Demographics and concomitant disorders in heart failure

Interpretable machine learning for 28-day all-cause in-hospital mortality prediction in critically ill patients with heart failure combined with hypertension: A retrospective cohort study based on medical information mart for intensive care database-IV and eICU databases

Background

Heart failure (HF) combined with hypertension is an extremely important cause of in-hospital mortality, especially for the intensive care unit (ICU) patients. However, under intense working pressure, the medical staff are easily overwhelmed by the large number of clinical signals generated in the ICU, which may lead to treatment delay, sub-optimal care, or even wrong clinical decisions. Individual risk stratification is an essential strategy for managing ICU patients with HF combined with hypertension. Artificial intelligence, especially machine learning (ML), can develop superior models to predict the prognosis of these patients. This study aimed to develop a machine learning method to predict the 28-day mortality for ICU patients with HF combined with hypertension.

Methods

We enrolled all critically ill patients with HF combined with hypertension in the Medical Information Mart for IntensiveCare Database-IV (MIMIC-IV, v.1.4) and the eICU Collaborative Research Database (eICU-CRD) from 2008 to 2019. Subsequently, MIMIC-IV was divided into training cohort and testing cohort in an 8:2 ratio, and eICU-CRD was designated as the external validation cohort. The least absolute shrinkage and selection operator (LASSO) Cox regression with internal tenfold cross-validation was used for data dimension reduction and identifying the most valuable predictive features for 28-day mortality. Based on its accuracy and area under the curve (AUC), the best model in the validation cohort was selected. In addition, we utilized the Shapley Additive Explanations (SHAP) method to highlight the importance of model features, analyze the impact of individual features on model output, and visualize an individual’s Shapley values.

Results

A total of 3,458 and 6582 patients with HF combined with hypertension in MIMIC-IV and eICU-CRD were included. The patients, including 1,756 males, had a median (Q1, Q3) age of 75 (65, 84) years. After selection, 22 out of a total of 58 clinical parameters were extracted to develop the machine-learning models. Among four constructed models, the Neural Networks (NN) model performed the best predictive performance with an AUC of 0.764 and 0.674 in the test cohort and external validation cohort, respectively. In addition, a simplified model including seven variables was built based on NN, which also had good predictive performance (AUC: 0.741). Feature importance analysis showed that age, mechanical ventilation (MECHVENT), chloride, bun, anion gap, paraplegia, rdw (RDW), hyperlipidemia, peripheral capillary oxygen saturation (SpO₂), respiratory rate, cerebrovascular disease, heart rate, white blood cell (WBC), international normalized ratio (INR), mean corpuscular hemoglobin concentration (MCHC), glucose, AIDS, mean corpuscular volume (MCV), N-terminal pro-brain natriuretic peptide (Npro. BNP), calcium, renal replacement therapy (RRT), and partial thromboplastin time (PTT) were the top 22 features of the NN model with the greatest impact. Finally, after hyperparameter optimization, SHAP plots were employed to make the NN-based model interpretable with an analytical description of how the constructed model visualizes the prediction of death.

Conclusion

We developed a predictive model to predict the 28-day mortality for ICU patients with HF combined with hypertension, which proved superior to the traditional logistic regression analysis. The SHAP method enables machine learning models to be more interpretable, thereby helping clinicians to better understand the reasoning behind the outcome and assess in-hospital outcomes for critically ill patients.

Inflammation-based assessment for the risk stratification of mortality in patients with heart failure

The Glasgow Prognostic Score (GPS) has been established as a useful resource to evaluate inflammation and malnutrition and predict prognosis in several cancers. However, its prognostic significance in patients with heart failure (HF) is not well established. To investigate the association between the GPS and mortality in patients with HF, we assessed 870 patients who were 20 years old and more and had been admitted for acute decompensated HF. The GPS ranged from 0 to 2 points as previously reported. Over the 18-month follow-up (follow-up rate, 83.9%), 143 patients died. Increasing GPS was associated with higher HF severity assessed by New York Heart Association functional class and B-type natriuretic peptide (BNP) levels. Kaplan–Meier analysis showed significant associations for mortality and increased GPS. In multivariate analysis, compared to the GPS 0 group, the GPS 2 group was associated with high mortality (hazard ratio 2.92, 95% confidence interval 1.77–4.81, p < 0.001) after adjustment for age, sex, blood pressure, HF history, HF severity, hemoglobin, renal function, sodium, BNP, left ventricular ejection fraction, and anti-HF medications. In conclusion, high GPS was significantly associated with worse prognosis in patients with HF. Inflammation-based assessment by the GPS may enable simple evaluation of HF severity and prognosis.

Impact of stroke work on the ability of left ventricular mass to account for pressure effects on function in a community with prevalent systemic flow-dependent hypertension

AIMS

To determine whether the confounding influence of stroke work on left ventricular mass (LVM) limits the ability of LVM to detect hypertensive LV dysfunction in systemic flow-dependent hypertension.

METHODS

In a community with prevalent systemic flow-dependent hypertension (n = 709), arterial haemodynamics, LVM and LV function were determined using central arterial pressure, aortic velocity and diameter measurements in the outflow tract, and echocardiography with tissue Doppler imaging.

RESULTS

In multivariate models, stroke work showed markedly stronger relations with LVM index (LVMI) than blood pressure load [central arterial SBP (SBPc), backward wave pressure (Pb), 24-h SBP] (P < 0.0001 for comparisons). In contrast, although SBPc, Pb, and 24-h SBP were inversely associated with myocardial tissue shortening (s') and lengthening (e') velocity, stroke work was not. With adjustments for stroke work, positive relationships between SBPc, Pb, or 24-h SBP and LVMI were eliminated (P = 0.20 to P = 0.89), but strong relations between BP and s', e' or E/e' (P = 0.009 to P < 0.0001) remained. In mediation analysis, stroke work fully accounted for BP effects on LVMI, but explained none of the effects of BP on LV function. Hence LVMI accounted for little of the impact of BP load on LV function. Although LVMI beyond stroke work (inappropriate LVM) improved on relations between LVMI and s', it failed to improve on relations with e' or E/e' and contributed little beyond LVMI to the impact of BP on LV function.

CONCLUSION

In systemic flow-dependent hypertension, the impact of stroke work markedly limits the ability of LVM to account for adverse effects of hypertension on LV function.

Heart Failure: A Palliative Medicine Review of Disease, Therapies, and Medications With a Focus on Symptoms, Function, and Quality of Life

Despite significant advances in heart failure (HF) treatment, HF remains a progressive, extremely symptomatic, and terminal disease with a median survival of 2.1 years after diagnosis. HF often leads to a constellation of symptoms, including dyspnea, fatigue, depression, anxiety, insomnia, pain, and worsened cognitive function. Palliative care is an approach that improves the quality of life of patients and their caregivers facing the problems associated with life-threatening illness and therefore is well suited to support these patients. However, historically, palliative care has often focused on supporting patients with malignant disease, rather than a progressive chronic disease such as HF. Predicting mortality in patients with HF is challenging. The lack of obvious transition points in disease progression also raises challenges to primary care providers and specialists to know at what point to integrate palliative care during a patient's disease trajectory. Although therapies for HF often result in functional and symptomatic improvements including health-related quality of life (HRQL), some patients with HF do not demonstrate these benefits, including those patients with a preserved ejection fraction. Provision of palliative care for patients with HF requires an understanding of HF pathogenesis and common medications used for these patients, as well as an approach to balancing life-prolonging and HRQL care strategies. This review describes HF and current targeted therapies and their effects on symptoms, hospital admission rates, exercise performance, HRQL, and survival. Pharmacological interactions with and precautions related to commonly used palliative care medications are reviewed. The goal of this review is to equip palliative care clinicians with information to make evidence-based decisions while managing the balance between optimal disease management and patient quality of life.

Complement Components sC5b-9 and CH50 Predict Prognosis in Heart Failure Patients Combined With Hypertension

BACKGROUND

Heart failure (HF), resulting from inflammation and vessel injury, is one of the leading causes of poor quality of life and premature death. The complement system plays a leading role in vessel integrity and inflammation response. However, the association between serum complement level and the prognosis of HF remains unclear.

METHODS

In our study, a total of 263 newly diagnosed hypertension patients with HF were included. Eight classical cardiovascular risk factors were collected, and plasma C3a, C3b, C5a, sC5b-9, and CH50 levels were detected.

RESULTS

Compared with the control group, plasma C5a (P<0.001), sC5b-9 (P<0.001), and CH50 (P = 0.004) levels of hypertension patients with HF were significantly increased. On the basis of univariate analysis, an older age, higher frequency of alcohol consumption, high level of body mass index, medium or high risk of hypertension, hyperlipidemia, and diabetes were poor prognostic factors whereas low levels of C5a, sC5b-9, and CH50 were associated with favorable overall survival (OS). When these factors fit into a multivariate regression model, patients with hyperlipidemia (P = 0.002, hazard ratio [HR] = 3.09), N-terminal pro-Brain Natriuretic Peptide (NT-pro-BNP) ≥ 14.8 (P < 0.001, HR = 11.14), sC5b-9 level ≥ 1,406.2 µg/ml (P = 0.180, HR = 5.51) or CH50 level ≥ 294.6 µg/ml (P < 0.001, HR = 4.57) remained statistically factors for worsened OS and regarded as independent risk factors. These independently associated risk factors were used to form an OS estimation nomogram. Nomogram demonstrated good accuracy in estimating the risk, with a bootstrap-corrected C index of 0.789.

CONCLUSIONS

sC5b-9 and CH50 levels are increased in hypertension patients with HF. Nomogram based on multivariate analysis has good accuracy in estimating the risk of OS.

The role of sodium glucose cotransporter-2 (SGLT-2) inhibitors in heart failure and chronic kidney disease in type 2 diabetes

Background: Heart failure (HF) and chronic kidney disease (CKD) are responsible for substantial morbidity and mortality in individuals with type 2 diabetes (T2D). Methods: This review discusses the significance of these comorbidities of T2D and current options for managing them, with a focus on sodium-glucose cotransporter-2 (SGLT-2) inhibitors. Based on a focused literature search of cardiovascular outcomes trials (CVOTs), this review assessed the effects of SGLT-2 inhibitors in individuals with T2D with or without established cardiovascular disease (CVD). Results: In addition to effective glycemic control and weight loss, SGLT-2 inhibitor treatment of T2D prevents adverse cardiovascular and renal outcomes in individuals with and without these comorbidities. Reduced rate of hospitalization due to HF (HHF) and improved renal outcomes appear to be class effects of SGLT-2 inhibitors. Reduction in CV events may be more significant in individuals with established cardiovascular disease. Conclusions: CVOTs and other studies confirm that the SGLT-2 inhibitors, mostly used in combination with other glucose-lowering drugs, offer several clinical benefits beyond improved glycemic control. These include reducing HHF risk and improving renal outcomes. HF and renal benefits are observed in individuals with and without established CVD, which may simplify therapeutic selection. Ongoing SGLT-2 inhibitor CVOTs will help clarify the potential of these drugs to treat T2D comorbid with different forms of HF (HF with preserved vs reduced ejection fraction) and different degrees of renal dysfunction, and in individuals with T2D vs pre-diabetes or normal glucose metabolism.

Prognostic Comparison of the Estimations of Renal Function in Patients With Acute Heart Failure

BACKGROUND

The prognostic significance of the eGFR calculated by either the four-level Race Chronic Kidney Disease-Epidemiology Collaboration study equation (CKD-EPI4R) or the Chinese-modified Modification of Diet in Renal Disease equation (cMDRD) has not been compared in Asian populations with acute heart failure (AHF).Methods and Results:A total of 3,044 patients hospitalized for AHF were enrolled. The National Death Registry was linked to identify deaths within a 5-year follow-up. Net reclassification improvement (NRI) was calculated to compare the prognostic value of either eGFR equation. During a median follow-up of 23.3 months, 1,424 (47%) patients died. Both eGFR_cMDRDand eGFR_CKD-EPI4Rwere independently predictive of death in the total study population (hazard ratio and 95% confidence intervals per 1-SD: 0.76, 0.71-0.81 and 0.74, 0.70-0.79, respectively), and in the subgroups of either reduced (HFrEF) or preserved (HFpEF) ejection fraction, after accounting for important confounders. With reference to eGFR_cMDRD, eGFR_CKD-EPI4Rmay improve the NRI by 2.0% (0.8-3.2%) for the prediction of death. The prognostic value of the CKD stages categorized by eGFR_CKD-EPI4Rsignificantly outperformed eGFR_cMDRDwith a categorical NRI of 9.5% (4.7-14.3%) in the total study population, 11.5% in HFrEF, and 8.3% in HFpEF.

CONCLUSIONS

Both eGFR_cMDRDand eGFR_CKD-EPI4Rwere independently associated with long-term survival in patients with AHF. However, the CKD stages derived from eGFR_CKD-EPI4Rimproved the risk stratification of death, compared with eGFR_cMDRD.

Predictors of cardiovascular outcome and rehospitalization in elderly patients with heart failure

BACKGROUND

Heart failure (HF) is a major public health problem and represents the only cardiac disease continuing to increase in prevalence, in particular among elderly patients. The frequent rehospitalizations have a negative impact on quality of life of patients with HF, constituting a substantial cost for patients and the health system. The aim of this review was to look into biochemical, echocardiographic and socioeconomical parameters as predictors of clinical outcomes and rehospitalizations.

METHODS

This narrative review is based on the material searched for and obtained via PubMed from January 2000 up to March 2018. The search terms we used were as follows: "elderly, heart failure, cardiovascular" in combination with "biomarker, echocardiography and hospitalization."

RESULTS

This review analyses the potential predictive role of biochemical and echocardiographic and socioeconomical parameters on clinical outcomes (particularly cardiovascular) and hospital readmissions in patients with chronic HF. We focused on risk stratification of elderly patients with HF, who constitute a category of frail subjects at higher risk for readmission to hospital.

CONCLUSIONS

In elderly subjects with chronic HF, the risk stratification could benefit of a multiparametric approach combining biochemical, echocardiographic, demographic and socioeconomical parameters, thus ensuring a better quality of life and at the same time a better allocation of financial resources.

Evaluation of Response Rate to Resynchronization Therapy: the Super-Responder

Cardiac resynchronization therapy (CRT) emerged as a therapeutic modality for patients with cardiac insufficiency (CI) refractory to pharmacological treatment. Over the last 20 years, several clinical studies have sought to establish their benefits in different populations. The review of the results of these studies has shown that in patients with advanced CI (functional class (FC) I, II, III and IV of the New York Heart Association (NYHA) CRT produces consistent improvements in quality of life, FC and exercise capacity, as well as reducing hospitalizations and mortality rates. Up to 70% of patients submitted to CRT evolve as responders. The criteria adopted in the evaluation of the CRT response rate will be elucidated in this article, in which the main objective is to highlight the concept of the CRT super-responder.

Avaliação da Taxa de Resposta à Terapia de Ressincronização: o Super-Respondedor

A terapia de ressincronização cardíaca (TRC) surgiu como modalidade terapêutica para pacientes com insufi ciência cardíaca (IC) refratária ao tratamento farmacológico. Ao longo dos últimos 20 anos, vários estudos clínicos buscaram estabelecer seus benefícios em diferentes populações. A revisão dos resultados desses estudos demonstrou que em pacientes com IC avançada [classes funcionais (CFs) I, II, III e IV da New York Heart Association (NYHA)] a TRC produz melhorias consistentes para a qualidade de vida, CF e capacidade de exercício, além de reduzir as hospitalizações e a taxa de mortalidade. Até 70% dos pacientes submetidos à TRC evoluem como respondedores. Os critérios adotados na avaliação da taxa de resposta à TRC serão elucidados neste artigo, no qual o objetivo maior é ressaltar o conceito do super-respondedor à TRC.

Role of Neprilysin Inhibitors in Heart Failure

Heart failure (HF) is a complex multifactorial medical condition that should be addressed according to its complexity and diversity. Currently, there is a medical arsenal available for the management of HF, but despite the advance in medical resources, its prevalence and social and financial impacts are still worrisome for the medical community and society. Among the numerous therapeutic options for the treatment of HF, neprilysin inhibitors have changed the perspective of the approach to titrate patients who suffer from this condition because neprilysin plays a role in the degradation of natriuretic peptides and various other vasoactive compounds that are crucial to counteract the devastating pathophysiology of HF. The purpose of this review was to analyze the role of neprilysin inhibitors in HF, focusing on newer therapy such as LCZ696 and studies that sustain its potential benefits in this medical entity.

Comorbidity health pathways in heart failure patients: A sequences-of-regressions analysis using cross-sectional data from 10,575 patients in the Swedish Heart Failure Registry

BACKGROUND

Optimally treated heart failure (HF) patients often have persisting symptoms and poor health-related quality of life. Comorbidities are common, but little is known about their impact on these factors, and guideline-driven HF care remains focused on cardiovascular status. The following hypotheses were tested: (i) comorbidities are associated with more severe symptoms and functional limitations and subsequently worse patient-rated health in HF, and (ii) these patterns of association differ among selected comorbidities.

METHODS AND FINDINGS

The Swedish Heart Failure Registry (SHFR) is a national population-based register of HF patients admitted to >85% of hospitals in Sweden or attending outpatient clinics. This study included 10,575 HF patients with patient-rated health recorded during first registration in the SHFR (1 February 2008 to 1 November 2013). An a priori health model and sequences-of-regressions analysis were used to test associations among comorbidities and patient-reported symptoms, functional limitations, and patient-rated health. Patient-rated health measures included the EuroQol-5 dimension (EQ-5D) questionnaire and the EuroQol visual analogue scale (EQ-VAS). EQ-VAS score ranges from 0 (worst health) to 100 (best health). Patient-rated health declined progressively from patients with no comorbidities (mean EQ-VAS score, 66) to patients with cardiovascular comorbidities (mean EQ-VAS score, 62) to patients with non-cardiovascular comorbidities (mean EQ-VAS score, 59). The relationships among cardiovascular comorbidities and patient-rated health were explained by their associations with anxiety or depression (atrial fibrillation, odds ratio [OR] 1.16, 95% CI 1.06 to 1.27; ischemic heart disease [IHD], OR 1.20, 95% CI 1.09 to 1.32) and with pain (IHD, OR 1.25, 95% CI 1.14 to 1.38). Associations of non-cardiovascular comorbidities with patient-rated health were explained by their associations with shortness of breath (diabetes, OR 1.17, 95% CI 1.03 to 1.32; chronic kidney disease [CKD, OR 1.23, 95% CI 1.10 to 1.38; chronic obstructive pulmonary disease [COPD], OR 95% CI 1.84, 1.62 to 2.10) and with fatigue (diabetes, OR 1.27, 95% CI 1.13 to 1.42; CKD, OR 1.24, 95% CI 1.12 to 1.38; COPD, OR 1.69, 95% CI 1.50 to 1.91). There were direct associations between all symptoms and patient-rated health, and indirect associations via functional limitations. Anxiety or depression had the strongest association with functional limitations (OR 10.03, 95% CI 5.16 to 19.50) and patient-rated health (mean difference in EQ-VAS score, -18.68, 95% CI -23.22 to -14.14). HF optimizing therapies did not influence these associations. Key limitations of the study include the cross-sectional design and unclear generalisability to other populations. Further prospective HF studies are required to test the consistency of the relationships and their implications for health.

CONCLUSIONS

Identification of distinct comorbidity health pathways in HF could provide the evidence for individualised person-centred care that targets specific comorbidities and associated symptoms.

Improving kNowledge Transfer to Efficaciously RAise the level of Contemporary Treatment in Heart Failure (INTERACT-in-HF): Study protocol of a mixed methods study

Heart failure is a complex disease with poor outcome. This complexity may prevent care providers from covering all aspects of care. This could not only be relevant for individual patient care, but also for care organisation. Disease management programmes applying a multidisciplinary approach are recommended to improve heart failure care. However, there is a scarcity of research considering how disease management programme perform, in what form they should be offered, and what care and support patients and care providers would benefit most. Therefore, the Improving kNowledge Transfer to Efficaciously Raise the level of Contemporary Treatment in Heart Failure (INTERACT-in-HF) study aims to explore the current processes of heart failure care and to identify factors that may facilitate and factors that may hamper heart failure care and guideline adherence. Within a cross-sectional mixed method design in three regions of the North-West part of Europe, patients (n = 88) and their care providers (n = 59) were interviewed. Prior to the in-depth interviews, patients were asked to complete three questionnaires: The Dutch Heart Failure Knowledge scale, The European Heart Failure Self-care Behaviour Scale and The global health status and social economic status. In parallel, retrospective data based on records from these (n = 88) and additional patients (n = 82) are reviewed. All interviews were audiotaped and transcribed verbatim for analysis.

Budget impact of intravenous iron therapy with ferric carboxymaltose in patients with chronic heart failure and iron deficiency in Germany

Aims

Treatment of iron deficiency (ID) in patients with heart failure (HF) with intravenous iron substitution [ferric carboxymaltose (FCM)] has previously shown significant improvements in exercise capacity, New York Heart Association (NYHA) functional class, quality of life, and reduction of hospitalization. The aim of this study was to estimate the budget impact of FCM treatment for patients with HF and ID.

Methods and results

Individual patient data from four double‐blind randomized controlled trials were pooled for this analysis. Expected outcomes were modelled for a treatment period of 1 year, using multivariate statistical methods. Associated unit costs were derived from claims data. Budget impact was calculated from the perspective of the Statutory Health Insurance. Multiple deterministic sensitivity analyses were performed. The annual budget impact for therapy with FCM vs. no‐iron therapy was €2 735 505 and €2 695 474 for 1000 patients, respectively, resulting in additional annual costs of €40.03 for each treated patient. Main costs drivers are the FCM treatment cost and cost of hospitalizations due to HF worsening. FCM therapy compared with no‐iron therapy resulted in reduced cost per 1000 patients: for reduced hospitalization due to HF worsening (52 vs. 129 hospitalizations amounting to €230 591 vs. €597 078), for reduced other medication (€1 611 007 vs. €1 679 908), fewer outpatient visits (€332 523 vs. €378 019), and home visits (€29 627 vs. €40 469). Sensitivity analyses showed robustness of the results.

Conclusions

Therapy with FCM has a minimal budget impact of €40 031 per 1000 patients per year. This budget impact translates into reduced and shorter hospitalizations and improved symptomatic status of the patients.

Cryptotanshinone Inhibits STAT3 Signaling to Alleviate Cardiac Fibrosis in Type 1-like Diabetic Rats

Cryptotanshinone is an active principal ingredient isolated from Salvia miltiorrhiza (Danshen), a medicinal plant used in China to treat cardiac disorders. The objective of this study was to investigate the effect of cryptotanshinone on myocardial fibrosis in diabetic rats. In streptozotocin-induced type 1 diabetic model hyperglycemic rats (STZ-treated rats), fasting blood glucose levels and heart weight/body weight ratio were markedly increased but both were not modified by cryptotanshinone. Additionally, cardiac performance in catheterized STZ-treated rats was improved. The histological results from Masson staining showed that cryptotanshinone attenuated cardiac fibrosis in STZ-treated rats. Moreover, both the mRNA and protein levels of the signal transducer and activator of transcription 3 (STAT3), matrix metalloproteinase-9, and connective tissue growth factor were reduced by cryptotanshinone in high glucose-cultured cardiomyocytes, similar to the reductions observed in the hearts of STZ-treated rats. In conclusion, while STAT3 regulates matrix metalloproteinase-9 and connective tissue growth factor expression in diabetic rats with cardiac fibrosis, cryptotanshinone inhibited fibrosis to improve cardiac function by suppressing the STAT3 pathway. Cryptotanshinone is suitable as an alternative remedy for therapy of cardiac fibrosis. Copyright © 2017 John Wiley & Sons, Ltd.

Heart Failure Pharmacotherapy and Supports in the Elderly - A Short Review

Heart failure is predominantly a disease of the elderly with an increasing prevalence with increasing age. Increasing age is also associated with increased multi-morbidity such that elderly heart failure patients typically have five to six comorbidities in addition to heart failure. Elderly patients are also more likely to have heart failure with preserved ejection fraction (HFpEF), and there are fewer evidence-based treatments with proven efficacy in HFpEF. Hence the management of heart failure in these patients is largely about managing the symptoms of heart failure, along with the other cardiovascular and non-cardiovascular comorbidities. Any proposed treatments need to be considered for the potential for reduced benefit due to the competing risk of morbidity and mortality from the patient’s other conditions. In patients with heart failure, health related quality of life is impacted by both comorbidities and frailty, and frailty is associated with an increased risk of emergency department visits and hospitalisation. Frailty may also be associated with increased adverse reactions to medications. Although newer guidelines have more information on the management of these comorbidities there are still many areas of uncertainty and potential treatment conflicts. Further research is required on the interactions between different comorbidities, their treatments and heart failure and its management.

The association between atrial fibrillation and cognitive function in patients with heart failure

BACKGROUND

Atrial fibrillation (AF) is associated with cognitive impairment in heart failure (HF).

AIMS

The purpose of this study was to examine whether AF independently predicted cognitive function in HF patients after controlling for more demographic, medical and psychological characteristics, and whether the timing of AF onset in relation to HF diagnosis independently contributed to cognitive function in HF patients with AF.

METHODS

A total of 188 hospitalized HF patients (62.8% male, age 66.3±10.6 years) completed cognitive function assessment with the Montreal Cognitive Assessment (MoCA). A history of AF, along with other medical characteristics, was ascertained through a review of participants' medical charts. The timing of AF onset in relation to HF diagnosis was categorized into AF occurring prior to HF diagnosis (i.e. prior AF) and AF developing after HF diagnosis (i.e. incident AF).

RESULTS

Altogether 72 participants had a positive diagnostic history of AF. Specifically, 41 had prior AF, and 31 developed AF subsequently. In HF patients, AF was associated with poorer performance on cognitive function after controlling for more confounders (β=-0.112, ΔR²=0.010, p=0.046). Among HF patients with AF, incident AF independently predicted poorer cognitive function (β=-0.238, ΔR²=0.027, p=0.047).

CONCLUSION

AF independently contributes to cognitive function in HF patients after adjusting for more confounding variables. The timing of AF onset in relation to HF diagnosis independently predicts cognitive function in HF patients with AF. Prospective studies are needed to elucidate possible mechanisms for the association between AF and cognitive function in HF populations.

Clinical Update: Cardiovascular Disease in Diabetes Mellitus: Atherosclerotic Cardiovascular Disease and Heart Failure in Type 2 Diabetes Mellitus - Mechanisms, Management, and Clinical Considerations

Cardiovascular disease remains the principal cause of death and disability among patients with diabetes mellitus. Diabetes mellitus exacerbates mechanisms underlying atherosclerosis and heart failure. Unfortunately, these mechanisms are not adequately modulated by therapeutic strategies focusing solely on optimal glycemic control with currently available drugs or approaches. In the setting of multifactorial risk reduction with statins and other lipid-lowering agents, antihypertensive therapies, and antihyperglycemic treatment strategies, cardiovascular complication rates are falling, yet remain higher for patients with diabetes mellitus than for those without. This review considers the mechanisms, history, controversies, new pharmacological agents, and recent evidence for current guidelines for cardiovascular management in the patient with diabetes mellitus to support evidence-based care in the patient with diabetes mellitus and heart disease outside of the acute care setting.

Dipeptidyl peptidase-4 inhibition improves cardiac function in experimental myocardial infarction: Role of stromal cell-derived factor-1α

BACKGROUND

In addition to degrading glucagon-like peptide-1 (GLP-1), dipeptidyl peptidase-4 (DPP-4) inactivates several chemokines, including stromal cell-derived factor-1α (SDF-1α), a pro-angiogenic and cardiomyocyte protective protein. We hypothesized that DPP-4 inhibition may confer benefit following myocardial infarction (MI) in the diabetic setting as a consequence of enhanced SDF-1α availability rather than potentiating GLP-1. To test this we compared the effects of saxagliptin with those of liraglutide and used the SDF-1α receptor (CXCR4) antagonist plerixafor.

METHODS

Studies were conducted in streptozotocin-diabetic rats. Rats were randomized to receive saxagliptin (10 mg/kg per day), liraglutide (0.2 mg/kg, s.c., b.i.d.), plerixafor (1 mg/kg per day, s.c.), saxagliptin plus plerixafor or vehicle (1% phosphate-buffered saline). Two weeks later, rats underwent experimental MI, with cardiac function examined 4 weeks after MI.

RESULTS

Glycemic control and MI size were similar in all groups. Four weeks after MI, mortality was reduced in saxagliptin-treated rats compared with vehicle treatment (P < 0.05). Furthermore, rats receiving saxagliptin had improved cardiac function compared with vehicle-treated rats (P < 0.05). Antagonism of CXCR4 prevented the improvement in cardiac function in saxagliptin-treated rats and was associated with increased mortality (P < 0.05).

CONCLUSION

Saxagliptin-mediated DPP-4 inhibition, but not liraglutide-mediated GLP-1R agonism, improved cardiac function after MI independent of glucose lowering. These findings suggest that non-GLP-1 actions of DPP-4 inhibition, such as SDF-1α potentiation, mediate biological effects.

Oxidative stress contributes to the impaired sonic hedgehog pathway in type 1 diabetic mice with myocardial infarction

Our previous study demonstrated that an impaired sonic hedgehog (Shh) pathway contributed to cardiac dysfunction in type 1 diabetic mice with myocardial infarction (MI). The present study aimed to test the hypothesis that oxidative stress may contribute to the impaired Shh pathway and cardiac dysfunction in type 1 diabetic mice with MI. Streptozotocin-induced type 1 diabetic mice (C57/Bl6, male) and rat neonatal cardiomyocytes were used in the present study. Mice were randomly assigned to undergo ligation of the coronary artery or pseudosurgery. A potent antioxidant Tempol was administered in vivo and in vitro. Cardiac function was assessed by echocardiography, capillary density by immunohistochemisty, percentage of myocardial infarct using Massons trichrome staining, reactive oxygen species detection using dihydroethidium dye or 2,7-dichlorofluorescein diacetate probe and protein expression levels of the Shh pathway by western blot analysis. The antioxidant Tempol was shown to significantly increase myocardial protein expression levels of Shh and patched-1 (Ptc1) at 7–18 weeks and improved cardiac function at 18 weeks in type 1 diabetic mice, as compared with mice receiving no drug treatment. Furthermore, myocardial protein expression levels of Shh and Ptc1 were significantly upregulated on day 7 after MI, and capillary density was enhanced. In addition, the percentage area of myocardial infarct was reduced, and the cardiac dysfunction and survival rate were improved on day 21 in diabetic mice treated with Tempol. In vitro, treatment of rat neonatal cardiomyocytes with a mixture of xanthine oxidase and xanthine decreased protein expression levels of Shh and Ptc1 in a concentration-dependent manner, and Tempol attenuated this effect. These results indicate that oxidative stress may contribute to an impaired Shh pathway in type 1 diabetic mice, leading to diminished myocardial healing and cardiac dysfunction. Antioxidative strategies aimed at restoring the endogenous Shh pathway may offer a useful means for improving diabetic cardiac function.

EFFECTS OF ACUTE HYPERGLYCEMIA AND INSULIN INTERVENTION ON THE SPONTANEOUS FIELD POTENTIAL OF SINOATRIAL NODE TISSUE BY USING MICROELECTRODE ARRAYS

Traditional studies on the relationship between hyperglycemia and heart diseases generally focused on the impact of chronic and long-term effect of diabetes on cardiac functions. Most of the methods were culturing myocardial cells and giving outside stimulations. However, recent studies show that acute hyperglycemia might play a significant role in spontaneous cardiac electrophysiology. In this research we applied microelectrode arrays (MEA) to record the spontaneous sinoatrial node field potentials of C57/BL6J mice and analyzed the effects of different glucose concentrations in time domain and frequency domain by using statistical method, vector maps and fast Fourier transform (FFT). Meanwhile, we studied the effects of insulin interference in the experimental process. When the concentration of the glucose solution was greater than 40 mmol/L, the spontaneous sinoatrial node field potential changed markedly. In the time domain, the amplitude decreased rapidly and the conductive characteristics were disordered. In the frequency domain, the two spectrum peaks decreased rapidly. These changes were irreversible. However, insulin preconditioning could inhibit the impact of high glucose.

Heart failure in diabetes: effects of anti-hyperglycaemic drug therapy

Individuals with diabetes are not only at high risk of developing heart failure but are also at increased risk of dying from it. Fortunately, antiheart failure therapies such as angiotensin-converting-enzyme inhibitors, β blockers and mineralocorticoid-receptor antagonists work similarly well in individuals with diabetes as in individuals without the disease. Response to intensive glycaemic control and the various classes of antihyperglycaemic agent therapy is substantially less well understood. Insulin, for example, induces sodium retention and thiazolidinediones increase the risk of heart failure. The need for new glucose-lowering drugs to show cardiovascular safety has led to the unexpected finding of an increase in the risk of admission to hospital for heart failure in patients treated with the dipeptidylpeptidase-4 (DPP4) inhibitor, saxagliptin, compared with placebo. Here we review the relation between glycaemic control and heart failure risk, focusing on the state of knowledge for the various types of antihyperglycaemic drugs that are used at present.

The impact of 1,25-dihydroxyvitamin D3 on the expression of connective tissue growth factor and transforming growth factor-β1 in the myocardium of rats with diabetes

AIMS

To define whether 1,25-dihydroxyvitamin D3 (1,25-(OH)2 D3) can protect against myocardial fibrosis and to investigate its impact on the expression of connective tissue growth factor (CTGF) and transforming growth factor-β1 (TGF-β1) in the myocardium of rats with diabetes.

METHODS

Male Sprague-Dawley rats were divided into normal (control), 1,25-(OH)2 D3 therapy, and diabetes groups. In the diabetes and 1,25-(OH)2 D3 therapy groups, type 2 diabetes models were established using a high-fat, high-sugar diet and streptozotocin. Rats in the 1,25-(OH)2 D3 therapy group were also treated with 1,25-(OH)2 D3. After 6 weeks, the body weight, cardiac weight, cardiac weight index, plasma glucose, lactic dehydrogenase (LDH) and creatine kinase (CK) were measured; morphological changes in the myocardium were observed using microscopy following hematoxylin-eosin and Masson staining. CTGF and TGF-β1 expressions in the myocardium were detected using immunohistochemistry staining and reverse transcription polymerase chain reaction.

RESULTS

The body and cardiac weights of the rats in the diabetes and 1,25-(OH)2 D3 group were lower, but the cardiac weight index, plasma glucose, LDH and CK were higher compared with the control group (P<0.05). The body weight and plasma glucose, LDH and CK were decreased in 1,25-(OH)2 D3 group compared with the diabetes group (P<0.05). Pathological changes in the 1,25-(OH)2 D3 group were milder than the diabetes group. CTGF and TGF-β1 expression in the diabetes and 1,25-(OH)2 D3 groups were increased significantly, but in the 1,25-(OH)2 D3 group were significantly lower than diabetes group at the mRNA level.

CONCLUSION

1,25-(OH)2 D3 had a partially protective effect on myocardial fibrosis of diabetic rats, which might inhibit CTGF and TGF-β1 expression in the myocardial tissues.

Guideline compliance in chronic heart failure patients with multiple comorbid diseases: evaluation of an individualised multidisciplinary model of care

OBJECTIVE

To assess the impact of individualised, reconciled evidence-based recommendations (IRERs) and multidisciplinary care in patients with chronic heart failure (CHF) on clinical guideline compliance for CHF and common comorbid conditions.

DESIGN AND SETTING

A retrospective hospital clinical audit conducted between 1st July 2006 and February 2011.

PARTICIPANTS

A total of 255 patients with a diagnosis of CHF who attended the Multidisciplinary Ambulatory Consulting Services (MACS) clinics, at the Royal Adelaide Hospital, were included.

MAIN OUTCOME MEASURES

Compliance with Australian clinical guideline recommendations for CHF, atrial fibrillation, diabetes mellitus and ischaemic heart disease.

RESULTS

Study participants had a median of eight medical conditions (IQR 6-10) and were on an average of 10 (±4) unique medications. Compliance with clinical guideline recommendations for pharmacological therapy for CHF, comorbid atrial fibrillation, diabetes or ischaemic heart disease was high, ranging from 86% for lipid lowering therapy to 98% anti-platelet agents. For all conditions, compliance with lifestyle recommendations was lower than pharmacological therapy, ranging from no podiatry reviews for CHF patients with comorbid diabetes to 75% for heart failure education. Concordance with many guideline recommendations was significantly associated if the patient had IRERs determined, a greater number of recommendations, more clinic visits or if patients participated in a heart failure program.

CONCLUSIONS

Despite the high number of comorbid conditions and resulting complexity of the management, high compliance to clinical guideline recommendations was associated with IRER determination in older patients with CHF. Importantly these recommendations need to be communicated to the patient's general practitioner, regularly monitored and adjusted at clinic visits.

Primary and secondary prevention of heart failure with statins

Statins are effective in the prevention of coronary heart disease (CHD), a leading cause of heart failure (HF). Secondary analyses from 11 randomized clinical trials of patients with high-risk acute or stable coronary heart disease, but without HF, suggest that statins may prevent new-onset HF or HF-related hospitalization. In persons with established HF, several cohort studies found an approximate 35% relative risk reduction in all-cause mortality. While ongoing randomized clinical trials will help to determine the efficacy of statins in persons with established HF, it is reasonable to consider this class of medications in patients with a history of cardiovascular disease, dyslipidemia or diabetes mellitus, and who have either developed, or who remain at risk of, HF.

Predictors of better self-care in patients with heart failure after six months of follow-up home visits

This study aimed to examine the predictors of better self-care behavior in patients with heart failure (HF) in a home visiting program. This is a longitudinal study nested in a randomized controlled trial (ISRCTN01213862) in which the home-based educational intervention consisted of a six-month followup that included four home visits by a nurse, interspersed with four telephone calls. The self-care score was measured at baseline and at six months using the Brazilian version of the European Heart Failure Self-Care Behaviour Scale. The associations included eight variables: age, sex, schooling, having received the intervention, social support, income, comorbidities, and symptom severity. A simple linear regression model was developed using significant variables (P ≤ 0.20), followed by a multivariate model to determine the predictors of better self-care. One hundred eighty-eight patients completed the study. A better self-care behavior was associated with patients who received intervention (P < 0.001), had more years of schooling (P = 0.016), and had more comorbidities (P = 0.008). Having received the intervention (P < 0.001) and having a greater number of comorbidities (P = 0.038) were predictors of better self-care. In the multivariate regression model, being in the intervention group and having more comorbidities were a predictor of better self-care.

Impaired sonic hedgehog pathway contributes to cardiac dysfunction in type 1 diabetic mice with myocardial infarction

AIMS

The incidence and mortality of myocardial infarction (MI) in diabetic patients are higher than in non-diabetic patients; however, the mechanisms by which diabetes results in cardiac dysfunction are poorly understood. The present study tested the hypothesis that an impaired sonic hedgehog (Shh) pathway contributes to cardiac dysfunction in type 1 diabetic mice with MI.

METHODS AND RESULTS

Adult male C57/B6 mice and streptozotocin-induced type 1 diabetic mice were used. Myocardial proteins of Shh, Patched-1 (Ptc1), and glioma-associated oncogene-1 (Gli1) were significantly decreased in type 1 diabetic mice at 10 weeks, and this was accompanied by cardiac dysfunction. Although myocardial proteins of Shh, Ptc1, and Gli1 were significantly increased 7 days after MI compared with the sham group in control mice, these proteins were markedly decreased in streptozotocin-induced diabetic mice. Treatment with Shh pathway agonist for 21 days significantly increased Ptc1 and Gli1 proteins, enhanced capillary density, reduced the percentage myocardial infarct, and then improved cardiac function in diabetic mice with MI compared with those with no drug treatment. This treatment had no effects in control mice with MI. Conversely, treatment with Shh pathway antagonist for 21 days significantly decreased Ptc1 and Gli1 proteins, reduced capillary density, enlarged the percentage myocardial infarct, and then exacerbated cardiac dysfunction in control mice with MI compared with those with no drug treatment.

CONCLUSIONS

These findings indicate that in type 1 diabetic mice the myocardial Shh pathway is impaired and that the impaired Shh pathway contributes to cardiac dysfunction. Strategies that are aimed at augmenting the Shh pathway may offer useful means for improving diabetic cardiac dysfunction.

Feasibility of intracoronary GLP-1 eluting CellBead™ infusion in acute myocardial infarction

Cell therapy is a field of growing interest in the prevention of post acute myocardial infarction (AMI) heart failure. Stem cell retention upon local delivery to the heart, however, is still unsatisfactory. CellBeads were recently developed as a potential solution to this problem. CellBeads are 170-μm alginate microspheres that contain mesenchymal stem cells (MSCs) genetically modified to express glucagon-like peptide-1 (GLP-1) supplementary to inherent paracrine factors. GLP-1 is an incretin hormone that has both antiapoptotic and cardioprotective effects. Transplanting CellBeads in the post-AMI heart might induce cardiomyocyte salvage and ultimately abrogate adverse cardiac remodeling. We aimed to investigate the feasibility of intracoronary infusion of CellBeads in a large animal model of AMI. Four pigs were used in a pilot study to assess the maximal safe dose of CellBeads. In the remaining 21 animals, an AMI was induced by balloon occlusion of the left circumflex coronary artery for 90 min. During reperfusion, 60,000 CellBeads (n = 11), control beads (n = 4), or lactated Ringers' (n = 6) were infused. Animals were sacrificed after 2 or 7 days, and the hearts were excised for histological analyses. Intracoronary infusion did not permanently affect coronary flow in any of the groups. Histological analysis revealed CellBeads containing viable MSCs up to 7 days. Viability and activity of the MSCs was confirmed by qPCR analysis that showed expression of recombinant GLP-1 and human genes after 2 and 7 days. CellBeads reduced inflammatory infiltration by 29% (p = 0.001). In addition, they decreased the extent of apoptosis by 25% (p = 0.001) after 2 days. We show that intracoronary infusion of 5 million encapsulated MSCs is safe and feasible. Also, several parameters indicate that the cells have paracrine effects, suggesting a potential therapeutic benefit of this new approach.

Renal dysfunction in patients with heart failure with preserved versus reduced ejection fraction: impact of the new Chronic Kidney Disease-Epidemiology Collaboration Group formula

BACKGROUND

Prior studies in heart failure (HF) have used the Modification of Diet in Renal Disease (MDRD) equation to calculate estimated glomerular filtration rate (eGFR). The Chronic Kidney Disease-Epidemiology Collaboration Group (CKD-EPI) equation provides a more-accurate eGFR than the MDRD when compared against the radionuclide gold standard. The prevalence and prognostic import of renal dysfunction in HF if the CKD-EPI equation is used rather than the MDRD is uncertain.

METHODS AND RESULTS

We used individual patient data from 25 prospective studies to stratify patients with HF by eGFR using the CKD-EPI and the MDRD equations and examined survival across eGFR strata. In 20 754 patients (15 962 with HF with reduced ejection fraction [HF-REF] and 4792 with HF with preserved ejection fraction [HF-PEF]; mean age, 68 years; deaths per 1000 patient-years, 151; 95% CI, 146-155), 10 589 (51%) and 11 422 (55%) had an eGFR <60 mL/min using the MDRD and CKD-EPI equations, respectively. Use of the CKD-EPI equation resulted in 3760 (18%) patients being reclassified into different eGFR risk strata; 3089 (82%) were placed in a lower eGFR category and exhibited higher all-cause mortality rates (net reclassification improvement with CKD-EPI, 3.7%; 95% CI, 1.5%-5.9%). Reduced eGFR was a stronger predictor of all-cause mortality in HF-REF than in HF-PEF.

CONCLUSIONS

Use of the CKD-EPI rather than the MDRD equation to calculate eGFR leads to higher estimates of renal dysfunction in HF and a more-accurate categorization of mortality risk. Renal function is more closely related to outcomes in HF-REF than in HF-PEF.

Combination angiotensin converting enzyme and direct renin inhibition in heart failure following experimental myocardial infarction

AIMS

Diminishing the activity of the renin-angiotensin system (RAS) plays a pivotal role in the treatment of heart failure. In addition to angiotensin converting enzyme (ACE) inhibitors and angiotensin-receptor blockers, direct renin inhibition has emerged as a potential adjunctive treatment to conventional RAS blockade. We sought to determine the effectiveness of this strategy after myocardial infarction (MI) in the setting of preexisting hypertension, a common premorbid condition in patients with ischemic heart disease.

METHODS AND RESULTS

Ten-week-old female heterozygous hypertensive (mRen-2)27 transgenic rats (Ren-2), were randomized to one of five groups (n = 8 per group); sham, MI, MI + aliskiren, MI + lisinopril and MI + combination lisinopril and aliskiren. Cardiac function was assessed by echocardiography and in vivo cardiac catheterization. Untreated MI animals developed heart failure with hypotension, dilation, reduced ejection fraction (EF), and raised left ventricular end-diastolic pressure (LVEDP). Treatment with single agent treatment had only modest effect on cardiac function though combination therapy was associated with significant improvements in EF and LVEDP when compared to untreated MI animals (P < 0.05). Histologic analysis demonstrated increase extracellular matrix deposition and cardiomyocyte hypertrophy in the noninfarct region of all MI groups when compared with sham operated animals (P < 0.05) that was reduced by ACE inhibitor monotherapy and combination treatment but not by aliskiren alone.

CONCLUSION

In a hypertensive rat model that underwent experimental MI, EF, and LVEDP, key functional indices of heart failure, were improved by treatment with combination ACE and direct renin inhibition when compared with either agent used alone.

Contribution of comorbidities to functional impairment is higher in heart failure with preserved than with reduced ejection fraction

BACKGROUND

Comorbidities negatively affect prognosis more strongly in heart failure with preserved (HFpEF) than with reduced (HFrEF) ejection fraction. Their comparative impact on physical impairment in HFpEF and HFrEF has not been evaluated so far.

METHODS AND RESULTS

The frequency of 12 comorbidities and their impact on NYHA class and SF-36 physical functioning score (SF-36 PF) were evaluated in 1,294 patients with HFpEF and 2,785 with HFrEF. HFpEF patients had lower NYHA class (2.0 ± 0.6 vs. 2.4 ± 0.6, p < 0.001) and higher SF-36 PF score (54.4 ± 28.3 vs. 54.4 ± 27.7, p < 0.001). All comorbidities were significantly (p < 0.05) more frequent in HFrEF, except hypertension and obesity, which were more frequent in HFpEF (p < 0.001). Adjusting for age and gender, COPD, anemia, hyperuricemia, atrial fibrillation, renal dysfunction, cerebrovascular disease and diabetes had a similar (p for interaction > 0.05) negative effect in both groups. Obesity, coronary artery disease and peripheral arterial occlusive disease exerted a significantly (p < 0.05) more adverse effect in HFpEF, while hypertension and hyperlipidemia were associated with fewer (p < 0.05) symptoms in HFrEF only. The total impact of comorbidities on NYHA (AUC for prediction of NYHA III/IV vs. I/II) and SF-36 PF (r(2)) in multivariate analyses was approximately 1.5-fold higher in HFpEF, and also much stronger than the impact of a 10% decrease in ejection fraction in HFrEF or a 5 mm decrease in left ventricular end-diastolic diameter in HFpEF.

CONCLUSION

The impact of comorbidities on physical impairment is higher in HFpEF than in HFrEF. This should be considered in the differential diagnosis and in the treatment of patients with HFpEF.

K(ATP) channel-dependent metaboproteome decoded: systems approaches to heart failure prediction, diagnosis, and therapy

Systems biology provides an integrative platform by which to account for the biological complexity related to cardiac health and disease. In this way, consequences of ATP-sensitive K(+) (K(ATP)) channel deficiency for heart failure prediction, diagnosis, and therapy were resolved recently at a proteomic level. Under stress-free conditions, knockout of the Kir6.2 K(ATP) channel pore induced metabolic proteome remodelling, revealing overrepresentation of markers of cardiovascular disease. Imposed stress precipitated structural and functional defects in Kir6.2-knockout hearts, decreasing survival and validating prediction of disease susceptibility. In the setting of hypertension, a leading risk for heart failure development, proteomic analysis diagnosed the metabolism-centric impact of K(ATP) channel deficiency in disease. Bioinformatic interrogation of K(ATP) channel-dependent proteome prioritized heart-specific adverse effects, exposing cardiomyopathic traits of aggravated contractility, fibrosis, and ventricular hypertrophy. In dilated cardiomyopathy induced by Kir6.2-knockout pressure overload, proteomic remodelling was exacerbated, underlying a multifaceted molecular pathology that indicates the necessity for a broad-based strategy to achieve repair. Embryonic stem cell intervention in cardiomyopathic K(ATP) channel knockout hearts elicited a distinct proteome signature that forecast amelioration of adverse cardiac outcomes. Functional/structural measurements validated improved contractile performance, reduced ventricular size, and decreased cardiac damage in the treated cohort, while systems assessment unmasked cardiovascular development as a prioritized biological function in stem cell-reconstructed hearts. Thus, proteomic deconvolution of K(ATP) channel-deficient hearts provides definitive evidence for the channel's homeostatic contribution to the cardiac metaboproteome and establishes the utility of systems-oriented approaches to predict disease susceptibility, diagnose consequences of heart failure progression, and monitor therapy outcome.