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Kawai A, Nagatomo Y, Yukino-Iwashita M, Ikegami Y, Takei M, Goda A, Kohno T, Mizuno A, Kitamura M, Nakano S, Sakamoto M, Shiraishi Y, Kohsaka S, Adachi T, Yoshikawa T. Supra-normal and mildly reduced ejection fraction in women -An overlooked vulnerable subpopulation in heart failure. Int J Cardiol 2024; 409:132166. [PMID: 38744340 DOI: 10.1016/j.ijcard.2024.132166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/04/2024] [Accepted: 05/11/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Recently, patients with supra-normal left ventricular ejection fraction (snEF) are reported to have high risk of adverse outcomes, especially in women. We sought to evaluate sex-related differences in the association between LVEF and long-term outcomes in heart failure (HF) patients. METHODS The multicenter WET-HF Registry enrolled all patients hospitalized for acute decompensated HF (ADHF). We analyzed 3943 patients (age 77 years; 40.1% female) registered from 2006 to 2017. According to LVEF the patients were divided into the 3 groups: HF with reduced EF (HFrEF), mildly reduced EF (HFmrEF) and preserved EF. The primary endpoint was defined as the composite of cardiac death and ADHF rehospitalization after discharge. RESULTS In HFmrEF, implementation of guideline-directed medical therapy (GDMT) such as the combination of renin-angiotensin-system inhibitor (RASi) and β-blocker at discharge was significantly lower in women than men even after adjustment for covariates (p = 0.007). There were no such sex-related differences in HFrEF. Female sex was associated with higher incidence of the primary endpoint and ADHF rehospitalization after adjustment for covariates exclusively in HFmrEF. Restricted cubic spline analysis demonstrated a U-shaped relationship between LVEF and the hazard ratio of the primary endpoint showing higher event rate in HFmrEF and HFsnEF in women, but such relationship was not observed in men (p for interaction = 0.037). CONCLUSIONS In women, mrEF and snEF were associated with worse long-term outcomes. Additionally, sex-related differences in the GDMT implementation for HFmrEF highlight the need for further exploration, which might lead to creation of sex-specific guidelines to optimize HF management.
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Affiliation(s)
- Akane Kawai
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan; Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan.
| | | | - Yukinori Ikegami
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
| | - Makoto Takei
- Department of Cardiology, Saiseikai Central Hospital, Tokyo, Japan
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Atsushi Mizuno
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | | | - Shintaro Nakano
- Department of Cardiology, Saitama Medical University, International Medical Center, Hidaka, Japan
| | - Munehisa Sakamoto
- Department of Cardiology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Adachi
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
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Inoue N, Ohtani H, Morikawa S, Takayama Y, Ogane T, Hiramatsu T, Kumihashi H, Murohara T. Risk of supranormal left ventricular ejection fraction in patients with aortic stenosis. Clin Cardiol 2024; 47:e24255. [PMID: 38469926 PMCID: PMC10928761 DOI: 10.1002/clc.24255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/22/2024] [Accepted: 03/01/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Cardiovascular events are increasing in patients with supranormal left ventricular ejection fraction (snLVEF). However, the effect of snLVEF in patients with aortic stenosis (AS) remains unclear, especially in patients with moderate AS. HYPOTHESIS This study aimed to evaluate the prognosis of mortality and heart failure (HF) in patients with LVEF ≥ 50% and moderate or severe AS. METHODS This retrospective study targeted patients with moderate or severe AS and LVEF > 50%. LVEF of 50%-65% was classified as normal LVEF (nLVEF, nEF group) and >65% as snLVEF (snEF group). AS severity was stratified based on the aortic valve area into moderate (1.0-1.5 cm²) and severe (<1.0 cm²). Primary outcomes included all-cause mortality and HF hospitalization. RESULTS A total of 226 participants were included in this study. There were 67 and 65 participants with moderate AS in snEF (m-snEF) and nEF groups (m-nEF), respectively, and 41 and 53 participants with severe AS in the snEF (s-snEF) and nEF groups (s-nEF), respectively. During the observation period (median: 554 days), the primary composite outcome occurred in 108 individuals. Cox hazard analysis revealed no significant differences among the four groups in primary composite outcomes. With respect to HF hospitalization, the adjusted hazard ratios (95% confidence intervals) with m-snEF as the reference were as follows: m-nEF, 0.41 (0.19-0.89); s-nEF, 1.43 (0.76-2.67); and s-snEF, 1.83 (1.00-3.35). CONCLUSIONS The risk of HF hospitalization for m-snLVEF was higher than m-nLVEF and not significantly different from s-nLVEF.
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Affiliation(s)
- Naoya Inoue
- Department of CardiologyChutoen General Medical Center, KakegawaShizuokaJapan
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaAichiJapan
| | - Hayato Ohtani
- Division of Cardiology, Internal Medicine IIIHamamatsu University School of MedicineShizuokaHamamatsuJapan
| | - Shuji Morikawa
- Department of CardiologyChutoen General Medical Center, KakegawaShizuokaJapan
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaAichiJapan
| | - Yohei Takayama
- Department of CardiologyChutoen General Medical Center, KakegawaShizuokaJapan
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaAichiJapan
| | - Takashi Ogane
- Department of CardiologyChutoen General Medical Center, KakegawaShizuokaJapan
| | - Takehiro Hiramatsu
- Department of CardiologyChutoen General Medical Center, KakegawaShizuokaJapan
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaAichiJapan
| | - Hiroki Kumihashi
- Department of CardiologyChutoen General Medical Center, KakegawaShizuokaJapan
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaAichiJapan
| | - Toyoaki Murohara
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaAichiJapan
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Kawai A, Nagatomo Y, Yukino-Iwashita M, Nakazawa R, Yumita Y, Taruoka A, Takefuji A, Yasuda R, Toya T, Ikegami Y, Masaki N, Adachi T. Sex Differences in Cardiac and Clinical Phenotypes and Their Relation to Outcomes in Patients with Heart Failure. J Pers Med 2024; 14:201. [PMID: 38392634 PMCID: PMC10890585 DOI: 10.3390/jpm14020201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/22/2024] [Accepted: 02/11/2024] [Indexed: 02/24/2024] Open
Abstract
Biological sex is one of the major factors characterizing the heart failure (HF) patient phenotype. Understanding sex-related differences in HF is crucial to implement personalized care for HF patients with various phenotypes. There are sex differences in left ventricular (LV) remodeling patterns in the HF setting, namely, more likely concentric remodeling and diastolic dysfunction in women and eccentric remodeling and systolic dysfunction in men. Recently supra-normal EF (snLVEF) has been recognized as a risk of worse outcome. This pathology might be more relevant in female patients. The possible mechanism may be through coronary microvascular dysfunction and sympathetic nerve overactivation from the findings of previous studies. Further, estrogen deficit might play a significant role in this pathophysiology. The sex difference in body composition may also be related to the difference in LV remodeling and outcome. Lower implementation in guideline-directed medical therapy (GDMT) in female HFrEF patients might also be one of the factors related to sex differences in relation to outcomes. In this review, we will discuss the sex differences in cardiac and clinical phenotypes and their relation to outcomes in HF patients and further discuss how to provide appropriate treatment strategies for female patients.
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Affiliation(s)
- Akane Kawai
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | | | - Ryota Nakazawa
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yusuke Yumita
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Akira Taruoka
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Asako Takefuji
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Risako Yasuda
- Department of Intensive Care, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Takumi Toya
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yukinori Ikegami
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Nobuyuki Masaki
- Department of Intensive Care, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Takeshi Adachi
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
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4
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Li B, Chen L, Zheng M, Yan P, Wang L, Feng S, Yin W, Zhang K, Zhang S, Chen X, Wang Z, Yuan H. Supra-Normal Left Ventricular Ejection Fraction as a Prognostic Marker for Long-Term Outcomes in Patients with Acute Coronary Syndrome. Int Heart J 2023; 64:979-985. [PMID: 37967991 DOI: 10.1536/ihj.22-661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Recently, the supra-normal left ventricular ejection fraction (snLVEF) has been proposed, based on extensive datasets indicating increased all-cause mortality in individuals with an LVEF exceeding 65%. However, the implications of an LVEF > 65% in the context of acute coronary syndrome (ACS) remain underexplored.The aim of the present study was to investigate the correlation between supra-normal left ventricular ejection fraction (snLVEF) and major adverse cardiovascular events (MACE) in patients with ACS.Methods: A total of 874 ACS patients (560 men, mean age 59.5 ± 10.0; 314 women, mean age 61.5 ± 8.9) who underwent their first coronary angiography during the period from March 2013 to October 2015 were divided into 2 groups: normal LVEF (nLVEF) (55% ≤ EF ≤ 65%) and snLVEF (EF > 65%), according to their echocardiography results. The patients were evaluated for MACE after surgery by collecting clinical data and long-term follow-up data. This correlation was further analyzed by Kaplan-Meier analysis and Cox regression analysis.The follow-up data revealed a significantly higher incidence of MACE among snLVEF patients compared to the nLVEF group (15.6% versus 7.4%; P = 0.020). This heightened risk persisted even after adjustment for multiple variables, indicating a strong association between snLVEF and increased MACE risk (HR: 2.346; 95% CI: 1.196-4.602; P = 0.013).SnLVEF was independently associated with poor prognosis after ACS. Enhanced management strategies for snLVEF patients could potentially reduce the incidence of MACE in ACS patients.
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Affiliation(s)
- Baona Li
- Department of Cardiology, Shandong Provincial Hospital, Shandong University
| | - Liuxin Chen
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University
| | - Man Zheng
- Department of Cardiology, Dongying People's Hospital
| | - Pengcheng Yan
- Department of Cardiology, Shandong Provincial Hospital, Shandong University
| | - Leiyan Wang
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University
| | - Shuai Feng
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University
| | - Wenchao Yin
- Department of Cardiology, Shandong Provincial Hospital, Shandong University
| | | | - Shaohui Zhang
- Department of Cardiology, Jining Key Laboratory for Diagnosis and Treatment of Cardiovascular Diseases, Affiliated Hospital of Jining Medical University
| | - Xueying Chen
- Department of Cardiology, Jining Key Laboratory for Diagnosis and Treatment of Cardiovascular Diseases, Affiliated Hospital of Jining Medical University
- Postdoctoral Mobile Station of Shandong University of Traditional Chinese Medicine
| | - Zhaoyang Wang
- Department of Cardiology, Shandong Provincial Hospital, Shandong University
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University
| | - Haitao Yuan
- Department of Cardiology, Shandong Provincial Hospital, Shandong University
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University
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5
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Ono R, Falcão LM. Supra-Normal Left Ventricular Function. Am J Cardiol 2023; 207:84-92. [PMID: 37734305 DOI: 10.1016/j.amjcard.2023.08.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/25/2023] [Accepted: 08/25/2023] [Indexed: 09/23/2023]
Abstract
Heart failure (HF) is often categorized by left ventricular (LV) ejection fraction (LVEF). A new category of HF characterized by supra-normal LVEF (>65%), named HF with supra-normal ejection fraction (HFsnEF), has been recently proposed. Some studies reported that patients with supra-normal LVEF might have an increased risk of long-term major adverse cardiovascular events and U-shaped mortality patterns. Currently, the prognosis of HFsnEF is not well established but seems to be associated with an increased risk of long-term major adverse cardiovascular events. It has been reported that HFsnEF is more prevalent in women and is associated with higher prevalence of nonischemic HF, higher blood urea nitrogen plasma levels, lower levels of natriuretic peptides, and to be less likely treated with β blockers. The pathophysiology of HFsnEF would be associated with microvascular dysfunction because of microvascular inflammation or reduced coronary flow reserve, and low stroke volume index with smaller cardiac chamber dimensions and concentric LV geometry. In this study, we systematically reviewed published data on patients with s supra-normal LV function and reported its definition, proposed pathophysiology, phenotypes, diagnostic strategy, and prognosis.
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Affiliation(s)
- Ryohei Ono
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Luiz Menezes Falcão
- Department of Clinical Semiology, Academic Medical Center of Lisbon (CAML); Cardiovascular Center University of Lisbon (CCUL@RISE), Faculty of Medicine University of Lisbon, Lisbon, Portugal
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6
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Regitz-Zagrosek V, Gebhard C. Gender medicine: effects of sex and gender on cardiovascular disease manifestation and outcomes. Nat Rev Cardiol 2023; 20:236-247. [PMID: 36316574 PMCID: PMC9628527 DOI: 10.1038/s41569-022-00797-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
Despite a growing body of evidence, the distinct contributions of biological sex and the sociocultural dimension of gender to the manifestations and outcomes of ischaemic heart disease and heart failure remain unknown. The intertwining of sex-based differences in genetic and hormonal mechanisms with the complex dimension of gender and its different components and determinants that result in different disease phenotypes in women and men needs to be elucidated. The relative contribution of purely biological factors, such as genes and hormones, to cardiovascular phenotypes and outcomes is not yet fully understood. Increasing awareness of the effects of gender has led to efforts to measure gender in retrospective and prospective clinical studies and the development of gender scores. However, the synergistic or opposing effects of sex and gender on cardiovascular traits and on ischaemic heart disease and heart failure mechanisms have not yet been systematically described. Furthermore, specific considerations of sex-related and gender-related factors in gender dysphoria or in heart-brain interactions and their association with cardiovascular disease are still lacking. In this Review, we summarize contemporary evidence on the distinct effects of sex and gender as well as of their interactions on cardiovascular disease and how they favourably or unfavourably influence the pathogenesis, clinical manifestations and treatment responses in patients with ischaemic heart disease or heart failure.
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Affiliation(s)
- Vera Regitz-Zagrosek
- Institute for Gender in Medicine, Charité University Medicine Berlin, Berlin, Germany.
- Faculty of Medicine, University of Zurich, Zurich, Switzerland.
| | - Catherine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
- Department of Cardiology, Inselspital Bern University Hospital, Bern, Switzerland
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7
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Gotsman I, Leibowitz D, Keren A, Amir O, Zwas DR. Echocardiographic Characteristics and Clinical Outcomes of the Hyperdynamic Heart: A 'Super-Normal' Heart is not a Normal Heart. Am J Cardiol 2023; 187:119-126. [PMID: 36459734 DOI: 10.1016/j.amjcard.2022.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/18/2022] [Accepted: 10/13/2022] [Indexed: 11/30/2022]
Abstract
A hyperdynamic heart is defined as a left ventricular (LV) with an ejection fraction (EF) above the normal range. Is this favorable? We looked at the diastolic properties of subjects with a hyperdynamic heart and its impact on outcome. Consecutive echocardiography examinations during 5 years were evaluated by EF subgroups, including a hyperdynamic heart (EF >70%). All examinations with significant LV hypertrophy or valve disease were excluded. The study included 16,994 subjects. A total of 720 subjects (4.2%) had a hyperdynamic heart. Subjects with a hyperdynamic heart were older, more likely to be women, and more likely to have hypertension, diabetes, and obesity. A total of 20% of patients had a diagnosis of heart failure. This group had a higher heart rate, smaller ventricular size, and the highest relative wall thickness. All indexes of diastolic dysfunction were significantly more prevalent in the hyperdynamic group. This included a higher LV mass, larger left atrial volume, reduced relaxation (smaller mitral e'), longer deceleration time, and higher LV end-diastolic pressures (high mitral E/e' ratio) and peak tricuspid regurgitation gradient. Diastolic dysfunction, defined by an abnormal functional or structural parameter, was present in 78% of the subjects. Survival was significantly lower in the group with a hyperdynamic heart. The Cox regression analysis after adjustment demonstrated reduced survival during a median 9-year follow-up in the hyperdynamic group compared with those with a normal EF (hazard ratio 1.56, 95% confidence interval 1.38 to 1.76, p <0.001). In conclusion, subjects with a hyperdynamic systolic function have increased prevalence of diastolic dysfunction and reduced survival. A hyperdynamic heart is not a normally functioning heart.
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Affiliation(s)
- Israel Gotsman
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - David Leibowitz
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Andre Keren
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Offer Amir
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Donna R Zwas
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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8
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van Essen BJ, Tromp J, Ter Maaten JM, Greenberg BH, Gimpelewicz C, Felker GM, Davison BA, Severin T, Pang PS, Cotter G, Teerlink JR, Metra M, Voors AA. Characteristics and clinical outcomes of patients with acute heart failure with a supranormal left ventricular ejection fraction. Eur J Heart Fail 2023; 25:35-42. [PMID: 36114655 PMCID: PMC10092799 DOI: 10.1002/ejhf.2695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 02/03/2023] Open
Abstract
AIM Recent data suggest that guideline-directed medical therapy of patients with heart failure (HF) with reduced ejection fraction (HFrEF) might improve clinical outcomes in patients with HF up to a left ventricular ejection fraction (LVEF) of 55-65%, whereas patients with higher LVEF do not seem to benefit. Recent data have shown that LVEF may have a U-shaped relation with outcome, with poorer outcome also in patients with supranormal values. This suggests that patients with supranormal LVEF may be a distinctive group of patients. METHODS AND RESULTS RELAX-AHF-2 was a multicentre, placebo-controlled trial on the effects of serelaxin on 180-day cardiovascular (CV) mortality and worsening HF at day 5 in patients with acute HF. Echocardiograms were performed at hospital admission in 6128 patients: 155 (2.5%) patients were classified as HF with supranormal ejection fraction (HFsnEF; LVEF >65%), 1440 (23.5%) as HF with preserved ejection fraction (HFpEF; LVEF 50-65%), 1353 (22.1%) as HF with mildly reduced ejection fraction (HFmrEF; LVEF 41-49%) and 3180 (51.9%) as HFrEF (LVEF <40%). Patients with HFsnEF compared to HFpEF were more often women, had higher prevalence of non-ischaemic HF, had lower levels of natriuretic peptides, were less likely to be treated with beta-blockers and had higher blood urea nitrogen plasma levels. All-cause mortality was not statistically different between groups, although patients with HFsnEF had the highest numerical rate. A declining trend was seen in the proportion of 180-day deaths due to CV causes from HFrEF (290/359, 80.8%) to HFsnEF (14/24, 58.3%). The reverse was observed with death from non-CV causes. No treatment effect of serelaxin was observed in any of the subgroups. CONCLUSIONS In this study, only 2.5% of patients were classified as HFsnEF. HFsnEF was primarily characterized by female sex, lower natriuretic peptides and a higher risk of non-CV death.
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Affiliation(s)
- Bart J van Essen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jasper Tromp
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Saw Swee Hock School of Public Health, National University of Singapore & the National University Health System, Singapore.,Duke-NUS Medical School, Singapore
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Beth A Davison
- Momentum Research Inc., Chapel Hill, NC, USA.,Inserm U 942 (MASCOT), Hopital Lariboisière, Paris, France
| | | | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gad Cotter
- Momentum Research Inc., Chapel Hill, NC, USA.,Inserm U 942 (MASCOT), Hopital Lariboisière, Paris, France
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, CA, USA
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiologic Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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9
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Sinagra G, Paldino A, Dal Ferro M. Heart failure with supra-normal left ventricular ejection fraction: distinct polygenic bases of an unrecognized phenotype. Eur J Heart Fail 2022; 24:2128-2130. [PMID: 35999647 DOI: 10.1002/ejhf.2657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
- Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Alessia Paldino
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Matteo Dal Ferro
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
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10
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Forrest IS, Rocheleau G, Bafna S, Argulian E, Narula J, Natarajan P, Do R. Genetic and phenotypic profiling of supranormal ejection fraction reveals decreased survival and underdiagnosed heart failure. Eur J Heart Fail 2022; 24:2118-2127. [PMID: 35278270 PMCID: PMC9464795 DOI: 10.1002/ejhf.2482] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/04/2022] [Accepted: 03/10/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Individuals with supranormal left ventricular ejection fraction (snLVEF; LVEF >70%) have increased mortality. However, the genetic and phenotypic profile of snLVEF remains unknown. This study aimed to determine the relationship of both snLVEF genetic risk and phenotype with survival and underdiagnosed heart failure (HF). METHODS AND RESULTS A snLVEF genetic risk score (GRS) was applied and cases of snLVEF were identified in 486 754 individuals across two population-based cohorts (BioMe Biobank and UK Biobank). The snLVEF GRS and phenotype were evaluated for association with survival, as well as HF diagnosis, markers, symptoms, and medications. Of 486 754 participants, the median age was 58 years, 20 069 (4.1%) died, and 10 088 (2.1%) had diagnosed HF. Both snLVEF GRS (hazard ratio [HR] 1.1 for top 10% vs. bottom 10% GRS; p = 0.002) and phenotype (HR 1.4; p = 0.003) were associated with increased all-cause mortality. Both snLVEF GRS and phenotype were associated with reduced HF diagnosis (odds ratio [OR] 0.97 and OR 0.63, respectively; both p ≤0.002). However, the snLVEF GRS and phenotype were both associated with elevated brain natriuretic peptide (BNP) levels (146 and 185 pg/ml increase, respectively; p <0.001), including 268 out of 455 (59%) individuals with snLVEF phenotype who had BNP >100 pg/ml. Among 476 666 participants without HF diagnoses, snLVEF GRS and phenotype were associated with increased HF symptoms (e.g. exertional dyspnoea OR 1.4 and OR 1.3; p <0.003) and HF medications (e.g. loop diuretic OR 1.2 and OR 1.03; p <0.02). Associations were consistent in hypertensive individuals without cardiac comorbidities. CONCLUSIONS Genetic predisposition to and presence of snLVEF are associated with decreased survival and underdiagnosed HF.
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Affiliation(s)
- Iain S. Forrest
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Medical Scientist Training Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- The BioMe Phenomics Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ghislain Rocheleau
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shantanu Bafna
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Edgar Argulian
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jagat Narula
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Pradeep Natarajan
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ron Do
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- The BioMe Phenomics Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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11
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Wang R, Li X, Huangfu S, Yao Q, Wu P, Wu Z, Li L, Wang Y, Yang M, Hacker M, Zhou H, Yan R, Li S. Combining body mass index with waist circumference to assess coronary microvascular function in patients with non-obstructive coronary artery disease. J Nucl Cardiol 2022; 29:2434-2445. [PMID: 34476781 PMCID: PMC9553765 DOI: 10.1007/s12350-021-02788-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 08/12/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) may precede clinically overt coronary artery disease (CAD). Overall and central obesity (CO) are major risk factors for CAD. This study sought to investigate the subclinical significance of body adiposity patterns based on the CMD risk. METHODS A total of 128 patients with non-obstructive CAD were prospectively enrolled. Patients were categorized into 4 anthropometric groups: normal weight and non-CO (NWNCO, n = 41), normal weight and CO (NWCO, n = 20), excess weight and non-CO (EWNCO, n = 26), and excess weight and CO (EWCO, n = 41). Patients underwent rest/stress electrocardiography-gated 13N-ammonia positron emission tomography to measure absolute myocardial blood flow (MBF), myocardial flow reserve (MFR), hemodynamic parameters, and cardiac function. RESULTS Resting MBF did not differ between groups (P = .36). Compared with the NWNCO group, hyperemic MBF and MFR were significantly lower in the NWCO and EWCO groups. Notably, patients with NWCO presented the lowest hyperemic MBF and MFR and the highest incidence of CMD. Waist circumference was an independent risk factor for CMD (OR 1.05, 95% CI 1.01 to 1.10, P = .02). CONCLUSION In patients with non-obstructive CAD, CO may be associated with an increased risk of CMD to better fit the study findings which did not assess management or monitoring of MBF and MFR.
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Affiliation(s)
- Ruonan Wang
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, Shanxi, China
| | - Xiang Li
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Shihao Huangfu
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, Shanxi, China
| | - Qi Yao
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, Shanxi, China
| | - Ping Wu
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, Shanxi, China
| | - Zhifang Wu
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, Shanxi, China
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, Shanxi, China
| | - Li Li
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, Shanxi, China
| | - Yuetao Wang
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Minfu Yang
- Department of Nuclear Medicine, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Haitao Zhou
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, Shanxi, China
| | - Rui Yan
- Shanxi Key Laboratory of Molecular Imaging, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Sijin Li
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, 030001, Shanxi, China.
- Key Laboratory of Cellular Physiology, Ministry of Education, Shanxi Medical University, Taiyuan, Shanxi, China.
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12
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Gu J, Ke JH, Wang Y, Wang CQ, Zhang JF. Characteristics, prognosis, and treatment response in HFpEF patients with high vs. normal ejection fraction. Front Cardiovasc Med 2022; 9:944441. [PMID: 36158822 PMCID: PMC9500210 DOI: 10.3389/fcvm.2022.944441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background Heart failure with preserved ejection fraction (HFpEF) patients varied by left ventricular ejection fraction (LVEF) have different clinical characteristics, prognosis, and treatment response. With data from our prospective HFpEF cohort, we assessed the possible relationship between clinical characteristics, outcome as well as treatment response and LVEF. Methods We compared differences in baseline characteristics and clinical outcomes across LVEF categories (50%≤LVEF <60% vs. LVEF≥60%) in 1,502 HFpEF patients, and determined whether LVEF modified the treatment response. During 5-year follow-up, all-cause mortality was used as the primary endpoints, and composite endpoints (all-cause mortality or HF hospitalization) were set as the secondary endpoint. Results Patients with higher LVEF were statistically older, more likely to be women and have a history of atrial fibrillation. Patients with lower LVEF category were more likely to have a history of coronary artery disease. The incidences of all-cause mortality and composite endpoints were higher in patients with higher LVEF. Also, LVEF modified the spironolactone treatment effect for the primary outcome and secondary endpoint with stronger estimated benefits at the lower LVEF category with respect to all-cause mortality (HR 0.734, 95% CI 0.541–0.997, P = 0.048) and all-cause mortality or HF hospitalization (HR 0.767, 95% CI 0.604–0.972, P = 0.029). Conclusion The characteristics and outcomes of HFpEF patients varied substantially by LVEF. Patients with higher LVEF encountered more adverse events than those with lower LVEF. The potential efficacy of spironolactone was greatest at the lower category of LVEF spectrum in HFpEF.
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13
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Mikail N, Rossi A, Bengs S, Haider A, Stähli BE, Portmann A, Imperiale A, Treyer V, Meisel A, Pazhenkottil AP, Messerli M, Regitz-Zagrosek V, Kaufmann PA, Buechel RR, Gebhard C. Imaging of heart disease in women: review and case presentation. Eur J Nucl Med Mol Imaging 2022; 50:130-159. [PMID: 35974185 PMCID: PMC9668806 DOI: 10.1007/s00259-022-05914-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/12/2022] [Indexed: 11/04/2022]
Abstract
Cardiovascular diseases (CVD) remain the leading cause of mortality worldwide. Although major diagnostic and therapeutic advances have significantly improved the prognosis of patients with CVD in the past decades, these advances have less benefited women than age-matched men. Noninvasive cardiac imaging plays a key role in the diagnosis of CVD. Despite shared imaging features and strategies between both sexes, there are critical sex disparities that warrant careful consideration, related to the selection of the most suited imaging techniques, to technical limitations, and to specific diseases that are overrepresented in the female population. Taking these sex disparities into consideration holds promise to improve management and alleviate the burden of CVD in women. In this review, we summarize the specific features of cardiac imaging in four of the most common presentations of CVD in the female population including coronary artery disease, heart failure, pregnancy complications, and heart disease in oncology, thereby highlighting contemporary strengths and limitations. We further propose diagnostic algorithms tailored to women that might help in selecting the most appropriate imaging modality.
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Affiliation(s)
- Nidaa Mikail
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Ahmed Haider
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland.,Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Barbara E Stähli
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Angela Portmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Alessio Imperiale
- Nuclear Medicine and Molecular Imaging - Institut de Cancérologie de Strasbourg Europe (ICANS), University of Strasbourg, Strasbourg, France.,Molecular Imaging - DRHIM, IPHC, UMR 7178, CNRS/Unistra, Strasbourg, France
| | - Valerie Treyer
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Alexander Meisel
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Aju P Pazhenkottil
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Vera Regitz-Zagrosek
- Charité, Universitätsmedizin, Berlin, Berlin, Germany.,University of Zurich, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Cathérine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. .,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland. .,Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.
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14
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Shah S, Segar MW, Kondamudi N, Ayers C, Chandra A, Matulevicius S, Agusala K, Peshock R, Abbara S, Michos ED, Drazner MH, Lima JAC, Longstreth WT, Pandey A. Supranormal Left Ventricular Ejection Fraction, Stroke Volume, and Cardiovascular Risk: Findings From Population-Based Cohort Studies. JACC. HEART FAILURE 2022; 10:583-594. [PMID: 35902163 DOI: 10.1016/j.jchf.2022.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/18/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Supranormal ejection fraction by echocardiography in clinically referred patient populations has been associated with an increased risk of cardiovascular disease (CVD). The prognostic implication of supranormal left ventricular ejection fraction (LVEF)-assessed by cardiac magnetic resonance (CMR)-in healthy, community-dwelling individuals is unknown. OBJECTIVES The purpose of this study is to investigate the prognostic implication of supranormal LVEF as assessed by CMR and its inter-relationship with stroke volume among community-dwelling adults without CVD. METHODS Participants from the MESA (Multi-Ethnic Study of Atherosclerosis) and DHS (Dallas Heart Study) cohorts free of CVD who underwent CMR with LVEF above the normal CMR cutoff (≥57%) were included. The association between cohort-specific LVEF categories and risk of clinically adjudicated major adverse cardiovascular events (MACE) was assessed using adjusted Cox models. Subgroup analysis was also performed to evaluate the association of LVEF and risk of MACE among individuals stratified by left ventricular stroke volume index. RESULTS The study included 4,703 participants from MESA and 2,287 from DHS with 727 and 151 MACE events, respectively. In adjusted Cox models, the risk of MACE was highest among individuals in LVEF Q4 (vs Q1) in both cohorts after accounting for potential confounders (MESA: HR = 1.27 [95% CI: 1.01-1.60], P = 0.04; DHS: HR = 1.72 [95% CI: 1.05-2.79], P = 0.03). A significant interaction was found between the continuous measures of LVEF and left ventricular stroke volume index (P interaction = 0.02) such that higher LVEF was significantly associated with an increased risk of MACE among individuals with low but not high stroke volume. CONCLUSIONS Among community-dwelling adults without CVD, LVEF in the supranormal range is associated with a higher risk of adverse cardiovascular outcomes, particularly in those with lower stroke volume.
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Affiliation(s)
- Sonia Shah
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew W Segar
- Department of Cardiology, Texas Heart Institute, Houston, Texas, USA
| | - Nitin Kondamudi
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Colby Ayers
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Alvin Chandra
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Susan Matulevicius
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Kartik Agusala
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ron Peshock
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Erin D Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Joao A C Lima
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - W T Longstreth
- Departments of Neurology and Epidemiology, University of Washington, Seattle, Washington, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA.
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15
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Feher A, Meadows J. Over the Edge: What Can Imaging Tell Us When the Ejection Fraction Is "Supranormal"? JACC. HEART FAILURE 2022; 10:595-597. [PMID: 35902164 DOI: 10.1016/j.jchf.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Attila Feher
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
| | - Judith Meadows
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
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16
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Wu P, Zhang X, Wu Z, Chen H, Guo X, Jin C, Qin G, Wang R, Wang H, Sun Q, Li L, Yan R, Li X, Hacker M, Li S. Impaired coronary flow reserve in patients with supra-normal left ventricular ejection fraction at rest. Eur J Nucl Med Mol Imaging 2022; 49:2189-2198. [PMID: 34988625 PMCID: PMC9165269 DOI: 10.1007/s00259-021-05566-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/17/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Recently, a "U" hazard ratio curve between resting left ventricular ejection fraction (LVEF) and prognosis has been observed in patients referred for routine clinical echocardiograms. The present study sought to explore whether a similar "U" curve existed between resting LVEF and coronary flow reserve (CFR) in patients without severe cardiovascular disease (CVD) and whether impaired CFR played a role in the adverse outcome of patients with supra-normal LVEF (snLVEF, LVEF ≥ 65%). METHODS Two hundred ten consecutive patients (mean age 52.3 ± 9.3 years, 104 women) without severe CVD underwent clinically indicated rest/dipyridamole stress electrocardiography (ECG)-gated 13 N-ammonia positron emission tomography/computed tomography (PET/CT). Major adverse cardiac events (MACE) were followed up for 27.3 ± 9.5 months, including heart failure, late revascularization, re-hospitalization, and re-coronary angiography for any cardiac reason. Clinical characteristics, corrected CFR (cCFR), and MACE were compared among the three groups categorized by resting LVEF detected by PET/CT. Dose-response analyses using restricted cubic spline (RCS) functions, multivariate logistic regression, and Kaplan-Meier survival analysis were conducted to evaluate the relationship between resting LVEF and CFR/outcome. RESULTS An inverted "U" curve existed between resting LVEF and cCFR (p = 0.06). Both patients with snLVEF (n = 38) and with reduced LVEF (rLVEF, LVEF < 55%) (n = 66) displayed a higher incidence of reduced cCFR than those with normal LVEF (nLVEF, 55% ≤ LVEF < 65%) (n = 106) (57.9% vs 54.5% vs 34.3%, p < 0.01, respectively). Both snLVEF (p < 0.01) and rLVEF (p < 0.05) remained independent predictors for reduced cCFR after multivariable adjustment. Patients with snLVEF encountered more MACE than those with nLVEF (10.5% vs 0.9%, log-rank p = 0.01). CONCLUSIONS Patients with snLVEF are prone to impaired cCFR, which may be related to the adverse prognosis. Further investigations are warranted to explore its underlying pathological mechanism and clinical significance.
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Affiliation(s)
- Ping Wu
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi China
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, 030001 Shanxi China
| | - Xiaoli Zhang
- Department of Nuclear Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhifang Wu
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi China
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, 030001 Shanxi China
| | - Huanzhen Chen
- Department of Cardiology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi China
| | - Xiaoshan Guo
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi China
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, 030001 Shanxi China
| | - Chunrong Jin
- Department of Cardiology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi China
| | - Gang Qin
- Department of Cardiology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi China
| | - Ruonan Wang
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi China
| | - Hongliang Wang
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi China
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, 030001 Shanxi China
- Key Laboratory of Cell Physiology of Ministry of Education, Shanxi Medical University, Taiyuan, Shanxi China
| | - Qiting Sun
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi China
| | - Li Li
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi China
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, 030001 Shanxi China
| | - Rui Yan
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, 030001 Shanxi China
- Key Laboratory of Cell Physiology of Ministry of Education, Shanxi Medical University, Taiyuan, Shanxi China
| | - Xiang Li
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Sijin Li
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, Shanxi China
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Taiyuan, 030001 Shanxi China
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17
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Rossi A, Mikail N, Bengs S, Haider A, Treyer V, Buechel RR, Wegener S, Rauen K, Tawakol A, Bairey Merz CN, Regitz-Zagrosek V, Gebhard C. Heart-brain interactions in cardiac and brain diseases: why sex matters. Eur Heart J 2022; 43:3971-3980. [PMID: 35194633 PMCID: PMC9794190 DOI: 10.1093/eurheartj/ehac061] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/24/2022] [Accepted: 01/30/2022] [Indexed: 12/31/2022] Open
Abstract
Cardiovascular disease and brain disorders, such as depression and cognitive dysfunction, are highly prevalent conditions and are among the leading causes limiting patient's quality of life. A growing body of evidence has shown an intimate crosstalk between the heart and the brain, resulting from a complex network of several physiological and neurohumoral circuits. From a pathophysiological perspective, both organs share common risk factors, such as hypertension, diabetes, smoking or dyslipidaemia, and are similarly affected by systemic inflammation, atherosclerosis, and dysfunction of the neuroendocrine system. In addition, there is an increasing awareness that physiological interactions between the two organs play important roles in potentiating disease and that sex- and gender-related differences modify those interactions between the heart and the brain over the entire lifespan. The present review summarizes contemporary evidence of the effect of sex on heart-brain interactions and how these influence pathogenesis, clinical manifestation, and treatment responses of specific heart and brain diseases.
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Affiliation(s)
- Alexia Rossi
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Nidaa Mikail
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland
| | - Ahmed Haider
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland,Center for Molecular Cardiology, University of Zurich, Schlieren, Switzerland,Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, USA
| | - Valerie Treyer
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Ronny Ralf Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Katrin Rauen
- Department of Geriatric Psychiatry, Psychiatric Hospital, Zurich, Switzerland,Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Ahmed Tawakol
- Cardiovascular Imaging Research Center, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Vera Regitz-Zagrosek
- Charité, Universitätsmedizin Berlin, Berlin, Germany,University of Zurich, Zurich, Switzerland
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18
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Santas E, Palau P, Llácer P, de la Espriella R, Miñana G, Núñez‐Marín G, Lorenzo M, Heredia R, Sanchis J, Chorro FJ, Bayés‐Genís A, Núñez J. Sex-Related Differences in Mortality Following Admission for Acute Heart Failure Across the Left Ventricular Ejection Fraction Spectrum. J Am Heart Assoc 2021; 11:e022404. [PMID: 34927464 PMCID: PMC9075214 DOI: 10.1161/jaha.121.022404] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background Following a heart failure (HF)‐decompensation, there is scarce data about sex‐related prognostic differences across left ventricular ejection fraction (LVEF) status. We sought to evaluate sex‐related differences in 6‐month mortality risk across LVEF following admission for acute HF. Methods and Results We retrospectively evaluated 4812 patients consecutively admitted for acute HF in a multicenter registry from 3 hospitals. Study end points were all‐cause, cardiovascular, and HF‐related mortality at 6‐month follow‐up. Multivariable Cox regression models were fitted to investigate sex‐related differences across LVEF. A total of 2243 (46.6%) patients were women, 2569 (53.4%) were men, and 2608 (54.2%) showed LVEF≥50%. At 6‐month follow‐up, 645 patients died (13.4%), being 544 (11.3%) and 416 (8.6%) cardiovascular and HF‐related deaths, respectively. LVEF was not independently associated with mortality (HR, 1.02; 95% CI 0.99–1.05; P=0.135). After multivariable adjustment, we found no sex‐related differences in all‐cause mortality (P value for interaction=0.168). However, a significant interaction between sex and cardiovascular and HF mortality risks was found across LVEF (P value for interaction=0.030 and 0.007, respectively). Compared with men, women had a significantly lower risk of cardiovascular and HF‐mortality at LVEF<25% and <43%, respectively. On the contrary, women showed a higher risk of HF‐mortality at the upper extreme of LVEF (>80%). Conclusions Following an admission for acute HF, no sex‐related differences were found in all‐cause mortality risk. However, when compared with men, women showed a lower risk of cardiovascular and HF‐mortality at the lower extreme of LVEF. On the contrary, they showed a higher risk of HF death at the upper extreme.
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Affiliation(s)
- Enrique Santas
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
| | - Patricia Palau
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
- Universitat de ValènciaValenciaSpain
| | - Pau Llácer
- Servicio de Medicina InternaHospital Universitario Ramón y CajalMadridSpain
| | - Rafael de la Espriella
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
| | - Gema Miñana
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
- Universitat de ValènciaValenciaSpain
| | - Gonzalo Núñez‐Marín
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
| | - Miguel Lorenzo
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
| | - Raquel Heredia
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
| | - Juan Sanchis
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
- Universitat de ValènciaValenciaSpain
- CIBERCVMadridSpain
| | - Francisco Javier Chorro
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
- Universitat de ValènciaValenciaSpain
| | - Antoni Bayés‐Genís
- CIBERCVMadridSpain
- Servicio de CardiologíaHospital Germans Trias i PujolUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Julio Núñez
- Servicio de CardiologíaHospital Clínico UniversitarioUniversitat de ValènciaINCLIVAValenciaSpain
- Universitat de ValènciaValenciaSpain
- CIBERCVMadridSpain
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Susceptibility of Women to Cardiovascular Disease and the Prevention Potential of Mind-Body Intervention by Changes in Neural Circuits and Cardiovascular Physiology. Biomolecules 2021; 11:biom11050708. [PMID: 34068722 PMCID: PMC8151888 DOI: 10.3390/biom11050708] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/25/2021] [Accepted: 05/05/2021] [Indexed: 12/28/2022] Open
Abstract
Women have been reported to be more vulnerable to the development, prognosis and mortality of cardiovascular diseases, yet the understanding of the underlying mechanisms and strategies to overcome them are still relatively undeveloped. Studies show that women's brains are more sensitive to factors affecting mental health such as depression and stress than men's brains. In women, poor mental health increases the risk of cardiovascular disease, and conversely, cardiovascular disease increases the incidence of mental illness such as depression. In connection with mental health and cardiovascular health, the presence of gender differences in brain activation, cortisol secretion, autonomic nervous system, vascular health and inflammatory response has been observed. This connection suggests that strategies to manage women's mental health can contribute to preventing cardiovascular disease. Mind-body interventions, such as meditation, yoga and qigong are forms of exercise that strive to actively manage both mind and body. They can provide beneficial effects on stress reduction and mental health. They are also seen as structurally and functionally changing the brain, as well as affecting cortisol secretion, blood pressure, heart rate variability, immune reactions and reducing menopausal symptoms, thus positively affecting women's cardiovascular health. In this review, we investigate the link between mental health, brain activation, HPA axis, autonomic nervous system, blood pressure and immune system associated with cardiovascular health in women and discuss the effects of mind-body intervention in modulating these factors.
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Gebhard C, Bengs S, Haider A, Fiechter M. The Neuro-Inflammatory-Vascular Circuit: Evidence for a Sex-Dependent Interrelation? Front Neurosci 2020; 14:614345. [PMID: 33362461 PMCID: PMC7756025 DOI: 10.3389/fnins.2020.614345] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/16/2020] [Indexed: 01/05/2023] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of death worldwide with mortality rates in women currently exceeding those in men. To date, evidence is widely lacking for unique female determinants of CVD. However, strong associations with psychological stress, obesity or elevated inflammatory biomarkers with adverse cardiovascular outcomes in women have been identified in various studies. Interestingly, amygdalar metabolic activity, a central neural structure involved in emotional stress processing, has proven to be an independent predictor of major adverse cardiovascular events (MACE). Moreover, upregulated amygdalar metabolism was directly linked to myocardial injury in women, but not in men. This newly suggested sex-dependent brain-heart interrelation was further supported by the discovery that bone marrow activity, a surrogate parameter of inflammation, represents a potential bridging link between amygdalar activity and cardiovascular pathology by fueling inflammatory processes that promote atherosclerotic disease. Such malignant cascade of events might account, at least in part, for the excess female mortality seen in women with coronary artery disease and calls for sex-specific research toward pharmacologic or behavioral modulators to improve cardiovascular outcomes, particularly in women. This mini review summarizes recent advances in cardiovascular sex-specific medicine, thereby focusing on the interplay between the limbic system, autonomic regulation and inflammatory biomarkers, which may help to tailor CVD management toward the female cardiovascular phenotype.
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Affiliation(s)
- Catherine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Ahmed Haider
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Michael Fiechter
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland.,Swiss Paraplegic Center, Nottwil, Switzerland
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Abstract
PURPOSE OF THE REVIEW This review summarizes sex-related changes in the heart and vasculature that occur with aging, both in the presence and absence of cardiovascular disease (CVD). RECENT FINDINGS In the presence of CVD risk factors and/or overt CVD, sex-specific changes in the number of cardiomyocytes, extent of the myocardial extracellular matrix, and myocellular hypertrophy promote unique patterns of LV remodeling in men and women. In addition, age- and sex-specific vascular stiffening is also well established, driven by changes in endothelial dysfunction, elastin-collagen content, microvascular dysfunction, and neurohormonal signaling. Together, these changes in LV chamber geometry and morphology, coupled with heightened vascular stiffness, appear to drive both age-related increases in systolic function and declines in diastolic function, particularly in postmenopausal women. Accordingly, estrogen has been implicated as a key mediator, given its direct vasodilating properties, association with nitric oxide excretion, and involvement in myocellular Ca2+ handling, mitochondrial energy production, and oxidative stress. The culmination of the abovementioned sex-specific cardiac and vascular changes across the lifespan provides important insight into heart failure development, particularly of the preserved ejection fraction variety, while offering promise for future preventive strategies and therapeutic approaches.
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