Increased left ventricular mass as a predictor of sudden cardiac death: is it time to put it to the test?

Left ventricular mass as a modulator of ventricular arrhythmia risk and sex differences after CRT for nonischemic cardiomyopathy and LBBB

BACKGROUND

The risk of ventricular arrhythmias (VAs) after cardiac resynchronization therapy (CRT) has been associated with ischemic disease/scar, sex, and possibly left ventricular mass (LVM).

OBJECTIVE

The purpose of this study was to evaluate sex differences and baseline/postimplant change in LVM on VA risk after CRT implantation in patients with nonischemic cardiomyopathy and left bundle branch block.

METHODS

In patients meeting the criteria, baseline and follow-up echocardiographic images were obtained for LVM assessment. VA events were reported from device diagnostics and therapies. VA risk was stratified by receiver operating characteristic (Youden index cutoff point) for baseline LVM and baseline/postimplant change in LVM. Multivariate Cox regression model was also used for VA risk stratification.

RESULTS

One hundred eighteen patients (71 female patients [60.2%]; mean age 60.5 ± 11.3 years; left ventricular ejection fraction 19.2% ± 7.0%; QRS duration 165.6 ± 20 ms; LVM 313.9 ± 108.8 g) were enrolled and followed up for a median of 90 months (interquartile range 44-158 months). Thirty-five patients (29.6%) received appropriate shocks or antitachycardia pacing at a median of 73.5 months (interquartile range 25-130 months) postimplantation. Males had a higher VA incidence (male patients 18 of 47 [38.3%] vs female patients 17 of 71 [23.9%]; P = .02). Baseline LVM > 308.9 g separated patients with higher VA risk (P = .001). Less than a 20% decrease in LVM increased VA risk (P < .001). Baseline LVM was the only baseline characteristic predicting VA events in the Cox regression model (hazard ratio 1.01; 95% confidence interval 1.001-1.009; log-rank, P = .003). Sex differences in VA risk were eliminated by the baseline LVM parameters.

CONCLUSION

VA risk after CRT implantation in nonischemic cardiomyopathy was associated with baseline LV > 308.9 g and a decrease in LVM ≤ 20%, without sex differences.

Crotonylation of NAE1 Modulates Cardiac Hypertrophy via Gelsolin Neddylation

BACKGROUND

Cardiac hypertrophy and its associated remodeling are among the leading causes of heart failure. Lysine crotonylation is a recently discovered posttranslational modification whose role in cardiac hypertrophy remains largely unknown. NAE1 (NEDD8 [neural precursor cell expressed developmentally downregulated protein 8]-activating enzyme E1 regulatory subunit) is mainly involved in the neddylation modification of protein targets. However, the function of crotonylated NAE1 has not been defined. This study aims to elucidate the effects and mechanisms of NAE1 crotonylation on cardiac hypertrophy.

METHODS

Crotonylation levels were detected in both human and mouse subjects with cardiac hypertrophy through immunoprecipitation and Western blot assays. Tandem mass tag (TMT)-labeled quantitative lysine crotonylome analysis was performed to identify the crotonylated proteins in a mouse cardiac hypertrophic model induced by transverse aortic constriction. We generated NAE1 knock-in mice carrying a crotonylation-defective K238R (lysine to arginine mutation at site 238) mutation (NAE1 K238R) and NAE1 knock-in mice expressing a crotonylation-mimicking K238Q (lysine to glutamine mutation at site 238) mutation (NAE1 K238Q) to assess the functional role of crotonylation of NAE1 at K238 in pathological cardiac hypertrophy. Furthermore, we combined coimmunoprecipitation, mass spectrometry, and dot blot analysis that was followed by multiple molecular biological methodologies to identify the target GSN (gelsolin) and corresponding molecular events contributing to the function of NAE1 K238 (lysine residue at site 238) crotonylation.

RESULTS

The crotonylation level of NAE1 was increased in mice and patients with cardiac hypertrophy. Quantitative crotonylomics analysis revealed that K238 was the main crotonylation site of NAE1. Loss of K238 crotonylation in NAE1 K238R knock-in mice attenuated cardiac hypertrophy and restored the heart function, while hypercrotonylation mimic in NAE1 K238Q knock-in mice significantly enhanced transverse aortic constriction-induced pathological hypertrophic response, leading to impaired cardiac structure and function. The recombinant adenoviral vector carrying NAE1 K238R mutant attenuated, while the K238Q mutant aggravated Ang II (angiotensin II)-induced hypertrophy. Mechanistically, we identified GSN as a direct target of NAE1. K238 crotonylation of NAE1 promoted GSN neddylation and, thus, enhanced its protein stability and expression. NAE1 crotonylation-dependent increase of GSN promoted actin-severing activity, which resulted in adverse cytoskeletal remodeling and progression of pathological hypertrophy.

CONCLUSIONS

Our findings provide new insights into the previously unrecognized role of crotonylation on nonhistone proteins during cardiac hypertrophy. We found that K238 crotonylation of NAE1 plays an essential role in mediating cardiac hypertrophy through GSN neddylation, which provides potential novel therapeutic targets for pathological hypertrophy and cardiac remodeling.

Echocardiographic Comparison of Left Ventricular Systolic Function and Aortic Blood Flow Velocimetry in Children with Ventricular Septal Defect

BACKGROUND

The assessments of left ventricular (LV) longitudinal systolic dynamics in children with ventricular septal defect (VSD) have achieved a major milestone in the evaluation of LV systolic function.

OBJECTIVES

This study aims to evaluate the LV function, LV mass (LVM), and the descending aorta blood flow in children with VSD compared to that obtained in age and sex-matched controls.

RESULTS

The mean LVM of the control, 113.5 ± 123.9 was higher than that of those who had VSD, 75.8 ± 83.9, and the difference in mean was found to be statistically significant (Mann-Whitney U = 2.322, P = 0.022). The mean EF of the control, 67.9 ± 10.3 was comparable to that of those with VSD, 65.6 ± 13.9, (Student's t = 1.223, P = 0.223). Similarly, the mean descending aorta blood flow of control, 1.6 ± 2.2 was comparable to that of those with VSD, 3.9 ± 16.1, (Mann-Whitney U = 1.002, P = 0.321). There was a very weak positive correlation between LVM and descending aorta blood flow among the subjects (n = 85, r = 0.117, P = 0.425). There was a very weak negative correlation between LVM and descending aorta blood flow among control. (n = 85, r = -0.065, P = 0.609).

CONCLUSION

The LVM among children with VSD is lower than controls but there is no difference between LV function in subjects and controls. There is a linear increase of LVM with descending aorta blood flow.

Effect of an NHE3 inhibitor in combination with an NPT2b inhibitor on gastrointestinal phosphate absorption in Rodent models

Many of the pathological consequences of chronic kidney disease can be attributed to an elevation in serum phosphate levels. Current therapies focused on decreasing intestinal phosphate absorption to treat hyperphosphatemia are inadequate. The most effective therapeutic strategy may be to target multiple absorptive pathways. In this study, the ability of a novel inhibitor of the intestinal sodium hydrogen exchanger 3 (NHE3), LY3304000, which inhibits paracellular, diffusional uptake of phosphate, to work in combination with an inhibitor of the active transporter, sodium dependent phosphate cotransporter 2b (NPT2b), LY3358966, was explored. LY3304000 modestly inhibited the acute uptake of phosphate into plasma of rats, while surprisingly, it doubled the rate of phosphate uptake in mice, an animal model dominated by NPT2b mediated acute phosphate uptake. In rats, LY3004000 and LY3358966 work in concert to inhibit acute phosphate uptake. On top of LY3358966, LY3304000 further decreased the acute uptake of phosphate into plasma. Studies measuring the recovery of radiolabeled phosphate in the intestine demonstrated LY3304000 and LY3358966 synergistically inhibited the absorption of phosphate in rats. We hypothesize the synergism is because the NHE3 inhibitor, LY3304000, has two opposing effects on intestinal phosphate absorption in rats, first it decreases diffusion mediated paracellular phosphate absorption, while second, it simultaneously increases phosphate absorption through the NPT2b pathway. NHE3 inhibition decreases proton export from enterocytes and raises the cell surface pH. In vitro, NPT2b mediated phosphate transport is increased at higher pHs. The increased NPT2b mediated transport induced by NHE3 inhibition is masked in rats which have relatively low levels of NPT2b mediated phosphate transport, by the more robust inhibition of diffusion mediated phosphate absorption. Thus, the inhibition of NPT2b mediated phosphate transport in rats in the presence of NHE3 inhibition has an effect that exceeds its effect in the absence of NHE3 inhibition, leading to the observed synergism on phosphate absorption between NPT2b and NHE3 inhibition.

Cytoskeletal disarray increases arrhythmogenic vulnerability during sympathetic stimulation in a model of hypertrophic cardiomyopathy

Familial hypertrophic cardiomyopathy (FHC) patients are advised to avoid strenuous exercise due to increased risk of arrhythmias. Mice expressing the human FHC-causing mutation R403Q in the myosin heavy chain gene (MYH6) recapitulate the human phenotype, including cytoskeletal disarray and increased arrhythmia susceptibility. Following in vivo administration of isoproterenol, mutant mice exhibited tachyarrhythmias, poor recovery and fatigue. Arrhythmias were attenuated with the β-blocker atenolol and protein kinase A inhibitor PKI. Mutant cardiac myocytes had significantly prolonged action potentials and triggered automaticity due to reduced repolarization reserve and connexin 43 expression. Isoproterenol shortened cycle length, and escalated electrical instability. Surprisingly isoproterenol did not increase CaV1.2 current. We found alterations in CaV1.2-β1 adrenergic receptor colocalization assessed using super-resolution nanoscopy, and increased CaV1.2 phosphorylation in mutant hearts. Our results reveal for the first time that altered ion channel expression, co-localization and β-adrenergic receptor signaling associated with myocyte disarray contribute to electrical instability in the R403Q mutant heart.

Sudden Death in Men Versus Women with Heart Failure

PURPOSE OF REVIEW

Sudden cardiac death (SCD) represents the most feared complication of heart failure (HF). This review intends to provide insight on our current knowledge of sex differences in SCD mechanisms, prevention, and management in HF patients.

RECENT FINDINGS

Women with HF present a better prognosis than men and have a lower incidence of SCD, irrespective of the presence of ischemic heart disease and age. The influence of sex hormones, sex differences in intracellular calcium handling, and a differential myocardial remodeling may explain such a gap between men and women. Both HF drugs and ventricular arrhythmias ablation seems also useful for the management of women at risk of SCD, but special care must be taken with the use of antiarrhythmic QT-prolonging drugs. However, implantable cardioverter defibrillator (ICD) use has not been shown to be equally effective in women than men. Sex-specific recommendations regarding SCD in HF are still lacking due to the scarcity of information and the under-representation of women in clinical trials. Further investigation is required to provide specific risk stratification models in women. Cardiac magnetic resonance imaging, genetics development, and personalized medicine will probably play an increasing role in this evaluation.

Preoperative Risk Prediction Score for and In-Hospital Clinical Outcomes of Reperfusion Ventricular Fibrillation After Release of Aortic Cross-Clamps: A Retrospective Study

Reperfusion ventricular fibrillation (VF) is a common arrhythmia after cardiac surgery. Predictors of reperfusion VF and its relationships with the adverse prognosis are still unclear. This study aimed to identify a risk score model to predict reperfusion VF and its effect on in-hospital outcomes. The authors enrolled 1,024 consecutive patients undergoing cardiac surgery, and a total of 823 patients were included in the study. A novel risk score model was developed following logistic regression analysis of the predictors of reperfusion VF. The receiver operating characteristic curve was used to validate this model, and the effect of VF on prognosis was later identified in multivariate or Kaplan-Meier analyses. Risk factors for reperfusion VF occurrence included weight >55 kg, preoperative left ventricular ejection fraction <50%, prior stroke, hypertension, aortic valve replacement, HTK solution, and the use of ≥3 grafts in coronary artery bypass grafting. A novel risk score model was developed using the abovementioned variables, and points were assigned to each risk factor according to its odds ratio. A high score (>6) predicted greater than 65% of patients with VF occurrence. Reperfusion VF increased the risk of in-hospital cardiovascular death (p = 0.03) and renal replacement therapy postoperatively (p = 0.022). More attention should be given to reperfusion VF due to an adverse postoperative prognosis, and the developed risk score model may predict this risk.

Increased Epicardial Adipose Tissue (EAT), Left Coronary Artery Plaque Morphology, and Valvular Atherosclerosis as Risks Factors for Sudden Cardiac Death from a Forensic Perspective

Background: In sudden cardiac deaths (SCD), visceral adipose tissue has begun to manifest interest as a standalone cardiovascular risk factor. Studies have shown that epicardial adipose tissue can be seen as a viable marker of coronary atherosclerosis. This study aimed to evaluate, from a forensic perspective, the correlation between body mass index (BMI), heart weight, coronary and valvular atherosclerosis, left ventricular morphology, and the thickness of the epicardial adipose tissue (EAT) in sudden cardiac deaths, establishing an increased thickness of EAT as a novel risk factor. Methods: This is a retrospective case−control descriptive study that included 80 deaths that were autopsied, 40 sudden cardiac deaths, and 40 control cases who hanged themselves and had unknown pathologies prior to their death. In all the autopsies performed, the thickness of the epicardial adipose tissue was measured in two regions of the left coronary artery, and the left ventricular morphology, macro/microscopically quantified coronary and valvular atherosclerosis, and weight of the heart were evaluated. Results: This study revealed a higher age in the SCD group (58.82 ± 9.67 vs. 53.4 ± 13.00; p = 0.03), as well as a higher incidence in females (p = 0.03). In terms of heart and coronary artery characteristics, there were higher values of BMI (p = 0.0009), heart weight (p < 0.0001), EAT of the left circumflex artery (LCx) (p < 0.0001), and EAT of the left anterior descending artery (LAD) (p < 0.0001). In the multivariate analysis, a high baseline value of BMI (OR: 4.05; p = 0.004), heart weight (OR: 5.47; p < 0.001), EAT LCx (OR: 23.72; p < 0.001), and EAT LAD (OR: 21.07; p < 0.001) were strong independent predictors of SCD. Moreover, age over 55 years (OR: 2.53; p = 0.045), type Vb plaque (OR: 17.19; p < 0.001), mild valvular atherosclerosis (OR: 4.88; p = 0.002), and moderate left ventricle dilatation (OR: 16.71; p = 0.008) all act as predictors of SCD. Conclusions: The data of this research revealed that higher baseline values of BMI, heart weight, EAT LCx, and EAT LAD highly predict SCD. Furthermore, age above 55 years, type Vb plaque, mild valvular atherosclerosis, and left ventricle dilatation were all risk factors for SCD.

Cardio-renal interaction - Clinical trials update 2022

AIMS

Chronic kidney disease is a common cardiovascular risk indicator and strongly associated with increased morbidity and mortality. The heart and kidneys are pathophysiologically closely connected, which becomes particularly obvious in patients with cardiorenal syndrome. This review summarizes clinically relevant studies on the cardio-renal interaction published in 2021 and 2022.

DATA SYNTHESIS

Selected trials published in high-impact journals were chosen from the database Pubmed and included in this review. New evidence about the selective mineralocorticoid receptor antagonist finerenone and the renoprotective sodium-glucose co-transporter-2-inhibitors (SGLT2-Inhibitors) are discussed and we update on novel insights about the treatment of arterial hypertension in patients with severe chronic kidney disease with the thiazide-like diuretic chlorthalidone. Finally, data on infective endocarditis in patients on chronic hemodialysis and the treatment of secondary hyperparathyroidism with the calcimimetic drug etelcalcetide in patients with end stage kidney disease are critically reviewed.

CONCLUSION

Several important studies investigating cardio-renal interactions were recently published may affect clinical practice. The graphical abstract (Fig. 1) depicts the most relevant clinical studies investigating cardio-renal interactions.

Multimodality Imaging of Sudden Cardiac Death and Acute Complications in Acute Coronary Syndrome

Sudden cardiac death (SCD) is a potentially fatal event usually caused by a cardiac arrhythmia, which is often the result of coronary artery disease (CAD). Up to 80% of patients suffering from SCD have concomitant CAD. Arrhythmic complications may occur in patients with acute coronary syndrome (ACS) before admission, during revascularization procedures, and in hospital intensive care monitoring. In addition, about 20% of patients who survive cardiac arrest develop a transmural myocardial infarction (MI). Prevention of ACS can be evaluated in selected patients using cardiac computed tomography angiography (CCTA), while diagnosis can be depicted using electrocardiography (ECG), and complications can be evaluated with cardiac magnetic resonance (CMR) and echocardiography. CCTA can evaluate plaque, burden of disease, stenosis, and adverse plaque characteristics, in patients with chest pain. ECG and echocardiography are the first-line tests for ACS and are affordable and useful for diagnosis. CMR can evaluate function and the presence of complications after ACS, such as development of ventricular thrombus and presence of myocardial tissue characterization abnormalities that can be the substrate of ventricular arrhythmias.

Lessons from effect of etelcalcetide on left ventricular hypertrophy in patients with end-stage kidney disease

PURPOSE OF REVIEW

Patients with end-stage kidney disease (ESKD) frequently develop left ventricular hypertrophy (LVH), which is associated with an exceptionally high risk of cardiovascular events and mortality. This review focuses on interventional studies that modify levels of fibroblast growth factor 23 (FGF23) and examine effects on myocardial hypertrophy, cardiovascular events and mortality.

RECENT FINDINGS

Quantitative evaluations of trials of calcimimetics found no effects on cardiovascular events and cardiovascular and all-cause mortality when compared with placebo. However, a recent randomized, controlled trial of etelcalcetide versus alfacalcidol showed that etelcalcetide effectively inhibited the progression of LVH in comparison to vitamin D in patients on haemodialysis after 1 year of treatment. Prior to that, oral calcimimetic treatment has already been shown to reduce left ventricular mass in patients on haemodialysis, whereas treatment with active vitamin D or mineralocorticoids was ineffective in patients with ESKD.

SUMMARY

Data from a recent trial of etelcalcetide on LVH suggest that FGF23 may be a possible therapeutic target for cardiac risk reduction in patients on haemodialysis. If these findings are confirmed by further research, it might be speculated that a treatment shift from active vitamin D towards FGF23-lowering therapy may occur in patients on haemodialysis.

Predictive value of the echocardiographic noninvasive myocardial work index for left ventricular reverse remodeling in patients with multivessel coronary artery disease after percutaneous coronary intervention

BACKGROUND

Coronary artery disease (CAD) can lead to left ventricular (LV) remodeling, which, in adverse cases, has been associated with heart failure and increased mortality. Here, we aimed to evaluate the predictive value of the noninvasive myocardial work index (NIMWI) for LV reverse remodeling in patients with multivessel CAD after percutaneous coronary intervention (PCI).

METHODS

A total of 88 consecutive patients with multivessel CAD treated with PCI were identified and categorized according to the presence of LV reverse remodeling 3 months after PCI [≥15% decrease in the LV end diastolic volume (LVEDV)]. With the LV pressure-strain loop (PSL) technique, NIMWIs, including the global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE), were statistically compared between the reverse LV remodeling group and nonreverse LV remodeling group 1 week before PCI.

RESULTS

Significantly lower GWI, GCW, and GWE, and significantly higher GWW were observed in the reverse LV remodeling group compared with the nonreverse LV remodeling group (P<0.05). Left ventricular mass index (LVMI), GCW, and GWE were independently associated with early LV reverse remodeling. Receiver operating characteristic (ROC) curve analysis demonstrated that GCW was the most powerful predictor of early LV reverse remodeling in patients with CAD [area under the curve (AUC) =0.867]. The optimal cutoff GCW value predictive of early LV reverse remodeling was 1,438.5 mmHg% (sensitivity, 85%; specificity, 70%).

CONCLUSIONS

GCW, among the NIMWIs, may be the major predictor of LV reverse remodeling in patients with multivessel CAD after PCI. NIMWI could potentially provide a new reference index for the quantitative evaluation of LV myocardial work.

Late Potential Abolition in Ventricular Tachycardia Ablation

Ventricular tachycardia (VT) substrate-based ablation has become the gold standard treatment for patients with structural heart disease-related VT. VT is linked to re-entry in relation to myocardial scarring, with areas of conduction block (core scar) and of slow conduction (border zone). Slow conduction areas can be detected in sinus rhythm as late potentials (LPs). LP abolition has been shown to be the best end point to avoid long-term recurrences. Our study aimed to analyze the challenges of LP abolition and the predictors of failure. We analyzed 169 consecutive patients with structural heart disease (61% ischemic cardiomyopathy, left ventricular ejection fraction: 37 ± 13%) who underwent VT ablation between 2013 and 2018. A preprocedural clinical evaluation, including cardiac magnetic resonance, was done in 66% of patients. Electroanatomical mapping with the identification of LPs was performed in all patients. Noninducibility was achieved in 71% (119), and complete LP abolition was achieved in 61% (103) of patients. Incomplete LP abolition was a powerful predictor of VT recurrence (67% vs 33%, hazard ratio 3.19 [2.1 to 4.7]; p <0.001). Lack of use of a high-density mapping catheter (odds ratio 6.2, 1.2 to 38.1; p = 0.028), the septal substrate (odds ratio 9.34, 2.27 to 38.4; p = 0.002), and larger left ventricular mass (190 ± 58 g vs 156 ± 46 g, p = 0.002) were predictors of incomplete LP abolition. The main reasons that contributed to unsuccessful LP abolition were anatomic obstacles (such as the conduction system) and large extension of the LP area. In conclusion, incomplete LP abolition is related to VT recurrence. Lack of use of a high-density mapping catheter, the septal substrate, and larger left ventricular mass are related to incomplete LP abolition.

Sudden cardiac death in heart failure with preserved ejection fraction: an updated review

Despite the advances in medical and device therapies for heart failure (HF), sudden cardiac death (SCD) remains a tremendous global burden in patients with HF. Among the risk factors for SCD, HF has the greatest impact. Previous studies focusing on patients with systolic dysfunction have found several predictive factors associated with SCD, leading to the subsequent development of strategies of primary prevention, like placement of implantable cardioverter-defibrillator (ICD) in high-risk patients. Although patients with HF with preserved ejection fraction (HFpEF) were less prone to SCD compared to patients with HF with reduced ejection fraction (HFrEF), patients with HFpEF did account for a significant proportion of all HF patients who encountered SCD. The cutoff value of left ventricular ejection fraction (LVEF) to define the subset of HF did not reach consensus until 2016 when the European Society of Cardiology proposed a new classification system by LVEF. There is a great unmet need in the field of SCD in HFpEF regarding risk stratification and appropriate device therapy with ICD implantation. In this article, we will approach SCD in HFpEF from HFrEF subsets. We also aim at clarifying the mechanisms, risk factors, and prevention of SCD in HFpEF.

Characterisation of hypertensive heart disease: pathological insights from a sudden cardiac death cohort to inform clinical practice

Hypertensive heart disease refers to changes in the myocardium that result from hypertension. The relationship between hypertensive heart disease and sudden cardiac death is well established, but there are few pathological studies. We examined the clinical and pathological features of hypertensive heart disease in sudden cardiac death victims from a national cardiovascular pathology registry. We investigated 5239 cases of sudden cardiac death between 1994 and 2018. Hearts were examined by two expert cardiac pathologists. Diagnostic criteria included history of hypertension, increased heart weight and left ventricular wall thickness in the absence of other causes. Collagen was quantified using picrosirius red staining and imaging software. Of 75 sudden cardiac death cases due to hypertensive heart disease (age at death: 54 ± 16 years; 56% males), 56 (75%) reported no prior cardiac symptoms. Thirty-four (45%) recorded a BMI ≥ 30. Only two (2.7%) had hypertensive heart disease diagnosed antemortem. Four (5%) were diagnosed clinically with hypertrophic cardiomyopathy, but lacked myocyte disarray at autopsy. All hearts showed concentric left ventricular hypertrophy and myocyte hypertrophy. Fibrosis was identified microscopically in 59 cases (81%). The posterior left ventricular wall showed the greatest increase in the percentage of collagen in hypertensive diseased hearts compared to controls (25.2% vs 17.9%, p = 0.034). Most sudden deaths due to hypertensive heart disease occur without prior cardiac symptoms; thus, clinical risk stratification is challenging. Hypertensive heart disease can be misdiagnosed in life as hypertrophic cardiomyopathy which has major implications for relatives. Pathologists require a history of hypertension and histology for a definitive diagnosis of hypertensive heart disease.

Left ventricular mass regression, all-cause and cardiovascular mortality in chronic kidney disease: a meta-analysis

Background

Cardiovascular disease is an important driver of the increased mortality associated with chronic kidney disease (CKD). Higher left ventricular mass (LVM) predicts increased risk of adverse cardiovascular outcomes and total mortality, but previous reviews have shown no clear association between intervention-induced LVM change and all-cause or cardiovascular mortality in CKD.

Methods

The primary objective of this meta-analysis was to investigate whether treatment-induced reductions in LVM over periods ≥12 months were associated with all-cause mortality in patients with CKD. Cardiovascular mortality was investigated as a secondary outcome. Measures of association in the form of relative risks (RRs) with associated variability and precision (95% confidence intervals [CIs]) were extracted directly from each study, when reported, or were calculated based on the published data, if possible, and pooled RR estimates were determined.

Results

The meta-analysis included 42 trials with duration ≥12 months: 6 of erythropoietin stimulating agents treating to higher vs. lower hemoglobin targets, 10 of renin-angiotensin-aldosterone system inhibitors vs. placebo or another blood pressure lowering agent, 14 of modified hemodialysis regimens, and 12 of other types of interventions. All-cause mortality was reported in 121/2584 (4.86%) subjects in intervention groups and 168/2606 (6.45%) subjects in control groups. The pooled RR estimate of the 27 trials ≥12 months with ≥1 event in ≥1 group was 0.72 (95% CI 0.57 to 0.90, p = 0.005), with little heterogeneity across studies. Directionalities of the associations in intervention subgroups were the same. Sensitivity analyses of ≥6 months (34 trials), ≥9 months (29 trials), and >12 months (10 trials), and including studies with no events in either group, demonstrated similar risk reductions to the primary analysis. The point estimate for cardiovascular mortality was similar to all-cause mortality, but not statistically significant: RR 0.67, 95% CI 0.39 to 1.16.

Conclusions

These results suggest that LVM regression may be a useful surrogate marker for benefits of interventions intended to reduce mortality risk in patients with CKD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02666-1.

Risk of sports-related sudden cardiac death in women

Sudden cardiac death (SCD) is a tragic incident accountable for up to 50% of deaths from cardiovascular disease. Sports-related SCD (SrSCD) is a phenomenon which has previously been associated with both competitive and recreational sport activities. SrSCD has been found to occur 5-33-fold less frequently in women than in men, and the sex difference persists despite a rapid increase in female participation in sports. Establishing the reasons behind this difference could pinpoint targets for improved prevention of SrSCD. Therefore, this review summarizes existing knowledge on epidemiology, characteristics, and causes of SrSCD in females, and elaborates on proposed mechanisms behind the sex differences. Although literature concerning the aetiology of SrSCD in females is limited, proposed mechanisms include sex-specific variations in hormones, blood pressure, autonomic tone, and the presentation of acute coronary syndromes. Consequently, these biological differences impact the degree of cardiac hypertrophy, dilation, right ventricular remodelling, myocardial fibrosis, and coronary atherosclerosis, and thereby the occurrence of ventricular arrhythmias in male and female athletes associated with short- and long-term exercise. Finally, cardiac examinations such as electrocardiograms and echocardiography are useful tools allowing easy differentiation between physiological and pathological cardiac adaptations following exercise in women. However, as a significant proportion of SrSCD causes in women are non-structural or unexplained after autopsy, channelopathies may play an important role, encouraging attention to prodromal symptoms and family history. These findings will aid in the identification of females at high risk of SrSCD and development of targeted prevention for female sport participants.

MicroRNAs Regulating Renin-Angiotensin-Aldosterone System, Sympathetic Nervous System and Left Ventricular Hypertrophy in Systemic Arterial Hypertension

MicroRNAs are small non-coding RNAs that regulate gene and protein expression. MicroRNAs also regulate several cellular processes such as proliferation, differentiation, cell cycle, apoptosis, among others. In this context, they play important roles in the human body and in the pathogenesis of diseases such as cancer, diabetes, obesity and hypertension. In hypertension, microRNAs act on the renin-angiotensin-aldosterone system, sympathetic nervous system and left ventricular hypertrophy, however the signaling pathways that interact in these processes and are regulated by microRNAs inducing hypertension and the worsening of the disease still need to be elucidated. Thus, the aim of this review is to analyze the pattern of expression of microRNAs in these processes and the possible associated signaling pathways.

Cardiovascular outcomes in systemic sclerosis with abnormal cardiovascular MRI and serum cardiac biomarkers

Objectives

To explore the prognostic value of subclinical cardiovascular (CV) imaging measures and serum cardiac biomarkers in systemic sclerosis (SSc) for the development of CV outcomes of primary heart involvement (pHI).

Methods

Patients with SSc with no clinical SSc-pHI and no history of heart disease underwent cardiovascular magnetic resonance (CMR) imaging, and measurement of serum high-sensitivity-troponin I (hs-TnI) and N-terminal-pro-brain natriuretic peptide (NT-proBNP). Follow-up clinical and CV outcome data were recorded. CV outcomes were defined as myocarditis, arrhythmia and/or echocardiographic functional impairment including systolic dysfunction and/or diastolic dysfunction.

Results

Seventy-four patients with a median (IQR) age of 57 (49, 63) years, 32% diffuse cutaneous SSc, 39% interstitial lung disease, 30% Scl70+ were followed up for median (IQR) 22 (15, 54) months. Ten patients developed CV outcomes, comprising one patient with myocarditis and systolic dysfunction and nine arrhythmias: three non-sustained ventricular tachycardia and six supraventricular arrhythmias. The probability of CV outcomes was considerably higher in those with NT-proBNP >125 pg/mL versus normal NT-proBNP (X²=4.47, p=0.035). Trend for poorer time-to-event was noted in those with higher extracellular volume (ECV; indicating diffuse fibrosis) and hs-TnI levels versus those with normal values (X²=2.659, p=0.103; X²=2.530, p=0.112, respectively). In a predictive model, NT-proBNP >125 pg/mL associated with CV outcomes (OR=5.335, p=0.040), with a trend observed for ECV >29% (OR=4.347, p=0.073).

Conclusion

These data indicate standard serum cardiac biomarkers (notably NT-proBNP) and CMR indices of myocardial fibrosis associate with adverse CV outcomes in SSc. This forms the basis to develop a prognostic model in larger, longitudinal studies.

Targeting mitochondrial reactive oxygen species-mediated oxidative stress attenuates nicotine-induced cardiac remodeling and dysfunction

Long-term nicotine intake is associated with an increased risk of myocardial damage and dysfunction. However, it remains unclear whether targeting mitochondrial reactive oxygen species (ROS) prevents nicotine-induced cardiac remodeling and dysfunction. This study investigated the effects of mitoTEMPO (a mitochondria-targeted antioxidant), and resveratrol (a sirtuin activator) , on nicotine-induced cardiac remodeling and dysfunction. Sprague–Dawley rats were administered 0.6 mg/kg nicotine daily with 0.7 mg/kg mitoTEMPO, 8 mg/kg resveratrol, or vehicle alone for 28 days. At the end of the study, rat hearts were collected to analyze the cardiac structure, mitochondrial ROS level, oxidative stress, and inflammation markers. A subset of rat hearts was perfused ex vivo to determine the cardiac function and myocardial susceptibility to ischemia–reperfusion injury. Nicotine administration significantly augmented mitochondrial ROS level, cardiomyocyte hypertrophy, fibrosis, and inflammation in rat hearts. Nicotine administration also induced left ventricular dysfunction, which was worsened by ischemia–reperfusion in isolated rat hearts. MitoTEMPO and resveratrol both significantly attenuated the adverse cardiac remodeling induced by nicotine, as well as the aggravation of postischemic ventricular dysfunction. Findings from this study show that targeting mitochondrial ROS with mitoTEMPO or resveratrol partially attenuates nicotine-induced cardiac remodeling and dysfunction.

Left ventricular hypertrophy and sudden cardiac death

Sudden cardiac death (SCD) is among the leading causes of death worldwide, and it remains a public health problem, as it involves young subjects. Current guideline-directed risk stratification for primary prevention is largely based on left ventricular (LV) ejection fraction (LVEF), and preventive strategies such as implantation of a cardiac defibrillator (ICD) are justified only for documented low LVEF (i.e., ≤ 35%). Unfortunately, only a small percentage of primary prevention ICDs, implanted on the basis of a low LVEF, will deliver life-saving therapies on an annual basis. On the other hand, the vast majority of patients that experience SCD have LVEF > 35%, which is clamoring for better understanding of the underlying mechanisms. It is mandatory that additional variables be considered, both independently and in combination with the EF, to improve SCD risk prediction. LV hypertrophy (LVH) is a strong independent risk factor for SCD regardless of the etiology and the severity of symptoms. Concentric and eccentric LV hypertrophy, and even earlier concentric remodeling without hypertrophy, are all associated with increased risk of SCD. In this paper, we summarize the physiology and physiopathology of LVH, review the epidemiological evidence supporting the association between LVH and SCD, briefly discuss the mechanisms linking LVH with SCD, and emphasize the need to evaluate LV geometry as a potential risk stratification tool regardless of the LVEF.

Smoking Status, Intensity of Smoking, and Their Relation to Left Ventricular Hypertrophy in Working Aged Korean Men

INTRODUCTION

Smoking is an established risk factor for atherosclerotic cardiovascular disease. However, the effect of smoking on left ventricular (LV) structure has been less studied. This study was designed to assess the association of smoking status and smoking intensity with left ventricular hypertrophy (LVH).

METHODS

Study subjects were 53,666 working aged Korean men who received echocardiography as an item of health check up. They were grouped by smoking status (never, former, and current smokers), pack-year of smoking (never, <10, 10-19.9, and ≥20 pack-year), and urine cotinine excretion (<100, 100-999, ≥1000 ng/mL). Multivariate logistic regression analysis was used in calculating adjusted odds ratios (ORs) and 95% confidence interval for LVH (adjusted odds ratios [95% confidence interval]). The proportions of abnormal LV geometry patterns were compared among groups.

RESULTS

Former and current smokers had the higher levels in LV mass index, relative wall thickness, and the prevalence of LVH than never smoker. The association with LVH increased in order of never (reference), former (1.44 [1.01-2.04]), and current smokers (2.10 [1.44-3.05]). LVH showed the proportional relationship with pack-year of smoking (never smoker: reference, <10: 1.45 [1.01-2.08], 10-19.9: 1.73 [1.17-2.57], ≥20: 2.43 [1.58-3.74]) and urine cotinine excretion (never smoker: reference, 100-999: 1.70 [1.21-2.37], >1000: 1.97 [1.43-2.72]). The proportions of abnormal LV geometry patterns were higher in smoking groups than never smoking group.

CONCLUSION

Exposure to tobacco use and intensity of smoking was associated with LVH in working aged population.

IMPLICATIONS

In working aged Koreans with mean age of 39.9 ± 7.0 years, former and current smokers are more likely to have LVH than never smoker. Dose-dependent relationship was found between the smoking status (never, former, and current smokers), pack-year of smoking, urine cotinine excretion, and LVH. These findings indicate that smoking has an adverse influence on LV structure even in relatively young age group.

Prognostic Significance of Echocardiographic Measures of Cardiac Remodeling in the Community

PURPOSE OF REVIEW

Echocardiography is a noninvasive tool of choice for evaluating cardiac structure and function in numerous cardiac conditions ranging from congenital heart disease, myocardial diseases, coronary artery disease (CAD), valvulopathies, arrhythmias, and pericardial disorders. We review the prognostic significance of echocardiographic indices of cardiac remodeling in the general population.

RECENT FINDINGS

Recent meta-analyses have confirmed the prognostic significance of echocardiographic measurements (left ventricular mass/hypertrophy, systolic and diastolic dysfunction, left atrial dimensions and function, and strain rate measures) in asymptomatic people in the community for adverse clinical outcomes including CAD, stroke, heart failure, atrial fibrillation, sudden death, and all-cause mortality. The clinical utility of screening echocardiography has been examined comprehensively in hypertensive patients, where it is challenged by measurement variability. Echocardiographic measures predict cardiovascular disease outcomes consistently in multiple community-based epidemiological studies. However, the clinical utility of screening asymptomatic individuals with echocardiography in population-based settings is limited.

Usefulness of echocardiography for predicting ventricular tachycardia detected by implantable loop recorder in syncope patients

Ventricular tachycardia (VT) may lead to syncope and sudden cardiac death. Implantable loop recorders (ILR) are recommended in the clinical work-up of patients with unexplained syncope. Our aim was to evaluate if echocardiographic parameters assessed prior to ILR implantation in patients with unexplained syncope may aid in identifying individuals with an increased risk of VT. The present study included 288 ambulatory patients (mean age 58 ± 19 years, 51% women) with syncope (90%) and presyncope (10%) who had an ILR implanted in the diagnostic workup. All patients underwent an echocardiographic examination prior to device implantation (median 3 months [IQR 1 to 6 months]). We examined incident VT, defined as a first-time episode of VT (> 30 s) or non-sustained VT (< 30 s) detected by the ILR. During median follow-up of 2.9 years [IQR 1.3 to 3.5 years] of continuous rhythm monitoring, 36 patients (13%) were diagnosed with incident VT (n = 25 non-sustained VT, n = 11 sustained VT). In unadjusted Cox proportional hazards models, left ventricular (LV) mass index (HR: 1.04 per 1 g/m² increase [1.00 to 1.08], P = 0.047), mean LV wall thickness (HR: 1.36 per 1 mm increase [1.08 to 1.71], P = 0.009), and global longitudinal strain (HR: 1.15 per 1% decrease [1.05 to 1.25], P = 0.002) were significantly associated with VT. After adjusting for age, sex, implantable loop recorder indication and known heart failure, the above-mentioned parameters remained significantly associated with incident VT. LV mass index, LV wall thickness, and GLS may aid in identifying patients with increased risk of incident VT among patients with syncope. Echocardiography may potentially help select patients who can benefit from ILR.

Randomized Trial of Etelcalcetide for Cardiac Hypertrophy in Hemodialysis

[Figure: see text].

The association between left ventricular hypertrophy and consumption of nuts, including peanuts, pine nuts, and almonds

BACKGROUND AND AIMS

Studies have reported that nut consumption is potentially beneficial in preventing cardiovascular disease. However, data are insufficient regarding the association between nut consumption and left ventricular hypertrophy (LVH).

METHODS AND RESULTS

In the Kangbuk Samsung Health Study, the participants were 34,617 men and 12,257 women who completed a food-frequency questionnaire for nut consumption and received echocardiography. Nut consumption was evaluated only for peanuts, pine nuts, and almonds defining 15 g as one serving/servings dose. Multivariable adjusted odds ratio (OR) and 95% confidence interval (CI) for LVH were evaluated according to the consumption frequency of one serving dose of nut. The frequency of nut consumption was categorized into five groups (<1/month, 1/month-1/week, 1-2/week, 2-4/week, and ≥4/week). The subgroup analysis was conducted by dividing the participants into the following two groups: the nonhypertensive/nondiabetic group and hypertensive or diabetic group. In women, nut consumption ≥2/week had the lower multivariable adjusted OR and 95% CI for LVH (2-4/week: 0.46 [0.26-0.81] and ≥4/week: 0.48 [0.25-0.92]) when compared with nut consumption <1/month. This association was identically observed in the subgroup analysis for women without hypertension and diabetes mellitus (DM) and women with hypertension or DM. However, men did not show the significant association.

CONCLUSION

In women, nut consumption ≥2/week was associated with the decreased probability of LVH. Further research studies should investigate whether the beneficial effect of nut consumption on LV structure results in better cardiovascular prognosis.

Deficit of glucocorticoid-induced leucine zipper amplifies angiotensin-induced cardiomyocyte hypertrophy and diastolic dysfunction

Poor prognosis in heart failure and the lack of real breakthrough strategies validate targeting myocardial remodelling and the intracellular signalling involved in this process. So far, there are no effective strategies to counteract hypertrophy, an independent predictor of heart failure progression and death. Glucocorticoid-induced leucine zipper (GILZ) is involved in inflammatory signalling, but its role in cardiac biology is unknown. Using GILZ-knockout (KO) mice and an experimental model of hypertrophy and diastolic dysfunction, we addressed the role of GILZ in adverse myocardial remodelling. Infusion of angiotensin II (Ang II) resulted in myocardial dysfunction, inflammation, apoptosis, fibrosis, capillary rarefaction and hypertrophy. Interestingly, GILZ-KO showed more evident diastolic dysfunction and aggravated hypertrophic response compared with WT after Ang II administration. Both cardiomyocyte and left ventricular hypertrophy were more pronounced in GILZ-KO mice. On the other hand, Ang II-induced inflammatory and fibrotic phenomena, cell death and reduction in microvascular density, remained invariant between the WT and KO groups. The analysis of regulators of hypertrophic response, GATA4 and FoxP3, demonstrated an up-regulation in WT mice infused with Ang II; conversely, such an increase did not occur in GILZ-KO hearts. These data on myocardial response to Ang II in mice lacking GILZ indicate that this protein is a new element that can be mechanistically involved in cardiovascular pathology.

Association of left ventricular hypertrophy with the level of thyroid hormone in euthyroid state

PURPOSE

It has been demonstrated that variation in thyroid hormone levels even within normal range was associated with increased cardiovascular risk. However, available data are still insufficient on association between left ventricular hypertrophy (LVH) and thyroid hormone levels within euthyroid state.

METHODS

In 69,298 Koreans with euthyroid function, we evaluated association between echocardiographically detected LVH and thyroid hormone levels within the normal range. Study participants were categorized into elderly (age ≥ 40) and younger (age < 40) groups, where subjects were divided into four groups according to quartile levels of thyroxine (FT4), triiodothyronine (FT3), and thyroid-stimulating hormone (TSH). Multivariable adjusted logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence interval (CI) for LVH (adjusted ORs [95% CI]) across quartile levels of thyroid hormones.

RESULTS

In elderly group, adjusted ORs for LVH generally higher in the first quartile group than other quartile groups, despite no statistical significance in some cases (first quartile: reference, second quartile: 0.86 [0.67-1.11] in TSH, 0.75 [0.58-0.95] in FT4 and 0.63 [0.49-0.81] in FT3, third quartile: 0.70 [0.54-0.92] in TSH, 0.79 [0.61-1.02] in FT4 and 0.72 [0.55-0.93] in FT3, fourth quartile: 0.81 [0.65-1.04] in TSH, 0.85 [0.65-1.10] in FT4 and 0.58 [0.44-0.77] in FT3). This finding was similarly found in the younger group, despite discrepancy in some cases.

CONCLUSION

In euthyroid state, low normal levels in FT4, FT3 and TSH were more strongly associated with LVH.

Pattern Analysis of Left Ventricular Remodeling Using Cardiac Computed Tomography in Children with Congenital Heart Disease: Preliminary Results

OBJECTIVE

To assess left ventricular remodeling patterns using cardiac computed tomography (CT) in children with congenital heart disease and correlate these patterns with their clinical course.

MATERIALS AND METHODS

Left ventricular volume and myocardial mass were quantified in 17 children with congenital heart disease who underwent initial and follow-up end-systolic cardiac CT studies with a mean follow-up duration of 8.4 ± 9.7 months. Based on changes in the indexed left ventricular myocardial mass (LVMi) and left ventricular mass-volume ratio (LVMVR), left ventricular remodeling between the two serial cardiac CT examinations was categorized into one of four patterns: pattern 1, increased LVMi and increased LVMVR; pattern 2, decreased LVMi and decreased LVMVR; pattern 3, increased LVMi and decreased LVMVR; and pattern 4, decreased LVMi and increased LVMVR. Left ventricular remodeling patterns were correlated with unfavorable clinical courses.

RESULTS

Baseline LVMi and LVMVR were 65.1 ± 37.9 g/m² and 4.0 ± 3.2 g/mL, respectively. LVMi increased in 10 patients and decreased in seven patients. LVMVR increased in seven patients and decreased in 10 patients. Pattern 1 was observed in seven patients, pattern 2 in seven, and pattern 3 in three patients. Unfavorable events were observed in 29% (2/7) of patients with pattern 1 and 67% (2/3) of patients with pattern 3, but no such events occurred in pattern 2 during the follow-up period (4.4 ± 2.7 years).

CONCLUSION

Left ventricular remodeling patterns can be characterized using cardiac CT in children with congenital heart disease and may be used to predict their clinical course.

The piRNA CHAPIR regulates cardiac hypertrophy by controlling METTL3-dependent N6-methyladenosine methylation of Parp10 mRNA

PIWI-interacting RNAs (piRNAs) are abundantly expressed during cardiac hypertrophy. However, their functions and molecular mechanisms remain unknown. Here, we identified a cardiac-hypertrophy-associated piRNA (CHAPIR) that promotes pathological hypertrophy and cardiac remodelling by targeting METTL3-mediated N⁶-methyladenosine (m⁶A) methylation of Parp10 mRNA transcripts. CHAPIR deletion markedly attenuates cardiac hypertrophy and restores heart function, while administration of a CHAPIR mimic enhances the pathological hypertrophic response in pressure-overloaded mice. Mechanistically, CHAPIR-PIWIL4 complexes directly interact with METTL3 and block the m⁶A methylation of Parp10 mRNA transcripts, which upregulates PARP10 expression. The CHAPIR-dependent increase in PARP10 promotes the mono-ADP-ribosylation of GSK3β and inhibits its kinase activity, which results in the accumulation of nuclear NFATC4 and the progression of pathological hypertrophy. Hence, our findings reveal that a piRNA-mediated RNA epigenetic mechanism is involved in the regulation of cardiac hypertrophy and that the CHAPIR-METTL3-PARP10-NFATC4 signalling axis could be therapeutically targeted for treating pathological hypertrophy and maladaptive cardiac remodelling.

Association of Sugar-Sweetened Carbonated Beverage with the Alteration in Left Ventricular Structure and Diastolic Function

BACKGROUND

High consumption of sugar-sweetened carbonated beverage (SSCB) has been associated with multiple metabolic risk factors for cardiovascular disease. However, published data is scarce regarding the influence of SSCB consumption on left ventricular (LV) structure and diastolic function. The present study is to investigate the association of SSCB consumption with alteration in LV structure and diastolic function.

METHOD

Study subjects were 46,417 Koreans who received echocardiography as an item of health checkup. They were categorized into 4 groups by SSCB consumption based on one serving dose (200 ml) with never/almost never, <1 serving/week, 1 ≤ serving/week <3 and ≥3 serving/week. Multivariate logistic regression analysis was used in calculating adjusted odd ratio (OR) and 95% confidence interval (CI) (adjusted OR [95% CI]) for left ventricular hypertrophy, increased relative wall thickness (IRWT) and impaired LV relaxation with each group (reference: never/almost never consumption). Subgroup analysis was conducted by age of ≥40 and <40.

RESULT

Compared with never/almost never consumption, SSCB consumption ≥3 serving/week had the higher mean levels in body mass index, blood pressure and triglyceride despite of younger age. In fully adjusted analysis, SSCB consumption ≥3 serving/week was associated with IRWT (1.14 [1.02-1.27]) and impaired LV relaxation (1.23 [1.08-1.41]). This association was reinforced in age subgroup ≥40 years, but not statistically significant in age subgroup <40 years.

CONCLUSION

SSCB consumption ≥3 serving/week was associated with the increased probability of IRWT and impaired LV relaxation.

Structural and Physiological Imaging to Predict the Risk of Lethal Ventricular Arrhythmias and Sudden Death

Identifying patients at risk of sudden cardiac death remains a major challenge in cardiovascular medicine. Advances in cardiovascular imaging have identified several anatomic and functional variables that can be quantified as continuous variables to predict the risk of developing lethal ventricular tachyarrhythmias in patients with depressed left ventricular (LV) systolic function. Some, such as LV mass, volume, and the dyssynchrony of contraction, can be derived from currently available echocardiographic and nuclear imaging modalities. Others require advanced cardiac imaging modalities with quantification of myocardial scar with gadolinium-enhanced cardiac magnetic resonance and myocardial sympathetic denervation using norepinephrine analogs and positron emission tomography or single-photon emission computed tomography offering the most promise. There is an immediate need to develop a sequential cost-effective approach that capitalizes on readily available clinical information complemented with advanced imaging modalities in selected patients to improve risk stratification for arrhythmic death beyond LV ejection fraction.

Sarcomeric Gene Variants and Their Role with Left Ventricular Dysfunction in Background of Coronary Artery Disease

: Cardiovascular diseases are one of the leading causes of death in developing countries, generally originating as coronary artery disease (CAD) or hypertension. In later stages, many CAD patients develop left ventricle dysfunction (LVD). Left ventricular ejection fraction (LVEF) is the most prevalent prognostic factor in CAD patients. LVD is a complex multifactorial condition in which the left ventricle of the heart becomes functionally impaired. Various genetic studies have correlated LVD with dilated cardiomyopathy (DCM). In recent years, enormous progress has been made in identifying the genetic causes of cardiac diseases, which has further led to a greater understanding of molecular mechanisms underlying each disease. This progress has increased the probability of establishing a specific genetic diagnosis, and thus providing new opportunities for practitioners, patients, and families to utilize this genetic information. A large number of mutations in sarcomeric genes have been discovered in cardiomyopathies. In this review, we will explore the role of the sarcomeric genes in LVD in CAD patients, which is a major cause of cardiac failure and results in heart failure.

Intense sport practices and cardiac biomarkers

Biomarkers are well established for the diagnosis of myocardial infarction, heart failure and cardiac fibrosis. Different papers on cardiac biomarker evolution during exercise have been published in the literature and generally show mild to moderate elevations. However, the mechanism responsible for these elevations, reflecting physiological or even pathophysiological changes, still has to be clearly elucidated. There are also indications of higher cardiac risk in poorly trained athletes than in well-trained athletes. Whether regular repetition of intensive exercise might lead, in the longer term, to fibrosis and heart failure remains to be determined. In this review, we summarized the main research about the effects of intense exercise (in particular, running) on cardiac biomarkers (including troponins, natriuretic peptides, etc.). We found that cardiac fibrosis biomarkers seemed to be the most informative regarding the biological impact of intense physical activity.

The Maximum Diameter of the Left Ventricle May Not Be the Optimum Target for Chest Compression During Cardiopulmonary Resuscitation: A Preliminary, Observational Study Challenging the Traditional Assumption

OBJECTIVE

Researchers have assumed that compressing the point beneath which the left ventricle (LV) diameter is maximum (P_max.LV) would improve cardiopulmonary resuscitation outcomes. Defining the midsternum, the currently recommended location for chest compression, as the reference (x = 0), the lateral deviation (x_max.LV) of personalized P_max.LV has become estimable using posteroanterior chest radiography. The authors investigated whether out-of-hospital cardiac arrest (OHCA) patients, whose x_max.LV was closer to the midsternum and thus had their P_max.LV compressed closer during cardiopulmonary resuscitation, showed better chances of return of spontaneous circulation (ROSC) and survival to discharge.

DESIGN

Retrospective, cross-sectional study.

SETTING

A university hospital.

PARTICIPANTS

Adult OHCA patients with available previous posteroanterior chest radiography.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

For each clinical outcome, multivariable logistic regression was performed, grouping x_max.LV into tertiles and adjusting the variables selected among the core elements of the Utstein template showing possible differences (p > 0.10) in univariate analysis. Odds ratios were presented as OR (95% confidence interval). Among 268 cases (age 64.4 ± 15.8 y, female 89 [33.2%]), 123 (45.9%) achieved ROSC and 40 (14.9%) survival to discharge. Compared with the third tertile of x_max.LV (59 to ∼101 mm), the first (31 to ∼48 mm) and second (48 to ∼59 mm) tertiles, which had a P_max.LV closer to the midsternum, were negatively associated with ROSC (OR 0.502 [0.262-0.960]; p = 0.037 and OR 0.442 [0.233-0.837]; p = 0.012, respectively) and survival to discharge (OR 0.286 [0.080-1.03]; p = 0.055 and OR 0.046 [0.007-0.308]; p = 0.002, respectively).

CONCLUSIONS

OHCA patients with a P_max.LV located closer to the midsternum showed worse chances of ROSC and survival to discharge, which challenges the traditional assumption of identifying P_max.LV as the optimum compression point.

Association of Left Ventricular Hypertrophy with Hemoglobin Levels in Nonanemic and Anemic Populations

<b><i>Introduction:</i></b> It is established that anemia leads to adaptive changes in cardiac geometry including left ventricular hypertrophy (LVH). However, published data are still scarce regarding the association of LVH with normal-range hemoglobin levels. <b><i>Objective:</i></b> To evaluate the association between hemoglobin level and LVH in subjects with or without anemia. <b><i>Methods:</i></b> The study included 48,034 Korean men and women who received echocardiography during their medical health checkup. They were divided into 4 groups according to their hemoglobin concentration (g/dL) in men (&#x3c;14, 14–14.9, 15–15.9, and ≥16) and women (&#x3c;12, 12–12.9, 13–13.9, and ≥15). Multivariate logistic regression analysis was used to calculate adjusted ORs and 95% CI for LVH in each group compared with the group with the lowest hemoglobin. Subgroup analysis was conducted for subjects within normal hemoglobin levels. <b><i>Results:</i></b> There was an inverse relationship between hemoglobin levels and LVH, where unadjusted and adjusted ORs and 95% CI for LVH decreased with increasing hemoglobin levels in both men and women. In subgroup analysis, this inverse relationship was also observed in subjects with hemoglobin in the nonanemic range. <b><i>Conclusion:</i></b> The decrease in hemoglobin was significantly associated with the increased probability of LVH, and this association was found even in nonanemic subjects.

Angiotensin II Type I Receptor Antagonism Attenuates Nicotine-Induced Cardiac Remodeling, Dysfunction, and Aggravation of Myocardial Ischemia-Reperfusion Injury in Rats

Increased exposure to nicotine contributes to the development of cardiac dysfunction by promoting oxidative stress, fibrosis, and inflammation. These deleterious events altogether render cardiac myocytes more susceptible to acute cardiac insults such as ischemia-reperfusion (I/R) injury. This study sought to elucidate the role of angiotensin II type I (AT1) receptors in cardiac injury resulting from prolonged nicotine administration in a rat model. Male Sprague-Dawley rats were given nicotine (0.6 mg/kg ip) for 28 days to induce cardiac dysfunction, alone or in combination with the AT1 receptor antagonist, irbesartan (10 mg/kg, po). Vehicle-treated rats were used as controls. Rat hearts isolated from each experimental group at study endpoint were examined for changes in function, histology, gene expression, and susceptibility against acute I/R injury determined ex vivo. Rats administered nicotine alone exhibited significantly increased cardiac expression of angiotensin II and angiotensin-converting enzyme (ACE) in addition to elevated systolic blood pressure (SBP) and heart rate. Furthermore, nicotine administration markedly reduced left ventricular (LV) performance with concomitant increases in myocardial oxidative stress, fibrosis, and inflammation. Concomitant treatment with irbesartan attenuated these effects, lowering blood pressure, heart rate, oxidative stress, and expression of fibrotic and inflammatory genes. Importantly, the irbesartan-treated group also manifested reduced susceptibility to I/R injury ex vivo. These findings suggest that AT1 receptors play an important role in nicotine-induced cardiac dysfunction, and pharmacological approaches targeting cardiac AT1 receptors may thus benefit patients with sustained exposure to nicotine.

Myocardial Microvascular Dysfunction in Rheumatoid ArthritisQuantitation by 13N-Ammonia Positron Emission Tomography/Computed Tomography

BACKGROUND

The goal of this study was to assess the prevalence of myocardial microvascular dysfunction in rheumatoid arthritis (RA) patients without clinical cardiovascular disease and its association with RA characteristics and measures of cardiac structure and function.

METHODS

Participants with RA underwent rest and vasodilator stress N-13 ammonia positron emission tomography and echocardiography. Global myocardial blood flow was quantified at rest and during peak hyperemia. Myocardial flow reserve (MFR) was calculated as peak stress myocardial blood flow/rest myocardial blood flow. A small number of asymptomatic and symptomatic non-RA controls were also evaluated.

RESULTS

In RA patients, mean±SD MFR was 2.9±0.8, with 29% having reduced MFR (<2.5). Male sex and higher interleukin-6 were significantly associated with lower MFR, while the use of tumor necrosis factor inhibitors was associated with higher MFR. Lower MFR was associated with higher left ventricle mass index and higher left ventricle volumes but not with ejection fraction or diastolic dysfunction. RA and symptomatic controls had comparable MFR (mean±SD: 2.9±0.8 versus 2.55±0.6; P=0.48). In contrast, MFR was higher in the asymptomatic controls (mean±SD: 3.25±0.7) although not statistically different.

CONCLUSIONS

Reduced MFR was observed in a third of RA patients without clinical cardiovascular disease and was associated with a measure of inflammation and with higher left ventricle mass and volumes. MFR in RA patients was similar to controls referred for clinical scans (symptomatic controls). Whether reduced MFR contributes to the increased risk for heart failure in RA remains unknown.

Conventional and new electrocardiographic criteria for hypertension-mediated cardiac organ damage: A narrative review

Hypertension-mediated organ damage (HMOD) is frequently observed in hypertensive patients at different cardiovascular (CV) risk profile. This may have both diagnostic and therapeutic implications for the choice of the most appropriate therapies. Among different markers of HMOD, the most frequent functional and structural adaptations can be observed at cardiac level, including left ventricular hypertrophy (LVH), diastolic dysfunction, aortic root dilatation, and left atrial enlargement. In particular, LVH was shown to be a strong and independent risk factor for major CV events, namely myocardial infarction, stroke, congestive heart failure, CV death. Thus, early identification of LVH is a key element for preventing CV events in hypertension. Although echocardiographic assessment of LVH represents the gold standard technique, this is not cost-effective and cannot be adopted in routine clinical practice of hypertension. On the other hand, electrocardiographic (ECG) assessment of HMOD relative to the heart is a simple, reproducible, widely available and cost-effective method to assess the presence of LVH, and could be preferred in large scale screening tests. Several new indicators have been proposed and tested in observational studies and clinical trials of hypertension, in order to improve the relatively low sensitivity of the conventional ECG criteria for LVH, despite high specificity. This article reviews the differences in the use of the main conventional and the new 12 lead ECG criteria of LVH for early assessment of asymptomatic, subclinical cardiac HMOD in a setting of clinical practice of hypertension.

Effect of the Single-Pill Amlodipine/Valsartan Combination on Hypertrophy and Myocardial Deformation Characteristics in Middle-Aged Patients with Essential Arterial Hypertension

Aim. To investigate the impact of amlodipine/valsartan single-pill combination (A/V SPC) on left ventricular hypertrophy (LVH) and left ventricular (LV) myocardial strain and stiffness parameters in naїve middle-aged patients with stage II grade 1-2 essential arterial hypertension (EAH).Material and methods. A group of patients with stage II grade 1-2 EAH who had not previously received regular antihypertensive treatment (AHT) [n=38; mean age 49.7±7.0 years] was retrospectively formed. All the patients were treated with A/V SPC and all of them achieved target office blood pressure (BP) (less than 140/90 mm Hg). And after 12 weeks follow-up (since the time of reaching the target BP) the AHT effectiveness assessment, its impact on LVH and LV myocardial strain and stiffness parameters (general clinical data, ambulatory blood pressure monitoring, conventional and 2D-speckle tracking echocardiography) were performed in all included patients.Results. The number of patients with LVH significantly (p=0.039) decreased from 25 individuals (65.8%) at baseline to 15 patients (39.5%) at the end of follow-up. Among patients with LVH at baseline after the treatment with A/V SPC significantly decreased (p<0.001 for all) interventricular septum thickness (from 1.36±0.19 to 1.28±0.18 cm), LV posterior wall thickness (from 1.08±0.09 to 0.97±0.11 cm) and the LV myocardial mass index (from 123.3±19.3 to 110.8±20.8 g/m2). At the end of follow-up end-systolic elastance significantly (p<0.001) decreased from 4.01±1.12 to 3.46±0.88 mm Hg/ml. In the subgroup of patients with reduced (in absolute value) LV longitudinal 2D-strain (n=27) at baseline, there was a significantly (p=0.005) increasing in this parameter at the end of the study (from -16.14±2.21% to -17.30±2.13%, Δ%=8.45±13.35).Conclusion. In naive patients 40-65 years old with stage II grade 1-2 EAH AHT with A/V SPC provides effective 24 hours BP control, significantly reduced LVH and improves LV strain parameters, which indicates decreasing of LV myocardial stiffness.

Difference in SBP between arms is a predictor of chronic kidney disease development in the general Korean population

OBJECTIVE

An increased inter-arm SBP difference (IASBPD) is associated with mortality and cardiovascular events, as well as peripheral vascular disease, which is attributed to subclavian stenosis. The aim of the present study was to investigate the association between the IASBPD and incident chronic kidney disease (CKD) in the Korean population.

METHODS

A retrospective cohort study was performed on 8780 Korean adults without baseline CKD. The bilateral blood pressure was measured sequentially and repeatedly at the first visit. IASBPD was defined as a BP at least 15 mmHg according to the National Institutes for Health and Clinical Excellence guidelines, and CKD was defined as an estimated glomerular filtration rate less than 60 ml/min per 1.73 m. We assessed the value of IASBPD to predict the incidence of CKD and investigated cardiovascular disease, including coronary heart disease and stroke.

RESULTS

Over a mean follow-up period of 8.5 years, 96 of 581 (16.5%) patients in the IASBPD group and 1037 of 8199 (12.6%) patients in the non-IASBPD group developed incident CKD. Compared with the non-IASBPD, an IASBPD was associated with incident CKD [hazard ratio (HR): 1.336, 95% confidence interval (CI): 1.08-1.65, P = 0.007]. After adjusting for potential confounders, including age, sex, hypertension, diabetes, and obesity, we found that the hazard ratio was also robust (hazard ratio 1.275, 95% CI 1.03-1.58, P = 0.024).

CONCLUSION

Increased IASBPD is an independent predictor of incident CKD in the general population.

Technical feasibility of semiautomatic three-dimensional threshold-based cardiac computed tomography quantification of left ventricular mass

BACKGROUND

Semiautomatic three-dimensional (3-D) threshold-based cardiac computed tomography (CT) quantification has not been attempted for left ventricular mass.

OBJECTIVE

To evaluate the technical feasibility of semiautomatic 3-D threshold-based cardiac CT quantification of left ventricular mass in patients with various degrees of left ventricular hypertrophy.

MATERIALS AND METHODS

In 99 patients, cardiac CT was utilized to quantify ventricular volume and mass by using a semiautomatic 3-D threshold-based method. Left ventricular mass values were compared between the end-systole and the end-diastole. Volumetric parameters were compared among three left ventricular hypertrophy groups (definite, borderline, none). The reproducibility was assessed. The t-test, one-way analysis of variance and Pearson correlation were used.

RESULTS

There were no technical failures. The left ventricular mass between the two sessions exhibited a small mean difference of 2.3±1.1% (mean±standard deviation). The indexed mass values were significantly higher at the end-systole than at the end-diastole (71.4±42.9 g/m² vs. 65.9±43.3 g/m², P<0.001), with significant correlation (R=0.99, P<0.001). The definite group (83.5±41.3 g/m²) showed statistically significantly higher indexed mass values than the borderline and none groups (64.7±26.9 and 55.6±23.9 g/m², respectively; P<0.03), while demonstrating no statistically significant difference between the latter two groups (P>0.05). Left ventricular volume-mass and mass-volume ratios could be calculated in all three groups.

CONCLUSION

CT quantification of left ventricular mass using semiautomatic 3-D threshold-based segmentation is feasible with high reproducibility and the mass values and its ratios with ventricular volumes may be used in patients with various degrees of left ventricular hypertrophy.