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Heart failure with preserved ejection fraction risk is associated with prevalence and severity of obstructive sleep apnea. J Clin Sleep Med 2024; 20:381-387. [PMID: 37962070 PMCID: PMC11019217 DOI: 10.5664/jcsm.10876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/13/2023] [Accepted: 10/13/2023] [Indexed: 11/15/2023]
Abstract
STUDY OBJECTIVES While heart failure with preserved ejection fraction (HFpEF) is associated with the presence of obstructive sleep apnea (OSA), few studies have examined the association between scoring systems used to predict HFpEF risk, such as the H2FPEF and HFA-PEFF scores, and OSA prevalence and severity. METHODS We performed chart review on all patients who underwent both an echocardiogram and sleep study at the University of Pennsylvania between July 1, 2020, and June 30, 2022. There were 277 patients in the final cohort after excluding patients with relevant comorbidities. Associations between echocardiographic parameters and OSA severity, as well as between H2FPEF score and OSA severity, were examined using linear tests of trend. The association between H2FPEF score and prevalent OSA was examined with logistic regression. RESULTS OSA severity was associated with echocardiographic markers, including left atrial volume index (P = .03) and left ventricular relative thickness (P = .008). Patients with high H2FPEF risk scores had over 17-fold higher odds of prevalent OSA compared with those with low-risk scores (17.7; 95% CI 4.3, 120.7; P < .001). Higher H2FPEF scores were strongly correlated with OSA severity (P < .001). After controlling for body mass index, H2FPEF scores were not associated with prevalence or severity of OSA. CONCLUSIONS In an ambulatory population referred for sleep study and echocardiogram, markers of diastolic dysfunction were associated with OSA severity. OSA prevalence and severity were associated with increased H2FPEF scores, although these associations were largely explained by obesity. Clinicians should have low thresholds for referring patients with OSA for cardiac workup and patients with HFpEF for sleep study. CITATION Connolly JE, Genuardi MV, Mora JI, Prenner SB. Heart failure with preserved ejection fraction risk is associated with prevalence and severity of obstructive sleep apnea. J Clin Sleep Med. 2024;20(3):381-387.
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Left Bundle Branch Area Pacing From a Femoral Approach in a Patient Without Superior Access. JACC Case Rep 2023; 9:101748. [PMID: 36909274 PMCID: PMC9998714 DOI: 10.1016/j.jaccas.2023.101748] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/19/2022] [Accepted: 01/05/2023] [Indexed: 02/03/2023]
Abstract
Limited venous access and lateral left ventricular scar are impediments to traditional cardiac resynchronization therapy. We present a case where placement of an implantable cardioverter-defibrillator from a femoral approach while using left bundle branch area pacing led to clinical improvement. (Level of Difficulty: Intermediate.).
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End Stage Mitochondrial Cardiomyopathy and Heart Transplantation Due to Biallelic Pathogenic C1QBP Variants. CIRCULATION. GENOMIC AND PRECISION MEDICINE 2022; 15:e003559. [PMID: 35119291 PMCID: PMC9085452 DOI: 10.1161/circgen.121.003559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Pragmatic assessment of resident performed cardiac point of care ultrasound using a validated scoring metric. IJC HEART & VASCULATURE 2022; 39:100993. [PMID: 35295903 PMCID: PMC8919212 DOI: 10.1016/j.ijcha.2022.100993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/22/2022] [Accepted: 03/04/2022] [Indexed: 10/27/2022]
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Multimodality assessment of heart failure with preserved ejection fraction skeletal muscle reveals differences in the machinery of energy fuel metabolism. ESC Heart Fail 2021; 8:2698-2712. [PMID: 33991175 PMCID: PMC8318475 DOI: 10.1002/ehf2.13329] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/25/2021] [Accepted: 03/12/2021] [Indexed: 02/06/2023] Open
Abstract
AIMS Skeletal muscle (SkM) abnormalities may impact exercise capacity in patients with heart failure with preserved ejection fraction (HFpEF). We sought to quantify differences in SkM oxidative phosphorylation capacity (OxPhos), fibre composition, and the SkM proteome between HFpEF, hypertensive (HTN), and healthy participants. METHODS AND RESULTS Fifty-nine subjects (20 healthy, 19 HTN, and 20 HFpEF) performed a maximal-effort cardiopulmonary exercise test to define peak oxygen consumption (VO2, peak ), ventilatory threshold (VT), and VO2 efficiency (ratio of total work performed to O2 consumed). SkM OxPhos was assessed using Creatine Chemical-Exchange Saturation Transfer (CrCEST, n = 51), which quantifies unphosphorylated Cr, before and after plantar flexion exercise. The half-time of Cr recovery (t1/2, Cr ) was taken as a metric of in vivo SkM OxPhos. In a subset of subjects (healthy = 13, HTN = 9, and HFpEF = 12), percutaneous biopsy of the vastus lateralis was performed for myofibre typing, mitochondrial morphology, and proteomic and phosphoproteomic analysis. HFpEF subjects demonstrated lower VO2,peak , VT, and VO2 efficiency than either control group (all P < 0.05). The t1/2, Cr was significantly longer in HFpEF (P = 0.005), indicative of impaired SkM OxPhos, and correlated with cycle ergometry exercise parameters. HFpEF SkM contained fewer Type I myofibres (P = 0.003). Proteomic analyses demonstrated (a) reduced levels of proteins related to OxPhos that correlated with exercise capacity and (b) reduced ERK signalling in HFpEF. CONCLUSIONS Heart failure with preserved ejection fraction patients demonstrate impaired functional capacity and SkM OxPhos. Reductions in the proportions of Type I myofibres, proteins required for OxPhos, and altered phosphorylation signalling in the SkM may contribute to exercise intolerance in HFpEF.
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Quantitative Proteomic Analysis of Diabetes Mellitus in Heart Failure With Preserved Ejection Fraction. JACC Basic Transl Sci 2021; 6:89-99. [PMID: 33665511 PMCID: PMC7907637 DOI: 10.1016/j.jacbts.2020.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/19/2020] [Accepted: 11/22/2020] [Indexed: 01/25/2023]
Abstract
Diabetes mellitus (DM) is associated with a higher risk of heart failure hospitalization and mortality in patients with heart failure with preserved ejection fraction (HFpEF). Using SomaScan assays and proteomics analysis of plasma from participants in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial and the Penn Heart Failure Study, this study identified 10 proteins with significantly different expression in patients with HFpEF and DM. Of these, apolipoprotein M was found to mediate 72% (95% CI: 36% to 100%; p < 0.001) of the association between DM and the risk of cardiovascular death, aborted cardiac arrest, and heart failure hospitalization.
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Improving cardiology fellow education of right heart catheterization using a simulation based curriculum. Catheter Cardiovasc Interv 2020; 97:503-508. [PMID: 32608175 DOI: 10.1002/ccd.29128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/18/2020] [Accepted: 06/14/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Medical procedures are traditionally taught informally at patients' bedside through observation and practice using the adage "see one, do one, teach one." This lack of formalized training can cause trainees to be unprepared to perform procedures independently. Simulation based education (SBE) increases competence, reduces complications, and decreases costs. We developed, implemented, and evaluated the efficacy of a right heart catheterization (RHC) SBE curriculum. METHODS The RHC curriculum consisted of a pretest, video didactics, deliberate practice, and a posttest. Pre-and posttest skills examinations consisted of a dichotomous 43-item checklist on RHC skills and a 14-item hemodynamic waveform quiz. We enrolled two groups of fellows: 6 first-year, novice cardiology fellows at Northwestern University in their first month of training, and 11 second- and third-year fellows who had completed traditional required, level I training in RHC. We trained the first-year fellows at the beginning of the 2018-2019 year using the SBE curriculum and compared them to the traditionally-trained cardiology fellows who did not complete SBE. RESULTS The SBE-trained fellows significantly improved RHC skills, hemodynamic knowledge, and confidence from pre- to posttesting. SBE-trained fellows performed similarly to traditionally-trained fellows on simulated RHC skills checklists (88.4% correct vs. 89.2%, p = .84), hemodynamic quizzes (94.0% correct vs. 86.4%, p = .12), and confidence (79.4 vs. 85.9 out of 100, p = .15) despite less clinical experience. CONCLUSIONS A SBE curriculum for RHC allowed novice cardiology fellows to achieve level I skills and knowledge at the beginning of fellowship and can train cardiology fellows before patient contact.
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Letter to Editor Reply: Therapeutic Strategy for Coronavirus Disease 2019 in Patients on Durable Left Ventricular Assist Device Support. J Card Fail 2020; 26:480-481. [PMID: 32405231 PMCID: PMC7217795 DOI: 10.1016/j.cardfail.2020.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/06/2020] [Indexed: 12/03/2022]
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Novel Coronavirus Disease 2019 in a Patient on Durable Left Ventricular Assist Device Support. J Card Fail 2020; 26:438-439. [PMID: 32305569 PMCID: PMC7162774 DOI: 10.1016/j.cardfail.2020.04.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 12/26/2022]
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Peripheral Determinants of Oxygen Utilization in Heart Failure With Preserved Ejection Fraction: Central Role of Adiposity. ACTA ACUST UNITED AC 2020; 5:211-225. [PMID: 32215346 PMCID: PMC7091498 DOI: 10.1016/j.jacbts.2020.01.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 12/27/2019] [Accepted: 01/02/2020] [Indexed: 01/04/2023]
Abstract
ΔAVo2 during exercise is a complex metric that incorporates into its calculation skeletal muscle blood flow and DmO2 across the skeletal muscle capillary membrane. Although ΔAVo2 was reduced in patients with HFpEF during both systemic and local (forearm) exercise, there was no difference in forearm DmO2 among subjects with HFpEF, those with hypertension, and healthy control subjects; therefore, abnormalities in forearm DmO2 cannot explain the reduced forearm ΔAVo2 seen in subjects with HFpEF. Local forearm exercise performance predicted about one-third of the variability in systemic aerobic capacity, demonstrating that peripheral factors are important in determining whole-body exercise tolerance. Degree of adiposity strongly correlated with ΔAVo2 during both local and whole-body exercise, suggesting that adipose tissue may play an active role in limiting exercise capacity in subjects with HFpEF.
The aim of this study was to determine the arteriovenous oxygen content difference (ΔAVo2) in adult subjects with and without heart failure with preserved ejection fraction (HFpEF) during systemic and forearm exercise. Subjects with HFpEF had reduced ΔAVo2. Forearm diffusional conductance for oxygen, a lumped conductance parameter that incorporates all impediments to the movement of oxygen from red blood cells in skeletal muscle capillaries into the mitochondria within myocytes, was estimated. Forearm diffusional conductance for oxygen was not different among adults with HFpEF, those with hypertension, and healthy control subjects; therefore, diffusional conductance cannot explain the reduced forearm ΔAVo2. Instead, adiposity was strongly associated with ΔAVo2, suggesting an active role for adipose tissue in reducing exercise capacity in patients with HFpEF.
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Key Words
- CO, cardiac output
- DEXA, dual-energy x-ray absorptiometry
- DmO2, skeletal muscle diffusional conductance for oxygen
- FIo2, fraction of inspired oxygen
- HFpEF
- HFpEF, heart failure with preserved ejection fraction
- MVC, maximal voluntary contraction force
- NT-proBNP, N-terminal pro–brain natriuretic peptide
- Po2, partial pressure of oxygen
- Vo2, oxygen consumption
- adiposity
- aerobic capacity
- exercise
- oxygen transport
- ΔAVo2, arteriovenous oxygen content difference
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Effect of Serum Albumin Levels in Patients With Heart Failure With Preserved Ejection Fraction (from the TOPCAT Trial). Am J Cardiol 2020; 125:575-582. [PMID: 31843232 DOI: 10.1016/j.amjcard.2019.11.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/31/2019] [Accepted: 11/07/2019] [Indexed: 01/09/2023]
Abstract
Little data are available regarding the determinants and prognostic significance of serum albumin in Heart Failure with Preserved Ejection Fraction (HFpEF). We sought to examine the phenotypic correlates of albumin and its independent prognostic implications in HFpEF. We analyzed data from 3,254 subjects enrolled the TOPCAT trial. We stratified subjects according to tertiles of albumin and examined differences in various phenotypic traits between these strata, including 8 protein biomarkers selected ad hoc and measured from frozen samples available in a subset of participants (n = 372). We also assessed the relationship between albumin and the trial primary endpoint. Lower albumin was associated with older age, black race, and greater prevalence of NYHA class III-IV, peripheral arterial disease, atrial fibrillation and diabetes mellitus. Lower albumin was also associated with increased levels of several inflammatory biomarkers, markers of liver fibrosis, albuminuria, and greater arterial stiffness, diastolic dysfunction and pulmonary hypertension. Albumin was a strong predictor of the primary trial endpoint, even after adjustment for the MAGGIC risk score (hazard ratio [HR] 0.72, confidence interval [CI] 0.67 to 0.78; p <0.0001) and prespecified traditional risk factors (HR 0.78, CI 0.71 to 0.85; p <0.0001). Lower albumin was strongly associated with a worse prognosis even well within normal ranges (>3.5 g/dL), with a sharp increase in risk between 4.6 and 3.6 g/dL. In conclusion, albumin is an integrated marker of various adverse processes in HFpEF, including inflammation, subclinical liver disease, arterial stiffness, and renal disease. Albumin is a powerful risk predictor independent of traditional risk prediction models, even within normal ranges.
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Serum Albumin Is a Marker of Myocardial Fibrosis, Adverse Pulsatile Aortic Hemodynamics, and Prognosis in Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2020; 9:e014716. [PMID: 32009529 PMCID: PMC7033884 DOI: 10.1161/jaha.119.014716] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Data regarding the phenotypic correlates and prognostic value of albumin in heart failure with preserved ejection fraction (HFpEF) are scarce. The goal of the current study is to determine phenotypic correlates (myocardial hypertrophy, myocardial fibrosis, detailed pulsatile hemodynamics, and skeletal muscle mass) and prognostic implications of serum albumin in HFpEF. Methods and Results We studied 118 adults with HFpEF. All‐cause death or heart‐failure–related hospitalization was ascertained over a median follow‐up of 57.6 months. We measured left ventricular mass, myocardial extracellular volume, and axial muscle areas using magnetic resonance imaging. Pulsatile arterial hemodynamics were assessed with a combination of arterial tonometry and phase‐contrast magnetic resonance imaging. Subjects with lower serum albumin exhibited a higher body mass index, and a greater proportion of black ethnicity and diabetes mellitus. A low serum albumin was associated with higher myocardial extracellular volume (52.3 versus 57.4 versus 39.3 mL in lowest to highest albumin tertile, respectively; P=0.0023) and greater N‐terminal pro B‐type natriuretic peptide levels, but not with a higher myocardial cellular volume (123 versus 114 versus 102 mL; P=0.13). Lower serum albumin was also associated with an increased forward wave amplitude and markedly increased pulsatile power in the aorta. Serum albumin was a strong predictor of death or heart failure hospitalization even after adjustment for N‐terminal pro B‐type natriuretic peptide levels and the Meta‐Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score (adjusted standardized hazard ratio=0.56; 95% CI=0.37–0.83; P<0.0001). Conclusions Serum albumin is associated with myocardial fibrosis, adverse pulsatile aortic hemodynamics, and prognosis in HFpEF. This readily available clinical biomarker can enhance risk stratification in HFpEF and identifies a subgroup with specific pathophysiological abnormalities.
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A Prospective Pilot Study of Pocket-Carried Ultrasound Pre- and Postdischarge Inferior Vena Cava Assessment for Prediction of Heart Failure Rehospitalization. J Card Fail 2018; 24:614-617. [PMID: 30081076 DOI: 10.1016/j.cardfail.2018.07.461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/26/2018] [Accepted: 07/19/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Rehospitalization for heart failure (HF) is common, and subclinical congestion may be present at discharge. Larger inferior vena cava (IVC) size and lower collapsibility at discharge assessed via bedside ultrasound are predictive of rehospitalization; however, the utility of IVC assessment with the use of pocket-carried ultrasound (PCUS) during the transition from discharge to the posthospitalization follow-up visit (FU) has not been investigated. METHODS AND RESULTS IVCmax and IVCmin were measured with the use of PCUS, and the collapsibility index (IVCCI = [IVCmax - IVCmin]/IVCmax) was determined. The primary outcome was 90-day rehospitalization or death. We prospectively enrolled 49 adults (71 ± 13 years of age, 51% male, 47% black, 43% preserved ejection fraction) hospitalized for HF. Nineteen patients (39%) experienced the outcome. Within the rehospitalized group, discharge and FU mean IVCmax were both >2.1 cm (2.2 ± 0.5 and 2.2 ± 0.7) and IVCCIs <50% (44 ± 20% and 45 ± 24%). Within those not rehospitalized, FU IVCmax was ≤2.1 cm (2.1 ± 0.6 and 1.9 ± 0.6; P = .038) and IVCCI >50% at both time points (55 ± 25% and 62 ± 19%; P = NS). FU IVCCI below an optimal cutoff of 42% had modest discrimination alone (c-statistic = 0.73). FU IVCCI <42% was associated with a greater hazard of the outcome independent of admission log B-type natriuretic peptide (adjusted hazard ratio = 6.8; 95% confidence interval 2.4-19.0; P < .001). CONCLUSIONS Posthospitalization IVCCI assessment with PCUS predicts HF rehospitalization and may identify patients in need of intervention.
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Effect of Trainee Performance Data on Standard-Setting Judgments Using the Mastery Angoff Method. J Grad Med Educ 2018; 10:301-305. [PMID: 29946387 PMCID: PMC6008037 DOI: 10.4300/jgme-d-17-00781.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/07/2018] [Accepted: 01/17/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Mastery learning in health professions education requires learners to learn and undergo assessment until they demonstrate a high level of competence. Setting defensible standards is key to accurately assessing educational outcomes in mastery learning. The Mastery Angoff method was proposed recently to set a minimum passing standard (MPS) for mastery learning curricula. However, it is unknown whether prior knowledge of trainee performance affects judges' decisions about setting an MPS using the Mastery Angoff method. OBJECTIVE We sought to determine the effect of introducing baseline data about trainee performance on faculty judges' decisions about the Mastery Angoff MPS for a written examination. METHODS We developed a mastery learning curriculum to train internal medicine residents and cardiology fellows about the correct interpretation of inpatient telemetry monitoring. All learners were required to meet or exceed an MPS on a 35-item written examination at the end of training. The MPS was set in 2017 by judges who used the item-based Mastery Angoff method without prior examinee performance information. The judges subsequently reevaluated the test items after receiving baseline data about trainee performance collected during pilot testing. Mastery Angoff MPSs with and without baseline performance data were compared. RESULTS Twelve judges participated in the standard-setting exercise. The initial MPS was similar to the repeat MPS set after judges received trainee performance data (86.2% versus 86.9%, P = .23). CONCLUSIONS Prior knowledge about medical trainee performance data did not affect MPS as determined by the Mastery Angoff procedure.
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Obesity and heart failure with preserved ejection fraction: A growing problem. Trends Cardiovasc Med 2017; 28:322-327. [PMID: 29305040 DOI: 10.1016/j.tcm.2017.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/07/2017] [Accepted: 12/04/2017] [Indexed: 01/09/2023]
Abstract
Heart Failure with Preserved Ejection Fraction (HFpEF) is increasing in prevalence due to the aging of the United States population as well as the current obesity epidemic. While obesity is very common in patients with HFpEF, obesity may represent a specific phenotype of HFpEF characterized by unique hemodynamics and structural abnormalities. Obesity induces a systemic inflammatory response that may contribute to myocardial fibrosis and endothelial dysfunction. The most obese patients continue to be excluded from HFpEF clinical trials, and thus ongoing research is needed to determine the role of pharmacologic and interventional approaches in this growing population.
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Differences in Repolarization Heterogeneity Among Heart Failure With Preserved Ejection Fraction Phenotypic Subgroups. Am J Cardiol 2017; 120:601-606. [PMID: 28651852 DOI: 10.1016/j.amjcard.2017.05.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 05/04/2017] [Accepted: 05/04/2017] [Indexed: 12/22/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a highly heterogeneous syndrome associated with multiple medical comorbidities and pathophysiologic pathways or phenotypes. We recently developed a phenomapping method combining deep phenotyping with machine learning analysis to classify HFpEF patients into 3 clinically distinct phenotypic subgroups (phenogroups) with different clinical outcomes. Phenogroup #1 was younger with lower B-type natriuretic peptide levels, phenogroup #2 had the highest prevalence of obesity and diabetes mellitus, and phenogroup #3 was the oldest with the most factors for chronic kidney disease, the most dysfunctional myocardial mechanics, and the highest adverse outcomes. The pathophysiological differences between these phenogroups, however, remain incompletely described. We sought to evaluate whether these 3 groups differ on the basis of repolarization heterogeneity, which has previously been linked to adverse outcomes in HFpEF. The T-peak to T-end (TpTe) interval, a well-validated index of repolarization heterogeneity, was measured by 2 readers blinded to each other and all other clinical data on the electrocardiograms of 201 HFpEF patients enrolled in a systematic observational study. TpTe duration was associated with higher B-type natriuretic peptide level (p = 0.006), increased QRS-T angle (p = 0.008), and lower septal e' velocity (p = 0.007). TpTe duration was greatest in phenogroup #3 (100.4 ± 24.5 ms) compared with phenogroups #1 (91.2 ± 17.3 ms) and #2 (90.2 ± 17.0 ms) (p = 0.0098). On multivariable analyses, increased TpTe was independently associated with the high-risk phenogroup #3 classification. In conclusion, repolarization heterogeneity is a marker of a specific subset of HFpEF patients identified using unsupervised machine learning analysis and therefore may be a key pathophysiologic marker in this subset of HFpEF patients.
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Simulation-based education leads to decreased use of fluoroscopy in diagnostic coronary angiography. Catheter Cardiovasc Interv 2017; 91:1054-1059. [DOI: 10.1002/ccd.27203] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 06/15/2017] [Indexed: 12/23/2022]
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A 51-Year-Old Man With Exercise-Induced Syncope. JAMA Cardiol 2017; 2:221-222. [DOI: 10.1001/jamacardio.2016.3866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Repolarization heterogeneity, diastolic dysfunction, and cardiovascular outcomes in heart failure with preserved ejection fraction. Int J Cardiol 2016; 223:116-117. [DOI: 10.1016/j.ijcard.2016.08.157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 08/07/2016] [Indexed: 10/21/2022]
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Selective association of electrocardiographic abnormalities with insulin sensitivity and beta-cell function in type 2 diabetes mellitus: a cross-sectional analysis. Diabetes Metab Res Rev 2016; 32:736-744. [PMID: 26889668 PMCID: PMC5764080 DOI: 10.1002/dmrr.2794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 12/29/2015] [Accepted: 01/29/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND We investigated the association of electrocardiographic (ECG) abnormalities with markers of insulin resistance and pancreatic beta-cell dysfunction in a cross-sectional study of type 2 diabetes patients. METHODS Electrocardiographic criteria were evaluated in the Penn Diabetes Heart Study participants (n = 1671; 64% male; 61% Caucasian), including a sub-sample (n = 710) that underwent oral glucose tolerance testing. The Matsuda Insulin Sensitivity Index and homeostasis model assessment of insulin resistance (HOMA-IR) estimated insulin sensitivity; Insulinogenic Index and homeostasis model assessment of beta-cell function assessed beta-cell function. Multivariable regression modelling was used to analyse associations of ECG changes with these indices. RESULTS In unadjusted analyses, subjects in the highest quartile of Matsuda index had the lowest prevalence of Q-waves (6.3% versus 15.3%, p = 0.005). In adjusted models, an inverse association was seen between Q-waves and log Matsuda index [one standard deviation increase; OR = 0.59 (95% CI 0.43-0.87 p = 0.001)]. In the full Penn Diabetes Heart Study, there was a direct association between Q-waves and HOMA-IR [one standard deviation increase; OR = 1.43 (95% CI 1.13-1.81, p = 0.003)]. In adjusted models, left ventricular hypertrophy also was inversely associated with Matsuda index and directly with HOMA-IR. Higher Insulinogenic Index scores were associated with a lower prevalence of nonspecific ST changes [OR = 0.78 (95% CI 0.62-0.98, p = 0.032)]. CONCLUSIONS In type 2 diabetic patients, both oral glucose tolerance testing-derived and HOMA-derived measures of insulin resistance were associated with pathologic Q-waves and left ventricular hypertrophy on ECGs. Copyright © 2016 John Wiley & Sons, Ltd.
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Repolarization Heterogeneity, Diastolic Dysfunction, and Cardiovascular Outcomes in Heart Failure with Preserved Ejection Fraction. J Card Fail 2016. [DOI: 10.1016/j.cardfail.2016.06.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Rapid Reversal of Focal Left Ventricular Hypertrophy and Systolic Dysfunction Resulting From Myocardial Infiltration by Acute Lymphoblastic Leukemia. Circulation 2016; 133:678-9. [PMID: 26884624 DOI: 10.1161/circulationaha.115.020035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Arterial stiffness is an age-related process that is a shared consequence of numerous diseases including diabetes mellitus (DM), and is an independent predictor of mortality both in this population and in the general population. While much has been published about arterial stiffness in patients with DM, a thorough review of the current literature is lacking. Using a systematic literature search strategy, we aimed to summarize our current understanding related to arterial stiffness in DM. We review key studies demonstrating that, among patients with established DM, arterial stiffness is closely related to the progression of complications of DM, including nephropathy, retinopathy, and neuropathy. It is also becoming clear that arterial stiffness can be increased even in pre-diabetic populations with impaired glucose tolerance, and in those with the metabolic syndrome (METS), well before the onset of overt DM. Some data suggests that arterial stiffness can predict the onset of DM. However, future work is needed to further clarify whether large artery stiffness and the pulsatile hemodynamic changes that accompany it are involved in the pathogenesis of DM, and whether interventions targeting arterial stiffness are associated with improved clinical outcomes in DM. We also review of the potential mechanisms of arterial stiffness in DM, with particular emphasis on the role of advanced glycation endproducts (AGEs) and nitric oxide dysregulation, and address potential future directions for research.
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Very low density lipoprotein cholesterol associates with coronary artery calcification in type 2 diabetes beyond circulating levels of triglycerides. Atherosclerosis 2014; 236:244-50. [PMID: 25105581 DOI: 10.1016/j.atherosclerosis.2014.07.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 06/19/2014] [Accepted: 07/06/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE While recent genomic studies have focused attention on triglyceride (TG) rich lipoproteins in cardiovascular disease (CVD), little is known of very low-density lipoprotein cholesterol (VLDL-C) relationship with atherosclerosis and CVD. We examined, in a high-risk type-2 diabetic population, the association of plasma VLDL-C with coronary artery calcification (CAC). METHODS The Penn Diabetes Heart Study (PDHS) is a cross-sectional study of CVD risk factors in type-2 diabetics (n = 2118, mean age 59.1 years, 36.5% female, 34.1% Black). Plasma lipids including VLDL-C were calculated (n = 1879) after ultracentrifugation. RESULTS In Tobit regression, VLDL-C levels were positively associated with increasing CAC after adjusting for age, race, gender, Framingham risk score, body mass index, C-reactive protein, exercise, medication and alcohol use, hemoglobin A1c, and diabetes duration [Tobit ratio (TR) and 95% confidence interval (CI) 0.38 (0.12-0.65), P = 0.005] and even after inclusion of apolipoprotein B data [TR 0.31 (0.03-0.58), P = 0.030]. Approximately 3-fold stronger effect was observed in women [TR 0.75 (0.16-1.34), P = 0.013] than men [TR 0.20 (-0.10-0.50), P = 0.189; gender interaction P = 0.034]. Plasma VLDL-C was related more strongly to CAC scores than TG levels (e.g., Akaike information criteria of 7263.65 vs. 7263.94) and had stronger CAC association in individuals with TGs >150 mg/dl (TR 0.80, P = 0.010) vs. those with TGs <150 mg/dl (TR 0.27, P = 0.185). CONCLUSIONS In PDHS, VLDL-C is associated with CAC independent of established CVD risk factors, particularly in women, and may have value even beyond apolipoprotein B levels and in patients with elevated TGs.
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Outcome of elective endovascular abdominal aortic aneurysm repair in octogenarians and nonagenarians. J Vasc Surg 2010; 51:1354-9. [DOI: 10.1016/j.jvs.2010.01.030] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Revised: 01/08/2010] [Accepted: 01/10/2010] [Indexed: 10/19/2022]
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