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Iwanek G, Ponikowska B, Zdanowicz A, Fudim M, Hurkacz M, Zymliński R, Ponikowski P, Biegus J. Relationship of Vascular Endothelial Growth Factor C, a Lymphangiogenesis Modulator, With Edema Formation, Congestion and Outcomes in Acute Heart Failure. J Card Fail 2023; 29:1629-1638. [PMID: 37121266 DOI: 10.1016/j.cardfail.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 04/07/2023] [Accepted: 04/10/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Although vascular endothelial growth factor C (VEGF-C) is a known lymphangiogenesis modulator, its relationship with congestion formation and outcomes in acute heart failure (AHF) is unknown. METHODS Serum VEGF-C levels were measured in 237 patients hospitalized for AHF. The population was stratified by VEGF-C levels and linked with clinical signs of congestion and outcomes. RESULTS The study's population was divided in VEGF-C tertiles: low (median [Q25-Q75]: 33 [15-175]), medium (606 [468-741]) and high (1141 [968-1442] pg/mL). The group with low VEGF-C on admission presented with the highest prevalence of severe lower-extremity edema (low VEGF-C vs medium VEGF-C vs high VEGF-C): 30% vs 13% vs 20%; P = 0.02); the highest percentage of patients with ascites: 22% vs 9% vs 6%; P = 0.006; and the lowest proportion of patients with pulmonary congestion: 22% vs 30% vs 46%; P = 0.004. The 1-year mortality rate was the highest in the low VEGF-C tertile: 35% vs 28% vs 18%, respectively; P = 0.049. The same pattern was observed for the composite endpoint (death and AHF rehospitalization): 45% vs 43% vs 26%; P = 0.029. The risks of death at 1-year follow-up and composite endpoint were significantly lower in the high VEGF-C group. CONCLUSIONS Low VEGF-C was associated with more severe signs of congestion (signs of fluid accumulation) and adverse clinical outcomes.
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Affiliation(s)
- Gracjan Iwanek
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.
| | - Barbara Ponikowska
- Student Scientific Organization, Wroclaw Medical University, Wroclaw, Poland
| | - Agata Zdanowicz
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Magdalena Hurkacz
- Department of Clinical Pharmacology, Wroclaw Medical University, Wroclaw, Poland
| | - Robert Zymliński
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
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Biegus J, Zymliński R, Testani J, Fudim M, Cox ZL, Guzik M, Iwanek G, Hurkacz M, Raj D, Marciniak D, Ponikowska B, Ponikowski P. The blunted loop diuretic response in acute heart failure is driven by reduced tubular responsiveness rather than insufficient tubular delivery. The role of furosemide urine excretion on diuretic and natriuretic response in acute heart failure. Eur J Heart Fail 2023; 25:1323-1333. [PMID: 37042083 DOI: 10.1002/ejhf.2852] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 03/01/2023] [Accepted: 04/07/2023] [Indexed: 04/13/2023] Open
Abstract
AIMS Diuretic response in heart failure is blunted when compared to healthy individuals, but the pathophysiology underlying this phenomenon is unclear. We aimed to investigate whether the diuretic resistance mechanism is related to insufficient furosemide tubular delivery or low tubular responsiveness. METHODS AND RESULTS We conducted a prospective, observational study of 50 patients with acute heart failure patients divided into two groups based on previous furosemide use (furosemide naïve: n = 28 [56%] and chronic furosemide users: n = 22 [44%]). Each patient received a protocol-derived, standardized furosemide dose based on body weight. We measured diuretic response and urine furosemide concentrations. The furosemide naïve group had significantly higher urine volumes and natriuresis when compared to chronic users at all timepoints (all p < 0.05). Urine furosemide delivery was similar in furosemide naïve versus chronic users after accounting for differences in estimated glomerular filtration rate (28.02 [21.03-35.89] vs. 29.70 [18.19-34.71] mg, p = 0.87). However, the tubular response to delivered diuretic was dramatically higher in naïve versus chronic users, that is the urine volume per 1 μg/ml of urine furosemide at 2 h was 148.6 ± 136.1 versus 50.6 ± 56.1 ml (p = 0.005). CONCLUSIONS Patients naïve to furosemide have significantly better diuresis and natriuresis when compared to chronic furosemide users. The blunted diuretic response in patients with chronic loop diuretic exposure is driven by decreased tubular responsiveness rather than insufficient furosemide tubular delivery.
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Affiliation(s)
- Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Robert Zymliński
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | | | - Marat Fudim
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Zachary L Cox
- Lipscomb University College of Pharmacy, Nashville, TN, USA
| | - Mateusz Guzik
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Gracjan Iwanek
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Magdalena Hurkacz
- Department of Clinical Pharmacology, Wroclaw Medical University, Wroclaw, Poland
| | - Danuta Raj
- Department of Pharmacognosy and Herbal Medicines, Wroclaw Medical University, Wroclaw, Poland
| | - Dominik Marciniak
- Department of Drugs Form Technology, Faculty of Pharmacy, Medical University, Wroclaw, Poland
| | - Barbara Ponikowska
- Student Scientific Organization, Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
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Zdanowicz A, Urban S, Ponikowska B, Iwanek G, Zymliński R, Ponikowski P, Biegus J. Novel Biomarkers of Renal Dysfunction and Congestion in Heart Failure. J Pers Med 2022; 12:jpm12060898. [PMID: 35743683 PMCID: PMC9224642 DOI: 10.3390/jpm12060898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/15/2022] [Accepted: 05/26/2022] [Indexed: 02/04/2023] Open
Abstract
Heart failure is a major public health problem and, despite the constantly emerging, new, effective treatments, it remains a leading cause of morbidity and mortality. Reliable tools for early diagnosis and risk stratification are crucial in the management of HF. This explains a growing interest in the development of new biomarkers related to various pathophysiological mechanisms of HF. In the course of this review, we focused on the markers of congestion and renal dysfunction in terms of their interference with cardiovascular homeostasis. Congestion is a hallmark feature of heart failure, contributing to symptoms, morbidity, and hospitalizations of patients with HF and has, therefore, become a therapeutic target in AHF. On the other hand, impaired renal function by altering the volume status contributes to the development and progression of HF and serves as a marker of an adverse clinical outcome. Early detection of congestion and an adequate assessment of renal status are essential for the prompt administration of patient-tailored therapy. This review provides an insight into recent advances in the field of HF biomarkers that could be potentially implemented in diagnosis and risk stratification of patients with HF.
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Affiliation(s)
- Agata Zdanowicz
- Institute of Heart Diseases, Medical University, 50-556 Wroclaw, Poland; (A.Z.); (G.I.); (R.Z.); (P.P.); (J.B.)
| | - Szymon Urban
- Institute of Heart Diseases, Medical University, 50-556 Wroclaw, Poland; (A.Z.); (G.I.); (R.Z.); (P.P.); (J.B.)
- Correspondence: ; Tel.: +48-71-733-11-12
| | - Barbara Ponikowska
- Student Scientific Organization, Institute of Heart Diseases, Medical University, 50-556 Wroclaw, Poland;
| | - Gracjan Iwanek
- Institute of Heart Diseases, Medical University, 50-556 Wroclaw, Poland; (A.Z.); (G.I.); (R.Z.); (P.P.); (J.B.)
| | - Robert Zymliński
- Institute of Heart Diseases, Medical University, 50-556 Wroclaw, Poland; (A.Z.); (G.I.); (R.Z.); (P.P.); (J.B.)
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, 50-556 Wroclaw, Poland; (A.Z.); (G.I.); (R.Z.); (P.P.); (J.B.)
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, 50-556 Wroclaw, Poland; (A.Z.); (G.I.); (R.Z.); (P.P.); (J.B.)
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Biegus J, Nawrocka-Millward S, Zymliński R, Fudim M, Testani J, Marciniak D, Rosiek-Biegus M, Ponikowska B, Guzik M, Garus M, Ponikowski P. Distinct renin/aldosterone activity profiles correlate with renal function, natriuretic response, decongestive ability and prognosis in acute heart failure. Int J Cardiol 2021; 345:54-60. [PMID: 34728260 DOI: 10.1016/j.ijcard.2021.10.149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/21/2021] [Accepted: 10/26/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although renin-angiotensin-aldosterone system (RAAS) activation is believed to be the major driver of acute heart failure (AHF) episodes our understanding of its prevalence and clinical relevance in contemporary settings is incomplete. METHODS Serum renin and aldosterone were measured at day-1 and at discharge in patients (n = 211) that were hospitalized between 2016 and 2017 for AHF in a single cardiology center. The population was profiled based on upper limits of normal (ULN) of both biomarkers assessed at day-1 and linked with the clinical course and outcomes. RESULTS The study population constituted of three profiles: RAAS-/- (n = 121 [57%]); RAAS+/- (n = 60 [28%]); and RAAS+/+ (n = 30 [14%]). The RAAS+/+ profile had the lowest blood pressure and serum sodium at admission, day-2 and discharge compared to the other profiles (p < 0.001). The RAAS+/+ patients had significantly lower urine Na+ at admission (57.8 ± 36.7 vs 97.3 ± 31.3 and 86.4 ± 35.0), day-1 (52.7 ± 32.7 vs 85.3 ± 36.3 and 75.5 ± 33.9) mmol/l, vs RAAS-/- and RAAS+/- profiles, respectively, all p < 0.001. There was also a gradual decrease of renal function across increasing RAAS profiles. The RAAS+/+ profile received higher dose of furosemide at discharge 120 [80-160] vs the other profiles 80 [40-120] mg, p < 0.01. The risks of one year mortality or HF rehospitalization increased across the RAAS profiles (p < 0.001). The trajectory of renin or aldosterone change during hospitalization was not related to outcomes. CONCLUSIONS The RAAS overactivity is not essential for development of AHF. However, elevated RAAS is a marker of more advanced stages of heart failure, is related to low natriuresis and adverse clinical outcomes.
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Affiliation(s)
- Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland; Institute of Heart Diseases, University Hospital, Wroclaw, Poland.
| | | | - Robert Zymliński
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland; Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | | | - Dominik Marciniak
- Department of Drugs Form Technology, Faculty of Pharmacy, Medical University, Wroclaw, Poland
| | - Marta Rosiek-Biegus
- Department of Internal Medicine, Pneumology and Allergology, Medical University, Wroclaw, Poland
| | - Barbara Ponikowska
- Student Scientific Club, Department of Heart Diseases, Medical University, Wroclaw, Poland
| | - Mateusz Guzik
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Mateusz Garus
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland; Institute of Heart Diseases, University Hospital, Wroclaw, Poland
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Biegus J, Niewinski P, Josiak K, Kulej K, Ponikowska B, Nowak K, Zymlinski R, Ponikowski P. Pathophysiology of Advanced Heart Failure: What Knowledge Is Needed for Clinical Management? Heart Fail Clin 2021; 17:519-531. [PMID: 34511202 DOI: 10.1016/j.hfc.2021.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Understanding of heart failure (HF) has evolved from a simple hemodynamic problem through a neurohormonally and proinflammatory-driven syndrome to a complex multiorgan dysfunction accompanied by inadequate energy handling. This article discusses the most important clinical aspects of advanced HF pathophysiology. It presents the concept of neurohormonal activation and its deleterious effect on cardiovascular system and reflex control. The current theories regarding the role of inflammation, cytokine activation, and myocardial remodeling in HF progression are presented. Advanced HF is a multiorgan syndrome with interplay between cardiovascular system and other organs. The role of iron deficiency is also discussed.
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Affiliation(s)
- Jan Biegus
- Department of Heart Diseases, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; Centre for Heart Diseases, Wrocław University Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Piotr Niewinski
- Department of Heart Diseases, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; Centre for Heart Diseases, Wrocław University Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Krystian Josiak
- Department of Heart Diseases, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; Centre for Heart Diseases, Wrocław University Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Katarzyna Kulej
- Department of Heart Diseases, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; Centre for Heart Diseases, Wrocław University Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Barbara Ponikowska
- Student Scientific Organization, Department of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Krzysztof Nowak
- Department of Heart Diseases, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; Centre for Heart Diseases, Wrocław University Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Robert Zymlinski
- Department of Heart Diseases, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; Centre for Heart Diseases, Wrocław University Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Piotr Ponikowski
- Department of Heart Diseases, Wrocław Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; Centre for Heart Diseases, Wrocław University Hospital, ul. Borowska 213, 50-556 Wrocław, Poland.
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Biegus J, Zymliński R, Fudim M, Testani J, Sokolski M, Marciniak D, Ponikowska B, Guzik M, Garus M, Urban S, Ponikowski P. Spot urine sodium in acute heart failure: differences in prognostic value on admission and discharge. ESC Heart Fail 2021; 8:2597-2602. [PMID: 33932273 PMCID: PMC8318409 DOI: 10.1002/ehf2.13372] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/28/2021] [Accepted: 04/08/2021] [Indexed: 12/16/2022] Open
Abstract
AIMS Most studies examined spot urine sodium's (sUNa+ ) prognostic utility during the early phase of acute heart failure (AHF) hospitalization. In AHF, sodium excretion is related to clinical status; therefore, we investigated the differences in the prognostic information of spot UNa+ throughout the course of hospitalization for AHF (admission vs. discharge). METHODS AND RESULTS The study population were AHF patients (n = 172), who survived the index hospitalization. We compared the relationship between early (on admission, at 24 and 48 h) and discharge sUNa+ measurements with post-discharge study endpoints: composite of 1 year all-cause mortality and AHF rehospitalization (with time to first event analysis) as well as with each event in separation. There were 49 (28.5%) deaths, 40 (23.3%) AHF rehospitalizations, while the composite endpoint occurred in 69 (40.1%) during 1 year follow-up. The sUNa+ had prognostic significance for the composite endpoint when assessed on admission, at 24 and at 48 h: hazard ratios (HRs) with 95% confidence intervals (CIs) (per 10 mmol/L) were 0.88 (0.82-0.94); 0.87 (0.81-0.91); 0.90 (0.84-0.96), all P < 0.005. In contrast to early, active decongestion phase, discharge sUNa+ had no prognostic significance HR (95% CI) (per 10 mmol/L): 0.99 (0.93-1.06) P = 0.79 for the composite endpoint, which was independent from the dose of oral furosemide prescribed at that timepoint (average causal mediation effects: -0.38; P = 0.71). Similarly, discharge sUNa+ was neither associated with 1 year mortality HR (95% CI) (per 10 mmol/L): 0.97 (0.89-1.05) P = 0.48 nor with AHF rehospitalizations HR (95% CI) (per 10 mmol/l): 1.03 (0.94-1.12), P = 0.56. The comparison of longitudinal profiles of sUNa+ during hospitalization showed significantly higher values within the early, active decongestive phase in those who did not experience composite endpoint when compared with those who did: admission: 94 ± 34 vs. 76 ± 35; Day 1: 85 ± 36 vs. 65 ± 37; Day 2: 84 ± 37 vs. 67 ± 35, all P < 0.005 (mmol/L), respectively. There was no difference between those groups in discharge sUNa+ : 73 ± 35 vs. 70 ± 35 P = 0.82 (mmol/L). CONCLUSIONS Spot UNa+ assessed at early phase of hospitalization and at discharge have different prognostic significance, which confirms that it should be always interpreted along with clinical context.
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Affiliation(s)
- Jan Biegus
- Department of Heart Diseases, Wroclaw Medical University, Borowska 213, Wroclaw, 50-556, Poland.,Centre for Heart Diseases, Wroclaw University Hospital, Wroclaw, Poland
| | - Robert Zymliński
- Department of Heart Diseases, Wroclaw Medical University, Borowska 213, Wroclaw, 50-556, Poland.,Centre for Heart Diseases, Wroclaw University Hospital, Wroclaw, Poland
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | | | - Mateusz Sokolski
- Department of Heart Diseases, Wroclaw Medical University, Borowska 213, Wroclaw, 50-556, Poland.,Centre for Heart Diseases, Wroclaw University Hospital, Wroclaw, Poland
| | - Dominik Marciniak
- Department of Drugs Form Technology, Faculty of Pharmacy, Wroclaw Medical University, Wroclaw, Poland
| | - Barbara Ponikowska
- Student scientific organization, Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Mateusz Guzik
- Centre for Heart Diseases, Wroclaw University Hospital, Wroclaw, Poland
| | - Mateusz Garus
- Centre for Heart Diseases, Wroclaw University Hospital, Wroclaw, Poland
| | - Szymon Urban
- Student scientific organization, Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Borowska 213, Wroclaw, 50-556, Poland.,Centre for Heart Diseases, Wroclaw University Hospital, Wroclaw, Poland
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Siennicka A, Quintana DS, Fedurek P, Wijata A, Paleczny B, Ponikowska B, Danel DP. Resting heart rate variability, attention and attention maintenance in young adults. Int J Psychophysiol 2019; 143:126-131. [PMID: 31255739 DOI: 10.1016/j.ijpsycho.2019.06.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/25/2019] [Accepted: 06/26/2019] [Indexed: 01/26/2023]
Abstract
Heart rate variability (HRV) is a widely used measure that reflects autonomic (parasympathetic) control of the heart. HRV has been linked with attentional performance, but it is unclear to what extent resting HRV is associated with both attention and attentional maintenance. In order to address this, we calculated HRV in seventy-four young and healthy volunteers (43 men, age: 21.6 ± 2.4), who completed the D2 Test of Attention (D2), which was used to calculate an index of Concentration Performance (CP) and a measure of attention maintenance, the coefficient of variation (CV). After accounting for the effects of sex and age on HRV, there was no significant association between HRV and CP (p = .2), but a significant relationship between HRV and CV (p = .03). Overall, our study demonstrates that attention maintenance, but not attentional performance, is associated with higher resting state HRV which suggests that attentional performance from D2 subtest-to-subtest may reflect HRV's facilitation of behaviour flexibility.
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Affiliation(s)
- A Siennicka
- Department of Physiology, Wroclaw Medical University, Wroclaw, Poland; Department of Cardiology, Military Hospital in Wroclaw, Poland.
| | - D S Quintana
- NORMENT, KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction, University of Oslo, and Oslo University Hospital, Oslo, Norway
| | - P Fedurek
- Department of Life Sciences, University of Roehampton, London, United Kingdom
| | - A Wijata
- Faculty of Biomedical Engineering, Silesian University of Technology, Zabrze, Poland
| | - B Paleczny
- Department of Physiology, Wroclaw Medical University, Wroclaw, Poland; Department of Cardiology, Military Hospital in Wroclaw, Poland
| | - B Ponikowska
- Department of Physiology, Wroclaw Medical University, Wroclaw, Poland
| | - D P Danel
- Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
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Jankowska EA, Rozentryt P, Witkowska A, Nowak J, Hartmann O, Ponikowska B, Borodulin-Nadzieja L, Banasiak W, Polonski L, Filippatos G, McMurray JJV, Anker SD, Ponikowski P. 'Iron deficiency: an ominous sign in patients with systolic chronic heart failure' [Eur Heart J 2010;31:1872-1880, doi:10.1093/eurheartj/ehq158]. Eur Heart J 2011. [DOI: 10.1093/eurheartj/ehr115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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