Effects of angiotensin receptor-neprilysin inhibitors (ARNIs) on the glucose and fat metabolism biomarkers leptin and fructosamin

Background

Heart Failure with reduced ejection fraction (HFrEF) has a life time risk about 20% among adults aged 40 years or older and a 5-year mortality rate about 60% [1,2]. However novel therapies have shown to improve this outcome. One novel agent are angiotensin receptor-neprilysin inhibitors (ARNIs) that increase the BNP levels via inhibiting neprilsyin [3]. This has beneficial effects on heart failure by reducing preload, inflammation and fibrosis. Neprilysin also interacts with leptin and is known to correlate with the incidence and progression of heart failure if chronically elevated [4]. Furthermore beneficial affects of ARNI therapy on glucose metabolism were reported in a post-hoc analysis of the PARADIGM-HF trial [5]. In this study we aim to investigate the effect of ARNI therapy on the fat metabolism markers leptin and on the glucose metabolism marker fructosamin.

Methods

In total, we included 74 patients with HFrEF with ischemic (N=37) and non-ischemic (n=37) origin in the present study. The mean NYHA class was II–III, the mean BMI 28 (SD 6.3). Patients had well established heart failure therapy before starting ARNI therapy with sacubitril/valsartan. 88% of patients were on ACE-inhibitors, 86% on beta blockers and 68% on mineralocorticoid receptor antagonists. Serum samples were obtained and analyzed for leptin, fructosamin and pBNP before and 3–6 month after ARNI therapy. The clinical parameters LVEF and NYHA class were assessed before and 3–6 month after ARNI therapy.

Results

Baseline leptin level was 15.0 (SD 17.2), baseline fructosamin level was 370.1 (SD 167.7) and baseline pBNP level was 1494.9 (SD 1281.4). Under therapy a significant improvement of ejection fraction from 29,8% to 37,5% (7,7 SD 8,5 P≤0.001), an improvement of NYHA stadium from 2.46 (SD 0.62) to 1.96 (SD 0.63, p=0.005) and a significant decrease of pBNP (562.1 SD 1256.4, p=0.018) was found. Along with that, a significant increase in leptin levels (3.6 SD 8.85, p=0.012) and a significant increase in fructosamine levels (93.5 SD 160.6, p=0.013) was shown.

Conclusion

Under therapy with ARNI we showed a sufficient therapy response with improvement of ejection fraction and decrease of pBNP in line with literature. Surprisingly metabolism biomarkers did significantly worsen under the first three to six month after new ARNI therapy. To distinguish between a side effect of ARNI therapy or consequence of heart failure itself further investigations are needed.

Funding Acknowledgement

Type of funding sources: None.

Prognostic impact of cavotricuspid isthmus ablation for typical atrial flutter in patients with heart failure and reduced ejection fraction

Background

The CASTLE-AF trial in 2018, showed that pulmonary vein isolation provides a survival benefit and a reduced hospitalization rate in patients with heart failure and concomitant atrial fibrillation. Typical atrial flutter (AFL) can also induce heart failure (tachymyopathy) or, if cardiomyopathy of other origin is prevalent, can further worsen it. Cavotricuspid isthmus ablation (CTI) is a simple, invasive electrophysiological procedure that can effectively treat AFL. Prognostic data on the impact of CTI in patients with heart failure and reduced ejection fraction (HFrEF) is lacking.

Purpose

This study focused on the analysis of the clinical impact of CTI vs. medical therapy in patients with HFrEF.

Methods

The present retrospective, international, multi-center study included 104 patients <85 years with AFL and heart failure (LVEF <50%). 64 patients underwent an electrophysiological study with successful CTI (ablation group), whereas 40 patients received medical therapy alone with frequency or rhythm control and guideline-compliant heart failure therapy (medical therapy group). Patients were followed up for a total of 2 years, with particular emphasis on recording the change in LVEF over time. The primary endpoints were cardiovascular mortality and hospitalization for cardiac causes.

Results

Patients after CTI showed a significant increase in LVEF after 1 year (with the exception of valvular cardiomyopathy). The optimization of LVEF was also reflected in the Kaplan-Meier curves, as the ablation group had a significantly lower 2-year, cardiovascular mortality (p<0.001). The hospitalization rate for cardiac causes in the overall cohort showed a tendency towards reduced hospitalizations (p=0.072). Elderly patients also benefited from CTI in this study. Specifically, Patients ≥70 years of age showed a significantly lower re-hospialization rate after CTI (p=0.043) as well as a significantly reduced mortality after 2 years (p=0.012).

Conclusions

CTI in patients with AFL and HFrEF was associated with significant optimization of LVEF and lower rates of hospitalization and mortality after 2 years. Patient age should not be a primary exclusion criterion for CTI because in this study, patients ≥70 years also benefited significantly from intervention in terms of mortality and hospitalization.

Funding Acknowledgement

Type of funding sources: None.

Neutrophil-to-lymphocyte ratio and monocyte-to-lymphocyte ratio predict length of hospital stay in acute myocarditis

Background

Neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) are associated with the severity of various diseases, for example sepsis and coronary artery disease. So far, these ratios have not been described in patients diagnosed with myocarditis. The aim of this study was to demonstrate the relationship of NLR and MLR with the severity of acute myocarditis.

Materials and methods

224 consecutive patients with myocarditis were retrospectively enrolled in this study. Laboratory parameters and clinical data were extracted from hospital records and discharge letters.

Results

Median NLR was 2.48 (IQR 1.51–4.71) and median MLR was 0.42 (IQR 0.29–0.58). NLR and MLR correlated with HF, CRP and leukocyte count. NLR further correlated with pBNP (rs= 0.390, p=0.037) and inversely with oxygen saturation (rs=−0.620, p=0.042), whereas MLR correlated inversely with LV systolic function (rs=−0.386, p=0.018). Both ratios correlated better with length of hospital stay (NLR: rs= 0.450, p=0.001, MLR: rs= 0.547, p<0.0001) than CRP, leukocyte count, troponin, CK or pBNP. In multiple linear regression analysis, a model with eGFR and MLR achieved the best predictive ability for length of stay (adj. R2= 0.61, p<0.0001). AUCs for the prediction of prolonged hospital stay (NLR= 0.79, MLR= 0.82), and optimal cut-offs therefor were calculated (NLR= 4.00 (sens.: 68%, spec.: 84%), MLR= 0.48 (sens.: 79%, spec.: 78%)). Patients who met the combined endpoint of in-hospital complications showed a higher NLR, however, this remained statistically insignificant (NLR: median 3.59 (IQR 1.60–10.13) vs. 2.49 (IQR 1.51–4.60), p=0.288).

Conclusion

NLR and MLR correlated with the length of stay, as well as with several clinical and laboratory parameters in patients with myocarditis. Since white blood cell differentials are relatively easy and fast to perform, both ratios could facilitate further risk stratification in patients with acute myocarditis.

Funding Acknowledgement

Type of funding sources: None.

sST2 is a promising biomarker in hypertensive patients undergoing renal denervation

Introduction

Therapy resistant arterial hypertension (raHTN) is a major clinical burden. While therapeutic alternatives are still missing, novel interventional procedures like renal denervation (RD) are still evolving. Indeed, despite discoursing results of the Simplicity HTN-3 trial, new promising results resulted in a revival of this procedure. Therefore, predictors for the success of future interventions would be of great clinical benefit. The novel biomarker sST2 shows promising results for risk stratification of cardiovascular patient. While, sST2 belongs to the IL-1 receptor family, it has an influence on immunologic processes with consequent cardioprotective effects including prevention of myocardial hypertrophy and fibrosis indicating predictive potential in hypertensive heart disease. Nevertheless, clinical implementation of this promising biomarker was not investigated in patients with raHTN undergoing RD.

Purpose

To investigate a potential clinical relevance of sST2 in patients with raHTN undergoing RD.

Methods

We evaluated 58 patients with raHTN (age: 63±11 years, systolic blood pressure at baseline: 178±24mmHg) undergoing bilateral RD. If available, serum levels of sST2 were analyzed at baseline as well as at follow-up at one and/or three month.

Results

While RD was able to decrease blood pressure levels after one month (systolic blood pressure at one month: 158±21mmHg, p<0.01), on echocardiography a reduction of left ventricular mass (LVM) was observed at one month with a further significant reduction at three month (LVM at baseline: 233±68g, LVM at one month: 218±59g and LVM at three month: 181±59, p<0.01). This observation was accompanied by a significant decrease of sST2 levels at three month (sST2 baseline: 6322±3578pg/ml vs. sST2 three month: 4704±1586pg/ml, p=0.02). Furthermore, baseline sST2 was positively correlated with systolic blood pressure at one month, measured either at office (r=0.57, p<0.01) or invasively in the aorta (r=0.49, p=0.03) indicating a potential predictive value of this biomarker.

Conclusion

In patients with raHTN, RD is associated with a significant decrease of sST2 levels, indicating sST2 to be involved in remodeling processes after RD. Furthermore, sST2 levels at baseline might be a potential predictor of intervention success of RD. Further, studies need to investigate the association of sST2 levels and RD.

Funding Acknowledgement

Type of funding source: None