Blood pressure and heart failure

Systolic blood pressure visit-to-visit variability and outcomes in Asian patients with atrial fibrillation

We aimed to assess the association between SBP-VVV and outcomes in Asian patients with atrial fibrillation (AF). AF patients in the COOL-AF registry with SBP measured at baseline, and at least two other visits were studied. We defined SBP-VVV using the standard deviation (SD) of average SBP. Patients were categorized according to the quartiles of SBP SD. The associations between SBP-VVV and outcomes were assessed in the adjusted Cox model. We studied 3172 patients (mean age 67.7 years; 41.8% female), with the prevalence of hypertension being 69%. Warfarin was used in 69% of patients, whereas 7% received non-vitamin K antagonist oral anticoagulants. The minimum and maximum SD of average SBP in the study population was 0.58 and 56.38 mmHg respectively. The cutoff of SD of average SBP for each quartile in our study were 9.09, 12.15, and 16.21 mmHg. The rates of all-cause mortality, ischemic stroke or systemic embolization (SSE), major bleeding, and intracranial hemorrhage (ICH) were 3.10, 1.42, 2.09, and 0.64 per 100 person-years, respectively. Compared with the first quartile, patients in the fourth quartile had a significantly higher risk of mortality (adjusted HR 1.60, 95%CI 1.13-2.25), bleeding (aHR 1.92, 95%CI 1.25-2.96) and ICH (aHR 3.51, 95%CI 1.40-8.76). The risk of SSE was not significantly different among the quartiles. SBP-VVV had a significant impact on the long-term outcomes of Asian patients with AF, particularly mortality and bleeding. Adequate SBP control and maintaining SBP stability over time may improve outcomes for AF patients.

Blood pressure and heart failure: focused on treatment

Heart failure (HF) remains a significant global health burden, and hypertension is known to be the primary contributor to its development. Although aggressive hypertension treatment can prevent heart changes in at-risk patients, determining the optimal blood pressure (BP) targets in cases diagnosed with HF is challenging owing to insufficient evidence. Notably, hypertension is more strongly associated with HF with preserved ejection fraction than with HF with reduced ejection fraction. Patients with acute hypertensive HF exhibit sudden symptoms of acute HF, especially those manifested with severely high BP; however, no specific vasodilator therapy has proven beneficial for this type of acute HF. Since the majority of medications used to treat HF contribute to lowering BP, and BP remains one of the most important hemodynamic markers, targeted BP management is very concerned in treatment strategies. However, no concrete guidelines exist, prompting a trend towards optimizing therapies to within tolerable ranges, rather than setting explicit BP goals. This review discusses the connection between BP and HF, explores its pathophysiology through clinical studies, and addresses its clinical significance and treatment targets.

Inter-relationships of risk factors and pathways associated with all-cause mortality in patients with chronic schizophrenia

Introduction

Of all psychiatric disorders, schizophrenia is associated with the highest risk of all-cause mortality. This study aimed to investigate independent risk factors for all-cause mortality in patients with chronic schizophrenia. In addition, the possible causal inter-relationships among these independent risk factors and all-cause mortality were also explored.

Methods

We conducted an analysis of 1,126 patients with chronic schizophrenia from our psychiatric department from April 2003 to August 2022, and retrospectively reviewed their medical records. The study endpoint was all-cause mortality. Baseline clinical characteristics including sociodemographic data, biochemical data, lifestyle factors, comorbidities and antipsychotic treatment were examined with Cox proportional hazards analysis.

Results

The all-cause mortality rate was 3.9% (44 patients). Multivariate Cox regression analysis revealed that several factors were independently associated with all-cause mortality, including diabetes mellitus (DM), hypertension, heart failure, gastroesophageal reflux disease (GERD), peptic ulcer disease, ileus, underweight, fasting glucose, triglycerides, albumin, and hemoglobin. Structural equation modeling (SEM) analysis revealed that several factors had statistically significant direct effects on all-cause mortality. Heart failure, hypertension, underweight, age at onset, and ileus showed positive direct effects, while albumin and hemoglobin demonstrated negative direct effects. In addition, several factors had indirect effects on all-cause mortality. GERD indirectly affected all-cause mortality through ileus, and peptic ulcer disease had indirect effects through albumin and ileus. Ileus, underweight, DM, and hypertension also exhibited indirect effects through various pathways involving albumin, hemoglobin, and heart failure. Overall, the final model, which included these factors, explained 13% of the variability in all-cause mortality.

Discussion

These results collectively suggest that the presence of DM, hypertension, heart failure, GERD, peptic ulcer disease, ileus, and underweight, along with lower levels of albumin or hemoglobin, were independently associated with all-cause mortality. The SEM analysis further revealed potential causal pathways and inter-relationships among these risk factors contributing to all-cause mortality in patients with chronic schizophrenia.

Knowledge, Attitudes, and Practices Among Elderly CHD Patients Towards Self-Perceived Health Abilities

Objective

This study aimed to assess the knowledge, attitudes and practices (KAP) among elderly coronary heart disease (CHD) patients toward self-perceived health abilities.

Methods

This web-based study was carried out between April 2023 and September 2023 at Guang'anmen Hospital, China Academy of Chinese Medical Sciences. A self-developed questionnaire was utilized to collect demographic information from elderly CHD patients, and evaluate their KAP towards self-perceived health abilities.

Results

A total of 568 valid questionnaires were collected. Among the participants, the average age was 65.97±5.50 years, and 298 (52.46%) were female, and the mean scores for knowledge, attitudes, and practices were 6.34±2.29 (possible range: 0-9), 35.24±4.99 (possible range: 9-45), and 27.79±10.09 (possible range: 9-45), respectively. The structural equation model demonstrated that elderly CHD patients' knowledge directly affects attitudes and practices, with path coefficient of 0.93 (P<0.001) and 0.39 (P=0.033), respectively. Moreover, attitudes play an intermediary role between knowledge and practice with path coefficient of 0.75 (P<0.001). Furthermore, residence directly affects knowledge with path coefficient of 0.67 (P<0.001), cardiac function directly affects knowledge with path coefficient of -0.97 (P<0.001) and history of interventional therapy directly affects practice with path coefficient of 4.23 (P<0.001).

Conclusion

Elderly CHD patients demonstrated sufficient knowledge, positive attitudes, and proactive practices towards self-perceived health abilities. However, educational programs and behavior modification are recommended, particularly for elderly with lower age and education, living in rural areas, lacking interventional therapy, obese, or taking multiple CHD medications.

[Clinical differences between transthyretin cardiac amyloidosis and hypertensive heart disease]

INTRODUCTION

A significant percentage of patients eventually diagnosed with cardiac transthyretin amyloidosis (TTRA) was previously diagnosed with hypertensive heart disease (HHD), since both conditions usually present with heart failure (HF) with preserved ejection fraction (HFpEF) and ventricular hypertrophy. Our objectives were to evaluate the clinical, electrocardiographic and echocardiographic differences, and to analyse whether there exists a differential prognosis between these two nosological entities.

MATERIALS AND METHODS

We retrospectively included all patients with HHD for whom a cardiac scintigraphy with 99mTc-diphosphonate (GDPD) and a free light chains test in blood and urine were ordered for ATTR screening in our centre, in the period between 2016 and 2021. Those diagnosed with other types of amyloidosis were excluded from the analysis.

RESULTS

A total of 72 patients were analyzed: 33 were finally diagnosed with TTRA and 39 with CHTA. Patients with TTRA had higher levels of ultrasensitive troponin I (TnI-US) and N-terminal brain natriuretic propeptide (NT-ProBNP); in electrocardiography (ECG) they presented a pseudo-infarction pattern more frequently as well as conduction disturbances; in echocardiography (TTE) they presented a higher degree of ventricular hypertrophy, left ventricular dysfunction and worse diastolic function parameters, with elevated filling pressures. In the 4-year follow-up, the ATTR group showed greater need for pacemaker (PCM), with no evidence regarding mortality, development of atrial fibrillation (AF), or more admissions for heart failure (HF).

CONCLUSIONS

In our series, patients with TTRA showed clinical, electrocardiographic and echocardiographic differences compared to patients with HHD, with increased risk of need for PCM.

Clinical Review of Hypertensive Acute Heart Failure

Although acute heart failure (AHF) is a common disease associated with significant symptoms, morbidity and mortality, the diagnosis, risk stratification and treatment of patients with hypertensive acute heart failure (H-AHF) still remain a challenge in modern medicine. Despite great progress in diagnostic and therapeutic modalities, this disease is still accompanied by a high rate of both in-hospital (from 3.8% to 11%) and one-year (from 20% to 36%) mortality. Considering the high rate of rehospitalization (22% to 30% in the first three months), the treatment of this disease represents a major financial blow to the health system of each country. This disease is characterized by heterogeneity in precipitating factors, clinical presentation, therapeutic modalities and prognosis. Since heart decompensation usually occurs quickly (within a few hours) in patients with H-AHF, establishing a rapid diagnosis is of vital importance. In addition to establishing the diagnosis of heart failure itself, it is necessary to see the underlying cause that led to it, especially if it is de novo heart failure. Given that hypertension is a precipitating factor of AHF and in up to 11% of AHF patients, strict control of arterial blood pressure is necessary until target values are reached in order to prevent the occurrence of H-AHF, which is still accompanied by a high rate of both early and long-term mortality.

Time in target range of systolic blood pressure and clinical outcomes in atrial fibrillation patients: results of the COOL-AF registry

We aimed to investigate the relationship between time in target range of systolic blood pressure (SBP-TTr) and clinical outcomes in patients with atrial fibrillation (AF). We analyzed the results from multicenter AF registry in Thailand. Blood pressure was recorded at baseline and at every 6 monthly follow-up visit. SBP-TTr were calculated using the Rosendaal method, based on a target SBP 120-140 mmHg. The outcomes were death, ischemic stroke/systemic embolism (SSE), major bleeding, and heart failure. A total of 3355 patients were studied (mean age 67.8 years; 41.9% female). Average follow-up time was 32.1 ± 8.3 months. SBP-TTr was classified into 3 groups according to the tertiles. The incidence rates of all-cause death, SSE, major bleeding, and heart failure were 3.90 (3.51-4.34), 1.52 (1.27-1.80), 2.2 (1.90-2.53), and 2.83 (2.49-3.21) per 100 person-years, respectively. Patients in the 3rd tertile of SBP-TTr had lower rates of death, major bleeding and heart failure with adjusted hazard ratios 0.62 (0.48-0.80), p < 0.001, 0.64 (0.44-0.92), p = 0.016, and 0.61 (0.44-0.84), p = 0.003, respectively, compared to 1st SBP-TTr tertile. In conclusion, high SBP-TTr was associated with better clinical outcomes compared to other groups with lower SBP-TTr. This underscores the importance of good blood pressure control in AF patients.

Ischemic cardiomyopathy: epidemiology, pathophysiology, outcomes, and therapeutic options

Ischemic cardiomyopathy (ICM) is the most prevalent cause of heart failure (HF) in developed countries, with significant morbidity and mortality, despite constant improvements in the management of coronary artery disease. Current literature on this topic remains fragmented. Therefore, this review aimed to summarize the most recent data on ICM, focusing on its definition, epidemiology, outcomes, and therapeutic options. The most widely accepted definition is represented by a left ventricular dysfunction in the presence of significant coronary artery disease. The prevalence of ICM is largely influenced by age and sex, with older individuals and males being more affected. Its pathophysiology is characterized by plaque buildup, thrombus formation, hypoperfusion, ischemic cell death, and left ventricular remodeling. Despite improvements in therapy, ICM still represents a public health burden, with a 1-year mortality rate of 16% and a 5-year mortality rate of approximately 40% in the USA and Europe. Therefore, optimization of cardiovascular function, prevention of progressive remodeling, reduction of HF symptoms, and improved survival are the main goals of treatment. Therapeutic options for ICM include lifestyle changes, optimal medical therapy, revascularization, device therapy, mechanical circulatory support, and cardiac transplantation. Personalized management strategies and tailored patient care are needed to improve the outcomes of patients with ICM.

Development of a facile electrochemical sensor based on GCE modified with one-step prepared PNMA-CeO2-fMWCNTs composite for simultaneous detection of UA and 5-FU

In this study, a poly(N-methyl aniline)-cerium oxide-functionalized MWCNTs (PNMA-CeO2-fMWCNTs) composite was synthesized in a one-step preparation technique. As a highly efficient modifier, the composite was used to modify the glassy carbon electrode surface for simultaneous detection of uric acid (UA) and 5-fluorouracil (5-FU). Morphological characterization of the GCE/PNMA-CeO2-fMWCNTs was studied using scanning electron microscopy. Structural characterization of the composite was performed using X-ray diffraction and Fourier-transformed infrared spectroscopy. Electron transfer properties of the prepared electrodes were carried out with electrochemical impedance spectroscopy and cyclic voltammetry. The linear working range for UA and 5-FU was found to be 0.25-50 μM and 0.5-750 μM, respectively. The limit of detection values for UA and 5-FU were 0.04 μM and 0.19 μM, respectively. The effects of various interfering substances on the electrochemical response of UA and 5-FU were investigated. The GCE/PNMA-CeO2-fMWCNTs sensor has excellent stability, reproducibility, anti-interference ability, and reproducibility. To demonstrate the practical application of the sensing platform, fetal bovine serum was selected and tested in the spiked samples, and satisfactory results were obtained. The prepared composite proved to be a promising platform for simple, rapid, and simultaneous analysis of UA and 5-FU.

Blood Pressure Control in a Diverse Population of Hypertensive Patients With Heart Failure

Hypertensive patients with heart failure (HF), with reduced or preserved ejection fraction, belong to a vulnerable subset with high mortality risks. In HF patients, the current clinical guideline recommends attaining a systolic blood pressure (BP) <130 mm Hg. However, levels of BP control and their correlates in this subgroup are not well understood. Our study aimed at establishing levels of BP control and its associated factors in a geographically, racially diverse population of hypertensive patients with HF. Our study involved 10,802 patients within a large health system in the Charlotte metropolitan area in 2019. We documented a high prevalence of systolic BP ≥130 mm Hg, 48.1% (95% confidence interval 47.4% to 48.8%), and of BP ≥130/80 mm Hg, 57.6% (57.0% to 58.3%). From a multivariate logistic regression model, systolic BP ≥130 mm Hg was associated with race-ethnicity (p <0.0001), gender (p = 0.0001), insurance (p <0.0001), attribution with a primary care physician (p = 0.0001). Non-Hispanic Blacks (vs non-Hispanic Whites odds ratio [OR] 1.38, 1.28 to 1.48), women (OR 1.12, 1.06 to 1.19), and uninsured patients (vs privately insured OR 1.43, 1.20 to 1.72) had a higher risk of systolic BP ≥130 mm Hg; patients with primary care physician attribution had a lower risk of systolic BP ≥130 mm Hg (OR 0.87, 0.81 to 0.94). Similar results were found with the outcome BP ≥130/80 mm Hg. Overall, further efforts are needed to optimize treatment in hypertensive patients with HF and improve health equity across patient communities.

Uncontrolled hypertension at the dentist: a case report of integrated healthcare

Hypertension is a risk factor for major cardiovascular events and it is usually detected and managed by general medical practitioners (GPs) in primary care. However, it is estimated that 4.8 million adults are living with untreated high blood pressure (BP) in the UK. Health authorities are encouraging more collaborative work across health professions to find and refer individuals with undiagnosed hypertension. In this case, in 2022, a 65-year-old man with a previous history of hypertension, taking antihypertensive medication, attended a BP clinic at the University of Plymouth, Peninsula Dental School as part of a hypertension case finding pilot. His systolic and diastolic BP were 150 and 85 mmHg, respectively, and as per the trial protocol, a referral letter was sent to his GP for suspected further assessment and investigation. Then, an onward referral was made to secondary care and the participant was subsequently hospitalised for 13 days for treatment of heart failure and suspected acute coronary syndrome. This case report highlights that BP readings taken in a primary care dental setting can be very useful and recommends better integration of dental services into primary care to reduce the risk of major cardiovascular events.

Pilot Investigation of Blood Pressure Control Using a Mobile App (Cardi.Health): Retrospective Chart Review Study

BACKGROUND

The high prevalence of hypertension necessitates effective, scalable interventions for blood pressure (BP) control. Self-monitoring has shown improved adherence to medication and better BP management. Mobile apps offer a promising approach with their increasing popularity and potential for large-scale implementation. Studies have demonstrated associations between mobile app interventions and lowered BP, yet real-world data on app effectiveness and engagement remain limited.

OBJECTIVE

In this study, we analyzed real-world user data from the Cardi.Health mobile app, which is aimed at helping its users monitor and control their BP. Our goal was to find out whether there is an association between the use of the mobile app and a decrease in BP. Additionally, the study explored how engagement with the app may influence this outcome.

METHODS

This was a retrospective chart review study. The initial study population comprised 4407 Cardi.Health users who began using the app between January 2022 and April 2022. After applying inclusion criteria, the final study cohort comprised 339 users with elevated BP at the baseline. The sample consisted of 108 (31.9%) men and 231 (68.1%) women (P=.04). This retrospective chart review study obtained permission from the Biomedical Research Alliance of New York Institutional Review Board (June 2022, registration ID 22-08-503-939).

RESULTS

The study's main findings were that there is a possible relationship between use of the Cardi.Health mobile app and a decrease in systolic BP. Additionally, there was a significant association between active use of the app and systolic BP decrease (χ21=5.311; P=.02). Finally, active users had an almost 2 times greater chance of reducing systolic BP by 5 mm Hg or more over 4 weeks (odds ratio 1.932, 95% CI 1.074-3.528; P=.03).

CONCLUSIONS

This study shows a possible relationship between Cardi.Health mobile app use and decreased BP. Additionally, engagement with the app may be related to better results-active use was associated with an almost 2-fold increase in the odds of reducing BP by 5 or more mm Hg.

Ameliorative effect of mussel-derived ACE inhibitory peptides on spontaneous hypertension rats

PURPOSE

The purpose of this study was to prepare the novel mussel-derived ACE inhibitory peptides (MEPs) by enzymatic hydrolysis of Mytilus edulis and investigate their antihypertensive effects in vivo.

METHODS

After assessing the stability of MEPs in vitro, we investigated the effect of MEPs on hypertension using spontaneously hypertensive rats (SHRs). Subsequently, MEPs were purified and identified by ultrafiltration, gel filtration chromatography and liquid chromatography-tandem mass spectrometry (LC-MS/MS).

RESULTS

Our study demonstrated that MEPs could keep stable ACE inhibitory activity after treatment with heat, acid, alkali, metal ions and simulated gastrointestinal digestive fluid. Additionally, the animal experiments showed that both short-term and long-term treatment with MEPs resulted in a significant reduction in systolic and diastolic blood pressure in SHRs. Mechanistically, the results suggested that MEPs could reduce vascular remodeling, regulate renin-angiotensin system (RAS), and inhibit kidney and myocardial fibrosis. Finally, we isolated and identified five peptides from MEPs, with the peptide Ile-Leu-Thr-Glu-Arg showed the highest ACE inhibition rate.

CONCLUSION

Our findings demonstrate the potential use of MEPs as active components in functional foods designed to lower blood pressure.

Evaluating the hypertension care cascade in middle-aged and older adults in The Gambia: findings from a nationwide survey

Background

Hypertension is a major public health problem in sub-Saharan Africa with poor treatment coverage and high case-fatality rates. This requires assessment of healthcare performance to identify areas where intervention is most needed. To identify areas where health resources should be most efficiently targeted, we assessed the hypertension care cascade i.e., loss and retention across the various stages of care, in Gambian adults aged 35 years and above.

Methods

This study was embedded within the nationally representative 2019 Gambia National Eye Health Survey of adults ≥35 years. We constructed a hypertension care cascade with four categories: prevalence of hypertension (defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg, and/or current use of medication prescribed for hypertension); those aware of their diagnosis; those treated; and those with a controlled blood pressure (defined as blood pressure <140/90 mmHg). Analyses were age- and sex-standardised to the population structure of The Gambia. Logistic regression was used to assess the socio-demographic factors associated with prevalence, awareness, treatment and control of hypertension.

Findings

Of 9171 participants with data for blood pressure, the prevalence of hypertension was 47.0%. Among people with hypertension, the prevalence of awareness was 54.7%, the prevalence of hypertension treatment was 32.5%, and prevalence of control was 10.0% with little difference between urban and rural residence. The cascade of care performance was better in women. However, there was no difference in achieving blood pressure control between men and women who were receiving treatment. Female sex, older age and higher body mass index were associated with higher hypertension awareness whilst having an occupation compared to being unemployed was associated with higher odds of being treated. Patients in the underweight category had higher odds of achieving blood pressure control.

Interpretation

There is a high prevalence of hypertension and low performance of the health care system that impact on the hypertension care cascade among middle-aged and older adults in The Gambia. Addressing the full cascade will be paramount especially in reducing the mounting prevalence and improving diagnosis of patients with hypertension, where the greatest dividends will be gained.

Funding

The Queen Elizabeth Diamond Jubilee Trust, Wellcome Trust.

Characterization of Individuals With Apparent Resistant Hypertension Using Contemporary Guidelines: Insights From CV-QUIC

BACKGROUND

Apparent resistant hypertension (aRH) carries excess cardiovascular risk beyond nonresistant forms of hypertension; however, our understanding of this at-risk population, as defined by current US practice guidelines, is limited. Accordingly, we sought to evaluate the prevalence, clinical characteristics, and pharmacotherapeutic patterns of patients with aRH using contemporary blood pressure guidance.

METHODS

We classified patients at 3 large healthcare systems by hypertensive status using contemporary hypertension guidelines. We subsequently described the demographic and clinical characteristics of patients with aRH and compared these factors among hypertensive patients without aRH and between those with controlled and uncontrolled aRH.

RESULTS

A total of 2 420 468 patients were analyzed, of whom 1 343 489 (55.6%) were hypertensive according to contemporary guidelines. Among hypertensive patients, 11 992 (8.5%) met criteria for aRH, with nearly all assessed comorbid conditions, particularly diabetes and heart failure, being more common in those with aRH. When compared with patients with uncontrolled aRH, those with controlled aRH were more frequently prescribed a beta-blocker, diuretic, and nitrate, with the largest standardized difference observed for a mineralocorticoid receptor antagonist (35.4% versus 10.4%, Cohen D 0.62). Consistent findings were noted in sensitivity analyses using the blood pressure threshold of 140/90 mm Hg.

CONCLUSIONS

In an analysis of over 2.4 million individuals, a lower prevalence of aRH was observed than previously reported (12%-15%), but with a high burden of comorbidities. Identification of differences in pharmacotherapy between patients with controlled and uncontrolled aRH, particularly lower rates of mineralocorticoid receptor antagonist use, help define potential opportunities to improve care and lower cardiovascular risk.

Protocatechuic acid prevents isoproterenol-induced heart failure in mice by downregulating kynurenine-3-monooxygenase

Protocatechuic acid (3,4-dihydroxybenzoic acid) prevents oxidative stress, inflammation and cardiac hypertrophy. This study aimed to investigate the therapeutic effects of protocatechuic acid in an isoproterenol-induced heart failure mouse model and to identify the underlying mechanisms. To establish the heart failure model, C57BL/6NTac mice were given high-dose isoproterenol (80 mg/kg body weight) for 14 days. Echocardiography revealed that protocatechuic acid reversed the isoproterenol-induced downregulation of fractional shortening and ejection fraction. Protocatechuic acid attenuated cardiac hypertrophy as evidenced by the decreased heart-weight-to-body-weight ratio and the expression of Nppb. RNA sequencing analysis identified kynurenine-3-monooxygenase (Kmo) as a potential target of protocatechuic acid. Protocatechuic acid treatment or transfection with short-interfering RNA against Kmo ameliorated transforming growth factor β1-induced upregulation of Kmo, Col1a1, Col1a2 and Fn1 in vivo or in neonatal rat cardiac fibroblasts. Kmo knockdown attenuated the isoproterenol-induced increase in cardiomyocyte size, as well as Nppb and Col1a1 expression in H9c2 cells or primary neonatal rat cardiomyocytes. Moreover, protocatechuic acid attenuated Kmo overexpression-induced increases in Nppb mRNA levels. Protocatechuic acid or Kmo knockdown decreased isoproterenol-induced ROS generation in vivo and in vitro. Thus, protocatechuic acid prevents heart failure by downregulating Kmo. Therefore, protocatechuic acid and Kmo constitute a potential novel therapeutic agent and target, respectively, against heart failure.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Management of the Underlying Etiologies and Comorbidities of Heart Failure

Most patients with heart failure (HF) have multiple comorbidities, which impact their quality of life, aggravate HF, and increase mortality. Cardiovascular comorbidities include systemic and pulmonary hypertension, ischemic and valvular heart diseases, and atrial fibrillation. Non-cardiovascular comorbidities include diabetes mellitus (DM), chronic kidney and pulmonary diseases, iron deficiency and anemia, and sleep apnea. In patients with HF with hypertension and left ventricular hypertrophy, renin-angiotensin system inhibitors combined with calcium channel blockers and/or diuretics is an effective treatment regimen. Measurement of pulmonary vascular resistance via right heart catheterization is recommended for patients with HF considered suitable for implantation of mechanical circulatory support devices or as heart transplantation candidates. Coronary angiography remains the gold standard for the diagnosis and reperfusion in patients with HF and angina pectoris refractory to antianginal medications. In patients with HF and atrial fibrillation, long-term anticoagulants are recommended according to the CHA2DS2-VASc scores. Valvular heart diseases should be treated medically and/or surgically. In patients with HF and DM, metformin is relatively safer; thiazolidinediones cause fluid retention and should be avoided in patients with HF and dyspnea. In renal insufficiency, both volume status and cardiac performance are important for therapy guidance. In patients with HF and pulmonary disease, beta-blockers are underused, which may be related to increased mortality. In patients with HF and anemia, iron supplementation can help improve symptoms. In obstructive sleep apnea, continuous positive airway pressure therapy helps avoid severe nocturnal hypoxia. Appropriate management of comorbidities is important for improving clinical outcomes in patients with HF.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Management of the Underlying Etiologies and Comorbidities of Heart Failure

Most patients with heart failure (HF) have multiple comorbidities, which impact their quality of life, aggravate HF, and increase mortality. Cardiovascular comorbidities include systemic and pulmonary hypertension, ischemic and valvular heart diseases, and atrial fibrillation. Non-cardiovascular comorbidities include diabetes mellitus (DM), chronic kidney and pulmonary diseases, iron deficiency and anemia, and sleep apnea. In patients with HF with hypertension and left ventricular hypertrophy, renin-angiotensin system inhibitors combined with calcium channel blockers and/or diuretics is an effective treatment regimen. Measurement of pulmonary vascular resistance via right heart catheterization is recommended for patients with HF considered suitable for implantation of mechanical circulatory support devices or as heart transplantation candidates. Coronary angiography remains the gold standard for the diagnosis and reperfusion in patients with HF and angina pectoris refractory to antianginal medications. In patients with HF and atrial fibrillation, long-term anticoagulants are recommended according to the CHA2DS2-VASc scores. Valvular heart diseases should be treated medically and/or surgically. In patients with HF and DM, metformin is relatively safer; thiazolidinediones cause fluid retention and should be avoided in patients with HF and dyspnea. In renal insufficiency, both volume status and cardiac performance are important for therapy guidance. In patients with HF and pulmonary disease, beta-blockers are underused, which may be related to increased mortality. In patients with HF and anemia, iron supplementation can help improve symptoms. In obstructive sleep apnea, continuous positive airway pressure therapy helps avoid severe nocturnal hypoxia. Appropriate management of comorbidities is important for improving clinical outcomes in patients with HF.

Loss of hepatic PPARα in mice causes hypertension and cardiovascular disease

The leading cause of death in patients with nonalcoholic fatty liver disease (NAFLD) is cardiovascular disease (CVD). However, the mechanisms are unknown. Mice deficient in hepatocyte proliferator-activated receptor-α (PPARα) (PparaHepKO) exhibit hepatic steatosis on a regular chow diet, making them prone to manifesting NAFLD. We hypothesized that the PparaHepKO mice might be predisposed to poorer cardiovascular phenotypes due to increased liver fat content. Therefore, we used PparaHepKO and littermate control mice fed a regular chow diet to avoid complications with a high-fat diet, such as insulin resistance and increased adiposity. After 30 wk on a standard diet, male PparaHepKO mice exhibited elevated hepatic fat content compared with littermates as measured by Echo MRI (11.95 ± 1.4 vs. 3.74 ± 1.4%, P < 0.05), hepatic triglycerides (1.4 ± 0.10 vs. 0.3 ± 0.01 mM, P < 0.05), and Oil Red O staining, despite body weight, fasting blood glucose, and insulin levels being the same as controls. The PparaHepKO mice also displayed elevated mean arterial blood pressure (121 ± 4 vs. 108 ± 2 mmHg, P < 0.05), impaired diastolic function, cardiac remodeling, and enhanced vascular stiffness. To determine mechanisms controlling the increase in stiffness in the aorta, we used state-of-the-art PamGene technology to measure kinase activity in this tissue. Our data suggest that the loss of hepatic PPARα induces alterations in the aortas that reduce the kinase activity of tropomyosin receptor kinases and p70S6K kinase, which might contribute to the pathogenesis of NAFLD-induced CVD. These data indicate that hepatic PPARα protects the cardiovascular system through some as-of-yet undefined mechanism.

Risk Factors for Bleeding Varicose Veins in Patients with Chronic Venous Disease

Background and Objectives: Chronic venous disease (CVD) is a widespread clinical condition that is very common in western countries in the adult general population with a wide range of clinical manifestations, such as varicose veins (VVs) that in certain circumstances may complicate with rupture and subsequent bleeding that may even be fatal. The aim of this study is to evaluate risk factors for bleeding VVs. Materials and Methods: This is a retrospective study conducted in patients with CVD complicating with bleeding of VVs over a 4-year period (2019-2022). A random sample, for the same 4-year period and with a 3:1 ratio, was selected from other CVD patients without VVs bleeding that served as the control group. Results: From a global population of 1048 patients with CVD over a 4-year period, a total of 33 patients (3.15%) with VVs bleeding were selected. A group of 99 patients without VVs bleeding were randomly selected from the total population of 1048 patients with CVD. Findings of this study showed that advanced clinical stage of CVD (i.e., C4b stage), advanced age, living alone, suffering from cardiovascular co-morbidity (i.e., hypertension and CHF), assuming certain drugs that act on blood coagulation (i.e., aspirin, anticoagulants), assuming psychotropic medication, having particular venous reflux patterns (i.e., below-knee GSV reflux, non-saphenous veins reflux, Cockett's perforators reflux), and not having been assessed and treated previously for CVD (i.e., with VADs, CT, or surgery) may predispose a high risk for bleeding VVs. Conclusions: Bleeding VVs may be a life-threatening complications of CVD patients, and monitoring risk factors found in this study and others that, hopefully, may be discovered in the future through further focused research will help to reduce the impact of this problem in this patient population.

Left Ventricular Ejection Fraction Association with Acute Ischemic Stroke Outcomes in Patients Undergoing Thrombolysis

(1) Background: Little is known about how left ventricular systolic dysfunction (LVSD) affects functional and clinical outcomes in acute ischemic stroke (AIS) patients undergoing thrombolysis; (2) Methods: A retrospective observational study conducted between 2006 and 2018 included 937 consecutive AIS patients undergoing thrombolysis. LVSD was defined as left ventricular ejection fraction (LVEF) < 50%. Univariate and multivariate binary logistic regression analysis was performed for demographic characteristics. Ordinal shift regression was used for functional modified Rankin Scale (mRS) outcome at 3 months. Survival analysis of mortality, heart failure (HF) admission, myocardial infarction (MI) and stroke/transient ischemic attack (TIA) was evaluated with a Cox-proportional hazards model; (3) Results: LVSD patients in comparison with LVEF ≥ 50% patients accounted for 190 and 747 patients, respectively. LVSD patients had more comorbidities including diabetes mellitus (100 (52.6%) vs. 280 (37.5%), p < 0.001), atrial fibrillation (69 (36.3%) vs. 212 (28.4%), p = 0.033), ischemic heart disease (130 (68.4%) vs. 145 (19.4%), p < 0.001) and HF (150 (78.9%) vs. 46 (6.2%), p < 0.001). LVSD was associated with worse functional mRS outcomes at 3 months (adjusted OR 1.41, 95% CI 1.03-1.92, p = 0.030). Survival analysis identified LVSD to significantly predict all-cause mortality (adjusted HR [aHR] 3.38, 95% CI 1.74-6.54, p < 0.001), subsequent HF admission (aHR 4.23, 95% CI 2.17-8.26, p < 0.001) and MI (aHR 2.49, 95% CI 1.44-4.32, p = 0.001). LVSD did not predict recurrent stroke/TIA (aHR 1.15, 95% CI 0.77-1.72, p = 0.496); (4) Conclusions: LVSD in AIS patients undergoing thrombolysis was associated with increased all-cause mortality, subsequent HF admission, subsequent MI and poorer functional outcomes, highlighting a need to optimize LVEF.

Prognostic Factors for Prolonged In-Hospital Stay in Patients with Heart Failure

Background and Objectives: Heart failure (HF) is a threatening health condition that is associated with an increasing prevalence and high expenses because of frequent patient hospitalizations. The purpose of this study was to evaluate the factors that influence the length of in-hospital stay in HF patients. Materials and Methods: A total of 220 patients (43.2% men), admitted to the Department of Cardiology, Kaunas Hospital of Lithuanian University of Health Sciences from the 1st of January 2021 to the 31st of May 2021, were included in this study. According to the length of in-hospital stay, patients were stratified into two groups: the first group's length of stay (LOS) was from 1 to 8 days, and the second group's LOS was 9 days or more. Results: The median LOS was 8 (6-10) days. Multivariate logistic regression analysis revealed five predictors as independent factors associated with prolonged hospitalization. These predictors included treatment interruption (OR 3.694; 95% CI 1.080-12.630, p = 0.037), higher value of NT-proBNP (OR 3.352; 95% CI 1.468-7.659, p = 0.004), estimated glomerular filtration rate (eGFR) ≤ 50 mL/min/1.73 m² (OR 2.423; 95% CI 1.090-5.383, p = 0.030), systolic blood pressure (BP) ≤ 135 mmHg (OR 3.100; 95% CI 1.421-6.761, p = 0.004) and severe tricuspid valve regurgitation (OR 2.473; 95% CI 1.086-5.632, p = 0.031). Conclusions: Several variables were identified as significant clinical predictors for prolonged length of in-hospital stay in HF patients where treatment interruption, higher NT-proBNP value and lower systolic BP at admission were the most important.

Consensus Statements from the Diabetologists & Endocrinologists Alliance for the Management of People with Hypertension and Type 2 Diabetes Mellitus

Hypertension and type 2 diabetes mellitus (T2DM) are important, intertwined public health issues. People with both conditions face significantly elevated risks of cardiovascular (CV) and renal complications. To optimize patient care, a multidisciplinary expert panel met to review recent evidence on optimal blood pressure (BP) targets, implications of albuminuria, and treatment regimens for hypertensive patients with T2DM, with the aim of providing recommendations for physicians in Hong Kong. The panel reviewed the relevant literature, obtained by searching PubMed for the publication period from January 2015 to June 2021, to address five discussion areas: (i) BP targets based on CV/renal benefits; (ii) management of isolated systolic or diastolic hypertension; (iii) roles of angiotensin II receptor blockers; (iv) implications of albuminuria for CV/renal events and treatment choices; and (v) roles and tools of screening for microalbuminuria. The panel held three virtual meetings using a modified Delphi method to address the discussion areas. After each meeting, consensus statements were derived and anonymously voted on by every panelist. A total of 17 consensus statements were formulated based on recent evidence and expert insights regarding cardioprotection and renoprotection for hypertensive patients with T2DM.

Characterization of Inclination Analysis for Predicting Onset of Heart Failure from Primary Care Electronic Medical Records

The aim of this study is to characterize the performance of an inclination analysis for predicting the onset of heart failure (HF) from routinely collected clinical biomarkers extracted from primary care electronic medical records. A balanced dataset of 698 patients (with/without HF), including a minimum of five longitudinal measures of nine biomarkers (body mass index, diastolic and systolic blood pressure, fasting glucose, glycated hemoglobin, low-density and high-density lipoproteins, total cholesterol, and triglycerides) is used. The proposed algorithm achieves an accuracy of 0.89 (sensitivity of 0.89, specificity of 0.90) to predict the inclination of biomarkers (i.e., their trend towards a 'survival' or 'collapse' as defined by an inclination analysis) on a labeled, balanced dataset of 40 patients. Decision trees trained on the predicted inclination of biomarkers have significantly higher recall (0.69 vs. 0.53) and significantly higher negative predictive value (0.60 vs. 0.55) than those trained on the average values computed from the measures of biomarkers available before the onset of the disease, suggesting that an inclination analysis can help identify the onset of HF in the primary care patient population from routinely available clinical data. This exploratory study provides the basis for further investigations of inclination analyses to identify at-risk patients and generate preventive measures (i.e., personalized recommendations to reverse the trend of biomarkers towards collapse).

The link between immunity and hypertension in the kidney and heart

Hypertension is the primary cause of cardiovascular disease, which is a leading killer worldwide. Despite the prevalence of this non-communicable disease, still between 90% and 95% of cases are of unknown or multivariate cause ("essential hypertension"). Current therapeutic options focus primarily on lowering blood pressure through decreasing peripheral resistance or reducing fluid volume, but fewer than half of hypertensive patients can reach blood pressure control. Hence, identifying unknown mechanisms causing essential hypertension and designing new treatment accordingly are critically needed for improving public health. In recent years, the immune system has been increasingly implicated in contributing to a plethora of cardiovascular diseases. Many studies have demonstrated the critical role of the immune system in the pathogenesis of hypertension, particularly through pro-inflammatory mechanisms within the kidney and heart, which, eventually, drive a myriad of renal and cardiovascular diseases. However, the precise mechanisms and potential therapeutic targets remain largely unknown. Therefore, identifying which immune players are contributing to local inflammation and characterizing pro-inflammatory molecules and mechanisms involved will provide promising new therapeutic targets that could lower blood pressure and prevent progression from hypertension into renal or cardiac dysfunction.

Effect of different blood pressure levels on short-term outcomes in hospitalized heart failure patients

Background

To investigate the influence of blood pressure (BP) level on short-term prognosis of heart failure (HF), the effect of the BP level on clinical end point events 3 months after discharge was observed.

Methods

A retrospective cohort study was performed on 1492 hospitalized HF patients. All patients were divided according to systolic blood pressure (SBP) per 20 mmHg and diastolic blood pressure (DBP) per 10 mmHg. Logistic regression analysis was used to analyze the relationship between BP level and heart failure rehospitalization, cardiac death, all-cause death and a composite end point of heart failure rehospitalization/all-cause death at 3 month follow-up after discharge.

Results

After multivariable adjustment, the relationship between SBP and DBP levels and outcomes followed an inverted J curve relationship. Compared with the reference group (110 < SBP≤130 mmHg), the risk of all end point events significantly increased in the SBP≤90 mmHg group included heart failure rehospitalization (OR 8.16, 95%CI 2.88-23.11, P < 0.001), cardiac death (OR 5.43, 95%CI 1.97-14.96, P = 0.001), all-cause death (OR 4.85, 95%CI 1.76-13.36, P = 0.002), and composite end point (OR 2.76, 95%CI 1.03-7.41, P = 0.044). SBP>150 mmHg significantly increased the risk of heart failure rehospitalization (OR 2.67, 95%CI 1.15-6.18, P = 0.022). Compared with.the reference group (65 < DBP≤75 mmHg), cardiac death (OR 2.64, 95%CI 1.15-6.05, P = 0.022) and all-cause death (OR 2.67, 95%CI 1.20-5.93, P = 0.016) was significantly increased in DBP≤55 mmHg group. There was no significant difference among subgroups according to left ventricular ejection fraction (P > 0.05).

Conclusions

There is a significant difference in the short-term prognosis 3 months after discharge in HF patients with different BP levels at discharge. There was an inverted J curve relationship between BP levels and prognosis.

Myocardial performance index as a measure of global left ventricular function improves following isometric exercise training in hypertensive patients

As the leading cause of cardiovascular disease and mortality, hypertension remains a global health problem. Isometric exercise training (IET) has been established as efficacious in reducing resting blood pressure (BP); however, no research to date has investigated its effects on the myocardial performance index (MPI). Twenty-four unmedicated hypertensive patients were randomized to 4 weeks of IET and a control period in a crossover design. Tissue Doppler imaging was used to acquire cardiac time intervals pre- and post-IET and during the control periods. IET significantly improved all measures of cardiac time intervals, including isovolumic relaxation time (83.1 ± 10.3 vs. 76.1 ± 11.2 ms, p = 0.006), isovolumic contraction time (84.8 ± 10.3 vs. 72.8 ± 6.4 ms, p < 0.001), ejection time (304.6 ± 30.2 vs. 321.4 ± 20.8 ms, p = 0.015) and the MPI (0.56 ± 0.09 vs. 0.47 ± 0.05, p < 0.001). This is the first study to demonstrate that IET significantly improves cardiac time intervals. These findings may have important clinical implications, highlighting the potential utility of IET in the management of cardiac health in hypertensive patients.

Effect of flaxseed supplementation on blood pressure: a systematic review, and dose-response meta-analysis of randomized clinical trials

Many clinical trials have revealed that flaxseed supplementation might exert a potent antihypertensive influence, but the findings are inconsistent. In this regard, a meta-analysis was carried out to provide a more accurate estimate of the impact of flaxseed supplementation on blood pressure. We searched international databases including PubMed, Cochrane Library, Web of Science, Scopus, Embase, and Google Scholar till July 2022. A random-effects model was used to calculate weighted mean differences (WMDs). Non-linear dose-response analysis and meta-regression were performed. Meta-analysis of 33 trials (comprising 43 treatment arms) with 2427 participants revealed significant reductions in both systolic (WMD: -3.19 mmHg; 95% CI: -4.15 to -2.24, p < 0.001; I² = 92.5%, p < 0.001) and diastolic blood pressure (WMD = -2.61 mmHg; 95% CI: -3.27, -1.94, p < 0.001; I² = 94.1%, p < 0.001) following flaxseed supplementation. Greater effects on SBP and DBP were found in trials with an intervention duration of >20 weeks, ≥30 g day^-1 of flaxseed, subjects with BMI 25-30 kg m^-2, and in patients with hypertension. Supplementation with various flaxseed products significantly reduced SBP and DBP levels, confirming the hypothesis that flaxseed could be used as an effective supplement for blood pressure management, alongside routine medications.

Afterload reduction after non-invasive vagus nerve stimulation in acute heart failure

Introduction

While central blood pressure (BP) has been recognized as a major indicator of left ventricular (LV) afterload, the reduction of central pressure decreases LV afterload and may prevent heart failure (HF) decompensation. Non-invasive transcutaneous vagus nerve stimulation (tVNS) was shown to improve cardiac function in HF patients. In this study, the relationship between active tVNS and reduction of central BP was investigated in patients with acute HF (AHF).

Methods

The 22 patients hospitalized for AHF after initial stabilization (median 80 yrs, males 60%) were randomly assigned to active or sham group. For 1 h daily over 5 days, low-level transcutaneous electrical stimulation (LLTS) (20 Hz, 1 mA) was performed after attaching an ear clip to the tragus (active group) or the earlobe (sham control group). Before and after stimulation, central aortic systolic pressure (CASP), brachial systolic BP (SBP), diastolic BP (DBP) as well as heart rate (HR) were noninvasively measured.

Results

No significant differences in baseline characteristics were observed between the active and sham groups. In the active group, CASP, SBP, DBP, and HR each decreased significantly after stimulation (all p < 0.05), whereas in the sham group, CASP, SBP, DBP, and HR each increased significantly after stimulation (all p < 0.05). All the changes in CASP, SBP, DBP and HR before and after stimulation were also significantly different between active and sham groups (all p < 0.01). There were no device-related side effects.

Conclusion

In this study, the left tragus tVNS resulted in an acute afterload reduction in the elderly AHF patients. Non-invasive LLTS may be useful and safe for reducing afterload in AHF.

Clinical trial registration

ClinicalTrials.gov, identifier UMIN000044121.

Ambient Temperature and Cardiac Biomarkers: A Meta-Analysis

This study quantified the effect of cold or heat exposure of ambient temperature on the alteration of well-known cardiac markers. A meta-analysis was performed using the PRISMA guidelines. Peer-reviewed studies on ambient temperature and cardiac biomarkers were retrieved from MEDLINE, ScienceDirect and Google Scholar from January 2000 to February 2022. The pooled effect sizes of ambient temperature on cardiac biomarkers c-reactive protein, soluble-cell adhesion-molecule-1, soluble-intercellular-adhesion-molecule-1, total cholesterol, low-densitylipoprotein, interleukin-6, B-type-Natriuretic-Peptide; systolic/diastolic blood pressure were quantified using a random-effects meta-analysis. A total of 26 articles were included in the metaanalysis after screening the titles, abstracts and full texts. The pooled results for a 1°C decrease of ambient temperature showed an increase of 0.31% (95% CI= 0.26 to 0.38) in cardiac biomarkers (p=0.00; I-squared=99.2%; Cochran's Q=5636.8). In contrast, the pooled results for a 1°C increase in ambient temperature showed an increase of 2.03% (95% CI= 1.08 to 3.82) in cardiac biomarkers (p=0.00; I-squared=95.7%; Cochran's Q=235.2). In the cardiovascular (CV) population, the percent increase in cardiac biomarkers levels due to a decrease/increase in ambient temperature was greater. This study showed the decrease/increase in ambient temperature has a direct correlation with the alterations in cardiac biomarkers. These findings are useful for managing temperatureassociated cardiovascular mortality.

[Impact of isometric training on blood pressure: an umbrella study of systematic reviews and meta-analyses]

High blood pressure causes 45% of deaths from heart diseases and 51% of deaths from stroke.

OBJECTIVE

To conduct systematic search and summarize the systematic reviews and/or meta-analyses about impact of isometric training on blood pressure.

MATERIAL AND METHODS

Systematic search for publications in PubMed, Cochrane Library and Epistemonikos databases for the period from January of 2017 yr. to 19 of January 2023 yr. was carried out. The search was done by keywords: isometric exercises, isometric training, blood pressure, arterial hypertension, static resistance training, handgrip test. Methodological quality of included articles was assessed using the «Assessment of methodological quality of systematic reviews» (AMSTAR-2) tool. The number of systematic reviews equal 15 was analyzed.

RESULTS

The overall methodological quality of 15 included reviews, obtained by AMSTAR-2, revealed a very low confidence rate (critically low confidence, 10 publications) for results of systematic review and meta-analyses. In total, analysis and generalization of all results of included systematic reviews about blood pressure decrease by isometric training showed, that systolic blood pressure against the background of this method decreases on average by 6.1±2.0 mm Hg, and diastolic blood pressure - by 3.0±1.0 mm Hg.

CONCLUSION

Authors of 15 systemic reviews, included in an umbrella study, reached a common conclusion about isometric training efficacy in secondary prevention of arterial hypertension.

Effect of Lycopene Supplementation on Some Cardiovascular Risk Factors and Markers of Endothelial Function in Iranian Patients with Ischemic Heart Failure: A Randomized Clinical Trial

Aim

This study aimed to explore if supplementary lycopene tablets may help heart failure (HF) patients improve their lipid profile, BP, and the flow-mediated dilation (FMD) index for endothelial function.

Methods

Fifty patients with ischemic HF with a reduced ejection fraction (HFrEF) were randomly assigned to one of two groups: the lycopene group which received 25 mg lycopene tablets once a day for 8 weeks and the control group which received placebo tablets containing starch once a day for 8 weeks.

Results

Our results showed that after two months, the amount of triglyceride (TG) and FMD improved significantly compared to the control, TG decreased (219.27 vs. 234.24), and the mean of FMD increased (5.68 vs. 2.95). Other variables, including total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density cholesterol (HDL-C), systolic blood pressure (SBP), and diastolic blood pressure (DBP), showed no improvement. Also, only SBP and FMD showed intragroup improvement in the intervention group. In the intervention group, only SBP and FMD exhibited intragroup improvement.

Conclusions

It can be concluded that supplementing with lycopene can enhance endothelial function and reduce the TG levels in ischemic HFrEF patients. However, it had no positive effect on BP, TC, LDL-C, or HDL-C. Trial Registration. This clinical trial was registered at the Iranian Registry of Clinical Trials with IRCT registration number: IRCT20210614051574N4.

Stable Gastric Pentadecapeptide BPC 157 as Useful Cytoprotective Peptide Therapy in the Heart Disturbances, Myocardial Infarction, Heart Failure, Pulmonary Hypertension, Arrhythmias, and Thrombosis Presentation

In heart disturbances, stable gastric pentadecapeptide BPC 157 especial therapy effects combine the therapy of myocardial infarction, heart failure, pulmonary hypertension arrhythmias, and thrombosis prevention and reversal. The shared therapy effect occurred as part of its even larger cytoprotection (cardioprotection) therapy effect (direct epithelial cell protection; direct endothelium cell protection) that BPC 157 exerts as a novel cytoprotection mediator, which is native and stable in human gastric juice, as well as easily applicable. Accordingly, there is interaction with many molecular pathways, combining maintained endothelium function and maintained thrombocytes function, which counteracted thrombocytopenia in rats that underwent major vessel occlusion and deep vein thrombosis and counteracted thrombosis in all vascular studies; the coagulation pathways were not affected. These appeared as having modulatory effects on NO-system (NO-release, NOS-inhibition, NO-over-stimulation all affected), controlling vasomotor tone and the activation of the Src-Caveolin-1-eNOS pathway and modulatory effects on the prostaglandins system (BPC 157 counteracted NSAIDs toxicity, counteracted bleeding, thrombocytopenia, and in particular, leaky gut syndrome). As an essential novelty noted in the vascular studies, there was the activation of the collateral pathways. This might be the upgrading of the minor vessel to take over the function of the disabled major vessel, competing with and counteracting the Virchow triad circumstances devastatingly present, making possible the recruitment of collateral blood vessels, compensating vessel occlusion and reestablishing the blood flow or bypassing the occluded or ruptured vessel. As a part of the counteraction of the severe vessel and multiorgan failure syndrome, counteracted were the brain, lung, liver, kidney, gastrointestinal lesions, and in particular, the counteraction of the heart arrhythmias and infarction.

Clinical and prognostic relevance of sST2 in adults with dengue-associated cardiac impairment and severe dengue

BACKGROUND

Dengue can be complicated by severe outcomes including cardiac impairment, and the lack of reliable prognostic biomarkers poses a challenge in managing febrile dengue patients. Here, we investigated the functionality of soluble suppressor of tumorigenicity (sST2) as a predictive marker of severe dengue and its association in dengue-associated cardiac impairment.

METHODS

Plasma samples, aged >16 years, collected from 36 dengue fever, 43 dengue with warning signs, 11 severe dengue (collected at febrile, critical and recovery phases) and 30 controls were assayed for plasma levels of sST2, troponin T and N-terminal (NT)-pro hormone brain natriuretic peptide (NT-proBNP) by ELISA. Cardiac parameters: stroke index (SI), cardiac index (CI) and Granov-Goor Index (GGI) were measured with a bioimpedance device during the different phases for dengue subjects and once for the controls.

PRINCIPAL FINDINGS

In the febrile, critical and early recovery phases, sST2 levels were significantly elevated in dengue participants and sST2 levels increased with increasing disease severity (P < 0.01 for all). sST2 concentrations were negatively correlated with SI (r = -0.48; P < 0.001, r = -0.55; P < 0.001), CI (r = -0.26; P = 0.02, r = -0.6: P < 0.001) and GGI (r = -0.44; P < 0.001, r = -0.57; P < 0.001) in the critical and early recovery phases. In contrast, sST2 levels in the febrile and critical phases, were positive correlated to troponin T (r = 0.44, P < 0.001; r = 0.22, P = 0.03, respectively) and NT-proBNP (r = 0.21, P = 0.03; r = 0.35, P < 0.001). ROC analysis demonstrated sST2 as a good biomarker of severe dengue in the critical phase, AUROC 0.79, P < 0.001.

CONCLUSION/SIGNIFICANCE

sST2 levels were elevated in patients with dengue especially in cases of severe dengue. Furthermore, increased sST2 levels were associated with cardiac indicators suggesting lower cardiac performance. While further research is needed to demonstrate its clinical utility, sST2 may be a useful prognostic biomarker of severe dengue.

Estimation of Left Ventricular Ejection Fraction Using Cardiovascular Hemodynamic Parameters and Pulse Morphological Characteristics with Machine Learning Algorithms

It is estimated that 360,000 patients have suffered from heart failure (HF) in Taiwan, mostly those over the age of 65 years, who need long-term medication and daily healthcare to reduce the risk of mortality. The left ventricular ejection fraction (LVEF) is an important index to diagnose the HF. The goal of this study is to estimate the LVEF using the cardiovascular hemodynamic parameters, morphological characteristics of pulse, and bodily information with two machine learning algorithms. Twenty patients with HF who have been treated for at least six to nine months participated in this study. The self-constructing neural fuzzy inference network (SoNFIN) and XGBoost regression models were used to estimate their LVEF. A total of 193 training samples and 118 test samples were obtained. The recursive feature elimination algorithm is used to choose the optimal parameter set. The results show that the estimating root-mean-square errors (ERMS) of SoNFIN and XGBoost are 6.9 ± 2.3% and 6.4 ± 2.4%, by comparing with echocardiography as the ground truth, respectively. The benefit of this study is that the LVEF could be measured by the non-medical image method conveniently. Thus, the proposed method may arrive at an application level for clinical practice in the future.

The potential of glucagon-like peptide-1 receptor agonists in heart failure

Heart failure (HF) remains one of the cardiovascular diseases (CVDs) associated with a high unmet medical need due to high morbidity and mortality rates and lack of efficacious interventions. HF is closely related to cardiometabolic diseases such as diabetes, obesity and chronic kidney disease, and strategies that address most or all these intertwined conditions are desirable. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are approved for type 2 diabetes (T2D), and some are also indicated for reduction of the risk of atherosclerotic CVD in T2D and for weight management. As we summarise in this concise review, preliminary evidence suggests that the cardioprotective benefits of GLP-1 RAs may also extend to HF. The most robust clinical evidence arguably originates from the large cardiovascular outcomes trials (CVOTs) completed for most GLP-1 RAs, of which the latest showed a significant relative risk reduction (RRR) of 39% (HR) with once-weekly efpeglenatide on HF requiring hospitalisation, corroborating a meta-analysis which found a significant RRR across eight GLP-1 RA CVOTs of 11%. Further, although incompletely described, multiple studies are available to provide insights into the mechanistic underpinnings, which appear to be associated mostly with indirect cardioprotective benefits owing to the ability of GLP-1 RAs to address hyperglycaemia, and reduce body weight, and, amongst others, inflammation. In sum, current evidence positions GLP-1 RAs as a potential cardioprotective strategy in HF, with HF with preserved ejection fraction emerging as the clinically most relevant phenotype for the drug class, especially when occurring in people with obesity with and without diabetes.

Clinical course and decision-making in heart failure by preload stress echocardiography: a preliminary study

AIMS

Abnormal left ventricular diastolic response to preload stress can be an early marker of heart failure (HF). The aim of this study was to assess clinical course in patients with HF with preserved ejection fraction (HFpEF) who underwent preload stress echocardiography. In the subgroup analysis, we assessed the prognosis of patients with unstable signs during preload stress classified by treatment strategies.

METHODS AND RESULTS

We prospectively conducted preload stress echocardiographic studies between January 2006 and December 2013 in 211 patients with HFpEF. Fifty-eight patients had abnormal diastolic reserve during preload stress (unstable impaired relaxation: unstable IR). Of 58 patients with unstable IR, 19 patients were assigned to additional therapy by increased or additional therapy and 39 patients were assigned to standard therapy. Composite outcomes were prespecified as the primary endpoint of death and hospitalization for deteriorating HF. During a median period of 6.9 years, 19 patients (33%) reached the composite outcome. Unstable group with standard therapy had significantly shorter event-free survival than stable group. Patients with uptitration of therapy had longer event-free survival than those with standard therapy group after adjustment of laboratory data (hazard ratio, 0.20, 95% confidence interval, 0.05-0.90; P = 0.036); the 10 year event-free survival in patients with and without uptitration of therapy was 93% and 51%, respectively (P = 0.023).

CONCLUSIONS

Patients with unstable sign had significantly shorter event-free survival than patients with stable sign. After additional therapy, the prognosis of patients with unstable signs improved. This technique may impact decision-making for improving their prognosis.

Role of ambulatory blood pressure monitoring in elderly hypertensive patients

Background

Arterial hypertension is facing some changes in the last years. Its prevalence is increasing in elderly subjects. This growing prevalence is due to longer survival of the population worldwide, among other factors. On the other hand, recent guidelines have insisted in the relevance of out of office blood pressure measurements, to improve diagnostic and management of hypertension. Therefore, elderly subjects with hypertension could benefit from out of office blood pressure measurements, like ambulatory blood pressure measurements; nevertheless, there are very few or no specific recommendations regarding this.

Aim

In this review, we will gather the most important information about this subject.

Results

As hypertension in the elderly has some specific characteristics related to aging of the cardiovascular system, the most important aspect could be that these characteristics make ambulatory blood pressure measurement suitable for its use in elderly. Among those a higher prevalence of white coat hypertension, white coat phenomenon, and a higher nocturnal blood pressure and higher prevalence of nondipper and riser pattern, represent aspects that should be considered for better diagnostic and an improved management.

Conclusion

As the prevalence of hypertension will grow in the next years, more studies specifically directed to this subject are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40885-022-00205-6.

Reshaping Treatment of Heart Failure with Preserved Ejection Fraction

Current data indicate that in the community, approximately 50% of patients with heart failure (HF) have preserved left ventricular (LV) ejection fraction (LVEF)—the so-called HFpEF. Treatment of HFpEF has been considered an unmet need for decades. We believe that the main underlying reasons have been (a) the ever-changing LVEF cut-offs used for HF classification; (b) controversies regarding the definition of the LVEF normal range; (c) the fact that HFpEF does not represent a phenotype, but a category of diseases with entirely different characteristics (hypertensive heart disease, valvular heart disease (VHD), hypertrophic cardiomyopathy (HCM) etc.); (d) the lack of recognition that hypertensive HFpEF is the most common and important HFpEF phenotype; (e) the assumption that neurohormonal overactivity is absent in HF patients with a LVEF > 45−50% which has been proven to be wrong. Current HFpEF trials, in which the vast majority of the participants suffered from hypertension (HTN), whereas VHD and HCM were absent, demonstrated that neurohormonal and sodium-glucose cotransporter 2 (SGLT2) inhibitors are effective in HF patients over a wide LVEF range. Thus, restricting these lifesaving treatments to HF patients with reduced LVEF is not justified anymore and it should be additionally considered for HFpEF patients suffering from HTN.

Prognostic Value of Time in Blood Pressure Target Range Among Patients With Heart Failure

BACKGROUND

Blood pressure (BP) is a continuous and dynamic measure. However, standard BP control metrics may not reflect the variability in BP over time.

OBJECTIVES

This study assessed the prognostic value of time in BP target range among hypertensive patients with heart failure (HF).

METHODS

The authors performed a post hoc analysis of data from the TOPCAT (Treatment of Preserved Cardiac Function HF with an Aldosterone Antagonist) trial and the BEST (Beta-Blocker Evaluation of Survival Trial). Time in target range (TTR) for each patient was calculated using linear interpolation across the study period with the target range of systolic BP between 120 and 130 mm Hg.

RESULTS

A total of 4,789 hypertensive patients (n = 1,654 from BEST and n = 3,135 from TOPCAT) were included. The cumulative incidences of primary endpoint (ie, cardiovascular death or HF hospitalization) were highest among the top quartile of TTR with a dose-dependent manner across quartiles (P_trend <0.005). The top quartile of TTR was significantly associated with a lower risk of primary outcome using adjusted Cox regression model (HR: 0.71; 95% CI: 0.60-0.82), cardiovascular mortality (HR: 0.68; 95% CI: 0.55-0.84), HF hospitalization (HR: 0.70; 95% CI: 0.58-0.85), all-cause mortality (HR: 0.69; 95% CI: 0.58-0.83), and any hospitalization (HR: 0.76; 95% CI: 0.67-0.85). Further analyses using restricted cubic spline indicated a linear relationship between TTR and primary outcome. Similar patterns were observed in the individual trial. Sensitivity analyses generated consistent results while redefining target range as 110 to 130 mm Hg for systolic BP or 70 to 80 mm Hg for diastolic BP.

CONCLUSIONS

TTR could independently predict major adverse cardiovascular events in hypertensive patients with HF.

Patterns and associated factors of electrocardiographic abnormality among type 2 diabetic patients in Amhara National Regional State Referral Hospitals, Ethiopia: a multicenter institution-based cross-sectional study

BACKGROUND

Cardiovascular diseases are the most causes of mortality and morbidity among diabetes mellitus (DM) patients. Electrocardiographic (ECG) changes are common in the early course of the disease. Little is known about the electrocardiographic abnormalities among type 2 DM patients in Ethiopia. This study determined the overall prevalence, its patterns, and the associated factors of ECG abnormalities among people living with T2DM in Amhara National Regional State referral hospitals, Ethiopia.

METHODS

A multicenter institution-based cross-sectional study was conducted from 01 April to 30 May 2021. A simple random sampling and systematic sampling techniques were employed to select the referral hospitals and study participants, respectively. A digital electrocardiograph was used to measure the ECG parameters and the other data were collected using an interviewer-administered questionnaire. Epi-data version-4.6 and Stata-14 were used for data entry and statistical analysis, respectively. The descriptive statistics were presented with tables and graphs. A binary logistic regression model was fitted to identify associated factors of ECG abnormality. In the final model, statistical significance was decided at p≤0.05, and the strength of association was indicated using an adjusted odds ratio with 95% CI.

RESULTS

Two-hundred and fifty-eight participants (response rate = 99.6%) were included for the analysis. The prevalence of overall ECG abnormality was 45% (95% CI: 39, 51%). On the basis of the electrocardiographic patterns, 57 (21.1%; 95% CI: 14.6, 32.6%) were presented with T-wave abnormality, 36 (14%; 95% CI: 10.1, 18.8%) left axis deviation, and 24 (9.3% [6.3, 13.5%]) sinus tachycardia. Higher monthly income (> 90$) (AOR = 0.51 [0.31, 0.83]), over 10 years duration of DM (AOR = 4.5[1.05, 18.94]), hypertension (AOR = 3.9 [1.6, 9.40]), fasting blood sugar of ≥ 130 mg/dl (AOR = 5.01[2.13, 12.20]), and overweight (AOR = 2.65[1.17, 5.98]) were statistically significant factors of overall ECG abnormality.

CONCLUSIONS

Nearly, half of the participants had at least one ECG abnormality. Higher-income, prolonged disease duration, hypertension, higher fasting blood sugar, and overweight were significantly associated with ECG abnormality. The findings of this study suggest the need to institute routine ECG screening for all T2DM patients to reduce ECG abnormalities and further complications.

Systolic Blood Pressure and 1-Year Clinical Outcomes in Patients Hospitalized for Heart Failure

Background

High systolic blood pressure (SBP) is an important risk factor for the progression of heart failure (HF); however, the association between SBP and prognosis among patients with established HF was uncertain. This study aimed to investigate the association between SBP and long-term clinical outcomes in patients hospitalized for HF.

Methods

This study prospectively enrolled adult patients hospitalized for HF in 52 hospitals from 20 provinces in China. SBPs were measured in a stable condition judged by clinicians during hospitalization before discharge according to the standard research protocol. The primary outcomes included 1-year all-cause death and HF readmission. The multivariable Cox proportional hazards regression models were fitted to examine the association between SBP and clinical outcomes. Restricted cubic splines were used to examine the non-linear associations.

Results

The 4,564 patients had a mean age of 65.3 ± 13.5 years and 37.9% were female. The average SBP was 123.2 ± 19.0 mmHg. One-year all-cause death and HF readmission were 16.9 and 32.7%, respectively. After adjustment, patients with SBP < 110 mmHg had a higher risk of all-cause death compared with those with SBP of 130–139 mmHg (HR 1.71; 95% CI: 1.32–2.20). Patients with SBP < 110 mmHg (HR 1.36; 95% CI: 1.14–1.64) and SBP ≥ 150 mmHg (HR 1.26; 95% CI: 1.01–1.58) had a higher risk of HF readmission, and the association between SBP and HF readmission followed a J-curve relationship with the nadir SBP around 130 mmHg. These associations were consistent regardless of age, sex, left ventricular ejection fraction, hypertension, coronary heart disease, and medications for HF.

Conclusion

In patients hospitalized for HF, lower SBP in a stable phase during hospitalization portends an increased risk of 1-year death, and a J-curve association has been observed between SBP and 1-year HF readmission. These associations were consistent among clinically important subgroups.

The Effect of Synbiotic Consumption on Serum NTproBNP, hsCRP and Blood Pressure in Patients With Chronic Heart Failure: A Randomized, Triple-Blind, Controlled Trial

Background

In recent years, there has been a positive attitude toward gut microbiota and its effect on cardiovascular diseases, including heart failure.

Objective

The purpose of this study was to evaluate the effect of synbiotics on left ventricular hypertrophy by measuring NT-proBNP, and their effect on blood pressure and hsCRP as an inflammatory biomarker in patients with chronic heart failure.

Design

In this triple-blind randomized clinical trial, 90 eligible patients were included in the study. They were randomly assigned to receive one capsule (500 mg) of synbiotics or placebo per day for 10 weeks. NTproBNP, hsCRP and blood pressure were measured at the beginning and end of the study. Statistical analysis was performed on 80 patients by using SPSS 24, and p < 0.05 as statistically significant.

Result

At the end of the study, the level of NT-proBNP decreased significantly in the synbiotic group compared to the placebo group (r = −256.55; P = 0.04). However, hsCRP increased in both groups as compared to the beginning of the study, but only in the placebo group the increase in hsCRP was significant (P = 0.01). The results showed that the changes in hs-CRP was not significant between the two groups. No statistically significant differences were observed in systolic and diastolic blood pressure between the two groups at the end of the intervention.

Conclusion

Synbiotics have favorable effect on cardiac hypertrophy index (NT-proBNP). Although the inflammatory factor increased in both groups, the significant increase in hsCRP in the placebo group could indicate the beneficial effects of synbiotics on the inflammatory status of these patients.

Clinical Trial Registration

https://en.irct.ir/user/trial/42905/view, identifier: IRCT20091114002709N52.

Characteristics and outcomes of patients admitted for acute heart failure in a single-centre study

Aims

Acute heart failure represents a medical condition with very high mortality. Accurate risk stratification can help physicians to improve the health care about these patients. The aim of our study was to characterize real‐life patients admitted for acute heart failure in a specific region with one tertiary medical centre and to describe risk factors of short‐term and long‐term mortality.

Methods and results

We performed a retrospective analysis of patients admitted from January 2017 to December 2017 to Department of cardiology of the tertiary medical centre University Hospital in Hradec Kralove. We identified 385 patients admitted for acute heart failure to the standard care and intensive care unit. The median of age was 74 years (IQR 67.5–80) and 34% of patients were female. Hospital admission was due to de novo heart failure in 222 (57.7%) patients. The most common comorbidities were arterial hypertension (77.7%), dyslipidaemia (67.3%) and coronary artery disease (63.1%). Coronary artery disease (52.7% of cases) and valve disease (28.1% of cases) were the most common aetiologies of heart failure. The all‐cause in‐hospital mortality was 12.7%, 30‐day mortality was 14.6% and 1 year mortality was 34%. Among risk factors of in‐hospital mortality, the most significant factors were haemodialysis during the hospitalization [odds ratio (OR) 15.82, 95% confidence interval (CI) 2.96–84.57, P = 0.0008], chronic heart failure (OR 4.27, 95% CI 1.66–11.03, P = 0.001) and STEMI as a precipitating factor of heart failure (OR 4.19, 95% CI 1.23–14.25, P = 0.023). Haemodialysis during the hospitalization (OR 4.28, 95% CI 1.17–15.61, P = 0.025) and the comorbidity depression and anxiety (OR 3.49, 95% CI 1.45–8.39, P = 0.005) were the most significant risk factors of long‐term mortality.

Conclusions

Our study confirms very high mortality rates among patients with acute heart failure underlying poor prognosis of these patients. Comorbidities (peripheral artery disease, atrial fibrillation, chronic heart failure and depression and anxiety), precipitating factors of heart failure (myocardial infarction with ST segment elevation), complications occurring during the hospitalization (acute kidney injury, pulmonary ventilation for respiratory failure and haemodialysis) and the age of patients should be included in the risk stratification of in‐hospital, 30 day and 1 year mortality.

Imaging techniques for the assessment of adverse cardiac remodeling in metabolic syndrome

Metabolic syndrome (MetS) includes different metabolic conditions (i.e. abdominal obesity, impaired glucose tolerance, hypertriglyceridemia, decreased HDL cholesterol, and/or hypertension) that concour in the development of cardiovascular disease and diabetes. MetS individuals often show adverse cardiac remodeling and myocardial dysfunction even in the absence of overt coronary artery disease or valvular affliction. Diastolic impairment and hypertrophy are hallmarks of MetS-related cardiac remodeling and represent the leading cause of heart failure with preserved ejection fraction (HFpEF). Altered cardiomyocyte function, increased neurohormonal tone, interstitial fibrosis, coronary microvascular dysfunction, and a myriad of metabolic abnormalities have all been implicated in the development and progression of adverse cardiac remodeling related to MetS. However, despite the enormous amount of literature produced on this argument, HF remains a leading cause of morbidity and mortality in such population. The early detection of initial adverse cardiac remodeling would enable the optimal implementation of effective therapies aiming at preventing the progression of the disease to the symptomatic phase. Beyond conventional imaging techniques, such as echocardiography, cardiac tomography, and magnetic resonance, novel post-processing tools and techniques provide information on the biological processes that underlie metabolic heart disease. In this review, we summarize the pathophysiology of MetS-related cardiac remodeling and illustrate the relevance of state-of-the-art multimodality cardiac imaging to identify and quantify the degree of myocardial involvement, prognosticate long-term clinical outcome, and potentially guide therapeutic strategies.

Glucagon-like peptide-1 attenuates cardiac hypertrophy via the AngII/AT1R/ACE2 and AMPK/mTOR/p70S6K pathways

Glucagon-like peptide-1 (GLP-1), a novel type of glucose-lowering agent, has been reported to exert cardioprotective effects. However, the cardioprotective mechanism of GLP-1 on spontaneous hypertension-induced cardiac hypertrophy has not been fully elucidated. In this study, we revealed that liraglutide or alogliptin treatment ameliorated spontaneous hypertension-induced cardiac hypertrophy, as evidenced by decreased levels of cardiac hypertrophic markers (atrial natriuretic peptide, brain natriuretic peptide, and β-myosin heavy chain), as well as systolic blood pressure, diastolic blood pressure, mean arterial pressure, and histological changes. Both drugs significantly reduced the levels of angiotensin II (AngII) and AngII type 1 receptor (AT1R) and upregulated the levels of AngII type 2 receptor (AT2R) and angiotensin-converting enzyme 2 (ACE2), as indicated by a reduced AT1R/AT2R ratio. Simultaneously, treatment with liraglutide or alogliptin significantly increased GLP-1 receptor expression and adenosine monophosphate-activated protein kinase (AMPK) phosphorylation and downregulated the phosphorylation of mammalian target of rapamycin (mTOR), p70 ribosomal S6 protein kinase, and eukaryotic translation initiation factor 4E binding protein 1 in spontaneous hypertension rats. Furthermore, our data demonstrated that the AMPK inhibitor compound C or mTOR activator MHY1485 inhibited the anti-hypertrophic effect of GLP-1. In summary, our study suggests that liraglutide or alogliptin protects the heart against cardiac hypertrophy by regulating the expression of AngII/AT1R/ACE2 and activating the AMPK/mTOR pathway, and GLP-1 agonist can be used in the treatment of patients with cardiac hypertrophy.

Time to cardiovascular benefits of empagliflozin: a post hoc observation from the EMPA-REG OUTCOME trial

Aims

In the EMPA‐REG OUTCOME trial, in patients with type 2 diabetes and established atherosclerotic cardiovascular (CV) disease, empagliflozin vs. placebo reduced the risk of hospitalization for heart failure (HHF) by 35%, CV death/HHF by 34%, and CV death by 38%, with an early separation of the cumulative incidence curves. We explored at what time point after randomization these benefits became apparent.

Methods and results

We expressed time trajectories for the effect of pooled empagliflozin doses vs. placebo on HHF, CV death/HHF, and CV death based on hazard ratios (95% confidence interval) and calculated the hazard ratio on the day the effect reached significance using Cox proportional hazards models. Overall, 7020 patients aged ≥18 years were treated with empagliflozin 10 mg (N = 2345), empagliflozin 25 mg (N = 2342), or placebo (N = 2333) once daily in addition to standard of care. Mean age (years ± SD) was 63.1 ± 8.6, and 72% were male. The benefit of empagliflozin on CV death first reached statistical significance on Day 59 (HR [95% confidence interval]) (0.28 [0.08, 0.96], P = 0.0424) and was generally sustained throughout the trial (overall 0.62 [0.49, 0.77], P < 0.0001). Risk reduction with empagliflozin on HHF reached statistical significance on Day 17 (0.10 [0.01, 0.87], P = 0.0372) and was sustained throughout the study (overall 0.65 [0.50, 0.85], P = 0.0017). For the composite outcome of CV death or HHF, risk reduction with empagliflozin reached statistical significance on Day 27 (0.28 [0.08, 0.97], P = 0.0445) and was sustained throughout follow‐up (overall 0.66 [0.55, 0.79], P < 0.0001).

Conclusions

In EMPA‐REG OUTCOME, the benefit of empagliflozin in reducing the risk of HHF, CV death/HHF, and CV death emerged within weeks after treatment initiation. The earliest benefit appears to be on HHF.