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Ricchi P, Pistoia L, Positano V, Spasiano A, Casini T, Putti MC, Borsellino Z, Cossu A, Messina G, Keilberg P, Fatigati C, Costantini S, Renne S, Peritore G, Cademartiri F, Meloni A. Liver steatosis in patients with transfusion-dependent thalassaemia. Br J Haematol 2024; 204:2458-2467. [PMID: 38685724 DOI: 10.1111/bjh.19496] [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: 01/15/2024] [Accepted: 04/17/2024] [Indexed: 05/02/2024]
Abstract
We evaluated the prevalence and the clinical associations of liver steatosis (LS) in patients with transfusion-dependent thalassaemia (TDT). We considered 301 TDT patients (177 females, median age = 40.61 years) enrolled in the Extension-Myocardial Iron Overload in Thalassaemia Network, and 25 healthy subjects. Magnetic resonance imaging was used to quantify iron overload and hepatic fat fraction (FF) by T2* technique and cardiac function by cine images. The glucose metabolism was assessed by the oral glucose tolerance test (OGTT). Hepatic FF was significantly higher in TDT patients than in healthy subjects (median value: 1.48% vs. 0.55%; p = 0.013). In TDT, hepatic FF was not associated with age, gender, serum ferritin levels or liver function parameters, but showed a weak inverse correlation with high-density lipoprotein cholesterol. The 36.4% of TDT patients showed LS (FF >3.7%). Active hepatitis C virus (HCV) infection, increased body mass index and hepatic iron were independent determinants of LS. A hepatic FF >3.53% predicted the presence of an abnormal OGTT. Hepatic FF was not correlated with cardiac iron, biventricular volumes or ejection fractions, but was correlated with left ventricular mass index. In TDT, LS is a frequent finding, associated with iron overload, increased weight and HCV, and conveying an increased risk for the alterations of glucose metabolism.
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Affiliation(s)
- Paolo Ricchi
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli", Napoli, Italy
| | - Laura Pistoia
- U.O.C. Ricerca Clinica, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
- Bioengineering Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Anna Spasiano
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli", Napoli, Italy
| | - Tommaso Casini
- Oncologia, Ematologia e Trapianto di Cellule Staminali Emopoietiche, Meyer Children's Hospital IRCCS, Firenze, Italy
| | - Maria Caterina Putti
- Dipartimento Della Salute Della Donna e del Bambino, Clinica di Emato-Oncologia Pediatrica, Azienda Ospedaliero-Università di Padova, Padova, Italy
| | - Zelia Borsellino
- Unità Operativa Complessa Ematologia Con Talassemia, ARNAS Civico "Benfratelli-Di Cristina", Palermo, Italy
| | - Antonella Cossu
- Servizio Immunoematologia e Medicina Trasfusionale - Dipartimento Dei Servizi, Presidio Ospedaliero "San Francesco" ASL Nuoro, Nuoro, Italy
| | - Giuseppe Messina
- Centro Microcitemie, Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Petra Keilberg
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Carmina Fatigati
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli", Napoli, Italy
| | - Silvia Costantini
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli", Napoli, Italy
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero "Giovanni Paolo II", Lamezia Terme, Italy
| | - Giuseppe Peritore
- Unità Operativa Complessa di Radiologia, ARNAS Civico "Benfratelli-Di Cristina", Palermo, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
- Bioengineering Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
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Dimopoulos S, Nanas S. The emerging importance of assessing recovery period gas exchange variables during cardiopulmonary exercise testing. Hellenic J Cardiol 2024:S1109-9666(24)00076-9. [PMID: 38583770 DOI: 10.1016/j.hjc.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024] Open
Affiliation(s)
- Stavros Dimopoulos
- Cardiac Surgery ICU, Onassis Cardiac Surgery Center, Athens, Greece; Cardiopulmonary Exercise Testing and Rehabilitation Laboratory, National Kapodestrian University of Athens, Athens, Greece.
| | - Serafim Nanas
- Cardiopulmonary Exercise Testing and Rehabilitation Laboratory, National Kapodestrian University of Athens, Athens, Greece
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Webb KL, Gorman EK, Morkeberg OH, Klassen SA, Regimbal RJ, Wiggins CC, Joyner MJ, Hammer SM, Senefeld JW. The relationship between hemoglobin and [Formula: see text]: A systematic review and meta-analysis. PLoS One 2023; 18:e0292835. [PMID: 37824583 PMCID: PMC10569622 DOI: 10.1371/journal.pone.0292835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 09/29/2023] [Indexed: 10/14/2023] Open
Abstract
OBJECTIVE There is widespread agreement about the key role of hemoglobin for oxygen transport. Both observational and interventional studies have examined the relationship between hemoglobin levels and maximal oxygen uptake ([Formula: see text]) in humans. However, there exists considerable variability in the scientific literature regarding the potential relationship between hemoglobin and [Formula: see text]. Thus, we aimed to provide a comprehensive analysis of the diverse literature and examine the relationship between hemoglobin levels (hemoglobin concentration and mass) and [Formula: see text] (absolute and relative [Formula: see text]) among both observational and interventional studies. METHODS A systematic search was performed on December 6th, 2021. The study procedures and reporting of findings followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Article selection and data abstraction were performed in duplicate by two independent reviewers. Primary outcomes were hemoglobin levels and [Formula: see text] values (absolute and relative). For observational studies, meta-regression models were performed to examine the relationship between hemoglobin levels and [Formula: see text] values. For interventional studies, meta-analysis models were performed to determine the change in [Formula: see text] values (standard paired difference) associated with interventions designed to modify hemoglobin levels or [Formula: see text]. Meta-regression models were then performed to determine the relationship between a change in hemoglobin levels and the change in [Formula: see text] values. RESULTS Data from 384 studies (226 observational studies and 158 interventional studies) were examined. For observational data, there was a positive association between absolute [Formula: see text] and hemoglobin levels (hemoglobin concentration, hemoglobin mass, and hematocrit (P<0.001 for all)). Prespecified subgroup analyses demonstrated no apparent sex-related differences among these relationships. For interventional data, there was a positive association between the change of absolute [Formula: see text] (standard paired difference) and the change in hemoglobin levels (hemoglobin concentration (P<0.0001) and hemoglobin mass (P = 0.006)). CONCLUSION These findings suggest that [Formula: see text] values are closely associated with hemoglobin levels among both observational and interventional studies. Although our findings suggest a lack of sex differences in these relationships, there were limited studies incorporating females or stratifying results by biological sex.
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Affiliation(s)
- Kevin L. Webb
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Ellen K. Gorman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Olaf H. Morkeberg
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Stephen A. Klassen
- Department of Kinesiology, Brock University, St. Catharines, Ontario, Canada
| | - Riley J. Regimbal
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Chad C. Wiggins
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Michael J. Joyner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Shane M. Hammer
- Department of Kinesiology, Applied Health, and Recreation, Oklahoma State University, Stillwater, Oklahoma, United States of America
| | - Jonathon W. Senefeld
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States of America
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois
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Cardiopulmonary testing in adult patients with β-thalassemia major in comparison to healthy subjects. Ann Hematol 2022; 101:2445-2452. [PMID: 36100732 PMCID: PMC9546789 DOI: 10.1007/s00277-022-04974-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 08/29/2022] [Indexed: 11/01/2022]
Abstract
β-Thalassemia patients often have a reduced capacity of exercise and abnormal respiratory function parameters, but the reasons are unclear. In order to identify the causes of the exercise limitation, we performed a cardiopulmonary exercise testing (CPET) in a group of 54 adult β-thalassemia major (TM) patients without pulmonary arterial hypertension and in a group of healthy control subjects. All subjects underwent cardiac echocardiography and carried out pulmonary function tests. TM patients also filled an IPAQ questionnaire on usual physical activity (PA).Overall, TM patients have a diminished exercise performance in comparison to control subjects. In fact, peak oxygen uptake (V'O2 peak), expressing maximum exercise capacity, was decreased in 81.5% of the patients; similarly, anaerobic threshold (V'O2@AT) and O2 pulse also resulted lowered. In multivariable regression models adjusted for gender, age, BMI, and mean haemoglobin, V'O2 peak and O2 pulse were positively associated with cardiac iron overload (T2*). No ventilatory limitation to exercise was observed. The most important causes of exercise limitation in these patients were muscular deconditioning and reduced cardiac inotropism due to iron deposition. Only 15/54 (27.8%) TM patients used to perform vigorous physical activity. These results suggest that a program of regular physical activity may be useful to increase the tolerance to effort and therefore to improve the quality of life in these patients.
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Lidoriki I, Stavrou G, Schizas D, Frountzas M, Fotis L, Kapelouzou A, Kokkota S, Fyntanidou B, Kotzampassi K. Nutritional Status in a Sample of Patients With β-Thalassemia Major. Cureus 2022; 14:e27985. [PMID: 36120275 PMCID: PMC9468758 DOI: 10.7759/cureus.27985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 01/19/2023] Open
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Relationships among Physical Activity, Pain, and Bone Health in Youth and Adults with Thalassemia: An Observational Study. THALASSEMIA REPORTS 2022; 12:90-100. [PMID: 37139496 PMCID: PMC10154047 DOI: 10.3390/thalassrep12030014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Patients with thalassemia (Thal) engage in less physical activity than non-Thal populations, which may contribute to pain and osteoporosis. The purpose of this study was to assess relationships between physical activity, pain, and low bone mass in a contemporary sample of patients with Thal. Seventy-one patients with Thal (50 adults ≥18 years, 61% male, 82% transfusion-dependent) completed the Brief Pain Inventory Short Form and validated physical activity questionnaires for youth and adults. Nearly half of the patients reported daily somatic pain. Using multiple regression, after controlling for age and gender, sedentary behavior was positively associated with pain severity (p = 0.017, r2 = 0.28). Only 37% of adult participants met CDC recommendations for physical activity. Spine BMD Z-score was higher (−2.1 ± 0.7) in those who met activity guidelines compared to those who did not (−2.8 ± 1.2, p = 0.048). A positive relationship was observed between self-reported physical activity (hours/week) and hip BMD Z-score in adults with Thal after controlling for transfusion status and sedentary activity time (p = 0.009, r2 = 0.25). These results suggest that decreased physical activity and increased sedentary behavior contribute to low bone mass, which may be related to pain severity in some patients with Thal. Studies focused on increasing physical activity may contribute to improved bone health and reduced pain in patients with Thal.
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Charoenphandhu N, Sooksawanwit S, Aeimlapa R, Thonapan N, Upanan P, Adulyaritthikul P, Krungchanuchat S, Panupinthu N, Teerapornpuntakit J, Rojviriya C, Lertsuwan K, Svasti S, Wongdee K. Mild-intensity physical activity prevents cardiac and osseous iron deposition without affecting bone mechanical property or porosity in thalassemic mice. Sci Rep 2022; 12:5959. [PMID: 35396390 PMCID: PMC8993875 DOI: 10.1038/s41598-022-09997-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/30/2022] [Indexed: 02/07/2023] Open
Abstract
Thalassemia causes anemia, ineffective erythropoiesis, bone loss and iron accumulation in several tissues, e.g., liver, bone and heart, the last of which leads to lethal cardiomyopathy and arrhythmia. Although exercise reportedly improves bone density in thalassemic mice, exercise performance is compromised and might pose risk of cardiovascular accident in thalassemic patients. Therefore, we sought to explore whether mild-intensity physical activity (MPA) with 30–50% of maximal oxygen consumption was sufficient to benefit the heart and bone. Herein, male hemizygous β-globin knockout (BKO) mice and wild-type littermates were subjected to voluntary wheel running 1 h/day, 5 days/week for 3 months (MPA group) or kept sedentary (SDN; control). As determined by atomic absorption spectroscopy, BKO-MPA mice had less iron accumulation in heart and bone tissues compared with BKO-SDN mice. Meanwhile, the circulating level of fibroblast growth factor-23—a factor known to reduce serum iron and intestinal calcium absorption—was increased early in young BKO-MPA mice. Nevertheless, MPA did not affect duodenal calcium transport or body calcium retention. Although MPA restored the aberrant bone calcium-phosphorus ratio to normal range, it did not change vertebral calcium content or femoral mechanical properties. Microstructural porosity in tibia of BKO-MPA mice remained unaltered as determined by synchrotron radiation X-ray tomographic microscopy. In conclusion, MPA prevents cardiac and bone iron accumulation, which is beneficial to thalassemic patients with limited physical fitness or deteriorated cardiac performance. However, in contrast to moderate-intensity exercise, MPA does not improve bone mechanical properties or reduce bone porosity.
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Affiliation(s)
- Narattaphol Charoenphandhu
- Department of Physiology, Faculty of Science, Mahidol University, Bangkok, 10400, Thailand.,Center of Calcium and Bone Research (COCAB), Faculty of Science, Mahidol University, Bangkok, 10400, Thailand.,Institute of Molecular Biosciences, Mahidol University, Nakhon Pathom, 73170, Thailand.,The Academy of Science, The Royal Society of Thailand, Bangkok, 10300, Thailand
| | - Supagarn Sooksawanwit
- Department of Physiology, Faculty of Science, Mahidol University, Bangkok, 10400, Thailand.,Center of Calcium and Bone Research (COCAB), Faculty of Science, Mahidol University, Bangkok, 10400, Thailand
| | - Ratchaneevan Aeimlapa
- Department of Physiology, Faculty of Science, Mahidol University, Bangkok, 10400, Thailand.,Center of Calcium and Bone Research (COCAB), Faculty of Science, Mahidol University, Bangkok, 10400, Thailand
| | - Natchayaporn Thonapan
- Center of Calcium and Bone Research (COCAB), Faculty of Science, Mahidol University, Bangkok, 10400, Thailand.,Molecular Medicine Graduate Program, Faculty of Science, Mahidol University, Bangkok, 10400, Thailand
| | - Pornpailin Upanan
- Faculty of Allied Health Sciences, Burapha University, Long-Hard Bangsaen Road, Chonburi, 20131, Thailand
| | - Punyanuch Adulyaritthikul
- Department of Physiology, Faculty of Science, Mahidol University, Bangkok, 10400, Thailand.,Center of Calcium and Bone Research (COCAB), Faculty of Science, Mahidol University, Bangkok, 10400, Thailand
| | - Saowalak Krungchanuchat
- Department of Physiology, Faculty of Science, Mahidol University, Bangkok, 10400, Thailand.,Center of Calcium and Bone Research (COCAB), Faculty of Science, Mahidol University, Bangkok, 10400, Thailand
| | - Nattapon Panupinthu
- Department of Physiology, Faculty of Science, Mahidol University, Bangkok, 10400, Thailand.,Center of Calcium and Bone Research (COCAB), Faculty of Science, Mahidol University, Bangkok, 10400, Thailand
| | - Jarinthorn Teerapornpuntakit
- Center of Calcium and Bone Research (COCAB), Faculty of Science, Mahidol University, Bangkok, 10400, Thailand.,Department of Physiology, Faculty of Medical Science, Naresuan University, Phitsanulok, 65000, Thailand
| | - Catleya Rojviriya
- Synchrotron Light Research Institute (Public Organization), Nakhon Ratchasima, 30000, Thailand
| | - Kornkamon Lertsuwan
- Center of Calcium and Bone Research (COCAB), Faculty of Science, Mahidol University, Bangkok, 10400, Thailand.,Department of Biochemistry, Faculty of Science, Mahidol University, Bangkok, 10400, Thailand
| | - Saovaros Svasti
- Thalassemia Research Center, Institute of Molecular Biosciences, Mahidol University, Nakhon Pathom, 73170, Thailand
| | - Kannikar Wongdee
- Center of Calcium and Bone Research (COCAB), Faculty of Science, Mahidol University, Bangkok, 10400, Thailand. .,Faculty of Allied Health Sciences, Burapha University, Long-Hard Bangsaen Road, Chonburi, 20131, Thailand.
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Piatti G, Giuditta M, Pierini A, Consonni D, Cassinerio E, Cappellini MD. Muscular de-conditioning and reduced cardiac inotropism due to iron deposition reduce exercise tolerance in beta thalassemia major. Am J Hematol 2021; 96:E370-E373. [PMID: 34152635 DOI: 10.1002/ajh.26278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 01/27/2023]
Affiliation(s)
- Gioia Piatti
- Department of Pathophysiology and Transplantation University of Milan and Unit of Bronchopneumology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Marianna Giuditta
- Department of Clinical Sciences and Community Health University of Milan and Center for Rare Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Alberto Pierini
- Cardiovascular Diseases Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Dario Consonni
- Epidemiology Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Elena Cassinerio
- Department of Clinical Sciences and Community Health University of Milan and Center for Rare Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community Health University of Milan and Center for Rare Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
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Early Cardiac Involvement and Risk Factors for the Development of Arrhythmia in Patients With β-Thalassemia Major. J Pediatr Hematol Oncol 2016; 38:5-11. [PMID: 26583617 DOI: 10.1097/mph.0000000000000467] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cardiac iron overload is the most serious complication in thalassemia; even patients treated with intensive chelation suffer at a certain point from cardiomyopathy and arrhythmia. AIM The aim of the study was to identify indicators of cardiac dysfunction in thalassemia as well as risk factors associated with the development of arrhythmia. PATIENTS AND METHODS A total of 45 patients with β-thalassemia major were enrolled in this cross-sectional study. Patients were divided into 2 groups according to the absence (group A) or the presence of arrhythmia (group B). Cardiac parameters in thalassemic groups were evaluated using 24-Holter recording, Stress electrocardiogram, and M-mode echocardiography. Serum ferritin and Cardiac T2* were used to assess the iron status. RESULTS Group B showed significantly higher values of cardiac T2* and serum ferritin (P<0.05). Group B patients had significantly higher maximum heart rate with significant attacks of bradycardia and ST segment changes. In addition, they achieved a lower percentage of maximum age predicted heart rate and lower values of maximum metabolic equivalents (P<0.05). Significantly higher values of the left atrial diameter, the interventricular septum diameter, and the left-ventricle posterior wall diameter (P<0.05) were identified in group B. CONCLUSIONS The increase in left atrial diameter, interventricular septum diameter, and left-ventricle posterior wall diameter seems to be related to the development of arrhythmia in patients with thalassemia, especially supraventricular arrhythmias.
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Benedetto D, Rao CM, Cefalù C, Aguglia DO, Cattadori G, D’Ascola DG, Benedetto FA, Agostoni P, Sciomer S. Effects of blood transfusion on exercise capacity in thalassemia major patients. PLoS One 2015; 10:e0127553. [PMID: 26010540 PMCID: PMC4444349 DOI: 10.1371/journal.pone.0127553] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 04/16/2015] [Indexed: 02/07/2023] Open
Abstract
Anemia has an important role in exercise performance. However, the direct link between rapid changes of hemoglobin and exercise performance is still unknown.To find out more on this topic, we studied 18 beta-thalassemia major patients free of relevant cardiac dysfunction (age 33.5±7.2 years,males = 10). Patients performed a maximal cardiopulmolmonary exercise test (cycloergometer, personalized ramp protocol, breath-by-breath measurements of expired gases) before and the day after blood transfusion (500 cc of red cell concentrates). After blood transfusion, hemoglobin increased from 10.5±0.8 g/dL to 12.1±1.2 (p<0.001), peak VO2 from 1408 to 1546mL/min (p<0.05), and VO2 at anaerobic threshold from 965 to 1024mL/min (p<0.05). No major changes were observed as regards heart and respiratory rates either at peak exercise or at anaerobic threshold. Similarly, no relevant changes were observed in ventilation efficiency, as evaluated by the ventilation vs. carbon dioxide production relationship, or in O2 delivery to the periphery as analyzed by the VO2 vs. workload relationship. The relationship between hemoglobin and VO2 changes showed, for each g/dL of hemoglobin increase, a VO2 increase = 82.5 mL/min and 35 mL/min, at peak exercise and at anaerobic threshold, respectively. In beta-thalassemia major patients, an acute albeit partial anemia correction by blood transfusion determinates a relevant increase of exercise performance, observed both at peak exercise and at anaerobic threshold.
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Affiliation(s)
| | - Carmelo Massimo Rao
- Azienda Bianchi Melacrino Morelli, Cardiology Department, Reggio di Calabria, Italy
| | | | | | | | | | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milano, Italy
- Dipartimento di Scienze Cliniche e di Comunità, Sezione cardiovascolare, Università di Milano, Milano, Italy
- * E-mail:
| | - Susanna Sciomer
- Dipartimento di Scienze Cardiovascolari e Respiratorie, Università “Sapienza”, Roma, Italy
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Pennell DJ, Udelson JE, Arai AE, Bozkurt B, Cohen AR, Galanello R, Hoffman TM, Kiernan MS, Lerakis S, Piga A, Porter JB, Walker JM, Wood J. Cardiovascular function and treatment in β-thalassemia major: a consensus statement from the American Heart Association. Circulation 2013; 128:281-308. [PMID: 23775258 DOI: 10.1161/cir.0b013e31829b2be6] [Citation(s) in RCA: 261] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This aim of this statement is to report an expert consensus on the diagnosis and treatment of cardiac dysfunction in β-thalassemia major (TM). This consensus statement does not cover other hemoglobinopathies, including thalassemia intermedia and sickle cell anemia, in which a different spectrum of cardiovascular complications is typical. There are considerable uncertainties in this field, with a few randomized controlled trials relating to treatment of chronic myocardial siderosis but none relating to treatment of acute heart failure. The principles of diagnosis and treatment of cardiac iron loading in TM are directly relevant to other iron-overload conditions, including in particular Diamond-Blackfan anemia, sideroblastic anemia, and hereditary hemochromatosis. Heart failure is the most common cause of death in TM and primarily results from cardiac iron accumulation. The diagnosis of ventricular dysfunction in TM patients differs from that in nonanemic patients because of the cardiovascular adaptation to chronic anemia in non-cardiac-loaded TM patients, which includes resting tachycardia, low blood pressure, enlarged end-diastolic volume, high ejection fraction, and high cardiac output. Chronic anemia also leads to background symptomatology such as dyspnea, which can mask the clinical diagnosis of cardiac dysfunction. Central to early identification of cardiac iron overload in TM is the estimation of cardiac iron by cardiac T2* magnetic resonance. Cardiac T2* <10 ms is the most important predictor of development of heart failure. Serum ferritin and liver iron concentration are not adequate surrogates for cardiac iron measurement. Assessment of cardiac function by noninvasive techniques can also be valuable clinically, but serial measurements to establish trends are usually required because interpretation of single absolute values is complicated by the abnormal cardiovascular hemodynamics in TM and measurement imprecision. Acute decompensated heart failure is a medical emergency and requires urgent consultation with a center with expertise in its management. The first principle of management of acute heart failure is control of cardiac toxicity related to free iron by urgent commencement of a continuous, uninterrupted infusion of high-dose intravenous deferoxamine, augmented by oral deferiprone. Considerable care is required to not exacerbate cardiovascular problems from overuse of diuretics or inotropes because of the unusual loading conditions in TM. The current knowledge on the efficacy of removal of cardiac iron by the 3 commercially available iron chelators is summarized for cardiac iron overload without overt cardiac dysfunction. Evidence from well-conducted randomized controlled trials shows superior efficacy of deferiprone versus deferoxamine, the superiority of combined deferiprone with deferoxamine versus deferoxamine alone, and the equivalence of deferasirox versus deferoxamine.
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12
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Sohn EY, Kato R, Noetzli LJ, Gera A, Coates T, Harmatz P, Keens TG, Wood JC. Exercise performance in thalassemia major: correlation with cardiac iron burden. Am J Hematol 2013; 88:193-7. [PMID: 23339082 DOI: 10.1002/ajh.23370] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 11/19/2012] [Accepted: 11/19/2012] [Indexed: 01/25/2023]
Abstract
Exercise performance is decreased in patients with Thalassemia major (TM), but the relative impact of anemia and iron overload on exercise capacity is unknown. We assessed the cardiopulmonary function of 71, well-transfused TM patients via graded treadmill exercise stress test. All patients underwent MRI of the heart, pancreas, and liver and diagnostic phlebotomy. Patients ranged in age from 13 to 46 years of age. Fifteen patients were excluded from analysis due to submaximal effort. Mean Vo2 max was 83.0% of predicted and was limited by abnormal cardiovascular mechanisms, consisting of a decreased O2 pulse (86.6% of predicted) in men and decreased maximum heart rate (HR) response (85% of predicted) in women. Patients with hemoglobin less than 12 g/dL had lower O2 pulse and Vo2 max, regardless of sex. Cardiac iron was negatively associated with maximum HR response and Vo2 max (r2 = 0.10 and 0.08, respectively, P < 0.05). Vo2 max was correlated with cardiac R2*, hs-CRP, sex and hemoglobin in decreasing strength of association. In thalassemia, exercise performance is limited by impaired stroke-volume reserve in men and blunted HR response in women. Iron toxicity may be mediated through vascular inflammation and direct modulation of HR response to exercise.
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Affiliation(s)
- Eugene Y. Sohn
- Division of Pediatric Pulmonology; Children's Hospital Los Angeles, USC Keck School of Medicine; Los Angeles; California
| | - Roberta Kato
- Division of Pediatric Pulmonology; Children's Hospital Los Angeles, USC Keck School of Medicine; Los Angeles; California
| | - Leila J. Noetzli
- Division of Pediatric Cardiology; Children's Hospital Los Angeles; USC Keck School of Medicine; Los Angeles; California
| | - Aakanksha Gera
- Division of Pediatric Cardiology; Children's Hospital Los Angeles; USC Keck School of Medicine; Los Angeles; California
| | - Thomas Coates
- Division of Hematology; Children's Hospital Los Angeles; USC Keck School of Medicine; Los Angeles; California
| | - Paul Harmatz
- Division of Gastroenterology; Children's Hospital Oakland; California
| | - Thomas G. Keens
- Division of Pediatric Pulmonology; Children's Hospital Los Angeles, USC Keck School of Medicine; Los Angeles; California
| | - John C. Wood
- Division of Pediatric Cardiology; Children's Hospital Los Angeles; USC Keck School of Medicine; Los Angeles; California
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Early detection of iron overload in the heart: a key role for MRI! Int J Cardiovasc Imaging 2009; 25:789-90. [PMID: 19937124 PMCID: PMC2784521 DOI: 10.1007/s10554-009-9538-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 11/09/2009] [Indexed: 01/19/2023]
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Carpenter JP, Pennell DJ. Cardiopulmonary exercise testing in thalassemia. Int J Cardiovasc Imaging 2009; 25:785-8. [PMID: 19937125 DOI: 10.1007/s10554-009-9537-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 11/09/2009] [Indexed: 11/25/2022]
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