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Liu Y, Wang W, Song J, Wang J, Fu Y, Tang Y. Circulating biomarker- and magnetic resonance-based nomogram predicting long-term outcomes in dilated cardiomyopathy. Chin Med J (Engl) 2024; 137:73-81. [PMID: 38178323 PMCID: PMC10766284 DOI: 10.1097/cm9.0000000000002688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Dilated cardiomyopathy (DCM) has a high mortality rate and is the most common indication for heart transplantation. Our study sought to develop a multiparametric nomogram to assess individualized all-cause mortality or heart transplantation (ACM/HTx) risk in DCM patients. METHODS The present study is a retrospective cohort study. The demographic, clinical, blood test, and cardiac magnetic resonance imaging (CMRI) data of DCM patients in the tertiary center (Fuwai Hospital) were collected. The primary endpoint was ACM/HTx. The least absolute shrinkage and selection operator (LASSO) Cox regression model was applied for variable selection. Multivariable Cox regression was used to develop a nomogram. The concordance index (C-index), area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis (DCA) were used to evaluate the performance of the nomogram. RESULTS A total of 218 patients were included in the present study. They were randomly divided into a training cohort and a validation cohort. The nomogram was established based on eight variables, including mid-wall late gadolinium enhancement, systolic blood pressure, diastolic blood pressure, left ventricular ejection fraction, left ventricular end-diastolic diameter, left ventricular end-diastolic volume index, free triiodothyronine, and N-terminal pro-B type natriuretic peptide. The AUCs regarding 1-year, 3-year, and 5-year ACM/HTx events were 0.859, 0.831, and 0.840 in the training cohort and 0.770, 0.789, and 0.819 in the validation cohort, respectively. The calibration curve and DCA showed good accuracy and clinical utility of the nomogram. CONCLUSIONS We established and validated a circulating biomarker- and CMRI-based nomogram that could provide a personalized prediction of ACM/HTx for DCM patients, which might help risk stratification and decision-making in clinical practice.
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Affiliation(s)
- Yupeng Liu
- Department of Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Wenyao Wang
- Department of Cardiology, Institute of Vascular Medicine, Peking University Third Hospital, Beijing 100191, China
- Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing 100191, China
| | - Jingjing Song
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Jiancheng Wang
- Beijing Key Laboratory of Molecular Pharmaceutics and New Drug Delivery Systems, State Key Laboratory of Natural and Biomimetic Drugs, School of Pharmaceutical Sciences, Peking University, Beijing 100083, China
| | - Yi Fu
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100083, China
| | - Yida Tang
- Department of Cardiology, Institute of Vascular Medicine, Peking University Third Hospital, Beijing 100191, China
- Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing 100191, China
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Samson R, Ennezat PV, Jemtel THL. Patient-Centered Heart Failure Therapy. Am J Med 2024; 137:23-29. [PMID: 37838238 DOI: 10.1016/j.amjmed.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/16/2023]
Abstract
Simultaneous initiation of quadruple therapy with angiotensin receptor-neprilysin inhibitor, beta-adrenergic receptor blocker, mineralocorticoid receptor antagonist, and sodium glucose cotransporter 2 inhibitor aims at prompt improvement and prevention of readmission in patients hospitalized for heart failure with reduced ejection fraction. However, titration of quadruple therapy is time consuming. Lengthy up-titration of quadruple therapy may negate the benefit of early initiation. Quadruple therapy should start with a sodium glucose cotransporter 2 inhibition and a mineralocorticoid antagonist, as both enable safe decongestion and require minimal or no titration. Depending on the level of decongestion and clinical characteristics, patients receive an angiotensin receptor-neprilysin inhibitor or a beta-adrenergic receptor blocker to be titrated after hospital discharge. Outpatient addition of an angiotensin receptor-neprilysin inhibitor to a beta-adrenergic receptor blocker or vice versa completes the quadruple therapy scheme. By focusing on decongestion and matching intervention to patients' profile, the present therapeutic sequence allows rapid implementation of quadruple therapy at fully recommended doses.
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Affiliation(s)
- Rohan Samson
- Advanced Heart Failure Therapies Program, University of Louisville Health-Jewish Hospital, Ky
| | - Pierre V Ennezat
- Department of Cardiology, AP-HP Hopitaux Universitaires Henri Mondor, Créteil, France
| | - Thierry H Le Jemtel
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, La.
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3
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Benz DC, Gräni C, Antiochos P, Heydari B, Gissler MC, Ge Y, Cuddy SAM, Dorbala S, Kwong RY. Cardiac magnetic resonance biomarkers as surrogate endpoints in cardiovascular trials for myocardial diseases. Eur Heart J 2023; 44:4738-4747. [PMID: 37700499 PMCID: PMC11032206 DOI: 10.1093/eurheartj/ehad510] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 07/05/2023] [Accepted: 07/25/2023] [Indexed: 09/14/2023] Open
Abstract
Cardiac magnetic resonance offers multiple facets in the diagnosis, risk stratification, and management of patients with myocardial diseases. Particularly, its feature to precisely monitor disease activity lends itself to quantify response to novel therapeutics. This review critically appraises the value of cardiac magnetic resonance imaging biomarkers as surrogate endpoints for prospective clinical trials. The primary focus is to comprehensively outline the value of established cardiac magnetic resonance parameters in myocardial diseases. These include heart failure, cardiac amyloidosis, iron overload cardiomyopathy, hypertrophic cardiomyopathy, cardio-oncology, and inflammatory cardiomyopathies like myocarditis and sarcoidosis.
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Affiliation(s)
- Dominik C Benz
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Panagiotis Antiochos
- Cardiology and Cardiac MR Centre, University Hospital Lausanne, Lausanne, Switzerland
| | - Bobak Heydari
- Cardiovascular Division, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mark Colin Gissler
- Department of Cardiology and Angiology, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Yin Ge
- Terrence Donnelly Heart Center, St Michael’s Hospital, Toronto, Canada
| | - Sarah A M Cuddy
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Sharmila Dorbala
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Raymond Y Kwong
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
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4
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Schurtz G, Mewton N, Lemesle G, Delmas C, Levy B, Puymirat E, Aissaoui N, Bauer F, Gerbaud E, Henry P, Bonello L, Bochaton T, Bonnefoy E, Roubille F, Lamblin N. Beta-blocker management in patients admitted for acute heart failure and reduced ejection fraction: a review and expert consensus opinion. Front Cardiovasc Med 2023; 10:1263482. [PMID: 38050613 PMCID: PMC10693984 DOI: 10.3389/fcvm.2023.1263482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/31/2023] [Indexed: 12/06/2023] Open
Abstract
The role of the beta-adrenergic signaling pathway in heart failure (HF) is pivotal. Early blockade of this pathway with beta-blocker (BB) therapy is recommended as the first-line medication for patients with HF and reduced ejection fraction (HFrEF). Conversely, in patients with severe acute HF (AHF), including those with resolved cardiogenic shock (CS), BB initiation can be hazardous. There are very few data on the management of BB in these situations. The present expert consensus aims to review all published data on the use of BB in patients with severe decompensated AHF, with or without hemodynamic compromise, and proposes an expert-recommended practical algorithm for the prescription and monitoring of BB therapy in critical settings.
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Affiliation(s)
- Guillaume Schurtz
- USICet Centre Hémodynamique, Institut Coeur Poumon, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Nathan Mewton
- Hôpital Cardio-Vasculaire Louis Pradel. Filière Insuffisance Cardiaque, Centre D'Investigation Clinique, INSERM 1407. Unité CarMeN, INSERM 1060, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Gilles Lemesle
- USICet Centre Hémodynamique, Institut Coeur Poumon, Centre Hospitalier Universitaire de Lille, Lille, France
- Institut Pasteur de Lille, Unité INSERM UMR1011, Lille, France
- Faculté de Médecine de l’Université de Lille, Lille, France
- FACT (French Alliance for Cardiovascular Trials), Paris, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France
| | - Bruno Levy
- Service de Réanimation Médicale Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy, INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy, Université de Lorraine, Nancy, France
| | - Etienne Puymirat
- Department of Cardiology, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Nadia Aissaoui
- Médecine Intensive Réanimation, Cochin, AfterROSC, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Cité, Paris, France
| | - Fabrice Bauer
- Heart Failure Network, Advanced Heart Failure Clinic and Pulmonary Hypertension Department, Cardiac Surgery Department, INSERM U1096, Rouen University Teaching Hospital, Rouen, France
| | - Edouard Gerbaud
- Cardiology Intensive Care Unit and Interventional Cardiology, Hôpital Cardiologique du Haut-Lévêque, Pessac, France
- Bordeaux Cardio-Thoracic Research Centre, INSERM U1045, Bordeaux University, Bordeaux, France
| | - Patrick Henry
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, INSERM U942, University of Paris, Paris, France
| | - Laurent Bonello
- Cardiology Department, APHM, Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Centre for CardioVascular and Nutrition Research (C2VN), INSERM 1263, INRA 1260, Aix-Marseille Univ, Marseille, France
| | - Thomas Bochaton
- Intensive Cardiological Care Division, Hospices Civils de Lyon-Hôpital Cardiovasculaire et Pulmonaire, Lyon, France
| | - Eric Bonnefoy
- Intensive Cardiological Care Division, Hospices Civils de Lyon-Hôpital Cardiovasculaire et Pulmonaire, Lyon, France
| | - François Roubille
- Cardiology Department, INI-CRT, CHU de Montpellier, PhyMedExp, INSERM, CNRS, Université de Montpellier, Montpellier, France
| | - Nicolas Lamblin
- Cardiology Department, Heart and Lung Institute, University Hospital of Lille, Lille, France
- INSERM U1167, Institut Pasteur of Lille, Lille, France
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5
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Sağlam EC, Yadigaroğlu M, Güzel M, Turan H, Hakan Aksu Ş, Ocak M, Gorgun S, Arslan U, Yücel M. Combined Use of Serum N-terminal Pro-B-Type Natriuretic Peptide and Glypican-6 in the Diagnosis of Heart Failure. Cureus 2023; 15:e45766. [PMID: 37872895 PMCID: PMC10590535 DOI: 10.7759/cureus.45766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 10/25/2023] Open
Abstract
OBJECTIVE The aim of this study was to investigate the efficacy of serum glypican-6 (GPC-6) levels and the combination of N-terminal pro-B-type natriuretic peptide (NT-ProBNP) and GPC-6 in the diagnosis of heart failure (HF). METHODS In this prospective study, patients older than 18 years of age, admitted to the emergency department of our hospital between December 2021 and April 2022, diagnosed with heart failure (patient group), and healthy volunteers with similar sociodemographic characteristics (control group) were included. The disease severity classification of the patient group was made according to the 2021 ESC guidelines, using echocardiographic findings. Serum GPC-6 and NT-ProBNP levels were measured by the enzyme-linked immunosorbent assay (ELISA) method, which determines the antigen-antibody relationship. Optimal GPC-6 and NT-ProBNP levels for the diagnosis of HF were determined by receiver operating characteristic (ROC) analysis. The patients were divided into three groups according to these levels. Group 1 consisted of patients with both markers below the cutoff values, Group 2 consisted of patients with either of these markers above the cutoff values, and Group 3 consisted of patients with both markers above the cutoff values. RESULTS The study included 65 heart failure patients and 20 healthy volunteers. When the patient and control groups were compared in terms of serum GPC-6 and serum NT-ProBNP levels, both parameters were evaluated as significantly higher in the patient group (p=0.038 and p<0.001; respectively). In the ROC analysis, it was determined that GPC-6 indicated HF with 58.46% sensitivity and 75% specificity for an optimal cutoff value of 390 pg/ml. In the ROC analysis, it was determined that serum NT-ProBNP indicated HF with 89.23% sensitivity and 70% specificity for an optimal cutoff value of 122 pg/ml. When the groups were compared according to the rate of HF, it was found to be higher in Group 3 compared to Group 2 (97.1% vs. 70.3%, p<0.002) and Group 1 (97.1% vs. 38.5%, p<0.001). This rate was seen to be significantly higher in Group 2 compared to Group 1 (70.3% vs. 38.5%, p=0.042). CONCLUSION The combination of GPC-6 and NT-ProBNP may help diagnose HF patients admitted to the emergency department.
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Affiliation(s)
- Emre Cem Sağlam
- Emergency Medicine, Sadıka Sabancı State Hospital, Sakarya, TUR
| | - Metin Yadigaroğlu
- Emergency Medicine, Samsun University Faculty of Medicine, Samsun, TUR
| | - Murat Güzel
- Emergency Medicine, Samsun University Faculty of Medicine, Samsun, TUR
| | - Hatice Turan
- Emergency Medicine, Kulu State Hospital, Konya, TUR
| | - Şakir Hakan Aksu
- Emergency Medicine, Samsun Education and Research Hospital, Samsun, TUR
| | - Metin Ocak
- Emergency Medicine, Samsun Education and Research Hospital, Samsun, TUR
| | - Selim Gorgun
- Microbiology, University of Health Sciences, Samsun Education and Research Hospital, Samsun, TUR
| | - Uğur Arslan
- Cardiology, Samsun University Faculty of Medicine, Samsun, TUR
| | - Murat Yücel
- Emergency Medicine, Samsun University Faculty of Medicine, Samsun, TUR
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6
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Dimza M, Kurup V, Canha C, Jimenez A, Al-Ani M, Parker AM, Vilaro JR, Ahmed MM, Aranda JM. Pharmacological Therapy Optimization for Heart Failure: A Practical Guide for the Internist. Am J Med 2023; 136:745-752. [PMID: 37148990 DOI: 10.1016/j.amjmed.2023.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 05/08/2023]
Abstract
Heart failure carries significant morbidity and mortality and affects a large population of patients cared for predominantly by primary care physicians. The complexity of managing heart failure patients is increasing as new therapies continue to emerge. This review outlines important clinical pearls and proposes strategies for optimization of medical therapy.
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Affiliation(s)
- Michelle Dimza
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville..
| | - Varsha Kurup
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville
| | - Catarina Canha
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville
| | - Arlene Jimenez
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville
| | - Mohammad Al-Ani
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville
| | - Alex M Parker
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville
| | - Juan R Vilaro
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville
| | - Mustafa M Ahmed
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville
| | - Juan M Aranda
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville
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7
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Bello L, Hoffman EP, Pegoraro E. Is it time for genetic modifiers to predict prognosis in Duchenne muscular dystrophy? Nat Rev Neurol 2023; 19:410-423. [PMID: 37308617 DOI: 10.1038/s41582-023-00823-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/14/2023]
Abstract
Patients with Duchenne muscular dystrophy (DMD) show clinically relevant phenotypic variability, despite sharing the same primary biochemical defect (dystrophin deficiency). Factors contributing to this clinical variability include allelic heterogeneity (specific DMD mutations), genetic modifiers (trans-acting genetic polymorphisms) and variations in clinical care. Recently, a series of genetic modifiers have been identified, mostly involving genes and/or proteins that regulate inflammation and fibrosis - processes increasingly recognized as being causally linked with physical disability. This article reviews genetic modifier studies in DMD to date and discusses the effect of genetic modifiers on predicting disease trajectories (prognosis), clinical trial design and interpretation (inclusion of genotype-stratified subgroup analyses) and therapeutic approaches. The genetic modifiers identified to date underscore the importance of progressive fibrosis, downstream of dystrophin deficiency, in driving the disease process. As such, genetic modifiers have shown the importance of therapies aimed at slowing this fibrotic process and might point to key drug targets.
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Affiliation(s)
- Luca Bello
- Department of Neurosciences (DNS), University of Padova, Padova, Italy
| | - Eric P Hoffman
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University (State University of New York), Binghamton, NY, USA
| | - Elena Pegoraro
- Department of Neurosciences (DNS), University of Padova, Padova, Italy.
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8
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Zhou Z, Zhuang X, Liu M, Jian B, Fu G, Liao X, Wu Z, Liang M. Left ventricular volume change and long-term outcomes in ischaemic cardiomyopathy with or without surgical revascularisation: A post-hoc analysis of a randomised controlled trial. EClinicalMedicine 2022; 53:101626. [PMID: 36060518 PMCID: PMC9433601 DOI: 10.1016/j.eclinm.2022.101626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/18/2022] [Accepted: 08/08/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Whether the association between post-therapeutic left ventricular volume change and long-term outcomes in ischaemic cardiomyopathy is influenced by the performance of coronary artery bypass grafting (CABG) remains unclear. We sought to perform a post-hoc analysis of the Surgical Treatment of Ischaemic Heart Failure (STICH) trial to investigate this association in patients treated with medical therapy (MED) with or without CABG. METHODS From July 24, 2002, to May 5, 2007, 1212 patients with ischaemic cardiomyopathy were enrolled in the STICH trial (NCT00023595) from 99 sites in 22 countries, and were randomly assigned to undergo CABG plus MED or MED alone. We completed a post-hoc analysis of this trial. Patients with paired left ventricular end-systolic volume index (ESVI) measured at baseline and 4-months were included in our analysis. The association between change in ESVI from baseline to 4-months and cardiovascular mortality or all-cause mortality was assessed in MED arm and CABG plus MED arm. FINDINGS 523 patients were included, with 291 (55.6%) assigned to MED arm and 232 (44.4%) to CABG plus MED arm. At a 4-month follow-up, ESVI reduction was more likely to occur among patients undergoing CABG plus MED. After a median follow-up of 10.3 years, for each 26% (1- standard deviation) decrement in ESVI, it was associated with a 22% lower risk of cardiovascular mortality (HR 0.78; 95% CI, 0.65-0.94) and 19% lower risk of all-cause mortality (HR 0.81; 95% CI, 0.69-0.95) in MED arm, whereas this association was not shown in CABG plus MED arm (cardiovascular mortality: HR 0.90; 95%CI, 0.74-1.10; all-cause mortality: HR 0.93; 95%CI, 0.79-1.09). A 16% reduction in ESVI was determined to be the most appropriate threshold of change in ESVI in the MED arm. INTERPRETATION In patients with ischaemic cardiomyopathy, left ventricular volume change was associated with long-term prognosis after medical therapy alone, whereas was likely not an optimal benchmark for evaluating the survival benefits associated with CABG. A more than 16% reduction in ESVI might assist in therapeutic efficacy assessment and prognostic evaluation in medically treated patients. FUNDING National Natural Science Foundation of China; Natural Science Funds of Guangdong Province.
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Affiliation(s)
- Zhuoming Zhou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiaodong Zhuang
- Departement of Cardiology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Menghui Liu
- Departement of Cardiology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Bohao Jian
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Guangguo Fu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xinxue Liao
- Departement of Cardiology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhongkai Wu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Corresponding authors at: Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou 510080, China.
| | - Mengya Liang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- Corresponding authors at: Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou 510080, China.
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9
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Shah AM, Claggett B, Prasad N, Li G, Volquez M, Jering K, Cikes M, Kovacs A, Mullens W, Nicolau JC, Køber L, van der Meer P, Jhund PS, Ibram G, Lefkowitz M, Zhou Y, Solomon SD, Pfeffer MA. Impact of Sacubitril/Valsartan Compared With Ramipril on Cardiac Structure and Function After Acute Myocardial Infarction: The PARADISE-MI Echocardiographic Substudy. Circulation 2022; 146:1067-1081. [PMID: 36082663 PMCID: PMC9529950 DOI: 10.1161/circulationaha.122.059210] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 08/04/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors attenuate left ventricular (LV) enlargement after acute myocardial infarction (AMI). Preclinical data suggest similar benefits with combined angiotensin receptor neprilysin inhibition, but human data are conflicting. The PARADISE-MI Echo Study (Prospective ARNI Versus ACE Inhibitor Trial to Determine Superiority in Reducing Heart Failure Events After Myocardial Infarction) tested the effect of sacubitril/valsartan compared with ramipril on LV function and adverse remodeling after high risk-AMI. METHODS In a prespecified substudy, 544 PARADISE-MI participants were enrolled in the Echo Study to undergo protocol echocardiography at randomization and after 8 months. Patients were randomized within 0.5 to 7 days of presentation with their index AMI to receive a target dose of sacubitril/valsartan 200 mg or ramipril 5 mg twice daily. Echocardiographic measures were performed at a core laboratory by investigators blinded to treatment assignment. The effect of treatment on change in echo measures was assessed with ANCOVA with adjustment for baseline value and enrollment region. The primary end points were change in LV ejection fraction (LVEF) and left atrial volume (LAV), and prespecified secondary end points included changes in LV end-diastolic and end-systolic volumes. RESULTS Mean age was 64±12 years; 26% were women; mean LVEF was 42±12%; and LAV was 49±17 mL. Of 544 enrolled patients, 457 (84%) had a follow-up echo at 8 months (228 taking sacubitril/valsartan, 229 taking ramipril). There was no significant difference in change in LVEF (P=0.79) or LAV (P =0.62) by treatment group. Patients randomized to sacubitril/valsartan demonstrated less increase in LV end-diastolic volume (P=0.025) and greater decline in LV mass index (P=0.037), increase in tissue Doppler e'lat (P=0.005), decrease in E/e'lat (P=0.045), and decrease in tricuspid regurgitation peak velocity (P=0.024) than patients randomized to ramipril. These differences remained significant after adjustment for differences in baseline characteristics. Baseline LVEF, LV end-diastolic volume, LV end-systolic volume, LV mass index, LAV, and Doppler-based diastolic indices were associated with risk of cardiovascular death or incident heart failure. CONCLUSIONS Treatment with sacubitril/valsartan compared with ramipril after AMI did not result in changes in LVEF or LAV at 8 months. Patients randomized to sacubitril/valsartan had less LV enlargement and greater improvement in filling pressure. Measures of LV size, systolic function, and diastolic properties were predictive of cardiovascular death and incident heart failure after AMI in this contemporary, well-treated cohort. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02924727.
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Affiliation(s)
- Amil M Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (A.M.S., B.C., N.P., G.L., M.V., K.J., S.D.S, M.A.P.)
| | - Brian Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (A.M.S., B.C., N.P., G.L., M.V., K.J., S.D.S, M.A.P.)
| | - Narayana Prasad
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (A.M.S., B.C., N.P., G.L., M.V., K.J., S.D.S, M.A.P.)
| | - Guichu Li
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (A.M.S., B.C., N.P., G.L., M.V., K.J., S.D.S, M.A.P.)
| | - Mayra Volquez
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (A.M.S., B.C., N.P., G.L., M.V., K.J., S.D.S, M.A.P.)
| | - Karola Jering
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (A.M.S., B.C., N.P., G.L., M.V., K.J., S.D.S, M.A.P.)
| | - Maja Cikes
- University of Zagreb School of Medicine and University Hospital Centre Zagreb, Croatia (M.C.)
| | - Attila Kovacs
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary (A.K.)
| | - Wilfried Mullens
- University Hasselt, Ziekenhuis Oost Limburg, Genk, Belgium (W.M.)
| | - Jose C Nicolau
- Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, Brazil (J.C.N.)
| | - Lars Køber
- Rigshospitalet, Copenhagen, Denmark (L.K.)
| | | | | | - Ghionul Ibram
- Novartis Pharmaceutical Corporation, East Hanover, NJ (G.I., M.L., Y.Z.)
| | - Martin Lefkowitz
- Novartis Pharmaceutical Corporation, East Hanover, NJ (G.I., M.L., Y.Z.)
| | - Yinong Zhou
- Novartis Pharmaceutical Corporation, East Hanover, NJ (G.I., M.L., Y.Z.)
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (A.M.S., B.C., N.P., G.L., M.V., K.J., S.D.S, M.A.P.)
| | - Marc A Pfeffer
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (A.M.S., B.C., N.P., G.L., M.V., K.J., S.D.S, M.A.P.)
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10
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Kelley EF, Cross TJ, McDonald CM, Investigators C, Hoffman EP, Spurney CF, Bello L. Influence of β 1 Adrenergic Receptor Genotype on Longitudinal Measures of Left Ventricular Ejection Fraction and Responsiveness to ß-Blocker Therapy in Patients With Duchenne Muscular Dystrophy. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2022; 16:11795468221116838. [PMID: 36046180 PMCID: PMC9421016 DOI: 10.1177/11795468221116838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 07/11/2022] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to determine whether the longitudinal progression of decline in left ventricular ejection fraction (LVEF) in Duchenne muscular dystrophy (DMD) patients is moderated by ADRB1 genotype and whether the efficacy of ß-blocker therapy is influenced by genotype status. About 147 DMD patients (6-34 years.) were analyzed with a focus on β1 adrenergic receptor (ADRB1) genotype variants. Patients were grouped by ADRB1 genotype resulting in Gly389 patients and Arg389 patients. A generalized additive mixed effects model was used to examine differences in the nonlinear trend of LVEF across patient ages between genotype groups and for ß-blocker use. Both genotype groups displayed a progressive decline in LVEF starting around the mean age of ambulation loss (~12 years). However, there was no difference between genotype groups in the progression of decline in LVEF. There was a significant effect of ß-blocker use on longitudinal LVEF, wherein patients on ß-blockers had systematically lower LVEF when compared to patients not on ß-blockers. However, the effect of ß-blocker therapy on LVEF was not affected by ADRB1 genotype. The current study did not demonstrate an influence of patient ADRB1 genotype on longitudinal LVEF in our cohort. Despite previous literature suggesting a positive influence of ß-blocker use on cardiac function in DMD patients and of an ADRB1 genotypic difference in responsiveness to ß-blocker use, we did not observe this in our cohort. Interestingly, our cohort did not demonstrate a positive influence of ß-blocker use on LVEF measures.
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Affiliation(s)
- Eli F Kelley
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Troy J Cross
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Craig M McDonald
- University of California Davis Medical Center, Sacramento, CA, USA
| | - Cinrg Investigators
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,University of California Davis Medical Center, Sacramento, CA, USA.,Binghamton University-SUNY, Binghamton, NY, USA.,Center for Genetic Medicine, Children's Research Institute, Children's National Health System, Washington, DC, USA.,Division of Cardiology, Children's National Heart Institute, Children's National Hospital, Washington, DC, USA.,Department of Neurosciences, University of Padova, Padova, Italy
| | - Eric P Hoffman
- Binghamton University-SUNY, Binghamton, NY, USA.,Center for Genetic Medicine, Children's Research Institute, Children's National Health System, Washington, DC, USA
| | - Christopher F Spurney
- Division of Cardiology, Children's National Heart Institute, Children's National Hospital, Washington, DC, USA
| | - Luca Bello
- Department of Neurosciences, University of Padova, Padova, Italy
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11
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Milwidsky A, Mathai SV, Topilsky Y, Jorde UP. Medical Therapy for Functional Mitral Regurgitation. Circ Heart Fail 2022; 15:e009689. [PMID: 35862021 DOI: 10.1161/circheartfailure.122.009689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Functional mitral regurgitation (FMR) can be broadly categorized into 2 main groups: ventricular and atrial, which often coexist. The former is secondary to left ventricular remodeling usually in the setting of heart failure with reduced ejection fraction or less frequently due to ischemic papillary muscle remodeling. Atrial FMR develops due to atrial and annular dilatation related to atrial fibrillation/flutter or from increased atrial pressures in the setting of heart failure with preserved ejection fraction. Guideline-directed medical therapy is the first step and prevails as the mainstay in the treatment of FMR. In this review, we address the medical therapeutic options for FMR management and highlight a targeted approach for each FMR category. We further address important clinical and echocardiographic characteristics to aid in determining when medical therapy is expected to have a low yield and an appropriate window for effective interventional approaches exists.
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Affiliation(s)
- Assi Milwidsky
- Department of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (A.M., U.P.J.).,Department of Cardiology, Tel-Aviv Sourasky Medical Center (affiliated with the Sackler School of Medicine), Tel-Aviv University, Israel (A.M., Y.T.)
| | - Sheetal Vasundara Mathai
- Department of Medicine, Jacobi Medical Center and Albert Einstein College of Medicine, Bronx, NY (S.V.M.)
| | - Yan Topilsky
- Department of Cardiology, Tel-Aviv Sourasky Medical Center (affiliated with the Sackler School of Medicine), Tel-Aviv University, Israel (A.M., Y.T.)
| | - Ulrich P Jorde
- Department of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (A.M., U.P.J.)
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12
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Jedrzejewska A, Braczko A, Kawecka A, Hellmann M, Siondalski P, Slominska E, Kutryb-Zajac B, Yacoub MH, Smolenski RT. Novel Targets for a Combination of Mechanical Unloading with Pharmacotherapy in Advanced Heart Failure. Int J Mol Sci 2022; 23:ijms23179886. [PMID: 36077285 PMCID: PMC9456495 DOI: 10.3390/ijms23179886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 12/19/2022] Open
Abstract
LVAD therapy is an effective rescue in acute and especially chronic cardiac failure. In several scenarios, it provides a platform for regeneration and sustained myocardial recovery. While unloading seems to be a key element, pharmacotherapy may provide powerful tools to enhance effective cardiac regeneration. The synergy between LVAD support and medical agents may ensure satisfying outcomes on cardiomyocyte recovery followed by improved quality and quantity of patient life. This review summarizes the previous and contemporary strategies for combining LVAD with pharmacotherapy and proposes new therapeutic targets. Regulation of metabolic pathways, enhancing mitochondrial biogenesis and function, immunomodulating treatment, and stem-cell therapies represent therapeutic areas that require further experimental and clinical studies on their effectiveness in combination with mechanical unloading.
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Affiliation(s)
- Agata Jedrzejewska
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
| | - Alicja Braczko
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
| | - Ada Kawecka
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
| | - Marcin Hellmann
- Department of Cardiac Diagnostics, Medical University of Gdansk, Smoluchowskiego 17, 80-214 Gdansk, Poland
| | - Piotr Siondalski
- Department of Cardiac Surgery, Medical University of Gdansk, Debinki 7 Street, 80-211 Gdansk, Poland
| | - Ewa Slominska
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
| | - Barbara Kutryb-Zajac
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
- Correspondence: (B.K.-Z.); (R.T.S.)
| | - Magdi H. Yacoub
- Heart Science Centre, Imperial College of London at Harefield Hospital, Harefield UB9 6JH, UK
| | - Ryszard T. Smolenski
- Department of Biochemistry, Medical University of Gdansk, Debinki 1 Street, 80-211 Gdansk, Poland
- Correspondence: (B.K.-Z.); (R.T.S.)
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13
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Hnat T, Veselka J, Honek J. Left ventricular reverse remodelling and its predictors in non-ischaemic cardiomyopathy. ESC Heart Fail 2022; 9:2070-2083. [PMID: 35437948 PMCID: PMC9288763 DOI: 10.1002/ehf2.13939] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 02/16/2022] [Accepted: 04/04/2022] [Indexed: 11/21/2022] Open
Abstract
Adverse remodelling following an initial insult is the hallmark of heart failure (HF) development and progression. It is manifested as changes in size, shape, and function of the myocardium. While cardiac remodelling may be compensatory in the short term, further neurohumoral activation and haemodynamic overload drive this deleterious process that is associated with impaired prognosis. However, in some patients, the changes may be reversed. Left ventricular reverse remodelling (LVRR) is characterized as a decrease in chamber volume and normalization of shape associated with improvement in both systolic and diastolic function. LVRR might occur spontaneously or more often in response to therapeutic interventions that either remove the initial stressor or alleviate some of the mechanisms that contribute to further deterioration of the failing heart. Although the process of LVRR in patients with new‐onset HF may take up to 2 years after initiating treatment, there is a significant portion of patients who do not improve despite optimal therapy, which has serious clinical implications when considering treatment escalation towards more aggressive options. On the contrary, in patients that achieve delayed improvement in cardiac function and architecture, waiting might avoid untimely implantable cardioverter‐defibrillator implantation. Therefore, prognostication of successful LVRR based on clinical, imaging, and biomarker predictors is of utmost importance. LVRR has a positive impact on prognosis. However, reverse remodelled hearts continue to have abnormal features. In fact, most of the molecular, cellular, interstitial, and genome expression abnormalities remain and a susceptibility to dysfunction redevelopment under biomechanical stress persists in most patients. Hence, a distinction should be made between reverse remodelling and true myocardial recovery. In this comprehensive review, current evidence on LVRR, its predictors, and implications on prognostication, with a specific focus on HF patients with non‐ischaemic cardiomyopathy, as well as on novel drugs, is presented.
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Affiliation(s)
- Tomas Hnat
- Department of Cardiology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, V Úvalu 84/1, Prague, 15006, Czech Republic
| | - Josef Veselka
- Department of Cardiology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, V Úvalu 84/1, Prague, 15006, Czech Republic
| | - Jakub Honek
- Department of Cardiology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, V Úvalu 84/1, Prague, 15006, Czech Republic
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14
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DeVore AD, Hellkamp AS, Thomas L, Albert NM, Butler J, Patterson JH, Spertus JA, Williams FB, Shen X, Hernandez AF, Fonarow GC. The Association of Improvement in Left Ventricular Ejection Fraction with Outcomes in Patients with Heart Failure with Reduced Ejection Fraction: Data from CHAMP-HF. Eur J Heart Fail 2022; 24:762-770. [PMID: 35293088 DOI: 10.1002/ejhf.2486] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 11/07/2022] Open
Abstract
AIMS We assessed for an association between improvements in left ventricular ejection fraction (LVEF) and future outcomes, including health status, in routine clinical practice. METHODS AND RESULTS CHAMP-HF was a registry of outpatients with heart failure (HF) and LVEF <40%. Enrolled participants completed the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) at regular intervals and were followed as part of routine care. We assessed for associations between improvements in LVEF (>10%) over time and concurrent changes in KCCQ-12, as well as the subsequent risk of poor outcomes. We included 2092 participants in the study. They had the following characteristics: median age 67 years (25th , 75th percentile 58, 75), 29% female, median duration of HF 2.7 years (0.6, 6.8), and median baseline LVEF 30% (23, 35). Of the study participants, 689 (34%) had a >10% absolute improvement in LVEF. Participants with an LVEF improvement also had an improvement in KCCQ-12 overall summary score compared with participants without an LVEF improvement (+7.6 vs +3.5, adjusted effect estimate +4.1 [95% CI 2.3 to 5.7]). Similarly, subsequent all-cause death or HF hospitalization occurred in 12% in the LVEF improvement group vs 25% in the group without an LVEF improvement (adjusted HR 0.50, 95% CI 0.41 to 0.61). CONCLUSION In a large cohort of outpatients with chronic HF, improvements in LVEF were associated with improved health status and a reduced risk for future clinical events. These data underscore the importance of improvement in LVEF as a treatment target for medical interventions for patients with chronic HF.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Laine Thomas
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Javed Butler
- University of Mississippi Medical Center, Jackson, MS, USA
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Xian Shen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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15
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Shibata N, Hiraiwa H, Kazama S, Kimura Y, Araki T, Mizutani T, Oishi H, Kuwayama T, Kondo T, Morimoto R, Okumura T, Murohara T. Clinical Effect of Pulmonary Artery Diameter/Ascending Aorta Diameter Ratio on Left Ventricular Reverse Remodeling in Patients With Dilated Cardiomyopathy. Circ J 2022; 86:1102-1112. [PMID: 35082187 DOI: 10.1253/circj.cj-21-0786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Many patients with dilated cardiomyopathy (DCM) progress to heart failure (HF), although some demonstrate left ventricular (LV) reverse remodeling (LVRR), which is associated with better outcomes. The pulmonary artery diameter (PAD) to ascending aortic diameter (AoD) ratio has been used as a prognostic predictor in patients with HF, although this tool's usefulness in predicting LVRR remains unknown.Methods and Results:Data from a prospective observational study of 211 patients diagnosed in 2000-2020 with DCM were retrospectively analyzed. Sixty-nine patients with New York Heart Association class I or II HF were included. LVRR was observed in 23 patients (33.3%). The mean LV ejection fraction (29%) and LV end-diastolic dimension (64.5 mm) were similar in patients with and without LVRR. The PAD/AoD ratio was significantly lower in patients with LVRR than those without (81.4% vs. 92.4%, respectively; P=0.003). The optimal PAD/AoD cut-off value for detecting LVRR was 0.9 according to the receiver operating characteristic curve analysis. Multivariate analysis identified a PAD/AoD ratio ≥0.9 as an independent predictor of presence/absence of LVRR. Cardiac events were significantly more common in patients with a PAD/AoD ratio ≥0.9 than those with a ratio <0.9, after a median follow up of 2.5 years (log-rank, P=0.007). CONCLUSIONS The PAD/AoD ratio can predict LVRR in patients with DCM.
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Affiliation(s)
- Naoki Shibata
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Shingo Kazama
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Yuki Kimura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Takashi Araki
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Takashi Mizutani
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hideo Oishi
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Tasuku Kuwayama
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Ryota Morimoto
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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16
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Influence of β2 Adrenergic Receptor Genotype on Longitudinal Measures of Forced Vital Capacity in Patients with Duchenne Muscular Dystrophy. Neuromuscul Disord 2022; 32:150-158. [DOI: 10.1016/j.nmd.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/23/2021] [Accepted: 12/29/2021] [Indexed: 11/21/2022]
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17
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Effect of sodium-glucose cotransporter 2 (SGLT2) inhibitors on left ventricular remodelling and longitudinal strain: a prospective observational study. BMC Cardiovasc Disord 2021; 21:456. [PMID: 34548011 PMCID: PMC8456580 DOI: 10.1186/s12872-021-02250-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/08/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors (SGLT2i) lower cardiovascular events in type 2 diabetes mellitus (T2DM) patients, although the mechanisms underlying these benefits are not clearly understood. Our aim was to study the effects of SGLT2i on left ventricular remodelling and longitudinal strain. METHODS Between November 2019 and April 2020, we included 52 patients with T2DM ≥ 18 years old, with HbA1c between 6.5 and 10.0%, and estimated glomerular filtration ≥ 45 ml/min/1.73 m2. Patients were classified into SGLT2i group and control group, according to prescribed treatment by their referring physician. Conventional and speckle tracking echocardiography were performed by blinded sonographers, at baseline and after 6 months of treatment. RESULTS Among the 52 included patients (44% females, mean age 66.8 ± 8.6 years, mean HbA1c was 7.40 ± 0.7%), 30 patients were prescribed SGLT2i and 22 patients were classified as control group. Mean change in indexed left ventricular mass (LVM) was - 0.85 ± 3.31 g/m2 (p = 0.003) in the SGLT2i group, and + 2.34 ± 4.13 g/m2 (p = 0.58) in the control group. Absolute value of Global Longitudinal Strain (GLS) increased by a mean of 1.29 ± 0.47 (p = 0.011) in the SGLT2i group, and 0.40 ± 0.62 (p = 0.34) in the control group. We did not find correlations between changes in LVM and GLS, and other variables like change in HbA1c. CONCLUSIONS Among patients with T2DM, SGLT2i were associated with a significant reduction in indexed LVM and a significant increment in longitudinal strain measured by speckle tracking echocardiography, which may explain in part the clinical benefits found in clinical trials.
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18
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Ito K, Li S, Homma S, Thompson JLP, Buchsbaum R, Matsumoto K, Anker SD, Qian M, Di Tullio MR. Left ventricular dimensions and cardiovascular outcomes in systolic heart failure: the WARCEF trial. ESC Heart Fail 2021; 8:4997-5009. [PMID: 34545701 PMCID: PMC8712869 DOI: 10.1002/ehf2.13560] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 04/23/2021] [Accepted: 08/03/2021] [Indexed: 11/16/2022] Open
Abstract
Aims There is limited information on the association between left ventricular (LV) dimensions and cardiovascular (CV) outcomes in patients with heart failure (HF) with reduced LV ejection fraction (HFrEF) receiving recommended HF treatment. We investigated the association between LV dimensions and CV outcomes in HFrEF patients receiving recommended HF treatment. Methods and results We investigated the association between LV echocardiographic dimensions and CV outcomes using conventional Cox models in 1138 HFrEF patients in sinus rhythm randomized to warfarin or aspirin treatment in the Warfarin vs. Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial. LV enlargement, whether by diameter [LV end‐diastolic diameter index (LVEDDI) and LV end‐systolic diameter index (LVESDI)] or volume [LV end‐diastolic volume index (LVEDVI) and LV end‐systolic volume index (LVESVI)], was independently associated with all‐cause death [LVEDDI: hazard ratio (HR) per cm/m2 1.53, LVESDI: HR per cm/m2 1.65, LVEDVI: HR per 10 mL/m2 1.07, and LVESVI: HR per 10 mL/m2 1.10; all P values < 0.001], CV death (HR 1.68, 1.79, 1.09, and 1.12, respectively; all P values < 0.001), and HF hospitalization (HR 1.59, 1.79, 1.06, and 1.08, respectively; all P values < 0.001). No association was observed with myocardial infarction or stroke. The associations were independent of LV ejection fraction values, and incremental to them. LV volumes conferred additional predictive value over LV diameters. Conclusions Left ventricular enlargement is an independent predictor of CV events in patients with HFrEF and recommended HF treatment. LV dimensions should be considered in the risk assessment.
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Affiliation(s)
- Kazato Ito
- Department of Medicine, Columbia University Irving Medical Center, PH3-342, 622 West 168th Street, New York, NY, 10032, USA
| | - Siyuan Li
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Shunichi Homma
- Department of Medicine, Columbia University Irving Medical Center, PH3-342, 622 West 168th Street, New York, NY, 10032, USA
| | - John L P Thompson
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Richard Buchsbaum
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Kenji Matsumoto
- Department of Medicine, Columbia University Irving Medical Center, PH3-342, 622 West 168th Street, New York, NY, 10032, USA
| | - Stefan D Anker
- Department of Cardiology, Berlin Institute of Health Center for Regenerative Therapies, and German Centre for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Min Qian
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Marco R Di Tullio
- Department of Medicine, Columbia University Irving Medical Center, PH3-342, 622 West 168th Street, New York, NY, 10032, USA
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19
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Abstract
Neurohormones and inflammatory mediators have effects in both the heart and the peripheral vasculature. In patients with heart failure (HF), neurohormonal activation and increased levels of inflammatory mediators promote ventricular remodeling and development of HF, as well as vascular dysfunction and arterial stiffness. These processes may lead to a vicious cycle, whereby arterial stiffness perpetuates further ventricular remodeling leading to exacerbation of symptoms. Although significant advances have been made in the treatment of HF, currently available treatment strategies slow, but do not halt, this cycle. The current treatment for HF patients involves the inhibition of neurohormonal activation, which can reduce morbidity and mortality related to this condition. Beyond benefits associated with neurohormonal blockade, other strategies have focused on inhibition of inflammatory pathways implicated in the pathogenesis of HF. Unfortunately, attempts to target inflammation have not yet been successful to improve prognosis of HF. Further work is required to interrupt key maladaptive mechanisms involved in disease progression.
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20
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Martin N, Manoharan K, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2021; 5:CD012721. [PMID: 34022072 PMCID: PMC8140651 DOI: 10.1002/14651858.cd012721.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin-aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction (LVEF); a review of the evidence is required to determine whether these treatments are beneficial for people with heart failure with preserved ejection fraction (HFpEF). OBJECTIVES To assess the effects of beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with HFpEF. SEARCH METHODS We updated searches of CENTRAL, MEDLINE, Embase, and one clinical trial register on 14 May 2020 to identify eligible studies, with no language or date restrictions. We checked references from trial reports and review articles for additional studies. SELECTION CRITERIA: We included randomised controlled trials with a parallel group design, enrolling adults with HFpEF, defined by LVEF greater than 40%. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 41 randomised controlled trials (231 reports), totalling 23,492 participants across all comparisons. The risk of bias was frequently unclear and only five studies had a low risk of bias in all domains. Beta-blockers (BBs) We included 10 studies (3087 participants) investigating BBs. Five studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 30 years to 81 years. A possible reduction in cardiovascular mortality was observed (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; number needed to treat for an additional benefit (NNTB) 25; 1046 participants; three studies), however, the certainty of evidence was low. There may be little to no effect on all-cause mortality (RR 0.82, 95% CI 0.67 to 1.00; 1105 participants; four studies; low-certainty evidence). The effects on heart failure hospitalisation, hyperkalaemia, and quality of life remain uncertain. Mineralocorticoid receptor antagonists (MRAs) We included 13 studies (4459 participants) investigating MRA. Eight studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 54.5 to 80 years. Pooled analysis indicated that MRA treatment probably reduces heart failure hospitalisation (RR 0.82, 95% CI 0.69 to 0.98; NNTB = 41; 3714 participants; three studies; moderate-certainty evidence). However, MRA treatment probably has little or no effect on all-cause mortality (RR 0.91, 95% CI 0.78 to 1.06; 4207 participants; five studies; moderate-certainty evidence) and cardiovascular mortality (RR 0.90, 95% CI 0.74 to 1.11; 4070 participants; three studies; moderate-certainty evidence). MRA treatment may have little or no effect on quality of life measures (mean difference (MD) 0.84, 95% CI -2.30 to 3.98; 511 participants; three studies; low-certainty evidence). MRA treatment was associated with a higher risk of hyperkalaemia (RR 2.11, 95% CI 1.77 to 2.51; number needed to treat for an additional harmful outcome (NNTH) = 11; 4291 participants; six studies; high-certainty evidence). Angiotensin-converting enzyme inhibitors (ACEIs) We included eight studies (2061 participants) investigating ACEIs. Three studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 70 to 82 years. Pooled analyses with moderate-certainty evidence suggest that ACEI treatment likely has little or no effect on cardiovascular mortality (RR 0.93, 95% CI 0.61 to 1.42; 945 participants; two studies), all-cause mortality (RR 1.04, 95% CI 0.75 to 1.45; 1187 participants; five studies) and heart failure hospitalisation (RR 0.86, 95% CI 0.64 to 1.15; 1019 participants; three studies), and may result in little or no effect on the quality of life (MD -0.09, 95% CI -3.66 to 3.48; 154 participants; two studies; low-certainty evidence). The effects on hyperkalaemia remain uncertain. Angiotensin receptor blockers (ARBs) Eight studies (8755 participants) investigating ARBs were included. Five studies used a placebo comparator and in three the comparator was usual care. The mean age of participants ranged from 61 to 75 years. Pooled analyses with high certainty of evidence suggest that ARB treatment has little or no effect on cardiovascular mortality (RR 1.02, 95% 0.90 to 1.14; 7254 participants; three studies), all-cause mortality (RR 1.01, 95% CI 0.92 to 1.11; 7964 participants; four studies), heart failure hospitalisation (RR 0.92, 95% CI 0.83 to 1.02; 7254 participants; three studies), and quality of life (MD 0.41, 95% CI -0.86 to 1.67; 3117 participants; three studies). ARB was associated with a higher risk of hyperkalaemia (RR 1.88, 95% CI 1.07 to 3.33; 7148 participants; two studies; high-certainty evidence). Angiotensin receptor neprilysin inhibitors (ARNIs) Three studies (7702 participants) investigating ARNIs were included. Two studies used ARBs as the comparator and one used standardised medical therapy, based on participants' established treatments at enrolment. The mean age of participants ranged from 71 to 73 years. Results suggest that ARNIs may have little or no effect on cardiovascular mortality (RR 0.96, 95% CI 0.79 to 1.15; 4796 participants; one study; moderate-certainty evidence), all-cause mortality (RR 0.97, 95% CI 0.84 to 1.11; 7663 participants; three studies; high-certainty evidence), or quality of life (high-certainty evidence). However, ARNI treatment may result in a slight reduction in heart failure hospitalisation, compared to usual care (RR 0.89, 95% CI 0.80 to 1.00; 7362 participants; two studies; moderate-certainty evidence). ARNI treatment was associated with a reduced risk of hyperkalaemia compared with valsartan (RR 0.88, 95% CI 0.77 to 1.01; 5054 participants; two studies; moderate-certainty evidence). AUTHORS' CONCLUSIONS There is evidence that MRA and ARNI treatment in HFpEF probably reduces heart failure hospitalisation but probably has little or no effect on cardiovascular mortality and quality of life. BB treatment may reduce the risk of cardiovascular mortality, however, further trials are needed. The current evidence for BBs, ACEIs, and ARBs is limited and does not support their use in HFpEF in the absence of an alternative indication. Although MRAs and ARNIs are probably effective at reducing the risk of heart failure hospitalisation, the treatment effect sizes are modest. There is a need for improved approaches to patient stratification to identify the subgroup of patients who are most likely to benefit from MRAs and ARNIs, as well as for an improved understanding of disease biology, and for new therapeutic approaches.
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Affiliation(s)
- Nicole Martin
- Institute of Health Informatics Research, University College London, London, UK
| | | | - Ceri Davies
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - R Thomas Lumbers
- Institute of Health Informatics, University College London, London, UK
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21
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Docherty KF, Campbell RT, Brooksbank KJM, Dreisbach JG, Forsyth P, Godeseth RL, Hopkins T, Jackson AM, Lee MMY, McConnachie A, Roditi G, Squire IB, Stanley B, Welsh P, Jhund PS, Petrie MC, McMurray JJV. Effect of Neprilysin Inhibition on Left Ventricular Remodeling in Patients With Asymptomatic Left Ventricular Systolic Dysfunction Late After Myocardial Infarction. Circulation 2021; 144:199-209. [PMID: 33983794 PMCID: PMC8284373 DOI: 10.1161/circulationaha.121.054892] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with left ventricular (LV) systolic dysfunction after myocardial infarction are at a high risk of developing heart failure. The addition of neprilysin inhibition to renin angiotensin system inhibition may result in greater attenuation of adverse LV remodeling as a result of increased levels of substrates for neprilysin with vasodilatory, antihypertrophic, antifibrotic, and sympatholytic effects. METHODS We performed a prospective, multicenter, randomized, double-blind, active-comparator trial comparing sacubitril/valsartan 97/103 mg twice daily with valsartan 160 mg twice daily in patients ≥3 months after myocardial infarction with a LV ejection fraction ≤40% who were taking a renin angiotensin system inhibitor (equivalent dose of ramipril ≥2.5 mg twice daily) and a β-blocker unless contraindicated or intolerant. Patients in New York Heart Association class ≥II or with signs and symptoms of heart failure were excluded. The primary outcome was change from baseline to 52 weeks in LV end-systolic volume index measured using cardiac magnetic resonance imaging. Secondary outcomes included other magnetic resonance imaging measurements of LV remodeling, change in NT-proBNP (N-terminal pro-B-type natriuretic peptide) and high-sensitivity cardiac troponin I, and a patient global assessment of change questionnaire. RESULTS From July 2018 to June 2019, we randomized 93 patients with the following characteristics: mean age, 60.7±10.4 years; median time from myocardial infarction, 3.6 years (interquartile range, 1.2-7.2); mean LV ejection fraction, 36.8%±7.1%; and median NT-proBNP, 230 pg/mL (interquartile range, 124-404). Sacubitril/valsartan, compared with valsartan, did not significantly reduce LV end-systolic volume index; adjusted between-group difference, -1.9 mL/m2 (95% CI, -4.9 to 1.0); P=0.19. There were no significant between-group differences in NT-proBNP, high-sensitivity cardiac troponin I, LV end-diastolic volume index, left atrial volume index, LV ejection fraction, LV mass index, or patient global assessment of change. CONCLUSIONS In patients with asymptomatic LV systolic dysfunction late after myocardial infarction, treatment with sacubitril/valsartan did not have a significant reverse remodeling effect compared with valsartan. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03552575.
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Affiliation(s)
- Kieran F Docherty
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (K.F.D., R.T.C., K.J.M.B., R.L.G., T.H., A.M.J., M.M.Y.L., G.R., P.W., P.S.J., M.C.P., J.J.V.M.), University of Glasgow, United Kingdom
| | - Ross T Campbell
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (K.F.D., R.T.C., K.J.M.B., R.L.G., T.H., A.M.J., M.M.Y.L., G.R., P.W., P.S.J., M.C.P., J.J.V.M.), University of Glasgow, United Kingdom
| | - Katriona J M Brooksbank
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (K.F.D., R.T.C., K.J.M.B., R.L.G., T.H., A.M.J., M.M.Y.L., G.R., P.W., P.S.J., M.C.P., J.J.V.M.), University of Glasgow, United Kingdom
| | - John G Dreisbach
- Golden Jubilee National Hospital, Glasgow, United Kingdom (J.G.D.)
| | - Paul Forsyth
- Pharmacy Services, National Health Service Greater Glasgow and Clyde, United Kingdom (P.F.)
| | - Rosemary L Godeseth
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (K.F.D., R.T.C., K.J.M.B., R.L.G., T.H., A.M.J., M.M.Y.L., G.R., P.W., P.S.J., M.C.P., J.J.V.M.), University of Glasgow, United Kingdom
| | - Tracey Hopkins
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (K.F.D., R.T.C., K.J.M.B., R.L.G., T.H., A.M.J., M.M.Y.L., G.R., P.W., P.S.J., M.C.P., J.J.V.M.), University of Glasgow, United Kingdom.,Glasgow Clinical Research Imaging Facility (T.H., G.R.), Queen Elizabeth University Hospital, United Kingdom (R.T.C.)
| | - Alice M Jackson
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (K.F.D., R.T.C., K.J.M.B., R.L.G., T.H., A.M.J., M.M.Y.L., G.R., P.W., P.S.J., M.C.P., J.J.V.M.), University of Glasgow, United Kingdom
| | - Matthew M Y Lee
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (K.F.D., R.T.C., K.J.M.B., R.L.G., T.H., A.M.J., M.M.Y.L., G.R., P.W., P.S.J., M.C.P., J.J.V.M.), University of Glasgow, United Kingdom
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing (A.M., B.S.), University of Glasgow, United Kingdom
| | - Giles Roditi
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (K.F.D., R.T.C., K.J.M.B., R.L.G., T.H., A.M.J., M.M.Y.L., G.R., P.W., P.S.J., M.C.P., J.J.V.M.), University of Glasgow, United Kingdom.,Glasgow Clinical Research Imaging Facility (T.H., G.R.), Queen Elizabeth University Hospital, United Kingdom (R.T.C.).,Department of Radiology, Glasgow Royal Infirmary, United Kingdom (G.R.)
| | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester and National Institute for Health Research Biomedical Research Centre, Glenfield Hospital, United Kingdom (I.B.S.)
| | - Bethany Stanley
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing (A.M., B.S.), University of Glasgow, United Kingdom
| | - Paul Welsh
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (K.F.D., R.T.C., K.J.M.B., R.L.G., T.H., A.M.J., M.M.Y.L., G.R., P.W., P.S.J., M.C.P., J.J.V.M.), University of Glasgow, United Kingdom
| | - Pardeep S Jhund
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (K.F.D., R.T.C., K.J.M.B., R.L.G., T.H., A.M.J., M.M.Y.L., G.R., P.W., P.S.J., M.C.P., J.J.V.M.), University of Glasgow, United Kingdom
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (K.F.D., R.T.C., K.J.M.B., R.L.G., T.H., A.M.J., M.M.Y.L., G.R., P.W., P.S.J., M.C.P., J.J.V.M.), University of Glasgow, United Kingdom
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (K.F.D., R.T.C., K.J.M.B., R.L.G., T.H., A.M.J., M.M.Y.L., G.R., P.W., P.S.J., M.C.P., J.J.V.M.), University of Glasgow, United Kingdom
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22
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Abstract
Heart failure (HF) continues to be a serious public health challenge despite significant advancements in therapeutics and is often complicated by multiple other comorbidities. Of particular concern is type 2 diabetes mellitus (T2DM) which not only amplifies the risk, but also limits the treatment options available to patients. The sodium-glucose linked cotransporter subtype 2 (SGLT2)-inhibitor class, which was initially developed as a treatment for T2DM, has shown great promise in reducing cardiovascular risk, particularly around HF outcomes - regardless of diabetes status.There are ongoing efforts to elucidate the true mechanism of action of this novel drug class. Its primary mechanism of inducing glycosuria and diuresis from receptor blockade in the renal nephron seems unlikely to be responsible for the rapid and striking benefits seen in clinical trials. Early mechanistic work around conventional therapeutic targets seem to be inconclusive. There are some emerging theories around its effect on myocardial energetics and calcium balance as well as on renal physiology. In this review, we discuss some of the cutting-edge hypotheses and concepts currently being explored around this drug class in an attempt better understand the molecular mechanics of this novel agent.
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Affiliation(s)
- Amir Fathi
- Department of Neuroanaesthesia and Critical Care, National Hospital for Neurology and Neurosurgery, University College London, London, UK
| | - Keeran Vickneson
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Jagdeep S Singh
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK.
- Department of Cardiology, The Edinburgh Heart Center, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
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23
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Lee MMY, Brooksbank KJM, Wetherall K, Mangion K, Roditi G, Campbell RT, Berry C, Chong V, Coyle L, Docherty KF, Dreisbach JG, Labinjoh C, Lang NN, Lennie V, McConnachie A, Murphy CL, Petrie CJ, Petrie JR, Speirits IA, Sourbron S, Welsh P, Woodward R, Radjenovic A, Mark PB, McMurray JJV, Jhund PS, Petrie MC, Sattar N. Effect of Empagliflozin on Left Ventricular Volumes in Patients With Type 2 Diabetes, or Prediabetes, and Heart Failure With Reduced Ejection Fraction (SUGAR-DM-HF). Circulation 2020; 143:516-525. [PMID: 33186500 PMCID: PMC7864599 DOI: 10.1161/circulationaha.120.052186] [Citation(s) in RCA: 211] [Impact Index Per Article: 52.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors reduce the risk of heart failure hospitalization and cardiovascular death in patients with heart failure and reduced ejection fraction (HFrEF). However, their effects on cardiac structure and function in HFrEF are uncertain. METHODS We designed a multicenter, randomized, double-blind, placebo-controlled trial (the SUGAR-DM-HF trial [Studies of Empagliflozin and Its Cardiovascular, Renal and Metabolic Effects in Patients With Diabetes Mellitus, or Prediabetes, and Heart Failure]) to investigate the cardiac effects of empagliflozin in patients in New York Heart Association functional class II to IV with a left ventricular (LV) ejection fraction ≤40% and type 2 diabetes or prediabetes. Patients were randomly assigned 1:1 to empagliflozin 10 mg once daily or placebo, stratified by age (<65 and ≥65 years) and glycemic status (diabetes or prediabetes). The coprimary outcomes were change from baseline to 36 weeks in LV end-systolic volume indexed to body surface area and LV global longitudinal strain both measured using cardiovascular magnetic resonance. Secondary efficacy outcomes included other cardiovascular magnetic resonance measures (LV end-diastolic volume index, LV ejection fraction), diuretic intensification, symptoms (Kansas City Cardiomyopathy Questionnaire Total Symptom Score, 6-minute walk distance, B-lines on lung ultrasound, and biomarkers (including N-terminal pro-B-type natriuretic peptide). RESULTS From April 2018 to August 2019, 105 patients were randomly assigned: mean age 68.7 (SD, 11.1) years, 77 (73.3%) male, 82 (78.1%) diabetes and 23 (21.9%) prediabetes, mean LV ejection fraction 32.5% (9.8%), and 81 (77.1%) New York Heart Association II and 24 (22.9%) New York Heart Association III. Patients received standard treatment for HFrEF. In comparison with placebo, empagliflozin reduced LV end-systolic volume index by 6.0 (95% CI, -10.8 to -1.2) mL/m2 (P=0.015). There was no difference in LV global longitudinal strain. Empagliflozin reduced LV end-diastolic volume index by 8.2 (95% CI, -13.7 to -2.6) mL/m2 (P=0.0042) and reduced N-terminal pro-B-type natriuretic peptide by 28% (2%-47%), P=0.038. There were no between-group differences in other cardiovascular magnetic resonance measures, diuretic intensification, Kansas City Cardiomyopathy Questionnaire Total Symptom Score, 6-minute walk distance, or B-lines. CONCLUSIONS The sodium-glucose cotransporter 2 inhibitor empagliflozin reduced LV volumes in patients with HFrEF and type 2 diabetes or prediabetes. Favorable reverse LV remodeling may be a mechanism by which sodium-glucose cotransporter 2 inhibitors reduce heart failure hospitalization and mortality in HFrEF. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03485092.
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Affiliation(s)
- Matthew M Y Lee
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom.,Queen Elizabeth University Hospital, Glasgow, United Kingdom (M.M.Y.L., K.M., G.R., R.T.C., C.B., K.F.D., N.N.L., R.W., P.B.M., J.J.V.M., P.S.J.).,Glasgow Royal Infirmary, United Kingdom (M.M.Y.L., G.R., J.R.P., M.C.P., N.S.)
| | - Katriona J M Brooksbank
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom
| | - Kirsty Wetherall
- Robertson Centre for Biostatistics (K.W., A.M.), University of Glasgow, United Kingdom
| | - Kenneth Mangion
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom.,Queen Elizabeth University Hospital, Glasgow, United Kingdom (M.M.Y.L., K.M., G.R., R.T.C., C.B., K.F.D., N.N.L., R.W., P.B.M., J.J.V.M., P.S.J.)
| | - Giles Roditi
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom.,Queen Elizabeth University Hospital, Glasgow, United Kingdom (M.M.Y.L., K.M., G.R., R.T.C., C.B., K.F.D., N.N.L., R.W., P.B.M., J.J.V.M., P.S.J.).,Glasgow Royal Infirmary, United Kingdom (M.M.Y.L., G.R., J.R.P., M.C.P., N.S.)
| | - Ross T Campbell
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom.,Queen Elizabeth University Hospital, Glasgow, United Kingdom (M.M.Y.L., K.M., G.R., R.T.C., C.B., K.F.D., N.N.L., R.W., P.B.M., J.J.V.M., P.S.J.).,Golden Jubilee National Hospital, Glasgow, United Kingdom (R.T.C., C.B., J.G.D., M.C.P.)
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom.,Queen Elizabeth University Hospital, Glasgow, United Kingdom (M.M.Y.L., K.M., G.R., R.T.C., C.B., K.F.D., N.N.L., R.W., P.B.M., J.J.V.M., P.S.J.).,Golden Jubilee National Hospital, Glasgow, United Kingdom (R.T.C., C.B., J.G.D., M.C.P.)
| | - Victor Chong
- University Hospital Crosshouse, Kilmarnock, United Kingdom (V.C.)
| | - Liz Coyle
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom
| | - Kieran F Docherty
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom.,Queen Elizabeth University Hospital, Glasgow, United Kingdom (M.M.Y.L., K.M., G.R., R.T.C., C.B., K.F.D., N.N.L., R.W., P.B.M., J.J.V.M., P.S.J.)
| | - John G Dreisbach
- Golden Jubilee National Hospital, Glasgow, United Kingdom (R.T.C., C.B., J.G.D., M.C.P.)
| | | | - Ninian N Lang
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom.,Queen Elizabeth University Hospital, Glasgow, United Kingdom (M.M.Y.L., K.M., G.R., R.T.C., C.B., K.F.D., N.N.L., R.W., P.B.M., J.J.V.M., P.S.J.)
| | - Vera Lennie
- University Hospital Ayr, United Kingdom (V.L.)
| | - Alex McConnachie
- Robertson Centre for Biostatistics (K.W., A.M.), University of Glasgow, United Kingdom
| | - Clare L Murphy
- Royal Alexandra Hospital, Paisley, United Kingdom (C.L.M.)
| | - Colin J Petrie
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom.,University Hospital Monklands, Airdrie, United Kingdom (C.J.P.)
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom.,Glasgow Royal Infirmary, United Kingdom (M.M.Y.L., G.R., J.R.P., M.C.P., N.S.)
| | - Iain A Speirits
- West Glasgow Ambulatory Care Hospital, United Kingdom (I.A.S.)
| | | | - Paul Welsh
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom
| | - Rosemary Woodward
- Queen Elizabeth University Hospital, Glasgow, United Kingdom (M.M.Y.L., K.M., G.R., R.T.C., C.B., K.F.D., N.N.L., R.W., P.B.M., J.J.V.M., P.S.J.)
| | - Aleksandra Radjenovic
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom.,Queen Elizabeth University Hospital, Glasgow, United Kingdom (M.M.Y.L., K.M., G.R., R.T.C., C.B., K.F.D., N.N.L., R.W., P.B.M., J.J.V.M., P.S.J.)
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom.,Queen Elizabeth University Hospital, Glasgow, United Kingdom (M.M.Y.L., K.M., G.R., R.T.C., C.B., K.F.D., N.N.L., R.W., P.B.M., J.J.V.M., P.S.J.)
| | - Pardeep S Jhund
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom.,Queen Elizabeth University Hospital, Glasgow, United Kingdom (M.M.Y.L., K.M., G.R., R.T.C., C.B., K.F.D., N.N.L., R.W., P.B.M., J.J.V.M., P.S.J.)
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom.,Glasgow Royal Infirmary, United Kingdom (M.M.Y.L., G.R., J.R.P., M.C.P., N.S.).,Golden Jubilee National Hospital, Glasgow, United Kingdom (R.T.C., C.B., J.G.D., M.C.P.)
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre (M.M.Y.L., K.J.M.B., K.M., G.R., R.T.C., C.B., L.C., K.F.D., N.N.L., C.J.P., J.R.P., P.W., A.R., P.B.M., J.J.V.M., P.S.J., M.C.P., N.S.), University of Glasgow, United Kingdom.,Glasgow Royal Infirmary, United Kingdom (M.M.Y.L., G.R., J.R.P., M.C.P., N.S.)
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Lee YH, Chiou WR, Hsu CY, Lin PL, Liang HW, Chung FP, Liao CT, Lin WY, Chang HY. Different left ventricular remodeling patterns and clinical outcomes between non-ischemic and ischemic etiologies in heart failure patients receiving sacubitril/valsartan treatment. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 8:118-129. [PMID: 33119090 DOI: 10.1093/ehjcvp/pvaa125] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/22/2020] [Accepted: 10/15/2020] [Indexed: 02/06/2023]
Abstract
AIMS Although the beneficial effect of sacubitril/valsartan (SAC/VAL) compared to enalapril was consistent across ischaemic (ICM) and non-ischaemic cardiomyopathy (NICM) groups, the PARADIGM-HF study did not analyze the effect of ventricular remodelling on patients with different etiologies, which may affect clinical treatment outcomes. This study aimed to compare left ventricular ejection fraction (LVEF) following SAC/VAL treatment and its association with clinical outcomes. METHODS AND RESULTS A total of 1,576 patients were analyzed. Patients were grouped by LVEF changes following SAC/VAL treatment for 8-month period. LVEF improvement ≥15% was defined as "significant improvement", and <5% or worse was classified as "lack of improvement". The primary outcome was a composite of cardiovascular death and unplanned hospitalization for heart failure.Patients with NICM had lower baseline LVEF but improvement was significantly greater comparing to those with ICM (baseline 28.0 ± 7.7% vs. 30.1 ± 7.1%, p < 0.001, LVEF increase of 11.1 ± 12.6% vs. 6.7 ± 10.2%, p < 0.001). The effect of functional improvement of SAC/VAL on NICM patients showed bimodal distribution. Primary endpoints were inversely associated with LVEF changes in NICM patients: adjusted hazard ratio was 0.42 (95% confidence interval [CI] 0.31-0.58, p < 0.001) for NICM patients with significant improvement, and was 1.73 (95% CI 1.38-2.16, p < 0.001) for NICM patients but lack of improvement. Primary endpoints of ICM patients did not demonstrate an association with LVEF changes. CONCLUSION Patients with NICM had higher degree of LVEF improvement than those with ICM following SAC/VAL treatment, and significant improvement of LVEF in NICM patients indicates favorable outcome.
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Affiliation(s)
- Ying-Hsiang Lee
- Cardiovascular Center, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei, Taiwan
| | - Wei-Ru Chiou
- Department of Medicine, Mackay Medical College, New Taipei, Taiwan.,Division of Cardiology, Taitung MacKay Memorial Hospital, Taitung, Taiwan
| | - Chien-Yi Hsu
- Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan.,Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Po-Lin Lin
- Department of Medicine, Mackay Medical College, New Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan
| | - Huai-Wen Liang
- Division of Cardiology, E-Da Hospital, Kaohsiung, Taiwan
| | - Fa-Po Chung
- Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Te Liao
- Division of Cardiology, Chi-Mei Medical Center, Tainan, Taiwan
| | - Wen-Yu Lin
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hung-Yu Chang
- Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan.,Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
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25
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Abstract
Ischemic heart disease is the most common cause of cardiovascular morbidity and mortality. Cardiac magnetic resonance (CMR) improves on other noninvasive modalities in detection, assessment, and prognostication of ischemic heart disease. The incorporation of CMR in clinical trials allows for smaller patient samples without the sacrifice of power needed to demonstrate clinical efficacy. CMR can accurately quantify infarct acuity, size, and complications; guide therapy; and prognosticate recovery. Timing of revascularization remains the holy grail of ischemic heart disease, and viability assessment using CMR may be the missing link needed to help reduce morbidity and mortality associated with the disease.
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Affiliation(s)
- Aneesh S Dhore-Patil
- Tulane University Heart and Vascular Center, Tulane University, 1415 Tulane Avenue, New Orleans, LA 70112, USA
| | - Ashish Aneja
- Department of Cardiovascular Diseases, Case Western Reserve University, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA.
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26
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Ozturk F, Atici A, Barman HA. Can Glypican-6 Level Predict Ejection Fraction Decline After Myocardial Infarction? Angiology 2020; 72:582-588. [PMID: 33094648 DOI: 10.1177/0003319720968376] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The main goals in the treatment of acute coronary syndrome are to prevent myocardial ischemia, damage, and possible complications. Accordingly, we evaluated the predictive value of glypican-6 (GPC6) for cardiac remodeling after myocardial infarction (MI). Baseline plasma GPC6 levels were measured in patients who underwent primary percutaneous coronary intervention (PCI) for acute MI. Left ventricular ejection fraction (LVEF) was measured at baseline and at 6 months with transthoracic echocardiography. Reduced LVEF persisted in 89 out of 276 patients after 6 months. The majority of the patients were male (n = 198, 72%) and the mean age was 57.8 ± 10.8 years. Glypican-6, N-terminal pro-brain natriuretic peptide (NT-proBNP), and high-sensitive troponin levels were significantly lower in the improved LVEF group compared with the low LVEF group (10.54 ± 4.46 vs 6.98 ± 3.34 ng/mL, P < .001; 500 pg/mL [range, 300-600 pg/mL] vs 350 pg/mL [range, 200-550 pg/mL], P = .008; 396 pg/mL [range, 159-579 pg/mL] vs 300 pg/mL [range, 100-500 pg/mL], P = .016, respectively). Logistic regression analysis revealed the SYNTAX Score 2, GPC6, and NT-proBNP as significant independent predictors of low LVEF (hazard ratio [HR]: 1.064, P = .041; HR: 1.215, P < .001; HR: 1.179, P < .001). Glypican-6 may prove to be useful for the detection of low LVEF development in patients undergoing PCI following MI.
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Affiliation(s)
- Fatih Ozturk
- Department of Cardiology, 64162Faculty of Medicine, Yuzunci Yil University, Van, Turkey
| | - Adem Atici
- Department of Cardiology, 64071Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Hasan Ali Barman
- Department of Cardiology, Institute of Cardiology, 532719Istanbul University-Cerrahpasa, Istanbul, Turkey
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27
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Perry AS, Mann DL, Brown DL. Improvement of ejection fraction and mortality in ischaemic heart failure. Heart 2020; 107:heartjnl-2020-316975. [PMID: 32843496 DOI: 10.1136/heartjnl-2020-316975] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/14/2020] [Accepted: 07/22/2020] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE The frequency and predictors of improvement in left ventricular ejection fraction (LVEF) in ischaemic cardiomyopathy and its association with mortality is poorly understood. We sought to assess the predictors of LVEF improvement ≥10% and its effect on mortality. METHODS We compared characteristics of patients enrolled in The Surgical Treatment for Ischaemic Heart Failure (STICH) trial with and without improvement of LVEF ≥10% at 24 months. A logistic regression model was constructed to determine the independent predictors of LVEF improvement. A Cox proportional hazards model was created to assess the independent association of improvement in LVEF ≥10% with mortality. RESULTS Of the 1212 patients enrolled in STICH, 618 underwent echocardiographic assessment of LVEF at baseline and 24 months. Of the patients randomised to medical therapy plus coronary artery bypass graft surgery (CABG), 58 (19%) had an improvement in LVEF >10% compared with 51 (16%) patients assigned to medical therapy alone (p=0.30). Independent predictors of LVEF improvement >10% included prior myocardial infarction (OR 0.44, 95% CI: 0.28 to 0.71, p=0.001) and lower baseline LVEF (OR 0.94, 95% CI: 0.91 to 0.97, p<0.001). Improvement in LVEF >10% (HR 0.61, 95% CI: 0.44 to 0.84, p=0.004) and randomisation to CABG (HR 0.72, 95% CI: 0.57 to 0.90, p=0.004) were independently associated with a reduced hazard of mortality. CONCLUSIONS Improvement of LVEF ≥10% at 24 months was uncommon in patients with ischaemic cardiomyopathy, did not differ between patients assigned to CABG and medical therapy or medical therapy alone and was independently associated with reduced mortality. TRIAL REGISTRATION NUMBER NCT00023595.
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Affiliation(s)
- Andrew S Perry
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Douglas L Mann
- Cardiovascular Division, Washington University in St. Louis, St. Louis, Missouri, USA
| | - David L Brown
- Cardiovascular Division, Washington University in St. Louis, St. Louis, Missouri, USA
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28
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Wang S, Wang H, Su X, Liu B, Wang L, Yan H, Mao S, Huang H, Huang C, Cheng M, Wu G. β-adrenergic activation may promote myosin light chain kinase degradation through calpain in pressure overload-induced cardiac hypertrophy: β-adrenergic activation results in MLCK degradation. Biomed Pharmacother 2020; 129:110438. [PMID: 32768940 DOI: 10.1016/j.biopha.2020.110438] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/13/2020] [Accepted: 06/17/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND β-adrenergic activation is able to exacerbate cardiac hypertrophy. Myosin light chain kinase (MLCK) and its phosphorylated substrate, phospho-myosin light chain 2 (p-MLC2), play vital roles in regulating cardiac hypertrophy. However, it is not yet clear whether there is a relationship between β-adrenergic activation and MLCK in the progression of cardiac hypertrophy. Therefore, we explored this relationship and the underlying mechanisms in this work. METHODS Cardiac hypertrophy and cardiomyocyte hypertrophy were induced by pressure overload and isoproterenol (ISO) stimulation, respectively. Echocardiography, histological analysis, immunofluorescence and qRT-PCR were used to confirm the successful establishment of the models. A β-blocker (metoprolol) and a calpain inhibitor (calpeptin) were administered to inhibit β-adrenergic activity in rats and calpain in cardiomyocytes, respectively. The protein expression levels of MLCK, myosin light chain 2 (MLC2), p-MLC2, myosin phosphatase 2 (MYPT2), calmodulin (CaM) and calpain were measured using western blotting. A cleavage assay was performed to assess the degradation of recombinant human MLCK by recombinant human calpain. RESULTS The β-blocker alleviated cardiac hypertrophy and dysfunction, increased MLCK and MLC2 phosphorylation and decreased calpain expression in pressure overload-induced cardiac hypertrophy. Additionally, the calpain inhibitor calpeptin attenuated cardiomyocyte hypertrophy, upregulated MLCK and p-MLC2 and reduced MLCK degradation in ISO-induced cardiomyocyte hypertrophy. Recombinant human calpain degraded recombinant human MLCK in vitro in concentration- and time-dependent manners, and this degradation was inhibited by the calpain inhibitor calpeptin. CONCLUSION Our study suggested that β-adrenergic activation may promote the degradation of MLCK through calpain in pressure overload-induced cardiac hypertrophy.
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Affiliation(s)
- Shun Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute, Hubei Key Laboratory of Cardiology, Wuhan, 430060, China
| | - Haixiong Wang
- Department of Cardiology, Shanxi Cardiovascular Hospital, Taiyuan, 030001, China
| | - Xiaoling Su
- Department of Cardiology, Qinghai Provincial People's Hospital, Xining, 810007, China
| | - Beilei Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute, Hubei Key Laboratory of Cardiology, Wuhan, 430060, China
| | - Le Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute, Hubei Key Laboratory of Cardiology, Wuhan, 430060, China
| | - Hui Yan
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute, Hubei Key Laboratory of Cardiology, Wuhan, 430060, China
| | - Shuai Mao
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute, Hubei Key Laboratory of Cardiology, Wuhan, 430060, China
| | - He Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute, Hubei Key Laboratory of Cardiology, Wuhan, 430060, China
| | - Congxin Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute, Hubei Key Laboratory of Cardiology, Wuhan, 430060, China
| | - Mian Cheng
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430074, China.
| | - Gang Wu
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute, Hubei Key Laboratory of Cardiology, Wuhan, 430060, China; Department of Cardiology, Ezhou Hospital, Renmin Hospital of Wuhan University, Ezhou, 436000, China.
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29
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Brener MI, Uriel N, Burkhoff D. Left Ventricular Volume Reduction and Reshaping as a Treatment Option for Heart Failure. STRUCTURAL HEART 2020. [DOI: 10.1080/24748706.2020.1777359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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30
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DeVore AD, Hellkamp AS, Thomas L, Albert NM, Butler J, Patterson JH, Spertus JA, Williams FB, Duffy CI, Hernandez AF, Fonarow GC. Improvement in Left Ventricular Ejection Fraction in Outpatients With Heart Failure With Reduced Ejection Fraction: Data From CHAMP-HF. Circ Heart Fail 2020; 13:e006833. [PMID: 32580657 DOI: 10.1161/circheartfailure.119.006833] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Among patients with heart failure (HF) with reduced ejection fraction (EF), improvements in left ventricular EF (LVEF) are associated with better outcomes and remain an important treatment goal. Patient factors associated with LVEF improvement in routine clinical practice have not been clearly defined. METHODS CHAMP-HF (Change the Management of Patients with Heart Failure) is a prospective registry of outpatients with HF with reduced EF. Assessments of LVEF are recorded when performed for routine care. We analyzed patients with both baseline and ≥1 follow-up LVEF assessments to describe factors associated with LVEF improvement. RESULTS In CHAMP-HF, 2623 patients had a baseline and follow-up LVEF assessment. The median age was 67 (interquartile range, 58-75) years, 40% had an ischemic cardiomyopathy, and median HF duration was 2.8 years (0.7-6.8). Median LVEF was 30% (23-35), and median change on follow-up was 4% (-2 to -13); 19% of patients had a decrease in LVEF, 31% had no change, 49% had a ≥5% increase, and 34% had a ≥10% increase. In a multivariable model, the following factors were associated with ≥5% LVEF increase: shorter HF duration (odds ratio [OR], 1.21 [95% CI, 1.17-1.25]), no implantable cardioverter defibrillator (OR, 1.46 [95% CI, 1.34-1.55]), lower LVEF (OR, 1.15 [95% CI, 1.10-1.19]), nonischemic cardiomyopathy (OR, 1.24 [95% CI, 1.09-1.36]), and no coronary disease (OR, 1.20 [95% CI, 1.03-1.35]). CONCLUSIONS In a large cohort of outpatients with chronic HF with reduced EF, improvements in LVEF were common. Common baseline cardiac characteristics identified a population that was more likely to respond over time. These data may inform clinical decision making and should be the basis for future research on myocardial recovery.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, Durham, NC (A.D.D., A.S.H., L.T., A.F.H.).,Department of Medicine, Duke University School of Medicine, Durham, NC (A.D.D., A.F.H.)
| | - Anne S Hellkamp
- Duke Clinical Research Institute, Durham, NC (A.D.D., A.S.H., L.T., A.F.H.)
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, NC (A.D.D., A.S.H., L.T., A.F.H.)
| | | | - Javed Butler
- University of Mississippi Medical Center, Jackson (J.B.)
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, MO (J.A.S.)
| | | | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (C.I.D.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (A.D.D., A.S.H., L.T., A.F.H.).,Department of Medicine, Duke University School of Medicine, Durham, NC (A.D.D., A.F.H.)
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.)
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31
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Stefanelli G, Bellisario A, Meli M, Chiurlia E, Barbieri A, Weltert L. Outcomes after surgical ventricular restoration for ischemic cardiomyopathy. J Thorac Cardiovasc Surg 2020; 163:1058-1067. [PMID: 32653287 DOI: 10.1016/j.jtcvs.2020.04.167] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The study objective was to evaluate the short- and long-term outcomes of patients with ischemic cardiomyopathy after surgical ventricular restoration and to identify risk factors related to poor results. METHODS Between August 2002 and April 2016, 62 patients affected by ischemic cardiomyopathy underwent surgical left ventricular restoration at our unit. Patients' mean age at operation was 63 years (39-79 years). Mean ejection fraction was 29.6%. The Surgical Treatment for Ischemic Heart Failure trial criteria have been used as indications for surgery. Fifty-seven patients (91%) received surgical myocardial revascularization. Mitral valve repair was performed in 39 patients (63%). The surgical technique consisted of the classic Dor operation or a different approach reducing the equatorial diameter of the left ventricle and avoiding the use of a patch. The data were analyzed retrospectively for perioperative results and short- and long-term clinical outcomes. RESULTS One patient died of noncardiac causes within 30 days (1.6%). All-cause death occurred in 36 patients (58%) during follow-up (0.6-14.7 years; median follow-up time, 7.02 years), of whom 15 died of cardiac causes. Age, need for preoperative intra-aortic balloon pump, reduction less than 35% of postoperative left ventricular end-diastolic and end-systolic volumes, type of surgical technique, and ejection fraction less than 25% were identified as risk factors for late cardiac mortality. Perioperative levosimendan administration and presence of preoperative moderate to severe mitral regurgitation influenced early and intermediate-term outcomes, but no statistical relevance on long-term results was demonstrated. CONCLUSIONS Patients with ischemic dilative cardiomyopathy have favorable short- and long-term outcomes after ventricular restoration. Age, preoperative ejection fraction less than 25%, inadequate left ventricular surgical reverse remodeling, and type of surgical technique negatively affect long-term survival.
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Affiliation(s)
| | - Alessandro Bellisario
- Department of Cardiac Surgery, European Hospital, Saint Camillus International University of Health and Medical Sciences, Rome, Italy
| | - Marco Meli
- Department of Cardiology and Cardiac Surgery, Hesperia Hospital, Modena, Italy
| | - Emilio Chiurlia
- Department of Cardiology and Cardiac Surgery, Hesperia Hospital, Modena, Italy
| | - Andrea Barbieri
- Department of Cardiology, University Hospitals, Modena, Italy
| | - Luca Weltert
- Department of Cardiac Surgery, European Hospital, Saint Camillus International University of Health and Medical Sciences, Rome, Italy
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32
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Rigopoulos AG, Ali M, Abate E, Torky AR, Matiakis M, Mammadov M, Melnyk H, Vogt A, de Vecchis R, Bigalke B, Wohlgemuth W, Mavrogeni S, Noutsias M. Advances in the diagnosis and treatment of transthyretin amyloidosis with cardiac involvement. Heart Fail Rev 2020; 24:521-533. [PMID: 30790171 DOI: 10.1007/s10741-019-09776-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Amyloidosis is caused by extracellular deposition of insoluble abnormal fibrils constituted by misfolded proteins, which can modify tissue anatomy and hinder the function of multiple organs including the heart. Amyloidosis that can affect the heart includes mostly systemic amyloidosis (amyloid light chain, AL) and transthyretin amyloidosis (ATTR). The latter can be acquired in elderly patients (ATTRwt), or be inherited in younger individuals (ATTRm). The diagnosis is demanding given the high phenotypic heterogeneity of the disease. Therefore, "red flags," which are suggestive features giving support to diagnostic suspicion, are extremely valuable. However, the lack of broad awareness among clinicians represents a major obstacle for early diagnosis and treatment of ATTR. Furthermore, recent implementation of noninvasive diagnostic techniques has revisited the need for endomyocardial biopsy (EMB). In fact, unlike AL amyloidosis, which requires tissue confirmation and typing for diagnosis, ATTR can now be diagnosed noninvasively with the combination of bone scintigraphy and the absence of a monoclonal protein. Securing the correct diagnosis is pivotal for the newly available therapeutic options targeting both ATTRm and ATTRwt, and are directed to either stabilization of the abnormal protein or the reduction of the production of transthyretin. The purpose of this article is to review the contemporary aspects of diagnosis and management of transthyretin amyloidosis with cardiac involvement, summarizing also the recent therapeutic advances with tafamidis, patisiran, and inotersen.
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Affiliation(s)
- Angelos G Rigopoulos
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Muhammad Ali
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Elena Abate
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Abdel-Rahman Torky
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Marios Matiakis
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Mammad Mammadov
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Hannes Melnyk
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Alexander Vogt
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Renato de Vecchis
- Preventive Cardiology and Rehabilitation Unit, DSB 29, S. Gennaro dei Poveri Hospital, 80136, Naples, Italy
| | - Boris Bigalke
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, D-12200, Berlin, Germany
| | - Walter Wohlgemuth
- Department of Radiology, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Sophie Mavrogeni
- Onassis Cardiac Surgery Center, 50 Esperou Street, 175-61, Palaeo Faliro, Athens, Greece
| | - Michel Noutsias
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany.
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Castrichini M, Manca P, Nuzzi V, Barbati G, De Luca A, Korcova R, Stolfo D, Di Lenarda A, Merlo M, Sinagra G. Sacubitril/Valsartan Induces Global Cardiac Reverse Remodeling in Long-Lasting Heart Failure with Reduced Ejection Fraction: Standard and Advanced Echocardiographic Evidences. J Clin Med 2020; 9:jcm9040906. [PMID: 32218231 PMCID: PMC7230879 DOI: 10.3390/jcm9040906] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/20/2020] [Accepted: 03/23/2020] [Indexed: 12/11/2022] Open
Abstract
Sacubitril/valsartan reduces mortality in heart failure with reduced ejection fraction (HFrEF) patients, partially due to cardiac reverse remodeling (RR). Little is known about the RR rate in long-lasting HFrEF and the evolution of advanced echocardiographic parameters, despite their known prognostic impact in this setting. We sought to evaluate the rates of left ventricle (LV) and left atrial (LA) RR through standard and advanced echocardiographic imaging in a cohort of HFrEF patients, after the introduction of sacubitril/valsartan. A multi-parametric standard and advanced echocardiographic evaluation was performed at the moment of introduction of sacubitril/valsartan and at 3 to 18 months subsequent follow-up. LVRR was defined as an increase in the LV ejection fraction ≥10 points associated with a decrease ≥10% in indexed LV end-diastolic diameter; LARR was defined as a decrease >15% in the left atrium end-systolic volume. We analyzed 77 patients (65 ± 11 years old, 78% males, 40% ischemic etiology) with 76 (28–165) months since HFrEF diagnosis. After a median follow-up of 9 (interquartile range 6–14) months from the beginning of sacubitril/valsartan, LVRR occurred in 20 patients (26%) and LARR in 33 patients (43%). Moreover, left ventricular global longitudinal strain (LVGLS) improved from −8.3 ± 4% to −12 ± 4.7% (p < 0.001), total left atrial emptying fraction (TLAEF) from 28.2 ± 14.4% to 32.6 ± 13.7% (p = 0.01) and peak atrial longitudinal strain (PALS) from 10.3 ± 6.9% to 13.7 ± 7.6% (p < 0.001). In HFrEF patients, despite a long history of the disease, the introduction of sacubitril/valsartan provides a rapid global (i.e., LV and LA) RR in >25% of cases, both at standard and advanced echocardiographic evaluations.
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Affiliation(s)
- Matteo Castrichini
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy; (P.M.); (V.N.); (A.D.L.); (R.K.); (D.S.); (M.M.); (G.S.)
- Correspondence: ; Tel.: +39-040-399-4865; Fax: +39-040-399-4878
| | - Paolo Manca
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy; (P.M.); (V.N.); (A.D.L.); (R.K.); (D.S.); (M.M.); (G.S.)
| | - Vincenzo Nuzzi
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy; (P.M.); (V.N.); (A.D.L.); (R.K.); (D.S.); (M.M.); (G.S.)
| | - Giulia Barbati
- Biostatistics Unit, Department of Medical Sciences, University of Trieste, 34149 Trieste, Italy;
| | - Antonio De Luca
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy; (P.M.); (V.N.); (A.D.L.); (R.K.); (D.S.); (M.M.); (G.S.)
| | - Renata Korcova
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy; (P.M.); (V.N.); (A.D.L.); (R.K.); (D.S.); (M.M.); (G.S.)
| | - Davide Stolfo
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy; (P.M.); (V.N.); (A.D.L.); (R.K.); (D.S.); (M.M.); (G.S.)
| | - Andrea Di Lenarda
- S.C. Centro Cardiovscolare, Azienda Sanitaria Universitaria Integrata, 34149 Trieste, Italy;
| | - Marco Merlo
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy; (P.M.); (V.N.); (A.D.L.); (R.K.); (D.S.); (M.M.); (G.S.)
| | - Gianfranco Sinagra
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy; (P.M.); (V.N.); (A.D.L.); (R.K.); (D.S.); (M.M.); (G.S.)
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Hajek P, Safarikova I, Baxa J. Image-guided left ventricular lead placement in cardiac resynchronization therapy: focused on image fusion methods. J Appl Biomed 2019; 17:199-208. [PMID: 34907722 DOI: 10.32725/jab.2019.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 10/30/2019] [Indexed: 11/05/2022] Open
Abstract
Cardiac resynchronization therapy is an effective and widely accessible treatment for patients with advanced, drug-refractory heart failure. It has been shown to reverse maladaptive ventricular remodeling, increase exercise capacity, and lower hospitalization and mortality rates. However, there still exists a considerable proportion of patients who do not respond favorably to the therapy. Tailored left ventricular (LV) lead positioning instead of empiric implantation is thought to have the greatest potential to increase response rates. In our paper, we focus on the rationale for guided LV lead implantation and provide a review of the non-invasive imaging modalities applicable for navigation during LV lead implantation, with special attention to the latest achievements in the field of multimodality imaging and image fusion techniques. Current limitations and future perspectives of the concept are discussed as well.
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Affiliation(s)
- Premysl Hajek
- Ceske Budejovice Hospital, Department of Cardiology, Ceske Budejovice, Czech Republic
| | - Iva Safarikova
- Ceske Budejovice Hospital, Department of Cardiology, Ceske Budejovice, Czech Republic.,University of South Bohemia in Ceske Budejovice, Faculty of Health and Social Sciences, Budejovice, Czech Republic
| | - Jan Baxa
- Charles University in Prague, University Hospital and Faculty of Medicine in Pilsen, Department of Imaging Methods, Pilsen, Czech Republic
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CD47 Deficiency Attenuates Isoproterenol-Induced Cardiac Remodeling in Mice. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2019; 2019:7121763. [PMID: 31827695 PMCID: PMC6885801 DOI: 10.1155/2019/7121763] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 09/11/2019] [Indexed: 12/11/2022]
Abstract
In this study, we investigated whether CD47 deficiency attenuates isoproterenol- (ISO-) induced cardiac remodeling in mice. Cardiac remodeling was induced by intraperitoneal (i.p.) injection of ISO (60 mg·kg−1·d−1 in 100 μl of sterile normal saline) daily for 14 days and was confirmed by increased levels of lactate dehydrogenase (LDH) and creatine kinase MB (CK-MB), increased heart weight to body weight (HW/BW) ratios, and visible cardiac fibrosis. Apoptosis was evaluated by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) staining. Levels of malondialdehyde (MDA) and reactive oxygen species (ROS) were found to be significantly higher in the ISO group than in the control group, while superoxide dismutase (SOD) levels were suppressed in the ISO group. However, CD47 knockout significantly limited ISO-induced increases in LDH, CK-MB, and HW/BW ratios, cardiac fibrosis, oxidative stress, and apoptosis in the heart. In addition, CD47 deficiency also increased p-AMPK and LAMP2 expression and decreased HDAC3, cleaved Caspase-3, cleaved Caspase-9, LC3II, and p62 expression in cardiac tissues. In conclusion, CD47 deficiency reduced i.p. ISO-induced cardiac remodeling probably by inhibiting the HDAC3 pathway, improving AMPK signaling and autophagy flux, and rescuing autophagic clearance.
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Rieger AC, Myerburg RJ, Florea V, Tompkins BA, Natsumeda M, Premer C, Khan A, Schulman IH, Vidro-Casiano M, DiFede DL, Heldman AW, Mitrani R, Hare JM. Genetic determinants of responsiveness to mesenchymal stem cell injections in non-ischemic dilated cardiomyopathy. EBioMedicine 2019; 48:377-385. [PMID: 31648988 PMCID: PMC6838383 DOI: 10.1016/j.ebiom.2019.09.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Non-ischemic dilated cardiomyopathy (NIDCM) responds variably to intramyocardial injection of mesenchymal stem cells (MSCs). We hypothesized that NIDCM genotype may influence responsiveness to MSC therapy and performed genotyping on all patients in the POSEIDON-DCM trial. METHODS POSEIDON-DCM patients (n = 34) underwent genetic sequence analysis and deletion/duplication testing. The results were classified as positive for pathological variants (PV+; n = 8), negative for any variants (V-; n = 6), or as variants of uncertain significance (VUS; n = 20). All outcomes of therapy were analysed for each category of genetic results. FINDINGS The 3 groups were indistinguishable at baseline with regard to ejection fraction (EF), demographics, medication use, or functional parameters. V- patients had an increase in EF at 12 months: +13.6% (IQR = +7.8%; +20.5%; p = 0.002), compared with VUS (+6.5%; IQR = +0.9%, +11.1%; p = 0.005) and PV+(-5.9%; IQR = -12.7%, +1.0; p = 0.2; p = 0.01 between groups). Six-minute walk distance improved in V- patients, but not in VUS and PV+. V- patients improved MLHFQ, compared to the other 2 groups, which did not improve over time. EPCCFUs increased by 9.7 ± 1.9 in V- (p = 0.009) compared to VUS and PV+ patients. V- patients had one-year survival (100%) compared with VUS (85%) and PV+ (40%; p = 0.015 log-rank). Similarly, MACE rates were lower in V- (0%) than PV+ (61.9%) or VUS (42.2%; p = 0.021 log-rank). INTERPRETATION Our findings support the concept that the genetic profile of NIDCM patients plays a role in responsiveness to MSC therapy, with V- patients more likely to benefit and the converse for PV+. This observation emphasizes the need for further genetic studies, because of important implications for the management of NIDCM syndromes.
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Affiliation(s)
- Angela C Rieger
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Robert J Myerburg
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Victoria Florea
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Bryon A Tompkins
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States; Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Makoto Natsumeda
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Courtney Premer
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Aisha Khan
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Ivonne H Schulman
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States; Katz Family Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Mayra Vidro-Casiano
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Darcy L DiFede
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Alan W Heldman
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Raul Mitrani
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Joshua M Hare
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States; Cardiovascular Division, University of Miami Miller School of Medicine, Miami, FL, United States.
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Kelley EF, Cross TJ, Snyder EM, McDonald CM, Hoffman EP, Bello L. Influence of β 2 adrenergic receptor genotype on risk of nocturnal ventilation in patients with Duchenne muscular dystrophy. Respir Res 2019; 20:221. [PMID: 31619245 PMCID: PMC6796481 DOI: 10.1186/s12931-019-1200-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 09/25/2019] [Indexed: 12/23/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) is a progressive neuromuscular disease resulting in severe respiratory derangements. As such, DMD patients are at a high risk of nocturnal hypoventilation, thereby requiring nocturnal ventilation (NV). To this end, NV is an important clinical milestone in the management of DMD. Emerging evidence suggests that ß2 adrenergic receptors (ADRB2) may play a role in determining respiratory function, whereby more functional ADRB2 genotype variants (e.g., Gly16) are associated with improved pulmonary function and respiratory muscle strength. These findings suggest that the more functional ADRB2 genotype may help to preserve respiratory function in patients with DMD. The purpose of this study was to identify the influence of ADRB2 genotype on the risk of NV use in DMD. Data from the CINRG Duchenne Natural History Study including 175 DMD patients (3–25 yrs) were analyzed focusing on ADRB2 genotype variants. Time-to-event analyses were used to examine differences in the age at prescription of full-time NV use between genotypes. There were no differences between genotype groups in age, height, weight, corticosteroid use, proportion of ambulatory patients, or age at loss of ambulation. DMD patients expressing the Gly16 polymorphism had a significantly (P < 0.05) lower mean age at NV prescription compared with those patients expressing the Arg16 polymorphism (21.80 ± 0.59 yrs. vs 25.91 ± 1.31 yrs., respectively). In addition, a covariate-adjusted Cox model revealed that the Gly16 variant group possessed a 6.52-fold higher risk of full-time NV use at any given age compared with the Arg16 polymorphism group. These data suggest that genetic variations in the ADRB2 gene may influence the age at which DMD patients are first prescribed NV, whereby patients with the Gly16 polymorphism are more likely to require NV assistance at an earlier age than their Arg16 counterparts.
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Affiliation(s)
- Eli F Kelley
- Department of Kinesiology, University of Minnesota, Minneapolis, MN, USA. .,Department of Cardiovascular Diseases, Mayo Clinic, RO_GE_MN_10, 1216 2nd Street SW, Rochester, MN, 55902, USA.
| | - Troy J Cross
- Department of Cardiovascular Diseases, Mayo Clinic, RO_GE_MN_10, 1216 2nd Street SW, Rochester, MN, 55902, USA
| | - Eric M Snyder
- Department of Kinesiology, University of Minnesota, Minneapolis, MN, USA
| | - Craig M McDonald
- University of California Davis Medical Center, Sacramento, CA, USA
| | | | - Eric P Hoffman
- Binghamton University - SUNY, Binghamton, NY, USA.,Center for Genetic Medicine, Children's Research Institute, Children's National Health System, Washington, DC, USA
| | - Luca Bello
- Department of Neurosciences, University of Padova, Padova, Italy
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Yamamoto H, Yokochi T. Transthyretin cardiac amyloidosis: an update on diagnosis and treatment. ESC Heart Fail 2019; 6:1128-1139. [PMID: 31553132 PMCID: PMC6989279 DOI: 10.1002/ehf2.12518] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/19/2019] [Accepted: 08/25/2019] [Indexed: 12/14/2022] Open
Abstract
Transthyretin cardiac amyloidosis (ATTR‐CA) demonstrates progressive, potentially fatal, and infiltrative cardiomyopathy caused by extracellular deposition of transthyretin‐derived insoluble amyloid fibrils in the myocardium. Two distinct types of transthyretin (wild type or variant) become unstable, and misfolding forms aggregate, resulting in amyloid fibrils. ATTR‐CA, which has previously been underrecognized and considered to be rare, has been increasingly recognized as a cause of heart failure with preserved ejection fraction among elderly persons. With the advanced technology, the diagnostic tools have been improving for cardiac amyloidosis. Recently, the efficacy of several disease‐modifying agents focusing on the amyloidogenic process has been demonstrated. ATTR‐CA has been changing from incurable to treatable. Nevertheless, there are still no prognostic improvements due to diagnostic delay or misdiagnosis because of phenotypic heterogeneity and co‐morbidities. Thus, it is crucial for clinicians to be aware of this clinical entity for early diagnosis and proper treatment. In this mini‐review, we focus on recent advances in diagnosis and treatment of ATTR‐CA.
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Affiliation(s)
- Hiroyuki Yamamoto
- Department of Cardiovascular Medicine, Narita-Tomisato Tokushukai Hospital, 1-1-1 Hiyoshidai, Tomisato, Chiba, 286-0201, Japan
| | - Tomoki Yokochi
- Department of Clinical Research, Chiba Tokushukai Hospital, Chiba, Japan
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Adabag S, Patton KK, Buxton AE, Rector TS, Ensrud KE, Vakil K, Levy WC, Poole JE. Association of Implantable Cardioverter Defibrillators With Survival in Patients With and Without Improved Ejection Fraction: Secondary Analysis of the Sudden Cardiac Death in Heart Failure Trial. JAMA Cardiol 2019; 2:767-774. [PMID: 28724134 DOI: 10.1001/jamacardio.2017.1413] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Importance Improvement in left ventricular ejection fraction (EF) to >35% occurs in many patients with reduced EF at baseline. To our knowledge, whether implantable cardioverter defibrillator (ICD) therapy improves survival for these patients is unknown. Objective To examine the efficacy of ICD therapy in reducing risk of all-cause mortality and sudden cardiac death among patients with an EF ≤35% at baseline, with or without an improvement in EF to >35% during follow-up. Design, Setting, and Participants This retrospective analysis examined data collected in the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT), which randomly assigned 2521 patients to placebo, amiodarone, or ICD between 1997 and 2001. A subset of 1902 participants (75.4%) of the SCD-HeFT had a repeated assessment of EF a mean (SD) of 13.5 (6) months after randomization. We stratified these patients by EF ≤35% and >35% based on the first repeated EF measurement after randomization and compared all-cause mortality in 649 patients randomized to placebo vs 624 patients randomized to ICD. Follow-up started with the repeated EF assessment. Analysis was performed between January 2016 and July 2016. Exposures Implantable cardioverter-defibrillator therapy. Main Outcomes and Measures All-cause mortality and sudden cardiac death. Results Of the included 1273 patients, the mean (SD) age was 59 (12) years, and 977 (76.7%) were male and 1009 (79.3%) were white. Repeated EF was >35% in 186 participants (29.8%) randomized to ICD and 185 participants (28.5%) randomized to placebo. During a median follow-up of 30 months, the all-cause mortality rate was lower in the ICD vs placebo group, both in patients whose EF remained ≤35% (7.7 vs 10.7 per 100 person-year follow-up) and in those whose EF improved to >35% (2.6 vs 4.5 per 100 person-year follow-up). Compared with placebo, the adjusted hazard ratio for the effect of ICD on mortality was 0.64 (95% CI, 0.48-0.85) in patients with a repeated EF of ≤35% and 0.62 (95% CI, 0.29-1.30) in those with a repeated EF >35%. There was no interaction between treatment assignment and repeated EF for predicting mortality. Conclusions and Relevance Among participants in the SCD-HeFT who had a repeated EF assessment during the course of follow-up, those who had an improvement in EF to >35% accrued a similar relative reduction in mortality with ICD therapy as those whose EF remained ≤35%. Prospective randomized clinical trials are needed to test ICD efficacy in patients with an EF >35%. Trial Registration clinicaltrials.gov Identifier: NCT01114269.
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Affiliation(s)
- Selcuk Adabag
- Division of Cardiology, Veterans Affairs Health Care System, Minneapolis, Minnesota2Division of Cardiovascular Diseases, University of Minnesota, Minneapolis
| | - Kristen K Patton
- Division of Cardiology, Department of Medicine, University of Washington, Seattle
| | - Alfred E Buxton
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Thomas S Rector
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Kristine E Ensrud
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota6Department of Medicine and Division of Epidemiology and Community Health, University of Minnesota, Minneapolis
| | - Kairav Vakil
- Division of Cardiology, Veterans Affairs Health Care System, Minneapolis, Minnesota2Division of Cardiovascular Diseases, University of Minnesota, Minneapolis
| | - Wayne C Levy
- Division of Cardiology, Department of Medicine, University of Washington, Seattle
| | - Jeanne E Poole
- Division of Cardiology, Department of Medicine, University of Washington, Seattle
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Clinical Characteristics of Young Patients With Heart Failure With Reduced Ejection Fraction in a Racially Diverse Cohort. Crit Pathw Cardiol 2019; 18:80-85. [PMID: 31094734 PMCID: PMC6553968 DOI: 10.1097/hpc.0000000000000172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background: Information on the clinical and echocardiographic characteristics of young patients with heart failure with reduced ejection fraction is scant, especially among racially diverse populations. Methods: Patients admitted to Montefiore Medical Center between 2000 and 2016 with heart failure and ejection fraction of <40% were categorized as young (18–39 years), middle-aged (40–64 years), and elderly (≥65 years). Multivariable Cox regression models were used to evaluate mortality risk. Results: A total of 1032 young, 8336 middle-aged, and 13,315 elderly patients were included. Median follow-up was 36 (14–69) months. The young group had more black individuals, lower socioeconomic scores, larger left ventricular chambers, but lower N-terminal pro b-type natriuretic peptide levels (P < 0.001). Better survival outcomes were observed in the young compared to the middle-aged [hazard ratio (HR), 1.52; 95% confidence interval (CI), 1.31–1.77] and elderly (HR, 3.19; 95% CI, 2.75–3.70). After multivariable adjustments, only β-blockers were associated with a significant reduction of mortality in young patients (HR, 0.33; 95% CI, 0.22–0.51). Conclusion: In conclusion, young patients with heart failure with reduced ejection fraction have distinct demographic, clinical, and echocardiographic characteristics. They had lower socioeconomic status yet received more aggressive treatments and had lower mortality rates. Only β-blockers were associated with improved survival in young patients from our cohort.
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Dziewięcka E, Wiśniowska-Śmiałek S, Khachatryan L, Karabinowska A, Szymonowicz M, Podolec P, Rubiś P. Relationships between left ventricular geometry and remodeling in dilated cardiomyopathy. Minerva Cardioangiol 2019; 67:261-271. [PMID: 31115242 DOI: 10.23736/s0026-4725.19.04856-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Since left ventricular reverse remodeling (LVRR) and sphericity index (SI) are correlated with DCM patients' survival, we attempted to establish the relationship between LVRR, SI and left ventricle (LV) dimensions. METHODS In 70 DCM patients, we measured EF, LV transverse (sLVd) and longitudinal (lLVd) diameters at hospital admission, then after 3 and 12 months. SI was assessed thus: SI=sLVd/lLVd. RESULTS LVRR was present in 32 patients (52%). SI measurements were similar in LVRR-present and -absent groups at baseline (0.71 vs. 0.70) and differed after 3 and 12 months (0.61 vs. 0.72, P<0.005; 0.59 vs. 0.73, P<0.001; respectively). During 12 months, SI and sLVd decreased in the LVRR-present (0.71 vs. 0.61 vs. 0.59, P<0.05; 5.75 vs. 5.00 vs. 4.82 cm, P<0.001; respectively) and increased in the LVRR-absent cohort (0.70 vs. 0.72 vs. 0.73, P<0.001; 6.01 vs. 6.15 vs. 6.67, P<0.001; respectively). lLVd remained stable (8.23 vs. 8.16 vs. 8.38cm; 8.66 vs. 8.85 vs. 9.13 cm; respectively). SI was significantly correlated with sLVd but not with lLVd. At 3-month follow-up, SI (P<0.005, OR=14000 [95% CI: 5 - 3.9*107]) was found to be a significant LVRR predictor via univariate logistic regression. CONCLUSIONS To summarize, changes in sLVd are crucial for changes in LV geometry, whereas lLVd has a negligible effect on this process. The presence of LVRR was not always associated with an improvement in SI and its absence with increase in SI. Since the assessment of SI is less complex than LVRR, SI as a significant LVRR predictor can be useful part of a regular echocardiography examination.
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Affiliation(s)
- Ewa Dziewięcka
- Department of Cardiac and Vascular Diseases, Medical College, John Paul II Hospital, Jagiellonian University, Krakow, Poland -
| | - Sylwia Wiśniowska-Śmiałek
- Department of Cardiac and Vascular Diseases, Medical College, John Paul II Hospital, Jagiellonian University, Krakow, Poland
| | - Lusine Khachatryan
- Department of Cardiac and Vascular Diseases, Medical Collage, Jagiellonian University, Krakow, Poland
| | - Aleksandra Karabinowska
- Department of Cardiac and Vascular Diseases, Medical Collage, Jagiellonian University, Krakow, Poland
| | - Maria Szymonowicz
- Department of Cardiac and Vascular Diseases, Medical Collage, Jagiellonian University, Krakow, Poland
| | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, Medical College, John Paul II Hospital, Jagiellonian University, Krakow, Poland
| | - Paweł Rubiś
- Department of Cardiac and Vascular Diseases, Medical College, John Paul II Hospital, Jagiellonian University, Krakow, Poland
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Frequency, predictors, and prognosis of ejection fraction improvement in heart failure: an echocardiogram-based registry study. Eur Heart J 2019; 40:2110-2117. [DOI: 10.1093/eurheartj/ehz233] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/28/2018] [Accepted: 04/02/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aims
To identify variables predicting ejection fraction (EF) recovery and characterize prognosis of heart failure (HF) patients with EF recovery (HFrecEF).
Methods and results
Retrospective study of adults referred for ≥2 echocardiograms separated by ≥6 months between 2008 and 2016 at the two largest echocardiography centres in Alberta who also had physician-assigned diagnosis of HF. Of 10 641 patients, 3124 had heart failure reduced ejection fraction (HFrEF) (EF ≤ 40%) at baseline: while mean EF declined from 30.2% on initial echocardiogram to 28.6% on the second echocardiogram in those patients with persistent HFrEF (defined by <10% improvement in EF), it improved from 26.1% to 46.4% in the 1174 patients (37.6%) with HFrecEF (defined by EF absolute improvement ≥10%). On multivariate analysis, female sex [adjusted odds ratio (aOR) 1.66, 95% confidence interval (CI) 1.40–1.96], younger age (aOR per decade 1.16, 95% CI 1.09–1.23), atrial fibrillation (aOR 2.00, 95% CI 1.68–2.38), cancer (aOR 1.52, 95% CI 1.03–2.26), hypertension (aOR 1.38, 95% CI 1.18–1.62), lower baseline ejection fraction (aOR per 1% decrease 1.07 (1.06–1.08), and using hydralazine (aOR 1.69, 95% CI 1.19–2.40) were associated with EF improvements ≥10%. HFrecEF patients demonstrated lower rates per 1000 patient years of mortality (106 vs. 164, adjusted hazard ratio, aHR 0.70 [0.62–0.79]), all-cause hospitalizations (300 vs. 428, aHR 0.87 [0.79–0.95]), all-cause emergency room (ER) visits (569 vs. 799, aHR 0.88 [0.81–0.95]), and cardiac transplantation or left ventricular assist device implantation (2 vs. 10, aHR 0.21 [0.10–0.45]) compared to patients with persistent HFrEF. Females with HFrEF exhibited lower mortality risk (aHR 0.94 [0.88–0.99]) than males after adjusting for age, time between echocardiograms, clinical comorbidities, medications, and whether their EF improved or not during follow-up.
Conclusion
HFrecEF patients tended to be younger, female, and were more likely to have hypertension, atrial fibrillation, or cancer. HFrecEF patients have a substantially better prognosis compared to those with persistent HFrEF, even after multivariable adjustment, and female patients exhibit lower mortality risk than men within each subgroup (HFrecEF and persistent HFrEF) even after multivariable adjustment.
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Mechanisms of Improved Mortality Following Ablation: Does Ablation Restore Beta-Blocker Benefit in Atrial Fibrillation/Heart Failure? Cardiol Clin 2019; 37:177-183. [PMID: 30926019 DOI: 10.1016/j.ccl.2019.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Observational trials have shown that atrial fibrillation ablation favorably impacts long-term outcomes in systolic heart failure. These outcomes have been confirmed by randomized prospective trials highlighting the favorable impact of ablation on left ventricular function and remodeling, risk of heart failure hospitalization, and mortality. Ablation along with established heart failure medications is new and supported conceptually by the value of restoring sinus rhythm, avoiding long-term antiarrhythmic drugs, and minimizing drug-drug interactions. Observational data suggest a potential long-term benefit of beta-blockers with ablation that becomes augmented as follow-up is extended from 1 to 5 years.
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Wessler BS, McCauley M, Morine K, Konstam MA, Udelson JE. Relation between therapy-induced changes in natriuretic peptide levels and long-term therapeutic effects on mortality in patients with heart failure and reduced ejection fraction. Eur J Heart Fail 2019; 21:613-620. [PMID: 30919541 DOI: 10.1002/ejhf.1411] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 12/13/2018] [Accepted: 12/17/2018] [Indexed: 12/11/2022] Open
Abstract
AIMS To assess whether natriuretic peptides (NPs) can be used to reliably predict long-term therapeutic effect on clinical outcomes for patients with heart failure and reduced ejection fraction (HFrEF). METHODS AND RESULTS HFrEF intervention trials with mortality data were identified. Subsequently, we identified trials assessing therapy-induced changes in NPs. We assessed the correlation between the average short-term placebo-corrected drug or device effect on NPs and the longer-term therapeutic effect on clinical outcomes. Of 35 distinct therapies with an identifiable mortality result (n = 105 062 patients), 20 therapies had corresponding data on therapeutic effect on NPs. No correlation was observed between therapy-induced placebo-corrected change in brain natriuretic peptide or N-terminal pro-brain natriuretic peptide and therapeutic effect on all-cause mortality (ACM) (Spearman r = -0.32, P = 0.18 and r = -0.20, P = 0.47, respectively). There was no correlation between therapy-induced placebo-corrected per cent change in NP and intervention effect on ACM or ACM-heart failure hospitalizations (r = -0.30, P = 0.11 and r = 0.10, P = 0.75, respectively). CONCLUSIONS Short-term intervention-induced changes in NP levels are not reliable predictors of therapeutic long-term effect on mortality or morbidity outcomes for patients with HFrEF.
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Affiliation(s)
- Benjamin S Wessler
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| | - Michael McCauley
- Department of Neurology, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Kevin Morine
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| | - Marvin A Konstam
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| | - James E Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA, USA
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Grande D, Iacoviello M, Aspromonte N. The effects of heart rate control in chronic heart failure with reduced ejection fraction. Heart Fail Rev 2019; 23:527-535. [PMID: 29687317 DOI: 10.1007/s10741-018-9704-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Elevated heart rate has been associated with worse prognosis both in the general population and in patients with heart failure. Heart rate is finely modulated by neurohormonal signals and it reflects the balance between the sympathetic and the parasympathetic limbs of the autonomic nervous system. For this reason, elevated heart rate in heart failure has been considered an epiphenomenon of the sympathetic hyperactivation during heart failure. However, experimental and clinical evidence suggests that high heart rate could have a direct pathogenetic role. Consequently, heart rate might act as a pathophysiological mediator of heart failure as well as a marker of adverse outcome. This hypothesis has been supported by the observation that the positive effect of beta-blockade could be linked to the degree of heart rate reduction. In addition, the selective heart rate control with ivabradine has recently been demonstrated to be beneficial in patients with heart failure and left ventricular systolic dysfunction. The objective of this review is to examine the pathophysiological implications of elevated heart rate in chronic heart failure and explore the mechanisms underlying the effects of pharmacological heart rate control.
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Affiliation(s)
- Dario Grande
- School of Cardiology, University of Bari, Bari, Italy
| | - Massimo Iacoviello
- Cardiology Unit, Cardiothoracic Department, Policlinic University Hospital, Bari, Italy
| | - Nadia Aspromonte
- Department of Cardiovascular Medicine, Foundation Policlinico Gemelli, Rome, Italy.
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Sutil-Vega M, Rizzo M, Martínez-Rubio A. Anemia and iron deficiency in heart failure: a review of echocardiographic features. Echocardiography 2019; 36:585-594. [DOI: 10.1111/echo.14271] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/04/2018] [Accepted: 01/06/2019] [Indexed: 12/14/2022] Open
Affiliation(s)
- Mario Sutil-Vega
- Cardiac Imaging Unit; Department of Cardiology; Parc Taulí University Hospital (Universitat Autònoma de Barcelona); Barcelona Spain
| | - Marcelo Rizzo
- Heart Failure Unit; Department of Cardiology; Parc Taulí University Hospital (Universitat Autònoma de Barcelona); Barcelona Spain
| | - Antoni Martínez-Rubio
- Chief of the Department of Cardiology; Parc Taulí University Hospital (Universitat Autònoma de Barcelona); Barcelona Spain
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Kelley EF, Snyder EM, Johnson BD. Influence of Beta-1 Adrenergic Receptor Genotype on Cardiovascular Response to Exercise in Healthy Subjects. Cardiol Res 2019; 9:343-349. [PMID: 30627284 PMCID: PMC6306116 DOI: 10.14740/cr785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 10/23/2018] [Indexed: 11/11/2022] Open
Abstract
Background The beta-1 adrenergic receptor (ADRB1) has been shown to play a functional role in cardiomyocyte function and accounts for up to 80% of the cardiac tissue adrenergic receptors with ADRB1 stimulation increasing cardiac rate, contractility and work. Multiple polymorphisms of the ADRB1 have been identified such as the Gly49 polymorphism that includes at least one glycine (Gly) for serine (Ser) at amino acid 49 resulting in either homozygous for Gly (Gly49Gly) or heterozygous for Gly (Gly49Ser) polymorphisms. Heart failure patients with this polymorphism (Gly49) have been shown to have improved cardiac function and decreased mortality risk, but if there is an effect in healthy subjects is less clear. The purpose of this study was to determine the effects of the Gly/Ser polymorphism at position 49 of the ADRB1on the cardiovascular response to exercise in healthy subjects. Methods We performed genotyping of the ADRB1 (amino acid 49) and high-intensity, steady-state exercise on 71 healthy subjects (Ser49Ser = 52, Gly49Ser = 19). Results There were no differences between genotype groups in age, height, weight, body mass index (BMI), or watts achieved (age = 28.9 ± 5.6 years (yrs.), 30.6 ± 6.4yrs., height = 173.6 ± 9.9 cm, 174 ± 7.5 cm, weight = 74.4 ± 13.3 kg, 71.9 ± 13.5 kg, BMI = 24.6 ± 3.5, 23.6 ± 3.3, and watts = 223.8 ± 76.8, 205 ± 49.4, for Ser49Ser and Gly49Ser respectively). Additionally, there were no differences for genotype groups for cardiac output (CO), systolic blood pressure (BPsys), or diastolic blood pressure (BPdias) at rest, maximal exercise, or in change from rest to maximal exercise. The genotype groups differed significantly in heart rate (HRmax) at maximal exercise and cardiac index at rest (CI) (HRmax = 184.2 ± 9.5 bpm, 190.7 ± 10.6 bpm, CI = 0.063 ± 0.014, 0.071 ± 0.013, for Ser49Ser and Gly49Ser respectively). There was a trend towards significance (P = 0.058) for the change in stroke volume from rest to peak exercise (ΔSV) (0.016 ± 0.018 L, 0.0076 ± 0.012 L, for Ser49Ser and Gly49Ser respectively). Conclusions These data suggest genetic variations of the ADRB1 may influence cardiovascular responses to exercise in healthy subjects.
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Affiliation(s)
- Eli F Kelley
- Department of Kinesiology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Eric M Snyder
- Department of Kinesiology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Bruce D Johnson
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA
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Maurer MS, Schwartz JH, Gundapaneni B, Elliott PM, Merlini G, Waddington-Cruz M, Kristen AV, Grogan M, Witteles R, Damy T, Drachman BM, Shah SJ, Hanna M, Judge DP, Barsdorf AI, Huber P, Patterson TA, Riley S, Schumacher J, Stewart M, Sultan MB, Rapezzi C. Tafamidis Treatment for Patients with Transthyretin Amyloid Cardiomyopathy. N Engl J Med 2018; 379:1007-1016. [PMID: 30145929 DOI: 10.1056/nejmoa1805689] [Citation(s) in RCA: 1398] [Impact Index Per Article: 233.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Transthyretin amyloid cardiomyopathy is caused by the deposition of transthyretin amyloid fibrils in the myocardium. The deposition occurs when wild-type or variant transthyretin becomes unstable and misfolds. Tafamidis binds to transthyretin, preventing tetramer dissociation and amyloidogenesis. METHODS In a multicenter, international, double-blind, placebo-controlled, phase 3 trial, we randomly assigned 441 patients with transthyretin amyloid cardiomyopathy in a 2:1:2 ratio to receive 80 mg of tafamidis, 20 mg of tafamidis, or placebo for 30 months. In the primary analysis, we hierarchically assessed all-cause mortality, followed by frequency of cardiovascular-related hospitalizations according to the Finkelstein-Schoenfeld method. Key secondary end points were the change from baseline to month 30 for the 6-minute walk test and the score on the Kansas City Cardiomyopathy Questionnaire-Overall Summary (KCCQ-OS), in which higher scores indicate better health status. RESULTS In the primary analysis, all-cause mortality and rates of cardiovascular-related hospitalizations were lower among the 264 patients who received tafamidis than among the 177 patients who received placebo (P<0.001). Tafamidis was associated with lower all-cause mortality than placebo (78 of 264 [29.5%] vs. 76 of 177 [42.9%]; hazard ratio, 0.70; 95% confidence interval [CI], 0.51 to 0.96) and a lower rate of cardiovascular-related hospitalizations, with a relative risk ratio of 0.68 (0.48 per year vs. 0.70 per year; 95% CI, 0.56 to 0.81). At month 30, tafamidis was also associated with a lower rate of decline in distance for the 6-minute walk test (P<0.001) and a lower rate of decline in KCCQ-OS score (P<0.001). The incidence and types of adverse events were similar in the two groups. CONCLUSIONS In patients with transthyretin amyloid cardiomyopathy, tafamidis was associated with reductions in all-cause mortality and cardiovascular-related hospitalizations and reduced the decline in functional capacity and quality of life as compared with placebo. (Funded by Pfizer; ATTR-ACT ClinicalTrials.gov number, NCT01994889 .).
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Affiliation(s)
- Mathew S Maurer
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Jeffrey H Schwartz
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Balarama Gundapaneni
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Perry M Elliott
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Giampaolo Merlini
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Marcia Waddington-Cruz
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Arnt V Kristen
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Martha Grogan
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Ronald Witteles
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Thibaud Damy
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Brian M Drachman
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Sanjiv J Shah
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Mazen Hanna
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Daniel P Judge
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Alexandra I Barsdorf
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Peter Huber
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Terrell A Patterson
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Steven Riley
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Jennifer Schumacher
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Michelle Stewart
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Marla B Sultan
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
| | - Claudio Rapezzi
- From the Columbia University Vagelos College of Physicians and Surgeons (M.S.M.) and Pfizer (J.H.S., A.I.B., P.H., J.S., M.B.S.), New York; Syneos Health, Raleigh, NC (B.G.); University College London and St. Bartholomew's Hospital, London (P.M.E.); the Amyloidosis Center, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, and the University of Pavia, Pavia (G.M.), and the Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna (C.R.) - both in Italy; the Amyloidosis Center (CEPARM), Federal University of Rio de Janeiro, Rio de Janeiro (M.W-C.); the Amyloidosis Center, Medical University of Heidelberg, Heidelberg, Germany (A.V.K.); the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.G.); Stanford University School of Medicine, Stanford, CA (R.W.); the French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, and INSERM Unité 955, Clinical Investigation Center 006, and DHU ATVB, Creteil, France (T.D.); Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.); the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S.); Cleveland Clinic, Cleveland (M.H.); the Medical University of South Carolina, Charleston (D.P.J.); and Pfizer, Groton, CT (T.A.P., S.R., M.S.)
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Abstract
BACKGROUND Cirrhotic cardiomyopathy is characterized by an attenuated contractile response to stress. Long-term exposure of β-adrenergic receptors to persistently high levels of catecholamines has been implicated in its pathogenesis. We hypothesized that β-blockade with metoprolol could reverse the changes in heart function and morphology in cirrhotic cardiomyopathy. PATIENTS AND METHODS In this prospective randomized trial, we included 78 patients aged between 18 and 60 years with abnormal cardiac output response under dobutamine stress echocardiography, without primary cardiac disease or a history of alcohol intake. Patients were assigned randomly to receive metoprolol or placebo for 6 months. The primary endpoint was the improvement in cardiac output response to stress, measured by an increase in the left ventricle stroke volume more than 30%. RESULTS Three (7.3%) patients in the metoprolol group and nine (24.3%) patients in the placebo group showed improved stroke volume (P=0.057). Diastolic dysfunction was found in two (4.8%) patients before and in five (15.6%) patients after therapy in the metoprolol group, and in 10 (27%) patients before and nine (31%) patients after therapy in the placebo group (P=0.67). After treatment, no echocardiography parameter of morphology was significantly different between metoprolol or placebo groups. No significant differences were observed in noradrenaline, plasma renin activity, and troponin levels between groups. Cirrhosis-related clinical events, including hospitalizations and mortality, were not significantly different between the two groups. Six months of therapy with β-blocker did not ameliorate heart function and morphology in patients with cirrhotic cardiomyopathy.
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