Heart Failure with Reduced Ejection Fraction-Does Sex Matter?

PURPOSE OF REVIEW

There is an increasing recognition of the importance of sex in susceptibility, clinical presentation, and outcomes for heart failure. This review focusses on heart failure with reduced ejection fraction (HFrEF), unravelling differences in biology, clinical and demographic features and evidence for diagnostic and therapeutic strategies. This is intended to inform clinicians and researchers regarding state-of-the-art evidence relevant to women, as well as areas of unmet need.

RECENT FINDINGS

Females are well recognised to be under-represented in clinical trials, but there have been some improvements in recent years. Data from the last 5 years reaffirms that women presenting with HFrEF women are older and have more comorbidities like hypertension, diabetes and obesity compared with men and are less likely to have ischaemic heart disease. Non-ischaemic aetiologies are more likely to be the cause of HFrEF in women, and women are more often symptomatic. Whilst mortality is less than in their male counterparts, HFrEF is associated with a bigger impact on quality of life in females. The implications of this for improved prevention, treatment and outcomes are discussed. This review reveals distinct sex differences in HFrEF pathophysiology, types of presentation, morbidity and mortality. In light of this, in order for future research and clinical medicine to be able to manage HFrEF adequately, there must be more representation of women in clinical trials as well as collaboration for the development of sex-specific management guidelines. Future research might also elucidate the biochemical foundation of the sex discrepancy in HFrEF.

Meta-analysis of natural, unnatural and cause-specific mortality rates following discharge from in-patient psychiatric facilities

BACKGROUND

People discharged from in-patient psychiatric facilities have highly elevated rates of suicide, and there is increasing concern about natural mortality among the seriously mentally ill.

METHOD

A meta-analysis of English-language, peer-reviewed longitudinal studies of mortality among patients discharged from in-patient psychiatric facilities was conducted using papers published in MEDLINE, PsycINFO or EMBASE (from 1 January 1960 to 1 April 2018) located using the terms ((suicid*).ti AND (hospital OR discharg* OR inpatient OR in-patient OR admit*)).ab and ((mortality OR outcome* OR death*) AND (psych* OR mental*)).ti AND (admit* OR admis* OR hospital* OR inpatient* OR in-patient* OR discharg*).ab. Pooled mortality rates for aggregated natural and unnatural causes, and the specific causes of suicide, accident, homicide, vascular, neoplastic, respiratory, gastrointestinal, infectious and metabolic death were calculated using a random-effects meta-analytic model. Between-study heterogeneity was investigated using subgroup analysis and metaregression.

RESULTS

The pooled natural death rate of 1128 per 100 000 person-years exceeded the pooled unnatural deaths of 479 per 100 000 person-year among studies with varying periods of follow-up. Natural deaths significantly exceeded unnatural deaths among studies with a mean follow-up of longer than 2 years, and vascular deaths exceeded suicide deaths among studies with mean period of follow-up of 5 years or longer.

CONCLUSION

Suicide may be the largest single cause of death in the short term after discharge from in-patient psychiatric facilities but vascular disease is the major cause of mortality in the medium- and long-term.

Meta-analysis of suicide rates among people discharged from non-psychiatric settings after presentation with suicidal thoughts or behaviours

OBJECTIVE

To quantify the suicide rate among people discharged from non-psychiatric settings after presentations with suicidal thoughts or behaviours.

METHOD

Meta-analysis of studies reporting suicide deaths among people with suicidal thoughts or behaviours after discharge from emergency departments or the medical or surgical wards of general hospitals.

RESULTS

A total of 115 studies reported 167 cohorts and 3747 suicide deaths among 248 005 patients during 1 263 727 person-years. The pooled suicide rate postdischarge was 483 suicide deaths per 100 000 person-years (95% confidence interval (CI) 445-520, prediction interval (PI) 200-770) with high between-sample heterogeneity (I²  = 92). The suicide rate was highest in the first year postdischarge (851 per 100 000 person-years) but remained elevated in the long term. Suicide rates were elevated among samples of men (716 per 100 000 person-years) and older people (799 per 100 000 person-years) but were lower in samples of younger people (107 per 100 000 person-years) and among studies published between 2010 and 2018 (329 per 100 000 person-years).

CONCLUSIONS

People with suicidal thoughts or behaviours who are discharged from non-psychiatric settings have highly elevated rates of suicide despite a clinically meaningful decline in these suicide rates in recent decades.

Meta-analysis of suicide rates in the first week and the first month after psychiatric hospitalisation

OBJECTIVE

To assess the magnitude of suicide rates in the first week and first month postdischarge following psychiatric hospitalisation.

DESIGN

Meta-analysis of relevant English-language, peer-reviewed papers published in MEDLINE, PsycINFO or Embase between 01 January 1945 and 31 March 2017 and supplemented by hand searching and personal communication. A generalised linear effects model was fitted to the number of suicides, with a Poisson distribution, log link and log of person years as an offset. A random effects model was used to calculate the overall pooled rates and within subgroups in sensitivity analyses.

OUTCOME MEASURES

Suicides per 100 000 person years in the first week and the first month after discharge from psychiatric hospitalisation.

RESULTS

Thirty-four included papers comprised 29 studies that reported suicides in the first month postdischarge (3551 suicides during 222 546 patient years) and 24 studies that reported suicides in the first week postdischarge (1928 suicides during 60 880 patient years). The pooled estimate of the suicide rate in the first month postdischarge suicide was 2060 per 100 000 person years (95% CI=1300 to 3280, I²=90). The pooled estimate of the suicide rate in the first week postdischarge suicide was 2950 suicides per 100 000 person years (95% CI=1740 to 5000, I²=88). Eight studies that were included after personal communication had lower pooled rates of suicide than studies included after data extraction and there was evidence of publication bias towards papers reporting a higher rate of postdischarge suicide.

CONCLUSION

Acknowledging the presence of marked heterogeneity between studies and the likelihood of bias towards publication of studies reporting a higher postdischarge suicide rate, the first week and first month postdischarge following psychiatric hospitalisation are periods of extraordinary suicide risk. Short-term follow-up of discharged patients should be augmented with greater focus on safe transition from hospital to community care.

PROSPERO REGISTRATION NUMBER

PROSPERO registration CRD42016038169.

Calibrated NEXAFS spectra of common conjugated polymers

Near edge x-ray absorption fine structure (NEXAFS) spectroscopy has evolved into a powerful characterization tool for polymeric materials and is increasingly being used to elucidate composition and orientation in thin films of relevance to organic electronic devices. For accurate quantitative compositional analysis, insight into the electronic structure and the ability to assess molecular orientation, reliable reference spectra with known energy resolution and calibrated energy scale are required. We report a set of such NEXAFS spectra from 23 semiconducting polymers and some related materials that are frequently used in organic device research.

Evolution of the nanomorphology of photovoltaic polyfluorene blends: sub-100 nm resolution with x-ray spectromicroscopy

We investigate the influence of annealing on the morphology of intimately mixed blends of the conjugated polymers poly(9,9'-dioctylfluorene-co-bis-N,N'-(4-butylphenyl)-bis-N,N'-phenyl-1,4-phenylene-diamine) (PFB) and poly(9,9'-dioctylfluorene-co-benzothiadiazole) (F8BT) with scanning transmission x-ray microscopy (STXM). Through the use of a zone plate with theoretical Rayleigh resolution of 30 nm, we are able to resolve sub-100 nm bulk structure in these films. Surprisingly, for unannealed films spin-coated from chloroform we observe features with an average diameter of 85 nm. The high degree of photoluminescence quenching in these as-spun films (>95%) implies that there is significant intermixing within the 85 nm structures, indicating that a hierarchy of phase separation exists even on the length scale of less than 100 nm. With annealing up to 160 °C, close to the T(g) of the components, there is little change in the feature sizes observed by STXM, although an increase in variation of the composition is observed. With annealing above 160 °C the imaged features begin to evolve in size, increasing to 225 nm in extent, alongside large changes in composition with annealing to 200 °C. Comparing the evolution of morphology imaged by STXM with the change in photoluminescence quenching with annealing, we propose that phase separation first evolves via the evolution of relatively pure phases on the length scale of a few to tens of nanometres within the larger 85 nm structures. Once the length scale of compositional fluctuations exceeds 85 nm (for anneal temperatures above 160 °C) the hierarchy of phase separation is lost and the subsequent morphological evolution is readily imaged by STXM. Applying the results of an exciton diffusion and quenching model, we find good agreement between the size of the domains measured by STXM (above 180 °C) and the results of the model for an exciton diffusion length of 15 nm. The growth in domain size and towards purer structures has also been observed with resonant soft x-ray scattering.

Assessing fluid responsiveness by stroke volume variation in mechanically ventilated patients with severe sepsis

BACKGROUND AND OBJECTIVE

Our hypothesis was that stroke volume variation during mechanical ventilation of the lungs would allow accurate prediction and monitoring of changes in cardiac index in response to fluid loading in patients with severe sepsis.

METHODS

This was a prospective clinical study in a university hospital. Ten mechanically ventilated patients with severe sepsis or septic shock were given fluid loading with 500 mL 10% hydroxyethylstarch 200/0.5 over 30 min. Before and after fluid loading pulmonary arterial occlusion pressure and central venous pressure were measured. Intrathoracic blood volume index, stroke volume variation and cardiac index were measured by the transpulmonary thermodilution technique. After verifying normal distribution of the data (skewness < 1.0) the paired t-test was used for statistical analysis.

RESULTS

After fluid loading stroke volume variation decreased significantly, whereas central venous pressure, pulmonary arterial occlusion pressure, intrathoracic blood volume index and cardiac index increased significantly. Changes of cardiac index in response to fluid loading were correlated to baseline values of stroke volume variation (r = 0.64, P = 0.02) and intrathoracic blood volume index (r = -0.73, P = 0.009). Changes in cardiac index were significantly correlated to percentage changes in stroke volume variation (r = -0.65, P < 0.001) and changes in intrathoracic blood volume index (r = 0.52, P = 0.002), whereas changes in cardiac index revealed no significant correlation to changes in central venous pressure (r = 0.28, P = 0.07) and changes in pulmonary arterial occlusion pressure (r = 0.29, P = 0.06).

CONCLUSIONS

Measuring stroke volume variation may be a useful way of guiding fluid therapy in ventilated patients with severe sepsis because it allows estimation of preload and prediction of cardiac index changes in response to fluid loading.

A novel transgenic model to characterize the specific effects of follicle-stimulating hormone on gonadal physiology in the absence of luteinizing hormone actions

Gonadal function is wholly reliant on the two pituitary-derived gonadotropins, FSH and LH. Identifying the specific effects of FSH has been difficult because of the intimate relationship between LH and FSH action and inherent limitations of classic research paradigms. We describe a novel transgenic model to characterize the definitive actions of FSH alone, distinct from LH effects, created by combining transgenic FSH expression with the gonadotropin-deficient background of the hypogonadal (hpg) mouse. A tandem transgene construct encoding each alpha- and beta-subunit of human FSH, under the rat insulin II promoter, expressed biologically active heterodimers at serum levels, by immunoassay, equivalent to circulating FSH concentrations in fertile humans (0.1-25 IU/liter). Transgenic mice were crossed into the hpg mouse genotype to obtain LH-deficient animals secreting FSH alone. Testis weights of adult FSHxhpg mice were increased up to 5-fold, relative to nontransgenic hpg controls (P < 0.001). However, only transgenic males with serum FSH levels more than 1 IU/liter showed testis weights increased relative to hpg controls, indicating a physiological FSH threshold for the testicular response. Histology of enlarged FSHxhpg testes revealed round spermatids and sparse numbers of elongated spermatids, demonstrating that the testosterone-independent FSH response targeting the Sertoli cell can facilitate completion of meiosis and minimal initiation, but not completion, of spermiogenesis. Transgenic FSH also induced inhibin B secretion in FSHxhpg mice, but showed a distinct sexual dimorphism with only females exhibiting a strong FSH dose-dependent increase in serum inhibin B levels (r(2) = 0.84). In addition, ovaries of FSHxhpg females were enlarged up to 10-fold (P < 0.001), characterized by increased follicular recruitment and development to type 7 antral follicles. Thus, these findings show that the transgenic FSHxhpg mouse provides a unique model for detailed investigations of the definitive in vivo actions of FSH alone.

Changes in glucose and lipid metabolism following weight loss produced by a very low calorie diet in obese subjects

OBJECTIVE

To study the effects of a very low calorie diet (VLCD) on glucose and lipid metabolism in obese subjects, in particular, the effects on insulin sensitivity and the activities of the key enzymes of glucose disposal, glycogen synthase (GS) and the pyruvate dehydrogenase complex (PDHC).

DESIGN

Clinical dietary intervention study (1.67 MJ (400 kcal)/day) until weight loss of > 10%.

SUBJECTS

11 (seven male, four female) non-diabetic, obese subjects (age: 27-62 y; BMI: 40.5 +/- 1.4 kg/m2).

MEASUREMENTS

Whole body glucose disposal (by euglycemic hyperinsulinemic clamp), respiratory quotient (RQ), resting energy expenditure (REE), glucose and lipid oxidation (by indirect calorimetry), insulin-stimulated PDHC and GS activity (in muscle biopsies) both before and immediately after VLCD (i.e. while still in a hypocaloric state), serum hormone and metabolite levels throughout the dietary period.

RESULTS

Weight loss was accompanied by reduced insulin and elevated NEFA levels, improved insulin sensitivity due to increased nonoxidative glycolysis with no increase in PDHC or GS activities. The rate of weight loss was inversely related to the initial RQ. PDHCa was strongly age-related.

CONCLUSION

A low RQ may be used as a predictor of the efficacy of VLCD treatment and that while VLCD improves nonoxidative glycolytic flux, changes in oxidative glucose disposal and muscle glucose storage are prevented by high NEFA availability during this catabolic phase of dietary intervention.