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Wang N, Rueter P, Ng M, Chandramohan S, Hibbert T, O'Sullivan JF, Kaye D, Lal S. Echocardiographic predictors of cardiovascular outcome in heart failure with preserved ejection fraction. Eur J Heart Fail 2024; 26:1778-1787. [PMID: 38714362 DOI: 10.1002/ejhf.3271] [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: 01/06/2024] [Revised: 02/23/2024] [Accepted: 04/17/2024] [Indexed: 05/09/2024] Open
Abstract
AIMS The optimal echocardiographic predictors of cardiovascular outcome in heart failure (HF) with preserved ejection fraction (HFpEF) are unknown. We aimed to identify independent echocardiographic predictors of cardiovascular outcome in patients with HFpEF. METHODS AND RESULTS Systematic literature search of three electronic databases was conducted from date of inception until November 2022. Hazard ratios (HRs) and their 95% confidence intervals (CIs) for echocardiographic variables from multivariate prediction models for the composite primary endpoint of cardiovascular death and HF hospitalization were pooled using a random effects meta-analysis. Specific subgroup analyses were conducted for studies that enrolled patients with acute versus chronic HF, and for those studies that included E/e', pulmonary artery systolic pressure (PASP), renal function, natriuretic peptides and diuretic use in multivariate models. Forty-six studies totalling 20 056 patients with HFpEF were included. Three echocardiographic parameters emerged as independent predictors in all subgroup analyses: decreased left ventricular (LV) global longitudinal strain (HR 1.24, 95% CI 1.10-1.39 per 5% decrease), decreased left atrial (LA) reservoir strain (HR 1.30, 95% CI 1.13-1.1.50 per 5% decrease) and lower tricuspid annular plane systolic excursion (TAPSE) to PASP ratio (HR 1.17, 95% CI 1.07-1.25 per 0.1 unit decrease). Other independent echocardiographic predictors of the primary endpoint were a higher E/e', moderate to severe tricuspid regurgitation, LV mass index and LA ejection fraction, although these variables were less robust. CONCLUSIONS Impaired LV global longitudinal strain, lower LA reservoir strain and lower TAPSE/PASP ratio predict cardiovascular death and HF hospitalization in HFpEF and are independent of filling pressures, clinical characteristics and natriuretic peptides. These echocardiographic parameters reflect key functional changes in HFpEF, and should be incorporated in future prospective risk prediction models.
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Affiliation(s)
- Nelson Wang
- The George Institute for Global Health UNSW, Sydney, Australia
- Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Phidias Rueter
- Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Melvin Ng
- UNSW Medical School, University of New South Wales, Sydney, Australia
| | - Sashiruben Chandramohan
- Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Thomas Hibbert
- UNSW Medical School, University of New South Wales, Sydney, Australia
| | - John F O'Sullivan
- Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - David Kaye
- Department of Cardiology, Alfred Health, Melbourne, Australia
- Baker Heart and Diabetes Institute Melbourne, Melbourne, Australia
| | - Sean Lal
- Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
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2
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Goetz WA, Yao J, Brener M, Puri R, Swaans M, Schopka S, Wiesner S, Creutzenberg M, Sievert H, Kassab GS. Inversion of Left Ventricular Axial Shortening: In Silico Proof of Concept for Treatment of HFpEF. Bioengineering (Basel) 2024; 11:676. [PMID: 39061758 PMCID: PMC11274197 DOI: 10.3390/bioengineering11070676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/24/2024] [Accepted: 06/28/2024] [Indexed: 07/28/2024] Open
Abstract
Left ventricular (LV) longitudinal function is mechanically coupled to the elasticity of the ascending aorta (AA). The pathophysiologic link between a stiff AA and reduced longitudinal strain and the subsequent deterioration in longitudinal LV systolic function is likely relevant in heart failure with preserved ejection fraction (HFpEF). The proposed therapeutic effect of freeing the LV apex and allowing for LV inverse longitudinal shortening was studied in silico utilizing the Living Left Heart Human Model (Dassault Systémes Simulia Corporation). LV function was evaluated in a model with (A) an elastic AA, (B) a stiff AA, and (C) a stiff AA with a free LV apex. The cardiac model simulation demonstrated that freeing the apex caused inverse LV longitudinal shortening that could abolish the deleterious mechanical effect of a stiff AA on LV function. A stiff AA and impairment of the LV longitudinal strain are common in patients with HFpEF. The hypothesis-generating model strongly suggests that freeing the apex and inverse longitudinal shortening may improve LV function in HFpEF patients with a stiff AA.
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Affiliation(s)
- Wolfgang A. Goetz
- Cardiothoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (W.A.G.); (S.S.)
| | - Jiang Yao
- Dassault Systémes, Johnston, RI 02919, USA;
| | - Michael Brener
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY 10027, USA
| | - Rishi Puri
- Cleveland Clinic, Cleveland, OH 44195, USA
| | - Martin Swaans
- St. Antonius Ziekenhuis, 3435 Nieuwegein, The Netherlands
| | - Simon Schopka
- Cardiothoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (W.A.G.); (S.S.)
| | - Sigrid Wiesner
- Cardiothoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (W.A.G.); (S.S.)
| | - Marcus Creutzenberg
- Cardiothoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (W.A.G.); (S.S.)
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3
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Goetz WA, Yao J, Brener M, Puri R, Swaans M, Schopka S, Wiesner S, Creutzenberg M, Sievert H, Kassab GS. The Stiffness of the Ascending Aorta Has a Direct Impact on Left Ventricular Function: An In Silico Model. Bioengineering (Basel) 2024; 11:603. [PMID: 38927839 PMCID: PMC11200724 DOI: 10.3390/bioengineering11060603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 06/04/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
During systole, longitudinal shortening of the left ventricle (LV) displaces the aortic root toward the apex of the heart and stretches the ascending aorta (AA). An in silico study (Living Left Heart Human Model, Dassault Systèmes Simulia Corporation) demonstrated that stiffening of the AA affects myocardial stress and LV strain patterns. With AA stiffening, myofiber stress increased overall in the LV, with particularly high-stress areas at the septum. The most pronounced reduction in strain was noted along the septal longitudinal region. The pressure-volume loops showed that AA stiffening caused a deterioration in LV function, with increased end-systolic volume, reduced systolic LV pressure, decreased stroke volume and effective stroke work, but elevated end-diastolic pressure. An increase in myofiber contractility indicated that stroke volume and effective stroke work could be recovered, with an increase in LV end-systolic pressure and a decrease in end-diastolic pressure. Longitudinal and radial strains remained reduced, but circumferential strains increased over baseline, compensating for lost longitudinal LV function. Myofiber stress increased overall, with the most dramatic increase in the septal region and the LV apex. We demonstrate a direct mechanical pathophysiologic link between stiff AA and reduced longitudinal left ventricular strain which are common in patients with HFpEF.
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Affiliation(s)
- Wolfgang Anton Goetz
- Cardiothoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (W.A.G.); (M.C.)
| | - Jiang Yao
- Dassault Systèmes, Johnston, RI 02919, USA
| | - Michael Brener
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY 10027, USA;
| | - Rishi Puri
- Cleveland Clinic, Cleveland, OH 44195, USA
| | - Martin Swaans
- St. Antonius Ziekenhuis, 3435 Nieuwegein, The Netherlands;
| | - Simon Schopka
- Cardiothoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (W.A.G.); (M.C.)
| | - Sigrid Wiesner
- Cardiothoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (W.A.G.); (M.C.)
| | - Marcus Creutzenberg
- Cardiothoracic Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (W.A.G.); (M.C.)
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4
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He J, Yang W, Wu W, Yin G, Zhuang B, Xu J, Zhou D, Zhang J, Wang Y, Zhu L, Sun X, Sirajuddin A, Teng Z, Kureshi F, Arai AE, Zhao S, Lu M. Heart Failure with Normal Natriuretic Peptide Levels and Preserved Ejection Fraction: A Prospective Clinical and Cardiac MRI Study. Radiol Cardiothorac Imaging 2024; 6:e230281. [PMID: 38695743 PMCID: PMC11211949 DOI: 10.1148/ryct.230281] [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: 09/14/2023] [Revised: 02/20/2024] [Accepted: 03/20/2024] [Indexed: 06/16/2024]
Abstract
Purpose To describe the clinical presentation, comprehensive cardiac MRI characteristics, and prognosis of individuals with predisposed heart failure with preserved ejection fraction (HFpEF). Materials and Methods This prospective cohort study (part of MISSION-HFpEF [Multimodality Imaging in the Screening, Diagnosis, and Risk Stratification of HFpEF]; NCT04603404) was conducted from January 1, 2019, to September 30, 2021, and included individuals with suspected HFpEF who underwent cardiac MRI. Participants who had primary cardiomyopathy and primary valvular heart disease were excluded. Participants were split into a predisposed HFpEF group, defined as HFpEF with normal natriuretic peptide levels based on an HFA-PEFF (Heart Failure Association Pretest Assessment, Echocardiography and Natriuretic Peptide, Functional Testing, and Final Etiology) score of 4 from the latest European Society of Cardiology guidelines, and an HFpEF group (HFA-PEFF score of ≥ 5). An asymptomatic control group without heart failure was also included. Clinical and cardiac MRI-based characteristics and outcomes were compared between groups. The primary end points were death, heart failure hospitalization, or stroke. Results A total of 213 participants with HFpEF, 151 participants with predisposed HFpEF, and 100 participants in the control group were analyzed. Compared with the control group, participants with predisposed HFpEF had worse left ventricular remodeling and function and higher systemic inflammation. Compared with participants with HFpEF, those with predisposed HFpEF, whether obese or not, were younger and had higher plasma volume, lower prevalence of atrial fibrillation, lower left atrial volume index, and less impaired left ventricular global longitudinal strain (-12.2% ± 2.8 vs -13.9% ± 3.1; P < .001) and early-diastolic global longitudinal strain rate (eGLSR, 0.52/sec ± 0.20 vs 0.57/sec ± 0.15; P = .03) but similar prognosis. Atrial fibrillation occurrence (hazard ratio [HR] = 3.90; P = .009), hemoglobin level (HR = 0.94; P = .001), and eGLSR (per 0.2-per-second increase, HR = 0.28; P = .002) were independently associated with occurrence of primary end points in participants with predisposed HFpEF. Conclusion Participants with predisposed HFpEF showed relatively unique clinical and cardiac MRI features, warranting greater clinical attention. eGLSR should be considered as a prognostic factor in participants with predisposed HFpEF. Keywords: Heart Failure with Preserved Ejection Fraction, Normal Natriuretic Peptide Levels, Cardiovascular Magnetic Resonance, Myocardial Strain, Prognosis Clinical trial registration no. NCT04603404 Supplemental material is available for this article. © RSNA, 2024.
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Affiliation(s)
- Jian He
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Wenjing Yang
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Weichun Wu
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Gang Yin
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Baiyan Zhuang
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Jing Xu
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Di Zhou
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Jian Zhang
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Yining Wang
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Leyi Zhu
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Xiaoxin Sun
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Arlene Sirajuddin
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Zhongzhao Teng
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Faraz Kureshi
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Andrew E. Arai
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Shihua Zhao
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
| | - Minjie Lu
- From the Department of Magnetic Resonance Imaging (J.H., W.Y., G.Y.,
B.Z., J.X., D.Z., Y.W., L.Z., S.Z., M.L.), Department of Echocardiography
(W.W.), Heart Failure Center (J.Z.), and Department of Nuclear Medicine (X.S.),
Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China; Department of
Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing,
China (J.H.); National Heart, Lung, and Blood Institute, National Institutes of
Health, Department of Health and Human Services, Bethesda, Md (A.S., A.E.A.);
Andrew Arai Consulting, Kensington, Md (A.E.A.); Department of Radiology,
University of Cambridge, Cambridge, UK (Z.T.); Axis Cardiovascular and Axis
Cardiovascular Advanced Imaging, St David’s Healthcare, Austin, Tex
(F.K.); and Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese
Academy of Medical Sciences, Peking Union Medical College, Beilishi Road No.
167, Xicheng District, Beijing 100037, China (W.W., G.Y., X.S., M.L.)
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5
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Foroshani S, Karp A, Aronow WS, Lanier GM. The role of phosphodiesterase 9A inhibitors in heart failure. Expert Opin Investig Drugs 2024; 33:543-547. [PMID: 38702878 DOI: 10.1080/13543784.2024.2349813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/26/2024] [Indexed: 05/06/2024]
Abstract
INTRODUCTION There are currently limited effective treatments available to improve lusitropy in patients suffering from heart failure with preserved ejection fraction. The role of PDE9A in diastolic dysfunction has been well-studied over recent years, with a special focus on its association with myocardial hypertrophy. Recent insights into PDE9A inhibition have brought to light the potential for reversal of cardiac remodeling, with multiple studies showing promising results in preclinical data. AREAS COVERED This expert opinion provides an overview of the role of PDE9A in diastolic heart dysfunction along with the efficacy of PDE9A inhibitors in laboratory models of heart failure with preserved ejection fraction. EXPERT OPINION The available data on PDE9A inhibition in preclinical studies suggest that there is potential for reversal of diastolic dysfunction and myocardial hypertrophy, however, conflicting data suggests that further studies are required before progressing to clinical trials.
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Affiliation(s)
| | - Avrohom Karp
- Medicine, New York Medical College, Valhalla, NY, USA
| | - Wilbert S Aronow
- Departments of Cardiology and Medicine Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Gregg M Lanier
- Departments of Cardiology and Medicine Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Di Fiore V, Cappelli F, Del Punta L, De Biase N, Armenia S, Maremmani D, Lomonaco T, Biagini D, Lenzi A, Mazzola M, Tricò D, Masi S, Mengozzi A, Pugliese NR. Novel Techniques, Biomarkers and Molecular Targets to Address Cardiometabolic Diseases. J Clin Med 2024; 13:2883. [PMID: 38792427 PMCID: PMC11122330 DOI: 10.3390/jcm13102883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/01/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024] Open
Abstract
Cardiometabolic diseases (CMDs) are interrelated and multifactorial conditions, including arterial hypertension, type 2 diabetes, heart failure, coronary artery disease, and stroke. Due to the burden of cardiovascular morbidity and mortality associated with CMDs' increasing prevalence, there is a critical need for novel diagnostic and therapeutic strategies in their management. In clinical practice, innovative methods such as epicardial adipose tissue evaluation, ventricular-arterial coupling, and exercise tolerance studies could help to elucidate the multifaceted mechanisms associated with CMDs. Similarly, epigenetic changes involving noncoding RNAs, chromatin modulation, and cellular senescence could represent both novel biomarkers and targets for CMDs. Despite the promising data available, significant challenges remain in translating basic research findings into clinical practice, highlighting the need for further investigation into the complex pathophysiology underlying CMDs.
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Affiliation(s)
- Valerio Di Fiore
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Federica Cappelli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Lavinia Del Punta
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Silvia Armenia
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Davide Maremmani
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Tommaso Lomonaco
- Department of Chemistry and Industrial Chemistry, University of Pisa, Via Giuseppe Moruzzi 13, 56124 Pisa, Italy; (T.L.)
| | - Denise Biagini
- Department of Chemistry and Industrial Chemistry, University of Pisa, Via Giuseppe Moruzzi 13, 56124 Pisa, Italy; (T.L.)
| | - Alessio Lenzi
- Department of Chemistry and Industrial Chemistry, University of Pisa, Via Giuseppe Moruzzi 13, 56124 Pisa, Italy; (T.L.)
| | - Matteo Mazzola
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Domenico Tricò
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Nicola Riccardo Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
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7
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Capone F, Nambiar N, Schiattarella GG. Beyond Weight Loss: the Emerging Role of Incretin-Based Treatments in Cardiometabolic HFpEF. Curr Opin Cardiol 2024; 39:148-153. [PMID: 38294187 DOI: 10.1097/hco.0000000000001117] [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] [Indexed: 02/01/2024]
Abstract
PURPOSE OF REVIEW Incretin-based drugs are potent weight-lowering agents, emerging as potential breakthrough therapy for the treatment of obesity-related phenotype of heart failure with preserved ejection fraction (HFpEF). In this review article, we will discuss the contribution of weight loss as part of the benefits of incretin-based medications in obese patients with HFpEF. Furthermore, we will describe the potential effects of glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor agonists on the heart, particularly in relation to HFpEF pathophysiology. RECENT FINDINGS In the STEP-HFpEF trial, the GLP-1 receptor agonist semaglutide significantly improved quality of life outcomes in obese HFpEF patients. Whether the beneficial effects of semaglutide in obese patients with HFpEF are merely a consequence of body weight reduction is unclear. Considering the availability of other weight loss strategies (e.g., caloric restriction, exercise training, bariatric surgery) to be used in obese HFpEF patients, answering this question is crucial to provide tailored therapeutic options in these subjects. SUMMARY Incretin-based drugs may represent a milestone in the treatment of obesity in HFpEF. Elucidating the contribution of weight loss in the overall benefit observed with these drugs is critical in the management of obese HFpEF patients, considering that other weight-lowering strategies are available and might represent potential alternative options for these patients.
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Affiliation(s)
- Federico Capone
- Translational Approaches in Heart Failure and Cardiometabolic Disease, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Division of Internal Medicine, Department of Medicine, University of Padua, Padua, Italy
| | - Natasha Nambiar
- Translational Approaches in Heart Failure and Cardiometabolic Disease, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Gabriele G Schiattarella
- Translational Approaches in Heart Failure and Cardiometabolic Disease, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Max Rubner Center for Cardiovascular Metabolic Renal Research (MRC), Deutsches Herzzentrum der Charité (DHZC), Charité -Universitätsmedizin Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
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Terlizzi VD, Barone R, Nunno ND, Alcidi G, Brunetti ND, Iacoviello M. The Atrioventricular Coupling in Heart Failure: Pathophysiological and Therapeutic Aspects. Rev Cardiovasc Med 2024; 25:169. [PMID: 39076484 PMCID: PMC11267188 DOI: 10.31083/j.rcm2505169] [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: 12/26/2023] [Revised: 01/30/2024] [Accepted: 02/26/2024] [Indexed: 07/31/2024] Open
Abstract
For a long time, the study of heart failure focused on single heart chamber disease. There is, instead, growing attention on the interplay between the atria and the ventricles during the cardiac cycle and on the consequences of an altered chamber coupling on global heart performance and heart failure. This review aimed to explore the principles of atrioventricular (AV) function and coupling of the left heart and the consequences that their disruption could have in several diseases. Furthermore, we will examine echocardiographic tips for analyzing the chamber function and the AV coupling. Finally, we will explore the most recent pharmacological acquisitions and the device therapies we have for use.
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Affiliation(s)
- Vito Di Terlizzi
- Cardiology Unit, University Policlinic Hospital Riuniti, 71122 Foggia, Italy
| | - Roberta Barone
- Cardiology Unit, University Policlinic Hospital Riuniti, 71122 Foggia, Italy
| | - Nicola Di Nunno
- Cardiology Unit, University Policlinic Hospital Riuniti, 71122 Foggia, Italy
| | - Gianmarco Alcidi
- Cardiology Unit, University Policlinic Hospital Riuniti, 71122 Foggia, Italy
| | - Natale Daniele Brunetti
- Cardiology Unit, University Policlinic Hospital Riuniti, 71122 Foggia, Italy
- Department of Surgical and Medical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Massimo Iacoviello
- Cardiology Unit, University Policlinic Hospital Riuniti, 71122 Foggia, Italy
- Department of Surgical and Medical Sciences, University of Foggia, 71122 Foggia, Italy
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9
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Minamisawa M, Inciardi RM, Claggett B, Cikes M, Liu L, Prasad N, Biering-Sørensen T, Lam CSP, Shah SJ, Zile MR, O'Meara E, Redfield MM, McMurray JJV, Solomon SD, Shah AM. Clinical implications of subclinical left ventricular dysfunction in heart failure with preserved ejection fraction: The PARAGON-HF study. Eur J Heart Fail 2024; 26:871-881. [PMID: 38369856 DOI: 10.1002/ejhf.3167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 02/20/2024] Open
Abstract
AIMS Left ventricular (LV) subclinical impairment has been described in heart failure with preserved ejection fraction (HFpEF). We assessed the relationship between LV myocardial deformation by strain imaging and recurrent hospitalization for heart failure (HF) or cardiovascular death in a large international HFpEF population. METHODS AND RESULTS We assessed two-dimensional speckle-tracking based global longitudinal strain (GLS) in 790 patients (mean age 74 ± 8 years, 54% female) with adequate image quality enrolled in the PARAGON-HF echocardiography study. We examined the relationship of GLS with total HF hospitalizations and cardiovascular death (the primary composite outcome) after accounting for clinical confounders. Approximately 47% of the population had evidence of LV subclinical dysfunction, defined as absolute GLS <16%. Impaired GLS was significantly associated with higher values of circulating baseline N-terminal pro-B-type-natriuretic peptide. After a median follow-up of 3.0 years, there were 407 total HF hospitalizations and cardiovascular deaths. After multivariable adjustment, worse GLS was associated with a greater risk for the primary composite outcome (adjusted hazard ratio per 1% decrease: 1.06; 95% confidence interval 1.02-1.11; p = 0.008). GLS did not modify the treatment effect of sacubitril/valsartan compared with valsartan for the composite outcome (p for interaction >0.1). CONCLUSIONS In a large HFpEF population, impaired LV function was observed even among patients with preserved ejection fraction, and was associated with an increased risk of total HF hospitalizations or cardiovascular death, accounting for clinical confounders. These findings highlight the key role of subtle LV systolic impairment in the pathophysiology of HFpEF.
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Affiliation(s)
- Masatoshi Minamisawa
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Riccardo M Inciardi
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maja Cikes
- Department for Cardiovascular Diseases, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - Li Liu
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Narayana Prasad
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tor Biering-Sørensen
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
- University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Michael R Zile
- The Medical University of South Carolina and the Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Eileen O'Meara
- Montreal Heart Institute and Université de Montréal, Montreal, QC, Canada
| | | | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amil M Shah
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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10
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Deharo F, Grapsa J. Global longitudinal strain as a predictor of risk in patients with heart failure with preserved ejection fraction: A deserved role? Eur J Heart Fail 2024; 26:882-884. [PMID: 38528727 DOI: 10.1002/ejhf.3211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/09/2024] [Indexed: 03/27/2024] Open
Affiliation(s)
- Francois Deharo
- Cardiology Department, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Julia Grapsa
- Cardiology Department, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
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11
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Melo Santos AC, de Melo EV, Sousa ACS, Oliveira JLM, Martins-Filho PR, Noronha NCM, do Nascimento CIS, Campos MDSB. Long-Term Impact of Left Bundle Branch Block on Cardiopulmonary Exercise Test Variables and Left Ventricular Systolic Function: A Two-Stage Observational Study. Cardiology 2024; 149:332-337. [PMID: 38531333 DOI: 10.1159/000538522] [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: 12/09/2023] [Accepted: 03/18/2024] [Indexed: 03/28/2024]
Abstract
INTRODUCTION Left bundle branch block (LBBB) disrupts the electrical activation of the left ventricle, potentially impairing its systolic function, leading to LBBB-induced cardiomyopathy. This study examined cardiopulmonary exercise test (CPET) variables in patients with and without LBBB and assessed the longitudinal development of left ventricular ejection fraction (LVEF). METHOD An observational, comparative clinical study was executed in two stages at a private hospital in Brazil. The sample consisted of 27 individuals: 11 with LBBB and 16 without LBBB, all with preserved LVEF (>50%) and without confirmed ischemia. CPET variables were assessed, and after 4 years, participants had a transthoracic echocardiogram for LVEF re-evaluation. Groups were compared using the t test or the χ2 test. Multivariate analysis of covariance determined effect magnitude. RESULTS Patients with LBBB demonstrated significant differences in CPET variables, particularly in predicted peak V˙O2, predicted peak PO2, V˙E/V˙CO2 slope, and T ½ V˙O2. They also exhibited a more significant decline in LVEF over a 4-year span compared to the patients without LBBB. Although initial preservation of LVEF, changes in contractile patterns due to LBBB interfered with its systolic function, suggesting early ventricular dysfunction indicated by a reduction in LVEF and an increase in the V˙E/V˙CO2 slope. Despite differences in cardiopulmonary function and changes in LVEF over time between patients with and without LBBB, the effect size was considered mild to moderate. CONCLUSIONS LBBB patients with initially preserved LVEF displayed reduced exercise tolerance and a decrease in LVEF over time, emphasizing the need for vigilant monitoring and early intervention in these patients.
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Affiliation(s)
| | | | - Antônio Carlos Sobral Sousa
- Department of Medicine, Federal University of Sergipe, Aracaju, Brazil
- Graduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Brazil
- São Lucas Clinic and Hospital/Rede D'Or São Luiz, Aracaju, Brazil
- Division of Cardiology, University Hospital, Federal University of Sergipe, Aracaju, Brazil
| | - Joselina Luzia Menezes Oliveira
- Department of Medicine, Federal University of Sergipe, Aracaju, Brazil
- Graduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Brazil
- São Lucas Clinic and Hospital/Rede D'Or São Luiz, Aracaju, Brazil
- Division of Cardiology, University Hospital, Federal University of Sergipe, Aracaju, Brazil
| | - Paulo Ricardo Martins-Filho
- Graduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Brazil
- Investigative Pathology Laboratory, Federal University of Sergipe, Aracaju, Brazil
| | | | | | - Milena Dos Santos Barros Campos
- Department of Medicine, Tiradentes University, Aracaju, Brazil
- Graduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Brazil
- São Lucas Clinic and Hospital/Rede D'Or São Luiz, Aracaju, Brazil
- Division of Cardiology, University Hospital, Federal University of Sergipe, Aracaju, Brazil
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12
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Misawa T, Hoshino M, Sugiyama T, Kanaji Y, Hada M, Nagamine T, Ueno H, Nogami K, Sayama K, Matsuda K, Yonetsu T, Sasano T, Kakuta T. Detection of unrecognized myocardial infarction by preprocedural transthoracic echocardiography in patients undergoing elective percutaneous coronary intervention. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:265-273. [PMID: 38069627 DOI: 10.1002/jcu.23626] [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: 10/13/2023] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 03/19/2024]
Abstract
BACKGROUND Previous studies showed that unrecognized myocardial infarction (UMI) identified on cardiac magnetic resonance (CMR) was related to worse prognosis. We aimed to investigate the efficacy of preprocedural transthoracic echocardiography (TTE) to detect the presence of UMI in patients undergoing percutaneous coronary intervention (PCI). METHODS A total of 138 patients with chronic coronary syndrome (CCS) and preserved left ventricular ejection fraction (LVEF) without history of myocardial infarction or revascularization were retrospectively studied. UMI was evaluated with pre-PCI late gadolinium enhancement (LGE)-CMR. TTE and two-dimensional speckle-tracking echocardiography (2D-STE) were performed before PCI. All patients were divided into two groups according to the presence or absence of UMI, and clinical and echocardiographic findings were compared between these two groups. RESULTS UMI was detected in 43 patients (31.2%). Multivariable logistic regression analysis revealed that higher SYNTAX score, the presence of wall motion abnormalities (WMAs) and lower global longitudinal strain (GLS) were independent predictors of the presence of UMI. Furthermore, GLS provided incremental efficacy for the detection of UMI over abnormal Q waves, SYNTAX score and WMAs. CONCLUSIONS Preprocedural TTE in combination with 2D-STE could help identify patients with UMI regardless of the presence or absence of ECG findings and WMAs.
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Affiliation(s)
- Toru Misawa
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Masahiro Hoshino
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Tomoyo Sugiyama
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Yoshihisa Kanaji
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Masahiro Hada
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Tatsuhiro Nagamine
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Hiroki Ueno
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Kai Nogami
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Kodai Sayama
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Kazuki Matsuda
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunekazu Kakuta
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
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Subramanian V, Keshvani N, Segar MW, Kondamudi NJ, Chandra A, Maddineni B, Matulevicius SA, Michos ED, Lima JAC, Berry JD, Pandey A. Association of global longitudinal strain by feature tracking cardiac magnetic resonance imaging with adverse outcomes among community-dwelling adults without cardiovascular disease: The Dallas Heart Study. Eur J Heart Fail 2024; 26:208-215. [PMID: 38345558 DOI: 10.1002/ejhf.3158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/20/2023] [Accepted: 01/19/2024] [Indexed: 03/27/2024] Open
Abstract
AIM Left ventricular (LV) global longitudinal strain (GLS) may detect subtle abnormalities in myocardial contractility among individuals with normal LV ejection fraction (LVEF). However, the prognostic implications of GLS among healthy, community-dwelling adults is not well-established. METHODS AND RESULTS Overall, 2234 community-dwelling adults (56% women, 47% Black) with LVEF ≥50% without a history of cardiovascular disease (CVD) from the Dallas Heart Study who underwent cardiac magnetic resonance (CMR) with GLS assessed by feature tracking CMR (FT-CMR) were included. The association of GLS with the risk of incident major adverse cardiovascular events (MACE; composite of incident myocardial infarction, incident heart failure [HF], hospitalization for atrial fibrillation, coronary revascularization, and all-cause death), and incident HF or death were assessed with adjusted Cox proportional hazards models. A total of 309 participants (13.8%) had MACE during a median follow-up duration of 17 years. Participants with the worst GLS (Q4) were more likely male and of the Black race with a history of tobacco use and diabetes with lower LVEF, higher LV end-diastolic volume, and higher LV mass index. Cumulative incidence of MACE was higher among participants with worse (Q4 vs. Q1) GLS (20.4% vs. 9.0%). In multivariable-adjusted Cox models that included clinical characteristics, cardiac biomarkers and baseline LVEF, worse GLS (Q4 vs. Q1) was associated with a significantly higher risk of MACE (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.07-2.24, p = 0.02) and incident HF or death (HR 1.57, 95% CI 1.03-2.38, p = 0.04). CONCLUSIONS Impaired LV GLS assessed by FT-CMR among adults free of cardiovascular disease is associated with a higher risk of incident MACE and incident HF or death independent of cardiovascular risk factors, cardiac biomarkers and LVEF.
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Affiliation(s)
- Vinayak Subramanian
- Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
| | - Neil Keshvani
- Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
| | - Matthew W Segar
- Division of Cardiology, Texas Heart Institute, Houston, TX, USA
| | - Nitin J Kondamudi
- Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
| | - Alvin Chandra
- Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Bhumika Maddineni
- Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Susan A Matulevicius
- Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joao A C Lima
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jarett D Berry
- Department of Medicine, UT Health Science Center at Tyler, Tyler, TX, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
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Huang XM, Li JJ, Yin W, Fu HL, Yu F, Gu LQ, Zhang Y, Du M, Ye Z, Xu L. Effect of sacubitril valsartan on heart failure with mid-range or preserved ejection fraction in patients on maintenance hemodialysis: real-world experience in a single-center, prospective study. BMC Cardiovasc Disord 2024; 24:79. [PMID: 38291395 PMCID: PMC10826098 DOI: 10.1186/s12872-024-03744-y] [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: 07/28/2023] [Accepted: 01/21/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND This study aimed to evaluate the effect of sacubitril valsartan (SV) on heart failure (HF) hospitalization and cardiovascular mortality in patients on hemodialysis with HF with preserved ejection fraction (EF; HFpEF). METHODS This single-center, prospective study enrolled 155 stable hemodialysis patients with EF > 40% who were followed up for 12 months. Fifty-nine patients were treated with SV; the others were matched for EF (57.89 ± 9.35 vs. 58.00 ± 11.82, P = 0.9) at a ratio of 1:1 and included as controls. The target dosage of SV was 200 mg/day. RESULTS Twenty-three (23/155; 14.84%) had HF with mid-range EF (HFmrEF), while 132 (85.16%) had HFpEF. After SV treatment, the peak early diastolic transmitral flow velocity/peak early diastolic mitral annular tissue velocity(E/e') improved from 17.19 ± 8.74 to 12.80 ± 5.52 (P = 0.006), the left ventricular (LV) end-diastolic diameter decreased from 53.14 ± 7.67 mm to 51.56 ± 7.44 mm (P = 0.03), and the LV mass index decreased from 165.7 ± 44.6 g/m2 to 154.8 ± 24.0 g/m2 (P = 0.02). LVEF (P = 0.08) and LV global longitudinal strain (P = 0.7) did not change significantly. The composite outcome of first and recurrent HF hospitalization or cardiovascular death showed no difference between group. However, the Acute Dialysis Quality Initiative Workgroup (ADQI) HF class improved in 39 and 15 patients and worsened in 1 and 11 patients in the SV and control groups, respectively (P < 0.001). Age, diabetes mellitus, and pulmonary arterial pressure were independent risk factors for HF hospitalization and cardiovascular mortality in patients with HFpEF. CONCLUSIONS SV improved LV hypertrophy, diastolic function, and the ADQI class for HF; however, it failed to reduce the composite endpoints of HF hospitalization and cardiovascular disease-related mortality over 12 months of follow-up in patients on maintenance hemodialysis with EF of > 40%.
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Affiliation(s)
- Xiao-Mei Huang
- Department of Nephrology, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, China.
| | - Jing-Jing Li
- Department of Ultrasound, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, China
| | - Wang Yin
- Department of Nephrology, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, China
| | - Hui-Ling Fu
- Department of Nephrology, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, China
| | - Fen Yu
- Department of Ultrasound, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, China
| | - Lian-Qing Gu
- Department of Nephrology, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, China
| | - Yi Zhang
- Department of Ultrasound, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, China
| | - Min Du
- Department of Public Health, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, China
| | - Zheng Ye
- Department of Nephrology, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, China
| | - Li Xu
- Department of Nephrology, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, China.
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15
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Kawata T, Omori Y, Suzuki M, Ikeda A. Usefulness of tissue Doppler-derived left ventricular isovolumic contraction velocity in patients with heart failure with preserved ejection fraction. Echocardiography 2024; 41:e15755. [PMID: 38284667 DOI: 10.1111/echo.15755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/13/2023] [Accepted: 01/02/2024] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is a group of diseases classified by left ventricular (LV) EF, a measure of pump function. However, LVEF does not reflect LV contractility. Previous studies have shown that tissue Doppler-derived LV isovolumic contraction velocity (IVCv) correlates well with the LV peak dP/dt, an index of LV contractility. We explored whether LV IVCv is associated with 1-year post-discharge outcomes in HFpEF. METHODS We enrolled 113 patients (median age, 86 years, 45 male) with HFpEF (EF on admission ≥ 50%) who were admitted to our hospital for the treatment of acute HF. Clinical characteristics including echocardiographic data were obtained before discharge. IVCv was obtained from the tissue Doppler waveforms of both the septal and lateral mitral annulus of the apical 4-chamber view and averaged data were used. Primary outcomes were all-cause death or unplanned hospitalization due to HF within the first year. RESULTS Among all patients, median LVEF was 61%, left atrial diameter was 47 mm, E/e' was 17.5, and IVCv was 4.5 cm/sec; mean tricuspid regurgitation velocity was 2.6 m/sec. Regarding laboratory data, the median plasma B-type natriuretic peptide level was 185 pg/mL. Thirty-four events occurred (15 deaths, 19 unplanned hospitalizations due to HF) within the first year. In multivariate Cox proportional hazards analyses, IVCv was significantly associated with outcomes (hazard ratio .68, 95% confidence interval .50-.89, p = .0095), independent of general characteristics, echocardiographic measures and pertinent laboratory parameters. CONCLUSION LV IVCv was independently associated with 1-year outcomes in patients with HFpEF.
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Affiliation(s)
- Takayuki Kawata
- Department of Cardiovascular Medicine, Sassa General Hospital, Tokyo, Japan
| | - Yuki Omori
- Department of Nursing, Sassa General Hospital, Tokyo, Japan
| | - Minako Suzuki
- Department of Clinical Laboratory, Sassa General Hospital, Tokyo, Japan
| | - Atsushi Ikeda
- Department of Cardiovascular Medicine, Sassa General Hospital, Tokyo, Japan
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16
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Gherbesi E, Gianstefani S, Angeli F, Ryabenko K, Bergamaschi L, Armillotta M, Guerra E, Tuttolomondo D, Gaibazzi N, Squeri A, Spaziani C, Pizzi C, Carugo S. Myocardial strain of the left ventricle by speckle tracking echocardiography: From physics to clinical practice. Echocardiography 2024; 41:e15753. [PMID: 38284665 DOI: 10.1111/echo.15753] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/21/2023] [Accepted: 01/02/2024] [Indexed: 01/30/2024] Open
Abstract
Speckle tracking echocardiography (STE) is a reliable imaging technique of recognized clinical value in several settings. This method uses the motion of ultrasound backscatter speckles within echocardiographic images to derive myocardial velocities and deformation parameters, providing crucial insights on several cardiac pathological and physiological processes. Its feasibility, reproducibility, and accuracy have been widely demonstrated, being myocardial strain of the various chambers inserted in diagnostic algorithms and guidelines for various pathologies. The most important parameters are Global longitudinal strain (GLS), Left atrium (LA) reservoir strain, and Global Work Index (GWI): based on large studies the average of the lower limit of normality are -16%, 23%, and 1442 mmHg%, respectively. For GWI, it should be pointed out that myocardial work relies primarily on non-invasive measurements of blood pressure and segmental strain, both of which exhibit high variability, and thus, this variability constitutes a significant limitation of this parameter. In this review, we describe the principal aspects of the theory behind the use of myocardial strain, from cardiac mechanics to image acquisition techniques, outlining its limitation, and its principal clinical applications: in particular, GLS have a role in determine subclinical myocardial dysfunction (in cardiomyopathies, cardiotoxicity, target organ damage in ambulatory patients with arterial hypertension) and LA strain in determine the risk of AF, specifically in ambulatory patients with arterial hypertension.
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Affiliation(s)
- Elisa Gherbesi
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Silvia Gianstefani
- Cardiology Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences - DIMEC - Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Francesco Angeli
- Cardiology Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences - DIMEC - Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Khrystyna Ryabenko
- Cardiology Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences - DIMEC - Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Luca Bergamaschi
- Cardiology Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences - DIMEC - Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Matteo Armillotta
- Cardiology Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences - DIMEC - Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Emiliano Guerra
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
| | - Domenico Tuttolomondo
- Cardiology Division, Parma University Hospital, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Nicola Gaibazzi
- Cardiology Division, Parma University Hospital, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Angelo Squeri
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Ravenna, Italy
| | - Cristina Spaziani
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Carmine Pizzi
- Cardiology Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences - DIMEC - Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Stefano Carugo
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
- Department of Clinical Sciences and Community Health, University of Milano, Milano, Italy
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17
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Iwakura K, Onishi T, Koyama Y, Iwamoto M, Watanabe S, Tanaka K, Hirao Y, Tanaka N, Sumiyoshi A, Okada M, Tanaka K, Harada S, Watanabe H, Okamura A. Influence of ultrasound transmit frequency on measurement of global longitudinal strain on 2D speckle tracking echocardiography. Sci Rep 2023; 13:22196. [PMID: 38097659 PMCID: PMC10721605 DOI: 10.1038/s41598-023-49664-3] [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: 09/08/2023] [Accepted: 12/11/2023] [Indexed: 12/17/2023] Open
Abstract
The reproducibility of longitudinal strain measured by 2D speckle tracking echocardiography (2DSTE) may be affected by ultrasound settings. This study investigated the effect of transmit ultrasound frequency on global longitudinal strain (GLS) by 2DSTE. Apical, 2- and 4-chamber, and long-axis views were obtained in consecutive 162 patients using Philips ultrasound devices. Three different frequency presets were used sequentially: high resolution (HRES, 1.9 to 2.1 MHz), general (HGEN, 1.6 to 1.8 MHz), and penetration mode (HPEN, 1.3 to 1.6 MHz). GLS values were determined for each preset using the Philips Q-station software, resulting in GLS-HRES, GLS-HGEN, and GLS-HPEN. Among the 151 patients with successfully measured GLS, a significant difference in GLS was observed among the three presets (p < 0.0001). GLS-HRES (- 17.9 ± 4.4%) showed a slightly smaller magnitude compared to GLS-HGEN (- 18.8 ± 4.5%, p < 0.0001) and GLS-HPEN (- 18.8 ± 4.5%, p < 0.0001), with absolute differences of 1.1 ± 1.0% and 1.1 ± 1.2%, respectively. This variation in GLS with frequency was evident in patients with both optimal (n = 104) and suboptimal (n = 47) image quality and remained consistent regardless of ultrasound devices, ischemic etiology, or ejection fraction. In conclusion, ultrasound frequency had only a modest effect on GLS measurements. GLS may be reliably assessed in most cases regardless of the ultrasound frequency used.
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Affiliation(s)
- Katsuomi Iwakura
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32, Umeda, Kita-ku, Osaka, Osaka, 5300001, Japan.
| | - Toshinari Onishi
- Department of Cardiovascular Medicine, Sakai City Medical Center, 1-1-1 Ebaraji-cho, Nishi-ku, Sakai, Osaka, 5938304, Japan
| | - Yasushi Koyama
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32, Umeda, Kita-ku, Osaka, Osaka, 5300001, Japan
| | - Mutsumi Iwamoto
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32, Umeda, Kita-ku, Osaka, Osaka, 5300001, Japan
| | - Satoshi Watanabe
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32, Umeda, Kita-ku, Osaka, Osaka, 5300001, Japan
| | - Koji Tanaka
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32, Umeda, Kita-ku, Osaka, Osaka, 5300001, Japan
| | - Yuko Hirao
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32, Umeda, Kita-ku, Osaka, Osaka, 5300001, Japan
| | - Nobuaki Tanaka
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32, Umeda, Kita-ku, Osaka, Osaka, 5300001, Japan
| | - Akinori Sumiyoshi
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32, Umeda, Kita-ku, Osaka, Osaka, 5300001, Japan
| | - Masato Okada
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32, Umeda, Kita-ku, Osaka, Osaka, 5300001, Japan
| | - Kota Tanaka
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32, Umeda, Kita-ku, Osaka, Osaka, 5300001, Japan
| | - Shinichi Harada
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32, Umeda, Kita-ku, Osaka, Osaka, 5300001, Japan
| | - Heitaro Watanabe
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32, Umeda, Kita-ku, Osaka, Osaka, 5300001, Japan
| | - Atsunori Okamura
- Division of Cardiology, Sakurabashi Watanabe Hospital, 2-4-32, Umeda, Kita-ku, Osaka, Osaka, 5300001, Japan
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18
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Watanabe S, Nakajima K, Toshima F, Wakabayashi H, Yoshida S, Yoneyama H, Komatsu J, Konishi T, Kinuya S. Transthyretin amyloid cardiomyopathy disease burden quantified using 99mTc-pyrophosphate SPECT/CT: volumetric parameters versus SUVmax ratio at 1 and 3 hours. J Nucl Cardiol 2023; 30:2721-2735. [PMID: 37605060 PMCID: PMC10682282 DOI: 10.1007/s12350-023-03353-w] [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: 05/28/2023] [Accepted: 07/20/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Various parameters derived from technetium-99m pyrophosphate (99mTc-PYP) single-photon emission computed tomography (SPECT) correlate with the severity of transthyretin amyloid cardiomyopathy (ATTR-CM). However, the optimal metrics and image acquisition timing required to quantify the disease burden remain uncertain. METHODS AND RESULTS We retrospectively evaluated 99mTc-PYP SPECT/CT images of 23 patients diagnosed with ATTR-CM using endomyocardial biopsies and/or gene tests. All patients were assessed by SPECT/CT 1 hour after 99mTc-PYP injection, and 13 of them were also assessed at 3 hours. We quantified 99mTc-PYP uptake using the volumetric parameters, cardiac PYP volume (CPV) and cardiac PYP activity (CPA). We also calculated the SUVmax ratios of myocardial SUVmax/blood pool SUVmax, myocardial SUVmax/bone SUVmax, and the SUVmax retention index. We assessed the correlations between uptake parameters and the four functional parameters associated with prognosis, namely left ventricular ejection fraction, global longitudinal strain, myocardial extracellular volume, and troponin T. CPV and CPA correlated more closely than the SUVmax ratios with the four prognostic factors. Significant correlations between volumetric parameters and prognostic factors were equivalent between 1 and 3 hours. CONCLUSIONS The disease burden of ATTR-CM was quantified more accurately by volumetric evaluation of 99mTc-PYP SPECT/CT than SUVmax ratios and the performance was equivalent between 1 and 3 hours.
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Affiliation(s)
- Satoru Watanabe
- Department of Functional Imaging and Artificial Intelligence, Kanazawa University, Kanazawa, Japan.
- Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, 920-8641, Japan.
| | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa University, Kanazawa, Japan
| | - Fumihito Toshima
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Hiroshi Wakabayashi
- Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Shohei Yoshida
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Hiroto Yoneyama
- Department of Radiological Technology, Kanazawa University Hospital, Kanazawa, Japan
| | - Junji Komatsu
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Takahiro Konishi
- Department of Radiological Technology, Kanazawa University Hospital, Kanazawa, Japan
| | - Seigo Kinuya
- Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
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19
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Almeida ALC, Melo MDTD, Bihan DCDSL, Vieira MLC, Pena JLB, Del Castillo JM, Abensur H, Hortegal RDA, Otto MEB, Piveta RB, Dantas MR, Assef JE, Beck ALDS, Santo THCE, Silva TDO, Salemi VMC, Rocon C, Lima MSM, Barberato SH, Rodrigues AC, Rabschkowisky A, Frota DDCR, Gripp EDA, Barretto RBDM, Silva SME, Cauduro SA, Pinheiro AC, Araujo SPD, Tressino CG, Silva CES, Monaco CG, Paiva MG, Fisher CH, Alves MSL, Grau CRPDC, Santos MVCD, Guimarães ICB, Morhy SS, Leal GN, Soares AM, Cruz CBBV, Guimarães Filho FV, Assunção BMBL, Fernandes RM, Saraiva RM, Tsutsui JM, Soares FLDJ, Falcão SNDRS, Hotta VT, Armstrong ADC, Hygidio DDA, Miglioranza MH, Camarozano AC, Lopes MMU, Cerci RJ, Siqueira MEMD, Torreão JA, Rochitte CE, Felix A. Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023. Arq Bras Cardiol 2023; 120:e20230646. [PMID: 38232246 DOI: 10.36660/abc.20230646] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
Central Illustration : Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023 Proposal for including strain in the integrated diastolic function assessment algorithm, adapted from Nagueh et al.67 Am: mitral A-wave duration; Ap: reverse pulmonary A-wave duration; DD: diastolic dysfunction; LA: left atrium; LASr: LA strain reserve; LVGLS: left ventricular global longitudinal strain; TI: tricuspid insufficiency. Confirm concentric remodeling with LVGLS. In LVEF, mitral E wave deceleration time < 160 ms and pulmonary S-wave < D-wave are also parameters of increased filling pressure. This algorithm does not apply to patients with atrial fibrillation (AF), mitral annulus calcification, > mild mitral valve disease, left bundle branch block, paced rhythm, prosthetic valves, or severe primary pulmonary hypertension.
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Affiliation(s)
| | | | | | - Marcelo Luiz Campos Vieira
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
| | - José Luiz Barros Pena
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
- Hospital Felicio Rocho, Belo Horizonte, MG - Brasil
| | | | - Henry Abensur
- Beneficência Portuguesa de São Paulo, São Paulo, SP - Brasil
| | | | | | | | | | | | | | | | | | - Vera Maria Cury Salemi
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
| | - Camila Rocon
- Hospital do Coração (HCor), São Paulo, SP - Brasil
| | - Márcio Silva Miguel Lima
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Eliza de Almeida Gripp
- Hospital Pró-Cardiaco, Rio de Janeiro, RJ - Brasil
- Hospital Universitário Antônio Pedro da Universidade Federal Fluminense (UFF), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | | | | | | | | | - Maria Veronica Camara Dos Santos
- Departamento de Cardiologia Pediátrica (DCC/CP) da Sociedade Brasileira de Cardiologia (SBC), São Paulo, SP - Brasil
- Sociedade Brasileira de Oncologia Pediátrica, São Paulo, SP - Brasil
| | | | | | - Gabriela Nunes Leal
- Instituto da Criança e do Adolescente do Hospital das Clinicas Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | | | | | | | - Viviane Tiemi Hotta
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
- Grupo Fleury, São Paulo, SP - Brasil
| | | | - Daniel de Andrade Hygidio
- Hospital Nossa Senhora da Conceição, Tubarão, SC - Brasil
- Universidade do Sul de Santa Catarina (UNISUL), Tubarão, SC - Brasil
| | - Marcelo Haertel Miglioranza
- EcoHaertel - Hospital Mae de Deus, Porto Alegre, RS - Brasil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS - Brasil
| | | | | | | | | | - Jorge Andion Torreão
- Hospital Santa Izabel, Salvador, BA - Brasil
- Santa Casa da Bahia, Salvador, BA - Brasil
| | - Carlos Eduardo Rochitte
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
- Hospital do Coração (HCor), São Paulo, SP - Brasil
| | - Alex Felix
- Diagnósticos da América SA (DASA), São Paulo, SP - Brasil
- Instituto Nacional de Cardiologia (INC), Rio de Janeiro, RJ - Brasil
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20
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Chung FP, Chao TF, Lee AS, Sung KT, Huang WH, Hsiao CC, Su CH, Yang LT, Chen YJ, Chen YY, Liao JN, Jia-Yin Hou C, Yeh HI, Hung CL. Discriminative Ability of Left Ventricular Strain in Mildly Reduced Ejection Fraction Heart Failure. JACC. ADVANCES 2023; 2:100654. [PMID: 38938730 PMCID: PMC11198133 DOI: 10.1016/j.jacadv.2023.100654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/14/2023] [Accepted: 08/15/2023] [Indexed: 06/29/2024]
Abstract
Background Left ventricular (LV) systolic strain is presumably a more sensitive myocardial indicator than LV ejection fraction (LVEF). Data regarding the use of LV strain in clinical risk stratification and in identifying angiotensin receptor-neprilysin inhibitor (ARNi) responders remain scarce in heart failure with mildly reduced ejection fraction (HFmrEF). Objectives The authors aimed to examine whether assessing LV strain may provide prognostic insight beyond LVEF and help discriminate the therapeutic efficacy of ARNi in HFmrEF patients. Methods LVEF and LV strain were quantified among 1,075 first-time hospitalized HFmrEF patients (mean age: 68.1 ± 15.1 years, 40% female). The MAGGIC (Meta-analysis Global Group in Chronic Heart Failure) risk score and its components were calculated. A Cox proportional hazard model was constructed for time-to-event analysis. Restrictive cubic spline curves were used to model the therapeutic effects of ARNi against renin-angiotensin system inhibitor according to baseline LVEF or LV strain. Results LV strain showed a statistically significant inverse association with MAGGIC cardiac risk (coefficient: -0.14, P < 0.001). LV strain was independently associated with clinical outcomes after accounting for LVEF. MAGGIC-LV strain strata outperformed MAGGIC-LVEF strata in overall survival (Harrell's C-index: 0.71 and 0.56, P for difference <0.001; category-free net reclassification index: 0.44, P < 0.001). Lower LV strain but not LVEF consistently showed the beneficial therapeutic effects of ARNi against renin-angiotensin system inhibitor by Cox models and restrictive cubic spline (all P interaction <0.05). Conclusions Among HFmrEF patients, LV strain may serve as an attractive systolic marker and provide a better prognostic and therapeutic discriminative measure for ARNi treatment than conventional LVEF.
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Affiliation(s)
- Fa-Po Chung
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tze-Fan Chao
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - An-Sheng Lee
- Department of Medicine, MacKay Medical College, New Taipei, Taiwan
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Kuo-Tzu Sung
- Department of Medicine, MacKay Medical College, New Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Wen-Hung Huang
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Chung Hsiao
- Department of Medicine, MacKay Medical College, New Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Cheng-Huang Su
- Department of Medicine, MacKay Medical College, New Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Li-Tan Yang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Ju Chen
- Department of Telehealth, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yun-Yu Chen
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Jo-Nan Liao
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Charles Jia-Yin Hou
- Department of Medicine, MacKay Medical College, New Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, New Taipei City, Taiwan
| | - Hung-I Yeh
- Department of Medicine, MacKay Medical College, New Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chung-Lieh Hung
- Department of Medicine, MacKay Medical College, New Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- Institute of Biomedical Sciences, MacKay Medical College, New Taipei, Taiwan
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21
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Winsløw U, Sakthivel T, Zheng C, Philbert B, Vinther M, Frandsen E, Iversen K, Bundgaard H, Jøns C, Risum N. The effect of increased plasma potassium on myocardial function; a randomized POTCAST substudy. Int J Cardiovasc Imaging 2023; 39:2097-2106. [PMID: 37470856 PMCID: PMC10673982 DOI: 10.1007/s10554-023-02914-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 06/30/2023] [Indexed: 07/21/2023]
Abstract
Plasma potassium (p-K) in the high-normal range has been suggested to reduce risk of cardiovascular arrythmias and mortality through electrophysiological and mechanical effects on the myocardium. In this study, it was to investigated if increasing p-K to high-normal levels improves systolic- and diastolic myocardial function in patients with low-normal to moderately reduced left ventricular ejection fraction (LVEF). The study included 50 patients (mean age 58 years (SD 14), 81% men), with a mean p-K 3.95 mmol/l (SD 0.19), mean LVEF 48% (SD 7), and mean Global Longitudinal Strain (GLS) -14.6% (SD 3.1) patients with LVEF 35-55% from "Targeted potassium levels to decrease arrhythmia burden in high-risk patients with cardiovascular diseases trial" (POTCAST). Patients were given standard therapy and randomized (1:1) to an intervention that included guidance on potassium-rich diets, potassium supplements, and mineralocorticoid receptor antagonists targeting high-normal p-K levels (4.5-5.0 mmol/l). Echocardiography was done at baseline and after a mean follow-up of 44 days (SD 18) and the echocardiograms were analyzed for changes in GLS, mechanical dispersion, E/A, e', and E/e'. At follow-up, mean difference in changes in p-K was 0.52 mmol/l (95%CI 0.35;0.69), P<0.001 in the intervention group compared to controls. GLS was improved with a mean difference in changes of -1.0% (-2;-0.02), P<0.05 and e' and E/e' were improved with a mean difference in changes of 0.9 cm/s (0.02;1.7), P = 0.04 and ? 1.5 (-2.9;-0.14), P = 0.03, respectively. Thus, induced increase in p-K to the high-normal range improved indices of systolic and diastolic function in patients with low-normal to moderately reduced LVEF.
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Affiliation(s)
- Ulrik Winsløw
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark.
| | - Tharsika Sakthivel
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Chaoqun Zheng
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
| | - Berit Philbert
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Michael Vinther
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Emil Frandsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Kasper Iversen
- Department of Cardiology, Copenhagen University Hospital, Herlev-Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henning Bundgaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Jøns
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Niels Risum
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
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22
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Farina JM, Pereyra M, Mahmoud AK, Scalia IG, Abbas MT, Chao CJ, Barry T, Ayoub C, Banerjee I, Arsanjani R. Artificial Intelligence-Based Prediction of Cardiovascular Diseases from Chest Radiography. J Imaging 2023; 9:236. [PMID: 37998083 PMCID: PMC10672462 DOI: 10.3390/jimaging9110236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/18/2023] [Accepted: 10/24/2023] [Indexed: 11/25/2023] Open
Abstract
Chest radiography (CXR) is the most frequently performed radiological test worldwide because of its wide availability, non-invasive nature, and low cost. The ability of CXR to diagnose cardiovascular diseases, give insight into cardiac function, and predict cardiovascular events is often underutilized, not clearly understood, and affected by inter- and intra-observer variability. Therefore, more sophisticated tests are generally needed to assess cardiovascular diseases. Considering the sustained increase in the incidence of cardiovascular diseases, it is critical to find accessible, fast, and reproducible tests to help diagnose these frequent conditions. The expanded focus on the application of artificial intelligence (AI) with respect to diagnostic cardiovascular imaging has also been applied to CXR, with several publications suggesting that AI models can be trained to detect cardiovascular conditions by identifying features in the CXR. Multiple models have been developed to predict mortality, cardiovascular morphology and function, coronary artery disease, valvular heart diseases, aortic diseases, arrhythmias, pulmonary hypertension, and heart failure. The available evidence demonstrates that the use of AI-based tools applied to CXR for the diagnosis of cardiovascular conditions and prognostication has the potential to transform clinical care. AI-analyzed CXRs could be utilized in the future as a complimentary, easy-to-apply technology to improve diagnosis and risk stratification for cardiovascular diseases. Such advances will likely help better target more advanced investigations, which may reduce the burden of testing in some cases, as well as better identify higher-risk patients who would benefit from earlier, dedicated, and comprehensive cardiovascular evaluation.
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Affiliation(s)
- Juan M. Farina
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA (M.P.); (M.T.A.); (T.B.)
| | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA (M.P.); (M.T.A.); (T.B.)
| | - Ahmed K. Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA (M.P.); (M.T.A.); (T.B.)
| | - Isabel G. Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA (M.P.); (M.T.A.); (T.B.)
| | - Mohammed Tiseer Abbas
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA (M.P.); (M.T.A.); (T.B.)
| | - Chieh-Ju Chao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Timothy Barry
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA (M.P.); (M.T.A.); (T.B.)
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA (M.P.); (M.T.A.); (T.B.)
| | - Imon Banerjee
- Department of Radiology, Mayo Clinic, Phoenix, AZ 85054, USA;
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA (M.P.); (M.T.A.); (T.B.)
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23
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Sciatti E, Coccia MG, Magnano R, Aakash G, Limonta R, Diep B, Balestrieri G, D'Isa S, Abramov D, Parwani P, D'Elia E. Heart Failure Preserved Ejection Fraction in Women: Insights Learned from Imaging. Heart Fail Clin 2023; 19:461-473. [PMID: 37714587 DOI: 10.1016/j.hfc.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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
While the prevalence of heart failure, in general, is similar in men and women, women experience a higher rate of HFpEF compared to HFrEF. Cardiovascular risk factors, parity, estrogen levels, cardiac physiology, and altered response to the immune system may be at the root of this difference. Studies have found that in response to increasing age and hypertension, women experience more concentric left ventricle remodeling, more ventricular and arterial stiffness, and less ventricular dilation compared to men, which predisposes women to developing more diastolic dysfunction. A multi-modality imaging approach is recommended to identify patients with HFpEF. Particularly, appreciation of sex-based differences as described in this review is important in optimizing the evaluation and care of women with HFpEF.
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Affiliation(s)
- Edoardo Sciatti
- Cardiology Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | | | | | - Gupta Aakash
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Raul Limonta
- School of Medicine and Surgery, Milano Bicocca University, Milano, Italy
| | - Brian Diep
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | | | - Salvatore D'Isa
- Cardiology Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Dmitry Abramov
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Emilia D'Elia
- Cardiology Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy.
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24
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Brann A, Miller J, Eshraghian E, Park JJ, Greenberg B. Global longitudinal strain predicts clinical outcomes in patients with heart failure with preserved ejection fraction. Eur J Heart Fail 2023; 25:1755-1765. [PMID: 37369633 DOI: 10.1002/ejhf.2947] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 06/09/2023] [Accepted: 06/21/2023] [Indexed: 06/29/2023] Open
Abstract
AIMS Patients with heart failure with preserved ejection fraction (HFpEF) are at high risk for hospitalization and mortality and many of these patients experience a deterioration in left ventricular ejection fraction (LVEF) over time. Global longitudinal strain (GLS) is a sensitive marker of myocardial dysfunction that could help predict risk for future events in this population. We assessed whether GLS can predict adverse clinical outcomes and future deterioration in LVEF in patients with HFpEF. METHODS AND RESULTS In this retrospective cohort study, patients with HFpEF were divided into groups according to abnormal GLS (>-15.8%) or normal GLS (<-15.8%).The primary outcomes were: a composite of cardiovascular mortality or heart failure hospitalization and deterioration in LVEF to <40%. Among the 311 patients with HFpEF, 128 patients (41%) had normal GLS and 183 patients (59%) had abnormal GLS. After a median follow-up of 4.6 years, the composite outcome occurred more commonly in patients with abnormal GLS compared to patients with normal GLS (62% vs. 44%; hazard ratio [HR] 1.74, 95% confidence interval [CI] 1.3-2.4, p < 0.001). Patients with abnormal GLS were also more likely to experience a deterioration in LVEF (19% vs. 10%; HR 2.2, 95% CI 1.2-4.3, p = 0.018). When assessed as a continuous variable, each 1% increase in GLS was associated with 10% increased odds for the composite outcome and 13% increased odds for deterioration in LVEF. CONCLUSION In patients with HFpEF, abnormal GLS is common and is a strong predictor for clinical events and future deterioration in LVEF.
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Affiliation(s)
- Alison Brann
- Division of Cardiology, University of California San Diego, La Jolla, CA, USA
| | - James Miller
- Department of Internal Medicine, University of California San Diego, La Jolla, CA, USA
| | - Emily Eshraghian
- Division of Cardiology, University of California San Diego, La Jolla, CA, USA
| | - Jin Joo Park
- Division of Cardiology, University of California San Diego, La Jolla, CA, USA
- Division of Cardiology, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Barry Greenberg
- Division of Cardiology, University of California San Diego, La Jolla, CA, USA
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25
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Pan J, Ng SM, Neubauer S, Rider OJ. Phenotyping heart failure by cardiac magnetic resonance imaging of cardiac macro- and microscopic structure: state of the art review. Eur Heart J Cardiovasc Imaging 2023; 24:1302-1317. [PMID: 37267310 PMCID: PMC10531211 DOI: 10.1093/ehjci/jead124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/26/2023] [Indexed: 06/04/2023] Open
Abstract
Heart failure demographics have evolved in past decades with the development of improved diagnostics, therapies, and prevention. Cardiac magnetic resonance (CMR) has developed in a similar timeframe to become the gold-standard non-invasive imaging modality for characterizing diseases causing heart failure. CMR techniques to assess cardiac morphology and function have progressed since their first use in the 1980s. Increasingly efficient acquisition protocols generate high spatial and temporal resolution images in less time. This has enabled new methods of characterizing cardiac systolic and diastolic function such as strain analysis, exercise real-time cine imaging and four-dimensional flow. A key strength of CMR is its ability to non-invasively interrogate the myocardial tissue composition. Gadolinium contrast agents revolutionized non-invasive cardiac imaging with the late gadolinium enhancement technique. Further advances enabled quantitative parametric mapping to increase sensitivity at detecting diffuse pathology. Novel methods such as diffusion tensor imaging and artificial intelligence-enhanced image generation are on the horizon. Magnetic resonance spectroscopy (MRS) provides a window into the molecular environment of the myocardium. Phosphorus (31P) spectroscopy can inform the status of cardiac energetics in health and disease. Proton (1H) spectroscopy complements this by measuring creatine and intramyocardial lipids. Hyperpolarized carbon (13C) spectroscopy is a novel method that could further our understanding of dynamic cardiac metabolism. CMR of other organs such as the lungs may add further depth into phenotypes of heart failure. The vast capabilities of CMR should be deployed and interpreted in context of current heart failure challenges.
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Affiliation(s)
- Jiliu Pan
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Level 0, John Radcliffe Hospital, Oxford, OX3 9DU, United Kingdom
| | - Sher May Ng
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Level 0, John Radcliffe Hospital, Oxford, OX3 9DU, United Kingdom
| | - Stefan Neubauer
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Level 0, John Radcliffe Hospital, Oxford, OX3 9DU, United Kingdom
| | - Oliver J Rider
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Level 0, John Radcliffe Hospital, Oxford, OX3 9DU, United Kingdom
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26
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Attaran F, Emami S, Sohrabi M, Malek M, Ajdarkosh H, Khoonsari M, Ismail-Beigi F, Khamseh ME. Effect of Empagliflozin and Pioglitazone on left ventricular function in patients with type two diabetes and nonalcoholic fatty liver disease without established cardiovascular disease: a randomized single-blind clinical trial. BMC Gastroenterol 2023; 23:327. [PMID: 37742004 PMCID: PMC10517489 DOI: 10.1186/s12876-023-02948-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/06/2023] [Indexed: 09/25/2023] Open
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is a complex metabolic disorder that increases the risk for cardiovascular disease in patients with type 2 diabetes mellitus (T2DM). Global longitudinal strain (GLS) is an indicator of left ventricular (LV) mechanics and can detect subclinical myocardial dysfunction. We compared the effects of pioglitazone and empagliflozin on GLS in patients with T2DM and NAFLD without established atherosclerotic cardiovascular disease. METHODS This study was a 24-week randomized, single-blind, and parallel-group (1: 1 ratio) clinical trial. Seventy-three participants with T2DM (being treated with metformin) and NAFLD but without established atherosclerotic cardiovascular disease (ASCVD) were randomized to empagliflozin or pioglitazone. Liver steatosis and fibrosis were measured using transient elastography, and GLS was measured by echocardiography. The primary endpoint was the change in GLS from baseline to week 24. Secondary end points include changes in controlled attenuation parameter (CAP) and Liver stiffness measure (LSM). RESULTS In this study, GLS improved by 1.56 ± 2.34% (P < 0.01) in the pioglitazone group and 1.06 ± 1.83% (P < 0.01) in the empagliflozin group without a significant difference between the two groups (P = 0.31). At baseline, GLS was inversely associated with the severity of liver fibrosis: r = - 0.311, P = 0.007. LSM in the pioglitazone and empagliflozin group [(-0.73 ± 1.59) and (-1.11 ± 1.33)] kpa (P < 0.01) decreased significantly. It was without substantial difference between the two groups (P = 0.26). Empagliflozin and pioglitazone both improved controlled attenuation parameter. The improvement was more critical in the empagliflozin group: -48.22 + 35.02 dB/m vs. -25.67 + 41.50 dB/m, P = 0.01. CONCLUSION Subclinical cardiac dysfunction is highly important in patients with T2DM and with NAFLD. Empagliflozin and Pioglitazone improve LV mechanics and fibrosis in patients without established ASCVD. This has a prognostic importance on cardiovascular outcomes in high-risk patients with T2DM. Moreover, empagliflozin ameliorates liver steatosis more effectively them pioglitazone. This study can serve as a start point hypothesis for the future. Further studies are needed to explore the concept in larger populations. TRIAL REGISTRATION This trial was registered in the Iranian Registry of Clinical Trials (IRCT): "A Comparison between the Effect of Empagliflozin and Pioglitazone on Echocardiographic Indices in Patients with Type 2 Diabetes Mellitus and Nonalcoholic Fatty Liver Disease" IRCT20190122042450N5, 29 November 2020. https://www.irct.ir/search/result?query=IRCT20190122042450N5 .
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Affiliation(s)
- Fereshte Attaran
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, Iran University of Medical Science, No. 10, Firoozeh St., Vali-asr Ave., Vali-asr Sq, Tehran, Iran
| | - Sepideh Emami
- Department of Cardiology, Firoozgar Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Masoudreza Sohrabi
- Gastrointestinal and liver diseases research center, Iran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Malek
- Research Center for Prevention of Cardiovascular Disease, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Hossein Ajdarkosh
- Gastrointestinal and liver diseases research center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahmoodreza Khoonsari
- Gastrointestinal and liver diseases research center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad E Khamseh
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Science, Tehran, Iran.
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27
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Dong G. Development and Challenges of Pre-Heart Failure with Preserved Ejection Fraction. Rev Cardiovasc Med 2023; 24:274. [PMID: 39076392 PMCID: PMC11270127 DOI: 10.31083/j.rcm2409274] [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: 03/26/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2024] Open
Abstract
Pre-heart failure with preserved ejection fraction (Pre-HFpEF) is a critical link to the development of heart failure with preserved ejection fraction (HFpEF). Early recognition and early intervention of pre-HFpEF will halt the progression of HFpEF. This article addresses the concept proposal, development, and evolution of pre-HFpEF, the mechanisms and risks of pre-HFpEF, the screening methods to recognize pre-HFpEF, and the treatment of pre-HFpEF. Despite the challenges, we believe more focus on the topic will resolve more problems.
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Affiliation(s)
- Guoju Dong
- Department of Cardiovascular Internal Medicine, Xiyuan Hospital, Chinese
Academy of Traditional Chinese Medicine, 100091 Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan
Hospital, Chinese Academy of Traditional Chinese Medicine, 100091 Beijing, China
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28
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Kerstens TP, Weerts J, van Dijk APJ, Weijers G, Knackstedt C, Eijsvogels TMH, Oxborough D, van Empel VPM, Thijssen DHJ. Association of left ventricular strain-volume loop characteristics with adverse events in patients with heart failure with preserved ejection fraction. Eur Heart J Cardiovasc Imaging 2023; 24:1168-1176. [PMID: 37259911 PMCID: PMC10445262 DOI: 10.1093/ehjci/jead117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/24/2023] [Accepted: 05/15/2023] [Indexed: 06/02/2023] Open
Abstract
AIMS Patients with heart failure with preserved ejection fraction (HFpEF) are characterized by impaired diastolic function. Left ventricular (LV) strain-volume loops (SVL) represent the relation between strain and volume during the cardiac cycle and provide insight into systolic and diastolic function characteristics. In this study, we examined the association of SVL parameters and adverse events in HFpEF. METHODS AND RESULTS In 235 patients diagnosed with HFpEF, LV-SVL were constructed based on echocardiography images. The endpoint was a composite of all-cause mortality and Heart Failure (HF)-related hospitalization, which was extracted from electronic medical records. Cox-regression analysis was used to assess the association of SVL parameters and the composite endpoint, while adjusting for age, sex, and NYHA class. HFpEF patients (72.3% female) were 75.8 ± 6.9 years old, had a BMI of 29.9 ± 5.4 kg/m2, and a left ventricular ejection fraction of 60.3 ± 7.0%. Across 2.9 years (1.8-4.1) of follow-up, 73 Patients (31%) experienced an event. Early diastolic slope was significantly associated with adverse events [second quartile vs. first quartile: adjusted hazards ratio (HR) 0.42 (95%CI 0.20-0.88)] after adjusting for age, sex, and NYHA class. The association between LV peak strain and adverse events disappeared upon correction for potential confounders [adjusted HR 1.02 (95% CI 0.96-1.08)]. CONCLUSION Early diastolic slope, representing the relationship between changes in LV volume and strain during early diastole, but not other SVL-parameters, was associated with adverse events in patients with HFpEF during 2.9 years of follow-up.
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Affiliation(s)
- Thijs P Kerstens
- Department of Medical BioSciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Jerremy Weerts
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), P. Debyeplein 25, 6200 MD Maastricht, The Netherlands
| | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Gert Weijers
- Medical UltraSound Imaging Center (MUSIC), Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), P. Debyeplein 25, 6200 MD Maastricht, The Netherlands
| | - Thijs M H Eijsvogels
- Department of Medical BioSciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - David Oxborough
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool L3 5UX, UK
| | - Vanessa P M van Empel
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), P. Debyeplein 25, 6200 MD Maastricht, The Netherlands
| | - Dick H J Thijssen
- Department of Medical BioSciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool L3 5UX, UK
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29
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Xanthopoulos A, Katsiadas N, Skoularigkis S, Magouliotis DE, Skopeliti N, Patsilinakos S, Briasoulis A, Triposkiadis F, Skoularigis J. Association between Dapagliflozin, Cardiac Biomarkers and Cardiac Remodeling in Patients with Diabetes Mellitus and Heart Failure. Life (Basel) 2023; 13:1778. [PMID: 37629635 PMCID: PMC10455594 DOI: 10.3390/life13081778] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/17/2023] [Accepted: 08/19/2023] [Indexed: 08/27/2023] Open
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are a relatively new class of antidiabetic drugs that have shown favorable effects in heart failure (HF) patients, irrespective of the left ventricular ejection fraction (LVEF). Recent studies have demonstrated the beneficial effects of empagliflozin on cardiac function and structure; however, less is known about dapagliflozin. The purpose of the current work was to investigate the association between the use of dapagliflozin and cardiac biomarkers as well as the cardiac structure in a cohort of patients with HF and diabetes mellitus (DM). The present work was an observational study that included 118 patients (dapagliflozin group n = 60; control group n = 58) with HF and DM. The inclusion criteria included: age > 18 years, a history of DM and HF, regardless of LVEF, and hospitalization for HF exacerbation within the previous 6 months. The exclusion criteria were previous treatment with SGLT2i or glucagon-like peptide-1 receptor agonists, a GFR< 30 and life expectancy < 1 year. The evaluation of patients (at baseline, 6 and 12 months) included a clinical assessment, laboratory blood tests and echocardiography. The Mann-Whitney test was used for the comparison of continuous variables between the two groups, while Friedman's analysis of variance for repeated measures was used for the comparison of continuous variables. Troponin (p < 0.001) and brain natriuretic peptide (BNP) (p < 0.001) decreased significantly throughout the follow-up period in the dapagliflozin group, but not in the control group (p > 0.05 for both). The LV end-diastolic volume index (p < 0.001 for both groups) and LV end-systolic volume index (p < 0.001 for both groups) decreased significantly in the dapagliflozin and the control group, respectively. The LVEF increased significantly (p < 0.001) only in the dapagliflozin group, whereas the global longitudinal strain (GLS) improved in the dapagliflozin group (p < 0.001) and was impaired in the control group (p = 0.021). The left atrial volume index decreased in the dapagliflozin group (p < 0.001) but remained unchanged in the control group (p = 0.114). Lastly, the left ventricular mass index increased significantly both in the dapagliflozin (p = 0.003) and control group (p = 0.001). Dapagliflozin, an SGLT2i, was associated with a reduction in cardiac biomarkers and with reverse cardiac remodeling in patients with HF and DM.
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Affiliation(s)
- Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece; (S.S.); (N.S.); (F.T.)
| | - Nikolaos Katsiadas
- Department of Cardiology, Konstantopoulio General Hospital, 14233 Nea Ionia, Greece
| | - Spyridon Skoularigkis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece; (S.S.); (N.S.); (F.T.)
| | - Dimitrios E. Magouliotis
- Unit of Quality Improvement, Department of Cardiothoracic Surgery, University of Thessaly, 41110 Larissa, Greece;
| | - Niki Skopeliti
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece; (S.S.); (N.S.); (F.T.)
| | | | - Alexandros Briasoulis
- Department of Therapeutics, Heart Failure and Cardio-Oncology Clinic, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Filippos Triposkiadis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece; (S.S.); (N.S.); (F.T.)
| | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece; (S.S.); (N.S.); (F.T.)
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Yoshida Y, Jin Z, Nakanishi K, Matsumoto K, Homma S, Mannina C, Shames S, Elkind MSV, Rundek T, Di Tullio MR. Subclinical Left Ventricular Dysfunction and Ventricular Arrhythmias in Older Adults With Normal Ejection Fraction. J Am Heart Assoc 2023; 12:e030274. [PMID: 37577940 PMCID: PMC10492955 DOI: 10.1161/jaha.123.030274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/18/2023] [Indexed: 08/15/2023]
Abstract
Background Premature ventricular contractions (PVCs) and nonsustained ventricular tachycardia (NSVT) are known to be associated with reduced left ventricular (LV) ejection fraction and adverse outcomes in patients with structural heart disease. The relationship between subclinical LV dysfunction and ventricular arrhythmias in the general population is not established. Methods and Results Participants in the SAFARIS (Subclinical Atrial Fibrillation and Risk of Ischemic Stroke) study with normal left ventricular ejection fraction (n=503; mean age 77 years, 63% women) underwent 14-day electrocardiographic monitoring and 2-dimensional echocardiography. Frequent PVCs were defined as PVCs >500 per 24 hours and NSVT as ≥4 consecutive ventricular ectopic beats. Reduced LV global longitudinal strain (GLS) was used as an indicator of subclinical LV dysfunction. Seventy-six participants (15.1%) had PVCs >500/d, 117 (23.3%) had NSVT episodes. LV GLS was significantly reduced in both frequent PVCs and NSVT groups (P<0.01). In multivariable analyses, lower LV GLS was associated with frequent PVCs (adjusted odds ratio [aOR], 1.19 [95% CI, 1.09-1.30 per unit reduction]; P<0.001) and NSVT (aOR, 1.09 [95% CI, 1.01-1.17]; P=0.036) independently of established risk factors and other echocardiographic parameters. Abnormal LV GLS (>-15.8%) carried a 2-fold increase in risk of ventricular arrhythmias (aOR, 2.18, P=0.029 for PVCs; aOR, 2.09, P=0.026 for NSVT). Conclusions PVCs and NSVT episodes were frequent in this community-based elderly cohort with normal left ventricular ejection fraction and were independently associated with lower LV GLS. The association between LV dysfunction and ventricular arrhythmias is present at an early, subclinical stage, an observation that carries possible preventative implications.
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Affiliation(s)
| | - Zhezhen Jin
- Department of BiostatisticsColumbia UniversityNew YorkNY
| | - Koki Nakanishi
- Department of Cardiovascular MedicineThe University of TokyoTokyoJapan
| | | | | | | | - Sofia Shames
- Department of MedicineColumbia UniversityNew YorkNY
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNY
- Department of Epidemiology, Mailman School of Public HealthColumbia UniversityNew YorkNY
| | - Tatjana Rundek
- Department of Neurology, Evelyn F. McKnight Brain Institute, Miller School of MedicineUniversity of MiamiFL
- Department of Public Health SciencesUniversity of MiamiFL
- Clinical and Translational Science Institute, Miller School of MedicineUniversity of MiamiFL
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31
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Giro P, Cunningham JW, Rasmussen-Torvik L, Bielinski SJ, Larson NB, Colangelo LA, Jacobs DR, Gross M, Reiner AP, Lloyd-Jones DM, Guo X, Taylor K, Vaduganathan M, Post WS, Bertoni A, Ballantyne C, Shah A, Claggett B, Boerwinkle E, Yu B, Solomon SD, Shah SJ, Patel RB. Missense Genetic Variation of ICAM1 and Incident Heart Failure. J Card Fail 2023; 29:1163-1172. [PMID: 36882149 PMCID: PMC10477308 DOI: 10.1016/j.cardfail.2023.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Intercellular adhesion molecule-1 (ICAM-1) is a cell surface protein that participates in endothelial activation and is hypothesized to play a central role in heart failure (HF). We evaluated associations of ICAM1 missense genetic variants with circulating ICAM-1 levels and with incident HF. METHODS AND RESULTS We identified 3 missense variants within ICAM1 (rs5491, rs5498 and rs1799969) and evaluated their associations with ICAM-1 levels in the Coronary Artery Risk Development in Young Adults Study and the Multi-Ethnic Study of Atherosclerosis (MESA). We determined the association among these 3 variants and incident HF in MESA. We separately evaluated significant associations in the Atherosclerosis Risk in Communities (ARIC) study. Of the 3 missense variants, rs5491 was common in Black participants (minor allele frequency [MAF] > 20%) and rare in other race/ethnic groups (MAF < 5%). In Black participants, the presence of rs5491 was associated with higher levels of circulating ICAM-1 at 2 timepoints separated by 8 years. Among Black participants in MESA (n = 1600), the presence of rs5491 was associated with an increased risk of incident HF with preserved ejection fraction (HFpEF; HR = 2.30; [95% CI 1.25-4.21; P = 0.007]). The other ICAM1 missense variants (rs5498 and rs1799969) were associated with ICAM-1 levels, but there were no associations with HF. In ARIC, rs5491 was significantly associated with incident HF (HR = 1.24 [95% CI 1.02 - 1.51]; P = 0.03), with a similar direction of effect for HFpEF that was not statistically significant. CONCLUSIONS A common ICAM1 missense variant among Black individuals may be associated with increased risk of HF, which may be HFpEF-specific.
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Affiliation(s)
- Pedro Giro
- From the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jonathan W Cunningham
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Laura Rasmussen-Torvik
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Nicholas B Larson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Laura A Colangelo
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - David R Jacobs
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN
| | - Myron Gross
- Department of Laboratory Medicine and Pathology, University of Minnesota School of Medicine, Minneapolis, MN
| | - Alex P Reiner
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Donald M Lloyd-Jones
- From the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Xiuqing Guo
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Kent Taylor
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Muthiah Vaduganathan
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Wendy S Post
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Alain Bertoni
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Amil Shah
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Brian Claggett
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Eric Boerwinkle
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center, Houston, TX
| | - Bing Yu
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center, Houston, TX
| | - Scott D Solomon
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Sanjiv J Shah
- From the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ravi B Patel
- From the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
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Motoi K, Iwano H, Ishizaka S, Nakamura K, Tamaki Y, Aoyagi H, Nakabachi M, Yokoyama S, Nishino H, Murayama M, Kaga S, Anzai T. Paradoxical increase in global longitudinal strain by handgrip exercise despite left ventricular diastolic dysfunction. Echocardiography 2023; 40:810-821. [PMID: 37449835 DOI: 10.1111/echo.15648] [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: 04/02/2023] [Revised: 06/11/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Although global longitudinal strain (GLS) is recognized as a sensitive marker of intrinsic left ventricular (LV) dysfunction, its afterload dependency has also been pointed. We hypothesized that decrease in GLS during handgrip exercise could be more sensitive marker of intrinsic myocardial dysfunction. METHODS Handgrip exercise-stress echocardiography was performed in 90 cardiovascular disease patients with preserved LV ejection fraction. LV diastolic function was graded according to the guidelines. Diastolic wall stress (DWS) and ratio of left atrial (LA) volume index to late-diastolic mitral annular velocity (LAVI/a') were measured at rest as LV stiffness. As well, LA strains were measured to assess LA function. GLS was expressed as absolute value and significant changes in GLS by handgrip exercise was defined as changes over prespecified mean absolute test-retest variability (2.65%). RESULTS While mean value of GLS did not change by the exercise, substantial patients showed significant changes in GLS: decreased (group I, n = 28), unchanged (group II, n = 34), and increased (group III, n = 28). Unexpectedly, patients in group I did not show any clinical and echocardiographic characteristics, while those in group III were characterized by elevated natriuretic peptide levels, blunted heart rate response to handgrip exercise, and advanced LV diastolic dysfunction. Multivariable analyses revealed that DWS, left atrial booster strain, and grade II or more diastolic dysfunction determined the increase in GLS even after adjustment for elevated natriuretic peptides and the changes in heart rate by the exercise. CONCLUSION In contrast to our hypothesis, paradoxical increase in GLS by handgrip exercise could be associated with advanced LV diastolic dysfunction in cardiovascular patients with preserved LV ejection fraction. Our findings suggest that HG exercise for heart failure patients does not enhance the afterload straightforward, resulting in variable changes of GLS according to the individual conditions.
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Affiliation(s)
- Ko Motoi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroyuki Iwano
- Division of Cardiology, Teine Keijinkai Hospital, Sapporo, Japan
- Diagnostic Center for Sonography, Hokkaido University Hospital, Sapporo, Japan
| | - Suguru Ishizaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kosuke Nakamura
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yoji Tamaki
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroyuki Aoyagi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masahiro Nakabachi
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Shinobu Yokoyama
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Hisao Nishino
- Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Sapporo, Japan
| | | | - Sanae Kaga
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Pergola V, D’Andrea A, Galzerano D, Mantovani F, Rizzo M, Giannuario GD, Khoury G, Polizzi V, Rabia G, Gimelli A, Campana M. Unveiling the Hidden Chamber: Exploring the Importance of Left Atrial Function and Filling Pressure in Cardiovascular Health. J Cardiovasc Echogr 2023; 33:117-124. [PMID: 38161774 PMCID: PMC10756315 DOI: 10.4103/jcecho.jcecho_44_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/17/2023] [Accepted: 09/28/2023] [Indexed: 01/03/2024] Open
Abstract
The left atrium (LA) is a vital component of the cardiovascular system, playing a crucial role in cardiac function. It acts as a reservoir, conduit, and contractile chamber, contributing to optimal left ventricle (LV) filling and cardiac output. Abnormalities in LA function have been associated with various cardiovascular conditions, including heart failure, atrial fibrillation, valvular heart disease, and hypertension. Elevated left ventricular filling pressures resulting from impaired LA function can lead to diastolic dysfunction and increase the risk of adverse cardiovascular events. Understanding the relationship between LA function and LV filling pressures is crucial for comprehending the pathophysiology of cardiovascular diseases and guiding clinical management strategies. This article provides an overview of the anatomy and physiology of the LA, discusses the role of LA mechanics in maintaining normal cardiac function, highlights the clinical implications of elevated filling pressures, and explores diagnostic methods for assessing LA function and filling pressures. Furthermore, it discusses the prognostic implications and potential therapeutic approaches for managing patients with abnormal LA function and elevated filling pressure. Continued research and clinical focus on left atrial function are necessary to improve diagnostic accuracy, prognostic assessment, and treatment strategies in cardiovascular diseases. It will explore the importance of assessing LA function as a marker of cardiac performance and evaluate its implications for clinical practice. In accordance with rigorous scientific methodology, our search encompassed PubMed database. We selected articles deemed pertinent to our subject matter. Subsequently, we extracted and synthesized the salient contents, capturing the essence of each selected article.
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Affiliation(s)
- Valeria Pergola
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | | | - Domenico Galzerano
- The Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | - Massimiliano Rizzo
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | | | - Vincenzo Polizzi
- Cardiology Unit, Ospedale Cervello, AOOR Villa Sofia Cervello, Palermo, Italy
| | - Granit Rabia
- Department of Cardiology, Carlo Poma Hospital, Mantua, Italy
| | - Alessia Gimelli
- Fondazione Toscana Gabriele Monasterio, Imaging Department, Pisa, Italy
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Yogeswaran V, Wadden E, Szewczyk W, Barac A, Simon MS, Eaton C, Cheng RK, Reding KW. A narrative review of heart failure with preserved ejection fraction in breast cancer survivors. Heart 2023:heartjnl-2022-321859. [PMID: 37258098 DOI: 10.1136/heartjnl-2022-321859] [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: 02/28/2023] [Accepted: 05/07/2023] [Indexed: 06/02/2023] Open
Abstract
Advances in breast cancer (BC) treatment have contributed to improved survival, but BC survivors experience significant short-term and long-term cardiovascular mortality and morbidity, including an elevated risk of heart failure with preserved ejection fraction (HFpEF). Most research has focused on HF with reduced ejection fraction (HFrEF) after BC; however, recent studies suggest HFpEF is the more prevalent subtype after BC and is associated with substantial health burden. The increased HFpEF risk observed in BC survivors may be explained by treatment-related toxicity and by shared risk factors that heighten risk for both BC and HFpEF. Beyond risk factors with physiological impacts that drive HFpEF risk, such as hypertension and obesity, social determinants of health (SDOH) likely contribute to HFpEF risk after BC, impacting diagnosis, management and prognosis.Increasing clinical awareness of HFpEF after BC and screening for cardiovascular (CV) risk factors, in particular hypertension, may be beneficial in this high-risk population. When BC survivors develop HFpEF, treatment focuses on initiating guideline-directed medical therapy and addressing underlying comorbidities with pharmacotherapy or behavioural intervention. HFpEF in BC survivors is understudied. Future directions should focus on improving HFpEF prevention and treatment by building a deeper understanding of HFpEF aetiology and elucidating contributing risk factors and their pathogenesis in HFpEF in BC survivors, in particular the association with different BC treatment modalities, including radiation therapy, chemotherapy, biological therapy and endocrine therapy, for example, aromatase inhibitors. In addition, characterising how SDOH intersect with these therapies is of paramount importance to develop future prevention and management strategies.
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Affiliation(s)
- Vidhushei Yogeswaran
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Elena Wadden
- Division of Internal Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Warren Szewczyk
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
| | - Ana Barac
- Department of Cardiology, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Michael S Simon
- Medical Oncology, Karmanos Cancer Center, Detroit, Michigan, USA
| | - Charles Eaton
- Family Medicine and Epidemiology Program, Brown University, Providence, Rhode Island, USA
| | - Richard K Cheng
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Kerryn W Reding
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
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35
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Bjerregaard CL, Skaarup KG, Lassen MCH, Biering-Sørensen T, Olsen FJ. Strain Imaging and Ventricular Arrhythmia. Diagnostics (Basel) 2023; 13:diagnostics13101778. [PMID: 37238262 DOI: 10.3390/diagnostics13101778] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
Ventricular arrhythmia is one of the main causes of sudden cardiac death. Hence, identifying patients at risk of ventricular arrhythmias and sudden cardiac death is important but can be challenging. The indication for an implantable cardioverter defibrillator as a primary preventive strategy relies on the left ventricular ejection fraction as a measure of systolic function. However, ejection fraction is flawed by technical constraints and is an indirect measure of systolic function. There has, therefore, been an incentive to identify other markers to optimize the risk prediction of malignant arrhythmias to select proper candidates who could benefit from an implantable cardioverter defibrillator. Speckle-tracking echocardiography allows for a detailed assessment of cardiac mechanics, and strain imaging has repeatedly been shown to be a sensitive technique to identify systolic dysfunction unrecognized by ejection fraction. Several strain measures, including global longitudinal strain, regional strain, and mechanical dispersion, have consequently been proposed as potential markers of ventricular arrhythmias. In this review, we will provide an overview of the potential use of different strain measures in the context of ventricular arrhythmias.
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Affiliation(s)
- Caroline Løkke Bjerregaard
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, 2900 Hellerup, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Kristoffer Grundtvig Skaarup
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, 2900 Hellerup, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Mats Christian Højbjerg Lassen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, 2900 Hellerup, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, 2900 Hellerup, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Flemming Javier Olsen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, 2900 Hellerup, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
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D’Andrea A, Ilardi F, Palermi S, Riegler L, Miele T, Giallauria F, D’Alto M, Russo V, Cice G. Multimodality imaging in decompensated heart failure. Eur Heart J Suppl 2023; 25:C292-C300. [PMID: 37125293 PMCID: PMC10132613 DOI: 10.1093/eurheartjsupp/suad052] [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: 05/02/2023]
Abstract
Heart failure (HF) is usually suspected by clinical history, symptoms, physical examination, electrocardiogram findings, and natriuretic peptides' values. However, echocardiography and other imaging techniques play an essential role in supporting HF diagnosis. Thanks to its non-invasiveness and safety, transthoracic echocardiography is the first-level technique of choice to assess myocardial structure and function, trying to establish the diagnosis of HF with reduced, mildly reduced, and preserved ejection fraction. The role of echocardiography is not limited to diagnosis but it represents a crucial tool in guiding therapeutic decision-making and monitoring response to therapy. Over the last decades, several technological advancements were made in the imaging field, aiming at better understanding the morphofunctional abnormalities occurring in cardiovascular diseases. The purpose of this review article is to summarize the incremental role of imaging techniques (in particular cardiac magnetic resonance and myocardial scintigraphy) in HF, highlighting their essential applications to HF diagnosis and management.
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Affiliation(s)
- Antonello D’Andrea
- Corresponding author. Department of Translational Medical Sciences, Unit of Cardiology, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, 80131 Naples, Italy; Unit of Cardiology and Intensive Coronary Care, “Umberto I” Hospital, 84014 Nocera Inferiore, Italy.
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via S. Pansini, 5, 80131 Naples, Italy
- Public Health Department, University of Naples Federico II, Via S. Pansini, 5, 80131 Naples, Italy
| | - Stefano Palermi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Via S. Pansini, 5, 80131 Naples, Italy
| | - Lucia Riegler
- Department of Cardiology, Umberto I Hospital, Via Alfonso de Nicola, 84014 Nocera Inferiore, Italy
| | - Tiziana Miele
- Unit of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Francesco Giallauria
- Unit of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Michele D’Alto
- Unit of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Vincenzo Russo
- Unit of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Naples, Italy
| | - Gennaro Cice
- Department of Cardiology, Policlinico Casilino, Via Casilina, 1049, 00169 Rome
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Popovic D, Alogna A, Omar M, Sorimachi H, Omote K, Reddy YNV, Redfield MM, Burkhoff D, Borlaug BA. Ventricular stiffening and chamber contracture in heart failure with higher ejection fraction. Eur J Heart Fail 2023; 25:657-668. [PMID: 36994635 PMCID: PMC10330082 DOI: 10.1002/ejhf.2843] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/02/2023] [Accepted: 03/26/2023] [Indexed: 03/31/2023] Open
Abstract
AIMS Ancillary analyses from clinical trials have suggested reduced efficacy for neurohormonal antagonists among patients with heart failure and preserved ejection fraction (HFpEF) and higher ranges of ejection fraction (EF). METHODS AND RESULTS A total of 621 patients with HFpEF were grouped into those with low-normal left ventricular EF (LVEF) (HFpEF<65% , n = 319, 50% ≤ LVEF <65%) or HFpEF≥65% (n = 302, LVEF ≥65%), and compared with 149 age-matched controls undergoing comprehensive echocardiography and invasive cardiopulmonary exercise testing. A sensitivity analysis was performed in a second non-invasive community-based cohort of patients with HFpEF (n = 244) and healthy controls without cardiovascular disease (n = 617). Patients with HFpEF≥65% had smaller left ventricular (LV) end-diastolic volume than HFpEF<65% , but LV systolic function assessed by preload recruitable stroke work and stroke work/end-diastolic volume was similarly impaired. Patients with HFpEF≥65% displayed an end-diastolic pressure-volume relationship (EDPVR) that was shifted leftward, with increased LV diastolic stiffness constant β, in both invasive and community-based cohorts. Cardiac filling pressures and pulmonary artery pressures at rest and during exercise were similarly abnormal in all EF subgroups. While patients HFpEF≥57% displayed leftward shifted EDPVR, those with HFpEF<57% had a rightward shifted EDPVR more typical of heart failure with reduced EF. CONCLUSION Most pathophysiologic differences in patients with HFpEF and higher EF are related to smaller heart size, increased LV diastolic stiffness, and leftward shift in the EDPVR. These findings may help to explain the absence of efficacy for neurohormonal antagonists in this group and raise a new hypothesis, that interventions to stimulate eccentric LV remodelling and enhance diastolic capacitance may be beneficial for patients with HFpEF and EF in the higher range.
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Affiliation(s)
- Dejana Popovic
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alessio Alogna
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Massar Omar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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38
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Peters AE, Clare RM, Chiswell K, Felker GM, Kelsey A, Mentz R, DeVore AD. Echocardiographic Features Beyond Ejection Fraction and Associated Outcomes in Patients With Heart Failure With Mildly Reduced or Preserved Ejection Fraction. Circ Heart Fail 2023; 16:e010252. [PMID: 37192287 PMCID: PMC10195029 DOI: 10.1161/circheartfailure.122.010252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/30/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Heart failure (HF) guidelines recommend assessment of left ventricular ejection fraction (LVEF) to classify patients and guide therapy implementation. However, LVEF alone may be insufficient to adequately characterize patients with HF, especially those with mildly reduced or preserved LVEF. Recommendations on additional testing are lacking, and there are limited data on use of echocardiographic features beyond LVEF in patients with heart failure with mildly reduced or preserved LVEF. METHODS In patients with HF with mildly reduced or preserved LVEF identified in a large US health care system, the association of the following metrics with mortality was evaluated: LV global longitudinal strain (LV GLS>-16), left atrial volume index (>28 mL/m2), left ventricular hypertrophy (LVH), and E/e´>13 and e´<9. A multivariable model for mortality was constructed including age, sex, and key comorbidities followed by stepwise selection of echocardiographic features. Characteristics and outcomes of subgroups with normal versus abnormal LV GLS and LVEF were evaluated. RESULTS Among 2337 patients with complete echocardiographic data assessed between 2017 and 2020, the following features were associated with all-cause mortality on univariate analysis over 3 years of follow-up: E/e´+e´, LV GLS, left atrial volume index (all P<0.01). In the multivariable model (C-index=0.65), only abnormal LV GLS was independently associated with all-cause mortality (HR, 1.35 [95% CI, 1.11-1.63]; P=0.002). Among patients with LVEF>55%, 498/1255 (40%) demonstrated abnormal LV GLS. Regardless of specific LVEF, patients with abnormal LV GLS demonstrated a higher burden of multiple comorbidities and higher event rates compared with patients with normal LV GLS. CONCLUSIONS In a large, real-world HF with mildly reduced or preserved LVEF population, echocardiographic features, led by LV GLS, were associated with adverse outcomes irrespective of LVEF. A large proportion of patients demonstrate adverse myocardial function by LV GLS despite preserved LVEF and may represent a key cohort of interest for HF medical therapies and future clinical studies.
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Affiliation(s)
- Anthony E. Peters
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Karen Chiswell
- Duke Clinical Research Institute, Durham, North Carolina
| | - G. Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Anita Kelsey
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Robert Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Adam D. DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
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Li Q, Zhong H, Yu S, Cheng Y, Dai Y, Huang F, Lin Z, Zhu P. The Role of MR Assessments of Cardiac Morphology, Function, and Tissue Characteristics on Exercise Capacity in Well-Functioning Older Adults. J Magn Reson Imaging 2023; 57:1262-1274. [PMID: 35924395 DOI: 10.1002/jmri.28373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/14/2022] [Accepted: 07/14/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The relationship between resting cardiac indices and exercise capacity in older adults was still not well understood. New developments in cardiac magnetic resonance imaging (MRI) enable a much fuller assessment of cardiac characteristics. PURPOSE/HYPOTHESIS To assess the association between exercise capacity and specific aspects of resting cardiac structure, function, and tissue. STUDY TYPE Cross-sectional study. POPULATION A total of 112 well-functioning older adults (mean age 69 years, 52 men). FIELD STRENGTH/SEQUENCE All participants underwent 3.0 T MRI, using scan protocols including balanced steady-state free precession cine sequence, modified look-locker inversion recovery, and T2-prepared single-shot balanced steady-state free precession. ASSESSMENT Demographic and geriatric characteristics were collected. Blood samples were assayed for lipid and glucose related biomarkers. All participants performed a symptom-limited cardiopulmonary exercise test to achieve peakVO2 . Cardiac MRI parameters were measured with semi-automatic software by S.Y., an 18-year experienced radiologist. STATISTICAL TESTS Demographic, geriatric characteristics and MR measurements were compared among quartiles of peakVO2, with different methods according to the data type. Spearman's partial correlation and least absolute shrinkage selection operator regression were performed to select significant MR features associated with peakVO2 . Mediation effect analysis was conducted to test any indirect connection between age and peakVO2 . A two-sided P value of <0.05 was defined statistical significance. RESULTS Epicardial fat volume, left atrial volume indexed to height, right ventricular end-systolic volume indexed to body surface area and global circumferential strain (GCS) were correlated with peakVO2 (regression coefficients were -0.040, -0.093, 0.127, and 0.408, respectively). Mediation analysis showed that the total effect of peakVO2 change was 43.6% from the change of age. The proportion of indirect effect from epicardial fat volume and GCS were 11.8% and 15.1% in total effect, respectively. DATA CONCLUSION PeakVO2 was associated with epicardial fat volume, left atrial volume, right ventricular volume and GCS of left ventricle. EVIDENCE LEVEL 4 TECHNICAL EFFICACY: Stage 5.
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Affiliation(s)
- Qiaowei Li
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People's Republic of China.,Department of Geriatric Medicine, Fujian Provincial Hospital, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Geriatrics, Fuzhou, People's Republic of China.,Fujian Provincial Center for Geriatrics, Fuzhou, People's Republic of China
| | - Huijuan Zhong
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Geriatrics, Fuzhou, People's Republic of China.,Fujian Provincial Center for Geriatrics, Fuzhou, People's Republic of China
| | - Shun Yu
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People's Republic of China.,Department of Radiology, Fujian Provincial Hospital, Fuzhou, Fujian, People's Republic of China
| | - Yanling Cheng
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Geriatrics, Fuzhou, People's Republic of China.,Fujian Provincial Center for Geriatrics, Fuzhou, People's Republic of China
| | - Yalan Dai
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Geriatrics, Fuzhou, People's Republic of China.,Fujian Provincial Center for Geriatrics, Fuzhou, People's Republic of China
| | - Feng Huang
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People's Republic of China.,Department of Geriatric Medicine, Fujian Provincial Hospital, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Geriatrics, Fuzhou, People's Republic of China.,Fujian Provincial Center for Geriatrics, Fuzhou, People's Republic of China
| | - Zhonghua Lin
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People's Republic of China.,Department of Geriatric Medicine, Fujian Provincial Hospital, Fuzhou, People's Republic of China.,Fujian Provincial Center for Geriatrics, Fuzhou, People's Republic of China
| | - Pengli Zhu
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, People's Republic of China.,Department of Geriatric Medicine, Fujian Provincial Hospital, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Geriatrics, Fuzhou, People's Republic of China.,Fujian Provincial Center for Geriatrics, Fuzhou, People's Republic of China
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Affiliation(s)
- Alicja Jasinska-Piadlo
- Cardiology Department, Southern Health and Social Care Trust, Portadown, UK
- School of Computing, Ulster University, Belfast, UK
| | - Patricia Campbell
- Cardiology Department, Southern Health and Social Care Trust, Portadown, UK
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Yoshida Y, Jin Z, Russo C, Homma S, Nakanishi K, Ito K, Mannina C, Elkind MSV, Rundek T, Yoshita M, DeCarli C, Wright CB, Sacco RL, Di Tullio MR. Subclinical left ventricular systolic dysfunction and incident stroke in the elderly: long-term findings from Cardiovascular Abnormalities and Brain Lesions. Eur Heart J Cardiovasc Imaging 2023; 24:522-531. [PMID: 35900282 PMCID: PMC10226754 DOI: 10.1093/ehjci/jeac145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/06/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS Heart disease is associated with an increased risk for ischaemic stroke. However, the predictive value of reduced left ventricular ejection fraction (LVEF) for stroke is controversial and only observed in patients with severe reduction. LV global longitudinal strain (LV GLS) can detect subclinical LV systolic impairment when LVEF is normal. We investigated the prognostic role of LV GLS for incident stroke in a predominantly elderly cohort. METHODS AND RESULTS Two-dimensional echocardiography with speckle tracking was performed in the Cardiac Abnormalities and Brain Lesions (CABL) study. Among 708 stroke-free participants (mean age 71.4 ± 9.4 years, 60.9% women), abnormal LV GLS (>-14.7%: 95% percentile of the subgroup without risk factors) was detected in 133 (18.8%). During a mean follow-up of 10.8 ± 3.9 years, 47 participants (6.6%) experienced an ischaemic stroke (26 cardioembolic or cryptogenic, 21 other subtypes). The cumulative incidence of ischaemic stroke was significantly higher in participants with abnormal LV GLS than with normal LV GLS (P < 0.001). In multivariate stepwise logistic regression analysis, abnormal LV GLS was associated with ischaemic stroke independently of cardiovascular risk factors including LVEF, LV mass, left atrial volume, subclinical cerebrovascular disease at baseline, and incident atrial fibrillation [hazard ratio (HR): 2.69, 95% confidence interval (CI): 1.47-4.92; P = 0.001]. Abnormal LV GLS independently predicted cardioembolic or cryptogenic stroke (adjusted HR: 3.57, 95% CI: 1.51-8.43; P = 0.004) but not other subtypes. CONCLUSION LV GLS was a strong independent predictor of ischaemic stroke in a predominantly elderly stroke-free cohort. Our findings provide insights into the brain-heart interaction and may help improve stroke primary prevention strategies.
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Affiliation(s)
- Yuriko Yoshida
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Zhezhen Jin
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Cesare Russo
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Shunichi Homma
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Koki Nakanishi
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Kazato Ito
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Carlo Mannina
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Mitchell S V Elkind
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Tatjana Rundek
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Mitsuhiro Yoshita
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Charles DeCarli
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Clinton B Wright
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Ralph L Sacco
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Marco R Di Tullio
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
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Ng ML, Ang X, Yap KY, Ng JJ, Goh ECH, Khoo BBJ, Richards AM, Drum CL. Novel Oxidative Stress Biomarkers with Risk Prognosis Values in Heart Failure. Biomedicines 2023; 11:biomedicines11030917. [PMID: 36979896 PMCID: PMC10046491 DOI: 10.3390/biomedicines11030917] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/17/2023] [Accepted: 02/26/2023] [Indexed: 03/18/2023] Open
Abstract
Oxidative stress (OS) is mediated by reactive oxygen species (ROS), which in cardiovascular and other disease states, damage DNA, lipids, proteins, other cellular and extra-cellular components. OS is both initiated by, and triggers inflammation, cardiomyocyte apoptosis, matrix remodeling, myocardial fibrosis, and neurohumoral activation. These have been linked to the development of heart failure (HF). Circulating biomarkers generated by OS offer potential utility in patient management and therapeutic targeting. Novel OS-related biomarkers such as NADPH oxidases (sNox2-dp, Nrf2), advanced glycation end-products (AGE), and myeloperoxidase (MPO), are signaling molecules reflecting pathobiological changes in HF. This review aims to evaluate current OS-related biomarkers and their associations with clinical outcomes and to highlight those with greatest promise in diagnosis, risk stratification and therapeutic targeting in HF.
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Affiliation(s)
- Mei Li Ng
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Xu Ang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Kwan Yi Yap
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Jun Jie Ng
- Vascular Surgery, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore 119074, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Eugene Chen Howe Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Benjamin Bing Jie Khoo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Arthur Mark Richards
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Cardiovascular Research Institute, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, NUHCS, Singapore 119228, Singapore
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117599, Singapore
| | - Chester Lee Drum
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Cardiovascular Research Institute, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, NUHCS, Singapore 119228, Singapore
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117599, Singapore
- Correspondence:
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Fairweather D, Beetler DJ, Musigk N, Heidecker B, Lyle MA, Cooper LT, Bruno KA. Sex and gender differences in myocarditis and dilated cardiomyopathy: An update. Front Cardiovasc Med 2023; 10:1129348. [PMID: 36937911 PMCID: PMC10017519 DOI: 10.3389/fcvm.2023.1129348] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/06/2023] [Indexed: 03/06/2023] Open
Abstract
In the past decade there has been a growing interest in understanding sex and gender differences in myocarditis and dilated cardiomyopathy (DCM), and the purpose of this review is to provide an update on this topic including epidemiology, pathogenesis and clinical presentation, diagnosis and management. Recently, many clinical studies have been conducted examining sex differences in myocarditis. Studies consistently report that myocarditis occurs more often in men than women with a sex ratio ranging from 1:2-4 female to male. Studies reveal that DCM also has a sex ratio of around 1:3 women to men and this is also true for familial/genetic forms of DCM. Animal models have demonstrated that DCM develops after myocarditis in susceptible mouse strains and evidence exists for this progress clinically as well. A consistent finding is that myocarditis occurs primarily in men under 50 years of age, but in women after age 50 or post-menopause. In contrast, DCM typically occurs after age 50, although the age that post-myocarditis DCM occurs has not been investigated. In a small study, more men with myocarditis presented with symptoms of chest pain while women presented with dyspnea. Men with myocarditis have been found to have higher levels of heart failure biomarkers soluble ST2, creatine kinase, myoglobin and T helper 17-associated cytokines while women develop a better regulatory immune response. Studies of the pathogenesis of disease have found that Toll-like receptor (TLR)2 and TLR4 signaling pathways play a central role in increasing inflammation during myocarditis and in promoting remodeling and fibrosis that leads to DCM, and all of these pathways are elevated in males. Management of myocarditis follows heart failure guidelines and there are currently no disease-specific therapies. Research on standard heart failure medications reveal important sex differences. Overall, many advances in our understanding of the effect of biologic sex on myocarditis and DCM have occurred over the past decade, but many gaps in our understanding remain. A better understanding of sex and gender effects are needed to develop disease-targeted and individualized medicine approaches in the future.
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Affiliation(s)
- DeLisa Fairweather
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
- Department of Environmental Health Sciences and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, United States
| | - Danielle J. Beetler
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, United States
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Jacksonville, FL, United States
| | - Nicolas Musigk
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bettina Heidecker
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Melissa A. Lyle
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Leslie T. Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
| | - Katelyn A. Bruno
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL, United States
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Coiro S, Huttin O, Kobayashi M, Lamiral Z, Simonovic D, Zannad F, Rossignol P, Girerd N. Validation of the MEDIA echo score for the prognosis of heart failure with preserved ejection fraction. Heart Fail Rev 2023; 28:453-464. [PMID: 36038694 DOI: 10.1007/s10741-022-10266-2] [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] [Accepted: 07/20/2022] [Indexed: 11/24/2022]
Abstract
There is currently no widely used prognostic score in heart failure (HF) with preserved ejection fraction (HFpEF). The MEDIA echo score, including four variables (pulmonary arterial systolic pressure > 40 mmHg, inferior vena cava collapsibility index < 50%, average E/e' > 9, and lateral mitral annular s' < 7 cm/s), has been proposed as a useful risk stratification tool. This study aimed at further validating the MEDIA echo score in both hospitalised and ambulatory HFpEF patients. The MEDIA echo score ranges from 0 to 4 (each criterion scores 1 point). The associations between MEDIA echo score and cardiovascular outcomes were assessed in two independent HFpEF cohorts, namely patients hospitalised for worsening HFpEF (N = 242, mean age 78 ± 11), and stable ambulatory HFpEF patients (N = 76, mean age 65 ± 8). Using multivariable Cox models, in the worsening HFpEF cohort, patients with a MEDIA echo score of 3-4 displayed a significant increased risk of death (HR 2.10, 95%CI 1.02-4.33, P = 0.043, score 0-1 as reference). In the ambulatory HFpEF cohort, patients with a MEDIA echo score of 2 had a significantly higher risk of death or HF hospitalisation (HR 3.44, 95%CI 1.27-9.30, P = 0.015, score 0 as reference), driven by HF hospitalisation; in that cohort, adding the MEDIA echo score to the clinical model significantly improved reclassification for the combined endpoint (integrated discrimination improvement 6.2%, P = 0.006). The MEDIA echo score significantly predicted the outcome of HFpEF patients in both hospital and ambulatory settings; its use may help refine routine risk stratification on top of well-established prognosticators in stable HFpEF patients.
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Affiliation(s)
- Stefano Coiro
- Cardiology Department, Santa Maria Della Misericordia Hospital, Perugia, Italy.,Centre D'Investigation Clinique-Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
| | - Olivier Huttin
- Centre D'Investigation Clinique-Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
| | - Masatake Kobayashi
- Centre D'Investigation Clinique-Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
| | - Zohra Lamiral
- Centre D'Investigation Clinique-Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
| | - Dejan Simonovic
- Institute for Treatment and Rehabilitation "Niska Banja", Clinic of Cardiology, University of Nis School of Medicine, Nis, Serbia
| | - Faiez Zannad
- Centre D'Investigation Clinique-Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
| | - Patrick Rossignol
- Centre D'Investigation Clinique-Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
| | - Nicolas Girerd
- Centre D'Investigation Clinique-Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France.
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Detection of myocardial dysfunction using global longitudinal strain with speckle-tracking echocardiography in patients with vs without rheumatoid arthritis: a systematic review and meta-analysis. J Echocardiogr 2023; 21:23-32. [PMID: 35987937 DOI: 10.1007/s12574-022-00583-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/04/2022] [Accepted: 07/19/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVES Rheumatoid arthritis (RA) is a systemic autoimmune disorder primarily involving the peripheral joints. Systemic involvement can occur, including myocardial dysfunction. Speckle tracking echocardiography (STE) is a novel diagnostic study which is recently being used to detect subclinical cardiac dysfunction. Global longitudinal strain (GLS) by STE is more sensitive than standard echocardiographic parameters to detect occult cardiac dysfunction. METHODS A systematic search of PUBMED, EMBASE, Cochrane, and Google Scholar databases was performed to identify studies comparing the STE parameters between RA and non-RA patients. RESULTS Left ventricular (LV) GLS was significantly lower in patients with RA compared to non-RA patients with a standard mean difference (SMD) of -1.09 (-1.48--0.70, P < 0.001). LV Global Circumferential Strain (GCS) was reported in five studies, and it was found to be lower in RA patients with an SMD of -1.25 (-2.59--0.10; P < 0.0010). Meta regression analysis studies failed to show any significant impact of disease duration, activity, age, sex and BMI on LV GLS and RV GLS. CONCLUSIONS RA patients have lower LV GLS and LV GCS compared to controls suggesting impaired myocardial dysfunction. Further studies need to be done to delineate the importance of lower GLS in asymptomatic rheumatoid patients to guide disease management and risk factor modification in this selected population.
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Li H, Zheng Y, Peng X, Liu H, Li Y, Tian Z, Hou Y, Jin S, Huo H, Liu T. Heart failure with preserved ejection fraction in post myocardial infarction patients: a myocardial magnetic resonance (MR) tissue tracking study. Quant Imaging Med Surg 2023; 13:1723-1739. [PMID: 36915319 PMCID: PMC10006144 DOI: 10.21037/qims-22-793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/11/2022] [Indexed: 12/28/2022]
Abstract
Background This study aimed to explore the value of cardiac magnetic resonance tissue tracking (CMR-TT) technology in evaluating heart failure with preserved ejection fraction (HFpEF) in patients with chronic myocardial infarction (CMI). Methods Between June 2016 and March 2022, we included a consecutive series of 92 patients with CMI and 40 healthy controls in this retrospective study. The CMI patients enrolled were divided into different subgroups [HFpEF-CMI group (n=54) and non- heart failure (HF)-CMI group (n=38)] according to the Heart Failure Association (HFA)-PEFF (step 1: P, pre-test assessment; step 2: E, echocardiography and natriuretic peptide score; step 3: F1, functional testing; step 4: F2, final aetiology) diagnostic algorithm. CMR scan was performed at the First Hospital of China Medical University. Quantitative measurements of myocardial damage, such as myocardial strain parameters of both ventricles derived by CMR-TT and infarct size and transmurality by late gadolinium enhancement (LGE), were assessed. One-way analysis of variance, independent samples t-test, and rank sum test were used to compare myocardial impairment among groups. Pearson or Spearman correlation coefficient was used to measure correlations between left ventricular (LV) strains and clinical and functional parameters. Logistic regression analysis and receiver operating characteristic (ROC) curve were performed to identify the best parameter for diagnosing HFpEF-CMI. Results HFpEF-CMI patients demonstrated significantly impaired LV strains and strain rates in all of the three directions (radial, circumferential and longitudinal) compared to non-HF-CMI patients and healthy controls (P<0.001 for all), whereas only global longitudinal strain (GLS) was significantly impaired in HFpEF-CMI patients vs. controls for right ventricular strain parameters (P<0.001). LV strains showed moderate correlation with N-terminal pro-brain natriuretic peptide (radial, circumferential and longitudinal strain, R=-0.401, R=0.408, R=0.407, respectively, P<0.001 for all). LV strains in the three directions (radial, circumferential and longitudinal) [area under ROC curve (AUC) =0.707, 95% confidence interval (CI): 0.603-0.797; AUC =0.708, 95% CI: 0.604-0.798; AUC =0.731, 95% CI: 0.628-0.818; respectively, P<0.01 for all] were discriminators for HFpEF-CMI and non-HF-CMI. LV strains and myocardial infarction volume were independent factors in multi-logistic regression analysis after adjusting for body mass index, age, and sex (P<0.05 for all). Conclusions CMR-TT provides clinicians with useful additional imaging parameters to facilitate the assessment of CMI patients with HFpEF. LV strain parameters can detect early cardiac insufficiency in patients with HFpEF-CMI and have potential value for discriminating between HFpEF and non-HF patients post-CMI.
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Affiliation(s)
- Han Li
- Department of Radiology, The First Hospital of China Medical University, Shenyang, China
| | - Yue Zheng
- Department of Radiology, The First Hospital of China Medical University, Shenyang, China
| | - Xin Peng
- Department of Radiology, The First Hospital of China Medical University, Shenyang, China
| | - Hui Liu
- Department of Radiology, The First Hospital of China Medical University, Shenyang, China
| | - Yue Li
- Department of Radiology, The First Hospital of China Medical University, Shenyang, China
| | - Zhaoxin Tian
- Department of Radiology, The First Hospital of China Medical University, Shenyang, China
| | - Yang Hou
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shiqi Jin
- Department of Radiology, The First Hospital of China Medical University, Shenyang, China
| | - Huaibi Huo
- Department of Radiology, The First Hospital of China Medical University, Shenyang, China
| | - Ting Liu
- Department of Radiology, The First Hospital of China Medical University, Shenyang, China
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Meucci MC, Stassen J, Tomsic A, Palmen M, Crea F, Bax JJ, Ajmone Marsan N, Delgado V. Prognostic impact of left ventricular global longitudinal strain in atrial mitral regurgitation. Heart 2023; 109:478-484. [PMID: 36270784 DOI: 10.1136/heartjnl-2022-321698] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/10/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Left atrial (LA) and left ventricular (LV) mechanics are impaired in patients with atrial functional mitral regurgitation (AFMR), but their prognostic value in this subset of patients remains unknown. The present study aimed to evaluate the association between LA and LV longitudinal strain and clinical outcomes in patients with AFMR. METHODS A total of 197 patients (mean age 73±10 years, 44% men) with at least moderate AFMR were retrospectively identified. LV global longitudinal strain (GLS) and left atrial reservoir strain (LAS) were calculated by two-dimensional speckle tracking echocardiography. All-cause mortality was the primary endpoint of the study. The threshold value of LV GLS (≤16.3%) to identify impaired LV mechanics was defined based on the risk excess of the primary endpoint described with a spline curve analysis. RESULTS Impaired LV GLS (≤16.3%) was found in 89 (45%) patients. During a median follow-up of 69 months, 45 (23%) subjects experienced the primary endpoint. Patients with impaired LV GLS (≤16.3%) had a significantly lower cumulative survival rate at 5 years, as compared with patients with LV GLS (>16.3%) (74% vs 93%, p<0.001). On multivariable Cox regression analysis, LV GLS expressed as continuous variable was independently associated with the occurrence of all-cause mortality (HR 0.856, 95% CI 0.763 to 0.960; p=0.008) after adjustment for age, LAS, pulmonary artery systolic pressure and severe tricuspid regurgitation. Conversely, LAS was not significantly associated with patients' outcome. CONCLUSIONS In patients with significant AFMR, the impairment of LV GLS was independently associated with worse outcomes.
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Affiliation(s)
- Maria Chiara Meucci
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Jan Stassen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Anton Tomsic
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Meindert Palmen
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.,Heart Center, University of Turku and Turku University Hospital, Turku, Finland
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands .,Hospital University Germans Trias i Pujol, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
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Considering Both GLS and MD for a Prognostic Value in Non-ST-Segment Elevated Acute Coronary Artery Syndrome. Diagnostics (Basel) 2023; 13:diagnostics13040745. [PMID: 36832233 PMCID: PMC9955699 DOI: 10.3390/diagnostics13040745] [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: 01/12/2023] [Revised: 02/06/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
Global longitudinal strain (GLS) and mechanical dispersion (MD), as determined by 2D speckle tracking echocardiography, have been demonstrated to be reliable indicators of prognosis in a variety of cardiovascular illnesses. There are not many papers that discuss the prognostic significance of GLS and MD in a population with non-ST-segment elevated acute coronary syndrome (NSTE-ACS). Our study objective was to examine the predictive utility of the novel GLS/MD two-dimensional strain index in NSTE-ACS patients. Before discharge and four to six weeks later, echocardiography was performed on 310 consecutive hospitalized patients with NSTE-ACS and effective percutaneous coronary intervention (PCI). Cardiac mortality, malignant ventricular arrhythmia, or readmission owing to heart failure or reinfarction were the major end points. A total of 109 patients (35.16%) experienced cardiac incidents during the follow-up period (34.7 ± 8 months). The GLS/MD index at discharge was determined to be the greatest independent predictor of composite result by receiver operating characteristic analysis. The ideal cut-off value was -0.229. GLS/MD was determined to be the top independent predictor of cardiac events by multivariate Cox regression analysis. Patients with an initial GLS/MD > -0.229 that deteriorated after four to six weeks had the worst prognosis for a composite outcome, readmission, and cardiac death according to a Kaplan-Meier analysis (all p < 0.001). In conclusion, the GLS/MD ratio is a strong indicator of clinical fate in NSTE-ACS patients, especially if it is accompanied by deterioration.
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49
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The Diagnostic and Prognostic Value of Cardiac Magnetic Resonance Strain Analysis in Heart Failure with Preserved Ejection Fraction. CONTRAST MEDIA & MOLECULAR IMAGING 2023; 2023:5996741. [PMID: 36793498 PMCID: PMC9925252 DOI: 10.1155/2023/5996741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/02/2022] [Accepted: 12/24/2022] [Indexed: 02/08/2023]
Abstract
Background Strain analysis of cardiac magnetic resonance (CMR) is critical for the diagnosis and prognosis of heart failure (HF) with preserved ejection fraction (HFpEF). Our study aimed to identify the diagnostic and prognostic value of strain analysis revealed by CMR in HFpEF. Methods Participants in HFpEF and control were recruited according to the guideline. Baseline information, clinical parameters, blood samples were collected, and echocardiography and CMR examination were performed. Various parameters, including global longitudinal strain, global circumferential strain (GCS) and global radial strain in left ventricle (LV), right ventricle (RV), and left atrium, were measured from CMR. Receiver operator curve (ROC) was established to evaluate the diagnostic and prognostic value of strains in HFpEF. Results Seven strains, with the exception of RVGCS, were employed to generate ROC curves after t-test. All strains had significant diagnostic value for HFpEF. The area under curve (AUC) of LV strains was greater than 0.7 and the AUC of the combined analysis of LV strains was 0.858 (95% confidence interval (CI): 0.798-0.919, sensitivity: 0.713, specificity: 0.875, P < 0.001), indicating that they had a higher diagnostic value than individual LV strains. However, individual strains had no predictive value in identifying end-point events in HFpEF, the AUC of coanalysis of LV strains was 0.722 (95% CI: 0.573-0.872, sensitivity: 0.500, specificity: 0.959, P = 0.004), indicating its prognostic relevance. Conclusion Individual strain analysis in CMR may be useful for diagnosing HFpEF, the combination of LV strain analysis had the highest diagnostic value. Moreover, the prognostic value of individual strain analysis in predicting HFpEF outcome was not satisfactory while the combined usage of LV strain analysis was prognostically valuable in HFpEF outcome prediction.
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50
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Borlaug BA, Jensen MD, Kitzman DW, Lam CSP, Obokata M, Rider OJ. Obesity and heart failure with preserved ejection fraction: new insights and pathophysiological targets. Cardiovasc Res 2023; 118:3434-3450. [PMID: 35880317 PMCID: PMC10202444 DOI: 10.1093/cvr/cvac120] [Citation(s) in RCA: 77] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/28/2022] [Accepted: 07/01/2022] [Indexed: 02/07/2023] Open
Abstract
Obesity and heart failure with preserved ejection fraction (HFpEF) represent two intermingling epidemics driving perhaps the greatest unmet health problem in cardiovascular medicine in the 21st century. Many patients with HFpEF are either overweight or obese, and recent data have shown that increased body fat and its attendant metabolic sequelae have widespread, protean effects systemically and on the cardiovascular system leading to symptomatic HFpEF. The paucity of effective therapies in HFpEF underscores the importance of understanding the distinct pathophysiological mechanisms of obese HFpEF to develop novel therapies. In this review, we summarize the current understanding of the cardiovascular and non-cardiovascular features of the obese phenotype of HFpEF, how increased adiposity might pathophysiologically contribute to the phenotype, and how these processes might be targeted therapeutically.
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Affiliation(s)
- Barry A Borlaug
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
| | | | - Dalane W Kitzman
- Department of Internal Medicine, Section on Cardiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Oliver J Rider
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, Oxford Centre for Clinical Magnetic Resonance Research, University of Oxford, Oxford, UK
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