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Aynaszyan S, Devia LG, Parry MW, Badve S, DelSole EM. Patterns of Misdiagnosis and Discordance in Detecting Osteoporosis: A Comparison of Dual-energy X-ray Absorptiometry and Lumbar Computed Tomography Hounsfield Units. Clin Spine Surg 2023; 36:E369-E374. [PMID: 37296490 DOI: 10.1097/bsd.0000000000001466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/09/2023] [Indexed: 06/12/2023]
Abstract
STUDY DESIGN This was a retrospective chart review. OBJECTIVE This study aims to identify the prevalence of osteoporosis (OP) by lumbar computed tomography (CT) Hounsfield units (HUs) in patients who have normal or osteopenic bone determined by dual-energy x-ray absorptiometry (DEXA). SUMMARY OF BACKGROUND DATA OP is a critical issue in the postmenopausal and aging population. Bone mineral density assessment by DEXA has been described as insensitive for diagnosing OP in the lumbar spine. Improving the detection of OP can bring more patients to treatment and reduce the risks associated with low bone mineral density. PATIENTS AND METHODS We retrospectively reviewed all patients with DEXA scans and noncontrast CTs of the lumbar spine over a 15-year period. Patients were diagnosed as non-OP if they had a normal DEXA T -score (≥ -1) or osteopenic DEXA T -score (between -1.1 and -2.4). Patients in this cohort were considered osteoporotic by CT if L1-HU ≤110. Demographics and lumbar HUs were compared between these stratified groups. RESULTS A total of 74 patients were included for analysis. All patients were demographically, similar, and the average patient age was 70 years. The prevalence of OP determined by CT L1-HU ≤110 was 46% (normal DEXA: 9%, osteopenic DEXA: 63%). A significant number of males in our study were considered osteoporotic by L1-HU ≤110 (74%, P = 0.03). All individual axial and sagittal lumbar HU measurements including L1-L5 average lumbar HUs were statistically significant among non-OP and OP groups except for the lower lumbar levels ( P > 0.05 for L4 axial HUs, and L4-L5 sagittal HUs). CONCLUSIONS The prevalence of OP in patients with normal or osteopenic T -scores is high. Among those with osteopenia by DEXA, more than 50% may lack appropriate medical treatment. The DEXA scan may be particularly insensitive to male bone quality making the CT HU the diagnostic method of choice for detecting OP. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Stephan Aynaszyan
- Department of Spine Surgery, Geisinger Commonwealth School of Medicine
| | - Luis G Devia
- Department of Spine Surgery, Geisinger Commonwealth School of Medicine
| | - Matthew W Parry
- Department of Spine Surgery, Geisinger Commonwealth School of Medicine
| | - Siddharth Badve
- Department of Spine Surgery, Geisinger Musculoskeletal Institute, Scranton, PA
| | - Edward M DelSole
- Department of Spine Surgery, Geisinger Commonwealth School of Medicine
- Department of Spine Surgery, Geisinger Musculoskeletal Institute, Scranton, PA
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Aynaszyan S, Devia LG, Udoeyo IF, Badve SA, DelSole EM. Patient physiology influences the MRI-based vertebral bone quality score. Spine J 2022; 22:1866-1874. [PMID: 35724811 DOI: 10.1016/j.spinee.2022.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/31/2022] [Accepted: 06/11/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Osteoporosis is a critical issue affecting postmenopausal women and the aging population. A novel magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) score has been proposed as a method to identify poor bone quality and predict fragility fractures. The diagnostic accuracy of this tool is not well understood. PURPOSE To examine the ability of VBQ to predict osteoporosis and osteopenia, its correlation with dual-energy x-ray absorptiometry (DEXA), and the influence of patient-specific factors upon the score. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE Patients over the age of 18 with a DEXA scan and noncontrast, T1-weighted MRI of the lumbar spine completed within a 2-year period. OUTCOME MEASURES Area-under-curve (AUC) values of the VBQ score predicting osteopenia and osteoporosis when controlling for patient characteristics. METHODS Patients with noncontrast, T1-weighted MRIs of the lumbar spine and DEXA scans completed within a 2-year time frame were retrospectively reviewed. Patient demographics and medical risk factors for osteoporosis were identified and compared. VBQ scores were measured by two trained researchers and interrater reliability was calculated. Patients were separated into three groups defined by lowest DEXA T-score: Healthy Bone, Osteopenia, and Osteoporosis. analysis of variance, Kruskal-Wallis test, chi-square, t tests, Mann-Whitney U tests, and multivariate linear regression were performed to examine the relationship between patient characteristics, DEXA t-scores, and VBQ scores. Receiver operating characteristic analysis and AUC values were generated for the prediction of osteopenia and osteoporosis. RESULTS A total of 156 patients were included for analysis. Sufficient inter-rater reliability was determined for VBQ measures (intraclass correlation coefficient: 0.81). Most patients were female (83%), postmenopausal (81%), and had hyperlipidemia (64%). Patients with hyperlipidemia and healthy bone density by DEXA had elevated baseline VBQ scores (p<.001) reflective of values seen in osteopenia and osteoporosis. The AUC of the VBQ score predicting osteopenia and osteoporosis changed to be more concordant with DEXA results after controlling for hyperlipidemia (AUC=0.72, 0.70 vs. AUC=0.88, 0.89; p<.001). Sub-analysis of hyperlipidemia subtypes revealed that elevated high-density lipoprotein is associated with elevated VBQ scores. CONCLUSIONS Hyperlipidemia increased the MRI-based VBQ score in our healthy bone population. The high signal intensities resembled values seen in osteopenia and osteoporosis, suggesting that physiologic variables which impact bone composition may influence the VBQ score. Specifically, elevated high-density lipoprotein may contribute to this. The microarchitectural changes and the clinical implications of these factors need further exploration.
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Affiliation(s)
- Stephan Aynaszyan
- Geisinger Commonwealth School of Medicine, 525 Pine St., Scranton, PA 18510, USA
| | - Luis G Devia
- Geisinger Commonwealth School of Medicine, 525 Pine St., Scranton, PA 18510, USA
| | - Idorenyin F Udoeyo
- Department of Spine Surgery, Geisinger Musculoskeletal Institute, 3 W. Olive St., Scranton, PA 18508, USA
| | - Siddharth A Badve
- Department of Spine Surgery, Geisinger Musculoskeletal Institute, 3 W. Olive St., Scranton, PA 18508, USA
| | - Edward M DelSole
- Geisinger Commonwealth School of Medicine, 525 Pine St., Scranton, PA 18510, USA; Department of Spine Surgery, Geisinger Musculoskeletal Institute, 3 W. Olive St., Scranton, PA 18508, USA.
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Lotteau S, Zhang R, Hazan A, Grabar C, Gonzalez D, Aynaszyan S, Philipson KD, Ottolia M, Goldhaber JI. Acute Genetic Ablation of Cardiac Sodium/Calcium Exchange in Adult Mice: Implications for Cardiomyocyte Calcium Regulation, Cardioprotection, and Arrhythmia. J Am Heart Assoc 2021; 10:e019273. [PMID: 34472363 PMCID: PMC8649274 DOI: 10.1161/jaha.120.019273] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Sodium‐calcium (Ca2+) exchanger isoform 1 (NCX1) is the dominant Ca2+ efflux mechanism in cardiomyocytes and is critical to maintaining Ca2+ homeostasis during excitation‐contraction coupling. NCX1 activity has been implicated in the pathogenesis of cardiovascular diseases, but a lack of specific NCX1 blockers complicates experimental interpretation. Our aim was to develop a tamoxifen‐inducible NCX1 knockout (KO) mouse to investigate compensatory adaptations of acute ablation of NCX1 on excitation‐contraction coupling and intracellular Ca2+ regulation, and to examine whether acute KO of NCX1 confers resistance to triggered arrhythmia and ischemia/reperfusion injury. Methods and Results We used the α‐myosin heavy chain promoter (Myh6)‐MerCreMer promoter to create a tamoxifen‐inducible cardiac‐specific NCX1 KO mouse. Within 1 week of tamoxifen injection, NCX1 protein expression and current were dramatically reduced. Diastolic Ca2+ increased despite adaptive reductions in Ca2+ current and action potential duration and compensatory increases in excitation‐contraction coupling gain, sarcoplasmic reticulum Ca2+ ATPase 2 and plasma membrane Ca2+ ATPase. As these adaptations progressed over 4 weeks, diastolic Ca2+ normalized and SR Ca2+ load increased. Left ventricular function remained normal, but mild fibrosis and hypertrophy developed. Transcriptomics revealed modification of cardiovascular‐related gene networks including cell growth and fibrosis. NCX1 KO reduced spontaneous action potentials triggered by delayed afterdepolarizations and reduced scar size in response to ischemia/reperfusion. Conclusions Tamoxifen‐inducible NCX1 KO mice adapt to acute genetic ablation of NCX1 by reducing Ca2+ influx, increasing alternative Ca2+ efflux pathways, and increasing excitation‐contraction coupling gain to maintain contractility at the cost of mild Ca2+‐activated hypertrophy and fibrosis and decreased survival. Nevertheless, KO myocytes are protected against spontaneous action potentials and ischemia/reperfusion injury.
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Affiliation(s)
- Sabine Lotteau
- Smidt Heart Institute Cedars-Sinai Medical Center Los Angeles CA
| | - Rui Zhang
- Smidt Heart Institute Cedars-Sinai Medical Center Los Angeles CA
| | - Adina Hazan
- Smidt Heart Institute Cedars-Sinai Medical Center Los Angeles CA
| | - Christina Grabar
- Smidt Heart Institute Cedars-Sinai Medical Center Los Angeles CA
| | - Devina Gonzalez
- Smidt Heart Institute Cedars-Sinai Medical Center Los Angeles CA
| | | | - Kenneth D Philipson
- Department of Physiology David Geffen School of Medicine at UCLA Los Angeles CA
| | - Michela Ottolia
- Division of Molecular Medicine Department of Anesthesiology and Perioperative Medicine David Geffen School of Medicine at UCLA Los Angeles CA
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Kilfoil PJ, Lotteau S, Zhang R, Yue X, Aynaszyan S, Solymani RE, Cingolani E, Marbán E, Goldhaber JI. Distinct features of calcium handling and β-adrenergic sensitivity in heart failure with preserved versus reduced ejection fraction. J Physiol 2020; 598:5091-5108. [PMID: 32829489 PMCID: PMC7693093 DOI: 10.1113/jp280425] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/19/2020] [Indexed: 12/21/2022] Open
Abstract
Key points Heart failure (HF), the leading cause of death in developed countries, occurs in the setting of reduced (HFrEF) or preserved (HFpEF) ejection fraction. Unlike HFrEF, there are no effective treatments for HFpEF, which accounts for ∼50% of heart failure. Abnormal intracellular calcium dynamics in cardiomyocytes have major implications for contractility and rhythm, but compared to HFrEF, very little is known about calcium cycling in HFpEF. We used rat models of HFpEF and HFrEF to reveal distinct differences in intracellular calcium regulation and excitation‐contraction (EC) coupling. While HFrEF is characterized by defective EC coupling at baseline, HFpEF exhibits enhanced coupling fidelity, further aggravated by a reduction in β‐adrenergic sensitivity. These differences in EC coupling and β‐adrenergic sensitivity may help explain why therapies that work in HFrEF are ineffective in HFpEF.
Abstract Heart failure with reduced or preserved ejection fraction (respectively, HFrEF and HFpEF) is the leading cause of death in developed countries. Although numerous therapies improve outcomes in HFrEF, there are no effective treatments for HFpEF. We studied phenotypically verified rat models of HFrEF and HFpEF to compare excitation‐contraction (EC) coupling and protein expression in these two forms of heart failure. Dahl salt‐sensitive rats were fed a high‐salt diet (8% NaCl) from 7 weeks of age to induce HFpEF. Impaired diastolic relaxation and preserved ejection fraction were confirmed in each animal echocardiographically, and clinical signs of heart failure were documented. To generate HFrEF, Sprague‐Dawley (SD) rats underwent permanent left anterior descending coronary artery ligation which, 8–10 weeks later, led to systolic dysfunction (verified echocardiographically) and clinical signs of heart failure. Calcium (Ca2+) transients were measured in isolated cardiomyocytes under field stimulation or patch clamp. Ultra‐high‐speed laser scanning confocal imaging captured Ca2+ sparks evoked by voltage steps. Western blotting and PCR were used to assay changes in EC coupling protein and RNA expression. Cardiomyocytes from rats with HFrEF exhibited impaired EC coupling, including decreased Ca2+ transient (CaT) amplitude and defective couplon recruitment, associated with transverse (t)‐tubule disruption. In stark contrast, HFpEF cardiomyocytes showed saturated EC coupling (increased ICa, high probability of couplon recruitment with greater Ca2+ release synchrony, increased CaT) and preserved t‐tubule integrity. β‐Adrenergic stimulation of HFpEF myocytes with isoprenaline (isoproterenol) failed to elicit robust increases in ICa or CaT and relaxation kinetics. Fundamental differences in EC coupling distinguish HFrEF from HFpEF. Heart failure (HF), the leading cause of death in developed countries, occurs in the setting of reduced (HFrEF) or preserved (HFpEF) ejection fraction. Unlike HFrEF, there are no effective treatments for HFpEF, which accounts for ∼50% of heart failure. Abnormal intracellular calcium dynamics in cardiomyocytes have major implications for contractility and rhythm, but compared to HFrEF, very little is known about calcium cycling in HFpEF. We used rat models of HFpEF and HFrEF to reveal distinct differences in intracellular calcium regulation and excitation‐contraction (EC) coupling. While HFrEF is characterized by defective EC coupling at baseline, HFpEF exhibits enhanced coupling fidelity, further aggravated by a reduction in β‐adrenergic sensitivity. These differences in EC coupling and β‐adrenergic sensitivity may help explain why therapies that work in HFrEF are ineffective in HFpEF.
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Affiliation(s)
- Peter J Kilfoil
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Sabine Lotteau
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Rui Zhang
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Xin Yue
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Stephan Aynaszyan
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Ryan E Solymani
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Eugenio Cingolani
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Eduardo Marbán
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Joshua I Goldhaber
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
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Yue X, Kilfoil P, Zhang R, Aynaszyan S, Zhang Y, Marban E, Goldhaber JI. Excitation-contraction coupling in HFpEF versus HFrEF: Role of transverse-axial tubule system. J Mol Cell Cardiol 2020. [DOI: 10.1016/j.yjmcc.2019.11.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zhang R, Lotteau S, Hazan AT, Aynaszyan S, Gonzalez D, Li L, Philipson KD, Ottolia M, Goldhaber JI. Cardioprotection Conferred by a CRISPR/Cas9 Single Amino Acid Substitution of NCX1 (H165A): the PH Insensitive NCX Mouse. Biophys J 2020. [DOI: 10.1016/j.bpj.2019.11.705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Cho JH, Zhang R, Aynaszyan S, Holm K, Goldhaber JI, Marbán E, Cingolani E. Ventricular Arrhythmias Underlie Sudden Death in Rats With Heart Failure and Preserved Ejection Fraction. Circ Arrhythm Electrophysiol 2019; 11:e006452. [PMID: 30030266 DOI: 10.1161/circep.118.006452] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/21/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Heart failure (HF) with preserved ejection fraction (HFpEF) is increasingly common clinically, now rivaling or exceeding HF with reduced ejection fraction . Sudden death is the leading mode of exodus in patients with HFpEF, but the underlying causes are largely unknown. Using ambulatory recordings in a rat model, we test the hypothesis that ventricular arrhythmias (VA) underlie sudden death in HFpEF. METHODS Dahl salt-sensitive rats (7 weeks of age) were fed a high-salt diet to induce HFpEF (n=13) or a normal-salt diet (controls, n=9). Transthoracic echocardiography was performed to check systolic and diastolic function at 14 to 18 weeks of age. Telemetric electrocardiographic recordings were analyzed for QT interval duration, burden of premature ventricular contractions, spontaneous VA, and heart rate variability. Survival was monitored twice daily. RESULTS High-salt-fed rats with clear diastolic dysfunction, preserved ejection fraction, and HF signs were diagnosed with HFpEF at 14 to 15 weeks of age. QT and QTc intervals were prolonged in HFpEF rats compared with controls. Heart rate variability was reduced in HFpEF rats compared with controls. Spontaneous VA were more prevalent in HFpEF rats (6/13=46.1% versus 0/9=0% in controls; P<0.05), and sudden death was observed in 4 of 13 HFpEF rats. Three of the 4 sudden deaths were associated with VA as the terminal rhythm. CONCLUSIONS In this rat model with phenotypically verified HFpEF, sudden death was common and generally associated with VA. Further clinical studies are warranted to determine whether these insights translate to sudden death in HFpEF patients.
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Affiliation(s)
- Jae Hyung Cho
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Rui Zhang
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Kevin Holm
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Eduardo Marbán
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Eugenio Cingolani
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA.
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Kilfoil PJ, Soetkamp D, Zhang R, Cho J, Aynaszyan S, Cingolani E, Marbán E, Goldhaber JI. Impaired β-Adrenergic Responsiveness in HFpEF Rats. Biophys J 2019. [DOI: 10.1016/j.bpj.2018.11.551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Angert DW, Kilfoil P, De Couto G, Aynaszyan S, Cho JH, Echavez A, Valle J, Jaghatspanyan E, Marban E. Abstract 453: Young Adult Female Dahl Salt-Sensitive Rats with Heart Failure with Preserved Ejection Fraction have a Distinct Survival Advantage over Age-Matched Afflicted Males. Circ Res 2018. [DOI: 10.1161/res.123.suppl_1.453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Cardiovascular disease is the #1 killer of women. Heart failure with preserved ejection fraction (HFpEF) represents ≥50% of HF patients, and affects women ~2x more than men. With no treatment strategies showing decreased mortality, this indicates a critical unmet medical need.
Objectives:
To identify sex difference in HFpEF, we are establishing the female model of HFpEF in the Dahl salt-sensitive (DS) rat. We aim to compare male (M) and female (F) DS rats with HFpEF to identify sex-related differences in underlying mechanisms of HFpEF, for the first time.
Methods:
7-week-old DS rats of both sexes are randomly assigned to low-salt (LS; control) or high-salt (HS; 8%) diets. At 7, 14 and 18-weeks of age, rats undergo echocardiography. The endpoint for LS and HS groups is 18-weeks, when HS diet groups have developed diastolic dysfunction and HFpEF. Invasive hemodynamics are performed prior to euthanasia.
Results:
HS (M) and (F) DS rats show a significant increase in systolic (M: 233±20; F: 243±15 bpm vs control; p<0.001) and diastolic (M: 186±18; F: 183±25 bpm vs control; p<0.001) blood pressure at 18-weeks, with no change in ejection fraction. Normalized LV wall thickness is differentially increased between sexes, with anterior wall thickness (systole) greater in (M) (M:F = 1.6-fold; p<0.001), but posterior wall thickness (diastole) greater in (F) (F:M = 1.5-fold; p<0.001), indicating structural differences. Normalized heart weight/tibia length in HS vs LS diets is increased in (F) (F: 0.39 vs. M: 0.23; p<0.001), indicating increased cardiac hypertrophy in (F). Hemodynamics show increased normalized end-diastolic pressure volume relationship in (F) (F: 1.01 vs. M: 0.64; p<0.01). Although (F) DS rats with HFpEF show increased cardiac hypertrophy and worse diastolic dysfunction compared with age-matched (M) DS rats with HFpEF, Kaplan-Meier survival analysis shows an 18-week mortality rate significantly greater in (M) (~50%) vs. (F) (~16%).
Conclusion:
This study characterizes the female DS model of HFpEF, and elucidates worsening (F) cardiac dysfunction vs. (M) at 18-weeks of age, with provocative results showing significantly decreased morbidity and mortality among females at the same time-point, indicating cardioprotective effects.
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Affiliation(s)
| | | | | | | | - Jae H Cho
- CEDARS-SINAI HEART INSTITUTE, W Hollywood, CA
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