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Schuermans A, Verbrugge FH. Decongestion (instead of ultrafiltration?). Curr Opin Cardiol 2024; 39:188-195. [PMID: 38362936 DOI: 10.1097/hco.0000000000001124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE OF REVIEW To summarize the contemporary evidence on decongestion strategies in patients with acute heart failure (AHF). RECENT FINDINGS While loop diuretic therapy has remained the backbone of decongestive treatment in AHF, multiple randomized clinical trials suggest that early combination with other diuretic classes or molecules with diuretic properties should be considered. Mineralocorticoid receptor antagonists and sodium-glucose co-transporter-2 inhibitors are disease-modifying drugs in heart failure that favourably influence prognosis early on, advocating their start as soon as possible in the absence of any compelling contraindications. Short-term upfront use of acetazolamide in adjunction to intravenous loop diuretic therapy relieves congestion faster, avoids diuretic resistance, and may shorten hospitalization length. Thiazide-like diuretics remain a good option to break diuretic resistance. Currently, ultrafiltration in AHF remains mainly reserved for patient with an inadequate response to pharmacological treatment. SUMMARY In most patients with AHF, decongestion can be achieved effectively and safely through combination diuretic therapies. Appropriate diuretic therapy may shorten hospitalization length and improve quality of life, but has not yet proven to reduce death or heart failure readmissions. Ultrafiltration currently has a limited role in AHF, mainly as bail-out strategy, but evidence for a more upfront use remains inconclusive.
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Affiliation(s)
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
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Dhont S, Verbrugge FH, Verwerft J, Bertrand PB. Non-invasive imaging in acute decompensated heart failure with preserved ejection fraction. Eur Heart J Acute Cardiovasc Care 2024:zuae041. [PMID: 38683589 DOI: 10.1093/ehjacc/zuae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/28/2024] [Accepted: 03/24/2024] [Indexed: 05/01/2024]
Abstract
Non-invasive imaging plays an increasingly important role in emergency medicine, given the trend towards smaller, portable ultrasound devices, the integration of ultrasound imaging across diverse medical disciplines, and the growing evidence supporting its clinical benefits for the patient. Heart failure with preserved ejection fraction (HFpEF) provides a compelling illustration of the impactful role that imaging plays in distinguishing diverse clinical presentations of heart failure with numerous associated comorbidities, including pulmonary, renal, or hepatic diseases. While a preserved left ventricular ejection fraction might misguide the clinician away from diagnosing cardiac disease, there are several clues provided by cardiac, vascular, and lung ultrasonography, as well as other imaging modalities, to rapidly identify (decompensated) HFpEF. Congestion remains the primary reason why patients with heart failure (irrespective of ejection fraction) seek emergency care. Furthermore, comprehensive phenotyping is becoming increasingly important, considering the development of targeted treatments for conditions exhibiting HFpEF physiology, such as cardiac amyloidosis. Timely recognition in such cases has lasting implications for long-term outcomes.
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Affiliation(s)
- Sebastiaan Dhont
- Faculty of Medicine and Life Sciences, Hasselt University, LCRC, Agoralaan, Diepenbeek 3590, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Synaps Park 1, Genk 3600, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Synaps Park 1, Genk 3600, Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jan Verwerft
- Faculty of Medicine and Life Sciences, Hasselt University, LCRC, Agoralaan, Diepenbeek 3590, Belgium
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Philippe B Bertrand
- Faculty of Medicine and Life Sciences, Hasselt University, LCRC, Agoralaan, Diepenbeek 3590, Belgium
- Department of Cardiology, Ziekenhuis Oost-Limburg, Synaps Park 1, Genk 3600, Belgium
- Department of Future Health, Ziekenhuis Oost-Limburg, Synaps Park 1, Genk 3600, Belgium
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Colson L, Vanhentenrijk S, Kalpakos T, Roosens B, Von Kemp B, Balthazar T, Lochy S, Verbrugge FH. Post-diuretic spot urine sodium assessment in acute heart failure: a retrospective analysis. Acta Clin Belg 2024:1-10. [PMID: 38613319 DOI: 10.1080/17843286.2024.2341193] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 04/05/2024] [Indexed: 04/14/2024]
Abstract
AIMS To provide real-world data on post-diuretic spot urine sodium concentration (UNa) assessment in acute heart failure (AHF) and its implications for treatment. METHODS AND RESULTS Automated query of the electronic medical record identified patients admitted to the cardiac intensive care unit of a single tertiary care hospital between November 2018 and December 2021, who received intravenous loop diuretics. Detailed manual chart review confirmed the AHF diagnosis. Stratification was performed based on whether post-diuretic UNa was assessed within 24 h of admission. AHF was confirmed in 340/380 identified patients. Post-diuretic UNa was assessed in 117 (34%), more frequently when ejection fraction was reduced and heart failure more advanced. Patients with versus without post-diuretic UNa assessment received higher doses of intravenous loop diuretics and more frequently acetazolamide and thiazide-like diuretics (p < 0.001 for all), resulting in similar urine output despite more advanced heart failure [2,488 mL (1,740-4,033 mL) vs. 2,400 mL (1,553-3,250 mL), respectively; p = 0.170]. Diuretic therapy remained more intense at discharge in the post-diuretic UNa group, with also a higher prescription rate of angiotensin-neprilysin inhibitors (p = 0.021). Serum creatinine increases/decreases were similarly frequent irrespectively from UNa assessment, with more dynamic changes observed in patients with UNa ≤ 80 mmol/L versus ≥ 81 mmol/L. After adjustments for baseline characteristics, the risk for death or heart failure readmission was similar in patients with versus without UNa assessment [HR (95%CI) = 1.43 (0.88-2.32); p = 0.150]. CONCLUSION Post-diuretic UNa assessment in AHF was associated with more intense diuretic regimens, preserving urine output despite its use in a sicker population.
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Affiliation(s)
- Lotte Colson
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Simon Vanhentenrijk
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
| | - Theodoros Kalpakos
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
| | - Bram Roosens
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
| | - Berlinde Von Kemp
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
| | - Tim Balthazar
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
| | - Stijn Lochy
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
| | - Frederik H Verbrugge
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
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Mullens W, Damman K, Dhont S, Banerjee D, Bayes-Genis A, Cannata A, Chioncel O, Cikes M, Ezekowitz J, Flammer AJ, Martens P, Mebazaa A, Mentz RJ, Miró Ò, Moura B, Nunez J, Ter Maaten JM, Testani J, van Kimmenade R, Verbrugge FH, Metra M, Rosano GMC, Filippatos G. Dietary sodium and fluid intake in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC. Eur J Heart Fail 2024. [PMID: 38606657 DOI: 10.1002/ejhf.3244] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
Sodium and fluid restriction has traditionally been advocated in patients with heart failure (HF) due to their sodium and water avid state. However, most evidence regarding the altered sodium handling, fluid homeostasis and congestion-related signs and symptoms in patients with HF originates from untreated patient cohorts and physiological investigations. Recent data challenge the beneficial role of dietary sodium and fluid restriction in HF. Consequently, the European Society of Cardiology HF guidelines have gradually downgraded these recommendations over time, now advising for the limitation of salt intake to no more than 5 g/day in patients with HF, while contemplating fluid restriction of 1.5-2 L/day only in selected patients. Therefore, the objective of this clinical consensus statement is to provide advice on fluid and sodium intake in patients with acute and chronic HF, based on contemporary evidence and expert opinion.
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Affiliation(s)
- Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
- Hasselt University, Hasselt, Belgium
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Sebastiaan Dhont
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
- Hasselt University, Hasselt, Belgium
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals National Health Service Foundation Trust, London, UK
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, CIBERCV, Barcelona, Spain
| | - Antonio Cannata
- School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases, University of Medicine Carol Davila, Bucharest, Romania
| | - Maja Cikes
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine & University Hospital Center Zagreb, Zagreb, Croatia
| | - Justin Ezekowitz
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
| | - Andreas J Flammer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Òscar Miró
- Department of Emergency, Hospital Clínic, 'Processes and Pathologies, Emergencies Research Group' IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Brenda Moura
- Hospital das Forças Armadas and Cintesis - Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Julio Nunez
- Cardiology Department and Heart Failure Unit, Hospital Clínico Universitario de Valencia, University of Valencia, INCLIVA, Valencia, Spain
| | - Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jeffrey Testani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Roland van Kimmenade
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Marco Metra
- Cardiology, ASST Spedali Civili, and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe M C Rosano
- Cardiology Clinical Academic Group, Molecular and Clinical Research Institute, St Georges University of London, London, UK
- Cardiology, San Raffaele Cassino, Rome, Italy
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Verbrugge FH, Krychtiuk KA. In perspective: CSL112 (Apolipoprotein A-I) Infusions and Cardiovascular Outcomes in Patients with Acute Myocardial Infarction: the ApoA-I Event Reducing in Ischemic Syndromes II (AEGIS-II) trial. Eur Heart J Acute Cardiovasc Care 2024:zuae046. [PMID: 38598460 DOI: 10.1093/ehjacc/zuae046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 04/12/2024]
Affiliation(s)
- Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Konstantin A Krychtiuk
- Department of Internal Medicine II - Division of Cardiology, Medical University of Vienna, Vienna, Austria
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Hoedemakers S, Pugliese NR, Stassen J, Vanoppen A, Claessens J, Gojevic T, Bekhuis Y, Falter M, Moura Ferreira S, Dhont S, De Biase N, Del Punta L, Di Fiore V, De Carlo M, Giannini C, Colli A, Dulgheru RE, Geers J, Yilmaz A, Claessen G, Bertrand P, Droogmans S, Lancellotti P, Cosyns B, Verbrugge FH, Herbots L, Masi S, Verwerft J. mPAP/CO Slope and Oxygen Uptake Add Prognostic Value in Aortic Stenosis. Circulation 2024; 149:1172-1182. [PMID: 38410954 DOI: 10.1161/circulationaha.123.067130] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 02/01/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Recent guidelines redefined exercise pulmonary hypertension as a mean pulmonary artery pressure/cardiac output (mPAP/CO) slope >3 mm Hg·L-1·min-1. A peak systolic pulmonary artery pressure >60 mm Hg during exercise has been associated with an increased risk of cardiovascular death, heart failure rehospitalization, and aortic valve replacement in aortic valve stenosis. The prognostic value of the mPAP/CO slope in aortic valve stenosis remains unknown. METHODS In this prospective cohort study, consecutive patients (n=143; age, 73±11 years) with an aortic valve area ≤1.5 cm2 underwent cardiopulmonary exercise testing with echocardiography. They were subsequently evaluated for the occurrence of cardiovascular events (ie, cardiovascular death, heart failure hospitalization, new-onset atrial fibrillation, and aortic valve replacement) during a follow-up period of 1 year. Findings were externally validated (validation cohort, n=141). RESULTS One cardiovascular death, 32 aortic valve replacements, 9 new-onset atrial fibrillation episodes, and 4 heart failure hospitalizations occurred in the derivation cohort, whereas 5 cardiovascular deaths, 32 aortic valve replacements, 1 new-onset atrial fibrillation episode, and 10 heart failure hospitalizations were observed in the validation cohort. Peak aortic velocity (odds ratio [OR] per SD, 1.48; P=0.036), indexed left atrial volume (OR per SD, 2.15; P=0.001), E/e' at rest (OR per SD, 1.61; P=0.012), mPAP/CO slope (OR per SD, 2.01; P=0.002), and age-, sex-, and height-based predicted peak exercise oxygen uptake (OR per SD, 0.59; P=0.007) were independently associated with cardiovascular events at 1 year, whereas peak systolic pulmonary artery pressure was not (OR per SD, 1.28; P=0.219). Peak Vo2 (percent) and mPAP/CO slope provided incremental prognostic value in addition to indexed left atrial volume and aortic valve area (P<0.001). These results were confirmed in the validation cohort. CONCLUSIONS In moderate and severe aortic valve stenosis, mPAP/CO slope and percent-predicted peak Vo2 were independent predictors of cardiovascular events, whereas peak systolic pulmonary artery pressure was not. In addition to aortic valve area and indexed left atrial volume, percent-predicted peak Vo2 and mPAP/CO slope cumulatively improved risk stratification.
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Affiliation(s)
- Sarah Hoedemakers
- Departments of Cardiology (S.H., J.S., M.F., S.M.F., G.C., L.H., J.V.), Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Agoralaan, Diepenbeek, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Limburg Clinical Research Center (-MHU), Hasselt, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium (S.H., J.G., S.D., B.C., F.H.V.)
| | - Nicola Riccardo Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Italy (N.R.P., N.D.B., L.D.P., V.D.F., S.M.)
| | - Jan Stassen
- Departments of Cardiology (S.H., J.S., M.F., S.M.F., G.C., L.H., J.V.), Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Agoralaan, Diepenbeek, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Limburg Clinical Research Center (-MHU), Hasselt, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
| | | | - Jade Claessens
- Department of Cardiothoracic Surgery (J.C., A.Y.), Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Agoralaan, Diepenbeek, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Limburg Clinical Research Center (-MHU), Hasselt, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
| | - Tin Gojevic
- Faculty of Medicine and Life Sciences, UHasselt, Agoralaan, Diepenbeek, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Limburg Clinical Research Center (-MHU), Hasselt, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
| | - Youri Bekhuis
- Faculty of Medicine and Life Sciences, UHasselt, Agoralaan, Diepenbeek, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Limburg Clinical Research Center (-MHU), Hasselt, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Faculty of Medicine, KU Leuven, Belgium (A.V., Y.B., M.F.)
| | - Maarten Falter
- Departments of Cardiology (S.H., J.S., M.F., S.M.F., G.C., L.H., J.V.), Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Agoralaan, Diepenbeek, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Limburg Clinical Research Center (-MHU), Hasselt, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Faculty of Medicine, KU Leuven, Belgium (A.V., Y.B., M.F.)
| | - Sara Moura Ferreira
- Departments of Cardiology (S.H., J.S., M.F., S.M.F., G.C., L.H., J.V.), Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Agoralaan, Diepenbeek, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Limburg Clinical Research Center (-MHU), Hasselt, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
| | - Sebastiaan Dhont
- Limburg Clinical Research Center (-MHU), Hasselt, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium (S.H., J.G., S.D., B.C., F.H.V.)
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (S.D., P.B.)
- Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Jette, Belgium (S.D., B.C., F.H.V.)
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Italy (N.R.P., N.D.B., L.D.P., V.D.F., S.M.)
| | - Lavinia Del Punta
- Department of Clinical and Experimental Medicine, University of Pisa, Italy (N.R.P., N.D.B., L.D.P., V.D.F., S.M.)
| | - Valerio Di Fiore
- Department of Clinical and Experimental Medicine, University of Pisa, Italy (N.R.P., N.D.B., L.D.P., V.D.F., S.M.)
| | - Marco De Carlo
- Cardiac, Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy (M.D.C., C.G., A.C.)
| | - Cristina Giannini
- Cardiac, Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy (M.D.C., C.G., A.C.)
| | - Andrea Colli
- Cardiac, Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy (M.D.C., C.G., A.C.)
| | - Raluca Elena Dulgheru
- Department of Cardiology, University Hospital of Liège, GIGA Cardiovascular Sciences, Liège, Belgium (R.E.D., P.L.)
| | - Jolien Geers
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium (S.H., J.G., S.D., B.C., F.H.V.)
| | - Alaaddin Yilmaz
- Department of Cardiothoracic Surgery (J.C., A.Y.), Jessa Hospital, Hasselt, Belgium
| | - Guido Claessen
- Departments of Cardiology (S.H., J.S., M.F., S.M.F., G.C., L.H., J.V.), Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Agoralaan, Diepenbeek, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Limburg Clinical Research Center (-MHU), Hasselt, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
| | - Philippe Bertrand
- Faculty of Medicine and Life Sciences, UHasselt, Agoralaan, Diepenbeek, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Limburg Clinical Research Center (-MHU), Hasselt, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (S.D., P.B.)
| | - Steven Droogmans
- Faculty of Medicine and Life Sciences, UHasselt, Agoralaan, Diepenbeek, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
| | - Patrizio Lancellotti
- Department of Cardiology, University Hospital of Liège, GIGA Cardiovascular Sciences, Liège, Belgium (R.E.D., P.L.)
- Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy (P.L.)
| | - Bernard Cosyns
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium (S.H., J.G., S.D., B.C., F.H.V.)
- Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Jette, Belgium (S.D., B.C., F.H.V.)
| | - Frederik H Verbrugge
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium (S.H., J.G., S.D., B.C., F.H.V.)
- Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Jette, Belgium (S.D., B.C., F.H.V.)
| | - Lieven Herbots
- Departments of Cardiology (S.H., J.S., M.F., S.M.F., G.C., L.H., J.V.), Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Agoralaan, Diepenbeek, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Limburg Clinical Research Center (-MHU), Hasselt, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Italy (N.R.P., N.D.B., L.D.P., V.D.F., S.M.)
| | - Jan Verwerft
- Departments of Cardiology (S.H., J.S., M.F., S.M.F., G.C., L.H., J.V.), Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Agoralaan, Diepenbeek, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
- Limburg Clinical Research Center (-MHU), Hasselt, Belgium (S.H., J.S., J.C., T.G., Y.B., M.F., S.M.F., S.D., G.C., P.B., L.H., J.V.)
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Van den Eynde J, Verbrugge FH. Renal Sodium Avidity in Heart Failure. Cardiorenal Med 2024:000538601. [PMID: 38565080 DOI: 10.1159/000538601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/22/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Increased renal sodium avidity is a hallmark feature of the heart failure syndrome. SUMMARY Increased renal sodium avidity refers to the inability of the kidneys to elicit potent natriuresis in response to sodium loading. This eventually causes congestion, which is a major contributor to hospital admissions and mortality in heart failure. KEY MESSAGES Important novel concepts such as the renal tamponade hypothesis, accelerated nephron loss, and the role of hypochloremia, the sympathetic nervous system, inflammation, the lymphatic system, and interstitial sodium buffers are involved in the pathophysiology of renal sodium avidity. A good understanding of these concepts is crucially important with respect to treatment recommendations regarding dietary sodium restriction, fluid restriction, rapid up titration of guideline-directed medical therapies, combination diuretic therapy, natriuresis guided diuretic therapy, use of hypertonic saline, and ultrafiltration.
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Vranckx P, Morrow D, Van Diepen S, Verbrugge FH. March 2024 issue of the European Heart Journal Acute Cardiovascular Care. Eur Heart J Acute Cardiovasc Care 2024; 13:263. [PMID: 38394554 DOI: 10.1093/ehjacc/zuae016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Affiliation(s)
- Pascal Vranckx
- Hartcentrum Hasselt, Jessaziekenhuis, Stadsomvaart 11, Hasselt 3500, Belgium
| | - David Morrow
- Brigham and Women's Hospital, TIMI-group, 75 Francis Street, Boston, MA 02115, USA
| | - Sean Van Diepen
- 2C2 Cardiology Walter MacKenzie Center, University of Alberta Hospital, 8440-112 St, Edmonton, Alberta T6G 2B7, Canada
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, UZ Brussels Faculty of Medicine & Pharmacy, VUB Laarbeeklaan 101, 1090 Jette, Belgium
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Mondellini GM, Verbrugge FH. Evaluation and Management of Hyponatremia in Heart Failure. Curr Heart Fail Rep 2024:10.1007/s11897-024-00651-3. [PMID: 38411885 DOI: 10.1007/s11897-024-00651-3] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW To provide a contemporary overview of the pathophysiology, evaluation, and treatment of hyponatremia in heart failure (HF). RECENT FINDINGS Potassium and magnesium losses due to poor nutritional intake and treatment with diuretics cause an intracellular sodium shift in HF that may contribute to hyponatremia. Impaired renal blood flow leading to a lower glomerular filtration rate and increased proximal tubular reabsorption lead to an impaired tubular flux through diluting distal segments of the nephron, compromising electrolyte-free water excretion. Hyponatremia in HF is typically a condition of impaired water excretion by the kidneys on a background of potassium and magnesium depletion. While those cations can and should be easily repleted, further treatment should mainly focus on improving the underlying HF and hemodynamics, while addressing congestion. For decongestive treatment, proximally acting diuretics such as sodium-glucose co-transporter-2 inhibitors, acetazolamide, and loop diuretics are the preferred options.
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Affiliation(s)
- Giulio M Mondellini
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090, Jette, Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090, Jette, Belgium.
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium.
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10
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Hoedemakers S, Verwerft J, Reddy YNV, Delvaux R, Stroobants S, Jogani S, Claessen G, Droogmans S, Cosyns B, Borlaug BA, Herbots L, Verbrugge FH. Cardiac dysfunction rather than aortic valve stenosis severity drives exercise intolerance and adverse haemodynamics. Eur Heart J Cardiovasc Imaging 2024; 25:302-312. [PMID: 37875135 DOI: 10.1093/ehjci/jead276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/16/2023] [Accepted: 10/16/2023] [Indexed: 10/26/2023] Open
Abstract
AIMS To study the impact of heart failure with preserved ejection fraction (HFpEF) vs. aortic stenosis (AS) lesion severity on left ventricular (LV) hypertrophy, diastolic dysfunction, left atrial (LA) dysfunction, haemodynamics, and exercise capacity. METHODS AND RESULTS Patients (n = 206) with at least moderate AS (aortic valve area ≤0.85 cm/m2) and discordant symptoms underwent cardiopulmonary exercise testing with simultaneous echocardiography. The population was stratified according to the probability of underlying HFpEF by the heavy, hypertension, atrial fibrillation, pulmonary hypertension, elder, filling pressure (H2FPEF) score [0-5 (AS/HFpEF-) vs. 6-9 points (AS/HFpEF+)] and AS severity (Moderate vs. Severe). Mean age was 73 ± 10 years with 40% women. Twenty-eight patients had Severe AS/HFpEF+ (14%), 111 Severe AS/HFpEF- (54%), 13 Moderate AS/HFpEF+ (6%), and 54 Moderate AS/HFpEF- (26%). AS/HFpEF+ vs. AS/HFpEF- patients, irrespective of AS severity, had a lower LV global longitudinal strain, impaired diastolic function, reduced LV compliance, and more pronounced LA dysfunction. The pulmonary arterial pressure-cardiac output slope was significantly higher in AS/HFpEF+ vs. AS/HFpEF- (5.4 ± 3.1 vs. 3.9 ± 2.2 mmHg/L/min, respectively; P = 0.003), mainly driven by impaired cardiac output and chronotropic reserve, with signs of right ventricular pulmonary arterial uncoupling. AS/HFpEF+ vs. AS/HFpEF- was associated with a lower peak aerobic capacity (11.5 ± 3.7 vs. 15.9 ± 5.9 mL/min/kg, respectively; P < 0.0001) but did not differ between Moderate and Severe AS (14.7 ± 5.5 vs. 15.2 ± 5.9 mL/min/kg, respectively; P = 0.6). CONCLUSION A high H2FPEF score is associated with a reduced exercise capacity and adverse haemodynamics in patients with moderate to severe AS. Both exercise performance and haemodynamics correspond better with intrinsic cardiac dysfunction than AS severity.
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Affiliation(s)
- Sarah Hoedemakers
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, University Hasselt (UHasselt), Hasselt, Belgium
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Jan Verwerft
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, University Hasselt (UHasselt), Hasselt, Belgium
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, 1216 2nd St SW, Rochester, MN 55902, USA
| | - Robin Delvaux
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, University Hasselt (UHasselt), Hasselt, Belgium
| | | | | | - Guido Claessen
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
- Department of Cardiology, University Hospital Leuven, Leuven, Belgium
| | - Steven Droogmans
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Jette, Belgium
| | - Bernard Cosyns
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Jette, Belgium
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, 1216 2nd St SW, Rochester, MN 55902, USA
| | - Lieven Herbots
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, University Hasselt (UHasselt), Hasselt, Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
- Department of Cardiovascular Medicine, Mayo Clinic, 1216 2nd St SW, Rochester, MN 55902, USA
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Jette, Belgium
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Vranckx P, Morrow DA, van Diepen S, Verbrugge FH. Acute cardiovascular and intensive care chronicles: 'inception revealed-navigating the veno-arterial extracorporeal membrane oxygenation terrain and beyond'. Eur Heart J Acute Cardiovasc Care 2024; 13:189-190. [PMID: 38271185 DOI: 10.1093/ehjacc/zuae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Affiliation(s)
- Pascal Vranckx
- Hartcentrum Hasselt, Jessaziekenhuis, Stadsomvaart 11, Hasselt 3500, Belgium
| | - David A Morrow
- Hartcentrum Hasselt, Jessaziekenhuis, Stadsomvaart 11, Hasselt 3500, Belgium
| | - Sean van Diepen
- Hartcentrum Hasselt, Jessaziekenhuis, Stadsomvaart 11, Hasselt 3500, Belgium
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Omote K, Sorimachi H, Obokata M, Verbrugge FH, Omar M, Popovic D, Reddy YNV, Pislaru SV, Pellikka PA, Borlaug BA. Biatrial myopathy in heart failure with preserved ejection fraction. Eur J Heart Fail 2024; 26:288-298. [PMID: 38059338 DOI: 10.1002/ejhf.3104] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/27/2023] [Accepted: 11/30/2023] [Indexed: 12/08/2023] Open
Abstract
AIM Left atrial (LA) myopathy is increasingly recognized as an important phenotypic trait in heart failure (HF) with preserved ejection fraction (HFpEF). Right atrial (RA) remodelling and dysfunction also develop in HFpEF, but little data are available regarding the clinical characteristics and pathophysiology among patients with isolated LA, RA, or biatrial myopathy. METHODS AND RESULTS Patients with HFpEF underwent invasive haemodynamic exercise testing, comprehensive imaging including speckle tracking strain echocardiography, and clinical follow-up at Mayo Clinic between 2006 and 2018. LA myopathy was defined as LA volume index >34 ml/m2 and/or LA reservoir strain ≤24% and RA myopathy by RA volume index >39 ml/m2 in men and >33 ml/m2 in women and/or RA reservoir strain ≤19.8%. Of 476 consecutively evaluated patients with HFpEF defined by invasive exercise testing with evaluable atrial structure/function, 125 (26%) had no atrial myopathy, 147 (31%) had isolated LA myopathy, 184 (39%) had biatrial myopathy, and 20 (4%) had isolated RA myopathy. Patients with HFpEF and biatrial myopathy had more atrial fibrillation, poorer left ventricular systolic and diastolic function, more severe pulmonary vascular disease, tricuspid regurgitation, ventricular interdependence and right ventricular dysfunction, and poorer cardiac output reserve with exercise. There were 94 patients with events over a median follow-up of 2.9 (interquartile range 1.4-4.6) years. Individuals with biatrial myopathy had an 84% higher risk of HF hospitalization or death as compared to those with isolated LA myopathy (hazard ratio 1.84; 95% confidence interval 1.16-2.92, p = 0.01). CONCLUSIONS Biatrial myopathy identifies patients with more advanced HFpEF characterized by more severe pulmonary vascular disease, right HF, poorer cardiac reserve, and a greater risk for adverse outcomes. Further study is required to define optimal strategies to treat and prevent biatrial myopathy in HFpEF.
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Affiliation(s)
- Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Frederik H Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
| | - Massar Omar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Dejana Popovic
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Balthazar T, Van Mieghem NM, Raes M, Van Loo I, Verbrugge FH. Short-term percutaneous mechanical circulatory support: no promise without positioning! Eur Heart J Acute Cardiovasc Care 2023; 12:869-877. [PMID: 37607271 DOI: 10.1093/ehjacc/zuad097] [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] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 07/17/2023] [Accepted: 08/14/2023] [Indexed: 08/24/2023]
Abstract
Short-term percutaneous mechanical circulatory support by a micro-axial flow pump is increasingly used to support the left ventricle in cardiogenic shock. After a correct indication and placement, appropriate device management in the cardiac intensive care unit is vital to ensure optimal pump function and adequate haemodynamic support. A key element hereby is a correct percutaneous ventricular assist device (pVAD) position. This review explains how an optimal left-sided pVAD position can be achieved and maintained, focusing on the correct insertion depth and rotational angle. Useful imaging techniques, placement and replacement manoeuvres, and monitoring options through the console are discussed. The frequently encountered problem of mal-rotation towards the mitral valve, which may cause suction alarms, haemolysis, aortic regurgitation, and inadequate haemodynamic support, is explained. Finally, a practical bedside approach to assess pVAD position and discern suction alarms due to mal-positioning from haemodynamic problems is proposed.
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Affiliation(s)
- Tim Balthazar
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, Jette 1090, Belgium
- Department of Intensive Care, University Hospital Brussels, Laarbeeklaan 101, Jette 1090, Belgium
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus Medical Centre, Rotterdam 3015 CN, The Netherlands
| | - Matthias Raes
- Department of Intensive Care, University Hospital Brussels, Laarbeeklaan 101, Jette 1090, Belgium
| | - Ines Van Loo
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, Jette 1090, Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, Jette 1090, Belgium
- Department of Intensive Care, University Hospital Brussels, Laarbeeklaan 101, Jette 1090, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette 1090, Belgium
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14
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Siegal DM, Verbrugge FH, Martin AC, Virdone S, Camm J, Pieper K, Gersh BJ, Goto S, Turpie AGG, Angchaisuksiri P, Fox KAA. Country and health expenditure are major predictors of withholding anticoagulation in atrial fibrillation patients at high risk of stroke. Open Heart 2023; 10:e002506. [PMID: 38097360 PMCID: PMC10729201 DOI: 10.1136/openhrt-2023-002506] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/14/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Guidelines for patients with atrial fibrillation (AF) at high thromboembolic risk recommend oral anticoagulants (OACs) for preventing stroke and systemic embolism (SE). The reasons for guideline non-adherence are still unclear. AIM The aim is to identify clinical, demographic and non-patient characteristics associated with withholding OAC in patients with AF at high stroke risk. METHODS Patients in the Global Anticoagulant Registry in the FIELD-AF, newly diagnosed with AF between March 2010 and August 2016, and with CHA2DS2-VASc Score≥2 (excluding sex), were grouped by OAC treatment at enrolment. Factors associated with OAC non-use were analysed by multivariable logistic regression. RESULTS Of 40 416 eligible patients, 12 126 (30.0%) did not receive OACs at baseline. Globally, OAC prescription increased over time, from 60.4% in 2010-2011 to 74.7% in 2015-2016. Country of enrolment was the major predictor for OAC withholding (χ2-df=2576). Clinical predictors of OAC non-use included type of AF (χ2-df=404), history of bleeding (χ2-df=263) and vascular disease (χ2-df=99). OACs were used most frequently around the age of 75 years and decreasingly with younger as well as older age beyond 75 years (χ2-df=148). Non-cardiologists (χ2-df=201) and emergency room physicians (χ2-df=14) were less likely to prescribe OACs. OAC prescription correlated positively with country health expenditure. CONCLUSIONS Approximately one out of three AF patients did not receive OAC, while eligible according to the guidelines. Country of enrolment was the major determinant of anticoagulation strategy, while higher country health expenditure was associated with lower likelihood of withholding anticoagulation.
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Affiliation(s)
- Deborah M Siegal
- Medicine, Ottawa Hospital General Campus, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Anne-Celine Martin
- Cardiology, European Hospital Georges-Pompidou, Paris, Île-de-France, France
| | - Saverio Virdone
- Department of Statistics, Thrombosis Research Institute, London, UK
| | - John Camm
- Cardiology, St George's Hospital, London, UK
| | | | | | - Shinya Goto
- Medicine, Tokai University School of Medicine Graduate School of Medicine, Isehara, Japan
| | | | | | - Keith A A Fox
- Cardiology, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, UK
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15
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Gruwez H, Verbrugge FH, Proesmans T, Evens S, Vanacker P, Rutgers MP, Vanhooren G, Bertrand P, Pison L, Haemers P, Vandervoort P, Nuyens D. Smartphone-based atrial fibrillation screening in the general population: feasibility and impact on medical treatment. Eur Heart J Digit Health 2023; 4:464-472. [PMID: 38045439 PMCID: PMC10689910 DOI: 10.1093/ehjdh/ztad054] [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] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/04/2023] [Indexed: 12/05/2023]
Abstract
Aims The aim of this study is to determine the feasibility, detection rate, and therapeutic implications of large-scale smartphone-based screening for atrial fibrillation (AF). Methods and results Subjects from the general population in Belgium were recruited through a media campaign to perform AF screening during 8 consecutive days with a smartphone application. The application analyses photoplethysmography traces with artificial intelligence and offline validation of suspected signals to detect AF. The impact of AF screening on medical therapy was measured through questionnaires. Atrial fibrillation was detected in the screened population (n = 60.629) in 791 subjects (1.3%). From this group, 55% responded to the questionnaire. Clinical AF [AF confirmed on a surface electrocardiogram (ECG)] was newly diagnosed in 60 individuals and triggered the initiation of anti-thrombotic therapy in 45%, adjustment of rate or rhythm controlling strategies in 62%, and risk factor management in 17%. In subjects diagnosed with known AF before screening, a positive screening result led to these therapy adjustments in 9%, 39%, and 11%, respectively. In all subjects with clinical AF and an indication for oral anti-coagulation (OAC), OAC uptake increased from 56% to 74% with AF screening. Subjects with clinical AF were older with more co-morbidities compared with subclinical AF (no surface ECG confirmation of AF) (P < 0.001). In subjects with subclinical AF (n = 202), therapy adjustments were performed in only 7%. Conclusion Smartphone-based AF screening is feasible at large scale. Screening increased OAC uptake and impacted therapy of both new and previously diagnosed clinical AF but failed to impact risk factor management in subjects with subclinical AF.
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Affiliation(s)
- Henri Gruwez
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
- Department of Cardiology, Hospital East-Limburg, Genk, Belgium
| | - Frederik H Verbrugge
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | - Peter Vanacker
- Department of Neurology, Antwerp University Hospital and Antwerp University, Antwerp, Belgium
- Department of Neurology, Groeninge Hospital, Kortrijk, Belgium
| | | | - Geert Vanhooren
- Department of Neurology, Sint-Jan Hospital Brugge-Oostende, Bruges, Belgium
| | - Philippe Bertrand
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Cardiology, Hospital East-Limburg, Genk, Belgium
| | - Laurent Pison
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Cardiology, Hospital East-Limburg, Genk, Belgium
| | - Peter Haemers
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Pieter Vandervoort
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Cardiology, Hospital East-Limburg, Genk, Belgium
| | - Dieter Nuyens
- Department of Cardiology, Hospital East-Limburg, Genk, Belgium
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16
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Weerts J, Amin H, Barandiarán Aizpurua A, Gevaert AB, Handoko ML, Dauw J, Tun HN, Rommel K, Verbrugge FH, Kresoja K, Sanders‐van Wijk S, Brunner‐La Rocca H, Bayés‐Genís A, Lumens J, Knackstedt C, van Empel VP. Webtool to enhance the accuracy of diagnostic algorithms for HFpEF: a prospective cross-over study. ESC Heart Fail 2023; 10:3493-3503. [PMID: 37724334 PMCID: PMC10682885 DOI: 10.1002/ehf2.14525] [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: 07/21/2023] [Accepted: 08/22/2023] [Indexed: 09/20/2023] Open
Abstract
AIMS Diagnosis of heart failure with preserved ejection fraction (HFpEF) can be challenging. This study aimed to evaluate the potential of a webtool to enhance the scoring accuracy when applying the complex HFA-PEFF and H2 FPEF algorithms, which are commonly used for diagnosing HFpEF. METHODS AND RESULTS We developed an online tool, the HFpEF calculator, that enables the automatic calculation of current HFpEF algorithms. We assessed the accuracy of manual vs. automatic scoring, defined as the percentage of correct scores, in a cohort of cardiologists with varying clinical experience. Cardiologists scored eight online clinical cases using a triple cross-over design (i.e. two manual-two automatic-two manual-two automatic). Data were analysed in study completers (n = 55, 29% heart failure specialists, 42% general cardiologists, and 29% cardiology residents). Manually calculated scores were correct in 50% (HFA-PEFF: 50% [50-75]; H2 FPEF: 50% [38-50]). Correct scoring improved to 100% using the HFpEF calculator (HFA-PEFF: 100% [88-100], P < 0.001; H2 FPEF: 100% [75-100], P < 0.001). Time spent on clinical cases was similar between scoring methods (±4 min). When corrections for faulty algorithm scores were displayed, cardiologists changed their diagnostic decision in up to 67% of cases. At least 67% of cardiologists preferred using the online tool for future cases in clinical practice. CONCLUSIONS Manual calculation of HFpEF diagnostic algorithms is often inaccurate. Using an automated webtool to calculate HFpEF algorithms significantly improved correct scoring. This new approach may impact the eventual diagnostic decision in up to two-thirds of cases, supporting its routine use in clinical practice.
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Affiliation(s)
- Jerremy Weerts
- Department of CardiologyCardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+)PO Box 6166200 MDMaastrichtThe Netherlands
| | - Hesam Amin
- Department of CardiologyCardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+)PO Box 6166200 MDMaastrichtThe Netherlands
- Department of CardiologyThoraxcentrum Twente, Medisch Spectrum TwenteEnschedeThe Netherlands
| | - Arantxa Barandiarán Aizpurua
- Department of CardiologyCardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+)PO Box 6166200 MDMaastrichtThe Netherlands
| | - Andreas B. Gevaert
- Research Group Cardiovascular Diseases, GENCOR DepartmentUniversity of AntwerpAntwerpBelgium
- Department of CardiologyAntwerp University Hospital (UZA)EdegemBelgium
| | - M. Louis Handoko
- Department of CardiologyAmsterdam University Medical Centers, Vrije UniversiteitAmsterdamThe Netherlands
- Amsterdam Cardiovascular Sciences/Heart Failure and ArrhythmiasAmsterdamThe Netherlands
| | - Jeroen Dauw
- Department of CardiologyAZ Sint‐LucasGhentBelgium
| | - Han Naung Tun
- Larner College of MedicineUniversity of VermontBurlingtonVTUSA
| | - Karl‐Philipp Rommel
- Department of Internal Medicine/CardiologyHeart Center Leipzig, Leipzig UniversityLeipzigGermany
| | - Frederik H. Verbrugge
- Centre for Cardiovascular DiseasesUniversity Hospital BrusselsJetteBelgium
- Faculty of Medicine and PharmacyVrije Universiteit BrusselBrusselsBelgium
| | - Karl‐Patrik Kresoja
- Department of Internal Medicine/CardiologyHeart Center Leipzig, Leipzig UniversityLeipzigGermany
| | | | - Hans‐Peter Brunner‐La Rocca
- Department of CardiologyCardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+)PO Box 6166200 MDMaastrichtThe Netherlands
| | - Antoni Bayés‐Genís
- Heart Institute, Hospital Universitari Germans Trias I Pujol, CIBERCVBadalonaSpain
| | - Joost Lumens
- Department of Biomedical EngineeringCardiovascular Research Institute Maastricht (CARIM), Maastricht UniversityMaastrichtThe Netherlands
| | - Christian Knackstedt
- Department of CardiologyCardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+)PO Box 6166200 MDMaastrichtThe Netherlands
| | - Vanessa P.M. van Empel
- Department of CardiologyCardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+)PO Box 6166200 MDMaastrichtThe Netherlands
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17
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Meekers E, Dauw J, Martens P, Dhont S, Verbrugge FH, Nijst P, Ter Maaten JM, Damman K, Mebazaa A, Filippatos G, Ruschitzka F, Tang WHW, Dupont M, Mullens W. Renal function and decongestion with acetazolamide in acute decompensated heart failure: the ADVOR trial. Eur Heart J 2023; 44:3672-3682. [PMID: 37623428 DOI: 10.1093/eurheartj/ehad557] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/09/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND AND AIMS In the ADVOR trial, acetazolamide improved decongestion in acute decompensated heart failure (ADHF). Whether the beneficial effects of acetazolamide are consistent across the entire range of renal function remains unclear. METHODS This is a pre-specified analysis of the ADVOR trial that randomized 519 patients with ADHF to intravenous acetazolamide or matching placebo on top of intravenous loop diuretics. The main endpoints of decongestion, diuresis, natriuresis, and clinical outcomes are assessed according to baseline renal function. Changes in renal function are evaluated between treatment arms. RESULTS On admission, median estimated glomerular filtration rate (eGFR) was 40 (30-52) mL/min/1.73 m². Acetazolamide consistently increased the likelihood of decongestion across the entire spectrum of eGFR (P-interaction = .977). Overall, natriuresis and diuresis were higher with acetazolamide, with a higher treatment effect for patients with low eGFR (both P-interaction < .007). Acetazolamide was associated with a higher incidence of worsening renal function (WRF; rise in creatinine ≥ 0.3 mg/dL) during the treatment period (40.5% vs. 18.9%; P < .001), but there was no difference in creatinine after 3 months (P = .565). This was not associated with a higher incidence of heart failure hospitalizations and mortality (P-interaction = .467). However, decongestion at discharge was associated with a lower incidence of adverse clinical outcomes irrespective of the onset of WRF (P-interaction = .805). CONCLUSIONS Acetazolamide is associated with a higher rate of successful decongestion across the entire range of renal function with more pronounced effects regarding natriuresis and diuresis in patients with a lower eGFR. While WRF occurred more frequently with acetazolamide, this was not associated with adverse clinical outcomes. CLINICALTRIALS.GOV IDENTIFIER NCT03505788.
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Affiliation(s)
- Evelyne Meekers
- Department of Cardiology, Ziekenhuis Oost-Limburg AV, Schiepse Bos 6, 3600 Genk, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Universiteitslaan, Diepenbeek, Belgium
| | - Jeroen Dauw
- Faculty of Medicine and Life Sciences, Hasselt University, Universiteitslaan, Diepenbeek, Belgium
- Department of Cardiology, AZ Sint-Lucas, Ghent, Belgium
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg AV, Schiepse Bos 6, 3600 Genk, Belgium
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sebastiaan Dhont
- Department of Cardiology, Ziekenhuis Oost-Limburg AV, Schiepse Bos 6, 3600 Genk, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Universiteitslaan, Diepenbeek, Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Petra Nijst
- Department of Cardiology, Ziekenhuis Oost-Limburg AV, Schiepse Bos 6, 3600 Genk, Belgium
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Kevin Damman
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Alexandre Mebazaa
- Department of Anesthesia & Critical Care, Université Paris Cité, Inserm MASCOT, APHP, Paris, France
| | | | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Wai Hong Wilson Tang
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg AV, Schiepse Bos 6, 3600 Genk, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg AV, Schiepse Bos 6, 3600 Genk, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Universiteitslaan, Diepenbeek, Belgium
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Verbrugge FH, Martens P, Mullens W. Reply: Acetazolamide in Acute Decompensated Heart Failure. J Am Coll Cardiol 2023; 82:e113. [PMID: 37730297 DOI: 10.1016/j.jacc.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 09/22/2023]
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Morrow DA, Verbrugge FH. In-perspective: the ARAMIS double-blind randomized placebo-controlled trial of anakinra for the treatment of acute myocarditis. Eur Heart J Acute Cardiovasc Care 2023; 12:627-628. [PMID: 37648656 DOI: 10.1093/ehjacc/zuad102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/01/2023]
Affiliation(s)
- David A Morrow
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Gómez-Rodríguez C, Tadeo-Espinoza H, Solis-Huerta F, Leal-Villarreal MADJ, Guerrero-Cabrera P, Cruz N, Gaytan-Arocha JE, Soto-Mota A, Vasquez Z, Gamba G, Verbrugge FH, Argaiz ER. Hemodynamic Evaluation of Right-Sided Congestion With Doppler Ultrasonography in Pulmonary Hypertension. Am J Cardiol 2023; 203:459-462. [PMID: 37542955 DOI: 10.1016/j.amjcard.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/25/2023] [Accepted: 07/05/2023] [Indexed: 08/07/2023]
Affiliation(s)
- César Gómez-Rodríguez
- Departamento de Medicina Interna, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Hiram Tadeo-Espinoza
- Departamento de Medicina Interna, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Fernando Solis-Huerta
- Departamento de Medicina Interna, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Paola Guerrero-Cabrera
- Departamento de Medicina Interna, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Néstor Cruz
- Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jorge E Gaytan-Arocha
- Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Adrián Soto-Mota
- Departamento de Medicina Interna, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Zuilma Vasquez
- Departamento de Cardiología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Gerardo Gamba
- Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Molecular Physiology Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium; Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Eduardo R Argaiz
- Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City, Mexico.
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Gruwez H, Barthels M, Haemers P, Verbrugge FH, Dhont S, Meekers E, Wouters F, Nuyens D, Pison L, Vandervoort P, Pierlet N. Detecting Paroxysmal Atrial Fibrillation From an Electrocardiogram in Sinus Rhythm: External Validation of the AI Approach. JACC Clin Electrophysiol 2023; 9:1771-1782. [PMID: 37354171 DOI: 10.1016/j.jacep.2023.04.008] [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: 02/06/2023] [Revised: 03/29/2023] [Accepted: 04/10/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) may occur asymptomatically and can be diagnosed only with electrocardiography (ECG) while the arrhythmia is present. OBJECTIVES The aim of this study was to independently validate the approach of using artificial intelligence (AI) to identify underlying paroxysmal AF from a 12-lead ECG in sinus rhythm (SR). METHODS An AI algorithm was trained to identify patients with underlying paroxysmal AF, using electrocardiographic data from all in- and outpatients from a single center with at least 1 ECG in SR. For patients without AF, all ECGs in SR were included. For patients with AF, all ECGs in SR starting 31 days before the first AF event were included. The patients were randomly allocated to training, internal validation, and testing datasets in a 7:1:2 ratio. In a secondary analysis, the AF prevalence of the testing group was modified. Additionally, the performance of the algorithm was validated at an external hospital. RESULTS The dataset consisted of 494,042 ECGs in SR from 142,310 patients. Testing the model on the first ECG of each patient (AF prevalence 9.0%) resulted in accuracy of 78.1% (95% CI: 77.6%-78.5%), area under the receiver-operating characteristic curve of 0.87 (95% CI: 0.86-0.87), and area under the precision recall curve (AUPRC) of 0.48 (95% CI: 0.46-0.50). In a low-risk group (AF prevalence 3%), the AUPRC decreased to 0.21 (95% CI: 0.18-0.24). In a high-risk group (AF prevalence 30%), the AUPRC increased to 0.76 (95% CI: 0.75-0.78). This performance was robust when validated in an external hospital. CONCLUSIONS The approach of using an AI-enabled electrocardiographic algorithm for the identification of patients with underlying paroxysmal AF from ECGs in SR was independently validated.
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Affiliation(s)
- Henri Gruwez
- Department of Cardiology, Hospital East-Limburg, Genk, Belgium; Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium; Doctoral School of Medicine and Life Science, Hasselt University, Hasselt, Belgium
| | - Myrte Barthels
- Data Science Department, Hospital East-Limburg, Genk, Belgium
| | - Peter Haemers
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium; Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Sebastiaan Dhont
- Department of Cardiology, Hospital East-Limburg, Genk, Belgium; Doctoral School of Medicine and Life Science, Hasselt University, Hasselt, Belgium
| | - Evelyne Meekers
- Department of Cardiology, Hospital East-Limburg, Genk, Belgium; Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium; Doctoral School of Medicine and Life Science, Hasselt University, Hasselt, Belgium
| | - Femke Wouters
- LCRC, Mobile Health Unit, Hasselt University, Hasselt, Belgium; Future Health Department, Hospital East-Limburg, Genk, Belgium
| | - Dieter Nuyens
- Department of Cardiology, Hospital East-Limburg, Genk, Belgium
| | - Laurent Pison
- Department of Cardiology, Hospital East-Limburg, Genk, Belgium
| | | | - Noëlla Pierlet
- Doctoral School of Medicine and Life Science, Hasselt University, Hasselt, Belgium; Data Science Department, Hospital East-Limburg, Genk, Belgium.
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Van den Eynde J, Schuermans A, Honigberg MC, Van De Bruaene A, Verbrugge FH. Pharmacologic Heart Rate Modulation in Heart Failure With Preserved Ejection Fraction: Pressure-Volume Loops Provide Insights. JACC Heart Fail 2023; 11:1032-1033. [PMID: 37558382 DOI: 10.1016/j.jchf.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 08/11/2023]
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Dhont S, Martens P, Meekers E, Dauw J, Verbrugge FH, Nijst P, Ter Maaten JM, Damman K, Mebazaa A, Filippatos G, Ruschitzka F, Tang WHW, Dupont M, Mullens W. Sodium and potassium changes during decongestion with acetazolamide - A pre-specified analysis from the ADVOR trial. Eur J Heart Fail 2023; 25:1310-1319. [PMID: 37062871 DOI: 10.1002/ejhf.2863] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/28/2023] [Accepted: 04/08/2023] [Indexed: 04/18/2023] Open
Abstract
AIMS Acetazolamide, an inhibitor of proximal tubular sodium reabsorption, leads to more effective decongestion in acute heart failure (AHF). It is unknown whether acetazolamide alters serum sodium and potassium levels on top of loop diuretics and if baseline values modify the treatment effect of acetazolamide. METHODS AND RESULTS This is a pre-specified sub-analysis of the ADVOR trial that randomized 519 patients with AHF and volume overload in a 1:1 ratio to intravenous acetazolamide or matching placebo on top of standardized intravenous loop diuretics. Mean potassium and sodium levels at randomization were 4.2 ± 0.6 and 139 ± 4 mmol/L in the acetazolamide arm versus 4.2 ± 0.6 and 140 ± 4 mmol/L in the placebo arm. Hypokalaemia (<3.5 mmol/L) on admission was present in 44 (9%) patients and hyponatraemia (≤135 mmol/L) in 82 (16%) patients. After 3 days of treatment, 44 (17%) patients in the acetazolamide arm and 35 (14%) patients in the placebo arm developed hyponatraemia (p = 0.255). Patients randomized to acetazolamide demonstrated a slight decrease in mean potassium levels during decongestion, which was non-significant over time (p = 0.053) and had no significant impact on hypokalaemia incidence (p = 0.061). Severe hypokalaemia (<3.0 mmol/L) occurred in only 7 (1%) patients, similarly distributed between the two treatment arms (p = 0.676). Randomization towards acetazolamide improved decongestive response irrespective of baseline serum sodium and potassium levels. CONCLUSIONS Acetazolamide on top of standardized loop diuretic therapy does not lead to clinically important hypokalaemia or hyponatraemia and improves decongestion over the entire range of baseline serum potassium and sodium levels.
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Affiliation(s)
- Sebastiaan Dhont
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
- Hasselt University, Diepenbeek/Hasselt, Belgium
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Evelyne Meekers
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
- Hasselt University, Diepenbeek/Hasselt, Belgium
| | - Jeroen Dauw
- Hasselt University, Diepenbeek/Hasselt, Belgium
- Department of Cardiology, AZ Sint-Lucas, Ghent, Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Petra Nijst
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Kevin Damman
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | | | | | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
- Hasselt University, Diepenbeek/Hasselt, Belgium
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Martens P, Verbrugge FH, Dauw J, Nijst P, Meekers E, Augusto SN, Ter Maaten JM, Heylen L, Damman K, Mebazaa A, Filippatos G, Ruschitzka F, Tang WHW, Dupont M, Mullens W. Pre-treatment bicarbonate levels and decongestion by acetazolamide: the ADVOR trial. Eur Heart J 2023; 44:1995-2005. [PMID: 37138385 DOI: 10.1093/eurheartj/ehad236] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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: 11/08/2022] [Revised: 03/26/2023] [Accepted: 04/04/2023] [Indexed: 05/05/2023] Open
Abstract
AIMS Acetazolamide inhibits proximal tubular sodium and bicarbonate re-absorption and improved decongestive response in acute heart failure in the ADVOR trial. It is unknown whether bicarbonate levels alter the decongestive response to acetazolamide. METHODS AND RESULTS This is a sub-analysis of the randomized, double-blind, placebo-controlled ADVOR trial that randomized 519 patients with acute heart failure and volume overload in a 1:1 ratio to intravenous acetazolamide (500 mg/day) or matching placebo on top of standardized intravenous loop diuretics (dose equivalent of twice oral maintenance dose). The primary endpoint was complete decongestion after 3 days of treatment (morning of day 4). Impact of baseline HCO3 levels on the treatment effect of acetazolamide was assessed. : Of the 519 enrolled patients, 516 (99.4%) had a baseline HCO3 measurement. Continuous HCO3 modelling illustrated a higher proportional treatment effect for acetazolamide if baseline HCO3 ≥ 27 mmol/l. A total of 234 (45%) had a baseline HCO3 ≥ 27 mmol/l. Randomization towards acetazolamide improved decongestive response over the entire range of baseline HCO3- levels (P = 0.004); however, patients with elevated baseline HCO3 exhibited a significant higher response to acetazolamide [primary endpoint: no vs. elevated HCO3; OR 1.37 (0.79-2.37) vs. OR 2.39 (1.35-4.22), P-interaction = 0.065), with higher proportional diuretic and natriuretic response (both P-interaction < 0.001), greater reduction in congestion score on consecutive days (treatment × time by HCO3-interaction <0.001) and length of stay (P-interaction = 0.019). The larger proportional treatment effect was mainly explained by the development of diminished decongestive response in the placebo arm (loop diuretics only), both with regard to reaching the primary endpoint of decongestion as well as reduction in congestion score. Development of elevated HCO3 further worsened decongestive response in the placebo arm (P-interaction = 0.041). A loop diuretic only strategy was associated with an increase in the HCO3 during the treatment phase which was prevented by acetazolamide (day 3: placebo 74.8% vs. acetazolamide 41.3%, P < 0.001). CONCLUSION Acetazolamide improves decongestive response over the entire range of HCO3- levels; however, the treatment response is magnified in patients with baseline or loop diuretic-induced elevated HCO3 (marker of proximal nephron NaHCO3 retention) by specifically counteracting this component of diuretic resistance.
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Affiliation(s)
- Pieter Martens
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Schiepse bos 6, 3600 Genk, Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Jeroen Dauw
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Schiepse bos 6, 3600 Genk, Belgium
- Faculty of Medicine and Life Science, Hasselt University, Martelarenlaan 42, 3500 Hasselt, Belgium
| | - Petra Nijst
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Schiepse bos 6, 3600 Genk, Belgium
| | - Evelyne Meekers
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Schiepse bos 6, 3600 Genk, Belgium
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
| | - Silvio Nunes Augusto
- Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jozine M Ter Maaten
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Line Heylen
- Department of Nefrology, Ziekenhuis Oost-Limburg A.V., Genk, Belgium
| | - Kevin Damman
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Alexandre Mebazaa
- Department of Medicine, Université Paris Cité, Inserm MASCOT, APHP, Paris, France
| | - Gerasimos Filippatos
- Department of Cardiology, National and Kapodistrian University of Athens, Athens University Hospital Attikon, Athens, Greece
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Wai Hong Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Schiepse bos 6, 3600 Genk, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Schiepse bos 6, 3600 Genk, Belgium
- Faculty of Medicine and Life Science, Hasselt University, Martelarenlaan 42, 3500 Hasselt, Belgium
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Verbrugge FH, Martens P, Dauw J, Nijst P, Meekers E, Augusto SN, Ter Maaten JM, Damman K, Filippatos G, Lassus J, Mebazaa A, Ruschitzka F, Dupont M, Mullens W. Natriuretic Response to Acetazolamide in Patients With Acute Heart Failure and Volume Overload. J Am Coll Cardiol 2023; 81:2013-2024. [PMID: 37197845 DOI: 10.1016/j.jacc.2023.03.400] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/03/2023] [Accepted: 03/07/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Acetazolamide facilitates decongestion in acute decompensated heart failure (ADHF). OBJECTIVES This study sought to investigate the effect of acetazolamide on natriuresis in ADHF and its relationship with outcomes. METHODS Patients from the ADVOR (Acetazolamide in Decompensated Heart Failure with Volume Overload) trial with complete data on urine output and urine sodium concentration (UNa) were analyzed. Predictors of natriuresis and its relationship with the main trial endpoints were evaluated. RESULTS This analysis included 462 of 519 patients (89%) from the ADVOR trial. During 2 days after randomization, UNa was 92 ± 25 mmol/L on average, and total natriuresis was 425 ± 234 mmol. Allocation to acetazolamide strongly and independently predicted natriuresis with a 16 mmol/L (19%) increase in UNa and 115 mmol (32%) greater total natriuresis. Higher systolic blood pressure, better renal function, higher serum sodium levels, and male sex also independently predicted both a higher UNa and greater total natriuresis. A stronger natriuretic response was associated with faster and more complete relief of signs of volume overload, and this effect was already significant on the first morning of assessment (P = 0.022). A significant interaction was observed between the effect of allocation to acetazolamide and UNa on decongestion (P = 0.007). Stronger natriuresis with better decongestion translated into a shorter hospital stay (P < 0.001). After multivariable adjustments, every 10 mmol/L UNa increase was independently associated with a lower risk of all-cause death or heart failure readmission (HR: 0.92; 95% CI: 0.85-0.99). CONCLUSIONS Increased natriuresis is strongly related to successful decongestion with acetazolamide in ADHF. UNa may be an attractive measure of effective decongestion for future trials. (Acetazolamide in Decompensated Heart Failure with Volume Overload [ADVOR]; NCT03505788).
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Affiliation(s)
- Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium; Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jeroen Dauw
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Petra Nijst
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Evelyne Meekers
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Silvio Nunes Augusto
- Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Kevin Damman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, Athens University Hospital Attikon, Chaidari, Greece
| | - Johan Lassus
- Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Alexandre Mebazaa
- Université Paris Cité, National Institute of Health and Medical Research MASCOT (Cardiovascular Markers in Situation of Stress), APHP (Public Assistance Hospital of Paris), Paris, France
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
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Gonzalez-Del-Hoyo M, Verbrugge FH. Managing patients with chest pain at the emergency department: have high-risk heart failure phenotypes been overlooked? European Heart Journal. Acute Cardiovascular Care 2023; 12:296-298. [PMID: 37021805 DOI: 10.1093/ehjacc/zuad040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 04/08/2023]
Affiliation(s)
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels , Jette , Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel , Brussels , Belgium
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27
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Verwerft J, Soens L, Wynants J, Meysman M, Jogani S, Plein D, Stroobants S, Herbots L, Verbrugge FH. Heart failure with preserved ejection fraction: relevance of a dedicated dyspnoea clinic. Eur Heart J 2023; 44:1544-1556. [PMID: 36924194 DOI: 10.1093/eurheartj/ehad141] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 10/15/2022] [Revised: 01/30/2023] [Accepted: 02/21/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND AND AIMS Heart failure with preserved ejection fraction (HFpEF) is a syndrome with a heterogeneous presentation. This study provides an in-;depth description of haemodynamic and metabolic alterations revealed by systematic assessment through cardiopulmonary exercise testing combined with exercise echocardiography (CPETecho) within a dedicated dyspnoea clinic. METHODS AND RESULTS Consecutive patients (n = 297), referred to a dedicated dyspnoea clinic using a standardized workup including CPETecho, with HFpEF diagnosed through a H2FPEF score ≥6 or HFA-PEFF score ≥5, were evaluated. A median of four haemodynamic/metabolic alterations was uncovered per patient: impaired stroke volume reserve (73%), impaired chronotropic reserve (72%), exercise pulmonary hypertension (65%), and impaired diastolic reserve (64%) were the most frequent cardiac alterations. Impaired peripheral oxygen extraction and a ventilatory limitation were present in 40% and 39%, respectively. In 267 patients (90%), 575 further diagnostic examinations were recommended (median of two tests per patient). Cardiac magnetic resonance imaging, coronary or amyloidosis workup, ventilation-perfusion scanning, and pulmonology referral were each recommended in approximately one out of three patients. In 293 patients (99%), 929 cardiovascular drug optimizations were performed (median of 3 modifications per patient). In 110 patients (37%), 132 cardiovascular interventions were performed, with ablation as the most frequent procedure. CONCLUSION Holistic workup of HFpEF patients within a multidisciplinary, dedicated dyspnoea clinic, including systematic implementation of CPETecho reveals various haemodynamic/metabolic alterations, leading to further diagnostic testing and potential treatment changes in the majority of cases.
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Affiliation(s)
- Jan Verwerft
- Department of Cardiology, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, Belgium.,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Martelarenlaan 42, 3500 Hasselt, Belgium
| | - Lucie Soens
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Jokke Wynants
- Department of Pulmonology, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, Belgium
| | - Marc Meysman
- Department of Pulmonology, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Siddharth Jogani
- Department of Cardiology, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, Belgium
| | - Danielle Plein
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Sarah Stroobants
- Department of Cardiology, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, Belgium
| | - Lieven Herbots
- Department of Cardiology, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, Belgium.,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Martelarenlaan 42, 3500 Hasselt, Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium.,Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Pleinlaan 2, 1050 Elsene, Belgium
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28
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Geers J, Luchian ML, Motoc A, De Winter J, Roosens B, Bjerke M, Van Eeckhaut A, Wittens MMJ, Demeester S, Forsyth R, de Ravel T, Bissay V, Schots R, Verbrugge FH, Weytjens C, Weets I, Cosyns B, Droogmans S. Prognostic value of left ventricular global constructive work in patients with cardiac amyloidosis. Int J Cardiovasc Imaging 2023; 39:585-593. [PMID: 36471103 DOI: 10.1007/s10554-022-02762-1] [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] [Subscribe] [Scholar Register] [Accepted: 11/19/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of the present study was to evaluate the role of ejection fraction (EF), left ventricular (LV) global longitudinal strain (LVGLS) and global constructive work (GCW) as prognostic variables in patients with cardiac amyloidosis (CA). METHODS CA patients were retrospectively identified between 2015 and 2021 at a tertiary care hospital. Comprehensive clinical, biochemical, and imaging evaluation including two-dimensional (2D) echocardiography with myocardial work (MW) analysis was performed. A clinical combined endpoint was defined as all-cause mortality and heart failure readmission. RESULTS 70 patients were followed for 16 (7-37) months and 37 (52.9%) reached the combined endpoint. Patient with versus without clinical events had a significantly lower LVEF (40.71% vs. 48.01%, p = 0.039), LVGLS (-9.26 vs. -11.32, p = 0.034) and GCW (1034.47mmHg% vs. 1424.86mmHg%, p = 0.011). Multivariable analysis showed that LVEF ( odds ratio (OR): 0.904; 95% confidence interval (CI): 0.839-0.973, p = 0.007), LVGLS ( OR: 0.620; 95% CI: 0.415-0.926, p = 0.020) and GCW ( OR: 0.995; 95% CI: 0.990-0.999, p = 0.016) were significant predictors of outcome, but the model including GCW had the best discriminative ability to predict the combined endpoint (C-index = 0.888). A GCW less than 1443mmHg% was able to predict the clinical endpoint with a sensitivity of 94% and a specificity of 64% (Area under the curve (AUC): 0.771 (95% CI: 0.581-0.961; p = 0.005)). CONCLUSION In CA patients, GCW may be of additional prognostic value to LVEF and GLS in predicting heart failure hospitalization and all-cause mortality.
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Affiliation(s)
- Jolien Geers
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Maria-Luiza Luchian
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Andreea Motoc
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jari De Winter
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Bram Roosens
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Maria Bjerke
- Department of Clinical Biology, Laboratory of Clinical Neurochemistry, Center for Neurosciences, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Ann Van Eeckhaut
- Department of Clinical Biology, Research Group Experimental Pharmacology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Mandy M J Wittens
- Department of Clinical Biology, Laboratory of Clinical Neurochemistry, Center for Neurosciences, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Simke Demeester
- Department of Clinical Biology, Laboratory of Hematology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Ramses Forsyth
- Department of Pathology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Thomy de Ravel
- Department of Human Genetics, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Véronique Bissay
- Department of Neurology, Center for Neurosciences, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Rik Schots
- Department of Hematology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Frederik H Verbrugge
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Caroline Weytjens
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Ilse Weets
- Department of Clinical Biology, Research Group Experimental Pharmacology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Bernard Cosyns
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Steven Droogmans
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
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29
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Platz E, Morrow DA, Verbrugge FH, Vranckx P, Cullen L. Acute cardiovascular care in the emergency department and beyond: a call for interdisciplinary collaboration in clinical research. Eur Heart J Acute Cardiovasc Care 2023; 12:77-79. [PMID: 36585901 DOI: 10.1093/ehjacc/zuac170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 12/28/2022] [Indexed: 01/01/2023]
Affiliation(s)
- Elke Platz
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - David A Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium & Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Pascal Vranckx
- Department of Cardiology and Critical Care medicine, Jessa Ziekenhuis Hasselt & Faculty of Medicine and Life Sciences, University of Hasselt, Hasselt, Belgium
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
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30
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Verwerft J, Bertrand PB, Claessen G, Herbots L, Verbrugge FH. Cardiopulmonary Exercise Testing With Simultaneous Echocardiography: Blueprints of a Dyspnea Clinic for Suspected HFpEF. JACC Heart Fail 2023; 11:243-249. [PMID: 36754531 DOI: 10.1016/j.jchf.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/01/2022] [Accepted: 11/09/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Jan Verwerft
- Department of Cardiology, Hartcentrum, Jessa Hospital, Hasselt, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Philippe B Bertrand
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium; Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Guido Claessen
- Department of Cardiovascular Diseases, University Hospital Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Lieven Herbots
- Department of Cardiology, Hartcentrum, Jessa Hospital, Hasselt, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium; Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.
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31
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Omote K, Verbrugge FH, Sorimachi H, Omar M, Popovic D, Obokata M, Reddy YNV, Borlaug BA. Central haemodynamic abnormalities and outcome in patients with unexplained dyspnoea. Eur J Heart Fail 2023; 25:185-196. [PMID: 36420788 PMCID: PMC9974926 DOI: 10.1002/ejhf.2747] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [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: 06/07/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/26/2022] Open
Abstract
AIMS Little data are available regarding prognostic implications of invasive exercise testing in heart failure with preserved ejection fraction (HFpEF). The present study aimed to investigate whether rest and exercise central haemodynamic abnormalities are associated with adverse clinical outcomes in patients with dyspnea. METHODS AND RESULTS Patients with exertional dyspnoea and ejection fraction ≥50% (n = 764) underwent invasive exercise testing and follow-up for heart failure hospitalization or death. There were 117 patients with events over a median follow-up of 2.7 (interquartile range 0.5-4.6) years. Among patients with normal resting pulmonary artery wedge pressure (PAWP) (<15 mmHg, n = 380 [50%]), increased exercise PAWP (≥25 mmHg) was present in 187 (24% of cohort) and was associated with 2.4-fold higher risk of events compared to those with normal exercise PAWP (<25 mmHg, n = 193 [25%]) (hazard ratio [HR] 2.44; 95% confidence interval [CI] 1.11-5.36; p = 0.03), while patients with elevated resting PAWP (≥15 mmHg, n = 384 [50%]) displayed even higher risk compared to HFpEF with normal resting PAWP (HR 2.24; 95% CI 1.38-3.65; p = 0.001). Similar findings were observed for rest/exercise right atrial pressure, and rest/exercise pulmonary artery pressures. Higher peak oxygen consumption was associated with decreased risk of events, and this relationship was solely explained by exercise cardiac output. In a multivariable-adjusted Cox model, each 1 standard deviation (SD) increase in exercise PAWP was associated with a 41% greater hazard of events (HR 1.41; 95% CI 1.13-1.76; p = 0.002), while each 1 SD decrease in exercise cardiac output was associated with a 37% increased risk (HR 0.63; 95% CI 0.47-0.83; p = 0.001). CONCLUSIONS Haemodynamic abnormalities currently used for diagnosis of HFpEF are associated with increased risk for adverse events. Treatments that reduce central pressures while improving cardiac output reserve may offer greatest benefit to improve outcomes in HFpEF.
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Affiliation(s)
- Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Frederik H. Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Massar Omar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Dejana Popovic
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Yogesh N. V. Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
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32
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Martens P, Dauw J, Verbrugge FH, Nijst P, Meekers E, Augusto SN, Ter Maaten JM, Damman K, Mebazaa A, Filippatos G, Ruschitzka F, Tang WHW, Dupont M, Mullens W. Decongestion With Acetazolamide in Acute Decompensated Heart Failure Across the Spectrum of Left Ventricular Ejection Fraction: A Prespecified Analysis From the ADVOR Trial. Circulation 2023; 147:201-211. [PMID: 36335479 DOI: 10.1161/circulationaha.122.062486] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acetazolamide inhibits proximal tubular sodium reabsorption and improved decongestion in the ADVOR (Acetazolamide in Decompensated Heart Failure with Volume Overload) trial. It remains unclear whether the decongestive effects of acetazolamide differ across the spectrum of left ventricular ejection fraction (LVEF). METHODS This is a prespecified analysis of the randomized, double-blind, placebo-controlled ADVOR trial that enrolled 519 patients with acute heart failure (HF), clinical signs of volume overload (eg, edema, pleural effusion, or ascites), NTproBNP (N-terminal pro-B-type natriuretic peptide) >1000 ng/L, or BNP (B-type natriuretic peptide) >250 ng/mL to receive intravenous acetazolamide (500 mg once daily) or placebo in addition to standardized intravenous loop diuretics (twice that of the oral home maintenance dose). Randomization was stratified according to LVEF (≤40% or >40%). The primary end point was successful decongestion, defined as the absence of signs of volume overload within 3 days from randomization without the need for mandatory escalation of decongestive therapy because of poor urine output. RESULTS Median LVEF was 45% (25th to 75th percentile; 30% to 55%), and 43% had an LVEF ≤40%. Patients with lower LVEF were younger and more likely to be male with a higher prevalence of ischemic heart disease, higher NTproBNP, less atrial fibrillation, and lower estimated glomerular filtration rate. No interaction on the overall beneficial treatment effect of acetazolamide to the primary end point of successful decongestion (OR, 1.77 [95% CI, 1.18-2.63]; P=0.005; all P values for interaction >0.401) was found when LVEF was assessed per randomization stratum (≤40% or >40%), or as HF with reduced ejection fraction, HF with mildly reduced ejection fraction, and HF with preserved ejection fraction, or on a continuous scale. Acetazolamide resulted in improved diuretic response measured by higher cumulative diuresis and natriuresis and shortened length of stay without treatment effect modification by baseline LVEF (all P values for interaction >0.160). CONCLUSIONS When added to treatment with loop diuretics in patients with acute decompensated HF, acetazolamide improves the incidence of successful decongestion and diuretic response, and shortens length of stay without treatment effect modification by baseline LVEF. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03505788.
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Affiliation(s)
- Pieter Martens
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute (P.M., W.H.W.T.), Cleveland Clinic, Cleveland, OH.,Ziekenhuis Oost-Limburg A.V., Genk, Belgium (P.M., J.D., P.N., E.M., M.D., W.M.)
| | - Jeroen Dauw
- Ziekenhuis Oost-Limburg A.V., Genk, Belgium (P.M., J.D., P.N., E.M., M.D., W.M.).,Hasselt University, Diepenbeek/Hasselt, Belgium (J.D., E.M., W.M.)
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium (F.H.V.).,Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium (F.H.V.)
| | - Petra Nijst
- Ziekenhuis Oost-Limburg A.V., Genk, Belgium (P.M., J.D., P.N., E.M., M.D., W.M.)
| | - Evelyne Meekers
- Ziekenhuis Oost-Limburg A.V., Genk, Belgium (P.M., J.D., P.N., E.M., M.D., W.M.).,Hasselt University, Diepenbeek/Hasselt, Belgium (J.D., E.M., W.M.)
| | - Silvio Nunes Augusto
- Cardiovascular and Metabolic Sciences, Lerner Research Institute (S.N.A.), Cleveland Clinic, Cleveland, OH
| | - Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Center Groningen, The Netherlands (J.M.T.M. K.D.)
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, The Netherlands (J.M.T.M. K.D.)
| | - Alexandre Mebazaa
- Université Paris Cité, Inserm MASCOT, Assistance Publique Hopitaux de Paris' France (A.M.)
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, Athens University Hospital Attikon, Greece (G.F.)
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital Zurich, University of Zurich, Switzerland (F.R.)
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute (P.M., W.H.W.T.), Cleveland Clinic, Cleveland, OH
| | - Matthias Dupont
- Ziekenhuis Oost-Limburg A.V., Genk, Belgium (P.M., J.D., P.N., E.M., M.D., W.M.)
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg A.V., Genk, Belgium (P.M., J.D., P.N., E.M., M.D., W.M.).,Hasselt University, Diepenbeek/Hasselt, Belgium (J.D., E.M., W.M.)
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33
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Verbrugge FH, Menon V. Torsemide comparison with furosemide for management of heart failure (TRANSFORM-HF) trial. Eur Heart J Acute Cardiovasc Care 2022; 11:931-932. [PMID: 36351030 DOI: 10.1093/ehjacc/zuac144] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 11/06/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Frederik H Verbrugge
- Department of Cardiology, Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium.,Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Venu Menon
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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Argaiz ER, Rola P, Haycock KH, Verbrugge FH. Fluid management in acute kidney injury: from evaluating fluid responsiveness towards assessment of fluid tolerance. Eur Heart J Acute Cardiovasc Care 2022; 11:786-793. [PMID: 36069621 DOI: 10.1093/ehjacc/zuac104] [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] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
Despite the widespread use of intravenous fluids in acute kidney injury (AKI), solid evidence is lacking. Intravenous fluids mainly improve AKI due to true hypovolaemia, which is difficult to discern at the bedside unless it is very pronounced. Empiric fluid resuscitation triggered only by elevated serum creatinine levels or oliguria is frequently misguided, especially in the presence of fluid intolerance syndromes such as increased extravascular lung water, capillary leak, intra-abdominal hypertension, and systemic venous congestion. While fluid responsiveness tests clearly identify patients who will not benefit from fluid administration (i.e. those without an increase in cardiac output), the presence of fluid responsiveness does not guarantee that fluid therapy is indicated or even safe. This review calls for more attention to the concept of fluid tolerance, incorporating it into a practical algorithm with systematic venous Doppler ultrasonography assessment to use at the bedside, thereby lowering the risk of detrimental kidney congestion in AKI.
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Affiliation(s)
- Eduardo R Argaiz
- Department of Nephrology and Mineral Metabolism, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montréal, QC, Canada
| | - Korbin H Haycock
- Department of Emergency Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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35
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Vanhentenrijk S, Verbrugge FH, Tang WHW, Menon V. PRO: Vasodilators remain an indispensable treatment for acute heart failure. European Heart Journal. Acute Cardiovascular Care 2022; 11:850-857. [DOI: 10.1093/ehjacc/zuac128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Simon Vanhentenrijk
- Centre for Cardiovascular Diseases, University Hospital Brussels , Jette , Belgium
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels , Jette , Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel , Brussels , Belgium
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic , Cleveland, OH , United States
| | - Venu Menon
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic , Cleveland, OH , United States
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36
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Mullens W, Dauw J, Martens P, Verbrugge FH, Nijst P, Meekers E, Tartaglia K, Chenot F, Moubayed S, Dierckx R, Blouard P, Troisfontaines P, Derthoo D, Smolders W, Bruckers L, Droogne W, Ter Maaten JM, Damman K, Lassus J, Mebazaa A, Filippatos G, Ruschitzka F, Dupont M. Acetazolamide in Acute Decompensated Heart Failure with Volume Overload. N Engl J Med 2022; 387:1185-1195. [PMID: 36027559 DOI: 10.1056/nejmoa2203094] [Citation(s) in RCA: 155] [Impact Index Per Article: 77.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Whether acetazolamide, a carbonic anhydrase inhibitor that reduces proximal tubular sodium reabsorption, can improve the efficiency of loop diuretics, potentially leading to more and faster decongestion in patients with acute decompensated heart failure with volume overload, is unclear. METHODS In this multicenter, parallel-group, double-blind, randomized, placebo-controlled trial, we assigned patients with acute decompensated heart failure, clinical signs of volume overload (i.e., edema, pleural effusion, or ascites), and an N-terminal pro-B-type natriuretic peptide level of more than 1000 pg per milliliter or a B-type natriuretic peptide level of more than 250 pg per milliliter to receive either intravenous acetazolamide (500 mg once daily) or placebo added to standardized intravenous loop diuretics (at a dose equivalent to twice the oral maintenance dose). Randomization was stratified according to the left ventricular ejection fraction (≤40% or >40%). The primary end point was successful decongestion, defined as the absence of signs of volume overload, within 3 days after randomization and without an indication for escalation of decongestive therapy. Secondary end points included a composite of death from any cause or rehospitalization for heart failure during 3 months of follow-up. Safety was also assessed. RESULTS A total of 519 patients underwent randomization. Successful decongestion occurred in 108 of 256 patients (42.2%) in the acetazolamide group and in 79 of 259 (30.5%) in the placebo group (risk ratio, 1.46; 95% confidence interval [CI], 1.17 to 1.82; P<0.001). Death from any cause or rehospitalization for heart failure occurred in 76 of 256 patients (29.7%) in the acetazolamide group and in 72 of 259 patients (27.8%) in the placebo group (hazard ratio, 1.07; 95% CI, 0.78 to 1.48). Acetazolamide treatment was associated with higher cumulative urine output and natriuresis, findings consistent with better diuretic efficiency. The incidence of worsening kidney function, hypokalemia, hypotension, and adverse events was similar in the two groups. CONCLUSIONS The addition of acetazolamide to loop diuretic therapy in patients with acute decompensated heart failure resulted in a greater incidence of successful decongestion. (Funded by the Belgian Health Care Knowledge Center; ADVOR ClinicalTrials.gov number, NCT03505788.).
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Affiliation(s)
- Wilfried Mullens
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Jeroen Dauw
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Pieter Martens
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Frederik H Verbrugge
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Petra Nijst
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Evelyne Meekers
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Katrien Tartaglia
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Fabien Chenot
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Samer Moubayed
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Riet Dierckx
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Philippe Blouard
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Pierre Troisfontaines
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - David Derthoo
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Walter Smolders
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Liesbeth Bruckers
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Walter Droogne
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Jozine M Ter Maaten
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Kevin Damman
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Johan Lassus
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Alexandre Mebazaa
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Gerasimos Filippatos
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Frank Ruschitzka
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
| | - Matthias Dupont
- From Ziekenhuis Oost-Limburg, Genk (W.M., J.D., P.M., P.N., E.M., K.T., M.D.), Hasselt University, Hasselt (W.M., J.D., E.M., L.B.), Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Jette (F.H.V.), Grand Hôpital de Charleroi (F.C.) and Centre Hospitalier Universitaire Charleroi (S.M.), Charleroi, OLV Hospital, Aalst (R.D.), Clinique Saint-Luc, Bouge (P.B.), Centre Hospitalier Régional Citadelle Hospital, Liege (P.T.), AZ Groeninge, Kortrijk (D.D.), AZ Klina, Brasschaat (W.S.), and University Hospitals Leuven, Leuven (W.D.) - all in Belgium; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (J.M.T.M., K.D.); the Heart and Lung Center, Department of Cardiology, Helsinki University Hospital, and Helsinki University, Helsinki (J.L.); Université Paris Cité, INSERM MASCOT (Cardiovascular Markers in Stressed Conditions), Assistance Publique-Hôpitaux de Paris, Paris (A.M.); the National and Kapodistrian University of Athens and Athens University Hospital Attikon, Athens (G.F.); and Universitäts Spital Zürich, Zurich (F.R.)
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Omote K, Sorimachi H, Obokata M, Reddy YNV, Verbrugge FH, Omar M, DuBrock HM, Redfield MM, Borlaug BA. Pulmonary vascular disease in pulmonary hypertension due to left heart disease: pathophysiologic implications. Eur Heart J 2022; 43:3417-3431. [PMID: 35796488 PMCID: PMC9794188 DOI: 10.1093/eurheartj/ehac184] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [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: 10/20/2021] [Revised: 02/10/2022] [Accepted: 03/28/2022] [Indexed: 12/31/2022] Open
Abstract
AIMS Pulmonary hypertension (PH) and pulmonary vascular disease (PVD) are common and associated with adverse outcomes in left heart disease (LHD). This study sought to characterize the pathophysiology of PVD across the spectrum of PH in LHD. METHODS AND RESULTS Patients with PH-LHD [mean pulmonary artery (PA) pressure >20 mmHg and PA wedge pressure (PAWP) ≥15 mmHg] and controls free of PH or LHD underwent invasive haemodynamic exercise testing with simultaneous echocardiography, expired air and blood gas analysis, and lung ultrasound in a prospective study. Patients with PH-LHD were divided into isolated post-capillary PH (IpcPH) and PVD [combined post- and pre-capillary PH (CpcPH)] based upon pulmonary vascular resistance (PVR <3.0 or ≥3.0 WU). As compared with controls (n = 69) and IpcPH-LHD (n = 55), participants with CpcPH-LHD (n = 40) displayed poorer left atrial function and more severe right ventricular (RV) dysfunction at rest. With exercise, patients with CpcPH-LHD displayed similar PAWP to IpcPH-LHD, but more severe RV-PA uncoupling, greater ventricular interaction, and more severe impairments in cardiac output, O2 delivery, and peak O2 consumption. Despite higher PVR, participants with CpcPH developed more severe lung congestion compared with both IpcPH-LHD and controls, which was associated lower arterial O2 tension, reduced alveolar ventilation, decreased pulmonary O2 diffusion, and greater ventilation-perfusion mismatch. CONCLUSIONS Pulmonary vascular disease in LHD is associated with a distinct pathophysiologic signature marked by greater exercise-induced lung congestion, arterial hypoxaemia, RV-PA uncoupling, ventricular interdependence, and impairment in O2 delivery, impairing aerobic capacity. Further study is required to identify novel treatments targeting the pulmonary vasculature in PH-LHD.
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Affiliation(s)
- Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Frederik H Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Massar Omar
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Margaret M Redfield
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
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38
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Martens P, Chen HH, Verbrugge FH, Testani JT, Mullens W, Tang WHW. Assessing Intrinsic Renal Sodium Avidity in Acute Heart Failure: Implications in Predicting and Guiding Decongestion. Eur J Heart Fail 2022; 24:1978-1987. [DOI: 10.1002/ejhf.2662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/11/2022] [Accepted: 08/19/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Pieter Martens
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Cleveland Ohio U.S.A
| | - Horng H. Chen
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases University Hospital Brussels Jette Belgium
- Faculty of Medicine and Pharmacy Vrije Universiteit Brussel Brussels Belgium
| | - Jeffrey T. Testani
- Division of Cardiovascular Medicine Yale School of Medicine New Haven Connecticut
| | - Wilfried Mullens
- Ziekenhuis Oost Limburg Genk and University Hasselt Diepenbeek Belgium
| | - W. H. Wilson Tang
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Cleveland Ohio U.S.A
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39
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Sorimachi H, Verbrugge FH, Omote K, Omar M, Obokata M, Reddy YNV, Ye Z, Michelena HI, Borlaug BA. Longitudinal Evolution of Cardiac Dysfunction in Heart Failure and Preserved Ejection Fraction With Normal Natriuretic Peptide Levels. Circulation 2022; 146:500-502. [PMID: 35939545 PMCID: PMC9366900 DOI: 10.1161/circulationaha.121.058592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Indexed: 12/14/2022]
Abstract
We compared longitudinal changes in cardiac function assessed by 2D speckle tracking in patients with HFpEF stratified by natriuretic peptide (NP) levels and healthy controls. LVGLS, LA reservoir strain, and RVFWS were higher in normal NP-HFpEF than high NP-HFpEF at index evaluation, indicating better myocardial function. LA reservoir strain was lower in normal NP-HFpEF than controls, but there were no significant differences in LVGLS or RVFWS at baseline. Over 3.1 years of follow up, LVGLS, LA reservoir strain and RVFWS deteriorated in patients with HFpEF, with no difference in the rate of change in patients with normal or high NP levels. In contrast, there was no change in biventricular or LA function in controls over the same interval. These data suggest that HFpEF with normal NP represents an earlier stage of HFpEF, rather than a fundamentally different phenotype.
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Affiliation(s)
- Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Frederik H. Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Massar Omar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Zi Ye
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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40
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Sorimachi H, Omote K, Omar M, Popovic D, Verbrugge FH, Reddy YNV, Lin G, Obokata M, Miles JM, Jensen MD, Borlaug BA. Sex and central obesity in heart failure with preserved ejection fraction. Eur J Heart Fail 2022; 24:1359-1370. [PMID: 35599453 DOI: 10.1002/ejhf.2563] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [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: 01/11/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 01/27/2023] Open
Abstract
AIMS Obesity is a risk factor for heart failure with preserved ejection fraction (HFpEF), particularly in women, but the mechanisms remain unclear. The present study aimed to investigate the impact of central adiposity in patients with HFpEF and explore potential sex differences. METHODS AND RESULTS A total of 124 women and 105 men with HFpEF underwent invasive haemodynamic exercise testing and rest echocardiography. Central obesity was defined as a waist circumference (WC) ≥88 cm for women and ≥102 cm for men. Exercise-normalized pulmonary capillary wedge pressure (PCWP) responses were evaluated by the ratio of PCWP to workload (PCWP/W) and after normalizing to body weight (PCWL). The prevalence of central obesity (77%) exceeded that of general obesity (62%) defined by body mass index ≥30 kg/m2 . Compared to patients without central adiposity, patients with HFpEF and central obesity displayed greater prevalence of diabetes and dyslipidaemia, higher right and left heart filling pressures and pulmonary artery pressures during exertion, and more severely reduced aerobic capacity. Associations between WC and fasting glucose, low-density lipoprotein (LDL) cholesterol, peak workload, and pulmonary artery pressures were observed in women but not in men with HFpEF. Although increased WC was associated with elevated PCWP in both sexes, the association with PCWP/W was observed in women but not in men. The strength of correlation between PCWP/W and WC was more robust in women with HFpEF as compared to men (Meng's test p = 0.0008), and a significant sex interaction was observed in the relationship between PCWL and WC (p for interaction = 0.02). CONCLUSIONS Central obesity is even more common than general obesity in HFpEF, and there appear to be important sexual dimorphisms in its relationships with metabolic abnormalities and haemodynamic perturbations, with greater impact in women.
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Affiliation(s)
- Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Massar Omar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Dejana Popovic
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Frederik H Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.,Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium.,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - John M Miles
- Division of Metabolism, Endocrinology and Genetics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Michael D Jensen
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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41
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Reddy YNV, Kaye DM, Handoko ML, van de Bovenkamp AA, Tedford RJ, Keck C, Andersen MJ, Sharma K, Trivedi RK, Carter RE, Obokata M, Verbrugge FH, Redfield MM, Borlaug BA. Diagnosis of Heart Failure With Preserved Ejection Fraction Among Patients With Unexplained Dyspnea. JAMA Cardiol 2022; 7:891-899. [PMID: 35830183 DOI: 10.1001/jamacardio.2022.1916] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Diagnosis of heart failure with preserved ejection fraction (HFpEF) among dyspneic patients without overt congestion is challenging. Multiple diagnostic approaches have been proposed but are not well validated against the independent gold standard for HFpEF diagnosis of an elevated pulmonary capillary wedge pressure (PCWP) during exercise. Objective To evaluate H2FPEF and HFA-PEFF scores and a PCWP/cardiac output (CO) slope of more than 2 mm Hg/L/min to diagnose HFpEF. Design, Setting, and Participants This retrospective case-control study included patients with unexplained dyspnea from 6 centers in the US, the Netherlands, Denmark, and Australia from March 2016 to October 2020. Diagnosis of HFpEF (cases) was definitively ascertained by the presence of elevated PCWP during exertion; control individuals were those with normal rest and exercise hemodynamics. Main Outcomes and Measures Logistic regression was used to evaluate the accuracy of HFA-PEFF and H2FPEF scores to discriminate patients with HFpEF from controls. Results Among 736 patients, 563 (76%) were diagnosed with HFpEF (mean [SD] age, 69 [11] years; 334 [59%] female) and 173 (24%) represented controls (mean [SD] age, 60 [15] years; 109 [63%] female). H2FPEF and HFA-PEFF scores discriminated patients with HFpEF from controls, but the H2FPEF score had greater area under the curve (0.845; 95% CI, 0.810-0.875) compared with the HFA-PEFF score (0.710; 95% CI, 0.659-0.756) (difference, -0.134; 95% CI, -0.177 to -0.094; P < .001). Specificity was robust for both scores, but sensitivity was poorer for HFA-PEFF, with a false-negative rate of 55% for low-probability scores compared with 25% using the H2FPEF score. Use of the PCWP/CO slope to redefine HFpEF rather than exercise PCWP reclassified 20% (117 of 583) of patients, but patients reclassified from HFpEF to control by this metric had clinical, echocardiographic, and hemodynamic features typical of HFpEF, including elevated resting PCWP in 66% (46 of 70) of reclassified patients. Conclusions and Relevance In this case-control study, despite requiring fewer data, the H2FPEF score had superior diagnostic performance compared with the HFA-PEFF score and PCWP/CO slope in the evaluation of unexplained dyspnea and HFpEF in the outpatient setting.
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Affiliation(s)
- Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - David M Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - M Louis Handoko
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Arno A van de Bovenkamp
- Department of Cardiology, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston
| | - Carson Keck
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston
| | - Mads J Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Kavita Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Rishi K Trivedi
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Rickey E Carter
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Frederik H Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
| | | | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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42
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Mullens W, Dauw J, Martens P, Meekers E, Nijst P, Verbrugge FH, Chenot F, Moubayed S, Dierckx R, Blouard P, Derthoo D, Smolders W, Ector B, Hulselmans M, Lochy S, Raes D, Van Craenenbroeck E, Vandekerckhove H, Hofkens PJ, Goossens K, Pouleur AC, De Ceuninck M, Gabriel L, Timmermans P, Prihadi EA, Van Durme F, Depauw M, Vervloet D, Viaene E, Vachiery JL, Tartaglia K, Ter Maaten JM, Bruckers L, Droogne W, Troisfontaines P, Damman K, Lassus J, Mebazaa A, Filippatos G, Ruschitzka F, Dupont M. Acetazolamide in Decompensated Heart Failure with Volume Overload trial (ADVOR): Baseline Characteristics. Eur J Heart Fail 2022; 24:1601-1610. [PMID: 35733283 DOI: 10.1002/ejhf.2587] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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: 05/13/2022] [Revised: 06/16/2022] [Accepted: 06/19/2022] [Indexed: 11/08/2022] Open
Abstract
AIMS To describe the baseline characteristics of participants in the Acetazolamide in Decompensated Heart Failure with Volume Overload (ADVOR) trial and compare these with other contemporary diuretic trials in acute heart failure (AHF). METHODS AND RESULTS ADVOR recruited 519 patients with AHF, clinically evident volume overload, elevated NT-proBNP and maintenance loop diuretictherapy prior to admission. All participants received standardized loop diuretics and were randomised towards once daily intravenous acetazolamide (500 mg) versus placebo, stratified according to study centre and left ventricular ejection fraction (LVEF) (≤40% vs. >40%). The primary endpoint was successful decongestion assessed by a dedicated score indicating no more than trace oedema and no other signs of congestion after 3 consecutive days of treatment without need for escalating treatment. Mean age was 78 years, 63% were men, mean LVEF was 43%, and median NT-proBNP 6173 pg/mL. The median clinical congestion score was 4 with an EuroQol-5 dimensions health utility index of 0.6. Patients with LVEF ≤40% were more often male, had more ischaemic heart disease, higher levels of NT-proBNP and less atrial fibrillation. Compared with diuretic trials in AHF, patients enrolled in ADVOR were considerably older with higher NT-proBNP levels, reflecting the real-world clinical situation. CONCLUSION ADVOR is the largest randomised diuretic trial in AHF, investigating acetazolamide to improve decongestion on top of standardized loop diuretics. The elderly enrolled population with poor quality of life provides a good representation of the real-world AHF population. The pragmatic design will provide novel insights in the diuretic treatment of patients with AHF.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost-Limburg, Genk, Belgium.,Hasselt University, Diepenbeek/Hasselt, Belgium
| | - Jeroen Dauw
- Ziekenhuis Oost-Limburg, Genk, Belgium.,Hasselt University, Diepenbeek/Hasselt, Belgium
| | | | - Evelyne Meekers
- Ziekenhuis Oost-Limburg, Genk, Belgium.,Hasselt University, Diepenbeek/Hasselt, Belgium
| | | | - Frederik H Verbrugge
- Universitair Ziekenhuis Brussel, Jette, Belgium.,Vrije Universiteit Brussel, Jette, Belgium
| | | | | | | | | | | | | | | | | | - Stijn Lochy
- Universitair Ziekenhuis Brussel, Jette, Belgium
| | | | - Emeline Van Craenenbroeck
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium.,Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, Wilrijk, Antwerp, Belgium
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | | | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Johan Lassus
- Helsinki University Central Hospital, Heart and Lung Center and Helsinki University Hospital, Helsinki, Finland
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43
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Verbrugge FH, Omote K, Reddy YNV, Sorimachi H, Obokata M, Borlaug BA. Heart failure with preserved ejection fraction in patients with normal natriuretic peptide levels is associated with increased morbidity and mortality. Eur Heart J 2022; 43:1941-1951. [PMID: 35139159 PMCID: PMC9649913 DOI: 10.1093/eurheartj/ehab911] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [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: 09/08/2021] [Revised: 11/22/2021] [Accepted: 12/23/2021] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND A substantial proportion of patients with heart failure (HF) with preserved ejection fraction (HFpEF) present with normal natriuretic peptide (NP) levels. The pathophysiology and natural history for this phenotype remain unclear. METHODS AND RESULTS Consecutive subjects undergoing invasive cardiopulmonary exercise testing for unexplained dyspnoea at Mayo Clinic in 2006-18 were studied. Heart failure with preserved ejection fraction was defined as a pulmonary arterial wedge pressure (PAWP) ≥15 mmHg (rest) or ≥25 mmHg (exercise). Patients with HFpEF and normal NP [N-terminal of the pro-hormone B-type natriuretic peptide (NT-proBNP) < 125 ng/L] were compared with HFpEF with high NP (NT-proBNP ≥ 125 ng/L) and controls with normal haemodynamics. Patients with HFpEF and normal (n = 157) vs. high NP (n = 263) were younger, yet older than controls (n = 161), with an intermediate comorbidity profile. Normal NP HFpEF was associated with more left ventricular hypertrophy and worse diastolic function compared with controls, but better diastolic function, lower left atrial volumes, superior right ventricular function, and less mitral/tricuspid regurgitation compared with high NP HFpEF. Cardiac output (CO) reserve with exercise was preserved in normal NP HFpEF [101% predicted, interquartile range (IQR): 75-124%], but this was achieved only at the cost of higher left ventricular transmural pressure (LVTMP) (14 ± 6 mmHg vs. 7 ± 4 mmHg in controls, P < 0.001). In contrast, CO reserve was decreased in high NP HFpEF (85% predicted, IQR: 59-109%), with lower LVTMP (10 ± 8 mmHg) compared with normal NP HFpEF (P < 0.001), despite similar PAWP. Patients with high NP HFpEF displayed the highest event rates, but normal NP HFpEF still had 2.7-fold higher risk for mortality or HF readmissions compared with controls (hazard ratio: 2.74, 95% confidence interval: 1.02-7.32) after adjusting for age, sex, and body mass index. CONCLUSION Patients with HFpEF and normal NP display mild diastolic dysfunction and preserved CO reserve during exercise, despite marked elevation in filling pressures. While clinical outcomes are not as poor compared with patients with high NP, patients with normal NP HFpEF exhibit increased risk of death or HF readmissions compared with patients without HF, emphasizing the importance of this phenotype.
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Affiliation(s)
- Frederik H Verbrugge
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
- Centre for Cardiovascular Diseases, University Hospital Brussels, Brussels, Belgium
- Faculty of Medicine and Life Sciences, Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - Kazunori Omote
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Hidemi Sorimachi
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Masaru Obokata
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Barry A Borlaug
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Affiliation(s)
- Frederik H Verbrugge
- Department of Cardiovascular Diseases, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA.,Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium.,Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Barry A Borlaug
- Department of Cardiovascular Diseases, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
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Mullens W, Martens P, Testani JM, Tang WHW, Skouri H, Verbrugge FH, Fudim M, Iacoviello M, Franke J, Flammer AJ, Palazzuoli A, Barragan PM, Thum T, Marcos MC, Miró Ò, Rossignol P, Metra M, Lassus J, Orso F, Jankowska EA, Chioncel O, Milicic D, Hill L, Seferovic P, Rosano G, Coats A, Damman K. Renal effects of guideline directed medical therapies in heart failure - a consensus document from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2022; 24:603-619. [PMID: 35239201 DOI: 10.1002/ejhf.2471] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/22/2022] [Accepted: 03/01/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
| | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, University Hasselt, Belgium.,Cleveland Clinic, Cleveland, Ohio, United States of America
| | | | | | - Hadi Skouri
- American University of Beirut Medical Center-Beirut, Lebanon
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussel, Jette, Belgium.,Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Marat Fudim
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Massimo Iacoviello
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | | | - Andreas J Flammer
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Medical Sciences Le Scotte Hospital Siena, Italy.,School of Nursing and Midwifery, Queen's University, Belfast, Northern Ireland
| | | | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany.,Fraunhofer Institute of Toxicology and Experimental Medicine, Hannover, Germany
| | - Marta Cobo Marcos
- Hospital Universitario Puerta de Hierro Majadahonda, CIBERCV, Madrid, Spain
| | - Òscar Miró
- Emergency Department, Hospital Clínic, Barcelona, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Patrick Rossignol
- Université de Lorraine, Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116, and F-CRIN INI-CRCT, Nancy, France
| | | | - Johan Lassus
- Heart and Lung Center, Cardiology, University of Helsinki and Helsinki University Hospital
| | | | - Ewa A Jankowska
- Institute of Heart Diseases, Wroclaw Medical University AND Institute of Heart Diseases, University Hospital in Wroclaw, Poland
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Davor Milicic
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine & University Hospital Centre Zagreb, Zagreb, Croatia
| | - Loreena Hill
- School of Nursing & Midwifery, Queen's University, Belfast, UK
| | - Petar Seferovic
- Universi Faculty of Medicine, University of Belgrade, and Serbian Academy of Arts and Sciences, Belgrade, Serbia
| | | | | | - Kevin Damman
- University of Groningen, University Medical Center Groningen, The Netherlands
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Omote K, Verbrugge FH, Sorimachi H, Omar M, Popovic D, Obokata M, Reddy YNV, Borlaug B. ELECTRICAL AND STRUCTURAL REMODELING IN HEART FAILURE AND PRESERVED EJECTION FRACTION WITH A PACEMAKER. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01353-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Verwerft J, Verbrugge FH, Claessen G, Herbots L, Dendale P, Gevaert AB. Exercise Systolic Reserve and Exercise Pulmonary Hypertension Improve Diagnosis of Heart Failure With Preserved Ejection Fraction. Front Cardiovasc Med 2022; 9:814601. [PMID: 35224049 PMCID: PMC8863971 DOI: 10.3389/fcvm.2022.814601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/11/2022] [Indexed: 01/08/2023] Open
Abstract
Aims Diastolic stress testing (DST) is recommended to confirm heart failure with preserved ejection fraction (HFpEF) in patients with exertional dyspnea, but current algorithms do not detect all patients. We aimed to identify additional echocardiographic markers of elevated pulmonary arterial wedge pressure during exercise (exPAWP) in patients referred for DST. Methods and Results We identified candidate parameters in 22 patients referred for exercise right heart catheterization with simultaneous echocardiography. Elevated exPAWP (≥25 mmHg) was present in 14 patients, and was best identified by peak septal systolic annular velocity <9.5 cm/s [exS', area under the receiver operating characteristic curve (AUC) 0.97, 95% confidence interval 0.92–1.0] and mean pulmonary artery pressure/cardiac output slope ≥3.2 mmHg/L [mPAP/CO, AUC 0.88 (0.72–1.0)]. We propose a decision tree to identify patients with elevated exPAWP. Applying this decision tree to 326 patients in an independent non-invasive DST cohort showed that patients labeled as “high probability of HFpEF” (n = 85) had reduced peak oxygen uptake [13.0 (10.7–15.1) mL/kg/min, p < 0.001 vs. intermediate/low probability], high H2FPEF score [53 (40–72) %, p < 0.001 vs. intermediate/low probability], and typical clinical characteristics. The diagnostic yield of DST increased from 11% using exercise E/e', to 62% using the decision tree. Conclusion In DST for suspected HFpEF, exS' was the most accurate echocardiographic parameter to identify elevated PAWP. We propose a decision tree including exS' and mPAP/CO for interpretation of DST. Application of this decision tree revealed typical HFpEF characteristics in patients labeled as high probability of HFpEF, and substantially reduced the number of inconclusive results.
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Affiliation(s)
- Jan Verwerft
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - Frederik H. Verbrugge
- Faculty of Medicine and Life Sciences, Biomedical Research Institute, Hasselt University, Hasselt, Belgium
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
- Centre for Cardiovascular Diseases, University Hospital Brussels, Brussels, Belgium
| | - Guido Claessen
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
- Division of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Paul Dendale
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - Andreas B. Gevaert
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
- Research Group Cardiovascular Diseases, Department GENCOR (Genetics, Pharmacology and Physiopathology of Heart, Blood Vessels and Skeleton), University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
- *Correspondence: Andreas B. Gevaert
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Abstract
Approximately half of all patients with heart failure (HF) have a preserved ejection fraction, and the prevalence is growing rapidly given the aging population in many countries and the rising prevalence of obesity, diabetes, and hypertension. Functional capacity and quality of life are severely impaired in heart failure with preserved ejection fraction (HFpEF), and morbidity and mortality are high. In striking contrast to HF with reduced ejection fraction, there are few effective treatments currently identified for HFpEF, and these are limited to decongestion by diuretics, promotion of a healthy active lifestyle, and management of comorbidities. Improved phenotyping of subgroups within the overall HFpEF population might enhance individualization of treatment. This review focuses on the current understanding of the pathophysiologic mechanisms underlying HFpEF and treatment strategies for this complex syndrome.
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Affiliation(s)
- Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Frederik H. Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States;,Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium;,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
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Verbrugge FH, Reddy YNV, Attia ZI, Friedman PA, Noseworthy PA, Lopez-Jimenez F, Kapa S, Borlaug BA. Detection of Left Atrial Myopathy Using Artificial Intelligence-Enabled Electrocardiography. Circ Heart Fail 2022; 15:e008176. [PMID: 34911362 PMCID: PMC8766932 DOI: 10.1161/circheartfailure.120.008176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 01/03/2023]
Abstract
BACKGROUND Left atrial (LA) myopathy is common in patients with heart failure and preserved ejection fraction and leads to the development of atrial fibrillation (AF). We investigated whether the likelihood of LA remodeling, LA dysfunction, altered hemodynamics, and risk for incident AF could be identified from a single 12-lead ECG using a novel artificial intelligence (AI)-enabled ECG analysis. METHODS Patients with heart failure and preserved ejection fraction (n=613) underwent AI-enabled ECG analysis, echocardiography, and cardiac catheterization. Individuals were grouped by AI-enabled ECG probability of contemporaneous AF, taken as an indicator of underlying LA myopathy. RESULTS Structural heart disease was more severe in patients with higher AI-probability of AF, with more left ventricular hypertrophy, larger LA volumes, and lower LA reservoir and booster strain. Cardiac filling pressures and pulmonary artery pressures were higher in patients with higher AI-probability, while cardiac output reserve was more impaired during exercise. Among patients with sinus rhythm and no prior AF, each 10% increase in AI-probability was associated with a 31% greater risk of developing new-onset AF (hazard ratio, 1.31 [95% CI, 1.20-1.42]; P<0.001). In the population as a whole, each 10% increase in AI-probability was associated with a 12% greater risk of death (hazard ratio, 1.12 [95% CI, 1.08-1.17]; P<0.001) during long-term follow-up, which was no longer significant after adjustments for baseline characteristics. CONCLUSIONS A novel AI-enabled score derived from a single 12-lead ECG identifies the presence of underlying LA myopathy in patients with heart failure and preserved ejection fraction as evidenced by structural, functional, and hemodynamic abnormalities, as well as long-term risk for incident AF. Further research is required to determine the role of the AI-enabled ECG in the evaluation and care of patients with heart failure and preserved ejection fraction.
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Affiliation(s)
- Frederik H. Verbrugge
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Yogesh N. V. Reddy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Zachi I Attia
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Paul A. Friedman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Peter A. Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | | | - Suraj Kapa
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Barry A. Borlaug
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
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50
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Koepp KE, Reddy YNV, Obokata M, Sorimachi H, Verbrugge FH, Jain CC, Egbe AC, Redfield MM, Olson TP, Borlaug BA. Identification of Patients with Preclinical Heart Failure with preserved Ejection Fraction Using the H 2FPEF Score. Nat Cardiovasc Res 2022; 1:59-66. [PMID: 35669933 PMCID: PMC9164289 DOI: 10.1038/s44161-021-00005-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/16/2021] [Indexed: 11/08/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a common disorder with few effective treatments. There is currently no evidence-based method to identify preclinical HFpEF. The H2FPEF score is a validated instrument to identify patients with overt HFpEF. Here we show the H2FPEF score can identify individuals with preclinical HFpEF. Among individuals where heart failure was excluded (n=160), increasing H2FPEF score was shown to be associated with greater left atrial dilation, left ventricular hypertrophy, and more severe diastolic dysfunction. Patients with increasing H2FPEF score displayed higher pulmonary artery pressures, higher left heart filling pressures, lower cardiac index, and more severely impaired aerobic capacity during exercise. In summary, we show that among adults without heart failure, higher H2FPEF score is associated with subclinical abnormalities that resemble those observed in HFpEF. These findings broaden the external validity of the H2FPEF score and suggest that this instrument may help identify patients positioned to benefit from preventive interventions.
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Affiliation(s)
- Katlyn E Koepp
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Frederik H Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Margaret M Redfield
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
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