"Working me to life" - Longitudinal Perceptions from Adults with Heart Failure with Preserved Ejection Fraction Enrolled in an Exercise Training Clinical Trial

AIMS

Adults with heart failure with preserved ejection fraction (HFpEF) responded more favorably to an exercise intervention compared to those with reduced ejection fraction. This study explores factors that contributed to this response focusing on the qualitative perceptions of adults with HFpEF enrolled in an exercise intervention.

METHODS AND RESULTS

This qualitative descriptive study is a secondary analysis of longitudinal interviews collected at 3, 6, 12, and 18-months from participants with HFpEF enrolled in a randomized controlled trial testing an intervention to promote adherence to exercise. We included participants with at least 2 interviews. Interviews were examined across and within participants and time points using thematic analysis. Analyses included 67 interviews from 21 adults with HFpEF enrolled in the intervention arm. The sample was 52% (11/21) male and over 47% (10/21) non-White. Mean age at enrollment was 63.7 ± 9.9 years. We identified 4 major themes: 1. Overcoming negative attitudes, barriers, and injury, 2. Motivations to exercise, 3. Exercise - the panacea for HFpEF symptoms and quality of life, and 4. Advice for others with HFpEF.

CONCLUSIONS

Our findings suggest that for many adults with HFpEF, initial hesitancy, fear, and negative attitudes about exercise can be overcome. Exercise coaching using social cognitive constructs, medical fitness center memberships, and heart rate self-monitoring are successful strategies of engaging adults with HFpEF in long-term unsupervised exercise training.

REGISTRATION

This study is registered at ClinicalTrials.gov, NCT01658670.

Impact of C-reactive protein levels and role of anakinra in patients with ST-elevation myocardial infarction

BACKGROUND

Interleukin-1 blockade with anakinra reduces C-reactive protein (CRP) levels and prevents heart failure (HF) events after ST-segment myocardial infarction (STEMI). The effectiveness of anakinra according to the degree of systemic inflammation in STEMI has not been addressed.

METHODS

We analyzed 139 patients from three Virginia Commonwealth University Anakinra Response Trial randomized clinical trials to assess whether CRP levels predicted HF hospitalization or death in patients with STEMI, and if CRP levels influenced the effects of treatment with anakinra.

RESULTS

CRP cut-off levels for prediction of the composite of death or HF hospitalization for CRP at admission, 3 and 14 days were, respectively 6.45 mg/L (100% of sensitivity and 66.1% specificity), 26 mg/L (100% of sensitivity and 78% specificity) and 9.56 mg/L (100% of sensitivity and 80% specificity). More patients with elevated CRP levels died or had a HF hospitalization (5/47 [11%] vs 0/82 [0%], p = 0.004 for CRP at admission; 5/32 [15.6%] vs 0/92 [0%], p < 0.001 for day 3 and 5/26 [19%] vs 0/89 [0%], p < 0.001 for day 14). A greater number of patients treated with anakinra had low CRP levels at 3 and 14 days compared to placebo (Odds Ratio 0.11 [95% IC 0.04-0.28], p < 0.0001 and OR 0.35 [95% CI 0.14-0.86], p = 0.02, respectively). Anakinra significantly prevented death or HF hospitalization in patients with high inflammatory burden (p = 0.04 for admission, p = 0.24 for day 3, and p = 0.05 for day 14).

CONCLUSION

Patients with elevated CRP had higher incidence of HF hospitalization or death. Anakinra reduced the number of patients with elevated CRP levels and prevented death or HF hospitalization in patients with elevated CRP levels.

Nutritional Aspects to Cardiovascular Diseases and Type 2 Diabetes Mellitus

PURPOSE OF REVIEW

In this narrative review, we discuss the current evidence related to the role of dietary interventions to prevent and treat type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). We also propose alternative therapeutic strategies other than weight loss in this population, namely, improvements in cardiorespiratory fitness and its determinants.

RECENT FINDINGS

While weight loss has been consistently associated with the prevention of T2DM and improvements in glycemic control in those with established diseases, its role in preventing and treating CVD is less clear. In fact, in this setting, improvements in diet quality have provided greater benefits, suggesting that this might represent an alternative, or an even more effective strategy than energy-restriction. Improvements in diet quality, with and without caloric restriction have been shown to improve CVD risk and to prevent the development of T2DM in individuals at risk; however, with regard to glycemic control in patients with T2DM, any dietary intervention resulting in significant weight loss may produce clinically meaningful benefits. Finally, dietary interventions with and without energy restriction that can improve cardiorespiratory fitness, even in absence of weight loss in patients with obesity, should be encouraged.

Chrononutrition in cardiometabolic diseases: Current evidence and future perspectives

Chrononutrition is the field of nutritional science that investigates the relationship between food intake, timing of food intake, and their effects and influence on circadian rhythms and overall health. By aligning eating patterns with body's internal clock, optimisation of metabolic processes, improvements of various aspects of health can be achieved. Cardiovascular (CV) and metabolic diseases remain the leading cause of morbidity and mortality worldwide. Notably, in the US alone, approximately half of all cardiometabolic deaths are attributed to modifiable dietary factors, suggesting that dietary changes could result in dramatic increases in lifespan and its related quality of life. Social media have also a great impact on chrononutrition and their role cannot be neglected. The impact of social media on chrononutrition can be multifaceted: information dissemination, influence on eating habits, digital detox challenges, cultural influence and social jet lag. This special issue will provide novel insights and clarifications on chrononutrition, but also on additional controversial topics. The articles we selected should promote future preclinical and clinical studies to ultimately identify the most appropriate approaches to reduce the unacceptable high burden of CV and metabolic diseases.

Time of eating and mortality in U.S. adults with heart failure: Analyses of the National Health and Nutrition Examination Survey 2003-2018

BACKGROUND AND AIMS

Promising associations have been demonstrated between delayed last eating occasion and cardiorespiratory fitness in adults with heart failure (HF), however, it is unknown if time of eating is associated with clinical endpoints such as mortality. This study aimed to examine associations between time of eating variables and all-cause and cardiovascular mortality in the National Health and Nutrition Examination Survey (NHANES).

METHODS AND RESULTS

Participants self-disclosed HF diagnosis. Two dietary recalls were obtained and categorical variables were created based on mean time of first eating occasion (8:31 AM), last eating occasion (7:33 PM) and eating window (11.02 h). Mortality was obtained through linkage to the National Death Index. Covariate-adjusted Cox proportional hazard regression models were created examining the association between time of eating and mortality. Participants (n = 991) were 68 (95 % CI 67-69) years of age, 52.6 (95 % CI 49.0-56.3)% men and had a body mass index of 32.5 (95 % CI 31.8-33.2) kg/m2 with follow up time of 68.9 (95 % CI 64.8-72.9) person-months. When models were adjusted for time of eating variables and all other covariates, extending the eating window beyond 11.02 h was associated with decreased risk of cardiovascular (HR 0.36 [95 % CI 0.16-0.81]), but not all-cause mortality. Time of first and last eating occasions were not associated with mortality.

CONCLUSIONS

In adults with HF, an extended eating window is associated with reduced risk for cardiovascular mortality. Randomized controlled trials should examine if extending the eating window can improve prognostic indicators such as cardiorespiratory fitness in this population.

Update on obesity, the obesity paradox, and obesity management in heart failure

Obesity is a major public health challenge worldwide. It is costly, predisposes to many cardiovascular (CV) diseases (CVD), is increasing at an alarming rate, and disproportionately affects people of low-socioeconomic status. It has a myriad of deleterious effects on the body, particularly on the CV system. Obesity is a major risk factor for heart failure (HF) and highly prevalent in this population, particularly in those with HF with preserved ejection fraction (HFpEF), to the extent that an obesity HFpEF phenotype has been proposed in the literature. However, once HF is developed, an obesity paradox exists where those with obesity have better short- and mid-term survival than normal or underweight individuals, despite a greater risk for hospitalizations. It may be argued that excess energy reserve, younger patient population, higher tolerability of HF therapy and better nutritional status may account for at least part of the obesity paradox on survival. Furthermore, body mass index (BMI) may not be an accurate measure of body composition, especially in HF, where there is an excess volume status. BMI also fails to delineate fat-free mass and its components, which is a better predictor of functional capacity and cardiorespiratory fitness (CRF), which particularly is increasingly being recognized as a risk modifier in both healthy individuals and in persons with comorbidities, particularly in HF. Notably, when CRF is accounted for, the obesity paradox disappears, suggesting that improving CRF might represent a therapeutic target with greater importance than changes in body weight in the setting of HF. In this narrative review, we discuss the current trends in obesity, the causal link between obesity and HF, an update on the obesity paradox, and a description of the major flaws of BMI in this population. We also present an overview of the latest in HF therapy, weight loss, CRF, and the application of these therapeutic approaches in patients with HF and concomitant obesity.

Skeletal muscle quality, measured via phase angle, and cardiorespiratory fitness in patients with obesity and heart failure with preserved ejection fraction

OBJECTIVES

Cardiorespiratory fitness (CRF) is influenced by body composition quantity and quality in heart failure with preserved ejection fraction (HFpEF) and obesity. Bioelectrical impedance analysis (BIA) provides a noninvasive quantitative and qualitative body composition assessment. The aim of this study was to determine the role of phase angle (PhA), a BIA-measure of skeletal muscle quality and body cell mass, on CRF in patients with obesity and HFpEF.

METHODS

Fifty-nine consecutive outpatients with HFpEF underwent cardiopulmonary exercise testing to measure CRF. Single-frequency segmental BIA was used to measure PhA and body composition quantity. Resting Doppler echocardiography and biomarkers were measured to assess cardiac function and systemic inflammation.

RESULTS

Compared with patients with lower PhA, patients with higher PhA (above mean 5.8°) presented a greater absolute peak oxygen consumption (VO2; 1.83 [1.3-2.1] versus 1.39 [1.1-1.6] L/min, P = 0.003), VO2 peak adjusted for body weight (17.5 [12.3-18.1] versus 13.3 [12.7-15.2] mL/kg/min, P = 0.040), and a lower edema index (48.7 [2.9] versus 51.4% [2.7], P < 0.001) and N-terminal pro-B-type natriuretic peptide (NT-proBNP; 64 [50-121] versus 183 [68-343.5] pg/dL, P < 0.001). In the overall sample, PhA was correlated with absolute VO2 peak (r = 0.468, P < 0.001), VO2 peak adjusted for body weight (r = 0.368, P = 0.004), VO2 peak adjusted for fat-free mass (r = 0.315, P = 0.015), edema index (r = -0.508, P < 0.001), and NT-proBNP (r = -0.579, P < 0.001). PhA remained a significant predictor for CRF even after adjustment for potential confounders and HFpEF severity.

CONCLUSION

In patients with obesity and HFpEF, a greater PhA is an independent predictor for favorable CRF.

Higher diet quality relates to better cardiac function in cancer survivors: The multi-ethnic study of atherosclerosis

BACKGROUND

Cancer therapies induce cardiac injury and increase cardiovascular disease (CVD) risk. In non-cancer populations, higher diet quality is associated with protection against CVD, but the relationship between diet and cardiac function in cancer survivors is unknown.

METHODS

This cross-sectional analysis from the Multi-Ethnic Study of Atherosclerosis (MESA) cohort included 113 cancer survivors (55 breast, 53 prostate, three lung, and three blood) and 4233 non-cancer controls. Dietary intake was reported via validated food frequency questionnaire. Alternate healthy eating index (AHEI) was calculated as a measure of quality. Cardiac function, determined as left ventricular ejection fraction (LVEF), was assessed by cardiac magnetic resonance.

RESULTS

Cancer survivors had a lower LVEF compared to controls (61.3 ± 6.5% v 62.4 ± 6.1%, p = 0.04). In all participants, total fat (β ± SE: -0.04 ± 0.01, p = 0.004), saturated fat (-0.11 ± 0.03, p < 0.001), and trans-fat (-0.36 ± 0.12, p = 0.002) intake were inversely associated with LVEF while AHEI (0.03 ± 0.01, p < 0.001) was positively associated with LVEF. Among cancer survivors only, sucrose intake was negatively related to LVEF (-0.15 ± 0.06, p = 0.02), and the ratio of unsaturated fat to saturated fat (2.7 ± 1.1, p = 0.01) and fiber intake (0.42 ± 0.14, p = 0.003) were positively related to LVEF.

DISCUSSION

In cancer survivors, improved dietary fat and carbohydrate quality (i.e., greater consumption of unsaturated fatty acids and fiber) was associated with favorable cardiac function, while higher sucrose was associated with worse cardiac function. Further research is needed to confirm these findings and test whether changes in the identified dietary factors will modulate cardiac function in cancer survivors.

Interleukin-1 Inhibition for the Prevention and Treatment of Heart Failure

ABSTRACT

Heart failure (HF) is a complex syndrome that remains a leading cause of morbidity and mortality worldwide. Abundant evidence suggests inflammation plays a key role in the development and perpetuation of HF, but there are currently no anti-inflammatory treatments approved for use in HF. Interleukin-1 (IL-1), the prototypical pro-inflammatory cytokine, has been implicated in adverse cardiac remodeling and left ventricular dysfunction. Multiple early phase clinical trials using IL-1 blockade in patients at risk for or diagnosed with HF have suggested favorable safety and efficacy in reducing inflammatory biomarkers, as well as positive signals in surrogate and clinical endpoints. Additional large scale clinical trials are urgently needed to confirm the safety and efficacy of this therapeutic approach specifically in HF. In this narrative review, we discuss current evidence regarding IL-1 blockade in the prevention and treatment of HF.

Interleukin-1 blockade in heart failure: an on-treatment and off-treatment cardiorespiratory fitness analysis

AIMS

Interleukin-1 (IL-1) blockade may improve exercise capacity in patients with heart failure (HF) patients. The extent of the improvement and its persistence beyond discontinuation of IL-1 blockade is unknown.

METHODS AND RESULTS

The primary objective was to determine changes in cardiorespiratory fitness and cardiac function on-treatment with IL-1 blocker, anakinra, and off-treatment, after treatment cessation. We performed cardiopulmonary exercise testing, Doppler echocardiography, and biomarkers in 73 patients with HF, 37 (51%) females, 52 (71%) Black-African-American, before and after treatment with anakinra 100 mg daily. In a subset of 46 patients, testing was also repeated after treatment cessation. Quality of life was assessed in each patient using standardized questionnaires. Data are presented as median and interquartile range. Treatment with anakinra for 4 [2-12] weeks was associated with a significant improvement in high-sensitivity C-reactive protein (from 6.2 [3.3-15.4] to 1.4 [0.8-3.4] mg/L, P < 0.001), peak oxygen consumption (VO2peak , from 13.9 [11.6-16.6] to 15.2 [12.9-17.4] mL/kg/min, P < 0.001). Ventilatory efficiency, exercise time, Doppler-derived signs and biomarkers of elevated intracardiac pressures, and quality-of-life measures also improved with anakinra. In the 46 patients in whom off-treatment data were available 12 [4-12] weeks later, many of the favourable changes seen with anakinra were largely reversed (from 1.5 [1.0-3.4] to 5.9 [1.8-13.1], P = 0.001 for C-reactive protein, and from 16.2 [14.0-18.4] to 14.9 [11.5-17.8] mL/kg/min, P = 0.017, for VO2peak ).

CONCLUSIONS

These data validate IL-1 as an active and dynamic modulator of cardiac function and cardiorespiratory fitness in HF.

Contribution of hemoglobin concentration to cardiorespiratory fitness in black African American patients with recently decompensated heart failure and reduced ejection fraction

BACKGROUND

Previous studies have shown that patients with heart failure with reduced ejection fraction (HFrEF) and anemia have reduced peak oxygen consumption (VO2). Black or African American (B-AA) patients have a higher prevalence of anemia and are underrepresented in clinical studies of HFrEF. The aim of this study was to determine the contribution of hemoglobin to peak VO2 in B-AA patients recently hospitalized for acute decompensated HFrEF.

METHODS

We analyzed cardiopulmonary exercise testing (CPX) data measured within two weeks of discharge for acute decompensated HF in B-AA patients with HFrEF (left ventricular ejection fraction [LVEF] ≤40%) without severe anemia (Hb<8 g/dL). Blood samples were collected prior to CPX. Data are reported as median [interquartile range] and compared between groups with the Mann-Whitney, Chi-Square, and Spearman's rank tests.

RESULTS

We included 81 patients; 27 (33%) women, 57 [27-79] years of age, Body Mass Index of 33 [15-55] kg/m2 and LVEF of 30 [23-36] %. Hemoglobin ranged between 9.1 to 18.1 g/dL (median= 13.3 [11.9-14.5] g/dL); 26 (32%) were considered to have anemia based on a Hb concentration of males <13 g/dL and females <12 g/dL. Peak VO2 was lower in patients with anemia (11.8 [10.0-14.2] vs. 14.1 [10.6-17.0] mL·kg-1·min-1; P=0.010) with a significant correlation between peak VO2 and hemoglobin concentration (R=+0.455; P<0.001).

CONCLUSIONS

Anemia is prevalent among B-AA patients with recently decompensated HFrEF and appears to be a significant contributor to reductions in peak VO2.

Energy restriction or improvements in diet quality: identifying the best pathway for a longer and healthier life

Obesity is a major risk factor for chronic non-communicable diseases (NCDs) and it has increased to epidemic proportions. Unhealthy diet represents a modifiable risk factor for both obesity and NCDs, however, there is no universal dietary intervention to improve obesity-related NCDs and particularly to reduce the risk for major adverse cardiovascular events. Energy restriction (ER) and diet quality changes, with and without ER, have been widely investigated in preclinical and clinical studies, however, the potential underlying mechanisms driving the benefits of those dietary interventions remain largely unclear. ER affects multiple metabolic, physiological, genetic, and cellular adaptation pathways associated with prolonged lifespan, particularly in preclinical models, while these benefits remain to be established in humans. Moreover, the sustainability of ER and its implementation across the different diseases remains challenging. On the other hand, diet quality with improvements, with or without ER, has been associated with more favorable long-term metabolic and cardiovascular outcomes. This narrative review will describe the role of ER and/or diet quality improvements on the risk for NCDs. It will also discuss the potential mechanisms of action underlying the potential beneficial effects of those dietary approaches.

Change in Eosinophil Count in Patients with Heart Failure Treated with Anakinra

BACKGROUND

Interleukin-1 blockade with anakinra leads to a transient increase in eosinophil blood count (eosinophils) in patients with acute myocardial infarction. We aimed to investigate the effect of anakinra on changes in eosinophils in patients with heart failure (HF) and their correlation with cardiorespiratory fitness (CRF).

METHODS

We measured eosinophils in 64 patients with HF (50% females), 55 (51-63) years of age, before and after treatment, and, in a subset of 41 patients, also after treatment cessation. We also evaluated CRF, measuring peak oxygen consumption (VO2) with a treadmill test.

RESULTS

Treatment with anakinra significantly and transiently increased eosinophils, from 0.2 [0.1-0.3] to 0.3 [0.1-0.4] × 103 cells/µL (p < 0.001) and from 0.3 [0.2-0.5] to 0.2 [0.1-0.3] × 103 cells/µL, with suspension (p < 0.001). Changes in eosinophils correlated with the changes in peak VO2 (Spearman's Rho = +0.228, p = 0.020). Eosinophils were higher in patients with injection site reactions (ISR) (n = 8, 13%; 0.5 [0.4-0.6] vs. 0.2 [0.1-0.4] × 103 cells/µL, p = 0.023), who also showed a greater increase in peak VO2 (3.0 [0.9-4.3] vs. 0.3 [-0.6-1.8] mLO2·kg-1·min-1, p = 0.015).

CONCLUSION

Patients with HF treated with anakinra experience a transient increase in eosinophils, which is associated with ISR and a greater improvement in peak VO2.

Abnormal left ventricular subendocardial perfusion and diastolic function in women with obesity and heart failure and preserved ejection fraction

PURPOSE

- Coronary microvascular dysfunction (CMD) is common in patients with heart failure with preserved ejection fraction (HFpEF) and obesity. Stress cardiovascular magnetic resonance (CMR) has been proposed as a non-invasive tool for detection of CMD. The aim of this study was to determine relationship between CMD and diastolic function in patients with HFpEF using a novel CMR technique.

METHODS

- Patients with obesity and HFpEF without epicardial coronary artery disease (CAD) underwent Doppler echocardiography to measure diastolic function, followed by vasodilator stress CMR, using a single bolus, dual sequence, quantitative myocardial perfusion mapping to measure myocardial blood flow (MBF) at rest and at peak hyperemia. With this, myocardial perfusion reserve (MPR), global stress endocardial-to-epicardial (endo:epi) perfusion ratio, and total ischemic burden (IB, defined as myocardial segments with MBF < 1.94 mL/min/g) were calculated. Results are reported as median and interquartile range.

RESULTS

- Nineteen subjects were enrolled (100% female, 42% Black). Median age was 64 [56-72] years. Global stress MBF was 2.43 ml/min/g [2.16-2.78] and global myocardial perfusion reserve (MPR) was 2.34 [2.07-2.88]. All had an abnormal subendocardial perfusion with an endo:epi of less than 1 (0.87 [0.81-0.90]). Regional myocardial hypoperfusion was detected in 14 (74%) patients with an IB of 6% [0-34.4]. Endo:epi ratio significantly correlated with IB (R=-0.510, p = 0.026) and measures of diastolic function (R = 0.531, p = 0.019 and R=-0.544, p = 0.014 for e' and E/e' respectively).

CONCLUSION

- Using a novel quantitative stress CMR myocardial perfusion mapping technique, women with obesity and HFpEF were found to have patterns of abnormal subendocardial perfusion which significantly correlated with measures of diastolic dysfunction.

Recognizing risk factors associated with poor outcomes among patients with COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has affected >610 million people globally, exerting major social, economic, and health impacts. Despite the large number of global casualities and severe symptomatology associated with COVID-19, a large number of individuals remain at elevated risk of infection and severe outcomes related to poor lifestyle behaviors and/or associated comorbidities. Beyond the well-known social distance and masking policies, maintaining an active lifestyle, minimizing the consumption of tobacco products, and maintaining an adequate nutrition status are some of the key factors that, in an affordable and accessible way, have the potential to improve health and minimize COVID-19 impact. In addition, bringing awareness of the higher risks and poor prognosis of COVID-19 when other conditions are present seems to be essential to protect those individuals with the highest risks.

Influence of extracellular volume fraction on peak exercise oxygen pulse following thoracic radiotherapy

Background

Radiation-induced myocardial fibrosis increases heart failure (HF) risk and is associated with a restrictive cardiomyopathy phenotype. The myocardial extracellular volume fraction (ECVF) using contrast-enhanced cardiac magnetic resonance (CMR) quantifies the extent of fibrosis which, in severe cases, results in a noncompliant left ventricle (LV) with an inability to augment exercise stroke volume (SV). The peak exercise oxygen pulse (O₂Pulse), a noninvasive surrogate for exercise SV, may provide mechanistic insight into cardiac reserve. The relationship between LV ECVF and O₂Pulse following thoracic radiotherapy has not been explored.

Methods

Patients who underwent thoracic radiotherapy for chest malignancies with significant incidental heart dose (≥5 Gray (Gy), ≥10% heart) without a pre-cancer treatment history of HF underwent cardiopulmonary exercise testing to determine O₂Pulse, contrast-enhanced CMR, and N-terminal pro-brain natriuretic peptide (NTproBNP) measurement. Multivariable-analyses were performed to identify factors associated with O₂Pulse normalized for age/gender/anthropometrics.

Results

Thirty patients (median [IQR] age 63 [57–67] years, 18 [60%] female, 2.0 [0.6–3.8] years post-radiotherapy) were included. The peak VO₂ was 1376 [1057–1552] mL·min^− 1, peak HR = 150 [122–164] bpm, resulting in an O₂Pulse of 9.2 [7.5–10.7] mL/beat or 82 (66–96) % of predicted. The ECVF, LV ejection fraction, heart volume receiving ≥10 Gy, and NTproBNP were independently associated with %O₂Pulse (P < .001).

Conclusions

In patients with prior radiotherapy heart exposure, %-predicted O₂Pulse is inversely associated markers of diffuse fibrosis (ECVF), ventricular wall stress (NTproBNP), radiotherapy heart dose, and positively related to LV function. Increased LV ECVF may reflect a potential etiology of impaired LV SV reserve in patients receiving thoracic radiotherapy for chest malignancies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40959-021-00127-6.

Nonpharmacological Strategies in Heart Failure with Preserved Ejection Fraction

Patients with heart failure with preserved ejection fraction (HFpEF) suffer from a high rate of cardiometabolic comorbidities with limited pharmaceutical therapies proven to improve clinical outcomes and cardiorespiratory fitness (CRF). Nonpharmacologic therapies, such as exercise training and dietary interventions, are promising strategies for this population. The aim of this narrative review is to present a summary of the literature published to date and future directions related to the efficacy of nonpharmacologic, lifestyle-related therapies in HFpEF, with a focus on exercise training and dietary interventions.

Patients’ migration for orthopaedic intensive rehabilitation among Italian Regions

Background

Interregional patients’ migration, according to Italian Law, can be considered an expression of the (inviolable?) right to health and freedom of choice regarding place of care. It contributing, albeit perversely, to guaranteeing equity in the Italian National Health Service allowing citizens to overcome territorial inequalities in the distribution of healthcare services. The aim of our study was to analyze fulfilment of needs for orthopaedic intensive rehabilitation hospital services on site and interregional patients’ migration trends.

Methods

We conducted an observational cross sectional study on Hospital Discharge Cards provided by the Ministry of Health, upon specific request, from 2011 to 2019. The study of interregional patients’ migration, for orthopaedic intensive rehabilitation, relative to single Italian regions was carried out from data of Residents, Attractions and Escapes, which were graphically developed through Gandy’s Nomogram. Trend analysis (Cuzick’s Test) was performed through STATA. Were considered statistically significant at level of 95% (p &lt; 0.05).

Results

In our studied period, Gandy’s Nomogram showed that only Piedmont, Lombardy, A.P. of Trento, E. Romagna, Umbria and Abruzzo had a good public hospital planning for orthopaedic intensive rehabilitation. Attractions increased significantly for Lombardy, A.P. of Trento, Veneto and Basilicata, while they decreased significantly for A.P. of Bolzano, Veneto, F.V. Giulia, Abruzzo, Calabria and Sicily. Escapes increased significantly for Veneto, F.V. Giulia, E. Romagna, Tuscany, Molise, Puglia and Basilicata, while they decreased significantly for Piedmont, Aosta Valley, A.P. of Trento, Umbria, Abruzzo and Sicily.

Conclusions

Only six regions (4 in the North, 1 in the Centre and 1 in the South) satisfied care needs of their Residents, with an Attractions minus Escapes positive balance. Only A.P. of Trento appears to have been able to reduce Escapes and increase Attractions at the same time.

Key messages

• Studying patients’ migration by type of health benefit makes it possible to identify specific situations of lack of supply.

• Patients’ migration is an indirect Index of a region’s health policy.

Sarcopenic Obesity Is Associated With Reduced Cardiorespiratory Fitness Compared With Nonsarcopenic Obesity in Patients With Heart Failure With Reduced Ejection Fraction

BACKGROUND

Sarcopenia impairs cardiorespiratory fitness (CRF) in patients with heart failure with reduced ejection fraction (HFrEF). Obesity has also been shown to impair CRF; however, the effects of sarcopenia on CRF in patients with obesity and HFrEF are unknown. The aim of this analysis was to examine differences in CRF between patients with sarcopenic obesity (SO) and non-SO (NSO) with HFrEF. We also assessed associations between skeletal muscle mass index (SMMI) and CRF.

METHODS

Forty patients with HFrEF and obesity underwent cardiopulmonary exercise testing to collect measures of CRF including peak oxygen consumption (VO2), circulatory power, oxygen uptake efficiency slope, O2 pulse, and exercise time. Body composition was performed in all patients using bioelectrical impedance analysis to quantify fat mass index and divide patients into SO and NSO based on SMMI cutoffs. Results are presented as mean (SD) or median [interquartile range] as appropriate.

RESULTS

Nearly half (43% [n=17]) of patients had SO. Patients with SO had a lower SMMI than those with NSO, and no differences in fat mass index were observed between groups. Those with SO achieved a lower absolute peak VO2 (NSO, 1.62±0.53 L·min-1 versus SO, 1.27±0.44 L·min-1, P=0.035), oxygen uptake efficiency slope (NSO, 1.92±0.59 versus SO, 1.54±0.48, P=0.036), and exercise time (NSO, 549±198 seconds versus SO, 413±140 seconds, P=0.021) compared to those with NSO. On multivariate analysis, SMMI remained a significant predictor of absolute peak VO2 when adjusted for age, sex, adiposity, and HF severity.

CONCLUSIONS

In patients with HFrEF and obesity, sarcopenia, defined as low SMMI, is associated with a clinically significant reduction in CRF, independent of adiposity.

Effects of Replacing Sedentary Time With Physical Activity on Mortality Among Patients With Heart Failure: National Health and Nutrition Examination Survey Follow-Up Study

A sedentary lifestyle is prevalent among patients with heart failure (HF) and is associated with poor prognosis and survival, possibly owing to the displacement of health-enhancing behaviors, such as physical activity (PA). However, there is limited evidence examining the displacement effects of reducing duration of sedentary time (ST) on clinical outcomes in patients with HF. The current study examined the theoretical effects of relocating ST with PA on all-cause and cardiovascular disease (CVD)-specific mortality risks in patients with HF. We analyzed 265 patients with HF who participated in the National Health and Nutrition Examination Survey from 2003 to 2006. Cox proportional hazards regression model was fitted to estimate mortality risks based on objectively measured ST well as time spent in light-intensity PA (LPA) and moderate- and vigorous-intensity PA (MVPA). The theoretical changes in the hazard ratio (HR) by replacing ST with LPA or MVPA were examined using isotemporal substitutional modeling. On average, patients with HF spent 70% of waking hours per day in ST (9.01 hours), followed by LPA (29%; 3.75 hours) and MVPA (1%; 0.13 hours). Ten-minute substitution of ST with LPA was associated with significantly lower all-cause and CVD-specific mortality risks (hazard ratio [HR]=0.93 for both). The mortality risks progressively decreased as more ST was relocated to LPA. The relocation effects of ST with MVPA were not statistically significant, possibly because of limited MVPA accrued in this clinical population. The current study provides empirical evidence about the potential health benefits of replacing a modest amount of ST with LPA among patients with HF.

LPS differentially affects expression of CD14 and CCR2 in monocyte subsets of Post-STEMI patients with hyperglycemia

AIMS

Following ST-segment elevation myocardial infarction (STEMI), recruitment and activation of monocytes [classical (CD14⁺⁺CD16^-CCR2⁺⁺), intermediate (CD14⁺⁺CD16⁺CCR2⁺), non-classical (CD14^LowCD16⁺⁺CCR2^Low)] are needed for myocardial wound healing. Monocyte surface receptor CC chemokine receptor type 2 (CCR2) is responsible for monocyte chemotaxis to sites of inflammation and the lipopolysaccharide (LPS)-binding protein co-receptor, CD14, is involved in pro-inflammatory monocyte activation. The purpose of this investigation was to determine the effects of ex-vivo LPS activation on monocyte subset CD14 and CCR2 expression in post-STEMI individuals with normal and elevated random blood glucose.

METHODS

Post-STEMI subjects were identified as normal random glucose (NG, <98 mg/dL, n = 13) or impaired random glucose (IG, ≥98 mg/dL, n = 26) and monocytes were analyzed for non-activated and LPS-activated (1 µg/mL for 4 h) CCR2 and CD14 expression.

RESULTS

Non-activated intermediate monocytes from IG showed decreased CD14 expression when compared to NG, which was maintained following LPS-activation. The NG group showed a larger absolute reduction in classical CCR2 expression, leading to a significant difference between NG and IG following LPS-activation.

CONCLUSION

Results suggest a heightened response to pro-inflammatory activation in IG following STEMI, which may impair or delay post-STEMI myocardial healing, and thus increase the incidence of chronic heart failure. NIH 1R34HL121402.

Physical activity, sedentary behaviors and all-cause mortality in patients with heart failure: Findings from the NHANES 2007–2014

Background

Limited data are available examining the effects of both moderate- and vigorous-intensity physical activity (MVPA) and sedentary behavior (SB) on longevity among patients with heart failure (HF). This study examined the associations of MVPA and SB with all-cause mortality in HF patients using a nationally representative survey data.

Methods

National Health and Nutrition Examination Survey data (2007–2014) were used. 711 adults with self-reported congestive HF, linked to 2015 mortality data were analyzed. Self-reported MVPA and SB minutes were used to create the three MVPA [No-MVPA, insufficient (I-MVPA; <150 min/wk), and sufficient (S-MVPA; ≥150 min/wk)] and two SB (<8 and ≥8 hrs/d) groups. Cox proportional hazard models were constructed to test the associations of MVPA and SB with all-cause mortality.

Results

119 deaths occurred over an average of 4.9 years of follow-up. Lower MVPA and higher SB were independently associated with poor survival (P < .001). Joint and stratified analyses showed that the protective effect of MVPA was most pronounced among patients with SB<8 hrs/d. There was no difference in the mortality risk by SB levels within I-MVPA and S-MVPA groups; however, in the No-MVPA group, those with SB≥8 hrs/d had a greater risk of mortality compared to those with <8 hrs/d (Hazard ratio = 1.60).

Conclusion

In this HF cohort, MVPA and SB were independently and jointly associated with all-cause mortality. The beneficial effect of MVPA is attenuated by excessive SB; however, engaging in some amount of MVPA may provide a protective effect and attenuates the detrimental effects associated with excessive SB.

Patient Perceptions of Exertion and Dyspnea With Interleukin-1 Blockade in Patients With Recently Decompensated Systolic Heart Failure

Interleukin-1 (IL-1) blockade is an anti-inflammatory treatment that may affect exercise capacity in heart failure (HF). We evaluated patient-reported perceptions of exertion and dyspnea at submaximal exercise during cardiopulmonary exercise testing (CPET) in a double-blind, placebo-controlled, randomized clinical trial of IL-1 blockade in patients with systolic HF (REDHART [Recently Decompensated Heart Failure Anakinra Response Trial]). Patients underwent maximal CPET at baseline, 2, 4, and 12 weeks and rated their perceived level of exertion (RPE, on a scale from 6 to 20) and dyspnea on exertion (DOE, on a scale from 0 to 10) every 3 minutes throughout exercise. Patients also answered 2 questionnaires to assess HF-related quality of life: the Duke Activity Status Index and the Minnesota Living with Heart Failure Questionnaire. From baseline to the 12-week follow-up, IL-1 blockade significantly reduced RPE and DOE at 3- and 6-minutes during CPET without changing values for heart rate, oxygen consumption, and cardiac workload at 3- and 6-minutes. Linear regression identified 6-minute RPE to be a strong independent predictor of both physical symptoms (Minnesota Living with Heart Failure Questionnaire; β = 0.474, p = 0.002) and perceived exercise capacity (Duke Activity Status Index; β = -0.443, p = 0.008). In conclusion, patient perceptions of exertion and dyspnea at submaximal exercise may be valuable surrogates for quality of life and markers of response to IL-1 blockade in patients with HF.

Midpoint of energy intake, non-fasting time and cardiorespiratory fitness in heart failure with preserved ejection fraction and obesity

BACKGROUND

Delayed time of evening meal is associated with favorable cardiorespiratory fitness (CRF) in patients with heart failure with preserved ejection fraction (HFpEF) and obesity. It is unknown, however, if increasing daily non-fasting time or delaying the midpoint of energy intake may also be associated with CRF.

OBJECTIVE

Our aim was to examine whether a longer non-fasting time, delayed midpoint of energy intake, or both, are associated with greater CRF in patients with HFpEF and obesity.

METHODS

We measured peak oxygen consumption (VO2), a measure of CRF, in 32 patients with HFpEF and obesity with cardiopulmonary exercise testing, and dietary intake using a five-pass 24-h dietary recall. Participants were divided into groups by having lesser (<11.6) or greater (≥11.6) periods of non-fasting time than the median and similarly, with earlier (<2:15 PM) or later (≥2:15 PM) than median midpoint of energy intake.

RESULTS

Median non-fasting time was 11.6 [10.6-12.9] hours and midpoint of energy intake was 2:15 [1:04-3:00] PM. There were no differences in CRF between those with a shorter (<11.6) or longer (≥11.6) non-fasting time. Participants with a delayed midpoint of energy intake (≥2:15 PM) had greater peak VO2 and exercise time. Midpoint of energy intake (r = 0.444, P = 0.011) and time of last meal (r = 0.550, P = 0.001) displayed a positive association with peak VO2, but not non-fasting time nor time of first meal.

CONCLUSIONS

Delaying the midpoint of energy intake by postponing last meal is associated with better peak VO2 and exercise time in patients with HFpEF and obesity.

The Impact of Obesity in Heart Failure

Overweight and obesity adversely impact cardiac structure and function, affecting systolic and diastolic ventricular function. Epidemiologic studies have documented an obesity paradox in large heart failure cohorts, where overweight and obese individuals with established heart failure have a better short- and medium-term prognosis compared with leaner patients; this relationship is strongly impacted by level of cardiorespiratory fitness. There are implications for therapies aimed at increasing lean mass as well as weight loss and improvements in quality of diet for the prevention and treatment of heart failure and concomitant obesity to improve cardiorespiratory fitness.

Nutrition Assessment and Dietary Interventions in Heart Failure: JACC Review Topic of the Week

Despite the high prevalence of nutrition disorders in patients with heart failure (HF), major HF guidelines lack specific nutrition recommendations. Because of the lack of standardized definitions and assessment tools to quantify nutritional status, nutrition disorders are often missed in patients with HF. Additionally, a wide range of dietary interventions and overall dietary patterns have been studied in this population. The resulting evidence of benefit is, however, conflicting, making it challenging to determine which strategies are the most beneficial. In this document, we review the available nutritional status assessment tools for patients with HF. In addition, we appraise the current evidence for dietary interventions in HF, including sodium restriction, obesity, malnutrition, dietary patterns, and specific macronutrient and micronutrient supplementation. Furthermore, we discuss the feasibility and challenges associated with the implementation of multimodal nutrition interventions and delineate potential solutions to facilitate addressing nutrition in patients with HF.

Glenoid version: the role of genetic and environmental factors on its variability. An MRI study on asymptomatic elderly twins

BACKGROUND

Glenoid version is the most variable parameter of the shoulder joint. No authors investigated if intrinsic genetic factors or influences from extrinsic sources are responsible for its variability.

AIM

We compared glenoid version between elderly monozygotic and dizygotic twins intending to separate the contributions of genetics from shared and unique environments.

METHODS

Glenoid version of the dominant shoulder was assessed by MRI using Friedman's method in 30 pairs of elderly twins (16 monozygotic-14 dizygotic; mean age ± SD: 63.72 ± 3.37, 53-72). Heritability was estimated as twice the difference between the intraclass correlation coefficients for monozygotic and dizygotic pairs. The influence of shared environment was calculated as the difference between monozygotic correlation coefficient and the heritability index. According to job category, one way analysis of variance was used to estimate the differences between groups in the total sample and within zygosity groups.

RESULTS

Glenoid version angle in monozygotic and dizygotic twins was -2° (SD: 2°) and -3° (SD: 3°), respectively (p = 0.334). Heritability index was 0.98, while the contributions of shared and unique environment were 0 and 0.02, respectively. According to working classes, no significant differences were found between the groups (p = 0.732, F = 0.31).

CONCLUSIONS

Glenoid version is mainly genetically determined and only marginally influenced by environments.Level of evidence: III.

Diabetes Status Modifies the Association Between Different Measures of Obesity and Heart Failure Risk Among Older Adults: A Pooled Analysis of Community-Based NHLBI Cohorts

BACKGROUND

Obesity and diabetes are associated with a higher risk of heart failure (HF). The interrelationships between different measures of adiposity-overall obesity, central obesity, fat mass (FM)-and diabetes status for HF risk are not well-established.

METHODS

Participant-level data from the ARIC study (Atherosclerosis Risk in Communities; visit 5) and the CHS (Cardiovascular Health Study; visit 1) cohorts were obtained from the National Heart, Lung, and Blood Institute Biologic Specimen and Data Repository Information Coordinating Center, harmonized, and pooled for the present analysis, excluding individuals with prevalent HF. FM was estimated in all participants using established anthropometric prediction equations additionally validated using the bioelectrical impedance-based FM in the ARIC subgroup. Incident HF events on follow-up were captured across both cohorts using similar adjudication methods. Multivariable-adjusted Fine-Gray models were created to evaluate the associations of body mass index (BMI), waist circumference (WC), and FM with risk of HF in the overall cohort as well as among those with versus without diabetes at baseline. The population attributable risk of overall obesity (BMI≥30 kg/m²), abdominal obesity (WC>88 and 102 cm in women and men, respectively), and high FM (above sex-specific median) for incident HF was evaluated among participants with and without diabetes.

RESULTS

The study included 10 387 participants (52.9% ARIC; 25.1% diabetes; median age, 74 years). The correlation between predicted and bioelectrical impedance-based FM was high (R²=0.90; n=5038). During a 5-year follow-up, 447 participants developed HF (4.3%). Higher levels of each adiposity measure were significantly associated with higher HF risk (hazard ratio [95% CI] per 1 SD higher BMI=1.15 [1.05, 1.27], WC=1.22 [1.10, 1.36]; FM=1.13 [1.02, 1.25]). A significant interaction was noted between diabetes status and measures of BMI (P interaction=0.04) and WC (P interaction=0.004) for the risk of HF. In stratified analysis, higher measures of each adiposity parameter were significantly associated with higher HF risk in individuals with diabetes (hazard ratio [95% CI] per 1 SD higher BMI=1.29 [1.14-1.47]; WC=1.48 [1.29-1.70]; FM=1.25 [1.09-1.43]) but not those without diabetes, including participants with prediabetes and euglycemia. The population attributable risk percentage of overall obesity, abdominal obesity, and high FM for incident HF was higher among participants with diabetes (12.8%, 29.9%, and 13.7%, respectively) versus those without diabetes (≤1% for each).

CONCLUSIONS

Higher BMI, WC, and FM are strongly associated with greater risk of HF among older adults, particularly among those with prevalent diabetes.

Effect of interleukin-1 blockade with anakinra on leukocyte count in patients with ST-segment elevation acute myocardial infarction

Leukocytosis is a common finding in patients with ST elevation myocardial infarction (STEMI) and portends a poor prognosis. Interleukin 1-β regulates leukopoiesis and pre-clinical studies suggest that anakinra (recombinant human interleukin-1 [IL-1] receptor antagonist) suppresses leukocytosis in myocardial infarction. However, the effect of IL-1 blockade with anakinra on leukocyte count in patients with STEMI is unknown. We reviewed the white blood cell (WBC) and differential count of 99 patients enrolled in a clinical trial of anakinra (n = 64) versus placebo (n = 35) for 14 days after STEMI. A complete blood cell count with differential count were obtained at admission, and after 72 h, 14 days and 3 months. After 72 h from treatment, anakinra compared to placebo led to a statistically significant greater percent reduction in total WBC count (− 35% [− 48 to − 24] vs. − 21% [− 34 to − 10], P = 0.008), absolute neutrophil count (− 48% [− 60 to − 22] vs. − 27% [− 46 to − 5], P = 0.004) and to an increase in absolute eosinophil count (+ 50% [0 to + 100] vs. 0% [− 50 to + 62], P = 0.022). These changes persisted while on treatment at 14 days and were no longer apparent at 3 months after treatment discontinuation. We found that in patients with STEMI IL-1 blockade with anakinra accelerates resolution of leukocytosis and neutrophilia. This modulation may represent one of the mechanisms by which IL-1 blockade improves clinical outcomes.

Comparison of Cardiorespiratory Fitness in Black or African American Versus Caucasian Patients With Heart Failure

PURPOSE

Cardiopulmonary exercise testing (CPX) is a well-established assessment with important insight into prognosis and therapeutic efficacy in patients with heart failure (HF). Prior studies have identified several clinical differences between Black or African American (B-AA) and Caucasian patients with HF. Differences in key CPX responses between these two groups require further investigation.

METHODS

Using a database consisting of subjects with symptomatic HF who had undergone CPX for inclusion in various prospective randomized clinical trials, we identified 198 (n = 94 [47%] B-AA; n = 105 [53%] Caucasian) patients with a qualifying baseline CPX. Significant univariate predictors of peak oxygen uptake (V˙o2peak) were included in a multivariate linear regression model.

RESULTS

When compared with Caucasian patients, B-AA were younger (mean ± SD = 54.8 ± 10.0 vs 57.9 ± 9.6 yr, P = .03), had higher C-reactive protein (CRP) (median [IQR] = 4.9 [2.3, 8.8] vs 1.9 [0.6, 5.5] mg/L, P < .0001), lower hemoglobin (13.0 ± 1.8 vs 13.8 ± 1.6 g/dL, P = .003), and lower left ventricular ejection fraction (LVEF) (40 [32, 51] vs 53 [43, 59]%, P < .00010). During CPX, B-AA patients also had lower V˙o2peak (14.6 ± 3.9 vs 17.6 ± 4.8 mL·kg-1·min-1, P < .0001). No differences were observed between B-AA and Caucasian in the minute ventilation/carbon dioxide production (V˙e/V˙co2) slope (P = .14). The difference in V˙o2peak between B-AA and Caucasian was largely attenuated after adjusting for age, body mass index, CRP, N-terminal pro-brain natriuretic peptide, hemoglobin, LVEF, and peak HR (14.1: 95% CI, 13.2-14.9 vs 15.6: 95% CI, 14.4-16.8 mL·kg-1·min-1, P = .053).

CONCLUSIONS

Directly measured V˙o2peak was significantly lower in B-AA than in Caucasians with HF. This is largely explained by differences in clinical characteristics, whereas no significant differences were observed in the V˙e/V˙co2 slope.

Acute Effects of Liothyronine Administration on Cardiovascular System and Energy Metabolism in Healthy Volunteers

CONTEXT

The pharmacokinetics of liothyronine causes concerns for cardiovascular toxicity. While the effects of sustained increase in serum T3 concentrations are well described, little is known on the effects of acute changes in T3 concentrations due to rapid action of thyroid hormone.

OBJECTIVE

To assess the clinical relevance of transient increase of T3 levels on cardiovascular system and energy metabolism.

SETTING

Double-blind, three arms, placebo controlled, cross-over study (ClinicalTrials.gov Identifier: NCT03098433).

STUDY PARTICIPANTS

Twelve volunteers (3 females, 9 males), age 27.7 ± 5.1 years.

INTERVENTION

Oral administration of liothyronine 0.7 mcg/kg, equimolar dose of levothyroxine (0.86 mcg/kg), or placebo in three identical study visits. Blood samples for total T3, free T4 were collected at times 0', 60' 120' 180' 240'. Continuous recording of heart rate, blood pressure, and hemodynamic data was performed using the volume clamp method. Resting energy expenditure was measured by indirect calorimetry. An echocardiogram was performed on each study visit at baseline and after the last blood sampling.

MAIN OUTCOME MEASURES

Changes in cardiovascular function and energy expenditure.

RESULTS

Following the administration of liothyronine, serum T3 reached a C_max of 421 ± 57 ng/dL with an estimated T_max of 120 ± 26 minutes. No differences between study arms were observed in heart rate, blood pressure, hemodynamics parameters, energy expenditure, and in echocardiogram parameters.

CONCLUSIONS

The absence of measurable rapid effects on the cardiovascular system following a high dose of liothyronine supports the rationale to perform long-term studies to assess its safety and effectiveness in patients affected by hypothyroidism.

Coronary Microvascular Dysfunction Across the Spectrum of Cardiovascular Diseases: JACC State-of-the-Art Review

Coronary microvascular dysfunction (CMD) encompasses several pathogenetic mechanisms involving coronary microcirculation and plays a major role in determining myocardial ischemia in patients with angina without obstructive coronary artery disease, as well as in several other conditions, including obstructive coronary artery disease, nonischemic cardiomyopathies, takotsubo syndrome, and heart failure, especially the phenotype associated with preserved ejection fraction. Unfortunately, despite the identified pathophysiological and prognostic role of CMD in several conditions, to date, there is no specific treatment for CMD. Due to the emerging role of CMD as common denominator in different clinical phenotypes, additional research in this area is warranted to provide personalized treatments in this "garden variety" of patients. The purpose of this review is to describe the pathophysiological mechanisms of CMD and its mechanistic and prognostic role across different cardiovascular diseases. We will also discuss diagnostic modalities and the potential therapeutic strategies resulting from recent clinical studies.

Effect of Canagliflozin Compared With Sitagliptin on Serum Lipids in Patients with Type 2 Diabetes Mellitus and Heart Failure with Reduced Ejection Fraction: A Post-Hoc Analysis of the CANA-HF Study

ABSTRACT

The sodium glucose co-transporter 2 inhibitors have demonstrated favorable effects on cardiovascular and renal disease; however, they may also increase low-density lipoprotein cholesterol (LDL-C). There are limited data directly comparing the effects of sodium glucose co-transporter 2inhibitors on serum lipids to other antihyperglycemic therapies. In this post-hoc analysis of the CANA-HF trial, we sought to compare the effects of canagliflozin to sitagliptin in patients with type 2 diabetes mellitus (T2DM) and heart failure and reduced ejection fraction (HFrEF). The CANA-HF trial was a prospective, randomized controlled study that compared the effects of canagliflozin 100 mg daily to sitagliptin 100 mg daily on cardiorespiratory fitness in patients with HFrEF and T2DM. Of the 36 patients enrolled in CANA-HF, 35 patients had both baseline and 12-weeks serum lipids obtained via venipuncture. The change in LDL-C from baseline to 12 weeks was 5 (-12.5 to 19.5) mg/dL versus -8 (-19 to -1) mg/dL (P = 0.82) and triglyceride levels was -4 (-26 to 9) mg/dL and -10.5 (-50 to 29.3) mg/dL (P = 0.52) for canagliflozin and sitagliptin, respectively. No significant differences were found between canagliflozin and sitagliptin for total cholesterol, high-density lipoprotein cholesterol or non-HDL-C (P > 0.5 for all). These data suggest that compared with sitagliptin, canagliflozin may not increase LDL-C in patients with T2DM and HFrEF.

Time of eating and cardiorespiratory fitness in patients with heart failure with preserved ejection fraction and obesity

BACKGROUND AND AIMS

Our objective was to examine the impact of caloric intake before or after the mean time of evening meal on cardiorespiratory fitness (CRF) in patients with heart failure with preserved ejection fraction (HFpEF) and obesity.

METHODS AND RESULTS

Twelve patients with HFpEF and obesity completed a cardiorespiratory exercise test to measure CRF, defined as peak oxygen consumption (VO₂). Three five-pass 24-h dietary recalls were performed for each participant and mean evening meal time was determined for each participant individually as well as the group. Participants were divided into those who ate before (Group I) and after (Group II) the mean time of evening meal, 7:25 PM. Peak VO₂ and exercise time were significantly greater in Group II compared to Group I, moreover, delaying time of evening meal was associated with greater peak VO₂.

CONCLUSION

Caloric intake after the mean time of evening meal was associated with better CRF in patients with HFpEF and concomitant obesity. Later nutrient intake may help prevent fasting related stress associated with cardiac metabolic disturbances present in HFpEF. Based on these findings, prospective trials aimed at examining the effects of later evening meal times in patients with HFpEF and obesity are warranted.

Diastolic Dysfunction Contributes to Impaired Cardiorespiratory Fitness in Patients with Lung Cancer and Reduced Lung Function Following Chest Radiation

Cardiorespiratory fitness (CRF) is a robust and independent predictor of cardiovascular health and overall mortality. Patients with lung cancer often have chronic lung disease, contributing to impaired CRF. Radiation to the heart during lung cancer treatment may further reduce CRF. The determinants of CRF in this population are not well understood. We prospectively evaluated 12 patients with lung cancer without known cardiovascular disease with reduced lung function receiving curative intent thoracic radiotherapy to determine whether cardiac diastolic function, as assessed by Doppler echocardiography and N-terminal pro-brain natriuretic peptide (NTproBNP) levels, correlate with CRF measured by peak oxygen consumption (VO₂). Doppler-derived measures of diastolic function and serum NTproBNP levels inversely correlated with peak VO_2. In a multivariate regression model, NTproBNP was the strongest independent variable associated with peak VO₂. These results suggest that diastolic dysfunction further contributes to reduced CRF in patients with lung cancer who have received radiotherapy.