Effects of mineralocorticoid receptor antagonists on left ventricular diastolic function, exercise capacity, and quality of life in heart failure with preserved ejection fraction: a meta-analysis of randomized controlled trials

What services are currently provided to people with heart failure with preserved ejection fraction in the UK, and what are their components? A protocol for a scoping literature review

AIMS

Heart failure (HF) with preserved ejection fraction (HFpEF) is increasing in incidence and is increasingly the most common HF diagnosis. Patients with HFpEF are often excluded from specialist HF services, which has negative impacts on their healthcare experiences and health-related outcomes. As emerging evidence-based treatments are being incorporated into clinical guidelines, it is timely to focus on the management of this phenotype. This review aims to explore literature around care provision for HFpEF in the UK, to characterize and assess HFpEF care pathways against current standards, and to generate evidence to create an optimized framework of care.

METHODS AND RESULTS

A scoping review of the evidence from six databases will be performed, alongside a search of grey literature search and consultation with relevant experts. Given the expected heterogeneity, multiple lines of synthesis are anticipated. Data analysis will follow best practice guidelines for the synthesizing methodologies selected. Patient and public representatives will assist with analysis and in identifying priority components for HFpEF clinical services.

CONCLUSION

This scoping literature review will enable an in-depth examination of the current health service provision for those with HFpEF in the UK. Synthesis of key components of services and illumination of challenges and barriers will inform current and future practice. There is a long history of specialist HF care in the UK, including seminal work on nurse-led care. Therefore, evidence derived from this review will likely be useful to HF services across Europe. The proposed combination of the search across both peer-reviewed literature and grey literature, combined with patient and public involvement, will identify the key components of a framework of care for those with HFpEF.

REGISTRATION

This scoping review protocol was published on the public Open Science Framework platform (no registration reference provided) and can be accessed at: https://osf.io/5gufq/.

Daucosterol alleviates heart failure with preserved ejection fraction through activating PPARα pathway

Heart failure with preserved ejection fraction (HFpEF) has been increasing in the population in recent years and is mainly characterized by preserved left ventricle ejection fraction (LVEF), diastolic dysfunction and systemic inflammation. Daucosterol (DAU), a glycoside of β-sitosterol, has good anti-inflammatory and antioxidative properties; however, its effects and mechanisms in HFpEF have not been investigated. To detect whether DAU could alleviate HFpEF, C57BL/6J male mice were fed with N-nitro-l-arginine methyl ester (L-NAME) in drinking water and high fat diet (HFD) and treated with DAU by gavage (i.g.) for 10 weeks. The results showed that DAU treatment significantly alleviated HFpEF in mice. Mechanistically, by controlling PPARα and preventing NF-κB phosphorylation, DAU reduced oxidative stress and the inflammatory response. In conclusion, our study provides a new clue for natural product DAU in alleviating HFpEF.

Mineralocorticoid receptor antagonists with sodium-glucose co-transporter-2 inhibitors in heart failure: a meta-analysis

BACKGROUND AND AIMS

To investigate the cardiovascular effects of sodium-glucose co-transporter-2 inhibitors (SGLT2i) with concomitant mineralocorticoid receptor antagonist (MRA) use in heart failure (HF) regardless of ejection fraction (EF) and explore the risk of MRA-associated adverse events in individuals randomized to SGLT2i vs. placebo.

METHODS

PubMed/MEDLINE, Web of Science, Embase, and clinical trial registries were searched for randomized controlled trials/post-hoc analyses evaluating SGLT2i in HF with or without MRA use (PROSPERO: CRD42023397129). The main outcomes were composite of first hospitalization or urgent visit for HF/cardiovascular death (HHF/CVD), HHF, and CVD. Others were all-cause mortality, composite renal and safety outcomes. Hazard ratios (HR)/risk ratios were extracted. Fixed-effects meta-analyses and subgroup analyses were performed.

RESULTS

Five eligible studies were included, pooling data from 21 947 people with HF (type 2 diabetes mellitus, n = 10 805). Compared to placebo, randomization to SGLT2i showed a similar reduction in HHF/CVD and HHF in people who were or were not using MRAs [HHF/CVD: hazard ratio (HR) 0.75; 95% confidence interval (CI) 0.68-0.81 vs. HR 0.79; 95% CI 0.72-0.86; P-interaction = .43; HHF: HR 0.74; 95% CI 0.67-0.83 vs. HR 0.71; 95% CI 0.63-0.80; P-interaction = .53], with a suggestion of greater relative reduction in CVD in chronic HF people randomized to SGLT2i and using MRAs irrespective of EF (HR 0.81; 95% CI 0.72-0.91 vs. HR 0.98; 95% CI 0.86-1.13; P-interaction = .034). SGLT2i reduced all-cause mortality (P-interaction = .27) and adverse renal endpoints regardless of MRA use (P-interaction = .73) despite a higher risk of volume depletion with concomitant MRAs (P-interaction = .082). SGLT2i attenuated the risk of mild hyperkalaemia (P-interaction < .001) and severe hyperkalaemia (P-interaction = .051) associated with MRA use.

CONCLUSIONS

MRAs did not influence SGLT2i effects on the composite of HHF/CVD, HHF or all-cause mortality; however, findings hinted at a more pronounced relative reduction in CVD in chronic HF patients regardless of EF who were randomized to SGLT2i and receiving an MRA compared to those randomized to SGLT2i and not receiving MRAs. SGLT2i attenuated the risk of MRA-associated treatment-emergent hyperkalaemia. These findings warrant further validation in well-designed randomized controlled trials.

Cardiac rehabilitation for heart failure: 'Cinderella' or evidence-based pillar of care?

Cardiac rehabilitation remains the 'Cinderella' of treatments for heart failure. This state-of-the-art review provides a contemporary update on the evidence base, clinical guidance, and status of cardiac rehabilitation delivery for patients with heart failure. Given that cardiac rehabilitation participation results in important improvements in patient outcomes, including health-related quality of life, this review argues that an exercise-based rehabilitation is a key pillar of heart failure management alongside drug and medical device provision. To drive future improvements in access and uptake, health services should offer heart failure patients a choice of evidence-based modes of rehabilitation delivery, including home, supported by digital technology, alongside traditional centre-based programmes (or combinations of modes, 'hybrid') and according to stage of disease and patient preference.

A case of venous stasis colitis possibly caused by eplerenone

A 50-year-old man was referred to our hospital for colitis with abdominal pain and diarrhea that had persisted for more than 8 months. 9 months earlier, he had been treated for fulminant eosinophilic myocarditis. During steroid therapy, ulceration appeared in the esophagus, stomach and large intestine. The biopsy results showed cytomegalovirus (CMV) inclusion bodies, and the patient was diagnosed with CMV gastrocolitis and treated with ganciclovir. Colonoscopy 7 months earlier revealed ischemia-like segmental colitis 10 cm in length in the hepatic flexure without evidence of CMV infection. Colonoscopy after 1 month and 3 months showed no improvement. We suspected drug-induced focal ischemic colitis, and discontinued eplerenone. Colonoscopy 2 months after withdrawal of eplerenone showed improvement in colitis, and colonoscopy 8 months later showed ulcer healing. Venous disorders are cautioned as a known side effect of eplerenone, but this is the first report of venous stasis colitis thought to be caused by eplerenone.

Factors associated with the intermediate probability of heart failure with preserved ejection fraction on the H₂FPEF score in asymptomatic patients in rotation work conditions in the Arctic

Aim. To study the factors associated with the intermediate probability of heart failure (HF) with preserved ejection fraction (HFpEF) according to the H2FPEF score (Heavy; Hypertensive; Atrial Fibrillation; Pulmonary Hypertension; Elder; Filling Pressure) in asymptomatic patients in rotation work conditions in the Arctic.

Material and methods. In the polar village of Yamburg (68° 21’ 40” northern latitude), 100 men and 80 women with grade 1, 2 hypertension and normotensive persons were examined on the basis of the Medical Unit of OOO Gazprom Dobycha Yamburg. All patients underwent echocardiography using generally accepted methods of imaging and data processing, according to European Society of Echocardiography guidelines. To calculate the probability of HFpEF, the H2FPEF score was used. The Bruce protocol treadmill test was performed. The SF-36 (Health Status Survey) questionnaire for assessment of life quality was used.

Results. Group 1 included 95 male and female patients with a low probability of HF (H2FPEF score — 0-1), group 2 — 85 patients of both sexes with an intermediate probability of HF (H2FPEF score — 2-5). Group 2 patients were older (p=0,038), worked longer on a shift (p=0,0143), and had higher ambulatory systolic (p=0,0001) and diastolic blood pressure (p=0,0013) with a higher body mass index (BMI) (p=0,0001). Based on the odds ratio (OR) analysis, the factor most strongly influencing the intermediate probability of HFpEF was BMI (OR=1,261, 95% confidence interval (CI): 1,140-1,393). SF-36 questionnaire revealed intergroup differences only on the role functioning scale (p=0,013) with lower values in group 2. In the logistic regression model, dyspnea during the treadmill test occupied a leading position as follows: OR=8,952; 95% CI: 3,454-15,197 (p<0,0001). The second place was taken by inotropic reserve value (OR=1,020; 95% CI: 1,006-1,035 (p=0,005), which was higher in group 2 and was regarded as one of the compensatory mechanisms for adapting to stress. In the group 2, echocardiography revealed significant differences in terms of left ventricular (LV) myocardial mass (p=0,0002), LV internal area (p=0,0002), isovolumic relaxation time (p=0,003), and ratio of transmitral diastolic flow rate to mean mitral annulus velocity (p=0,0001), which indirectly indicates the presence of LV diastolic dysfunction.

Conclusion. There are following factors associated with H2FPEF intermediate probability of HFpEF in asymptomatic patients on shift in the Arctic: BMI, length of shift, dyspnea and an increase in inotropic reserve during exercise due to a decrease in adaptive potential, impaired LV diastolic function. Initiating management strategies that target identified factors in patients with asymptomatic HF may slow symptomatic disease progression in shift workers in the Arctic region.

Evolution of the cardiometabolic profile of primary hyperaldosteronism patients treated with adrenalectomy and with mineralocorticoid receptor antagonists: results from the SPAIN-ALDO Registry

OBJECTIVE

To analyze the evolution of the cardiometabolic profile of patients with primary hyperaldosteronism (PA) after the treatment with surgery and with mineralocorticoid receptor antagonists (MRA).

DESIGN

Retrospective multicentric study of patients with PA on follow-up in twelve Spanish centers between 2018 and 2020.

RESULTS

268 patients with PA treated by surgery (n = 100) or with MRA (n = 168) were included. At baseline, patients treated with surgery were more commonly women (54.6% vs 41.7%, P = 0.042), had a higher prevalence of hypokalemia (72.2% vs 58%, P = 0.022) and lower prevalence of obesity (37.4% vs 51.3%, P = 0.034) than patients treated with MRA. Adrenalectomy resulted in complete biochemical cure in 94.0% and clinical response in 83.0% (complete response in 41.0% and partial response in 42.0%). After a median follow-up of 23.6 (IQR 9.7-53.8) months, the reduction in blood pressure (BP) after treatment was similar between the group of surgery and MRA, but patients surgically treated reduced the number of antihypertensive pills for BP control more than those medically treated (∆antihypertensives: -1.3 ± 1.3 vs 0.0 ± 1.4, P < 0.0001) and experienced a higher increased in serum potassium levels (∆serum potassium: 0.9 ± 0.7 vs 0.6 ± 0.8mEq/ml, P = 0.003). However, no differences in the risk of the onset of new renal and cardiometabolic comorbidities was observed between the group of surgery and MRA (HR = 0.9 [0.5-1.5], P = 0.659).

CONCLUSION

In patients with PA, MRA and surgery offer a similar short-term cardiovascular protection, but surgery improves biochemical control and reduces pill burden more commonly than MRA, and lead to hypertension cure or improvement in up to 83% of the patients.

Roles of Mineralocorticoid Receptors in Cardiovascular and Cardiorenal Diseases

Mineralocorticoid receptor (MR) activation in the heart and vessels leads to pathological effects, such as excessive extracellular matrix accumulation, oxidative stress, and sustained inflammation. In these organs, the MR is expressed in cardiomyocytes, fibroblasts, endothelial cells, smooth muscle cells, and inflammatory cells. We review the accumulating experimental and clinical evidence that pharmacological MR antagonism has a positive impact on a battery of cardiac and vascular pathological states, including heart failure, myocardial infarction, arrhythmic diseases, atherosclerosis, vascular stiffness, and cardiac and vascular injury linked to metabolic comorbidities and chronic kidney disease. Moreover, we present perspectives on optimization of the use of MR antagonists in patients more likely to respond to such therapy and review the evidence suggesting that novel nonsteroidal MR antagonists offer an improved safety profile while retaining their cardiovascular protective effects. Finally, we highlight future therapeutic applications of MR antagonists in cardiovascular injury.

The paradoxical effect of aldosterone on cardiovascular outcome in maintenance hemodialysis patients

Background

Patients with end-stage kidney disease face increased risk of cardiovascular events, and left ventricular diastolic dysfunction (LVDD) contributes to the high occurrence of cardiovascular mortality (CM). Although a high serum aldosterone (sALD) level is involved in the development of cardiovascular complications in the general population, this association is unclear in patients undergoing hemodialysis. We aimed to determine the impact of sALD on LVDD and CM among hemodialysis patients (HDPs).

Methods

We performed a prospective cohort study of maintenance HDPs without cardiovascular disease. The patients were divided into two groups according to the median level of sALD. All patients underwent baseline echocardiography to evaluate diastolic dysfunction (E/e´ ratio > 15). The LVDD and CM rates were compared between the high and low aldosterone groups.

Results

We enrolled a total of 60 adult patients (mean age, 57.9 ± 12.1 years; males, 30.0%). The low aldosterone group had an increased left ventricular diastolic dimension compared with the high aldosterone group (52.2 ± 8.4 mm vs. 50.3 ± 5.2 mm, respectively; p = 0.03). Low log-aldosterone (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.19-0.86) and large left atrial dimension (OR, 1.31; 95% CI, 1.11-1.54) were independent risk factors for LVDD at baseline. In addition, Cox regression analysis demonstrated that low sALD was an independent predictor of CM in HDPs (hazard ratio, 0.46; 95% CI, 0.25-0.85; p = 0.01) during follow-up.

Conclusion

Low sALD was not only associated with LVDD but was also an independent predictor of CM among HDPs regardless of their interdialytic weight gain.

Improving exercise capacity and quality of life using non-invasive heart failure treatments: evidence from clinical trials

Endpoints of large-scale trials in chronic heart failure have mostly been defined to evaluate treatments with regard to hospitalizations and mortality. However, patients with heart failure are also affected by very severe reductions in exercise capacity and quality of life. We aimed to evaluate the effects of heart failure treatments on these endpoints using available evidence from randomized trials. Interventions with evidence for improvements in exercise capacity include physical exercise, intravenous iron supplementation in patients with iron deficiency, and - with less certainty - testosterone in highly selected patients. Erythropoiesis-stimulating agents have been reported to improve exercise capacity in anaemic patients with heart failure. Sinus rhythm may have some advantage when compared with atrial fibrillation, particularly in patients undergoing pulmonary vein isolation. Studies assessing treatments for heart failure co-morbidities such as sleep-disordered breathing, diabetes mellitus, chronic kidney disease and depression have reported improvements of exercise capacity and quality of life; however, the available data are limited and not always consistent. The available evidence for positive effects of pharmacologic interventions using angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists on exercise capacity and quality of life is limited. Studies with ivabradine and with sacubitril/valsartan suggest beneficial effects at improving quality of life; however, the evidence base is limited in particular for exercise capacity. The data for heart failure with preserved ejection fraction are even less positive, only sacubitril/valsartan and spironolactone have shown some effectiveness at improving quality of life. In conclusion, the evidence for state-of-the-art heart failure treatments with regard to exercise capacity and quality of life is limited and appears not robust enough to permit recommendations for heart failure. The treatment of co-morbidities may be important for these patient-related outcomes. Additional studies on functional capacity and quality of life in heart failure are required.

The endothelial mineralocorticoid receptor: Contributions to sex differences in cardiovascular disease

Cardiovascular disease remains the leading cause of death for both men and women. The observation that premenopausal women are protected from cardiovascular disease relative to age-matched men, and that this protection is lost with menopause, has led to extensive study of the role of sex steroid hormones in the pathogenesis of cardiovascular disease. However, the molecular basis for sex differences in cardiovascular disease is still not fully understood, limiting the ability to tailor therapies to male and female patients. Therefore, there is a growing need to investigate molecular pathways outside of traditional sex hormone signaling to fully understand sex differences in cardiovascular disease. Emerging evidence points to the mineralocorticoid receptor (MR), a steroid hormone receptor activated by the adrenal hormone aldosterone, as one such mediator of cardiovascular disease risk, potentially serving as a sex-dependent link between cardiovascular risk factors and disease. Enhanced activation of the MR by aldosterone is associated with increased risk of cardiovascular disease. Emerging evidence implicates the MR specifically within the endothelial cells lining the blood vessels in mediating some of the sex differences observed in cardiovascular pathology. This review summarizes the available clinical and preclinical literature concerning the role of the MR in the pathophysiology of endothelial dysfunction, hypertension, atherosclerosis, and heart failure, with a special emphasis on sex differences in the role of endothelial-specific MR in these pathologies. The available data regarding the molecular mechanisms by which endothelial-specific MR may contribute to sex differences in cardiovascular disease is also summarized. A paradigm emerges from synthesis of the literature in which endothelial-specific MR regulates vascular function in a sex-dependent manner in response to cardiovascular risk factors to contribute to disease. Limitations in this field include the relative paucity of women in clinical trials and, until recently, the nearly exclusive use of male animals in preclinical investigations. Enhanced understanding of the sex-specific roles of endothelial MR could lead to novel mechanistic insights underlying sex differences in cardiovascular disease incidence and outcomes and could identify additional therapeutic targets to effectively treat cardiovascular disease in men and women.