The relationship between arterial stiffness and heart failure with preserved ejection fraction: a systemic meta-analysis

Association of Extracoronary Calcification and Incident Heart Failure in the Multiethnic Study of Atherosclerosis (MESA)

BACKGROUND

Extracoronary calcification (ECC) is a prevalent cardiovascular risk factor.

OBJECTIVES

The aim of this study was to examine the association between ECC and heart failure (HF), including heart failure with preserved ejection fraction (HFpEF).

METHODS

MESA (Multi-Ethnic Study of Atherosclerosis) participants with computed tomographic imaging at baseline for calcification of the aortic valve, aortic root, mitral valve, and thoracic aorta were included. ECC score was calculated by rescaling Agatston scores from 0 to 1 for each ECC site and summing the rescaled scores. Multivariable Cox proportional hazards regression was performed to examine the association between ECC quartiles and incident HF.

RESULTS

Of all MESA participants, 3,617 (53.1%) and 3,192 (46.9%) had ECC scores of 0 and >0, respectively. During a mean follow-up period of 12.9 ± 4.2 years, 358 HF events were observed, 179 HF with reduced ejection fraction and 135 HFpEF. After controlling for demographics and risk factors, the highest ECC quartile (compared with the lowest quartile) had 1.7-fold greater hazard of incident HF (adjusted HR: 1.72 [95% CI: 1.16-2.55]; P = 0.007), though this was attenuated to borderline significance after additional adjustment for coronary artery calcification. In contrast for HFpEF, the highest ECC quartile (compared with the lowest quartile) remained independently and statistically significantly associated with 3-fold greater hazard of incident HFpEF (adjusted HR: 3.09 [95% CI: 1.45-6.60]; P = 0.003) after full adjustment, including for coronary artery calcification.

CONCLUSIONS

ECC is associated with increased risk for HF, in particular HFpEF. If this finding is confirmed in other studies, ECC could help improve traditional risk factor estimation and clinical risk assessments for HF and HFpEF.

Pulse pressure and aortic valve peak velocity and incident heart failure after myocardial infarction: a cohort study

BACKGROUND

Heart failure with preserved ejection fraction is a recognised outcome in patients with myocardial infarction, although heart failure with reduced ejection fraction is more common. Identifying early indicators specific to heart failure with preserved ejection fraction in patients with myocardial infarction could support targeted preventive strategies. This study aimed to determine if pulse pressure and aortic valve peak velocity could serve as early predictors of heart failure with preserved ejection fraction in patients with myocardial infarction.

METHODS

We retrospectively analysed data from 5188 participants in the Atherosclerosis Risk in Communities Study who were free from heart failure at baseline, including 802 individuals with a history of myocardial infarction. Heart failure events were classified as either heart failure with preserved ejection fraction (left ventricular ejection fraction ≥50%) or heart failure with mildly reduced or reduced ejection fraction (left ventricular ejection fraction <50%). Competing risk regression models were used to examine associations of baseline pulse pressure and aortic valve peak velocity with heart failure subtypes.

RESULTS

Over 6 years of follow-up, 217 cases of heart failure with preserved ejection fraction (including 50 in patients with myocardial infarction) and 127 cases of heart failure with mildly reduced or reduced ejection fraction (33 in patients with myocardial infarction) were identified. Among patients with myocardial infarction, a 1-SD increase in pulse pressure was associated with a 1.60-fold higher risk of heart failure with preserved ejection fraction (95% CI 1.30 to 1.97), and a similar association was observed for aortic valve peak velocity (HR: 1.37, 95% CI 1.19 to 1.58). Patients with pulse pressure ≥68 mm Hg had a 3.83-fold higher risk of heart failure with preserved ejection fraction compared with those with lower pulse pressure, and those with aortic valve peak velocity ≥1.4 m/s had a 2.10-fold higher risk compared with those with lower values. Patients with myocardial infarction with two or more risk factors among elevated pulse pressure, aortic valve peak velocity, diabetes and atrial fibrillation had over 16 times the risk of developing heart failure with preserved ejection fraction compared with those without these risk factors (p<0.001).

CONCLUSIONS

Pulse pressure and aortic valve peak velocity are significant predictors of heart failure with preserved ejection fraction in patients with myocardial infarction, suggesting their potential value in early risk stratification. These findings support the use of these markers to guide timely interventions aimed at preventing the progression to heart failure with preserved ejection fraction.

Relationship of proteins and subclinical cardiovascular traits in the population-based LIFE-Adult study

BACKGROUND AND AIMS

Understanding molecular processes of the early phase of atherosclerotic cardiovascular disease conditions is of utmost importance for early prediction and intervention measures.

METHODS

We measured 92 cardiovascular-disease-related proteins (Olink, Cardiovascular III) in 2024 elderly participants of the population-based LIFE-Adult study. We analysed the impact of 27 covariables on these proteins including blood counts, cardiovascular risk factors and life-style-related parameters. We also analysed protein associations with 13 subclinical cardiovascular traits comprising carotid intima media thickness, plaque burden, three modes of Vicorder-based pulse-wave velocities, ankle-brachial index and ECLIA-based N-terminal prohormone of brain natriuretic peptide (NT-proBNP).

RESULTS

Estimated glomerular filtration rate, triglycerides and sex where the most relevant covariables explaining more than 1 % variance of 49, 22 and 20 proteins, respectively. A total of 43 proteins were significantly associated with at least one of the analysed subclinical cardiovascular traits. NT-pro-BNP, brachial-ankle pulse-wave velocity (baPWV) and parameters of carotid plaque burden accounted for the largest number of associations. Association overlaps were relatively sparse. Only growth/differentiation factor 15, low density lipoprotein receptor and interleukin-1 receptor type 2 are associated with these three different cardiovascular traits. We confirmed several literature findings and found yet unreported associations for carotid plaque presence (von-Willebrand factor, galectin 4), carotid intima-media thickness (carboxypeptidase A1 andB1), baPWV (cathepsin D) and NT-proBNP (cathepsin Z, low density lipoprotein receptor, neurogenic locus homolog protein 3, trem-like transcript 2). Sex-interaction effects were observed, e.g. for spondin-1 and growth/differentiation factor 15 likely regulated by androgen response elements.

CONCLUSIONS

We extend the catalogue of proteome biomarkers possibly involved in early stages of cardiovascular disease pathologies providing targets for early risk prediction or intervention strategies.

The Role of Vascular Aging in the Development of Hypertension

Vascular stiffness is an age-related pathophysiological process that represents a significant risk of cardiovascular morbidity and mortality in the older adult.

Inversion of Left Ventricular Axial Shortening: In Silico Proof of Concept for Treatment of HFpEF

Left ventricular (LV) longitudinal function is mechanically coupled to the elasticity of the ascending aorta (AA). The pathophysiologic link between a stiff AA and reduced longitudinal strain and the subsequent deterioration in longitudinal LV systolic function is likely relevant in heart failure with preserved ejection fraction (HFpEF). The proposed therapeutic effect of freeing the LV apex and allowing for LV inverse longitudinal shortening was studied in silico utilizing the Living Left Heart Human Model (Dassault Systémes Simulia Corporation). LV function was evaluated in a model with (A) an elastic AA, (B) a stiff AA, and (C) a stiff AA with a free LV apex. The cardiac model simulation demonstrated that freeing the apex caused inverse LV longitudinal shortening that could abolish the deleterious mechanical effect of a stiff AA on LV function. A stiff AA and impairment of the LV longitudinal strain are common in patients with HFpEF. The hypothesis-generating model strongly suggests that freeing the apex and inverse longitudinal shortening may improve LV function in HFpEF patients with a stiff AA.

Effects of a medium cut-off dialyzer on inflammation and cardiac and vascular function in hemodialysis patients with heart failure

INTRODUCTION

Expanded hemodialysis (HDx) could provide clearance of larger middle-molecule uremic toxins. We compared the effect of hemodialysis with medium cut-off membranes and high-flux (HFHD) membranes regarding changes in inflammation and vascular and left ventricular function.

METHODS

This was a single-center, prospective, parallel-group comparative study. Patients were divided into two groups (HDx: 25 patients and HFHD: 26 patients). All measurements were performed at baseline and 12 weeks. Serum c-reactive protein, interkelukin-18, pentraxin-3, β-2 microglobulin, and brain natriuretic peptide were measured. We used pulse wave velocity and augmentation index to assess arterial stiffness and echocardiography to evaluate left and right ventricular function.

FINDINGS

We enrolled 51 patients. Although serum c-reactive protein, interkelukin-18, pentraxin 3, and β-2 microglobulin were significantly decreased in the HDx group (p = 0.02, p < 0.001, p = 0.002, and p = 0.02, respectively), there was no significant change in HFHD group at 12th week. Serum c-reactive protein and interkelukin-18were significantly lower in the HDx group compared to the HFHD group in the 12th week (p = 0.007 and p = 0.03, respectively). We observed a significant decrease in pulse wave velocity in the HDx group at the end of the study (p = 0.03). Although there was no significant change in pulse wave velocity in the HFHD group, pulse wave velocity was similar between the HDx and HFHD groups in the 12th week. We detected a significant decrease in the mean isovolumetric relaxation time in the HDx group (p = 0.006). However, there was no significant difference in isovolumetric relaxation time between the HDx and HFHD groups in the 12th week.

DISCUSSION

HDx provides better clearance of middle molecular uremic toxins and inflammatory biomarkers, and it may be associated with better central hemodynamic parameters and diastolic functions.

The Stiffness of the Ascending Aorta Has a Direct Impact on Left Ventricular Function: An In Silico Model

During systole, longitudinal shortening of the left ventricle (LV) displaces the aortic root toward the apex of the heart and stretches the ascending aorta (AA). An in silico study (Living Left Heart Human Model, Dassault Systèmes Simulia Corporation) demonstrated that stiffening of the AA affects myocardial stress and LV strain patterns. With AA stiffening, myofiber stress increased overall in the LV, with particularly high-stress areas at the septum. The most pronounced reduction in strain was noted along the septal longitudinal region. The pressure-volume loops showed that AA stiffening caused a deterioration in LV function, with increased end-systolic volume, reduced systolic LV pressure, decreased stroke volume and effective stroke work, but elevated end-diastolic pressure. An increase in myofiber contractility indicated that stroke volume and effective stroke work could be recovered, with an increase in LV end-systolic pressure and a decrease in end-diastolic pressure. Longitudinal and radial strains remained reduced, but circumferential strains increased over baseline, compensating for lost longitudinal LV function. Myofiber stress increased overall, with the most dramatic increase in the septal region and the LV apex. We demonstrate a direct mechanical pathophysiologic link between stiff AA and reduced longitudinal left ventricular strain which are common in patients with HFpEF.

Empagliflozin ameliorates vascular calcification in diabetic mice through inhibiting Bhlhe40-dependent NLRP3 inflammasome activation

Type 2 diabetes mellitus (T2DM) patients exhibit greater susceptibility to vascular calcification (VC), which has a higher risk of death and disability. However, there is no specific drug for VC therapy. NLRP3 inflammasome activation as a hallmark event of medial calcification leads to arterial stiffness, causing vasoconstrictive dysfunction in T2DM. Empagliflozin (EMPA), a sodium-glucose co-transporter 2 inhibitor (SGLT2i), restrains hyperglycemia with definite cardiovascular benefits. Given the anti-inflammatory activity of EMPA, herein we investigated whether EMPA protected against VC in the aorta of T2DM mice by inhibiting NLRP3 inflammasome activation. Since db/db mice receiving a normal diet developed VC at the age of about 20 weeks, we administered EMPA (5, 10, 20 mg·kg-1·d-1, i.g) to 8 week-old db/db mice for 12 weeks. We showed that EMPA intervention dose-dependently ameliorated the calcium deposition, accompanied by reduced expression of RUNX2 and BMP2 proteins in the aortas. We found that EMPA (10 mg·kg-1·d-1 for 6 weeks) also protected against VC in vitamin D3-overloaded mice, suggesting the protective effects independent of metabolism. We showed that EMPA (10 mg·kg-1·d-1) inhibited the abnormal activation of NLRP3 inflammasome in aortic smooth muscle layer of db/db mice. Knockout (KO) of NLRP3 significantly alleviated VC in STZ-induced diabetic mice. The protective effects of EMPA were verified in high glucose (HG)-treated mouse aortic smooth muscle cells (MOVASs). In HG-treated NLRP3 KO MOVASs, EMPA (1 μM) did not cause further improvement. Bioinformatics and Western blot analysis revealed that EMPA significantly increased the expression levels of basic helix-loop-helix family transcription factor e40 (Bhlhe40) in HG-treated MOVASs, which served as a negative transcription factor directly binding to the promotor of Nlrp3. We conclude that EMPA ameliorates VC by inhibiting Bhlhe40-dpendent NLRP3 inflammasome activation. These results might provide potential significance for EMPA in VC therapy of T2DM patients.

Is atrial fibrillation in HFpEF a distinct phenotype? Insights from multiparametric MRI and circulating biomarkers

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) frequently co-exist. There is a limited understanding on whether this coexistence is associated with distinct alterations in myocardial remodelling and mechanics. We aimed to determine if patients with atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) represent a distinct phenotype.

METHODS

In this secondary analysis of adults with HFpEF (NCT03050593), participants were comprehensively phenotyped with stress cardiac MRI, echocardiography and plasma fibroinflammatory biomarkers, and were followed for the composite endpoint (HF hospitalisation or death) at a median of 8.5 years. Those with AF were compared to sinus rhythm (SR) and unsupervised cluster analysis was performed to explore possible phenotypes.

RESULTS

136 subjects were included (SR = 75, AF = 61). The AF group was older (76 ± 8 vs. 70 ± 10 years) with less diabetes (36% vs. 61%) compared to the SR group and had higher left atrial (LA) volumes (61 ± 30 vs. 39 ± 15 mL/m2, p < 0.001), lower LA ejection fraction (EF) (31 ± 15 vs. 51 ± 12%, p < 0.001), worse left ventricular (LV) systolic function (LVEF 63 ± 8 vs. 68 ± 8%, p = 0.002; global longitudinal strain 13.6 ± 2.9 vs. 14.7 ± 2.4%, p = 0.003) but higher LV peak early diastolic strain rates (0.73 ± 0.28 vs. 0.53 ± 0.17 1/s, p < 0.001). The AF group had higher levels of syndecan-1, matrix metalloproteinase-2, proBNP, angiopoietin-2 and pentraxin-3, but lower level of interleukin-8. No difference in clinical outcomes was observed between the groups. Three distinct clusters were identified with the poorest outcomes (Log-rank p = 0.029) in cluster 2 (hypertensive and fibroinflammatory) which had equal representation of SR and AF.

CONCLUSIONS

Presence of AF in HFpEF is associated with cardiac structural and functional changes together with altered expression of several fibro-inflammatory biomarkers. Distinct phenotypes exist in HFpEF which may have differing clinical outcomes.

Heart Failure with Preserved Ejection Fraction: The Pathophysiological Mechanisms behind the Clinical Phenotypes and the Therapeutic Approach

Heart failure (HF) with preserved ejection fraction (HFpEF) is an increasingly frequent form and is estimated to be the dominant form of HF. On the other hand, HFpEF is a syndrome with systemic involvement, and it is characterized by multiple cardiac and extracardiac pathophysiological alterations. The increasing prevalence is currently reaching epidemic levels, thereby making HFpEF one of the greatest challenges facing cardiovascular medicine today. Compared to HF with reduced ejection fraction (HFrEF), the medical attitude in the case of HFpEF was a relaxed one towards the disease, despite the fact that it is much more complex, with many problems related to the identification of physiopathogenetic mechanisms and optimal methods of treatment. The current medical challenge is to develop effective therapeutic strategies, because patients suffering from HFpEF have symptoms and quality of life comparable to those with reduced ejection fraction, but the specific medication for HFrEF is ineffective in this situation; for this, we must first understand the pathological mechanisms in detail and correlate them with the clinical presentation. Another important aspect of HFpEF is the diversity of patients that can be identified under the umbrella of this syndrome. Thus, before being able to test and develop effective therapies, we must succeed in grouping patients into several categories, called phenotypes, depending on the pathological pathways and clinical features. This narrative review critiques issues related to the definition, etiology, clinical features, and pathophysiology of HFpEF. We tried to describe in as much detail as possible the clinical and biological phenotypes recognized in the literature in order to better understand the current therapeutic approach and the reason for the limited effectiveness. We have also highlighted possible pathological pathways that can be targeted by the latest research in this field.

Antifibrotic effects of sodium-glucose cotransporter-2 inhibitors: A comprehensive review

BACKGROUND AND AIMS

Scar tissue accumulation in organs is the underlying cause of many fibrotic diseases. Due to the extensive array of organs affected, the long-term nature of fibrotic processes and the large number of people who suffer from the negative impact of these diseases, they constitute a serious health problem for modern medicine and a huge economic burden on society. Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are a relatively new class of anti-diabetic pharmaceuticals that offer additional benefits over and above their glucose-lowering properties; these medications modulate a variety of diseases, including fibrosis. Herein, we have collated and analyzed all available research on SGLT2is and their effects on organ fibrosis, together with providing a proposed explanation as to the underlying mechanisms.

METHODS

PubMed, ScienceDirect, Google Scholar and Scopus were searched spanning the period from 2012 until April 2023 to find relevant articles describing the antifibrotic effects of SGLT2is.

RESULTS

The majority of reports have shown that SGLT2is are protective against lung, liver, heart and kidney fibrosis as well as arterial stiffness. According to the results of clinical trials and animal studies, many SGLT2 inhibitors are promising candidates for the treatment of fibrosis. Recent studies have demonstrated that SGLT2is affect an array of cellular processes, including hypoxia, inflammation, oxidative stress, the renin-angiotensin system and metabolic activities, all of which have been linked to fibrosis.

CONCLUSION

Extensive evidence indicates that SGLT2is are promising treatments for fibrosis, demonstrating protective effects in various organs and influencing key cellular processes linked to fibrosis.

Inconsistent Benefits From Mobile Information Communication Technology in Adults With Peripheral Arterial Disease

INTRODUCTION

Quality of evidence regarding telemedicine in adults with peripheral arterial disease has not been systematically appraised.

OBJECTIVES

To explore benefits and harms from mobile information communication technology devices and applications in peripheral arterial disease.

METHODS

Systematic rapid evidence review and appraisal with the grading of recommendations assessment, development, and evaluation working group approach.

RESULTS

Sixteen randomized controlled clinical trials (RCT) examined various self-monitoring devices, telemedicine platforms, and individualized telephone counseling. Low-quality evidence suggested that the odds of treatment failure (pooled Peto odds ratio 0.8; 95% CI, 0.4-1.7; 5 RCTs), adverse effects (pooled Peto odds ratio 0.9; 95% CI, 0.5-1.5; 2 RCTs), and physical performance (standardized mean difference in 6-minute walking test 0.2; 95% CI, -0.3-0.7; 4 RCTs) did not differ between mobile interventions and usual care. Single RCTs suggested large but inconsistent improvement in the quality of life: EuroQol5D standardized mean difference = 5.0 (95% CI, 4.4-5.7; 1 RCT) after telehealth program for promoting patient self-management and standardized mean difference = 1.4 (95% CI, 0.4-2.3; 1 RCT) after structured rehabilitation with mobile self-monitoring. Inconsistent reporting of patient-centered outcomes and small sample sizes hampered the quality of evidence.

CONCLUSIONS

Improved quality of life after specific mobile applications should be confirmed in powered RCTs and large postmarketing studies.

Association between estimated pulse wave velocity and all-cause death in patients with heart failure

BACKGROUND

Arteriosclerosis has been proven to be a risk factor for the development of heart failure and readmission. ePWV is a novel non-invasive and simple indicator of arterial stiffness, and this study aims to investigate its relationship with all-cause mortality rate in patients with heart failure.

METHODS

This study is a cohort study that included 1272 patients with heart failure from NHANES data from 1999 to 2018. The ePWV was divided into three groups, and the cumulative mortality rate of heart failure patients was calculated using KM survival curves. The relationship between ePWV and all-cause mortality rate in heart failure patients was represented by a smoothed curve fitting. COX regression analysis was used to assess the association between ePWV and all-cause mortality rate in heart failure patients.

RESULTS

The average age of the study population was 67.8 ± 12.6 years, with 862 males and 650 females. During the 12-month follow-up period, there were 790 cases of all-cause mortality. Cox regression analysis was used to validate the relationship between ePWV and all-cause mortality rate in patients with heart failure. Patients with higher levels of ePWV tended to have a higher all-cause mortality rate. After adjustment for multiple factors, an increase in ePWV was positively associated with all-cause mortality rate (HR = 1.17, 95% confidence interval (CI): (1.12, 1.22)). Compared to the lowest tertile, the multivariable-adjusted HR and 95% CI for the highest tertile of ePWV were 1.81 (95% CI: (1.45, 2.27)). Additionally, a smoothed curve fitting was used to observe the relationship between ePWV and mortality rate, where the curve demonstrated a positive correlation between ePWV and all-cause mortality rate. Furthermore, KM survival curves indicated that all-cause mortality rate increased with the increase in ePWV. Subgroup analysis suggested a correlation between ePWV and mortality rate.

CONCLUSION

Our study shows that ePWV is positively associated with all-cause mortality in patients with heart failure.

Cardiopulmonary Exercise Testing in Heart Failure With Preserved Ejection Fraction: Technique Principles, Current Evidence, and Future Perspectives

Heart failure with preserved ejection fraction (HFpEF) is a multifactorial clinical syndrome involving a rather complex pathophysiologic substrate and quite a challenging diagnosis. Exercise intolerance is a major feature of HFpEF, and in many cases, diagnosis is suspected in subjects presenting with exertional dyspnea. Cardiopulmonary exercise testing (CPET) is a noninvasive, dynamic technique that provides an integrative evaluation of cardiovascular, pulmonary, hematopoietic, neuropsychological, and metabolic functions during maximal or submaximal exercise. The assessment is based on the principle that system failure typically occurs when the system is under stress, and thus, CPET is currently considered to be the gold standard for identifying exercise intolerance, allowing the differential diagnosis of underlying causes. CPET is used in observational studies and clinical trials in HFpEF; however, in most cases, only a few from a wide variety of CPET parameters are examined, while the technique is largely underused in everyday cardiology practice. This article discusses the basic principles and methodology of CPET and studies that utilized CPET in patients with HFpEF, in an effort to increase awareness of CPET capabilities among practicing cardiologists.

Reimagining the Value of Brachial-Ankle Pulse Wave Velocity as a Biomarker of Cardiovascular Disease Risk-A Call to Action on Behalf of VascAgeNet

This review critiques the literature supporting clinical assessment and management of cardiovascular disease and cardiovascular disease risk stratification with brachial-ankle pulse wave velocity (baPWV). First, we outline what baPWV actually measures-arterial stiffness of both large central elastic arteries and medium-sized muscular peripheral arteries of the lower limb. Second, we argue that baPWV is not a surrogate for carotid-femoral pulse wave velocity. While both measures are dependent on the properties of the aorta, baPWV is also strongly dependent on the muscular arteries of the lower extremities. Increased lower-extremity arterial stiffness amplifies and hastens wave reflections at the level of the aorta, widens pulse pressure, increases afterload, and reduces coronary perfusion. Third, we used an established evaluation framework to identify the value of baPWV as an independent vascular biomarker. There is sufficient evidence to support (1) proof of concept; (2) prospective validation; (3) incremental value; and (4) clinical utility. However, there is limited or no evidence to support (5) clinical outcomes; (6) cost-effectiveness; (8) methodological consensus; or (9) reference values. Fourth, we address future research requirements. The majority of the evaluation criteria, (1) proof of concept, (2) prospective validation, (3) incremental value, (4) clinical utility and (9) reference values, can be supported using existing cohort datasets, whereas the (5) clinical outcomes and (6) cost-effectiveness criteria require prospective investigation. The (8) methodological consensus criteria will require an expert consensus statement. Finally, we finish this review by providing an example of a future clinical practice model.

Relationship between arterial stiffness, left ventricular diastolic function, and renal function in chronic kidney disease

AIM

In chronic kidney disease, IgA nephropathy, and left ventricular diastolic dysfunction have prognostic significance as well. However, the relationship between diastolic dysfunction, arterial stiffness, and renal function has not been fully elucidated.

METHODS

79 IgA nephropathy patients (aged 46 ± 11 years) and 50 controls were investigated. Tissue Doppler imaging was used to measure early (Ea) and late (Aa) diastolic velocities. Arterial stiffness was measured by a photoplethysmographic (stiffness index (SI)) and an oscillometric method (aortic pulse wave velocity (PWVao)).

RESULTS

We compared the IgAN patients to a similar cardiovascular risk group with a preserved eGFR. A strong correlation was found between Ea/Aa and SI (p < 0.001), also with PWVao (p < 0.001), just in IgAN, and with eGFR (p < 0.001) in both groups. IgAN patients were divided into groups CKD1-2 vs. CKD3-5. In the CKD 3-5 group, the incidence of diastolic dysfunction increased significantly: 39% vs. 72% (p = 0.003). Left ventricle rigidity (LVR) was calculated, which showed a close correlation with SI (p = 0.009) and eGFR (p = 0.038). By linear regression analysis, the independent predictors of SI were age, E/A, and E/Ea; SI was the predictor of LVR; and E/A and hypertension were the predictors of eGFR.

CONCLUSION

In chronic kidney disease, increased cardiac rigidity and vascular stiffness coexist with decreased renal function, which is directly connected to diastolic dysfunction and vascular stiffness. On the basis of comparing the CKD group to the control group, vascular alterations in very early CKD can be identified.

Indoxyl sulfate in atherosclerosis

Atherosclerosis (AS), a chronic vascular inflammatory disease, has become a main focus of attention worldwide for its chronic progressing disease course and serious complications in the later period. Nevertheless, explanations for the exact molecular mechanisms of AS initiation and development remain to be an unsolved problem. The classic pathogenesis theories, such as lipid percolation and deposition, endothelium injury, inflammation and immune damage, provide the foundation for discovering the new key molecules or signaling mechanisms. Recently, indoxyl sulfate (IS), one of non-free uremia toxins, has been noticeable for its multiple atherogenic effects. IS exists at high concentration in plasma for its great albumin binding rate. Patients with uremia have markedly elevated serum levels of IS due both to the deterioration of renal function and to the high binding affinity of IS to albumin. Nowadays, elevated incidence of circulatory disease among patients with renal dysfunction indicates correlation of uremic toxins with cardiovascular damage. In this review, the atherogenic effects of IS and the underlying mechanisms are summarized with emphasis on several key pathological events associated with AS developments, such as vascular endothelium dysfunction, arterial medial lesions, vascular oxidative stress, excessive inflammatory responses, calcification, thrombosis and foam cell formation. Although recent studies have proved the great correlation between IS and AS, deciphering cellular and pathophysiological signaling by confirming key factors involved in IS-mediated atherosclerosis development may enable identification of novel therapeutic targets.

Degree of Joint Risk Factor Control and Incident Heart Failure in Hypertensive Patients

BACKGROUND

Heart failure (HF) is a major complication in patients with hypertension.

OBJECTIVES

This study aimed to investigate the extent to which joint risk factor control could attenuate hypertension-related excess risk of HF.

METHODS

The study included a total of 75,293 participants with diagnosed hypertension from the UK Biobank and matched with 256,619 nonhypertensive control subjects, followed up until May 31, 2021. The degree of joint risk factor control was assessed on the basis of the major cardiovascular risk factors, including blood pressure, body mass index, low-density lipoprotein cholesterol, hemoglobin A1c, albuminuria, smoking, and physical activity. The Cox proportional hazards models were used to estimate associations between the degree of risk factor control and risk of HF.

RESULTS

Among hypertensive patients, joint risk factor control showed an association with a stepwise reduction of incident HF risk. Each additional risk factor control was related to a 20% lower risk, and the optimal risk factor control (controlling ≥6 risk factors) was associated with a 62% lower risk (HR: 0.38; 95% CI: 0.31-0.45). In addition, the study found that the hypertension-related excess risk of HF among participants jointly controlling ≥6 risk factors were even lower than in nonhypertensive control subjects (HR: 0.79; 95% CI: 0.67-0.94). The protective associations of joint risk factor control and risk of incident HF were broadly stronger among men than women and among medication users than nonusers (P for interaction < 0.05).

CONCLUSIONS

The joint risk factor control is associated with a lower risk of incident HF in an accumulative and sex-specific manner. Optimal risk factor control may eliminate hypertension-related excess risk of HF.

Handgrip strength is inversely associated with augmentation index in patients with type 2 diabetes

Handgrip strength (HGS) is a measure of overall skeletal muscle strength and is used to identify risks for cardiovascular disease and mortality. Furthermore, HGS is an indicator of arterial stiffness that leads to atherosclerotic cardiovascular disease. This study aimed to examine the relationship between HGS and augmentation index (AIx) in patients with type 2 diabetes. A cross-sectional study was conducted to examine patients with type 2 diabetes whose HGS and AIx were measured in our hospital. AIx was measured noninvasively using an applanation tonometer, and multiple regression analyses were conducted to assess the independent relationship between HGS and AIx. This study included 404 patients. After adjusting for age, gender, body mass index, duration of diabetes, smoking and exercise habit, biochemical parameters, and physiological parameters related to arterial stiffness, HGS was found to be independently and inversely associated with AIx (β = - 0.270, p = 0.006). HGS was independently and inversely associated with AIx in patients with type 2 diabetes. Patients with diminished HGS should be subjected to intensive exercise therapy for reducing the risk of arterial stiffness and cardiovascular disease.Trial registration: UMIN000023010.

Plasma Amyloid-β in Relation to Cardiac Function and Risk of Heart Failure in General Population

BACKGROUND

Amyloid-β (Aβ) may be related to cardiac function. However, there are limited data on the association of plasma Aβ with cardiac function and risk of heart failure (HF) in the general population.

OBJECTIVES

This study sought to determine the associations of plasma amyloid-β40 (Aβ40) and amyloid-β42 (Aβ42) with echocardiographic measurements of cardiac dysfunction and with incident HF in the general population.

METHODS

The study included 4,156 participants of the population-based Rotterdam Study (mean age: 71.4 years; 57.1% women), who had plasma Aβ samples collected between 2002 and 2005 and had no established dementia and HF at baseline. Multivariable linear regression models were used to explore the cross-sectional association of plasma Aβ with echocardiographic measures. Participants were followed up until December 2016. Cox proportional hazards models were used to assess the association of Aβ levels with incident HF. Models were adjusted for cardiovascular risk factors.

RESULTS

A per 1-SD increase in log-transformed plasma Aβ40 was associated with a 0.39% (95% CI: -0.68 to -0.10) lower left ventricular ejection fraction and a 0.70 g/m² (95% CI: 0.06-1.34) larger left ventricular mass indexed by body surface area. Aβ42 was not significantly associated with echocardiographic measures cross-sectionally. During follow-up (median: 10.2 years), 472 incident HF cases were identified. A per 1-SD increase in log-transformed Aβ40 was associated with a 32% greater risk of HF (HR: 1.32; 95% CI: 1.15-1.51), and the association was significant in men, but not in women. Higher plasma Aβ42 levels were associated with an increased risk of HF (HR: 1.12; 95% CI: 1.02-1.24), although the association was attenuated after further adjustment for concomitant Aβ40 (HR: 1.03; 95% CI: 0.92-1.16).

CONCLUSIONS

Higher levels of Aβ40 were associated with worse cardiac function and higher risk of new onset HF in the general population, in particular among men.

The anti-hypertensive effects of sodium-glucose cotransporter-2 inhibitors

INTRODUCTION

Hypertension is a well-established risk factor for cardiovascular (CV) events in patients with chronic kidney disease (CKD), heart failure, obesity, and diabetes. Despite the usual prescribed antihypertensive therapies, many patients fail to achieve the recommended blood pressure (BP) targets.

AREAS COVERED

This review summarizes the clinical BP-lowering data presented in major CV and kidney outcome trials for sodium-glucose cotransporter-2 (SGLT2) inhibitors, as well as smaller dedicated BP trials in high-risk individuals with and without diabetes. We have also highlighted potential mechanisms that may contribute to the antihypertensive effects of SGLT2 inhibitors, including natriuresis and hemodynamic changes, a loop diuretic-like effect, and alterations in vascular physiology.

EXPERT OPINION

The antihypertensive properties of SGLT2 inhibitors are generally modest but may be larger in certain patient populations. SGLT2 inhibitors may have an additional role as an adjunctive BP-lowering therapy in patients with hypertension at high risk of CV disease or kidney disease.

Visualizing diastolic failure: Non-invasive imaging-biomarkers in patients with heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction is an increasing challenge for modern day medicine and has been drawing more attention recently. Invasive right heart catheterization represents the mainstay for the diagnosis of diastolic dysfunction, however due to its attributable risk of an invasive procedure, other non-invasive clinical pathways are trying to approach this pathology in clinical practice. Diastolic failure is complex, and imaging is based on various parameters. In addition to transthoracic echocardiography, numerous novel imaging approaches, such as cardiac magnetic resonance imaging, computed tomography, positron emission (computed) tomography or single photon emission computed tomography techniques are being used to supplement deeper insights into causal pathology and might open targets for dedicated therapy options. This article provides insights into these sophisticated imaging techniques, their incremental value for the diagnosis of this poorly understood disease and recent promising results for an enhanced prognostication of outcome and therapy monitoring.

The mechanosensitive Piezo1 channels contribute to the arterial medial calcification

Vascular calcification (VC) is associated with a number of cardiovascular diseases, as well as chronic kidney disease. The role of smooth muscle cells (SMC) has already been widely explored in VC, as has the role of intracellular Ca²⁺ in regulating SMC function. Increased intracellular calcium concentration ([Ca²⁺]_i) in vascular SMC has been proposed to stimulate VC. However, the contribution of the non-selective Piezo1 mechanosensitive cation channels to the elevation of [Ca²⁺]_i, and consequently to the process of VC has never been examined. In this work the essential contribution of Piezo1 channels to arterial medial calcification is demonstrated. The presence of Piezo1 was proved on human aortic smooth muscle samples using immunohistochemistry. Quantitative PCR and Western blot analysis confirmed the expression of the channel on the human aortic smooth muscle cell line (HAoSMC). Functional measurements were done on HAoSMC under control and calcifying condition. Calcification was induced by supplementing the growth medium with inorganic phosphate (1.5 mmol/L, pH 7.4) and calcium (CaCl₂, 0.6 mmol/L) for 7 days. Measurement of [Ca²⁺]_i using fluorescent Fura-2 dye upon stimulation of Piezo1 channels (either by hypoosmolarity, or Yoda1) demonstrated significantly higher calcium transients in calcified as compared to control HAoSMCs. The expression of mechanosensitive Piezo1 channel is augmented in calcified arterial SMCs leading to a higher calcium influx upon stimulation. Activation of the channel by Yoda1 (10 μmol/L) enhanced calcification of HAoSMCs, while Dooku1, which antagonizes the effect of Yoda1, reduced this amplification. Application of Dooku1 alone inhibited the calcification. Knockdown of Piezo1 by siRNA suppressed the calcification evoked by Yoda1 under calcifying conditions. Our results demonstrate the pivotal role of Piezo1 channels in arterial medial calcification.

Grape exosome-like nanoparticles: A potential therapeutic strategy for vascular calcification

Vascular calcification (VC) is prevalent in hypertension, diabetes mellitus, chronic kidney disease, and aging and has been identified as an important predictor of adverse cardiovascular events. With the complicated mechanisms involved in VC, there is no effective therapy. Thus, a strategy for attenuating the development of VC is of clinical importance. Recent studies suggest that grape exosome-like nanoparticles (GENs) are involved in cell-cell communication as a means of regulating oxidative stress, inflammation, and apoptosis, which are known to modulate VC development. In this review, we discuss the roles of GENs and their potential mechanisms in the development of VC.

Association between arterial stiffness and left ventricular diastolic function: A large population-based cross-sectional study

Background

The association between arterial stiffness and left ventricular (LV) diastolic function has been demonstrated in several studies, but the samples size in those studies was small. This study aims to verify this issue in a large number of study subjects.

Methods

A total of 7,013 consecutive participants (mean age 60.6 years and 43.3% female) who underwent both baPWV and transthoracic echocardiography were retrospectively analyzed. Subjects with significant cardiac structural abnormalities were excluded.

Results

There were significant correlations of baPWV with septal e′ velocity (r = – 0.408; P < 0.001), septal E/e′ (r = 0.349; P < 0.001), left atrial volume index (LAVI) (r = 0.122; P < 0.001) and maximal velocity of tricuspid valve regurgitation (TR Vmax) (r = 0.322; P < 0.001). The baPWV values increased proportionally with an increase in the number of LV diastolic indices meeting LV diastolic dysfunction criteria (P-for-trend < 0.001). In multivariable analyses with adjustment for confounding effects of various clinical covariates, higher baPWV was independently associated with septal e′ < 7 (odds ratio [OR], 1.30; 95% confidence interval [CI] 1.20–1.60; P < 0.001), septal E/e′ ≥ 15 (OR, 1.46; 95% CI, 1.21–1.78; P < 0.001), and TR Vmax > 2.8 m/s (OR, 1.60; 95% CI, 1.23–2.09; P < 0.001) but not with LAVI ≥ 34 mL/m² (OR, 0.89; 95% CI, 0.76–1.03; P = 0.123).

Conclusions

Increased arterial stiffness, as measured by baPWV, was associated with abnormal diastolic function parameters in a large number of study participants, providing strong evidence to the existing data about ventricular-vascular coupling.

Sphingolipid metabolism and signaling in cardiovascular diseases

Sphingolipids are a structural component of the cell membrane, derived from sphingosine, an amino alcohol. Its sphingoid base undergoes various types of enzymatic transformations that lead to the formation of biologically active compounds, which play a crucial role in the essential pathways of cellular signaling, proliferation, maturation, and death. The constantly growing number of experimental and clinical studies emphasizes the pivotal role of sphingolipids in the pathophysiology of cardiovascular diseases, including, in particular, ischemic heart disease, hypertension, heart failure, and stroke. It has also been proven that altering the sphingolipid metabolism has cardioprotective properties in cardiac pathologies, including myocardial infarction. Recent studies suggest that selected sphingolipids may serve as valuable biomarkers useful in the prognosis of cardiovascular disorders in clinical practice. This review aims to provide an overview of the current knowledge of sphingolipid metabolism and signaling in cardiovascular diseases.

Impact of Modified H2FPEF Score on Chronic Limb-Threatening Ischemia in Patients With Lower Extremity Artery Disease Who Underwent Endovascular Therapy

Background: Lower extremity artery disease (LEAD) is an arterial occlusive disease characterized by an insufficient blood supply to the lower limb arteries. The H2FPEF score, comprising Heavy, Hypertensive, atrial Fibrillation, Pulmonary hypertension, Elder, and Filling pressure, has been developed to identify patients at high risk of heart failure (HF) with preserved ejection fraction. This study assessed the impact of modified H2FPEF scores on chronic limb-threatening ischemia (CLTI) in patients with LEAD. Methods and Results: This study was a prospective observational study. Because the definition of obesity differs by race, we calculated the modified H2FPEF score using a body mass index >25 kg/m2 to define obesity in 293 patients with LEAD who underwent first endovascular therapy. The primary endpoints were newly developed and recurrent CLTI. The secondary endpoint was a composite of events, including mortality and rehospitalization due to worsening HF and/or CLTI. The modified H2FPEF score increased significantly with advancing Fontaine classes. Multivariate Cox proportional hazard analysis revealed that the modified H2FPEF score was an independent predictor of newly developed and recurrent CLTI and composite events. The net reclassification index and integrated discrimination improvement were significantly improved by adding the modified H2FPEF score to the basic predictors. Conclusions: The modified H2FPEF score was associated with LEAD severity and future CLTI development, suggesting that it could be a feasible marker for patients with LEAD.

Relationship of arterial tonometry and exercise in patients with chronic heart failure: a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Arterial stiffness is a common characteristic in patients with chronic heart failure (CHF), and arterial tonometric technologies related to arterial stiffness are novel and effective methods and have an important value in the diagnosis and prognosis of CHF. In terms of ameliorating arterial stiffness in patients with CHF, exercise training is considered an adjuvant treatment and also an effective means in the diagnosis and judgment of prognosis. However, there are huge controversies and inconsistencies in these aspects. The objective of this meta-analysis was to systematically test the connection of arterial tonometry and exercise in patients with CHF.

METHODS

Databases, including MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, were accessed from inception to 7 March 2022. The meta-analysis was then conducted, and trial sequential analysis (TSA) was performed jointly to further verify our tests and reach more convincing conclusions by using RevMan version 5.4 software, STATA version 16.0 software, and TSA version 0.9.5.10 Beta software.

RESULTS

Eighteen articles were included, with a total of 876 participants satisfying the inclusion criteria. The pooling revealed that flow-mediated dilation (FMD) was lower in basal condition [standardized mean difference (SMD): - 2.28%, 95% confidence interval (CI) - 3.47 to - 1.08, P < 0.001] and improved significantly after exercise (SMD: 5.96%, 95% CI 2.81 to 9.05, P < 0.001) in patients with heart failure with reduced ejection fraction (HFrEF) compared with healthy participants. The high-intensity training exercise was more beneficial (SMD: 2.88%, 95% CI 1.78 to 3.97, P < 0.001) than the moderate-intensity training exercise to improve FMD in patients with CHF. For augmentation index (AIx), our study indicated no significant differences (SMD: 0.50%, 95% CI - 0.05 to 1.05, P = 0.074) in patients with heart failure with preserved ejection fraction (HFpEF) compared with healthy participants. However, other outcomes of our study were not identified after further verification using TSA, and more high-quality studies are needed to reach definitive conclusions in the future.

CONCLUSIONS

This review shows that FMD is lower in basal condition and improves significantly after exercise in patients with HFrEF compared with healthy population; high-intensity training exercise is more beneficial than moderate-intensity training exercise to improve FMD in patients with CHF; besides, there are no significant differences in AIx in patients with HFpEF compared with the healthy population. More high-quality studies on this topic are warranted.

Curcumin attenuates vascular calcification via the exosomal miR-92b-3p/KLF4 axis

Vascular calcification (VC) is the most widespread pathological change in diseases of the vascular system. However, we do not have a good understanding of the molecular mechanisms and effective therapeutic approaches for VC. Curcumin (CUR) is a natural polyphenolic compound that has hypolipidemic, anti-inflammatory, and antioxidant effects on the cardiovascular system. Exosomes are known to have extensive miRNAs for intercellular regulation. This study investigated whether CUR attenuates VC by affecting the secretion of exosomal miRNAs. Calcification models were established in vivo and in vitro using vitamin D3 and β-glycerophosphate, respectively. Appropriate therapeutic concentrations of CUR were detected on vascular smooth muscle cells (VSMCs) using a cell counting kit 8. Exosomes were extracted by super speed centrifugation from the supernatant of cultured VSMCs and identified by transmission electron microscopy and particle size analysis. Functional and phenotypic experiments were performed in vitro to verify the effects of CUR and exosomes secreted by VSMCs treated with CUR on calcified VSMCs. Compared with the calcified control group, both CUR and exosomes secreted by VSMCs after CUR intervention attenuated calcification in VSMCs. Real-Time quantitative PCR (RT-qPCR) experiments showed that miR-92b-3p, which is important for alleviating VC, was expressed highly in both VSMCs and exosomes after CUR intervention. The mimic miR-92b-3p significantly decreased the expression of transcription factor KLF4 and osteogenic factor RUNX2 in VSMCs, while the inhibitor miR-92b-3p had the opposite effect. Based on bioinformatics databases and dual luciferase experiments, the prospective target of miR-92b-3p was determined to be KLF4. Both mRNA and protein of RUNX2 were decreased and increased in VSMCs by inhibiting and overexpressing of KLF4, respectively. In addition, in the rat calcification models, CUR attenuated vitamin D3-induced VC by increasing miR-92b-3p expression and decreasing KLF4 expression in the aorta. In conclusion, our study suggests that CUR attenuates vascular calcification via the exosomal miR-92b-3p/KLF4 axis.

Effect of sodium-glucose co-transporter-2 inhibitors on arterial stiffness: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Arterial stiffness represents an established cardiovascular risk marker. Sodium-glucose co-transporter-2 (SGLT-2) inhibitors have significant cardio-protective effects. Herein we sought to determine the effect of SGLT-2 inhibitors on pulse wave velocity (PWV).

METHODS

We searched PubMed, Cochrane Library, and grey literature from inception to 7^th February 2022 for randomized controlled trials (RCTs) enrolling adult subjects with or without type 2 diabetes mellitus (T2DM), assigned to a SGLT-2 inhibitor versus control and addressing their effect on PWV. We set as primary efficacy outcome the change in PWV with SGLT-2 inhibitors versus placebo or control.

RESULTS

We pooled data from six trials in a total of 452 enrolled participants assigned either to SGLT-2 inhibitor or control. Overall, SGLT-2 inhibitor treatment compared to control resulted in a nonsignificant decrease in PWV. Exclusion of a trial utilizing cardiac magnetic resonance imaging for the assessment of PWV demonstrated that SGLT-2 inhibitors induce a significant reduction in PWV by 0.21 m/s. When we restricted our analysis to RCTs enrolling subjects with T2DM, we observed that SGLT-2 inhibitor compared to control resulted in a significant decrease in PWV by 0.17 m/s.

CONCLUSION

SGLT-2 inhibitors do not decrease PWV in patients with established cardiovascular disease or cardiovascular risk factors. However, we have shown that SGLT-2 inhibitors lead to a slight, but significant decrease in PWV in patients with T2DM. The latter finding is of great value, based on the significant correlation between PWV and micro- and macro-vascular complications of T2DM.

The Analysis of Arterial Stiffness in Heart Failure Patients: The Prognostic Role of Pulse Wave Velocity, Augmentation Index and Stiffness Index

Background: The role of arterial stiffness in the pathogenesis and clinical outcome of heart failure (HF) patients has to be clarified. The aim of this study was to evaluate the prognostic role of arterial stiffness in HF patients discharged after acute episode of decompensation by evaluating cut-off values for clinical assessment. Methods: Patients admitted for decompensated heart failure (ADHF) underwent pre-discharge evaluation. Arterial stiffness was measured by aortic pulse wave velocity (aPWV), augmentation index (AIx75) and stiffness index (β0). Patients were also evaluated after discharge for a variable follow-up time. Results: We observed 199 patients (male 61.3%, age 76.2 ± 10.7 years) after discharge for a median of 437 days (IQR 247-903), 69 (34.7%) patients suffered HF with preserved ejection fraction (HFpEF), 45 (22.6%) patients experienced HF with mid-range ejection fraction (HFmEF) and 85 (42.7%) reported an HF with reduced ejection fraction (HFrEF). After the adjustment for principal confounders, aPWV, AIx75 and β0 were inversely correlated with free-event survival (p = 0.006, p < 0.001, p = 0.001): only β0 was inversely correlated with overall survival (p = 0.03). Analysing the threshold, overall survival was inversely correlated with β0 ≥3 (HR 2.1, p = 0.04) and free-event survival was inversely correlated with aPWV ≥10 m/s (HR 1.7, p = 0.03), AIx75 ≥ 25 (HR 2.4, p < 0.001), and β0 ≥ 3 (HR 2.0, p = 0.009). Dividing HF patients for LV ejection fraction, β0 and AIx75 appeared to be accurate prognostic predictors among the three different classes according to free-event survival. Conclusions: The non-invasive measurements of arterial stiffness proved to be strong prognostic parameters in HF patients discharged after an acute HF decompensation.

Determining patterns of vascular function and structure in wild-type transthyretin cardiac amyloidosis. A comparative study

BACKGROUND

The impact of wild-type transthyretin-related cardiac amyloidosis (ATTRwt) on functional and structural peripheral vascular measures is unknown. In the present study, we explored patterns of vascular dysfunction in patients with ATTRwt in comparison to diseases with similar cardiac phenotype.

METHODS

Treatment-naïve patients with ATTRwt (n = 32) were compared to: 1. Age-and sex-matched reference population without amyloidosis (n = 32), 2. Age-and sex-matched patients with systemic AL amyloidosis (n = 32), and 3. patients with cardiac AL amyloidosis (AL-HF, n = 23) or elderly patients with heart failure with preserved ejection fraction (HFpEF) (n = 16). All subjects underwent peripheral vascular assessment using carotid artery ultrasonography, brachial artery flow-mediated dilation (FMD), measurement of arterial stiffness and aortic hemodynamics including heart rate-adjusted time of return of reflected waves (Tr/HR).

RESULTS

After adjustment for traditional cardiovascular risk factors and coronary artery disease (core model), peripheral and aortic blood pressures (BP) were lower in patients with ATTRwt (p < 0.05) whereas other vascular markers were preserved compared to the reference non-amyloidosis group. ATTRwt was independently associated with lower BP and longer Tr/HR compared to AL. Compared to AL-HF, FMD was lower in ATTRwt (p = 0.033). ATTRwt patients had lower BP and higher Tr/HR than HFpEF (p < 0.05). By ROC analysis, Tr/HR discriminated ATTRwt vs. AL-HF (sensitivity 93%, specificity 75%) and HFpEF (sensitivity 100%, specificity 94%) and lower FMD increased the likelihood for ATTRwt at low Tr/HR values.

CONCLUSION

ATTRwt patients present a distinct peripheral vascular fingerprint which is different from AL-HF or HFpEF, consisting of lower peripheral and aortic BP, prolonged Tr/HR and FMD at reference-population range.

Impact of Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors on Arterial Stiffness and Vascular Aging-What Do We Know So Far? (A Narrative Review)

Vascular aging, early vascular aging or supernormal vascular aging are concepts used for estimating the cardiovascular risk at a certain age. From the famous line of Thomas Sydenham that "a man is as old as his arteries" to the present day, clinical studies in the field of molecular biology of the vasculature have demonstrated the active role of vascular endothelium in the onset of cardiovascular diseases. Arterial stiffness is an important cardiovascular risk factor associated with the occurrence of cardiovascular events and a high risk of morbidity and mortality, especially in the presence of diabetes. Sodium-glucose cotransporter 2 inhibitors decrease arterial stiffness and vascular resistance by decreasing endothelial cell activation, stimulating direct vasorelaxation and ameliorating endothelial dysfunction or expression of pro-atherogenic cells and molecules.

Association of arterial stiffness and heart failure with preserved ejection fraction in the elderly population - results from the CARLA study

Arterial stiffness has been suspected as a cause of left ventricular diastolic dysfunction and may thereby contribute to the development of heart failure with preserved ejection fraction (HFpEF). However, this association is derived from a small number of studies and application of outdated criteria to diagnose HFpEF. This study aimed to investigate the association of arterial stiffness measured by the augmentation index (AIx) and criteria for diagnosing HFpEF according to the recommended HFA-PEFF score. Our analysis based on data from the first follow-up of the CARdiovascular Disease, Living and Ageing in Halle study. The current analysis included participants with available information about comorbidities and risk factors for HFpEF, parameters for calculation of the HFA-PEFF and noninvasive AIx estimated by applanation tonometry. The association of AIx and HFA-PEFF was investigated through descriptive and inductive statistics. A total of 767 participants were included in the analysis. AIx was associated with E/e', left ventricular wall thickness (LVWT), relative wall thickness, left ventricular mass index (LVMI) and NT-proBNP but not with e' or left atrial volume index. However, after adjustment for confounders, only LVMI and LVWT remained associated with AIx. Males with a high AIx had a 3.2-fold higher likelihood of HFpEF than those with a low AIx. In contrast, that association was not present in females. In summary, AIx is associated with the morphological domain of the HFA-PEFF score represented by LVMI and LVWT. Higher values of AIx are associated with a higher likelihood for HFpEF in elderly males but not in females.

Association between brachial-ankle pulse wave velocity and cardiovascular and cerebrovascular disease in different age groups

BACKGROUND

To investigate the association between brachial-ankle pulse wave velocity (baPWV) and cardiovascular and cerebrovascular disease (CVD) in different age groups.

METHODS

A total of 39 417 people, receiving Kailuan physical examination, completing baPWV examination from 2010 to 2017, with no history of CVD and atrial fibrillation, were selected as the observation objects. The population was categorized into one age group per 10 years, namely the <50, 50-59, 60-69, 70-79, and ≥80-year-old groups, and the total population, and each group was further assigned into three classes according to the triple quartiles of baPWV. Kaplan-Meier method helped to calculate the cumulative incidence of CVD in different age groups. The effect of baPWV on CVD in different age groups was evaluated using the Cox proportional hazards regression model.

RESULTS

Kaplan-Meier survival curve indicated statistical significance (p < .05) in the cumulative incidence of CVD among the whole population, <50, 50-59, and 60-69-year-old groups, while the cumulative incidence of end-point events among the baPWV subgroups of 70-79 and ≥80-year-old groups exhibited no statistical significance (p > .05). Compared with baPWV in the Q1 group, hazard ratio value (95% confidence interval [CI]) of CVD in the Q3 group was 4.14 (95% CI: 2.98-5.75) in the total population, 2.98 (95% CI: 1.08-8.21) in <50-year-old population, 4.49 (95% CI: 2.89-7.00) in 50-59-year-old population, 2.78 (95% CI: 1.76-4.39) in 60-69-year-old population, 1.39 (95% CI: 0.86-2.24) in 70-79-year-old population, and 1.15 (95% CI: 0.55-2.41) in ≥80-year-old population.

CONCLUSION

CVD risk attributed to increased arterial stiffness reduces with age.

Cardio-Ankle Vascular Index and Heart Failure Hospitalization in Patients With Aortic Stenosis Following Transcatheter Aortic Valve Implantation

Background: The cardio-ankle vascular index (CAVI) is associated with the severity of vascular stiffness and heart failure (HF). However, little is known about CAVI in aortic stenosis (AS) patients, probably because of the difficulty of accurately measuring CAVI in these patients owing to their slow-rising pulse. In this study, we investigated the prevalence and prognostic impact of abnormally elevated CAVI measured after transcatheter aortic valve implantation (TAVI).

Methods and Results: Among patients with AS who underwent TAVI, those with bilateral peripheral artery disease, atrial fibrillation, and systolic HF were excluded. The effect of post-TAVI elevated CAVI (defined as ≥9.0) on HF readmission after the index discharge was investigated. In all, 149 patients (mean [±SD] age 84.8±5.6 years, 24.2% men, mean [±SD] post-TAVI CAVI 9.6±1.4) were included in the study. There was no significant difference in baseline characteristics between groups with and without elevated CAVI, except for lower high-density lipoprotein cholesterol (HDL-C) and a higher prevalence of HF history in the group with elevated CAVI (P<0.05 for both). Post-TAVI elevated CAVI (n=102) was associated with lower freedom from HF recurrence during the observational period (89.1% vs. 100%; median 726 days [interquartile range 329–1,104 days]; P<0.05). Moreover, CAVI was an independent predictor of HF occurrence (hazard ratio 1.62; 95% confidence interval 1.07–2.46; P=0.022).

Conclusions: Elevated CAVI was associated with HF occurrence before and after TAVI.

Cardiovascular function in 8- to 9-year-old singletons born after ART with frozen and fresh embryo transfer

STUDY QUESTION

Do 8- to 9-year-old singletons conceived after frozen embryo transfer (FET) or fresh embryo transfer (Fresh-ET) have increased arterial stiffness compared to naturally conceived (NC) children?

SUMMARY ANSWER

The process of FET or Fresh-ET is not associated with altered cardiovascular function in 8- to 9-year-old singletons, including arterial stiffness, as compared to NC children.

WHAT IS KNOWN ALREADY

ART has been suggested to influence cardiovascular risk factors (i.e. endothelial dysfunction, increased arterial blood pressure and insulin resistance). It is not known if ART procedures alter arterial stiffness in singletons.

STUDY DESIGN, SIZE, DURATION

A cohort study was carried out, including 8- to 9-year-old singletons conceived after FET, Fresh-ET and NC children (50 children in each group). This study was conducted between November 2018 and August 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In total, 150 singletons were identified through the Danish IVF Registry and the Medical Birth Registry. They underwent cardiac magnetic resonance imaging (CMR) and anthropometric measurements. Parental data were collected using questionnaires. NC children were matched by sex and birth year with FET/Fresh-ET children. Exclusion criteria were congenital heart disease, maternal gestational diabetes or maternal diabetes mellitus. Our primary outcome was arterial stiffness, which is assessed from noninvasive arterial blood pressure and aortic ascendens distensibility. The secondary outcome was the pulse wave velocity of total aorta and exploratory outcomes were left ventricular ejection fraction, mean arterial pressure, cardiac output and total peripheral resistance. Measurements and analyses were performed blinded to the child group.

MAIN RESULTS AND THE ROLE OF CHANCE

Aortic ascendens distensibility of children conceived after FET and Fresh-ET did not differ from NC children (mean (SD): FET 11.1 (3.6) 10-3 mmHg-1, Fresh-ET 11.8 (3.0) 10-3 mmHg-1, NC 11.4 (2.8) 10-3 mmHg-1, P > 0.05). Multivariate linear regression was performed to adjust for potential confounders (i.e. child sex and age, maternal BMI at early pregnancy and maternal educational level). Data showed no statistically significant differences between study groups and aortic ascendens distensibility. However, the fully adjusted model showed a non-significant tendency of lowered aortic ascendens distensibility in children born after FET compared to Fresh-ET (β estimate (95% CI): -0.99 10-3 mmHg-1 (-2.20; 0.21)) and NC children (β estimate (95% CI): -0.77 10-3 mmHg-1 (-1.98; 0.44)). Lastly, secondary and exploratory outcomes did not differ between the groups. Primary and secondary outcomes showed good intra-rater reliability.

LIMITATIONS, REASONS FOR CAUTION

This study is possibly limited by potential selection bias as the participation rate was higher in the ART compared to the NC group. Also, in some variables, the study groups differed slightly from the non-participant population. The non-participant population (n = 1770) included those who were excluded, not invited to CMR scan, or declined to participate in this study.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings indicate that children born after FET or Fresh-ET do not have altered cardiovascular function, including arterial stiffness. This is reassuring for the future use of ART.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Novo Nordisk Foundation (grant reference number: NNF19OC0054340) and The Research Foundation of Rigshospitalet. All authors declared no conflict of interests.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT03719703.

X-box Binding Protein 1: An Adaptor in the Pathogenesis of Atherosclerosis

Atherosclerosis (AS), the formation of fibrofatty lesions in the vessel wall, is the primary cause of heart disease and stroke and is closely associated with aging. Disrupted metabolic homeostasis is a primary feature of AS and leads to endoplasmic reticulum (ER) stress, which is an abnormal accumulation of unfolded proteins. By orchestrating signaling cascades of the unfolded protein response (UPR), ER stress functions as a double-edged sword in AS, where adaptive UPR triggers synthetic metabolic processes to restore homeostasis, whereas the maladaptive response programs the cell to the apoptotic pathway. However, little is known regarding their precise coordination. Herein, an advanced understanding of the role of UPR in the pathological process of AS is reviewed. In particular, we focused on a critical mediator of the UPR, X-box binding protein 1 (XBP1), and its important role in balancing adaptive and maladaptive responses. The XBP1 mRNA is processed from the unspliced isoform (XBP1u) to the spliced isoform of XBP1 (XBP1s). Compared with XBP1u, XBP1s predominantly functions downstream of inositol-requiring enzyme-1α (IRE1α) and transcript genes involved in protein quality control, inflammation, lipid metabolism, carbohydrate metabolism, and calcification, which are critical for the pathogenesis of AS. Thus, the IRE1α/XBP1 axis is a promising pharmaceutical candidate against AS.

Relationship Between Subclinical Cardiovascular Diseases and Cardiac Morpho-Functional Parameters in Preclinical Stage A/B Heart Failure Adults with Type 2 Diabetes

PURPOSE

Type 2 diabetes mellitus (T2DM) is a common risk factor for cardiovascular disease which increases the risk of heart failure. This study aimed to determine whether clinical characteristics and subclinical cardiovascular disease (CVD) features are correlated with echocardiographic morpho-functional parameters of T2DM patients.

PATIENTS AND METHODS

Two hundred and fifty-five T2DM patients without a history of coronary heart disease were enrolled in this cross-sectional study. The demographic characteristics, glucose and lipid levels were assessed for each patient. Carotid ultrasonography and peripheral artery examination were performed to measure carotid intima-media thickness (cIMT), carotid plaque, ankle-brachial index (ABI), brachial artery pulse wave velocity (baPWV), and carotid-femoral pulse wave velocity (cfPWV). Furthermore, echocardiography was conducted to evaluate cardiac morphology and systolic and diastolic function. The relationship between clinical characteristics, subclinical cardiovascular diseases, and cardiac morpho-functional parameters was explored with the Pearson and stepwise multivariable linear regression analyses.

RESULTS

A total of 255 subjects aged 18-80 years were enrolled in the study. Multiple regression analysis revealed that left ventricular mass index (LVMI) was correlated with age (β=0.463, p = 0.000) and systolic blood pressure (SBP) (β=0.179, p = 0.003). Relative wall thickness (RWT) was related to cfPWV (β=0.006, p = 0.007) and homeostasis model assessment of insulin resistance (HOMA-IR) (β=0.000, p = 0.036). In contrast, left ventricular ejection fraction (LVEF) was inversely related to cIMT (β=-0.925, p = 0.019). The ratio of the peak flow velocity of early diastole to atrial contraction (peak E/A) was correlated with age (β=-0.014, p = 0.000), diastolic blood pressure (DBP) (β=-0.006, p = 0.001) and cfPWV (β=-0.025, p = 0.044).

CONCLUSION

In preclinical stage A/B heart failure adults with T2DM, age, BP, HOMA-IR, cfPWV and cIMT are correlated with cardiac morpho-functional parameters.

EAT Thickness as a Predominant Feature for Evaluating Arterial Stiffness in Patients with Heart Failure with Preserved Ejection Fraction

OBJECTIVE

Heart failure with preserved ejection fraction (HFpEF) is an intricacy heterogeneous syndrome. However, the association between EAT and arterial stiffness in HFpEF patients remains unknown.

METHODS

A total of 102 patients were enrolled into the study, and brachial-ankle pulse-wave velocity (baPWV), epicardial adipose tissue (EAT) and body composition were assessed. Linear regression analysis was carried out to model the relationship between variables (especially EAT thickness) and baPWV.

RESULTS

The results showed that patients with the thicker EAT fat pad (≥3.55 mm) tended to have comorbidities of hypertension, coronary artery disease (CAD), diabetes and hyperlipidemia, also with a higher level of obesity, fasting blood glucose (FBG), glycosylated hemoglobin (HbA1c), total cholesterol (TC) and triglyceride (TG). The level of baPWV was higher in EAT ≥3.55 mm group than the other group. BaPWV was positively associated with EAT, age, heart rate, waist circumference, visceral fat area, systolic and diastolic blood pressure, CRP and FBG. After adjusting for EAT, age and visceral fat area, EAT thickness (β = 0.256, P = 0.009) and visceral fat area (β = 0.229, P = 0.036) significantly associated with baPWV.

CONCLUSION

The study assessed for the first time that the increased EAT thickness was closely related with baPWV in HFpEF patients, suggesting patients with the thicker EAT may be independently associated with arterial stiffness under the context of HFpEF.

Effects of the sodium-glucose cotransporter 2 inhibitor empagliflozin on vascular function in patients with chronic heart failure

AIMS

Impairment of vascular function contributes to the progression of chronic heart failure (HF) by increasing the afterload. Treatment with selective sodium-glucose cotransporter 2 (SGLT2) inhibitors improves the prognosis of HF, but the precise mechanisms remain unclear. The aim of this study was to analyse the effect of empagliflozin on vascular function in patients with HF.

METHODS AND RESULTS

In an investigator initiated, double-blind, randomized, placebo-controlled, parallel-group, clinical study, patients with HF NYHA II-III and an ejection fraction of 49% or less were randomized 2:1 to receive empagliflozin 10 mg once daily or placebo for 3 months. A total of 74 patients (15% female), aged 66 ± 9 years, with a mean ejection fraction of 39 ± 8% and a median NTproBNP of 558 pg/mL (IQR 219-1051 pg/mL), were included. Vascular parameters such as central systolic blood pressure (cSBP), central pulse pressure (cPP), forward (FPH), and reflected pressure pulse height (RPH) decreased under resting conditions after 1 and 3 months (1 month: cSBP -6.4 ± 8.3 mmHg, P < 0.001, cPP -3.0 ± 6.6 mmHg, P = 0.004, FPH -2.5 ± 4.5 mmHg, P = 0.001, RPH -1.6 ± 3.0 mmHg, P = 0.001; 3 months: cSBP -4.6 ± 8.4 mmHg, P = 0.001, cPP -3.1 ± 4.8 mmHg, P < 0.001, FPH -1.7 ± 3.7 mmHg, P = 0.004, RPH -1.4 ± 2.5 mmHg, P = 0.001) in patients treated with empagliflozin (n = 45). In accordance, cSBP and cPP decreased in patients with empagliflozin treatment under 24 h ambulatory conditions after 1 and 3 months (1 month: cSBP -4.8 ± 10.1 mmHg, P = 0.003, cPP -2.0 ± 5.7 mmHg, P = 0.026; 3 months: cSBP -4.7 ± 9.0 mmHg, P = 0.002, cPP -2.1 ± 6.4 mmHg, P = 0.044). In the placebo group, there was no significant change after 1 and 3 months. The decrease in cSBP under resting conditions (-5.7 ± 2.4 mmHg, P = 0.019) after 1 month and in cSBP (-6.0 ± 2.6, P = 0.027) as well as in pulse wave velocity (-0.5 ± 0.2 m/s, P = 0.021) under 24 h ambulatory conditions after 3 months was greater in the empagliflozin group than in the placebo group.

CONCLUSIONS

We found an improvement of vascular function after treatment with empagliflozin that indicates decreased afterload of the left ventricle and may contribute to the beneficial effects of SGLT2 inhibition in HF.

Effects of different exercise programs on cardiorespiratory reserve in HFpEF: a systematic review and meta-analysis

HFpEF represents an heterogeneous syndrome with complex pathophysiologic substrate and multiple clinical manifestations. Much attention has been recently focused on cardiac rehabilitation programs for HFpEF patients and studies have examined the effects of exercise training on this specific population. This systematic review and meta-analysis included studies of adult patients with HFpEF and evaluated the impact of exercise on cardiorespiratory fitness variables measured during CPET. The primary outcome was the difference between groups in the change of peak oxygen uptake (Δpeak VO₂). Literature search involved PubMed/MEDLINE, Cochrane/CENTRAL and Scopus databases. From an initial 5,143 literature records, we identified 18 studies fulfilling inclusion criteria; 11 studies with 515 patients were finally included in primary outcome analysis. Δpeak VO₂ between baseline and study-end was significantly higher in the groups of exercise training versus control (WMD 2.25 ml/kg/min, 95%CI 1.81-2.70). Exercise training resulted in greater change in the 6MWT distance (WMD 2.25 meters, 95%CI 1.81-2.70). Health related quality of life (WMD: -3.36, 95%CI -9.42-2.70, I²=14%, p=0.33) and echocardiographic indexes of diastolic function showed no differences between exercise and control groups at study end. In subgroup analysis, no difference between resistance versus aerobic exercise was noted on Δpeak VO₂, but high intensity interval training showed greater increase in peak VO₂ versus aerobic exercise (WMD 1.62 ml/kg/min, 95%CI 0.96-2.29, I²=0%, p=0.82). Exercise training in HFpEF results in significant improvements in peak VO₂ and 6MWT distance compared to controls. High intensity interval training may offer greater enhancement of exercise capacity of these patients than standard aerobic exercise.

High vitamin K status is prospectively associated with decreased left ventricular mass in women: the Hoorn Study

Background

Vitamin K is associated with reduced cardiovascular disease risk such as heart failure, possibly by carboxylation of matrix-gla protein (MGP), a potent inhibitor of vascular calcification. The relationship of vitamin K intake or status with cardiac structure and function is largely unknown. Therefore this study aims to investigate the prospective association of vitamin K status and intake with echocardiographic measures.

Methods

This study included 427 participants from the Hoorn Study, a population-based cohort. Vitamin K status was assessed at baseline by plasma desphospho-uncarboxylated MGP (dp-ucMGP) with higher concentrations reflecting lower vitamin K status. Vitamin K intake was assessed at baseline with a validated food-frequency questionnaire. Echocardiography was performed at baseline and after a mean follow-up time of 7.6, SD=±0.7 years. We used linear regression for the association of vitamin K status and intake with left ventricular ejection fraction (LVEF), left atrial volume index (LAVI) and left ventricular mass index (LVMI), adjusted for potential confounders.

Results

The mean age was 66.8, SD=±6.1 years (51% were male). A high vitamin K status was prospectively associated with decreased LVMI (change from baseline to follow-up: -5.0, 95% CI: -10.5;0.4 g/m^2.7) for the highest quartile compared to the lowest in women (P-interaction sex=0.07). No association was found in men. Vitamin K status was not associated with LVEF or LAVI. Vitamin K intake was not associated with any of the echocardiographic measures.

Conclusions

This study showed a high vitamin K status being associated with decreased LVMI only in women, while intakes of vitamin K were not associated with any cardiac structure or function measures. These results extend previous findings for a role of vitamin K status to decrease heart failure risk.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12937-021-00742-0.

Association Between Arterial Stiffness and Heart Failure With Preserved Ejection Fraction

Cardiovascular diseases are the leading cause of mortality in the world. Heart failure with preserved ejection fraction (HFpEF) accounts for about half of all heart failure. Unfortunately, the mechanisms of HFpEF are still unclear, leading to little progress of effective treatment of HFpEF. Arterial stiffness is the decrement of arterial compliance. The media of large arteries degenerate in both physiological and pathological conditions. Many studies have proven that arterial stiffness is an independent risk factor for cardiovascular disorders including diastolic dysfunction. In this perspective, we discussed if arterial stiffness is related to HFpEF, and how does arterial stiffness contribute to HFpEF. Finally, we briefly summarized current treatment strategies on arterial stiffness and HFpEF. Though some new drugs were developed, the safety and effectiveness were not adequately assessed. New pharmacologic treatment for arterial stiffness and HFpEF are urgently needed.

Hemodynamic arterial changes in heart failure: a proposed new paradigm of "Heart and Vessels Failure (HVF)"

BACKGROUND

Although heart failure (HF) is one of the most common conditions affecting the heart, little attention has been placed on the role of arteries in contributing to the progression of this disease. We sought to determine the hemodynamic change of arteries in HF patients subdivided according to left ventricular ejection fraction. The major goal was to establish the active compensatory role of arteries in HF.

METHODS

Using sphygmography, we systematically studied a cohort of 228 HF patients and 52 healthy controls. We focused on the common carotid as the main elastic artery and the posterior tibial as the main muscular artery. Moreover, we categorized the three HF groups, HFrEF, HFmrEF, HFpEF, into two subgroups (A and B) according to the presence or absence of HF signs at baseline.

RESULTS

We discovered that all the parameters of measured arterial kinetics, i.e., work, power, acceleration, and speed, were significantly increased (p<0.001 by one-way ANOVA) in the groups without HF signs. In contrast, all the arterial kinetics parameters were significantly reduced (p<0.001) in the groups exhibiting HF signs. Similar results were obtained in both types of arteries and were consistently observed across all the three different types of HF, although with some differences in magnitude. Finally, we discovered that HFpEF patients exhibited more compromised arterial function vis-à-vis HFrEF patients.

CONCLUSIONS

We provide the first documentation of an active compensatory role of arteries during HF. Mechanistically, we explain these findings by a dual activity of large arteries accomplished via an active propulsive work and a concurrent hemodynamic suction. These underestimated arterial functions partially compensate for the heart dysfunction in HF, underlining a key interplay between the heart and the vessels. We propose a new paradigm that we define as "heart and vessels failure" that explicitly focuses on both heart and vessels' interaction during the progression of HF.

Contribution of Gut Microbiota-Derived Uremic Toxins to the Cardiovascular System Mineralization

Chronic kidney disease (CKD) affects more than 10% of the world population and leads to excess morbidity and mortality (with cardiovascular disease as a leading cause of death). Vascular calcification (VC) is a phenomenon of disseminated deposition of mineral content within the media layer of arteries preceded by phenotypic changes in vascular smooth muscle cells (VSMC) and/or accumulation of mineral content within the atherosclerotic lesions. Medial VC results in vascular stiffness and significantly contributes to increased cardio-vascular (CV) morbidity, whereas VC of plaques may rather increase their stability. Mineral and bone disorders of CKD (CKD-MBD) contribute to VC, which is further aggravated by accumulation of uremic toxins. Both CKD-MBD and uremic toxin accumulation affect not only patients with advanced CKD (glomerular filtration rate (GFR) less than 15 mL/min/1.72 m², end-stage kidney disease) but also those on earlier stages of a disease. The key uremic toxins that contribute to VC, i.e., p-cresyl sulphate (PCS), indoxyl sulphate (IS) and trimethylamine-N-oxide (TMAO) originate from bacterial metabolism of gut microbiota. All mentioned toxins promote VC by several mechanisms, including: Transdifferentiation and apoptosis of VSMC, dysfunction of endothelial cells, oxidative stress, interaction with local renin–angiotensin–aldosterone system or miRNA profile modification. Several attractive methods of gut microbiota manipulations have been proposed in order to modify their metabolism and to limit vascular damage (and VC) triggered by uremic toxins. Unfortunately, to date no such method was demonstrated to be effective at the level of “hard” patient-oriented or even clinically relevant surrogate endpoints.