional cardiac biomarkers, such as natriuretic peptides (NPs), soluble suppressor tumorigenisity-2, high-sensitivity circulating cardiac troponins and galectin-3, were useful to ascertain cardiovascular (CV) risk. Each cardiac biomarker has its strengths and weaknesses that affect the price of usage, specificity, sensitivity, predictive value and superiority in face-to-face comparisons. Additionally, there have been confusing reports regarding their abilities to be predictably relevant among patients without known CV disease. The large spectrum of promising cardiac biomarkers (growth/differential factor-15, heart-type fatty acid-binding protein, cardiotrophin-1, carboxy-terminal telopeptide of collagen type 1, apelin and non-coding RNAs) is discussed in the context of predicting CV diseases and events in patients with known prediabetes and T2DM. Various reasons have been critically discussed related to the variable findings regarding biomarker-based prediction of CV risk among patients with metabolic disease. It was found that NPs and hs-cTnT are still the most important tools that have an affordable price as well as high sensitivity and specificity to predict clinical outcomes among patients with pre-DM and DM in routine clinical practice, but other circulating biomarkers need to be carefully investigated in large trials in the future.

Extracellular Endothelial Cell-Derived Vesicles: Emerging Role in Cardiac and Vascular Remodeling in Heart Failure

Extracellular vesicles play a pivotal role in numerous physiological (immune response, cell-to-cell cooperation, angiogenesis) and pathological (reparation, inflammation, thrombosis/coagulation, atherosclerosis, endothelial dysfunction) processes. The development of heart failure is strongly associated with endothelial dysfunction, microvascular inflammation, alteration in tissue repair, and cardiac and vascular remodeling. It has been postulated that activated endothelial cell-derived vesicles are not just transfer forms of several active molecules (such as regulatory peptides, coagulation factors, growth factors, active molecules, hormones that are embedded onto angiogenesis, tissue reparation, proliferation, and even prevention from ischemia/hypoxia), but are instead involved in direct myocardial and vascular damage due to regulation of epigenetic responses of the tissue. These responses are controlled by several factors, such as micro-RNAs, that are transferred inside extracellular vesicles from mother cells to acceptor cells and are transductors of epigenetic signals. Finally, it is not a uniform opinion whether different phenotypes of heart failure are the result of altered cardiac and vascular reparation due to certain epigenetic responses, which are yielded by co-morbidities, such as diabetes mellitus and obesity. The aim of the review is to summarize knowledge regarding the role of various types of extracellular endothelial cell-derived vesicles in the regulation of cardiac and vascular remodeling in heart failure.

P6603The predictive role of T786C single nucleotide polymorphism in endothelial no-synthase gene in late left ventricular remodeling after ST-segment elevation myocardial infarction

Introduction

Endothelial NO-synthase (eNOS) is constitutive enzyme, which is expressed in mature endothelial cells and promotes direct vascular dilatation. Single nucleotide polymorphism (SNP) of T786C in eNOS gene may influence on adverse cardiac remodeling after ST-elevation myocardial infarction (STEMI).

Purpose

To investigate possible associations between SNP T786C in eNOS gene and adverse cardiac remodeling after STEMI

Methods

177 acute STEMI patients treated with primary and facilitate percutaneous coronary intervention that were admitted to intensive care unit of a Therapy National Institute were enrolled in the study. Anthropometry, cardiovascular risk assay, coronary angiography, echocardiography and biomarkers' measure were performed at baseline. The DNA extraction was performed with a commercial kit using real-time polymerase chain reaction PCR. All procedures performed in the study involving human participants were in accordance with the ethical standards and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards and approved by the local ethics committee (Protocol No. 8, 29.08.2016). Written informed consent was obtained from each patient.

Results

There were correlations between 786CC polymorphism in eNOs gene and adverse cardiac remodeling (r=0.48; p=0.001), LDL cholesterol (r=0.32; p=0.012), type 2 diabetes mellitus (r=0.30; p=0.042), diastolic BP (r=−0.26; p=0.048), unstable angina prior to STEMI (r=0.25; p=0.047) and total quantity of complicated STEMI (r=0.23; p=0.042). Additionally, there were not significant relations between 786CC polymorphism in eNOs gene and multiple coronary vessel injury, STEMI localization, levels of circulating biomarkers of myocardial injury, and amount of damaged coronary arteries. Using univariate and multivariate regressive logistic analysis we found that 786CC genotype of eNOS was independent predictor for late adverse LV remodeling (β-coefficient = 1.57342; odds ratio = 4.8231; 95% confidence interval = 1.5349–15.1552; p=0.0071).

Conclusions

The polymorphism 786CC in eNOs gene was found as an independent predictor for late adverse cardiac remodeling after STEMI.

Acknowledgement/Funding

None

Impaired function of fibroblast growth factor 23 / Klotho protein axis in prediabetes and diabetes mellitus: Promising predictor of cardiovascular risk

The discovery of clear molecular mechanisms of early cardiac and vascular complications in patients with prediabetes and known diabetes mellitus are core element of stratification at risk with predictive model creation further. Previous clinical studies have shown a pivotal role of impaired signaling axis of fibroblast growth factor 23 (FGF23), FGF23 receptor isoforms and its co-factor Klotho protein in cardiovascular (CV) complications in prediabetes and diabetes. Although there were data received in clinical studies, which confirmed a causative role of altered function of FGF-23/Klotho protein axis in manifestation of CV disease in prediabetes and type 2 diabetes mellitus (T2DM), the target therapy of these diseases directing on improvement of metabolic profiles, systemic and adipokine-relating inflammation by beneficial restoring of dysregulation in FGF-23/Klotho protein axis remain to be not fully clear. The aim of the review was to summarize findings regarding the role of impaired FGF-23/Klotho protein axis in developing CV complications in patients with prediabetes and type 2 diabetes mellitus. It has been elucidated that elevated levels of FGF-23 and deficiency of Klotho protein in peripheral blood are predictors of CV disease and CV outcomes in patients with (pre) diabetes, while predictive values of dynamic changes of the concentrations of these biomarkers require to be elucidated in detail in the future.

Association of growth-differentiation factor-15 with the number of circulating proangiogenic endothelial progenitor cells in patients with type 2 diabetes mellitus

The objective: to investigate the relationship between levels of growth differentiation factor-15 (GDF-15) and circulating number of endothelial progenitor cells (EPCs) with angiopoietin phenotypes: CD34+CD14+CD309+, and CD34+CD14+CD309+Tie2+ in patients with type 2 DM. Methods: The study was retrospectively involved 76 patients with type 2 DM aged 38 to 55 years and 30 healthy volunteers. Data collection included demographic and anthropometric information, hemodynamic performances and biomarkers of the diseases. Flow cytometry was used to determine EPCs' populations. Results: The levels of GDF-15 in peripheral blood of diabetics associated with age (r = 0.31, P = 0.044), high-sensitive C-reactive protein [hs-CRP] (r = 0.40, P = 0.001), smoking (r = 0.38, P = 0.001), body mass index [BMI] (r = 0.34, P = 0.001), LDL cholesterol (r = 0.28, P = 0.001), glycated hemoglobin [HbA1c] (r = -0.28, P = 0.001), number of CV risk factors (r = 0.26, P = 0.001). In univariate logistic regression analysis we found that level of GDF-15 ≥ 618 pg/mL, hs-CRP ≥7.12 mg/L, HbA1c ≥6.4%, fasting glucose ≥6.7 mmol/L, and BMI ≥27.3 kg/m2 predicted deficiency of both angiopoetic phenotypes of EPCs. In multivariate logistic regression model GDF-15 ≥618 pg/mL demonstrated the best odds ratio values for declining of EPCs in diabetics in comparison with other predictors including BMI, HbA1c and hs-CRP. Conclusion: GDF-15 was remarkably evaluated in type 2 DM population to healthy volunteers, and it was an independent factor that contributes to mobilization and probably proliferation of endothelial precursors with high angiopoetic activity.

Isotopic Self-Organization as an Informational Factor in Biological Systems

We outline possible effects of isotopic randomness and isotopic self-organization (isotopicity) for biology, genetics, neurodynamics and conscious-ness. Prime ideas are (a) isotopic genetic code based on isotopic permutations in genomes, and (b) catalytic effects of decays of radioactive isotopes in physiology and psychology. We discuss the reasons why these ideas are presently severely under-appreciated by the biomedical research community. We propose some steps to foster interest in isotopic effects in biology.

Non-Thermal Plasma Techniques for the Reduction of Volatile Organic Compounds in Air Streams: A Critical Review

This paper critically reviews the non-thermal plasma techniques for reduction of volatile organic compounds (VOC) in air streams. The currently used technologies fall into two categories: those based on nonthermal plasma generated from various forms of corona discharge and those exploiting high energy electron beams. Relative advantages and disadvantages of non-thermal plasma and conventional techniques are discussed.

On the possible physical foundations of health related effects of crystals

I propose a possible physical mechanism to account for widely claimed health related effects of crystals. The hypothesis relates the mechanism of such action to the isotropic diversity of crystals which leads to an enormous information storage capacity of crystal lattices. Sublattices of particular isotopes form an interactive network similar to simulated neural networks based on spin glass models.

Isotopical positional correlations as a possible model for Benveniste experiments

I suggest a hypothetic explanation of recently found 'memory effect' in water (water 'remembers' the presence of some biologically active molecules even when they are diluted to levels less then one molecule per total volume). My explanation is based on isotopic diversity water, namely that some positional correlations of stable isotope (H, D, 16O, 17O and 18O) might work as 'templates' of the originally dissolved molecules. These isotopic correlations are equivalent to the choice of a particular isotopic pattern out of the highly degenerate manyfold of potentially available patterns. This pattern is further reproduced at each next dilution level by some sort of 'locking-in' mechanism. Among possible physical candidates for such locking-in action is the polaronic self-stabilization in non-linear media.