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Ainab I, Van Ochten N, Suckow E, Pierce K, Arent C, Kay J, Forbes LM, Cornwell WK. Determinants of cardiac output in health and heart failure. Exp Physiol 2025; 110:637-648. [PMID: 40121540 PMCID: PMC12053893 DOI: 10.1113/ep091505] [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: 09/16/2024] [Accepted: 02/20/2025] [Indexed: 03/25/2025]
Abstract
Sustained physical exercise depends on delivery of oxygenated blood to exercising muscle. At least among healthy individuals, bulk transport of blood is tightly matched to metabolic demand, such that cardiac output increases by ∼6 L/min for every 1 L/min increase in oxygen uptake. Multiple factors contribute to the regulation of cardiac output, including central command, the exercise pressor reflex (EPR) and arterial baroreceptors. Pulmonary arterial and left ventricular pressures increase in proportion to the rise in cardiac output and exercise intensity. The right ventricle augments contractility to maintain ventricular-arterial (VA) coupling and lusitropy to facilitate venous return. Among patients with heart failure (HF), however, the ability to deliver blood to exercising muscle is compromised as a result of multiple abnormalities impacting EPR, ventricular contractility, haemodynamics and VA coupling. The purpose of this review is to provide an overview of the factors limiting exercise capacity and cardiac output among patients with HF compared to what is known about normal physiology among healthy individuals.
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Affiliation(s)
- Ibrahim Ainab
- Department of Medicine‐CardiologyUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Natalie Van Ochten
- Department of MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Emmett Suckow
- Department of Medicine‐CardiologyUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Kathryn Pierce
- Clinical Translational Research CenterUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Chelsea Arent
- Clinical Translational Research CenterUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Joseph Kay
- Department of MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Lindsey M. Forbes
- Department of Medicine, Division of Pulmonary and Critical Care MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - William K. Cornwell
- Department of MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
- Clinical Translational Research CenterUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
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Kittipibul V, Novelli A, Yaranov D, Swavely A, Ferreira LF, Molinger J, Jefferies JL, Miller WL, Fudim M. Relationship of red blood cell mass profiles and anemia type to outcomes and cardiopulmonary exercise performance in chronic heart failure. Am Heart J 2025; 288:131-139. [PMID: 40306395 DOI: 10.1016/j.ahj.2025.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2024] [Revised: 04/19/2025] [Accepted: 04/22/2025] [Indexed: 05/02/2025]
Abstract
BACKGROUND Blood volume analysis (BVA) allows direct measurement of red blood cell mass (RBCM) and differentiation of true and dilutional anemia in heart failure (HF). This study aimed to characterize the relationships of RBCM profiles and anemia types to HF outcomes and cardiopulmonary exercise test (CPET) parameters. METHODS Chronic stable HF patients were prospectively enrolled. All patients underwent BVA; a subset underwent supine invasive CPET within 24 hours of BVA. RBCM profiles were defined using RBCM %deviation (deficit: <-10%, normal: -10 to 10%, excess: >10%). Anemia defined by World Health Organization criteria alone was categorized using RBCM %deviation (<-10% true anemia, ≥-10% dilutional pseudo-anemia). HF hospitalization at 6 months and CPET parameters were compared among RBCM profiles and anemia types. RESULTS One-hundred twenty patients (58 years, 40% female, 41% Black, 63% HFrEF) were enrolled. Forty percent had RBCM deficit, 37.5% had normal RBCM, and 22.5% had excess RBCM. Fifty-eight patients (48%) were anemic: 60% true anemia and 40% dilutional pseudo-anemia. Patients with dilutional pseudo-anemia had a higher incidence of HF hospitalization (44.8%) compared to no anemia (22.7%) and true anemia (20.6%) (P = .040). There was no difference in HF hospitalization among RBCM profiles (P = .99). There was a nonsignificant trend toward worse peak VO2 in RBCM deficit and true anemia, with no differences in other CPET parameters. CONCLUSIONS Dilutional pseudo-anemia demonstrated higher HF hospitalizations compared to true anemia, while true anemia had a trend towards worse peak VO2. The implications of BVA-identified RBCM profiles and anemia types for clinical management warrant further investigation.
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Affiliation(s)
- Veraprapas Kittipibul
- Division of Cardiology, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Alexandra Novelli
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC
| | - Dmitry Yaranov
- Department of Cardiology, Baptist Memorial Hospital, Memphis, TN
| | - Ashley Swavely
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | | | - Jeroen Molinger
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | | | - Wayne L Miller
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC.
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Selvaraj S, Karaj A, Chirinos JA, Denney N, Grosso G, Fernando M, Chambers K, Demastus C, Reddy R, Langham M, Kumar D, Maynard H, Pourmussa B, Prenner SB, Cohen JB, Ischiropoulos H, Rickels MR, Poole DC, Church DD, Wolfe RR, Kelly DP, Putt M, Margulies KB, Zamani P. Crossover Trial of Exogenous Ketones on Cardiometabolic Endpoints in Heart Failure With Preserved Ejection Fraction. JACC. HEART FAILURE 2025:102435. [PMID: 40243975 DOI: 10.1016/j.jchf.2025.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2025] [Revised: 03/10/2025] [Accepted: 03/19/2025] [Indexed: 04/18/2025]
Abstract
BACKGROUND The etiology of exercise intolerance in heart failure with preserved ejection fraction (HFpEF) is multifactorial. Several contributing pathways may be improved by ketone ester (KE). OBJECTIVES This study aims to determine whether KE improves exercise tolerance in HFpEF. METHODS KETO-HFpEF (Ketogenic Exogenous Therapies in HFpEF) is a randomized, crossover, placebo-controlled trial of acute KE dosing in 20 symptomatic HFpEF participants. Coprimary endpoints include peak oxygen consumption (VO2) during incremental cardiopulmonary exercise testing and time to exhaustion during an additional constant-intensity exercise (75% peak workload) bout. RESULTS The average age was 71 ± 8 years, 60% were women, and 65% were White. KE did not improve peak VO2 (KE: 10.4 ± 3.6 vs placebo: 10.5 ± 4.0 mL/kg/min; P = 0.75). At rest, heart rate, biventricular systolic function, and cardiac output (0.6 L/min [95% CI: 0.3-1.0 L/min]) were greater with KE vs placebo, whereas total peripheral resistance (-3.2 WU [95% CI: -5.2 to -1.2 WU]) and the arteriovenous oxygen content difference (-0.7 mL of O2/dL blood [95% CI: -1.2 to -0.2 mL]) were lower. These differences mostly disappeared during incremental exercise. KE did not improve exercise endurance during the constant-intensity protocol (9.7 ± 7.3 minutes vs 8.7 ± 4.4 minutes; P = 0.51). In 6 participants receiving 6,6-2H2-glucose infusions during constant-intensity exercise, plasma glucose appearance rate before and during exercise was lower with KE (-0.24 mg/kg/min; P < 0.001). During both exercise protocols, KE lowered: 1) respiratory exchange ratios, demonstrating decreased systemic carbohydrate use; 2) nonesterified fatty acids and glucose; and 3) estimated left ventricular filling pressures (E/e'). CONCLUSIONS Despite robust ketosis, shifting substrate use away from carbohydrates, and decreasing estimated left ventricular filling pressures, acute KE supplementation did not improve peak VO2 or constant-intensity exercise in HFpEF. (Ketogenic Exogenous Therapies in HFpEF [KETO-HFpEF]; NCT04633460).
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Affiliation(s)
- Senthil Selvaraj
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Duke University Medical Center, Durham, North Carolina, USA; Duke Molecular Physiology Institute, Durham, North Carolina, USA; Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Antoneta Karaj
- Department of Biostatistics, Epidemiology, and Informatics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Julio A Chirinos
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicole Denney
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gabby Grosso
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Melissa Fernando
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kishon Chambers
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cassandra Demastus
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ravinder Reddy
- Department of Medicine and Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Langham
- Department of Medicine and Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dushyant Kumar
- Department of Medicine and Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hannah Maynard
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bianca Pourmussa
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stuart B Prenner
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jordana B Cohen
- Division of Nephrology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Harry Ischiropoulos
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania, USA
| | - Michael R Rickels
- Division of Endocrinology, Diabetes & Metabolism, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Institute for Diabetes, Obesity and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David C Poole
- Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan, Kansas, USA
| | - David D Church
- Department of Geriatrics, Donald W. Reynolds Institute on Aging, Center for Translational Research in Aging and Longevity, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Robert R Wolfe
- Department of Geriatrics, Donald W. Reynolds Institute on Aging, Center for Translational Research in Aging and Longevity, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Daniel P Kelly
- Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mary Putt
- Department of Biostatistics, Epidemiology, and Informatics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kenneth B Margulies
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Payman Zamani
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
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Oliveira MI, Bragança B, Gomes JR, Santos M. Cardiac Involvement and Heart Failure Staging in Patients with Systemic Sclerosis Without Pulmonary Arterial Hypertension. J Clin Med 2025; 14:2211. [PMID: 40217662 PMCID: PMC11989942 DOI: 10.3390/jcm14072211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2025] [Revised: 03/17/2025] [Accepted: 03/19/2025] [Indexed: 04/14/2025] Open
Abstract
Background/Objectives: Systemic sclerosis (SSc) is an autoimmune connective tissue disease characterized by fibrosis and vascular damage, significantly increasing the risk of heart failure (HF). Methods: This cross-sectional study included 61 SSc patients (92% female, mean age 63 ± 13 years), excluding those with pulmonary arterial hypertension, referred to a tertiary pulmonary hypertension center. HF stages were classified according to updated guidelines. Clinical, echocardiographic, hemodynamic, and functional capacity data were analyzed in relation to HF stages. Results: A total of 48% of patients had pre-symptomatic HF (5% stage A, 43% stage B), while 38% had symptomatic HF (stage C). Advanced HF stages were significantly associated with older age (p = 0.02) and multiorgan involvement (p = 0.045) but not with SSc subtype or autoantibodies. Structural and functional echocardiographic abnormalities were prevalent (77% and 10%, respectively). Markers of elevated ventricular filling pressure such as left atrial volume (p = 0.011) and E/e' ratio (p = 0.03) correlated with HF severity. Functional impairment was observed with lower 6 min walk test (6MWT) distance (p = 0.017), reduced VO2 peak (p = 0.015), and increased VE/VCO2 slope (p = 0.002). Resting pulmonary artery wedge pressure did not correlate with HF stage (p = 0.93). VE/VCO2 slope and 6MWT were independently associated with HF severity. Conclusions: Preclinical and symptomatic HF are highly prevalent in SSc patients. HF staging was linked to disease severity, age, and cardiovascular risk factors. Functional capacity tests (6MWT and CPET) serve as valuable tools for HF risk stratification. These findings highlight the critical need for comprehensive cardiovascular assessment and targeted management strategies to mitigate HF progression in SSc patients.
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Affiliation(s)
- Maria Isilda Oliveira
- Pulmonary Vascular Disease Unit, Department of Cardiology, Unidade Local de Saúde de Santo António, 4099-001 Porto, Portugal;
- Department of Immuno-Physiology and Pharmacology, Unidade Multidisciplinar de Investigação Biomédica (UMIB), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, 4050-313 Porto, Portugal
- Physical Activity, Health and Leisure Research Centre (CIAFEL), Faculty of Sports, University of Porto, 4200-450 Porto, Portugal
| | - Bruno Bragança
- Department of Cardiology, Unidade Local de Saúde Tâmega e Sousa, 4564-007 Penafiel, Portugal;
- Department of Immuno-Physiology and Pharmacology, Centro de Investigação Farmacológica e Inovação Medicamentosa (MedInUP), RISE-Health, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), University of Porto, 4050-313 Porto, Portugal
| | - José Rodrigues Gomes
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), University of Porto, 4050-313 Porto, Portugal
| | - Mário Santos
- Pulmonary Vascular Disease Unit, Department of Cardiology, Unidade Local de Saúde de Santo António, 4099-001 Porto, Portugal;
- Department of Immuno-Physiology and Pharmacology, Unidade Multidisciplinar de Investigação Biomédica (UMIB), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, 4050-313 Porto, Portugal
- ITR—Laboratory for Integrative and Translational Research in Population Health, Rua das Taipas 135, 4050-600 Porto, Portugal
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Pecchia B, Samuel R, Shah V, Newman E, Gibson GT. Mechanisms of exercise intolerance in heart failure with preserved ejection fraction (HFpEF). Heart Fail Rev 2025:10.1007/s10741-025-10504-3. [PMID: 40080287 DOI: 10.1007/s10741-025-10504-3] [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: 03/04/2025] [Indexed: 03/15/2025]
Abstract
Exercise intolerance is a well-established symptom of heart failure with preserved ejection fraction (HFpEF) and is associated with impaired quality of life and worse clinical outcomes. Historically attributed to diastolic dysfunction of the left ventricle, exercise intolerance in HFpEF is now known to result not only from diastolic dysfunction, but also from impairments in left ventricular systolic function, left atrial pathology, right ventricular dysfunction, and valvular disease. Disorders of heart rate and rhythm such as chronotropic incompetence and atrial fibrillation have also been implicated in exercise intolerance in this population. Pathologic changes to extra-cardiac organ systems including the respiratory, vascular, hormonal, and skeletal muscle systems are also thought to play a role in exercise impairment. Finally, comorbidities such as obesity, inflammation, and anemia are common and likely contributory in many cases. The role of each of these factors is discussed in this review of exercise intolerance in patients with HFpEF.
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Affiliation(s)
- Brandon Pecchia
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Roy Samuel
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Vacha Shah
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Emily Newman
- Division of Cardiology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA 19107, US, Philadelphia, PA, 19107, USA
| | - Gregory T Gibson
- Division of Cardiology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA 19107, US, Philadelphia, PA, 19107, USA.
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Washio T, Takeda R, Hissen SL, Akins JD, D'Souza AW, Wakeham DJ, Brazile T, Lutz K, Hearon CM, MacNamara JP, Sarma S, Levine BD, Fadel PJ, Fu Q. Maintained sympathetic reactivity but blunted pressor response to static handgrip exercise in heart failure with preserved ejection fraction. Clin Auton Res 2025:10.1007/s10286-025-01114-y. [PMID: 40000578 DOI: 10.1007/s10286-025-01114-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2024] [Accepted: 01/22/2025] [Indexed: 02/27/2025]
Abstract
PURPOSE Recent studies have reported blunted increases in blood pressure (BP) during static handgrip (SHG) in patients with heart failure with preserved ejection fraction (HFpEF), which may be attributed to abnormal sympathetic reactivity during exercise and/or impaired muscle metaboreflex function. However, it is unknown whether the sympathetic neural response to SHG and isolated muscle metaboreflex activation via post-exercise circulatory occlusion (PECO) are attenuated in HFpEF. METHODS Thirty-nine patients with HFpEF and 24 age-matched non-HFpEF controls were studied in the supine position. BP, heart rate (HR), and muscle sympathetic nerve activity (MSNA) were measured during SHG at 40% of maximal voluntary contraction until fatigue followed by 2-min PECO. RESULTS Resting mean arterial pressure (MAP) was lower and peak increase (Δ) in MAP was smaller in patients with HFpEF than in controls during SHG (Δ23 ± 15 [standard deviation] vs. Δ34 ± 15 mmHg; P = 0.007) and PECO (Δ15 ± 11 vs. Δ19 ± 9 mmHg; P = 0.047). HR was greater in patients at rest but did not differ between the two groups at peak SHG. Patients had higher resting MSNA burst frequency than controls (37 ± 14 vs. 27 ± 13 bursts/min; P = 0.031); however, burst incidence was not different between the groups (P = 0.226). There were no differences in MSNA responses to SHG (Δ19 ± 15 vs. Δ18 ± 10 bursts/min at peak; P = 0.841) or PECO (Δ3 ± 12 vs. Δ5 ± 7 bursts/min; P = 0.495) between groups. CONCLUSION The patients with HFpEF maintained sympathetic reactivity but had an attenuated pressor response during fatiguing SHG. Additionally, muscle metaboreflex activation of vasomotor sympathetic outflow appeared to be minimal in both groups, with no significant difference between patients and controls.
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Affiliation(s)
- Takuro Washio
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ryosuke Takeda
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sarah L Hissen
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John D Akins
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Andrew W D'Souza
- Division of Pulmonary Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Denis J Wakeham
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tiffany Brazile
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kevin Lutz
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Christopher M Hearon
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James P MacNamara
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Satyam Sarma
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Paul J Fadel
- University of Texas at Arlington, Arlington, TX, USA
| | - Qi Fu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, 7232 Greenville Avenue, Dallas, TX, 75231, USA.
- University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Brazile TL, Levine BD, Shafer KM. Cardiopulmonary Exercise Testing. NEJM EVIDENCE 2025; 4:EVIDra2400390. [PMID: 39873542 DOI: 10.1056/evidra2400390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2025]
Abstract
AbstractBecause symptoms of cardiopulmonary disease often occur with exertion, cardiopulmonary exercise testing (CPET) has a unique role in the assessment of patient symptoms, disease severity, prognosis, and response to therapy. In addition to the evaluation of cardiovascular and pulmonary physiology, CPET provides an assessment of the interaction of the cardiovascular and pulmonary systems with the musculoskeletal, nervous, and hematological systems. In this article, we review key CPET variables, protocols, and clinical indications.
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Affiliation(s)
- Tiffany L Brazile
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Keri M Shafer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
- Department of Cardiology, Boston Children's Hospital
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8
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Balmain BN, Tomlinson AR, Goh JT, MacNamara JP, Wakeham DJ, Brazile TL, Leahy MG, Lutz KC, Hynan LS, Levine BD, Sarma S, Babb TG. Pulmonary gas exchange in relation to exercise pulmonary hypertension in patients with heart failure with preserved ejection fraction. Eur Respir J 2025; 65:2400722. [PMID: 39510552 DOI: 10.1183/13993003.00722-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 10/16/2024] [Indexed: 11/15/2024]
Abstract
BACKGROUND Exercise pulmonary hypertension, defined as a mean pulmonary arterial pressure (mPAP)/cardiac output (Q̇c) slope >3 WU during exercise, is common in patients with heart failure with preserved ejection fraction (HFpEF). However, the pulmonary gas exchange-related effects of an exaggerated exercise pulmonary hypertension (EePH) response are not well defined, especially in relation to dyspnoea on exertion and exercise intolerance. METHODS 48 HFpEF patients underwent invasive (pulmonary and radial artery catheters) constant-load (20 W) and maximal incremental cycle testing. Haemodynamic measurements (mPAP and Q̇c), arterial blood and expired gases, and ratings of perceived breathlessness (Borg 0-10 scale) were obtained. The mPAP/Q̇c slope was calculated from rest to 20 W. Those with a mPAP/Q̇c slope ≥4.2 (median) were classified as HFpEF+EePH (n=24) and those with a mPAP/Q̇c slope <4.2 were classified as HFpEF (without EePH) (n=24). The alveolar-arterial oxygen tension difference, dead space to tidal volume ratio (Bohr equation) and the minute ventilation to carbon dioxide production slope (from rest to 20 W) were calculated. RESULTS Arterial oxygen tension was lower (p=0.03) and dead space to tidal volume ratio was higher (p=0.03) at peak exercise in HFpEF+EePH than in HFpEF. The alveolar-arterial oxygen tension difference was similar at peak exercise between groups (p=0.14); however, patients with HFpEF+EePH achieved the peak alveolar-arterial oxygen tension difference at a lower peak work rate (p<0.01). The minute ventilation to carbon dioxide production slope was higher in HFpEF+EePH than in HFpEF (p=0.01). Perceived breathlessness was ≥1 unit higher at 20 W and peak oxygen uptake was lower (p<0.01) in HFpEF+EePH than in HFpEF. CONCLUSIONS These data suggest that EePH contributes to pulmonary gas exchange impairments during exercise by causing a ventilation/perfusion mismatch that provokes both ventilatory inefficiency and hypoxaemia, both of which seem to contribute to dyspnoea on exertion and exercise intolerance in patients with HFpEF.
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Affiliation(s)
- Bryce N Balmain
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Andrew R Tomlinson
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Josh T Goh
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James P MacNamara
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Denis J Wakeham
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tiffany L Brazile
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael G Leahy
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kevin C Lutz
- The O'Donnell School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Linda S Hynan
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Satyam Sarma
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tony G Babb
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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9
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MacNamara JP, Ayers MP. Cardiac Plasticity in Hypertrophic Cardiomyopathy: Exercise as Medicine? Circulation 2025; 151:145-148. [PMID: 39804911 DOI: 10.1161/circulationaha.124.072649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2025]
Affiliation(s)
- James P MacNamara
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas (J.P.M.)
- Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas (J.P.M.)
| | - Michael P Ayers
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville (M.P.A.)
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Berger JH, Shi Y, Matsuura TR, Batmanov K, Chen X, Tam K, Marshall M, Kue R, Patel J, Taing R, Callaway R, Griffin J, Kovacs A, Hirenallur-Shanthappa D, Miller R, Zhang BB, Flach RJR, Kelly DP. Two-hit mouse model of heart failure with preserved ejection fraction combining diet-induced obesity and renin-mediated hypertension. Sci Rep 2025; 15:422. [PMID: 39747575 PMCID: PMC11696687 DOI: 10.1038/s41598-024-84515-9] [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: 09/03/2024] [Accepted: 12/24/2024] [Indexed: 01/04/2025] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is increasingly common but its pathogenesis is poorly understood. The ability to assess genetic and pharmacologic interventions is hampered by the lack of robust preclinical mouse models of HFpEF. We developed a novel "two-hit" model, which combines obesity and insulin resistance with chronic pressure overload to recapitulate clinical features of HFpEF. C57Bl6/NJ mice fed a high-fat diet (HFD) for > 10 weeks were administered an AAV8-driven vector resulting in constitutive overexpression of mouse Renin1d. HFD-Renin (aka "HFpEF") mice demonstrated obesity and insulin resistance, moderate left ventricular hypertrophy, preserved systolic function, and diastolic dysfunction indicated by echocardiographic measurements; increased left atrial mass; elevated natriuretic peptides; and exercise intolerance. Transcriptomic and metabolomic profiling of HFD-Renin myocardium demonstrated upregulation of pro-fibrotic pathways and downregulation of metabolic pathways, in particular branched chain amino acid catabolism, similar to human HFpEF. Treatment with empagliflozin, an effective but incompletely understood HFpEF therapy, improved multiple endpoints. The HFD-Renin mouse model recapitulates key features of human HFpEF and will enable studies dissecting the contribution of individual pathogenic drivers to this complex syndrome. Additional preclinical HFpEF models allow for orthogonal studies to increase validity in assessment of interventions.
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Affiliation(s)
- Justin H Berger
- Cardiovascular Institute, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Pediatrics, Washington University School of Medicine, 660 S. Euclide, MSC 8116-0043-08, St. Louis, MO, 63110, USA.
| | - Yuji Shi
- Internal Medicine Research Unit, Pfizer Worldwide Research, Development & Medical, Cambridge, USA
| | - Timothy R Matsuura
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kirill Batmanov
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Xian Chen
- Department of Pediatrics, Washington University School of Medicine, 660 S. Euclide, MSC 8116-0043-08, St. Louis, MO, 63110, USA
| | - Kelly Tam
- Internal Medicine Research Unit, Pfizer Worldwide Research, Development & Medical, Cambridge, USA
| | - Mackenzie Marshall
- Internal Medicine Research Unit, Pfizer Worldwide Research, Development & Medical, Cambridge, USA
| | - Richard Kue
- Internal Medicine Research Unit, Pfizer Worldwide Research, Development & Medical, Cambridge, USA
| | - Jiten Patel
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Renee Taing
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Russell Callaway
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joanna Griffin
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Attila Kovacs
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Russell Miller
- Internal Medicine Research Unit, Pfizer Worldwide Research, Development & Medical, Cambridge, USA
| | - Bei B Zhang
- Internal Medicine Research Unit, Pfizer Worldwide Research, Development & Medical, Cambridge, USA
| | - Rachel J Roth Flach
- Internal Medicine Research Unit, Pfizer Worldwide Research, Development & Medical, Cambridge, USA
| | - Daniel P Kelly
- Cardiovascular Institute, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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11
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Sarma S. Exercise Hemodynamics in Heart Failure with Preserved Ejection Fraction. Heart Fail Clin 2025; 21:27-34. [PMID: 39550078 PMCID: PMC11569380 DOI: 10.1016/j.hfc.2024.08.003] [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] [Indexed: 11/18/2024]
Abstract
Exercise intolerance is common in patients with heart failure with preserved ejection fraction. This review will discuss the utility of exercise hemodynamics under both diagnostic and prognostic circumstances and highlight challenges associated with making and interpreting measures taken during exercise.
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Affiliation(s)
- Satyam Sarma
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, TX, USA.
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12
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Fudim M, Kittipibul V, Swavely A, Gray A, Mikitka J, Young E, Dobbin O, Radzom M, Fee J, Molinger J, Patterson B, Battista Perego G, Badano LP, Parati G, Vachiéry JL, Senni M, Lanzarone E, Previdi F, Paleari S, Baratto C, Caravita S. Discrepancy in the Diagnosis of Heart Failure With Preserved Ejection Fraction Between Supine Versus Upright Exercise Hemodynamic Testing. Circ Heart Fail 2024; 17:e012020. [PMID: 39513293 DOI: 10.1161/circheartfailure.124.012020] [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: 05/23/2024] [Accepted: 10/01/2024] [Indexed: 11/15/2024]
Abstract
BACKGROUND Invasive exercise right heart catheterization is a gold standard in diagnosing heart failure with preserved ejection fraction (HFpEF). Body positions during the test influence hemodynamics. However, the discrepancy in HFpEF diagnosis between exercise testing in supine versus upright position is unknown. METHODS We conducted a 2-center prospective study enrolling patients referred for exercise right heart catheterization for HFpEF. We performed a Supright protocol integrating submaximal supine bicycle ergometry (20 W) followed by maximal upright bicycle ergometry with a breath-by-breath oxygen analyzer. HFpEF hemodynamic criteria specific to testing positions were applied. Patients were considered to have concordant HFpEF if they met criteria in both positions or discordant HFpEF if they met criteria only in the supine position. RESULTS Of 36 patients who met HFpEF criteria in supine position, 18 (50%) did not meet criteria in upright position (discordant HFpEF). Discordant HFpEF had less atrial fibrillation (0% versus 55%; P<0.001), lower left atrial volume (60±14 versus 77±21 mL; P=0.010), and lower H2FPEF score (2.1±1.3 versus 5.1±2.3; P<0.001). In supine position, pulmonary arterial wedge pressure was lower in discordant HFpEF at rest (15±4 versus 19±7 mm Hg; P=0.040). In upright position, pulmonary arterial wedge pressure was lower in discordant HFpEF both at rest (8±4 versus 14±6 mm Hg; P=0.002) and at peak exercise (14±4 versus 27±7 mm Hg; P<0.001). Pulmonary arterial wedge pressure/cardiac output slope was lower in discordant HFpEF (1.6±1.7 versus 3.6±2.9; P<0.001). Maximal workload (46±18 versus 49±24 W; P=0.59) or peak oxygen consumption (11.4±2.8 versus 12.9±3.4 mL/[kg·min]; P=0.15) was similar between groups. CONCLUSIONS Half of patients who met HFpEF criteria in the supine position did not meet the criteria in the upright position. Patients with a discordant HFpEF phenotype had less structural and hemodynamic abnormalities compared with those with concordant HFpEF. A Supright exercise right heart catheterization approach is feasible and merits further investigation to determine the clinical implications of discordant exercise hemodynamic findings in supine and upright positions.
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Affiliation(s)
- Marat Fudim
- Department of Medicine (M.F., V.K., A.S., A.G., J. Mikitka, E.Y., O.D., M.R., J.F., J. Molinger, B.P.), Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC (M.F., V.K.)
- Institute of Heart Diseases, Wroclaw Medical University, Poland (M.F.)
| | - Veraprapas Kittipibul
- Department of Medicine (M.F., V.K., A.S., A.G., J. Mikitka, E.Y., O.D., M.R., J.F., J. Molinger, B.P.), Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC (M.F., V.K.)
| | - Ashley Swavely
- Department of Medicine (M.F., V.K., A.S., A.G., J. Mikitka, E.Y., O.D., M.R., J.F., J. Molinger, B.P.), Duke University Medical Center, Durham, NC
| | - Anna Gray
- Department of Medicine (M.F., V.K., A.S., A.G., J. Mikitka, E.Y., O.D., M.R., J.F., J. Molinger, B.P.), Duke University Medical Center, Durham, NC
| | - Jeffrey Mikitka
- Department of Medicine (M.F., V.K., A.S., A.G., J. Mikitka, E.Y., O.D., M.R., J.F., J. Molinger, B.P.), Duke University Medical Center, Durham, NC
| | - Erin Young
- Department of Medicine (M.F., V.K., A.S., A.G., J. Mikitka, E.Y., O.D., M.R., J.F., J. Molinger, B.P.), Duke University Medical Center, Durham, NC
| | - Olivia Dobbin
- Department of Medicine (M.F., V.K., A.S., A.G., J. Mikitka, E.Y., O.D., M.R., J.F., J. Molinger, B.P.), Duke University Medical Center, Durham, NC
| | - Matthew Radzom
- Department of Medicine (M.F., V.K., A.S., A.G., J. Mikitka, E.Y., O.D., M.R., J.F., J. Molinger, B.P.), Duke University Medical Center, Durham, NC
| | - Jacqueline Fee
- Department of Medicine (M.F., V.K., A.S., A.G., J. Mikitka, E.Y., O.D., M.R., J.F., J. Molinger, B.P.), Duke University Medical Center, Durham, NC
| | - Jeroen Molinger
- Department of Medicine (M.F., V.K., A.S., A.G., J. Mikitka, E.Y., O.D., M.R., J.F., J. Molinger, B.P.), Duke University Medical Center, Durham, NC
- Department of Anesthesiology (J. Molinger), Duke University Medical Center, Durham, NC
| | - Brandy Patterson
- Department of Medicine (M.F., V.K., A.S., A.G., J. Mikitka, E.Y., O.D., M.R., J.F., J. Molinger, B.P.), Duke University Medical Center, Durham, NC
| | - Giovanni Battista Perego
- Department of Cardiology, Ospedale San Luca Istituto di Ricerca e Cura a Carattere Scientifico, Istituto Auxologico Italiano, Milan, Italy (G.B.P., L.P.B., G.P., C.B., S.C.)
| | - Luigi P Badano
- Department of Cardiology, Ospedale San Luca Istituto di Ricerca e Cura a Carattere Scientifico, Istituto Auxologico Italiano, Milan, Italy (G.B.P., L.P.B., G.P., C.B., S.C.)
- Department of Medicine and Surgery, University of Milano-Bicocca, Italy (L.P.B., G.P., M.S.)
| | - Gianfranco Parati
- Department of Cardiology, Ospedale San Luca Istituto di Ricerca e Cura a Carattere Scientifico, Istituto Auxologico Italiano, Milan, Italy (G.B.P., L.P.B., G.P., C.B., S.C.)
- Department of Medicine and Surgery, University of Milano-Bicocca, Italy (L.P.B., G.P., M.S.)
| | - Jean-Luc Vachiéry
- Department of Cardiology, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Belgium (J.-L.V.)
| | - Michele Senni
- Department of Medicine and Surgery, University of Milano-Bicocca, Italy (L.P.B., G.P., M.S.)
- Cardiovascular Department, Azienda Socio Sanitaria Territoriale, Papa Giovanni XXIII, Bergamo, Italy (M.S.)
| | - Ettore Lanzarone
- Department of Management, Information, and Production Engineering, University of Bergamo, Dalmine BG, Italy (E.L., F.P., S.P., S.C., C.B.)
| | - Fabio Previdi
- Department of Management, Information, and Production Engineering, University of Bergamo, Dalmine BG, Italy (E.L., F.P., S.P., S.C., C.B.)
| | - Stefano Paleari
- Department of Management, Information, and Production Engineering, University of Bergamo, Dalmine BG, Italy (E.L., F.P., S.P., S.C., C.B.)
| | - Claudia Baratto
- Department of Cardiology, Ospedale San Luca Istituto di Ricerca e Cura a Carattere Scientifico, Istituto Auxologico Italiano, Milan, Italy (G.B.P., L.P.B., G.P., C.B., S.C.)
- Department of Management, Information, and Production Engineering, University of Bergamo, Dalmine BG, Italy (E.L., F.P., S.P., S.C., C.B.)
| | - Sergio Caravita
- Department of Cardiology, Ospedale San Luca Istituto di Ricerca e Cura a Carattere Scientifico, Istituto Auxologico Italiano, Milan, Italy (G.B.P., L.P.B., G.P., C.B., S.C.)
- Department of Management, Information, and Production Engineering, University of Bergamo, Dalmine BG, Italy (E.L., F.P., S.P., S.C., C.B.)
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13
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Zhang Z, Wang Y, Chen X, Wu C, Zhou J, Chen Y, Liu X, Tang X. The aging heart in focus: The advanced understanding of heart failure with preserved ejection fraction. Ageing Res Rev 2024; 101:102542. [PMID: 39396676 DOI: 10.1016/j.arr.2024.102542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 09/25/2024] [Accepted: 10/05/2024] [Indexed: 10/15/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) accounts for 50 % of heart failure (HF) cases, making it the most common type of HF, and its prevalence continues to increase in the aging society. HFpEF is a systemic syndrome resulting from many risk factors, such as aging, metabolic syndrome, and hypertension, and its clinical features are highly heterogeneous in different populations. HFpEF syndrome involves the dysfunction of multiple organs, including the heart, lung, muscle, and vascular system. The heart shows dysfunction of various cells, including cardiomyocytes, endothelial cells, fibroblasts, adipocytes, and immune cells. The complex etiology and pathobiology limit experimental research on HFpEF in animal models, delaying a comprehensive understanding of the mechanisms and making treatment difficult. Recently, many scientists and cardiologists have attempted to improve the clinical outcomes of HFpEF. Recent advances in clinically related animal models and systemic pathology studies have improved our understanding of HFpEF, and clinical trials involving sodium-glucose cotransporter 2 inhibitors have significantly enhanced our confidence in treating HFpEF. This review provides an updated comprehensive discussion of the etiology and pathobiology, molecular and cellular mechanisms, preclinical animal models, and therapeutic trials in animals and patients to enhance our understanding of HFpEF and improve clinical outcomes.
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Affiliation(s)
- Zhewei Zhang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, National Health Commission Key Laboratory of Chronobiology, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Children's Medicine Key Laboratory of Sichuan Province, State Key Laboratory of Biotherapy, West China Second University Hospital, Sichuan University, No.2222 Xinchuan Road, Chengdu 610041, China; Department of Cardiology and Laboratory of Cardiovascular Diseases, Institute of Cardiovascular Diseases, West China Hospital, Sichuan University, Chengdu 610041, China; West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu 610041, China
| | - Yu Wang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, National Health Commission Key Laboratory of Chronobiology, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Children's Medicine Key Laboratory of Sichuan Province, State Key Laboratory of Biotherapy, West China Second University Hospital, Sichuan University, No.2222 Xinchuan Road, Chengdu 610041, China; West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu 610041, China
| | - Xiangqi Chen
- Department of Pharmacy, Institute of Metabolic Diseases and Pharmacotherapy, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Chuan Wu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, National Health Commission Key Laboratory of Chronobiology, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Children's Medicine Key Laboratory of Sichuan Province, State Key Laboratory of Biotherapy, West China Second University Hospital, Sichuan University, No.2222 Xinchuan Road, Chengdu 610041, China
| | - Jingyue Zhou
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, National Health Commission Key Laboratory of Chronobiology, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Children's Medicine Key Laboratory of Sichuan Province, State Key Laboratory of Biotherapy, West China Second University Hospital, Sichuan University, No.2222 Xinchuan Road, Chengdu 610041, China
| | - Yan Chen
- Department of Cardiology and Laboratory of Cardiovascular Diseases, Institute of Cardiovascular Diseases, West China Hospital, Sichuan University, Chengdu 610041, China.
| | - Xiaojing Liu
- Department of Cardiology and Laboratory of Cardiovascular Diseases, Institute of Cardiovascular Diseases, West China Hospital, Sichuan University, Chengdu 610041, China.
| | - Xiaoqiang Tang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, National Health Commission Key Laboratory of Chronobiology, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Children's Medicine Key Laboratory of Sichuan Province, State Key Laboratory of Biotherapy, West China Second University Hospital, Sichuan University, No.2222 Xinchuan Road, Chengdu 610041, China.
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14
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Tada A, Burkhoff D, Naser JA, Harada T, Pourmussa B, Reddy YNV, Jensen MD, Carter R, Demmer RT, Testani J, Chirinos JA, Borlaug BA. Dapagliflozin Enhances Arterial and Venous Compliance During Exercise in Heart Failure With Preserved Ejection Fraction: Insights From the CAMEO-DAPA Trial. Circulation 2024; 150:997-1009. [PMID: 39101201 PMCID: PMC11433515 DOI: 10.1161/circulationaha.124.068788] [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: 02/20/2024] [Accepted: 06/27/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Systemic arterial compliance and venous capacitance are typically impaired in patients with heart failure with preserved ejection fraction (HFpEF), contributing to hemodynamic congestion with stress. Sodium-glucose cotransporter-2 inhibitors reduce hemodynamic congestion and improve clinical outcomes in patients with HFpEF, but the mechanisms remain unclear. This study tested the hypothesis that Dapagliflozin would improve systemic arterial compliance and venous capacitance during exercise in patients with HFpEF. METHODS In this secondary analysis from the CAMEO-DAPA trial (Cardiac and Metabolic Effects of Dapagliflozin in Heart Failure With Preserved Ejection Fraction Trial), 37 patients with HFpEF (mean age 68 ± 9 years, women 65%) underwent invasive hemodynamic exercise testing with simultaneous echocardiography at baseline and following treatment for 24 weeks with Dapagliflozin or placebo. Radial artery pressure (BP) was measured continuously using a fluid-filled catheter with transformation to aortic pressure, central hemodynamics were measured using high-fidelity micromanometers, and stressed blood volume was estimated from hemodynamic indices fit to a comprehensive cardiovascular model. RESULTS There was no statistically significant effect of Dapagliflozin on resting BP, but Dapagliflozin reduced systolic BP during peak exercise (estimated treatment difference [ETD], -18.8 mm Hg [95% CI, -33.9 to -3.7] P=0.016). Reduction in BP was related to improved exertional total arterial compliance (ETD, 0.06 mL/mm Hg/m2 [95% CI, 0.003-0.11] P=0.039) and aortic root characteristic impedance (ETD, -2.6 mm Hg/mL*sec [95% CI: -5.1 to -0.03] P=0.048), with no significant effect on systemic vascular resistance. Dapagliflozin reduced estimated stressed blood volume at rest and during peak exercise (ETD, -292 mm Hg [95% CI, -530 to -53] P=0.018), and improved venous capacitance evidenced by a decline in ratio of estimated stressed blood volume to total blood volume (ETD, -7.3% [95% CI, -13.3 to -1.3] P=0.020). Each of these effects of Dapagliflozin at peak exercise were also observed during matched 20W exercise intensity. Improvements in total arterial compliance and estimated stressed blood volume were correlated with decreases in body weight, and reduction in systolic BP with treatment was correlated with the change in estimated stressed blood volume during exercise (r=0.40, P=0.019). Decreases in BP were correlated with reduction in pulmonary capillary wedge pressure during exercise (r=0.56, P<0.001). CONCLUSIONS In patients with HFpEF, treatment with Dapagliflozin improved systemic arterial compliance and venous capacitance during exercise, while reducing aortic characteristic impedance, suggesting a reduction in arterial wall stiffness. These vascular effects may partially explain the clinical benefits with sodium-glucose cotransporter-2 inhibitors in HFpEF. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04730947.
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Affiliation(s)
- Atsushi Tada
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Jwan A. Naser
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Tomonari Harada
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bianca Pourmussa
- Division of Cardiology, Hospital of the University of Pennsylvania
| | - Yogesh N. V. Reddy
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael D. Jensen
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism,Mayo Clinic, Rochester, Minnesota
| | - Rickey Carter
- Department of Quantitative Health Sciences, Division of Clinical Trials & Biostatistics,Mayo Clinic, Jacksonville, Florida
| | - Ryan T. Demmer
- Division of Epidemiology, Department of Quantitative Health Sciences, College of Medicine and Science, Mayo Clinic, Rochester, MN
| | | | | | - Barry A. Borlaug
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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15
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Verwerft J, Stassen J, Falter M, Bekhuis Y, Hoedemakers S, Gojevic T, Ferreira SM, Vanhentenrijk S, Stroobants S, Jogani S, Hansen D, Jasaityte R, Cosyns B, Van De Bruaene A, Bertrand PB, de Boer RA, Gevaert AB, Verbrugge FH, Herbots L, Claessen G. Clinical Significance of Exercise Pulmonary Hypertension With a Negative Diastolic Stress Test for Suspected Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2024; 13:e032228. [PMID: 39028104 PMCID: PMC11964069 DOI: 10.1161/jaha.123.032228] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 04/19/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Half of patients with heart failure with preserved ejection fraction (HFpEF) remain undiagnosed by resting evaluation alone. Therefore, exercise testing is proposed. The diastolic stress test (DST), however, has limited sensitivity. We aimed to determine the clinical significance of adding the mean pulmonary artery pressure over cardiac output (mPAP/CO) slope to the DST in suspected HFpEF. METHODS AND RESULTS In this prospective cohort study, consecutive patients (n=1936) with suspected HFpEF underwent exercise echocardiography with simultaneous respiratory gas analysis. These patients were stratified by exercise E over e' (exE/e') and mPAP/CO slope, and peak oxygen uptake, natriuretic peptides (NT-proBNP [N-terminal pro-B-type natriuretic peptide]), and score-based HFpEF likelihood were compared. Twenty-two percent of patients (n=428) had exE/e'<15 despite a mPAP/CO slope>3 mm Hg/L per min, 24% (n=464) had a positive DST (exE/e'≥15), and 54% (n=1044) had a normal DST and slope. Percentage of predicted oxygen uptake was similar in the group with exE/e'<15 but high mPAP/CO slope and the positive DST group (-2% [-5% to +1%]), yet worse than in those with normal DST and slope (-12% [-14% to -9%]). Patients with exE/e'<15 but a high slope had NT-proBNP levels and H2FPEF (heavy, hypertensive, atrial fibrillation, pulmonary hypertension, elder; filling pressure) scores intermediate to the positive DST group and the group with both a normal DST and slope. CONCLUSIONS Twenty-two percent of patients with suspected HFpEF presented with a mPAP/CO slope>3 mm Hg/L per min despite a negative DST. These patients had HFpEF characteristics and a peak oxygen uptake as low as patients with a positive DST. Therefore, an elevated mPAP/CO slope might indicate HFpEF irrespective of the DST result.
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Affiliation(s)
- Jan Verwerft
- Department of CardiologyJessa HospitalHasseltBelgium
- Faculty of Medicine and Life SciencesBiomedical Research Institute, Hasselt UniversityHasseltBelgium
| | - Jan Stassen
- Department of CardiologyJessa HospitalHasseltBelgium
- Faculty of Medicine and Life SciencesBiomedical Research Institute, Hasselt UniversityHasseltBelgium
| | - Maarten Falter
- Department of CardiologyJessa HospitalHasseltBelgium
- Faculty of Medicine and Life SciencesBiomedical Research Institute, Hasselt UniversityHasseltBelgium
| | - Youri Bekhuis
- Department of CardiologyJessa HospitalHasseltBelgium
- Faculty of Medicine and Life SciencesBiomedical Research Institute, Hasselt UniversityHasseltBelgium
- Centre for Cardiovascular DiseasesUniversity Hospital BrusselsJetteBelgium
- Faculty of Medicine and PharmacyVrije Universiteit BrusselBrusselsBelgium
- Department of CardiologyZiekenhuis‐Oost LimburgGenkBelgium
- Department of Cardiovascular SciencesKU LeuvenLeuvenBelgium
| | - Sarah Hoedemakers
- Department of CardiologyJessa HospitalHasseltBelgium
- Faculty of Medicine and Life SciencesBiomedical Research Institute, Hasselt UniversityHasseltBelgium
- Centre for Cardiovascular DiseasesUniversity Hospital BrusselsJetteBelgium
- Faculty of Medicine and PharmacyVrije Universiteit BrusselBrusselsBelgium
| | - Tin Gojevic
- Faculty of Medicine and PharmacyVrije Universiteit BrusselBrusselsBelgium
| | - Sara Moura Ferreira
- Department of CardiologyJessa HospitalHasseltBelgium
- Faculty of Medicine and Life SciencesBiomedical Research Institute, Hasselt UniversityHasseltBelgium
| | - Simon Vanhentenrijk
- Department of CardiologyJessa HospitalHasseltBelgium
- Centre for Cardiovascular DiseasesUniversity Hospital BrusselsJetteBelgium
- Faculty of Medicine and PharmacyVrije Universiteit BrusselBrusselsBelgium
| | - Sarah Stroobants
- Department of CardiologyJessa HospitalHasseltBelgium
- Faculty of Medicine and Life SciencesBiomedical Research Institute, Hasselt UniversityHasseltBelgium
| | - Siddharth Jogani
- Department of CardiologyJessa HospitalHasseltBelgium
- Faculty of Medicine and Life SciencesBiomedical Research Institute, Hasselt UniversityHasseltBelgium
| | - Dominique Hansen
- Faculty of Rehabilitation SciencesREVAL/BIOMED, Hasselt UniversityHasseltBelgium
| | - Ruta Jasaityte
- Department of CardiologyJessa HospitalHasseltBelgium
- Faculty of Medicine and Life SciencesBiomedical Research Institute, Hasselt UniversityHasseltBelgium
| | - Bernard Cosyns
- Centre for Cardiovascular DiseasesUniversity Hospital BrusselsJetteBelgium
- Faculty of Medicine and PharmacyVrije Universiteit BrusselBrusselsBelgium
| | - Alexander Van De Bruaene
- Department of CardiologyJessa HospitalHasseltBelgium
- Department of Cardiovascular SciencesKU LeuvenLeuvenBelgium
| | - Philippe B. Bertrand
- Faculty of Medicine and Life SciencesBiomedical Research Institute, Hasselt UniversityHasseltBelgium
- Department of CardiologyZiekenhuis‐Oost LimburgGenkBelgium
| | | | - Andreas B. Gevaert
- Research Group Cardiovascular Diseases, GENCOR DepartmentUniversity of AntwerpBelgium
- Department of CardiologyAntwerp University Hospital (UZA)EdegemBelgium
| | - Frederik H. Verbrugge
- Centre for Cardiovascular DiseasesUniversity Hospital BrusselsJetteBelgium
- Faculty of Medicine and PharmacyVrije Universiteit BrusselBrusselsBelgium
| | - Lieven Herbots
- Department of CardiologyJessa HospitalHasseltBelgium
- Faculty of Medicine and Life SciencesBiomedical Research Institute, Hasselt UniversityHasseltBelgium
| | - Guido Claessen
- Department of CardiologyJessa HospitalHasseltBelgium
- Faculty of Medicine and Life SciencesBiomedical Research Institute, Hasselt UniversityHasseltBelgium
- Department of Cardiovascular SciencesKU LeuvenLeuvenBelgium
- Faculty of Rehabilitation SciencesREVAL/BIOMED, Hasselt UniversityHasseltBelgium
- Baker Heart and Diabetes InstituteMelbourneAustralia
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16
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Skow RJ, Sarma S, MacNamara JP, Bartlett MF, Wakeham DJ, Martin ZT, Samels M, Nandadeva D, Brazile TL, Ren J, Fu Q, Babb TG, Balmain BN, Nelson MD, Hynan LS, Levine BD, Fadel PJ, Haykowsky MJ, Hearon CM. Identifying the Mechanisms of a Peripherally Limited Exercise Phenotype in Patients With Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2024; 17:e011693. [PMID: 39051098 PMCID: PMC11335445 DOI: 10.1161/circheartfailure.123.011693] [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: 02/09/2024] [Accepted: 06/11/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND We identified peripherally limited patients using cardiopulmonary exercise testing and measured skeletal muscle oxygen transport and utilization during invasive single leg exercise testing to identify the mechanisms of the peripheral limitation. METHODS Forty-five patients with heart failure with preserved ejection fraction (70±7 years, 27 females) completed seated upright cardiopulmonary exercise testing and were defined as having a (1) peripheral limitation to exercise if cardiac output/oxygen consumption (VO2) was elevated (≥6) or 5 to 6 with a stroke volume reserve >50% (n=31) or (2) a central limitation to exercise if cardiac output/VO2 slope was ≤5 or 5 to 6 with stroke volume reserve <50% (n=14). Single leg knee extension exercise was used to quantify peak leg blood flow (Doppler ultrasound), arterial-to-venous oxygen content difference (femoral venous catheter), leg VO2, and muscle oxygen diffusive conductance. In a subset of participants (n=36), phosphocreatine recovery time was measured by magnetic resonance spectroscopy to determine skeletal muscle oxidative capacity. RESULTS Peak VO2 during cardiopulmonary exercise testing was not different between groups (central: 13.9±5.7 versus peripheral: 12.0±3.1 mL/min per kg; P=0.135); however, the peripheral group had a lower peak arterial-to-venous oxygen content difference (central: 13.5±2.0 versus peripheral: 11.1±1.6 mLO2/dL blood; P<0.001). During single leg knee extension, there was no difference in peak leg VO2 (P=0.306), but the peripherally limited group had greater blood flow/VO2 ratio (P=0.024), lower arterial-to-venous oxygen content difference (central: 12.3±2.5 versus peripheral: 10.3±2.2 mLO2/dL blood; P=0.013), and lower muscle oxygen diffusive conductance (P=0.021). A difference in magnetic resonance spectroscopy-derived phosphocreatine recovery time was not detected (P=0.199). CONCLUSIONS Peripherally limited patients with heart failure with preserved ejection fraction identified by cardiopulmonary exercise testing have impairments in oxygen transport and utilization at the level of the skeletal muscle quantified by invasive knee extension exercise testing, which includes an increased blood flow/V̇O2 ratio and poor muscle diffusive capacity. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04068844.
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Affiliation(s)
- Rachel J Skow
- Department of Kinesiology, University of Texas at Arlington (R.J.S., M.F.B., Z.T.M., D.N., M.D.N., P.J.F.)
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, AB, Canada (R.J.S., M.J.H.)
| | - Satyam Sarma
- Institute of Exercise and Environmental Medicine (S.S., J.P.M., D.J.W., M.S., T.L.B., Q.F., T.G.B., B.N.B., B.D.L., C.M.H.), University of Texas Southwestern Medical Center, Dallas
| | - James P MacNamara
- Institute of Exercise and Environmental Medicine (S.S., J.P.M., D.J.W., M.S., T.L.B., Q.F., T.G.B., B.N.B., B.D.L., C.M.H.), University of Texas Southwestern Medical Center, Dallas
| | - Miles F Bartlett
- Department of Kinesiology, University of Texas at Arlington (R.J.S., M.F.B., Z.T.M., D.N., M.D.N., P.J.F.)
| | - Denis J Wakeham
- Institute of Exercise and Environmental Medicine (S.S., J.P.M., D.J.W., M.S., T.L.B., Q.F., T.G.B., B.N.B., B.D.L., C.M.H.), University of Texas Southwestern Medical Center, Dallas
| | - Zachary T Martin
- Department of Kinesiology, University of Texas at Arlington (R.J.S., M.F.B., Z.T.M., D.N., M.D.N., P.J.F.)
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (Z.T.M.)
| | - Mitchel Samels
- Institute of Exercise and Environmental Medicine (S.S., J.P.M., D.J.W., M.S., T.L.B., Q.F., T.G.B., B.N.B., B.D.L., C.M.H.), University of Texas Southwestern Medical Center, Dallas
| | - Damsara Nandadeva
- Department of Kinesiology, University of Texas at Arlington (R.J.S., M.F.B., Z.T.M., D.N., M.D.N., P.J.F.)
- Department of Physiology, Faculty of Medicine, University of Peradeniya, Sri Lanka (D.N.)
| | - Tiffany L Brazile
- Institute of Exercise and Environmental Medicine (S.S., J.P.M., D.J.W., M.S., T.L.B., Q.F., T.G.B., B.N.B., B.D.L., C.M.H.), University of Texas Southwestern Medical Center, Dallas
| | - Jimin Ren
- Advanced Imaging Research Center (J.R.), University of Texas Southwestern Medical Center, Dallas
- Department of Radiology (J.R.), University of Texas Southwestern Medical Center, Dallas
| | - Qi Fu
- Institute of Exercise and Environmental Medicine (S.S., J.P.M., D.J.W., M.S., T.L.B., Q.F., T.G.B., B.N.B., B.D.L., C.M.H.), University of Texas Southwestern Medical Center, Dallas
| | - Tony G Babb
- Institute of Exercise and Environmental Medicine (S.S., J.P.M., D.J.W., M.S., T.L.B., Q.F., T.G.B., B.N.B., B.D.L., C.M.H.), University of Texas Southwestern Medical Center, Dallas
| | - Bryce N Balmain
- Institute of Exercise and Environmental Medicine (S.S., J.P.M., D.J.W., M.S., T.L.B., Q.F., T.G.B., B.N.B., B.D.L., C.M.H.), University of Texas Southwestern Medical Center, Dallas
| | - Michael D Nelson
- Department of Kinesiology, University of Texas at Arlington (R.J.S., M.F.B., Z.T.M., D.N., M.D.N., P.J.F.)
| | - Linda S Hynan
- Peter O'Donnell Jr School of Public Health and Department of Psychiatry (L.S.H.), University of Texas Southwestern Medical Center, Dallas
| | - Benjamin D Levine
- Institute of Exercise and Environmental Medicine (S.S., J.P.M., D.J.W., M.S., T.L.B., Q.F., T.G.B., B.N.B., B.D.L., C.M.H.), University of Texas Southwestern Medical Center, Dallas
| | - Paul J Fadel
- Department of Kinesiology, University of Texas at Arlington (R.J.S., M.F.B., Z.T.M., D.N., M.D.N., P.J.F.)
| | - Mark J Haykowsky
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, AB, Canada (R.J.S., M.J.H.)
| | - Christopher M Hearon
- Institute of Exercise and Environmental Medicine (S.S., J.P.M., D.J.W., M.S., T.L.B., Q.F., T.G.B., B.N.B., B.D.L., C.M.H.), University of Texas Southwestern Medical Center, Dallas
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17
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Berger JH, Shi Y, Matsuura TR, Batmanov K, Chen X, Tam K, Marshall M, Kue R, Patel J, Taing R, Callaway R, Griffin J, Kovacs A, Shanthappa DH, Miller R, Zhang BB, Roth Flach RJ, Kelly DP. Two-hit mouse model of heart failure with preserved ejection fraction combining diet-induced obesity and renin-mediated hypertension. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.06.597821. [PMID: 38895483 PMCID: PMC11185718 DOI: 10.1101/2024.06.06.597821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is increasingly common but its pathogenesis is poorly understood. The ability to assess genetic and pharmacologic interventions is hampered by the lack of robust preclinical mouse models of HFpEF. We have developed a novel "2-hit" model, which combines obesity and insulin resistance with chronic pressure overload to recapitulate clinical features of HFpEF. C57BL6/NJ mice fed a high fat diet for >10 weeks were administered an AAV8-driven vector resulting in constitutive overexpression of mouse Renin1d . Control mice, HFD only, Renin only and HFD-Renin (aka "HFpEF") littermates underwent a battery of cardiac and extracardiac phenotyping. HFD-Renin mice demonstrated obesity and insulin resistance, a 2-3-fold increase in circulating renin levels that resulted in 30-40% increase in left ventricular hypertrophy, preserved systolic function, and diastolic dysfunction indicated by altered E/e', IVRT, and strain measurements; increased left atrial mass; elevated natriuretic peptides; and exercise intolerance. Transcriptomic and metabolomic profiling of HFD-Renin myocardium demonstrated upregulation of pro-fibrotic pathways and downregulation of metabolic pathways, in particular branched chain amino acid catabolism, similar to findings in human HFpEF. Treatment of these mice with the sodium-glucose cotransporter 2 inhibitor empagliflozin, an effective but incompletely understood HFpEF therapy, improved exercise tolerance, left heart enlargement, and insulin homeostasis. The HFD-Renin mouse model recapitulates key features of human HFpEF and will enable studies dissecting the contribution of individual pathogenic drivers to this complex syndrome. Addition of HFD-Renin mice to the preclinical HFpEF model platform allows for orthogonal studies to increase validity in assessment of interventions. NEW & NOTEWORTHY Heart failure with preserved ejection fraction (HFpEF) is a complex disease to study due to limited preclinical models. We rigorously characterize a new two-hit HFpEF mouse model, which allows for dissecting individual contributions and synergy of major pathogenic drivers, hypertension and diet-induced obesity. The results are consistent and reproducible in two independent laboratories. This high-fidelity pre-clinical model increases the available, orthogonal models needed to improve our understanding of the causes and assessment treatments for HFpEF.
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18
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MacNamara JP, Turlington WM, Dias KA, Hearon CM, Ivey E, Delgado VA, Brazile TL, Wakeham DJ, Turer AT, Link MS, Levine BD, Sarma S. Impaired longitudinal systolic-diastolic coupling and cardiac response to exercise in patients with hypertrophic cardiomyopathy. Echocardiography 2024; 41:e15857. [PMID: 38895911 PMCID: PMC11250570 DOI: 10.1111/echo.15857] [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: 03/06/2024] [Revised: 05/22/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND In patients with hypertrophic cardiomyopathy (HCM), impaired augmentation of stroke volume and diastolic dysfunction contribute to exercise intolerance. Systolic-diastolic (S-D) coupling characterizes how systolic contraction of the left ventricle (LV) primes efficient elastic recoil during early diastole. Impaired S-D coupling may contribute to the impaired cardiac response to exercise in patients with HCM. METHODS Patients with HCM (n = 25, age = 47 ± 9 years) and healthy adults (n = 115, age = 49 ± 10 years) underwent a cardiopulmonary exercise testing (CPET) and echocardiogram. S-D coupling was defined as the ratio of LV longitudinal excursion of the mitral annulus during early diastole (EDexc) and systole (Sexc) and compared between groups. Peak oxygen uptake (peak V̇O2) (Douglas bags), cardiac index (C2H2 rebreathe), and stroke volume index (SVi) were assessed during CPET. Linear regression was performed between S-D coupling and peak V̇O2, peak cardiac index, and peak SVi. RESULTS S-D coupling was lower in HCM (Controls: 0.63 ± 0.08, HCM: 0.56 ± 0.10, p < 0.001). Peak V̇O2 and stroke volume reserve were lower in patients with HCM (Peak VO2 Controls: 28.5 ± 5.5, HCM: 23.7 ± 7.2 mL/kg/min, p < 0.001, SV reserve: Controls 39 ± 16, HCM 30 ± 18 mL, p = 0.008). In patients with HCM, S-D coupling was associated with peak V̇O2 (r = 0.47, p = 0.018), peak cardiac index (r = 0.60, p = 0.002), and peak SVi (r = 0.63, p < 0.001). CONCLUSION Systolic-diastolic coupling was impaired in patients with HCM and was associated with fitness and the cardiac response to exercise. Inefficient S-D coupling may link insufficient stroke volume generation, diastolic dysfunction, and exercise intolerance in HCM.
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Affiliation(s)
- James P MacNamara
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, Texas, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - William M Turlington
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, Texas, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Katrin A Dias
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, Texas, USA
| | - Christopher M Hearon
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, Texas, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Erika Ivey
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, Texas, USA
| | - Vincent A Delgado
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Tiffany L Brazile
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, Texas, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Denis J Wakeham
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, Texas, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Aslan T Turer
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mark S Link
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, Texas, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Satyam Sarma
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, Dallas, Texas, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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19
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Oraii A, Chaumont C, Marchlinski FE, Hyman MC. Rate-adaptive pacing in heart failure with preserved ejection fraction: Too much of a good thing? Heart Rhythm O2 2024; 5:334-337. [PMID: 38840761 PMCID: PMC11148503 DOI: 10.1016/j.hroo.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Affiliation(s)
- Alireza Oraii
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Corentin Chaumont
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E. Marchlinski
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew C. Hyman
- Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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20
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Dhont S, van den Acker G, van Loon T, Verbrugge FH, Verwerft J, Deferm S, Churchill TW, Mullens W, Lumens J, Bertrand PB. Mitral regurgitation in heart failure with preserved ejection fraction: The interplay of valve, ventricle, and atrium. Eur J Heart Fail 2024; 26:974-983. [PMID: 38629747 PMCID: PMC11184410 DOI: 10.1002/ejhf.3231] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/22/2024] [Accepted: 03/26/2024] [Indexed: 05/31/2024] Open
Abstract
Mitral regurgitation (MR) is highly prevalent among patients with heart failure and preserved ejection fraction (HFpEF). Despite this combination being closely associated with unfavourable outcomes, it remains relatively understudied. This is partly due to the inherent heterogeneity of patients with HFpEF. To address this gap, dissecting HFpEF into mechanism-based phenotypes may offer a promising avenue for advancing our comprehension of these complex intertwined conditions. This review employs the validated CircAdapt model to explore the haemodynamic implications of moderate to severe MR across a well-defined spectrum of myocardial disease, characterized by impaired relaxation and reduced myocardial compliance. Both heart failure and mitral valve disease share overlapping symptomatology, primarily attributed to elevated pulmonary pressures. The intricate mechanisms contributing to these elevated pressures are multifaceted, potentially influenced by diastolic dysfunction, left atrial myopathy, and MR. Accurate evaluation of the haemodynamic and clinical impact of MR necessitates a comprehensive approach, taking into account the characteristics of both the left atrium and left ventricle, as well as their intricate interactions, which may currently be underemphasized in diagnostic practice. This holistic assessment is imperative for enhancing our understanding and refining therapeutic strategies within this patient cohort.
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Affiliation(s)
- Sebastiaan Dhont
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Gitte van den Acker
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Tim van Loon
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Frederik H. Verbrugge
- Center for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jan Verwerft
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Sébastien Deferm
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Cardiology, Inselspital Bern, Bern, Switzerland
| | | | - Wilfried Mullens
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Joost Lumens
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Philippe B. Bertrand
- Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium
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21
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Bunsawat K, Nelson MD, Hearon CM, Wray DW. Exercise intolerance in heart failure with preserved ejection fraction: Causes, consequences and the journey towards a cure. Exp Physiol 2024; 109:502-512. [PMID: 38063130 PMCID: PMC10984794 DOI: 10.1113/ep090674] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/22/2023] [Indexed: 04/04/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) accounts for over 50% of all heart failure cases nationwide and continues to rise in its prevalence. The complex, multi-organ involvement of the HFpEF clinical syndrome requires clinicians and investigators to adopt an integrative approach that considers the contribution of both cardiac and non-cardiac function to HFpEF pathophysiology. Thus, this symposium review outlines the key points from presentations covering the contributions of disease-related changes in cardiac function, arterial stiffness, peripheral vascular function, and oxygen delivery and utilization to exercise tolerance in patients with HFpEF. While many aspects of HFpEF pathophysiology remain poorly understood, there is accumulating evidence for a decline in vascular health in this patient group that may be remediable through pharmacological and lifestyle interventions and could improve outcomes and clinical status in this ever-growing patient population.
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Affiliation(s)
- Kanokwan Bunsawat
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical CenterSalt Lake CityUtahUSA
- Department of Internal Medicine, Division of GeriatricsUniversity of UtahSalt Lake CityUtahUSA
| | - Michael D. Nelson
- Department of KinesiologyUniversity of Texas at ArlingtonArlingtonTexasUSA
| | - Christopher M. Hearon
- Department of Applied Clinical ResearchThe University of Texas Southwestern Medical CenterDallasTexasUSA
| | - D. Walter Wray
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical CenterSalt Lake CityUtahUSA
- Department of Internal Medicine, Division of GeriatricsUniversity of UtahSalt Lake CityUtahUSA
- Department of Nutrition and Integrative PhysiologyUniversity of UtahSalt Lake CityUtahUSA
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22
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Washio T, Hissen SL, Takeda R, Akins JD, Wakeham DJ, Brazile T, Hearon CM, MacNamara JP, Sarma S, Levine BD, Fadel PJ, Fu Q. Potential for reducing resting sympathetic nerve activity with new classes of glucose-lowering drugs in heart failure with preserved ejection fraction. Clin Auton Res 2024; 34:223-226. [PMID: 38285071 PMCID: PMC11031183 DOI: 10.1007/s10286-023-01013-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/28/2023] [Indexed: 01/30/2024]
Affiliation(s)
- Takuro Washio
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas, 7232 Greenville Ave., Ste. 435, Dallas, TX, 75231-8205, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sarah L Hissen
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas, 7232 Greenville Ave., Ste. 435, Dallas, TX, 75231-8205, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ryosuke Takeda
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas, 7232 Greenville Ave., Ste. 435, Dallas, TX, 75231-8205, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John D Akins
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas, 7232 Greenville Ave., Ste. 435, Dallas, TX, 75231-8205, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Denis J Wakeham
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas, 7232 Greenville Ave., Ste. 435, Dallas, TX, 75231-8205, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tiffany Brazile
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas, 7232 Greenville Ave., Ste. 435, Dallas, TX, 75231-8205, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Christopher M Hearon
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas, 7232 Greenville Ave., Ste. 435, Dallas, TX, 75231-8205, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James P MacNamara
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas, 7232 Greenville Ave., Ste. 435, Dallas, TX, 75231-8205, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Satyam Sarma
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas, 7232 Greenville Ave., Ste. 435, Dallas, TX, 75231-8205, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas, 7232 Greenville Ave., Ste. 435, Dallas, TX, 75231-8205, USA
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Paul J Fadel
- University of Texas at Arlington, Arlington, TX, USA
| | - Qi Fu
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas, 7232 Greenville Ave., Ste. 435, Dallas, TX, 75231-8205, USA.
- University of Texas Southwestern Medical Center, Dallas, TX, USA.
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23
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Hardin KM, Giverts I, Campain J, Farrell R, Cunningham T, Brooks L, Christ A, Wooster L, Bailey CS, Schoenike M, Sbarbaro J, Baggish A, Nayor M, Ho JE, Malhotra R, Shah R, Lewis GD. Systemic Arterial Oxygen Levels Differentiate Pre- and Post-capillary Predominant Hemodynamic Abnormalities During Exercise in Undifferentiated Dyspnea on Exertion. J Card Fail 2024; 30:39-47. [PMID: 37467924 DOI: 10.1016/j.cardfail.2023.05.023] [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: 12/06/2022] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Whether systemic oxygen levels (SaO2) during exercise can provide a window into invasively derived exercise hemodynamic profiles in patients with undifferentiated dyspnea on exertion is unknown. METHODS We performed cardiopulmonary exercise testing with invasive hemodynamic monitoring and arterial blood gas sampling in individuals referred for dyspnea on exertion. Receiver operator analysis was performed to distinguish heart failure with preserved ejection fraction from pulmonary arterial hypertension. RESULTS Among 253 patients (mean ± SD, age 63 ± 14 years, 55% female, arterial O2 [PaO2] 87 ± 14 mmHg, SaO2 96% ± 4%, resting pulmonary capillary wedge pressure [PCWP] 18 ± 4mmHg, and pulmonary vascular resistance [PVR] 2.7 ± 1.2 Wood units), there was no exercise PCWP threshold, measured up to 49 mmHg, above which hypoxemia was consistently observed. Exercise PaO2 was not correlated with exercise PCWP (rho = 0.04; P = 0.51) but did relate to exercise PVR (rho = -0.46; P < 0.001). Exercise PaO2 and SaO2 levels distinguished left-heart-predominant dysfunction from pulmonary-vascular-predominant dysfunction with an area under the curve of 0.89 and 0.89, respectively. CONCLUSION Systemic O2 levels during exercise distinguish relative pre- and post-capillary pulmonary hemodynamic abnormalities in patients with undifferentiated dyspnea. Hypoxemia during upright exercise should not be attributed to isolated elevation in left heart filling pressures and should prompt consideration of pulmonary vascular dysfunction.
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Affiliation(s)
- Kathryn M Hardin
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston. MA; Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Ilya Giverts
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston. MA
| | - Joseph Campain
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston. MA
| | - Robyn Farrell
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston. MA
| | - Thomas Cunningham
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston. MA
| | - Liana Brooks
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston. MA
| | - Anastasia Christ
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston. MA
| | - Luke Wooster
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston. MA
| | - Cole S Bailey
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston. MA
| | - Mark Schoenike
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston. MA
| | - John Sbarbaro
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston. MA
| | - Aaron Baggish
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston. MA
| | - Matthew Nayor
- Sections of Cardiology and Preventive Medicine and Epidemiology, Division of Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Jennifer E Ho
- CardioVascular Institute and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Rajeev Malhotra
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston. MA
| | - Ravi Shah
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University School of Medicine, Nashville, TN
| | - Gregory D Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston. MA; Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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24
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Babb TG, Balmain BN, Tomlinson AR, Hynan LS, Levine BD, MacNamara JP, Sarma S. Ventilatory limitations in patients with HFpEF and obesity. Respir Physiol Neurobiol 2023; 318:104167. [PMID: 37758032 PMCID: PMC11079902 DOI: 10.1016/j.resp.2023.104167] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/13/2023] [Accepted: 09/24/2023] [Indexed: 10/01/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) patients have an increased ventilatory demand. Whether their ventilatory capacity can meet this increased demand is unknown, especially in those with obesity. Body composition (DXA) and pulmonary function were measured in 20 patients with HFpEF (69 ± 6 yr;9 M/11 W). Cardiorespiratory responses, breathing mechanics, and ratings of perceived breathlessness (RPB, 0-10) were measured at rest, 20 W, and peak exercise. FVC correlated with %body fat (R2 =0.51,P = 0.0006), V̇O2peak (%predicted,R2 =0.32,P = 0.001), and RPB (R2 =0.58,P = 0.0004). %Body fat correlated with end-expiratory lung volume at rest (R2 =0.76,P < 0.001), 20 W (R2 =0.72,P < 0.001), and peak exercise (R2 =0.74,P < 0.001). Patients were then divided into two groups: those with lower ventilatory reserve (FVC<3 L,2 M/10 W) and those with higher ventilatory reserve (FVC>3.8 L,7 M/1 W). V̇O2peak was ∼22% less (p < 0.05) and RPB was twice as high at 20 W (p < 0.01) in patients with lower ventilatory reserve. Ventilatory reserves are limited in patients with HFpEF and obesity; indeed, the margin between ventilatory demand and capacity is so narrow that exercise capacity could be ventilatory limited in many patients.
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Affiliation(s)
- Tony G Babb
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, TX, USA; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Bryce N Balmain
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, TX, USA; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Andrew R Tomlinson
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, TX, USA; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Linda S Hynan
- Peter O'Donnell Jr. School of Public Health and Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, TX, USA; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James P MacNamara
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, TX, USA; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Satyam Sarma
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, TX, USA; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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25
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Bunsawat K, Skow RJ, Kaur J, Wray DW. Neural control of the circulation during exercise in heart failure with reduced and preserved ejection fraction. Am J Physiol Heart Circ Physiol 2023; 325:H998-H1011. [PMID: 37682236 PMCID: PMC10907034 DOI: 10.1152/ajpheart.00214.2023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/23/2023] [Accepted: 09/06/2023] [Indexed: 09/09/2023]
Abstract
Patients with heart failure with reduced (HFrEF) and preserved ejection fraction (HFpEF) exhibit severe exercise intolerance that may be due, in part, to inappropriate cardiovascular and hemodynamic adjustments to exercise. Several neural mechanisms and locally released vasoactive substances work in concert through complex interactions to ensure proper adjustments to meet the metabolic demands of the contracting skeletal muscle. Specifically, accumulating evidence suggests that disease-related alterations in neural mechanisms (e.g., central command, exercise pressor reflex, arterial baroreflex, and cardiopulmonary baroreflex) contribute to heightened sympathetic activation and impaired ability to attenuate sympathetic vasoconstrictor responsiveness that may contribute to reduced skeletal muscle blood flow and severe exercise intolerance in patients with HFrEF. In contrast, little is known regarding these important aspects of physiology in patients with HFpEF, though emerging data reveal heightened sympathetic activation and attenuated skeletal muscle blood flow during exercise in this patient population that may be attributable to dysregulated neural control of the circulation. The overall goal of this review is to provide a brief overview of the current understanding of disease-related alterations in the integrative neural cardiovascular responses to exercise in both HFrEF and HFpEF phenotypes, with a focus on sympathetic nervous system regulation during exercise.
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Affiliation(s)
- Kanokwan Bunsawat
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
| | - Rachel J Skow
- Department of Kinesiology, The University of Texas at Arlington, Arlington, Texas, United States
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Jasdeep Kaur
- Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, Texas, United States
| | - D Walter Wray
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
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26
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Wernhart S, Goertz A, Hedderich J, Papathanasiou M, Hoffmann J, Rassaf T, Luedike P. Diastolic exercise stress testing in heart failure with preserved ejection fraction: The DEST-HF study. Eur J Heart Fail 2023; 25:1768-1780. [PMID: 37565370 DOI: 10.1002/ejhf.2995] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023] Open
Abstract
AIMS Pulmonary capillary wedge pressure (PAWP) ≥25 mmHg during bicycle ergometry is recommended to uncover occult heart failure with preserved ejection fraction. We hypothesized that PAWP increase would differ in available diastolic stress tests and that the margin of PAWP ≥25 mmHg would only be reliably achieved through ergometry. METHODS AND RESULTS We conducted a prospective, single-arm study in patients with an intermediate risk for heart failure with preserved ejection fraction according to the ESC HFA-PEFF score. A total of 19 patients underwent four stress test modalities in randomized order: leg raise, fluid challenge, handgrip, and bicycle ergometry. The primary outcome was the difference (Δ) between resting and exercise PAWP in each modality. Secondary outcomes were differences (Δ) in mean pulmonary artery pressure (mPAP), cardiac output (CO), as well as the ratios between mPAP and PAWP to CO. Compared to resting values, passive leg raise (Δ7.7 ± 8.0 mmHg, p = 0.030), fluid challenge (Δ9.2 ± 6.4 mmHg, p = 0.003), dynamic handgrip (Δ9.6 ± 7.5 mmHg, p = 0.002), and bicycle ergometry (Δ22.3 ± 5.0 mmHg, p < 0.001) uncovered increased PAWP during exercise. Amongst these, bicycle ergometry also demonstrated the highest ΔmPAP (27.2 ± 7.1 mmHg, p < 0.001), ΔCO (3.3 ± 2.6 L/min, p < 0.001), ΔmPAP/CO ratio (2.3 ± 2.0 mmHg/L/min, p < 0.001), and ΔPAWP/CO ratio (2.2 ± 1.4 mmHg/L/min, p < 0.001) compared to other modalities. PAWP ≥25 mmHg was only reliably achieved in bicycle ergometry (31.1 ± 3.9 mmHg). In all other modalities only 10.5% of patients achieved PAWP ≥25 mmHg (handgrip 18.4 ± 6.6 mmHg, fluid 18.1 ± 5.6 mmHg, leg raise 16.5 ± 7.0 mmHg). CONCLUSIONS We demonstrate that bicycle ergometry exhibits a distinct haemodynamic response with higher increase of PAWP compared to other modalities. This finding needs to be considered for valid detection of exercise PAWP ≥25 mmHg when non-bicycle tests remain inconclusive.
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Affiliation(s)
- Simon Wernhart
- Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, West German Heart and Vascular Center, Essen, Germany
| | - Annika Goertz
- Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, West German Heart and Vascular Center, Essen, Germany
| | | | - Maria Papathanasiou
- Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, West German Heart and Vascular Center, Essen, Germany
| | - Julia Hoffmann
- Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, West German Heart and Vascular Center, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, West German Heart and Vascular Center, Essen, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, West German Heart and Vascular Center, Essen, Germany
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27
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Balmain BN, Tomlinson AR, MacNamara JP, Hynan LS, Wakeham DJ, Levine BD, Sarma S, Babb TG. Reducing Pulmonary Capillary Wedge Pressure During Exercise Exacerbates Exertional Dyspnea in Patients With Heart Failure With Preserved Ejection Fraction: Implications for V˙/Q˙ Mismatch. Chest 2023; 164:686-699. [PMID: 37030529 PMCID: PMC10548458 DOI: 10.1016/j.chest.2023.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/29/2023] [Accepted: 04/01/2023] [Indexed: 04/09/2023] Open
Abstract
BACKGROUND The primary cause of dyspnea on exertion in heart failure with preserved ejection fraction (HFpEF) is presumed to be the marked rise in pulmonary capillary wedge pressure during exercise; however, this hypothesis has never been tested directly. Therefore, we evaluated invasive exercise hemodynamics and dyspnea on exertion in patients with HFpEF before and after acute nitroglycerin (NTG) treatment to lower pulmonary capillary wedge pressure. RESEARCH QUESTION Does reducing pulmonary capillary wedge pressure during exercise with NTG improve dyspnea on exertion in HFpEF? STUDY DESIGN AND METHODS Thirty patients with HFpEF performed two invasive 6-min constant-load cycling tests (20 W): one with placebo (PLC) and one with NTG. Ratings of perceived breathlessness (0-10 scale), pulmonary capillary wedge pressure (right side of heart catheter), and arterial blood gases (radial artery catheter) were measured. Measurements of V˙/Q˙ matching, including alveolar dead space (Vdalv; Enghoff modification of the Bohr equation) and the alveolar-arterial Po2 difference (A-aDO2; alveolar gas equation), were also derived. The ventilation (V˙e)/CO2 elimination (V˙co2) slope was also calculated as the slope of the V˙e and V˙co2 relationship, which reflects ventilatory efficiency. RESULTS Ratings of perceived breathlessness increased (PLC: 3.43 ± 1.94 vs NTG: 4.03 ± 2.18; P = .009) despite a clear decrease in pulmonary capillary wedge pressure at 20 W (PLC: 19.7 ± 8.2 vs NTG: 15.9 ± 7.4 mm Hg; P < .001). Moreover, Vdalv (PLC: 0.28 ± 0.07 vs NTG: 0.31 ± 0.08 L/breath; P = .01), A-aDO2 (PLC: 19.6 ± 6.7 vs NTG: 21.1 ± 6.7; P = .04), and V˙e/V˙co2 slope (PLC: 37.6 ± 5.7 vs NTG: 40.2 ± 6.5; P < .001) all increased at 20 W after a decrease in pulmonary capillary wedge pressure. INTERPRETATION These findings have important clinical implications and indicate that lowering pulmonary capillary wedge pressure does not decrease dyspnea on exertion in patients with HFpEF; rather, lowering pulmonary capillary wedge pressure exacerbates dyspnea on exertion, increases V˙/Q˙ mismatch, and worsens ventilatory efficiency during exercise in these patients. This study provides compelling evidence that high pulmonary capillary wedge pressure is likely a secondary phenomenon rather than a primary cause of dyspnea on exertion in patients with HFpEF, and a new therapeutic paradigm is needed to improve symptoms of dyspnea on exertion in these patients.
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Affiliation(s)
- Bryce N Balmain
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Andrew R Tomlinson
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - James P MacNamara
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Linda S Hynan
- The O'Donnell School of Public Health and Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX
| | - Denis J Wakeham
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Satyam Sarma
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Tony G Babb
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, Dallas, TX; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.
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28
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Upadhya B, Kitzman DW. Mechanisms of Exercise Intolerance in Chronic Heart Failure With Preserved Ejection Fraction: Challenging the Traditional Hypothesis. Chest 2023; 164:574-577. [PMID: 37689469 DOI: 10.1016/j.chest.2023.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 09/11/2023] Open
Affiliation(s)
- Bharathi Upadhya
- Cardiovascular Medicine Sections, Duke University School of Medicine, Durham, NC
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29
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Dimopoulos S, Nanas S. Letter by Dimopoulos and Nanas Regarding Article, "Challenging the Hemodynamic Hypothesis in Heart Failure With Preserved Ejection Fraction: Is Exercise Capacity Limited by Elevated Pulmonary Capillary Wedge Pressure?". Circulation 2023; 148:617-618. [PMID: 37579007 DOI: 10.1161/circulationaha.123.063855] [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] [Indexed: 08/16/2023]
Affiliation(s)
- Stavros Dimopoulos
- Cardiopulmonary Exercise Testing and Rehabilitation Laboratory, 1st Critical Care Medicine Department, Evaggelismos Hospital, National and Kapodistrian University of Athens, Greece (S.D., S.N.)
- Department of Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece (S.D.)
| | - Serafim Nanas
- Cardiopulmonary Exercise Testing and Rehabilitation Laboratory, 1st Critical Care Medicine Department, Evaggelismos Hospital, National and Kapodistrian University of Athens, Greece (S.D., S.N.)
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30
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Sarma S, Levine BD. Response by Sarma and Levine to Letters Regarding Article, "Challenging the Hemodynamic Hypothesis in Heart Failure With Preserved Ejection Fraction: Is Exercise Capacity Limited by Elevated Pulmonary Capillary Wedge Pressure?". Circulation 2023; 148:620-621. [PMID: 37579011 DOI: 10.1161/circulationaha.123.065133] [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] [Indexed: 08/16/2023]
Affiliation(s)
- Satyam Sarma
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., B.D.L.)
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas (S.S., B.D.L.)
- University of Texas Southwestern Medical Center, Dallas (S.S., B.D.L.)
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31
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Wussler D, Belkin M, Mueller C. Letter by Wussler et al Regarding Article, "Challenging the Hemodynamic Hypothesis in Heart Failure With Preserved Ejection Fraction: Is Exercise Capacity Limited by Elevated Pulmonary Capillary Wedge Pressure?". Circulation 2023; 148:619. [PMID: 37579009 DOI: 10.1161/circulationaha.123.064413] [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] [Indexed: 08/16/2023]
Affiliation(s)
- Desiree Wussler
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland. Global Research on Acute Conditions Team (GREAT) Network
| | - Maria Belkin
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland. Global Research on Acute Conditions Team (GREAT) Network
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University of Basel, Switzerland. Global Research on Acute Conditions Team (GREAT) Network
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32
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Guazzi M. The biventricular paths to exercise dyspnoea in heart failure with preserved ejection fraction: the future is now. Eur J Heart Fail 2023; 25:967-969. [PMID: 37199380 DOI: 10.1002/ejhf.2914] [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: 05/12/2023] [Accepted: 05/14/2023] [Indexed: 05/19/2023] Open
Affiliation(s)
- Marco Guazzi
- University of Milan School of Medicine, Cardiology Division, San Paolo University Hospital, Milan, Italy
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33
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Pandey A, Keshvani N, Alonso W. Skeletal Muscle Mitochondrial Dysfunction and Exercise Intolerance in Heart Failure With Preserved Ejection Fraction. JAMA Cardiol 2023:2804715. [PMID: 37163277 DOI: 10.1001/jamacardio.2023.0963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Windy Alonso
- College of Nursing, University of Nebraska Medical Center, Lincoln
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34
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Joseph P, Savarimuthu S, Oakland HT, Cullinan M, Heerdt PM, Singh I. Response to letter to the editor "noninvasive determinants of pulmonary hypertension in interstitial lung disease". Pulm Circ 2023; 13:e12238. [PMID: 37180828 PMCID: PMC10166920 DOI: 10.1002/pul2.12238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 04/15/2023] [Indexed: 05/16/2023] Open
Affiliation(s)
- Phillip Joseph
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of MedicineYale New Haven Hospital, Yale School of MedicineNew HavenConnecticutUSA
| | - Stella Savarimuthu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of MedicineYale New Haven Hospital, Yale School of MedicineNew HavenConnecticutUSA
| | - Hannah T. Oakland
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of MedicineYale New Haven Hospital, Yale School of MedicineNew HavenConnecticutUSA
| | - Marjorie Cullinan
- Department of AnaesthesiologyYale New Haven Hospital, Yale School of MedicineNew HavenConnecticutUSA
| | - Paul M. Heerdt
- Department of Respiratory CareYale New Haven HospitalNew HavenConnecticutUSA
| | - Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of MedicineYale New Haven Hospital, Yale School of MedicineNew HavenConnecticutUSA
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35
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Affiliation(s)
- Dalane W Kitzman
- Sections on Cardiovascular Medicine and Geriatrics, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Bharathi Upadhya
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
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36
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Mastoris I, Campain J, Lewis GD. Invasive exercise haemodynamics: an oracle in heart failure with preserved ejection fraction diagnosis and prognostication. Eur J Heart Fail 2023; 25:197-200. [PMID: 36644824 DOI: 10.1002/ejhf.2774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/08/2023] [Indexed: 01/17/2023] Open
Affiliation(s)
- Ioannis Mastoris
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph Campain
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Gregory D Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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