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Hadid S, Hajj ME, Hadid B, Siddiqui Z, Wang A, Frishman WH, Aronow WS. Diastolic Dysfunction and Atrial Fibrillation: Recognition, Interplay, and Management. Cardiol Rev 2024:00045415-990000000-00273. [PMID: 38780254 DOI: 10.1097/crd.0000000000000724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Diastolic dysfunction occurs when the left ventricle loses its ability to relax normally, impairing ventricular filling during diastole. This most commonly occurs as a pathological sequela of left ventricular hypertrophy and remodeling due to chronic hypertension and/or age-related sclerotic changes of the aortic valve. This can subsequently deteriorate to diastolic heart failure or heart failure with preserved ejection fraction. There is a substantive interplay between atrial fibrillation and diastolic dysfunction, as atrial fibrillation can cause, exacerbate, or be a direct result of diastolic dysfunction and vice versa. In this review, we first independently define diastolic heart failure and atrial fibrillation while discussing the diagnostic guidelines, which encompass various modalities such as medical history, electrocardiography, echocardiography, and laboratory tests. We subsequently examine their interplay and pathophysiological links drawing on recent evidence in the literature. Finally, we discuss management approaches, including pharmacological interventions targeting rate and rhythm control, diuretics, and addressing comorbidities.
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Affiliation(s)
- Somar Hadid
- From the School of Medicine, New York Medical College, Valhalla, NY
| | - Mahmoud El Hajj
- Department of Internal Medicine, Montefiore St. Luke's Cornwall Hospital, Newburgh, NY
| | - Bana Hadid
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Zoya Siddiqui
- From the School of Medicine, New York Medical College, Valhalla, NY
| | - Andy Wang
- Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - William H Frishman
- From the School of Medicine, New York Medical College, Valhalla, NY
- Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Wilbert S Aronow
- From the School of Medicine, New York Medical College, Valhalla, NY
- Department of Medicine, Westchester Medical Center, Valhalla, NY
- Department of Cardiology, Westchester Medical Center, Valhalla, NY
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2
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Yaku H, Fudim M, Shah SJ. Role of splanchnic circulation in the pathogenesis of heart failure: State-of-the-art review. J Cardiol 2024; 83:330-337. [PMID: 38369183 DOI: 10.1016/j.jjcc.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/07/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
A hallmark of heart failure (HF), whether it presents itself during rest or periods of physical exertion, is the excessive elevation of intracardiac filling pressures at rest or with exercise. Many mechanisms contribute to the elevated intracardiac filling pressures, and notably, the concept of volume redistribution has gained attention as a cause of the elevated intracardiac filling pressures in patients with HF, particularly HF with preserved ejection fraction, who often present without symptoms at rest, with shortness of breath and fatigue appearing only during exertion. This phenomenon suggests cardiopulmonary system non-compliance and inappropriate volume distribution between the stressed and unstressed blood volume components. A substantial proportion of the intravascular blood volume is in the splanchnic vascular compartment in the abdomen. Preclinical and clinical investigations support the critical role of the sympathetic nervous system in modulating the capacitance and compliance of the splanchnic vascular bed via modulation of the greater splanchnic nerve (GSN). The GSN activation by stressors such as exercise causes excessive splanchnic vasoconstriction, which may contribute to the decompensation of chronic HF via volume redistribution from the splanchnic vascular bed to the central compartment. Accordingly, for example, GSN ablation for volume management has been proposed as a potential therapeutic intervention to increase unstressed blood volume. Here we provide a comprehensive review of the role of splanchnic circulation in the pathogenesis of HF and potential novel treatment options for redistributing blood volume to improve symptoms and prognosis in patients with HF.
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Affiliation(s)
- Hidenori Yaku
- Division of Cardiology, Department of Medicine, and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, NC, USA; Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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3
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Ostrominski JW, DeFilippis EM, Bansal K, Riello RJ, Bozkurt B, Heidenreich PA, Vaduganathan M. Contemporary American and European Guidelines for Heart Failure Management: JACC: Heart Failure Guideline Comparison. JACC. HEART FAILURE 2024; 12:810-825. [PMID: 38583167 DOI: 10.1016/j.jchf.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/31/2024] [Accepted: 02/19/2024] [Indexed: 04/09/2024]
Abstract
This review serves to compare contemporary clinical practice recommendations for the management of heart failure (HF), as codified in the 2021 European Society of Cardiology (ESC) guideline, the 2022 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) guideline, and the 2023 focused update of the 2021 ESC document. Overall, these guidelines aim to solidify significant advances throughout the HF continuum since the publication of previous full guideline iterations (2013 and 2016 for the ACC/AHA and ESC, respectively). All guidelines provide new recommendations for an increasingly complex landscape of HF care, with focus on primary HF prevention, HF stages, rapid initiation and optimization of evidence-based pharmacotherapies, overlapping cardiac and noncardiac comorbidities, device-based therapies, and management pathways for special groups of patients, including those with cardiac amyloidosis. Importantly, the ACC/AHA/HFSA document features special emphasis on HF risk prediction and screening, cost/value, social determinants of health, and health care disparities. The review discusses major similarities and differences between these recent guidelines and guideline updates, as well as their potential downstream implications for clinical care.
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Affiliation(s)
- John W Ostrominski
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Kannu Bansal
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
| | - Ralph J Riello
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, Connecticut, USA
| | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiovascular Research Institute, Baylor College of Medicine and DeBakey VA Medical Center, Houston, Texas, USA
| | - Paul A Heidenreich
- Department of Medicine, VA Palo Alto Healthcare System, Palo Alto, California, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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4
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Hiraiwa H, Okumura T, Murohara T. Drug Therapy for Acute and Chronic Heart Failure with Preserved Ejection Fraction with Hypertension: A State-of-the-Art Review. Am J Cardiovasc Drugs 2024; 24:343-369. [PMID: 38575813 PMCID: PMC11093799 DOI: 10.1007/s40256-024-00641-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 04/06/2024]
Abstract
In this comprehensive state-of-the-art review, we provide an evidence-based analysis of current drug therapies for patients with heart failure with preserved ejection fraction (HFpEF) in the acute and chronic phases with concurrent hypertension. Additionally, we explore the latest developments and emerging evidence on the efficacy, safety, and clinical outcomes of common and novel drug treatments in the management of HFpEF with concurrent hypertension. During the acute phase of HFpEF, intravenous diuretics, mineralocorticoid receptor antagonists (MRAs), and vasodilators are pivotal, while in the chronic phase, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have proven effective in enhancing clinical outcomes. However, the use of calcium channel blockers in HFpEF with hypertension should be approached with caution, owing to their potential negative inotropic effects. We also explored emerging drug therapies for HFpEF, such as sodium-glucose co-transporter 2 (SGLT2) inhibitors, angiotensin receptor-neprilysin inhibitor (ARNI), soluble guanylate cyclase (sGC) stimulators, novel MRAs, and ivabradine. Notably, SGLT2 inhibitors have shown promise in reducing heart failure hospitalizations and cardiovascular mortality in patients with HFpEF, regardless of their diabetic status. Additionally, ARNI and sGC stimulators have demonstrated potential in improving symptoms, functional capacity, and quality of life. Nonetheless, additional research is necessary to pinpoint optimal treatment strategies for HFpEF with concurrent hypertension. Furthermore, long-term studies are essential to assess the durability and sustained benefits of emerging drug therapies. Identification of novel targets and mechanisms underlying HFpEF pathophysiology will pave the way for innovative drug development approaches in the management of HFpEF with concurrent hypertension.
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Affiliation(s)
- Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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5
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Infeld M. Accelerated physiologic pacing in patients with heart failure with preserved ejection fraction: An argument in support of therapeutic heart rate modulation. Heart Rhythm O2 2024; 5:327-333. [PMID: 38840759 PMCID: PMC11148487 DOI: 10.1016/j.hroo.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Affiliation(s)
- Margaret Infeld
- Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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Kozaily E, Akdogan ER, Dorsey NS, Tedford RJ. Management of Pulmonary Hypertension in the Context of Heart Failure with Preserved Ejection Fraction. Curr Hypertens Rep 2024:10.1007/s11906-024-01296-2. [PMID: 38558124 DOI: 10.1007/s11906-024-01296-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW To review the current evidence and modalities for treating pulmonary hypertension (PH) in heart failure with preserved ejection fraction (HFpEF). RECENT FINDINGS In recent years, several therapies have been developed that improve morbidity in HFpEF, though these studies have not specifically studied patients with PF-HFpEF. Multiple trials of therapies specifically targeting the pulmonary vasculature such as phosphodiesterase (PDE) inhibitors, prostacyclin analogs, endothelin receptor antagonists (ERA), and soluble guanylate cyclase stimulators have also been conducted. However, these therapies demonstrated lack of consistency in improving hemodynamics or functional outcomes in PH-HFpEF. There is limited evidence to support the use of pulmonary vasculature-targeting therapies in PH-HFpEF. The mainstay of therapy remains the treatment of the underlying HFpEF condition. There is emerging evidence that newer HF therapies such as sodium-glucose transporter 2 inhibitors and angiotensin-receptor-neprilysin inhibitors are associated with improved hemodynamics and quality of life of patients with PH-HFpEF. There is also a growing realization that more robust phenotyping PH and right ventricular (RV) function may hold promise for therapeutic strategies for patients with PH-HFpEF.
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Affiliation(s)
- Elie Kozaily
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Ecem Raziye Akdogan
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | | | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA.
- Advanced Heart Failure & Transplant Fellowship Training Program, Medical University of South Carolina (MUSC), 30 Courtenay Drive, BM215, MSC592, Charleston, SC, 29425, USA.
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7
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Zach DK, Schwegel N, Santner V, Winkelbauer L, Hoeller V, Kolesnik E, Gollmer J, Seggewiss H, Batzner A, Perl S, Wallner M, Reiter U, Rainer PP, Zirlik A, Ablasser K, Verheyen N. Low-grade systemic inflammation and left ventricular dysfunction in hypertensive compared to non-hypertensive hypertrophic cardiomyopathy. Int J Cardiol 2024; 399:131661. [PMID: 38158132 DOI: 10.1016/j.ijcard.2023.131661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/13/2023] [Accepted: 12/18/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Arterial hypertension (HTN) is associated with excess mortality in hypertrophic cardiomyopathy (HCM), but underlying mechanisms are largely elusive. The objective of this study was to investigate the association between HTN and markers of left ventricular (LV) dysfunction and low-grade systemic inflammation in a HCM cohort. METHODS This was a single-center cross-sectional case-control study comparing echocardiographic and plasma-derived indices of LV dysfunction and low-grade systemic inflammation between 30 adult patients with HCM and HTN (HTN+) and 30 sex- and age-matched HCM patients without HTN (HTN-). Echocardiographic measures were assessed using post-processing analyses by blinded investigators. RESULTS Mean age of the study population was 55.1 ± 10.4 years, 30% were women. Echocardiographic measures of systolic and diastolic dysfunction, including speckle-tracking derived parameters, did not differ between HTN+ and HTN-. Moreover, levels of N-terminal pro B-type natriuretic peptide were balanced between cases and controls. Compared with HTN-, HTN+ patients exhibited a higher white blood cell count [8.1 ± 1.8 109/l vs. 6.4 ± 1.6 109/l; p < 0.001] as well as higher plasma levels of interleukin-6 [2.8 pg/ml (2.0, 5.4) vs. 2.1 pg/ml (1.5, 3.4); p = 0.008] and high-sensitivity C-reactive protein [2.6 mg/l (1.4, 6.5) vs. 1.1 mg/l (0.9, 2.4); p = 0.004]. CONCLUSION This study demonstrates that HTN is associated with indices of low-grade systemic inflammation among HCM patients. Moreover, this analysis indicates that the adverse impact of HTN in HCM patients is a consequence of systemic effects rather than alterations of cardiac function, as measures of LV systolic and diastolic dysfunction did not differ between HTN+ and HTN-.
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Affiliation(s)
- David K Zach
- University Heart Center, Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.
| | - Nora Schwegel
- University Heart Center, Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Viktoria Santner
- University Heart Center, Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Larissa Winkelbauer
- University Heart Center, Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Viktoria Hoeller
- University Heart Center, Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ewald Kolesnik
- University Heart Center, Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Johannes Gollmer
- University Heart Center, Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Hubert Seggewiss
- Comprehensive Heart Failure Center and Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Angelika Batzner
- Comprehensive Heart Failure Center and Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Sabine Perl
- University Heart Center, Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Markus Wallner
- University Heart Center, Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ursula Reiter
- Division of General Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Peter P Rainer
- University Heart Center, Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria; BioTechMed Graz, Graz, Austria
| | - Andreas Zirlik
- University Heart Center, Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Klemens Ablasser
- University Heart Center, Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Nicolas Verheyen
- University Heart Center, Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Cruz M, Ferreira JP, Diaz SO, Ferrão D, Ferreira AI, Girerd N, Sampaio F, Pimenta J. Lung ultrasound and diuretic therapy in chronic heart failure: a randomised trial. Clin Res Cardiol 2024; 113:425-432. [PMID: 37289237 DOI: 10.1007/s00392-023-02238-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/24/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Lung congestion is frequent in heart failure (HF) and is associated with symptoms and poor prognosis. Lung ultrasound (LUS) identification of B-lines may help refining congestion assessment on top of usual care. Three small trials comparing LUS-guided therapy to usual care in HF suggested that LUS-guided therapy could reduce urgent HF visits. However, to our knowledge, the usefulness of LUS in influencing loop diuretic dose adjustment in ambulatory chronic HF has not been studied. AIMS To study whether to show or not LUS results to the HF assistant physician would change loop diuretic adjustments in "stable" chronic ambulatory HF patients. METHODS Prospective randomised single-blinded trial comparing two strategies: (1) open 8-zone LUS with B-line results available to clinicians, or (2) blind LUS. The primary outcome was change in loop diuretic dose (up- or down-titration). RESULTS A total of 139 patients entered the trial, 70 were randomised to blind LUS and 69 to open LUS. The median (percentile25-75) age was 72 (63-82) years, 82 (62%) were men, and the median LVEF was 39 (31-51) %. Randomisation groups were well balanced. Furosemide dose changes (up- and down-titration) were more frequent among patients in whom LUS results were open to the assistant physician: 13 (18.6%) in blind LUS vs. 22 (31.9%) in open LUS, OR 2.55, 95%CI 1.07-6.06. Furosemide dose changes (up- and down-titration) were more frequent and correlated significantly with the number of B-lines when LUS results were open (Rho = 0.30, P = 0.014), but not when LUS results were blinded (Rho = 0.19, P = 0.13). Compared to blind LUS, when LUS results were open, clinicians were more likely to up-titrate furosemide dose if the result "presence of pulmonary congestion" was identified and more likely to decrease furosemide dose in the case of an "absence of pulmonary congestion" result. The risk of HF events or cardiovascular death did not differ by randomisation group: 8 (11.4%) in blind LUS vs. 8 (11.6%) in open LUS. CONCLUSIONS Showing the results of LUS B-lines to assistant physicians allowed more frequent loop diuretic changes (both up- and down-titration), which suggests that LUS may be used to tailor diuretic therapy to each patient congestion status.
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Affiliation(s)
- Marli Cruz
- Cardiovascular R&D Centre-UnIC@RISE, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of the University of Porto, Porto, Portugal
- Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - João Pedro Ferreira
- Cardiovascular R&D Centre-UnIC@RISE, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of the University of Porto, Porto, Portugal.
- Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France.
| | - Silvia O Diaz
- Cardiovascular R&D Centre-UnIC@RISE, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Diana Ferrão
- Internal Medicine Department, Centro Hospitalar de São João, Porto, Portugal
| | - Ana Isabel Ferreira
- Internal Medicine Department, Centro Hospitalar de São João, Porto, Portugal
| | - Nicolas Girerd
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Francisco Sampaio
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Joana Pimenta
- Cardiovascular R&D Centre-UnIC@RISE, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of the University of Porto, Porto, Portugal
- Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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Asakage A, Mebazaa A, Deniau B. New insights in acute heart failure. Presse Med 2024; 53:104184. [PMID: 37865335 DOI: 10.1016/j.lpm.2023.104184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/05/2023] [Indexed: 10/23/2023] Open
Abstract
Acute heart failure (AHF) is a clinical complex disease and a worldwide issue due to its inconsistent diagnosis and poor prognosis. The cornerstone of pathophysiology of AHF is systemic venous congestion, which is led by the underlying structural and functional cardiac condition. Systemic venous congestion is a major target for AHF management because it causes symptoms and organs dysfunction, and is associated with poor prognosis. The mainstay of decongestive therapy is diuresis with intravenous loop diuretics combined with other diuretics including thiazides when necessary, and non-invasive ventilation. The presence of unresolved congestion at discharge can lead heart failure related rehospitalization, and careful follow-up is required especially during "vulnerable phase", several months after discharge. The updated recommendation for management of AHF has been provided by latest guidelines from European Society of Cardiology and American Heart Association/American College of Cardiology/Heart Failure Society of America. Several large studies have currently demonstrated the benefits of guideline-directed oral medical therapies, and trials are ongoing on medication such as selective sodium-glucose transport proteins 2 inhibitors and protocols for congestive therapy. This review aimed to summarize the latest insights in AHF, based primarily on the most recent guidelines and large randomized controlled trials.
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Affiliation(s)
- Ayu Asakage
- Université de Paris Cité, Paris, France; INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France.
| | - Alexandre Mebazaa
- Université de Paris Cité, Paris, France; INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France; Department of Anesthesiology, Critical Care and Burn Unit, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; FHU PROMICE
| | - Benjamin Deniau
- Université de Paris Cité, Paris, France; INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France; Department of Anesthesiology, Critical Care and Burn Unit, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; FHU PROMICE; INI-CRCT
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10
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Fu D, Ramakrishna H, Stawiarski KM. Remote Pulmonary Artery Pressure Monitoring Systems: Analysis of Evolving Data. J Cardiothorac Vasc Anesth 2024; 38:839-842. [PMID: 38195274 DOI: 10.1053/j.jvca.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 01/11/2024]
Affiliation(s)
- Danni Fu
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, NY
| | - Harish Ramakrishna
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, NY.
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11
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Sagmeister P, Rosch S, Fengler K, Kresoja KP, Gori T, Thiele H, Lurz P, Burkhoff D, Rommel KP. Running on empty: Factors underpinning impaired cardiac output reserve in heart failure with preserved ejection fraction. Exp Physiol 2024. [PMID: 38421268 DOI: 10.1113/ep091776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/13/2024] [Indexed: 03/02/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is frequently attributed etiologically to an underlying left ventricular (LV) diastolic dysfunction, although its pathophysiology is far more complex and can exhibit significant variations among patients. This review endeavours to systematically unravel the pathophysiological heterogeneity by illustrating diverse mechanisms leading to an impaired cardiac output reserve, a central and prevalent haemodynamic abnormality in HFpEF patients. Drawing on previously published findings from our research group, we propose a pathophysiology-guided phenotyping based on the presence of: (1) LV diastolic dysfunction, (2) LV systolic pathologies, (3) arterial stiffness, (4) atrial impairment, (5) right ventricular dysfunction, (6) tricuspid valve regurgitation, and (7) chronotopic incompetence. Tailored to each specific phenotype, we explore various potential treatment options such as antifibrotic medication, diuretics, renal denervation and more. Our conclusion underscores the pivotal role of cardiac output reserve as a key haemodynamic abnormality in HFpEF, emphasizing that by phenotyping patients according to its individual pathomechanisms, insights into personalized therapeutic approaches can be gleaned.
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Affiliation(s)
- Paula Sagmeister
- Department of Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Sebastian Rosch
- Department of Cardiology, University Hospital Mainz, Mainz, Germany
| | - Karl Fengler
- Department of Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | | | - Tommaso Gori
- Department of Cardiology, University Hospital Mainz, Mainz, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Philipp Lurz
- Department of Cardiology, University Hospital Mainz, Mainz, Germany
| | | | - Karl-Philipp Rommel
- Department of Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
- Cardiovascular Research Foundation, New York, New York, USA
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12
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Badrish N, Sheifer S, Rosner CM. Systems of care for ambulatory management of decompensated heart failure. Front Cardiovasc Med 2024; 11:1350846. [PMID: 38455722 PMCID: PMC10918851 DOI: 10.3389/fcvm.2024.1350846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/25/2024] [Indexed: 03/09/2024] Open
Abstract
Heart failure (HF) represents a worldwide health burden and the annual per patient cost to treat HF in the US is estimated at $24,383, with most of this expense driven by HF related hospitalizations. Decompensated HF is a leading cause for hospital admissions and is associated with an increased risk of subsequent morbidity and mortality. Many hospital admissions for decompensated HF are considered preventable with timely recognition and effective intervention.Systems of care that include interventions to facilitate early recognition, timely and appropriate intervention, intensification of care, and optimization to prevent recurrence can help successfully manage decompensated HF in the ambulatory setting and avoid hospitalization.
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Affiliation(s)
- Narotham Badrish
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
| | - Stuart Sheifer
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
- Department of Cardiology, Virginia Heart, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
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Wu Y, Song M, Wu M, Lin L. Advances in device-based treatment of heart failure with preserved ejection fraction: evidence from clinical trials. ESC Heart Fail 2024; 11:13-27. [PMID: 37986663 PMCID: PMC10804156 DOI: 10.1002/ehf2.14562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/10/2023] [Accepted: 10/02/2023] [Indexed: 11/22/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a group of clinical syndromes that exhibit a remarkably heterogeneous phenotype, characterized by symptoms and signs of heart failure, left ventricular diastolic dysfunction, elevated levels of natriuretic peptides, and an ejection fraction greater than or equal to 50%. With the aging of the population and the escalating prevalence of hypertension, obesity, and diabetes, the incidence of HFpEF is progressively rising. Drug therapy options for HFpEF are currently limited, and the associated high risk of cardiovascular mortality and heart failure rehospitalization significantly impact patients' quality of life and longevity while imposing a substantial economic burden on society. Recent research indicates that certain device-based therapies may serve as valuable adjuncts to drug therapy in patients with specific phenotypes of HFpEF, effectively improving symptoms and quality of life while reducing the risk of readmission for heart failure. These include inter-atrial shunt and greater splanchnic nerve ablation to reduce left ventricular filling pressure, implantable heart failure monitor to guide diuresis, left atrial pacing to correct interatrial dyssynchrony, cardiac contractility modulation to enhance cardiac calcium handling, as well as renal denervation, baroreflex activation therapy, and vagus nerve stimulation to restore the autonomic imbalance. In this review, we provide a comprehensive overview of the mechanisms and clinical evidence pertaining to these devices, with the aim of enhancing therapeutic strategies for HFpEF.
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Affiliation(s)
- Ying Wu
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
| | - Meiyan Song
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
| | - Meifang Wu
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
| | - Liming Lin
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
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Benza RL, Adamson PB, Bhatt DL, Frick F, Olsson G, Bergh N, Dahlöf B. CS1, a controlled-release formulation of valproic acid, for the treatment of patients with pulmonary arterial hypertension: Rationale and design of a Phase 2 clinical trial. Pulm Circ 2024; 14:e12323. [PMID: 38174159 PMCID: PMC10763516 DOI: 10.1002/pul2.12323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/13/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
Although rare, pulmonary arterial hypertension (PAH) is associated with substantial morbidity and a median survival of approximately 7 years, even with treatment. Current medical therapies have a primarily vasodilatory effect and do not modify the underlying pathology of the disease. CS1 is a novel oral, controlled-release formulation of valproic acid, which exhibits a multi-targeted mode of action (pulmonary pressure reduction, reversal of vascular remodeling, anti-inflammatory, anti-fibrotic, and anti-thrombotic) and therefore potential for disease modification and right ventricular modeling in patients with PAH. A Phase 1 study conducted in healthy volunteers indicated favorable safety and tolerability, with no increased risk of bleeding and significant reduction of plasminogen activator inhibitor 1. In an ongoing randomized Phase 2 clinical trial, three doses of open-label CS1 administered for 12 weeks is evaluating the use of multiple outcome measures. The primary endpoint is safety and tolerability, as measured by the occurrence of adverse events. Secondary outcome measures include the use of the CardioMEMS™ HF System, which provides a noninvasive method of monitoring pulmonary artery pressure, as well as cardiac magnetic resonance imaging and echocardiography. Other outcomes include changes in risk stratification (using the REVEAL 2.0 and REVEAL Lite 2 tools), patient reported outcomes, functional capacity, 6-min walk distance, actigraphy, and biomarkers. The pharmacokinetic profile of CS1 will also be evaluated. Overall, the novel design and unique, extensive clinical phenotyping of participants in this trial will provide ample evidence to inform the design of any future Phase 3 studies with CS1.
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Affiliation(s)
- Raymond L. Benza
- Ohio State Wexner Medical CenterThe Ohio State UniversityColumbusOhioUSA
| | | | - Deepak L. Bhatt
- Mount Sinai HeartIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | | | - Gunnar Olsson
- Institute of MedicineUniversity of GothenburgGothenburgSweden
| | - Niklas Bergh
- Institute of MedicineUniversity of GothenburgGothenburgSweden
- Early Clinical Development, Biopharmaceuticals Research and Development—CardiovascularRenal and Metabolism, AstraZenecaMölndalSweden
| | - Björn Dahlöf
- Cereno ScientificGothenburgSweden
- Institute of MedicineUniversity of GothenburgGothenburgSweden
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15
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Habel N, Infeld M, Bernknopf J, Meyer M, Lustgarten D. Rationale and design of the PACE HFpEF trial: Physiologic accelerated pacing as a holistic treatment of heart failure with preserved ejection fraction. Heart Rhythm O2 2024; 5:41-49. [PMID: 38312209 PMCID: PMC10837182 DOI: 10.1016/j.hroo.2023.12.001] [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] [Indexed: 02/06/2024] Open
Abstract
Background In heart failure with preserved ejection fraction (HFpEF), it has been assumed that pharmacologic heart rate suppression should provide clinical benefits through an increase in diastolic filling time. Contrary to this assumption, heart rate lowering in patients with preserved left ventricular ejection fraction and hypertension or coronary artery disease results in adverse outcomes and suggests that the opposite may be beneficial. Namely, shortening the diastolic filling time with a higher heart rate might normalize the elevated filling pressures that are the sine qua non of HFpEF. Initial clinical studies that assessed the effects of accelerated heart rates in pacemaker patients with preclinical and overt HFpEF provide support for this latter hypothesis, having shown improvements in quality of life, natriuretic peptide and activity levels, and atrial fibrillation burden. Objective The study sought to determine the effects of continued resting heart rate elevation with and without superimposed nocturnal pacing in HFpEF patients without standard pacing indication. Methods The physiologic accelerated pacing as treatment for heart failure with preserved ejection fraction (PACE HFpEF) trial is an investigator-initiated, prospective, patient-blinded multiple crossover pilot study that assesses the impact of accelerated pacing on quality of life, physical activity, N-terminal pro-B-type natriuretic peptide, and echocardiographic measures of cardiac structure and function. Results Twenty patients were enrolled and underwent dual-chamber pacemaker implantation under U.S. Food and Drug Administration investigational device exemption with both atrial and ventricular physiologic lead placement targeting the Bachmann bundle and the His bundle. Conclusion This manuscript describes the rationale and design of the PACE HFpEF trial, which tests the safety and feasibility of continuous accelerated physiological pacing as a treatment strategy in HFpEF.
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Affiliation(s)
- Nicole Habel
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Margaret Infeld
- Cardiovascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Jacob Bernknopf
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Markus Meyer
- Lillehei Heart Institute, Department of Medicine, University of Minnesota College of Medicine, Minneapolis, Minnesota
| | - Daniel Lustgarten
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
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16
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Clephas PRD, de Boer RA, Brugts JJ. Benefits of remote hemodynamic monitoring in heart failure. Trends Cardiovasc Med 2023:S1050-1738(23)00111-1. [PMID: 38109949 DOI: 10.1016/j.tcm.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/28/2023] [Accepted: 12/13/2023] [Indexed: 12/20/2023]
Abstract
Despite treatment advancements, HF mortality remains high, prompting interest in reducing HF-related hospitalizations through remote monitoring. These advances are necessary considering the rapidly rising prevalence and incidence of HF worldwide, presenting a burden on hospital resources. While traditional approaches have failed in predicting impending HF-related hospitalizations, remote hemodynamic monitoring can detect changes in intracardiac filling pressure weeks prior to HF-related hospitalizations which makes timely pharmacological interventions possible. To ensure successful implementation, structural integration, optimal patient selection, and efficient data management are essential. This review aims to provide an overview of the rationale, the available devices, current evidence, and the implementation of remote hemodynamic monitoring.
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Affiliation(s)
- P R D Clephas
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - R A de Boer
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - J J Brugts
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.
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17
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Deniau B, Costanzo MR, Sliwa K, Asakage A, Mullens W, Mebazaa A. Acute heart failure: current pharmacological treatment and perspectives. Eur Heart J 2023; 44:4634-4649. [PMID: 37850661 DOI: 10.1093/eurheartj/ehad617] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 08/23/2023] [Accepted: 09/08/2023] [Indexed: 10/19/2023] Open
Abstract
Acute heart failure (AHF) represents the most frequent cause of unplanned hospital admission in patients older than 65 years. Symptoms and clinical signs of AHF (e.g. dyspnoea, orthopnoea, oedema, jugular vein distension, and variation of body weight) are mostly related to systemic venous congestion secondary to various mechanisms including extracellular fluids, increased ventricular filling pressures, and/or auto-transfusion of blood from the splanchnic into the pulmonary circulation. Thus, the initial management of AHF patients should be mostly based on decongestive therapies on admission followed, before discharge, by rapid implementation of guideline-directed oral medical therapies for heart failure. The therapeutic management of AHF requires the identification and rapid diagnosis of the disease, the diagnosis of the cause (or triggering factor), the evaluation of severity, the presence of comorbidities, and, finally, the initiation of a rapid treatment. The most recent guidelines from ESC and ACC/AHA/HFSA have provided updated recommendations on AHF management. Recommended pharmacological treatment for AHF includes diuretic therapy aiming to relieve congestion and achieve optimal fluid status, early and rapid initiation of oral therapies before discharge combined with a close follow-up. Non-pharmacological AHF management requires risk stratification in the emergency department and non-invasive ventilation in case of respiratory failure. Vasodilators should be considered as initial therapy in AHF precipitated by hypertension. On the background of recent large randomized clinical trials and international guidelines, this state-of-the-art review describes current pharmacological treatments and potential directions for future research in AHF.
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Affiliation(s)
- Benjamin Deniau
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, 2 rue Ambroise Paré, 75010 Paris, France
- UMR-S 942, INSERM, MASCOT, Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
- FHU PROMICE, France
| | | | - Karen Sliwa
- Cape Heart Institute, Department of Cardiology and Medicine, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, South Africa
| | - Ayu Asakage
- UMR-S 942, INSERM, MASCOT, Université de Paris Cité, Paris, France
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg A.V., Genk, Belgium
- Hasselt University, Diepenbeek/Hasselt, Belgium
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, 2 rue Ambroise Paré, 75010 Paris, France
- UMR-S 942, INSERM, MASCOT, Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
- FHU PROMICE, France
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18
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Durukan E, Jensen CFS, Skaarup KG, Østergren PB, Sønksen J, Biering-Sørensen T, Fode M. Erectile Dysfunction Is Associated with Left Ventricular Diastolic Dysfunction: A Systematic Review and Meta-analysis. Eur Urol Focus 2023; 9:903-912. [PMID: 37355365 DOI: 10.1016/j.euf.2023.06.001] [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: 05/03/2023] [Revised: 05/21/2023] [Accepted: 06/09/2023] [Indexed: 06/26/2023]
Abstract
CONTEXT Erectile dysfunction (ED) is associated with an increased risk of cardiovascular morbidity and mortality. OBJECTIVE To systematically review and analyze the cardiac structure and function in men with ED assessed with echocardiography. EVIDENCE ACQUISITION We performed a systematic review and meta-analysis according to the guideline of the Preferred Reporting Items for Systematic Reviews and Meta-analyses. We searched PubMed and the Cochrane Library on June 2, 2022, and included studies evaluating cardiac structure and function using echocardiography in men with ED compared with controls without ED. The Newcastle-Ottawa Quality Assessment Scale was used for assessing the quality of studies. We analyzed the mean differences in left ventricular ejection fraction (LVEF), the ratio of early transmitral filling velocity to early diastolic mitral annular velocity (E/e'), ratio of the early to late diastolic transmitral flow velocity (E/A), isovolumic relaxation time (IVRT), and left ventricular mass index (LVMi) in a random-effect model computed using means and standard deviations. The review was preregistered with PROSPERO (CRD42022337183). We received no funding. EVIDENCE SYNTHESIS We included ten studies with 763 men diagnosed with ED (mean age: 55.6 yr) and 358 control men (mean age: 54.4 yr). E/e' was significantly worse in men with ED than in controls (mean absolute difference = 1.17, 95% confidence interval or CI [0.68, 1.65], p < 0.005). No significant differences were observed in LVEF, E/A, IVRT, or LVMi (-0.06, 95% CI [-1.06, 0.95], p = 0.91; -0.06, 95% CI [-0.24, 0.13], p = 0.55; 11.76, 95% CI [-0.88, 24.39], p = 0.07; and 4.37, 95% CI [-2.91, 11.65], respectively). The studies exhibited heterogeneity regarding study populations, reported echocardiography data, and variations in adjustments for confounding factors. CONCLUSIONS Left ventricle diastolic dysfunction, as assessed by E/e', was more frequent in men with ED than in matched controls without ED. The results imply that echocardiography may be useful in the cardiovascular evaluation of men with ED to help identify myocardial impairment. PATIENT SUMMARY This study reviewed for the first time previous research on cardiac structure and function in men with erectile dysfunction (ED), as assessed by echocardiography. We found that men with ED, compared with men without ED, had a higher ratio of early transmitral filling velocity to early diastolic mitral annular velocity , indicating a potentially higher rate of impaired diastolic function-a potential early indicator of heart disease. Identification of early signs of heart problems in men with ED may help initiate necessary lifestyle modifications or preventative therapies before the development of heart disease. However, more research is required to determine the clinical utility of using echocardiography as a risk assessment method.
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Affiliation(s)
- Emil Durukan
- Department of Urology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark.
| | | | | | - Peter Busch Østergren
- Department of Urology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jens Sønksen
- Department of Urology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark; Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel Fode
- Department of Urology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Filippini FB, Ribeiro HB, Bocchi E, Bacal F, Marcondes-Braga FG, Avila MS, Sturmer JD, Marchi MFDS, Kanhouche G, Freire AF, Cassar R, Abizaid AA, de Brito FS. Percutaneous Strategies in Structural Heart Diseases: Focus on Chronic Heart Failure. Arq Bras Cardiol 2023; 120:e20220496. [PMID: 38126512 PMCID: PMC10773459 DOI: 10.36660/abc.20220496] [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: 07/11/2023] [Revised: 04/05/2023] [Accepted: 05/17/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Central Illustration : Percutaneous Strategies in Structural Heart Diseases: Focus on Chronic Heart Failure Transcatheter devices for monitoring and treating advanced chronic heart failure patients. PA: pulmonary artery; LA: left atrium; AFR: atrial flow regulator; TASS: Transcatheter Atrial Shunt System; VNS: vagus nerve stimulation; BAT: baroreceptor activation therapy; RDN: renal sympathetic denervation; F: approval by the American regulatory agency (FDA); E: approval by the European regulatory agency (CE Mark). BACKGROUND Innovations in devices during the last decade contributed to enhanced diagnosis and treatment of patients with cardiac insufficiency. These tools progressively adapted to minimally invasive strategies with rapid, widespread use. The present article focuses on actual and future directions of device-related diagnosis and treatment of chronic heart failure.
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Affiliation(s)
- Filippe Barcellos Filippini
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Alemão Oswaldo CruzSão PauloSPBrasil Hospital Alemão Oswaldo Cruz , São Paulo , SP – Brasil
| | - Henrique Barbosa Ribeiro
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
| | - Edimar Bocchi
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Fernando Bacal
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Fabiana G. Marcondes-Braga
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Monica S. Avila
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Janine Daiana Sturmer
- Hospital Alemão Oswaldo CruzSão PauloSPBrasil Hospital Alemão Oswaldo Cruz , São Paulo , SP – Brasil
| | - Mauricio Felippi de Sá Marchi
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Gabriel Kanhouche
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Antônio Fernando Freire
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
| | - Renata Cassar
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
| | - Alexandre A. Abizaid
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
| | - Fábio Sândoli de Brito
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
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Kresoja KP, Unterhuber M, Wachter R, Rommel KP, Besler C, Shah S, Thiele H, Edelmann F, Lurz P. Treatment response to spironolactone in patients with heart failure with preserved ejection fraction: a machine learning-based analysis of two randomized controlled trials. EBioMedicine 2023; 96:104795. [PMID: 37689023 PMCID: PMC10498181 DOI: 10.1016/j.ebiom.2023.104795] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 09/11/2023] Open
Abstract
BACKGROUND Whether there is a subset of patients with heart failure with preserved ejection fraction (HFpEF) that benefit from spironolactone therapy is unclear. We applied a machine learning approach to identify responders and non-responders to spironolactone among patients with HFpEF in two large randomized clinical trials. METHODS Using a reiterative cluster allocating permutation approach, patients from the derivation cohort (Aldo-DHF) were identified according to their treatment response to spironolactone with respect to improvement in E/e'. Heterogenous features of response ('responders' and 'non-responders') were characterized by an extreme gradient boosting (XGBoost) algorithm. XGBoost was used to predict treatment response in the validation cohort (TOPCAT). The primary endpoint of the validation cohort was a combined endpoint of cardiovascular mortality, aborted cardiac arrest, or heart failure hospitalization. Patients with missing variables for the XGboost model were excluded from the validation analysis. FINDINGS Out of 422 patients from the derivation cohort, reiterative cluster allocating permutation identified 159 patients (38%) as spironolactone responders, in whom E/e' significantly improved (p = 0.005). Within the validation cohort (n = 525) spironolactone treatment significantly reduced the occurrence of the primary outcome among responders (n = 185, p log rank = 0.008), but not among patients in the non-responder group (n = 340, p log rank = 0.52). INTERPRETATION Machine learning approaches might aid in identifying HFpEF patients who are likely to show a favorable therapeutic response to spironolactone. FUNDING See Acknowledgements section at the end of the manuscript.
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Affiliation(s)
- Karl-Patrik Kresoja
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany; Leipzig Heart Institute at Heart Center Leipzig, Leipzig, Germany
| | - Matthias Unterhuber
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany; Leipzig Heart Institute at Heart Center Leipzig, Leipzig, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig and Clinic for Cardiology and Pneumology, University Medicine Göttingen, Germany; German Cardiovascular Research Center (DZHK), Partner Site Göttingen, Germany
| | - Karl-Philipp Rommel
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany; Leipzig Heart Institute at Heart Center Leipzig, Leipzig, Germany
| | - Christian Besler
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany; Leipzig Heart Institute at Heart Center Leipzig, Leipzig, Germany
| | - Sanjiv Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, USA
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany; Leipzig Heart Institute at Heart Center Leipzig, Leipzig, Germany
| | - Frank Edelmann
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum and German Cardiovascular Research Center (DZHK), Partner Site Berlin, Germany
| | - Philipp Lurz
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany; Leipzig Heart Institute at Heart Center Leipzig, Leipzig, Germany.
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21
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Clephas PRD, Radhoe SP, Boersma E, Gregson J, Jhund PS, Abraham WT, McMurray JJV, de Boer RA, Brugts JJ. Efficacy of pulmonary artery pressure monitoring in patients with chronic heart failure: a meta-analysis of three randomized controlled trials. Eur Heart J 2023; 44:3658-3668. [PMID: 37210750 PMCID: PMC10542655 DOI: 10.1093/eurheartj/ehad346] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 05/23/2023] Open
Abstract
AIMS Adjustment of treatment based on remote monitoring of pulmonary artery (PA) pressure may reduce the risk of hospital admission for heart failure (HF). We have conducted a meta-analysis of large randomized trials investigating this question. METHODS AND RESULTS A systematic literature search was performed for randomized clinical trials with PA pressure monitoring devices in patients with HF. The primary outcome of interest was the total number of HF hospitalizations. Other outcomes assessed were urgent visits leading to treatment with intravenous diuretics, all-cause mortality, and composites. Treatment effects are expressed as hazard ratios, and pooled effect estimates were obtained applying random effects meta-analyses. Three eligible randomized clinical trials were identified that included 1898 outpatients in New York Heart Association functional classes II-IV, either hospitalized for HF in the prior 12 months or with elevated plasma NT-proBNP concentrations. The mean follow-up was 14.7 months, 67.8% of the patients were men, and 65.8% had an ejection fraction ≤40%. Compared to patients in the control group, the hazard ratio (95% confidence interval) for total HF hospitalizations in those randomized to PA pressure monitoring was 0.70 (0.58-0.86) (P = .0005). The corresponding hazard ratio for the composite of total HF hospitalizations, urgent visits and all-cause mortality was 0.75 (0.61-0.91; P = .0037) and for all-cause mortality 0.92 (0.73-1.16). Subgroup analyses, including ejection fraction phenotype, revealed no evidence of heterogeneity in the treatment effect. CONCLUSION The use of remote PA pressure monitoring to guide treatment of patients with HF reduces episodes of worsening HF and subsequent hospitalizations.
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Affiliation(s)
- Pascal R D Clephas
- Department of Cardiology, Erasmus MC University Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Sumant P Radhoe
- Department of Cardiology, Erasmus MC University Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus MC University Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, 410 W 10th Ave, Columbus, OH 43210, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Rudolf A de Boer
- Department of Cardiology, Erasmus MC University Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Erasmus MC University Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
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Bachmann JC, Kirchhoff JE, Napolitano JE, Sorota S, Gordon WM, Feric N, Aschar‐Sobbi R, Lv J, Cao Z, Coppieters K, Borghetti G, Nyberg M. C-type natriuretic peptide induces inotropic and lusitropic effects in human 3D-engineered cardiac tissue: Implications for the regulation of cardiac function in humans. Exp Physiol 2023; 108:1172-1188. [PMID: 37493451 PMCID: PMC10988518 DOI: 10.1113/ep091303] [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: 05/17/2023] [Accepted: 07/06/2023] [Indexed: 07/27/2023]
Abstract
The role of C-type natriuretic peptide (CNP) in the regulation of cardiac function in humans remains to be established as previous investigations have been confined to animal model systems. Here, we used well-characterized engineered cardiac tissues (ECTs) generated from human stem cell-derived cardiomyocytes and fibroblasts to study the acute effects of CNP on contractility. Application of CNP elicited a positive inotropic response as evidenced by increases in maximum twitch amplitude, maximum contraction slope and maximum calcium amplitude. This inotropic response was accompanied by a positive lusitropic response as demonstrated by reductions in time from peak contraction to 90% of relaxation and time from peak calcium transient to 90% of decay that paralleled increases in maximum contraction decay slope and maximum calcium decay slope. To establish translatability, CNP-induced changes in contractility were also assessed in rat ex vivo (isolated heart) and in vivo models. Here, the effects on force kinetics observed in ECTs mirrored those observed in both the ex vivo and in vivo model systems, whereas the increase in maximal force generation with CNP application was only detected in ECTs. In conclusion, CNP induces a positive inotropic and lusitropic response in ECTs, thus supporting an important role for CNP in the regulation of human cardiac function. The high degree of translatability between ECTs, ex vivo and in vivo models further supports a regulatory role for CNP and expands the current understanding of the translational value of human ECTs. NEW FINDINGS: What is the central question of this study? What are the acute responses to C-type natriuretic peptide (CNP) in human-engineered cardiac tissues (ECTs) on cardiac function and how well do they translate to matched concentrations in animal ex vivo and in vivo models? What is the main finding and its importance? Acute stimulation of ECTs with CNP induced positive lusitropic and inotropic effects on cardiac contractility, which closely reflected the changes observed in rat ex vivo and in vivo cardiac models. These findings support an important role for CNP in the regulation of human cardiac function and highlight the translational value of ECTs.
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Affiliation(s)
| | | | | | | | | | | | | | - Juan Lv
- Research & Early DevelopmentNovo Nordisk A/SMaaloevDenmark
| | - Zhiyou Cao
- Research & Early DevelopmentNovo Nordisk A/SMaaloevDenmark
| | - Ken Coppieters
- Research & Early DevelopmentNovo Nordisk A/SMaaloevDenmark
| | | | - Michael Nyberg
- Research & Early DevelopmentNovo Nordisk A/SMaaloevDenmark
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23
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Kerwagen F, Koehler K, Vettorazzi E, Stangl V, Koehler M, Halle M, Koehler F, Störk S. Remote patient management of heart failure across the ejection fraction spectrum: A pre-specified analysis of the TIM-HF2 trial. Eur J Heart Fail 2023; 25:1671-1681. [PMID: 37368507 DOI: 10.1002/ejhf.2948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/27/2023] [Accepted: 06/20/2023] [Indexed: 06/29/2023] Open
Abstract
AIMS The benefit of non-invasive remote patient management (RPM) for patients with heart failure (HF) has been demonstrated. We evaluated the effect of left ventricular ejection fraction (LVEF) on treatment outcomes in the TIM-HF2 (Telemedical Interventional Management in Heart Failure II; NCT01878630) randomized trial. METHODS AND RESULTS TIM-HF2 was a prospective, randomized, multicentre trial investigating the effect of a structured RPM intervention versus usual care in patients who had been hospitalized for HF within 12 months before randomization. The primary endpoint was the percentage of days lost due to all-cause death or unplanned cardiovascular hospitalization. Key secondary endpoints were all-cause and cardiovascular mortality. Outcomes were assessed by LVEF in guideline-defined subgroups of ≤40% (HF with reduced EF [HFrEF]), 41-49% (HF with mildly reduced EF [HFmrEF]), and ≥50% (HF with preserved EF [HFpEF]). Out of 1538 participants, 818 (53%) had HFrEF, 224 (15%) had HFmrEF, and 496 (32%) had HFpEF. Within each LVEF subgroup, the primary endpoint was lower in the treatment group, i.e. the incidence rate ratio [IRR] remained below 1.0. Comparing intervention and control group, the percentage of days lost was 5.4% versus 7.6% for HFrEF (IRR 0.72, 95% confidence interval [CI] 0.54-0.97), 3.3% versus 5.9% for HFmrEF (IRR 0.85, 95% CI 0.48-1.50) and 4.7% versus 5.4% for HFpEF (IRR 0.93, 95% CI 0.64-1.36). No interaction between LVEF and the randomized group became apparent. All-cause and cardiovascular mortality were also reduced by RPM in each subgroup with hazard ratios <1.0 across the LVEF spectrum for both endpoints. CONCLUSION In the clinical set-up deployed in the TIM-HF2 trial, RPM appeared effective irrespective of the LVEF-based HF phenotype.
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Affiliation(s)
- Fabian Kerwagen
- Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
- Department of Medicine I, Cardiology, University Hospital Würzburg, Würzburg, Germany
| | - Kerstin Koehler
- Centre for Cardiovascular Telemedicine, Campus Charité Mitte, German Heart Center Charité, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Eik Vettorazzi
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Verena Stangl
- German Center for Cardiovascular Research (DZHK), Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care, Campus Charité Mitte, German Heart Center Charité, Berlin, Germany
| | - Magdalena Koehler
- Ludwig-Maximilians Universität München, Munich, Germany
- Department of Preventive Sports Medicine and Sports Cardiology, University Hospital 'Klinikum rechts der Isar', School of Medicine, Technical University Munich, Munich, Germany
| | - Martin Halle
- Department of Preventive Sports Medicine and Sports Cardiology, University Hospital 'Klinikum rechts der Isar', School of Medicine, Technical University Munich, Munich, Germany
| | - Friedrich Koehler
- Centre for Cardiovascular Telemedicine, Campus Charité Mitte, German Heart Center Charité, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Stefan Störk
- Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
- Department of Medicine I, Cardiology, University Hospital Würzburg, Würzburg, Germany
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24
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Quennelle S, Bonnet D. Pediatric heart failure with preserved ejection fraction, a review. Front Pediatr 2023; 11:1137853. [PMID: 37601131 PMCID: PMC10433757 DOI: 10.3389/fped.2023.1137853] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 07/05/2023] [Indexed: 08/22/2023] Open
Abstract
Diastolic dysfunction refers to a structural or functional abnormality of the left ventricle, resulting in impaired filling of the heart. Severe diastolic dysfunction can lead to congestive heart failure even when the left ventricle systolic function is normal. Heart failure with preserved ejection fraction (HFpEF) accounts for nearly half of the hospitalizations for acute heart failure in the adult population but the clinical recognition and understanding of HFpEF in children is poor. The condition is certainly much less frequent than in the adult population but the confirmatory diagnosis of diastolic dysfunction in children is also challenging. The underlying causes of HFpEF in children are diverse and differ from the main cause in adults. This review addresses the underlying causes and prognostic factors of HFpEF in children. We describe the pulmonary hypertension profiles associated with this cardiac condition. We discuss diagnosis difficulties in clinical practice, and we provide a simplified diagnostic algorithm for HFpEF in children.
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Affiliation(s)
- Sophie Quennelle
- Pediatric Cardiology Department, Necker-Enfants Malades Hospital, Paris, France
- Equipe Projet HeKA, Paris, France
- Université Paris Cité, Paris, France
| | - Damien Bonnet
- Pediatric Cardiology Department, Necker-Enfants Malades Hospital, Paris, France
- Université Paris Cité, Paris, France
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25
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Iaconelli A, Pellicori P, Caiazzo E, Rezig AOM, Bruzzese D, Maffia P, Cleland JGF. Implanted haemodynamic telemonitoring devices to guide management of heart failure: a review and meta-analysis of randomised trials. Clin Res Cardiol 2023; 112:1007-1019. [PMID: 36241896 PMCID: PMC9568893 DOI: 10.1007/s00392-022-02104-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/06/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIMS Congestion is a key driver of morbidity and mortality in heart failure. Implanted haemodynamic monitoring devices might allow early identification and management of congestion. Here, we provide a state-of-the-art review of implanted haemodynamic monitoring devices for patients with heart failure, including a meta-analysis of randomised trials. METHODS AND RESULTS We did a systematic search for pre-print and published trials in Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) on the 22nd of September 2021. We included randomised trials that compared management with or without information from implanted haemodynamic monitoring devices for patients with heart failure. Outcomes selected were hospitalisation for heart failure and all-cause mortality. Changes in treatment associated with haemodynamic monitoring resulted in only a small reduction in mean pulmonary artery pressure (typically < 1 mmHg as a daily average), which generally remained much greater than 20 mmHg. Haemodynamic monitoring reduced hospitalisations for heart failure (HR 0.75; 95% CI 0.58-0.96; p = 0.03) but not mortality (RR 0.92; 95% CI 0.68-1.26; p = 0.48). CONCLUSIONS Haemodynamic monitoring for patients with heart failure may reduce the risk of hospitalization for heart failure but this has not yet translated into a reduction in mortality, perhaps because the duration of trials was too short or the reduction in pulmonary artery pressure was not sufficiently large. The efficacy and safety of aiming for larger reductions in pulmonary artery pressure should be explored. After selecting key words, a systematic review for implanted haemodynamic telemonitoring devices was performed in different dataset and 4 randomised clinical trials were identified and included in this meta-analysis. Three different devices (Chronicle, Chronicle/ICD and CardioMEMS) were tested. All-cause mortality and total heart failure hospitalisations were selected as outcomes. No reduction in all-cause mortality rate was reported but a potential benefit on total heart failure hospitalisation was identified.
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Affiliation(s)
- Antonio Iaconelli
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK.
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy.
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Elisabetta Caiazzo
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Asma O M Rezig
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Dario Bruzzese
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Pasquale Maffia
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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26
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Borlaug BA, Sharma K, Shah SJ, Ho JE. Heart Failure With Preserved Ejection Fraction: JACC Scientific Statement. J Am Coll Cardiol 2023; 81:1810-1834. [PMID: 37137592 DOI: 10.1016/j.jacc.2023.01.049] [Citation(s) in RCA: 70] [Impact Index Per Article: 70.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 05/05/2023]
Abstract
The incidence and prevalence of heart failure with preserved ejection fraction (HFpEF) continue to rise in tandem with the increasing age and burdens of obesity, sedentariness, and cardiometabolic disorders. Despite recent advances in the understanding of its pathophysiological effects on the heart, lungs, and extracardiac tissues, and introduction of new, easily implemented approaches to diagnosis, HFpEF remains under-recognized in everyday practice. This under-recognition presents an even greater concern given the recent identification of highly effective pharmacologic-based and lifestyle-based treatments that can improve clinical status and reduce morbidity and mortality. HFpEF is a heterogenous syndrome and recent studies have suggested an important role for careful, pathophysiological-based phenotyping to improve patient characterization and to better individualize treatment. In this JACC Scientific Statement, we provide an in-depth and updated examination of the epidemiology, pathophysiology, diagnosis, and treatment of HFpEF.
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Affiliation(s)
- Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Kavita Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jennifer E Ho
- CardioVascular Institute and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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27
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Kittleson MM, Panjrath GS, Amancherla K, Davis LL, Deswal A, Dixon DL, Januzzi JL, Yancy CW. 2023 ACC Expert Consensus Decision Pathway on Management of Heart Failure With Preserved Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2023; 81:1835-1878. [PMID: 37137593 DOI: 10.1016/j.jacc.2023.03.393] [Citation(s) in RCA: 71] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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28
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Gill J. Implantable Cardiovascular Devices: Current and Emerging Technologies for Remote Heart Failure Monitoring. Cardiol Rev 2023; 31:128-138. [PMID: 35349243 DOI: 10.1097/crd.0000000000000432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Heart failure remains a substantial socioeconomic burden to our health care system. With the aging of the population, the incidence is expected to rise in the ensuing years. Standard heart failure management strategies have failed to reduce hospitalizations and mortality. In patients with heart failure, remote hemodynamic monitoring with implantable devices provides essential data, which can be used in unison with standard patient management to reduce heart failure hospitalizations. This review will chronicle the important clinical trials of various implantable devices and describe the emerging technologies in remote heart failure management. Cardiovascular implantable electronic devices, namely implanted cardioverter-defibrillator and cardiac resynchronization therapy devices with defibrillator, have evolved beyond sole resynchronization and currently can deliver real-time cardiac hemodynamics. Clinical data regarding hemodynamic monitoring with implanted cardioverter-defibrillator and cardiac resynchronization therapy devices with defibrillator have not consistently demonstrated a reduction in heart failure or mortality benefit. However, there is promise in the future with the application of multiparameter diagnostic algorithms with these devices. The most efficacious implantable device has been the pulmonary artery pressure sensor, CardioMEMS. This device has been proven to be safe and shown to reduce heart failure hospitalizations. Moreover, multiple newly developed devices are currently under investigation after successful first-in-man studies.
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Affiliation(s)
- Jashan Gill
- From the Department of Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL
- Department of Medicine, Northwestern McHenry Hospital, McHenry, IL
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29
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Tran H, Shapiro H. Preventing Readmissions by Preventing the First Admission. JACC. HEART FAILURE 2023:S2213-1779(23)00178-6. [PMID: 37178082 DOI: 10.1016/j.jchf.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Hao Tran
- Division of Cardiology, Department of Medicine, University of California-San Diego, La Jolla, California, USA.
| | - Hilary Shapiro
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
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30
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Desai AS, Lam CSP, McMurray JJV, Redfield MM. How to Manage Heart Failure With Preserved Ejection Fraction: Practical Guidance for Clinicians. JACC. HEART FAILURE 2023:S2213-1779(23)00142-7. [PMID: 37140514 DOI: 10.1016/j.jchf.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/15/2023] [Accepted: 03/07/2023] [Indexed: 05/05/2023]
Abstract
Although patients with heart failure with preserved ejection fraction (HFpEF) (left ventricular ejection fraction ≥50%) comprise nearly half of those with chronic heart failure, evidence-based treatment options for this population have historically been limited. Recently, however, emerging data from prospective, randomized trials enrolling patients with HFpEF have greatly altered the range of pharmacologic options to modify disease progression in selected patients with HFpEF. In the context of this evolving landscape, clinicians are increasingly in need of practical guidance regarding the best approach to management of this growing population. In this review, we build on the recently published heart failure guidelines by integrating contemporary data from recent randomized trials to provide a contemporary framework for diagnosis and evidence-based treatment of patients with HFpEF. Where gaps in knowledge persist, we provide "best available" data from post hoc analyses of clinical trials or data from observational studies to guide management until more definitive studies are available.
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Affiliation(s)
- Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Carolyn S P Lam
- National Heart Centre, Singapore; Duke-National University of Singapore, Singapore
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Margaret M Redfield
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA
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31
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Sachdev V, Sharma K, Keteyian SJ, Alcain CF, Desvigne-Nickens P, Fleg JL, Florea VG, Franklin BA, Guglin M, Halle M, Leifer ES, Panjrath G, Tinsley EA, Wong RP, Kitzman DW. Supervised Exercise Training for Chronic Heart Failure With Preserved Ejection Fraction: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2023; 81:1524-1542. [PMID: 36958952 DOI: 10.1016/j.jacc.2023.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is one of the most common forms of heart failure; its prevalence is increasing, and outcomes are worsening. Affected patients often experience severe exertional dyspnea and debilitating fatigue, as well as poor quality of life, frequent hospitalizations, and a high mortality rate. Until recently, most pharmacological intervention trials for HFpEF yielded neutral primary outcomes. In contrast, trials of exercise-based interventions have consistently demonstrated large, significant, clinically meaningful improvements in symptoms, objectively determined exercise capacity, and usually quality of life. This success may be attributed, at least in part, to the pleiotropic effects of exercise, which may favorably affect the full range of abnormalities-peripheral vascular, skeletal muscle, and cardiovascular-that contribute to exercise intolerance in HFpEF. Accordingly, this scientific statement critically examines the currently available literature on the effects of exercise-based therapies for chronic stable HFpEF, potential mechanisms for improvement of exercise capacity and symptoms, and how these data compare with exercise therapy for other cardiovascular conditions. Specifically, data reviewed herein demonstrate a comparable or larger magnitude of improvement in exercise capacity from supervised exercise training in patients with chronic HFpEF compared with those with heart failure with reduced ejection fraction, although Medicare reimbursement is available only for the latter group. Finally, critical gaps in implementation of exercise-based therapies for patients with HFpEF, including exercise setting, training modalities, combinations with other strategies such as diet and medications, long-term adherence, incorporation of innovative and more accessible delivery methods, and management of recently hospitalized patients are highlighted to provide guidance for future research.
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Abstract
IMPORTANCE Heart failure with preserved ejection fraction (HFpEF), defined as HF with an EF of 50% or higher at diagnosis, affects approximately 3 million people in the US and up to 32 million people worldwide. Patients with HFpEF are hospitalized approximately 1.4 times per year and have an annual mortality rate of approximately 15%. OBSERVATIONS Risk factors for HFpEF include older age, hypertension, diabetes, dyslipidemia, and obesity. Approximately 65% of patients with HFpEF present with dyspnea and physical examination, chest radiographic, echocardiographic, or invasive hemodynamic evidence of HF with overt congestion (volume overload) at rest. Approximately 35% of patients with HFpEF present with "unexplained" dyspnea on exertion, meaning they do not have clear physical, radiographic, or echocardiographic signs of HF. These patients have elevated atrial pressures with exercise as measured with invasive hemodynamic stress testing or estimated with Doppler echocardiography stress testing. In unselected patients presenting with unexplained dyspnea, the H2FPEF score incorporating clinical (age, hypertension, obesity, atrial fibrillation status) and resting Doppler echocardiographic (estimated pulmonary artery systolic pressure or left atrial pressure) variables can assist with diagnosis (H2FPEF score range, 0-9; score >5 indicates more than 95% probability of HFpEF). Specific causes of the clinical syndrome of HF with normal EF other than HFpEF should be identified and treated, such as valvular, infiltrative, or pericardial disease. First-line pharmacologic therapy consists of sodium-glucose cotransporter type 2 inhibitors, such as dapagliflozin or empagliflozin, which reduced HF hospitalization or cardiovascular death by approximately 20% compared with placebo in randomized clinical trials. Compared with usual care, exercise training and diet-induced weight loss produced clinically meaningful increases in functional capacity and quality of life in randomized clinical trials. Diuretics (typically loop diuretics, such as furosemide or torsemide) should be prescribed to patients with overt congestion to improve symptoms. Education in HF self-care (eg, adherence to medications and dietary restrictions, monitoring of symptoms and vital signs) can help avoid HF decompensation. CONCLUSIONS AND RELEVANCE Approximately 3 million people in the US have HFpEF. First-line therapy consists of sodium-glucose cotransporter type 2 inhibitors, exercise, HF self-care, loop diuretics as needed to maintain euvolemia, and weight loss for patients with obesity and HFpEF.
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Affiliation(s)
- Margaret M Redfield
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota
| | - Barry A Borlaug
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota
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33
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Saito Y, Obokata M, Harada T, Kagami K, Sorimachi H, Yuasa N, Kato T, Wada N, Okumura Y, Ishii H. Disproportionate exercise-induced pulmonary hypertension in relation to cardiac output in heart failure with preserved ejection fraction: a non-invasive echocardiographic study. Eur J Heart Fail 2023. [PMID: 36915276 DOI: 10.1002/ejhf.2821] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 01/22/2023] [Accepted: 02/26/2023] [Indexed: 03/16/2023] Open
Abstract
AIMS Pulmonary hypertension (PH) and pulmonary vascular remodelling are common in patients with heart failure with preserved ejection fraction (HFpEF). Many patients with HFpEF demonstrate an abnormal pulmonary haemodynamic response to exercise that is not identifiable at rest. This can be estimated non-invasively by the mean pulmonary artery pressure-cardiac output relationship (mPAP/CO slope). We sought to characterize the pathophysiology of disproportionate exercise-induced PH in relation to CO (DEi-PH) and its prognostic impact in patients with HFpEF. METHODS AND RESULTS A total of 345 patients (166 HFpEF and 179 controls) underwent ergometry exercise stress echocardiography with simultaneous expired gas analysis. DEi-PH was defined as the mPAP/CO slope >5.2 mmHg/L/min (median value). At rest, there were no differences in right ventricular (RV) function and severity of PH between HFpEF patients with and without DEi-PH. Compared with controls (n = 179) and HFpEF without DEi-PH (n = 83), HFpEF with DEi-PH (n = 83) demonstrated worse exercise capacity (lower peak oxygen consumption), depressed RV systolic function, impaired RV-pulmonary artery coupling, limitation in CO augmentation, more right-sided congestion, and worse ventilatory efficiency (higher minute ventilation vs. carbon dioxide volume) during peak exercise. Kaplan-Meier analyses showed that HFpEF patients with DEi-PH had higher rates of composite outcomes of all-cause mortality or heart failure events than those without (log-rank p = 0.0002). CONCLUSION Patients with HFpEF and DEi-PH demonstrated distinct pathophysiologic features that become apparent only during exercise. These data suggest that DEi-PH is a pathophysiologic phenotype of HFpEF and reinforce the importance of exercise stress echocardiography for detailed characterization of HFpEF.
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Affiliation(s)
- Yuki Saito
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan.,Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Kazuki Kagami
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan.,Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Naoki Yuasa
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Naoki Wada
- Department of Rehabilitation Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
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Feasibility of tele-guided patient-administered lung ultrasound in heart failure. Ultrasound J 2023; 15:8. [PMID: 36757582 PMCID: PMC9911571 DOI: 10.1186/s13089-023-00305-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/02/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Readmission rates for heart failure remain high, and affordable technology for early detection of heart failure decompensation in the home environment is needed. Lung ultrasound has been shown to be a sensitive tool to detect pulmonary congestion due to heart failure, and monitoring patients in their home environment with lung ultrasound could help to prevent hospital admissions. The aim of this project was to investigate whether patient-performed tele-guided ultrasound in the home environment using an ultraportable device is feasible.Affiliations: Journal instruction requires a country for affiliations; however, these are missing in affiliations [1, 2]. Please verify if the provided country are correct and amend if necessary.Correct METHODS: Stable ambulatory patients with heart failure received a handheld ultrasound probe connected to a smart phone or tablet. Instructions for setup were given in person during a clinic visit or over the phone. During each ultrasound session, patients obtained six ultrasound clips from the anterior and lateral chest with verbal and visual tele-guidance from an ultrasound trained clinician. Patients also reported their weight and degree of dyspnea, graded on a 5-point scale. Two independent reviewers graded the ultrasound clips based on the visibility of the pleural line and A or B lines. RESULTS Eight stable heart failure patients each performed 10-12 lung ultrasound examinations at home under remote guidance within a 1-month period. There were no major technical difficulties. A total of 89 ultrasound sessions resulted in 534 clips of which 88% (reviewer 1) and 84% (reviewer 2) were interpretable. 91% of ultrasound sessions produced interpretable clips bilaterally from the lateral chest area, which is most sensitive for the detection of pulmonary congestion. The average time to complete an ultrasound session was 5 min with even shorter recording times for the last session. All patients were clinically stable during the study period and no false positive B-lines were observed. CONCLUSIONS In this feasibility study, patients were able to produce interpretable lung ultrasound exams in more than 90% of remotely supervised sessions in their home environment. Larger studies are needed to determine whether remotely guided lung ultrasound could be useful to detect heart failure decompensation early in the home environment.
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Costanzo MR. Prevention Supersedes Prediction of Worsening Heart Failure. JACC. HEART FAILURE 2023; 11:157-160. [PMID: 36754526 DOI: 10.1016/j.jchf.2022.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/17/2022] [Indexed: 02/09/2023]
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Elkammash A, Tam SSC, Yogarajah G, You J. Management of Heart Failure With Preserved Ejection Fraction in Elderly Patients: Effectiveness and Safety. Cureus 2023; 15:e35030. [PMID: 36938226 PMCID: PMC10023169 DOI: 10.7759/cureus.35030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/17/2023] Open
Abstract
The proportion of the elderly population continues to increase due to the global increase in longevity. Heart failure with preserved ejection fraction (HFpEF) is common in the elderly due to cellular aging, myocardial stiffness, and multiple comorbidities. This age group is often under-represented in clinical trials. In this narrative review, we looked into the latest evidence-based lines of management of HFpEF in this vulnerable cohort. In this narrative review, we brought the latest evidence on the treatment of HFpEf in the elderly. We searched the largest three scientific databases (Pubmed, Google Scholar, and EMBASE) using the search words (elderly, HFpEF, heart failure with preserved ejection fraction, guidelines, treatment, and management) in different combinations. To date, screening for and treatment of the causes of HFpEF (such as hypertension, coronary artery disease [CAD], valvular heart disease, and cardiac amyloidosis) and associated comorbidities (such as diabetes mellitus [DM], iron deficiency, obesity, and thyroid dysfunction) are the main line of management of HFpEF. A multidisciplinary team, including an HF specialist cardiologist, an HF nurse, a geriatrician, a dietician, a psychologist, a physiotherapist, and an occupational therapist, should manage HFpEF elderly patients. Other specialist input may be needed according to the patient's requirements. The evidence on the effective management of HFpEF in the elderly age group is scarce and controversial. Some studied non-pharmacological approaches include supervised exercise training, pulmonary artery pressure monitoring, and the interatrial shunt device (an emerging modality that includes a small percutaneously inserted interatrial left to right valve aiming to reduce the left atrial and pulmonary wedge pressures). These modalities can only improve the symptoms and HF hospitalizations without robustly impacting cardiovascular (CV) death. Among the pharmacological approaches to treat HFpEF, only the sodium-glucose cotransporter 2 (SGLT-2) inhibitors proved efficacy in reducing the hard outcomes of CV death, HF hospitalizations, and urgent visits for HF when used in elderly HFpEF patients, irrespective of the presence of diabetes mellitus. Diuretics are only beneficial to alleviate the symptoms of fluid overload, with a risk of renal impairment in volume-depleted patients. The evidence on the effectiveness of other HF-specific disease-modifying agents in elderly HFpEF patients is controversial. Elderly patients have a higher risk of having side effects from HF medications due to the higher prevalence of polypharmacy, cognitive decline, and impairment of kidney and liver functions. Therefore, cautious initiation of HF treatment with a close follow-up of the blood pressure, liver functions, kidney functions, and electrolytes are of utmost importance.
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Affiliation(s)
- Amr Elkammash
- Department of Cardiology, The Royal Papworth Hospital NHS Foundation Trust, Cambridge, GBR
| | | | | | - Jianing You
- School of Clinical Medicine, University of Cambridge, Cambridge, GBR
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Sarma S, MacNamara JP, Balmain BN, Hearon CM, Wakeham DJ, Tomlinson AR, Hynan LS, Babb TG, Levine BD. Challenging the Hemodynamic Hypothesis in Heart Failure With Preserved Ejection Fraction: Is Exercise Capacity Limited by Elevated Pulmonary Capillary Wedge Pressure? Circulation 2023; 147:378-387. [PMID: 36524474 PMCID: PMC9892242 DOI: 10.1161/circulationaha.122.061828] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/31/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Exercise intolerance is a defining characteristic of heart failure with preserved ejection fraction (HFpEF). A marked rise in pulmonary capillary wedge pressure (PCWP) during exertion is pathognomonic for HFpEF and is thought to be a key cause of exercise intolerance. If true, acutely lowering PCWP should improve exercise capacity. To test this hypothesis, we evaluated peak exercise capacity with and without nitroglycerin to acutely lower PCWP during exercise in patients with HFpEF. METHODS Thirty patients with HFpEF (70±6 years of age; 63% female) underwent 2 bouts of upright, seated cycle exercise dosed with sublingual nitroglycerin or placebo control every 15 minutes in a single-blind, randomized, crossover design. PCWP (right heart catheterization), oxygen uptake (breath × breath gas exchange), and cardiac output (direct Fick) were assessed at rest, 20 Watts (W), and peak exercise during both placebo and nitroglycerin conditions. RESULTS PCWP increased from 8±4 to 35±9 mm Hg from rest to peak exercise with placebo. With nitroglycerin, there was a graded decrease in PCWP compared with placebo at rest (-1±2 mm Hg), 20W (-5±5 mm Hg), and peak exercise (-7±6 mm Hg; drug × exercise stage P=0.004). Nitroglycerin did not affect oxygen uptake at rest, 20W, or peak (placebo, 1.34±0.48 versus nitroglycerin, 1.32±0.46 L/min; drug × exercise P=0.984). Compared with placebo, nitroglycerin lowered stroke volume at rest (-8±13 mL) and 20W (-7±11 mL), but not peak exercise (0±10 mL). CONCLUSIONS Sublingual nitroglycerin lowered PCWP during submaximal and maximal exercise. Despite reduction in PCWP, peak oxygen uptake was not changed. These results suggest that acute reductions in PCWP are insufficient to improve exercise capacity, and further argue that high PCWP during exercise is not by itself a limiting factor for exercise performance in patients with HFpEF. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04068844.
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Affiliation(s)
- Satyam Sarma
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
| | - James P MacNamara
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
| | - Bryce N Balmain
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
| | - Christopher M Hearon
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
| | - Denis J Wakeham
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
| | - Andrew R Tomlinson
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
| | - Linda S Hynan
- Peter O'Donnell Jr School of Public Health and Department of Psychiatry (L.S.H.)
| | - Tony G Babb
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., J.P.M., B.N.B., C.M.H., D.J.W., A.R.T., T.G.B., B.D.L.)
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Clephas PRD, Aydin D, Radhoe SP, Brugts JJ. Recent Advances in Remote Pulmonary Artery Pressure Monitoring for Patients with Chronic Heart Failure: Current Evidence and Future Perspectives. SENSORS (BASEL, SWITZERLAND) 2023; 23:s23031364. [PMID: 36772403 PMCID: PMC9921931 DOI: 10.3390/s23031364] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 05/27/2023]
Abstract
Chronic heart failure (HF) is associated with high hospital admission rates and has an enormous burden on hospital resources worldwide. Ideally, detection of worsening HF in an early phase would allow physicians to intervene timely and proactively in order to prevent HF-related hospitalizations, a concept better known as remote hemodynamic monitoring. After years of research, remote monitoring of pulmonary artery pressures (PAP) has emerged as the most successful technique for ambulatory hemodynamic monitoring in HF patients to date. Currently, the CardioMEMS and Cordella HF systems have been tested for pulmonary artery pressure monitoring and the body of evidence has been growing rapidly over the past years. However, several ongoing studies are aiming to fill the gap in evidence that is still very clinically relevant, especially for the European setting. In this comprehensive review, we provide an overview of all available evidence for PAP monitoring as well as a detailed discussion of currently ongoing studies and future perspectives for this promising technique that is likely to impact HF care worldwide.
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Riccardi M, Tomasoni D, Vizzardi E, Metra M, Adamo M. Device-based percutaneous treatments to decompress the left atrium in heart failure with preserved ejection fraction. Heart Fail Rev 2023; 28:315-330. [PMID: 36402928 PMCID: PMC9941240 DOI: 10.1007/s10741-022-10280-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/21/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) accounts for more than half of heart failure hospital admissions in the last years and is burdened by high mortality and poor quality of life. Providing effective management for HFpEF patients is a major unmet clinical need. Increase in left atrial pressure is the key determinant of pulmonary congestion, with consequent dyspnoea and exercise limitation. Evidence on benefits of medical treatment in HFpEF patients is limited. Thus, alternative strategies, including devices able to reduce left atrial pressure, through an interatrial communication determining a left-right shunt, were developed. This review aims to summarize evidence regarding the use of percutaneous interatrial shunting devices. These devices are safe and effective in improving hemodynamic and clinical parameters, including pulmonary capillary wedge pressure, 6-min walking distance, and New York Heart Association functional class. Data on cardiovascular mortality and re-hospitalization for heart failure are still scarce.
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Affiliation(s)
- Mauro Riccardi
- Department of Medical and Surgical Specialties, Radiological Sciences, ASST Spedali Civili Di Brescia, and Public Health University of Brescia, CardiologyBrescia, Italy
| | - Daniela Tomasoni
- Department of Medical and Surgical Specialties, Radiological Sciences, ASST Spedali Civili Di Brescia, and Public Health University of Brescia, CardiologyBrescia, Italy
| | - Enrico Vizzardi
- Department of Medical and Surgical Specialties, Radiological Sciences, ASST Spedali Civili Di Brescia, and Public Health University of Brescia, CardiologyBrescia, Italy
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences, ASST Spedali Civili Di Brescia, and Public Health University of Brescia, CardiologyBrescia, Italy.
| | - Marianna Adamo
- Department of Medical and Surgical Specialties, Radiological Sciences, ASST Spedali Civili Di Brescia, and Public Health University of Brescia, CardiologyBrescia, Italy
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40
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Curtain JP, Lee MMY, McMurray JJ, Gardner RS, Petrie MC, Jhund PS. Efficacy of implantable haemodynamic monitoring in heart failure across ranges of ejection fraction: a systematic review and meta-analysis. Heart 2022; 109:823-831. [PMID: 36522146 DOI: 10.1136/heartjnl-2022-321885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
AimsWe conducted a meta-analysis of randomised controlled trials (RCTs) of implantable haemodynamic monitoring (IHM)-guided care.MethodsPubMed and Ovid MEDLINE were searched for RCTs of IHM in patients with heart failure (HF). Outcomes were examined in total (first and recurrent) event analyses.ResultsFive trials comparing IHM-guided care with standard care alone were identified and included 2710 patients across ejection fraction (EF) ranges. Data were available for 628 patients (23.2%) with heart failure with preserved ejection fraction (HFpEF) (EF ≥50%) and 2023 patients (74.6%) with heart failure with a reduced ejection fraction (HFrEF) (EF <50%). Chronicle, CardioMEMS and HeartPOD IHMs were used. In all patients, regardless of EF, IHM-guided care reduced total HF hospitalisations (HR 0.74, 95% CI 0.66 to 0.82) and total worsening HF events (HR 0.74, 95% CI 0.66 to 0.84). In patients with HFrEF, IHM-guided care reduced total worsening HF events (HR 0.75, 95% CI 0.66 to 0.86). The effect of IHM-guided care on total worsening HF events in patients with HFpEF was uncertain (fixed-effect model: HR 0.72, 95% CI 0.59 to 0.88; random-effects model: HR 0.60, 95% CI 0.32 to 1.14). IHM-guided care did not reduce mortality (HR 0.92, 95% CI 0.71 to 1.20). IHM-guided care reduced all-cause mortality and total worsening HF events (HR 0.80, 95% CI 0.72 to 0.88).ConclusionsIn patients with HF across all EFs, IHM-guided care reduced total HF hospitalisations and worsening HF events. This benefit was consistent in patients with HFrEF but not consistent in HFpEF. Further trials with pre-specified analyses of patients with an EF of ≥50% are required.PROSPERO registration numberCRD42021253905.
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Affiliation(s)
- James P Curtain
- BHF Cardiovascular Research Centre, University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Matthew M Y Lee
- BHF Cardiovascular Research Centre, University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - John Jv McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Roy S Gardner
- BHF Cardiovascular Research Centre, University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
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Zito A, Princi G, Romiti GF, Galli M, Basili S, Liuzzo G, Sanna T, Restivo A, Ciliberti G, Trani C, Burzotta F, Cesario A, Savarese G, Crea F, D'Amario D. Device-based remote monitoring strategies for congestion-guided management of patients with heart failure: a systematic review and meta-analysis. Eur J Heart Fail 2022; 24:2333-2341. [PMID: 36054801 PMCID: PMC10086988 DOI: 10.1002/ejhf.2655] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 08/02/2022] [Accepted: 08/13/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Pre-clinical congestion markers of worsening heart failure (HF) can be monitored by devices and may support the management of patients with HF. We aimed to assess whether congestion-guided HF management according to device-based remote monitoring strategies is more effective than standard therapy. METHODS AND RESULTS A comprehensive literature research for randomized controlled trials (RCTs) comparing device-based remote monitoring strategies for congestion-guided HF management versus standard therapy was performed on PubMed, Embase, and CENTRAL databases. Incidence rate ratios (IRRs) and associated 95% confidence intervals (CIs) were calculated using the Poisson regression model with random study effects. The primary outcome was a composite of all-cause death and HF hospitalizations. Secondary endpoints included the individual components of the primary outcome. A total of 4347 patients from eight RCTs were included. Findings varied according to the type of parameters monitored. Compared with standard therapy, haemodynamic-guided strategy (4 trials, 2224 patients, 12-month follow-up) reduced the risk of the primary composite outcome (IRR 0.79, 95% CI 0.70-0.89) and HF hospitalizations (IRR 0.76, 95% CI 0.67-0.86), without a significant impact on all-cause death (IRR 0.93, 95% CI 0.72-1.21). In contrast, impedance-guided strategy (4 trials, 2123 patients, 19-month follow-up) did not provide significant benefits. CONCLUSION Haemodynamic-guided HF management is associated with better clinical outcomes as compared to standard clinical care.
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Affiliation(s)
- Andrea Zito
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Princi
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giulio Francesco Romiti
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Stefania Basili
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Giovanna Liuzzo
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Sanna
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Attilio Restivo
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Ciliberti
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Carlo Trani
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alfredo Cesario
- Open Innovation Unit, Scientific Directorate, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Innovation Sprint Sprl, Brussels, Belgium
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico D'Amario
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Ambulatory pulmonary artery pressure monitoring reduces costs and improves outcomes in symptomatic heart failure: a single center Canadian experience. CJC Open 2022; 5:237-249. [PMID: 37013072 PMCID: PMC10066443 DOI: 10.1016/j.cjco.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/20/2022] [Indexed: 12/27/2022] Open
Abstract
Background Pulmonary artery pressure (PAP) monitoring reduces heart failure (HF) hospitalizations (HFHs) and improves quality of life in New York Heart Association (NYHA) class III HF. We evaluated the impact of PAP monitoring on outcomes and health spending in a Canadian ambulatory HF cohort. Methods Twenty NYHA III HF patients underwent wireless PAP implantation at Foothills Medical Centre, Calgary, Alberta. Baseline, and 3-, 6-, 9-, and 12-month assessments of laboratory parameters, hemodynamics, 6-minute walk text and Kansas City Cardiomyopathy Questionnaire scores were collected. Healthcare costs 1 year pre- and post-implantation were collected from administrative databases. Results Mean age was 70.6 years; 45% were female. Results were as follows: an 88% reduction in emergency room visits (P = 0.0009); an 87% reduction in HFHs (P < 0.0003); a 29% reduction in heart function clinic visits (P = 0.033), and a 178% increase in nurse calls (P < 0.0002). Questionnaire and 6-minute walk test scores at baseline vs last follow-up were 45.4 vs 48.4 (P = 0.48) and 364.4 vs 402.8 m (P = 0.58), respectively. Mean PAP at baseline vs follow-up was 31.5 vs 24.8 mm Hg (P = 0.005). NYHA class improved by at least one class in 85% of patients. Mean measurable HF-related spending preimplantation was CAD$29,814 per patient per year and postimplantation was CAD$25,642 per patient per year (including device cost). Conclusions PAP monitoring demonstrated reductions in HFHs, and emergency room and heart function clinic visits, with improvements in NYHA class. Although further economic evaluation is needed, these results support the use of PAP monitoring as an effective and cost-neutral tool in HF management in appropriately selected patients in a publicly funded healthcare system.
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Valika A, Sulemanjee N, Pedersen R, Heidenreich D. Reduction in 90 day readmission rates utilizing ambulatory pulmonary pressure monitoring. ESC Heart Fail 2022; 10:685-690. [PMID: 36436826 PMCID: PMC9871649 DOI: 10.1002/ehf2.14253] [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: 08/26/2022] [Revised: 10/31/2022] [Accepted: 11/14/2022] [Indexed: 11/29/2022] Open
Abstract
AIMS In the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in New York Heart Association Functional Class III Heart Failure Patients) trial, heart failure hospitalization (HFH) rates were lower in patients with ambulatory pulmonary artery pressure (PAP) monitoring guidance. We investigated the effect of ambulatory haemodynamic monitoring on 90 day readmission rates after HFH. METHODS AND RESULTS We retrospectively analysed patients across the Advocate Aurora Health hospital network who had undergone PAP sensor implantation between 1 October 2015 and 31 October 2019. Patients with a ventricular assist device (VAD) or transplant prior to implantation were excluded. Rates of total HFH and 30 and 90 day all-cause readmission up to 12 months after implantation were collected, while censoring for an endpoint of heart transplantation, VAD, or death. Event rates were compared using Poisson regression. Of 459 patients included, there were 404 HFHs before and 179 after implantation. Compared with pre-implantation, 30 day all-cause readmission [incidence rate ratio (IRR): 0.55 (0.39-0.77), P = 0.0006] and 90 day all cause readmission rates were lower post-implantation [IRR: 0.45 (0.35-0.58), P < 0.0001]. The effect of PAP sensor implantation on 90 day all-cause readmission incidence rates was consistent across multiple subgroups. CONCLUSIONS Across a large hospital network, ambulatory haemodynamic monitoring was associated with lower HFH rates, as well as 30 and 90 day all-cause readmission rates. This supports the utility of ambulatory PAP monitoring to improve HF management in the era of value-based medicine.
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Affiliation(s)
- Ali Valika
- Advocate Heart InstituteAdvocate Good Samaritan Hospital, Advocate Aurora HealthTower 2, 3825 Highland Ave., Ste 400Downers GroveIL60515USA
| | - Nasir Sulemanjee
- Aurora Cardiovascular and Thoracic ServicesAurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health2801 W. Kinnickinnic River Parkway, Ste. 880MilwaukeeWI53215USA
| | - Rachel Pedersen
- Aurora Cardiovascular and Thoracic ServicesAurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health2801 W. Kinnickinnic River Parkway, Ste. 880MilwaukeeWI53215USA
| | - Debra Heidenreich
- Advocate Heart InstituteAdvocate Good Samaritan Hospital, Advocate Aurora HealthTower 2, 3825 Highland Ave., Ste 400Downers GroveIL60515USA
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Abraham J. The Pressure for Progress in Heart Failure. JACC: HEART FAILURE 2022; 10:945-947. [DOI: 10.1016/j.jchf.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/26/2022] [Indexed: 11/10/2022]
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45
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Epidemiology, Diagnosis, Pathophysiology, and Initial Approach to Heart Failure with Preserved Ejection Fraction. Cardiol Clin 2022; 40:397-413. [DOI: 10.1016/j.ccl.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Ovchinnikov AG, Potekhina A, Belyavskiy E, Gvozdeva A, Ageev F. Left atrial dysfunction as the major driver of heart failure with preserved ejection fraction syndrome. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:1073-1083. [PMID: 36218205 DOI: 10.1002/jcu.23318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/21/2022] [Accepted: 07/23/2022] [Indexed: 06/16/2023]
Abstract
Left atrial (LA) dysfunction seems to play a central role in the pathophysiology of heart failure with preserved ejection fraction (HFpEF), is associated with disease severity and poor outcomes and potentially impacts management. Identifying LA myopathy can help guide tailored therapy for HFpEF. Echocardiography allows the accurate measurement of atrial size and function, where LA strain appears to be a sensitive measure of intrinsic LA myopathy. Several therapies and devices that decompress of left atrium are being tested for HFpEF. Further investigation is required to understand the specific atrial effects of statins, mineralocorticoid receptor antagonists, and other therapies.
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Affiliation(s)
- Artem G Ovchinnikov
- Out-Patient Department, Institute of Clinical Cardiology, National Medical Research Center of Cardiology named after Academician E.I. Chazov, Moscow, Russia
- Department of Clinical Functional Diagnostics, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Alexandra Potekhina
- Out-Patient Department, Institute of Clinical Cardiology, National Medical Research Center of Cardiology named after Academician E.I. Chazov, Moscow, Russia
| | - Evgeny Belyavskiy
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow - Klinikum - Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Gvozdeva
- Out-Patient Department, Institute of Clinical Cardiology, National Medical Research Center of Cardiology named after Academician E.I. Chazov, Moscow, Russia
| | - Fail Ageev
- Out-Patient Department, Institute of Clinical Cardiology, National Medical Research Center of Cardiology named after Academician E.I. Chazov, Moscow, Russia
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Zile MR, Mehra MR, Ducharme A, Sears SF, Desai AS, Maisel A, Paul S, Smart F, Grafton G, Kumar S, Nossuli TO, Johnson N, Henderson J, Adamson PB, Costanzo MR, Lindenfeld J. Hemodynamically-Guided Management of Heart Failure Across the Ejection Fraction Spectrum. JACC: HEART FAILURE 2022; 10:931-944. [DOI: 10.1016/j.jchf.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 11/07/2022]
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Correia ETDO, Mesquita ET. Novidades e Reflexões sobre o Tratamento Farmacológico da Insuficiência Cardíaca com Fração de Ejeção Preservada. Arq Bras Cardiol 2022; 119:627-630. [PMID: 36102421 PMCID: PMC9563882 DOI: 10.36660/abc.20210753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 03/09/2022] [Indexed: 11/21/2022] Open
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Patel AH, Natarajan B, Pai RG. Current Management of Heart Failure with Preserved Ejection Fraction. Int J Angiol 2022; 31:166-178. [PMID: 36157094 PMCID: PMC9507602 DOI: 10.1055/s-0042-1756173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) encompasses nearly half of heart failure (HF) worldwide, and still remains a poor prognostic indicator. It commonly coexists in patients with vascular disease and needs to be recognized and managed appropriately to reduce morbidity and mortality. Due to the heterogeneity of HFpEF as a disease process, targeted pharmacotherapy to this date has not shown a survival benefit among this population. This article serves as a comprehensive historical review focusing on the management of HFpEF by reviewing past, present, and future randomized controlled trials that attempt to uncover a therapeutic value. With a paradigm shift in the pathophysiology of HFpEF as an inflammatory, neurohormonal, and interstitial process, a phenotypic approach has increased in popularity focusing on the treatment of HFpEF as a systemic disease. This article also addresses common comorbidities associated with HFpEF as well as current and ongoing clinical trials looking to further elucidate such links.
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Affiliation(s)
- Akash H. Patel
- Department of Internal Medicine, University of California Irvine Medical Center, Orange, California
| | - Balaji Natarajan
- Department of Cardiology, University of California Riverside School of Medicine, Riverside, California
- Department of Cardiology, St. Bernardine Medical Center, San Bernardino, California
| | - Ramdas G. Pai
- Department of Cardiology, University of California Riverside School of Medicine, Riverside, California
- Department of Cardiology, St. Bernardine Medical Center, San Bernardino, California
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Peters AE, DeVore AD. Pharmacologic Therapy for Heart Failure with Preserved Ejection Fraction. Cardiol Clin 2022; 40:473-489. [DOI: 10.1016/j.ccl.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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