Adiposity, body composition and ventricular-arterial stiffness in the elderly: the Atherosclerosis Risk in Communities Study

Classification, Diagnosis, and Treatment of Obesity-Related Heart Diseases

Evidence-based medicine shows that obesity is associated with a wide range of cardiovascular (CV) diseases. Obesity can lead to changes in cardiac structure and function, which can lead to obese cardiomyopathy, subclinical cardiac dysfunction, and even heart failure. It also increases the risk of atrial fibrillation and sudden cardiac death. Many invasive and noninvasive diagnostic methods can detect obesity-related heart disease at an early stage, so that appropriate measures can be selected to prevent adverse CV events. However, studies have shown a protective effect of obesity on clinical outcomes of CV disease, a phenomenon that has been termed the obesity paradox. The "obesity paradox" essentially refers to the fact that the classification of obesity defined by body mass index (BMI) does not consider the impact of obesity heterogeneity on CV disease prognosis, but simply puts subjects with different clinical and biochemical characteristics into the same category. In any case, indicators such as waist-to-hip ratio, ectopic body fat qualitative and quantitative, and CV fitness have been shown to be able to distinguish different CV risks in patients with the same BMI, which is convenient for early intervention in an appropriate way. A multidisciplinary approach, including lifestyle modification, evidence-based generic and novel pharmacotherapy, and surgical intervention, can improve CV outcomes in overweight/obese patients.

Abnormal left ventricular systolic reserve function detected by treadmill exercise stress echocardiography in asymptomatic type 2 diabetes

Aims

Subclinical left ventricular (LV) dysfunction may occur in T2DM patients at the early asymptomatic stage, and LV reserve function is a sensitive index to detect subtle LV dysfunction. The purpose of our study is (1) to assess the LV reserve function using treadmill exercise stress echocardiography (ESE) in asymptomatic type 2 diabetes mellitus (T2DM) patients; (2) to explore the link of serum biological parameters and LV reserve function.

Methods

This study included 84 patients with asymptomatic T2DM from September 2021 to July 2022 and 41 sex- and age-matched healthy controls during the corresponding period. All subjects completed treadmill ESE, LV systolic function-related parameters such as global longitudinal strain (GLS) and systolic strain rate (SRs), as well as diastolic function-related parameters such as E wave (E), early diastolic velocity (e'), E/e' ratio, early diastolic SR (SRe), and late diastolic SR (SRa) were compared at rest and immediately after exercise. The difference between LV functional parameters after treadmill exercise and its corresponding resting value was used to compute LV reserve function. In addition, the associations of LV reserve function and serum biological parameters were analyzed.

Results

Patients with T2DM did not significantly vary from the controls in terms of alterations in LV diastolic reserve measures, the changes of LVGLS and SRs (ΔGLS: 2.19 ± 2.72% vs. 4.13 ± 2.79%, P < 0.001 and ΔSRs:0.78 ± 0.33 s-1 vs. 1.02 ± 0.28 s-1, P < 0.001) in the T2DM group were both lower than those in the control group. Glycated hemoglobin (HbA1c), N-terminal pro-brain natriuretic peptide (NTproBNP), waist circumference, and high-sensitive C-reactive protein (hsCRP) were identified as independent predictors of LV systolic reserve by stepwise multiple linear regression analysis.

Conclusion

LV systolic reserve function, as measured by pre- and post-exercise differences in GLS and SRs were significantly impaired in patients with asymptomatic T2DM, whereas diastolic reserve remained normal during exercise and was comparable to that of the control group. This was different from previous findings. High levels of HbA1c, NTproBNP, hsCRP, and increasing waist circumference were independent predictors of LV systolic reserve.

Association of metal exposure with arterial stiffness in Chinese adults

BACKGROUND

Arterial stiffness is an important indicator of cardiovascular aging. However, studies assessing the association between metal exposure and arterial stiffness are limited.

OBJECTIVE

The aim of this study was to investigate the independent and joint associations of metal exposure with arterial stiffness.

METHODS

This cross-sectional study recruited 2982 Chinese adults from August 2018 to March 2019 in Wuhan, China. The concentrations of 20 urinary metals were determined using inductively coupled plasma mass spectrometer. Arterial stiffness was assessed by brachial-ankle pulse wave velocity (baPWV). We used generalized linear model (GLM) to estimate the association of single metal exposure with baPWV. We used weighted quantile sum (WQS) regression to estimate the association of metal mixture with baPWV.

RESULTS

In GLM regression analysis, each doubling of urinary copper (Cu) and chromium (Cr) concentrations were associated with 6.48 (95 % CI: 2.51-10.45) cm/s and 3.78 (95 % CI: 0.42-7.14) cm/s increase in baPWV, respectively. In WQS regression analysis, each unit increase in WQS index of the metal mixture was associated with a 9.10 (95 % CI: 2.39-15.82) cm/s increase in baPWV. Cu, Zn, and Cr were the dominant urinary metals associated with baPWV.

CONCLUSION

Metal exposure, both individually and in mixture, was associated with an increased risk of arterial stiffness. Our findings may provide a target for preventative strategies against cardiovascular aging.

Obesity and heart failure with preserved ejection fraction: new insights and pathophysiological targets

Obesity and heart failure with preserved ejection fraction (HFpEF) represent two intermingling epidemics driving perhaps the greatest unmet health problem in cardiovascular medicine in the 21st century. Many patients with HFpEF are either overweight or obese, and recent data have shown that increased body fat and its attendant metabolic sequelae have widespread, protean effects systemically and on the cardiovascular system leading to symptomatic HFpEF. The paucity of effective therapies in HFpEF underscores the importance of understanding the distinct pathophysiological mechanisms of obese HFpEF to develop novel therapies. In this review, we summarize the current understanding of the cardiovascular and non-cardiovascular features of the obese phenotype of HFpEF, how increased adiposity might pathophysiologically contribute to the phenotype, and how these processes might be targeted therapeutically.

Short Video Viewing, and Not Sedentary Time, Is Associated with Overweightness/Obesity among Chinese Women

Previous studies have found that the relationship between sedentary time (ST) and overweightness/obesity is unclear. The association between sedentary behavior and overweightness/obesity may depend on the type of sedentary behavior engaged in. Nowadays, in older Chinese adults, especially females, short video viewing (SVV) is the most popular leisure sedentary behavior. However, the association between SVV and overweightness/obesity remains to be determined. This study aimed to examine the associations between ST and SVV and overweightness/obesity in Chinese community-dwelling older women. A cross-sectional analysis of baseline data from the Physical Activity and Health in Older Women Study was carried out in this study. A total of 1105 older Chinese women aged 60–70 years were included. SVV was estimated using a self-reported questionnaire, and ST was objectively measured using a tri-axial accelerometer. Overweightness/obesity indicators, including body fat ratio (BFR), fat mass (FM), visceral fat mass (VFM), subcutaneous fat mass (SFM), trunk fat mass (TFM), and limb fat mass (LFM), were assessed using multi-frequency bioimpedance analysis. The covariates included socio-demographic data and a range of health-related factors. Multiple linear regression analyses were used to assess the association between ST and SVV and overweightness/obesity. ST was significantly positively associated with all indicators of overweightness/obesity; however, the associations disappeared after adjusting for moderate-to-vigorous-intensity physical activity (MVPA). A higher SVV time was associated with a higher body mass index (BMI) (β = 0.19, 95% confidence interval (CI): 0.05 to 0.32), BFR (β = 0.31, 95% CI: 0.07 to 0.56), FM (β = 0.33, 95% CI: 0.04 to 0.61), VFM (β = 0.09, 95% CI: 0.01 to 0.16), SFM (β = 0.24, 95% CI: 0.03 to 0.45), TFM (β = 0.21, 95% CI: 0.04 to 0.39), and LFM (β = 0.11, 95% CI: 0.00 to 0.23) in the fully adjusted models. Compared with non-food short videos, short food videos had a greater effect on overweightness/obesity. SVV was an independent risk factor for overweightness/obesity. A reduction in SVV (especially the food category) rather than ST might be an effective way to prevent overweightness/obesity when incorporated in future public health policy formulations.

Causal Associations of Obesity With Chronic Kidney Disease and Arterial Stiffness: A Mendelian Randomization Study

CONTEXT

Observational studies have been associated obesity with chronic kidney disease (CKD) and arterial stiffness, but the causality remains unclear.

OBJECTIVE

We aimed to investigate the causality of obesity with CKD and arterial stiffness using mendelian randomization (MR) analysis.

METHODS

We genotyped 14 body mass index (BMI)-associated variants validated in East Asians in 11 384 Chinese adults. A genetic risk score based on the 14 variants and the 14 individual single-nucleotide variations (SNVs, formerly single-nucleotide polymorphisms [SNPs]) were respectively used as instrumental variables (IVs). CKD was defined as estimated glomerular filtration rate less than 60 mL/min/1.73 m2. Arterial stiffness was defined as brachial-ankle pulse wave velocity greater than 1550 cm/s.

RESULTS

Using the genetic risk score as the IV, we demonstrated causal relations of each 1-SD increment in BMI with CKD (odds ratio [OR]: 2.36; 95% CI, 1.11-5.00) and arterial stiffness (OR: 1.71; 95% CI, 1.22-2.39). Using the 14 SNVs individually as IVs, each 1-SD increment in BMI was casually associated with CKD (OR: 2.58; 95% CI, 1.39-4.79) and arterial stiffness (OR: 1.87; 95% CI, 1.24-2.81) in the inverse-variance weighted analysis, and MR-Egger regression revealed no evidence of horizontal pleiotropy (both P for intercept ≥ .34). The causality between obesity and CKD was validated in 2-sample MR analysis among Europeans (681 275 of Genetic Investigation of ANthropometric Traits and 133 413 of CKD Genetics).

CONCLUSION

This study provided novel insights into the causality of obesity with CKD and arterial stiffness, highlighting the importance of weight management for primary prevention and control of subclinical vascular diseases.

Single-cell RNA-seq reveals cellular heterogeneity of mouse carotid artery under disturbed flow

Disturbed blood flow (d-flow) has been known to induce changes of the cells in the arterial wall, increasing the risk of atherosclerosis. However, the heterogeneity of the vascular cell populations under d-flow remains less understood. To generate d-flow in vivo, partial carotid artery ligation (PCL) was performed. Seven days after ligation, single-cell RNA sequencing of nine left carotid arteries (LCA) from the PCL group (10,262 cells) or control group (14,580 cells) was applied and a single-cell atlas of gene expression was constructed. The integrated analysis identified 15 distinct carotid cell clusters, including 10 d-flow-relevant subpopulations. Among endothelial cells, at least four subpopulations were identified, including Klk8hi ECs, Lrp1hi ECs, Dkk2hi ECs, and Cd36hi ECs. Analysis of GSVA and single-cell trajectories indicated that the previously undescribed Dkk2hi ECs subpopulation was mechanosensitive and potentially transformed from Klk8hi ECs under d-flow. D-flow-induced Spp1hi VSMCs subpopulation that appeared to be endowed with osteoblast differentiation, suggesting a role in arterial stiffness. Among the infiltrating cell subpopulations, Trem2hi Mφ, Birc5hi Mφ, DCs, CD4+ T cells, CXCR6+ T cells, NK cells, and granulocytes were identified under d-flow. Of note, the novel Birc5hi Mφ was identified as a potential contributor to the accumulation of macrophages in atherosclerosis. Finally, Dkk2hi ECs, and Cd36hi ECs were also found in the proatherosclerotic area of the aorta where the d-flow occurs. In conclusion, we presented a comprehensive single-cell atlas of all cells in the carotid artery under d-flow, identified previously unrecognized cell subpopulations and their gene expression signatures, and suggested their specialized functions.

Radiation exposure after myocardial perfusion imaging with Cadmium-Zinc-Telluride camera versus conventional camera

BACKGROUND

Patient exposure to radiation during the management of coronary heart disease (CHD) can be reduced with more efficient technologies in nuclear medicine, such as the Cadmium-Zinc-Telluride (CZT) gamma-camera for myocardial perfusion imaging (MPI) studies. However, it has been suggested that CZT has lower specificity, which might lead to more downstream radiological procedures, particularly among obese individuals.

METHODS AND RESULTS

We evaluated 244 patients with suspected CHD who underwent CZT-SPECT and matched 1:1 according to sex, age, and body mass index (BMI) with those undergoing MPI study with the Anger gamma-camera (Anger-SPECT). The outcome was the total radiation exposure from the MPI study added to the radiation exposure from all subsequent cardiac examinations during a 90-day follow-up. The total radiation dose after 90 days was significantly lower in the CZT-SPECT group (6.4 ± 4.8 vs 9.5±4.9 mSv, P < .001). After adjusting for potential confounders, CZT-SPECT remained associated with lower total radiation dose, but it significantly attenuated among obese individuals (Beta coefficient - 3.73 ± 0.86 for BMI < 30 vs - 2.30 ± 0.92 for BMI ≥ 30 Kg/m2, P for interaction < 0.032).

CONCLUSIONS

CZT-SPECT was associated with lower total radiation doses compared to Anger-SPECT, albeit this benefit may be attenuated in obese individuals.

Obesity cardiomyopathy: evidence, mechanisms, and therapeutic implications

The prevalence of heart failure is on the rise and imposes a major health threat, in part, due to the rapidly increased prevalence of overweight and obesity. To this point, epidemiological, clinical, and experimental evidence supports the existence of a unique disease entity termed “obesity cardiomyopathy,” which develops independent of hypertension, coronary heart disease, and other heart diseases. Our contemporary review evaluates the evidence for this pathological condition, examines putative responsible mechanisms, and discusses therapeutic options for this disorder. Clinical findings have consolidated the presence of left ventricular dysfunction in obesity. Experimental investigations have uncovered pathophysiological changes in myocardial structure and function in genetically predisposed and diet-induced obesity. Indeed, contemporary evidence consolidates a wide array of cellular and molecular mechanisms underlying the etiology of obesity cardiomyopathy including adipose tissue dysfunction, systemic inflammation, metabolic disturbances (insulin resistance, abnormal glucose transport, spillover of free fatty acids, lipotoxicity, and amino acid derangement), altered intracellular especially mitochondrial Ca²⁺ homeostasis, oxidative stress, autophagy/mitophagy defect, myocardial fibrosis, dampened coronary flow reserve, coronary microvascular disease (microangiopathy), and endothelial impairment. Given the important role of obesity in the increased risk of heart failure, especially that with preserved systolic function and the recent rises in COVID-19-associated cardiovascular mortality, this review should provide compelling evidence for the presence of obesity cardiomyopathy, independent of various comorbid conditions, underlying mechanisms, and offer new insights into potential therapeutic approaches (pharmacological and lifestyle modification) for the clinical management of obesity cardiomyopathy.

Shared genetic etiology and causality between body fat percentage and cardiovascular diseases: a large-scale genome-wide cross-trait analysis

BACKGROUND

Accumulating evidences have suggested that high body fat percentage (BF%) often occurs in parallel with cardiovascular diseases (CVDs), implying a common etiology between them. However, the shared genetic etiology underlying BF% and CVDs remains unclear.

METHODS

Using large-scale genome-wide association study (GWAS) data, we investigated shared genetics between BF% (N = 100,716) and 10 CVD-related traits (n = 6968-977,323) with linkage disequilibrium score regression, multi-trait analysis of GWAS, and transcriptome-wide association analysis, and evaluated causal associations using Mendelian randomization.

RESULTS

We found strong positive genetic correlations between BF% and heart failure (HF) (Rg = 0.47, P = 1.27 × 10^- 22) and coronary artery disease (CAD) (Rg = 0.22, P = 3.26 × 10^- 07). We identified 5 loci and 32 gene-tissue pairs shared between BF% and HF, as well as 16 loci and 28 gene-tissue pairs shared between BF% and CAD. The loci were enriched in blood vessels and brain tissues, while the gene-tissue pairs were enriched in the nervous, cardiovascular, and exo-/endocrine system. In addition, we observed that BF% was causally related with a higher risk of HF (odds ratio 1.63 per 1-SD increase in BF%, P = 4.16 × 10-04) using a MR approach.

CONCLUSIONS

Our findings suggest that BF% and CVDs have shared genetic etiology and targeted reduction of BF% may improve cardiovascular outcomes. This work advances our understanding of the genetic basis underlying co-morbid obesity and CVDs and opens up a new way for early prevention of CVDs.

Stiffness of aortic arch and carotid arteries increases in ApoE-knockout mice with high-fat diet: evidence from echocardiography

Arterial stiffness is an effective predictor of atherosclerosis. Measurement of pulse-wave velocity (PWV) is a gold-standard approach to study arterial stiffness. This study aims to examine arterial stiffness and heart functions via echocardiography at an early stage of atherosclerosis. A model of atherosclerosis in ApoE-knockout (ApoE^-/- ) mice fed on high-fat diet (HFD) was used, with normal chow diet (ND) as a control. Stiffness of aortic arch and carotid arteries and left ventricular (LV) systolic/diastolic functions were measured by echocardiography. The plasma cholesterol levels and atherosclerotic plaque areas in the aortas were measured. The PWV values of aortic arch and carotid arteries were compared at 2, 4, 6 and 8 weeks with different diets. Compared with ND mice, PWV values in aortic arch and carotid arteries were significantly increased in HFD mice after 8 weeks (Aortic arch: 516.65 ± 216.89 cm/s vs. 192.53 ± 71.71 cm/s; Carotid arteries: 514.26 ± 211.01 cm/s vs. 188.03 ± 75.14 cm/s, respectively; both P < 0.01) accompanied by the decrease in LV systolic/diastolic functions. These were well correlated with the increase in plasma cholesterol levels. Echo-based PWV measurement in the aortic arch was found more sensitive to predict atherosclerosis than in the carotid arteries in ApoE^-/- mice. Measuring aortic arch PWV via echocardiography could represent a new diagnostic strategy for early detection of atherosclerosis.

The relationship between changes in deoxy Hb and body composition before and after cycling exercise during unilateral lower extremity occlusion

[Purpose] To clarify the relationship between changes in deoxygenated hemoglobin level due to cycling exercise and body composition in healthy participants with unilateral lower-limb obstruction. [Participants and Methods] The height, weight, body mass index, and body composition (skeletal muscle mass, body water content, and body fat percentage) of nine healthy males were measured along with the anaerobic threshold. The protocol consisted of 7 minutes of rest followed by 4 minutes of cycling exercise (anaerobic threshold level) with unilateral lower extremity occlusion. After exercise, ischemia was released, and the participants was allowed rest for 5 minutes. Deoxygenated hemoglobin levels before and after the exercise and the relationship between the level of variation and each index were examined. [Results] Body water content and skeletal muscle mass showed a significant negative correlation with changes in deoxygenated hemoglobin level; however, no correlation was found for the other indices. Body water content and skeletal muscle mass were found to be significantly positively correlated. they showed a significant positive correlation with deoxygenated hemoglobin levels. [Conclusion] Our study indicates that body water content and skeletal muscle mass play a significant role in the recovery of blood flow following exercise.

Heart failure in the last year: progress and perspective

Research about heart failure (HF) has made major progress in the last years. We give here an update on the most recent findings. Landmark trials have established new treatments for HF with reduced ejection fraction. Sacubitril/valsartan was superior to enalapril in PARADIGM‐HF trial, and its initiation during hospitalization for acute HF or early after discharge can now be considered. More recently, new therapeutic pathways have been developed. In the DAPA‐HF and EMPEROR‐Reduced trials, dapagliflozin and empagliflozin reduced the risk of the primary composite endpoint, compared with placebo [hazard ratio (HR) 0.74; 95% confidence interval (CI) 0.65–0.85; P < 0.001 and HR 0.75; 95% CI 0.65–0.86; P < 0.001, respectively]. Second, vericiguat, an oral soluble guanylate cyclase stimulator, reduced the composite endpoint of cardiovascular death or HF hospitalization vs. placebo (HR 0.90; 95% CI 0.82–0.98; P = 0.02). On the other hand, both the diagnosis and treatment of HF with preserved ejection fraction, as well as management of advanced HF and acute HF, remain challenging. A better phenotyping of patients with HF would be helpful for prognostic stratification and treatment selection. Further aspects, such as the use of devices, treatment of arrhythmias, and percutaneous treatment of valvular heart disease in patients with HF, are also discussed and reviewed in this article.

Imaging Interstitial Fibrosis, Left Ventricular Remodeling, and Function in Stage A and B Heart Failure

Myocardial interstitial fibrosis is part of the advanced disease stage of most cardiovascular pathologies. It has been characterized histologically in various disease settings from hypertensive heart disease and diabetic cardiomyopathy to severe aortic stenosis. It is also involved in the process of aging. In cardiovascular medicine, myocardial interstitial fibrosis is associated with several adverse outcomes, especially heart failure (HF) and sudden cardiac death. Until recently, clinical measures of interstitial fibrosis could only be made by invasive myocardial biopsy. The availability of cardiac magnetic resonance (CMR) T1 mapping techniques allows for the indirect measurement of interstitial space characteristics and extracellular volume size, which is closely correlated with collagen content and interstitial infiltration by amyloid and other molecules. There has been significant improvement in the accuracy and reproducibility of T1 acquisition sequences in the last decade; however, the correct use of this technique requires a solid CMR expertise in daily imaging practice. CMR has become the gold standard to assess left ventricular (LV) remodeling and functional features associated with interstitial fibrosis. These features can be detected in the early stages of HF. The main objective of this paper is to review the relevant results of preclinical and clinical observational studies that demonstrate the prognostic impact of interstitial fibrosis assessed by T1 mapping, as well as adverse left ventricular remodeling, as determinants of HF. Therefore, this review focuses on the pathological mechanisms underlying LV remodeling and interstitial fibrosis, in addition to the technical considerations involved in the assessment of interstitial LV fibrosis by CMR. It provides a thorough review of clinical evidence that demonstrates the association of interstitial fibrosis and other-CMR derived LV phenotypes with Stages A and B HF.

CD5L, Macrophage Apoptosis Inhibitor, Was Identified in Epicardial Fat-Secretome and Regulated by Isoproterenol From Patients With Heart Failure

Objectives

Neurohormonal dysfunction, which can regulate epicardial fat activity, is one of the main promoters of atrial fibrillation (AF) in patients with heart failure (HF). Our aim was to study the epicardial fat mediators for AF in patients with HF and its catecholaminergic regulation.

Methods

We have included 29 patients with HF who underwent cardiac surgery and were followed up for 5 years. Released proteins by epicardial adipose tissue (EAT) after isoproterenol treatment were identified by nano-high-performance liquid chromatography (HPLC) and triple time-of-flight (TOF) analysis. Common and differential identified proteins in groups of patients with AF before and after surgery were determined by the FunRich tool. Plasma and epicardial fat biopsy proteins were quantified by western blot.

Results

Our results identified 17 common released proteins by EAT, after isoproterenol treatment, from HF patients who suffered AF or developed new-onset AF during follow-up. Mostly, they were involved on inflammatory response and extracellular matrix. One of them was CD5L, a macrophage apoptosis inhibitor. Its secretion by isoproterenol treatment was validated on western blot. The CD5L levels on epicardial fat were also higher in the group of male patients who present or develop AF (0.44 ± 0.05 vs. 0.18 ± 0.15; p < 0.016). However, there were no differences regarding plasma levels.

Conclusion

Our results suggest the role of epicardial fat CD5L as a mediator of AF and its possible paracrine effect by catecholaminergic activity.

Early Stages of Obesity-related Heart Failure Are Associated with Natriuretic Peptide Deficiency and an Overall Lack of Neurohormonal Activation: The Copenhagen Heart Failure Risk Study

Objective

This study evaluated the associations between the natriuretic peptide activity and the neurohormonal response in non-obese and obese outpatients with and without heart failure (HF).

Background

Obesity-related HF may be a distinct subtype of HF. Obesity is associated with lower plasma concentrations of natriuretic peptides. The associations between obesity and neurohormonal activation estimated by mid-regional pro-adrenomedullin (MR-proADM) and copeptin in patients with HF is not elucidated.

Methods

This prospective cohort-study included 392 outpatients ≥60years, plus ≥1 risk-factor(-s) for HF (hypertension, ischemic heart disease, atrial fibrillation, diabetes, chronic kidney disease), and without known HF. Patients were categorized 'non-obese' BMI = 18.5-29.9 kg/m2 (n = 273) and 'obese' BMI ≥ 30 kg/m2 (n = 119). The diagnosis of HF required signs, symptoms, and abnormal echocardiography. NT-proBNP, MR-proANP, MR-proADM, and copeptin were analyzed.

Results

Obese patients were younger, had a higher prevalence of diabetes and chronic kidney disease, but a lower prevalence of atrial fibrillation. A total of 39 (14.3%) non-obese and 26 (21.8%) obese patients were diagnosed with HF. In obese patients, HF was not associated with higher plasma concentrations of NT-proBNP (Estimate: 0.063; 95%CI: -0.037-1.300; P = 0.064), MR-proANP (Estimate: 0.207; 95%CI: -0.101-0.515; P = 0.187), MR-proADM (Estimate: 0.112; 95%CI: -0.047-0.271; P = 0.168), or copeptin (Estimate: 0.093; 95%CI: -0.333-0.518; P = 0.669). Additionally, obese patients with HF had lower plasma concentrations of NT-proBNP (Estimate: -0.998; 95%CI: -1.778-0.218; P = 0.012), and MR-proANP (Estimate: -0.488; 95%CI: -0.845-0.132; P = 0.007) compared to non-obese patients with HF, whereas plasma concentrations of MR-proADM (Estimate: 0.066; 95%CI: -0.119-0.250; P = 0.484) and copeptin (Estimate: 0.140; 95%CI: -0.354-0.633; P = 0.578) were comparable.

Conclusions

Patients with obesity-related HF have natriuretic peptide deficiency and lack of increased plasma concentrations of MR-proADM and copeptin suggesting that patients with obesity-related HF have a blunted overall neurohormonal activity.

Correlative Study on Impaired Prostaglandin E2 Regulation in Epicardial Adipose Tissue and its Role in Maladaptive Cardiac Remodeling via EPAC2 and ST2 Signaling in Overweight Cardiovascular Disease Subjects

There is recent evidence that the dysfunctional responses of a peculiar visceral fat deposit known as epicardial adipose tissue (EAT) can directly promote cardiac enlargement in the case of obesity. Here, we observed a newer molecular pattern associated with LV dysfunction mediated by prostaglandin E2 (PGE₂) deregulation in EAT in a cardiovascular disease (CVD) population. A series of 33 overweight CVD males were enrolled and their EAT thickness, LV mass, and volumes were measured by echocardiography. Blood, plasma, EAT, and SAT biopsies were collected for molecular and proteomic assays. Our data show that PGE₂ biosynthetic enzyme (PTGES-2) correlates with echocardiographic parameters of LV enlargement: LV diameters, LV end diastolic volume, and LV masses. Moreover, PTGES-2 is directly associated with EPAC2 gene (r = 0.70, p < 0.0001), known as a molecular inducer of ST2/IL-33 mediators involved in maladaptive heart remodelling. Furthermore, PGE₂ receptor 3 (PTEGER3) results are downregulated and its expression is inversely associated with ST2/IL-33 expression. Contrarily, PGE₂ receptor 4 (PTGER4) is upregulated in EAT and directly correlates with ST2 molecular expression. Our data suggest that excessive body fatness can shift the EAT transcriptome to a pro-tissue remodelling profile, may be driven by PGE₂ deregulation, with consequent promotion of EPAC2 and ST2 signalling.

Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction: Understanding Mechanisms by Using Noninvasive Methods

Research in the last decade has substantially advanced our understanding of the pathophysiology of heart failure with preserved ejection fraction (HFpEF). However, treatment options remain limited as clinical trials have largely failed to identify effective therapies. Part of this failure may be related to mechanistic heterogeneity. It is speculated that categorizing HFpEF patients based upon underlying pathophysiological phenotypes may represent the key next step in delivering the right therapies to the right patients. Echocardiography may provide valuable insight into both the pathophysiology and underlying phenotypes in HFpEF. Echocardiography also plays a key role in the evaluation of patients with unexplained dyspnea, where HFpEF is suspected but the diagnosis remains unknown. The combination of the E/e' ratio and right ventricular systolic pressure has recently been shown to add independent value to the diagnostic evaluation of patients suspected of having HFpEF. Finally, echocardiography enables identification of the different causes that mimic HFpEF but are treated differently, such as valvular heart disease, pericardial constriction, and high-output heart failure or infiltrative myopathies such as cardiac amyloid. This review summarizes the current understanding of the pathophysiology and phenotyping of HFpEF with particular attention to the role of echocardiography in this context.

Drug therapy in elderly heart failure patients

Although heart failure (HF) is considered as a cardiogeriatric syndrome, elderly and very elderly patients are under-represented in the vast majority of clinical trials investigating novel drugs and therapies in this population. The homoeostatic systems of elderly subjects are very fragile, and the management of HF accompanied by numerous comorbidities requires a holistic approach towards the patient, with special emphasis not only on psychosomatic problems but also on the individual (including social) needs of each particular patient, along with the support for the family and/or caregivers. In this article, we summarize current evidence regarding pharmacotherapy of elderly patients with HF and summarize the clinical problems occurring in this population.

Highlights in heart failure

Heart failure (HF) remains a major cause of mortality, morbidity, and poor quality of life. It is an area of active research. This article is aimed to give an update on recent advances in all aspects of this syndrome. Major changes occurred in drug treatment of HF with reduced ejection fraction (HFrEF). Sacubitril/valsartan is indicated as a substitute to ACEi/ARBs after PARADIGM-HF (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.73 to 0.87 for sacubitril/valsartan vs. enalapril for the primary endpoint and Wei, Lin and Weissfeld HR 0.79, 95% CI 0.71-0.89 for recurrent events). Its initiation was then shown as safe and potentially useful in recent studies in patients hospitalized for acute HF. More recently, dapagliflozin and prevention of adverse-outcomes in DAPA-HF trial showed the beneficial effects of the sodium-glucose transporter type 2 inhibitor dapaglifozin vs. placebo, added to optimal standard therapy [HR, 0.74; 95% CI, 0.65 to 0.85;0.74; 95% CI, 0.65 to 0.85 for the primary endpoint]. Trials with other SGLT 2 inhibitors and in other patients, such as those with HF with preserved ejection fraction (HFpEF) or with recent decompensation, are ongoing. Multiple studies showed the unfavourable prognostic significance of abnormalities in serum potassium levels. Potassium lowering agents may allow initiation and titration of mineralocorticoid antagonists in a larger proportion of patients. Meta-analyses suggest better outcomes with ferric carboxymaltose in patients with iron deficiency. Drugs effective in HFrEF may be useful also in HF with mid-range ejection fraction. Better diagnosis and phenotype characterization seem warranted in HF with preserved ejection fraction. These and other burning aspects of HF research are summarized and reviewed in this article.

Age-Dependent Impairment in Endothelial Function and Arterial Stiffness in Former High Class Male Athletes Is No Different to That in Men With No History of Physical Training

Background

Physical activity is generally considered to exert positive effects on the cardiovascular system in humans. However, surprisingly little is known about the delayed effect of professional physical training performed at a young age on endothelial function and arterial stiffness in aging athletes. The present study aimed to assess the impact of long‐lasting professional physical training (endurance and sprint) performed at a young age on the endothelial function and arterial stiffness reported in older age in relation to glycocalyx injury, prostacyclin and nitric oxide production, inflammation, basal blood lipid profile, and glucose homeostasis.

Methods and Results

This study involved 94 male subjects with varied training backgrounds, including young athletes (mean age ∼25 years), older former high class athletes (mean age ∼60 years), and aged‐matched untrained control groups. Aging increased arterial stiffness, as reflected by an enhancement in pulse wave velocity, augmentation index, and stiffness index (P<10⁻⁴), as well as decreased endothelial function, as judged by the attenuation of flow‐mediated vasodilation (FMD) in the brachial artery (P=0.03). Surprisingly, no effect of the training performed at a young age on endothelial function and arterial stiffness was observed in the former athletes. Moreover, no effect of training performed at a young age (P>0.05) on blood lipid profile, markers of inflammation, and glycocalyx shedding were observed in the former athletes.

Conclusions

Our study clearly shows that aging, but not physical training history, represents the main contributing factor responsible for decline in endothelial function and increase in arterial stiffness in former athletes.