The progression of hypertensive heart disease

Joint influences of obesity, diabetes, and hypertension on indices of ventricular remodeling: Findings from the community-based Framingham Heart Study

Introduction

Obesity, hypertension, and diabetes are independently associated with cardiac remodeling and frequently co-cluster. The conjoint and separate influences of these conditions on cardiac remodeling have not been investigated.

Materials and methods

We evaluated 5,741 Framingham Study participants (mean age 50 years, 55% women) who underwent echocardiographic measurements of left ventricular (LV) mass (LVM), LV ejection fraction (LVEF), global longitudinal strain (GLS), mitral E/e’, left atrial end-systolic (peak) dimension (LASD) and emptying fraction (LAEF). We used multivariable generalized linear models to estimate the adjusted-least square means of these measures according to cross-classified categories of body mass index (BMI; normal, overweight and obese), hypertension (yes/no), and diabetes (yes/no).

Results

We observed statistically significant interactions of BMI category, hypertension, and diabetes with LVM, LVEF, GLS, and LAEF (p for all 3-way interactions <0.01). Overweight and obesity (compared to normal BMI), hypertension, and diabetes status were individually and conjointly associated with higher LVM and worse GLS (p<0.01 for all). We observed an increase of 34% for LVM and of 9% for GLS between individuals with a normal BMI and without hypertension or diabetes compared to obese individuals with hypertension and diabetes. Presence of hypertension was associated with higher LVEF, whereas people with diabetes had lower LVEF.

Conclusions

Obesity, hypertension, and diabetes interact synergistically to influence cardiac remodeling. These findings may explain the markedly heightened risk of heart failure and cardiovascular disease when these factors co-cluster.

Exercise-Induced Hypertension in Healthy Individuals and Athletes: Is it an Alarming Sign?

Exercise-induced hypertension (EIH) is defined as elevated blood pressure (BP) > 190mm Hg for females and > 210 mmHg for males during exercise. EIH is prevalent among athletes and healthy individuals with no cardiovascular (CV) risk factors. While previous data corroborates exercise in reducing hypertension and cardiovascular risk, the development of EIH and its attendant cardiovascular risk necessitates a review of the pathophysiological mechanisms resulting in EIH. To date, these mechanisms causing EIH are not fully understood, nor are there any established guidelines on the management of EIH. In this article, we discuss in detail the pathophysiological mechanisms, the prognostic value, clinical implications, possible treatment, and future directions in managing EIH.

Sacubitril/Valsartan Inhibits Cardiomyocyte Hypertrophy in Angiotensin II-Induced Hypertensive Mice Independent of a Blood Pressure-Lowering Effect

Background

Hypertensive left ventricular hypertrophy is associated with the risk of heart failure, coronary heart disease and cerebrovascular disease. Although sacubitril/valsartan (SAC/VAL), a first-in-class angiotensin receptor neprilysin inhibitor, reduces the risks of death and hospitalization for patients with heart failure, its mechanism of action is not fully understood. We hypothesized that SAC/VAL is superior to other conventional drugs in reducing cardiac hypertrophy.

Methods

Male C57BL/6J mice were implanted with an osmotic pump containing angiotensin II (Ang II). After 7 days of Ang II infusion, mice were also treated with either SAC/VAL, valsartan, enalapril or vehicle alone each day for 2 weeks. Blood pressure measurement was done weekly, and echocardiography was performed before and 3 weeks after infusion of Ang II. Histological analyses were done using extracted heart to investigate cardiac hypertrophy and fibrosis.

Results

Ang II markedly elevated blood pressures in all of the treatment groups, and there were no differences in the degree of blood pressure reduction among the SAC/VAL-, valsartan- and enalapril-treated groups. Echocardiography showed that SAC/VAL significantly suppressed the increase in left ventricular (LV) wall thickness and tended to decrease LV mass. In a histological analysis, SAC/VAL inhibited Ang II-induced cardiomyocyte hypertrophy, and individual cardiomyocytes in the SAC/VAL group were smaller than those in the valsartan and enalapril groups. Although previous studies using animal models of heart failure have indicated that SAC/VAL attenuates cardiac fibrosis, we found no supporting evidence in this setting.

Conclusions

SAC/VAL, valsartan and enalapril all attenuated cardiomyocyte hypertrophy in a mouse model of Ang II-induced cardiac hypertrophy. Of note, SAC/VAL most strongly suppressed hypertrophy in spite of similar blood pressure-lowering effects as valsartan and enalapril. The present study suggests that SAC/VAL may have a beneficial effect on the early stage of hypertensive heart disease.

Systematic examination of a heart failure risk prediction tool: The pooled cohort equations to prevent heart failure

Identification of individuals at risk for heart failure is needed to deliver targeted preventive strategies and maximize net benefit of interventions. To examine the clinical utility of the recently published heart failure-specific risk prediction model, the Pooled Cohort Equations to Prevent Heart Failure, we sought to demonstrate the range of risk values associated with diverse risk factor combinations in White and Black men and women. We varied individual risk factors while holding the other risk factors constant at age-adjusted national mean values for risk factors in each race-sex and age group. We also examined multiple combinations of risk factor levels and examined the range of predicted 10-year heart failure risk using the Pooled Cohort Equations to Prevent Heart Failure risk tool. Ten-year predicted heart failure risk varied widely for each race-sex group across a range of ages and risk factor scenarios. For example, predicted 10-year heart failure risk in a hypothetical 40 year old varied from 0.1% to 9.7% in a White man, 0.5% to 12.3% in a Black man, <0.1% to 9.3% in a White woman, and 0.2% to 28.0% in a Black woman. Higher risk factor burden (e.g. diabetes and hypertension requiring treatment) consistently drove higher risk estimates in all race-sex groups and across all ages. Our analysis highlights the importance of a race and sex-specific multivariable risk prediction model for heart failure to personalize the clinician-patient discussion, inform future practice guidelines, and provide a framework for future risk-based prevention trials for heart failure.

Exploring cardiac macrophage heterogeneity in the healthy and diseased myocardium

Cardiac macrophages maintain homeostasis and orchestrate response to disease. Utilization of genetic fate-mapping and single-cell RNA sequencing shifted the paradigm of macrophage heterogeneity from the canonical M1/M2 classification in favour of a nuanced approach that reconciles divergent origins, lifecycles, and transcriptional states. Here, we provide a conceptual framework to assess cardiac macrophage complexity that integrates transcriptional and functional heterogeneity that tracks with subset-specific markers (TIMD4 and CCR2). Our goal is to provide a starting point for researchers to dissect the functions of known resident cardiac macrophage subpopulations. We discuss recent advances and limitations in our understanding of cardiac macrophage diversity in ischemic injury, hypertension and myocarditis.

Ketogenic diet aggravates cardiac remodeling in adult spontaneously hypertensive rats

BACKGROUND

Ketogenic diet (KD) has been proposed to be an effective lifestyle intervention in metabolic syndrome. However, the effects of KD on cardiac remodeling have not been investigated. Our aim was to investigate the effects and the underling mechanisms of KD on cardiac remodeling in spontaneously hypertensive rats (SHRs).

METHODS

10-week-old spontaneously hypertensive rats were subjected to normal diet or ketogenic diet for 4 weeks. Then, their blood pressure and cardiac remodeling were assessed. Cardiac fibroblasts were isolated from 1- to 3-day-old neonatal pups. The cells were then cultured with ketone body with or without TGF-β to investigate the mechanism in vitro.

RESULTS

4 weeks of KD feeding aggravated interstitial fibrosis and cardiac remodeling in SHRs. More interestingly, ketogenic diet feeding increased the activity of mammalian target of rapamyoin (mTOR) complex 2 pathway in the heart of SHRs. In addition, β-hydroxybutyrate strengthened the progression of TGF-β-induced fibrosis in isolated cardiac fibroblasts. mTOR inhibition reversed this effect, indicating that ketone body contributes to cardiac fibroblasts via mTOR pathway.

CONCLUSIONS

These data suggest that ketogenic diet may lead to adverse effects on the remodeling in the hypertensive heart, and they underscore the necessity to fully evaluate its reliability before clinical use.

Coronary microvascular dysfunction in hypertrophy and heart failure

Left ventricular (LV) hypertrophy (LVH) is a growth in left myocardial mass mainly caused by increased cardiomyocyte size. LVH can be a physiological adaptation to physical exercise or a pathological condition either primary, i.e. genetic, or secondary to LV overload. Patients with both primary and secondary LVH have evidence of coronary microvascular dysfunction (CMD). The latter is mainly due to capillary rarefaction and adverse remodelling of intramural coronary arterioles due to medial wall thickening with an increased wall/lumen ratio. An important feature of this phenomenon is the diffuse nature of this remodelling, which generally affects the coronary microvessels in the whole of the left ventricle. Patients with LVH secondary to arterial hypertension can develop both heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). These patients can develop HFrEF via a 'direct pathway' with an interval myocardial infarction and also in its absence. On the other hand, patients can develop HFpEF that can then progress to HFrEF with or without interval myocardial infarction. A similar evolution towards LV dysfunction and both HFpEF and HFrEF can occur in patients with hypertrophic cardiomyopathy, the most common genetic cardiomyopathy with a phenotype characterized by massive LVH. In this review article, we will discuss both the experimental and clinical studies explaining the mechanisms responsible for CMD in LVH as well as the evidence linking CMD with HFpEF and HFrEF.

Evaluation of Myocardial Stiffness in Hypertensive Patients by Intrinsic Wave Propagation of the Myocardial Stretch

The objective of the study was to evaluate myocardial stiffness in hypertensive patients by measuring the intrinsic velocity propagation (IVP) of the myocardial stretch and to explore the correlation between IVP and cardiac systolic and diastolic functions. Eighty-one hypertensive patients and 53 healthy patients were prospectively enrolled in this study. IVP was measured using high-frame rate tissue Doppler (350-450 frames per second). IVP was significantly higher in hypertensive patients than in the control group (1.53 ± 0.39 m/s vs. 1.40 ± 0.19 m/s, p = 0.031). In the hypertensive group, IVP was significantly higher in patients with electrocardiogram (ECG) strain than in those without ECG strain (1.63 ± 0.46 m/s vs. 1.45 ± 0.32 m/s, p = 0.047). Moreover, IVP exhibited a good correlation with interventricular septal thickness at end-diastole (r = 0.434, p < 0.001), left ventricular posterior wall thickness at end-diastole (r = 0.439, p < 0.001), E/A ratio (r = 0.245, p = 0.004) and global longitudinal systolic strain (r = 0.405, p < 0.001). IVP was significantly higher in hypertensive patients, which indicates elevated myocardial stiffness in this cohort of patients. This novel measurement exhibited great potential for use in clinical practice to assess myocardial stiffness in patients with hypertension non-invasively.

Cardiac magnetic resonance-derived fibrosis, strain and molecular biomarkers of fibrosis in hypertensive heart disease

AIMS

Myocardial fibrosis is a relevant component of hypertensive heart disease (HHD). Novel cardiovascular magnetic resonance (CMR) imaging techniques have shown potential in quantification of diffuse cardiac fibrosis, with T1 mapping, and estimating preclinical cardiac dysfunction, with strain analysis. Molecular biomarkers of fibrosis have been related with clinical outcomes and histologically proven myocardial fibrosis. The relationship between these CMR-imaging techniques and circulating biomarkers is not fully understood.

METHODS AND RESULTS

CMR was performed on a 3T scanner in 36 individuals with HHD. Extracellular volume fraction (ECV) and the partition coefficient were assessed using the T1 mapping technique shMOLLI. Longitudinal, circumferential and radial strain was assessed using CMR-Feature Tracking. Molecular biomarkers of collagen synthesis (PICP and PIIINP) and collagen degradation (CITP and MMP-1) were measured in blood using commercial kits. Correlation models showed a significant relationship of T1 mapping measures with left atrial diameter, LV mass, LV posterior wall thickness, LV end-diastolic volume and longitudinal strain. In fully adjusted regression models, ECV was associated with left atrial diameter (β=0.75, P = 0.005) and longitudinal strain (β = 0.43, P = 0.030); the partition coefficient was associated with LV posterior wall thickness (β = 0.53, P = 0.046). Strain measures were associated with cardiac geometry, and longitudinal strain was marginally associated with CITP.

CONCLUSION

In individuals with HHD, CMR-derived measures of myocardial fibrosis and function are related and might be useful tools for the identification and characterization of preclinical cardiac dysfunction and diffuse myocardial fibrosis. Molecular biomarkers of fibrosis were marginally associated with myocardial strain, but not with the extension of CMR-measured cardiac fibrosis.

Pressure overload by suprarenal aortic constriction in mice leads to left ventricular hypertrophy without c-Kit expression in cardiomyocytes

Animal models of pressure overload are valuable for understanding hypertensive heart disease. We characterised a surgical model of pressure overload-induced hypertrophy in C57BL/6J mice produced by suprarenal aortic constriction (SAC). Compared to sham controls, at one week post-SAC systolic blood pressure was significantly elevated and left ventricular (LV) hypertrophy was evident by a 50% increase in the LV weight-to-tibia length ratio due to cardiomyocyte hypertrophy. As a result, LV end-diastolic wall thickness-to-chamber radius (h/R) ratio increased, consistent with the development of concentric hypertrophy. LV wall thickening was not sufficient to normalise LV wall stress, which also increased, resulting in LV systolic dysfunction with reductions in ejection fraction and fractional shortening, but no evidence of heart failure. Pathological LV remodelling was evident by the re-expression of fetal genes and coronary artery perivascular fibrosis, with ischaemia indicated by enhanced cardiomyocyte Hif1a expression. The expression of stem cell factor receptor, c-Kit, was low basally in cardiomyocytes and did not change following the development of robust hypertrophy, suggesting there is no role for cardiomyocyte c-Kit signalling in pathological LV remodelling following pressure overload.

Heart Failure With Preserved Ejection Fraction in Hypertension Patients: A Myocardial MR Strain Study

BACKGROUND

Despite current recommendations for heart failure with preserved ejection fraction (HFpEF), few studies have demonstrated the ability of MRI to identify subtle functional differences between HFpEF with essential hypertension (HFpEF-HTN) patients and hypertension patients (HTN).

PURPOSE

This study aimed to detect and evaluate HFpEF in patients with HTN using feature-tracking (FT) and to ascertain optimal strain cutoffs for the diagnosis of HFpEF-HTN.

STUDY TYPE

Retrospective study.

POPULATION

Three groups (84 with HFpEF-HTN; 72 with HTN; and 70 healthy controls).

FIELD STRENGTH

1.5T, steady-state free precession (SSFP), and half-Fourier single-shot turbo spin-echo (HASTE) sequences.

ASSESSMENT

All patients underwent laboratory testing and imaging protocols (echocardiography and MRI). FT-derived left ventricular (LV) strain and strain rate (SR) were measured and compared among the three groups with adjustment for confounding factors.

STATISTICAL TESTS

Kolmogorov-Smirnov's test, independent-sample t-tests, one-way analysis of variance (ANOVA), Pearson's correlation coefficient, area under the receiver-operator characteristic (ROC) curve (AUC), and logistic regression.

RESULTS

Compared to 72 HTN patients and 70 healthy controls, HFpEF-HTN patients (84 patients) demonstrated significantly impaired LV strains (except for global peak systolic radial strain, GRS, P < 0.05 for all). Only LV global peak systolic longitudinal strain (GLS) was significantly impaired in HTN patients vs. controls (P < 0.05). The global peak systolic circumferential SR (sGCSR) showed the highest diagnostic value for the differentiation of HFpEF-HTN patients from HTN patients (AUC, 0.731; cutoff value, -1.11/s; sensitivity, 56.0%; specificity, 84.7%). Only global peak early diastolic longitudinal SR (eGLSR) remained independently associated with a diagnosis of HFpEF-HTN in multilogistic analysis. The major strain parameters significantly correlated with LV ejection fraction, end-systolic volume index, and N-terminal pro-brain natriuretic peptide (P < 0.05 for all) and also demonstrated differences between NYHA functional class.

DATA CONCLUSION

HFpEF-HTN patients suffer from both systolic and diastolic cardiac dysfunction. FT-derived strain parameters have potential value for the diagnosis and risk stratification of HFpEF-HTN patients. Level of Evidence 3. Technical Efficacy Stage 2.

Coronary Microvascular Dysfunction

Many patients with chest pain undergoing coronary angiography do not show significant obstructive coronary lesions. A substantial proportion of these patients have abnormalities in the function and structure of coronary microcirculation due to endothelial and smooth muscle cell dysfunction. The coronary microcirculation has a fundamental role in the regulation of coronary blood flow in response to cardiac oxygen requirements. Impairment of this mechanism, defined as coronary microvascular dysfunction (CMD), carries an increased risk of adverse cardiovascular clinical outcomes. Coronary endothelial dysfunction accounts for approximately two-thirds of clinical conditions presenting with symptoms and signs of myocardial ischemia without obstructive coronary disease, termed "ischemia with non-obstructive coronary artery disease" (INOCA) and for a small proportion of "myocardial infarction with non-obstructive coronary artery disease" (MINOCA). More frequently, the clinical presentation of INOCA is microvascular angina due to CMD, while some patients present vasospastic angina due to epicardial spasm, and mixed epicardial and microvascular forms. CMD may be associated with focal and diffuse epicardial coronary atherosclerosis, which may reinforce each other. Both INOCA and MINOCA are more common in females. Clinical classification of CMD includes the association with conditions in which atherosclerosis has limited relevance, with non-obstructive atherosclerosis, and with obstructive atherosclerosis. Several studies already exist which support the evidence that CMD is part of systemic microvascular disease involving multiple organs, such as brain and kidney. Moreover, CMD is strongly associated with the development of heart failure with preserved ejection fraction (HFpEF), diabetes, hypertensive heart disease, and also chronic inflammatory and autoimmune diseases. Since coronary microcirculation is not visible on invasive angiography or computed tomographic coronary angiography (CTCA), the diagnosis of CMD is usually based on functional assessment of microcirculation, which can be performed by both invasive and non-invasive methods, including the assessment of delayed flow of contrast during angiography, measurement of coronary flow reserve (CFR) and index of microvascular resistance (IMR), evaluation of angina induced by intracoronary acetylcholine infusion, and assessment of myocardial perfusion by positron emission tomography (PET) and magnetic resonance (CMR).

Hypertension as a Road to Treatment of Heart Failure with Preserved Ejection Fraction

PURPOSE OF REVIEW

Hypertension heralds the diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF) in 75-85% of cases and shares many of its adverse outcomes as well as its acute and chronic symptoms. This review provides important new data about the pathophysiology and mechanisms that connect hypertension and HFpEF as well as therapy used in both conditions.

RECENT FINDINGS

The traditional model of HFpEF pathophysiology emphasizes the role of hypertension causing increased afterload on the left ventricle (LV), leading to LV hypertrophy (LVH) and subsequent LV diastolic dysfunction. Recent work has provided valuable insights into the mechanisms underlying the transition from hypertension to HFpEF, showing that the pathophysiology extends beyond LVH and diastolic dysfunction. An evolving paradigm suggests that HFpEF is inflammatory in nature with multifactorial pathophysiology, affected by age-related changes and comorbidities. Hypertension shares many of the proinflammatory mechanisms of HFpEF. Furthermore, hypertension precedes HFpEF in the majority of cases. Because of its clinically heterogeneous nature, development of standardized therapies for HFpEF has been challenging. As there are standardized approaches to hypertension, we suggest that similar approaches be used for the treatment of HFpEF, including medical and non-medical therapies. With medical therapies, a treat-to-target blood pressure (BP) strategy could be employed, such as systolic BP < 130 mmHg. With non-medical therapies, approaches to deal with physical inactivity, obesity, and sleep apnea could be used. Due to its heterogeneity, delineation of standardized therapies for HFpEF has been challenging. Focusing on the tremendous overlap of hypertensive heart disease with HFpEF, it is proposed that approaches currently used to guide therapies for hypertension be applied to the treatment of HFpEF.

MicroRNA-26a Protects the Heart Against Hypertension-Induced Myocardial Fibrosis

Background Hypertensive myocardial fibrosis (MF) is characterized by excessive deposition of extracellular matrix and cardiac fibroblast proliferation, which can lead to heart failure, malignant arrhythmia, and sudden death. In recent years, with the deepening of research, microRNAs have been found to have an important role in blood pressure control and maintaining normal ventricular structure and function. Methods and Results In this study, we first documented the downregulation of microRNA-26a (miR-26a) in the plasma and myocardium of spontaneously hypertensive rats; more importantly, miR-26a-deficient mice showed MF, whereas overexpression of miR-26a significantly prevented elevated blood pressure and inhibited MF in vivo and angiotensin II-induced fibrogenesis in cardiac fibroblasts by directly targeting connective tissue growth factor and Smad4. miR-26a inhibited cardiac fibroblast proliferation by the enhancer of zeste homolog 2/p21 pathway. Conclusions Our study identified a novel role for miR-26a in blood pressure control and hypertensive MF and provides a possible treatment strategy for miR-26a to alleviate and reverse hypertensive MF.

The Role of the NOD1/Rip2 Signaling Pathway in Myocardial Remodeling in Spontaneously Hypertensive Rats

BACKGROUND Chronic hypertension changes the function and structure of the heart and blood vessels. This study aimed to explore the role of the NOD1/Rip2 (nucleotide-binding oligomerization domain 1/receptor-interacting protein 2) signaling pathway in myocardial remodeling in spontaneously hypertensive rats (SHRs). MATERIAL AND METHODS Blood pressure was measured using a tail cuff. The cardiac structure was observed using echocardiography. Slices of the myocardium were stained with hematoxylin and eosin. The expression of NOD1 and Rip2 was detected using real-time polymerase chain reaction, western blot, and immunohistochemistry. The content and distribution of collagen in the myocardium were observed using Van Gieson staining. Enzyme-linked immunosorbent assay was used to detect the interleukin-1 (IL-1) concentrations. SHRs were treated with the NOD1 agonist iE-DAP and NOD1 inhibitor ML130. RESULTS The NOD1 agonist increased blood pressure in SHRs, and the NOD1 inhibitor decreased blood pressure; the interventricular septum thickness (IVST) and left ventricular posterior wall thickness (LVPWT) of the agonist-treated group were thicker than those of the control group, and the antagonist exerted the opposite effects. The levels of the NOD1 and Rip2 mRNAs and proteins, serum IL-1 concentration, and myocardial collagen volume fraction (CVF%) increased in SHRs in the NOD1 agonist group, but the levels of NOD1 and Rip2, serum IL-1 concentration, and myocardial collagen volume fraction (CVF%) decreased in SHRs in the NOD1 inhibitor group. CONCLUSIONS NOD1/Rip2 expression increased during the progression of myocardial remodeling in SHRs. The NOD1 agonist increased NOD1 expression and promoted myocardial remodeling, while the NOD1 antagonist reduced NOD1/Rip2 expression and protected against myocardial remodeling.

Longitudinal changes of left and right cardiac structure and function in patients with end-stage renal disease on replacement therapy

BACKGROUND

Few data are available regarding longitudinal changes of cardiac structure and function in end-stage chronic kidney disease (CKD). Aim of the present study is to describe serial echocardiographic findings in a cohort of dialyzed CKD patients.

METHODS

In this retrospective longitudinal study, we included n = 120 dialyzed CKD patients who underwent at least 2 echocardiograms either 1, 2 or 3 years apart. After baseline echocardiogram, n = 112 had a further examination at year 1, n = 76 at year 2 and n = 45 at year 3. Echocardiographic examination included Tissue Doppler Imaging of both left (LV) and right (RV) ventricle.

RESULTS

LV geometry and LV mass index did not significantly change over time. RV progressively dilated (mean change +1.3 mm, +1.1 mm and +3.1 mm at year 1, 2 and 3 respectively, p = 0.002, adjusted p = 0.003). Tissue Doppler parameters showed significant changes with regard to both LV (mean change of E/E' +0.7, +1.3, +1.7 at year 1, 2 and 3 respectively p<0.001, adjusted p = 0.079) and RV (mean change of S wave (cm/sec) -1, -1.7, -2 at year 1, 2 and 3 respectively, p <0.001, adjusted p = 0.041). Decrease of RV S wave negatively correlated with E/E' changes (r=-0.303, p = 0.002; r=-0.246, p = 0.049; r=-0.265, p = 0.089; at year 1, 2 and 3 respectively). LV ejection fraction (LVEF) progressively declined (p = 0.034, adjusted p = 0.140), albeit being significant lower against baseline only at year 3 (mean change -4.3%, p<0.05).

CONCLUSIONS

In dialyzed CKD patients we observed parallel worsening of LV diastolic and RV systolic function accompanied by RV dilation. LVEF decreased less sharply.

US trends in premature heart disease mortality over the past 50 years: Where do we go from here?

Despite the premature heart disease mortality rate among adults aged 25-64 decreasing by 70% since 1968, the rate has remained stagnant from 2011 on and, in 2017, still accounted for almost 1-in-5 of all deaths among this age group. Moreover, these overall findings mask important differences and continued disparities observed by demographic characteristics and geography. For example, in 2017, rates were 134% higher among men compared to women and 87% higher among blacks compared to whites, and, while the greatest burden remained in the southeastern US, almost two-thirds of all US counties experienced increasing rates among adults aged 35-64 during 2010-2017. Continued high rates of uncontrolled blood pressure and increasing prevalence of diabetes and obesity pose obstacles for re-establishing a downward trajectory for premature heart disease mortality; however, proven public health and clinical interventions exist that can be used to address these conditions.

Genomic characterization reveals novel mechanisms underlying the valosin-containing protein-mediated cardiac protection against heart failure

Chronic hypertension is a key risk factor for heart failure. However, the underlying molecular mechanisms are not fully understood. Our previous studies found that the valosin-containing protein (VCP), an ATPase-associated protein, was significantly decreased in the hypertensive heart tissues. In this study, we tested the hypothesis that restoration of VCP protected the heart against pressure overload-induced heart failure. With a cardiac-specific transgenic (TG) mouse model, we showed that a moderate increase of VCP was able to attenuate chronic pressure overload-induced maladaptive cardiac hypertrophy and dysfunction. RNA sequencing and a comprehensive bioinformatic analysis further demonstrated that overexpression of VCP in the heart normalized the pressure overload-stimulated hypertrophic signals and repressed the stress-induced inflammatory response. In addition, VCP overexpression promoted cell survival by enhancing the mitochondria resistance to the oxidative stress via activating the Rictor-mediated-gene networks. VCP was also found to be involved in the regulation of the alternative splicing and differential isoform expression for some genes that are related to ATP production and protein synthesis by interacting with long no-coding RNAs and histone deacetylases, indicating a novel epigenetic regulation of VCP in integrating coding and noncoding genomic network in the stressed heart. In summary, our study demonstrated that the rescuing of a deficient VCP in the heart could prevent pressure overload-induced heart failure by rectifying cardiac hypertrophic and inflammatory signaling and enhancing the cardiac resistance to oxidative stress, which brought in novel insights into the understanding of the mechanism of VCP in protecting patients from hypertensive heart failure.

•

Deficiency of VCP contributes to the pathogenesis of hypertensive heart failure.

•

Rescue of VCP prevents stress-induced cardiac remodeling and cell death.

•

VCP attenuates stress-induced inflammatory and hypertrophic signaling.

•

VCP promotes cardiac resistance to oxidative stress.

•

VCP mediates a novel epigenetic integrating regulation in the stressed heart.

L-type Ca2+ channel blockers promote vascular remodeling through activation of STIM proteins

Voltage-gated L-type Ca2+ channel (Cav1.2) blockers (LCCBs) are major drugs for treating hypertension, the preeminent risk factor for heart failure. Vascular smooth muscle cell (VSMC) remodeling is a pathological hallmark of chronic hypertension. VSMC remodeling is characterized by molecular rewiring of the cellular Ca2+ signaling machinery, including down-regulation of Cav1.2 channels and up-regulation of the endoplasmic reticulum (ER) stromal-interacting molecule (STIM) Ca2+ sensor proteins and the plasma membrane ORAI Ca2+ channels. STIM/ORAI proteins mediate store-operated Ca2+ entry (SOCE) and drive fibro-proliferative gene programs during cardiovascular remodeling. SOCE is activated by agonists that induce depletion of ER Ca2+, causing STIM to activate ORAI. Here, we show that the three major classes of LCCBs activate STIM/ORAI-mediated Ca2+ entry in VSMCs. LCCBs act on the STIM N terminus to cause STIM relocalization to junctions and subsequent ORAI activation in a Cav1.2-independent and store depletion-independent manner. LCCB-induced promotion of VSMC remodeling requires STIM1, which is up-regulated in VSMCs from hypertensive rats. Epidemiology showed that LCCBs are more associated with heart failure than other antihypertensive drugs in patients. Our findings unravel a mechanism of LCCBs action on Ca2+ signaling and demonstrate that LCCBs promote vascular remodeling through STIM-mediated activation of ORAI. Our data indicate caution against the use of LCCBs in elderly patients or patients with advanced hypertension and/or onset of cardiovascular remodeling, where levels of STIM and ORAI are elevated.

Circulating microRNA-133a in Patients With Arterial Hypertension, Hypertensive Heart Disease, and Left Ventricular Diastolic Dysfunction

Aim: The aim of the work was to study the circulating microRNA-133a levels in blood plasma of patients with arterial hypertension (AH), hypertensive heart disease (HHD), and left ventricular (LV) diastolic dysfunction (DD). Materials and Methods: A total of 48 patients with grade 2-3 AH and HHD at the age of 52.23 ± 7.26 (23 patients had LV DD [main group] and 25 patients had normal LV diastolic function [comparison group]) and 21 practically healthy individuals of comparable gender and age were examined. Diagnosis of AH and HHD was carried out according to the 2018 ESC/ESH recommendations. LV DD was determined according to the 2016 ASE/EACVI recommendations. Plasma microRNA-133a level was obtained by polymerase chain reaction using the CFX96 Touch System (BioRad), ≪TaqMan microRNA Assay≫ and ≪TaqMan® Universal PCR Master Mix≫ reagent kits (Thermo Fisher Scientific, USA). Results: We have found that in patients from the main and comparison groups plasma microRNA-133a levels were significantly lower than in practically healthy individuals (0.094 [0.067, 0.147]) and (0.182 [0.102, 0.301]) vs. (0.382 [0.198,0.474]), p = 0.002 and p = 0.04, respectively. In all this among patients with AH, HHD, and LV DD, plasma microRNA-133a levels were significantly lower than in patients with AH, HHD, and normal diastolic function (p = 0.03). In the main and comparison groups there was a statistically significant negative relationship between plasma microRNA-133a level and left ventricular mass index (LVMI) (R = -0.40, p = 0.003 and R = -0.35, p = 0.04, respectively). Conclusions: The findings suggest the significant role of decreased microRNA-133a levels in blood plasma of patients with AH in the pathogenesis and development of both HHD and LV DD.

Overweight during lactation and its implications for biometric, nutritional and cardiovascular parameters of young and adult male and female rats

Litter size reduction can induce early overnourishment, being an attractive experimental model to study short- and long-term consequences of childhood obesity. Epidemiological data indicate sex differences regarding cardiometabolic disorders and hypertrophic cardiomyopathy. The present study aimed to describe biometric, nutritional and cardiovascular changes related to neonatal overweight promoted by litter size reduction in young and adult Wistar rats of both sexes. Litter adjustment to eight or four pups/mother (1:1 male-to-female ratio) gave, respectively, control and overweight groups. Body mass, food intake, haemodynamic and echocardiographic parameters and cardiorespiratory capacity were evaluated at postnatal days 30 and 150. Diminished litters were correlated with higher body mass and weight gain (12 %) during lactation, validating the experimental model of neonatal overweight. Soon after weaning male (16 %) and female (25 %) offspring of these litters presented a lower food intake than their respective control, without differences in body mass. Adult males from reduced litters presented higher abdominal circumference (7 %), systolic blood pressure (10 %), interventricular septum thickness (15 %) and relative wall thickness (15 %) compared with their respective control. Rats' performance on the maximal effort ergometer test was not affected by neonatal overweight. Data suggest the occurrence of catch-down growth and hypophagia in male and female rats submitted to neonatal overweight. However, only male rats presented haemodynamic and cardiac structural changes. These findings are crucial to personalised/gender medicine.

Endothelial Dysfunction: A Contributor to Adverse Cardiovascular Remodeling and Heart Failure Development in Type 2 Diabetes beyond Accelerated Atherogenesis

Endothelial dysfunction, associated with depressed nitric oxide (NO) bioavailability, is awell-recognized contributor to both accelerated atherogenesis and microvascular complications intype 2 diabetes (DM). However, growing evidence points to the comorbidities-driven endothelialdysfunction within coronary microvessels as a key player responsible for left ventricular (LV)diastolic dysfunction, restrictive LV remodeling and heart failure with preserved ejection fraction(HFpEF), the most common form of heart failure in DM. In this review we have described: (1)multiple cellular pathways which may link depressed NO bioavailability to LV diastolicdysfunction and hypertrophy; (2) hemodynamic consequences and prognostic effects of restrictiveLV remodeling and combined diastolic and mild systolic LV dysfunction on cardiovascularoutcomes in DM and HFpEF, with a focus on the clinical relevance of endothelial dysfunction; (3)novel therapeutic strategies to improve endothelial function in DM. In summary, beyondassociations with accelerated atherogenesis and microvascular complications, endothelialdysfunction supplements the multiple interwoven pathways affecting cardiomyocytes, endothelialcells and the extracellular matrix with consequent LV dysfunction in DM patients. The associationamongst impaired endothelial function, reduced coronary flow reserve, combined LV diastolic anddiscrete systolic dysfunction, and low LV stroke volume and preload reserve-all of which areadverse outcome predictors-is a dangerous constellation of inter-related abnormalities, underlyingthe development of heart failure. Nevertheless, the relevance of endothelial effects of novel drugsin terms of their ability to attenuate cardiovascular remodeling and delay heart failure onset in DMpatients remains to be investigated.

Hypertensive coronary microvascular dysfunction: a subclinical marker of end organ damage and heart failure

AIMS

Hypertension is a well-established heart failure (HF) risk factor, especially in the context of adverse left ventricular (LV) remodelling. We aimed to use myocardial flow reserve (MFR) and global longitudinal strain (GLS), markers of subclinical microvascular and myocardial dysfunction, to refine hypertensive HF risk assessment.

METHODS AND RESULTS

Consecutive patients undergoing symptom-prompted stress cardiac positron emission tomography (PET)-computed tomography and transthoracic echocardiogram within 90 days without reduced left ventricular ejection fraction (<40%) or flow-limiting coronary artery disease (summed stress score ≥ 3) were included. Global MFR was quantified by PET, and echocardiograms were retrospectively analysed for cardiac structure and function. Patients were followed over a median 8.75 (Q1-3 4.56-10.04) years for HF hospitalization and a composite of death, HF hospitalization, MI, or stroke. Of 194 patients, 155 had adaptive LV remodelling while 39 had maladaptive remodelling, which was associated with lower MFR and impaired GLS. Across the remodelling spectrum, diastolic parameters, GLS, and N-terminal pro-B-type natriuretic peptide were independently associated with MFR. Maladaptive LV remodelling was associated with increased adjusted incidence of HF hospitalization and death. Importantly, the combination of abnormal MFR and GLS was associated with a higher rate of HF hospitalization compared to normal MFR and GLS [adjusted hazard ratio (HR) 3.21, 95% confidence interval (CI) 1.09-9.45, P = 0.034), including in the adaptive remodelling subset (adjusted HR 3.93, 95% CI 1.14-13.56, P = 0.030).

CONCLUSION

We have demonstrated important associations between coronary microvascular dysfunction and myocardial mechanics that refine disease characterization and HF risk assessment of patients with hypertension based on subclinical target organ injury.

Tandospirone enhances the anti-myocardial fibrosis effect of valsartan in spontaneously hypertensive rats

PURPOSE

Myocardial fibrosis (MF) is an unavoidable complication in patients with hypertensive heart disease. Valsartan, a widely used antihypertensive drug, was reported to inhibit MF. Deficiency in the 5-hydroxytryptamine (5-HT, serotonin) transporter gene has been proven to cause MF. Long-term sympathetic nerve excitability activates renin angiotensin aldosterone system leading to MF. Tandospirone, a partial agonist of the 5-HT1A receptor, has been commonly used to relieve psychiatric symptoms. However, there is limited evidence on the combination of valsartan and tandospirone for the treatment of MF. Therefore, we investigated the synergistic effect of tandospirone on the anti-MF activity of valsartan in spontaneously hypertensive rats (SHRs).

METHODS

Systolic blood pressure (SBP) of SHRs (12-week-old) was measured weekly using the tail-cuff method for eight weeks; the left ventricular was collected and weighted for calculation of the left ventricular mass index (LVMI). The myocardial histopathology of left ventricle was evaluated in rats by hematoxylin and eosin (H&E) and Mason's trichrome staining assays. The mRNA and protein expressions of transforming growth factor β (TGF-β1), Sma- and Mad-related protein 3 (Smad3), and fibronectin (Fn) were investigated by real time PCR, immunohistochemistry, and Western blotting analysis, respectively.

RESULTS

Tandospirone (40 mg/kg) could significantly improve the effect of valsartan (30 mg/kg) in decreasing the SBP of SHRs and lower the ratio of the LVMI in SHRs, compared to that of rats treated with valsartan or tandospirone alone. Tandospirone could also enhance the valsartan-induced reduction in collagen deposition in the myocardial tissues of SHRs. Furthermore, tandospirone could enhance the effect of valsartan on downregulating the expression levels of TGF-β1, Smad3, and Fn at both mRNA and protein levels.

CONCLUSION

We report for the first time that tandospirone could improve the anti-MF efficacy of valsartan via the TGF-β1/Smad3 signaling pathway in SHRs. Our findings may provide valuable insight into the scientific rationale for combining tandospirone and valsartan in the treatment of MF clinically.

FoxO1-Dio2 signaling axis governs cardiomyocyte thyroid hormone metabolism and hypertrophic growth

Forkhead box O (FoxO) proteins and thyroid hormone (TH) have well established roles in cardiovascular morphogenesis and remodeling. However, specific role(s) of individual FoxO family members in stress-induced growth and remodeling of cardiomyocytes remains unknown. Here, we report that FoxO1, but not FoxO3, activity is essential for reciprocal regulation of types II and III iodothyronine deiodinases (Dio2 and Dio3, respectively), key enzymes involved in intracellular TH metabolism. We further show that Dio2 is a direct transcriptional target of FoxO1, and the FoxO1-Dio2 axis governs TH-induced hypertrophic growth of neonatal cardiomyocytes in vitro and in vivo. Utilizing transverse aortic constriction as a model of hemodynamic stress in wild-type and cardiomyocyte-restricted FoxO1 knockout mice, we unveil an essential role for the FoxO1-Dio2 axis in afterload-induced pathological cardiac remodeling and activation of TRα1. These findings demonstrate a previously unrecognized FoxO1-Dio2 signaling axis in stress-induced cardiomyocyte growth and remodeling and intracellular TH homeostasis.

Cardiovascular Changes Associated with Hypertensive Heart Disease and Aging

Cardiovascular diseases are the leading cause of mortality and morbidity worldwide and account for more than 17.9 million deaths (World Health Organization report). Hypertension and aging are two major risk factors for the development of cardiac structural and functional abnormalities. Hypertension, or elevated blood pressure, if left untreated can result in myocardial hypertrophy leading to heart failure (HF). Left ventricular hypertrophy consequent to pressure overload is recognized as the most important predictor of congestive HF and sudden death. The pathological changes occurring during hypertensive heart disease are very complex and involve many cellular and molecular alterations. In contrast, the cardiac changes that occur with aging are a slow but life-long process and involve all of the structural components in the heart and vasculature. However, these structural changes in the cardiovascular system lead to alterations in overall cardiac physiology and function. The pace at which these pathophysiological changes occur varies between individuals owing to many genetic and environmental risk factors. This review highlights the molecular mechanisms of cardiac structural and functional alterations associated with hypertension and aging.

Correlates and Long-Term Implications of Left Ventricular Mechanical Dispersion by Two-Dimensional Speckle-Tracking Echocardiography in Patients with ST-Segment Elevation Myocardial Infarction

BACKGROUND

Left ventricular (LV) mechanical dispersion (LVMD), measured with speckle-tracking echocardiography (STE) after ST-segment elevation myocardial infarction (STEMI), has been proposed as a measurement of regional heterogeneity of myocardial contraction and may reflect changes in the myocardial structure (e.g., fibrosis or edema). Further insight into this parameter may aid in the risk stratification of STEMI patients.

METHODS

A total of 1,000 STEMI patients (77% male, 60 ± 12 years) treated with primary percutaneous coronary intervention were retrospectively analyzed. The LVMD was assessed with two-dimensional STE within 48 hours following the index infarction. Patients were followed for the occurrence of all-cause mortality.

RESULTS

After a median follow-up of 117 months, 229 (23%) patients died. Nonsurvivors showed worse LV ejection fraction (43% ± 10% vs 48% ± 9%; P < .001) and global longitudinal strain (-12.0% ± 3.5% vs -14.2% ± 3.5%; P = .001) and prolonged LVMD (63 [interquartile range, 50-85] msec vs 52 [interquartile range, 42-63] msec; P < .001) compared with survivors. Increasing age, systolic blood pressure, and heart rate at discharge as well as diabetes mellitus, anterior STEMI, TIMI flow < 2, less usage of angiotensin converter enzyme inhibitors or angiotensin receptor blockers, and impaired LV global longitudinal strain were independently associated with more prolonged LVMD. On multivariable analysis, prolonged LVMD was independently associated with increased risk of all-cause mortality (hazard ratio = 1.012; 95% CI, 1.005-1.018; P = .001) and had incremental value for all-cause mortality over clinical and echocardiographic parameters.

CONCLUSIONS

In contemporary STEMI patients, prolonged LVMD was associated with various clinical and echocardiographic parameters. Prolonged LVMD was associated with worse long-term outcome.

Chronic activation of hexosamine biosynthesis in the heart triggers pathological cardiac remodeling

The hexosamine biosynthetic pathway (HBP) plays critical roles in nutrient sensing, stress response, and cell growth. However, its contribution to cardiac hypertrophic growth and heart failure remains incompletely understood. Here, we show that the HBP is induced in cardiomyocytes during hypertrophic growth. Overexpression of Gfat1 (glutamine:fructose-6-phosphate amidotransferase 1), the rate-limiting enzyme of HBP, promotes cardiomyocyte growth. On the other hand, Gfat1 inhibition significantly blunts phenylephrine-induced hypertrophic growth in cultured cardiomyocytes. Moreover, cardiac-specific overexpression of Gfat1 exacerbates pressure overload-induced cardiac hypertrophy, fibrosis, and cardiac dysfunction. Conversely, deletion of Gfat1 in cardiomyocytes attenuates pathological cardiac remodeling in response to pressure overload. Mechanistically, persistent upregulation of the HBP triggers decompensated hypertrophy through activation of mTOR while Gfat1 deficiency shows cardioprotection and a concomitant decrease in mTOR activity. Taken together, our results reveal that chronic upregulation of the HBP under hemodynamic stress induces pathological cardiac hypertrophy and heart failure through persistent activation of mTOR.

Metabolic remodeling plays an important role in pathological cardiac hypertrophy. Here, the authors show that hexosamine biosynthetic pathway is elevated in the heart by pressure overload, which contributes to heart failure by persistent activation of mTOR.

Diagnostic and prognostic value of right ventricular eccentricity index in pulmonary artery hypertension

The right ventricle experiences dynamic changes under pressure overload in pulmonary artery hypertension. This study aimed to evaluate the diagnostic and prognostic value of right ventricular eccentricity index (RVEI) in pulmonary artery hypertension. A total of 100 pulmonary artery hypertension patients (mean age, 36.85 (SD, 13.60) years; males, 30.0%) confirmed by right heart catheterization and 147 healthy volunteers (mean age 45.58 (SD, 17.58) years; males, 42.50%) were enrolled in this prospective study. All participants underwent cardiac magnetic resonance imaging (MRI) examination, and balanced steady-state free precession (bSSFP) cine sequences were acquired. RVEI was measured on short-axis cine images at the mid-ventricular level of the right ventricle in end systole. The study found that RVEI was significantly lower in pulmonary artery hypertension patients than in healthy volunteers (1.84 (SD, 0.40) vs. 2.46 (SD, 0.40); p < 0.001). In pulmonary artery hypertension patients, RVEI was correlated with log(NT-proBNP) (r = -0.388; p < 0.001), right ventricular end-diastolic volume index (r = -0.452; p < 0.001), right ventricular end-systolic volume index (r = -0.518; p < 0.001), and right ventricular ejection fraction (r = 0.552; p < 0.001). RVEI could discriminate pulmonary artery hypertension patients from healthy volunteers with 91.8% sensitivity and 68.0% specificity. Over median follow-up of 14.8 months (interquartile range: 6.7-26.9 months), RVEI was demonstrated to be an independent predictor for adverse outcome (HR = 0.076; 95% CI, 0.013-0.458; p = 0.005). In conclusion, MRI-derived RVEI appears to be a useful diagnostic and prognostic value in pulmonary artery hypertension, and it provides incremental value to risk stratification strategy.

Left ventricular hypertrophy in athletes: How to differentiate between hypertensive heart disease and athlete’s heart

Athlete’s heart is typically accompanied by a remodelling of the cardiac chambers induced by exercise. However, although competitive athletes are commonly considered healthy, they can be affected by cardiac disorders characterised by an increase in left ventricular mass and wall thickness, such as hypertension. Unfortunately, training-induced increase in left ventricular mass, wall thickness, and atrial and ventricular dilatation observed in competitive athletes may mimic the pathological remodelling of pathological hypertrophy. As a consequence, distinguishing between athlete’s heart and hypertension can sometimes be challenging. The present review aimed to focus on the differential diagnosis between hypertensive heart disease and athlete’s heart, providing clinical information useful to distinguish between physiological and pathological remodelling.

Analysis of mast cells and myocardial fibrosis in autopsied patients with hypertensive heart disease

OBJECTIVE

To analyze the percentage of collagen fibers and mast cell density in the left ventricular myocardium of autopsied patients with and without hypertensive heart disease.

METHODS

Thirty fragments of left ventricular myocardium were obtained from individuals autopsied at the Clinical Hospital of the Federal University of Triângulo Mineiro (UFTM) in the period from 1987 to 2017. Individuals were divided into two groups: those with hypertensive heart disease (HD) and those with no heart disease (ND). Subjects were also assessed according to age, gender and race (white and non-white). Collagen fibers were quantified by computed morphometry and mast cell density was assessed by immunohistochemical methods.

RESULTS

There were significantly more collagen fibers in the left ventricle in the HD group than in the ND group (p<0.001). Mast cell density was significantly higher in the left ventricle of individuals with HD immunolabeled with anti-chymase and anti-tryptase antibodies (p=0.02) and also of those immunolabeled only with anti-tryptase antibodies (p=0.03). Analyzing the HD group, there was a significant positive correlation between the percentage of collagen fibers in the left ventricle and mast cell density immunolabeled by anti-chymase and anti-tryptase antibodies (p=0.04) and also mast cell density immunolabeled only with anti-tryptase antibodies (p=0.02).

CONCLUSIONS

Mast cells are involved in the development of hypertensive heart disease, contributing to the remodeling of collagen fibers in this disease.

Early and Quantitative Assessment of Myocardial Deformation in Essential Hypertension Patients by Using Cardiovascular Magnetic Resonance Feature Tracking

The aims of the study were to identify subclinical global systolic function abnormalities and evaluate influencing factors associated with left ventricular (LV) strain parameters in hypertensive subjects using cardiovascular magnetic resonance imaging feature tracking (CMR-FT). The study enrolled 57 patients with essential hypertension (mean age: 43.04 ± 10.90 years; 35 males) and 26 healthy volunteers (mean age: 38.69 ± 10.44 years; 11 males) who underwent clinical evaluation and CMR examination. Compared with controls, hypertensive patients had significantly impaired myocardial strain values while ejection fraction (EF) did not differ. After multivariate regression analyses adjustment for confounders, the global radial strains (GRS) was independently associated with the mean arterial pressure (MAP) and left ventricular mass index (LVMI) (β = -0.219, p = 0.009 and β = -0.224, p = 0.015, respectively; Adjusted R² = 0.4); the global circumferential strains (GCS) was also independently associated with the MAP and LVMI (β = 0.084, p = 0.002 and β = 0.073, p = 0.01, respectively; Adjusted R² = 0.439); the global longitudinal strains (GLS) was independently associated with the Age and MAP (β = 0.065, p = 0.021 and β = 0.077, p = 0.009, respectively; Adjusted R² = 0.289). Myocardial strain can early detect the myocardial damage and may be an appropriate target for preventive strategies before abnormalities of EF.

The association between microRNA-21 and hypertension-induced cardiac remodeling

Hypertension is a major public health problem among the aging population worldwide. It causes cardiac remodeling, including hypertrophy and interstitial fibrosis, which leads to development of hypertensive heart disease (HHD). Although microRNA-21 (miR-21) is associated with fibrogenesis in multiple organs, its contribution to cardiac remodeling in hypertension is poorly understood. Circulating miR-21 level was higher in patients with HHD than that in the control subjects. It also positively correlated with serum myocardial fibrotic markers. MiR-21 expression levels were significantly upregulated in the mice hearts after angiotensin II (Ang II) infusion or transverse aortic constriction (TAC) compared with control mice. Expression level of programmed cell death 4 (PDCD4), a main target of miR-21, was significantly decreased in Ang II infused mice and TAC mice compared with control mice. Expression levels of transcriptional activator protein 1 (AP-1) and transforming growth factor-β1 (TGF-β1), which were downstream targets of PDCD4, were increased in Ang II infused mice and TAC mice compared with control mice. In vitro, mirVana-miR-21-specific inhibitor attenuated Ang II-induced PDCD4 downregulation and contributed to subsequent deactivation of AP-1/TGF-β1 signaling pathway in neonatal rat cardiomyocytes. Thus, suppression of miR-21 prevents hypertrophic stimulation-induced cardiac remodeling by regulating PDCD4, AP-1, and TGF-β1 signaling pathway.

The 3' Untranslated Region Protects the Heart from Angiotensin II-Induced Cardiac Dysfunction via AGGF1 Expression

The messenger RNA (mRNA) 3' untranslated regions (3' UTRs), as cis-regulated elements bound by microRNAs (miRNAs), affect their gene translation. However, the role of the trans-regulation of 3' UTRs during heart dysfunction remains elusive. Compared with administration of angiogenic factor with G-patch and forkhead-associate domains 1 (Aggf1), ectopic expression of Aggf1 with its 3' UTR significantly suppressed cardiac dysfunction in angiotensin II-infused mice, with upregulated expression of both Aggf1 and myeloid cell leukemia 1 (Mcl1). Along their 3' UTRs, Mcl1 and Aggf1 mRNAs share binding sites for the same miRNAs, including miR-105, miR-101, and miR-93. We demonstrated that the protein-coding Mcl1 and Aggf1 mRNAs communicate and co-regulate each other's expression through competition for these three miRNAs that target both transcripts via their 3' UTRs. Our results indicate that Aggf1 3' UTR, as a trans-regulatory element, accelerates the cardioprotective role of Aggf1 in response to hypertensive conditions by elevating Mcl1 expression. Our work broadens the scope of gene therapy targets and provides a new insight into gene therapy strategies involving 3' UTRs.

Association of Cardiac Injury and Malignant Left Ventricular Hypertrophy With Risk of Heart Failure in African Americans: The Jackson Heart Study

Importance

African Americans have a higher burden of heart failure (HF) risk factors and clinical HF than other racial/ethnic groups. However, the factors underlying the transition from at-risk to clinical HF in African Americans are not well understood.

Objective

To evaluate the contributions of left ventricular hypertrophy (LVH) and subclinical myocardial injury as determined by abnormal high-sensitivity cardiac troponin-I (hs-cTnI) measurements toward HF risk among African Americans.

Design, Setting, and Participants

This prospective, community-based cohort study was conducted between July 2016 and September 2018 and included African American participants from Jackson, Mississippi enrolled in the Jackson Heart Study without prevalent HF who had hs-cTnI measurements and an echocardiographic examination at baseline. Participants were stratified into categories based on the presence or absence of LVH and subclinical myocardial injury (category 1: hs-cTnI <4 ng/L in women and <6 ng/L in men; category 2: 4-10 ng/L in women and 6-12 ng/L in men; category 3: >10 ng/L in women and >12 ng/L in men).

Main Outcomes and Measures

Adjusted associations between LVH, subclinical myocardial injury, and the risk of incident HF hospitalization were assessed using Cox proportional hazards models.

Results

The study included 3987 participants (2552 women [64%]; 240 (6.0%) with LVH; 1003 (25.1%) with myocardial injury) with 285 incident HF events over a median follow-up of 9.8 years (interquartile range, 8.9-10.6 years). In adjusted analyses, higher LV mass and subclinical myocardial injury were independently associated with the risk of HF with a significant interaction between the 2 (Pint < 0.001). The highest risk of HF was noted among individuals with both LVH and myocardial injury (absolute incidence, 35%; adjusted hazard ratio [aHR; vs no LVH and no myocardial injury], 5.35; 95% CI, 3.66-7.83). A significant interaction by sex was also observed. Men with LVH and subclinical myocardial injury had an almost 15-fold higher risk of HF (aHR, 14.62; 95% CI, 7.61-28.10) vs those with neither LVH nor injuries. By contrast, women with this phenotype had a nearly 4-fold higher risk of HF (aHR, 3.81; 95% CI, 2.40-6.85).

Conclusions and Relevance

The combination of LVH and subclinical myocardial injury identifies a malignant, preclinical HF phenotype in African Americans with a very high risk of HF, particularly among men. This finding could have implications for future screening strategies that are designed to prevent HF in the population.

Predictive Value of Endoplasmic Reticulum Stress Markers in Low Ejection Fractional Heart Failure

BACKGROUND/AIM

Endoplasmic reticulum (ER) stress plays a critical role in the development of cardiac hypertrophy and heart failure. Heart failure is a crucial health problem that affects 23 million people worldwide, causes approximately 2.4 million people to be hospitalized every year in the USA, and leads to the death of more than 300,000 people. In this study, we aimed to investigate the clinical significance of ER stress markers and the predictive value of acute decompensated heart failure in patients with low ejection fraction heart failure (ADHF).

PATIENTS AND METHODS

This is a prospective case control study. The data included laboratory parameters pertaining to patients with ADHF in the emergency service and lipid parameters obtained during their admission to the hospital. In addition, the same parameters obtained from the control group patients with chronic heart failure (CHF) during their routine polyclinic control were recorded in the data set. Admission time to the hospital and length of hospital stay were included in the data. The levels of glucose regulated protein (GRP78), protein kinase RNA-like endoplasmic reticulum kinase (PERK), and C/EBP homologous protein (CHOP) in peripheral blood serum obtained from the patients and the control group were measured using the ELISA method.

RESULTS

Serum GRP78 concentration was lower in the HF group (p=0.003) compared to the control. The median value of serum PERK concentration in the HF group was higher than that of the control group (573 pg/ml, IQR=477.5-650 vs. 495.5 pg/ml, IQR=294-648, respectively) (p=0.001). However, there were no statistically significant differences in GRP78 and PERK serum concentrations between ADHF and CHF subgroups. Receiver operating characteristic (ROC) curve analysis showed greater area under the curve (AUC) for the serum GRP78 levels of the healthy individuals (AUC=0.748, 95% CI=0.681-0.814, p=0.0003). The serum GRP78 level was found to be 80% sensitive and 70% specific at 147.5 pg/ml (p=0.0003) for distinguishing healthy individuals from HF patients. In the ADHF subgroup, there was a moderate correlation between hospitalization time and serum CHOP concentrations (Spearman rho=0.586 and p=0.001).

CONCLUSION

High GRP78 serum concentration may protect the patient from ER stress. In addition, the serum PERK level is high in patients with HF, whereas it is insufficient in predicting acute decompensation. CHOP may be useful in predicting the length of hospital stay in patients with ADHF.

Left ventricular eccentricity index measured with SPECT myocardial perfusion imaging: An additional parameter of adverse cardiac remodeling

BACKGROUND

Single-photon emission computed-tomography (SPECT) allows the quantification of LV eccentricity index (EI), a measure of cardiac remodeling. We sought to evaluate the feasibility of EI measurement with SPECT myocardial perfusion imaging and its interactions with relevant LV functional and structural parameters.

METHODS AND RESULTS

Four-hundred and fifty-six patients underwent myocardial perfusion imaging on a Cadmium-Zinc-Telluride (CZT) camera. The summed rest, stress, and difference scores were calculated. From rest images, the LV end-diastolic (EDV) and end-systolic volumes, ejection fraction (EF), and peak filling rate (PFR) were calculated. In every patient, the EI, ranging from 0 (sphere) to 1 (line), was computed using a dedicated software (QGS/QPS; Cedars-Sinai Medical Center). Three-hundred and thirty-eight/456 (74%) patients showed a normal EF (>50%), while 26% had LV systolic dysfunction. The EI was computed from CZT images with excellent reproducibility (interclass correlation coefficient: 0.99, 95% CI 0.98-0.99). More impaired EI values correlated with the presence of a more abnormal LV perfusion (P < .001), function (EF and PFR, P < .001), and structure (EDV, P < .001). On multivariate analysis, higher EDV (P < .001) and depressed EF (P = .014) values were independent predictors of abnormal EI.

CONCLUSIONS

The evaluation of LV eccentricity is feasible on gated CZT images. Abnormal EI associates with significant cardiac structural and functional abnormalities.

Tongsaimai reverses the hypertension and left ventricular remolding caused by abdominal aortic constriction in rats

Treating ventricular remodeling continues to be a clinical challenge. Studies have shown that hypertension is one of the most common causes of ventricular remodeling, and is a major cause of cardiovascular risk in adults. Here, we report that Tongsaimai (TSM), a Chinese traditional medicine, could inhibit arterial pressure and left ventricular pressure to improve hemodynamic abnormalities in rats impaired by abdominal aortic constriction (AAC). Administration of TSM significantly reduced the heart mass index and the left ventricular mass index significantly in AAC rats. TSM could also markedly ameliorate cardiac collagen deposition and reduce the concentration of hydroxyproline in the heart of AAC rats. Moreover, TSM alleviated cardiac histomorphology injury resulting from AAC, including reducing cardiomyocyte hypertrophy, fibrous connective tissue hyperplasia, cardiomyocyte apoptosis, replacement fibrosis and the disorders of myocardial myofibrils, intercalated discs, mitochondria and mitochondrial crista. In addition, the levels of transforming growth factor (TGF) - β and inflammation-related molecules including tumor necrosis factor-α (TNF-α), which were over-expressed with AAC, were decreased by STM. In conclusion, STM could reverse the hypertension and left ventricular remolding caused by abdominal aortic constriction in rats.

Limitations of Electrocardiography for Detecting Left Ventricular Hypertrophy or Concentric Remodeling in Athletes

BACKGROUND

Electrocardiography (ECG) is used to screen for left ventricular hypertrophy (LVH), but common ECG-LVH criteria have been found less effective in athletes. The purpose of this study was to comprehensively evaluate the value of ECG for identifying athletes with LVH or a concentric cardiac phenotype.

METHODS

A retrospective analysis of 196 male Division I college athletes routinely screened with ECG and echocardiography within the Stanford Athletic Cardiovascular Screening Program was performed. Left-ventricular mass and volume were determined using echocardiography. LVH was defined as left ventricular mass (LVM) >102 g/m²; a concentric cardiac phenotype as LVM-to-volume (M/V) ≥1.05 g/mL. Twelve-lead electrocardiograms including high-resolution time intervals and QRS voltages were obtained. Thirty-seven previously published ECG-LVH criteria were applied, of which the majority have never been evaluated in athletes. C-statistics, including area under the receiver operating curve (AUC) and likelihood ratios were calculated.

RESULTS

ECG lead voltages were poorly associated with LVM (r = 0.18-0.30) and M/V (r = 0.15-0.25). The proportion of athletes with ECG-LVH was 0%-74% across criteria, with sensitivity and specificity ranging between 0% and 91% and 27% and 99.5%, respectively. The average AUC of the criteria in identifying the 11 athletes with LVH was 0.57 (95% confidence interval [CI] 0.56-0.59), and the average AUC for identifying the 8 athletes with a concentric phenotype was 0.59 (95% CI 0.56-0.62).

CONCLUSION

The diagnostic capacity of all ECG-LVH criteria were inadequate and, therefore, not clinically useful in screening for LVH or a concentric phenotype in athletes. This is probably due to the weak association between LVM and ECG voltage.

Longitudinal changes in cardiac function in the very elderly: the Jerusalem longitudinal cohort study

Background

People over the age of 85 are a rapidly growing age group with a high incidence of congestive heart failure (CHF), in particular heart failure with preserved ejection fraction (HFpEF). The diagnosis of CHF is challenging and longitudinal data assessing cardiac structure and function are necessary to distinguish physiologic from pathologic cardiac aging. The objective of the study was to determine longitudinal changes in cardiac struture and function from ages 85 to 94 years using home echocardiography.

Methods

Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Sixty three members of the initial cohort (32F, 31M) who underwent home echocardiography at age 85 were the subjects of the current study and underwent repeat home 2-D and Doppler echocardiographic assessment at age 94.

Results

There were no significant longitudinal changes in left ventricular mass index (LVMI), however LV end-diastolic volume significantly decreased from 113.4 ± 30 to 103.6 ± 35.5 mL (P < 0.02). Ejection fraction (EF) remained stable, however longitudinal systolic function significantly decreased with age from 7.9 ± 1.8 to 6.6 ± 1.4 cm/s² (P < 0.0001). Diastolic function as assessed by increased E: e' (11.2 ± 3.4 to 16 ± 7.5, P < 0.0001) and increased left atrial volume index (34.1 ± 11.3 to 42.4 ± 13.7 mL/m², P < 0.0001) was reduced with aging.

Conclusions

This study demonstrated preserved EF with decreased longitudinal systolic function and diastolic function without significant change in LV mass. Changes in LV function in the very elderly may be independent of changes in LV geometry.

The Prognostic Effect of Circadian Blood Pressure Pattern on Long-Term Cardiovascular Outcome is Independent of Left Ventricular Remodeling

We aimed to investigate the predictive value of 24 h blood pressure (BP) patterns on adverse cardiovascular (CV) outcome in the initially untreated hypertensive patients during long-term follow-up. This study included 533 initially untreated hypertensive patients who were involved in this study in the period between 2007 and 2012. All participants underwent laboratory analysis, 24 h BP monitoring, and echocardiographic examination at baseline. The patients were followed for a median period of nine years. The adverse outcome was defined as the hospitalization due to CV events (atrial fibrillation, myocardial infarction, myocardial revascularization, heart failure, stroke, or CV death). During the nine-year follow-up period, adverse CV events occurred in 85 hypertensive patients. Nighttime SBP, non-dipping BP pattern, LV hypertrophy (LVH), left atrial enlargement (LAE), and LV diastolic dysfunction (LV DD) were risk factors for occurrence of CV events. However, nighttime SBP, non-dipping BP pattern, LVH, and LV DD were the only independent predictors of CV events. When all four BP pattern were included in the model, non-dipping and reverse dipping BP patterns were associated with CV events, but only reverse-dipping BP pattern was independent predictor of CV events. The current study showed that reverse-dipping BP pattern was predictor of adverse CV events independently of nighttime SBP and LV remodeling during long-term follow-up. The assessment of BP patterns has very important role in the long-time prediction in hypertensive population.

Staging Cardiac Damage in Patients With Hypertension

Ventricular and extraventricular response to pressure overload may be a common process in aortic stenosis and hypertension. We aimed to evaluate the association of a newly defined staging classification characterizing the extent of cardiac damage, originally developed for aortic stenosis, with long-term outcomes in patients with hypertension. We retrospectively analyzed 1639 patients with hypertension who had undergone both scheduled transthoracic echocardiography and electrocardiography in 2013 in a Japanese hospital, after excluding severe and moderate aortic stenosis, aortic regurgitation, mitral stenosis, previous myocardial infarction, or cardiomyopathy. We classified patients according to the presence or absence of cardiac damage as detected on echocardiography as follows: stage 0, no cardiac damage (n=858; 52.3%); stage 1, left ventricular damage (n=358; 21.8%); stage 2, left atrial or mitral valve damage (n=360; 22.0%); or stage 3 and 4, pulmonary vasculature, tricuspid valve, or right ventricular damage (n=63; 3.8%). The primary outcome was a composite of all-cause death and major adverse cardiac events. Cumulative 3-year incidence of the primary outcome was 15.5% in stage 0, 20.7% in stage 1, 31.8% in stage 2, and 60.6% in stage 3. After adjusting for confounders, the stage was incrementally associated with higher risk of the primary outcome (per 1-stage increase: hazard ratio, 1.46 [95% CI, 1.31–1.61]; P <0.001). The staging classification characterizing the extent of cardiac damage, originally developed for aortic stenosis, was associated with long-term outcomes in patients with hypertension in a stepwise manner.

Hypertensive Disorders of Pregnancy and Future Maternal Health: How Can the Evidence Guide Postpartum Management?

PURPOSE OF REVIEW

To review the postpartum management of hypertensive disorders of pregnancy.

RECENT FINDINGS

Hypertensive disorders are associated with an increased risk of future cardiovascular disease; however, there is a poor understanding of the underlying mechanisms and few recommendations to guide care in the postpartum period. Recent studies have shown high rates of masked hypertension and home blood pressure monitoring in the first year postpartum may be a promising opportunity to monitor health given evidence of high maternal adherence to this approach. In longer term, women with a history of a hypertensive disorder of pregnancy have higher blood pressures, increased risk of metabolic syndrome, and perhaps excess diastolic dysfunction. Triaging risk and improving handoff from the obstetrician to the primary care provider or subspecialist should be a priority in this population. Hypertensive disorders of pregnancy remain an untapped opportunity to identify excess cardiovascular risk in affected women at a time when mitigating that risk during the reproductive years has the potential to improve future pregnancy health as well as improve women's long-term cardiometabolic health.

Independent parameters of left atrium function in hypertensive heart disease

BACKGROUND

The left atrium reservoir function has an important role in the global cardiac performance and is determined by multiple cardiac and extra-cardiac factors. A new parameter is introduced, the independent strain, which quantifies left atrium reservoir phase deformation during isovolumetric relaxation.

AIMS

Is evaluated whether independent strain can identify intrinsic atrial myocardial damage in hypertension.

MATERIAL AND METHODS

Prospective observational study in which echocardiography was done to 50 hypertensive patients and 80 healthy volunteers. Myocardial deformation was evaluated with two-dimensional speckle tracking and left atrium volumes were calculated whit 3D-echocardiography.

RESULTS

In hypertensive patients, the indexed left atrium volume was greater than in the control group (34 ± 7.8 vs 24 ± 4.9 mL/m² ); strain of pump (-5.7 ± 2.4% vs -17±3.5%) and reservoir phases (34 ± 9% vs 48 ± 10%) were worst. The minimum left atrium volume was higher (26 ± 10 vs 15 ± 8 mL) and left atrium independent strain was lower in hypertensive patients (4.0% vs 6.5%, P = .001). Left atrium independent strain only correlated with minimum left atrium volume (r = -.31, P = .048).

DISCUSSION

The left ventricle longitudinal performance has an important contributing role in the left atrium reservoir function; despite this finding, the independent strain was unrelated to left ventricle longitudinal function.

CONCLUSION

Independent strain can identify atrial myocyte contractile dysfunction in hypertension given the relative absence of hemodynamic loads during this period. Additionally, quantification of left atrium minimum volume suggests indirectly the presence of atrial myocyte contractile dysfunction.

GRP78 (Glucose-Regulated Protein of 78 kDa) Promotes Cardiomyocyte Growth Through Activation of GATA4 (GATA-Binding Protein 4)

The heart manifests hypertrophic growth in response to elevation of afterload pressure. Cardiac myocyte growth involves new protein synthesis and membrane expansion, of which a number of cellular quality control machineries are stimulated to maintain function and homeostasis. The unfolded protein response is potently induced during cardiac hypertrophy to enhance protein-folding capacity and eliminate terminally misfolded proteins. However, whether the unfolded protein response directly regulates cardiac myocyte growth remains to be fully determined. Here, we show that GRP78 (glucose-regulated protein of 78 kDa)-an endoplasmic reticulum-resident chaperone and a critical unfolded protein response regulator-is induced by cardiac hypertrophy. Importantly, overexpression of GRP78 in cardiomyocytes is sufficient to potentiate hypertrophic stimulus-triggered growth. At the in vivo level, TG (transgenic) hearts overexpressing GRP78 mount elevated hypertrophic growth in response to pressure overload. We went further to show that GRP78 increases GATA4 (GATA-binding protein 4) level, which may stimulate Anf (atrial natriuretic factor) expression and promote cardiac hypertrophic growth. Silencing of GATA4 in cultured neonatal rat ventricular myocytes significantly diminishes GRP78-mediated growth response. Our results, therefore, reveal that protein-folding chaperone GRP78 may directly enhance cardiomyocyte growth by stimulating cardiac-specific transcriptional factor GATA4.