Insulin resistance is associated with impaired cardiac sympathetic innervation in patients with heart failure

Associations of the triglyceride-glucose index with short-term mortality in patients with cardiogenic shock: a cohort study

BACKGROUND

Cardiogenic shock (CS) is a severe cardiac disorder with a high mortality rate. The triglyceride-glucose (TyG) index, a biomarker of insulin resistance, is associated with cardiovascular disease-related mortality. This study aimed to investigate the association between the TyG index and mortality in patients with CS.

METHODS

This retrospective cohort study analyzed 727 patients with CS from the Medical Information Mart for Intensive Care IV database. The TyG index was calculated as follows: ln[triglycerides (mg/dL) × fasting blood glucose (mg/dL)/2]. Outcomes included 28-day intensive care unit (ICU) mortality and 28-day in-hospital mortality. Kaplan-Meier survival curve models and Cox proportional hazards regression models were used to evaluate the prognostic significance of the TyG index. Receiver Operating Characteristic (ROC) curve analysis was used to determine the predictive efficacy of the TyG index for mortality. Subgroup analyses were conducted to determine the association between the TyG index and mortality across different groups.

RESULTS

Non-survivors had a significantly higher TyG index (ICU: 9.30 vs. 9.13, p = 0.008; in-hospital: 9.29 vs. 9.13, p = 0.004). Adjusted Cox models showed that each 1-unit increase in the TyG index increased ICU mortality risk by 24% (hazard ratio [HR] = 1.24, 95% confidence interval [CI]:1.04-1.48; p = 0.015) and in-hospital mortality by 44% (HR = 1.44, 95% CI:1.11-1.88; p = 0.007). The Quartile 4 TyG index ICU mortality was increased by 77% (HR = 1.77, 95% CI:1.09-2.89) compared to that for Quartile 1 and in-hospital mortality was increased by 61% (HR = 1.61, 95% CI:1.08-2.38). The area under the ROC curve (AUROC) showed a modest standalone predictive ability of 0.56, but when combined with clinical variables, the AUROC improved to 0.80 (ICU) and 0.78 (in-hospital). Subgroup analyses identified stronger associations in patients ≥ 60 years, females, non-septic, and those with acute myocardial infarction or heart failure.

CONCLUSIONS

The TyG index is significantly associated with short-term mortality in patients with CS and may serve as a useful biomarker for risk stratification.

TRIAL REGISTRATION

Not applicable.

Emirates consensus recommendations on cardiovascular risk management in type 2 diabetes

Background

The combination of cardiovascular disease and diabetes is a highly prevalent condition in the United Arab Emirates. Development and dissemination of evidence-based regional recommendations for optimal screening, treatment and referrals of people with diabetes and high cardiovascular risk is an important priority.

Consensus panel

An expert panel of diabetologists, endocrinologists and cardiologists from the Emirates Cardiac Society and Emirates Diabetes and Endocrine Society as well as different entities in the UAE, discussed and reviewed evidence and also a consensus report from the American Diabetes Association to formulate contextualized recommendations that could be applied for optimal management of cardiovascular risk in people with diabetes in the UAE.

Consensus findings

The combination of heart failure and other cardiovascular risks is a highly prevalent finding among people with diabetes in the United Arab Emirates. The causal inter-relationships between diabetes and heart failure are multifactorial and regular assessments of symptoms and steps for mitigation of risk factors are an important priority. The universal definition and classification of heart failure provides a useful framework for recommending optimal screening, treatment, and referral strategies to diabetic individuals at various stages of the cardiovascular continuum. Routine measurement (at least yearly) of natriuretic peptides and high-sensitivity troponins can help identify patients requiring cardiac imaging referrals. However, recommending routine measurements of natriuretic peptides and/or high-sensitivity troponins to all diabetic individuals must balance clinical judgment and cost implications. While SGLT2i must be an important part of the standard of care, insulin, GLP1 receptor agonists and/or metformin can be useful for additional glycemic control.

Conclusion

The consensus panel hopes that the recommendations presented herein can offer guidance for optimal screening, treatment and referral of people with a concomitance of diabetes and high cardiovascular risk in the United Arab Emirates.

Association of cumulative non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio with the risk of cardiometabolic disease

Background

One measurement of non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) is considered to be associated with insulin resistance and cardiovascular disease (CVD) risk. This study aimed to exploring the association between cumulative non-high-density lipoprotein cholesterol/high-density lipoprotein cholesterol (Cum NHHR) exposure levels and the risk of cardiometabolic disease (CMD).

Methods

This prospective cohort study included 43,735 participants, who participated in three consecutive health examinations in 2006, 2008, 2010 and had no history of CMD or cancer. The participants were divided into quartiles bases on their cum NHHR. Multivariate Cox proportional hazards model was used to assess the association between cum NHHR and the risk of CMD. Additionally, the direct method of standardized ratios was employed to calculate the absolute risk of CMD attributable to cum NHHR.

Results

Over a median follow-up period of 10.92 years (IQR: 10.22-11.26 years), 7,388 participants were newly diagnosed with CMD. In the multivariate-adjusted model, participants in quartiles Q2, Q3 and Q4 showed a progressively increased relative risk of CMD compared to those in Q1, The fully adjusted hazard ratios (95% confidence intervals) for the risk of CMD in the Q2, Q3, and Q4 groups were 1.11 (1.04-1.20), 1.23 (1.14-1.32), and 1.29 (1.20-1.38), respectively, compared with the Q1 group. This association remained significant even after further adjustment for single measurements of NHHR. Moreover, cum NHHR was positively correlated with the absolute risk of CMD, cardiovascular diseases (CVD), and type 2 diabetes (T2DM).

Conclusions

Higher cum NHHR is significantly associated with an increased risk of CMD, independent of single-point NHHR level. Additionally, there are significant different strengths of correlations between cum NHHR and different diseases.

Insulin Resistance-Nutritional Index: A Simple Index and Potential Predictor of Mortality Risk in Patients with Chronic Heart Failure and Type 2 Diabetes

Background

Patients with chronic heart failure (CHF) and type 2 diabetes mellitus (DM) are prone to insulin resistance and malnutrition, both of which are significant prognostic factors for CHF. However, the combined effect of the triglyceride-glucose index (TyG index) and prognostic nutritional index (PNI) on the mortality risk in patients with CHF and type 2 DM has not yet been studied.

Methods

We enrolled 3,315 patients with CHF and type 2 DM. We used a multivariate Cox regression model to assess hazard ratios (HRs) with 95% confidence intervals (CIs) for mortality risk based on TyG index and PNI levels. Furthermore, we constructed a novel index, the insulin resistance-nutritional index (IRNI), defined as TyG index/Ln (PNI), and evaluated its prognostic significance.

Results

During follow-up, 1,214 deaths occurred. Participants with a high TyG index and non-high PNI had a significantly higher mortality risk compared to those with a non-high TyG index and high PNI, with an adjusted HR of 1.91 (95% CI, 1.57-2.32). The multivariate Cox regression analysis revealed HRs for all-cause and cardiovascular deaths of 1.93 (95% CI, 1.66-2.26; P < 0.001) and 2.50 (95% CI, 2.05-3.06; P < 0.001), respectively, when comparing the highest and lowest IRNI tertiles. IRNI's predictive power was stronger in groups with higher adapted Diabetes Complications Severity Index scores (P for interaction < 0.05). Additionally, adding IRNI to the baseline risk model significantly improved predictive performance, showing a greater effect compared to the TyG index or PNI.

Conclusion

IRNI, a novel and composite index reflecting insulin resistance and nutritional status, emerges as a potentially valuable prognostic marker for patients with CHF and type 2 DM.

Associations between metabolic overweight/obesity phenotypes and mortality risk among patients with chronic heart failure

Background

Metabolic disorders and overweight or obesity are highly prevalent and intricately linked in patients with chronic heart failure (CHF). However, it remains unclear whether there is an interactive effect between these conditions and the prognosis of heart failure, and whether such an interaction is influenced by stratification based on age and sex.

Methods

A total of 4,955 patients with CHF were enrolled in this study. Metabolic status was assessed according to the presence or absence of metabolic syndrome (MetS). BMI categories included normal weight and overweight or obesity (BMI < 24, ≥ 24 kg/m2). Patients were divided into four phenotypes according to their metabolic status and BMI: metabolically healthy with normal weight (MHNW), metabolically unhealthy with normal weight (MUNW), metabolically healthy with overweight or obesity (MHO), and metabolically unhealthy with overweight or obesity (MUO). The incidence of primary outcomes, including all-cause and cardiovascular (CV) death, was recorded.

Results

During a mean follow-up of 3.14 years, a total of 1,388 (28.0%) all-cause deaths and 815 (16.4%) CV deaths were documented. Compared to patients with the MHNW phenotype, those with the MUNW (adjusted hazard ratio [aHR], 1.66; 95% confidence interval [CI], 1.38-2.00) or MUO (aHR, 1.42 [95% CI, 1.24-1.63]) phenotypes had a greater risk of all-cause death, and those with the MHO phenotype (aHR, 0.61 [95% CI, 0.51-0.72]) had a lower risk of all-cause death. Moreover, the above phenomenon existed mainly among males and elderly females (aged ≥ 60 years). In nonelderly females (aged < 60 years), the detrimental effects of MetS were lower (aHR, 1.05 [95% CI, 0.63-1.75] among MUNW group and aHR, 0.52 [95% CI, 0.34-0.80] among MUO group), whereas the protective effects of having overweight or obesity persisted irrespective of metabolic status (aHR, 0.43 [95% CI, 0.26-0.69] among MHO group and aHR, 0.52 [95% CI, 0.34-0.80] among MUO group). Similar results were obtained in the Cox proportional risk analysis of the metabolic overweight/obesity phenotypes and CV death.

Conclusions

In male and elderly female patients with CHF, the detrimental effects of MetS outweighed the protective benefits of having overweight or obesity. Conversely, in nonelderly females, the protective effects of having overweight or obesity were significantly greater than the adverse impacts of MetS.

Metabolic score for insulin resistance as a predictor of mortality in heart failure with preserved ejection fraction: results from a multicenter cohort study

BACKGROUND

The metabolic score for insulin resistance (METS-IR) has been validated as a novel, simple, and reliable surrogate marker for insulin resistance; however, its utility for evaluating the prognosis of heart failure with preserved ejection fraction (HFpEF) remains to be elucidated. Therefore, we aimed to analyze the association between METS-IR and the long-term prognosis of HFpEF.

METHODS

We enrolled a total of 4,702 participants with HFpEF in this study. The participants were divided into three groups according to METS-IR tertiles: (Ln [2 × fasting plasma glucose + fasting triglycerides] × body mass index) / (Ln [high-density lipoprotein cholesterol]). The occurrence of primary endpoints, including all-cause mortality and cardiovascular (CV) death, was documented.

RESULTS

There were 3,248 participants with HFpEF (mean age, 65.7 ± 13.8 years; male, 59.0%) in total who were included in the final analysis. The incidence of primary outcomes from the lowest to the highest METS-IR tertiles were 46.92, 86.01, and 124.04 per 1000 person-years for all-cause death and 26.75, 49.01, and 64.62 per 1000 person-years for CV death. The multivariate Cox hazards regression analysis revealed hazard ratios for all-cause and CV deaths of 2.48 (95% CI 2.10-2.93; P < 0.001) and 2.29 (95% CI 1.83-2.87; P < 0.001) when the highest and lowest METS-IR tertiles were compared, respectively. In addition, the predictive efficacy of METS-IR remained significant across various comorbidity subgroups (all P < 0.05). Further, adding the METS-IR to the baseline risk model for all-cause death improved the C-statistic value (0.690 for the baseline model vs. 0.729 for the baseline model + METS-IR, P < 0.01), the integrated discrimination improvement value (0.061, P < 0.01), the net reclassification improvement value (0.491, P < 0.01), and the clinical net benefit.

CONCLUSIONS

An elevated METS-IR, which is associated with an increased mortality risk, is a potential valuable prognostic marker for individuals with HFpEF.

Predictive Effect of Alternative Insulin Resistance Indexes on Adverse Cardiovascular Events in Patients with Metabolic Syndrome with Heart Failure

Purpose

Metabolic Syndrome (MS) greatly increases the risk of heart disease and Heart Failure(HF). Insulin Resistance (IR) is considered to be the key to the pathophysiology of MS. The purpose of this study was to evaluate the predictive effect of different alternative indicators of IR on adverse cardiovascular events in patients with MS complicated with HF.

Methods

Patients with HF who were diagnosed with MS in the heart center of the first affiliated Hospital of Xinjiang Medical University were selected continuously. The baseline data of the patients in the group were compared. The diagnostic value of alternative indexes of IR was evaluated by the working characteristic curve of subjects. The relationship between different alternative indicators of IR and survival rate was evaluated by survival curve. COX regression was used to analyze the effects of different alternative indicators of IR on the risk of end-point events.

Results

The levels of TyG, TyG-BMI, TyG-WC, TG/HDL-C and METS-IR were significantly increased in patients with Major Adverse Cardiovascular Events (MACEs). Among the five alternative indexes of IR, METS-IR had the highest AUC (0.691, 95% CI:0.657-0.752, P < 0.001) in predicting MACEs. No matter which alternative index of IR was used, the survival rate of MACEs in High group was significantly decreased. TyG, TyG-BMI, TyG-WC, TG/HDL-C and METS-IR can independently predict the occurrence of MACEs events, even if some confounding factors are adjusted.

Conclusion

Our study shows that alternative indicators of IR, especially METS-IR, are independently associated with adverse cardiovascular events in patients with MS and HF.

Association between triglyceride glucose-body mass index and long-term adverse outcomes of heart failure patients with coronary heart disease

BACKGROUND

The triglyceride glucose-body mass index (TyG-BMI) is recognized as a reliable surrogate for evaluating insulin resistance and an effective predictor of cardiovascular disease. However, the link between TyG-BMI index and adverse outcomes in heart failure (HF) patients remains unclear. This study examines the correlation of the TyG-BMI index with long-term adverse outcomes in HF patients with coronary heart disease (CHD).

METHODS

This single-center, prospective cohort study included 823 HF patients with CHD. The TyG-BMI index was calculated as follows: ln [fasting triglyceride (mg/dL) × fasting blood glucose (mg/dL)/2] × BMI. To explore the association between the TyG-BMI index and the occurrences of all-cause mortality and HF rehospitalization, we utilized multivariate Cox regression models and restricted cubic splines with threshold analysis.

RESULTS

Over a follow-up period of 9.4 years, 425 patients died, and 484 were rehospitalized due to HF. Threshold analysis revealed a significant reverse "J"-shaped relationship between the TyG-BMI index and all-cause mortality, indicating a decreased risk of all-cause mortality with higher TyG-BMI index values below 240.0 (adjusted model: HR 0.90, 95% CI 0.86-0.93; Log-likelihood ratio p = 0.003). A distinct "U"-shaped nonlinear relationship was observed with HF rehospitalization, with the inflection point at 228.56 (adjusted model: below: HR 0.95, 95% CI 0.91-0.98; above: HR 1.08, 95% CI 1.03-1.13; Log-likelihood ratio p < 0.001).

CONCLUSIONS

This study reveals a nonlinear association between the TyG-BMI index and both all-cause mortality and HF rehospitalization in HF patients with CHD, positioning the TyG-BMI index as a significant prognostic marker in this population.

Atherogenic index predicts all-cause and cardiovascular mortality in incident peritoneal dialysis patients

BACKGROUND AND AIMS

Atherosclerosis, the main cause of cardiovascular disease (CVD), is prevalent in patients undergoing peritoneal dialysis (PD). Atherogenic index (AI) is a strong predictor of atherosclerosis. However, its prognostic value in CVD outcomes and all-cause mortality among patients undergoing PD remains uncertain. Therefore, we aimed to evaluate the association between AI and all-cause and CVD mortality in PD patients.

METHODS

Calculated based on lipid profiles obtained through standard laboratory procedures, AI was evaluated in 2682 patients who underwent PD therapy between January 2006 and December 2017 and were followed up until December 2018. The study population was divided into four groups according to the quartile distribution of AI (Q1: <2.20, Q2: 2.20 to <2.97, Q3: 2.97 to <4.04, and Q4: ≥4.04). Multivariable Cox models were employed to explore the associations between AI and CVD and all-cause mortality was evaluated.

RESULTS

During a median follow-up of 35.5 months (interquartile range, 20.9-57.2 months), 800 patients died, including 416 deaths from CVD. Restricted cubic splines showed non-linear relationship between AI and adverse clinical outcomes. The risks of all-cause and CVD mortality gradually increased across quartiles (log-rank, p < 0.001). After adjusting for potential confounders, the highest quartile (Q4) showed significantly elevated hazard ratio (HR) for both all-cause mortality (HR 1.54 [95% confidence interval (CI), 1.21-1.96]) and CVD mortality risk (HR 1.78 [95% CI, 1.26-2.52]), compared to the lowest quartile (Q1).

CONCLUSIONS

AI was independently associated with all-cause and CVD mortality in patients undergoing PD, suggesting that AI might be a useful prognostic marker.

Association between the triglyceride-glucose index and the risk of mortality among patients with chronic heart failure: results from a retrospective cohort study in China

BACKGROUND

The triglyceride-glucose (TyG) index has been demonstrated to be a reliable surrogate marker of insulin resistance (IR) and an effective predictive index of cardiovascular (CV) disease risk. However, its long-term prognostic value in patients with chronic heart failure (CHF) remains uncertain.

METHODS

A total of 6697 consecutive patients with CHF were enrolled in this study. Patients were divided into tertiles according to their TyG index. The incidence of primary outcomes, including all-cause death and CV death, was recorded. The TyG index was calculated as ln [fasting triglycerides (mg/dL) × fasting blood glucose (mg/dL)/2].

RESULTS

During a median follow-up of 3.9 years, a total of 2158 (32.2%) all-cause deaths and 1305 (19.5%) CV deaths were documented. The incidence of primary events from the lowest to the highest TyG index tertiles were 50.61, 64.64, and 92.25 per 1000 person-years for all-cause death and 29.05, 39.40, and 57.21 per 1000 person-years for CV death. The multivariate Cox hazards regression analysis revealed hazard ratios for all-cause and CV deaths of 1.84 (95% CI 1.61-2.10; P for trend < 0.001) and 1.94 (95% CI 1.63-2.30; P for trend < 0.001) when the highest and lowest TyG index tertiles were compared. In addition, the predictive ability of the TyG index against all-cause death was more prominent among patients with metabolic syndrome and those with heart failure with preserved ejection fraction phenotype (both P for interaction < 0.05). Furthermore, adding the TyG index to the established model for all-cause death improved the C‑statistic value (0.710 for the established model vs. 0.723 for the established model + TyG index, P < 0.01), the integrated discrimination improvement value (0.011, P < 0.01), the net reclassification improvement value (0.273, P < 0.01), and the clinical net benefit (probability range, 0.07-0.36).

CONCLUSIONS

The TyG index was significantly associated with the risk of mortality, suggesting that it may be a reliable and valuable predictor for risk stratification and an effective prognostic indicator in patients with CHF.

Re-evaluation of dipeptidyl peptidase-4 inhibitors in patients with heart failure and diabetes mellitus

OBJECTIVES

The question of whether dipeptidyl peptidase-4 inhibitors (DPP-4i) should be preferred as new glucose-lowering agents in heart failure is controversial. This studyaimed to evaluate the effects of DPP-4i treatment on all-cause mortality and cardiovascular outcomes in patients with heart failure.

METHODS

We searched for available studies of DPP-4i therapy in heart failure and performed a pooled analysis. Outcomes included all-cause mortality, cardiovascular death, hospitalization for heart failure, left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), acute coronary syndrome, and acute myocardial infarction.

RESULTS

Treatment with DPP-4i did not reduce the risk of all-cause death, cardiovascular death, or hospitalization for heart failure. Subgroup analyses showed that DPP-4i significantly reduced all-cause mortality in trials with >40% female patients (OR 0.30, 95% CI [0.16, 0.58], P=0.0003) and in trials with >20% patients with heart failure with preserved ejection fraction (HFpEF) (OR 0.34, 95% CI [0.19, 0.60], P=0.0003). Changes in LVEF and LVEDV showed no statistical differences between the 2 groups. Accordingly, DPP-4i did not alter the risk of acute coronary syndrome and acute myocardial infarction.

CONCLUSIONS

DPP-4i may reduce all-cause mortality in heart failure patients in subgroups of women and HFpEF and has a high coronary safety profile.

Value of estimated glucose disposal rate to detect prevalent left ventricular hypertrophy: implications from a general population

BACKGROUND

Insulin resistance plays a pivotal role in developing left ventricular hypertrophy (LVH). Researchers have identified the estimated glucose disposal rate (eGDR) as a simple and cost-effective surrogate of insulin resistance. Our work aims to investigate the association between eGDR and the prevalent LVH and explore the incremental value of eGDR to detect prevalent LVH.

METHODS

The present work enrolled 3839 subjects from a cross-sectional survey conducted between October 2019 to April 2020 in the rural areas of southeastern China. eGDR was calculated based on waist-to-hip circumference ratio, hypertension, and glycated hemoglobin.

RESULTS

The prevalence of LVH was 17.30%. After adjusting demographic, anthropometric, laboratory, and medical history co-variates, each standard deviation increase of eGDR decreased a 29.6% risk of prevalent LVH. When dividing eGDR into quartiles, the top quartile had a 38.4% risk compared to the bottom quartile. Moreover, smooth curve fitting revealed that the association between eGDR and prevalent LVH was linear in the whole range of eGDR. Additionally, subgroup analysis demonstrated that our main finding was robust to age, sex, BMI, hypertension, and diabetes subgroups. Finally, ROC analysis exhibited a significant improvement by adding eGDR into LVH risk factors (0.780 vs. 0.803, P < 0.001), and category-free net reclassification index (0.702, P < 0.001) and integrated discrimination index (0.027, P < 0.001) also confirmed the improvement from eGDR to detect prevalent LVH.

CONCLUSION

Our analysis revealed a linear, robust association between eGDR and prevalent LVH and demonstrated the incremental value of eGDR to optimize the detection of prevalent LVH.

123I-MIBG imaging in heart failure: impact of comorbidities on cardiac sympathetic innervation

PURPOSE

Heart failure (HF) is a primary cause of morbidity and mortality worldwide, with significant impact on life quality and extensive healthcare costs. Assessment of myocardial sympathetic innervation function plays a central role in prognosis assessment in HF patients. The aim of this review is to summarize the most recent evidence regarding the clinical applications of iodine-123 metaiodobenzylguanidine (¹²³I-MIBG) imaging in patients with HF and related comorbidities.

METHODS

A comprehensive literature search was conducted on PubMed and Web of Science databases. Articles describing the impact of ¹²³I-MIBG imaging on HF and related comorbidities were considered eligible for the review.

RESULTS

We collected several data reporting that ¹²³I-MIBG imaging is a safe and non-invasive tool to evaluate dysfunction of cardiac sympathetic neuronal function and to assess risk stratification in HF patients. HF is frequently associated with comorbidities that may affect cardiac adrenergic innervation. Furthermore, HF is frequently associated with comorbidities and chronic conditions, such as diabetes, obesity, kidney disease and others, that may affect cardiac adrenergic innervation.

CONCLUSION

Comorbidities and chronic conditions lead to more severe impairment of sympathetic nervous system in patients with HF, with a negative impact on disease progression and outcome. Cardiac imaging with ¹²³I-MIBG can be a useful tool to reduce morbidity and prevent adverse events in HF patients.

Insulin Resistance Is Associated With Heart Failure With Recovered Ejection Fraction in Patients Without Diabetes

Background Because of advances in medical treatments, a substantial proportion of patients with heart failure (HF) have experienced recovery of ejection fraction (EF), termed HF with recovered EF (HFrecEF). Insulin resistance (IR) is prevalent in HF and tightly related with prognosis. This study investigates the relationship between IR and the incidence of HFrecEF in patients who are nondiabetic. Methods and Results A total of 262 patients with HF with reduced EF (HFrEF) who were nondiabetic were consecutively enrolled. Patients were classified into HFrecEF (follow-up EF>40% and ≥10% absolute increase) or otherwise persistent HFrEF based on repeat echocardiograms after 12 months. IR was estimated by an updated homeostasis model assessment for IR (HOMA2-IR). The median HOMA2-IR level was 1.05 (interquartile range [IQR], 0.67-1.63) in our cohort of patients with HF who were nondiabetic. During follow-up, 121 (odds ratio [OR], 46.2% [95% CI 40.2-52.2]) patients developed HFrecEF. Compared with patients with HFrEF, patients with HFrecEF had significantly lower HOMA2-IR levels (0.92 [IQR, 0.61-1.37] versus 1.14 [IQR, 0.75-1.78], P=0.007), especially in nonischemic HF. Log₂-transformed HOMA2-IR was inversely correlated to improvements in EF (Pearson's r=-0.25, P<0.001). After multivariable adjustment, a doubling of HOMA2-IR was associated with a 42.8% decreased likelihood of HFrecEF (OR, 0.572 [95% CI, 0.385-0.827]). Conclusions This study reveals that IR is independently associated with compromised development of HFrecEF in patients who are nondiabetic.

Role of the Gut Microbiota in Glucose Metabolism During Heart Failure

Background

Blood glucose disorders are prevalent in heart failure, while the influence of the gut microbiota on this process remains unclear. Here, we used heart failure model mice and fecal microbiota transplantation (FMT) mice to evaluate the effect of the gut microbiota on the regulation of blood glucose during heart failure.

Methods

Thoracic aortic constriction (TAC) surgery was performed in a heart failure model, while an antibiotic cocktail was used to eliminate the microbiota to establish a germ-free (GF) model. Blood glucose, insulin, and glucagon levels were measured, and an intraperitoneal glucose tolerance test (IPGTT) was performed. 16S rRNA sequencing and metabolomics were used to evaluate the changes in gut microbiota structure and metabolism induced by TAC. Another group of FMT mice was established to observe the effect of the gut microbiota on host metabolism.

Results

After microbiota clearance, the glucagon concentration, the homeostasis model assessment for insulin resistance (HOMA-IR), and the area under the curve (AUC) of the IPGTT were decreased significantly in the TAC germ-free (TAC-GF) group in the third month as compared to the other groups. 16S rRNA sequencing indicated that TAC surgery affected the gut microbiota structure, and fecal metabolomics suggested that noradrenaline and adrenaline levels were higher in the TAC group than in the sham group. The FMT mice transplanted with the feces of the TAC (FMT-TAC) mice displayed a higher AUC of IPGTT, accompanied by a higher glucagon level, insulin level, and HOMA-IR than those of the mice in the other groups. The serum metabolomics of the FMT-TAC group showed that noradrenaline levels were significantly higher than those of the FMT-sham group.

Conclusion

The gut microbiota and its metabolism were altered during heart failure, which increased blood glucose and glucagon in the host.

Prevalence and trends of type 2 diabetes mellitus and prediabetes among community-dwelling heart failure patients in the United States

AIMS

This study estimated national prevalence and trends of diagnosed and undiagnosed type 2 diabetes mellitus (T2DM) and prediabetes among heart failure (HF) patients in the U.S.

METHODS

This cross-sectional study included 527 participants aged 20+ years with a diagnosis of HF, using data from the National Health and Nutrition Examination Survey 2005-2016. We assessed prevalence estimates of diagnosed and undiagnosed T2DM and prediabetes stratified by age-standardized sociodemographic and health characteristics. Trends of T2DM and prediabetes prevalence were examined using logistic regressions.

RESULTS

Prevalence rates of diagnosed and undiagnosed T2DM among HF patients were 34.7% (95% confidence interval (CI), 29.2-40.3%) and 12.8% (95% CI, 9.2-16.9%), respectively. Prediabetes affected 39.1% (95% CI, 33.6-44.9%) of HF patients. Prevalence estimates of diagnosed T2DM were significantly different between non-Hispanic White (20.1% [95% CI, 13.5-27.6%]) and Hispanic participants (52.1% [95% CI, 35.9-68.0%]) (P < 0.001). The prevalence of T2DM and prediabetes did not significantly change between 2005 and 2016.

CONCLUSIONS

Prevalence rates of T2DM and prediabetes among community-dwelling HF patients in the U.S. remained high between 2005 and 2016. Prevention of and targeted intervention for T2DM among at-risk HF patients is needed, particularly among those of Hispanic origin.

Effects of sacubitril/valsartan on both metabolic parameters and insulin resistance in prediabetic non-obese patients with heart failure and reduced ejection fraction

BACKGROUND

The effects of sacubitril/valsartan (sac/val) on metabolic parameters and insulin resistance (IR) in non-obese/prediabetic patients have not been previously described.

AIM

To evaluate the effects of sac/val on glycemic and metabolic parameters, Homeostatic Model Assessment of IR (HOMA-IR), and echocardiographic parameters in prediabetic patients with heart failure with reduced ejection fraction (HFrEF).

METHODS

Fifty-nine patients with HFrEF (EF < 35%) but without obesity and/or type 2 diabetes mellitus have been enrolled. All the patients at baseline and week 24 underwent complete anthropometrical evaluation and were subjected to an echocardiogram test. IR has been assessed by HOMA-IR.

RESULTS

After 24-week of treatment with sac/val, a significant reduction in fasting plasma glucose (109 ± 9 vs 103 ± 8 mg/dl, p < 0.0001), fasting plasma insulin (16 ± 4 vs 10 ± 4 UI/L), and hemoglobin A1c (HbA1c) value (6% ± 0.5% vs 5.3% ± 0.3%, p < 0.0001) was observed. Similarly, we observed a significant improvement in IR (HOMA-IR, 4.4 ± 0.9 vs 2.5 ± 0.6, p < 0.0001). The echocardiogram evaluation showed a significant reduction of the left ventricular end-diastolic volume (168 ± 24 vs 158 ± 22 ml, p < 0.05), a significant reduction of the left ventricular end-systolic volume (111 ± 26 vs 98 ± 22 ml, p < 0.005), and a significant reduction of E/e' ratio. Sac/val use was also associated with an average 5.1% increase in ejection fraction.

CONCLUSIONS

Our data seem to indicate that sal/val enhances metabolic control and improves insulin resistance also in prediabetic non-obese patients with HFrEF.

Novel Treatments from Inhibition of the Intestinal Sodium-Hydrogen Exchanger 3

Plasma membrane sodium–hydrogen exchangers (NHE) transport Na⁺ into cells in exchange for H⁺. While there are nine isoforms of NHE in humans, this review focuses on the NHE3 isoform, which is abundantly expressed in the gastrointestinal tract, where it plays a key role in acid–base balance and water homeostasis. NHE3 inhibition in the small intestine results in luminal sodium and water retention, leading to a general decrease in paracellular water flux and diffusional driving force, reduced intestinal sodium absorption, and increased stool sodium excretion. The resulting softer and more frequent stools are the rationale for the development of tenapanor as a novel, first-in-class NHE3 inhibitor to treat irritable bowel syndrome with constipation. NHE3 also has additional therapeutic implications in nephrology. Inhibition of intestinal NHE3 also lowers blood pressure by reducing intestinal sodium absorption. Perhaps, the most novel effect is its ability to decrease intestinal phosphate absorption by inhibiting the paracellular phosphate absorption pathway. Therefore, selective pharmacological inhibition of NHE3 could be a potential therapeutic strategy to treat not only heart failure and hypertension but also hyperphosphatemia. This review presents an overview of the molecular and physiological functions of NHE3 and discusses how these functions translate to potential clinical applications in nephrology.

Pharmacological treatment of type 2 diabetes in elderly patients with heart failure: randomized trials and beyond

Heart failure (HF) and type 2 diabetes mellitus (T2DM) represent two important public health problems, and despite improvements in the management of both diseases, they are responsible for high rates of hospitalizations and mortality. T2DM accelerates physiological cardiac aging through hyperglycemia and hyperinsulinemia. Thus, HF and T2DM are chronic diseases widely represented in elderly people who often are affected by numerous comorbidities with important functional limitations making it difficult to apply the current guidelines. Several antidiabetic drugs should be used with caution in elderly individuals with T2DM. For instance, sulfonylureas should be avoided due to the risk of hypoglycemia associated with its use. Insulin should be used with caution because it is associated with higher risk of hypoglycemia, and may determine fluid retention which can lead to worsening of HF. Thiazolindinediones should be avoided due to the increased risk of fluid retention and HF. Biguanides may lead to a slightly increased risk of lactic acidosis in particular in elderly individuals with impaired renal function. Dipeptidyl peptidase 4 (DPP-4) inhibitors are safe having few side effects, minimal risk of hypoglycemia, and a neutral effect on cardiovascular (CV) outcome, even if it has been reported that saxagliptin treatment is associated with increased risk of hospitalizations for HF (hHF). Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have shown a CV protection without a significant reduction in hHF. On the other hand, sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown a significant improvement in CV outcome, with a strong reduction of hHF and a positive impact on renal damage progression. However, it is necessary to consider the possible some side effects related to their use in elderly individuals including hypotension, bone fractures, and ketoacidosis.It is important to remark that elderly patients, in particular the very elderly, are not sufficiently represented in the trials; thus, the management and treatment of elderly diabetic patients with HF should be mainly based on the integration of scientific evidence with clinical judgment and patients' condition, with respect to the dignity and quality of life.

Intersection Between Diabetes and Heart Failure: Is SGLT2i the "One Stone for Two Birds" Approach?

Purpose of Review

Diabetes mellitus (DM) is a major comorbidity of heart failure (HF). Comparing the similarities and differences in disease characteristics and treatment between the HF patients with and without DM, this review was to investigate whether and how the novel class of sodium-glucose transport protein 2 inhibitors (SGLT2i) would benefit both populations.

Recent Findings

Despite the obviously different clinical profiles, patients of HF with reduced ejection fraction (HFrEF) should be treated the same with guideline directed medical therapy, irrespective of DM status. Upon the mounting evidence that supported its use in diabetic patients at high risk of HF, recent large clinical trials demonstrated that SGLT2i could further reduce HF hospitalization or cardiovascular mortality and improve quality of life in diabetic and non-diabetic HFrEF patients who were optimally managed.

Summary

SGLT2i expands the foundation of HFrEF therapy. Whether it is equally effective in HF with preserved ejection fraction awaits more evidence.

Renal function and cardiac adrenergic impairment in patients affected by heart failure

Although in heart failure (HF) there is a strict correlation between heart and kidney, no data are available on the potential relationship in HF between renal dysfunction (RD) and the impaired sympathetic innervation. Aim of the present study was to assess the relationship between RD and cardiac sympathetic innervation in HF patients with reduced ejection fraction. Two hundred and sixty-three patients with mild-to-severe HF underwent iodine-123 meta-iodobenzylguanidine myocardial scintigraphy to assess sympathetic innervation, evaluating early and late heart-to-mediastinum (H/M) ratios and washout rate. In all patients, glomerular filtration rate (eGFR) by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula was assessed. A direct association was found between EPI-eGFR and late H/M (r = .215; P < .001). Dividing the population into moderate-to-severe eGFR reduction and normal-to-mildly reduced eGFR (cutoff ≤ 60 mL·min-1·1.73 m-2), a statistically significant reduction of late H/M value was found in patients with RD compared to patients with preserved eGFR (P = .030). By multivariable linear regression analysis, eGFR resulted in the prediction of impaired late H/M in patients with RD (P = .005). Patients with RD and HF show more impaired cardiac sympathetic activity than HF patients with preserved renal function, and reduced eGFR is a predictor of reduced late H/M.

Diabetes Mellitus and Heart Failure

Diabetes mellitus (DM) is a major risk factor for new-onset heart failure (HF) and vice versa. The pathogenesis of new-onset HF in DM is complex and has been largely attributed to the toxic cardiovascular effects of hyperglycemia and relevant metabolic abnormalities (diabetic cardiomyopathy) as well as the frequently coexisting morbidities such as hypertension (HTN), coronary artery disease (CAD), and diabetic nephropathy. In patients with type 1 DM (T1DM), HF develops in the setting of a dysregulated immune response, whereas in most patients with type 2 DM (T2DM), against a background of overweight/obesity. HF prevention in DM is feasible with rigorous treatment of cardiovascular risk factors and selective antidiabetic agents. Conversely, development of new-onset T2DM in HF (cardiogenic DM) is common and has been attributed to an increase in the resistance to insulin, especially in the skeletal muscle, liver, and adipose tissue as well as in diminished insulin secretory response to hyperglycemia by pancreatic β-cells. Cardiogenic DM further deteriorates cardiac dysfunction and adversely affects outcome in HF. Novel lifesaving medications employed in HF management such as sacubitril/valsartan and sodium glucose cotransporter 2 inhibitors (SGLT-2i) have a favorable metabolic profile and lower the incidence of cardiogenic diabetes. Whether mitigation of cardiogenic DM should be a treatment target in HF deserves further investigation.

Cardiovascular risk management in type 2 diabetes mellitus: A joint position paper of the Italian Cardiology (SIC) and Italian Diabetes (SID) Societies

AIM

This review represents a joint effort of the Italian Societies of Cardiology (SIC) and Diabetes (SID) to define the state of the art in a field of great clinical and scientific interest which is experiencing a moment of major cultural advancements, the cardiovascular risk management in type 2 diabetes mellitus.

DATA SYNTHESIS

Consists of six chapters that examine various aspects of pathophysiology, diagnosis and therapy which in recent months have seen numerous scientific innovations and several clinical studies that require extensive sharing.

CONCLUSIONS

The continuous evolution of our knowledge in this field confirms the great cultural vitality of these two cultural spheres, which requires, under the leadership of the scientific Societies, an ever greater and effective collaboration.

The metabolic syndrome in heart failure: insights to specific mechanisms

The presence of comorbidities significantly influences long-term morbidity and mortality of symptomatic and asymptomatic heart failure (HF) patients. Metabolic syndrome and diabetic cardiomyopathy are two clinical conditions that share multiple pathophysiological mechanisms and that might be both responsible for cardiac dysfunction. However, it is argued whether metabolic syndrome (MS) independently increases HF risk or the association between MS and HF merely reflects the impact of individual risk factors included in its definition on HF development. Similarly, in the context of diabetic cardiomyopathy, many aspects are still challenging starting from the definition up to the therapeutic management. In this clinical review, we focused the attention on molecular pathways, myocyte alterations, and specific patterns of metabolic syndrome and diabetic cardiomyopathy in order to better define the potential diagnostic and therapeutic approaches of these two pathological conditions.

Comorbidities in chronic heart failure: An update from Italian Society of Cardiology (SIC) Working Group on Heart Failure

The increasing number of patients with heart failure HF and comorbidities is due to aging population and increase of life expectancy of patients with cardiovascular disease. Encouraging results derived by recent trials may suggest some comorbidities as new targets for new drugs, highlighting the need for a better understanding of the comorbidities' effects in HF patients and the need of a multidisciplinary approach for the management of chronic HF with comorbidities. We report a brief review about main cardiovascular and non-cardiovascular comorbidities in HF patients in order to update physicians and researchers engaged in the HF research or in "fight against heart failure."

Important Considerations for the Treatment of Patients with Diabetes Mellitus and Heart Failure from a Diabetologist's Perspective: Lessons Learned from Cardiovascular Outcome Trials

Heart failure (HF) represents an important cardiovascular complication of type 2 diabetes mellitus (T2DM) associated with substantial morbidity and mortality, and is emphasized in recent cardiovascular outcome trials (CVOTs) as a critical outcome for patients with T2DM. Treatment of T2DM in patients with HF can be challenging, considering that these patients are usually elderly, frail and have extensive comorbidities, most importantly chronic kidney disease. The complexity of medical regimens, the high risk clinical characteristics of patients and the potential of HF therapies to interfere with glucose metabolism, and conversely the emerging potential of some antidiabetic agents to modulate HF outcomes, are only some of the challenges that need to be addressed in the framework of a team-based personalized approach. The presence of established HF or the high risk of developing HF in the future has influenced recent guideline recommendations and can guide therapeutic decision making. Metformin remains first-line treatment for overweight T2DM patients at moderate cardiovascular risk. Although not contraindicated, metformin is no longer considered as first-line therapy for patients with established HF or at risk for HF, since there is robust scientific evidence that treatment with other glucose-lowering agents such as sodium-glucose cotransporter 2 inhibitors (SGLT2i) should be prioritized in this population due to their strong and remarkably consistent beneficial effects on HF outcomes.

The Triglyceride-Glucose Index Predicts Coronary Artery Disease Severity and Cardiovascular Outcomes in Patients with Non-ST-Segment Elevation Acute Coronary Syndrome

Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is the leading cause of morbidity and mortality from cardiovascular disease worldwide. Several recent studies have shown the relationship between the triglyceride-glucose (TyG) index and vascular disease; however, the role of the TyG index in NSTE-ACS has not been extensively assessed. Thus, we aimed to investigate the association of the TyG index with cardiovascular risk factors and outcomes in NSTE-ACS. Overall, 438 patients with NSTE-ACS were enrolled to examine the association of the TyG index with the SYNTAX score and major adverse cardiovascular events (MACEs). The TyG index was calculated as ln (fasting triglyceride (mg/dL) × fasting glucose (mg/dL)/2). The severity of coronary lesions was quantified by the SYNTAX score. MACEs included cardiac death, nonfatal myocardial infarction, target vessel revascularization, congestive heart failure, and nonfatal stroke. All the patients underwent a 12-month follow-up for MACEs after admission. Multivariate regression analysis identified metabolic risk factors as independent parameters correlated with the TyG index. The prevalence of glucose metabolism disorder, metabolic syndrome, and MACEs increased with increasing TyG index. The TyG index showed a strong diagnostic performance for cardiovascular risk factors and was independently associated with the SYNTAX score (OR 6.055, 95% CI 2.915–12.579, P < 0.001). The risk of MACEs (12.8% and 22.8% for the low TyG index and high TyG index groups, respectively; adjusted HR = 1.791, 95% CI 1.045–3.068, P = 0.034) significantly increased in the high TyG index group as compared with the low TyG index group. The multivariate Cox regression analysis further revealed that the TyG index was an independent predictor of MACEs (HR 1.878, 95% CI 1.130–3.121, P = 0.015). In conclusion, the TyG index might be an independent predictor of coronary artery disease severity and cardiovascular outcomes in NSTE-ACS.

Type 2 Diabetes Mellitus and Heart Failure: A Scientific Statement From the American Heart Association and the Heart Failure Society of America: This statement does not represent an update of the 2017 ACC/AHA/HFSA heart failure guideline update

Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.

Type 2 Diabetes Mellitus and Heart Failure, A Scientific Statement From the American Heart Association and Heart Failure Society of America

Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.

Prognostic Value of Hormonal Abnormalities in Heart Failure Patients

The model used to explain the pathophysiologic substrate and progressive worsening in chronic heart failure (CHF) is based on the hyperactivity of renin-angiotensin-aldosterone system and adrenergic pathway. Although the neurohormonal medical approach has many advantages, it has several pitfalls, as demonstrated by high rates of CHF mortality and hospitalization. A growing body of evidence has led to the hypothesis that CHF is a multiple hormone deficiency syndrome, characterized by a reduced anabolic drive that has relevant functional and prognostic implications. The aim of this review is to summarize the evidence of reduced drive of main anabolic axes in CHF.

Diabetic Cardiomyopathy: Definition, Diagnosis, and Therapeutic Implications

A strict bidirectional relationship exists between diabetes mellitus and heart failure. Diabetic cardiomyopathy is a specific cardiac manifestation of patients with diabetes characterized by left ventricular hypertrophy and diastolic dysfunction in the early phase up to overt heart failure with reduced systolic function in the advanced stages. The pathogenesis of this condition is multifactorial and recognizes as main promoting factors the presence of insulin resistance and hyperglycemia. Diabetic cardiomyopathy exerts a negative prognostic impact in affected patients and no target treatments are currently available. More efforts are needed to better define the diagnostic and therapeutic approach in this specific setting.

Metabolic Syndrome in Heart Failure: Friend or Foe?

The interplay between metabolic syndrome (MetS) and heart failure (HF) is intricate. Population studies show that MetS confers an increased risk to develop HF and this effect is mediated by insulin resistance (IR). However, obesity, a key component in MetS and common partner of IR, is protective in patients with established HF, although IR confers an increased risk of dying by HF. Such phenomenon, known as "obesity paradox," accounts for the complexity of the HF-MetS relationship. Because IR impacts more on outcomes than MetS itself, the former may be considered the actual target for MetS in HF patients.

An adiponectin-S1P axis protects against lipid induced insulin resistance and cardiomyocyte cell death via reduction of oxidative stress

BACKGROUND

Adiponectin exerts several beneficial cardiovascular effects, however their specific molecular mechanisms require additional understanding. This study investigated the mechanisms of adiponectin action in the heart during high fat diet (HFD) feeding or in palmitate (PA) treated H9c2 cardiomyoblasts.

METHODS

6-week-old male adiponectin knock out (Ad-KO) mice were fed chow or 60% HFD for 6 weeks then received saline or recombinant adiponectin (3μg/g body weight) for an additional 2 weeks. After acute insulin stimulation (4 U/kg), tissue and serum samples were collected for analysis. H9c2 cardiomyocytes were treated ±0.1 mM PA, the adiponectin receptor agonist AdipoRon, or the antioxidant MnTBAP then assays to analyze reactive oxygen species (ROS) production and cell death were conducted. To specifically determine the mechanistic role of S1P, gain and loss of function studies were conducted with adding S1P to cells or the inhibitors THI and SKI-II, respectively.

RESULTS

HFD feeding induced cardiac insulin resistance in Ad-KO mice, which was reversed following replenishment of normal circulating adiponectin levels. In addition, myocardial total triglyceride was elevated by HFD and lipidomic analysis showed increased levels of ceramides and sphingosine-1-phosphate (S1P), with only the latter being corrected by adiponectin administration. Similarly, treatment of H9C2 cardiomyoblasts with PA led to a significant increase of intracellular S1P but not in conditioned media whereas AdipoRon significantly increased S1P production and secretion from cells. AdipoRon or the antioxidant MnTBAP significantly reduced PA-induced cell death. Gain and loss of function studies suggested S1P secretion and autocrine receptor activation mediated the effect of AdipoRon to attenuate PA-induced ROS production and cell death.

CONCLUSION

Our data establish adiponectin signaling-mediated increase in S1P secretion as a mechanism via which HFD or PA induced cardiomyocyte lipotoxicity, leading to insulin resistance and cell death, is attenuated.

Metabolic Dysfunction in Heart Failure: Diagnostic, Prognostic, and Pathophysiologic Insights From Metabolomic Profiling

Metabolic impairment is an intrinsic component of heart failure (HF) pathophysiology. Although initially conceived as a myocardial defect, metabolic dysfunction is now recognized as a systemic process with complex interplay between the myocardium and peripheral tissues and organs. Specifically, HF-associated metabolic dysfunction includes alterations in substrate utilization, insulin resistance, defects in energy production, and imbalanced anabolic-catabolic signaling leading to cachexia. Each of these metabolic abnormalities is associated with significant morbidity and mortality in patients with HF; however, their detection and therapeutic management remains challenging. Given the difficulty in obtaining human cardiac tissue for research purposes, peripheral blood metabolomic profiling, a well-established approach for characterizing small-molecule metabolite intermediates from canonical biochemical pathways, may be a useful technology for dissecting biomarkers and mechanisms of metabolic impairment in HF. In this review, metabolic abnormalities in HF will be discussed with particular emphasis on the application of metabolomic profiling to detecting, risk stratifying, and identifying novel targets for metabolic therapy in this heterogeneous population.

The role of metabolic syndrome in heart failure

Metabolic syndrome (MS) is a highly prevalent condition in patients affected by heart failure (HF); however, it is still unclear whether, in the setting of cardiac dysfunction, it represents an adverse risk factor for the occurrence of cardiac events. The epidemiologic implications of MS in HF have been studied intensely, as many of its components contribute to the incidence and severity of HF. In particular, insulin resistance, diabetes mellitus, and lipid abnormalities represent the main components that negatively influence disease progression and evolution. Yet, other components of the MS, i.e. overweight/obesity and high blood pressure, are favourably associated with outcome in HF patients. The aim of this review was to report epidemiology and prognostic role of MS in HF and to investigate current clinical implications and future research needs.

Alterations of left ventricular deformation and cardiac sympathetic derangement in patients with systolic heart failure: a 3D speckle tracking echocardiography and cardiac ¹²³I-MIBG study

PURPOSE

Myocardial contractile function is under the control of cardiac sympathetic activity. Three-dimensional speckle tracking echocardiography (3D-STE) and cardiac imaging with (123)I-metaiodobenzylguanidine ((123)I-MIBG) are two sophisticated techniques for the assessment of left ventricular (LV) deformation and sympathetic innervation, respectively, which offer important prognostic information in patients with heart failure (HF). The purpose of this investigation was to explore, in patients with systolic HF, the relationship between LV deformation assessed by 3D-STE and cardiac sympathetic derangement evaluated by (123)I-MIBG imaging.

METHODS

We prospectively studied 75 patients with systolic HF. All patients underwent a 3D-STE study (longitudinal, circumferential, area and radial) and (123)I-MIBG planar and SPECT cardiac imaging.

RESULTS

3D-STE longitudinal, circumferential and area strain values were correlated with (123)I-MIBG late heart to mediastinum (H/M) ratio and late SPECT total defect score. After stratification of the patients according to ischaemic or nonischaemic HF aetiology, we observed a good correlation of all 3D-STE measurements with late H/M ratio and SPECT data in the ischaemic group, but in patients with HF of nonischaemic aetiology, no correlation was found between LV deformation and cardiac sympathetic activity. At the regional level, the strongest correlation between LV deformation and adrenergic innervation was found for the left anterior descending coronary artery distribution territory for all four 3D-STE values. In multivariate linear regression analyses, including age, gender, LV ejection fraction, NYHA class, body mass index, heart rate and HF aetiology, only 3D-STE area and radial strain values significantly predicted cardiac sympathetic derangement on (123)I-MIBG late SPECT.

CONCLUSION

This study indicated that 3D-STE measurements are correlated with (123)I-MIBG planar and SPECT data. Furthermore, 3D-STE area and radial strain values, but not LVEF, predict cardiac sympathetic derangement in human postischaemic HF.