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Sample records for ejection fraction obtained

  1. Ejection Fraction Heart Failure Measurement

    MedlinePlus

    ... Thromboembolism Aortic Aneurysm More Ejection Fraction Heart Failure Measurement Updated:Feb 15,2017 The ejection fraction (EF) is an important measurement in determining how well your heart is pumping ...

  2. Ejection Fraction: What Does It Measure?

    MedlinePlus

    ... does the term "ejection fraction" mean? What does it measure? Answers from Rekha Mankad, M.D. Ejection fraction ... percentage of blood leaving your heart each time it contracts. During each heartbeat pumping cycle, the heart ...

  3. Comparison of left ventricular ejection fraction values obtained using invasive contrast left ventriculography, two-dimensional echocardiography, and gated single-photon emission computed tomography

    PubMed Central

    Garg, Nadish; Dresser, Thomas; Aggarwal, Kul; Gupta, Vishal; Mittal, Mayank K; Alpert, Martin A

    2016-01-01

    Objectives: Left ventricular ejection fraction can be measured by a variety of invasive and non-invasive cardiac techniques. This study assesses the relation of three diagnostic modalities to each other in the measurement of left ventricular ejection fraction: invasive contrast left ventriculography, two-dimensional echocardiography, and quantitative gated single-photon emission computed tomography. Methods: Retrospective chart review was conducted on 58 patients hospitalized with chest pain, who underwent left ventricular ejection fraction evaluation using each of the aforementioned modalities within a 3-month period not interrupted by myocardial infarction or revascularization. Results: The mean left ventricular ejection fraction values were as follows: invasive contrast left ventriculography (0.44±0.15), two-dimensional echocardiography (0.46±0.13), and gated single-photon emission computed tomography (0.37±0.10). Correlations coefficients and associated p values were as follows: invasive contrast left ventriculography versus two-dimensional echocardiography (r=0.69, p<0.001), invasive contrast left ventriculography versus gated single-photon emission computed tomography (r=0.80, p<0.0001), and gated single-photon emission computed tomography versus two-dimensional echocardiography (r=0.69, p<0.001). Conclusion: Our results indicate that strong positive correlations exist among the three techniques studied. PMID:27621804

  4. Optimal reproducibility of gated sestamibi and thallium myocardial perfusion study left ventricular ejection fractions obtained on a solid-state CZT cardiac camera requires operator input.

    PubMed

    Cherk, Martin H; Ky, Jason; Yap, Kenneth S K; Campbell, Patrina; McGrath, Catherine; Bailey, Michael; Kalff, Victor

    2012-08-01

    To evaluate the reproducibility of serial re-acquisitions of gated Tl-201 and Tc-99m sestamibi left ventricular ejection fraction (LVEF) measurements obtained on a new generation solid-state cardiac camera system during myocardial perfusion imaging and the importance of manual operator optimization of left ventricular wall tracking. Resting blinded automated (auto) and manual operator optimized (opt) LVEF measurements were measured using ECT toolbox (ECT) and Cedars-Sinai QGS software in two separate cohorts of 55 Tc-99m sestamibi (MIBI) and 50 thallium (Tl-201) myocardial perfusion studies (MPS) acquired in both supine and prone positions on a cadmium zinc telluride (CZT) solid-state camera system. Resting supine and prone automated LVEF measurements were similarly obtained in a further separate cohort of 52 gated cardiac blood pool scans (GCBPS) for validation of methodology and comparison. Appropriate use of Bland-Altman, chi-squared and Levene's equality of variance tests was used to analyse the resultant data comparisons. For all radiotracer and software combinations, manual checking and optimization of valve planes (+/- centre radius with ECT software) resulted in significant improvement in MPS LVEF reproducibility that approached that of planar GCBPS. No difference was demonstrated between optimized MIBI/Tl-201 QGS and planar GCBPS LVEF reproducibility (P = .17 and P = .48, respectively). ECT required significantly more manual optimization compared to QGS software in both supine and prone positions independent of radiotracer used (P < .02). Reproducibility of gated sestamibi and Tl-201 LVEF measurements obtained during myocardial perfusion imaging with ECT toolbox or QGS software packages using a new generation solid-state cardiac camera with improved image quality approaches that of planar GCBPS however requires visual quality control and operator optimization of left ventricular wall tracking for best results. Using this superior cardiac technology, Tl-201

  5. Heart failure with preserved ejection fraction

    PubMed Central

    ElGuindy, Ahmed; Yacoub, Magdi H

    2012-01-01

    Abstract Heart failure with preserved ejection fraction (HFpEF) has recently emerged as a major cause of cardiovascular morbidity and mortality. Contrary to initial beliefs, HFpEF is now known to be as common as heart failure with reduced ejection fraction (HFrEF) and carries an unacceptably high mortality rate. With a prevalence that has been steadily rising over the past two decades, it is very likely that HFpEF will represent the dominant heart failure phenotype over the coming few years. The scarcity of trials in this semi-discrete form of heart failure and lack of unified enrolment criteria in the studies conducted to date might have contributed to the current absence of specific therapies. Understanding the epidemiological, pathophysiological and molecular differences (and similarities) between these two forms of heart failure is cornerstone to the development of targeted therapies. Carefully designed studies that adhere to unified diagnostic criteria with the recruitment of appropriate controls and adoption of practical end-points are urgently needed to help identify effective treatment strategies. PMID:25610841

  6. Nontraumatic determination of left ventricular ejection fraction by radionuclide angiocardiography.

    PubMed

    Schelbert, H R; Verba, J W; Johnson, A D; Brock, G W; Alazraki, N P; Rose, F J; Ashburn, W L

    1975-05-01

    Previous reports have suggested that left ventricular ejection fraction can be assessed by recording the passage of peripherally administered radioactive bolus through the heart. The accuracy and validity of this technique were examined in 20 patients undergoing diagnostic cardiac catheterization. 99m-Tc-human serum albumin was injected via a central venous catheter into the superior vena cava and precordial activity recorded with a gamma scintillation camera interfaced to a small digital computer. A computer program was designed to generate time-activity curves from the left ventricular blood pool and to calculate left ventricular ejection fractions from the cyclic fluctuations of the left ventricular time-activity curve which correspond to left ventricular volume changes during each cardiac cycle. The results correlated well with those obtained by biplane cineangiocardiography (r equals 0.94) and indicated that the technique should allow accurate and reproducible determination of left ventricular ejection fraction. The findings, however, demonstrated that the time-activity curve must be generated from a region-of-interest which fits the left ventricular blood pool precisely and must be corrected for contributions arising from noncardiac background structures. This nontraumatic and potentially noninvasive technique appears particularly useful for serial evaluation of the acutely ill patient and for follow-up studies in nonhospitalized patients.

  7. Heart failure with reduced ejection fraction.

    PubMed

    Bloom, Michelle W; Greenberg, Barry; Jaarsma, Tiny; Januzzi, James L; Lam, Carolyn S P; Maggioni, Aldo P; Trochu, Jean-Noël; Butler, Javed

    2017-08-24

    Heart failure is a global public health problem that affects more than 26 million people worldwide. The global burden of heart failure is growing and is expected to increase substantially with the ageing of the population. Heart failure with reduced ejection fraction accounts for approximately 50% of all cases of heart failure in the United States and is associated with substantial morbidity and reduced quality of life. Several diseases, such as myocardial infarction, certain infectious diseases and endocrine disorders, can initiate a primary pathophysiological process that can lead to reduced ventricular function and to heart failure. Initially, ventricular impairment is compensated for by the activation of the sympathetic nervous system and the renin-angiotensin-aldosterone system, but chronic activation of these pathways leads to worsening cardiac function. The symptoms of heart failure can be associated with other conditions and include dyspnoea, fatigue, limitations in exercise tolerance and fluid accumulation, which can make diagnosis difficult. Management strategies include the use of pharmacological therapies and implantable devices to regulate cardiac function. Despite these available treatments, heart failure remains incurable, and patients have a poor prognosis and high mortality rate. Consequently, the development of new therapies is imperative and requires further research.

  8. Air pollution and heart failure: Relationship with the ejection fraction

    PubMed Central

    Dominguez-Rodriguez, Alberto; Abreu-Afonso, Javier; Rodríguez, Sergio; Juarez-Prera, Ruben A; Arroyo-Ucar, Eduardo; Gonzalez, Yenny; Abreu-Gonzalez, Pedro; Avanzas, Pablo

    2013-01-01

    AIM: To study whether the concentrations of particulate matter in ambient air are associated with hospital admission due to heart failure in patients with heart failure with preserved ejection fraction and reduced ejection fraction. METHODS: We studied 353 consecutive patients admitted into a tertiary care hospital with a diagnosis of heart failure. Patients with ejection fraction of ≥ 45% were classified as having heart failure with preserved ejection fraction and those with an ejection fraction of < 45% were classified as having heart failure with reduced ejection fraction. We determined the average concentrations of different sizes of particulate matter (< 10, < 2.5, and < 1 μm) and the concentrations of gaseous pollutants (carbon monoxide, sulphur dioxide, nitrogen dioxide and ozone) from 1 d up to 7 d prior to admission. RESULTS: The heart failure with preserved ejection fraction population was exposed to higher nitrogen dioxide concentrations compared to the heart failure with reduced ejection fraction population (12.95 ± 8.22 μg/m3 vs 4.50 ± 2.34 μg/m3, P < 0.0001). Multivariate analysis showed that nitrogen dioxide was a significant predictor of heart failure with preserved ejection fraction (odds ratio ranging from (1.403, 95%CI: 1.003-2.007, P = 0.04) to (1.669, 95%CI: 1.043-2.671, P = 0.03). CONCLUSION: This study demonstrates that short-term nitrogen dioxide exposure is independently associated with admission in the heart failure with preserved ejection fraction population. PMID:23538391

  9. Air pollution and heart failure: Relationship with the ejection fraction.

    PubMed

    Dominguez-Rodriguez, Alberto; Abreu-Afonso, Javier; Rodríguez, Sergio; Juarez-Prera, Ruben A; Arroyo-Ucar, Eduardo; Gonzalez, Yenny; Abreu-Gonzalez, Pedro; Avanzas, Pablo

    2013-03-26

    To study whether the concentrations of particulate matter in ambient air are associated with hospital admission due to heart failure in patients with heart failure with preserved ejection fraction and reduced ejection fraction. We studied 353 consecutive patients admitted into a tertiary care hospital with a diagnosis of heart failure. Patients with ejection fraction of ≥ 45% were classified as having heart failure with preserved ejection fraction and those with an ejection fraction of < 45% were classified as having heart failure with reduced ejection fraction. We determined the average concentrations of different sizes of particulate matter (< 10, < 2.5, and < 1 μm) and the concentrations of gaseous pollutants (carbon monoxide, sulphur dioxide, nitrogen dioxide and ozone) from 1 d up to 7 d prior to admission. The heart failure with preserved ejection fraction population was exposed to higher nitrogen dioxide concentrations compared to the heart failure with reduced ejection fraction population (12.95 ± 8.22 μg/m(3) vs 4.50 ± 2.34 μg/m(3), P < 0.0001). Multivariate analysis showed that nitrogen dioxide was a significant predictor of heart failure with preserved ejection fraction (odds ratio ranging from (1.403, 95%CI: 1.003-2.007, P = 0.04) to (1.669, 95%CI: 1.043-2.671, P = 0.03). This study demonstrates that short-term nitrogen dioxide exposure is independently associated with admission in the heart failure with preserved ejection fraction population.

  10. Noninvasive iPhone Measurement of Left Ventricular Ejection Fraction Using Intrinsic Frequency Methodology.

    PubMed

    Pahlevan, Niema M; Rinderknecht, Derek G; Tavallali, Peyman; Razavi, Marianne; Tran, Thao T; Fong, Michael W; Kloner, Robert A; Csete, Marie; Gharib, Morteza

    2017-07-01

    The study is based on previously reported mathematical analysis of arterial waveform that extracts hidden oscillations in the waveform that we called intrinsic frequencies. The goal of this clinical study was to compare the accuracy of left ventricular ejection fraction derived from intrinsic frequencies noninvasively versus left ventricular ejection fraction obtained with cardiac MRI, the most accurate method for left ventricular ejection fraction measurement. After informed consent, in one visit, subjects underwent cardiac MRI examination and noninvasive capture of a carotid waveform using an iPhone camera (The waveform is captured using a custom app that constructs the waveform from skin displacement images during the cardiac cycle.). The waveform was analyzed using intrinsic frequency algorithm. Outpatient MRI facility. Adults able to undergo MRI were referred by local physicians or self-referred in response to local advertisement and included patients with heart failure with reduced ejection fraction diagnosed by a cardiologist. Standard cardiac MRI sequences were used, with periodic breath holding for image stabilization. To minimize motion artifact, the iPhone camera was held in a cradle over the carotid artery during iPhone measurements. Regardless of neck morphology, carotid waveforms were captured in all subjects, within seconds to minutes. Seventy-two patients were studied, ranging in age from 20 to 92 years old. The main endpoint of analysis was left ventricular ejection fraction; overall, the correlation between ejection fraction-iPhone and ejection fraction-MRI was 0.74 (r = 0.74; p < 0.0001; ejection fraction-MRI = 0.93 × [ejection fraction-iPhone] + 1.9). Analysis of carotid waveforms using intrinsic frequency methods can be used to document left ventricular ejection fraction with accuracy comparable with that of MRI. The measurements require no training to perform or interpret, no calibration, and can be repeated at the bedside to generate almost

  11. Is heart failure with midrange ejection fraction similar to preserved ejection fraction? Against.

    PubMed

    Formiga, F

    2017-03-14

    The new European guidelines (2016) for heart failure (HF) include the concept of HF with intermediate left ventricular ejection fraction (LVEF), i.e. an LVEF between 40 and 49%. Although few studies have been carried out, there are claims that HF with intermediate LVEF is not the same as HF with preserved LVEF. Perhaps the most consistent claim is the high percentage of associated ischemic heart disease, which could reflect LVEF recovery after adequate anti-ischemic treatment of HF with depressed LVEF, or even the progressive deterioration of LVEF following an ischemic event.

  12. Videodensitometric ejection fraction from intravenous digital subtraction right ventriculograms: correlation with first pass radionuclide ejection fraction

    SciTech Connect

    Detrano, R.; MacIntyre, W.; Salcedo, E.E.; O'Donnell, J.; Underwood, D.A.; Simpfendorfer, C.; Go, R.T.; Butters, K.; Withrow, S.

    1985-06-01

    Thirty-one consecutive patients undergoing intravenous blurred mask digital subtraction right ventriculography were submitted to first pass radionuclide angiography. Second order mask resubtraction of end-diastolic and end-systolic right ventricular digital image frames was executed using preinjection end-diastolic and end-systolic frames to rid the digital subtraction images of mis-registration artifact. End-diastolic and end-systolic perimeters were drawn manually by two independent observers with a light pen. Ejection fractions calculated from the integrated videodensitometric counts within these perimeters correlated well with those derived from the first pass radionuclide right ventriculogram (r = 0.84) and the interobserver correlation was acceptable (r = 0.91). Interobserver differences occurred more frequently in patients with atrial fibrillation and in those whose tricuspid valve planes were difficult to discern on the digital subtraction right ventriculograms. These results suggest that videodensitometric analysis of digital subtraction right ventriculograms is an accurate method of determining right ventricular ejection fraction and may find wide clinical applicability.

  13. Classification of Contextual Use of Left Ventricular Ejection Fraction Assessments.

    PubMed

    Kim, Youngjun; Garvin, Jennifer; Goldstein, Mary K; Meystre, Stéphane M

    2015-01-01

    Knowledge of the left ventricular ejection fraction is critical for the optimal care of patients with heart failure. When a document contains multiple ejection fraction assessments, accurate classification of their contextual use is necessary to filter out historical findings or recommendations and prioritize the assessments for selection of document level ejection fraction information. We present a natural language processing system that classifies the contextual use of both quantitative and qualitative left ventricular ejection fraction assessments in clinical narrative documents. We created support vector machine classifiers with a variety of features extracted from the target assessment, associated concepts, and document section information. The experimental results showed that our classifiers achieved good performance, reaching 95.6% F1-measure for quantitative assessments and 94.2% F1-measure for qualitative assessments in a five-fold cross-validation evaluation.

  14. Assessment of poststress left ventricular ejection fraction by gated SPECT: comparison with equilibrium radionuclide angiocardiography.

    PubMed

    Acampa, Wanda; Caprio, Maria Grazia; Nicolai, Emanuele; Liuzzi, Raffaele; De Luca, Serena; Capasso, Enza; Luongo, Luca; Petretta, Mario; Cuocolo, Alberto

    2010-02-01

    We compared left ventricular (LV) ejection fraction obtained by gated SPECT with that obtained by equilibrium radionuclide angiocardiography in a large cohort of patients. Within 1 week, 514 subjects with suspected or known coronary artery disease underwent same-day stress-rest (99m)Tc-sestamibi gated SPECT and radionuclide angiocardiography. For both studies, data were acquired 30 min after completion of exercise and after 3 h rest. In the overall study population, a good correlation between ejection fraction measured by gated SPECT and by radionuclide angiocardiography was observed at rest (r=0.82, p<0.0001) and after stress (r=0.83, p<0.0001). In Bland-Altman analysis, the mean differences in ejection fraction (radionuclide angiocardiography minus gated SPECT) were -0.6% at rest and 1.7% after stress. In subjects with normal perfusion (n=362), a good correlation between ejection fraction measured by gated SPECT and by radionuclide angiocardiography was observed at rest (r=0.72, p<0.0001) and after stress (r=0.70, p<0.0001) and the mean differences in ejection fraction were -0.9% at rest and 1.4% after stress. Also in patients with abnormal perfusion (n=152), a good correlation between the two techniques was observed both at rest (r=0.89, p<0.0001) and after stress (r=0.90, p<0.0001) and the mean differences in ejection fraction were 0.1% at rest and 2.5% after stress. In a large study population, a good agreement was observed in the evaluation of LV ejection fraction between gated SPECT and radionuclide angiocardiography. However, in patients with perfusion abnormalities, a slight underestimation in poststress LV ejection fraction was observed using gated SPECT as compared to equilibrium radionuclide angiocardiography.

  15. Biomarkers of Heart Failure with Preserved and Reduced Ejection Fraction.

    PubMed

    Senni, Michele; D'Elia, Emilia; Emdin, Michele; Vergaro, Giuseppe

    2017-02-09

    Biomarkers are increaingly being used in the management of heart failure not only for the purpose of screening, diagnosis, and risk stratification, but also as a guide to evaluate the response to treatment in the individual patient and as an entry criterion and/or a surrogate marker of efficacy in clinical trials testing novel drugs. In this chapter, we review the role of established biomarkers for heart failure management, according to the main classification of HF phenotypes, based on the measurement of left ventricular ejection fraction, including heart failure with reduced (<40%), preserved (≥50%), and, as recently proposed, mid-range (40-49%) ejection fraction.

  16. Diagnosis of heart failure with preserved ejection fraction.

    PubMed

    Wachter, Rolf; Edelmann, Frank

    2014-07-01

    Heart failure with preserved ejection fraction (HFpEF) constitutes a growing health care burden worldwide. Although definitions vary somewhat among guidelines, in general the presence of typical heart failure symptoms and signs in combination with a preserved left ventricular ejection fraction (≥50%) and functional and/or structural left ventricular changes makes the diagnosis likely. This review focuses on the current understanding of diagnostic criteria, as presented in current guidelines and consensus recommendations, and on new insights from recent papers. The role of comorbidities that often contribute to symptoms and hamper the HFpEF diagnostics is also reviewed.

  17. Heart Failure with Preserved Ejection Fraction: Diagnosis and Management.

    PubMed

    Oren, Ohad; Goldberg, Sheldon

    2017-05-01

    Heart failure with preserved ejection fraction (HFpEF) is a prevalent condition with substantial individual and societal burden. In this article, we review the current status of understanding of HFpEF, focusing on the challenges and uncertainties regarding diagnosis and treatment. We then propose a scientific roadmap to facilitate research that may translate into improved clinical outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

  18. Pharmacotherapy of heart failure with preserved ejection fraction.

    PubMed

    Basaraba, Jade E; Barry, Arden R

    2015-04-01

    Heart failure with preserved ejection fraction (HFpEF) constitutes ~50% of all heart failure diagnoses and is associated with considerable morbidity and mortality. The treatment of HFpEF can be challenging due to a lack of evidence supporting the benefit of various drug therapies. In practice, treatment can be divided into acute and chronic management. Acute therapy for decompensated heart failure is similar for both HFpEF and heart failure with reduced ejection fraction. The mainstay of treatment is diuretics to reduce volume overload and improve dyspnea. Patients with an acute exacerbation of HFpEF and rapid atrial fibrillation (AF) should be rate controlled with negative chronotropic agents. For chronic therapy, patients with HFpEF should not be treated like patients with heart failure with reduced ejection fraction. Chronic management of HFpEF can be simplified by using three strategies based on applicability: treat precipitating conditions (e.g., hypertension, AF), control symptoms by maintaining euvolemia with diuretics, and avoid therapies that have been shown not to be beneficial unless another compelling indication exists. Nondrug interventions for HFpEF include salt and fluid restriction, regular physical activity, and referral to a heart function clinic, if appropriate.

  19. How Do Videodensitometric Ejection Fractions From Intravenous Digital Subtraction Ventriculograms Compare With First Pass Radionuclide Ejection Fractions? (Technical Aspects)

    NASA Astrophysics Data System (ADS)

    Detrano, Robert; MacIntyre, William; MacIntyre, Raymond; Jones, Houston; Withrow, Susan; Simpfendorfer, Conrad; Salcedo, Ernesto E.; Lando, Anthony

    1985-06-01

    Three major errors implicit in the determination of ejection fractions from videodensi-tometric analysis of intravenous digital subtraction ventriculograms are errors due to: (1) nonlinear transfer of densitometric information about relative volumes, (2) inadequate background subtraction and (3) overlapping atrial contrast. Nonlinear errors associated with our imaging system were estimated using balloon phantoms in a water bath. These were small for a tube voltage of 90 kV and an iodine concentration of approximately 37 mg/cc commonly used in clinical studies. Background subtraction errors are approached by using phase matched second order mask images temporally close to the contrast images. Atrial overlap errors remain a significant problem. However, videodensitometric ejection frac-tions from intravenous digital studies correlated well with first pass right ventriculo-grams (r = 0.84) and left ventriculograms (r = 0.85).

  20. Extracellular Volume Fraction for Characterization of Patients With Heart Failure and Preserved Ejection Fraction.

    PubMed

    Rommel, Karl-Philipp; von Roeder, Maximilian; Latuscynski, Konrad; Oberueck, Christian; Blazek, Stephan; Fengler, Karl; Besler, Christian; Sandri, Marcus; Lücke, Christian; Gutberlet, Matthias; Linke, Axel; Schuler, Gerhard; Lurz, Philipp

    2016-04-19

    Optimal patient characterization in heart failure with preserved ejection fraction (HFpEF) is essential to tailor successful treatment strategies. Cardiac magnetic resonance (CMR)-derived T1 mapping can noninvasively quantify diffuse myocardial fibrosis as extracellular volume fraction (ECV). This study aimed to elucidate the diagnostic performance of T1 mapping in HFpEF by examining the relationship between ECV and invasively measured parameters of diastolic function. It also investigated the potential of ECV to differentiate among pathomechanisms in HFpEF. We performed T1 mapping in 24 patients with HFpEF and 12 patients without heart failure symptoms. Pressure-volume loops were obtained with a conductance catheter during basal conditions and handgrip exercise. Transient pre-load reduction was used to extrapolate the diastolic stiffness constant. Patients with HFpEF showed higher ECV (p < 0.01), elevated load-independent passive left ventricular (LV) stiffness constant (beta) (p < 0.001), and a longer time constant of active LV relaxation (p = 0.02). ECV correlated highly with beta (r = 0.75; p < 0.001). Within the HFpEF cohort, patients with ECV greater than the median showed a higher beta (p = 0.05), whereas ECV below the median identified patients with prolonged active LV relaxation (p = 0.01) and a marked hypertensive reaction to exercise due to pathologic arterial elastance (p = 0.04). On multiple linear regression analyses, ECV independently predicted intrinsic LV stiffness (β = 0.75; p < 0.01). Diffuse myocardial fibrosis, assessed by CMR-derived T1 mapping, independently predicts invasively measured LV stiffness in HFpEF. Additionally, ECV helps to noninvasively distinguish the role of passive stiffness and hypertensive exercise response with impaired active relaxation. (Left Ventricular Stiffness vs. Fibrosis Quantification by T1 Mapping in Heart Failure With Preserved Ejection Fraction [STIFFMAP]; NCT02459626). Copyright © 2016 American College of

  1. Exercise physiology in heart failure and preserved ejection fraction.

    PubMed

    Haykowsky, Mark J; Kitzman, Dalane W

    2014-07-01

    Recent advances in the pathophysiology of exercise intolerance in patients with heart failure with preserved ejection fraction (HFPEF) suggest that noncardiac peripheral factors contribute to the reduced peak V(o2) (peak exercise oxygen uptake) and to its improvement after endurance exercise training. A greater understanding of the peripheral skeletal muscle vascular adaptations that occur with physical conditioning may allow for tailored exercise rehabilitation programs. The identification of specific mechanisms that improve whole body and peripheral skeletal muscle oxygen uptake could establish potential therapeutic targets for medical therapies and a means to follow therapeutic response.

  2. Spironolactone for heart failure with preserved ejection fraction.

    PubMed

    Pitt, Bertram; Pfeffer, Marc A; Assmann, Susan F; Boineau, Robin; Anand, Inder S; Claggett, Brian; Clausell, Nadine; Desai, Akshay S; Diaz, Rafael; Fleg, Jerome L; Gordeev, Ivan; Harty, Brian; Heitner, John F; Kenwood, Christopher T; Lewis, Eldrin F; O'Meara, Eileen; Probstfield, Jeffrey L; Shaburishvili, Tamaz; Shah, Sanjiv J; Solomon, Scott D; Sweitzer, Nancy K; Yang, Song; McKinlay, Sonja M

    2014-04-10

    Mineralocorticoid-receptor antagonists improve the prognosis for patients with heart failure and a reduced left ventricular ejection fraction. We evaluated the effects of spironolactone in patients with heart failure and a preserved left ventricular ejection fraction. In this randomized, double-blind trial, we assigned 3445 patients with symptomatic heart failure and a left ventricular ejection fraction of 45% or more to receive either spironolactone (15 to 45 mg daily) or placebo. The primary outcome was a composite of death from cardiovascular causes, aborted cardiac arrest, or hospitalization for the management of heart failure. With a mean follow-up of 3.3 years, the primary outcome occurred in 320 of 1722 patients in the spironolactone group (18.6%) and 351 of 1723 patients in the placebo group (20.4%) (hazard ratio, 0.89; 95% confidence interval [CI], 0.77 to 1.04; P=0.14). Of the components of the primary outcome, only hospitalization for heart failure had a significantly lower incidence in the spironolactone group than in the placebo group (206 patients [12.0%] vs. 245 patients [14.2%]; hazard ratio, 0.83; 95% CI, 0.69 to 0.99, P=0.04). Neither total deaths nor hospitalizations for any reason were significantly reduced by spironolactone. Treatment with spironolactone was associated with increased serum creatinine levels and a doubling of the rate of hyperkalemia (18.7%, vs. 9.1% in the placebo group) but reduced hypokalemia. With frequent monitoring, there were no significant differences in the incidence of serious adverse events, a serum creatinine level of 3.0 mg per deciliter (265 μmol per liter) or higher, or dialysis. In patients with heart failure and a preserved ejection fraction, treatment with spironolactone did not significantly reduce the incidence of the primary composite outcome of death from cardiovascular causes, aborted cardiac arrest, or hospitalization for the management of heart failure. (Funded by the National Heart, Lung, and Blood

  3. Invasive hemodynamic characterization of heart failure with preserved ejection fraction.

    PubMed

    Andersen, Mads J; Borlaug, Barry A

    2014-07-01

    Recent hemodynamic studies have advanced our understanding of heart failure with preserved ejection fraction (HFpEF). Despite improved pathophysiologic insight, clinical trials have failed to identify an effective treatment for HFpEF. Invasive hemodynamic assessment can diagnose or exclude HFpEF, making it invaluable in understanding the basis of the disease. This article reviews the hemodynamic mechanisms underlying HFpEF and how they manifest clinically, discusses invasive hemodynamic assessment as a diagnostic tool, and explores how invasive hemodynamic profiling may allow understanding of pathophysiological differences and inform the design and entry criteria for future trials. Copyright © 2014 Elsevier Inc. All rights reserved.

  4. Right ventricular ejection fraction: an indicator of increased mortality in patients with congestive heart failure associated with coronary artery disease

    SciTech Connect

    Polak, J.F.; Holman, B.L.; Wynne, J.; Colucci, W.S.

    1983-08-01

    The predictive value of radionuclide ventriculography was studied in 34 patients with depressed left ventricular ejection fraction (less than 40%) and clinically evident congestive heart failure secondary to atherosclerotic coronary artery disease. In addition to left ventricular ejection fraction, right ventricular ejection fraction and extent of left ventricular paradox were obtained in an attempt to identify a subgroup at increased risk of mortality during the ensuing months. The 16 patients who were alive after a 2 year follow-up period had a higher right ventricular ejection fraction and less extensive left ventricular dyskinesia. When a right ventricular ejection fraction of less than 35% was used as a discriminant, mortality was significantly greater among the 21 patients with a depressed right ventricular ejection fraction (71 versus 23%), a finding confirmed by a life table analysis. It appears that the multiple factors contributing to the reduction in right ventricular ejection fraction make it a useful index not only for assessing biventricular function, but also for predicting patient outcome.

  5. The interval ejection fraction: a cineangiographic and radionuclide study

    SciTech Connect

    Kemper, A.J.; Bianco, J.A.; Shulman, R.M.; Folland, E.D.; Parisi, A.F.; Tow, D.E.

    1982-06-01

    To evaluate the clinical usefulness of the first-third ejection fraction (1/3 EF) for detecting patients with coronary artery disease (CAD), resting contrast ventriculography and first-pass radionuclide angiography with a high-count-rate, multicrystal camera system were performed in 47 subjects: 22 normal controls and 25 patients with clinically stable angina pectoris and severe CAD without and with resting wall motion abnormalities. By contrast angiography, only group 3 had depressed global EF or 1/3 EF compared with control. Whereas 11 of 25 CAD patients had global EF outside the normal range, only two of 25 had depressed 1/3 EF. Both had left ventricular asynergy and a depressed global EF. Studies performed using first-pass radionuclide angiography revealed similar results. A wide range of 1/3 EF values was found in normal subjects by both techniques. Thus, the ejection fraction during the first third of systole at rest is of limited value for detecting patients with CAD.

  6. Epidemiology of heart failure with preserved ejection fraction.

    PubMed

    Dunlay, Shannon M; Roger, Véronique L; Redfield, Margaret M

    2017-10-01

    Heart failure (HF) with preserved ejection fraction (HFpEF) is a clinical syndrome associated with poor quality of life, substantial health-care resource utilization, and premature mortality. We summarize the current knowledge regarding the epidemiology of HFpEF with a focus on community-based studies relevant to quantifying the population burden of HFpEF. Current data regarding the prevalence and incidence of HFpEF in the community as well as associated conditions and risk factors, risk of morbidity and mortality after diagnosis, and quality of life are presented. In the community, approximately 50% of patients with HF have HFpEF. Although the age-specific incidence of HF is decreasing, this trend is less dramatic for HFpEF than for HF with reduced ejection fraction (HFrEF). The risk of HFpEF increases sharply with age, but hypertension, obesity, and coronary artery disease are additional risk factors. After adjusting for age and other risk factors, the risk of HFpEF is fairly similar in men and women, whereas the risk of HFrEF is much lower in women. Multimorbidity is common in both types of HF, but slightly more severe in HFpEF. A majority of deaths in patients with HFpEF are cardiovascular, but the proportion of noncardiovascular deaths is higher in HFpEF than HFrEF.

  7. Ejection Fraction and ESPVR. A study from a theoretical perspective.

    PubMed

    Shoucri, Rachad M

    2013-01-01

    A formula derived by using large elastic deformation for the contraction of the myocardium is used to describe the pressure-volume relation (PVR) in the heart left ventricle, it is also used to calculate a mathematical expression for the non-linear end-systolic pressure-volume relation (ESPVR) in the left ventricle. An important feature of the mathematical formalism used is the inclusion of the isovolumic pressure Piso (equal active pressure generated by the myocardium) in the formalism describing the PVR. Relations between the ejection fraction (EF) and parameters describing the non-linear ESPVR are presented. It is shown that the non-linear ESPVR offers a rich collection of parameters that can be used to study the performance of the ventricles, like the areas under the ESPVR (units of energy) or the ordinates of the ESPVR (units of pressure), slopes and intercepts of the curves involved. The mathematical procedure can be easily implemented in a non-invasive way in routine clinical work when ratios of variables are calculated, it necessitates only the non-invasive measurement of the dimensions of the ventricles. Applications to clinical data published in the literature are presented, and they give results that show the consistency of the mathematical formalism used. The implications of the results of this research work on the study of the problem of heart failure with normal or preserved ejection fraction (HFpEF) are discussed.

  8. Two-dimensional echocardiographic assessment of left ventricular volumes and ejection fraction in children

    SciTech Connect

    Mercier, J.C.; DiSessa, T.G.; Jarmakani, J.M.; Nakanishi, T.; Hiraishi, S.; Isabel-Jones, J.; Friedman, W.F.

    1982-05-01

    The ability of two-dimensional echocardiography to measure left ventricular volumes and ejection fraction was evaluated in 25 children with congenital heart disease. Dimensions and planimetered areas were obtained in the short-axis view at the mitral valve and high and low papillary muscle levels and in the apical two- and four-chamber views. Eight algorithms using five geometric models were assessed. Left ventricular end-diastolic volume, end-systolic volume and ejection fraction were compared with data from biplane cineangiocardiograms. The correlation varied with the algorithm used. Algorithms using short-axis views appeared superior to those using only apical long-axis views. Four algorithms estimated left ventricular volumes with equal accuracy (Simpson's rule, assuming the ventricle to be a truncated cone; Simpson's rule, algorithm that best estimated left ventricular ejection fraction was the ellipsoid biplane formula using the short-axis view at the papillary muscle level (r = 0.91, slope = 0.94, SEE = 6.7%). Thus, two-dimensional echocardiography can accurately assess left ventricular volumes and ejection fraction in children with congenital heart disease.

  9. Assessment of left ventricular ejection fraction by radionuclide angiography. Comparison to echocardiography and serial measurements in patients with myocardial infarction

    NASA Technical Reports Server (NTRS)

    Schelbert, H. R.; Henning, H.; Orourke, R. A.; Ashburn, W. L.

    1975-01-01

    Measurements of the left ventricular ejection fraction were compared in patients with previous myocardial infarctions. Left ventricular ejection fraction was measured by the radioisotopic method serially in patients early after an acute myocardial infarction and during the convalescence period. Ultrasound recordings were obtained utilizing a commercially available ultrasonoscope and a 1/9 cm transducer focused at 10 cm with a repetition rate of 1000 impulses per second. All recordings were made on a visicorder oscillography.

  10. Assessment of left ventricular ejection fraction by radionuclide angiography. Comparison to echocardiography and serial measurements in patients with myocardial infarction

    NASA Technical Reports Server (NTRS)

    Schelbert, H. R.; Henning, H.; Orourke, R. A.; Ashburn, W. L.

    1975-01-01

    Measurements of the left ventricular ejection fraction were compared in patients with previous myocardial infarctions. Left ventricular ejection fraction was measured by the radioisotopic method serially in patients early after an acute myocardial infarction and during the convalescence period. Ultrasound recordings were obtained utilizing a commercially available ultrasonoscope and a 1/9 cm transducer focused at 10 cm with a repetition rate of 1000 impulses per second. All recordings were made on a visicorder oscillography.

  11. Right heart dysfunction in heart failure with preserved ejection fraction

    PubMed Central

    Melenovsky, Vojtech; Hwang, Seok-Jae; Lin, Grace; Redfield, Margaret M.; Borlaug, Barry A.

    2014-01-01

    Aim Right heart function is not well characterized in patients with heart failure and preserved ejection fraction (HFpEF). The goal of this study was to examine the haemodynamic, clinical, and prognostic correlates of right ventricular dysfunction (RVD) in HFpEF. Methods and results Heart failure and preserved ejection fraction patients (n = 96) and controls (n = 46) underwent right heart catheterization, echocardiographic assessment, and follow-up. Right and left heart filling pressures, pulmonary artery (PA) pressures, and right-sided chamber dimensions were higher in HFpEF compared with controls, while left ventricular size and EF were similar. Right ventricular dysfunction (defined by RV fractional area change, FAC <35%) was present in 33% of HFpEF patients and was associated with more severe symptoms and greater comorbidity burden. Right ventricular function was impaired in HFpEF compared with controls using both load-dependent (FAC: 40 ± 10 vs. 53 ± 7%, P < 0.0001) and load-independent indices (FAC adjusted to PA pressure, P = 0.003), with enhanced afterload-sensitivity compared with controls (steeper FAC vs. PA pressure relationship). In addition to haemodynamic load, RVD in HFpEF was associated with male sex, atrial fibrillation, coronary disease, and greater ventricular interdependence. Over a median follow-up of 529 days (IQR: 143–1066), 31% of HFpEF patients died. In Cox analysis, RVD was the strongest predictor of death (HR: 2.4, 95% CI: 1.6–2.6; P < 0.0001). Conclusion Right heart dysfunction is common in HFpEF and is caused by both RV contractile impairment and afterload mismatch from pulmonary hypertension. Right ventricular dysfunction in HFpEF develops with increasing PA pressures, atrial fibrillation, male sex, and left ventricular dysfunction, and may represent a novel therapeutic target. PMID:24875795

  12. The Association Between Alcohol Consumption and Left Ventricular Ejection Fraction

    PubMed Central

    Li, Zhao; Guo, Xiaofan; Bai, Yinglong; Sun, Guozhe; Guan, Yufan; Sun, Yingxian; Roselle, Abraham Maria

    2016-01-01

    Abstract The results of previous studies on the relation between alcohol consumption and heart failure (HF) have been inconsistent. This study aimed to evaluate the association between alcohol consumption and left ventricular ejection fraction (LVEF) in a general population. A total of 10,824 adults were examined using a multistage cluster sampling method to select a representative sample of individuals who were at least 35-years old. The participants were asked to provide information about their alcohol consumption. Echocardiograms were obtained, and LVEF was calculated using modified Simpson's rule. Of the 10,824 participants included in the present study, 46.1% were males, and the mean participant age was 54 years; age ranged from 35 to 93 years. The overall prevalence of LVEF< 0.50 and LVEF < 0.40 in the studied population was 11.6% and 2.9%, respectively. The prevalence of LVEF < 0.5 and LVEF < 0.04 was higher in both the moderate and heavy drinker groups than in the nondrinker group (P <0.05). Multivariate logistic regression analyses corrected according to the different levels of alcohol consumption showed that moderate and heavy drinkers had an –1.3-fold and 1.2-fold higher risk of LVEF <0.5, respectively, than nondrinkers (OR: 1.381, 95% CI: 1.115–1.711, P = 0.003 for moderate drinkers; OR: 1.246, 95% CI: 1.064–1.460, P = 0.006 for heavy drinkers). Heavy drinkers had an ∼1.5-fold higher risk of decreased LVEF < 0.4 than nondrinkers (OR: 1.482, 95% CI: 1.117–1.965, P = 0.006). Moderate drinkers did not show a risk of decreased LVEF < 0.4 that was significantly higher than that of nondrinkers (OR: 1.183, 95% CI: 0.774–1.808, P = 0.437). According to these results, we concluded that increased alcohol consumption was associated with decreased LVEF compared with no alcohol consumption in this general population. PMID:27227945

  13. Isosorbide Mononitrate in Heart Failure with Preserved Ejection Fraction

    PubMed Central

    Redfield, Margaret M.; Anstrom, Kevin J.; Levine, James A.; Koepp, Gabe A.; Borlaug, Barry A.; Chen, Horng H.; LeWinter, Martin M.; Joseph, Susan M.; Shah, Sanjiv J.; Semigran, Marc J.; Felker, G. Michael; Cole, Robert T.; Reeves, Gordon R.; Tedford, Ryan J.; Tang, W.H. Wilson; McNulty, Steven E.; Velazquez, Eric J.; Shah, Monica R.; Braunwald, Eugene

    2015-01-01

    BACKGROUND Nitrates are commonly prescribed to enhance activity tolerance in patients with heart failure and a preserved ejection fraction. We compared the effect of isosorbide mononitrate or placebo on daily activity in such patients. METHODS In this multicenter, double-blind, crossover study, 110 patients with heart failure and a preserved ejection fraction were randomly assigned to a 6-week dose-escalation regimen of isosorbide mononitrate (from 30 mg to 60 mg to 120 mg once daily) or placebo, with subsequent crossover to the other group for 6 weeks. The primary end point was the daily activity level, quantified as the average daily accelerometer units during the 120-mg phase, as assessed by patient-worn accelerometers. Secondary end points included hours of activity per day during the 120-mg phase, daily accelerometer units during all three dose regimens, quality-of-life scores, 6-minute walk distance, and levels of N-terminal pro–brain natriuretic peptide (NT-proBNP). RESULTS In the group receiving the 120-mg dose of isosorbide mononitrate, as compared with the placebo group, there was a nonsignificant trend toward lower daily activity (−381 accelerometer units; 95% confidence interval [CI], −780 to 17; P = 0.06) and a significant decrease in hours of activity per day (−0.30 hours; 95% CI, −0.55 to −0.05; P = 0.02). During all dose regimens, activity in the isosorbide mononitrate group was lower than that in the placebo group (−439 accelerometer units; 95% CI, −792 to −86; P = 0.02). Activity levels decreased progressively and significantly with increased doses of isosorbide mononitrate (but not placebo). There were no significant between-group differences in the 6-minute walk distance, quality-of-life scores, or NT-proBNP levels. CONCLUSIONS Patients with heart failure and a preserved ejection fraction who received isosorbide mononitrate were less active and did not have better quality of life or submaximal exercise capacity than did

  14. Systems Biology Applied to Heart Failure With Normal Ejection Fraction

    PubMed Central

    Mesquita, Evandro Tinoco; Jorge, Antonio Jose Lagoeiro; de Souza, Celso Vale; Cassino, João Paulo Pedroza

    2014-01-01

    Heart failure with normal ejection fraction (HFNEF) is currently the most prevalent clinical phenotype of heart failure. However, the treatments available have shown no reduction in mortality so far. Advances in the omics sciences and techniques of high data processing used in molecular biology have enabled the development of an integrating approach to HFNEF based on systems biology. This study aimed at presenting a systems-biology-based HFNEF model using the bottom-up and top-down approaches. A literature search was conducted for studies published between 1991 and 2013 regarding HFNEF pathophysiology, its biomarkers and systems biology. A conceptual model was developed using bottom-up and top-down approaches of systems biology. The use of systems-biology approaches for HFNEF, a complex clinical syndrome, can be useful to better understand its pathophysiology and to discover new therapeutic targets. PMID:24918915

  15. Heart failure with preserved ejection fraction and skeletal muscle physiology.

    PubMed

    Farris, Stephen D; Moussavi-Harami, Farid; Stempien-Otero, April

    2017-03-01

    Heart failure with preserved ejection fraction (HFpEF) accounts for half of all heart failure in the USA, increases in prevalence with aging, and has no effective therapies. Intriguingly, the pathophysiology of HFpEF has many commonalities with the aged cardiovascular system including reductions in diastolic compliance, chronotropic defects, increased resistance in the peripheral vasculature, and poor energy substrate utilization. Decreased exercise capacity is a cardinal symptom of HFpEF. However, its severity is often out of proportion to changes in cardiac output. This observation has led to studies of muscle function in HFpEF revealing structural, biomechanical, and metabolic changes. These data, while incomplete, support a hypothesis that similar to aging, HFPEF is a systemic process. Understanding the mechanisms leading to exercise intolerance in this condition may lead to strategies to improve morbidity in both HFpEF and aging.

  16. Interval ejection fraction: a cineangiographic and radionuclide study

    SciTech Connect

    Kemper, A.J.; Bianco, J.A.; Shulman, R.M.; Folland, E.D.; Paris, A.F.; Tow, D.E.

    1982-06-01

    To evaluate the clinical usefulness of the first-third ejection fraction (1/3 EF) for detecting patients with coronary artery disease (CAD), resting contrast ventriculography and first-pass radionuclide angiography with a high-count-rate, multicrystal camera system were performed in 47 subjects: 22 normal controls (group 1) and 25 patients with clinically stable angina pectoris and severe CAD (mean 2.3 vessels) without (group 2, n = 12) and with (group 3, n = 13) resting wall motion abnormalities. By contrast angiography, only group 3 had depressed global EF or 1/3 EF compared with control (global EF: group 1, 0.71 = 0.09; group 2, 0.67 = 0.09 (NS); group 3, 0.49 = 0.05 (p < 0.01 vs groups 1 and 2); 1/3 EF: group 1, 0.29 = 0.06; group 2, 0.28 = 0.05 (NS); group 3, 0.22 = 0.05 (p < 0.01 vs groups 1 and 2)). Whereas 11 of 25 CAD patients had global EF outside the normal range, only two of 25 had depressed 1/3 EF. Both had left ventricular asynergy and a depressed global EF. Studies performed using first-pass radionuclide angiography revealed similar results, i.e., only four of 25 CAD patients, all with left ventricular asynergy and depressed global EF, had depressed 1/3 EF values. A wide range of 1/3 EF values was found in normal subjects by both techniques. Thus, the ejection fraction during the first third of systole at rest is of limited value for detecting patients with CAD.

  17. Heart failure with preserved ejection fraction: emerging drug strategies.

    PubMed

    Zouein, Fouad A; de Castro Brás, Lisandra E; da Costa, Danielle V; Lindsey, Merry L; Kurdi, Mazen; Booz, George W

    2013-07-01

    Approximately half of heart failure patients have a normal ejection fraction, a condition designated as heart failure with preserved ejection fraction (HFpEF). This heart failure subtype disproportionately affects women and the elderly and is commonly associated with other cardiovascular comorbidities, such as hypertension and diabetes. HFpEF is increasing at a steady rate and is predicted to become the leading cause of heart failure within a decade. HFpEF is characterized by impaired diastolic function, thought to be due to concentric remodeling of the heart along with increased stiffness of both the extracellular matrix and myofilaments. In addition, oxidative stress and inflammation are thought to have a role in HFpEF progression, along with endothelial dysfunction and impaired nitric oxide-cyclic guanosine monophosphate-protein kinase G signaling. Surprisingly a number of clinical studies have failed to demonstrate any benefit of drugs effective in heart failure with systolic dysfunction in HFpEF patients. Thus, HFpEF is one of the largest unmet needs in cardiovascular medicine, and there is a substantial need for new therapeutic approaches and strategies that target mechanisms specific for HFpEF. This conclusion is underscored by the recently reported disappointing results of the RELAX trial, which assessed the use of phosphodiesterase-5 inhibitor sildenafil for treating HFpEF. In animal models, endothelial nitric oxide synthase activators and If current inhibitors have shown benefit in improving diastolic function, and there is a rationale for assessing matrix metalloproteinase 9 inhibitors and nitroxyl donors. LCZ696, a combination drug of angiotensin II receptor blocker and neprilysin inhibitor, and the aldosterone receptor antagonist spironolactone are currently in clinical trial for treating HFpEF. Here we present an overview of the etiology and diagnosis of HFpEF that segues into a discussion of new therapeutic approaches emerging from basic research and

  18. Metabolomic Fingerprint of Heart Failure with Preserved Ejection Fraction

    PubMed Central

    Zordoky, Beshay N.; Sung, Miranda M.; Ezekowitz, Justin; Mandal, Rupasri; Han, Beomsoo; Bjorndahl, Trent C.; Bouatra, Souhaila; Anderson, Todd; Oudit, Gavin Y.; Wishart, David S.; Dyck, Jason R. B.

    2015-01-01

    Background Heart failure (HF) with preserved ejection fraction (HFpEF) is increasingly recognized as an important clinical entity. Preclinical studies have shown differences in the pathophysiology between HFpEF and HF with reduced ejection fraction (HFrEF). Therefore, we hypothesized that a systematic metabolomic analysis would reveal a novel metabolomic fingerprint of HFpEF that will help understand its pathophysiology and assist in establishing new biomarkers for its diagnosis. Methods and Results Ambulatory patients with clinical diagnosis of HFpEF (n = 24), HFrEF (n = 20), and age-matched non-HF controls (n = 38) were selected for metabolomic analysis as part of the Alberta HEART (Heart Failure Etiology and Analysis Research Team) project. 181 serum metabolites were quantified by LC-MS/MS and 1H-NMR spectroscopy. Compared to non-HF control, HFpEF patients demonstrated higher serum concentrations of acylcarnitines, carnitine, creatinine, betaine, and amino acids; and lower levels of phosphatidylcholines, lysophosphatidylcholines, and sphingomyelins. Medium and long-chain acylcarnitines and ketone bodies were higher in HFpEF than HFrEF patients. Using logistic regression, two panels of metabolites were identified that can separate HFpEF patients from both non-HF controls and HFrEF patients with area under the receiver operating characteristic (ROC) curves of 0.942 and 0.981, respectively. Conclusions The metabolomics approach employed in this study identified a unique metabolomic fingerprint of HFpEF that is distinct from that of HFrEF. This metabolomic fingerprint has been utilized to identify two novel panels of metabolites that can separate HFpEF patients from both non-HF controls and HFrEF patients. Clinical Trial Registration ClinicalTrials.gov NCT02052804 PMID:26010610

  19. Ejection fraction response to exercise in patients with chest pain and normal coronary arteriograms

    SciTech Connect

    Gibbons, R.L.; Lee, K.L.; Cobb, F.; Jones, R.H.

    1981-11-01

    In this study we describe the ejection fraction response to upright exercise using first-pass radionuclide angiocardiography in a group of 60 patients with chest pain, normal coronary ateriograms and normal resting ventricular function. A wide range of resting function (heart rate and ejection fraction) and exercise function (heart rate, ejection fraction, peak work load and estimated peak oxygen uptake) were measured. The ejection fraction response to exercise demonstrated wide variation, ranging from a decrease of 23% to an increase of 24%. Six of 22 clinical and radionuclide angiocardiographic variables (resting ejection fraction, peak work load, age, sex, body surface area and the change in end-diastolic volume index with exercise) were significant univariate predictors of the ejection fraction response to exercise. Multivariable analysis identified resting ejection fraction, the change in end-diastolic volume index with exercise and either sex or peak work load as variables that provided significant independent predictive information. These observations indicate that the ejection fraction response to exercise is a complex response that is influenced by multiple physiologic variables. The wide variation in this population suggests that the ejection fraction response to exercise is not a reliable test for the diagnosis of coronary artery disease because of its low specificity.

  20. Left ventricular volumes and ejection fraction derived from apical two-dimensional echocardiography

    PubMed Central

    Edelman, Sidney K.; Rowe, Dennis W.; Pechacek, Leonard W.; Garcia, Efrain

    1981-01-01

    Two-dimensional echocardiographic data in orthogonal apical projections were used to calculate left ventricular ejection fraction and volumes in 18 patients, 10 of whom had asynergy. The left ventricular chamber was modeled as a stack of 20 elliptical discs in order to minimize errors associated with assumptions of regular geometry. Calculations were compared to data from biplane angiography and yielded correlation coefficients of 0.91 for ejection fraction and 0.90 for volumes. The technique significantly underestimated volumes; the average ventricular volume was 161 ± 23 ml from cineangiography and 104 ± 25 ml from echocardiography (p < 0.001). Since this technique utilizes the most readily obtained echocardiographic views and allows for variations in ventricular architecture, its potential utility in long-term, serial evaluation of cardiac function appears promising. Images PMID:15216191

  1. Inelastic compression increases venous ejection fraction more than elastic bandages in patients with superficial venous reflux.

    PubMed

    Mosti, G; Mattaliano, V; Partsch, H

    2008-01-01

    To investigate the influence of compression bandages, manufactured using materials with different elastic properties, on the impaired venous pumping function in patients with venous insufficiency. Ejection volume (EV) and ejection fraction (EF) were measured using strain gauge plethysmography distal from the patella without and with elastic and inelastic compression bandages in a total of 30 patients with major venous reflux in the great saphenous vein. The interface pressure of the bandages was measured simultaneously in the medial gaiter area. Normal values of EV and EF were obtained from 15 healthy controls. Patients with venous insufficiency showed a statistically significant reduction of EV and EF compared to controls. Elastic bandages with an average pressure of 42 mm Hg in the supine position achieved a moderate increase of EV and a significant improvement of EF (p < .01), while inelastic bandages applied with comparable resting pressure (41 mm Hg) raised EV and EF into a normal range (p < .001). The improvement of the ejection fraction correlates well with the pressure differences between standing and lying (Static Stiffness Index) and between muscle systole and diastole during exercise (Pearson r = 0.69 and 0.74 respectively, p < .001). Elastic bandages applied with high stretch in order to achieve standing pressures comparable to those of inelastic bandages (>60 mm Hg) led only to a minor improvement of the venous pumping function. Ejected volume and ejection fraction, which are severely reduced in venous insufficiency, can be increased by compression therapy. Inelastic compression is much more effective than elastic bandages, and is able to normalize venous pumping function. With elastic bandages EV and EF always remain below the normal range even when applied with high stretch producing a resting pressure that is barely tolerable.

  2. [New therapy concepts for heart failure with preserved ejection fraction].

    PubMed

    Tschöpe, C; Pieske, B

    2015-04-01

    The management of patients with heart failure and preserved ejection fraction (HFpEF) remains challenging and requires an accurate diagnosis. Although currently no convincing therapy that can prolong survival in patients with HFpEF has been established, treatment of fluid retention, heart rate and control of comorbidities are important cornerstones to improve the quality of life and symptoms. In recent years many new therapy targets have been tested for development of successful interventional strategies for HFpEF. Insights into new mechanisms of HFpEF have shown that heart failure is associated with dysregulation of the nitric oxide-cyclic guanosine monophosphate-protein kinase (NO-cGMP-PK) pathway. Two new drugs are currently under investigation to test whether this pathway can be significantly improved by either the neprilysin inhibitor LCZ 696 due to an increase in natriuretic peptides or by the soluble guanylate cyclase stimulator vericiguat, which is also able to increase cGMP. In addition, several preclinical or early phase studies which are currently investigating new mechanisms for matrix, intracellular calcium and energy regulation including the role of microRNAs and new devices are presented and discussed.

  3. [Heart failure with preserved left ventricular ejection fraction].

    PubMed

    Maeder, Micha T; Rickli, Hans

    2013-10-16

    Heart failure with preserved left ventricular ejection fraction (LVEF; HFpEF) is a common type of heart failure in the elderly, and it typically represents advanced hypertensive heart disease. The left ventricle in patients with HFpEF is characterized by concentric remodeling, normal LVEF, but reduced left longitudinal shortening, and importantly diastolic dysfunction. Dyspnoe and fatigue in patients with HFpEF are due to impaired left ventricular filling with a rapid increase in filling pressures and the lack of an increase in stroke volume during exercise. The diagnosis of HFpEF requires the careful exclusion of non-cardiac causes of dyspnoe as well as cardiac causes of dyspnoe associated with preserved LVEF other than HFpEF, primarily coronary artery disease and valve disease. Then, the following findings are required to make a diagnosis of HFpEF: a non-dilated left ventricle with an LVEF >50% and the presence of a significant diastolic impairment, which can be assessed using invasive haemodynamics, echocardiography, natriuretic peptides, or a combination of these tools. In contrast to patients with heart failure and reduced LVEF there is still no established treatment for patients with HFpEF, which prolongs survival or reduces the rate of hospitalizations for heart failure. There is currently however intense research going on in this field, and results from large trials evaluating the effects of various interventions on clinical endpoints are expected within the next years.

  4. Spironolactone in patients with heart failure and preserved ejection fraction.

    PubMed

    Sánchez-Sánchez, C; Mendoza-Ruiz de Zuazu, H F; Formiga, F; Manzano, L; Ceresuela, L M; Carrera-Izquierdo, M; González Franco, Á; Epelde-Gonzalo, F; Cerqueiro-González, J M; Montero-Pérez-Barquero, M

    2015-01-01

    Aldosterone inhibitors have been shown to be beneficial for patients with systolic heart failure. However, the evidence from patients with heart failure and preserved ejection fraction (HFPEF) is limited. We evaluated the role of spironolactone in the prognosis of a cohort of patients with HFPEF. We analyzed the outcomes of patients hospitalized for HFPEF in 52 departments of internal medicine of the Spanish RICA registry according to those who did and did not take spironolactone. We recorded the posthospital mortality rate and readmissions at 1 year and performed a multivariate survival analysis. We included 1212 patients with HFPEF, with a mean age of 79 years (standard deviation, 7.9), (64.1% women), the majority of whom had hypertensive heart disease (50.7%). The patients treated with spironolactone, compared with those who were not treated with this diuretic, had a more advanced functional class, a higher number of readmissions (44.3 vs. 29.1%; p<0.001) and a higher rate in the combined variable of readmissions/mortality (39.0 vs. 29.0%; p=0.001). In the multivariate analysis, the administration of spironolactone was associated with an increase in readmissions (RR, 1.4; 95% CI, 1.16-1.78; p=0.001). For patients with HFPEF, the administration of spironolactone was associated with an increase in all-cause readmission, perhaps due to the higher rate of hyperpotassemia. Copyright © 2015. Published by Elsevier España, S.L.U.

  5. Review: Heart failure with preserved ejection fraction in African Americans.

    PubMed

    Shah, Sachil

    2012-01-01

    Heart failure (HF) affects 5,700 000 people in the United States, with heart failure with preserved ejection fraction (HFPEF) being responsible for between 30%-50% of acute admissions. Epidemiological studies and HF registries have found HFPEF patients to be older, hypertensive and to have a history of atrial fibrillation. These findings, however, may not be fully applicable to African Americans, as they have been poorly studied making up only a minority of the test subjects. This review article is intended to discuss the pathophysiology and epidemiology of HFPEF within African Americans, highlight the differences compared to Caucasian populations and review current treatment guidelines. Studies looking at African Americans in particular have shown them to be younger, female and have worse diastolic dysfunction compared to Caucasian populations. African Americans also have been shown to have a worse mortality outcome especially in patients without coronary artery disease. The treatment of HFPEF is primarily symptomatic with no survival benefit seen in randomized controlled trials. Mechanisms postulated for the worse prognosis in African Americans with HFPEF include: greater incidence of hypertension and diastolic dysfunction, undefined race-driven genetic predispositions or relative resistance to medications that treat HF in general. The biological predispositions may also be compounded by inequality of healthcare access; something still felt to exist today. Prospective studies and randomized controlled trials need to be conducted with particular emphasis on African American populations to fully elucidate this disease and to formulate race specific treatment outcomes for the future.

  6. Right Ventricular Ejection Fraction Is Incremental to Left Ventricular Ejection Fraction for the Prediction of Future Arrhythmic Events in Patients With Systolic Dysfunction.

    PubMed

    Mikami, Yoko; Jolly, Umjeet; Heydari, Bobak; Peng, Mingkai; Almehmadi, Fahad; Zahrani, Mohammed; Bokhari, Mahmoud; Stirrat, John; Lydell, Carmen P; Howarth, Andrew G; Yee, Raymond; White, James A

    2017-01-01

    Left ventricular ejection fraction remains the primary risk stratification tool used in the selection of patients for implantable cardioverter defibrillator therapy. However, this solitary marker fails to identify a substantial portion of patients experiencing sudden cardiac arrest. In this study, we examined the incremental value of considering right ventricular ejection fraction for the prediction of future arrhythmic events in patients with systolic dysfunction using the gold standard of cardiovascular magnetic resonance. Three hundred fourteen consecutive patients with ischemic cardiomyopathy or nonischemic dilated cardiomyopathy undergoing cardiovascular magnetic resonance were followed for the primary outcome of sudden cardiac arrest or appropriate implantable cardioverter defibrillator therapy. Blinded quantification of left ventricular and right ventricular (RV) volumes was performed from standard cine imaging. Quantification of fibrosis from late gadolinium enhancement imaging was incrementally performed. RV dysfunction was defined as right ventricular ejection fraction ≤45%. Among all patients (164 ischemic cardiomyopathy, 150 nonischemic dilated cardiomyopathy), the mean left ventricular ejection fraction was 32±12% (range, 6-54%) with mean right ventricular ejection fraction of 48±15% (range, 7-78%). At a median of 773 days, 49 patients (15.6%) experienced the primary outcome (9 sudden cardiac arrest, 40 appropriate implantable cardioverter defibrillator therapies). RV dysfunction was independently predictive of the primary outcome (hazard ratio=2.98; P=0.002). Among those with a left ventricular ejection fraction >35% (N=121; mean left ventricular ejection fraction, 45±6%), RV dysfunction provided an adjusted hazard ratio of 4.2 (P=0.02). RV dysfunction is a strong, independent predictor of arrhythmic events. Among patients with mild to moderate LV dysfunction, a cohort greatly contributing to global sudden cardiac arrest burden, this marker

  7. Heart failure with preserved ejection fraction: uncertainties and dilemmas.

    PubMed

    Ferrari, Roberto; Böhm, Michael; Cleland, John G F; Paulus, Walter J S; Pieske, Burkert; Rapezzi, Claudio; Tavazzi, Luigi

    2015-07-01

    Many uncertainties surround the syndrome of heart failure with preserved ejection fraction (HFpEF), which was the topic reviewed in an Expert Meeting at the University of Ferrara. This concluded that the absence of clear diagnostic clinical criteria was the major barrier to progress. There was general agreement that symptoms or signs of heart failure, normal LVEF despite an elevated plasma concentration of natriuretic peptides, and signs of abnormal LV relaxation, LV filling, LV hypertrophy, or left atrial enlargement, or diastolic dysfunction supported the diagnosis. However, HFpEF, like all heart failure syndromes, is heterogeneous in aetiology and pathophysiology, rather than being a single disease. HFpEF may account for about half of all patients with heart failure. The classical risk factors for developing HFpEF include age and co-morbidities, notably hypertension, atrial fibrillation, and the metabolic syndrome. When complicated by increasing congestion requiring hospital admission, the prognosis is poor; 30% or more of patients will die within 1 year (nearly two-thirds die from cardiovascular causes). Patients with chronic stable symptoms have a much better prognosis. Despite many clinical trials, there is no solid evidence that any treatment alters the natural history of HFpEF. Several treatments have shown promising early results and are now being tested in substantial randomized clinical trials. Further basic research is required to better characterize the disease and accelerate progress. Our review highlights the many difficulties encountered in performing randomized clinical trials in HFpEF, often due to difficulties in characterizing HFpEF itself.

  8. Measurement of left ventricular ejection fraction using gated 99mTc-sestamibi myocardial planar images: Comparison to contrast ventriculography

    SciTech Connect

    Parker, D.A.; Lloret, R.L.; Barilla, F.; Douthat, L.; Gheorghiade, M. )

    1991-01-01

    Using the new myocardial perfusion agent 99mTc-sestamibi and multigated acquisition on a nuclear medicine gamma camera, the left ventricular ejection fraction (LVEF) was derived in 13 patients with coronary artery disease (CAD). Cross-sectional activity profiles were used to measure the left ventricle from end-diastolic and end-systolic images. Several different geometric methods were then utilized to derive ejection fractions from the nuclear data. Comparison of the resultant ejection fractions to those obtained from contrast ventriculography showed significant correlation for all geometric methods (P less than 0.01, Sy X x = 6.2 to 9.6). The authors conclude that in patients with CAD one or more of these simple geometric methods can provide a useful estimate of the LVEF when performing 99mTc-sestamibi multigated myocardial perfusion imaging.

  9. Serial measurements of left ventricular ejection fraction by radionuclide angiography early and late after myocardial infarction.

    PubMed

    Schelbert, H R; Henning, H; Ashburn, W L; Verba, J W; Karliner, J S; O'Rourke, R A

    1976-10-01

    The left ventricular ejection fraction was determined serially with radioisotope angiography in 63 patients with acute myocardial infarction. After the peripheral injection of a bolus of technetium-99m, precordial radioactivity was recorded with a gamma scintillation camera and the ejection fraction calculated from the high frequency left ventricular time-activity curve. Since this technique requires no assumptions with respect to left ventricular geometry, it is particularly useful in patients with segmental left ventricular dysfunction. Serial measurements during the first 5 days after hospital admission were made in 50 patients, 30 of whom were studied during the subsequent 2 to 39 months (mean 19.9 months). Late follow-up serial studies were also performed in an additional 13 patients who had only one measurement of the left ventricular ejection fraction during the early postinfarction period. Early after infarction, the left ventricular ejection fraction was normal (more than 0.52) in only 15 of the 63 patients, and averaged 0.52 +/- 0.05 (standard deviation) in the 27 patients with an uncomplicated infarct. The ejection fraction was reduced in 24 patients with mild to moderate left ventricular failure (0.40 +/- 0.05, P less than 0.0001) and in the 12 patients with overt pulmonary edema (0.33 +/- 0.07, P less than 0.0001). In 35 patients the ejection fraction correlated with the mean pulmonary arterial wedge pressure (r = 0.72). In 15 patients with normal left ventricular wall motion by heart motion videotracking, the ejection fraction was significantly higher (0.53 +/- 0.08) than in the 26 patients with regional left ventricular dysfunction (0.41 +/- 0.10, P less than 0.0001). During the early postinfarction period, the left ventricular ejection fraction improved in 55 percent of patients and remained unchanged or decreased in 45 percent. A further increase in the ejection fraction was noted in 61 percent of patients during the late follow-up period. Patients

  10. Burden of Recurrent Hospitalizations Following an Admission for Acute Heart Failure: Preserved Versus Reduced Ejection Fraction.

    PubMed

    Santas, Enrique; Valero, Ernesto; Mollar, Anna; García-Blas, Sergio; Palau, Patricia; Miñana, Gema; Núñez, Eduardo; Sanchis, Juan; Chorro, Francisco Javier; Núñez, Julio

    2017-04-01

    Heart failure with preserved ejection fraction and reduced ejection fraction share a high mortality risk. However, differences in the rehospitalization burden over time between these 2 entities remains unclear. We prospectively included 2013 consecutive patients discharged for acute heart failure. Of these, 1082 (53.7%) had heart failure with preserved ejection fraction and 931 (46.2%) had heart failure with reduced ejection fraction. Cox and negative binomial regression methods were used to evaluate the risks of death and repeat hospitalizations, respectively. At a median follow-up of 2.36 years (interquartile range: 0.96-4.65), 1018 patients (50.6%) died, and 3804 readmissions were registered in 1406 patients (69.8%). Overall, there were no differences in mortality between heart failure with preserved ejection fraction and heart failure with reduced ejection fraction (16.7 vs 16.1 per 100 person-years, respectively; P=0794), or all-cause repeat hospitalization rates (62.1 vs 62.2 per 100 person-years, respectively; P=.944). After multivariable adjustment, and compared with patients with heart failure with reduced ejection fraction, patients with heart failure with preserved ejection fraction exhibited a similar risk of all-cause readmissions (incidence rate ratio=1.04; 95%CI, 0.93-1.17; P=.461). Regarding specific causes, heart failure with preserved ejection fraction showed similar risks of cardiovascular and heart failure-related rehospitalizations (incidence rate ratio=0.93; 95%CI, 0.82-1.06; P=.304; incidence rate ratio=0.96; 95% confidence interval, 0.83-1.13; P=.677, respectively), but had a higher risk of noncardiovascular readmissions (incidence rate ratio=1.24; 95%CI, 1.04-1.47; P=.012). Following an admission for acute heart failure, patients with heart failure with preserved ejection fraction have a similar rehospitalization burden to those with heart failure with reduced ejection fraction. However, patients with heart failure with preserved ejection

  11. Diastolic dysfunction and heart failure with a preserved ejection fraction: Relevance in critical illness and anaesthesia

    PubMed Central

    Maharaj, R.

    2012-01-01

    Epidemiological and clinical studies suggest that HF with a preserved ejection fraction will become the more common form of HF which clinicians will encounter. The spectrum of diastolic disease extends from the asymptomatic phase to fulminant cardiac failure. These patients are commonly encountered in operating rooms and critical care units. A clearer understanding of the underlying pathophysiology and clinical implications of HF with a preserved ejection fraction is fundamental to directing further research and to evaluate interventions. This review highlights the impact of diastolic dysfunction and HF with a preserved ejection fraction during the perioperative period and during critical illness. PMID:23960679

  12. Comparison of the reliability of E/E' to estimate pulmonary capillary wedge pressure in heart failure patients with preserved ejection fraction versus those with reduced ejection fraction.

    PubMed

    Matsushita, Kenichi; Minamishima, Toshinori; Goda, Ayumi; Ishiguro, Haruhisa; Kosho, Hideyasu; Sakata, Konomi; Satoh, Toru; Yoshino, Hideaki

    2015-12-01

    Accurate assessment of pulmonary capillary wedge pressure (PCWP) is essential for physicians to effectively manage patients with acute decompensated heart failure. The ratio of early transmittal velocity to tissue Doppler mitral annular early diastolic velocity (E/E') is used to estimate PCWP noninvasively in a wide range of cardiac patients. However, it remains contentious as to whether mitral E/E' is a reliable predictor of PCWP. In the present study, acute heart failure patients were divided into two groups on the basis of left ventricular (LV) systolic function: those with preserved ejection fraction (HFpEF) and those with reduced ejection fraction (HFrEF). The usefulness of mitral E/E' in estimating PCWP was compared between the two groups. Fifty consecutive patients who were admitted with acute decompensated heart failure and underwent both right-sided cardiac catheterization and transthoracic echocardiography during hospitalization were analyzed retrospectively. Pearson's correlation was used to evaluate associations between Doppler parameters and PCWP. E/E' was positively correlated with PCWP (r = 0.56, P = 0.01) in the heart failure with preserved ejection fraction group. However, no significant relationship was observed between PCWP and mitral E/E' (P = 0.85) in the heart failure with reduced ejection fraction group. There were no significant correlations between any of the conventional parameters considered (LVEF, left atrial dimension, E/A, IVRT, and DT) with PCWP in either group. In conclusion, mitral E/E' is useful for estimating PCWP in patients with acute heart failure with preserved ejection fraction but may not in those with reduced ejection fraction.

  13. Fractionation of hydrogen and deuterium on Venus due to collisional ejection

    NASA Technical Reports Server (NTRS)

    Gurwell, Mark A.; Yung, Yuk L.

    1993-01-01

    The collisional ejection process for hydrogen on Venus is reanalyzed. Improved values for the efficiency of H and D escape as a function of the ionospheric temperature are reported. It is proposed that the reduction of the hydrogen flux for collisional ejection be reduced from 8 to 3.5 x 10 exp 6/sq cm/s, and a revised D/H fractional factor of 0.47 due to collisional ejection is suggested. The resulting deuterium flux is 3.1 x 10 exp 4/sq cm/s, roughly six times the flux due to charge exchange, making collisional ejection the dominant escape mechanism for deuterium on Venus.

  14. Fractionation of hydrogen and deuterium on Venus due to collisional ejection

    NASA Astrophysics Data System (ADS)

    Gurwell, M. A.; Yung, Y. L.

    1993-02-01

    The collisional ejection process for hydrogen on Venus is reanalyzed. Improved values for the efficiency of H and D escape as a function of the ionospheric temperature are reported. It is proposed that the reduction of the hydrogen flux for collisional ejection be reduced from 8 to 3.5 x 10 exp 6/sq cm/s, and a revised D/H fractional factor of 0.47 due to collisional ejection is suggested. The resulting deuterium flux is 3.1 x 10 exp 4/sq cm/s, roughly six times the flux due to charge exchange, making collisional ejection the dominant escape mechanism for deuterium on Venus.

  15. Global and regional left ventricular ejection fraction abnormalities during exercise in patients with silent myocardial ischemia

    SciTech Connect

    Cohn, P.F.; Brown, E.J. Jr.; Wynne, J.; Holman, B.L.; Atkins, H.L.

    1983-03-01

    Sixteen asymptomatic patients with coronary artery disease and silent myocardial ischemia were studied with exercise radionuclide ventriculography. Radionuclide ventriculograms were analyzed for changes in ejection fraction globally and in three regions. Results were compared with radionuclide ventriculograms in 24 symptomatic patients. Both groups (silent myocardial ischemia and angina) were similar in prevalence of multivessel disease and previous myocardial infarction, as well as in age and sex. Global ejection fraction decreased by 0.06 in both groups during exercise; regional ejection fraction also decreased by similar amounts in the two groups. Furthermore, the percent of regions with normal ejection fraction at rest that demonstrated a decrease during exercise was identical: 19 (60%) of 33 versus 26 (60%) of 46. These exercise radionuclide ventriculographic results suggest that abnormalities in regional and global left ventricular wall motion are similar in patients with coronary artery disease with and without silent myocardial ischemia.

  16. Heart Failure and Mid-Range Ejection Fraction: Implications of Recovered Ejection Fraction for Exercise Tolerance and Outcomes

    PubMed Central

    Nadruz, Wilson; West, Erin; Santos, Mário; Skali, Hicham; Groarke, John D.; Forman, Daniel E.; Shah, Amil M.

    2016-01-01

    Background Evidence-based therapies for heart failure (HF) differ significantly according to left ventricular ejection fraction (LVEF). However, few data are available regarding the phenotype and prognosis of HF patients with mid-range LVEF of 40–55%, and the impact of recovered systolic function on the clinical features, functional capacity and outcomes of this population is not known. Methods and Results We studied 944 HF patients who underwent clinically indicated cardiopulmonary exercise testing. The study population was categorized according to LVEF as: HFrEF (LVEF<40%; n=620); HFmEF (LVEF was consistently between 40–55%; n=107); HFm-recEF (LVEF=40–55% but previous LVEF<40%; n=170); and HFpEF (LVEF>55%; n=47). HFmEF and HFm-recEF had similar clinical characteristics, which were intermediate between those of HFrEF and HFpEF, and comparable values of predicted peak oxygen consumption and minute-ventilation/carbon dioxide production slope, which were better than HFrEF and similar to HFpEF. After a median of 4.4 [2.9–5.7] years, there were 253 composite events (death, left ventricular assistant device implantation or transplantation). In multivariable Cox-regression analysis, HFm-recEF had lower risk of composite events than HFrEF (HR=0.25; 95%CI=0.13–0.47) and HFmEF (HR=0.31; 95%CI=0.15–0.67), and similar prognosis when compared to HFpEF. In contrast, HFmEF tended to show intermediate risk of outcomes in comparison with HFpEF and HFrEF, albeit not reaching statistical significance in fully adjusted analyses. Conclusions HF patients with mid-range LVEF demonstrate a distinct clinical profile from HFpEF and HFrEF patients, with objective measures of functional capacity similar to HFpEF. Within the mid-range LVEF HF population, recovered systolic function is a marker of more favorable prognosis. PMID:27009553

  17. Predictors of two-year mortality in Asian patients with heart failure and preserved ejection fraction.

    PubMed

    Yap, Jonathan; Sim, David; Lim, Choon Pin; Chia, Shaw Yang; Go, Yun Yun; Jaufeerally, Fazlur Rehman; Sim, Ling Ling; Liew, Reginald; Ching, Chi-Keong

    2015-03-15

    Mortality in patients with heart failure and preserved ejection fraction (HFpEF) remains high. Data from Asia is lacking. We aim to study the impact of ethnicity and other predictors of mortality in patients admitted for HFpEF in a multi-ethnic Asian country. Consecutive patients admitted to two local institutions with heart failure and ejection fraction ≥50% on transthoracic echocardiogram from Jan 2008 to Dec 2009 were included. All patients were followed-up for 2 years. Overall mortality was obtained from the national registry of deaths in our country. A total of 1960 patients with heart failure were included. 751 (38.3%) patients had HFpEF. Overall mortality at two years was 26.6% (n=200) compared to 37.1% (n=449) in patients with reduced ejection fraction (HR 0.618 (95% CI 0.508-0.753), p<0.001). Ethnicity did not predict mortality. On multivariable Cox regression analysis, significant predictors of two-year mortality in HFpEF patients were older age (HR 1.027 (1.011-1.044)), prior myocardial infarction (HR 1.577 (1.104-2.253)), prior stroke (HR 1.475 (1.055-2.061)), smoking (HR 1.467 (1.085-1.985)), higher creatinine levels (HR 1.002 (1.001-1.003)) and use of mineralocorticoid receptor antagonists (HR 1.884 (1.226-2.896)). Use of warfarin (HR 0.506 (0.304-0.842)) and statins (HR 0.585 (0.435-0.785)) were associated with significantly lower mortality. In our Asian population presenting with HFpEF, two-year mortality was 26.6%. Ethnicity did not predict mortality. Older age, prior myocardial infarction, prior stroke, smoking, and higher creatinine levels were found to be significant predictors of mortality. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

  18. Mechanisms of Effort Intolerance in Patients With Heart Failure and Borderline Ejection Fraction.

    PubMed

    Topilsky, Yan; Rozenbaum, Zach; Khoury, Shafik; Pressman, Gregg S; Gura, Yaniv; Sherez, Jack; Man, Avi; Shimiaie, Jason; Edwards, Sanford; Berookhim, Joshua; Le Tourneau, Thierry; Halkin, Amir; Biner, Simon; Keren, Gad; Aviram, Galit

    2017-02-01

    Combining echocardiography and cardiopulmonary stress testing allows noninvasive assessment of hemodynamics, and oxygen extraction (A-VO2 difference). We evaluated mechanisms of effort intolerance in patients with heart failure with borderline (40% to 49%) left ventricular ejection fraction (EF) (HF and Borderline Ejection fraction). We included 89 consecutive patients with HF and Borderline Ejection fraction (n = 25; 63.6 ± 14 years, 64% men), control subjects (n = 22), patients with HF with preserved EF (n = 26; EF ≥50%), and patients with HF with reduced EF (n = 16; <40%). Various echo parameters (left ventricular volumes, EF, stroke volume, mitral regurgitation [MR] volume, e', right ventricle end-diastolic area, and right ventricle end-systolic area), and ventilatory or combined parameters (peak oxygen consumption [VO2] and A-VO2 difference) were measured at 4 predefined activity stages. Effort-induced functional MR was frequent and more prevalent in HF and Borderline Ejection fraction than in all the other types of HF. In multivariable analysis heart rate response (p <0.0001), A-VO2 difference (p = 0.02), stroke volume (p = 0.002), and right ventricle end-systolic area were the only independent predictors of exercise capacity in HF and Borderline Ejection fraction but peak EF was not. In HF and Borderline Ejection fraction exercise intolerance is predominantly due to chronotropic incompetence, peripheral factors, and limited stroke volume reserve, which are related to right ventricle dysfunction and functional MR but not to left ventricular ejection fraction. Combined testing can be helpful in determining mechanisms of exercise intolerance in HF and Borderline Ejection fraction. Copyright © 2016 Elsevier Inc. All rights reserved.

  19. The cardio-renal-anemia syndrome in elderly subjects with heart failure and a normal ejection fraction: a comparison with heart failure and low ejection fraction.

    PubMed

    Cohen, Rose S; Mubashir, Asyia; Wajahat, Raja; Mani, Susan; Hummel, Scott; Maurer, Mathew S

    2006-01-01

    The prevalence and severity of anemia and renal dysfunction in heart failure patients with a normal ejection fraction (HFNEF) is uncharacterized. Two hundred eighty-five consecutive patients admitted to a community hospital with heart failure were stratified by the presence or absence of anemia and a normal or reduced ejection fraction. Comparisons of clinical variables were performed. In this sample, 62% of subjects were anemic, with no difference between those with a normal and a reduced ejection fraction (63% vs. 61%). Anemic HFNEF subjects had a lower glomerular filtration rate (37 +/- 21 mL/min vs. 52 +/- 35 mL/min; p < 0.05) and more severe self-reported symptom scores than nonanemic HFNEF subjects. Multivariate analysis confirmed the association of renal dysfunction and anemia. The authors conclude that the degree and magnitude of anemia in elderly inpatients with heart failure does not differ by ejection fraction. Worse symptoms and more severe renal dysfunction were seen in HFNEF subjects with anemia than in HFNEF subjects without anemia.

  20. Are beta-blockers effective in heart failure with preserved ejection fraction?

    PubMed

    Alegría, Javier; Rada, Gabriel

    2016-11-02

    Beta-blockers constitute standard therapy for heart failure with reduced ejection. However, their role in patients with preserved ejection fraction is not clear. Searching in Epistemonikos database, which is maintained by screening multiple databases, we identified four systematic reviews covering 19 primary studies, including seven randomized trials answering the question of this summary. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded the use of beta-blockers probably leads to little or no difference in the risk of death or hospitalization in patients with heart failure with preserved ejection fraction.

  1. Value of left ventricular ejection fraction during exercise in predicting the extent of coronary artery disease.

    PubMed

    DePace, N L; Iskandrian, A S; Hakki, A H; Kane, S A; Segal, B L

    1983-04-01

    To determine the relation between left ventricular performance during exercise and the extent of coronary artery disease, the results of exercise radionuclide ventriculography were analyzed in 65 patients who also underwent cardiac catheterization. A scoring system was used to quantitate the extent of coronary artery disease. This system takes into account the number and site of stenoses of the major coronary vessels and their secondary branches. The conventional method of interpreting the coronary angiograms indicated that 26 patients had significant coronary artery disease (defined as 70% or more narrowing of luminal diameter) of one vessel, 21 had multivessel disease and 18 had no significant coronary artery disease. Although the exercise left ventricular ejection fraction was significantly higher in patients with no coronary artery disease than in patients with one or multivessel disease (probability [p] less than 0.001), there was considerable overlap among the three groups. With the scoring system, a good correlation was found between the coronary artery disease score and the exercise left ventricular ejection fraction (r = -0.70; p less than 0.001). If the exercise heart rate was 130 beats/min or greater or the age of the patient was 50 years or less, an even better correlation was found (r = -0.73 and r = -0.82, respectively). The exercise ejection fraction (but not the change in ejection fraction, end-diastolic volume and end-systolic volume from rest to exercise) correlated with the extent of coronary artery disease. The exercise ejection fraction is the most important exercise variable that correlates with the extent of coronary artery disease when the latter is assessed quantitatively by a scoring system rather than the conventional method of reporting coronary angiograms. Young age and greater exercise heart rate strengthened the correlation. The change in ejection fraction from rest to exercise is useful in the diagnosis of coronary artery disease

  2. Left-ventricular peak ejection rate, filling rate, and ejection fraction--frame rate requirements at rest and exercise: concise communication.

    PubMed

    Bacharach, S L; Green, M V; Borer, J S; Hyde, J E; Farkas, S P; Johnston, G S

    1979-03-01

    The effect of framing rate on the measurement of left-ventricular (LV) ejection fraction (EF), peak ejection rate (PER), and peak filling rate (PFR) was evaluated at rest and during exercise in 11 normal subjects and 21 patients who underwent gated equilibrium blood-pool imaging. Left-ventricular time-activity curves were obtained in each subject, at rest and during stress, at temporal resolutions of 10, 20, 30, 40, and 50 msec per frame. Ejection fraction, PER, and PFR were determined for each frame duration. By observing changes in the measured values of these quantities with framing rate we conclude that: a) for the measurement of EF, 50 msec per frame at rest and 40 msec per frame at exercise is sufficient; b) PER requires 40 msec per frame at rest and 20 msec per frame during exercise; and c) for the measurement of PFR, at least 40 msec per frame at rest and 20 msec per frame during exercise are needed. These results should hold for both first-pass and gated equilibrium studies.

  3. Automatic analysis of left ventricular ejection fraction using stroke volume images.

    PubMed

    Nelson, T R; Verba, J W; Bhargava, V; Shabetai, R; Slutsky, R

    1983-01-01

    The purpose of this study was to analyze, validate, and report on an automatic computer algorithm for analyzing left ventricular ejection fraction and to indicate future applications of the technique to other chambers and more advanced measurements. Thirty-eight patients were studied in the cardiac catheterization laboratory by equilibrium radionuclide ventriculography and concurrent contrast ventriculography. The temporal and spatial behavior of each picture element in a filtered stroke volume image series was monitored throughout the cardiac cycle. Pixels that met specific phase, amplitude, and derivative criteria were assigned to the appropriate chamber. Volume curves were generated from regions of interest for each chamber to enable calculation of the left ventricular ejection fraction. Left ventricular ejection fractions showed a good correlation (r = 0.89) between the two techniques. Ejection fractions ranged between 0.12 and 0.88, showing a wide range of application. It is concluded that automatic analysis of left ventricular ejection fraction is possible using the present algorithm and will be useful in improving the reproducibility and providing more accurate information during exercise protocols, pharmaceutical interventions, and routine clinical studies.

  4. Ivabradine, a novel medication for treatment of heart failure with reduced ejection fraction.

    PubMed

    Foster, Jenna L; Bobadilla, Rodel V

    2016-11-01

    To critically evaluate current literature, review pharmacology, and discuss clinical role of ivabradine for patients with heart failure (HF) with reduced ejection fraction. A PubMed search was conducted using the search terms ivabradine and HF. All human studies analyzing the use of ivabradine in patients with HF with reduced ejection fraction and prescribing information were evaluated. Greater benefit was seen in the prespecified subgroup with heart rate (HR) > 70 beats per minute (bpm) in the BEAUTIFUL study. Therefore, SHIFT examined the effect of ivabradine on patients with higher resting HR, lower ejection fraction, who had been hospitalized for HF within the previous year. A significant difference was found in the composite primary endpoint of cardiovascular death and hospitalizations for worsening HF in patients with HF and left ventricular systolic dysfunction, driven primarily by reduction in hospitalizations for worsening HF. The most common adverse effect was bradycardia. Ivabradine is a safe and effective medication for HR reduction to reduce hospitalizations in patients with stable, symptomatic HF (ejection fraction < 35%), in sinus rhythm, and HR > 70 bpm. ©2016 American Association of Nurse Practitioners.

  5. Correlation of right and left ventricular ejection fraction and volume measurements

    SciTech Connect

    Benedetto, A.R.; Nusynowitz, M.L.

    1988-06-01

    First-pass radiocardiography and biplane angiocardiography were performed on 13 patients with left-sided regurgitant valvular disease (R+) and 7 patients without regurgitation but with coronary artery disease and/or cardiomyopathy (R-). Right and left ventricular volumes and ejection fractions were calculated and compared. In the R- group, corresponding right and left ventricular volumes and ejection fractions correlated highly with each other (r = 0.86-0.89, p approximately equal to 0.01). Ejection fractions in the R+ group correlated (r = 0.64, p less than 0.05) only because stroke volume correlation was very high (r = 0.93), with end-diastolic and end-systolic volumes showing no significant correlation. Right ventricular ejection fraction (RVEF) decreased significantly with increasing mean pulmonary artery pressure (PAP) in both R- and R+ groups. The correlation of RVEF and LVEF in the R- group appears to be multifactorial in origin, consisting of effects of increased PAP, the mechanical interference of an enlarged left ventricle on the right ventricle, and direct biventricular ischemic effects. In the R+ group, the correlation appears to be due to only increased PAP and its sequelae.

  6. Relationship between ankle brachial index and ejection fraction in elderly Egyptians with ischemic heart disease.

    PubMed

    Amer, Moatasem S; Tawfik, Heba M; Abd Elmotteleb, Ayman M; Maamoun, Manar M A

    2015-04-01

    There is a high prevalence of combined peripheral and coronary artery disease, with increasing morbidity and decline in cardiac function. The aim of the present study was to find an association between ankle brachial index, a non-invasive measure of peripheral artery disease, and ejection fraction in elderly patients with severe coronary artery disease. A case-control study recruiting 200 elderly male and female ischemic patients in Ain Shams University hospitals was carried out. All participants had significant coronary artery disease lesions in coronary angiography carried out before the study. Cases and controls were divided according to ankle brachial index, with further subdivision of each group according to age. Measurements include: ankle brachial index using Bistos handheld vascular Doppler (BT 200V,8 MHz), electrocardiography and echocardiography showing left ventricular ejection fraction. Coronary artery disease severity was estimated using the number of diseased vessels. The mean age of our study group was 67 years. Although our participants had mild to moderate peripheral artery disease, ejection fraction statistically decreased with decreasing ankle brachial index, being the lowest in participants aged > 70 years (46.84 ± 9.82 years) and the highest in controls aged >70 years (53.02 ± 5.53 years; P = 0.009). Ejection fraction was positively correlated with ankle brachial index (P = 0.011, 0.006) for cases and controls, respectively. Ankle brachial index can correlate with ejection fraction in elderly ischemic Egyptians with more severe coronary artery disease. © 2014 Japan Geriatrics Society.

  7. [Determination of right ventricular ejection fraction by thermodilution catheter technique during exercise: a comparison with radionuclide ventriculography].

    PubMed

    Perings, S M; Perings, C; Kelm, M; Strauer, B E

    2001-01-01

    Since the development of a Swan-Ganz Thermodilution Ejection Fraction Catheter, several studies have been published which compare this technique for obtaining right ventricular ejection fraction (RVEFTD) with alternative methods. However, the reliability of RVEFTD measurements under exercise conditions remains undetermined. Therefore, the aim of the present study was to evaluate RVEFTD with the Gated Blood Pool method (RVEFGBP) under exercise conditions. Twenty patients with different cardiac diseases (coronary artery disease, valvular incompetence, cardiomyopathy) underwent right heart catheterization, including RVEFTD and simultaneous RVEFGBP determination at rest and during supine bicycle exercise. Cardiac index at rest-/exercise was 2.9 +/- 0.8/5.7 +/- 2.2 l/min/m2, mean pulmonary artery pressure was 15 +/- 5/25 +/- 8 mmHg, RVEFTD was 38 +/- 6/41 +/- 11% and RVEFRNV was 39 +/- 6/43 +/- 8%. Linear regression analysis showed a significant correlation between RVEFTD and RVEFGBP at rest (r = 0.72, p < or = 0.0005) and during exercise (r = 0.72, p < or = 0.0005). It is concluded that the Thermodilution Ejection Fraction Catheter is a useful device for reliable, repetitive and safe RVEF measurements, not only at rest but also under exercise conditions. This is clinically important, because RVEF, as a sensitive parameter of primary or secondary right ventricular dysfunction, can be determined in the course of standard right heart catheterization.

  8. Reduced First-Phase Ejection Fraction and Sustained Myocardial Wall Stress in Hypertensive Patients With Diastolic Dysfunction

    PubMed Central

    Gu, Haotian; Li, Ye; Fok, Henry; Simpson, John; Kentish, Jonathan C.; Shah, Ajay M.

    2017-01-01

    Impaired shortening deactivation of cardiac myocytes could sustain myocardial contraction, preserving ejection fraction at the expense of diastolic dysfunction. We examined the relationship between first-phase ejection fraction (EF1), the fraction of left ventricular volume ejected from the start of systole to the time of the first peak in left ventricular pressure (corresponding to the time of maximal ventricular shortening) to the duration of myocardial contraction and diastolic function in patients with hypertension (n=163), and varying degrees of diastolic dysfunction. Left ventricular systolic pressure was estimated by carotid tonometry; time-resolved left ventricular cavity and wall volume were obtained by echocardiography with speckle wall tracking. Measurements were repeated after nitroglycerin, a drug known to influence ventricular dynamics, in a subsample (n=18) of patients. EF1 and time of onset of ventricular relaxation (as determined from the temporal pattern of myocardial wall stress) were independently correlated with diastolic relaxation as measured by tissue Doppler early diastolic mitral annular velocity (E′, standardized regression coefficients 0.48 and −0.34 for EF1 and time of onset of ventricular relaxation, respectively, each P<0.001, irrespective of adjustment for age, sex, antihypertensive treatment, measures of afterload, and ventricular geometry) and with diastolic function measured by the ratio of transmitral Doppler early filling velocity (E) to E′ (E/E′, regression coefficients −0.34 and 0.34, respectively, each P<0.001). Nitroglycerin increased EF1, decreased time of onset of ventricular relaxation, and improved diastolic function (each P<0.05). Hypertensive patients with diastolic dysfunction exhibit reduced EF1 which may sustain myocardial contraction, preserving systolic ejection fraction at the expense of impaired diastolic function. PMID:28223475

  9. [Assessment of the ejection fraction of the right ventricle with echocardiography].

    PubMed

    Espinosa, R A; Yong, R; Enciso, R; Baduí, E

    1991-01-01

    The purpose of this article is to evaluate and compare the right ventricular ejection fraction (RVEF) as parameter of right ventricular function by means of echocardiography. We studied 16 patients (15 male, 1 female) from 48 to 82 years of age (mean 58 years) from whom 8 had history of myocardial infarction (MI) with extension to the right ventricle (RV) in a period of time no longer than 7 days. The MI was diagnosed clinically as well as by enzymes, electrocardiogram and cardiac gammagram with 99mTc-pyrophosphate. The other 8 patients were healthy subjects or patients with stable angina pectoris. In all patients a two dimensional echocardiogram was performed with and apical four and two chamber view according to Simpson's rule; a subcostal approach was performed for the area-length method of Dodge. The values obtained of RVEF with each method were compared with those obtained by nuclear medicine. The apical views were obtained in 14 patients (87%) and the RV outflow tract was seen in 15 patients (93%). There were no significant statistical difference between the two methods. The highest correlation for RVEF respect to nuclear medicine was obtained with the area-length method with r = 0.85 and p less than 0.001 while for the Simpson method we obtained r = 0.79 and a p less than 0.001. We conclude that the determination of the RVEF is achievable in patients with MI of the RV and area-length method is the most useful.

  10. RECURRENT STROKE IN THE WARFARIN VERSUS ASPIRIN IN REDUCED EJECTION FRACTION (WARCEF) TRIAL

    PubMed Central

    Pullicino, Patrick M.; Qian, Min; Sacco, Ralph L.; Freudenberger, Ron; Graham, Susan; Teerlink, John R.; Mann, Douglas; Di Tullio, Marco R.; Ponikowski, Piotr; Lok, Dirk J.; Anker, Stefan D.; Lip, Gregory Y.H.; Estol, Conrado J.; Levin, Bruce; Mohr, J.P.; Thompson, John L. P.; Homma, Shunichi

    2014-01-01

    Background and Purpose WARCEF randomized 2305 patients in sinus rhythm with ejection fraction (EF) ≤35% to warfarin (INR 2.0–3.5) or aspirin 325 mg. Warfarin reduced the incident ischemic stroke (IIS) hazard rate by 48% over aspirin in a secondary analysis. The IIS rate in heart failure (HF) is too low to warrant routine anticoagulation but epidemiologic studies show that prior stroke increases the stroke risk in HF. We here explore IIS rates in WARCEF patients with and without baseline stroke to look for risk factors for IIS and determine if a subgroup with an IIS rate high enough to give a clinically relevant stroke risk reduction can be identified. Methods We compared potential stroke risk factors between patients with baseline stroke and those without using the exact conditional score test for Poisson variables. We looked for risk factors for IIS, by comparing IIS rates between different risk factors. For EF we tried cutoff points of 10%, 15% and 20%. 15% was used as it was the highest EF that was associated with a significant increase in IIS rate. IIS and EF strata were balanced as to warfarin/aspirin assignment by the stratified randomized design. A multiple Poisson regression examined the simultaneous effects of all risk factors on IIS rate. IIS rates per hundred patient years (/100PY) were calculated in patient groups with significant risk factors. Missing values were assigned the modal value. Results Twenty of 248 (8.1%) patients with baseline stroke and 64 of 2048 (3.1%) without had IIS. IIS rate in patients with baseline stroke (2.37/100PY) was greater than patients without (0.89/100PY)(rate ratio 2.68, p<0.001). Fourteen of 219 (6.4%) patients with ejection fraction (EF)<15% and 70 of 2079 (3.4%) with EF ≥15% had IIS. In the multiple regression analysis stroke at baseline (p<0.001) and EF<15% vs. ≥15% (p=.005) remained significant predictors of IIS. IIS rate was 2.04/100PY in patients with EF<15% and 0.95/100PY in patients with EF ≥15% (p=0

  11. [What is new in heart failure with preserved ejection fraction within last five years?].

    PubMed

    Gregorová, Zdeňka; Meluzín, Jaroslav; Spinarová, Lenka

    2014-01-01

    Heart failure with preserved ejection fraction of left ventricle (heart failure with normal ejection fraction, HFPEF, HFNEF) is frequent disease with serious consequences. Incidence of HFPEF in population is still growing. The exact pathophysiological mechanism of HFPEF remain unclear .Recent evidence suggests a relationship between inflammation associated with obesity or Diabetes mellitus and progression of HFPEF. Consistently, it has been reported that serum concentration of some pro-inflammatory markers such as adiponectin is positively related to HFPEF. By HFPEF is attended diastolic dysfunction. Diastolic dysfunction is linked to many other cardiac and non-cardiac diseases. Despite the great effort and new therapeutic approaches the prognosis of HFPEF does not improve. The gold standard in HFPEF diagnosis remains heart catheterization. Electrocardiography, chest X-ray, blood examination including diagnostic markers of heart failure and mainly echocardiography with Doppler imaging are used diagnose the underlying disease leading to heart failure.

  12. Comparison of ejection fraction and zonal mean velocity of myocardial fiber shortening.

    PubMed

    Nakhjavan, F K; Natarajan, G; Goldberg, H

    1975-08-01

    To determine the extent of cardiac involvement until a diminished ejection fraction (EF) is present, zonal mean velocity of circumferential fiber shortening (Vcf) was measured from the left ventriculogram in 36 patients. The longitudinal axis (apex to mid-point of the aortic valve plane) in right anterior oblique view was divided into four equal parts by three perpeendicular chords. Zonal Vct and percent shortening along the proximal, middle and distal chords were measured. The results of this study indicate that a normal EF is frequently associated with a reduced Vct in one or even two zones. A reduced EF is generally accompanied by a diminished Vct in all three zones of the heart. In addition, a close correlation was found between zonal Vct and percent shortening. Hence the latter, which is much simpler to measure, can be instead of Vct Ejection fraction as a measure of myocardial performance is not as sensitive as Vct, especially in hearts with asynchrony of contraction.

  13. Sleep Apnea and Left Atrial Phasic Function in Heart Failure With Reduced Ejection Fraction.

    PubMed

    Haruki, Nobuhiko; Tsang, Wendy; Thavendiranathan, Paaladinesh; Woo, Anna; Tomlinson, George; Logan, Alexander G; Bradley, T Douglas; Floras, John S

    2016-12-01

    The study aim was to determine whether phasic left atrial (LA) function of patients with heart failure with reduced ejection fraction differs between those with obstructive sleep apnea (OSA) and central sleep apnea (CSA). Participation in the Adaptive Servo Ventilation for Therapy of Sleep Apnea in Heart Failure (ADVENT-HF) trial requires 2-dimensional echocardiographic documentation of left ventricular ejection fraction ≤ 45% and a polysomnographic apnea hypopnea index (AHI) ≥ 15 events per hour. Of initial enrollees, we identified 132 patients in sinus rhythm (82 with predominantly OSA and 50 with CSA). To determine LA reservoir (expansion index; EI), conduit (passive emptying index; PEI), and booster function (active emptying index), we blindly quantified maximum and minimum LA volume and LA volume before atrial contraction. Each of EI (P = 0.004), PEI (P < 0.001), and active emptying index (P = 0.045) was less in participants with CSA compared with those with OSA, whereas average left ventricular ejection fraction and LA and left ventricular volumes were similar. Multivariable analysis identified an independent relationship between central AHI and LA EI (P = 0.040) and PEI (P = 0.005). In contrast, the obstructive AHI was unrelated to any LA phasic index, and slopes relating central AHI to EI and PEI differed significantly from corresponding relationships with obstructive AHI (P = 0.018; P = 0.006). In these ADVENT-HF patients with heart failure with reduced ejection fraction, all 3 components of LA phasic function (reservoir, conduit, and contractile) were significantly reduced in those with CSA compared with participants with OSA. The severity of CSA, but not OSA associated inversely and independently with LA reservoir and conduit function. Impaired LA phasic function might be consequent to or could exacerbate CSA. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

  14. Renal dysfunction and anemia in patients with heart failure with reduced versus normal ejection fraction.

    PubMed

    Villacorta, Humberto; Saenz-Tello, Bolivar F; Santos, Eduarda Barcellos dos; Steffen, Ricardo; Wiefels, Christiane; Lima, Luiz Costa; Sales, Ana Luíza F; Soares, Pedro; Mesquita, Evandro Tinoco

    2010-03-01

    The presence of anemia and renal dysfunction grants a bad prognosis for patients with heart failure and reduced ejection fraction (HFREF). The impact on patients with heart failure and normal ejection fraction (HFNEF) is not widely studied. To study the prevalence and the prognosis of anemia and renal dysfunction (RD) in patients with heart failure according to the type of ventricular dysfunction. A total of 209 patients with chronic and stable heart failure were prospectively studied. Individuals with ejection fraction <50% were considered as HFREF patients. Anemia was defined, based on WHO criteria, as hemoglobin <13 g/dl for men and <12 g/dl for women. Renal function was calculated by means of the Simplified Modified Diet Renal Disease (sMDRD) formula. Hospitalizations, emergency admittances and obit by cardiac causes were considered as cardiac events. Ninety patients had HFREF and 119 had HFNEF. The glomerular filtration rate (GFR) was smaller in HFREF group (57.6 +/- 66.2 versus 94.8 +/- 36.6 ml/min/1.73m(2); p=0.01). There was no difference in the prevalence of anemia between groups (23.3% versus 18.5%; p=0.34). Moderate to severe RD prevalence was higher in HFREF group (32.2% versus 16.8%; p=0.01). RD was the only factor associated with anemia that was independently associated with cardiac events (HR 2.52; 95%CI=1.27-5.2; p=0.01). RD was less prevalent in HFNEF, while the prevalence of anemia did not differ between groups. RD was predictor of cardiac events independently on ejection fraction.

  15. Radionuclide assessment of the natural heart ejection fraction before and after LVAD implantation.

    PubMed

    Moritz, A; Napoli, C A; Feiglin, D; Uchida, N; Harasaki, H; Smith, W A; Nose, Y

    1989-01-01

    Complete pressure unloading of the ventricles can preserve ischemically damaged myocardium. Most clinical left heart assist device (LVAD) systems used after ischemic injury of the heart apply atrial cannulation which does not ensure pressure unloading. In order to assess the effect of the implantation of an intracorporeal LVAD on the function of the natural heart, we determined the ejection fraction (EF) in four male Holstein calves (90-105 kg) before and after insertion of a Cleveland Clinic pneumatic LVAD. A gated blood pool scan was obtained with a gamma camera after injection of 40 mCi Tc-labelled albumin. The animals were restrained in a sling to avoid movement artifacts. All animals showed a drop of 65 +/- 12% to 42 +/- 14% EF in the first postoperative (p.o.) week. Left ventricular output did not maintain sufficient blood pressure as assessed by pump-off tests. Systolic blood pressure dropped from 122 +/- 6.5 mm Hg to 81 +/- 6 mm Hg without pump support on the morning of the first p.o. day. Apical coring and possible restrained heart movement by the implanted LVAD may lead to impaired myocardial function that renders the individual LVAD dependent until adaptative corrections take place.

  16. Inappropriate left ventricular mass and poor outcomes in patients with angina pectoris and normal ejection fraction.

    PubMed

    Huang, Bao-Tao; Peng, Yong; Liu, Wei; Zhang, Chen; Huang, Fang-Yang; Wang, Peng-Ju; Zuo, Zhi-Liang; Liao, Yan-Biao; Chai, Hua; Li, Qiao; Zhao, Zhen-Gang; Luo, Xiao-Lin; Ren, Xin; Huang, Kai-Sen; Meng, Qing-Tao; Chen, Chi; Huang, De-Jia; Chen, Mao

    2015-03-01

    Although inappropriate left ventricular mass has been associated with clustered cardiac geometric and functional abnormalities, its predictive value in patients with coronary artery disease is still unknown. This study examined the association of inappropriate left ventricular mass with clinical outcomes in patients with angina pectoris and normal ejection fraction. Consecutive patients diagnosed with angina pectoris whose ejection fraction was normal were recruited from 2008 to 2012. Inappropriate left ventricular mass was determined when the ratio of actual left ventricular mass to the predicted one exceeded 150%. The primary endpoint was a composite of all-cause death, nonfatal myocardial infarction, and nonfatal stroke. Clinical outcomes between the inappropriate and appropriate left ventricular mass group were compared before and after propensity matching. Of the total of 1515 participants, 18.3% had inappropriate left ventricular mass. Patients with inappropriate left ventricular mass had a higher composite event rate compared with those with appropriate left ventricular mass (11.2 vs. 6.6%, P=0.010). Multivariate Cox regression analyses showed that inappropriate left ventricular mass was an independent risk factor for adverse events (adjusted hazard ratio, 1.59; 95% confidence interval, 1.03-2.45; P=0.035). The worse outcome in patients with inappropriate left ventricular mass was further validated in a propensity matching cohort and patients with the traditional definition of left ventricular hypertrophy. Inappropriate left ventricular mass was associated with an increased risk of adverse events in patients with angina pectoris and normal ejection fraction.

  17. Physical therapy in heart failure with preserved ejection fraction: A systematic review.

    PubMed

    Palau, Patricia; Núñez, Eduardo; Domínguez, Eloy; Sanchis, Juan; Núñez, Julio

    2016-01-01

    About 50% of patients with heart failure (HF) have preserved ejection fraction (HFpEF) which is especially common in elderly people with highly prevalent co-morbid conditions. HFpEF is usually defined as an ejection fraction equal to or greater than 50%, although some studies have used a limit as low as 40%. The prevalence of this syndrome is expected to increase over the next decades. The associated impact on mortality and hospital readmissions has made of this entity a major public health issue. Despite the fact that mortality and re-hospitalisation rates of HFpEF are similar to the syndrome of HF with reduced ejection fraction (HFrEF), currently there is no available evidence-based therapy as effective as is the case for HFrEF. Exercise intolerance is the principal clinical feature in HFpEF. The pathophysiological mechanisms behind impaired exercise capacity in these patients are complex and not yet fully elucidated. Current guidelines and consensus documents recommend the implementation of exercise training in HFpEF; however, they are based mostly on results from a few small trials evaluating surrogate endpoints such as exercise capacity and quality of life. The aim of this work was to review the current evidence that supports the effect of the different modalities of physical therapies in HFpEF. © The European Society of Cardiology 2014.

  18. A porcine model of hypertensive cardiomyopathy: implications for heart failure with preserved ejection fraction.

    PubMed

    Schwarzl, Michael; Hamdani, Nazha; Seiler, Sebastian; Alogna, Alessio; Manninger, Martin; Reilly, Svetlana; Zirngast, Birgit; Kirsch, Alexander; Steendijk, Paul; Verderber, Jochen; Zweiker, David; Eller, Philipp; Höfler, Gerald; Schauer, Silvia; Eller, Kathrin; Maechler, Heinrich; Pieske, Burkert M; Linke, Wolfgang A; Casadei, Barbara; Post, Heiner

    2015-11-01

    Heart failure with preserved ejection fraction (HFPEF) evolves with the accumulation of risk factors. Relevant animal models to identify potential therapeutic targets and to test novel therapies for HFPEF are missing. We induced hypertension and hyperlipidemia in landrace pigs (n = 8) by deoxycorticosteroneacetate (DOCA, 100 mg/kg, 90-day-release subcutaneous depot) and a Western diet (WD) containing high amounts of salt, fat, cholesterol, and sugar for 12 wk. Compared with weight-matched controls (n = 8), DOCA/WD-treated pigs showed left ventricular (LV) concentric hypertrophy and left atrial dilatation in the absence of significant changes in LV ejection fraction or symptoms of heart failure at rest. The LV end-diastolic pressure-volume relationship was markedly shifted leftward. During simultaneous right atrial pacing and dobutamine infusion, cardiac output reserve and LV peak inflow velocities were lower in DOCA/WD-treated pigs at higher LV end-diastolic pressures. In LV biopsies, we observed myocyte hypertrophy, a shift toward the stiffer titin isoform N2B, and reduced total titin phosphorylation. LV superoxide production was increased, in part attributable to nitric oxide synthase (NOS) uncoupling, whereas AKT and NOS isoform expression and phosphorylation were unchanged. In conclusion, we developed a large-animal model in which loss of LV capacitance was associated with a titin isoform shift and dysfunctional NOS, in the presence of preserved LV ejection fraction. Our findings identify potential targets for the treatment of HFPEF in a relevant large-animal model.

  19. Nuclear cardiac ejection fraction and cardiac index in abdominal aortic surgery

    SciTech Connect

    Fiser, W.P.; Thompson, B.W.; Thompson, A.R.; Eason, C.; Read, R.C.

    1983-11-01

    Since atherosclerotic heart disease results in more than half of the perioperative deaths that follow abdominal aortic surgery, a prospective protocol was designed for preoperative evaluation and intraoperative hemodynamic monitoring. Twenty men who were prepared to undergo elective operation for aortoiliac occlusive disease (12 patients) and abdominal aortic aneurysm (eight patients) were evaluated with a cardiac scan and right heart catheterization. The night prior to operation, each patient received volume loading with crystalloid based upon ventricular performance curves. At the time of the operation, all patients were anesthetized with narcotics and nitrous oxide, and hemodynamic parameters were recorded throughout the operation. Aortic crossclamping resulted in a marked depression in CI in all patients. CI remained depressed after unclamping in the majority of patients. There were two perioperative deaths, both from myocardial infarction or failure. Both patients had ejection fractions less than 30% and initial CIs less than 2 L/M2, while the survivors' mean ejection fraction was 63% +/- 1 and their mean CI was 3.2 L/M2 +/- 0.6. The authors conclude that preoperative evaluation of ejection fraction can select those patients at a high risk of cardiac death from abdominal aortic operation. These patients should receive intensive preoperative monitoring with enhancement of ventricular performance.

  20. [Baroreflex activation therapy. A novel interventional approach to treat heart failure with reduced ejection fraction].

    PubMed

    Halbach, M; Fritz, T; Madershahian, N; Pfister, R; Reuter, H

    2015-11-01

    Sympathovagal imbalance plays an important role in the progression of heart failure with reduced ejection fraction. Baroreflex activation therapy (BAT), i. e. electrical stimulation of baroreceptors located at the carotid sinus, can reduce sympathetic and enhance parasympathetic tone. Large animal studies on BAT demonstrated improvements in cardiac function, arrhythmogenic risk and a survival benefit compared to untreated controls. The recently published Neo Randomized Heart Failure Study, the first multicenter, randomized and controlled trial of optimal medical and device therapy alone or plus BAT in patients with a left ventricular ejection fraction ≤ 35 %, demonstrated a reasonable safety profile of BAT in this severely ill patient population and no relevant interactions with other devices. The study found significant improvements in the New York Heart Association (NYHA) class of heart failure, quality of life as well as 6 min walking distance and data pointed to a reduction in hospitalization rates. Moreover, N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were significantly reduced. This review gives an overview on BAT for the treatment of heart failure with reduced ejection fraction, from the rationale and animal experiments to the most recent clinical data and future perspectives.

  1. Clinical Utility of Exercise Training in Heart Failure with Reduced and Preserved Ejection Fraction

    PubMed Central

    Asrar Ul Haq, Muhammad; Goh, Cheng Yee; Levinger, Itamar; Wong, Chiew; Hare, David L

    2015-01-01

    Reduced exercise tolerance is an independent predictor of hospital readmission and mortality in patients with heart failure (HF). Exercise training for HF patients is well established as an adjunct therapy, and there is sufficient evidence to support the favorable role of exercise training programs for HF patients over and above the optimal medical therapy. Some of the documented benefits include improved functional capacity, quality of life (QoL), fatigue, and dyspnea. Major trials to assess exercise training in HF have, however, focused on heart failure with reduced ejection fraction (HFREF). At least half of the patients presenting with HF have heart failure with preserved ejection fraction (HFPEF) and experience similar symptoms of exercise intolerance, dyspnea, and early fatigue, and similar mortality risk and rehospitalization rates. The role of exercise training in the management of HFPEF remains less clear. This article provides a brief overview of pathophysiology of reduced exercise tolerance in HFREF and heart failure with preserved ejection fraction (HFPEF), and summarizes the evidence and mechanisms by which exercise training can improve symptoms and HF. Clinical and practical aspects of exercise training prescription are also discussed. PMID:25698883

  2. Benefits and Harms of Sacubitril in Adults With Heart Failure and Reduced Left Ventricular Ejection Fraction.

    PubMed

    Aronow, Wilbert S; Shamliyan, Tatyana A

    2017-10-01

    The quality of evidence regarding patient-centered outcomes in adults with heart failure (HF) after sacubitril combined with valsartan has not been systematically appraised. We searched 4 databases in February 2017 and graded the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation working group approach. We reviewed 1 meta-analysis and multiple publications of 2 randomized controlled trials (RCT) and 1 unpublished RCT. In adults with HF and reduced ejection fraction, low-quality evidence from 1 RCT of 8,432 patients suggests that sacubitril combined with valsartan reduces all-cause (number needed to treat [NNT] to prevent 1 event [NNTp] = 35) and cardiovascular mortality (NNTp = 32), hospitalization (NNTp = 11), emergency visits (NNTp = 69), and serious adverse effects, leading to treatment discontinuation (NNTp = 63) and improves quality of life when compared with enalapril. In adults with HF and preserved ejection fraction, very low-quality evidence from 1 RCT of 301 patients suggests that there are no differences in mortality, morbidity, or adverse effects between sacubitril combined with valsartan and valsartan alone. In conclusion, in adults with HF and reduced ejection fraction, to reduce cardiovascular mortality and hospitalizations and improve quality of life, clinicians may recommend sacubitril combined with valsartan over angiotensin-converting enzyme inhibitors. Copyright © 2017 Elsevier Inc. All rights reserved.

  3. Comparison of different segmentation approaches without using gold standard. Application to the estimation of the left ventricle ejection fraction from cardiac cine MRI sequences

    PubMed Central

    Lebenberg, Jessica; Buvat, Irène; Garreau, Mireille; Casta, Christopher; Constantinidès, Constantin; Cousty, Jean; Cochet, Alexandre; Jehan-Besson, Stéphanie; Tilmant, Christophe; Lefort, Muriel; Roullot, Elodie; Najman, Laurent; Sarry, Laurent; Clarysse, Patrick; De Cesare, Alain; Lalande, Alain; Frouin, Frédérique

    2011-01-01

    A statistical method is proposed to compare several estimates of a relevant clinical parameter when no gold standard is available. The method is illustrated by considering the left ventricle ejection fraction derived from cardiac magnetic resonance images and computed using seven approaches with different degrees of automation. The proposed method did not use any a priori regarding with the reliability of each method and its degree of automation. The results showed that the most accurate estimates of the ejection fraction were obtained using manual segmentations, followed by the semi-automatic methods, while the methods with the least user input yielded the least accurate ejection fraction estimates. These results were consistent with the expected performance of the estimation methods, suggesting that the proposed statistical approach might be helpful to assess the performance of estimation methods on clinical data for which no gold standard is available. PMID:22254889

  4. Comparison of characteristics and outcomes of patients with heart failure preserved ejection fraction versus reduced left ventricular ejection fraction in an urban cohort.

    PubMed

    Quiroz, Rene; Doros, Gheorghe; Shaw, Peter; Liang, Chang-Seng; Gauthier, Diane F; Sam, Flora

    2014-02-15

    Despite significant advances in therapies for patients with heart failure with reduced ejection fraction (HFrEF), there are no evidence-based therapies for heart failure with preserved ejection fraction (HFpEF), also known as diastolic heart failure (HF). Differences in pathophysiologic mechanisms are touted as to why patients with HFpEF purportedly do not derive similar therapeutic benefits compared with HFrEF. Similarly, the relative frequencies of HFpEF and HFrEF may differ between hospitalized and ambulatory settings. There are limited data on the prevalence, characteristics, treatment, and short-term outcomes of patients hospitalized with HFpEF. We sought to investigate these in patients hospitalized with HFpEF in an urban, hospitalized setting using the Get With The Guidelines registry. We retrospectively reviewed all consecutive discharges (n = 1,701) with a diagnosis of acute decompensated HF from December 1, 2006 to September 30, 2008. Patients with HFpEF (n = 499) were older, overweight, predominantly women, and had underlying hypertension and dyslipidemia. Presenting blood pressure and levels of creatinine were higher, with lower brain natriuretic peptide levels compared with patients with HFrEF (n = 598). Length of stay and 30-day mortality were comparable between patients with HFpEF and HFrEF. Thirty-day readmission was initially lower in patients with HFpEF. However 30-day mortality from any cause after the index HF hospitalization and survival curve at 1-year was no different between patients with HFpEF and HFrEF. In conclusion, lower 30-day readmissions do not translate into improved long-term outcome in patients with HFpEF.

  5. Heart Failure with Preserved Ejection Fraction - Concept, Pathophysiology, Diagnosis and Challenges for Treatment.

    PubMed

    Miljkovik, Lidija Veterovska; Spiroska, Vera

    2015-09-15

    Heart failure (HF) with preserved left ventricular (LV) ejection fraction (HFpEF) occurs in 40 to 60% of the patients with HF, with a prognosis which is similar to HF with reduced ejection fraction (HFrEF). HFpEF pathophysiology is different from that of HFrEF, and has been characterized with diastolic dysfunction. Diastolic dysfunction has been defined with elevated left ventricular stiffness, prolonged iso-volumetric LV relaxation, slow LV filing and elevated LV end-diastolic pressure. Arterial hypertension occurs in majority cases with HFpEF worldwide. Patients are mostly older and obese. Diabetes mellitus and atrial fibrillation appear proportionally in a high frequency of patients with HFpEF. The HFpEF diagnosis is based on existence of symptoms and signs of heart failure, normal or approximately normal ejection and diagnosing of LV diastolic dysfunction by means of heart catheterization or Doppler echocardiography and/or elevated concentration of plasma natriuretic peptide. The present recommendations for HFpEF treatment include blood pressure control, heart chamber frequency control when atrial fibrillation exists, in some situations even coronary revascularization and an attempt for sinus rhythm reestablishment. Up to now, it is considered that no medication or a group of medications improve the survival of HFpEF patients. Due to these causes and the bad prognosis of the disorder, rigorous control is recommended of the previously mentioned precipitating factors for this disorder. This paper presents a universal review of the most important parameters which determine this disorder.

  6. Ventricular-arterial uncoupling in heart failure with preserved ejection fraction after myocardial infarction in dogs - invasive versus echocardiographic evaluation.

    PubMed

    Mathieu, Myrielle; El Oumeiri, Bachar; Touihri, Karim; Hadad, Ielham; Mahmoudabady, Maryam; Thoma, Philippe; Metens, Thierry; Bartunek, Jozef; Heyndrickx, Guy R; Brimioulle, Serge; Naeije, Robert; Mc Entee, Kathleen

    2010-06-29

    Heart failure with preserved left ventricular ejection fraction and abnormal diastolic function is commonly observed after recovery from an acute myocardial infarction. The aim of this study was to investigate the physiopathology of heart failure with preserved ejection fraction in a model of healed myocardial infarction in dogs. Echocardiography, levels of neurohormones and conductance catheter measurements of left ventricular pressure-volume relationships were obtained in 17 beagle dogs 2 months after a coronary artery ligation, and in 6 controls. Healed myocardial infarction was associated with preserved echocardiographic left ventricular ejection fraction (0.57 +/- 0.01, mean +/- SEM) and altered Doppler mitral indices of diastolic function. NT-proBNP was increased, aldosterone was decreased, and norepinephrine was unchanged. Invasive measurements showed a markedly decreased end-systolic elastance (2.1 +/- 0.2 vs 6.1 +/- 0.8, mmHg/ml, p < 0.001) and end-systolic elastance to effective arterial elastance ratio (0.6 +/- 0.1 vs 1.4 +/- 0.2, p < 0.001), with altered active relaxation (dP/dtmin -1992 +/- 71 vs -2821 +/- 305, mmHg/s, p < 0.01) but preserved left ventricular capacitance (70 +/- 6 vs 61 +/- 3, ml at 20 mmHg, p = NS) and stiffness constant. Among echocardiographic variables, the wall motion score index was the most reliable indicator of cardiac contractility while E', E/A and E'/A' were correlated to dP/dtmin. In the canine model of healed myocardial infarction induced by coronary ligation, heart failure is essentially characterized by an altered contractility with left ventricular-arterial uncoupling despite vascular compensation rather than by abnormal diastolic function.

  7. Ventricular-arterial uncoupling in heart failure with preserved ejection fraction after myocardial infarction in dogs - invasive versus echocardiographic evaluation

    PubMed Central

    2010-01-01

    Background Heart failure with preserved left ventricular ejection fraction and abnormal diastolic function is commonly observed after recovery from an acute myocardial infarction. The aim of this study was to investigate the physiopathology of heart failure with preserved ejection fraction in a model of healed myocardial infarction in dogs. Methods Echocardiography, levels of neurohormones and conductance catheter measurements of left ventricular pressure-volume relationships were obtained in 17 beagle dogs 2 months after a coronary artery ligation, and in 6 controls. Results Healed myocardial infarction was associated with preserved echocardiographic left ventricular ejection fraction (0.57 ± 0.01, mean ± SEM) and altered Doppler mitral indices of diastolic function. NT-proBNP was increased, aldosterone was decreased, and norepinephrine was unchanged. Invasive measurements showed a markedly decreased end-systolic elastance (2.1 ± 0.2 vs 6.1 ± 0.8, mmHg/ml, p < 0.001) and end-systolic elastance to effective arterial elastance ratio (0.6 ± 0.1 vs 1.4 ± 0.2, p < 0.001), with altered active relaxation (dP/dtmin -1992 ± 71 vs -2821 ± 305, mmHg/s, p < 0.01) but preserved left ventricular capacitance (70 ± 6 vs 61 ± 3, ml at 20 mmHg, p = NS) and stiffness constant. Among echocardiographic variables, the wall motion score index was the most reliable indicator of cardiac contractility while E', E/A and E'/A' were correlated to dP/dtmin. Conclusions In the canine model of healed myocardial infarction induced by coronary ligation, heart failure is essentially characterized by an altered contractility with left ventricular-arterial uncoupling despite vascular compensation rather than by abnormal diastolic function PMID:20587034

  8. Coronary microvascular rarefaction and myocardial fibrosis in heart failure with preserved ejection fraction.

    PubMed

    Mohammed, Selma F; Hussain, Saad; Mirzoyev, Sultan A; Edwards, William D; Maleszewski, Joseph J; Redfield, Margaret M

    2015-02-10

    Characterization of myocardial structural changes in heart failure with preserved ejection fraction (HFpEF) has been hindered by the limited availability of human cardiac tissue. Cardiac hypertrophy, coronary artery disease (CAD), coronary microvascular rarefaction, and myocardial fibrosis may contribute to HFpEF pathophysiology. We identified HFpEF patients (n=124) and age-appropriate control subjects (noncardiac death, no heart failure diagnosis; n=104) who underwent autopsy. Heart weight and CAD severity were obtained from the autopsy reports. With the use of whole-field digital microscopy and automated analysis algorithms in full-thickness left ventricular sections, microvascular density (MVD), myocardial fibrosis, and their relationship were quantified. Subjects with HFpEF had heavier hearts (median, 538 g; 169% of age-, sex-, and body size-expected heart weight versus 335 g; 112% in controls), more severe CAD (65% with ≥1 vessel with >50% diameter stenosis in HFpEF versus 13% in controls), more left ventricular fibrosis (median % area fibrosis, 9.6 versus 7.1) and lower MVD (median 961 versus 1316 vessels/mm(2)) than control (P<0.0001 for all). Myocardial fibrosis increased with decreasing MVD in controls (r=-0.28, P=0.004) and HFpEF (r=-0.26, P=0.004). Adjusting for MVD attenuated the group differences in fibrosis. Heart weight, fibrosis, and MVD were similar in HFpEF patients with CAD versus without CAD. In this study, patients with HFpEF had more cardiac hypertrophy, epicardial CAD, coronary microvascular rarefaction, and myocardial fibrosis than controls. Each of these findings may contribute to the left ventricular diastolic dysfunction and cardiac reserve function impairment characteristic of HFpEF. © 2014 American Heart Association, Inc.

  9. Renal resistance index and its prognostic significance in patients with heart failure with preserved ejection fraction.

    PubMed

    Ennezat, Pierre Vladimir; Maréchaux, Sylvestre; Six-Carpentier, Marie; Pinçon, Claire; Sediri, Ibrahim; Delsart, Pascal; Gras, Marc; Mounier-Véhier, Claire; Gautier, Corinne; Montaigne, David; Jude, Brigitte; Asseman, Philippe; Le Jemtel, Thierry H

    2011-12-01

    Functional renal impairment is a common feature of heart failure with preserved ejection fraction (HFpEF). The link between functional renal impairment and HFpEF remains incompletely understood. With hypertension and diabetes as frequent co-morbidities, patients with HFpEF are at risk of developing intra-renal vascular hemodynamic alterations that may lead to functional renal impairment and impact on prognosis. Renal resistive index (RRI) was non-invasively determined by Doppler ultrasonic examination in 90 HFpEF patients and 90 age- and sex-matched hypertensive patients without evidence of heart failure (HF) who served as controls. Clinical, laboratory and cardiac echocardiography data were obtained in HFpEF patients and controls. To investigate its possible clinical relevance, RRI was evaluated as a prognostic index of all-cause mortality and hospitalization for HF. Mean RRI was substantially greater in HFpEF patients than in controls (P < 0.0001), while mean blood pressure, glomerular filtration rate, hemoglobin and serum protein levels were significantly lower in HFpEF patients than in controls. On multivariable analysis, mean RRI was independently associated with HFpEF. In addition, increased mean RRI was an independent predictor of poor outcome [hazard ratio = 1.06 95% confidence interval (1.01-1.10), P = 0.007] and remained significantly associated with the outcome after adjustment for univariate predictors that included low mean blood pressure, low hemoglobin concentration and low glomerular filtration rate. Conclusion. Patients with HFpEF exhibit intra-renal vascular hemodynamic alterations. The severity of intra-renal vascular hemodynamic alterations correlates with a poor outcome.

  10. Tai chi in patients with heart failure with preserved ejection fraction.

    PubMed

    Yeh, Gloria Y; Wood, Malissa J; Wayne, Peter M; Quilty, Mary T; Stevenson, Lynne W; Davis, Roger B; Phillips, Russell S; Forman, Daniel E

    2013-01-01

    Although exercise is an important component of heart failure management, optimal regimens, particularly in heart failure with preserved ejection fraction (HFPEF), are uncertain. Tai chi (TC) is a mind-body exercise that may have potential benefits but has not been studied in this population. The authors randomized 16 patients with HFPEF to either 12 weeks TC or aerobic exercise. Assessments included peak oxygen uptake, 6-minute walk, quality of life, echocardiography, mood, and self-efficacy at baseline and at 12 weeks. Cardiorespiratory measures during exercise were obtained to characterize training intensities. Baseline characteristics were as follows: age 66±12 years, E/A ratio 1.3±0.7, and E/e' ratio 15.9±4.8. Overall, adherence was excellent (89% attendance). Change in peak oxygen uptake was similar between groups after 12 weeks, but 6-minute walk distance increased more after TC (69±46 m vs 10±31 m, P=.02). While both groups had improved Minnesota Living With Heart Failure scores and self-efficacy, Profile of Mood States (POMS)-Depression scores improved more with TC (-1.7±2.8 vs 1.6±3, P=.05). Cardiorespiratory assessment during TC showed lower oxygen uptake (4.3 mL/kg/min vs 9.4 mL/kg/min, P<.01), respiratory rate, and heart rate. TC is feasible and safe in HFPEF. Therepeutic endpoints appear similar with TC relative to aerobic exercise despite a lower aerobic training workload. © 2012 Wiley Periodicals, Inc.

  11. Magnetic resonance imaging--cardiac ejection fraction measurements. Phantom study comparing four different methods.

    PubMed

    Debatin, J F; Nadel, S N; Sostman, H D; Spritzer, C E; Evans, A J; Grist, T M

    1992-03-01

    The accuracy of cardiac ejection fraction (EF) measurements with thin, contiguous cine-magnetic resonance imaging (MR) sections is well established. Still, faster imaging and measurement techniques would be desirable. The authors evaluated the accuracy of four different MR EF measurements methods in a biventricular, anthropomorphic, foam-latex rubber phantom which was connected via noncompliant fluid-filled tubing to a pulsatile flow pump. Nine contiguous 10 mm cine-MR sections (TR/TE, 25/13; flip angle, 45 degrees) were obtained through the heart in long and short cardiac axes at 16 frames per cardiac cycle at a pump rate of 60 beats/minute. EF measurements were based on either the multi-slice summation technique (nine contiguous 10-mm sections versus four 10-mm sections spaced 10 mm apart) or the area-length method (single largest long section versus combination of largest long- and short-axis section). Three replications were performed for each of the tested EFs (40.8%, 29.4%, and 13.4%), which were compared with actual EFs. EF measurements based on contiguous 1-cm sections correlated best with the actual EFs. Average relative errors ranged from 3.2% to 6.0%. EF measurements based on every other section were less accurate; average relative errors were between 5.2% and 10.2%. Single and biplane area-length algorithm EF measurements were significantly less accurate; average relative errors were as high as 59%. EF measurements based on multi-slice summation are more accurate than those based on the area-length algorithm. Contiguous 1-cm section acquisitions are most accurate and most time consuming. With slight decrease of accuracy, acquisition and processing times can be halved by skipping every other slice.

  12. Time-Dependent Regional Myocardial Strains in Patients with Heart Failure with a Preserved Ejection Fraction

    PubMed Central

    Smith, Shane P.; Secomb, Timothy W.; Hong, Brian D.; Moulton, Michael J.

    2016-01-01

    Objectives. To better understand the etiology of HFpEF in a controlled human population, regional time-varying strains were computed using echocardiography speckle tracking in patients with heart failure with a preserved ejection fraction and normal subjects. Methods. Eleven normal volunteers and ten patients with echo-graded diastolic dysfunction and symptoms of heart failure were imaged with echocardiography and longitudinal, circumferential, and rotational strains were determined using speckle-tracking. Diastolic strain rate was also determined. Patient demographics and echo-derived flows, volumes, and pressures were recorded. Results. Peak longitudinal and circumferential strain was globally reduced in patients (p < 0.001), when compared to controls. The patients attained peak longitudinal and circumferential strain at a consistently later point in systole than controls. Rotational strains were not different in most LV regions. Early diastolic strain rate was significantly reduced in the patients (p < 0.001). LV mass and wall thickness were significantly increased in the patients; however ejection fraction was preserved and stroke volume was diminished (p < 0.001). Conclusions. This study shows that patients with HFpEF have reduced early diastolic strain rate and reduced peak strain that is regionally homogeneous and that they also utilize a longer fraction of systole to achieve peak axial strains. PMID:27042673

  13. Mid-range Ejection Fraction Does Not Permit Risk Stratification Among Patients Hospitalized for Heart Failure.

    PubMed

    Gómez-Otero, Inés; Ferrero-Gregori, Andreu; Varela Román, Alfonso; Seijas Amigo, José; Pascual-Figal, Domingo A; Delgado Jiménez, Juan; Álvarez-García, Jesús; Fernández-Avilés, Francisco; Worner Diz, Fernando; Alonso-Pulpón, Luis; Cinca, Juan; Gónzalez-Juanatey, José Ramón

    2017-05-01

    European Society of Cardiology heart failure guidelines include a new patient category with mid-range (40%-49%) left ventricular ejection fraction (HFmrEF). HFmrEF patient characteristics and prognosis are poorly defined. The aim of this study was to analyze the HFmrEF category in a cohort of hospitalized heart failure patients (REDINSCOR II Registry). A prospective observational study was conducted with 1420 patients classified according to ejection fraction as follows: HFrEF, < 40%; HFmrEF, 40%-49%; and HFpEF, ≥ 50%. Baseline patient characteristics were examined, and outcome measures were mortality and readmission for heart failure at 1-, 6-, and 12-month follow-up. Propensity score matching was used to compare the HFmrEF group with the other ejection fraction groups. Among the study participants, 583 (41%) had HFrEF, 227 (16%) HFmrEF, and 610 (43%) HFpEF. HFmrEF patients had a clinical profile similar to that of HFpEF patients in terms of age, blood pressure, and atrial fibrillation prevalence, but shared with HFrEF patients a higher proportion of male participants and ischemic etiology, and use of class I drugs targeting HFrEF. All other features were intermediate, and comorbidities were similar among the 3 groups. There were no significant differences in all-cause mortality, cause of death, or heart failure readmission. The similar outcomes were confirmed in the propensity score matched cohorts. The HFmrEF patient group has characteristics between the HFrEF and HFpEF groups, with more similarities to the HFpEF group. No between-group differences were observed in total mortality, cause of death, or heart failure readmission. Copyright © 2016 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

  14. Neprilysin Inhibition in Heart Failure with Reduced Ejection Fraction: A Clinical Review.

    PubMed

    King, Jordan B; Bress, Adam P; Reese, Austin D; Munger, Mark A

    2015-09-01

    There has been a 10-year hiatus in the approval of a new pharmacotherapy for patients with chronic heart failure with a reduced ejection fraction (HFrEF). Combining an angiotensin receptor blocker, valsartan, with sacubitril, an inhibitor of neprilysin, results in increasing levels of natriuretic peptides that counterbalance high circulating levels of neurohormones in HFrEF. This has resulted in the development of a new agent, LCZ696. A comprehensive overview of LCZ696, its pharmacology, its role in the pathophysiology of HFrEF, completed and future clinical trial information, specific critical issues, and the place of LCZ696 in HFrEF therapy are presented.

  15. Cholecystokinin enhanced hepatobiliary scanning with ejection fraction calculation as an indicator of disease of the gallbladder

    SciTech Connect

    Zech, E.R.; Simmons, L.B.; Kendrick, R.R.; Soballe, P.W.; Olcese, J.A.; Goff, W.B. II; Lawrence, D.P.; DeWeese, R.A. )

    1991-01-01

    Chronic acalculous cholecystitis represents 5 to 20 per cent of electively treated diseases of the gallbladder. A 70 per cent success rate in relieving these patients of chronic pain was reported when surgical treatment was recommended based on symptoms alone. The cholecystokinin ejection fraction, which is a quantitative measure of emptying of the gallbladder, was 95 per cent accurate in predicting which patients would be relieved of symptoms by surgical treatment. In this study, we report our consecutive experience during a 20 month period with 83 patients.

  16. Plasma Biomarkers Reflecting Profibrotic Processes in Heart Failure With a Preserved Ejection Fraction

    PubMed Central

    Zile, Michael R.; Jhund, Pardeep S.; Baicu, Catalin F.; Claggett, Brian L.; Pieske, Burkert; Voors, Adriaan A.; Prescott, Margaret F.; Shi, Victor; Lefkowitz, Martin; McMurray, John J.V.; Solomon, Scott D.

    2017-01-01

    Background Heart failure with preserved ejection fraction is a clinical syndrome that has been associated with changes in the extracellular matrix. The purpose of this study was to determine whether profibrotic biomarkers accurately reflect the presence and severity of disease and underlying pathophysiology and modify response to therapy in patients with heart failure with preserved ejection fraction. Methods and Results Four biomarkers, soluble form of ST2 (an interleukin-1 receptor family member), galectin-3, matrix metalloproteinase-2, and collagen III N-terminal propeptide were measured in the Prospective Comparison of ARNI With ARB on Management of Heart Failure With Preserved Ejection Fraction (PARAMOUNT) trial at baseline, 12 and 36 weeks after randomization to valsartan or LCZ696. We examined the relationship between baseline biomarkers, demographic and echocardiographic characteristics, change in primary (change in N-terminal pro B-type natriuretic peptide) and secondary (change in left atrial volume) end points. The median (interquartile range) value for soluble form of ST2 (33 [24.6–48.1] ng/mL) and galectin 3 (17.8 [14.1–22.8] ng/mL) were higher, and for matrix metalloproteinase-2 (188 [155.5–230.6] ng/mL) lower, than in previously published referent controls; collagen III N-terminal propeptide (5.6 [4.3–6.9] ng/mL) was similar to referent control values. All 4 biomarkers correlated with severity of disease as indicated by N-terminal pro B-type natriuretic peptide, E/E′, and left atrial volume. Baseline biomarkers did not modify the response to LCZ696 for lowering N-terminal pro B-type natriuretic peptide; however, left atrial volume reduction varied by baseline level of soluble form of ST2 and galectin 3; patients with values less than the observed median (<33 ng/mL soluble form of ST2 and <17.8 ng/mL galectin 3) had reduction in left atrial volume, those above median did not. Although LCZ696 reduced N-terminal pro B-type natriuretic peptide

  17. The sympathetic/parasympathetic imbalance in heart failure with reduced ejection fraction

    PubMed Central

    Floras, John S.; Ponikowski, Piotr

    2015-01-01

    Cardiovascular autonomic imbalance, a cardinal phenotype of human heart failure, has adverse implications for symptoms during wakefulness and sleep; for cardiac, renal, and immune function; for exercise capacity; and for lifespan and mode of death. The objectives of this Clinical Review are to summarize current knowledge concerning mechanisms for disturbed parasympathetic and sympathetic circulatory control in heart failure with reduced ejection fraction and its clinical and prognostic implications; to demonstrate the patient-specific nature of abnormalities underlying this common phenotype; and to illustrate how such variation provides opportunities to improve or restore normal sympathetic/parasympathetic balance through personalized drug or device therapy. PMID:25975657

  18. Normal Gallbladder Ejection Fraction Occurring Unexpectedly Obviates Need for Sincalide Stimulation.

    PubMed

    Hadi, Samir; Tulchinsky, Mark

    2017-02-17

    A 25-year-old man was referred for chronic right upper quadrant abdominal pain for hepatobiliary scintigraphy to evaluate the gallbladder (GB) function. An unexpected GB contraction with ejection fraction (EF) of 90% was observed during the first hour of baseline imaging. Subsequent stimulation with sincalide produced GB EF of 99%. A similar case previously reported also showed normal unexpected GB EF that predicted similar post-sincalide GB EF. These examples support what should be evident: A normal unexpected GB EF is a sufficient evidence for a normal GB function and should obviate need for sincalide stimulation.

  19. Global Longitudinal Strain or Left Ventricular Twist and Torsion? Which Correlates Best with Ejection Fraction?

    PubMed Central

    Lima, Marcio Silva Miguel; Villarraga, Hector R; Abduch, Maria Cristina Donadio; Lima, Marta Fernandes; Cruz, Cecilia Beatriz Bittencourt Viana; Sbano, João Cesar Nunes; Voos, Mariana Callil; Mathias Junior, Wilson; Tsutsui, Jeane Mike

    2017-01-01

    Background Estimative of left ventricular ejection fraction (LVEF) is a major indication for echocardiography. Speckle tracking echocardiography (STE) allows analysis of LV contraction mechanics which includes global longitudinal strain (GLS) and twist/torsion, both the most widely used. Direct comparison of correlations between these novel parameters and LVEF has never been done before. Objective This study aims to check which one has the highest correlation with LVEF. Methods Patients with normal LVEF (> 0,55) and systolic dysfunction (LVEF <0,55) were prospectively enrolled, and underwent echocardiogram with STE analysis. Correlation of variables was performed by linear regression analysis. In addition, correlation among levels of LV systolic impairment was also tested. Results A total of 131 patients were included (mean age, 46 ± 14y; 43%, men). LVEF and GLS showed a strong correlation (r = 0.95; r2 = 0.89; p < 0.001), more evident in groups with LV systolic dysfunction than those with preserved LVEF. Good correlation was also found with global longitudinal strain rate (r = 0.85; r2 = 0.73; p < 0.001). Comparing to GLS, correlation of LVEF and torsional mechanics was weaker: twist (r = 0.78; r2 = 0.60; p < 0.001); torsion (r = 0.75; r2 = 0.56; p < 0.001). Conclusion GLS of the left ventricle have highly strong positive correlation with the classical parameter of ejection fraction, especially in cases with LV systolic impairment. Longitudinal strain rate also demonstrated a good correlation. GLS increments analysis of LV systolic function. On the other hand, although being a cornerstone of LV mechanics, twist and torsion have a weaker correlation with LV ejection, comparing to GLS. PMID:28678927

  20. Response of left ventricular ejection fraction to recovery from general anesthesia: measurement by gated radionuclide angiography

    SciTech Connect

    Coriat, P.; Mundler, O.; Bousseau, D.; Fauchet, M.; Rous, A.C.; Echter, E.; Viars, P.

    1986-06-01

    To test the hypothesis that, after anesthesia for noncardiac surgical procedures, the increased cardiac work during recovery induces wall motion and ejection fraction (EF) abnormalities in patients with mild angina pectoris, gated radionuclide angiography was performed in patients undergoing simple cholecystectomy under narcotic-relaxant general anesthesia. The ejection fraction was determined during anesthesia at the end of surgery, and then determined 3 min and 3 hr after extubation. A new angiography was performed 24 hr later, and a myocardial scintigraphy (Thallium 201) was performed during infusion of the coronary vasodilator, dipyridamole. In the first part of the investigation, eight patients without coronary artery disease (CAD) (group 1) and 20 patients with mild angina (group 2) were studied. In the second part of the study, seven patients (group 3) with mild angina pectoris received an intravenous infusion of 0.4 microgram X kg-1 X min-1 of nitroglycerin started before surgery and gradually decreased 4 hr after extubation. In group 1, EF remained unchanged at recovery. In contrast in group 2, EF responded abnormally to recovery: EF decreased from 55% during anesthesia to 45% 3 min after extubation (P less than 0.001). Patients in group 3, who received intravenous nitroglycerin, showed no change of EF at recovery. This study demonstrates that recovery from general anesthesia causes abnormalities in left ventricular function in patients suffering from CAD. These abnormalities are prevented by prophylactic intravenous nitroglycerin.

  1. Heart failure with preserved ejection fraction in the elderly: scope of the problem.

    PubMed

    Upadhya, Bharathi; Taffet, George E; Cheng, Che Ping; Kitzman, Dalane W

    2015-06-01

    Heart failure with preserved ejection fraction (HFpEF) is the most common form of heart failure (HF) in older adults, particularly women, and is increasing in prevalence as the population ages. With morbidity and mortality on par with HF with reduced ejection fraction, it remains a most challenging clinical syndrome for the practicing clinician and basic research scientist. Originally considered to be predominantly caused by diastolic dysfunction, more recent insights indicate that HFpEF in older persons is typified by a broad range of cardiac and non-cardiac abnormalities and reduced reserve capacity in multiple organ systems. The globally reduced reserve capacity is driven by: 1) inherent age-related changes; 2) multiple, concomitant co-morbidities; 3) HFpEF itself, which is likely a systemic disorder. These insights help explain why: 1) co-morbidities are among the strongest predictors of outcomes; 2) approximately 50% of clinical events in HFpEF patients are non-cardiovascular; 3) clinical drug trials in HFpEF have been negative on their primary outcomes. Embracing HFpEF as a true geriatric syndrome, with complex, multi-factorial pathophysiology and clinical heterogeneity could provide new mechanistic insights and opportunities for progress in management. This article is part of a Special Issue entitled CV Aging. Copyright © 2015 Elsevier Ltd. All rights reserved.

  2. Facts and numbers on epidemiology and pharmacological treatment of heart failure with preserved ejection fraction

    PubMed Central

    2015-01-01

    Abstract Heart failure with preserved ejection fraction (HFpEF) is a major and growing public health problem. Epidemiologic studies demonstrated that heart failure (HF) can be clinically diagnosed in patients with normal or preserved left ventricular ejection fraction. These patients are therefore termed as having HFpEF. In the past, this was often called diastolic HF. Because of the permanent increase of the prevalence of HFpEF during the past decades, HFpEF now accounts for more than 50% of the total HF population. There are uncertainties and debates regarding the definition, diagnosis, and pathophysiology with the consequence that all outcome trials performed so far used criteria for inclusion and exclusion that were not consistent. These trials also failed to document improved prognosis. Recent smaller proof‐of‐concept or Phase II clinical trials investigating different pathophysiological approaches with substances such as the neprilysin inhibitor–angiotensin receptor blocker− combination (LCZ 696), ranolazine, or ivabradine were successful to improve biomarkers, haemodynamics, or functional capacity. Future trials will need to document whether also prognosis can be improved. PMID:27708850

  3. Left Ventricle Hypertrophy, Dilatation and Ejection Fraction Changes Before and After Kidney Transplantation

    PubMed Central

    Tayebi-Khosroshahi, Hamid; Abbasnezhad, Mohsen; Habibzadeh, Afshin; Bakhshandeh, Masumeh; Chaichi, Parastoo

    2013-01-01

    Background Patients with end stage renal disease (ESRD) are at risk of complications in different organs including cardiovascular system. Renal transplantation is the best choice in these patients which diminishes these complications. It is observed that after renal transplantation, cardiac parameters have appropriate improvement. Current study evaluates echocardiographic findings in renal transplant recipients before and after kidney transplantation. Methods In an analytic cross sectional study, 30 patients (50% male, mean age of 45.57 ± 13.32 years) with ESRD who underwent renal transplantation were studied. All patients had echocardiographic studies after the last dialysis before and 6 months after transplantation. Echocardiographic study was done by Color Doppler two dimension methods and left ventricle ejection fraction was measured by Simpson method. All echocardiograms before and after transplantation were interpreted by the same cardiologist. Results Mean left ventricle ejection fraction before and after renal transplantation was 53.83±10.14% and 57.33±4.49%, respectively (P = 0.09). Left ventricle hypertrophy, mitral regurgitation and tricuspid regurgitation existed in 46.7%, 76.7% and 33.3% respectively, which was improved in 30%, 50% and 33.3% after renal transplantation. Conclusion According to the results of current study it is suggested that renal transplantation could improve left ventricle parameters in patients with end stage renal disease.

  4. Heart failure with preserved ejection fraction: Defining the function of ROS and NO.

    PubMed

    Zuo, Li; Chuang, Chia-Chen; Hemmelgarn, Benjamin T; Best, Thomas M

    2015-10-15

    The understanding of complex molecular mechanisms underlying heart failure (HF) is constantly under revision. Recent research has paid much attention to understanding the growing number of patients that exhibit HF symptoms yet have an ejection fraction similar to a normal phenotype. Termed heart failure with preserved ejection fraction (HFpEF), this novel hypothesis traces its roots to a proinflammatory state initiated in part by the existence of comorbidities that create a favorable environment for the production of reactive oxygen species (ROS). Triggering a cascade that involves reduced nitric oxide (NO) availability, elevated ROS levels in the coronary endothelium eventually contribute to hypertrophy and increased resting tension in cardiomyocytes. Improved understanding of the molecular pathways associated with HFpEF has led to studies that concentrate on reducing ROS production in the heart, boosting NO availability, and increasing exercise capacity for HFpEF patients. This review will explore the latest research into the role of ROS and NO in the progression of HFpEF, as well as discuss the encouraging results of numerous therapeutic studies.

  5. How do patients with heart failure with preserved ejection fraction die?

    PubMed

    Chan, Michelle M Y; Lam, Carolyn S P

    2013-06-01

    Understanding how patients with heart failure with preserved ejection fraction (HFPEF) die provides insight into the natural history and pathophysiology of this complex syndrome, thereby allowing better prediction of response to therapy in designing clinical trials. This review summarizes the current state of knowledge surrounding mortality rates, modes of death, and prognostic factors in HFPEF. Despite the lack of uniform reporting, the following conclusions may be drawn from previous studies. The mortality burden of HFPEF is substantial, ranging from 10% to 30% annually, and higher in epidemiological studies than in clinical trials. Mortality rates compared with heart failure with reduced ejection fraction (HFREF) appear to be strongly influenced by the type of study, but are clearly elevated compared with age- and co-morbidity-matched controls without heart failure. The majority of deaths in HFPEF are cardiovascular deaths, comprising 51-60% of deaths in epidemiological studies and ∼70% in clinical trials. Among cardiovascular deaths, sudden death and heart failure death are the leading cardiac modes of death in HFPEF clinical trials. Compared with HFREF, the proportions of cardiovascular deaths, sudden death, and heart failure deaths are lower in HFPEF. Conversely, non-cardiovascular deaths constitute a higher proportion of deaths in HFPEF than in HFREF, particularly in epidemiological studies, where this difference may be related to fewer coronary heart deaths in HFPEF. Key mortality risk factors, including age, gender, body mass index, burden of co-morbidities, and coronary artery disease, offer some explanation for the differences in mortality rates observed across studies.

  6. Understanding heart failure with preserved ejection fraction: where are we today?

    PubMed

    van Heerebeek, L; Paulus, W J

    2016-04-01

    Heart failure with preserved ejection fraction (HFpEF) represents a complex and heterogeneous clinical syndrome, which is increasingly prevalent and associated with poor outcome. In contrast to heart failure with reduced ejection fraction (HFrEF), modern heart failure pharmacotherapy did not improve outcome in HFpEF, which was attributed to incomplete understanding of HFpEF pathophysiology, patient heterogeneity and lack of insight into primary pathophysiological processes. HFpEF patients are frequently elderly females and patients demonstrate a high prevalence of non-cardiac comorbidities, which independently adversely affect myocardial structural and functional remodelling. Furthermore, although diastolic left ventricular dysfunction represents the dominant abnormality in HFpEF, numerous ancillary mechanisms are frequently present, which also negatively impact on cardiovascular reserve. Over the past decade, clinical and translational research has improved insight into HFpEF pathophysiology and the importance of comorbidities and patient heterogeneity. Recently, a new paradigm for HFpEF was proposed, which states that comorbidities drive myocardial dysfunction and remodelling in HFpEF through coronary microvascular inflammation. Regarding the conceptual framework of HFpEF treatment, emphasis may need to shift from a 'one fits all' strategy to an individualised approach based on phenotypic patient characterisation and diagnostic and pathophysiological stratification of myocardial disease processes. This review will describe these novel insights from a pathophysiological standpoint.

  7. Riser Pattern: Another Determinant of Heart Failure With Preserved Ejection Fraction.

    PubMed

    Komori, Takahiro; Eguchi, Kazuo; Saito, Toshinobu; Hoshide, Satoshi; Kario, Kazuomi

    2016-10-01

    Paradoxical increase in blood pressure (BP) during sleep, exceeding those of awake BP, is called the "riser" BP pattern, and known as an abnormal circadian BP rhythm, has been reported to be associated with adverse cardiovascular prognoses. However, the significance of ambulatory BP in heart failure patients with preserved ejection fraction (HFpEF) has never been reported. Here, we tested our hypothesis that abnormal circadian BP rhythm is associated with HFpEF. The authors enrolled 508 patients with hospitalized HF (age 68±13 years; 315 men, 193 women). There were 232 cases of HFpEF and 276 cases of heart failure with reduced ejection fraction (HFrEF). The riser BP pattern was significantly more frequent in the HFpEF (28.9%) group compared with the HFrEF group (19.9%). In a multivariable logistic regression analysis, the riser BP pattern was associated with HFpEF (odds ratio, 1.73; 95% confidence interval, 1.02-2.91; P=.041) independent of the other covariates. In conclusion, the riser BP pattern was associated with HFpEF.

  8. Outcome of Heart Failure with Preserved Ejection Fraction: A Multicentre Spanish Registry

    PubMed Central

    Castillo, Juan C; Anguita1, Manuel P; Jiménez, Manuel

    2009-01-01

    Background: Studies on clinical features, treatment and prognosis of patients with congestive heart failure (CHF) and preserved left ventricular ejection fraction (LVEF) are few and their results frequently conflicting. Aims: To investigate the characteristics and long term prognosis of patients with CHF and preserved (≥ 45%) LVEF. Methods and Results: We conducted a prospective multicentre study with 4720 patients attended in 62 heart failure clinics from 1999 to 2003 in Spain (BADAPIC registry). LVEF was preserved in 30% patients. Age, female gender, prevalence of atrial fibrillation, hypertension and non-ischaemic cardiopathy were all significantly greater in patients with preserved LVEF. Mean follow-up was 40±12 months. Mortality and other cardiovascular complication rates during follow up were similar in both groups. On multivariate analysis ejection fraction was not an independent predictor for mortality. Survival at one and five years was similar in both groups (79% and 59% for patients with preserved LVEF and 78% and 57% for those with reduced LVEF, respectively). Conclusions: In the BADAPIC registry, a high percentage of heart failure patients had preserved LVEF. Although clinical differences were seen between groups, morbidity and mortality were similar in both groups. PMID:21037850

  9. Heart Failure with Preserved Ejection Fraction in the Elderly: Scope of the Problem

    PubMed Central

    Upadhya, Bharathi; Taffet, George E; Cheng, Che Ping; Kitzman, Dalane W

    2017-01-01

    Heart failure with preserved ejection fraction (HFpEF) is the most common form of heart failure (HF) in older adults, particularly women, and is increasing in prevalence as the population ages. With morbidity and mortality on par with HF with reduced ejection fraction, it remains a most challenging clinical syndrome for the practicing clinician and basic research scientist. Originally considered to be predominantly caused by diastolic dysfunction, more recent insights indicate that HFpEF in older persons is typified by a broad range of cardiac and non-cardiac abnormalities and reduced reserve capacity in multiple organ systems. The globally reduced reserve capacity is driven by: 1) inherent age-related changes; 2) multiple, concomitant co-morbidities; 3) HFpEF itself, which is likely a systemic disorder. These insights help explain why: 1) comorbidities are among the strongest predictors of outcomes; 2) approximately 50% of clinical events in HFpEF patients are non-cardiovascular; 3) clinical drug trials in HFpEF have been negative on their primary outcomes. Embracing HFpEF as a true geriatric syndrome, with complex, multi-factorial pathophysiology and clinical heterogeneity could provide new mechanistic insights and opportunities for progress in management. PMID:25754674

  10. Facts and numbers on epidemiology and pharmacological treatment of heart failure with preserved ejection fraction.

    PubMed

    Edelmann, Frank

    2015-06-01

    Heart failure with preserved ejection fraction (HFpEF) is a major and growing public health problem. Epidemiologic studies demonstrated that heart failure (HF) can be clinically diagnosed in patients with normal or preserved left ventricular ejection fraction. These patients are therefore termed as having HFpEF. In the past, this was often called diastolic HF. Because of the permanent increase of the prevalence of HFpEF during the past decades, HFpEF now accounts for more than 50% of the total HF population. There are uncertainties and debates regarding the definition, diagnosis, and pathophysiology with the consequence that all outcome trials performed so far used criteria for inclusion and exclusion that were not consistent. These trials also failed to document improved prognosis. Recent smaller proof-of-concept or Phase II clinical trials investigating different pathophysiological approaches with substances such as the neprilysin inhibitor-angiotensin receptor blocker- combination (LCZ 696), ranolazine, or ivabradine were successful to improve biomarkers, haemodynamics, or functional capacity. Future trials will need to document whether also prognosis can be improved.

  11. Quantification of the relative contribution of the different right ventricular wall motion components to right ventricular ejection fraction: the ReVISION method.

    PubMed

    Lakatos, Bálint; Tősér, Zoltán; Tokodi, Márton; Doronina, Alexandra; Kosztin, Annamária; Muraru, Denisa; Badano, Luigi P; Kovács, Attila; Merkely, Béla

    2017-03-27

    Three major mechanisms contribute to right ventricular (RV) pump function: (i) shortening of the longitudinal axis with traction of the tricuspid annulus towards the apex; (ii) inward movement of the RV free wall; (iii) bulging of the interventricular septum into the RV and stretching the free wall over the septum. The relative contribution of the aforementioned mechanisms to RV pump function may change in different pathological conditions.Our aim was to develop a custom method to separately assess the extent of longitudinal, radial and anteroposterior displacement of the RV walls and to quantify their relative contribution to global RV ejection fraction using 3D data sets obtained by echocardiography.Accordingly, we decomposed the movement of the exported RV beutel wall in a vertex based manner. The volumes of the beutels accounting for the RV wall motion in only one direction (either longitudinal, radial, or anteroposterior) were calculated at each time frame using the signed tetrahedron method. Then, the relative contribution of the RV wall motion along the three different directions to global RV ejection fraction was calculated either as the ratio of the given direction's ejection fraction to global ejection fraction and as the frame-by-frame RV volume change (∆V/∆t) along the three motion directions.The ReVISION (Right VentrIcular Separate wall motIon quantificatiON) method may contribute to a better understanding of the pathophysiology of RV mechanical adaptations to different loading conditions and diseases.

  12. Improving the appropriateness of sudden arrhythmic death primary prevention by implantable cardioverter-defibrillator therapy in patients with low left ventricular ejection fraction. Point of view

    PubMed Central

    Disertori, Marcello; Gulizia, Michele M.; Casolo, Giancarlo; Delise, Pietro; Di Lenarda, Andrea; Di Tano, Giuseppe; Lunati, Maurizio; Mestroni, Luisa; Salerno-Uriarte, Jorge; Tavazzi, Luigi

    2016-01-01

    It is generally accepted that the current guidelines for the primary prevention of sudden arrhythmic death, which are based on ejection fraction, do not allow the optimal selection of patients with low left ventricular ejection fraction of ischemic and nonischemic etiology for implantation of a cardioverter-defibrillator. Ejection fraction alone is limited in both sensitivity and specificity. An analysis of the risk of sudden arrhythmic death with a combination of multiple tests (ejection fraction associated with one or more arrhythmic risk markers) could partially compensate for these limitations. We propose a polyparametric approach for defining the risk of sudden arrhythmic death using ejection fraction in combination with other clinical and arrhythmic risk markers (i.e. late gadolinium enhancement cardiac magnetic resonance, T-wave alternans, programmed ventricular stimulation, autonomic tone, and genetic testing) that have been validated in nonrandomized trials. In this article, we examine these approaches to identify three subsets of patients who cannot be comprehensively assessed by the current guidelines: patients with ejection fraction of 35% or less and a relatively low risk of sudden arrhythmic death despite the ejection fraction value; patients with ejection fraction of 35% or less and high competitive risk of death due to evolution of heart failure or noncardiac causes; and patients with ejection fraction between 35 and 45% with relatively high risk of sudden arrhythmic death despite the ejection fraction value. PMID:26895401

  13. Left Atrial Structure and Function in Heart Failure with Preserved Ejection Fraction: A RELAX Substudy

    PubMed Central

    McNulty, Steven E.; Hernandez, Adrian F.; Semigran, Marc J.; Lewis, Gregory D.; Jerosch-Herold, Michael; Kim, Raymond J.; Redfield, Margaret M.; Kwong, Raymond Y.

    2016-01-01

    Given the emerging recognition of left atrial structure and function as an important marker of disease in heart failure with preserved ejection fraction (HF-pEF), we investigated the association between left atrial volume and function with markers of disease severity and cardiac structure in HF-pEF. We studied 100 patients enrolled in the PhosphdiesteRasE-5 Inhibition to Improve CLinical Status and EXercise Capacity in Diastolic Heart Failure (RELAX) trial who underwent cardiac magnetic resonance (CMR), cardiopulmonary exercise testing, and blood collection before randomization. Maximal left atrial volume index (LAVi; N = 100), left atrial emptying fraction (LAEF; N = 99; including passive and active components (LAEFP, LAEFA; N = 80, 79, respectively) were quantified by CMR. After adjustment for multiple testing, maximal LAVi was only associated with age (ρ = 0.39), transmitral filling patterns (medial E/e’ ρ = 0.43), and N-terminal pro-BNP (NT-proBNP; ρ = 0.65; all p<0.05). Lower LAEF was associated with older age, higher transmitral E/A ratio and higher NT-proBNP. Peak VO2 and VE/VCO2 slope were not associated with left atrial structure or function. After adjustment for age, sex, transmitral E/A ratio, CMR LV mass, LV ejection fraction, and creatinine clearance, NT-proBNP remained associated with maximal LAVi (β = 0.028, p = 0.0007) and total LAEF (β = -0.033, p = 0.001). Passive and active LAEF were most strongly associated with age and NT-proBNP, but not gas exchange or other markers of ventricular structure or filling properties. Left atrial volume and emptying function are associated most strongly with NT-proBNP and diastolic filling properties, but not significantly with gas exchange, in HFpEF. Further research to explore the relevance of left atrial structure and function in HF-pEF is warranted. PMID:27812147

  14. Ejection fraction change and coronary artery disease severity: a vasodilator contrast stress-echocardiography study.

    PubMed

    Squeri, Angelo; Gaibazzi, Nicola; Reverberi, Claudio; Caracciolo, Maria Michela; Ardissino, Diego; Gherli, Tiziano

    2012-04-01

    An important goal of noninvasive stress testing is the identification of patients with left main coronary artery or three-vessel disease, because coronary artery disease extension and severity are major prognostic factors in ischemic heart disease. Wall motion abnormalities during vasodilator stress echocardiography become apparent in more than one coronary territory only in a small number of patients with multivessel disease. The aim of this study was to assess the value of change in left ventricular ejection fraction change (ΔLVEF) to identify patients with multivessel obstructive coronary artery disease during dipyridamole stress echocardiography. All dipyridamole stress echocardiographic studies performed at the authors' institution from October 2007 through March 2010 were retrospectively reviewed, and 150 patients who underwent coronary angiography within the next 60 days were selected. Left ventricular end-diastolic volume and end-systolic volume were measured at baseline and at the end of high-dose dipyridamole; ΔLVEF was calculated as stress ejection fraction minus rest ejection fraction. Patients were divided into four groups (controls and patients with single-vessel, two-vessel, and three-vessel disease) on the basis of coronary angiographic results. The mean LVEF increased significantly from rest to peak stress in all groups except the three-vessel disease group. Mean ΔLVEF was negative in patients with three-vessel or left main coronary artery disease (-2.8 ± 5.1%) and significantly lower compared with all other angiographic groups (10.2 ± 5.1% and 6.2 ± 4.1%, respectively, for single-vessel and two-vessel disease). The negative value of ΔLVEF for three-vessel disease was due mainly to increased end-systolic volume at peak stress. Receiver operating characteristic curves demonstrated excellent accuracy of ΔLVEF compared with change in wall motion score index in identifying patients with multivessel disease, with areas under the curves of 0

  15. Transthyretin Cardiac Amyloidosis: Pathogenesis, Treatments, and Emerging Role in Heart Failure with Preserved Ejection Fraction

    PubMed Central

    Ton, Van-Khue; Mukherjee, Monica; Judge, Daniel P

    2014-01-01

    Transthyretin (TTR) amyloidosis causes heart failure from cardiac deposition of TTR amyloid fibrils, the by-product of TTR homotetramer disassembly. Wild-type (WT) TTR deposition leads to senile amyloidosis, predominantly manifesting with cardiomyopathy. Missense mutations in the TTR gene result in familial TTR amyloidosis. Certain mutations are more likely to affect the heart, while others cause more neurologic involvement. Extracellular fibril deposition triggers intracellular stress response, upregulation of the inflammatory cascades, apoptosis, and organ dysfunction. Recent studies suggest that TTR cardiac amyloid may be a significant contributor to the pathogenesis of heart failure with preserved ejection fraction (HFpEF). Summarized in this review are the molecular pathways underlying the cellular toxicity of TTR amyloid fibrils and the emerging therapies aimed at TTR tetramer stabilization, abrogation of TTR synthesis in the liver, or inhibition of amyloidogenesis. PMID:25628512

  16. Epidemiology of "Heart Failure with Recovered Ejection Fraction": What do we do After Recovery?

    PubMed

    Kuttab, Johny S; Kiernan, Michael S; Vest, Amanda R

    2015-12-01

    Improvement in functional status, long-term survival, and quality of life has always been the goal of therapy in patients with heart failure with reduced ejection fraction. Neurohormonal modulating medications help patients achieve these goals and, in a subgroup of patients, can promote "reverse remodeling" resulting in the recovery of left ventricular systolic function. In the era of durable mechanical support, myocardial recovery that leads to explantation of the ventricular assist device occurs in a minority of cases. Optimal medical therapy appears to be a key component of achieving myocardial recovery, with recovery more likely in patients with a shorter duration of heart failure and a non-ischemic etiology. However, little is known about future management of patients who attain myocardial recovery, either with or without mechanical support. This review explores the epidemiology, physiology, cellular biology, and long-term outcomes for this subgroup of heart failure patients and outlines areas for future study.

  17. Breakthrough in heart failure with preserved ejection fraction: are we there yet?

    PubMed Central

    Lim, Shir Lynn; Lam, Carolyn Su Ping

    2016-01-01

    Heart failure with preserved ejection fraction (HFPEF) is a global health problem of considerable socioeconomic burden. It is projected to worsen with the aging population worldwide. The lack of effective therapies underscores our incomplete understanding of this complex heterogeneous syndrome. A novel paradigm has recently emerged, in which central roles are ascribed to systemic inflammation and generalized endothelial dysfunction in the pathophysiology of HFPEF. In this review, we discuss the role of the endothelium in cardiovascular homeostasis and how deranged endothelial-related signaling pathways contribute to the development of HFPEF. We also review the novel therapies in various stages of research and development that target different components of this signaling pathway. PMID:26767852

  18. Treatment of Heart Failure With Reduced Ejection Fraction-Recent Developments.

    PubMed

    Travessa, André Miguel Ramos; de Menezes Falcão, Luiz Filipe

    2016-01-01

    Heart failure with reduced ejection fraction (HFrEF) represents at least half of the cases of heart failure, which is a syndrome defined as the inability of the heart to supply the body's tissues with an adequate amount of blood under conditions of normal cardiac filling pressure. HFrEF is responsible for high costs and rates of mortality, morbidity, and hospital admissions, mainly in developed countries. Thus, the need for better diagnostic methods and therapeutic approaches and consequently better outcomes is clear. In this article, we review the principal aspects of pathophysiology and diagnosis of HFrEF, with focus on emerging biomarkers and on recent echocardiographic methods for the assessment of left ventricular function. Furthermore, we discuss several major developments in pharmacological and nonpharmacological treatment of HFrEF in the last years, including cardiac resynchronization therapy, implantable cardioverter defibrillators, and the recent and promising drug LCZ696, focusing on current indications, unanswered questions, and other relevant aspects.

  19. Ventricular fibrillation via torsade des pointes of cardiac sarcoidosis with preserved left ventricular ejection fraction.

    PubMed

    Sekihara, Takayuki; Nakane, Eisaku; Nakasone, Kazutaka; Inoko, Moriaki

    2016-10-25

    Generally, low left ventricular ejection fraction (LVEF) is a risk for ventricular arrhythmia in patients with cardiac sarcoidosis. We present a case of cardiac sarcoidosis with preserved LVEF that evoked ventricular fibrillation (VF). A 73-year-old woman with VF presented to our emergency department. She had a history of ocular sarcoidosis, with gradual thinning of the basal intraventricular septum. LVEF was 62% on the most recent echocardiography. The electrocardiogram after defibrillation showed complete atrioventricular block (CAVB) with QT segment prolongation and frequent ventricular premature beats. VF via torsade des pointes (TdP) was suspected, and temporary intravenous ventricular pacing and magnesium sulfate infusion suppressed her VF. Cardiac sarcoidosis was diagnosed, and an implantable cardioverter defibrillator was implanted. Patients with cardiac sarcoidosis with CAVB are at risk of evoking VF via TdP regardless of LVEF. If cardiac sarcoidosis is suspected, early diagnosis and risk stratification of ventricular arrhythmia are important. 2016 BMJ Publishing Group Ltd.

  20. Pioglitazone-induced congestive heart failure and pulmonary edema in a patient with preserved ejection fraction

    PubMed Central

    Jearath, Vaneet; Vashisht, Rajan; Rustagi, Vipul; Raina, Sujeet; Sharma, Rajesh

    2016-01-01

    Pioglitazone-induced heart failure is known in patients with underlying heart disease, but is not well documented in patients with normal left ventricular function. Pioglitazone has been very popular as it is an insulin sensitizer and insulin resistance is prevalent among Indians. Fluid retention exacerbates pre-existing heart failure or precipitates heart failure in a patient with underlying left ventricular dysfunction. However, pathogenesis of heart failure in a patient with normal left ventricular function is not known. Probably it is due to dose-related effect on pulmonary endothelial permeability, rather than alterations in left ventricular mass or ejection fraction. We report a patient who developed congestive heart failure and pulmonary edema with normal left ventricular function within 1 year of starting pioglitazone therapy. We have to be careful in monitoring all possible side effects during followup when patients are on pioglitazone therapy. PMID:27127397

  1. Determination of right ventricular ejection fraction in children with cystic fibrosis

    SciTech Connect

    Piepsz, A.; Ham, H.R.; Millet, E.; Dab, I.

    1987-01-01

    The radionuclide right ventricular ejection fraction (RVEF) determined by means of Krypton-81m represents a simple, noninvasive, and accurate procedure to quantify the right ventricular contractility. This procedure was applied to 25 young patients with cystic fibrosis. The RVEF tended to decrease with the progression of the lung disease, as assessed by the clinical S-K score, the degree of the defects on lung scintigraphy, the PaO/sub 2/, and the lung function tests. However, the decrease of RVEF in patients with marked lung function tests. However, the decrease of RVEF in patients with marked lung involvement was moderate, and terminal lung disease was sometimes associated with normal right heart contractility.

  2. [Isotope angiocardiography: amelioration of the measurement of ejection fraction by a new treatment of the image].

    PubMed

    Widmann, T; Righetti, A; de Lorgeril, M; Soulier, B; Brandon, G; Fournet, P C

    1981-11-07

    Some of the limitations affecting radioisotopic images are their insufficient resolution, structure boundaries and accurate subtraction of background noise. In order to improve the signal-to-noise ratio the images of the recorded heart cycles are treated by the Karhunen-Loeve transformation. Edge detection is based on compression of the image to a bitmap at a chosen level and following of all bits set to one by a pointer. The outlines of the structures as determined by edge tracking are used to define the regions of interest within the enhanced images. Background subtraction applies the principle of interpolative background subtraction by computing an individual background for each point in an irregular region of interest. The resultant images are used to calculate an index of cardiac efficiency which shows high correlation (r = 0.92) with the ejection fraction of contrast biplane left ventricular angiography.

  3. Pharmacokinetics and Pharmacodynamics of Inorganic Nitrate in Heart Failure With Preserved Ejection Fraction.

    PubMed

    Zamani, Payman; Tan, Victor; Soto-Calderon, Haideliza; Beraun, Melissa; Brandimarto, Jeffrey A; Trieu, Lien; Varakantam, Swapna; Doulias, Paschalis-Thomas; Townsend, Raymond R; Chittams, Jesse; Margulies, Kenneth B; Cappola, Thomas P; Poole, David C; Ischiropoulos, Harry; Chirinos, Julio A

    2017-03-31

    Nitrate-rich beetroot juice has been shown to improve exercise capacity in heart failure with preserved ejection fraction, but studies using pharmacological preparations of inorganic nitrate are lacking. To determine (1) the dose-response effect of potassium nitrate (KNO3) on exercise capacity; (2) the population-specific pharmacokinetic and safety profile of KNO3 in heart failure with preserved ejection fraction. We randomized 12 subjects with heart failure with preserved ejection fraction to oral KNO3 (n=9) or potassium chloride (n=3). Subjects received 6 mmol twice daily during week 1, followed by 6 mmol thrice daily during week 2. Supine cycle ergometry was performed at baseline (visit 1) and after each week (visits 2 and 3). Quality of life was assessed with the Kansas City Cardiomyopathy Questionnaire. The primary efficacy outcome, peak O2-uptake, did not significantly improve (P=0.13). Exploratory outcomes included exercise duration and quality of life. Exercise duration increased significantly with KNO3 (visit 1: 9.87, 95% confidence interval [CI] 9.31-10.43 minutes; visit 2: 10.73, 95% CI 10.13-11.33 minute; visit 3: 11.61, 95% CI 11.05-12.17 minutes; P=0.002). Improvements in the Kansas City Cardiomyopathy Questionnaire total symptom (visit 1: 58.0, 95% CI 52.5-63.5; visit 2: 66.8, 95% CI 61.3-72.3; visit 3: 70.8, 95% CI 65.3-76.3; P=0.016) and functional status scores (visit 1: 62.2, 95% CI 58.5-66.0; visit 2: 68.6, 95% CI 64.9-72.3; visit 3: 71.1, 95% CI 67.3-74.8; P=0.01) were seen after KNO3. Pronounced elevations in trough levels of nitric oxide metabolites occurred with KNO3 (visit 2: 199.5, 95% CI 98.7-300.2 μmol/L; visit 3: 471.8, 95% CI 377.8-565.8 μmol/L) versus baseline (visit 1: 38.0, 95% CI 0.00-132.0 μmol/L; P<0.001). KNO3 did not lead to clinically significant hypotension or methemoglobinemia. After 6 mmol of KNO3, systolic blood pressure was reduced by a maximum of 17.9 (95% CI -28.3 to -7.6) mm Hg 3.75 hours later. Peak nitric oxide

  4. Pioglitazone-induced congestive heart failure and pulmonary edema in a patient with preserved ejection fraction.

    PubMed

    Jearath, Vaneet; Vashisht, Rajan; Rustagi, Vipul; Raina, Sujeet; Sharma, Rajesh

    2016-01-01

    Pioglitazone-induced heart failure is known in patients with underlying heart disease, but is not well documented in patients with normal left ventricular function. Pioglitazone has been very popular as it is an insulin sensitizer and insulin resistance is prevalent among Indians. Fluid retention exacerbates pre-existing heart failure or precipitates heart failure in a patient with underlying left ventricular dysfunction. However, pathogenesis of heart failure in a patient with normal left ventricular function is not known. Probably it is due to dose-related effect on pulmonary endothelial permeability, rather than alterations in left ventricular mass or ejection fraction. We report a patient who developed congestive heart failure and pulmonary edema with normal left ventricular function within 1 year of starting pioglitazone therapy. We have to be careful in monitoring all possible side effects during followup when patients are on pioglitazone therapy.

  5. A Practical Guide for the Treatment of Symptomatic Heart Failure with Reduced Ejection Fraction (HFrEF)

    PubMed Central

    Reed, Brent N; Sueta, Carla A

    2015-01-01

    This review will outline the management of patients with symptomatic systolic heart failure or heart failure with reduced ejec-tion fraction (HFrEF), i.e., those with structural heart disease and previous or current symptoms. Determination of volume status and appropriate diuretic administration is important in heart failure management. Inhibition of the renin-angiotensin-aldosterone and sympathetic nervous systems improves survival and decreases hospitalizations in patients with systolic or reduced ejection fraction HF (HFrEF). Beta blockers and aldosterone antagonists improve ejection fraction. Indications for additional agents including nitrates plus hydralazine, digoxin, statins, omega 3 polyunsaturated fatty acids, anticoagulants, and antiarrhythmics will be discussed. Choice of agents, dose-related effects, strategies to minimize adverse effects, and medications to avoid will be presented. PMID:24251455

  6. Determinants of the response of left ventricular ejection fraction to vasodilator stress in electrocardiographically gated (82)rubidium myocardial perfusion PET.

    PubMed

    Brown, Tracy L Y; Merrill, Jennifer; Volokh, Lana; Bengel, Frank M

    2008-02-01

    Myocardial perfusion imaging with (82)Rb PET allows for ECG-gated studies to be obtained early after radiotracer injection, capturing ventricular function close to peak pharmacologic action of dipyridamole. This is different from gated SPECT and may potentially provide additional diagnostic information. We sought to identify potential correlates of the PET-derived ejection fraction response to vasodilator stress. One hundred ten consecutive patients undergoing (82)Rb PET myocardial perfusion imaging during evaluation for coronary artery disease were included. Using a GE Discovery STRx PET-CT scanner, ECG-gated images (eight bins) were obtained at rest and 4 min after dipyridamole infusion, 90 s after infusion of 1,480-2,220 MBq of (82)Rb. Summed rest, stress, and difference scores (SRS, SSS, and SDS) were determined using a five-point scoring system and 20-segment model. Ejection fraction was calculated using automated QGS software. Significant reversibility (SDS > or = 4) was found in 23 patients (21%). Mean LVEF in all patients was 47 +/- 13% at rest and 53 +/- 13% during dipyridamole. LVEF increased in 89 patients, and decreased in 17 patients during vasodilation. The change in LVEF was inversely correlated with SDS (r = -0.26; p = 0.007). Additionally, it was inversely correlated with resting LVEF (r = -0.20; p = 0.03) and SSS (r = -0.25; p = 0.009). No significant correlations were observed with SRS, heart rate, blood pressure, age, hypertension, hypercholesterolemia, or pretest likelihood of disease. At multivariate regression analysis, SDS was an independent predictor of the change in LVEF. Gated (82)Rb PET during pharmacologic stress allows for assessment of the functional response to vasodilation. The magnitude of LVEF increase is determined by stress perfusion/reversible perfusion defects. Functional response to hyperemia may thus be incorporated in future evaluations of diagnostic and prognostic algorithms based on (82)Rb PET.

  7. Computer-based assessment of left ventricular regional ejection fraction in patients after myocardial infarction

    NASA Astrophysics Data System (ADS)

    Teo, S.-K.; Su, Y.; Tan, R. S.; Zhong, L.

    2014-03-01

    After myocardial infarction (MI), the left ventricle (LV) undergoes progressive remodeling which adversely affects heart function and may lead to development of heart failure. There is an escalating need to accurately depict the LV remodeling process for disease surveillance and monitoring of therapeutic efficacy. Current practice of using ejection fraction to quantitate LV function is less than ideal as it obscures regional variation and anomaly. Therefore, we sought to (i) develop a quantitative method to assess LV regional ejection fraction (REF) using a 16-segment method, and (ii) evaluate the effectiveness of REF in discriminating 10 patients 1-3 months after MI and 9 normal control (sex- and agematched) based on cardiac magnetic resonance (CMR) imaging. Late gadolinium enhancement (LGE) CMR scans were also acquired for the MI patients to assess scar extent. We observed that the REF at the basal, mid-cavity and apical regions for the patient group is significantly lower as compared to the control group (P < 0.001 using a 2-tail student t-test). In addition, we correlated the patient REF over these regions with their corresponding LGE score in terms of 4 categories - High LGE, Low LGE, Border and Remote. We observed that the median REF decreases with increasing severity of infarction. The results suggest that REF could potentially be used as a discriminator for MI and employed to measure myocardium homogeneity with respect to degree of infarction. The computational performance per data sample took approximately 25 sec, which demonstrates its clinical potential as a real-time cardiac assessment tool.

  8. Serum uric acid is associated with cardiac diastolic dysfunction among women with preserved ejection fraction.

    PubMed

    Nogi, Shinpei; Fujita, Shu-Ichi; Okamoto, Yusuke; Kizawa, Shun; Morita, Hideaki; Ito, Takahide; Sakane, Kazushi; Sohmiya, Koichi; Hoshiga, Masaaki; Ishizaka, Nobukazu

    2015-09-01

    Serum uric acid (SUA) is associated with the severity and prognosis of systolic heart failure. We investigated the potential association between SUA and cardiac diastolic dysfunction among total of 744 cardiac patients (202 women and 542 men) who had preserved left ventricular ejection fraction. Presence of diastolic dysfunction was assessed by echocardiographic data, plasma B-type natriuretic peptide concentration, and left ventricular hypertrophy. Univariate analysis showed that the prevalence of diastolic dysfunction increased with increasing SUA value in women, but not in men. When sex-nonspecific SUA quartiles were used, multivariate logistic regression analysis, among female patients who were not taking uric acid lowering medication, showed that the third (SUA, 5.7-6.4 mg) and the fourth (SUA, ≥6.5 mg/dl) SUA quartiles were associated with diastolic dysfunction with an odds ratio of 3.25 (P < 0.05) and 8.06 (P < 0.001), respectively, when compared with the first SUA quartile (≤4.7 mg/dl). When sex-specific SUA quartiles were used among these population, multivariate logistic regression analysis showed that the fourth SUA quartile (≥5.7 mg/dl) was associated with diastolic dysfunction with an odds ratio of 5.34 (P < 0.05) when compared with the first SUA quartile (≤4.1 mg/dl). By contrast, the relationship between SUA and diastolic dysfunction was not significant in men, irrespective of which of the sex-nonspecific or sex-specific SUA quartiles were used. These data indicated that among cardiac patients with preserved ejection fraction, SUA was significantly associated with diastolic dysfunction in women but not in men.

  9. Cardiac I123-MIBG Correlates Better than Ejection Fraction with Symptoms Severity in Systolic Heart Failure

    PubMed Central

    Miranda, Sandra M.; Moscavitch, Samuel D.; Carestiato, Larissa R.; Felix, Renata M.; Rodrigues, Ronaldo C.; Messias, Leandro R.; Azevedo, Jader C.; Nóbrega, Antonio Cláudio L.; Mesquita, Evandro Tinoco; Mesquita, Claudio Tinoco

    2013-01-01

    Background The association of autonomic activation, left ventricular ejection fraction (LVEF) and heart failure functional class is poorly understood. Objective Our aim was to correlate symptom severity with cardiac sympathetic activity, through iodine-123-metaiodobenzylguanidine (123I-MIBG) scintigraphy and with LVEF in systolic heart failure (HF) patients without previous beta-blocker treatment. Methods Thirty-one patients with systolic HF, class I to IV of the New York Heart Association (NYHA), without previous beta-blocker treatment, were enrolled and submitted to 123I-MIBG scintigraphy and to radionuclide ventriculography for LVEF determination. The early and delayed heart/mediastinum (H/M) ratio and the washout rate (WR) were performed. Results According with symptom severity, patients were divided into group A, 13 patients in NYHA class I/II, and group B, 18 patients in NYHA class III/IV. Compared with group B patients, group A had a significantly higher LVEF (25% ± 12% in group B vs. 32% ± 7% in group A, p = 0.04). Group B early and delayed H/M ratios were lower than group A ratios (early H/M 1.49 ± 0.15 vs. 1.64 ± 0.14, p = 0.02; delayed H/M 1.39 ± 0.13 vs. 1.58 ± 0.16, p = 0.001, respectively). WR was significantly higher in group B (36% ± 17% vs. 30% ± 12%, p= 0.04). The variable that showed the best correlation with NYHA class was the delayed H/M ratio (r= -0.585; p=0.001), adjusted for age and sex. Conclusion This study showed that cardiac 123I-MIBG correlates better than ejection fraction with symptom severity in systolic heart failure patients without previous beta-blocker treatment. PMID:23917506

  10. Outcomes and worsening renal function in patients hospitalized with heart failure with preserved ejection fraction.

    PubMed

    Sharma, Kavita; Hill, Terence; Grams, Morgan; Daya, Natalie R; Hays, Allison G; Fine, Derek; Thiemann, David R; Weiss, Robert G; Tedford, Ryan J; Kass, David A; Schulman, Steven P; Russell, Stuart D

    2015-11-15

    Heart failure with preserved ejection fraction (HFpEF) has been described as a disease of elderly subjects with female predominance and hypertension. Our clinical experience suggests patients with HFpEF from an urban population are far more heterogenous, with greater co-morbidities and significant inhospital morbidity. There are limited data on the hospitalization course and outcomes in acute decompensated HFpEF. Hospitalizations for acute heart failure at our institution from July 2011 to June 2012 were identified by International Classification of Diseases, Ninth Revision, codes and physician review for left ventricular ejection fraction ≥50% and were reviewed for patient characteristics and clinical outcomes. Worsening renal function (WRF) was defined as creatinine increase of ≥0.3 mg/dl by 72 hours after admission. Hospital readmission and mortality data were captured from electronic medical records and the Social Security Death Index. Of 434 heart failure admissions, 206 patients (47%) with HFpEF were identified. WRF developed in 40%, the highest reported in HFpEF to date, and was associated with higher blood pressure and lower volume of diuresis. Compared to previous reports, hospitalized patients with HFpEF were younger (mean age 63.2 ± 13.6 years), predominantly black (74%), and had more frequent and severe co-morbidities: hypertension (89%), diabetes (56%), and chronic kidney disease (55%). There were no significant differences in 1- and 12-month outcomes by gender, race, or WRF. In conclusion, we found hospitalized patients with HFpEF from an urban population develop a high rate of WRF are younger than previous cohorts, often black, and have greater co-morbidities than previously described.

  11. Diagnosis and management of heart failure with preserved ejection fraction: 10 key lessons.

    PubMed

    Oktay, A Afşin; Shah, Sanjiv J

    2015-01-01

    Heart failure with preserved ejection fraction (HFpEF) is a common clinical syndrome associated with high rates of morbidity and mortality. Due to the lack of evidence-based therapies and increasing prevalence of HFpEF, clinicians are often confronted with these patients and yet have little guidance on how to effectively diagnose and manage them. Here we offer 10 key lessons to assist with the care of patients with HFpEF: (1) Know the difference between diastolic dysfunction, diastolic heart failure, and HFpEF; (2) diagnosing HFpEF is challenging, so be thorough and consider invasive hemodynamic testing to confirm the diagnosis; (3) a normal B-type natriuretic peptide does not exclude the diagnosis of HFpEF; (4) elevated pulmonary artery systolic pressure on echocardiography in the presence of a normal ejection fraction should prompt consideration of HFpEF; (5) use dynamic testing in evaluating the possibility of HFpEF in patients with unexplained dyspnea or exercise tolerance; (6) all patients with HFpEF should be systematically evaluated for the presence of coronary artery disease; (7) use targeted treatment for HFpEF patients based on their phenotypic classification; (8) treat HFpEF patients now by treating their comorbidities; (9) understand the importance of heart rate in HFpEF- lower is not always better; and (10) do not forget to consider rare diseases ("zebras") as causes for HFpEF when evaluating and treating patients. Taken together, these 10 key lessons can help clinicians care for challenging patients with HFpEF while we eagerly await the results of ongoing HFpEF clinical trials and observational studies.

  12. Follistatin like 1 Regulates Hypertrophy in Heart Failure with Preserved Ejection Fraction

    PubMed Central

    Wilson, Richard M.; Essick, Eric E.; Fowler, Conor T.; Nakamura, Kazuto; van den Hoff, Maurice; Ouchi, Noriyuki; Sam, Flora

    2016-01-01

    Objective We sought to determine whether Fstl1 plays a role in the regulation of cardiac hypertrophy in HFpEF. Background Heart failure (HF) with preserved ejection fraction (HFpEF), accounts for ~50% of all clinical presentations of HF and its prevalence is expected to increase. However, there are no evidence-based therapies for HFpEF; thus, HFpEF represents a major unmet need. Although hypertension is the single most important risk factor for HFpEF, with a prevalence of 60-89% from clinical trials and human HF registries, blood pressure therapy alone is insufficient to prevent and treat HFpEF. Follistatin like 1 (Fstl1), a divergent member of the follistatin family of extracellular glycoproteins, has previously been shown to be elevated in HF with reduced ejection fraction (HFrEF) and associated with increased left ventricular mass. Methods and Results In this study, blood levels of Fstl1 were increased in humans with HFpEF. This increase was also evident in mice with hypertension-induced HFpEF and adult rat ventricular myocytes stimulated with aldosterone. Treatment with recombinant Fstl1 abrogated aldosterone-induced cardiac myocyte hypertrophy, suggesting a role for Fstl1 in the regulation of hypertrophy in HFpEF. There was also a reduction in the E/A ratio, a measure of diastolic dysfunction. Furthermore, HFpEF induced in a mouse model that specifically ablates Fstl1 in cardiac myocytes (cFstl1-KO), showed exacerbation of HFpEF with worsened diastolic dysfunction. In addition, cFstl1-KO-HFpEF mice demonstrated more marked cardiac myocyte hypertrophy with increased molecular markers of anp and bnp expression. Conclusions These findings indicate that Fstl1exerts therapeutic effects by modulating cardiac hypertrophy in HFpEF. PMID:27430031

  13. Diastolic relaxation and compliance reserve during dynamic exercise in heart failure with preserved ejection fraction.

    PubMed

    Borlaug, Barry A; Jaber, Wissam A; Ommen, Steve R; Lam, Carolyn S P; Redfield, Margaret M; Nishimura, Rick A

    2011-06-01

    Recent studies have examined haemodynamic changes with stressors such as isometric handgrip and rapid atrial pacing in heart failure with preserved ejection fraction (HFpEF), but little is known regarding left ventricular (LV) pressure-volume responses during dynamic exercise. To assess LV haemodynamic responses to dynamic exercise in patients with HFpEF. Twenty subjects with normal ejection fraction (EF) and exertional dyspnoea underwent invasive haemodynamic assessment during dynamic exercise to evaluate suspected HFpEF. LV end-diastolic pressure was elevated at rest (>15 mm Hg, n=18) and with exercise (≥20 mm Hg, n=20) in all subjects, consistent with HFpEF. Heart rate (HR), blood pressure, arterial elastance and cardiac output increased with exercise (all p<0.001). Minimal and mean LV diastolic pressures increased by 43-56% with exercise (both p<0.0001), despite a trend towards a reduction in LV end-diastolic volume (p=0.08). Diastolic filling time was abbreviated with increases in HR and the proportion of diastole that elapsed prior to estimated complete relaxation increased (p<0.0001), suggesting inadequate relaxation reserve relative to the shortening of diastole. LV diastolic chamber elastance acutely increased 50% during exercise (p=0.0003). Exercise increases in LV filling pressures correlated with changes in diastolic relaxation rates, chamber stiffness and arterial afterload but were not related to alterations in preload volume, HR or cardiac output. In patients with newly diagnosed HFpEF, LV filling pressures increase during dynamic exercise in association with inadequate enhancement of relaxation and acute increases in LV chamber stiffness. Therapies that enhance diastolic reserve function may improve symptoms of exertional intolerance in patients with hypertensive heart disease and early HFpEF.

  14. Cost-Effectiveness of Sacubitril-Valsartan in Patients With Heart Failure With Reduced Ejection Fraction.

    PubMed

    Sandhu, Alexander T; Ollendorf, Daniel A; Chapman, Richard H; Pearson, Steven D; Heidenreich, Paul A

    2016-11-15

    Sacubitril-valsartan therapy reduces cardiovascular mortality compared with enalapril therapy in patients with heart failure with reduced ejection fraction. To evaluate the cost-effectiveness of sacubitril-valsartan versus angiotensin-converting enzyme inhibitor therapy in patients with chronic heart failure. Markov decision model. Clinical trials, observational analyses, reimbursement data from the Centers for Medicare & Medicaid Services, drug pricing databases, and Centers for Disease Control and Prevention life tables. Patients at an average age of 64 years, New York Heart Association (NYHA) class II to IV heart failure, and left ventricular ejection fraction of 0.40 or less. Lifetime. Societal. Treatment with sacubitril-valsartan or lisinopril. Life-years, quality-adjusted life-years (QALYs), costs, heart failure hospitalizations, and incremental cost-effectiveness ratios. The sacubitril-valsartan group experienced 0.08 fewer heart failure hospitalization, 0.69 additional life-year, 0.62 additional QALY, and $29 203 in incremental costs, equating to a cost per QALY gained of $47 053. The cost per QALY gained was $44 531 in patients with NYHA class II heart failure and $58 194 in those with class III or IV heart failure. Sacubitril-valsartan treatment was most sensitive to the duration of improved outcomes, with a cost per QALY gained of $120 623 if the duration was limited to the length of the trial (median, 27 months). No variations in other parameters caused the cost to exceed $100 000 per QALY gained. The benefit of sacubitril-valsartan is based on a single clinical trial. Treatment with sacubitril-valsartan provides reasonable value in reducing cardiovascular mortality and morbidity in patients with NYHA class II to IV heart failure. U.S. Department of Veterans Affairs and Institute for Clinical and Economic Review.

  15. Prognostic importance of comorbidities in heart failure with preserved left ventricular ejection fraction.

    PubMed

    Maréchaux, Sylvestre; Six-Carpentier, Marie M; Bouabdallaoui, Nadia; Montaigne, David; Bauchart, Jean Jacques; Mouquet, Frédéric; Auffray, Jean Luc; Le Tourneau, Thierry; Asseman, Philippe; LeJemtel, Thierry H; Ennezat, Pierre Vladimir

    2011-05-01

    The relative impact of comorbidities and parameters of left ventricular diastolic function on clinical outcome has not been thoroughly investigated in patients who are hospitalized for heart failure decompensation and found to have preserved ejection fraction. We identified 98 HFpEF patients among 1452 patients admitted with acute heart failure. Clinical characteristics, hemoglobin levels, estimated glomerular filtration rate (eGFR), B-type natriuretic peptide (BNP) and Doppler-echocardiographic parameters were analyzed. The primary end point of the study combined death and rehospitalization for decompensated heart failure after the index hospitalization. Mean age was 76 ± 9 years. LV ejection fraction, E/E (a) ratio, and estimated systolic pulmonary artery pressure were 61 (55-67)%, 12.9 (9.4-15.1), 40 (32-46) mmHg, respectively. BNP values, hemoglobin and eGFR were 287 (164-562) pg/mL, 11.3 (10.4-12.4) g/dL and 45 (37-74) mL/min/m(2), respectively. During a mean follow-up of 17 ± 11 months, 56% reached the primary endpoint of the study: 31 died and 24 were re-hospitalised for heart failure. Diabetes [HR = 1.76 (1.03-3.00), P = 0.039], lower systolic blood pressure [HR = 0.99 (0.97-0.99), P = 0.016], hemoglobin [HR = 0.62 (0.49-0.76), P < 0.0001], and eGFR [HR = 0.98 (0.97-0.99), P = 0.004] were associated with a poor outcome. Neither BNP nor echocardiographic parameters were correlated with outcome. Comorbidities primarily correlate with outcome in patients with HFpEF.

  16. Left ventricular systolic dysfunction detected by speckle tracking in hypertensive patients with preserved ejection fraction.

    PubMed

    Gonçalves, Susana; Cortez-Dias, Nuno; Nunes, Ana; Belo, Adriana; Zimbarra Cabrita, Inês; Sousa, Catarina; Pinto, Fausto J

    2014-01-01

    The spectrum of hypertensive heart disease is wide, and can include left ventricular dysfunction. The development of echocardiographic parameters to improve patient stratification and to identify early adverse changes could be clinically useful. Aim To identify subclinical left ventricular dysfunction in hypertensive subjects with preserved ejection fraction (>55%), identified by global parameters of myocardial strain on speckle tracking imaging. This was a comparative observational study of two groups of individuals: normotensive (n=20, age 59 ± 7 years, 55% male) and hypertensive (n=229, age 62 ± 12 years, 57% male). Left ventricular function was assessed by various conventional clinical and echocardiographic parameters and global longitudinal and circumferential myocardial strain. Cut-off values to detect subclinical left ventricular dysfunction were established and applied in the hypertensive group. The Student's t test, Mann-Whitney test and chi-square test were used for the comparative statistical analysis. Most hypertensive subjects (53.7%) had grade I hypertension; blood pressure was controlled in 64.9%, and 54.8% showed left ventricular structural changes. Comparison between the normotensive and hypertensive groups showed no significant differences in parameters of global longitudinal or circumferential systolic strain. Application of the cut-offs to the hypertensive group identified 35 individuals (15.3%) as having subclinical left ventricular systolic dysfunction as assessed by global longitudinal myocardial strain parameters. In this group of hypertensive patients, global myocardial strain parameters identified a group of individuals with subclinical left ventricular systolic dysfunction despite preserved ejection fraction. The clinical relevance of these findings needs to be assessed in long-term follow-up studies. Copyright © 2013 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

  17. Systolic Strain Abnormalities to Predict Hospital Readmission in Patients With Heart Failure and Normal Ejection Fraction

    PubMed Central

    Borer, Steven M.; Kokkirala, Aravind; O'Sullivan, David M.; Silverman, David I.

    2011-01-01

    Background Despite intensive investigation, the pathogenesis of heart failure with normal ejection fraction (HFNEF) remains unclear. We hypothesized that subtle abnormalities of systolic function might play a role, and that abnormal systolic strain and strain rate would provide a marker for adverse outcomes. Methods Patients of new CHF and left ventricular ejection fraction > 50% were included. Exclusion criteria were recent myocardial infarction, severe valvular heart disease, severe left ventricular hypertrophy (septum >1.8 cm), or a technically insufficient echocardiogram. Average peak systolic strain and strain rate were measured using an off-line grey scale imaging technique. Systolic strain and strain rate for readmitted patients were compared with those who remained readmission-free. Results One hundred consecutive patients with a 1st admission for HFNEF from January 1, 2004 through December 31, 2007, inclusive, were analyzed. Fifty two patients were readmitted with a primary diagnosis of heart failure. Systolic strain and strain rates were reduced in both study groups compared to controls. However, systolic strain did not differ significantly between the two groups (-11.7% for those readmitted compared with -12.9% for those free from readmission, P = 0.198) and systolic strain rates also were similar (-1.05 s-1 versus -1.09 s-1, P = 0.545). E/e’ was significantly higher in readmitted patients compared with those who remained free from readmission (14.5 versus 11.0, P = 0.013). E/e’ (OR 1.189, 95% CI 1.026-1.378; P = 0.021) was found to be an independent predictor for HFNEF readmission. Conclusions Among patients with new onset HFNEF, SS and SR rates are reduced compared with patients free of HFNEF, but do not predict hospital readmission. Elevated E/e’ is a predictor of readmission in these patients.

  18. A prediction model for sudden cardiac death in patients with heart failure and preserved ejection fraction.

    PubMed

    Adabag, Selcuk; Rector, Thomas S; Anand, Inder S; McMurray, John J; Zile, Michael; Komajda, Michel; McKelvie, Robert S; Massie, Barry; Carson, Peter E

    2014-11-01

    Sudden cardiac death (SCD) accounts for ∼ 25% of all deaths in heart failure with preserved ejection fraction (HFpEF). However, strategies to identify HFpEF patients at a higher risk of SCD have not been developed. We studied 4128 patients with HFpEF enrolled in the Irbesartan in Patients with Heart Failure and Preserved Ejection Fraction (I-PRESERVE) trial. All SCDs were adjudicated by a clinical endpoint committee. Cumulative incidences of SCD were estimated counting other deaths as competing risks. Cox regression analysis was used to generate a risk model for SCD. During a mean follow-up of 4.1 years, 231 (5.6%) patients died suddenly and 650 (15.7%) died non-suddenly. A multivariable model in 3480 patients including age, gender, history of diabetes and myocardial infarction, LBBB on ECG, and the natural logarithm of NT-proBNP identified a subgroup of 837 (24%) patients with ≥10% cumulative incidence of SCD over 5 years, accounting for other deaths as competing risk (Harrell's C index 0.75). The 5-year cumulative incidences of SCD in the higher and lower risk groups were 11% and 4%, respectively. In the higher risk group, 32% of deaths were SCD compared with 26% in the entire I-PRESERVE cohort. A multivariable prediction model identified patients with HFpEF who have a ≥10% risk of SCD over 5 years, similar to the risk of SCD in the Sudden Cardiac Death in Heart Failure (SCD-Heft) trial. This model may be useful for selecting patients with HFpEF for SCD prevention trials. © 2014 The Authors. European Journal of Heart Failure © 2014 European Society of Cardiology.

  19. Diagnosis and Management of Heart Failure with Preserved Ejection Frac-tion: 10 Key Lessons

    PubMed Central

    A, Afşin Oktay; Shah, Sanjiv J

    2015-01-01

    Heart failure with preserved ejection fraction (HFpEF) is a common clinical syndrome associated with high rates of morbidi-ty and mortality. Due to the lack of evidence-based therapies and increasing prevalence of HFpEF, clinicians are often con-fronted with these patients and yet have little guidance on how to effectively diagnose and manage them. Here we offer 10 key lessons to assist with the care of patients with HFpEF: (1) Know the difference between diastolic dysfunction, diastolic heart failure, and HFpEF; (2) diagnosing HFpEF is challenging, so be thorough and consider invasive hemodynamic testing to confirm the diagnosis; (3) a normal B-type natriuretic peptide does not exclude the diagnosis of HFpEF; (4) elevated pul-monary artery systolic pressure on echocardiography in the presence of a normal ejection fraction should prompt considera-tion of HFpEF; (5) use dynamic testing in evaluating the possibility of HFpEF in patients with unexplained dyspnea or exer-cise tolerance; (6) all patients with HFpEF should be systematically evaluated for the presence of coronary artery disease; (7) use targeted treatment for HFpEF patients based on their phenotypic classification; (8) treat HFpEF patients now by treating their comorbidities; (9) understand the importance of heart rate in HFpEF—lower is not always better; and (10) do not forget to consider rare diseases (“zebras”) as causes for HFpEF when evaluating and treating patients. Taken together, these 10 key lessons can help clinicians care for challenging patients with HFpEF while we eagerly await the results of ongoing HFpEF clinical trials and observational studies. PMID:24251461

  20. Heterogeneous responses of systolic and diastolic left ventricular function to exercise in patients with heart failure and preserved ejection fraction

    PubMed Central

    Sinning, David; Lober, Jil; Post, Heiner; Fraser, Alan G.; Pieske, Burkert; Burkhoff, Daniel; Tschöpe, Carsten

    2015-01-01

    Abstract Aims This study aimed to evaluate ventricular diastolic properties using three‐dimensional echocardiography and tissue Doppler imaging at rest and during exercise in heart failure with preserved ejection fraction (HFpEF) patients with borderline evidence of diastolic dysfunction at rest. Methods and results Results obtained from 52 HFpEF patients (left ventricular ejection fraction ≥ 50%) identified on the basis of heart failure symptoms and E/E′ values between 8 and 15 were compared with those obtained in 26 control patients with no evidence of cardiovascular disease. Mitral flow patterns, tissue Doppler imaging, and volume analysis obtained by three‐dimensional echocardiography were performed at rest and during bicycle exercise. Diastolic compliance was indexed by the E/E′ ratio and left ventricular end‐diastolic volume [(E/E′)/EDV]. There were no significant differences in end‐diastolic volume (EDV), stroke volume (SV), or ejection fraction at rest between groups. In 27 of the 52 patients, E/E′ increased during exercise (11.2 ± 3.7 to 16.8 ± 10.5), driven by a failure to augment early diastole (E′). This correlated with a fall in SV and was associated with an increase in the diastolic index (E/E′)/EDV as a measure for LV stiffness (0.122 ± 0.038 to 0.217 ± 0.14/mL), indicating that impaired diastolic reserve (designated PEF‐IDR) contributed to exercise intolerance. Of the 52 patients, 25 showed no changes in E/E′ during exercise associated with a significant rise in SV and cardiac output, still inappropriate compared with controls. Despite disturbed early diastole (E′), a blunted increase in estimated systolic LV elastance indicated that impaired systolic reserve and chronotropic incompetence rather than primarily diastolic disturbances contributed to exercise intolerance in this group (designated PEF). Conclusion Three‐dimensional stress echocardiography may allow non‐invasive analysis of changes

  1. Immunogenic Activity of a Ribosomal Fraction Obtained from Mycobacterium tuberculosis

    PubMed Central

    Youmans, Anne S.; Youmans, Guy P.

    1965-01-01

    Youmans, Anne S. (Northwestern University Medical School, Chicago, Ill.), and Guy P. Youmans. Immunogenic activity of a ribosomal fraction obtained from Mycobacterium tuberculosis. J. Bacteriol. 89:1291–1298. 1965.—The highly immunogenic particulate fraction obtained from mechanically ruptured cells of the H37Ra strain of Mycobacterium tuberculosis was suspended and centrifuged at 20,360 × g. The supernatant liquid from this centrifugation was centrifuged at 56,550 × g to remove the larger particles, and the supernatant liquid from this was centrifuged at 144,000 × g to obtain a ribosomal fraction. The sediments from the first two centrifugations were highly immunogenic, but the ribosomal fraction showed only slight capacity to immunize mice. However, when the ribosomal fraction was mixed with Freund's incomplete adjuvant, the immunogenic activity was equivalent to the particulate fraction from which it was prepared. To test the hypothesis that some membranous substance in the particulate fraction was acting as an adjuvant for the smaller particles in the ribosomal fraction, portions of the particulate fraction were treated separately with each of the membrane-disrupting agents, sodium deoxycholate, sodium lauryl sulfate, and 1 m sodium chloride. The treated materials were then centrifuged at 144,000 × g, and the sediments were tested for immunogenicity both with and without the addition of Freund's incomplete adjuvant. Without the adjuvant, the immunizing activities were very weak or absent; with the adjuvant, they were equivalent to that of the particulate fraction from which they were prepared. Other factors which have been found to damage or destroy membranes, such as freezing and thawing, and heat, also significantly decreased the immunogenic activity of the particulate fraction unless it was incorporated into Freund's incomplete adjuvant. The larger particles which sedimented at 56,550 × g were also treated with sodium lauryl sulfate and sodium

  2. Determination of cardiac ejection fraction and left ventricular volume: contrast-enhanced ultrafast cine MR imaging vs IV digital subtraction ventriculography.

    PubMed

    Matsumura, K; Nakase, E; Haiyama, T; Takeo, K; Shimizu, K; Yamasaki, K; Kohno, K

    1993-05-01

    To assess the accuracy of contrast-enhanced, single breath-hold cine MR imaging in the calculation of left ventricular volume and ejection fraction, we compared values obtained by using this method with those obtained by using IV digital subtraction angiography (IV-DSA). All patients (n = 28) had conventional cine and contrast-enhanced ultrafast cine MR imaging. For ultrafast cine MR imaging, a phase-rewind gradient-echo (rewind-SMASH) sequence was used: TR, 8 msec (standard excitation and acquisition block of 6 msec with phase rewind pulse of 2 msec); TE, 3.2 msec; a 128 x 96 matrix (pile encode factor, 6; k-space segment, 16); a 200-mm field of view; and one excitation. Values for left ventricular volume and ejection fraction obtained with ultrafast cine MR imaging correlated well with those obtained with IV-DSA (end-diastolic volume, y = 0.986x - 7.79, r = .985; end-systolic volume, y = 0.863x + 0.71, r = .984; ejection fraction, y = 0.877x + 6.44, r = .887). In the calculation of left ventricular volume by the area-length method, manual tracing of the left ventricular cavity was more difficult when the conventional cine method was used than when the enhanced ultrafast cine method was used. Our results show that cardiac multiphase study with horizontal long-axis, first-pass, contrast-enhanced, single breath-hold, cine MR imaging is an accurate and highly reproducible method of evaluating left ventricular volume and ejection fraction.

  3. Effects of gender, ejection fraction and weight on cardiac force development in patients undergoing cardiac surgery – an experimental examination

    PubMed Central

    2013-01-01

    Background It has long been recognized that differences exist between men and women in the impact of risc factors, symptoms, development and outcome of special diseases like the cardiovascular disease. Gender determines the cardiac baseline parameters like the number of cardiac myocyte, size and demand and may suggest differences in myofilament function among genders, which might be pronounced under pathological conditions. Does gender impact and maybe impair the contractile apparatus? Are the differences more prominent when other factors like weight, age, ejection fraction are added? Therefore we performed a study on 36 patients (21 male, 15 female) undergoing aortic valve replacement (AVR) or aortocoronary bypass operation (CABG) to examine the influence of gender, ejection fraction, surgical procedure and body mass index (BMI) on cardiac force development. Methods Tissue was obtained from the right auricle and was stored in a special solution to prevent any stretching of the fibers. We used the skinned muscle fiber model and single muscle stripes, which were mounted on the “muscle machine” and exposed to a gradual increase of calcium concentration calculated by an attached computer program. Results 1.) In general female fibers show more force than male fibers: 3.9 mN vs. 2.0 mN (p = 0.03) 2.) Female fibers undergoing AVR achieved more force than those undergoing CABG operation: 5.7 mN vs. 2.8 mN (p = 0.02) as well as male fibers with AVR showed more force values compared to those undergoing CABG: 2.0 mN vs. 0.5 mN (p = 0.01). 3.) Male and female fibers of patients with EF > 55% developed significantly more force than from those with less ejection fraction than 30%: p = 0.002 for the male fibers (1.6 vs. 2.8 mN) and p = 0.04 for the female fibers (5.7 vs. 2.8 mN). 4.) Patients with a BMI between 18 till 25 develop significant more force than those with a BMI > 30: Females 5.1 vs. 2.6 mN; p 0.03, Males 3.8 vs. 0.8 mN; p 0

  4. Reverse left ventricular remodeling: effect of cardiac rehabilitation exercise training in myocardial infarction patients with preserved ejection fraction.

    PubMed

    McGREGOR, Gordon; Gaze, David; Oxborough, David; O'Driscoll, Jamie; Shave, Rob

    2016-06-01

    In the increasingly prevalent population of postmyocardial infarction (MI) patients with preserved left ventricular (LV) ejection fraction (>45%), the effect of cardiac rehabilitation (CR) exercise training on LV structure and function is unknown. To examine the reverse LV remodeling effect of CR exercise training in post-MI patients with preserved LV ejection fraction (>45%). Prospective, longitudinal, controlled trial. Outpatient CR programme. Fifty six asymptomatic, post-MI patients without residual myocardial ischemia and LV ejection fraction >45%. Within 3-6 weeks of MI, and 10 weeks later, echocardiography and cardiopulmonary exercise testing were performed. An exercise training group (N.=36) completed twice weekly gym based cardiovascular exercise (60-80% VO2 peak) and a resistance training programme, whilst a non-exercise group (N.=20) did not. In comparison to the non-exercise group, in which there was no change, 10 weeks of CR exercise training resulted in increased VO2peak and reduced LV end diastolic and systolic volumes (all P<0.05 vs. non-exercise group). In post-MI patients with preserved LV ejection fraction (>45%), CR exercise training is effective in improving functional capacity and reducing LV volumes. In this previously unstudied population, the measurement of reverse LV volumetric remodeling may prove useful as an indicator of CR exercise programme efficacy. To maximize the potential clinical benefit from reverse LV remodeling, this patient group, should be actively encouraged to engage in CR exercise training.

  5. High-Intensity Interval Training in Patients With Heart Failure With Reduced Ejection Fraction

    PubMed Central

    Halle, Martin; Conraads, Viviane; Støylen, Asbjørn; Dalen, Håvard; Delagardelle, Charles; Larsen, Alf-Inge; Hole, Torstein; Mezzani, Alessandro; Van Craenenbroeck, Emeline M.; Videm, Vibeke; Beckers, Paul; Christle, Jeffrey W.; Winzer, Ephraim; Mangner, Norman; Woitek, Felix; Höllriegel, Robert; Pressler, Axel; Monk-Hansen, Tea; Snoer, Martin; Feiereisen, Patrick; Valborgland, Torstein; Kjekshus, John; Hambrecht, Rainer; Gielen, Stephan; Karlsen, Trine; Prescott, Eva; Linke, Axel

    2017-01-01

    Background: Small studies have suggested that high-intensity interval training (HIIT) is superior to moderate continuous training (MCT) in reversing cardiac remodeling and increasing aerobic capacity in patients with heart failure with reduced ejection fraction. The present multicenter trial compared 12 weeks of supervised interventions of HIIT, MCT, or a recommendation of regular exercise (RRE). Methods: Two hundred sixty-one patients with left ventricular ejection fraction ≤35% and New York Heart Association class II to III were randomly assigned to HIIT at 90% to 95% of maximal heart rate, MCT at 60% to 70% of maximal heart rate, or RRE. Thereafter, patients were encouraged to continue exercising on their own. Clinical assessments were performed at baseline, after the intervention, and at follow-up after 52 weeks. Primary end point was a between-group comparison of change in left ventricular end-diastolic diameter from baseline to 12 weeks. Results: Groups did not differ in age (median, 60 years), sex (19% women), ischemic pathogenesis (59%), or medication. Change in left ventricular end-diastolic diameter from baseline to 12 weeks was not different between HIIT and MCT (P=0.45); left ventricular end-diastolic diameter changes compared with RRE were −2.8 mm (−5.2 to −0.4 mm; P=0.02) in HIIT and −1.2 mm (−3.6 to 1.2 mm; P=0.34) in MCT. There was also no difference between HIIT and MCT in peak oxygen uptake (P=0.70), but both were superior to RRE. However, none of these changes was maintained at follow-up after 52 weeks. Serious adverse events were not statistically different during supervised intervention or at follow-up at 52 weeks (HIIT, 39%; MCT, 25%; RRE, 34%; P=0.16). Training records showed that 51% of patients exercised below prescribed target during supervised HIIT and 80% above target in MCT. Conclusions: HIIT was not superior to MCT in changing left ventricular remodeling or aerobic capacity, and its feasibility remains unresolved in

  6. Characterization of Coconut Oil Fractions Obtained from Solvent Fractionation Using Acetone.

    PubMed

    Sonwai, Sopark; Rungprasertphol, Poonyawee; Nantipipat, Nantinee; Tungvongcharoan, Satinee; Laiyangkoon, Nantikan

    2017-09-01

    This work was aimed to study the solvent fraction of coconut oil (CNO). The fatty acid and triacylglycerol compositions, solid fat content (SFC) and the crystallization properties of CNO and its solid and liquid fractions obtained from fractionation at different conditions were investigated using various techniques. CNO was dissolved in acetone (1:1 w/v) and left to crystallize isothermally at 10°C for 0.5, 1 and 2 h and at 12°C for 2, 3 and 6 h. The solid fractions contained significantly lower contents of saturated fatty acids of ≤ 10 carbon atoms but considerably higher contents of saturated fatty acids with > 12 carbon atoms with respect to those of CNO and the liquid fractions. They also contained higher contents of high-melting triacylglycerol species with carbon number ≥ 38. Because of this, the DSC crystallization onset temperatures and the crystallization peak temperatures of the solid fractions were higher than CNO and the liquid fractions. The SFC values of the solid fractions were significantly higher than CNO at all measuring temperatures before reaching 0% just below the body temperature with the fraction obtained at 12°C for 2 h exhibiting the highest SFC. On the contrary, the SFC values of the liquid fractions were lower than CNO. The crystallization duration exhibited strong influence on the solid fractions. There was no effect on the crystal polymorphic structure possibly because CNO has β'-2 as a stable polymorph. The enhanced SFC of the solid fractions would allow them to find use in food applications where a specific melting temperature is desired such as sophisticated confectionery fats, and the decreased SFC of the liquid fractions would provide them with a higher cold stability which would be useful during extended storage time.

  7. An evidence-based review of recent advances in therapy for heart failure with reduced ejection fraction (HFrEF).

    PubMed

    Raj, Leah; Adhyaru, Bhavin

    2016-12-01

    An estimated 5.1 million Americans have chronic heart failure and this is expected to increase 25% by 2030. Heart failure is a clinical syndrome that evolves from either functional or structural changes to the ventricles that lead to filling or ejection abnormalities. Thus far, pharmacotherapy has been show to be beneficial in patients only with reduced ejection fraction; however, new therapies have been developed in hopes of reducing the burden of heart failure. In this review, we will discuss current pharmacotherapies recommended in American College of Cardiology/American Heart Association guidelines, the evidence behind these recommendations as well as new and emerging therapies that have been developed.

  8. Quantitation of left ventricular ejection fraction reserve from early gated regadenoson stress Tc-99m high efficiency SPECT

    PubMed Central

    Brodov, Yafim; Fish, Mathews; Rubeaux, Mathieu; Otaki, Yuka; Gransar, Heidi; Lemley, Mark; Gerlach, Jim; Berman, Daniel; Germano, Guido; Slomka, Piotr

    2016-01-01

    Background Ejection fraction (EF) reserve has been found to be a useful adjunct for identifying high risk coronary artery disease in cardiac positron emission tomography (PET). We aimed to evaluate EF reserve obtained from technetium-99m sestamibi (Tc-99m) high-efficiency (HE) SPECT. Methods Fifty patients (mean age 69 y) undergoing regadenoson same-day rest (8–11 mCi)/stress (32–42mCi) Tc-99m gated HE SPECT were enrolled. Stress imaging was started one min after sequential intravenous regadenoson 0.4mg and Tc-99m injection, and was composed of five 2 min supine gated acquisitions followed by two 4 min supine and upright images. Ischemic total perfusion deficit (ITPD) ≥ 5 % was considered as significant ischemia. Results Significantly lower mean EF reserve was obtained in the 5th and 9th min after regadenoson bolus in patients with significant ischemia versus patients without (5th min: −4.2 ± 4.6% vs. 1.3 ± 6.6%, p = 0.006; 9th min: −2.7 ± 4.8% vs. 2.0 ± 6.6%, p = 0.03). Conclusions Negative EF reserve obtained between 5th and 9th min of regadenoson stress demonstrated best concordance with significant ischemia and may be a promising tool for detection of myocardial stunning with Tc-99m HE-SPECT. PMID:27387521

  9. Current Perspectives on Systemic Hypertension in Heart Failure with Preserved Ejection Fraction.

    PubMed

    Tam, Marty C; Lee, Ran; Cascino, Thomas M; Konerman, Matthew C; Hummel, Scott L

    2017-02-01

    Heart failure with preserved ejection fraction (HFpEF) is a prevalent but incompletely understood syndrome. Traditional models of HFpEF pathophysiology revolve around systemic HTN and other causes of increased left ventricular afterload leading to left ventricular hypertrophy (LVH) and diastolic dysfunction. However, emerging models attribute the development of HFpEF to systemic proinflammatory changes secondary to common comorbidities which include HTN. Alterations in passive ventricular stiffness, ventricular-arterial coupling, peripheral microvascular function, systolic reserve, and chronotropic response occur. As a result, HFpEF is heterogeneous in nature, making it difficult to prescribe uniform therapies to all patients. Nonetheless, treating systemic HTN remains a cornerstone of HFpEF management. Antihypertensive therapies have been linked to LVH regression and improvement in diastolic dysfunction. However, to date, no therapies have definitive mortality benefit in HFpEF. Non-pharmacologic management for HTN, including dietary modification, exercise, and treating sleep disordered breathing, may provide some morbidity benefit in the HFpEF population. Future research is need to identify effective treatments, perhaps in more specific subgroups, and focus may need to shift from reducing mortality to improving exercise capacity and symptoms. Tailoring antihypertensive therapies to specific phenotypes of HFpEF may be an important component of this strategy.

  10. The Nitrate-nitrite-NO pathway and its implications for Heart Failure and Preserved Ejection Fraction

    PubMed Central

    Chirinos, Julio A.; Zamani, Payman

    2016-01-01

    The pathogenesis of exercise intolerance in patients with heart failure and preserved ejection fraction (HFpEF) is likely multifactorial. In addition to cardiac abnormalities (diastolic dysfunction, abnormal contractile reserve, chronotropic incompetence), several peripheral abnormalities are likely to be involved. These include abnormal pulsatile hemodynamics, abnormal arterial vasodilatory responses to exercise, and abnormal peripheral O2 delivery, extraction and utilization. The nitrate-nitrite-NO pathway is emerging as a potential target to modify key physiologic abnormalities, including late systolic LV load from arterial wave reflections (which has deleterious short- and long-term consequences for the LV), arterial vasodilatory reserve, muscle O2 delivery, and skeletal muscle mitochondrial function. In a recently completed randomized trial, the administration of a single dose of exogenous inorganic nitrate has been shown exert various salutary arterial hemodynamic effects, ultimately leading to enhanced aerobic capacity in patients with HFpEF. These effects have the potential for both immediate improvements in exercise tolerance and for long-term “disease-modifying” effects. In this review, we provide an overview of key mechanistic contributors to exercise intolerance in HFpEF, and of the potential therapeutic role of drugs that target the nitrate-nitrite-NO pathway. PMID:26792295

  11. Role of preoperative radionuclide ejection fraction in direct abdominal aortic aneurysm repair

    SciTech Connect

    Kazmers, A.; Cerqueira, M.D.; Zierler, R.E.

    1988-08-01

    Preoperative radionuclide ventriculography was performed in 60 patients to assess whether such testing could define those at increased risk after direct abdominal aortic aneurysm (AAA) repair. None of the patients had prophylactic coronary artery reconstruction to reduce the risk of AAA repair despite angina in 27% and previous myocardial infarction (MI) in 42%. The mean ejection fraction (EF) was 52% +/- 15% (range 14% to 78%). Low EF (normal greater than 50%) was present in 40%, whereas ventricular wall motion abnormalities were present in 39% of patients. The overall perioperative (30-day) mortality rate was 5%. MI occurred in 7% within 30 postoperative days; none was fatal. Life-table analysis revealed that overall survival after AAA repair was significantly lower in patients with an EF of 50% or less (p less than 0.025, Mantel-Cox) during a follow-up of 20.1 +/- 11.9 months. Overall survival differences were even more striking for those with an EF of 35% or less (p = 0.003, Mantel-Cox). There was a marked difference in the cumulative mortality rate during follow-up, being 50% in those patients with an EF of 35% or less (n = 10) compared with 14% in those with an EF greater than 35% (n = 50, p = 0.036, Fisher exact test). There was no statistical difference in the incidence of perioperative MI or perioperative death for those with an EF of 35% or less vs EF greater than 35%. 50 references.

  12. Radionuclide fourier amplitude analysis to predict post-aneurysmectomy ejection fraction

    SciTech Connect

    McCarthy, D.M.; Kleaveland, J.P.; Makler, P.T. Jr.; Alavi, A.

    1984-01-01

    Post-operative LV ejection fraction (EF) is an important determinant of outcome following aneurysmectomy but is difficult to predict noninvasively. First harmonic Fourier analysis of radionuclide angiography (RNA) in patients with aneurysms gives characteristic phase and amplitude images which delineate contractile and dyskinetic regions. Since pixel amplitude is proportional to stroke counts, the summed amplitude values from the contractile region (CR) and the aneurysm should reflect regional stroke volumes. A predicted post-operative LVEF may be determined from the pre-operative global LVEF and the proportion of the total amplitude located in the CR. The authors studied 19 patients undergoing LV aneurysmectomy with pre- and post-operative RNA. Three patients were excluded for technical reasons, leaving 16 patients for analysis. There were 13 males, and the mean age was 56.8 yrs (range 45-78). All patients had a history of anterior myocardial infarction and were undergoing surgery for recurrent sustained ventricular tachycardia. The global LVEF increased from 0.25 +- .13 (sd) pre-operatively to 0.38+-.11 following surgery (p<.001). The predicted post-operative LVEF (from amplitude analysis of the pre-operative RNA) averaged 0.35 +- .13 and correlated significantly with the actual post-operative LVEf (r=0.87, SEE=.06, p<.01). The results suggest that the LVEF following aneurysmectomy can be predicted from Fourier amplitude analysis of the pre-operative RNA.

  13. Sacubitril/Valsartan: A Review in Chronic Heart Failure with Reduced Ejection Fraction.

    PubMed

    McCormack, Paul L

    2016-03-01

    Sacubitril/valsartan (Entresto™; LCZ696) is an orally administered supramolecular sodium salt complex of the neprilysin inhibitor prodrug sacubitril and the angiotensin receptor blocker (ARB) valsartan, which was recently approved in the US and the EU for the treatment of chronic heart failure (NYHA class II-IV) with reduced ejection fraction (HFrEF). In the large, randomized, double-blind, PARADIGM-HF trial, sacubitril/valsartan reduced the incidence of death from cardiovascular causes or first hospitalization for worsening heart failure (composite primary endpoint) significantly more than the angiotensin converting enzyme (ACE) inhibitor enalapril. Sacubitril/valsartan was also superior to enalapril in reducing death from any cause and in limiting the progression of heart failure. Sacubitril/valsartan was generally well tolerated, with no increase in life-threatening adverse events. Symptomatic hypotension was significantly more common with sacubitril/valsartan than with enalapril; the incidence of angio-oedema was low. Therefore, sacubitril/valsartan is a more effective replacement for an ACE inhibitor or an ARB in the treatment of HFrEF, and is likely to influence the basic approach to treatment.

  14. A feasibility study of arrhythmia risk prediction in patients with myocardial infarction and preserved ejection fraction.

    PubMed

    Deng, Dongdong; Arevalo, Hermenegild J; Prakosa, Adityo; Callans, David J; Trayanova, Natalia A

    2016-12-01

    To predict arrhythmia susceptibility in myocardial infarction (MI) patients with left ventricular ejection fraction (LVEF)  >35% using a personalized virtual heart simulation approach. A total of four contrast enhanced magnetic resonance imaging (MRI) datasets of patient hearts with MI and average LVEF of 44.0 ± 2.6% were used in this study. Because of the preserved LVEF, the patients were not indicated for implantable cardioverter defibrillator (ICD) insertion. One patient had spontaneous ventricular tachycardia (VT) prior to the MRI scan; the others had no arrhythmic events. Simulations of arrhythmia susceptibility were blind to clinical outcome. Models were constructed from patient MRI images segmented to identify myocardium, grey zone, and scar based on pixel intensity. Grey zone was modelled as having altered electrophysiology. Programmed electrical stimulation (PES) was performed to assess VT inducibility from 19 bi-ventricular sites in each heart model. Simulations successfully predicted arrhythmia risk in all four patients. For the patient with arrhythmic event, in-silico PES resulted in VT induction. Simulations correctly predicted that VT was non-inducible for the three patients with no recorded VT events. Results demonstrate that the personalized virtual heart simulation approach may provide a novel risk stratification modality to non-invasively and effectively identify patients with LVEF  >35% who could benefit from ICD implantation. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For Permissions, please email: journals.permissions@oup.com.

  15. Heart failure preserved ejection fraction (HFpEF): an integrated and strategic review.

    PubMed

    Lekavich, Carolyn L; Barksdale, Debra J; Neelon, Virginia; Wu, Jia-Rong

    2015-11-01

    In the USA, 5.7 million Americans ≥20 years have heart failure (HF) and heart failure preserved ejection fraction (HFpEF) accounts for at least 50 % of all hospital admissions for HF. HFpEF has no single guideline for diagnosis or treatment, the patient population is heterogeneously and inconsistently described, and longitudinal studies are lacking. The primary aims of this manuscript were to present an integrated review of the current state of the science on HFpEF, demonstrate gaps in the literature and provide the rationale for the design and implementation of future research to yield insights into the syndrome of HFpEF. The scientific literature was comprehensively reviewed on HFpEF pathophysiology, patient characteristics, diagnostic criteria, echocardiography biomarkers, treatment approaches and outcomes. Discrepancies in patient characteristics, diagnostic criteria, study methods and echocardiographic biomarkers were identified. This review indicates that no single test or guideline exists for diagnosis or treatment for HFpEF; heterogeneity of the population is complicated by multiple comorbidities that factor into etiology, race and age are likely important factors that define the phenotype, and limited information is available that designates early markers of impending HFpEF. Studies designed and adequately powered to study the impact of race and age along with consistent use of HFpEF diagnostic criteria are critically needed to further incident HFpEF research.

  16. Prognostic value of right ventricular ejection fraction in pulmonary arterial hypertension.

    PubMed

    Courand, Pierre-Yves; Pina Jomir, Géraldine; Khouatra, Chahéra; Scheiber, Christian; Turquier, Ségolène; Glérant, Jean-Charles; Mastroianni, Bénédicte; Gentil, Béatrice; Blanchet-Legens, Anne-Sophie; Dib, Alfred; Derumeaux, Geneviève; Humbert, Marc; Mornex, Jean-François; Cordier, Jean-François; Cottin, Vincent

    2015-01-01

    Right ventricle ejection fraction (RVEF) evaluated with magnetic resonance imaging is a strong determinant of patient outcomes in pulmonary arterial hypertension. We evaluated the prognostic value of RVEF assessed with conventional planar equilibrium radionuclide angiography at baseline and change 3-6 months after initiating pulmonary arterial hypertension-specific therapy. In a prospective cohort of newly diagnosed patients with idiopathic, heritable or anorexigen-associated pulmonary arterial hypertension, RVEF was measured at baseline (n=100) and 3-6 months after initiation of therapy (n=78). After a median follow-up of 4.1 years, 41 deaths occurred, including 35 from cardiovascular causes. Patients with a (median) baseline RVEF >25% had better survival than those with a RVEF <25% using Kaplan-Meier analysis (p=0.010). RVEF at baseline was an independent predictor of all-cause and cardiovascular mortality in adjusted Cox regression model (p=0.002 and p=0.007, respectively; HR 0.93 for both). Patients with stable or increased RVEF at 3-6 months had a trend for improved all-cause survival (HR 2.43, p=0.086) and had less cardiovascular mortality (HR 3.25, p=0.034) than those in whom RVEF decreased despite therapy. RVEF assessed with conventional planar equilibrium radionuclide angiography at baseline and change in RVEF 3-6 months after therapy initiation independently predict outcomes in patients with pulmonary arterial hypertension.

  17. Precision Medicine for Heart Failure with Preserved Ejection Fraction: An Overview.

    PubMed

    Shah, Sanjiv J

    2017-06-01

    There are few proven therapies for heart failure with preserved ejection fraction (HFpEF). The lack of therapies, along with increased recognition of the disorder and its underlying pathophysiology, has led to the acknowledgement that HFpEF is heterogeneous and is not likely to respond to a one-size-fits-all approach. Thus, HFpEF is a prime candidate to benefit from a precision medicine approach. For this reason, we have assembled a compendium of papers on the topic of precision medicine in HFpEF in the Journal of Cardiovascular Translational Research. These papers cover a variety of topics relevant to precision medicine in HFpEF, including automated identification of HFpEF patients; machine learning, novel molecular approaches, genomics, and deep phenotyping of HFpEF; and clinical trial designs that can be used to advance precision medicine in HFpEF. In this introductory article, we provide an overview of precision medicine in HFpEF with the hope that the work described here and in the other papers in this special theme issue will stimulate investigators and clinicians to advance a more targeted approach to HFpEF classification and treatment.

  18. Update of treatment of heart failure with reduction of left ventricular ejection fraction

    PubMed Central

    2016-01-01

    Underlying and precipitating causes of heart failure (HF) with reduced left ventricular ejection fraction (HFrEF) should be identified and treated when possible. Hypertension should be treated with diuretics, angiotensin-converting enzyme (ACE) inhibitors, and β-blockers. Diuretics are the first-line drugs in the treatment of patients with HFrEF and volume overload. Angiotensin-converting enzyme inhibitors and β-blockers (carvedilol, sustained-release metoprolol succinate, or bisoprolol) should be used in treatment of HFrEF. Use an angiotensin II receptor blocker (ARB) (candesartan or valsartan) if intolerant to ACE inhibitors because of cough or angioneurotic edema. Sacubitril/valsartan may be used instead of an ACE inhibitor or ARB in patients with chronic symptomatic HFrEF class II or III to further reduce morbidity and mortality. Add an aldosterone antagonist (spironolactone or eplerenone) in selected patients with class II–IV HF who can be carefully monitored for renal function and potassium concentration. (Serum creatinine should be ≤ 2.5 mg/dl in men and ≤ 2.0 mg/dl in women. Serum potassium should be < 5.0 mEq/l). Add isosorbide dinitrate plus hydralazine in patients self-described as African Americans with class II–IV HF being treated with diuretics, ACE inhibitors, and β-blockers. Ivabradine can be used in selected patients with HFrEF.

  19. [Sacubitril/valsartan, a new and effective treatment for heart failure with reduced ejection fraction].

    PubMed

    Senni, Michele; Trimarco, Bruno; Emdin, Michele; De Biase, Luciano

    2017-01-01

    Despite significant therapeutic advances, patients with chronic heart failure and reduced ejection fraction (HFrEF) remain at high risk for heart failure progression and death. The PARADIGM-HF study, the largest outcome trial in HFrEF, has shown improved cardiovascular outcomes with sacubitril/valsartan (Entresto®, Novartis), previously known as LCZ696, compared with angiotensin-converting enzyme (ACE) inhibitor therapy, possibly leading us to a new era for heart failure treatment. Sacubitril/valsartan represents a first-in-class drug acting through inhibition of angiotensin receptor and neprilysin, thus modulating the renin-angiotensin-aldosterone system and vasoactive substances such as natriuretic peptides. This approach can be considered a "paradigm shift" from neurohumoral inhibition to neurohumoral modulation. Based on the PARADIGM-HF results, the European Society of Cardiology and the American Heart Association/American College of Cardiology guidelines proposed a substitution of ACE-inhibitor/angiotensin receptor blocker therapy rather than an "add-on" strategy in HFrEF. Sacubitril/valsartan can be considered a milestone in cardiovascular therapy, like aspirin, statins, beta-blockers. Of course there are many questions that arise spontaneously from this trial, three recognized experts can help us to answer them.

  20. The challenge of frailty and sarcopenia in heart failure with preserved ejection fraction.

    PubMed

    Kinugasa, Yoshiharu; Yamamoto, Kazuhiro

    2017-02-01

    Frailty is a clinical state in which there is an increase in an individual's vulnerability for developing increased dependency and/or mortality when exposed to stressors. Frailty is often accompanied by heart failure with preserved ejection fraction (HFpEF), and frailty is likely to affect its clinical features and outcomes. Frail patients with HFpEF are frequently associated with sarcopenia (ie, muscle loss and weakness), which is a major component of the pathophysiology of frailty. Sarcopenia is a systemic skeletal muscle disease that impairs the function of limb skeletal muscles, as well as respiratory muscles, and this results in further functional decline. In addition, sarcopenia may contribute to cardiovascular remodelling and dysfunction, leading to the development of HFpEF through several metabolic and endocrine abnormalities. Although there is no established strategy for frail patients with HFpEF, a multidisciplinary approach, including various types of muscular training and nutritional intervention, may provide beneficial effects for these patients. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

  1. Tensor Factorization for Precision Medicine in Heart Failure with Preserved Ejection Fraction.

    PubMed

    Luo, Yuan; Ahmad, Faraz S; Shah, Sanjiv J

    2017-01-23

    Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous clinical syndrome that may benefit from improved subtyping in order to better characterize its pathophysiology and to develop novel targeted therapies. The United States Precision Medicine Initiative comes amid the rapid growth in quantity and modality of clinical data for HFpEF patients ranging from deep phenotypic to trans-omic data. Tensor factorization, a form of machine learning, allows for the integration of multiple data modalities to derive clinically relevant HFpEF subtypes that may have significant differences in underlying pathophysiology and differential response to therapies. Tensor factorization also allows for better interpretability by supporting dimensionality reduction and identifying latent groups of data for meaningful summarization of both features and disease outcomes. In this narrative review, we analyze the modest literature on the application of tensor factorization to related biomedical fields including genotyping and phenotyping. Based on the cited work including work of our own, we suggest multiple tensor factorization formulations capable of integrating the deep phenotypic and trans-omic modalities of data for HFpEF, or accounting for interactions between genetic variants at different omic hierarchies. We encourage extensive experimental studies to tackle challenges in applying tensor factorization for precision medicine in HFpEF, including effectively incorporating existing medical knowledge, properly accounting for uncertainty, and efficiently enforcing sparsity for better interpretability.

  2. Electrophysiologic testing guided risk stratification approach for sudden cardiac death beyond the left ventricular ejection fraction.

    PubMed

    Gatzoulis, Konstantinos A; Tsiachris, Dimitris; Arsenos, Petros; Tousoulis, Dimitris

    2016-01-26

    Sudden cardiac death threats ischaemic and dilated cardiomyopathy patients. Anti- arrhythmic protection may be provided to these patients with implanted cardiac defibrillators (ICD), after an efficient risk stratification approach. The proposed risk stratifier of an impaired left ventricular ejection fraction has limited sensitivity meaning that a significant number of victims will remain undetectable by this risk stratification approach because they have a preserved left ventricular systolic function. Current risk stratification strategies focus on combinations of non invasive methods like T wave alternans, late potentials, heart rate turbulence, deceleration capacity and others, with invasive methods like the electrophysiologic study. In the presence of an electrically impaired substrate with formed post myocardial infarction fibrotic zones, programmed ventricular stimulation provides important prognostic information for the selection of the patients expected to benefit from an ICD implantation, while due to its high negative predictive value, patients at low risk level may also be detected. Clustering evidence from different research groups and electrophysiologic labs support an electrophysiologic testing guided risk stratification approach for sudden cardiac death.

  3. Determination of right ventricular ejection fraction in children with cystic fibrosis, using krypton-81m

    SciTech Connect

    Piepsz, A.; Ham, H.R.; Millet, E.; Dab, I.

    1984-01-01

    The diagnosis of cor pulmonale and incipient heart failure remains difficult to assess in cystic fibrosis (CF) on the basis of the clinical as well as the biological parameters. The measurement of the right ventricular ejection fraction has been facilitated these last years by the introduction of the radionuclide methods. Methodological difficulties are however encountered when Tc-99m RBC are used, and are mainly related to heart chambers superposition (equilibrium method) or the low count density (first pass method). Few papers have been published on RVEF in cystic fibrosis and the results are somewhat contradictory. The authors have recently introduced a new method for the determination of RVEF, using equilibrium study during continuous injection of Kr-81m in glucose solution. This method offers several advantages related to an increased accuracy and a favorable dosimetry. In 25 patients aged 2 to 23 years with CF, one or more RVEF studies were performed. The severity of the disease was evaluated on the basis of the clinical Schwachman score, the lung function tests, the ventilation scan and the pa02. RVEF tended to decrease with the progression of the lung disease, although, owing to the spread of the results, no RVEF could be predicted on the basis of the other parameters. The decrease of RVEF in patients with advanced lung disease was moderate and terminal lung disease was sometimes associated with normal right heart contractility.

  4. Mineralocorticoid receptor antagonists for heart failure with reduced ejection fraction: integrating evidence into clinical practice.

    PubMed

    Zannad, Faiez; Gattis Stough, Wendy; Rossignol, Patrick; Bauersachs, Johann; McMurray, John J V; Swedberg, Karl; Struthers, Allan D; Voors, Adriaan A; Ruilope, Luis M; Bakris, George L; O'Connor, Christopher M; Gheorghiade, Mihai; Mentz, Robert J; Cohen-Solal, Alain; Maggioni, Aldo P; Beygui, Farzin; Filippatos, Gerasimos S; Massy, Ziad A; Pathak, Atul; Piña, Ileana L; Sabbah, Hani N; Sica, Domenic A; Tavazzi, Luigi; Pitt, Bertram

    2012-11-01

    Mineralocorticoid receptor antagonists (MRAs) improve survival and reduce morbidity in patients with heart failure, reduced ejection fraction (HF-REF), and mild-to-severe symptoms, and in patients with left ventricular systolic dysfunction and heart failure after acute myocardial infarction. These clinical benefits are observed in addition to those of angiotensin converting enzyme inhibitors or angiotensin receptor blockers and beta-blockers. The morbidity and mortality benefits of MRAs may be mediated by several proposed actions, including antifibrotic mechanisms that slow heart failure progression, prevent or reverse cardiac remodelling, or reduce arrhythmogenesis. Both eplerenone and spironolactone have demonstrated survival benefits in individual clinical trials. Pharmacologic differences exist between the drugs, which may be relevant for therapeutic decision making in individual patients. Although serious hyperkalaemia events were reported in the major MRA clinical trials, these risks can be mitigated through appropriate patient selection, dose selection, patient education, monitoring, and follow-up. When used appropriately, MRAs significantly improve outcomes across the spectrum of patients with HF-REF.

  5. The aortic ejection fraction: A new technique for diagnosing aortic insufficiency

    SciTech Connect

    Kantor, J.C.; Siegel, M.E.; Colletti, P.; McKay, C.; Lee, K.; Halls, J.; Jacobs, L.; Yamauchi, D.; Rahimtoola, S.

    1984-01-01

    Pulsations of the ascending aorta during fluoroscopy in patients (pts) with aortic insufficiency (AI) have been described. The authors observed a similar phenomenon in pts undergoing scintiangiography who have documented AI. This paper describes a technique to validate and quantitate this observation. The authors studied 17 patients with AI documented by cardiac catheterization and 14 subjects of a demographically matched control group with no evidence of AI. First pass studies were acquired in the RAO 15/sup 0/ projection after a bolus of 20 mCi of Tc-99m pertechnetate. After framing, identical ROI's were placed over the proximal aorta during systole and diastole excluding activity of the pulmonary arteries and/or atria. An aortic ejection fraction (AEF) was determined. The calculated AEF data was correlated with the presence or absence of AI. The mean AEF from the group of 17 patients was 26.9 +- 7.0, while the mean for the non AI group was 12.0 +- 6.5. These are statistically different at the P < .01 level. An AEF of 18 optimally separates the 2 groups with a sensitivity, specificity, and accuracy of 88%, 86%, and 87% respectively. Preliminary data demonstrates a mean reduction in AEF of 14.6 units in the AI patients who, to date, have undergone aortic valve replacement. Initial data suggests that this technique, using the AEF, may be able to identify patients with AI without the task of isolating the right ventricle.

  6. Validity of automated measurement of left ventricular ejection fraction and volume using the Philips EPIQ system.

    PubMed

    Hovnanians, Ninel; Win, Theresa; Makkiya, Mohammed; Zheng, Qi; Taub, Cynthia

    2017-10-10

    To assess the efficiency and reproducibility of automated measurements of left ventricular (LV) volumes and LV ejection fraction (LVEF) in comparison to manually traced biplane Simpson's method. This is a single-center prospective study. Apical four- and two-chamber views were acquired in patients in sinus rhythm. Two operators independently measured LV volumes and LVEF using biplane Simpson's method. In addition, the image analysis software a2DQ on the Philips EPIQ system was applied to automatically assess the LV volumes and LVEF. Time spent on each analysis, using both methods, was documented. Concordance of echocardiographic measures was evaluated using intraclass correlation (ICC) and Bland-Altman analysis. Manual tracing and automated measurement of LV volumes and LVEF were performed in 184 patients with a mean age of 67.3 ± 17.3 years and BMI 28.0 ± 6.8 kg/m(2) . ICC and Bland-Altman analysis showed good agreements between manual and automated methods measuring LVEF, end-systolic, and end-diastolic volumes. The average analysis time was significantly less using the automated method than manual tracing (116 vs 217 seconds/patient, P < .0001). Automated measurement using the novel image analysis software a2DQ on the Philips EPIQ system produced accurate, efficient, and reproducible assessment of LV volumes and LVEF compared with manual measurement. © 2017, Wiley Periodicals, Inc.

  7. Myocardial Hypertrophy and Its Role in Heart Failure with Preserved Ejection Fraction

    PubMed Central

    Heinzel, Frank R.; Hohendanner, Felix; Jin, Ge; Sedej, Simon; Edelmann, Frank

    2015-01-01

    Left ventricular hypertrophy (LVH) is the most common myocardial structural abnormality associated with heart failure with preserved ejection fraction (HFpEF). LVH is driven by neurohumoral activation, increased mechanical load and cytokines associated with arterial hypertension, chronic kidney disease, diabetes and other co-morbidities. Here we discuss the experimental and clinical evidence that links LVH to diastolic dysfunction and qualifies LVH as one diagnostic marker for HFpEF. Mechanisms leading to diastolic dysfunction in LVH are incompletely understood but may include extracellular matrix changes, vascular dysfunction as well as altered cardiomyocyte mechano-elastical properties. Beating cardiomyocytes from HFpEF patients have not yet been studied, but we and others have shown increased Ca2+ turnover and impaired relaxation in cardiomyocytes from hypertrophied hearts. Structural myocardial remodeling can lead to heterogeneity in regional myocardial contractile function, which contributes to diastolic dysfunction in HFpEF. In the clinical setting of patients with compound co-morbidities, diastolic dysfunction may occur independently of LVH. This may be one explanation why current approaches to reduce LVH have not been effective to improve symptoms and prognosis in HFpEF. Exercise training on the other hand, in clinical trials improved exercise tolerance and diastolic function but did not reduce LVH. Thus, current clinical evidence does not support regression of LVH as a surrogate marker for (short-term) improvement of HFpEF. PMID:26183480

  8. Extraction of left ventricular ejection fraction information from various types of clinical reports.

    PubMed

    Kim, Youngjun; Garvin, Jennifer H; Goldstein, Mary K; Hwang, Tammy S; Redd, Andrew; Bolton, Dan; Heidenreich, Paul A; Meystre, Stéphane M

    2017-03-01

    Efforts to improve the treatment of congestive heart failure, a common and serious medical condition, include the use of quality measures to assess guideline-concordant care. The goal of this study is to identify left ventricular ejection fraction (LVEF) information from various types of clinical notes, and to then use this information for heart failure quality measurement. We analyzed the annotation differences between a new corpus of clinical notes from the Echocardiography, Radiology, and Text Integrated Utility package and other corpora annotated for natural language processing (NLP) research in the Department of Veterans Affairs. These reports contain varying degrees of structure. To examine whether existing LVEF extraction modules we developed in prior research improve the accuracy of LVEF information extraction from the new corpus, we created two sequence-tagging NLP modules trained with a new data set, with or without predictions from the existing LVEF extraction modules. We also conducted a set of experiments to examine the impact of training data size on information extraction accuracy. We found that less training data is needed when reports are highly structured, and that combining predictions from existing LVEF extraction modules improves information extraction when reports have less structured formats and a rich set of vocabulary.

  9. Sarcopenic Obesity and the Pathogenesis of Exercise Intolerance in Heart Failure With Preserved Ejection Fraction

    PubMed Central

    Upadhya, Bharathi; Haykowsky, Mark J.; Eggebeen, Joel; Kitzman, Dalane W.

    2016-01-01

    Heart failure with preserved ejection fraction (HFpEF) is the most common form of heart failure (HF) in older adults. The primary chronic symptom in patients with HFpEF, even when well compensated, is severe exercise intolerance. Cardiac and peripheral functions contribute equally to exercise intolerance in HFpEF, though the latter has been the focus of fewer studies. Of note, multiple studies with exercise training have shown that exercise intolerance can improve significantly in the absence of improvements in exercise cardiac output, indicating a role of peripheral, non-cardiac adaptations. In addition, clinical drug trials performed to date in HFpEF, all of which have focused on influencing cardiovascular function, have not been positive on primary clinical outcomes and most have not improved exercise capacity. Mounting evidence indicates that sarcopenic obesity, characterized by the coexistence of excess fat mass and decreased muscle mass, could contribute to the pathophysiology of exercise intolerance in older HFpEF patients and may provide avenues for novel treatments. PMID:25750186

  10. Exercise intolerance in heart failure with preserved ejection fraction: more than a heart problem

    PubMed Central

    Upadhya, Bharathi; Haykowsky, Mark J; Eggebeen, Joel; Kitzman, Dalane W

    2015-01-01

    Heart failure (HF) with preserved ejection fraction (HFpEF) is the most common form of HF in older adults, and is increasing in prevalence as the population ages. Furthermore, HFpEF is increasing out of proportion to HF with reduced EF (HFrEF), and its prognosis is worsening while that of HFrEF is improving. Despite the importance of HFpEF, our understanding of its pathophysiology is incomplete, and optimal treatment remains largely undefined. A cardinal feature of HFpEF is reduced exercise tolerance, which correlates with symptoms as well as reduced quality of life. The traditional concepts of exercise limitations have focused on central dysfunction related to poor cardiac pump function. However, the mechanisms are not exclusive to the heart and lungs, and the understanding of the pathophysiology of this disease has evolved. Substantial attention has focused on defining the central versus peripheral mechanisms underlying the reduced functional capacity and exercise tolerance among patients with HF. In fact, physical training can improve exercise tolerance via peripheral adaptive mechanisms even in the absence of favorable central hemodynamic function. In addition, the drug trials performed to date in HFpEF that have focused on influencing cardiovascular function have not improved exercise capacity. This suggests that peripheral limitations may play a significant role in HF limiting exercise tolerance, a hallmark feature of HFpEF. PMID:26089855

  11. Noncardiac Comorbidities in Heart Failure With Reduced Versus Preserved Ejection Fraction

    PubMed Central

    Mentz, Robert J.; Kelly, Jacob P.; von Lueder, Thomas G.; Voors, Adriaan A.; Lam, Carolyn S. P.; Cowie, Martin R.; Kjeldsen, Keld; Jankowska, Ewa A.; Atar, Dan; Butler, Javed; Fiuzat, Mona; Zannad, Faiez; Pitt, Bertram; O’Connor, Christopher M.

    2014-01-01

    Heart failure patients are classified by ejection fraction (EF) into distinct groups: heart failure with preserved EF (HFpEF) or heart failure with reduced EF (HFrEF). Although patients with heart failure commonly have multiple comorbidities that complicate management and may adversely affect outcomes, their role in the HFpEF and HFrEF groups is not well-characterized. This review summarizes the role of noncardiac comorbidities in patients with HFpEF versus HFrEF, emphasizing prevalence, underlying pathophysiologic mechanisms, and outcomes. Pulmonary disease, diabetes mellitus, anemia, and obesity tend to be more prevalent in HFpEF patients, but renal disease and sleep-disordered breathing burdens are similar. These comorbidities similarly increase morbidity and mortality risk in HFpEF and HFrEF patients. Common pathophysiologic mechanisms include systemic and endomyocardial inflammation with fibrosis. We also discuss implications for clinical care and future HF clinical trial design. The basis for this review was discussions between scientists, clinical trialists, and regulatory representatives at the 10th Global CardioVascular Clinical Trialists Forum. PMID:25456761

  12. A comparison of visual and quantitative assessment of left ventricular ejection fraction by cardiac magnetic resonance.

    PubMed

    Holloway, Cameron J; Edwards, Lindsay M; Rider, Oliver J; Fast, Angela; Clarke, Kieran; Francis, Jane M; Myerson, Saul G; Neubauer, Stefan

    2011-04-01

    To determine the accuracy of visual analysis of left ventricular (LV) function in comparison with the accepted quantitative gold standard method, cardiac magnetic resonance (CMR). Cine CMR imaging was performed at 1.5 T on 44 patients with a range of ejection fractions (EF, 5-80%). Clinicians (n = 18) were asked to visually assess EF after sequentially being shown cine images of a four chamber (horizontal long axis; HLA), two chamber (vertical long axis; VLA) and a short axis stack (SAS) and results were compared to a commercially available analysis package. There were strong correlations between visual and quantitative assessment. However, the EF was underestimated in all categories (by 8.4% for HLA, 8.4% for HLA + VLA and 7.9% for HLA + VLA + SAS, P all < 0.01) and particularly underestimated in mild LV impairment (17.4%, P < 0.01), less so for moderate (4.9%) and not for severe impairment (1%). Assessing more than one view of the heart improved visual assessment of LV, EF, however, clinicians underestimated EF by 8.4% on average, with particular inaccuracy in those with mild dysfunction. Given the important clinical information provided by LV assessment, quantitative analysis is recommended for accurate assessment.

  13. Myocardial hypertrophy and its role in heart failure with preserved ejection fraction.

    PubMed

    Heinzel, Frank R; Hohendanner, Felix; Jin, Ge; Sedej, Simon; Edelmann, Frank

    2015-11-15

    Left ventricular hypertrophy (LVH) is the most common myocardial structural abnormality associated with heart failure with preserved ejection fraction (HFpEF). LVH is driven by neurohumoral activation, increased mechanical load, and cytokines associated with arterial hypertension, chronic kidney disease, diabetes, and other comorbidities. Here we discuss the experimental and clinical evidence that links LVH to diastolic dysfunction and qualifies LVH as one diagnostic marker for HFpEF. Mechanisms leading to diastolic dysfunction in LVH are incompletely understood, but may include extracellular matrix changes, vascular dysfunction, as well as altered cardiomyocyte mechano-elastical properties. Beating cardiomyocytes from HFpEF patients have not yet been studied, but we and others have shown increased Ca(2+) turnover and impaired relaxation in cardiomyocytes from hypertrophied hearts. Structural myocardial remodeling can lead to heterogeneity in regional myocardial contractile function, which contributes to diastolic dysfunction in HFpEF. In the clinical setting of patients with compound comorbidities, diastolic dysfunction may occur independently of LVH. This may be one explanation why current approaches to reduce LVH have not been effective to improve symptoms and prognosis in HFpEF. Exercise training, on the other hand, in clinical trials improved exercise tolerance and diastolic function, but did not reduce LVH. Thus current clinical evidence does not support regression of LVH as a surrogate marker for (short-term) improvement of HFpEF.

  14. Expression of epicardial adipose tissue thermogenic genes in patients with reduced and preserved ejection fraction heart failure.

    PubMed

    Pérez-Belmonte, Luis M; Moreno-Santos, Inmaculada; Gómez-Doblas, Juan J; García-Pinilla, José M; Morcillo-Hidalgo, Luis; Garrido-Sánchez, Lourdes; Santiago-Fernández, Concepción; Crespo-Leiro, María G; Carrasco-Chinchilla, Fernando; Sánchez-Fernández, Pedro L; de Teresa-Galván, Eduardo; Jiménez-Navarro, Manuel

    2017-01-01

    Epicardial adipose tissue has been proposed to participate in the pathogenesis of heart failure. The aim of our study was to assess the expression of thermogenic genes (Uncoupling protein 1 (UCP1), peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1α), and PR-domain-missing 16 (PRDM16) in epicardial adipose tissue in patients with heart failure, stablishing the difference according to left ventricular ejection fraction (reduced or preserved). Among the 75 patients in our study, 42.7% (n=32) had reduced left ventricular ejection fraction. UCP1, PGC1α and PRDM16 mRNA in EAT were significantly lower in patients with reduced left ventricular ejection fraction. Multiple regression analysis showed that age, male gender, body max index, presence of obesity, type-2-diabetes mellitus, hypertension and coronary artery disease and left ventricular ejection fraction were associated with the expression levels of UCP1, PGC1α and PRDM16 mRNA. Thermogenic genes expressions in epicardial adipose tissue (UCP1: OR 0.617, 95%CI 0.103-0.989, p=0.042; PGC1α: OR 0.416, 95%CI 0.171-0.912, p=0.031; PRDM16: OR 0.643, 95%CI 0.116-0.997, p=0.044) were showed as protective factors against the presence of heart failure with reduced left ventricular ejection fraction, and age (OR 1.643, 95%CI 1.001-3.143, p=0.026), presence of coronary artery disease (OR 6.743, 95%CI 1.932-15.301, p<0.001) and type-2-diabetes mellitus (OR 4.031, 95%CI 1.099-7.231, p<0.001) were associated as risk factors. The adequate expression of thermogenic genes has been shown as possible protective factors against heart failure with reduced ejection fraction, suggesting that a loss of functional epicardial adipose tissue brown-like features would participate in a deleterious manner on heart metabolism. Thermogenic genes could represent a future novel therapeutic target in heart failure.

  15. Expression of epicardial adipose tissue thermogenic genes in patients with reduced and preserved ejection fraction heart failure

    PubMed Central

    Pérez-Belmonte, Luis M.; Moreno-Santos, Inmaculada; Gómez-Doblas, Juan J.; García-Pinilla, José M.; Morcillo-Hidalgo, Luis; Garrido-Sánchez, Lourdes; Santiago-Fernández, Concepción; Crespo-Leiro, María G.; Carrasco-Chinchilla, Fernando; Sánchez-Fernández, Pedro L.; de Teresa-Galván, Eduardo; Jiménez-Navarro, Manuel

    2017-01-01

    Epicardial adipose tissue has been proposed to participate in the pathogenesis of heart failure. The aim of our study was to assess the expression of thermogenic genes (Uncoupling protein 1 (UCP1), peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1α), and PR-domain-missing 16 (PRDM16) in epicardial adipose tissue in patients with heart failure, stablishing the difference according to left ventricular ejection fraction (reduced or preserved). Among the 75 patients in our study, 42.7% (n=32) had reduced left ventricular ejection fraction. UCP1, PGC1α and PRDM16 mRNA in EAT were significantly lower in patients with reduced left ventricular ejection fraction. Multiple regression analysis showed that age, male gender, body max index, presence of obesity, type-2-diabetes mellitus, hypertension and coronary artery disease and left ventricular ejection fraction were associated with the expression levels of UCP1, PGC1α and PRDM16 mRNA. Thermogenic genes expressions in epicardial adipose tissue (UCP1: OR 0.617, 95%CI 0.103-0.989, p=0.042; PGC1α: OR 0.416, 95%CI 0.171-0.912, p=0.031; PRDM16: OR 0.643, 95%CI 0.116-0.997, p=0.044) were showed as protective factors against the presence of heart failure with reduced left ventricular ejection fraction, and age (OR 1.643, 95%CI 1.001-3.143, p=0.026), presence of coronary artery disease (OR 6.743, 95%CI 1.932-15.301, p<0.001) and type-2-diabetes mellitus (OR 4.031, 95%CI 1.099-7.231, p<0.001) were associated as risk factors. The adequate expression of thermogenic genes has been shown as possible protective factors against heart failure with reduced ejection fraction, suggesting that a loss of functional epicardial adipose tissue brown-like features would participate in a deleterious manner on heart metabolism. Thermogenic genes could represent a future novel therapeutic target in heart failure. PMID:28824327

  16. [Obtaining protein fractions from commercial sesame cakes (Sesamum indicum)].

    PubMed

    Guerra, M J; Jaffe, W G; Sangronis, E

    1984-09-01

    Sesame press cake represents an important potential protein source for human consumption. Some of the limiting factors are its high crude fiber content, oxalic acid content, and its bitter taste. By fractionation of solvent-extracted sesame meal, several preparations were obtained which were analyzed for their nutrient content, protein utilization and digestibility. PER values were low, and supplementation with lysine, skim-milk powder, soymeal or fish meal, improved the PER values considerably. Based on these findings, formulas for use as a protein supplement for children are presented.

  17. Arterial Stiffness and Risk of Overall Heart Failure, Heart Failure With Preserved Ejection Fraction, and Heart Failure With Reduced Ejection Fraction: The Health ABC Study (Health, Aging, and Body Composition).

    PubMed

    Pandey, Ambarish; Khan, Hassan; Newman, Anne B; Lakatta, Edward G; Forman, Daniel E; Butler, Javed; Berry, Jarett D

    2017-02-01

    Higher arterial stiffness is associated with increased risk of atherosclerotic events. However, its contribution toward risk of heart failure (HF) and its subtypes, HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF), independent of other risk factors is not well established. In this study, we included Health ABC study (Health, Aging, and Body Composition) participants without prevalent HF who had arterial stiffness measured as carotid-femoral pulse wave velocity (cf-PWV) at baseline (n=2290). Adjusted Cox-proportional hazards models were constructed to determine the association between continuous and data-derived categorical measures (tertiles) of cf-PWV and incidence of HF and its subtypes (HFpEF [ejection fraction >45%] and HFrEF [ejection fraction ≤45%]). We observed 390 HF events (162 HFpEF and 145 HFrEF events) over 11.4 years of follow-up. In adjusted analysis, higher cf-PWV was associated with greater risk of HF after adjustment for age, sex, ethnicity, mean arterial pressure, and heart rate (hazard ratio [95% confidence interval] for cf-PWV tertile 3 versus tertile 1 [ref] =1.35 [1.05-1.73]). However, this association was not significant after additional adjustment for other cardiovascular risk factors (hazard ratio [95% confidence interval], 1.14 [0.88-1.47]). cf-PWV velocity was also not associated with risk of HFpEF and HFrEF after adjustment for potential confounders (most adjusted hazard ratio [95% confidence interval] for cf-PWV tertile 3 versus tertile 1 [ref]: HFpEF, 1.06 [0.72-1.56]; HFrEF, 1.28 [0.83-1.97]). In conclusion, arterial stiffness, as measured by cf-PWV, is not independently associated with risk of HF or its subtypes after adjustment for traditional cardiovascular risk factors. © 2016 American Heart Association, Inc.

  18. Sildenafil Treatment in Heart Failure With Preserved Ejection Fraction: Targeted Metabolomic Profiling in the RELAX Trial.

    PubMed

    Wang, Hanghang; Anstrom, Kevin; Ilkayeva, Olga; Muehlbauer, Michael J; Bain, James R; McNulty, Steven; Newgard, Christopher B; Kraus, William E; Hernandez, Adrian; Felker, G Michael; Redfield, Margaret; Shah, Svati H

    2017-08-01

    Phosphodiesterase-5 inhibition with sildenafil compared with a placebo had no effect on the exercise capacity or clinical status of patients with heart failure with preserved ejection fraction (HFpEF) in the PhosphodiesteRasE-5 Inhibition to Improve Clinical Status and Exercise Capacity in Diastolic Heart Failure with Preserved Ejection Fraction (RELAX) clinical trial. Metabolic impairments may explain the neutral results. To test the hypothesis that profiling metabolites in the RELAX trial would clarify the mechanisms of sildenafil effects and identify metabolites associated with clinical outcomes in HFpEF. Paired baseline and 24-week plasma samples of 160 stable outpatient individuals with HFpEF enrolled in the RELAX clinical trial were analyzed using flow injection tandem mass spectrometry (60 metabolites) and conventional assays (5 metabolites). Sildenafil (n = 79) or a placebo (n = 81) administered orally at 20 mg, 3 times daily for 12 weeks, followed by 60 mg, 3 times daily for 12 weeks. The primary measure was metabolite level changes between baseline and 24 weeks stratified by treatments. Secondary measures included correlations between metabolite level changes and clinical biomarkers and associations between baseline metabolite levels and the composite clinical score. No metabolites changed between baseline and 24 weeks in the group treated with a placebo; however, 7 metabolites changed in the group treated with sildenafil, including decreased amino acids (alanine and proline; median change [25th-75th], -38.26 [-100.3 to 28.19] and -28.24 [-56.29 to 12.08], respectively; false discovery rate-adjusted P = .01 and .03, respectively), and increased short-chain dicarboxylacylcarnitines glutaryl carnitine, octenedioyl carnitine, and adipoyl carnitine (median change, 6.19 [-3.37 to 14.18], 2.72 [-3 to 12.57], and 10.72 [-11.23 to 29.57], respectively; false discovery rate-adjusted P = .01, .04, and .05, respectively), and 1 long

  19. Hemodynamic responses to small muscle mass exercise in heart failure patients with reduced ejection fraction.

    PubMed

    Barrett-O'Keefe, Zachary; Lee, Joshua F; Berbert, Amanda; Witman, Melissa A H; Nativi-Nicolau, Jose; Stehlik, Josef; Richardson, Russell S; Wray, D Walter

    2014-11-15

    To better understand the mechanisms responsible for exercise intolerance in heart failure with reduced ejection fraction (HFrEF), the present study sought to evaluate the hemodynamic responses to small muscle mass exercise in this cohort. In 25 HFrEF patients (64 ± 2 yr) and 17 healthy, age-matched control subjects (64 ± 2 yr), mean arterial pressure (MAP), cardiac output (CO), and limb blood flow were examined during graded static-intermittent handgrip (HG) and dynamic single-leg knee-extensor (KE) exercise. During HG exercise, MAP increased similarly between groups. CO increased significantly (+1.3 ± 0.3 l/min) in the control group, but it remained unchanged across workloads in HFrEF patients. At 15% maximum voluntary contraction (MVC), forearm blood flow was similar between groups, while HFrEF patients exhibited an attenuated increase at the two highest intensities compared with controls, with the greatest difference at the highest workload (352 ± 22 vs. 492 ± 48 ml/min, HFrEF vs. control, 45% MVC). During KE exercise, MAP and CO increased similarly across work rates between groups. However, HFrEF patients exhibited a diminished leg hyperemic response across all work rates, with the most substantial decrement at the highest intensity (1,842 ± 64 vs. 2,675 ± 81 ml/min; HFrEF vs. control, 15 W). Together, these findings indicate a marked attenuation in exercising limb perfusion attributable to impairments in peripheral vasodilatory capacity during both arm and leg exercise in patients with HFrEF, which likely plays a role in limiting exercise capacity in this patient population.

  20. Plasma osmolality predicts mortality in patients with heart failure with reduced ejection fraction.

    PubMed

    Kaya, HakkI; Yücel, Oğuzhan; Ege, Meltem Refiker; Zorlu, Ali; Yücel, Hasan; Güneş, Hakan; Ekmekçi, Ahmet; Yılmaz, Mehmet Birhan

    2017-01-01

    Heart failure (HF) is a fatal disease. Plasma osmolality with individual impacts of sodium, blood urea nitrogen (BUN), and glucose has not been studied prognostically in patients with HF. This study aims to investigate the impact of serum osmolality on clinical endpoints in HF patients. A total of 509 patients (383 males, 126 females) with HF with reduced ejection fraction in three HF centres were retrospectively analysed between January 2007 and December 2013. Follow-up data were completed for 496 patients. Plasma osmolality was calculated as (2 × Na) + (BUN/2.8) + (Glucose/18). Quartiles of plasma osmolality were produced, and the possible relationship between plasma osmolality and cardiovascular mortality was investigated. The mean follow-up was 25 ± 22 months. The mean age was 56.5 ± 17.3 years with a mean EF of 26 ± 8%. The mean levels of plasma osmolality were as follows in the quartiles: 1st % = 280 ± 6, 2nd % = 288 ± 1, 3rd % = 293 ± 2 (95% confidence interval [CI] 292.72-293.3), and 4th % = 301 ± 5 mOsm/kg. The EF and B-type natriuretic peptide levels were similar in the four quartiles. Univariate and multivariate analyses in the Cox proportional hazard model revealed a significantly higher rate of mortality in the patients with hypo-osmolality. The Kaplan-Meier plot showed graded mortality curves with the 1st quartile having the worst prognosis, followed by the 4th quartile and the 2nd quartile, while the 3rd quartile was shown to have the best prognosis. Our study results suggest that normal plasma osmolality is between 275 and 295 mOsm/kg. However, being close to the upper limit of normal range (292-293 mOsm/kg) seems to be the optimal plasma osmolality level in terms of cardiovascular prognosis in patients with HF.

  1. Left ventricular ejection fraction response during exercise in asymptomatic systemic hypertension

    SciTech Connect

    Miller, D.D.; Ruddy, T.D.; Zusman, R.M.; Okada, R.D.; Strauss, H.W.; Kanarek, D.J.; Christensen, D.; Federman, E.B.; Boucher, C.A.

    1987-02-15

    To study the effect of mild-to-moderate elevations in diastolic blood pressure (BP) on systolic left ventricular (LV) function, 28 hypertensive patients and 20 normal subjects underwent upright exercise first-pass radionuclide angiography. All were asymptomatic, had normal rest and exercise electrocardiographic findings and no evidence of LV hypertrophy or coronary artery disease. LV function at rest was similar in the 2 groups, but with exercise hypertensive patients had a greater end-systolic volume (69 +/- 19 vs 51 +/- 19 ml, p less than 0.002) and lower ejection fraction (EF) (0.59 +/- 0.09 vs 0.72 +/- 0.07, p less than 0.0001), stroke volume (101 +/- 28 vs 130 +/- 36 ml, p less than 0.005) and peak oxygen uptake (23 +/- 7 vs 33 +/- 9 ml/kl/min, p less than 0.05). Hypertensive patients were separated into 3 groups: group 1-12 patients with an increase in EF with exercise greater than or equal to 0.05; group 2-7 patients with a change in EF with exercise less than 0.05; and group 3-9 patients with a decrease in EF with exercise greater than or equal to 0.05. Group 3 hypertensive patients were older, had a higher heart rate at rest and lower peak oxygen uptake. Rest LV function was similar in the 3 hypertensive subgroups, but exercise end-systolic volumes were higher in groups 2 and 3. Exercise thallium-201 images was normal in all but 1 of 14 hypertensive group 2 or 3 patients.

  2. Effect of Selective Heart Rate Slowing in Heart Failure With Preserved Ejection Fraction.

    PubMed

    Pal, Nikhil; Sivaswamy, Nadiya; Mahmod, Masliza; Yavari, Arash; Rudd, Amelia; Singh, Satnam; Dawson, Dana K; Francis, Jane M; Dwight, Jeremy S; Watkins, Hugh; Neubauer, Stefan; Frenneaux, Michael; Ashrafian, Houman

    2015-11-03

    Heart failure with preserved ejection fraction (HFpEF) is associated with significant morbidity and mortality but is currently refractory to therapy. Despite limited evidence, heart rate reduction has been advocated, on the basis of physiological considerations, as a therapeutic strategy in HFpEF. We tested the hypothesis that heart rate reduction improves exercise capacity in HFpEF. We conducted a randomized, crossover study comparing selective heart rate reduction with the If blocker ivabradine at 7.5 mg twice daily versus placebo for 2 weeks each in 22 symptomatic patients with HFpEF who had objective evidence of exercise limitation (peak oxygen consumption at maximal exercise [o2 peak] <80% predicted for age and sex). The result was compared with 22 similarly treated matched asymptomatic hypertensive volunteers. The primary end point was the change in o2 peak. Secondary outcomes included tissue Doppler-derived E/e' at echocardiography, plasma brain natriuretic peptide, and quality-of-life scores. Ivabradine significantly reduced peak heart rate compared with placebo in the HFpEF (107 versus 129 bpm; P<0.0001) and hypertensive (127 versus 145 bpm; P=0.003) cohorts. Ivabradine compared with placebo significantly worsened the change in o2 peak in the HFpEF cohort (-2.1 versus 0.9 mL·kg(-1)·min(-1); P=0.003) and significantly reduced submaximal exercise capacity, as determined by the oxygen uptake efficiency slope. No significant effects on the secondary end points were discernable. Our observations bring into question the value of heart rate reduction with ivabradine for improving symptoms in a HFpEF population characterized by exercise limitation. URL: http://www.clinicaltrials.gov. Unique identifier: NCT02354573. © 2015 The Authors.

  3. Fluid status and outcome in patients with heart failure and preserved ejection fraction.

    PubMed

    Koell, Benedikt; Zotter-Tufaro, Caroline; Duca, Franz; Kammerlander, Andreas A; Aschauer, Stefan; Dalos, Daniel; Antlanger, Marlies; Hecking, Manfred; Säemann, Marcus; Mascherbauer, Julia; Bonderman, Diana

    2017-03-01

    Most heart failure with preserved ejection fraction (HFpEF) patients, at some point, present to an emergency department with typical symptoms of volume overload. Clinically, most respond well to standard diuretic therapy, sometimes at the cost of renal function. The study sought to define the prognostic significance of fluid status versus renal function in patients with HFpEF. One hundred sixty-two consecutive patients with HFpEF were enrolled in our prospective registry. Twelve patients with clinically overt decompensation were excluded. Fluid status at baseline was determined by bioelectrical impedance spectroscopy. The primary outcome measure was a combined end point consisting of hospitalization for heart failure and/or death for cardiac reason. Mean age was 74.4±8.4years. Ninety-one (61%) patients were hypo- or normovolemic (relative fluid overload [Rel. FO] -0.7±5.7%) while 59 (39%) patients presented with fluid overload (Rel. FO 11.5±2.7%). During a median follow-up of 24.3months (interquartile range: 19.8-33.2), 34% of patients reached the combined end point. Multivariate Cox hazard analysis identified fluid overload (hazard ratio: 3.09; 95% confidence interval: 1.68-5.68; p<0.001) as an independent predictor of adverse outcome. Patients with fluid overload and normal renal function showed a worse event-free survival compared to the subgroup with normohydration and impaired renal function (log-rank: p=0.042). HFpEF patients with measurable fluid overload face a dismal prognosis as compared to euvolemic patients. Our data, while preliminary, suggest that patients with fluid overload may face a better outcome under continued fluid removal irrespective of changes in eGFR. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  4. Impact of Ejection Fraction and Aortic Valve Gradient on Outcomes of Transcatheter Aortic Valve Replacement

    PubMed Central

    Baron, Suzanne J.; Arnold, Suzanne V.; Herrmann, Howard C.; Holmes, David; Szeto, Wilson Y.; Allen, Keith B.; Chhatriwalla, Adnan K.; Vemulapali, Sreekaanth; O’Brien, Sean; Dai, Dadi; Cohen, David J.

    2017-01-01

    Background In patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), prior studies have suggested that reduced left ventricular ejection fraction (LVEF) and low aortic valve gradient (AVG) are associated with worse long-term outcomes. Since these conditions commonly coexist, the extent to which they are independently associated with outcomes after TAVR is unknown. Objectives To evaluate the impact of LVEF and AVG on clinical outcomes after TAVR and to determine whether the effect of AVG on outcomes is modified by LVEF. Methods Using data from 11,292 patients who underwent TAVR as part of the TVT Registry, we examined rates of 1-year mortality and recurrent heart failure in patients with varying levels of LV dysfunction (LVEF < 30% vs. 30–50% vs. > 50%) and AVG (< 40mmHg vs. ≥ 40mmHg). Multivariable models were used to estimate the independent effect of AVG and LVEF on outcomes. Results Over the first year of follow-up after TAVR, patients with LV dysfunction and low AVG had higher rates of death and recurrent heart failure. After adjustment for other clinical factors, only low AVG was associated with higher mortality (HR 1.21, 95% CI 1.11–1.32; p < 0.001) and higher rates of heart failure (HR 1.52; 95% CI 1.36–1.69; p < 0.001), whereas the effect of LVEF was no longer significant. There was no evidence of effect modification between AVG and LVEF with respect to either endpoint. Conclusion In this large series of real world patients undergoing TAVR, low AVG, but not LV dysfunction, was associated with higher rates of mortality and recurrent heart failure. Although these findings suggest that AVG should be considered when evaluating the risks and benefits of TAVR for individual patients, neither severe LV dysfunction nor low AVG alone or in combination provide sufficient prognostic discrimination to preclude treatment with TAVR. PMID:27199058

  5. Geometry as a Confounder When Assessing Ventricular Systolic Function: Comparison Between Ejection Fraction and Strain.

    PubMed

    Stokke, Thomas M; Hasselberg, Nina E; Smedsrud, Marit K; Sarvari, Sebastian I; Haugaa, Kristina H; Smiseth, Otto A; Edvardsen, Thor; Remme, Espen W

    2017-08-22

    Preserved left ventricular (LV) ejection fraction (EF) and reduced myocardial strain are reported in patients with hypertrophic cardiomyopathy, ischemic heart disease, diabetes mellitus, and more. The authors performed a combined mathematical and echocardiographic study to understand the inconsistencies between EF and strains. An analytical equation showing the relationship between EF and the 4 parameters, global longitudinal strain (GLS), global circumferential strain (GCS), wall thickness, and short-axis diameter, was derived from an elliptical LV model. The equation was validated by measuring the 4 parameters by echocardiography in 100 subjects with EF ranging from 16% to 72% and comparing model-predicted EF with measured EF. The effect of the different parameters on EF was explored in the model and compared with findings in the patients. Calculated EF had very good agreement with measured EF (r = 0.95). The model showed that GCS contributes more than twice as much to EF than GLS. A significant reduction of GLS could be compensated by a small increase of GCS or wall thickness or reduced diameter. The model further demonstrated how EF can be maintained in ventricles with increased wall thickness or reduced diameter, despite reductions in both longitudinal and circumferential shortening. This was consistent with similar EF in 20 control subjects and 20 hypertrophic cardiomyopathy patients with increased wall thickness and reductions in both circumferential and longitudinal shortening (all p < 0.01). Reduced deformation despite preserved EF can be explained through geometric factors. Due to geometric confounders, strain better reflects systolic function in patients with preserved EF. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

  6. Impaired skeletal muscle vasodilation during exercise in heart failure with preserved ejection fraction.

    PubMed

    Lee, Joshua F; Barrett-O'Keefe, Zachary; Nelson, Ashley D; Garten, Ryan S; Ryan, John J; Nativi-Nicolau, Jose N; Richardson, Russell S; Wray, D Walter

    2016-05-15

    Exercise intolerance is a hallmark symptom of heart failure patients with preserved ejection fraction (HFpEF), which may be related to an impaired ability to appropriately increase blood flow to the exercising muscle. We evaluated leg blood flow (LBF, ultrasound Doppler), heart rate (HR), stroke volume (SV), cardiac output (CO), and mean arterial blood pressure (MAP, photoplethysmography) during dynamic, single leg knee-extensor (KE) exercise in HFpEF patients (n=21; 68 ± 2 yrs) and healthy controls (n=20; 71 ± 2 yrs). HFpEF patients exhibited a marked attrition during KE exercise, with only 60% able to complete the exercise protocol. In participants who completed all exercise intensities (0-5-10-15 W; HFpEF, n=13; Controls, n=16), LBF was not different at 0 W and 5 W, but was 15-25% lower in HFpEF compared to controls at 10 W and 15 W (P<0.001). Likewise, leg vascular conductance (LVC), an index of vasodilation, was not different at 0 W and 5 W, but was 15-20% lower in HFpEF compared to controls at 10 W and 15 W (P<0.05). In contrast to these peripheral deficits, exercise-induced changes in central variables (HR, SV, CO), as well as MAP, were similar between groups. These data reveal a marked reduction in LBF and LVC in HFpEF patients during exercise that cannot be attributed to a disease-related alteration in central hemodynamics, suggesting that impaired vasodilation in the exercising skeletal muscle vasculature may play a key role in the exercise intolerance associated with this patient population. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  7. Biological factors and overestimation of left ventricular ejection fraction by gated SPECT.

    PubMed

    Oliveira, Marco Antônio Condé de; Duarte, Paulo Schiavom; Gonzalez, Maria Margarita C; Moises, Valdir Ambrósio; Alonso, Gilberto; Lima, Eduardo Vilaça; Smanio, Paola Emanuela; Martins, Luiz Roberto Fernandes; Oliveira, Carlos A R; Mastrocolla, Luiz Eduardo

    2008-05-01

    Some patients present an overestimated left ventricular ejection fraction (LVEF) on electrocardiogram-gated myocardial scintigraphy (gated SPECT). To establish the relationship between biological factors and overestimated LVEF. We selected 3838 patients who underwent gated SPECT between May 20, 2000 and September 16, 2005 with normal perfusion images and LVEF > or =50%. The following variables were analyzed: gender (29.4% females and 70.6% males), age (from 20 to 94 years - mean: 56 years), weight (from 33.5 to 150 kg - mean: 79.6 kg), height (from 138 to 220 cm - mean: 171 cm) and BMI (from 13.9 to 54 - mean: 27.2). In a subgroup of 1002 patients who underwent echocardiogram, the diastolic diameter (from 36 to 68 mm - mean 47.5 mm) and systolic diameter (from 22 to 41 mm - mean 29.8 mm) variables were included. The patients were divided into two groups: normal LVEF (< or =80%) and overestimated LVEF (>80%). The odds ratio (OR) for presenting an overestimated LVEF was calculated for each variable using logistic regression. The following odds ratios were found (p < 0.005): female gender OR = 3.585 (95%CI: 2.745 to 4.683), age in years OR = 1.020 (95%CI: 1.011 to 1.029) and height in cm OR = 0.893 (95%CI: 0.829 to 0.962). Weight and BMI were not significantly associated with LVEF (p>0.2). In the subgroup of 1002 patients, a statistically significant influence was found in overestimated LVEF values for the systolic diameter, gender and height variables. Although systolic diameter influences the overestimation of LVEF, the gender and height variables have an independent influence on LVEF overestimation by gated SPECT.

  8. Enhancing ejection fraction measurement through 4D respiratory motion compensation in cardiac PET imaging.

    PubMed

    Tang, Jing; Wang, Xinhui; Gao, Xiangzhen; Segars, Paul; Lodge, Martin; Rahmim, Arman

    2017-03-02

    ECG gated cardiac PET imaging measures functional parameters such as left ventricle (LV) ejection fraction (EF), providing diagnostic and prognostic information for management of patients with coronary artery disease (CAD). Respiratory motion degrades spatial resolution and affects the accuracy in measuring the LV volumes for EF calculation. The goal of this study is to systematically investigate the effect of respiratory motion correction on the estimation of end-diastolic volume (EDV), end-systolic volume (ESV), and EF, especially on the separation of normal and abnormal EFs. We developed a respiratory motion incorporated 4D PET image reconstruction technique which uses all gated-frame data to acquire a motion-suppressed image. Using the standard XCAT phantom and two individual-specific volunteer XCAT phantoms, we simulated dual-gated myocardial perfusion imaging data for normally and abnormally beating hearts. With and without respiratory motion correction, we measured the EDV, ESV, and EF from the cardiac gated reconstructed images. For all the phantoms, the estimated volumes increased and the biases significantly reduced with motion correction compared with those without. Furthermore, the improvement of ESV measurement in the abnormally beating heart led to better separation of normal and abnormal EFs. The simulation study demonstrated the significant effect of respiratory motion correction on cardiac imaging data with motion amplitude as small as 0.7 cm. The larger the motion amplitude the more improvement respiratory motion correction brought about on the measurement of EF. Using data-driven respiratory gating, we also demonstrated the effect of respiratory motion correction on estimation of the above functional parameters from list mode patient data. Respiratory motion correction is shown to improve the accuracy of EF measurement in clinical cardiac PET imaging.

  9. Long-Term Survival for Patients with Acute Decompensated Heart Failure According to Ejection Fraction Findings

    PubMed Central

    Coles, Andrew H.; Fisher, Kimberly; Darling, Chad; Yarzebski, Jorge; McManus, David D.; Gore, Joel M.; Lessard, Darleen; Goldberg, Robert J.

    2014-01-01

    Limited data exists about the long-term prognosis of patients with acute decompensated heart failure (ADHF) further stratified according to ejection fraction (EF) findings. The primary objective of this population-based observational study was to characterize and compare trends in long-term prognosis after an episode of ADHF across 3 EF strata. Hospital medical records were reviewed for 3,604 residents of the Worcester (MA) metropolitan area who were discharged after ADHF from all 11 medical centers in central Massachusetts during 1995, 2000, 2002, and 2004 and had EF measurements during their index hospitalization. The average age of this population was 75 years, the majority was white, and 44% were men. Approximately 49% of the population had preserved EF HF (HF-PEF) (≥50%), 37% had reduced EF HF (HF-REF) (<40%), and 14% had borderline EF HF (41-49%) (HF-BREF). Patients with HF-PEF experienced higher post discharge survival rates than patients with either HF-REF or HF-BREF at 1, 2, and 5-years after discharge from all central Massachusetts medical centers. While prognosis at 1-year after hospital discharge improved for all patient groups during the years under study, especially for those with HF-REF and HF-PEF, these encouraging trends declined with increasing duration of follow-up. In conclusion, although improvements in 1-year post-discharge survival were observed for patients in each of the 3 EF groups examined to varying degrees, the post-discharge prognosis of all patients with ADHF remains guarded. PMID:25092194

  10. Phenotype-Specific Treatment of Heart Failure With Preserved Ejection Fraction: A Multiorgan Roadmap.

    PubMed

    Shah, Sanjiv J; Kitzman, Dalane W; Borlaug, Barry A; van Heerebeek, Loek; Zile, Michael R; Kass, David A; Paulus, Walter J

    2016-07-05

    Heart failure (HF) with preserved ejection fraction (EF; HFpEF) accounts for 50% of HF cases, and its prevalence relative to HF with reduced EF continues to rise. In contrast to HF with reduced EF, large trials testing neurohumoral inhibition in HFpEF failed to reach a positive outcome. This failure was recently attributed to distinct systemic and myocardial signaling in HFpEF and to diversity of HFpEF phenotypes. In this review, an HFpEF treatment strategy is proposed that addresses HFpEF-specific signaling and phenotypic diversity. In HFpEF, extracardiac comorbidities such as metabolic risk, arterial hypertension, and renal insufficiency drive left ventricular remodeling and dysfunction through systemic inflammation and coronary microvascular endothelial dysfunction. The latter affects left ventricular diastolic dysfunction through macrophage infiltration, resulting in interstitial fibrosis, and through altered paracrine signaling to cardiomyocytes, which become hypertrophied and stiff because of low nitric oxide and cyclic guanosine monophosphate. Systemic inflammation also affects other organs such as lungs, skeletal muscle, and kidneys, leading, respectively, to pulmonary hypertension, muscle weakness, and sodium retention. Individual steps of these signaling cascades can be targeted by specific interventions: metabolic risk by caloric restriction, systemic inflammation by statins, pulmonary hypertension by phosphodiesterase 5 inhibitors, muscle weakness by exercise training, sodium retention by diuretics and monitoring devices, myocardial nitric oxide bioavailability by inorganic nitrate-nitrite, myocardial cyclic guanosine monophosphate content by neprilysin or phosphodiesterase 9 inhibition, and myocardial fibrosis by spironolactone. Because of phenotypic diversity in HFpEF, personalized therapeutic strategies are proposed, which are configured in a matrix with HFpEF presentations in the abscissa and HFpEF predispositions in the ordinate.

  11. Mineralocorticoid receptor antagonists in heart failure with preserved ejection fraction (HFpEF).

    PubMed

    Capuano, Annalisa; Scavone, Cristina; Vitale, Cristiana; Sportiello, Liberata; Rossi, Francesco; Rosano, Giuseppe M C; Coats, Andrew J Stewart

    2015-12-01

    The role of spironolactone and eplerenone in patients with Heart Failure with preserved Ejection Fraction (HFpEF) is not well defined. Since a growing medical literature has suggested that mineralocorticoid receptor antagonists may be beneficial for patients with HFpEF, this review gives an in-depth update on the role of spironolactone and eplerenone and their implications for therapy in the setting of HFpEF. Eleven clinical studies, including seven randomized trials, were reviewed. Two randomized controlled trials evaluated the effect of eplerenone on different end-points, including 6 minute walk distance (6 MWD), cardiovascular mortality, non-fatal reinfarction, hospitalization for unstable angina and congestive heart failure. Eplerenone did not affect either 6 MWD or event-free survival rates in the overall study population in these two reports. The effects of spironolactone on similar composite endpoints were evaluated in 7 studies in patients with HFpEF. Compared to placebo, hospitalization for heart failure was significantly lower in the spironolactone group and spironolactone was also shown to improve diastolic function and induced beneficial remodeling through a reduction in myocardial fibrosis. The safety profile of spironolactone and eplerenone has been assessed in two recent studies. Data showed that eplerenone and spironolactone are both associated with the occurrence of gynecomastia, mastodynia, and abnormal vaginal bleeding and in addition, they can increase natriuresis and cause renal retention of potassium; furthermore, eplerenone may cause hyperkalemia and promote the onset of metabolic acidosis or hyponatremia. In conclusion although the mineralocorticoid receptor antagonists eplerenone and spironolactone improve clinical outcomes in patients with HFrEF, additional data will be necessary to better define their risk-benefit profile, especially for eplerenone, in the treatment of HFpEF.

  12. PHENOTYPE-SPECIFIC TREATMENT OF HEART FAILURE WITH PRESERVED EJECTION FRACTION: A MULTIORGAN ROADMAP

    PubMed Central

    Shah, Sanjiv J; Kitzman, Dalane W; Borlaug, Barry A; van Heerebeek, Loek; Zile, Michael R.; Kass, David A.; Paulus, Walter J.

    2016-01-01

    Heart failure (HF) with preserved ejection fraction (EF) (HFpEF) accounts for 50% of HF cases and its prevalence relative to HF with reduced EF (HFrEF) continues to rise. In contrast to HFrEF, large trials testing neurohumoral inhibition in HFpEF failed to reach a positive outcome. This failure was recently attributed to distinct systemic and myocardial signaling in HFpEF and to diversity of HFpEF phenotypes. In this review, a HFpEF treatment strategy is proposed which addresses HFpEF-specific signaling and phenotypic diversity. In HFpEF, extracardiac comorbidities such as metabolic risk, arterial hypertension and renal insufficiency drive left ventricular (LV) remodeling and dysfunction through systemic inflammation and coronary microvascular endothelial dysfunction. The latter affects LV diastolic dysfunction through macrophage infiltration resulting in interstitial fibrosis and through altered paracrine signaling to cardiomyocytes, which become hypertrophied and stiff because of low nitric oxide (NO) and cyclic guanosine monophosphate (cGMP). Systemic inflammation also affects other organs such as lungs, skeletal muscle and kidneys leading respectively to pulmonary hypertension, muscle weakness and sodium retention. Individual steps of these signaling cascades can be targeted by specific interventions: metabolic risk by caloric restriction, systemic inflammation by statins, pulmonary hypertension by phosphodiesterase (PDE) 5 inhibitors, muscle weakness by exercise training, sodium retention by diuretics and monitoring devices, myocardial NO bioavailability by inorganic nitrate-nitrite, myocardial cGMP content by neprilysin or PDE 9 inhibition and myocardial fibrosis by spironolactone. Because of phenotypic diversity in HFpEF, personalized therapeutic strategies are proposed, which are configured in a matrix with HFpEF presentations in the abscissa and HFpEF predispositions in the ordinate. PMID:27358439

  13. Influence of atrial fibrillation on the mortality of patients with heart failure with preserved ejection fraction.

    PubMed

    Franco, Jonathan; Formiga, Francesc; Cepeda, Jose; Llacer, Pau; Arévalo-Lorido, Juan; Cerqueiro, Jose; González-Franco, Alvaro; Epelde, Francesc; Manzano, Luis; Montero Pérez-Barquero, Manuel

    2017-09-01

    The impact of atrial fibrillation (AF) on the prognosis of heart failure with preserved ejection fraction (HFpEF) is still the subject of debate. We analysed the influence of AF on the prognosis on mortality and readmission in patients with HFpEF. Prospective observational study in 1,971 patients with HFpEF, who were admitted for acute heart failure. Patients were divided into 2 groups according to the presence or absence of AF. We analysed mortality, readmissions and combined mortality/readmissions at one year follow-up. A total of 1,177 (59%) patients had AF, mean age 80.3 (7.8) years and 1,233 (63%) were women. Patients with HFpEF and AF were older, female, greater valvular aetiology and lower comorbidity measured by the Charlson index. At the one year follow-up, 430 (22%) patients had died and 840 (43%) had been readmitted. In the 2 groups analysed, there was no difference in all-cause mortality (22 vs. 21%; P=.739, AF vs. no-AF, respectively) or cardiovascular causes (9.6 vs. 8.2%; P=.739, AF vs. no-AF, respectively). In the multivariable analysis, factors associated with higher mortality were: age, male, valvular aetiology, uric acid, and comorbidity. In the analysis of the subgroup with HFpEF with AF, the presence of chronic AF compared to de novo AF was associated with higher mortality (HR 1,716; 95% CI 1,099-2,681; P=.018). In patients with HFpEF, the presence of AF is frequent. During the one-year follow-up, the presence of AF does not influence mortality or readmissions in patients with HFpEF. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

  14. Prognostic value of ejection fraction in patients admitted with acute coronary syndrome

    PubMed Central

    Perelshtein Brezinov, Olga; Klempfner, Robert; Zekry, Sagit Ben; Goldenberg, Ilan; Kuperstein, Rafael

    2017-01-01

    Abstract There are limited data regarding factors affecting outcomes among acute coronary syndrome (ACS) patients presenting with varying degrees of left ventricle (LV) dysfunction. We aimed to identify factors associated with mortality according to LV ejection fraction (LVEF) at 1st admission in ACS patients. A total of 8983 ACS patients prospectively enrolled in the Acute Coronary Syndrome Israeli Survey (2000–2010) were categorized according to their LVEF at admission: severe LV dysfunction (LVEF < 30% [n = 845]), mild-moderate LV dysfunction (LVEF 30%–49% [n = 4470]); preserved LV function (LVEF ≥ 50% [n = 3659]). Multivariable Cox proportional hazards regression modeling was used to assess the risk factors for 1-year mortality according to LVEF on admission. Over the past decade there was a gradual decline in the proportion of patients admitted with low LVEF. Mortality rates were highest among patients with severe LV dysfunction (36%), intermediate among those with mild-moderate LV dysfunction (10%), and lowest among those with preserved LV function (4%, P < 0.001). We recognized different risk factors for mortality according to LVEF at admission. Admission clinical features (syncope, anterior myocardial infarction, and ST elevation myocardial infarction [STEMI]) predicted mortality risk in patients with severe LV dysfunction (all P < 0.05), whereas the presence of comorbidities (hypertension, diabetes mellitus, chronic renal failure, and peripheral arterial disease) predicted mortality risk in patients with more preserved LV function. Age and admission Killip class ≥II were consistent predictors in all LVEF subsets. LVEF at admission is a strong predictor of mortality in ACS, and prognostic factors differ according to LVEF during admission. In patients with severe LV dysfunction signs of clinical instability are related to 1-year mortality; in patients with a more preserved LV function the prognosis is related to the

  15. Hemodynamic responses to small muscle mass exercise in heart failure patients with reduced ejection fraction

    PubMed Central

    Barrett-O'Keefe, Zachary; Lee, Joshua F.; Berbert, Amanda; Witman, Melissa A. H.; Nativi-Nicolau, Jose; Stehlik, Josef; Richardson, Russell S.

    2014-01-01

    To better understand the mechanisms responsible for exercise intolerance in heart failure with reduced ejection fraction (HFrEF), the present study sought to evaluate the hemodynamic responses to small muscle mass exercise in this cohort. In 25 HFrEF patients (64 ± 2 yr) and 17 healthy, age-matched control subjects (64 ± 2 yr), mean arterial pressure (MAP), cardiac output (CO), and limb blood flow were examined during graded static-intermittent handgrip (HG) and dynamic single-leg knee-extensor (KE) exercise. During HG exercise, MAP increased similarly between groups. CO increased significantly (+1.3 ± 0.3 l/min) in the control group, but it remained unchanged across workloads in HFrEF patients. At 15% maximum voluntary contraction (MVC), forearm blood flow was similar between groups, while HFrEF patients exhibited an attenuated increase at the two highest intensities compared with controls, with the greatest difference at the highest workload (352 ± 22 vs. 492 ± 48 ml/min, HFrEF vs. control, 45% MVC). During KE exercise, MAP and CO increased similarly across work rates between groups. However, HFrEF patients exhibited a diminished leg hyperemic response across all work rates, with the most substantial decrement at the highest intensity (1,842 ± 64 vs. 2,675 ± 81 ml/min; HFrEF vs. control, 15 W). Together, these findings indicate a marked attenuation in exercising limb perfusion attributable to impairments in peripheral vasodilatory capacity during both arm and leg exercise in patients with HFrEF, which likely plays a role in limiting exercise capacity in this patient population. PMID:25260608

  16. Impaired Skeletal Muscle Vasodilation during Exercise in Heart Failure with Preserved Ejection Fraction

    PubMed Central

    Lee, Joshua F.; Barrett-O’Keefe, Zachary; Nelson, Ashley D.; Garten, Ryan S.; Ryan, John J.; Nativi-Nicolau, Jose N.; Richardson, Russell S.; Wray, D. Walter

    2016-01-01

    Background Exercise intolerance is a hallmark symptom of heart failure patients with preserved ejection fraction (HFpEF), which may be related to an impaired ability to appropriately increase blood flow to the exercising muscle. Methods We evaluated leg blood flow (LBF, ultrasound Doppler), heart rate (HR), stroke volume (SV), cardiac output (CO), and mean arterial blood pressure (MAP, photoplethysmography) during dynamic, single leg knee-extensor (KE) exercise in HFpEF patients (n = 21; 68 ± 2 yrs) and healthy controls (n = 20; 71 ± 2 yrs). Results HFpEF patients exhibited a marked attrition during KE exercise, with only 60% able to complete the exercise protocol. In participants who completed all exercise intensities (0-5-10-15W; HFpEF, n = 13; Controls, n = 16), LBF was not different at 0W and 5W, but was 15-25% lower in HFpEF compared to controls at 10W and 15W (P < 0.001). Likewise, leg vascular conductance (LVC), an index of vasodilation, was not different at 0W and 5W, but was 15-20% lower in HFpEF compared to controls at 10W and 15W (P < 0.05). In contrast to these peripheral deficits, exercise-induced changes in central variables (HR, SV, CO), as well as MAP, were similar between groups. Conclusions These data reveal a marked reduction in LBF and LVC in HFpEF patients during exercise that cannot be attributed to a disease-related alteration in central hemodynamics, suggesting that impaired vasodilation in the exercising skeletal muscle vasculature may play a key role in the exercise intolerance associated with this patient population. PMID:26970959

  17. Enhancing ejection fraction measurement through 4D respiratory motion compensation in cardiac PET imaging

    NASA Astrophysics Data System (ADS)

    Tang, Jing; Wang, Xinhui; Gao, Xiangzhen; Segars, W. Paul; Lodge, Martin A.; Rahmim, Arman

    2017-06-01

    ECG gated cardiac PET imaging measures functional parameters such as left ventricle (LV) ejection fraction (EF), providing diagnostic and prognostic information for management of patients with coronary artery disease (CAD). Respiratory motion degrades spatial resolution and affects the accuracy in measuring the LV volumes for EF calculation. The goal of this study is to systematically investigate the effect of respiratory motion correction on the estimation of end-diastolic volume (EDV), end-systolic volume (ESV), and EF, especially on the separation of normal and abnormal EFs. We developed a respiratory motion incorporated 4D PET image reconstruction technique which uses all gated-frame data to acquire a motion-suppressed image. Using the standard XCAT phantom and two individual-specific volunteer XCAT phantoms, we simulated dual-gated myocardial perfusion imaging data for normally and abnormally beating hearts. With and without respiratory motion correction, we measured the EDV, ESV, and EF from the cardiac-gated reconstructed images. For all the phantoms, the estimated volumes increased and the biases significantly reduced with motion correction compared with those without. Furthermore, the improvement of ESV measurement in the abnormally beating heart led to better separation of normal and abnormal EFs. The simulation study demonstrated the significant effect of respiratory motion correction on cardiac imaging data with motion amplitude as small as 0.7 cm. The larger the motion amplitude the more improvement respiratory motion correction brought about on the EF measurement. Using data-driven respiratory gating, we also demonstrated the effect of respiratory motion correction on estimating the above functional parameters from list mode patient data. Respiratory motion correction has been shown to improve the accuracy of EF measurement in clinical cardiac PET imaging.

  18. Reporting trends of randomised controlled trials in heart failure with preserved ejection fraction: a systematic review

    PubMed Central

    Zheng, Sean L; Chan, Fiona T; Maclean, Edd; Jayakumar, Shruti; Nabeebaccus, Adam A

    2016-01-01

    Background Heart failure with preserved ejection fraction (HFpEF) causes significant cardiovascular morbidity and mortality. Current consensus guidelines reflect the neutral results from randomised controlled trials (RCTs). Adequate trial reporting is a fundamental requirement before concluding on RCT intervention efficacy and is necessary for accurate meta-analysis and to provide insight into future trial design. The Consolidated Standards of Reporting Trials (CONSORT) 2010 statement provides a framework for complete trial reporting. Reporting quality of HFpEF RCTs has not been previously assessed, and this represents an important validation of reporting qualities to date. Objectives The aim was to systematically identify RCTs investigating the efficacy of pharmacological therapies in HFpEF and to assess the quality of reporting using the CONSORT 2010 statement. Methods MEDLINE, EMBASE and CENTRAL databases were searched from January 1996 to November 2015, with RCTs assessing pharmacological therapies on clinical outcomes in HFpEF patients included. The quality of reporting was assessed against the CONSORT 2010 checklist. Results A total of 33 RCTs were included. The mean CONSORT score was 55.4% (SD 17.2%). The CONSORT score was strongly correlated with journal impact factor (r=0.53, p=0.003) and publication year (r=0.50, p=0.003). Articles published after the introduction of CONSORT 2010 statement had a significantly higher mean score compared with those published before (64% vs 50%, p=0.02). Conclusions Although the CONSORT score has increased with time, a significant proportion of HFpEF RCTs showed inadequate reporting standards. The level of adherence to CONSORT criteria could have an impact on the validity of trials and hence the interpretation of intervention efficacy. We recommend improving compliance with the CONSORT statement for future RCTs. PMID:27547434

  19. Left ventricular volume regulation in heart failure with preserved ejection fraction

    PubMed Central

    Kerkhof, Peter L M; Yasha Kresh, J; Li, John K-J; Heyndrickx, Guy R

    2013-01-01

    Ejection Fraction (EF) has attained the recognition as indicator of global ventricular performance. Remarkably, precise historical origins promoting the apparent importance of EF are scant. During early utilization EF has been declared a gold standard for the evaluation of the heart as a pump. In contrast, during the last two decades, clinicians have developed a measure of doubt in the universal applicability of EF. This reluctance lead to the introduction of a new and prevalent syndrome in which heart failure (HF) is diagnosed as having a preserved EF (pEF). We examine the existing criticism regarding EF, and describe a novel avenue to characterize ventricular function within the unifying framework of cardiac input–output volume regulation. This approach relates end-systolic volume (ESV) to end-diastolic volume (EDV), and derives for a subgroup matching pEF criteria a distinct pattern in the ESV–EDV domain. In patients with pEF (n = 34), a clear difference (P < 0.0004) in the slope of the regression line for ESV versus EDV was demonstrated compared to control patients with EF < 50% (n = 29). These findings are confirmed by analysis of data presented in two independent publications. The volume regulation approach proposed employs primary end-point determinants (such as ESV and EDV) rather than derived quantities (e.g., the ratio EF or its differential parameter, that is, stroke volume) and confirms a distinct advantage over the classical Starling curve. Application of the ESV-EDV-construct provides the basis and clarifies why some patients present as HFpEF, while others have reduced EF. PMID:24303121

  20. Novel pathomechanisms of cardiomyocyte dysfunction in a model of heart failure with preserved ejection fraction.

    PubMed

    Primessnig, Uwe; Schönleitner, Patrick; Höll, Alexander; Pfeiffer, Susanne; Bracic, Taja; Rau, Thomas; Kapl, Martin; Stojakovic, Tatjana; Glasnov, Toma; Leineweber, Kirsten; Wakula, Paulina; Antoons, Gudrun; Pieske, Burkert; Heinzel, Frank R

    2016-08-01

    Heart failure with preserved ejection fraction (HFpEF) is increasingly common, but the underlying cellular mechanisms are not well understood. We investigated cardiomyocyte function and the role of SEA0400, an Na(+) /Ca(2+) exchanger (NCX) inhibitor in a rat model of chronic kidney disease (CKD) with HFpEF. Male Wistar rats were subjected to subtotal nephrectomy (NXT) or sham operation (Sham). After 8 and 24 weeks, in vivo (haemodynamics, echocardiography) and in vitro function (LV cardiomyocyte cell shortening (CS), and Ca(2+) transients (CaT)) were determined without and with SEA0400. In a subgroup of rats, SEA0400 or vehicle was given p.o. (1 mg/kg b.w.) between week 8 and 24. NXT resulted in stable compensated CKD and HFpEF [hypertrophied left ventricle, prolonged LV isovolumetric relaxation constant TAU (IVRc TAU), elevated end diastolic pressure (EDP), increased lung weight (pulmonary congestion), and preserved LV systolic function (EF, dP/dt)]. In NXT cardiomyocytes, the amplitude of CS and CaT were unchanged but relaxation and CaT decay were progressively prolonged at 8 and 24 weeks vs. Sham, individually correlating with diastolic dysfunction in vivo. NCX forward mode activity (caffeine response) was progressively reduced, while NCX protein expression was up-regulated, suggesting increased NCX reverse mode activity in NXT. SEA0400 acutely improved relaxation in NXT in vivo and in cardiomyocytes and improved cardiac remodelling and diastolic function when given chronically. This model of renal HFpEF is associated with slowed relaxation of LV cardiomyocytes. Treatment with SEA0400 improved cardiomyocyte function, remodelling, and HFpEF. © 2016 The Authors. European Journal of Heart Failure © 2016 European Society of Cardiology.

  1. Effect of Selective Heart Rate Slowing in Heart Failure With Preserved Ejection Fraction

    PubMed Central

    Pal, Nikhil; Sivaswamy, Nadiya; Mahmod, Masliza; Yavari, Arash; Rudd, Amelia; Singh, Satnam; Dawson, Dana K.; Francis, Jane M.; Dwight, Jeremy S.; Watkins, Hugh; Neubauer, Stefan; Frenneaux, Michael

    2015-01-01

    Background— Heart failure with preserved ejection fraction (HFpEF) is associated with significant morbidity and mortality but is currently refractory to therapy. Despite limited evidence, heart rate reduction has been advocated, on the basis of physiological considerations, as a therapeutic strategy in HFpEF. We tested the hypothesis that heart rate reduction improves exercise capacity in HFpEF. Methods and Results— We conducted a randomized, crossover study comparing selective heart rate reduction with the If blocker ivabradine at 7.5 mg twice daily versus placebo for 2 weeks each in 22 symptomatic patients with HFpEF who had objective evidence of exercise limitation (peak oxygen consumption at maximal exercise [o2 peak] <80% predicted for age and sex). The result was compared with 22 similarly treated matched asymptomatic hypertensive volunteers. The primary end point was the change in o2 peak. Secondary outcomes included tissue Doppler–derived E/e′ at echocardiography, plasma brain natriuretic peptide, and quality-of-life scores. Ivabradine significantly reduced peak heart rate compared with placebo in the HFpEF (107 versus 129 bpm; P<0.0001) and hypertensive (127 versus 145 bpm; P=0.003) cohorts. Ivabradine compared with placebo significantly worsened the change in o2 peak in the HFpEF cohort (-2.1 versus 0.9 mL·kg−1·min−1; P=0.003) and significantly reduced submaximal exercise capacity, as determined by the oxygen uptake efficiency slope. No significant effects on the secondary end points were discernable. Conclusion— Our observations bring into question the value of heart rate reduction with ivabradine for improving symptoms in a HFpEF population characterized by exercise limitation. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT02354573. PMID:26338956

  2. Impaired Myocardial Oxygen Availability Contributes to Abnormal Exercise Hemodynamics in Heart Failure With Preserved Ejection Fraction

    PubMed Central

    van Empel, Vanessa P. M.; Mariani, Justin; Borlaug, Barry A.; Kaye, David M.

    2014-01-01

    Background Hypertension is a frequent risk factor for the development of heart failure with preserved ejection fraction (HFPEF). Progressive extracellular matrix accumulation has been presumed to be the fundamental pathophysiologic mechanism that leads to the transition to impaired diastolic reserve. However, the contribution of other mechanisms affecting active and passive components of diastolic function has not been comprehensively assessed. In this study, we investigated the potential role of impaired myocardial oxygen delivery in the pathophysiology of HFPEF. Methods and Results Patients with HFPEF, those with controlled hypertension, and healthy controls underwent simultaneous right‐heart catheterization, echocardiography, and paired arterial and coronary sinus blood gas sampling at rest and during supine‐cycle ergometry. Despite a lower workload (HFPEF vs control, hypertension: 43±8 versus 114±12, 87±14 W; P<0.001 and P<0.05, respectively), peak exercise pulmonary capillary wedge pressure was markedly higher in HFPEF patients compared with healthy and hypertensive controls (32±2 versus 16±1 and 17±1 mm Hg, both P<0.001). During exercise, the transcardiac oxygen gradient increased significantly in all groups; however, the peak transcardiac oxygen gradient was significantly lower in HFPEF patients (P<0.05). In addition, the left ventricular–work corrected transcardiac oxygen gradient remained significantly lower in HFPEF patients compared with controls (P<0.001). Conclusion The current study provides unique data suggesting that the abnormal diastolic reserve observed during exertion in HFPEF patients may, in part, be explained by impaired myocardial oxygen delivery due possibly to microvascular dysfunction. Further studies are required to confirm the structural and functional basis of these findings and to investigate the influence of potential therapies on this abnormality. PMID:25468660

  3. Comparison of biventricular ejection fractions using cadmium-zinc-telluride SPECT and planar equilibrium radionuclide angiography.

    PubMed

    Chen, Yi-Chieh; Ko, Chi-Lun; Yen, Rouh-Fang; Lo, Mei-Fang; Huang, Yih-Hwen; Hsu, Pei-Ying; Wu, Yen-Wen; Cheng, Mei-Fang

    2016-06-01

    We compared biventricular ejection fractions (EFs) from gated blood-pool single-photon emission computed tomography (SPECT) using a cadmium-zinc-telluride camera (CZT-SPECT) with planar equilibrium radionuclide angiography (ERNA) using a NaI gamma camera (NaI-planar). We also evaluated whether imaging time can be reduced without compromising image quality using the CZT camera. Forty-eight patients underwent NaI-planar and CZT-SPECT on the same day. CZT-SPECT datasets were re-projected at an LAO orientation similar to ERNA acquisition, forming CZT-repro planar datasets. The resulting biventricular volumetric measurements and EFs were compared. LVEF calculated from CZT-SPECT and CZT-repro correlated better with NaI-planar (r = 0.93 and 0.99, respectively) than RVEF (r = 0.76 and 0.82, respectively). Excellent intra-class correlation and low bias in intra-observer comparisons were observed for the biventricular EFs derived from three datasets. A wider limit of agreement in CZT-SPECT-derived LVEFs, lower correlation and significant bias for NaI-planar, and CZT-repro-derived RVEFs was found in the inter-observer analyses. Nonetheless, the imaging time can be reduced to 4 minutes without increasing variability in EFs using the CZT camera (P = NS). LVEFs calculated from CZT-SPECT and CZT-repro correlated well with NaI-planar. CZT camera may reduce imaging time while preserving image quality in the assessment of biventricular EFs.

  4. Renin-Angiotensin Activation and Oxidative Stress in Early Heart Failure with Preserved Ejection Fraction

    PubMed Central

    Negi, Smita I.; Jeong, Euy-Myoung; Shukrullah, Irfan; Veleder, Emir; Jones, Dean P.; Fan, Tai-Hwang M.; Varadarajan, Sudhahar; Danilov, Sergei M.; Fukai, Tohru; Dudley, Samuel C.

    2015-01-01

    Animal models have suggested a role of renin-angiotensin system (RAS) activation and subsequent cardiac oxidation in heart failure with preserved ejection fraction (HFpEF). Nevertheless, RAS blockade has failed to show efficacy in treatment of HFpEF. We evaluated the role of RAS activation and subsequent systemic oxidation in HFpEF. Oxidative stress markers were compared in 50 subjects with and without early HFpEF. Derivatives of reactive oxidative metabolites (DROMs), F2-isoprostanes (IsoPs), and ratios of oxidized to reduced glutathione (Eh GSH) and cysteine (Eh CyS) were measured. Angiotensin converting enzyme (ACE) levels and activity were measured. On univariate analysis, HFpEF was associated with male sex (p = 0.04), higher body mass index (BMI) (p = 0.003), less oxidized Eh CyS (p = 0.001), lower DROMs (p = 0.02), and lower IsoP (p = 0.03). Higher BMI (OR: 1.3; 95% CI: 1.1–1.6) and less oxidized Eh CyS (OR: 1.2; 95% CI: 1.1–1.4) maintained associations with HFpEF on multivariate analysis. Though ACE levels were higher in early HFpEF (OR: 1.09; 95% CI: 1.01–1.05), ACE activity was similar to that in controls. HFpEF is not associated with significant systemic RAS activation or oxidative stress. This may explain the failure of RAS inhibitors to alter outcomes in HFpEF. PMID:26504834

  5. Peak Exercise Oxygen Uptake Predicts Recurrent Admissions in Heart Failure With Preserved Ejection Fraction.

    PubMed

    Palau, Patricia; Domínguez, Eloy; Núñez, Eduardo; Ramón, José María; López, Laura; Melero, Joana; Sanchis, Juan; Bellver, Alejandro; Santas, Enrique; Bayes-Genis, Antoni; Chorro, Francisco J; Núñez, Julio

    2017-06-27

    Heart failure with preserved ejection fraction (HFpEF) is a highly prevalent syndrome with an elevated risk of morbidity and mortality. To date, there is scarce evidence on the role of peak exercise oxygen uptake (peak VO2) for predicting the morbidity burden in HFpEF. We sought to evaluate the association between peak VO2 and the risk of recurrent hospitalizations in patients with HFpEF. A total of 74 stable symptomatic patients with HFpEF underwent a cardiopulmonary exercise test between June 2012 and May 2016. A negative binomial regression method was used to determine the association between the percentage of predicted peak VO2 (pp-peak VO2) and recurrent hospitalizations. Risk estimates are reported as incidence rate ratios. The mean age was 72.5 ± 9.1 years, 53% were women, and all patients were in New York Heart Association functional class II to III. Mean peak VO2 and median pp-peak VO2 were 10 ± 2.8mL/min/kg and 60% (range, 47-67), respectively. During a median follow-up of 276 days [interquartile range, 153-1231], 84 all-cause hospitalizations in 31 patients (41.9%) were registered. A total of 15 (20.3%) deaths were also recorded. On multivariate analysis, accounting for mortality as a terminal event, pp-peak VO2 was independently and linearly associated with the risk of recurrent admission. Thus, and modeled as continuous, a 10% decrease of pp-peak VO2 increased the risk of recurrent hospitalizations by 32% (IRR, 1.32; 95%CI, 1.03-1.68; P = .028). In symptomatic elderly patients with HFpEF, pp-peak VO2 predicts all-cause recurrent admission. Copyright © 2017 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

  6. Relationship between pre-implant ejection fraction and outcome after cardiac resynchronization therapy in symptomatic patients.

    PubMed

    Schuchert, Andreas; Muto, Carmine; Maounis, Themistoklis; Ella, Rita Omega; Polauck, Alexander; Padeletti, Luigi

    2014-08-01

    Left-ventricular ejection fraction (LVEF) is regarded as a strong predictor for morbidity and mortality in heart failure patients. The aim of the analysis was to assess the relationship between pre-implant LVEF and outcome of patients with advanced heart failure who received cardiac resynchronization therapy (CRT). We analysed the two-year follow-up of 366 patients who had been enrolled in the MASCOT study which included NYHA class III/IV patients with a class I CRT indication. Pre-implant LVEF was stratified by tertile. The boundaries for pre-implant LVEF were < 22% (n = 128; 18.2 +/- 3.1%; T(low)), 22% to 28% (n = 121; 25.4 +/- 1.4%; T(middle)) and > 28% (n = 117; 32.6 +/- 3.9%; T(high)) for each tertile.Two-year post-implant LVEF was 32.0 +/- 11.5% (T(low)), 33.7 +/- 10.8% (T(middle)) and 36.4 +/- 9.9% (T(high)). T(Iow) had a greater increase between pre- and post-implant LVEF compared to T(middle) (P = 0.03) and T(high) (P = 0.0001). NYHA class improved similarly among the three groups as well as the quality of life score. No significant differences were detected between the three groups for all-cause mortality, cardiac death, all-cause hospitalization, and hospitalization due to worsening heart failure. Symptomatic heart failure patients with a wide QRS complex and a severe impaired LV function had a better improvement of their pre-implant LVEF than patients with a more preserved LVEF. This may be one reason that in these patient groups long-term morbidity and mortality were not related to their pre-implant LVEF. Pre-implant LVEF was in symptomatic CRT patients not predictive for their long-term cardiovascular morbidity and mortality.

  7. Prognostic value of ejection fraction in patients admitted with acute coronary syndrome: A real world study.

    PubMed

    Perelshtein Brezinov, Olga; Klempfner, Robert; Zekry, Sagit Ben; Goldenberg, Ilan; Kuperstein, Rafael

    2017-03-01

    There are limited data regarding factors affecting outcomes among acute coronary syndrome (ACS) patients presenting with varying degrees of left ventricle (LV) dysfunction. We aimed to identify factors associated with mortality according to LV ejection fraction (LVEF) at 1st admission in ACS patients.A total of 8983 ACS patients prospectively enrolled in the Acute Coronary Syndrome Israeli Survey (2000-2010) were categorized according to their LVEF at admission: severe LV dysfunction (LVEF < 30% [n = 845]), mild-moderate LV dysfunction (LVEF 30%-49% [n = 4470]); preserved LV function (LVEF ≥ 50% [n = 3659]). Multivariable Cox proportional hazards regression modeling was used to assess the risk factors for 1-year mortality according to LVEF on admission.Over the past decade there was a gradual decline in the proportion of patients admitted with low LVEF. Mortality rates were highest among patients with severe LV dysfunction (36%), intermediate among those with mild-moderate LV dysfunction (10%), and lowest among those with preserved LV function (4%, P < 0.001). We recognized different risk factors for mortality according to LVEF at admission. Admission clinical features (syncope, anterior myocardial infarction, and ST elevation myocardial infarction [STEMI]) predicted mortality risk in patients with severe LV dysfunction (all P < 0.05), whereas the presence of comorbidities (hypertension, diabetes mellitus, chronic renal failure, and peripheral arterial disease) predicted mortality risk in patients with more preserved LV function. Age and admission Killip class ≥II were consistent predictors in all LVEF subsets.LVEF at admission is a strong predictor of mortality in ACS, and prognostic factors differ according to LVEF during admission. In patients with severe LV dysfunction signs of clinical instability are related to 1-year mortality; in patients with a more preserved LV function the prognosis is related to the presence of co-morbidities.

  8. Endothelial Senescence Contributes to Heart Failure With Preserved Ejection Fraction in an Aging Mouse Model.

    PubMed

    Gevaert, Andreas B; Shakeri, Hadis; Leloup, Arthur J; Van Hove, Cor E; De Meyer, Guido R Y; Vrints, Christiaan J; Lemmens, Katrien; Van Craenenbroeck, Emeline M

    2017-06-01

    Because of global aging, the prevalence of heart failure with preserved ejection fraction (HFpEF) continues to rise. Although HFpEF pathophysiology remains incompletely understood, endothelial inflammation is stated to play a central role. Cellular senescence is a process of cellular growth arrest linked with aging and inflammation. We used mice with accelerated aging to investigate the role of cellular senescence in HFpEF development. Senescence-accelerated mice (SAM, n=18) and control mice with normal senescence (n=15) were fed normal chow or a high-fat, high-salt diet (WD). Vascular and cardiac function was assessed at 8, 16, and 24 weeks of age. At 24 weeks, both SAM on WD (SAM-WD) and SAM on regular diet displayed endothelial dysfunction, as evidenced by impaired acetylcholine-induced relaxation of aortic segments and reduced basal nitric oxide. At week 24, SAM-WD had developed HFpEF, characterized by diastolic dysfunction, left ventricular hypertrophy, left atrial dilatation, and interstitial fibrosis. Also, exercise capacity was reduced and lung weight increased. Cardiovascular inflammation and senescence were assessed by immunohistochemical and immunofluorescence staining of hearts and aortas. SAM-WD showed increased endothelial inflammation (intercellular adhesion molecule 1 expression) and increased endothelial senescence (acetyl-p53/CD31 costaining). The latter correlated with diastolic function and intercellular adhesion molecule 1 expression. SAM develop endothelial dysfunction. Adding a high-salt, high-fat diet accelerates endothelial senescence and instigates endothelial inflammation. This coincides with hemodynamic and structural changes typical of HFpEF. Targeting endothelial senescence could be a new therapeutic avenue in HFpEF. © 2017 American Heart Association, Inc.

  9. Modes of death in patients with heart failure and preserved ejection fraction.

    PubMed

    Aschauer, Stefan; Zotter-Tufaro, Caroline; Duca, Franz; Kammerlander, Andreas; Dalos, Daniel; Mascherbauer, Julia; Bonderman, Diana

    2017-02-01

    Recent studies suggest that reduced right ventricular function is an important predictor of outcome in patients with heart failure and preserved ejection fraction (HFpEF). Because affected patients suffer from a broad spectrum of non-cardiac co-morbidities, it remains unclear, whether they actually die from right heart failure (RHF) or as a consequence of other conditions. Consecutive patients with a confirmed diagnosis of HFpEF were enrolled in this prospective registry. Local and external medical records, as well as telephone interviews with relatives were used to ascertain modes of death. RHF was accepted as a mode of death, if the following criteria were met: 1. right ventricular dysfunction assessed by transthoracic echocardiography, and 2. clinical signs of right heart decompensation at the time of death. Out of 230 patients with complete follow-up, 16.5% (n=38) died after a mean of 30±17months. 60.5% deaths were classified as cardiovascular and 34.2% as non-cardiovascular. In 5.3% patients, the reason for death remained unknown. Of the cardiovascular cases (n=23), 91.4% of deaths were attributed to RHF, 4.3% died from stroke and 4.3% from sudden cardiac death. Of the non-cardiovascular deaths (n=13), 46.2% of deaths were attributed to major infections and 38.4% deaths were related to cancer. Other reasons for death included ileus (7.7%) and major bleeding (7.7%). In our well-characterised HFpEF cohort, more than half of all deaths could directly be attributed to RHF. The right ventricle seems to be a meaningful therapeutic target in a subset of patients. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  10. Relation of Pre-anthracycline Serum Bilirubin Levels to Left Ventricular Ejection Fraction After Chemotherapy.

    PubMed

    Vera, Trinity; D'Agostino, Ralph B; Jordan, Jennifer H; Whitlock, Matthew C; Meléndez, Giselle C; Lamar, Zanetta S; Porosnicu, Mercedes; Bonkovsky, Herbert L; Poole, Leslie B; Hundley, W Gregory

    2015-12-01

    Myocardial injury because of oxidative stress manifesting through reductions in left ventricular ejection fraction (LVEF) may occur after the administration of anthracycline-based chemotherapy (A-bC). We hypothesized that bilirubin, an effective endogenous antioxidant, may attenuate the reduction in LVEF that sometimes occurs after receipt of A-bC. We identified 751 consecutively treated patients with cancer who underwent a pre-A-bC LVEF measurement, exhibited a serum total bilirubin level <2 mg/dl, and then received a post-A-bC LVEF assessment because of symptomatology associated with heart failure. Analysis of variance, Tukey's Studentized range test, and chi-square tests were used to evaluate an association between bilirubin and LVEF changes. The LVEF decreased by 10.7 ± 13.7%, 8.9 ± 11.8%, and 7.7 ± 11.5% in group 1 (bilirubin at baseline ≤0.5 mg/dl), group 2 (bilirubin 0.6 to 0.8 mg/dl), and group 3 (bilirubin 0.9 to 1.9 mg/dl), respectively. More group 1 patients experienced >15% decrease in LVEF compared with those in group 3 (p = 0.039). After adjusting for age, coronary artery disease/myocardial infarction, diabetes mellitus, hematocrit, and the use of cardioactive medications, higher precancer treatment bilirubin levels and lesser total anthracycline doses were associated with LVEF preservation (p = 0.047 and 0.011, respectively). In patients treated with anthracyclines who subsequently develop symptoms associated with heart failure, pre-anthracycline treatment serum bilirubin levels inversely correlate with subsequent deterioration in post-cancer treatment LVEF. In conclusion, these results suggest that increased levels of circulating serum total bilirubin, an intrinsic antioxidant, may facilitate preservation of LVEF in patients receiving A-bC for cancer.

  11. Influence of different background and left-ventricular assignments on the ejection fraction in equilibrium radionuclide angiography.

    PubMed

    Slutsky, R; Pfisterer, M; Verba, J; Battler, A; Ashburn, W

    1980-06-01

    Seventy-six patients were studied within one week of contrast ventriculography to assess the influence of differing background assignments on ejection fractions derived from gated equilibrium radionuclide anigograms. "Fixed" and "variable" left-ventricular regions on interest and five different backgrounds were used. Inter- and intra-observer variability were determined, and 15 patients underwent a second study 2 weeks later. Variable left-ventricular regions of interest produced higher ejection fractions than fixed ones. A computer-assigned background or a ring drawn manually around the left ventricle correlated best with contrast ventriculography, giving greater serial and inter- and intra-observer variability. Automated background assignments reduced variability and increased reproducibility, though not always associated with the best correlation with contrast ventriculography. Thus a variety of left-ventricular and background regions of interest gives excellent reproducibility and accuracy.

  12. Abnormal responses of ejection fraction to exercise, in healthy subjects, caused by region-of-interest selection

    SciTech Connect

    Sorenson, S.G.; Caldwell, J.; Ritchie, J.; Hamilton, G.

    1981-01-01

    We performed serial exercise equilibrium radionuclide angiography in eight normal subjects with each subject executing three tests: control, after nitroglycerin, and after propranolol. The left-ventricular ejection fraction (EF) was calculated by two methods: (a) fixed region-of-interest (FROI) using a single end-diastolic ROI, and (b) variable region-of-interest (VROI) where an end-diastolic and end-systolic region of interest were used. Abnormal maximal EF responses occurred in five of eight subjects during control using FROI but in zero of eight employing VROI (p < 0.05). After nitroglycerin, three of eight subjects had abnormal responses by FROI, but zero of eight were abnormal by VROI (p < 0.05). After propranolol, blunted EF responses occurred in three of seven by both methods. Falsely abnormal EF responses to exercise RNA may occur due to the method of region-of-interest selection in normal subjects with normal or high ejection fractions.

  13. Blood volume, heart rate, and left ventricular ejection fraction changes in dogs before and after exercise during endurance training

    SciTech Connect

    Mackintosh, I.C.; Dormehl, I.C.; van Gelder, A.L.; du Plessis, M.

    1983-10-01

    In Beagles after 7 weeks' endurance training, resting blood volume increased by an average of 13.1%. Resting heart rates were not significantly affected, but heart rates measured 2 minutes after exercise were significantly lower after the endurance training than before. Left ventricular ejection fractions determined by radionuclide angiography from 2 minutes after exercise showed no significant changes in response to a single exercise period or over the 50 days' training.

  14. Anaesthetic management of laparoscopic surgery for rectal cancer in patients of dilated cardiomyopathy with poor ejection fraction: a case report

    PubMed Central

    Wu, Yao-Hua; Hu, Liang; Xia, Jin; Hao, Quan-Shui; Feng, Li; Xiang, Hong-Bing

    2015-01-01

    A patient with dilated cardiomyopathy with poor ejection fraction posted for laparoscopic surgery for rectal cancer which was successfully performed under general anesthesia with endotracheal intubation and mechanical ventilation was reported. Our observations strongly indicate that detailed preoperative assessment, watchful intraoperative monitoring, and skillful optimization of fluid status and hemodynamic play important role in the high risk patient under general anesthesia with endotracheal intubation and mechanical ventilation. PMID:26309623

  15. [New therapeutic era in heart failure with reduced ejection fraction: Which population of French patients is concerned?].

    PubMed

    Juillière, Y; Ferrières, J

    2016-09-01

    A new class of cardiovascular drugs, angiotensin receptor neprilysin inhibitors, has shown its efficacy in the PARADIGM-HF study in replacement of renin-angiotensin blockers in symptomatic heart failure patients with reduced ejection fraction, and already treated according to the recommendations. Recent French epidemiological data in the literature allow assessing the number of French patients who could be concerned by the new treatment in taking account the different parameters from the PARADIGM-HF study.

  16. Short-Term Effects of Ketamine and Isoflurane on Left Ventricular Ejection Fraction in an Experimental Swine Model

    PubMed Central

    Wessler, Benjamin; Madias, Christopher; Pandian, Natesa; Link, Mark S.

    2011-01-01

    Background. General anesthesia is an essential element of experimental medical procedures. Ketamine and isoflurane are agents commonly used to induce and maintain anesthesia in animals. The cardiovascular effects of these anesthetic agents are diverse, and the response of global myocardial function is unknown. Methods. In a series of 15 swine, echocardiography measurements of left ventricular ejection fraction (LVEF) were obtained before the animals received anesthesia (baseline), after an intramuscular injection of ketamine (postketamine) and after inhaled isoflurane (postisoflurane). Results. The mean LVEF of an unanesthetized swine was 47 ± 3%. There was a significant decrease in the mean LVEF after administration of ketamine to 41 + 6.5% (P = 0.003). The addition of inhaled isoflurane did not result in further decrease in mean LVEF (mean LVEF 38 ± 7.2%, P = 0.22). Eight of the swine had an increase in their LVEF with sympathetic stimulation. Conclusions. In our experimental model the administration of ketamine was associated with decreased LV function. The decrease may be largely secondary to a blunting of sympathetic tone. The addition of isoflurane to ketamine did not significantly change LV function. A significant number of animals had returned to preanesthesia LV function with sympathetic stimulation. PMID:22347646

  17. Increased Left Ventricular Stiffness Impairs Exercise Capacity in Patients with Heart Failure Symptoms Despite Normal Left Ventricular Ejection Fraction

    PubMed Central

    Sinning, David; Kasner, Mario; Westermann, Dirk; Schulze, Karsten; Schultheiss, Heinz-Peter; Tschöpe, Carsten

    2011-01-01

    Aims. Several mechanisms can be involved in the development of exercise intolerance in patients with heart failure despite normal left ventricular ejection fraction (HFNEF) and may include impairment of left ventricular (LV) stiffness. We therefore investigated the influence of LV stiffness, determined by pressure-volume loop analysis obtained by conductance catheterization, on exercise capacity in HFNEF. Methods and Results. 27 HFNEF patients who showed LV diastolic dysfunction in pressure-volume (PV) loop analysis performed symptom-limited cardiopulmonary exercise testing (CPET) and were compared with 12 patients who did not show diastolic dysfunction in PV loop analysis. HFNEF patients revealed a lower peak performance (P = .046), breathing reserve (P = .006), and ventilation equivalent for carbon dioxide production at rest (P = .002). LV stiffness correlated with peak oxygen uptake (r = −0.636, P < .001), peak oxygen uptake at ventilatory threshold (r = −0.500, P = .009), and ventilation equivalent for carbon dioxide production at ventilatory threshold (r = 0.529, P = .005). Conclusions. CPET parameters such as peak oxygen uptake, peak oxygen uptake at ventilatory threshold, and ventilation equivalent for carbon dioxide production at ventilatory threshold correlate with LV stiffness. Increased LV stiffness impairs exercise capacity in HFNEF. PMID:21403885

  18. Ergospirometry and Echocardiography in Early Stage of Heart Failure with Preserved Ejection Fraction and in Healthy Individuals

    PubMed Central

    Garcia, Eduardo Lima; Menezes, Márcio Garcia; Stefani, Charles de Moraes; Danzmann, Luiz Cláudio; Torres, Marco Antonio Rodrigues

    2015-01-01

    Background Heart failure with preserved ejection fraction is a syndrome characterized by changes in diastolic function; it is more prevalent among the elderly, women, and individuals with systemic hypertension (SH) and diabetes mellitus. However, in its early stages, there are no signs of congestion and it is identified in tests by adverse remodeling, decreased exercise capacity and diastolic dysfunction. Objective To compare doppler, echocardiographic (Echo), and cardiopulmonary exercise test (CPET) variables - ergospirometry variables - between two population samples: one of individuals in the early stage of this syndrome, and the other of healthy individuals. Methods Twenty eight outpatients diagnosed with heart failure according to Framingham’s criteria, ejection fraction > 50% and diastolic dysfunction according to the european society of cardiology (ESC), and 24 healthy individuals underwent Echo and CPET. Results The group of patients showed indexed atrial volume and left ventricular mass as well as E/E’ and ILAV/A´ ratios significantly higher, in addition to a significant reduction in peak oxygen consumption and increased VE/VCO2 slope, even having similar left ventricular sizes in comparison to those of the sample of healthy individuals. Conclusion There are significant differences between the structural and functional variables analyzed by Echo and CPET when comparing two population samples: one of patients in the early stage of heart failure with ejection fraction greater than or equal to 50% and another of healthy individuals. PMID:26247247

  19. The Relationship of Right- and Left-Sided Filling Pressures in Patients With Heart Failure and a Preserved Ejection Fraction

    PubMed Central

    Drazner, Mark H.; Prasad, Anand; Ayers, Colby; Markham, David W.; Hastings, Jeffrey; Bhella, Paul S.; Shibata, Shigeki; Levine, Benjamin D.

    2013-01-01

    Background Although right-sided filling pressures often mirror left-sided filling pressures in systolic heart failure, it is not known whether a similar relationship exists in heart failure with preserved ejection fraction. Methods and Results Eleven subjects with heart failure with preserved ejection fraction underwent right heart catheterization at rest and under loading conditions manipulated by lower body negative pressure and saline infusion. Right atrial pressure (RAP) was classified as elevated when ≥10 mm Hg and pulmonary capillary wedge pressure (PCWP) when ≥22 mm Hg. If both the RAP and the PCWP were elevated or both not elevated, they were classified as concordant; otherwise, they were classified as discordant. Correlation of RAP and PCWP was determined by a repeated measures model. Among 66 paired measurements of RAP and PCWP, 44 (67%) had a low RAP and PCWP and 8 (12%) a high RAP and PCWP, yielding a concordance rate of 79%. In a sensitivity analysis performed by varying the definition of elevated RAP (from 8 to 12 mm Hg) and PCWP (from 15 to 25 mm Hg), the mean±SD concordance of RAP and PCWP was 76±10%. The correlation coefficient of RAP and PCWP for the overall cohort was r=0.86 (P<0.0001). Conclusions Right-sided filling pressures often reflect left-sided filling pressures in heart failure with preserved ejection fraction, supporting the role of estimation of jugular venous pressure to assess volume status in this condition. PMID:20233992

  20. Pulmonary hypertension and right heart failure in heart failure with preserved left ventricular ejection fraction: pathophysiology and natural history.

    PubMed

    Segers, Vincent F M; Brutsaert, Dirk L; De Keulenaer, Gilles W

    2012-05-01

    Pulmonary hypertension and right heart failure are common findings in patients suffering from heart failure with preserved ejection fraction (HFpEF). In this review, we summarize our current understanding of the pathophysiology of pulmonary hypertension related to heart failure. HFpEF is a clinical syndrome with increasing prevalence and a mortality rate similar to heart failure with reduced ejection fraction. Because the pathophysiology and even the definition of this disease are still controversial, we will first outline the current conceptual framework around heart failure with preserved ejection fraction. Next, we will outline our current knowledge on the pathophysiology of pulmonary hypertension related to left ventricular failure and diastolic dysfunction. Diastolic dysfunction induces pulmonary hypertension through passive transmission of elevated end diastolic pressures, reactive pulmonary vasoconstriction, and vascular remodeling. Eventually, right ventricular failure develops that can further potentiate left ventricular failure because of their close mechanical, cellular, and biochemical integration. Exciting new studies have led to an increased understanding of the underlying pathophysiology and indicate that pulmonary hypertension in heart failure may be treatable.

  1. Quantification of Left Ventricular Volumes, Mass and Ejection Fraction using Cine Displacement Encoding with Stimulated Echoes (DENSE) MRI

    PubMed Central

    Haggerty, Christopher M.; Kramer, Sage P.; Skrinjar, Oskar; Binkley, Cassi M.; Powell, David K.; Mattingly, Andrea C.; Epstein, Frederick H.; Fornwalt, Brandon K.

    2014-01-01

    Purpose To test the hypothesis that magnitude images from cine Displacement Encoding with Stimulated Echoes (DENSE) MRI can accurately quantify left ventricular (LV) volumes, mass, and ejection fraction. Materials and Methods Thirteen mice (C57BL/6J) were imaged using a 7T ClinScan MRI. A short-axis stack of cine T2-weighted black blood (BB) images was acquired for calculation of left ventricular volumes, mass, and ejection fraction (EF) using the gold standard sum-of-slices methodology. DENSE images were acquired during the same imaging session in three short-axis (basal, mid, apical) and two long-axis orientations. A custom surface fitting algorithm was applied to epicardial and endocardial borders from the DENSE magnitude images to calculate volumes, mass, and EF. Agreement between the DENSE-derived measures and BB-derived measures was assessed via coefficient of variation (CoV). Results 3D surface reconstruction was completed on the order of seconds from segmented images, and required fewer slices to be segmented. Volumes, mass, and EF from DENSE-derived surfaces matched well with BB data (CoVs ≤11%). Conclusion LV mass, volumes, and ejection fraction in mice can be quantified through sparse (5 slices) sampling with DENSE. This consolidation significantly reduces the time required to assess both mass/volume-based measures of cardiac function and advanced cardiac mechanics. PMID:24923710

  2. Submaximal oxygen uptake kinetics, functional mobility, and physical activity in older adults with heart failure and reduced ejection fraction

    PubMed Central

    Hummel, Scott L; Herald, John; Alpert, Craig; Gretebeck, Kimberlee A; Champoux, Wendy S; Dengel, Donald R; Vaitkevicius, Peter V; Alexander, Neil B

    2016-01-01

    Background Submaximal oxygen uptake measures are more feasible and may better predict clinical cardiac outcomes than maximal tests in older adults with heart failure (HF). We examined relationships between maximal oxygen uptake, submaximal oxygen kinetics, functional mobility, and physical activity in older adults with HF and reduced ejection fraction. Methods Older adults with HF and reduced ejection fraction (n = 25, age 75 ± 7 years) were compared to 25 healthy age- and gender-matched controls. Assessments included a maximal treadmill test for peak oxygen uptake (VO2peak), oxygen uptake kinetics at onset of and on recovery from a submaximal treadmill test, functional mobility testing [Get Up and Go (GUG), Comfortable Gait Speed (CGS), Unipedal Stance (US)], and self-reported physical activity (PA). Results Compared to controls, HF had worse performance on GUG, CGS, and US, greater delays in submaximal oxygen uptake kinetics, and lower PA. In controls, VO2peak was more strongly associated with functional mobility and PA than submaximal oxygen uptake kinetics. In HF patients, submaximal oxygen uptake kinetics were similarly associated with GUG and CGS as VO2peak, but weakly associated with PA. Conclusions Based on their mobility performance, older HF patients with reduced ejection fraction are at risk for adverse functional outcomes. In this population, submaximal oxygen uptake measures may be equivalent to VO2 peak in predicting functional mobility, and in addition to being more feasible, may provide better insight into how aerobic function relates to mobility in older adults with HF. PMID:27594875

  3. Evolving approaches to the management of heart failure with preserved ejection fraction in patients with coronary artery disease.

    PubMed

    Shah, Sanjiv J

    2010-01-01

    Coronary artery disease (CAD) is a major cause of heart failure with preserved ejection fraction (HFpEF). In studies of HFpEF, the reported prevalence of CAD varies widely, which may be the result of inconsistent definitions of CAD, geographic and ethnic differences in CAD burden, varying definitions of HFpEF (including different cutoffs for "preserved ejection fraction"), and differences in study design. Despite these limitations, pooled analysis of prospective HFpEF studies demonstrates that CAD is common in HFpEF, with an estimated prevalence of approximately 50%. Based on available data, patients with signs and symptoms of heart failure who have preserved left ventricular ejection fraction and evidence of CAD (HFpEF-CAD) most likely comprise a distinct etiologic and pathophysiologic subset of HFpEF. Therefore, future clinical trials in HFpEF should a priori stratify by CAD or specifically target patients with CAD, strategies that may improve the disappointing track record of therapies tested in HFpEF. The combination of systematic evaluation and management of CAD in HFpEF, along with promising future therapies for HFpEF-CAD, may lead to improved outcomes for this challenging clinical syndrome.

  4. Global Longitudinal Strain or Left Ventricular Twist and Torsion? Which Correlates Best with Ejection Fraction?

    PubMed

    Lima, Marcio Silva Miguel; Villarraga, Hector R; Abduch, Maria Cristina Donadio; Lima, Marta Fernandes; Cruz, Cecilia Beatriz Bittencourt Viana; Sbano, João Cesar Nunes; Voos, Mariana Callil; Mathias, Wilson; Tsutsui, Jeane Mike

    2017-07-01

    Estimative of left ventricular ejection fraction (LVEF) is a major indication for echocardiography. Speckle tracking echocardiography (STE) allows analysis of LV contraction mechanics which includes global longitudinal strain (GLS) and twist/torsion, both the most widely used. Direct comparison of correlations between these novel parameters and LVEF has never been done before. This study aims to check which one has the highest correlation with LVEF. Patients with normal LVEF (> 0,55) and systolic dysfunction (LVEF <0,55) were prospectively enrolled, and underwent echocardiogram with STE analysis. Correlation of variables was performed by linear regression analysis. In addition, correlation among levels of LV systolic impairment was also tested. A total of 131 patients were included (mean age, 46 ± 14y; 43%, men). LVEF and GLS showed a strong correlation (r = 0.95; r2 = 0.89; p < 0.001), more evident in groups with LV systolic dysfunction than those with preserved LVEF. Good correlation was also found with global longitudinal strain rate (r = 0.85; r2 = 0.73; p < 0.001). Comparing to GLS, correlation of LVEF and torsional mechanics was weaker: twist (r = 0.78; r2 = 0.60; p < 0.001); torsion (r = 0.75; r2 = 0.56; p < 0.001). GLS of the left ventricle have highly strong positive correlation with the classical parameter of ejection fraction, especially in cases with LV systolic impairment. Longitudinal strain rate also demonstrated a good correlation. GLS increments analysis of LV systolic function. On the other hand, although being a cornerstone of LV mechanics, twist and torsion have a weaker correlation with LV ejection, comparing to GLS. A estimativa da fração de ejeção do ventrículo esquerdo (FEVE) é uma das pincipais indicações para a ecocardiografia. Speckle tracking (ST) permite a análise da mecânica de contração do VE que inclui a deformação (strain) longitudinal global (SLG) e o twist / torção, sendo ambos os mais utilizados. A compara

  5. Mitral regurgitation in patients with coronary artery disease and low left ventricular ejection fractions. How should it be treated?

    PubMed Central

    Christenson, J T; Simonet, F; Maurice, J; Bloch, A; Velebit, V; Schmuziger, M

    1995-01-01

    In recent years, coronary artery bypass grafting has been extended to include patients with very low left ventricular ejection fractions. Should concomitant mitral valve regurgitation be corrected simultaneously? Between January 1990 and July 1994, 43 patients with preoperative left ventricular ejection fractions < or = 25% and echocardiographic evidence of concomitant mitral valve regurgitation (grade I, 18 patients; II, 19 patients; and III, 6 patients) underwent primary coronary artery bypass grafting. None of these patients underwent simultaneous mitral valve surgery. Twenty-four patients (56%) had pulmonary artery pressures > or = 40 mmHg (pulmonary hypertension). The mean preoperative left ventricular ejection fraction was 18.7% +/- 4.4% (range, 10% to 25%), and the mean pulmonary artery pressure was 45.6 +/- 15.8 mmHg. The average of number of grafts per patient was 4.5 +/- 1.5. Five patients underwent simultaneous repair of a left ventricular aneurysm. The hospital mortality rate was 4.7% (2/43). Transient low cardiac output occurred postoperatively in 13 patients (30%). Sixteen patients (37%) had no postoperative complications. The average follow-up of the 41 hospital survivors was 6 months (range, 1 to 32 months). One patient died 8 months after surgery for an overall mortality rate of 7%. Another 2 patients had graft occlusions that did not require reoperation. In the 40 surviving patients, follow-up echocardiography revealed that 37 patients (93%) had either no mitral valve regurgitation or only very mild mitral valve regurgitation (grade I). Three patients had grade II mitral valve regurgitation, but none required mitral valve surgery. The New York Heart Association functional class improved significantly in all hospital survivors (from 3.4 +/- 0.6 to 1.7 +/- 0.7; p > 0.001), and left ventricular ejection fractions rose from 19.0% +/- 4.6% to 42.0% +/- 8.3%. Coronary artery bypass grafting is possible in patients with very low left ventricular ejection

  6. Prolonged vortex formation during the ejection period in the left ventricle with low ejection fraction: a study by vector flow mapping.

    PubMed

    Fukuda, Nobuaki; Itatani, Keiichi; Kimura, Koichi; Ebihara, Aya; Negishi, Kazuaki; Uno, Kansei; Miyaji, Kagami; Kurabayashi, Masahiko; Takenaka, Katsu

    2014-07-01

    Vortex formation in the left ventricle (LV) can be visualized by novel vector flow mapping (VFM) based on color Doppler and speckle tracking data. The aim of this study was to evaluate the impact of a vortex during the ejection period using VFM. Color Doppler images were obtained to produce VFM images in 80 subjects (20 normal, 29 with dilated cardiomyopathy, and 31 with old myocardial infarction). The duration of the LV vortex was measured and expressed as the ratio to the ejection time (VTRe). The VTRe showed significant correlations with EDV (ρ = 0.672, p < 0.001), ESV (ρ = 0.772, p < 0.001), EF (ρ = -0.783, p < 0.001), left atrium diameter (LAd) (ρ = 0.302, p = 0.007), stroke volume (ρ = -0.600, p < 0.001), e' (ρ = -0.389, p < 0.001), a' (ρ = -0.314, p = 0.005), s' (ρ = -0.512, p < 0.001), and E/e' (ρ = 0.330, p = 0.003). The diastolic parameters (e', a', E/e', LAd) were not correlated when they were adjusted by EF. In the normal LV, a vortex existed for only a limited time during the early ejection period. In contrast, the lower the EF was, the longer the vortex remained during systole. Evaluation of vortices by VFM may noninvasively provide novel insights into the pathophysiology of impaired cardiac function.

  7. Comparison and co-relation of invasive and noninvasive methods of ejection fraction measurement.

    PubMed Central

    Godkar, Darshan; Bachu, Kalyan; Dave, Bijal; Megna, Robert; Niranjan, Selva; Khanna, Ashok

    2007-01-01

    BACKGROUND: Accurate estimation of left ventricular ejection fraction (LVEF) has assumed great significance in the era of automatic implantable cardioverter defibrillators (AICDs), and a low EF may be one of the sole deciding factor in determining AICD implantation in certain patient populations. AIM: There are various methods, invasive and noninvasive, which can help calculate EF. We sought to conduct a retrospective study comparing EF estimation by invasive (angiography) and noninvasive methods [MUGA (multiple-gated acquisition), echocardiography (echo), single-photon emission computed tomography (SPECT)] in 5,558 patients in our hospital from 1995-2004. METHODS AND RESULTS: EF was estimated by > or = 1 method (angiography, MUGA, echo, SPECT) within a one-month period. Values for the four tests in 5,558 patients were as follows: angiography mean 46.2, range 20-75, standard deviation (SD) 13.1; MUGA mean 45.7, range 20-70, SD 11.6; echo mean 45.7, range 22-70, SD 11.2; and SPECT mean 54.4, range 30-75, SD 11.9. Excellent positive correlations were found among all four tests as follows: angiography and MUGA, correlation coefficient (r) = 0.97, angiography and echo r = 0.96, angiography and SPECT r = 0.94, MUGA and echo r = 0.97, MUGA and SPECT r = 0.94, and echo and SPECT r = 0.94. Values for SPECT were significantly higher than for angiography, echo and MUGA (p < 0.001). The arithmetic difference between angiography and MUGA (mean 0.50, range -5.0-5.0) and the arithmetic difference between angiography and echo (mean 0.52, range -5.0-15.0) were similar (p = 0.59). The arithmetic difference between SPECT and angiography (mean 8.2, range -15.0-20.0) was significantly larger than the arithmetic difference between angiography and echo (p < 0.001). CONCLUSIONS: All the four methods used to estimate EF corelate well with each other. However, values estimated during stress testing by SPECT overestimate EF and are significantly higher as compared to MUGA, echo and

  8. Assessing Strategies for Heart Failure with Preserved Ejection Fraction at the Outpatient Clinic

    PubMed Central

    Jorge, Antonio José Lagoeiro; Rosa, Maria Luiza Garcia; Ribeiro, Mario Luiz; Fernandes, Luiz Claudio Maluhy; Freire, Monica Di Calafiori; Correia, Dayse Silva; Teixeira, Patrick Duarte; Mesquita, Evandro Tinoco

    2014-01-01

    Background: Heart failure with preserved ejection fraction (HFPEF) is the most common form of heart failure (HF), its diagnosis being a challenge to the outpatient clinic practice. Objective: To describe and compare two strategies derived from algorithms of the European Society of Cardiology Diastology Guidelines for the diagnosis of HFPEF. Methods: Cross-sectional study with 166 consecutive ambulatory patients (67.9±11.7 years; 72% of women). The strategies to confirm HFPEF were established according to the European Society of Cardiology Diastology Guidelines criteria. In strategy 1 (S1), tissue Doppler echocardiography (TDE) and electrocardiography (ECG) were used; in strategy 2 (S2), B-type natriuretic peptide (BNP) measurement was included. Results: In S1, patients were divided into groups based on the E/E'ratio as follows: GI, E/E'> 15 (n = 16; 9%); GII, E/E'8 to 15 (n = 79; 48%); and GIII, E/E'< 8 (n = 71; 43%). HFPEF was confirmed in GI and excluded in GIII. In GII, TDE [left atrial volume index (LAVI) ≥ 40 mL/m2; left ventricular mass index LVMI) > 122 for women and > 149 g/m2 for men] and ECG (atrial fibrillation) parameters were assessed, confirming HFPEF in 33 more patients, adding up to 49 (29%). In S2, patients were divided into three groups based on BNP levels. GI (BNP > 200 pg/mL) consisted of 12 patients, HFPEF being confirmed in all of them. GII (BNP ranging from 100 to 200 pg/mL) consisted of 20 patients with LAVI > 29 mL/m2, or LVMI ≥ 96 g/m2 for women or ≥ 116 g/m2 for men, or E/E'≥ 8 or atrial fibrillation on ECG, and the diagnosis of HFPEF was confirmed in 15. GIII (BNP < 100 pg/mL) consisted of 134 patients, 26 of whom had the diagnosis of HFPEF confirmed when GII parameters were used. Measuring BNP levels in S2 identified 4 more patients (8%) with HFPEF as compared with those identified in S1. Conclusion: The association of BNP measurement and TDE data is better than the isolated use of those parameters. BNP can be useful in

  9. Baroreflex Activation Therapy for the Treatment of Heart Failure With a Reduced Ejection Fraction.

    PubMed

    Abraham, William T; Zile, Michael R; Weaver, Fred A; Butter, Christian; Ducharme, Anique; Halbach, Marcel; Klug, Didier; Lovett, Eric G; Müller-Ehmsen, Jochen; Schafer, Jill E; Senni, Michele; Swarup, Vijay; Wachter, Rolf; Little, William C

    2015-06-01

    The objective of this clinical trial was to assess the safety and efficacy of carotid BAT in advanced HF. Increased sympathetic and decreased parasympathetic activity contribute to heart failure (HF) symptoms and disease progression. Baroreflex activation therapy (BAT) results in centrally mediated reduction of sympathetic outflow and increased parasympathetic activity. Patients with New York Heart Association (NYHA) functional class III HF and ejection fractions ≤35% on chronic stable guideline-directed medical therapy (GDMT) were enrolled at 45 centers in the United States, Canada, and Europe. They were randomly assigned to receive ongoing GDMT alone (control group) or ongoing GDMT plus BAT (treatment group) for 6 months. The primary safety end point was system- and procedure-related major adverse neurological and cardiovascular events. The primary efficacy end points were changes in NYHA functional class, quality-of-life score, and 6-minute hall walk distance. One hundred forty-six patients were randomized, 70 to control and 76 to treatment. The major adverse neurological and cardiovascular event-free rate was 97.2% (lower 95% confidence bound 91.4%). Patients assigned to BAT, compared with control group patients, experienced improvements in the distance walked in 6 min (59.6 ± 14 m vs. 1.5 ± 13.2 m; p = 0.004), quality-of-life score (-17.4 ± 2.8 points vs. 2.1 ± 3.1 points; p < 0.001), and NYHA functional class ranking (p = 0.002 for change in distribution). BAT significantly reduced N-terminal pro-brain natriuretic peptide (p = 0.02) and was associated with a trend toward fewer days hospitalized for HF (p = 0.08). BAT is safe and improves functional status, quality of life, exercise capacity, N-terminal pro-brain natriuretic peptide, and possibly the burden of heart failure hospitalizations in patients with GDMT-treated NYHA functional class III HF. (Barostim Neo System in the Treatment of Heart Failure; NCT01471860; Barostim HOPE4HF [Hope for

  10. Prognostic importance of left ventricular mechanical dyssynchrony in heart failure with preserved ejection fraction.

    PubMed

    Biering-Sørensen, Tor; Shah, Sanjiv J; Anand, Inder; Sweitzer, Nancy; Claggett, Brian; Liu, Li; Pitt, Bertram; Pfeffer, Marc A; Solomon, Scott D; Shah, Amil M

    2017-08-01

    Left ventricular mechanical dyssynchrony has been described in heart failure with preserved ejection fraction (HFpEF), but its prognostic significance is not known. Of 3445 patients with HFpEF enrolled in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial, dyssynchrony analysis was performed on 424 patients (12%) by multiple speckle tracking echocardiography strain-based criteria. The primary dyssynchrony analysis was the standard deviation of the time to peak longitudinal strain (SD T2P LS). Cox proportional hazards models assessed the association of dyssynchrony with the composite outcome of cardiovascular death or heart failure hospitalization. Mean age was 70 ± 10 years, LVEF was 60 ± 8%, and QRS duration was 101 ± 27 ms. Worse dyssynchrony, reflected in SD T2P LS, was associated with wider QRS, prior myocardial infarction, larger LV volume and mass, and worse systolic (lower LVEF and global longitudinal strain) and diastolic (lower e' and higher E/e') function. During a median follow-up of 2.6 (interquartile range 1.5-3.8) years, 107 patients experienced the composite outcome. Worse dyssynchrony was associated with the composite outcome in unadjusted analysis [hazard ratio (HR) 1.04, 95% confidence interval (CI) 1.01-1.07; P = 0.021, per 10 ms increase], but not after adjusting for clinical characteristics, or after further adjustment for LVEF, AF, NYHA class, stroke, heart rate, creatinine, haematocrit, and QRS duration (HR 1.03, 95% CI 0.99-1.06; P = 0.16, per 10 ms increase). Worse LV mechanical dyssynchrony, assessed by speckle tracking echocardiography, is not an independent predictor of adverse outcomes in HFpEF, suggesting that mechanical dyssynchrony is unlikely to be an important mechanism underlying this syndrome. These findings warrant validation in an independent study specifically designed to assess the prognostic utility of mechanical dyssynchrony in HFpEF. NCT00094302.

  11. Ethnic differences in the association of QRS duration with ejection fraction and outcome in heart failure.

    PubMed

    Gijsberts, Crystel M; Benson, Lina; Dahlström, Ulf; Sim, David; Yeo, Daniel P S; Ong, Hean Yee; Jaufeerally, Fazlur; Leong, Gerard K T; Ling, Lieng H; Richards, A Mark; de Kleijn, Dominique P V; Lund, Lars H; Lam, Carolyn S P

    2016-09-15

    QRS duration (QRSd) criteria for device therapy in heart failure (HF) were derived from predominantly white populations and ethnic differences are poorly understood. We compared the association of QRSd with ejection fraction (EF) and outcomes between 839 Singaporean Asian and 11 221 Swedish white patients with HF having preserved EF (HFPEF)and HF having reduced EF (HFREF) were followed in prospective population-based HF studies. Compared with whites, Asian patients with HF were younger (62 vs 74 years, p<0.001), had smaller body size (height 163 vs 171 cm, weight 70 vs 80 kg, both p<0.001) and had more severely impaired EF (EF was <30% in 47% of Asians vs 28% of whites). Overall, unadjusted QRSd was shorter in Asians than whites (101 vs 104 ms, p<0.001). Lower EF was associated with longer QRSd (p<0.001), with a steeper association among Asians than whites (pinteraction<0.001), independent of age, sex and clinical covariates (including body size). Excluding patients with left bundle branch block (LBBB) and adjusting for clinical covariates, QRSd was similar in Asians and whites with HFPEF, but longer in Asians compared with whites with HFREF (p=0.001). Longer QRSd was associated with increased risk of HF hospitalisation or death (absolute 2-year event rate for ≤120 ms was 40% and for >120 ms it was 52%; HR for 10 ms increase of QRSd was 1.04 (1.03 to 1.06), p<0.001), with no interaction by ethnicity. We found ethnic differences in the association between EF and QRSd among patients with HF. QRS prolongation was similarly associated with increased risk, but the implications for ethnicity-specific QRSd cut-offs in clinical decision-making require further study. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

  12. [Predictive variables for mortality in elderly patients hospitalized due to heart failure with preserved ejection fraction].

    PubMed

    Carrasco-Sánchez, Francisco Javier; Páez-Rubio, María Inmaculada; García-Moreno, Juana María; Vázquez-García, Irene; Araujo-Sanabria, Joaquín; Pujo-de la Llave, Emilio

    2013-11-16

    The prevalence of heart failure (HF) increases with age. Even though the mortality of patients ≥ 80 years of age with HF and preserved left ventricle ejection fraction (LVEF) is very high, the predictor variables are not well-known. The main goal of this study was to evaluate the mortality predictor factors in this subgroup of the elderly population. An observational and prospective study of patients hospitalized due to HF with preserved LVEF has been conducted. The demographic, clinical, functional and analytic factors were evaluated when the patients were admitted with special attention to the co-morbidities. The primary endpoint was the total mortality in the subgroup of patients ≥ 80 years of age after a year of follow-up. The predictor variables were studied by means of a multivariate Cox regression model. From a total of 218 patients with an average age of 75.6 (±8.7) years of age, 75 patients (34.4%) were ≥ 80 years. The mortality rate of patients ≥ 80 years of age totaled 42.7%, in relation to 26.6% for the lower age group (log-rank<.001). After a multivariate analysis using the Cox regression model in patients ≥ 80, the serum urea levels above the average (hazard ratio [HR] 3.93; 95% confidence interval [95% CI] 1.58-9.75; P = .003), the age (HR 1.17; 95% CI 1.07-1.28; P<.001), the hyponatremia (HR 3.19; 95% CI 1.51-6.74; P = .002) and a lower score on the Barthel index (BI) (HR 1.016; 95% CI 1.002-1.031; P = .034) were independent mortality predictors after an one-year follow-up. Serum urea levels, age, hyponatremia and a low BI score could be proposed as independent mortality predictors in patients ≥ 80 of age hospitalized for HF with preserved LVEF. Copyright © 2012 Elsevier España, S.L. All rights reserved.

  13. Effects of Sildenafil on Ventricular and Vascular Function in Heart Failure With Preserved Ejection Fraction

    PubMed Central

    Borlaug, Barry A.; Lewis, Gregory D.; McNulty, Steven E.; Semigran, Marc J.; LeWinter, Martin; Chen, Horng; Lin, Grace; Deswal, Anita; Margulies, Kenneth B.; Redfield, Margaret M.

    2015-01-01

    Background Early studies showed beneficial effects of phosphodiesterase 5 inhibitors (PDE5i) on cardiovascular function in heart failure (HF) patients, but the RELAX trial observed no improvement in exercise capacity with sildenafil treatment in subjects with HF and preserved ejection fraction (HFpEF). Methods and Results A subgroup of participants in the RELAX trial (n=48) underwent comprehensive noninvasive cardiovascular assessment before and after treatment with sildenafil or placebo in a prospective ancillary study. Left ventricular (LV) contractility was assessed by peak power index (PWR/EDV) and stroke work index (SW/EDV). Systemic arterial load was assessed by arterial elastance (Ea) and right ventricular afterload by pulmonary artery systolic pressure (PASP). Endothelial function was assessed by reactive hyperemia index (RHI) following upper arm cuff occlusion. Compared to placebo (n=25), sildenafil (n=23) decreased Ea (−0.29±0.28mmHg/ml vs +0.02±0.29, p=0.008) and tended to improve RHI (+0.30±0.45 vs −0.17±0.30, p=0.054). In contrast, LV contractility was reduced by 11–16% with sildenafil compared to placebo (ΔPWR/EDV −52±70 vs +0±40 mmHg/s, p=0.006; ΔSW/EDV +0.3±5.8 vs −6.0±5.1 mmHg, p=0.04). Sildenafil had no effect on PASP. Conclusions In subjects with HFpEF, sildenafil displayed opposing effects on ventricular and vascular function. We speculate that beneficial effects of PDE5i in the systemic vasculature and endothelium were insufficient to improve clinical status, or that the deleterious effects on left ventricular function offset any salutary vascular effects, contributing to the absence of benefit observed with sildenafil in subjects with HFpEF in the RELAX trial. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00094302. PMID:25782985

  14. Skeletal muscle abnormalities and exercise intolerance in older patients with heart failure and preserved ejection fraction

    PubMed Central

    Nicklas, Barbara; Kraus, William E.; Lyles, Mary F.; Eggebeen, Joel; Morgan, Timothy M.; Haykowsky, Mark

    2014-01-01

    Heart failure (HF) with preserved ejection fraction (HFPEF) is the most common form of HF in older persons. The primary chronic symptom in HFPEF is severe exercise intolerance, and its pathophysiology is poorly understood. To determine whether skeletal muscle abnormalities contribute to their severely reduced peak exercise O2 consumption (V̇o2), we examined 22 older HFPEF patients (70 ± 7 yr) compared with 43 age-matched healthy control (HC) subjects using needle biopsy of the vastus lateralis muscle and cardiopulmonary exercise testing to assess muscle fiber type distribution and capillarity and peak V̇o2. In HFPEF versus HC patients, peak V̇o2 (14.7 ± 2.1 vs. 22.9 ± 6.6 ml·kg−1·min−1, P < 0.001) and 6-min walk distance (454 ± 72 vs. 573 ± 71 m, P < 0.001) were reduced. In HFPEF versus HC patients, the percentage of type I fibers (39.0 ± 11.4% vs. 53.7 ± 12.4%, P < 0.001), type I-to-type II fiber ratio (0.72 ± 0.39 vs. 1.36 ± 0.85, P = 0.001), and capillary-to-fiber ratio (1.35 ± 0.32 vs. 2.53 ± 1.37, P = 0.006) were reduced, whereas the percentage of type II fibers was greater (61 ± 11.4% vs. 46.3 ± 12.4%, P < 0.001). In univariate analyses, the percentage of type I fibers (r = 0.39, P = 0.003), type I-to-type II fiber ratio (r = 0.33, P = 0.02), and capillary-to-fiber ratio (r = 0.59, P < 0.0001) were positively related to peak V̇o2. In multivariate analyses, type I fibers and the capillary-to-fiber ratio remained significantly related to peak V̇o2. We conclude that older HFPEF patients have significant abnormalities in skeletal muscle, characterized by a shift in muscle fiber type distribution with reduced type I oxidative muscle fibers and a reduced capillary-to-fiber ratio, and these may contribute to their severe exercise intolerance. This suggests potential new therapeutic targets in this difficult to treat disorder. PMID:24658015

  15. Effect of Nebivolol on MIBG Parameters and Exercise in Heart Failure with Normal Ejection Fraction.

    PubMed

    Messias, Leandro Rocha; Ferreira, Aryanne Guimarães; Miranda, Sandra Marina Ribeiro de; Teixeira, José Antônio Caldas; Azevedo, Jader Cunha de; Messias, Ana Carolina Nader Vasconcelos; Maróstica, Elisabeth; Mesquita, Claudio Tinoco

    2016-05-01

    More than 50% of the patients with heart failure have normal ejection fraction (HFNEF). Iodine-123 metaiodobenzylguanidine (123I-MIBG) scintigraphy and cardiopulmonary exercise test (CPET) are prognostic markers in HFNEF. Nebivolol is a beta-blocker with vasodilating properties. To evaluate the impact of nebivolol therapy on CPET and123I-MIBG scintigraphic parameters in patients with HFNEF. Twenty-five patients underwent 123I-MIBG scintigraphy to determine the washout rate and early and late heart-to-mediastinum ratios. During the CPET, we analyzed the systolic blood pressure (SBP) response, heart rate (HR) during effort and recovery (HRR), and oxygen uptake (VO2). After the initial evaluation, we divided our cohort into control and intervention groups. We then started nebivolol and repeated the tests after 3 months. After treatment, the intervention group showed improvement in rest SBP (149 mmHg [143.5-171 mmHg] versus 135 mmHg [125-151 mmHg, p = 0.016]), rest HR (78 bpm [65.5-84 bpm] versus 64.5 bpm [57.5-75.5 bpm, p = 0.028]), peak SBP (235 mmHg [216.5-249 mmHg] versus 198 mmHg [191-220.5 mmHg], p = 0.001), peak HR (124.5 bpm [115-142 bpm] versus 115 bpm [103.7-124 bpm], p= 0.043), HRR on the 1st minute (6.5 bpm [4.75-12.75 bpm] versus 14.5 bpm [6.7-22 bpm], p = 0.025) and HRR on the 2nd minute (15.5 bpm [13-21.75 bpm] versus 23.5 bpm [16-31.7 bpm], p = 0.005), but no change in peak VO2 and 123I-MIBG scintigraphic parameters. Despite a better control in SBP, HR during rest and exercise, and improvement in HRR, nebivolol failed to show a positive effect on peak VO2 and 123I-MIBG scintigraphic parameters. The lack of effect on adrenergic activity may be the cause of the lack of effect on functional capacity.

  16. Inspiratory Muscle Function and Exercise Capacity in Patients With Heart Failure With Preserved Ejection Fraction.

    PubMed

    Palau, Patricia; Domínguez, Eloy; Núñez, Eduardo; Ramón, Jose María; López, Laura; Melero, Joana; Bellver, Alejandro; Chorro, Francisco J; Bodí, Vicent; Bayés-Genis, Antoni; Sanchis, Juan; Núñez, Julio

    2017-06-01

    Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome characterized by impaired exercise capacity resulting from dyspnea and fatigue. The pathophysiological mechanisms underlying the exercise intolerance in HFpEF are not well established. We sought to evaluate the effects of inspiratory muscle function on exercise tolerance in symptomatic patients with HFpEF. A total of 74 stable symptomatic patients with HFpEF and New York Heart Association class II-III underwent a cardiopulmonary exercise test between June 2012 and May 2016. Inspiratory muscle weakness was defined as maximum inspiratory pressure (MIP)  <70% of normal predicted values. Pearson correlation coefficient and multivariate linear regression analysis were used to assess the association between percent of predicted MIP (pp-MIP) and maximal exercise capacity [measured by peak oxygen uptake (peak VO2) and percent of predicted peak VO2 (pp-peak VO2)]. Thirty-one patients (42%) displayed inspiratory muscle weakness. Mean (standard deviation) age was 72.5 ± 9.1 years, 53% were women, and 35.1% displayed New York Heart Association class III. Mean peak VO2 and pp-peak VO2 were 10 ± 2.8 mL•min•kg and 57.3 ± 13.8%, respectively. The median (interquartile range) of pp-MIP was 72% (58%-90%). pp-MIP was not correlated with peak VO2 (r = -0.047, P = .689) nor pp-peak VO2 (r = -0.078, P = .509). Furthermore, in multivariable analysis, pp-MIP showed no association with peak VO2 (β coefficient = 0.01, 95% confidence interval -0.01 to 0.03, P = .241) and pp-peak VO2 (β coefficient = -0.00, 95% confidence interval -0.10 to 0.10, P = .975). In symptomatic elderly patients with HFpEF, we found that pp-MIP was not associated with either peak VO2 or pp-peak VO2. Copyright © 2017 Elsevier Inc. All rights reserved.

  17. Abnormal haemodynamic response to exercise in heart failure with preserved ejection fraction

    PubMed Central

    Bhella, Paul S.; Prasad, Anand; Heinicke, Katja; Hastings, Jeff L.; Arbab-Zadeh, Armin; Adams-Huet, Beverley; Pacini, Eric L.; Shibata, Shigeki; Palmer, M. Dean; Newcomer, Bradley R.; Levine, Benjamin D.

    2011-01-01

    Aims Peak oxygen uptake (VO2) is diminished in patients with heart failure with preserved ejection fraction (HFpEF) suggesting impaired cardiac reserve. To test this hypothesis, we assessed the haemodynamic response to exercise in HFpEF patients. Methods and results Eleven HFpEF patients (73 ± 7 years, 7 females/4 males) and 13 healthy controls (70 ± 4 years, 6 females/7 males) were studied during submaximal and maximal exercise. The cardiac output (Qc, acetylene rebreathing) response to exercise was determined from linear regression of Qc and VO2 (Douglas bags) at rest, ∼30% and ∼60% of peak VO2, and maximal exercise. Peak VO2 was lower in HFpEF patients than in controls (13.7 ± 3.4 vs. 21.6 ± 3.6 mL/kg/min; P < 0.001), while indices of cardiac reserve were not statistically different: peak cardiac power output [CPO = Qc × mean arterial pressure (MAP); HFpEF 1790 ± 509 vs. controls 2119 ± 581 L/mmHg/min; P = 0.20]; peak stroke work [SW = stroke volume (SV) × MAP; HFpEF 13 429 ± 2269 vs. controls 13 200 ± 3610 mL/mmHg; P = 0.80]. The ΔQc/ΔVO2 slope was abnormally elevated in HFpEF patients vs. controls (11.2 ±3.6 vs. 8.3 ± 1.5; P = 0.015). Conclusion Contrary to our hypothesis, cardiac reserve is not significantly impaired in well-compensated outpatients with HFpEF. The abnormal haemodynamic response to exercise (decreased peak VO2, increased ΔQc/ΔVO2 slope) is similar to that observed in patients with mitochondrial myopathies, suggesting an element of impaired skeletal muscle oxidative metabolism. This impairment may limit functional capacity by two mechanisms: (i) premature skeletal muscle fatigue and (ii) metabolic signals to increase the cardiac output response to exercise which may be poorly tolerated by a left ventricle with impaired diastolic function. PMID:21979991

  18. Left atrial decompression pump for severe heart failure with preserved ejection fraction: theoretical and clinical considerations.

    PubMed

    Burkhoff, Daniel; Maurer, Mathew S; Joseph, Susan M; Rogers, Joseph G; Birati, Edo Y; Rame, J Eduardo; Shah, Sanjiv J

    2015-04-01

    The purpose of this study was to provide insight into the potential for left atrium (LA) to aortic mechanical circulatory support as a treatment for patients with heart failure with preserved ejection fraction (HFpEF). Although HFpEF arises from different etiologies, 1 hallmark of all forms of this syndrome is a small or minimally-dilated left ventricle (LV). Consequently, the use of traditional mechanical circulatory support in end-stage patients has been difficult. In contrast, HFpEF is also characterized by a large LA. Hemodynamic characteristics of 4 distinct HFpEF phenotypes were characterized from the published data: 1) hypertrophic cardiomyopathies; 2) infiltrative diseases; 3) nonhypertrophic HFpEF; and 4) HFpEF with common cardiovascular comorbidities (e.g., hypertension). Employing a previously-described cardiovascular simulation, the effects of a low-flow, micropump-based LA decompression device were modeled. The effect of sourcing blood from the LV versus the LA was compared. For all HFpEF phenotypes, mechanical circulatory support significantly increased cardiac output, provided a mild increase in blood pressure, and markedly reduced pulmonary and LA pressures. LV sourcing of blood reduced LV end-systolic volume into a range likely to induce suction. With LA sourcing, however, LV end-systolic volume increased compared with baseline. Due to pre-existing LA enlargement, LA volumes remained sufficiently elevated, thus minimizing the risk of suction. This theoretical analysis suggests that a strategy involving pumping blood from the LA to the arterial system may provide a viable option for end-stage HFpEF. Special considerations apply to each of the 4 types of HFpEF phenotypes described. Finally, an HFpEF-specific clinical profile scoring system (such as that of INTERMACS [Interagency Registry for Mechanically Assisted Circulatory Support]) would aid in the selection of patients with the appropriate risk-benefit ratio for implantation of an active pump

  19. Heart Failure With Preserved Ejection Fraction Induces Beiging in Adipose Tissue.

    PubMed

    Valero-Muñoz, María; Li, Shanpeng; Wilson, Richard M; Hulsmans, Maarten; Aprahamian, Tamar; Fuster, José J; Nahrendorf, Matthias; Scherer, Philipp E; Sam, Flora

    2016-01-01

    Despite the increasing prevalence of heart failure with preserved ejection fraction (HFpEF) in humans, there are no evidence-based therapies for HFpEF. Clinical studies suggest a relationship between obesity-associated dysfunctional adipose tissue (AT) and HFpEF. However, an apparent obesity paradox exists in some HF populations with a higher body mass index. We sought to determine whether HFpEF exerted effects on AT and investigated the involved mechanisms. Mice underwent d-aldosterone infusion, uninephrectomy, and were given 1% saline for 4 weeks. HFpEF mice developed hypertension, left ventricular hypertrophy, and diastolic dysfunction and had higher myocardial natriuretic peptide expression. Although body weights were similar in HFpEF and sham-operated mice, white AT was significantly smaller in HFpEF than in sham (epididymal AT, 7.59 versus 10.67 mg/g; inguinal AT, 6.34 versus 8.38 mg/g). These changes were associated with smaller adipocyte size and increased beiging markers (ucp-1, cidea, and eva) in white AT. Similar findings were seen in HFpEF induced by transverse aortic constriction. Increased activation of natriuretic peptide signaling was seen in white AT of HFpEF mice. The ratio of the signaling receptor, natriuretic peptide receptor type A, to the clearance receptor, nprc, was increased as was p38 mitogen-activated protein kinase activation. However, HFpEF mice failed to regulate body temperature during cold temperature exposure. In HFpEF, despite a larger brown AT mass (5.96 versus 4.50 mg/g), brown AT showed reduced activity with decreased uncoupling protein 1 (ucp-1), cell death-inducing DFFA-like effector a (cidea), and epithelial V-like antigen (eva) expression and decreased expression of lipolytic enzymes (hormone-sensitive lipase, lipoprotein lipase, and fatty acid binding protein 4) versus sham. These findings show that HFpEF is associated with beiging in white AT and with dysfunctional brown AT. © 2015 American Heart Association, Inc.

  20. Outcome of cardiac surgery in patients with low preoperative ejection fraction.

    PubMed

    Pieri, Marina; Belletti, Alessandro; Monaco, Fabrizio; Pisano, Antonio; Musu, Mario; Dalessandro, Veronica; Monti, Giacomo; Finco, Gabriele; Zangrillo, Alberto; Landoni, Giovanni

    2016-10-18

    In patients undergoing cardiac surgery, a reduced preoperative left ventricular ejection fraction (LVEF) is common and is associated with a worse outcome. Available outcome data for these patients address specific surgical procedures, mainly coronary artery bypass graft (CABG). Aim of our study was to investigate perioperative outcome of surgery on patients with low pre-operative LVEF undergoing a broad range of cardiac surgical procedures. Data from patients with pre-operative LVEF ≤40 % undergoing cardiac surgery at a university hospital were reviewed and analyzed. A subgroup analysis on patients with pre-operative LVEF ≤30 % was also performed. A total of 7313 patients underwent cardiac surgery during the study period. Out of these, 781 patients (11 %) had a pre-operative LVEF ≤40 % and were included in the analysis. Mean pre-operative LVEF was 33.9 ± 6.1 % and in 290 patients (37 %) LVEF was ≤30 %. The most frequently performed operation was CABG (31 % of procedures), followed by mitral valve surgery (22 %) and aortic valve surgery (19 %). Overall perioperative mortality was 5.6 %. Mitral valve surgery was more frequent among patients who did not survive, while survivors underwent more frequently CABG. Post-operative myocardial infarction occurred in 19 (2.4 %) of patients, low cardiac output syndrome in 271 (35 %). Acute kidney injury occurred in 195 (25 %) of patients. Duration of mechanical ventilation was 18 (12-48) hours. Incidence of complications was higher in patients with LVEF ≤30 %. Stepwise multivariate analysis identified chronic obstructive pulmonary disease, pre-operative insertion of intra-aortic balloon pump, and pre-operative need for inotropes as independent predictors of mortality among patients with LVEF ≤40 %. We confirmed that patients with low pre-operative LVEF undergoing cardiac surgery are at higher risk of post-operative complications. Cardiac surgery can be performed with acceptable mortality rates

  1. The Fraction of Interplanetary Coronal Mass Ejections That Are Magnetic Clouds: Evidence for a Solar Cycle Variation

    NASA Technical Reports Server (NTRS)

    Richardson, I. G.; Cane, H. V.

    2004-01-01

    "Magnetic clouds" (MCs) are a subset of interplanetary coronal mass ejections (ICMEs) characterized by enhanced magnetic fields with an organized rotation in direction, and low plasma beta. Though intensely studied, MCs only constitute a fraction of all the ICMEs that are detected in the solar wind. A comprehensive survey of ICMEs in the near- Earth solar wind during the ascending, maximum and early declining phases of solar cycle 23 in 1996 - 2003 shows that the MC fraction varies with the phase of the solar cycle, from approximately 100% (though with low statistics) at solar minimum to approximately 15% at solar maximum. A similar trend is evident in near-Earth observations during solar cycles 20 - 21, while Helios 1/2 spacecraft observations at 0.3 - 1.0 AU show a weaker trend and larger MC fraction.

  2. Cardiac Amyloidosis and its New Clinical Phenotype: Heart Failure with Preserved Ejection Fraction.

    PubMed

    Mesquita, Evandro Tinoco; Jorge, Antonio José Lagoeiro; Souza, Celso Vale; Andrade, Thais Ribeiro de

    2017-07-01

    Heart failure with preserved ejection fraction (HFpEF) is now an emerging cardiovascular epidemic, being identified as the main phenotype observed in clinical practice. It is more associated with female gender, advanced age and comorbidities such as hypertension, diabetes, obesity and chronic kidney disease. Amyloidosis is a clinical disorder characterized by the deposition of aggregates of insoluble fibrils originating from proteins that exhibit anomalous folding. Recently, pictures of senile amyloidosis have been described in patients with HFpEF, demonstrating the need for clinical cardiologists to investigate this etiology in suspect cases. The clinical suspicion of amyloidosis should be increased in cases of HFPS where the cardio imaging methods are compatible with infiltrative cardiomyopathy. Advances in cardio imaging methods combined with the possibility of performing genetic tests and identification of the type of amyloid material allow the diagnosis to be made. The management of the diagnosed patients can be done in partnership with centers specialized in the study of amyloidosis, which, together with the new technologies, investigate the possibility of organ or bone marrow transplantation and also the involvement of patients in clinical studies that evaluate the action of the new emerging drugs. Resumo A insuficiência cardíaca com fração de ejeção preservada (ICFEP) é hoje uma epidemia cardiovascular emergente, sendo identificada como o principal fenótipo observado na prática clínica. Está mais associado ao sexo feminino, idade avançada e a comorbidades como hipertensão arterial, diabetes, obesidade e doença renal crônica. A amiloidose é uma desordem clínica caracterizada pelo depósito de agregados de fibrilas insolúveis originadas de proteínas que apresentam dobramento anômalo. Recentemente, têm sido descritos quadros de amiloidose senil em pacientes com ICFEP, demonstrando a necessidade de os cardiologistas clínicos investigarem

  3. Evidence Supporting the Existence of a Distinct Obese Phenotype of Heart Failure with Preserved Ejection Fraction.

    PubMed

    Obokata, Masaru; Reddy, Yogesh N V; Pislaru, Sorin V; Melenovsky, Vojtech; Borlaug, Barry A

    2017-04-05

    Background -Heart failure (HF) with preserved ejection fraction (HFpEF) is a heterogeneous syndrome. Phenotyping patients into pathophysiologically homogenous groups may enable better targeting of treatment. Obesity is common in HFpEF and has many cardiovascular effects, suggesting it may be a viable candidate for phenotyping. We compared cardiovascular structure, function, and reserve capacity in subjects with obese HFpEF, non-obese HFpEF, and controls. Methods -Subjects with obese HFpEF (BMI≥35kg/m(2), n=99), non-obese HFpEF (BMI<30kg/m(2), n=96), and non-obese controls free of HF (n=71) underwent detailed clinical assessment, echocardiography and invasive hemodynamic exercise testing. Results -Compared to both non-obese HFpEF and controls, subjects with obese HFpEF displayed increased plasma volume (3907 [3563,4333] vs. 2772 [2555,3133] and 2680 [2380,3006] ml, p<0.0001), more concentric left ventricular remodeling, greater right ventricular dilatation (base 34±7 vs. 31±6 and 30±6 mm, p=0.0005; length 66±7 vs. 61±7 and 61±7 mm, p<0.0001), more right ventricular dysfunction, increased epicardial fat thickness (10±2 vs. 7±2 and 6±2 mm, p<0.0001), and greater total epicardial heart volume (945 [831,1105] vs. 797 [643,979] and 632 [517,768] ml, p<0.0001), despite lower NT-proBNP levels. Pulmonary capillary wedge pressure was correlated with body mass and plasma volume in obese HFpEF (r=0.22 and 0.27, both p<0.05), but not in non-obese HFpEF (p≥0.3). The increase in heart volumes in obese HFpEF was associated with greater pericardial restraint and heightened ventricular interdependence, reflected by increased ratio of right to left heart filling pressures (0.64±0.17 vs. 0.56±0.19 and 0.53±0.20, p=0.0004), higher pulmonary venous pressure relative to left ventricular transmural pressure, and greater left ventricular eccentricity index (1.10±0.19 vs 0.99±0.06 and 0.97±0.12, p<0.0001). Interdependence was enhanced as pulmonary artery pressure load

  4. Current Treatment of Heart Failure with Preserved Ejection Fraction: Should We Add Life to the Remaining Years or Add Years to the Remaining Life?

    PubMed Central

    Li, Jia; Blankenberg, Stefan; Westermann, Dirk

    2013-01-01

    According to the ejection fraction, patients with heart failure may be divided into two different groups: heart failure with preserved or reduced ejection fraction. In recent years, accumulating studies showed that increased mortality and morbidity rates of these two groups are nearly equal. More importantly, despite decline in mortality after treatment in regard to current guideline in patients with heart failure with reduced ejection fraction, there are still no trials resulting in improved outcome in patients with heart failure with preserved ejection fraction so far. Thus, novel pathophysiological mechanisms are under development, and other new viewpoints, such as multiple comorbidities resulting in increased non-cardiac deaths in patients with heart failure and preserved ejection fraction, were presented recently. In this review, we will focus on the tested as well as the promising therapeutic options that are currently studied in patients with heart failure with preserved ejection fraction, along with a brief discussion of pathophysiological mechanisms and diagnostic options that are helpful to increase our understanding of novel therapeutic strategies. PMID:24251065

  5. Acute pulmonary edema in patients with reduced left ventricular ejection fraction is associated with concentric left ventricular geometry.

    PubMed

    Imanishi, Junichi; Kaihotsu, Kenji; Yoshikawa, Sachiko; Nishimori, Makoto; Sone, Naohiko; Honjo, Tomoyuki; Iwahashi, Masanori

    2017-08-02

    Although acute pulmonary edema (APE) is common in patients with heart failure (HF) with preserved ejection fraction (EF), its pathogenesis in patients with HF with reduced EF (HFrEF) is not completely understood. The purpose of our study was to explore the contributions of left ventricular (LV) geometry to understand the difference between HFrEF patients with or without APE. We studied 122 consecutive acute decompensated HF patients with HFrEF (≤40%). APE was defined as acute-onset dyspnea and radiographic alveolar edema requiring immediate airway intervention. LV geometry was determined from a combination of the LV mass index and relative wall thickness (RWT). Long-term unfavorable outcome events were tracked during a follow-up of a median of 21 months (interquartile range, 10-28 months), during which APE was observed in 29 patients (24%). Compared to those without APE, hospitalized patients with APE had a higher systolic blood pressure, RWT, and LVEF and lower end-diastolic dimension. Among echocardiographic variables, a multivariate logistic regression analysis identified RWT as the only independent determinant of APE (hazard ratio: 2.46, p < 0.001). Those with concentric geometry (n = 25; RWT > 0.42) had a higher incidence of APE relative to those with non-concentric geometry. Furthermore, among patients with APE, mortality was significantly higher among those with concentric geometry (log-rank, p = 0.008). Compared with non-concentric geometry, concentric geometry (increased RWT, not LV mass) was strongly associated with APE onset and a poorer outcome among APE patients. An easily obtained echocardiographic RWT index may facilitate the risk stratification of patients.

  6. Application of the Age, Creatinine, and Left Ventricular Ejection Fraction Score for Patients on Extracorporeal Membrane Oxygenation.

    PubMed

    Tsai, Tsung-Yu; Tsai, Feng-Chun; Fan, Pei-Chun; Chang, Chih-Hsiang; Lin, Chan-Yu; Chang, Wei-Wen; Lee, Shen-Yang; Hsu, Hsiang-Hao; Tian, Ya-Chung; Fang, Ji-Tseng; Yang, Chih-Wei; Chen, Yung-Chang

    2017-02-01

    Patients on extracorporeal membrane oxygenation (ECMO) usually have high mortality rate and poor outcome. Age, Creatinine, and Left Ventricular Ejection Fraction (ACEF) score is an easy-calculating score and provides good performance on mortality prediction in patients undergoing cardiac operations or percutaneous coronary intervention, but it has not been applied to patients on ECMO before. In this study, we aimed to use ACEF score obtained within 1 week of ECMO support for in-hospital mortality prediction in patients on ECMO due to severe myocardial failure. This study reviewed the medical records of 306 patients on ECMO at a specialized intensive care unit (CVSICU) in a tertiary-care university hospital between March 2002 and December 2011, and 105 patients on veno-arterial ECMO due to severe myocardial failure were enrolled. Demographic, clinical, and laboratory variables were retrospectively collected as survival predictors. The overall mortality rate was 47.6%. The most frequent condition requiring ICU admission was postcardiotomy cardiogenic shock. Multiple logistic regression analysis indicated that post-ECMO ACEF score, Sequential Organ Failure Assessment score, and troponin I on day 1 of ECMO support were independent risk factors for in-hospital mortality. Using the area under the receiver operating characteristic curve (AUROC), the post-ECMO ACEF score indicated a good discriminative power (AUROC 0.801 ± 0.042). Finally, cumulative survival rates at 6-month follow-up differed significantly (P < 0.001) for an ACEF score ≤ 2.22 versus those with an ACEF score > 2.22. After ECMO treatment due to severe myocardial failure, post-ECMO ACEF score provides an easy-calculating method with a reproducible evaluation tool with excellent prognostic abilities in these patients.

  7. Right atrial volume by cardiovascular magnetic resonance predicts mortality in patients with heart failure with reduced ejection fraction

    PubMed Central

    Ivanov, Alexander; Mohamed, Ambreen; Asfour, Ahmed; Ho, Jean; Khan, Saadat A.; Chen, Onn; Klem, Igor; Ramasubbu, Kumudha; Brener, Sorin J.; Heitner, John F.

    2017-01-01

    Background Right Atrial Volume Index (RAVI) measured by echocardiography is an independent predictor of morbidity in patients with heart failure (HF) with reduced ejection fraction (HFrEF). The aim of this study is to evaluate the predictive value of RAVI assessed by cardiac magnetic resonance (CMR) for all-cause mortality in patients with HFrEF and to assess its additive contribution to the validated Meta-Analysis Global Group in Chronic heart failure (MAGGIC) score. Methods and results We identified 243 patients (mean age 60 ± 15; 33% women) with left ventricular ejection fraction (LVEF) ≤ 35% measured by CMR. Right atrial volume was calculated based on area in two- and four -chamber views using validated equation, followed by indexing to body surface area. MAGGIC score was calculated using online calculator. During mean period of 2.4 years 33 patients (14%) died. The mean RAVI was 53 ± 26 ml/m2; significantly larger in patients with than without an event (78.7±29 ml/m2 vs. 48±22 ml/m2, p<0.001). RAVI (per ml/m2) was an independent predictor of mortality [HR = 1.03 (1.01–1.04), p = 0.001]. RAVI has a greater discriminatory ability than LVEF, left atrial volume index and right ventricular ejection fraction (RVEF) (C-statistic 0.8±0.08 vs 0.55±0.1, 0.62±0.11, 0.68±0.11, respectively, all p<0.02). The addition of RAVI to the MAGGIC score significantly improves risk stratification (integrated discrimination improvement 13%, and category-free net reclassification improvement 73%, both p<0.001). Conclusion RAVI by CMR is an independent predictor of mortality in patients with HFrEF. The addition of RAVI to MAGGIC score improves mortality risk stratification. PMID:28369148

  8. Prospective Association of Physical Activity and Heart Failure Hospitalizations Among Black Adults With Normal Ejection Fraction: The Jackson Heart Study.

    PubMed

    Koo, Patrick; Gjelsvik, Annie; Choudhary, Gaurav; Wu, Wen-Chih; Wang, Wei; McCool, F Dennis; Eaton, Charles B

    2017-09-07

    Given high rates of obesity, hypertension, and diabetes mellitus, black persons are at risk to develop heart failure. The association of moderate to vigorous physical activity (MVPA) and heart failure in black adults is underresearched. The purpose of this study was to explore whether greater MVPA was associated with lower risk of heart failure hospitalizations (HFHs) among black adults with normal ejection fractions. We performed a prospective analysis of 4066 black adults who participated in the Jackson Heart Study and who had physical activity measured, had normal ejection fraction on 2-dimensional echocardiograms, and were followed for 7 years for incident HFH. We used Cox proportional regression analyses adjusted for age, sex, body mass index, smoking status, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, coronary heart disease, atrial fibrillation, and chronic kidney disease and examined effect modification by sex and body mass index. Of the eligible population, 1925 participants, according to the duration of MVPA, had poor health (0 minutes/week), 1332 had intermediate health (1-149 minutes/week), and 809 had ideal health (≥150 minutes/week). There were 168 incident HFHs. MVPA for intermediate and ideal health was associated with decreasing risk of incident HFH (hazard ratio: 0.70 [95% confidence interval, 49-1.00] and 0.35 [95% confidence interval, 0.19-0.64], respectively; Ptrend=0.003). The full model revealed hazard ratios of 0.74 [95% confidence interval, 0.52-1.07] and 0.41 [95% confidence interval, 0.22-0.74], respectively. There was no effect modification between MVPA and body mass index or sex on incident HFH. A dose-response relationship between increasing levels of MVPA and protection from incident HFH was found in black men and women with normal ejection fractions. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

  9. Thirty Years of Evidence on the Efficacy of Drug Treatments for Chronic Heart Failure With Reduced Ejection Fraction

    PubMed Central

    Earley, Amy; Voors, Adriaan A.; Senni, Michele; McMurray, John J.V.; Deschaseaux, Celine; Cope, Shannon

    2017-01-01

    Background— Treatments that reduce mortality and morbidity in patients with heart failure with reduced ejection fraction, including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), β-blockers (BB), mineralocorticoid receptor antagonists (MRA), and angiotensin receptor–neprilysin inhibitors (ARNI), have not been studied in a head-to-head fashion. This network meta-analysis aimed to compare the efficacy of these drugs and their combinations regarding all-cause mortality in patients with heart failure with reduced ejection fraction. Methods and Results— A systematic literature review identified 57 randomized controlled trials published between 1987 and 2015, which were compared in terms of study and patient characteristics, baseline risk, outcome definitions, and the observed treatment effects. Despite differences identified in terms of study duration, New York Heart Association class, ejection fraction, and use of background digoxin, a network meta-analysis was considered feasible and all trials were analyzed simultaneously. The random-effects network meta-analysis suggested that the combination of ACEI+BB+MRA was associated with a 56% reduction in mortality versus placebo (hazard ratio 0.44, 95% credible interval 0.26–0.66); ARNI+BB+MRA was associated with the greatest reduction in all-cause mortality versus placebo (hazard ratio 0.37, 95% credible interval 0.19–0.65). A sensitivity analysis that did not account for background therapy suggested that ARNI monotherapy is more efficacious than ACEI or ARB monotherapy. Conclusions— The network meta-analysis showed that treatment with ACEI, ARB, BB, MRA, and ARNI and their combinations were better than the treatment with placebo in reducing all-cause mortality, with the exception of ARB monotherapy and ARB plus ACEI. The combination of ARNI+BB+MRA resulted in the greatest mortality reduction. PMID:28087688

  10. Dual antiplatelet compared to triple antithrombotic therapy in anterior wall acute myocardial infarction complicated by depressed left ventricular ejection fraction.

    PubMed

    Oyetayo, Ola O; Slicker, Kipp; De La Rosa, Lisa; Lane, Wesley; Langsjoen, Dane; Patel, Chhaya; Brough, Kevin; Michel, Jeffrey; Chiles, Christopher

    2015-10-01

    Current guidelines recommend triple antithrombotic therapy (TT) consisting of warfarin, aspirin, and a P2Y12 inhibitor following an anterior ST elevation myocardial infarction (STEMI) complicated by extensive wall motion abnormalities. This recommendation, however, is based on data collected before percutaneous coronary intervention (PCI) became the standard of care for the treatment of STEMI. We designed a retrospective study of patients who received PCI for anterior STEMI over an 8-year period to compare rates of thromboembolic and bleeding events between patients receiving dual antiplatelet therapy (DAPT) and those receiving TT, including warfarin. Patients were included if the predischarge echocardiogram showed extensive wall motion abnormality and an ejection fraction ≤35%. Patients with known left ventricular thrombus were excluded. A total of 124 patients met the criteria, with 80 patients in the DAPT group and 44 in the TT group. The median age was 58 years in the TT group and 64 years in the DAPT group (P < 0.04), with an average ejection fraction of 31%. Thromboembolic events occurred in 4 patients (5%) in the DAPT group compared with 3 patients (6.8%) in the TT group (P = 0.70). Bleeding occurred in 2 patients in the DAPT group and 4 patients in the TT group (2.5% in DAPT vs. 9.1% in TT group, P = 0.18). No differences in rates of clinical embolism or left ventricular thrombus were found. Our data support recent findings that warfarin may not be indicated for patients following PCI for anterior STEMI, even when significant wall motion abnormalities and reduced ejection fraction ≤35% are present.

  11. Dual antiplatelet compared to triple antithrombotic therapy in anterior wall acute myocardial infarction complicated by depressed left ventricular ejection fraction

    PubMed Central

    Oyetayo, Ola O.; Slicker, Kipp; De La Rosa, Lisa; Lane, Wesley; Langsjoen, Dane; Patel, Chhaya; Brough, Kevin; Chiles, Christopher

    2015-01-01

    Current guidelines recommend triple antithrombotic therapy (TT) consisting of warfarin, aspirin, and a P2Y12 inhibitor following an anterior ST elevation myocardial infarction (STEMI) complicated by extensive wall motion abnormalities. This recommendation, however, is based on data collected before percutaneous coronary intervention (PCI) became the standard of care for the treatment of STEMI. We designed a retrospective study of patients who received PCI for anterior STEMI over an 8-year period to compare rates of thromboembolic and bleeding events between patients receiving dual antiplatelet therapy (DAPT) and those receiving TT, including warfarin. Patients were included if the predischarge echocardiogram showed extensive wall motion abnormality and an ejection fraction ≤35%. Patients with known left ventricular thrombus were excluded. A total of 124 patients met the criteria, with 80 patients in the DAPT group and 44 in the TT group. The median age was 58 years in the TT group and 64 years in the DAPT group (P < 0.04), with an average ejection fraction of 31%. Thromboembolic events occurred in 4 patients (5%) in the DAPT group compared with 3 patients (6.8%) in the TT group (P = 0.70). Bleeding occurred in 2 patients in the DAPT group and 4 patients in the TT group (2.5% in DAPT vs. 9.1% in TT group, P = 0.18). No differences in rates of clinical embolism or left ventricular thrombus were found. Our data support recent findings that warfarin may not be indicated for patients following PCI for anterior STEMI, even when significant wall motion abnormalities and reduced ejection fraction ≤35% are present. PMID:26424937

  12. The value of the QRS scoring system in assessing regional and global left ventricular ejection fraction early after myocardial infarction.

    PubMed

    Bergovec, M; Prpìć, H; Mihatov, S; Zigman, M; Vukosavić, D; Birtić, K; Franceschi, D; Barić, L

    1993-08-01

    In 71 patients with a myocardial infarction (MI) (anterior in 27, inferior in 44 patients) global (GEF) and regional (REF) left ventricular ejection fractions were determined by radionuclide ventriculography and estimated from a 12 lead electrocardiogram (ECG), using Selvester's QRS score, during the early phase of a MI (15 to 21 days following MI). Global ejection fractions determined by radionuclide ventriculography and from ECG using Palmeri's method were: for all MI 40.8 +/- 12.6% vs 39.6 +/- 11.4%; in the group of anterior MI 32.0 +/- 10.0% vs 30.0 +/- 9.7% and in the group of inferior MI 48.9 +/- 12.0% vs 45.1 +/- 8.2%. A good correlation was found between global ejection fractions determined by radionuclide ventriculography and ECG, as well as between radionuclide GEF and ECG score. A weaker correlation was found between radionuclide GEF and enzymes among all MIs and in the group of anterior MI, while in the group of inferior MI this correlation was insignificant. The analysis of REF determined by radionuclide ventriculography and ECG showed the greatest abnormalities in the infarct region, but in the group of anterior MI, dysfunction was present in the whole left ventricle. The comparison of infarct-related REF derived from radionuclide ventriculography, with the QRS score showed a significantly higher correlation than the comparison with enzymes. ECG estimation of REF from a modified Palmeri's equation showed a better correlation with radionuclide REF than did GEF derived from the standard Palmeri's equation: anterior MI; r = 0.90 vs r = 0.82, inferior MI; r = 0.84 vs r = 0.69, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

  13. Circulating Levels of Tumor Necrosis Factor-Alpha Receptor 2 Are Increased in Heart Failure with Preserved Ejection Fraction Relative to Heart Failure with Reduced Ejection Fraction: Evidence for a Divergence in Pathophysiology

    PubMed Central

    Putko, Brendan N.; Wang, Zuocheng; Lo, Jennifer; Anderson, Todd; Becher, Harald; Dyck, Jason R. B.; Kassiri, Zamaneh; Oudit, Gavin Y.

    2014-01-01

    Background Various pathways have been implicated in the pathogenesis of heart failure (HF) with preserved ejection fraction (HFPEF). Inflammation in response to comorbid conditions, such as hypertension and diabetes, may play a proportionally larger role in HFPEF as compared to HF with reduced ejection fraction (HFREF). Methods and Results This study investigated inflammation mediated by the tumor necrosis factor-alpha (TNFα) axis in community-based cohorts of HFPEF patients (n = 100), HFREF patients (n = 100) and healthy controls (n = 50). Enzyme-linked immunosorbent assays were used to investigate levels of TNFα, its two receptors (TNFR1 and TNFR2), and a non-TNFα cytokine, interleukin-6 (IL-6), in plasma derived from peripheral blood samples. Plasma levels of TNFα and TNFR1 were significantly elevated in HFPEF relative to controls, while levels of TNFR2 were significantly higher in HFPEF than both controls and HFREF. TNFα, TNFR1 and TNFR2 were each significantly associated with at least two of the following: age, estimated glomerular filtration rate, hypertension, diabetes, smoking, peripheral vascular disease or history of atrial fibrillation. TNFR2 levels were also significantly associated with increasing grade of diastolic dysfunction and severity of symptoms in HFPEF. Conclusions Inflammation mediated through TNFα and its receptors, TNFR1 and TNFR2, may represent an important component of a comorbidity-induced inflammatory response that partially drives the pathophysiology of HFPEF. PMID:24923671

  14. Fractionation of Organosolv Lignin Using Acetone:Water and Properties of the Obtained Fractions

    SciTech Connect

    Sadeghifar, Hasan; Wells, Tyrone; Le, Rosemary Khuu; Sadeghifar, Fatemeh; Yuan, Joshua S.; Jonas Ragauskas, Arthur

    2016-11-07

    In this study, lignin fractions with different molecular weight were prepared using a simple and almost green method from switchgrass and pine organosolv lignin. Different proportions of acetone in water, ranging from 30 to 60%, were used for lignin fractionation. A higher concentration of acetone dissolved higher molecular weight fractions of the lignin. Fractionated organosolv lignin showed different molecular weight and functional groups. Higher molecular weight fractions exhibited more aliphatic and less phenolic OH than lower molecular weight fractions. Lower molecular weight fractions lead to more homogeneous structure compared to samples with a higher molecular weight. In conclusion, all fractions showed strong antioxidant activity.

  15. Fractionation of Organosolv Lignin Using Acetone:Water and Properties of the Obtained Fractions

    SciTech Connect

    Sadeghifar, Hasan; Wells, Tyrone; Le, Rosemary Khuu; Sadeghifar, Fatemeh; Yuan, Joshua S.; Jonas Ragauskas, Arthur

    2016-11-07

    In this study, lignin fractions with different molecular weight were prepared using a simple and almost green method from switchgrass and pine organosolv lignin. Different proportions of acetone in water, ranging from 30 to 60%, were used for lignin fractionation. A higher concentration of acetone dissolved higher molecular weight fractions of the lignin. Fractionated organosolv lignin showed different molecular weight and functional groups. Higher molecular weight fractions exhibited more aliphatic and less phenolic OH than lower molecular weight fractions. Lower molecular weight fractions lead to more homogeneous structure compared to samples with a higher molecular weight. In conclusion, all fractions showed strong antioxidant activity.

  16. End-systolic Pressure-Volume Relation, Ejection Fraction, and Heart Failure: Theoretical Aspect and Clinical Applications.

    PubMed

    Shoucri, Rachad M

    2015-01-01

    A mathematical formalism describing the nonlinear end-systolic pressure-volume relation (ESPVR) is used to derive new indexes that can be used to assess the performance of the heart left ventricle by using the areas under the ESPVR (units of energy), the ordinates of the ESPVR (units of pressure), or from slopes of the curvilinear ESPVR. New relations between the ejection fraction (EF) and the parameters describing the ESPVR give some insight into the problem of heart failure (HF) with normal or preserved ejection fraction. Relations between percentage occurrence of HF and indexes derived from the ESPVR are also discussed. When ratios of pressures are used, calculation can be done in a noninvasive way with the possibility of interesting applications in routine clinical work. Applications to five groups of clinical data are given and discussed (normal group, aortic stenosis, aortic valvular regurgitation, mitral valvular regurgitation, miscellaneous cardiomyopathies). No one index allows a perfect segregation between all clinical groups, it is shown that appropriate use of two indexes (bivariate analysis) can lead to better separation of different clinical groups.

  17. The restoration of chronotropic competence in heart failure patients with normal ejection fraction (RESET) study: rationale and design.

    PubMed

    Kass, David A; Kitzman, Dalane W; Alvarez, Guy E

    2010-01-01

    Heart failure with preserved ejection fraction (HFpEF) is the predominant form of heart failure among the elderly and in women. However, there are few if any evidence-based therapeutic options for HFpEF. The chief complaint of HFpEF is reduced tolerance to physical exertion. Recent data revealed that 1 potential mechanism of exertional intolerance in HFpEF patients is inadequate chronotropic response. Although there is considerable evidence demonstrating the benefits of rate-adaptive pacing (RAP) provided from implantable cardiac devices in patients with an impaired chronotropic response, the effect of RAP in HFpEF is unknown. The Restoration of Chronotropic CompEtence in Heart Failure PatientS with Normal Ejection FracTion (RESET) study is a prospective, multicenter, double-blind, randomized with stratification, study assessing the effect of RAP on peak oxygen consumption and quality of life. RAP therapy will be evaluated in a crossover paired fashion for each patient within each study stratum. Study strata are based on patient beta-blocker usage at time of enrollment. The study is powered to assess the impact of pacing independently in both strata. The RESET study seeks to evaluate the potential benefit of RAP in patients with symptomatic mild to moderate HFpEF and chronotropic impairment. Study enrollment began in July 2008.

  18. Changing the treatment of heart failure with reduced ejection fraction: clinical use of sacubitril-valsartan combination

    PubMed Central

    Kaplinsky, Edgardo

    2016-01-01

    Despite significant therapeutic advances, patients with chronic heart failure (HF) remain at high risk of morbidity and mortality. Sacubitril valsartan (previously known as LCZ696) is a new oral agent approved for the treatment of symptomatic chronic heart failure in adults with reduced ejection fraction. It is described as the first in class angiotensin receptor neprilysin inhibitor (ARNI) since it incorporates the neprilysin inhibitor, sacubitril and the angiotensin II receptor antagonist, valsartan. Neprilysin is an endopeptidase that breaks down several vasoactive peptides including natriuretic peptides (NPs), bradykinin, endothelin and angiotensin II (Ang-II). Therefore, a natural consequence of its inhibition is an increase of plasmatic levels of both, NPs and Ang-II (with opposite biological actions). So, a combined inhibition of these both systems (Sacubitril / valsartan) may enhance the benefits of NPs effects in HF (natriuresis, diuresis, etc) while Ang-II receptor is inhibited (reducing vasoconstriction and aldosterone release). In a large clinical trial (PARADIGM-HF with 8442 patients), this new agent was found to significantly reduce cardiovascular and all cause mortality as well as hospitalizations due to HF (compared to enalapril). This manuscript reviews clinical evidence for sacubitril valsartan, dosing and cautions, future directions and its considered place in the therapy of HF with reduced ejection fraction. PMID:28133468

  19. Changing the treatment of heart failure with reduced ejection fraction: clinical use of sacubitril-valsartan combination.

    PubMed

    Kaplinsky, Edgardo

    2016-11-01

    Despite significant therapeutic advances, patients with chronic heart failure (HF) remain at high risk of morbidity and mortality. Sacubitril valsartan (previously known as LCZ696) is a new oral agent approved for the treatment of symptomatic chronic heart failure in adults with reduced ejection fraction. It is described as the first in class angiotensin receptor neprilysin inhibitor (ARNI) since it incorporates the neprilysin inhibitor, sacubitril and the angiotensin II receptor antagonist, valsartan. Neprilysin is an endopeptidase that breaks down several vasoactive peptides including natriuretic peptides (NPs), bradykinin, endothelin and angiotensin II (Ang-II). Therefore, a natural consequence of its inhibition is an increase of plasmatic levels of both, NPs and Ang-II (with opposite biological actions). So, a combined inhibition of these both systems (Sacubitril / valsartan) may enhance the benefits of NPs effects in HF (natriuresis, diuresis, etc) while Ang-II receptor is inhibited (reducing vasoconstriction and aldosterone release). In a large clinical trial (PARADIGM-HF with 8442 patients), this new agent was found to significantly reduce cardiovascular and all cause mortality as well as hospitalizations due to HF (compared to enalapril). This manuscript reviews clinical evidence for sacubitril valsartan, dosing and cautions, future directions and its considered place in the therapy of HF with reduced ejection fraction.

  20. Association of anemia and renal dysfunction with in-hospital mortality among patients hospitalized for acute heart failure syndromes with preserved or reduced ejection fraction.

    PubMed

    Kajimoto, Katsuya; Sato, Naoki; Takano, Teruo

    2016-11-01

    The aim of this study was to evaluate the association of anemia and renal dysfunction with in-hospital outcomes in acute heart failure syndromes patients with preserved or reduced ejection fraction. Of the 4842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 4693 patients were evaluated to investigate the association among anemia, renal dysfunction, a preserved or reduced ejection fraction and in-hospital mortality. They were divided into four groups based on hemoglobin and estimated glomerular filtration rate at admission. The in-hospital mortality rate was 5.9% and 6.9% of the preserved and reduced ejection fraction groups, respectively. After adjustment for multiple comorbidities, there was no association of either anemia or renal dysfunction alone with in-hospital mortality in preserved ejection fraction patients, but the combination of anemia and renal dysfunction was associated with a somewhat higher risk of in-hospital mortality than that without either condition (odds ratio (OR), 2.75; 95% confidence interval (CI), 0.72-10.41; p=0.137). In reduced ejection fraction patients, adjusted analysis showed that a significantly higher risk of in-hospital mortality was associated with anemia alone (OR, 2.56; 95% CI, 1.10 -5.94; p=0.029) and with anemia plus renal dysfunction (OR, 2.34; 95% CI, 1.09-5.03; p=0.029) relative to the risk without either condition. Our findings demonstrate that anemia combined with renal dysfunction is not a risk factor for in-hospital mortality in patients with a preserved ejection fraction, whereas anemia is an independent predictor of in-hospital mortality risk in reduced ejection fraction patients regardless of renal dysfunction.

  1. Assessing left ventricular systolic dysfunction after myocardial infarction: are ejection fraction and dP/dtmax complementary or redundant?

    PubMed Central

    Ishikawa, Kiyotake; Chemaly, Elie R.; Tilemann, Lisa; Fish, Kenneth; Ladage, Dennis; Aguero, Jaime; Vahl, Torsten; Santos-Gallego, Carlos; Kawase, Yoshiaki

    2012-01-01

    Among the various cardiac contractility parameters, left ventricular (LV) ejection fraction (EF) and maximum dP/dt (dP/dtmax) are the simplest and most used. However, these parameters are often reported together, and it is not clear if they are complementary or redundant. We sought to compare the discriminative value of EF and dP/dtmax in assessing systolic dysfunction after myocardial infarction (MI) in swine. A total of 220 measurements were obtained. All measurements included LV volumes and EF analysis by left ventriculography, invasive ventricular pressure tracings, and echocardiography. Baseline measurements were performed in 132 pigs, and 88 measurements were obtained at different time points after MI creation. Receiver operator characteristic (ROC) curves to distinguish the presence or absence of an MI revealed a good predictive value for EF [area under the curve (AUC): 0.998] but not by dP/dtmax (AUC: 0.69, P < 0.001 vs. EF). Dividing dP/dtmax by LV end-diastolic pressure and heart rate (HR) significantly increased the AUC to 0.87 (P < 0.001 vs. dP/dtmax and P < 0.001 vs. EF). In naïve pigs, the coefficient of variation of dP/dtmax was twice than that of EF (22.5% vs. 9.5%, respectively). Furthermore, in n = 19 pigs, dP/dtmax increased after MI. However, echocardiographic strain analysis of 23 pigs with EF ranging only from 36% to 40% after MI revealed significant correlations between dP/dtmax and strain parameters in the noninfarcted area (circumferential strain: r = 0.42, P = 0.05; radial strain: r = 0.71, P < 0.001). In conclusion, EF is a more accurate measure of systolic dysfunction than dP/dtmax in a swine model of MI. Despite the variability of dP/dtmax both in naïve pigs and after MI, it may sensitively reflect the small changes of myocardial contractility. PMID:22307667

  2. Assessing left ventricular systolic dysfunction after myocardial infarction: are ejection fraction and dP/dt(max) complementary or redundant?

    PubMed

    Ishikawa, Kiyotake; Chemaly, Elie R; Tilemann, Lisa; Fish, Kenneth; Ladage, Dennis; Aguero, Jaime; Vahl, Torsten; Santos-Gallego, Carlos; Kawase, Yoshiaki; Hajjar, Roger J

    2012-04-01

    Among the various cardiac contractility parameters, left ventricular (LV) ejection fraction (EF) and maximum dP/dt (dP/dt(max)) are the simplest and most used. However, these parameters are often reported together, and it is not clear if they are complementary or redundant. We sought to compare the discriminative value of EF and dP/dt(max) in assessing systolic dysfunction after myocardial infarction (MI) in swine. A total of 220 measurements were obtained. All measurements included LV volumes and EF analysis by left ventriculography, invasive ventricular pressure tracings, and echocardiography. Baseline measurements were performed in 132 pigs, and 88 measurements were obtained at different time points after MI creation. Receiver operator characteristic (ROC) curves to distinguish the presence or absence of an MI revealed a good predictive value for EF [area under the curve (AUC): 0.998] but not by dP/dt(max) (AUC: 0.69, P < 0.001 vs. EF). Dividing dP/dt(max) by LV end-diastolic pressure and heart rate (HR) significantly increased the AUC to 0.87 (P < 0.001 vs. dP/dt(max) and P < 0.001 vs. EF). In naïve pigs, the coefficient of variation of dP/dt(max) was twice than that of EF (22.5% vs. 9.5%, respectively). Furthermore, in n = 19 pigs, dP/dt(max) increased after MI. However, echocardiographic strain analysis of 23 pigs with EF ranging only from 36% to 40% after MI revealed significant correlations between dP/dt(max) and strain parameters in the noninfarcted area (circumferential strain: r = 0.42, P = 0.05; radial strain: r = 0.71, P < 0.001). In conclusion, EF is a more accurate measure of systolic dysfunction than dP/dt(max) in a swine model of MI. Despite the variability of dP/dt(max) both in naïve pigs and after MI, it may sensitively reflect the small changes of myocardial contractility.

  3. Fractionation of Organosolv Lignin Using Acetone:Water and Properties of the Obtained Fractions

    DOE PAGES

    Sadeghifar, Hasan; Wells, Tyrone; Le, Rosemary Khuu; ...

    2016-11-07

    In this study, lignin fractions with different molecular weight were prepared using a simple and almost green method from switchgrass and pine organosolv lignin. Different proportions of acetone in water, ranging from 30 to 60%, were used for lignin fractionation. A higher concentration of acetone dissolved higher molecular weight fractions of the lignin. Fractionated organosolv lignin showed different molecular weight and functional groups. Higher molecular weight fractions exhibited more aliphatic and less phenolic OH than lower molecular weight fractions. Lower molecular weight fractions lead to more homogeneous structure compared to samples with a higher molecular weight. In conclusion, all fractionsmore » showed strong antioxidant activity.« less

  4. Fractionation of Organosolv Lignin Using Acetone:Water and Properties of the Obtained Fractions

    DOE PAGES

    Sadeghifar, Hasan; Wells, Tyrone; Le, Rosemary Khuu; ...

    2016-11-07

    In this study, lignin fractions with different molecular weight were prepared using a simple and almost green method from switchgrass and pine organosolv lignin. Different proportions of acetone in water, ranging from 30 to 60%, were used for lignin fractionation. A higher concentration of acetone dissolved higher molecular weight fractions of the lignin. Fractionated organosolv lignin showed different molecular weight and functional groups. Higher molecular weight fractions exhibited more aliphatic and less phenolic OH than lower molecular weight fractions. Lower molecular weight fractions lead to more homogeneous structure compared to samples with a higher molecular weight. In conclusion, all fractionsmore » showed strong antioxidant activity.« less

  5. Role of Myocardial Collagen in Severe Aortic Stenosis With Preserved Ejection Fraction and Symptoms of Heart Failure.

    PubMed

    Echegaray, Kattalin; Andreu, Ion; Lazkano, Ane; Villanueva, Iñaki; Sáenz, Alberto; Elizalde, María Reyes; Echeverría, Tomás; López, Begoña; Garro, Asier; González, Arantxa; Zubillaga, Elena; Solla, Itziar; Sanz, Iñaki; González, Jesús; Elósegui-Artola, Alberto; Roca-Cusachs, Pere; Díez, Javier; Ravassa, Susana; Querejeta, Ramón

    2017-10-01

    We investigated the anatomical localization, biomechanical properties, and molecular phenotype of myocardial collagen tissue in 40 patients with severe aortic stenosis with preserved ejection fraction and symptoms of heart failure. Two transmural biopsies were taken from the left ventricular free wall. Mysial and nonmysial regions of the collagen network were analyzed. Myocardial collagen volume fraction (CVF) was measured by picrosirius red staining. Young's elastic modulus (YEM) was measured by atomic force microscopy in decellularized slices to assess stiffness. Collagen types I and III were measured as CIVF and CIIIVF, respectively, by confocal microscopy in areas with YEM evaluation. Compared with controls, patients exhibited increased mysial and nonmysial CVF and nonmysial:mysial CVF ratio (P < .05). In patients, nonmysial CVF (r = 0.330; P = .046) and the nonmysial:mysial CVF ratio (r = 0.419; P = .012) were directly correlated with the ratio of maximal early transmitral flow velocity in diastole to early mitral annulus velocity in diastole. Both the CIVF:CIIIVF ratio and YEM were increased (P ≤ .001) in nonmysial regions compared with mysial regions in patients, with a direct correlation (r = 0.895; P < .001) between them. These findings suggest that, in patients with severe aortic stenosis with preserved ejection fraction and symptoms of heart failure, diastolic dysfunction is associated with increased nonmysial deposition of collagen, predominantly type I, resulting in increased extracellular matrix stiffness. Therefore, the characteristics of collagen tissue may contribute to diastolic dysfunction in these patients. Copyright © 2016 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

  6. The acute effects of low flow oxygen and isosorbide dinitrate on left and right ventricular ejection fractions in chronic obstructive pulmonary disease

    SciTech Connect

    Morrison, D.; Caldwell, J.; Lakshminaryan, S.; Ritchie, J.L.; Kennedy, J.W.

    1983-10-01

    The objectives of this study were to determine the effects of low flow oxygen and isosorbide dinitrate on rest and exercise biventricular ejection fractions in patients with chronic obstructive pulmonary disease and to relate these ejection fraction responses to changes in pressure and flow. Nine patients with stable, moderate to severe chronic obstructive pulmonary disease who had no prior history of heart failure performed supine exercise with simultaneous hemodynamic and radionuclide ventriculographic monitoring. Eight patients performed a second exercise during low flow oxygen breathing and five performed a third exercise after ingesting 10 mg oral isosorbide. Oxygen led to a decrease in exercise pulmonary artery pressure in all subjects and a decline in total pulmonary resistance in five of the seven in whom it was measured. Right ventricular ejection fraction increased 0.05 or more only in subjects who had a decrease in total pulmonary resistance. Isosorbide led to an increase in rest and exercise right and left ventricular ejection fractions with simultaneous decreases in pulmonary artery pressure, total pulmonary resistance, blood pressure and arterial oxygen tension. These results suggest that in patients with chronic obstructive pulmonary disease but without a history of right heart failure, the right ventricular systolic functional response to low flow oxygen and isosorbide at rest and exercise is, in part, determined by changes in total pulmonary resistance. The chronic relation between right ventricular ejection fraction and pulmonary hemodynamics in patients with chronic obstructive pulmonary disease remains to be evaluated.

  7. Different Determinants of Ventilatory Inefficiency at Different Stages of Reduced Ejection Fraction Chronic Heart Failure Natural History.

    PubMed

    Mezzani, Alessandro; Giordano, Andrea; Komici, Klara; Corrà, Ugo

    2017-05-09

    It is not known whether determinants of ventilation (VE)/volume of exhaled carbon dioxide (VCO2) slope during incremental exercise may differ at different stages of reduced ejection fraction chronic heart failure natural history. VE/VCO2 slope was fitted up to lowest VE/VCO2 ratio, that is, a proxy of the VE/perfusion ratio devoid of nonmetabolic stimuli to ventilatory drive. VE/VCO2 slope tertiles were generated from our database (<27.5 [tertile 1], ≥27.5 to <32.0 [tertile 2], and ≥32.0 [tertile 3]), and 147 chronic heart failure patients with repeated tests yielding VE/VCO2 slopes in 2 different tertiles were selected. Determinants of VE/VCO2 slope changes across tertile pairs 1 versus 2, 2 versus 3, and 1 versus 3 were assessed by exploring changes in VE and VCO2 at lowest VE/VCO2 and those in VE/work rate (W) and VCO2/W slope. Resting and peak cardiac output (CO) were calculated as VO2/estimated arteriovenous O2 difference and the CO/W slope analyzed. Notwithstanding a progressively lower W with increasing tertile, VE at lowest VE/VCO2 and VE/W slope were significantly higher in tertiles 2 and 3 versus tertile 1. Conversely, VCO2 at lowest VE/VCO2 and CO/W slope significantly decreased across tertiles, whereas VCO2/W slope did not. Difference (Δ) in VE/W slope between tertiles accounted for 71% of ΔVE/VCO2 slope variance, with ΔVCO2/W slope explaining an additional 26% (model r=0.99; r(2)=0.97; P<0.0001). Similar results were obtained substituting ΔVCO2/W slope with ΔCO/W slope. Ventilatory overactivation is the predominant cause of VE/VCO2 slope increase at initial stages of chronic heart failure, whereas hemodynamic impairment plays an additional role at more-advanced pathophysiological stages. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

  8. Risk Related to Pre–Diabetes Mellitus and Diabetes Mellitus in Heart Failure With Reduced Ejection Fraction

    PubMed Central

    Kristensen, Søren L.; Preiss, David; Jhund, Pardeep S.; Squire, Iain; Cardoso, José Silva; Merkely, Bela; Martinez, Felipe; Starling, Randall C.; Desai, Akshay S.; Lefkowitz, Martin P.; Rizkala, Adel R.; Rouleau, Jean L.; Shi, Victor C.; Solomon, Scott D.; Swedberg, Karl; Zile, Michael R.; Packer, Milton

    2016-01-01

    Background— The prevalence of pre–diabetes mellitus and its consequences in patients with heart failure and reduced ejection fraction are not known. We investigated these in the Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial. Methods and Results— We examined clinical outcomes in 8399 patients with heart failure and reduced ejection fraction according to history of diabetes mellitus and glycemic status (baseline hemoglobin A1c [HbA1c]: <6.0% [<42 mmol/mol], 6.0%–6.4% [42–47 mmol/mol; pre–diabetes mellitus], and ≥6.5% [≥48 mmol/mol; diabetes mellitus]), in Cox regression models adjusted for known predictors of poor outcome. Patients with a history of diabetes mellitus (n=2907 [35%]) had a higher risk of the primary composite outcome of heart failure hospitalization or cardiovascular mortality compared with those without a history of diabetes mellitus: adjusted hazard ratio, 1.38; 95% confidence interval, 1.25 to 1.52; P<0.001. HbA1c measurement showed that an additional 1106 (13% of total) patients had undiagnosed diabetes mellitus and 2103 (25%) had pre–diabetes mellitus. The hazard ratio for patients with undiagnosed diabetes mellitus (HbA1c, >6.5%) and known diabetes mellitus compared with those with HbA1c<6.0% was 1.39 (1.17–1.64); P<0.001 and 1.64 (1.43–1.87); P<0.001, respectively. Patients with pre–diabetes mellitus were also at higher risk (hazard ratio, 1.27 [1.10–1.47]; P<0.001) compared with those with HbA1c<6.0%. The benefit of LCZ696 (sacubitril/valsartan) compared with enalapril was consistent across the range of HbA1c in the trial. Conclusions— In patients with heart failure and reduced ejection fraction, dysglycemia is common and pre–diabetes mellitus is associated with a higher risk of adverse cardiovascular outcomes (compared with patients with no diabetes mellitus and HbA1c <6.0%). LCZ696 was beneficial compared with enalapril

  9. Aortic valve replacement in patients with a left ventricular ejection fraction ≤35% performed via a minimally invasive right thoracotomy

    PubMed Central

    Xydas, Steve; Williams, Roy F.; La Pietra, Angelo; Mawad, Maurice; Behrens, Vicente; Escolar, Esteban; Mihos, Christos G.

    2017-01-01

    Background We evaluated the outcomes of patients with aortic valve pathology in the setting of a left ventricular ejection fraction ≤35% who underwent minimally invasive aortic valve replacement (AVR), with or without concomitant mitral valve (MV) surgery. Methods All minimally invasive AVR in patients with a left ventricular ejection fraction ≤35%, performed via a right thoracotomy for aortic stenosis or regurgitation between January 2009 and March 2013, were retrospectively evaluated. The operative characteristics, perioperative outcomes, and 30-day mortality were analyzed. Results There were 75 patients identified: 51 who underwent isolated AVR, and 24 who had combined AVR plus MV surgery for moderate to severe mitral regurgitation. In patients undergoing MV surgery, there were 22 (91.7%) MV repairs [ring annuloplasty =7 (37.5%), transaortic edge-to-edge repair =15 (62.5%)], and 2 (8.3%) replacements. No patient required conversion to sternotomy for inadequate surgical field exposure. The median total mechanical ventilation time and intensive care unit length of stay were 14 (IQR, 8–20) and 42 hours (IQR, 26–93 hours) in the isolated AVR group, and 16.5 hours (IQR, 12–61.5 hours) and 95.5 hours (IQR, 43.5–159 hours) in the AVR plus MV surgery group, respectively. The most common post-operative complication was new-onset atrial fibrillation, which occurred in 15 (29.4%) isolated AVR and 4 (16.7%) AVR plus MV surgery patients. The median hospital length of stay and 30-day mortality was 7 days (IQR, 5–12 days) and 1 (2%) in the isolated AVR group, and 10.5 days (IQR, 5–21 days) and 1 (4.3%) for AVR plus MV surgery. Conclusions In patients with aortic valve pathology in the setting of a left ventricular ejection fraction ≤35%, minimally invasive AVR can be performed, with or without concomitant MV surgery, with a low morbidity and mortality. PMID:28740714

  10. Impaired left ventricular global longitudinal strain in patients with heart failure with preserved ejection fraction: insights from the RELAX trial.

    PubMed

    DeVore, Adam D; McNulty, Steven; Alenezi, Fawaz; Ersboll, Mads; Vader, Justin M; Oh, Jae K; Lin, Grace; Redfield, Margaret M; Lewis, Gregory; Semigran, Marc J; Anstrom, Kevin J; Hernandez, Adrian F; Velazquez, Eric J

    2017-07-01

    While abnormal left ventricular (LV) global longitudinal strain (GLS) has been described in patients with heart failure with preserved ejection fraction (HFpEF), its prevalence and clinical significance are poorly understood. Patients enrolled in the RELAX trial of sildenafil in HFpEF (LV ejection fraction ≥50%) in whom two-dimensional, speckle-tracking LV GLS was possible (n = 187) were analysed. The distribution of LV GLS and its associations with clinical characteristics, LV structure and function, biomarkers, exercise capacity and quality of life were assessed. Baseline median LV GLS was -14.6% (25th and 75th percentile, -17.0% and -11.9%, respectively) and abnormal (≥ - 16%) in 122/187 (65%) patients. Patients in the tertile with the best LV GLS had lower N-terminal pro-brain natriuretic peptide (NT-proBNP) [median 505 pg/mL (161, 1065) vs. 875 pg/mL (488, 1802), P = 0.008) and lower collagen III N-terminal propeptide (PIIINP) levels [median 6.7 µg/L (5.1, 8.1) vs. 8.1 µg/L (6.5, 10.5), P = 0.001] compared with the tertile with the worst LV GLS. There was also a modest linear relationship with LV GLS and log-transformed NT-proBNP and PIIINP (r = 0.29, P < 0.001 and r = 0.19, P = 0.009, respectively). We observed no linear association of LV GLS with Minnesota Living with Heart Failure scores, 6-min walk distance, peak oxygen consumption, or expiratory minute ventilation/carbon dioxide excretion slope. Impaired LV GLS is common among HFpEF patients, indicating the presence of covert systolic dysfunction despite normal LV ejection fraction. Impaired LV GLS was associated with biomarkers of wall stress and collagen synthesis and diastolic dysfunction but not with quality of life or exercise capacity, suggesting other processes may be more responsible for these aspects of the HFpEF syndrome. © 2017 The Authors. European Journal of Heart Failure © 2017 European Society of Cardiology.

  11. Arterial Stiffening With Exercise in Patients With Heart Failure and Preserved Ejection Fraction.

    PubMed

    Reddy, Yogesh N V; Andersen, Mads J; Obokata, Masaru; Koepp, Katlyn E; Kane, Garvan C; Melenovsky, Vojtech; Olson, Thomas P; Borlaug, Barry A

    2017-07-11

    Aortic stiffening and reduced nitric oxide (NO) availability may contribute to the pathophysiology of heart failure with preserved ejection fraction (HFpEF). This study compared indices of arterial stiffness at rest and during exercise in subjects with HFpEF and hypertensive control subjects to examine their relationships to cardiac hemodynamics and determine whether exertional arterial stiffening can be mitigated by inorganic nitrite. A total of 22 hypertensive control subjects and 98 HFpEF subjects underwent hemodynamic exercise testing with simultaneous expired gas analysis to measure oxygen consumption. Invasively measured radial artery pressure waveforms were converted to central aortic waveforms by transfer function to assess integrated measures of pulsatile aortic load, including arterial compliance, resistance, elastance, and wave reflection. Arterial load and wave reflections in HFpEF were similar to those in control subjects at rest. During submaximal exercise, HFpEF subjects displayed reduced total arterial compliance and higher effective arterial elastance despite similar mean arterial pressures in control subjects. This was directly correlated with higher ventricular filling pressures and depressed cardiac output reserve (both p < 0.0001). With peak exercise, increased wave reflections, impaired compliance, and increased resistance and elastance were observed in subjects with HFpEF. A subset of HFpEF subjects (n = 52) received sodium nitrite or placebo therapy in a 1:1 double-blind, randomized fashion. Compared to placebo, nitrite decreased aortic wave reflections at rest and improved arterial compliance and elastance and central hemodynamics during exercise. Abnormal pulsatile aortic loading during exercise occurs in HFpEF independent of hypertension and is correlated with classical hemodynamic derangements that develop with stress. Inorganic nitrite mitigates arterial stiffening with exercise and improves hemodynamics, indicating that arterial

  12. Cost-effectiveness Analysis of Sacubitril/Valsartan vs Enalapril in Patients With Heart Failure and Reduced Ejection Fraction.

    PubMed

    Gaziano, Thomas A; Fonarow, Gregg C; Claggett, Brian; Chan, Wing W; Deschaseaux-Voinet, Celine; Turner, Stuart J; Rouleau, Jean L; Zile, Michael R; McMurray, John J V; Solomon, Scott D

    2016-09-01

    The angiotensin receptor neprilysin inhibitor sacubitril/valsartan was associated with a reduction in cardiovascular mortality, all-cause mortality, and hospitalizations compared with enalapril. Sacubitril/valsartan has been approved for use in heart failure (HF) with reduced ejection fraction in the United States and cost has been suggested as 1 factor that will influence the use of this agent. To estimate the cost-effectiveness of sacubitril/valsartan vs enalapril in the United States. Data from US adults (mean [SD] age, 63.8 [11.5] years) with HF with reduced ejection fraction and characteristics similar to those in the PARADIGM-HF trial were used as inputs for a 2-state Markov model simulated HF. Risks of all-cause mortality and hospitalization from HF or other reasons were estimated with a 30-year time horizon. Quality of life was based on trial EQ-5D scores. Hospital costs combined Medicare and private insurance reimbursement rates; medication costs included the wholesale acquisition cost for sacubitril/valsartan and enalapril. A discount rate of 3% was used. Sensitivity analyses were performed on key inputs including: hospital costs, mortality benefit, hazard ratio for hospitalization reduction, drug costs, and quality-of-life estimates. Hospitalizations, quality-adjusted life-years (QALYs), costs, and incremental costs per QALY gained. The 2-state Markov model of US adult patients (mean age, 63.8 years) calculated that there would be 220 fewer hospital admissions per 1000 patients with HF treated with sacubitril/valsartan vs enalapril over 30 years. The incremental costs and QALYs gained with sacubitril/valsartan treatment were estimated at $35 512 and 0.78, respectively, compared with enalapril, equating to an incremental cost-effectiveness ratio (ICER) of $45 017 per QALY for the base-case. Sensitivity analyses demonstrated ICERs ranging from $35 357 to $75 301 per QALY. For eligible patients with HF with reduced ejection fraction, the Markov

  13. Determination of left ventricular volume, ejection fraction, and myocardial mass by real-time three-dimensional echocardiography

    NASA Technical Reports Server (NTRS)

    Qin, J. X.; Shiota, T.; Thomas, J. D.

    2000-01-01

    Reconstructed three-dimensional (3-D) echocardiography is an accurate and reproducible method of assessing left ventricular (LV) functions. However, it has limitations for clinical study due to the requirement of complex computer and echocardiographic analysis systems, electrocardiographic/respiratory gating, and prolonged imaging times. Real-time 3-D echocardiography has a major advantage of conveniently visualizing the entire cardiac anatomy in three dimensions and of potentially accurately quantifying LV volumes, ejection fractions, and myocardial mass in patients even in the presence of an LV aneurysm. Although the image quality of the current real-time 3-D echocardiographic methods is not optimal, its widespread clinical application is possible because of the convenient and fast image acquisition. We review real-time 3-D echocardiographic image acquisition and quantitative analysis for the evaluation of LV function and LV mass.

  14. The evolution of heart failure with reduced ejection fraction pharmacotherapy: What do we have and where are we going?

    PubMed

    Selim, Ahmed; Zolty, Ronald; Chatzizisis, Yiannis S

    2017-10-01

    Cardiovascular diseases represent a leading cause of mortality and increased healthcare expenditure worldwide. Heart failure, which simply describes an inability of the heart to meet the body's needs, is the end point for many other cardiovascular conditions. The last three decades have witnessed significant efforts aiming at the discovery of treatments to improve the survival and quality of life of patients with heart failure; many were successful, while others failed. Given that most of the successes in treating heart failure were achieved in patients with reduced left ventricular ejection fraction (HFrEF), we constructed this review to look at the recent evolution of HFrEF pharmacotherapy. We also explore some of the ongoing clinical trials for new drugs, and investigate potential treatment targets and pathways that might play a role in treating HFrEF in the future. Copyright © 2017 Elsevier Inc. All rights reserved.

  15. Connecting heart failure with preserved ejection fraction and renal dysfunction: the role of endothelial dysfunction and inflammation.

    PubMed

    Ter Maaten, Jozine M; Damman, Kevin; Verhaar, Marianne C; Paulus, Walter J; Duncker, Dirk J; Cheng, Caroline; van Heerebeek, Loek; Hillege, Hans L; Lam, Carolyn S P; Navis, Gerjan; Voors, Adriaan A

    2016-06-01

    Renal dysfunction in heart failure with preserved ejection fraction (HFpEF) is common and is associated with increased mortality. Impaired renal function is also a risk factor for developing HFpEF. A new paradigm for HFpEF, proposing a sequence of events leading to myocardial remodelling and dysfunction in HFpEF, was recently introduced, involving inflammatory, microvascular, and cardiac components. The kidney might play a key role in this systemic process. Renal impairment causes metabolic and systemic derangements in circulating factors, causing an activated systemic inflammatory state and endothelial dysfunction, which may lead to cardiomyocyte stiffening, hypertrophy, and interstitial fibrosis via cross-talk between the endothelium and cardiomyocyte compartments. Here, we review the role of endothelial dysfunction and inflammation to explain the link between renal dysfunction and HFpEF, which allows for identification of new early risk markers, prognostic factors, and unique targets for intervention.

  16. [Heart failure with preserved ejection fraction (HFPEF). Impact of change in the paradigm of isolated diastolic dysfunction].

    PubMed

    Magaña-Serrano, José Antonio; Rosas-Peralta, Martín; Candanosa-Arias, Carlos; Valencia-Sánchez, Salvador; Garrido-Garduño, Martín; Arriaga-Nava, Roberto; Calderón-Abbo, Moisés C

    2015-01-01

    Heart failure with preserved ejection fraction is a significant and growing public health problem, since it currently represents half of all patients with heart failure. Despite improvements in the understanding of the disease, there is no benefit form treatments tested at all. Advances in diagnostic imaging and invasive evaluation algorithms will allow a more accurate and early diagnosis so that treatment of earliest forms in the progression of the disease are applied since the potential for benefit may be higher. Although important progress has been made in our understanding of the pathophysiology, cardiac catheterization, and cellular of diastolic failure mechanisms and not diastolic mechanisms of disease, further research is required promptly to determine how best to address these anomalies to reduce the significant burden of morbidity and mortality in this form of heart failure, which is reaching pandemic proportions.

  17. [Valvular surgery for an exercise-induced functional mitral regurgitation in heart failure and preserved ejection fraction: a case study].

    PubMed

    Attari, M; Legrand, M; Philippe, C; Rosak, P

    2013-08-01

    We here report the case of a 67-year-old woman with moderate mitral regurgitation without significant structural abnormalities that get worse during severe recurrent heart failures and preserved ejection fraction with concomitant paroxysmal atrial fibrillation. Atrial fibrillation became permanent and despite a well-controlled cardiac frequency, new heart failure episodes occurred. Exercise doppler echocardiography showed that the mechanism of this mitral regurgitation was a two leaflet mitral tenting. We discuss here the different mechanisms that could induce these kinds of mitral regurgitation with excessive tenting. We emphasize the interest of early detection by exercise doppler echocardiography even when a triggering factor like atrial fibrillation seems to be involved. We also discuss the interest of mitral valve replacement for these patients.

  18. Cardiac diastolic and autonomic dysfunction are aggravated by central chemoreflex activation in heart failure with preserved ejection fraction rats.

    PubMed

    Toledo, Camilo; Andrade, David C; Lucero, Claudia; Arce-Alvarez, Alexis; Díaz, Hugo S; Aliaga, Valentín; Schultz, Harold D; Marcus, Noah J; Manríquez, Mónica; Faúndez, Marcelo; Del Rio, Rodrigo

    2017-04-15

    Heart failure with preserved ejection fraction (HFpEF) is associated with disordered breathing patterns, and sympatho-vagal imbalance. Although it is well accepted that altered peripheral chemoreflex control plays a role in the progression of heart failure with reduced ejection fraction (HFrEF), the pathophysiological mechanisms underlying deterioration of cardiac function in HFpEF are poorly understood. We found that central chemoreflex is enhanced in HFpEF and neuronal activation is increased in pre-sympathetic regions of the brainstem. Our data showed that activation of the central chemoreflex pathway in HFpEF exacerbates diastolic dysfunction, worsens sympatho-vagal imbalance and markedly increases the incidence of cardiac arrhythmias in rats with HFpEF. Heart failure (HF) patients with preserved ejection fraction (HFpEF) display irregular breathing, sympatho-vagal imbalance, arrhythmias and diastolic dysfunction. It has been shown that tonic activation of the central and peripheral chemoreflex pathway plays a pivotal role in the pathophysiology of HF with reduced ejection fraction. In contrast, no studies to date have addressed chemoreflex function or its effect on cardiac function in HFpEF. Therefore, we tested whether peripheral and central chemoreflexes are hyperactive in HFpEF and if chemoreflex activation exacerbates cardiac dysfunction and autonomic imbalance. Sprague-Dawley rats (n = 32) were subjected to sham or volume overload to induce HFpEF. Resting breathing variability, chemoreflex gain, cardiac function and sympatho-vagal balance, and arrhythmia incidence were studied. HFpEF rats displayed [mean ± SD; chronic heart failure (CHF) vs. Sham, respectively] a marked increase in the incidence of apnoeas/hypopnoeas (20.2 ± 4.0 vs. 9.7 ± 2.6 events h(-1) ), autonomic imbalance [0.6 ± 0.2 vs. 0.2 ± 0.1 low/high frequency heart rate variability (LF/HFHRV )] and cardiac arrhythmias (196.0 ± 239.9 vs. 19.8 ± 21.7 events h(-1

  19. Determination of left ventricular volume, ejection fraction, and myocardial mass by real-time three-dimensional echocardiography

    NASA Technical Reports Server (NTRS)

    Qin, J. X.; Shiota, T.; Thomas, J. D.

    2000-01-01

    Reconstructed three-dimensional (3-D) echocardiography is an accurate and reproducible method of assessing left ventricular (LV) functions. However, it has limitations for clinical study due to the requirement of complex computer and echocardiographic analysis systems, electrocardiographic/respiratory gating, and prolonged imaging times. Real-time 3-D echocardiography has a major advantage of conveniently visualizing the entire cardiac anatomy in three dimensions and of potentially accurately quantifying LV volumes, ejection fractions, and myocardial mass in patients even in the presence of an LV aneurysm. Although the image quality of the current real-time 3-D echocardiographic methods is not optimal, its widespread clinical application is possible because of the convenient and fast image acquisition. We review real-time 3-D echocardiographic image acquisition and quantitative analysis for the evaluation of LV function and LV mass.

  20. Increased left ventricular ejection fraction after a meal: potential source of error in performance of radionuclide angiography

    SciTech Connect

    Brown, J.M.; White, C.J.; Sobol, S.M.; Lull, R.J.

    1983-06-01

    The effect of a standardized meal on left ventricular (LV) ejection fraction (EF) was determined by equilibrium radionuclide angiography in 16 patients with stable congestive heart failure but without pulmonary or valvular heart disease. LVEF was determined in the fasting state and 15, 30, and 45 minutes after a meal. Patients with moderately depressed fasting LVEF (30 to 50%), Group I, had a mean increase of 6.9 +/- 2.9% (p less than 0.005) in the LVEF at 45 minutes after the meal. Patients with severely depressed fasting LVEF (less than 30%), Group II, had no change after the meal. It is concluded that significant increases in LVEF may occur after meals in patients with moderate but not severe left ventricular dysfunction. Equilibrium radionuclide angiography studies that are not standardized for patients' mealtimes may introduce an important unmeasured variable that will affect the validity of data in serial studies of left ventricular function.

  1. [Comparative Evaluation of -blockers and If-Channel Inhibitor in Patients With Chronic Heart Failure and Preserved Left Ventricular Ejection Fraction].

    PubMed

    Kanorsky, S G; Borisenko, Y V

    2016-02-01

    Treatment of patients with chronic heart failure (CHF) and preserved left ventricular (LV) ejection fraction remains largely empirical, as none of the methods of therapy improves the prognosis of patients. In a prospective randomized study on 126 patients with CHF and LV ejection fraction more or equal 50% we compared effectiveness of long-term treatment with bisoprolol (n=62) and ivabradine (n=64). Assessment of clinical status, exercise tolerance (ET), quality of life, blood level of N-terminal brain natriuretic peptide precursor, and parameters of echocardiography was performed at baseline and after 12 months of therapy. Unlike bisoprolol ivabradine, significantly improved exercise tolerance, quality of life, and reduced level of N-terminal brain natriuretic peptide precursor. Improvement of echocardiographic indices of active relaxation and compliance of the left ventricle was also observed. Key words: heart failure with preserved ejection fraction; ivabradine; bisoprolol; left ventricle diastolic dysfunction.

  2. Comparison of transesophageal echocardiographic and scintigraphic estimates of left ventricular end-diastolic volume index and ejection fraction in patients following coronary artery bypass grafting

    SciTech Connect

    Urbanowicz, J.H.; Shaaban, M.J.; Cohen, N.H.; Cahalan, M.K.; Botvinick, E.H.; Chatterjee, K.; Schiller, N.B.; Dae, M.W.; Matthay, M.A. )

    1990-04-01

    Transesophageal echocardiography (TEE) has become a commonly used monitor of left ventricular (LV) function and filling during cardiac surgery. Its use is based on the assumption that changes in LV short-axis ID reflect changes in LV volume. To study the ability of TEE to estimate LV volume and ejection immediately following CABG, 10 patients were studied using blood pool scintigraphy, TEE, and thermodilution cardiac output (CO). A single TEE short-axis cross-sectional image of the LV at the midpapillary muscle level was used for area analysis. Between 1 and 5 h postoperatively, simultaneous data sets (scintigraphy, TEE, and CO) were obtained three to five times in each patient. End-diastolic (EDa) and end-systolic (ESa) areas were measured by light pen. Ejection fraction area (EFa) was calculated (EFa = (EDa - ESa)/EDa). When EFa was compared with EF by scintigraphy, correlation was good (r = 0.82 SEE = 0.07). EDa was taken as an indicator of LV volume and compared with LVEDVI which was derived from EF by scintigraphy and CO. Correlation between EDa and LVEDVI was fair (r = 0.74 SEE = 3.75). The authors conclude that immediately following CABG, a single cross-sectional TEE image provides a reasonable estimate of EF but not LVEDVI.

  3. Association of physical activity and heart failure with preserved vs. reduced ejection fraction in the elderly: the Framingham Heart Study.

    PubMed

    Kraigher-Krainer, Elisabeth; Lyass, Asya; Massaro, Joseph M; Lee, Douglas S; Ho, Jennifer E; Levy, Daniel; Kannel, William B; Vasan, Ramachandran S

    2013-07-01

    Reduced physical activity is associated with increased risk of heart failure (HF) in middle-aged individuals. We hypothesized that physical inactivity is also associated with greater HF risk in older individuals, and examined if the association was consistent for HF with preserved ejection fraction (HFPEF) vs. HF with a reduced ejection fraction (HFREF). We evaluated 1142 elderly participants (mean age 76 years) from the Framingham Study without prior myocardial infarction and who attended a routine examination when daily physical activity was assessed systematically with a questionnaire. A composite score, the physical activity index (PAI), was calculated and modelled as tertiles, and related to incidence of HF, HFPEF, and HFREF on follow-up using proportional hazards regression models adjusting for age and sex, and then additionally for standard HF risk factors. Participants with HF and EF <45% vs. ≥45% were categorized as HFREF and HFPEF, respectively. On follow-up (mean 10 years), 250 participants developed HF (108 with HFPEF, 106 with HFREF, 36 with unavailable EF). In age- and sex-adjusted models, the middle and highest PAI tertiles were associated with a 15-56% lower risk of any HF, of HFREF, and of HFPEF, with a graded response across tertiles. In multivariable models, the association of higher PAI with lower risk of any HF and with HFPEF was maintained, whereas the association with HFREF was attenuated. Our study of an older community-based sample extends to the elderly and to HFPEF previous findings of a protective effect of physical activity on HF risk.

  4. Speckle strain echocardiography predicts outcome in patients with heart failure with both depressed and preserved left ventricular ejection fraction.

    PubMed

    Stampehl, Mark R; Mann, Douglas L; Nguyen, John S; Cota, Francisco; Colmenares, Cristina; Dokainish, Hisham

    2015-01-01

    While speckle imaging has been shown to predict outcome in patients with heart failure (HF), it remains unclear whether speckle strain predicts outcome in patients with HF with preserved ejection fraction (HFPEF). Four hundred twenty patients with HF by Framingham criteria and either: left ventricular (LV) EF <50%, or elevated LV filling pressure by comprehensive echo Doppler study in the setting of left ventricular ejection fraction (LVEF) ≥50%, were enrolled. Speckle tracking was used to measure strain and strain rate in multiple vectors. The primary endpoint was HF hospitalization or cardiovascular death. Follow-up was completed in 380/420 patients (90%). The mean age was 55.7 ± 0.8 years, 191/380 (50%) were male, 319/380 (84%) were hypertensive, 183/380 (48%) were diabetic, and 152/380 (40%) had known coronary artery disease. At a mean follow-up of 369 ± 30 days, 107/380 patients (28%) reached the primary endpoint: 97 HF rehospitalizations and 10 cardiac deaths. The best univariate predictors of outcome were global longitudinal peak strain (GLPS) (χ(2) = 25.6, P < 0.001), mitral DT (χ(2) = 16.8, P < 0.001), LVEF (χ(2) = 16.7, P < 0.0001), longitudinal early diastolic strain (χ(2) = 8.7, P = 0.003), and circumferential peak strain (χ(2) = 7.9, P = 0.005). On multivariate analysis, GLPS (P < 0.0001), LVEF (P = 0.0002), and mitral DT (P = 0.005) were independent predictors of outcome. In the 100 HF patients with preserved LVEF, there were 17 events. Patients with GPLS ≤-15 had significantly better event-free survival than patients with GPLS >-15 (χ(2) = 4.1, P = 0.04), whereas LVEF did not predict event-free survival. Speckle strain echocardiography is an important predictor of outcome in HF patients with both depressed and preserved LVEF. © 2014, Wiley Periodicals, Inc.

  5. Computer-based assessment of right ventricular regional ejection fraction in patients with repaired Tetralogy of Fallot

    NASA Astrophysics Data System (ADS)

    Teo, S.-K.; Wong, S. T.; Tan, M. L.; Su, Y.; Zhong, L.; Tan, Ru-San

    2015-03-01

    After surgical repair for Tetralogy of Fallot (TOF), most patients experience long-term complications as the right ventricle (RV) undergoes progressive remodeling that eventually affect heart functions. Thus, post-repair surgery is required to prevent further deterioration of RV functions that may result in malignant ventricular arrhythmias and mortality. The timing of such post-repair surgery therefore depends crucially on the quantitative assessment of the RV functions. Current clinical indices for such functional assessment measure global properties such as RV volumes and ejection fraction. However, these indices are less than ideal as regional variations and anomalies are obscured. Therefore, we sought to (i) develop a quantitative method to assess RV regional function using regional ejection fraction (REF) based on a 13-segment model, and (ii) evaluate the effectiveness of REF in discriminating 6 repaired TOF patients and 6 normal control based on cardiac magnetic resonance (CMR) imaging. We observed that the REF for the individual segments in the patient group is significantly lower compared to the control group (P < 0.05 using a 2-tail student t-test). In addition, we also observed that the aggregated REF at the basal, mid-cavity and apical regions for the patient group is significantly lower compared to the control group (P < 0.001 using a 2-tail student t-test). The results suggest that REF could potentially be used as a quantitative index for assessing RV regional functions. The computational time per data set is approximately 60 seconds, which demonstrates our method's clinical potential as a real-time cardiac assessment tool.

  6. New strategies for heart failure with preserved ejection fraction: the importance of targeted therapies for heart failure phenotypes.

    PubMed

    Senni, Michele; Paulus, Walter J; Gavazzi, Antonello; Fraser, Alan G; Díez, Javier; Solomon, Scott D; Smiseth, Otto A; Guazzi, Marco; Lam, Carolyn S P; Maggioni, Aldo P; Tschöpe, Carsten; Metra, Marco; Hummel, Scott L; Edelmann, Frank; Ambrosio, Giuseppe; Stewart Coats, Andrew J; Filippatos, Gerasimos S; Gheorghiade, Mihai; Anker, Stefan D; Levy, Daniel; Pfeffer, Marc A; Stough, Wendy Gattis; Pieske, Burkert M

    2014-10-21

    The management of heart failure with reduced ejection fraction (HF-REF) has improved significantly over the last two decades. In contrast, little or no progress has been made in identifying evidence-based, effective treatments for heart failure with preserved ejection fraction (HF-PEF). Despite the high prevalence, mortality, and cost of HF-PEF, large phase III international clinical trials investigating interventions to improve outcomes in HF-PEF have yielded disappointing results. Therefore, treatment of HF-PEF remains largely empiric, and almost no acknowledged standards exist. There is no single explanation for the negative results of past HF-PEF trials. Potential contributors include an incomplete understanding of HF-PEF pathophysiology, the heterogeneity of the patient population, inadequate diagnostic criteria, recruitment of patients without true heart failure or at early stages of the syndrome, poor matching of therapeutic mechanisms and primary pathophysiological processes, suboptimal study designs, or inadequate statistical power. Many novel agents are in various stages of research and development for potential use in patients with HF-PEF. To maximize the likelihood of identifying effective therapeutics for HF-PEF, lessons learned from the past decade of research should be applied to the design, conduct, and interpretation of future trials. This paper represents a synthesis of a workshop held in Bergamo, Italy, and it examines new and emerging therapies in the context of specific, targeted HF-PEF phenotypes where positive clinical benefit may be detected in clinical trials. Specific considerations related to patient and endpoint selection for future clinical trials design are also discussed. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.

  7. Heart Failure with Recovered Ejection Fraction in African Americans: Results From the African-American Heart Failure Trial.

    PubMed

    Chang, Kay-Won; Beri, Neil; Nguyen, Nghia H; Arbit, Boris; Fox, Sutton; Mojaver, Sean; Clopton, Paul; Tam, S William; Taylor, Anne L; Cohn, Jay N; Maisel, Alan S; Anand, Inder S

    2017-09-13

    Recent studies have described the entity of heart failure with recovered ejection fraction (HFrecEF), but population specific studies remain lacking. The aim of this study was to characterize patients enrolled in the African-American Heart Failure Trial (A-HeFT) who had significant improvement in their ejection fraction (EF) during the first 6 months of follow-up. Subjects (n = 59) with HFrecEF (improvement in EF from < 35% to > 40% in 6 months) were compared to 259 with heart failure and persistently reduced EF (HFrEF), defined as EF ≤ 40% at 6 month follow-up. The effects of improvement in EFon all-cause mortality, first and all hospitalizations were analyzed. Compared to HFrEF, subjects with HFrecEF had a non-significant trend towards lower mortality (hazard ratio [HR] 0.16, 95% confidence interval [CI] 0.02 - 1.15, P = 0.068), fewer first HF hospitalizations (HR 0.22, 95% CI 0.07 - 0.71, P = 0.011), fewer recurrent HF hospitalizations (HR 0.13, 95% CI 0.05 - 0.37, P < 0.001), similar first all-cause hospitalizations (HR 0.67, 95% CI 0.39 - 1.15, P = 0.150), and fewer recurrent all-cause hospitalizations (HR 0.41, 95% CI 0.24 - 0.68, P < 0.001). These data confirm that as in other populations, a small subgroup of black patients receiving standard of care improve their EF with favorable outcomes. Further studies are required to determine whether myocardial recovery is permanent and the best management strategies in such patients. Copyright © 2017 Elsevier Inc. All rights reserved.

  8. Diastolic function is associated with quality of life and exercise capacity in stable heart failure patients with reduced ejection fraction

    PubMed Central

    Bussoni, M.F.; Guirado, G.N.; Roscani, M.G.; Polegato, B.F.; Matsubara, L.S.; Bazan, S.G.Z.; Matsubara, B.B.

    2013-01-01

    Exercise capacity and quality of life (QOL) are important outcome predictors in patients with systolic heart failure (HF), independent of left ventricular (LV) ejection fraction (LVEF). LV diastolic function has been shown to be a better predictor of aerobic exercise capacity in patients with systolic dysfunction and a New York Heart Association (NYHA) classification ≥II. We hypothesized that the currently used index of diastolic function E/e' is associated with exercise capacity and QOL, even in optimally treated HF patients with reduced LVEF. This prospective study included 44 consecutive patients aged 55±11 years (27 men and 17 women), with LVEF<0.50 and NYHA functional class I-III, receiving optimal pharmacological treatment and in a stable clinical condition, as shown by the absence of dyspnea exacerbation for at least 3 months. All patients had conventional transthoracic echocardiography and answered the Minnesota Living with HF Questionnaire, followed by the 6-min walk test (6MWT). In a multivariable model with 6MWT as the dependent variable, age and E/e' explained 27% of the walked distance in 6MWT (P=0.002; multivariate regression analysis). No association was found between walk distance and LVEF or mitral annulus systolic velocity. Only normalized left atrium volume, a sensitive index of diastolic function, was associated with decreased QOL. Despite the small number of patients included, this study offers evidence that diastolic function is associated with physical capacity and QOL and should be considered along with ejection fraction in patients with compensated systolic HF. PMID:24036912

  9. Left ventricular longitudinal systolic dysfunction is associated with right atrial dyssynchrony in heart failure with preserved ejection fraction.

    PubMed

    Bytyçi, Ibadete; Haliti, Edmond; Berisha, Gëzim; Tishukaj, Arbërie; Shatri, Faik; Bajraktari, Gani

    2016-04-01

    We aimed in this study to assess the role of longitudinal left ventricular (LV) systolic function in heart failure with preserved ejection fraction (HFpEF) in delayed intra- and interatrial conduction time. In 85 consecutive patients with HFpEF (age 60±11 years, ejection fraction [EF] ≥45%), a complete M-mode echocardiographic and tissue Doppler imaging (TDI) study was performed. The times from the onset of the P wave on the ECG to the beginning of the A' wave (PA) from the lateral and septal mitral and tricuspid annuli on TDI were recorded. The difference between these intervals gave the intra- and interatrial dyssynchrony. Based on mitral annular plane systolic excursion (MAPSE), patients were classified as having HFpEF with impaired (MAPSE ≤1.2 cm) or normal (MAPSE >1.2 cm) longitudinal systolic function. Patients with impaired MAPSE were older (p<0.001), had higher LV mass index (p<0.001), greater left atrial (LA) minimum volume (p=0.007), reduced left atrial EF (p<0.001), higher E/e' ratio (p=0.002), reduced lateral and septal e' wave (p=0.005 and p=0.006, respectively), prolonged tricuspid PA' (p=0.03) and significantly increased right atrial (RA) dyssynchrony (p=0.001) compared with normal MAPSE. MAPSE correlated with RA dyssynchrony (r=-0.40, p<0.001) but not with interatrial and LA dyssynchrony. In patients with HFpEF and impaired MAPSE, RA dyssynchrony is increased, compared to those with normal MAPSE. As patients with RA dyssynchrony are at higher risk for arrhythmia, assessment of this dyssynchrony may help to improve treatment, as well as to predict outcome in these patients. Copyright © 2016 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

  10. New strategies for heart failure with preserved ejection fraction: the importance of targeted therapies for heart failure phenotypes

    PubMed Central

    Senni, Michele; Paulus, Walter J.; Gavazzi, Antonello; Fraser, Alan G.; Díez, Javier; Solomon, Scott D.; Smiseth, Otto A.; Guazzi, Marco; Lam, Carolyn S. P.; Maggioni, Aldo P.; Tschöpe, Carsten; Metra, Marco; Hummel, Scott L.; Edelmann, Frank; Ambrosio, Giuseppe; Stewart Coats, Andrew J.; Filippatos, Gerasimos S.; Gheorghiade, Mihai; Anker, Stefan D.; Levy, Daniel; Pfeffer, Marc A.; Stough, Wendy Gattis; Pieske, Burkert M.

    2014-01-01

    The management of heart failure with reduced ejection fraction (HF-REF) has improved significantly over the last two decades. In contrast, little or no progress has been made in identifying evidence-based, effective treatments for heart failure with preserved ejection fraction (HF-PEF). Despite the high prevalence, mortality, and cost of HF-PEF, large phase III international clinical trials investigating interventions to improve outcomes in HF-PEF have yielded disappointing results. Therefore, treatment of HF-PEF remains largely empiric, and almost no acknowledged standards exist. There is no single explanation for the negative results of past HF-PEF trials. Potential contributors include an incomplete understanding of HF-PEF pathophysiology, the heterogeneity of the patient population, inadequate diagnostic criteria, recruitment of patients without true heart failure or at early stages of the syndrome, poor matching of therapeutic mechanisms and primary pathophysiological processes, suboptimal study designs, or inadequate statistical power. Many novel agents are in various stages of research and development for potential use in patients with HF-PEF. To maximize the likelihood of identifying effective therapeutics for HF-PEF, lessons learned from the past decade of research should be applied to the design, conduct, and interpretation of future trials. This paper represents a synthesis of a workshop held in Bergamo, Italy, and it examines new and emerging therapies in the context of specific, targeted HF-PEF phenotypes where positive clinical benefit may be detected in clinical trials. Specific considerations related to patient and endpoint selection for future clinical trials design are also discussed. PMID:25104786

  11. Measurement of Dyspnea in Ambulatory African Americans With Heart Failure and a Preserved or Reduced Ejection Fraction.

    PubMed

    Vuckovic, Karen M; DeVon, Holli A; Piano, Mariann R

    2016-01-01

    Dyspnea is a burdensome and disabling heart failure (HF) symptom. Few studies examining dyspnea in HF have included African Americans (AAs), despite their developing HF at a younger age and having the highest mortality rates. The purpose of this cross-sectional study was to examine dyspnea in AA patients with HF and a preserved ejection fraction (HFpEF) compared with those with a reduced ejection fraction (HFrEF), before and after the 6-minute walk test (6MWT). A convenience sample of ambulatory AA patients (HFrEF, n = 26; HFpEF, n = 19) 50 years or older was recruited from an urban HF clinic. The Borg Scale and a visual analog scale (VAS) were used to measure dyspnea intensity before and after the 6MWT. Activity limitations related to dyspnea were described using the modified Medical Research Council Dyspnea Scale. Group comparisons were analyzed using repeated-measures analysis of variance and χ 2tests. Convergent validity was determined between the Borg and VAS using Bland-Altman plots. No significant differences were found in age, gender, and comorbidities between HF groups. Most HFpEF patients reported dyspnea at baseline (Borg, 63%; VAS, 73%) and after the 6MWT (Borg, 78%; VAS, 79%). In the HFrEF group, the prevalence of baseline dyspnea was greater when measured with the VAS (Borg, 34%; VAS, 80%) but was similar between instruments after the 6MWT (Borg, 64%; VAS, 77%). Both groups reported a similar change in dyspnea intensity during and after the 6MWT. The Bland-Altman plots indicated moderate agreement at each time point. Most patients described walking hurriedly or uphill as dyspnea-provoking on the Modified Respiratory Council Dyspnea Scale. The prevalence of dyspnea at baseline and after the 6MWT was high for both groups, but intensity varied with the dyspnea instrument used.

  12. Left Ventricular Ejection Fraction and Risk of Stroke and Cardiac Events in Heart Failure: Data from the WARCEF trial

    PubMed Central

    Di Tullio, Marco R.; Qian, Min; Thompson, John L.P.; Labovitz, Arthur J.; Mann, Douglas L.; Sacco, Ralph L.; Pullicino, Patrick M.; Freudenberger, Ronald S.; Teerlink, John R.; Graham, Susan; Lip, Gregory Y. H.; Levin, Bruce; Mohr, J P; Buchsbaum, Richard; Estol, Conrado J.; Lok, Dirk J.; Ponikowski, Piotr; Anker, Stefan D.; Homma, Shunichi

    2016-01-01

    Background and Purpose In heart failure (HF), left ventricular ejection fraction (LVEF) is inversely associated with mortality and cardiovascular (CV) outcomes. Its relationship with stroke is controversial, as is the effect of antithrombotic treatment. We studied the relationship of LVEF with stroke and CV events in HF patients, and the effect of different antithrombotic treatments. Methods In the Warfarin versus Aspirin in Reduced Ejection Fraction (WARCEF) trial, 2305 patients with systolic HF (LVEF ≤ 35%) and sinus rhythm were randomized to warfarin or aspirin and followed for 3.5±1.8 years. While no differences between treatments were observed on primary outcome (death, stroke or intracerebral hemorrhage), warfarin decreased the stroke risk. The present report compares the incidence of stroke and CV events across different LVEF and treatment subgroups. Results Baseline LVEF was inversely and linearly associated with primary outcome, mortality and its components (sudden and CV death) and HF hospitalization, but not myocardial infarction. A relationship with stroke was only observed for LVEF <15% (incidence rates: 2.04 vs. 0.95/100 pt. yrs; p=0.009), which more than doubled the adjusted stroke risk (adjusted HR: 2.125, 95% CI 1.182, 3.818; p=0.012). In warfarin-treated patients, each 5% LVEF decrement significantly increased the stroke risk (adjusted HR: 1.346, 95% CI 1.044, 1.737; p=0.022; p-value for interaction=0.04). Conclusions In patients with systolic HF and sinus rhythm, LVEF is inversely associated with death and its components, whereas an association with stroke exists for very low LVEF values. An interaction with warfarin treatment on stroke risk may exist. Clinical Trial Registration - URL:http://www.clinicaltrials.gov. Unique identifier: NCT00041938 PMID:27354224

  13. Characterization of Subgroups of Heart Failure Patients with Preserved Ejection Fraction with Possible Implications for Prognosis and Treatment Response

    PubMed Central

    Kao, David P; Lewsey, James D; Anand, Inder S; Massie, Barry M; Zile, Michael; Carson, Peter E; McKelvie, Robert; Komajda, Michel; McMurray, John; Lindenfeld, JoAnn

    2015-01-01

    Background Patients with heart failure and preserved ejection fraction (HFpEF) have a poor prognosis, and no therapies have been proven to improve outcomes. It has been proposed that heart failure, including HFpEF, represents overlapping syndromes that may have different prognoses. We present an exploratory study of patients enrolled in the Irbesartan in Heart Failure with Preserved Ejection Fraction Study (I-PRESERVE) using latent class analysis (LCA) with validation using the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM)-Preserved study to identify HFpEF subgroups. Methods and results In total, 4113 HFpEF patients randomized to irbesartan or placebo were characterized according to 11 clinical features. HFpEF subgroups were identified using LCA. Event-free survival and effect of irbesartan on the composite of all-cause mortality and cardiovascular hospitalization were determined for each subgroup. Subgroup definitions were applied to 3203 patients enrolled in CHARM-Preserved to validate observations regarding prognosis and treatment response. Six subgroups were identified with significant differences in event-free survival (p<0.001). Clinical profiles and prognoses of the 6 subgroups were similar in CHARM-Preserved. The two subgroups with the worst event-free survival in both studies were characterized by a high prevalence of obesity, hyperlipidemia, diabetes mellitus, anemia, and renal insufficiency (Subgroup C) and by female predominance, advanced age, lower body mass index, and high rates of atrial fibrillation, valvular disease, renal insufficiency, and anemia (Subgroup F). Conclusion Using a data-driven approach, we identified HFpEF subgroups with significantly different prognoses. Further development of this approach for characterizing HFpEF subgroups is warranted. PMID:26250359

  14. Risk Factors for Incident Hospitalized Heart Failure With Preserved Versus Reduced Ejection Fraction in a Multiracial Cohort of Postmenopausal Women.

    PubMed

    Eaton, Charles B; Pettinger, Mary; Rossouw, Jacques; Martin, Lisa Warsinger; Foraker, Randi; Quddus, Abdullah; Liu, Simin; Wampler, Nina S; Hank Wu, Wen-Chih; Manson, JoAnn E; Margolis, Karen; Johnson, Karen C; Allison, Matthew; Corbie-Smith, Giselle; Rosamond, Wayne; Breathett, Khadijah; Klein, Liviu

    2016-10-01

    Heart failure is an important and growing public health problem in women. Risk factors for incident hospitalized heart failure with preserved ejection fraction (HFpEF) compared with heart failure with reduced ejection fraction (HFrEF) in women and differences by race/ethnicity are not well characterized. We prospectively evaluated the risk factors for incident hospitalized HFpEF and HFrEF in a multiracial cohort of 42 170 postmenopausal women followed up for a mean of 13.2 years. Cox regression models with time-dependent covariate adjustment were used to define risk factors for HFpEF and HFrEF. Differences by race/ethnicity about incidence rates, baseline risk factors, and their population-attributable risk percentage were analyzed. Risk factors for both HFpEF and HFrEF were as follows: older age, white race, diabetes mellitus, cigarette smoking, and hypertension. Obesity, history of coronary heart disease (other than myocardial infarction), anemia, atrial fibrillation, and more than one comorbidity were associated with HFpEF but not with HFrEF. History of myocardial infarction was associated with HFrEF but not with HFpEF. Obesity was found to be a more potent risk factor for African American women compared with white women for HFpEF (P for interaction=0.007). For HFpEF, the population-attributable risk percentage was greatest for hypertension (40.9%) followed by obesity (25.8%), with the highest population-attributable risk percentage found in African Americans for these risk factors. In this multiracial cohort of postmenopausal women, obesity stands out as a significant risk factor for HFpEF, with the strongest association in African American women. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000611. © 2016 American Heart Association, Inc.

  15. Relationship between right and left ventricular function in candidates for implantable cardioverter defibrillator with low left ventricular ejection fraction.

    PubMed

    Jimenez-Juan, Laura; Karur, Gauri R; Connelly, Kim A; Deva, Djeven; Yan, Raymond T; Wald, Rachel M; Singh, Sheldon; Leung, General; Oikonomou, Anastasia; Dorian, Paul; Angaran, Paul; Yan, Andrew T

    2017-04-01

    Indications for the primary prevention of sudden death using an implantable cardioverter defibrillator (ICD) are based predominantly on left ventricular ejection fraction (LVEF). However, right ventricular ejection fraction (RVEF) is also a known prognostic factor in a variety of structural heart diseases that predispose to sudden cardiac death. We sought to investigate the relationship between right and left ventricular parameters (function and volume) measured by cardiovascular magnetic resonance (CMR) among a broad spectrum of patients considered for an ICD. In this retrospective, single tertiary-care center study, consecutive patients considered for ICD implantation who were referred for LVEF assessment by CMR were included. Right and left ventricular function and volumes were measured. In total, 102 patients (age 62±14 years; 23% women) had a mean LVEF of 28±11% and RVEF of 44±12%. The left ventricular and right ventricular end diastolic volume index was 140±42 mL/m(2) and 81±27 mL/m(2), respectively. Eighty-six (84%) patients had a LVEF <35%, and 63 (62%) patients had right ventricular systolic dysfunction. Although there was a significant and moderate correlation between LVEF and RVEF (r=0.40, p<0.001), 32 of 86 patients (37%) with LVEF <35% had preserved RVEF, while 9 of 16 patients (56%) with LVEF ≥35% had right ventricular systolic dysfunction (Kappa=0.041). Among patients being considered for an ICD, there is a positive but moderate correlation between LVEF and RVEF. A considerable proportion of patients who qualify for an ICD based on low LVEF have preserved RVEF, and vice versa.

  16. Ejection fractions and pressure-heart rate product to evaluate cardiac efficiency. Continuous, real-time diagnosis using blood pressure and heart rate.

    PubMed

    Kunig, H; Tassani-Prell, P; Engelmann, L

    2014-04-01

    Ejection fractions, derived from ventricular volumes, and double product, related to myocardial oxygen consumption, are important diagnostic parameters, as they describe the efficiency with which oxygen is consumed. Present technology often allows only intermittent determination of physiological status. This deficiency may be overcome if ejection fractions and myocardial oxygen consumption could be determined from continuous blood pressure and heart rate measurements. The purpose of this study is to determine the viability of pressure-derived ejection fractions and pressure-heart rate data in a diverse patient population and the use of ejection fractions to monitor patient safety. Volume ejection fractions, derived from ventricular volumes, EF(V), are defined by the ratio of the difference of end-diastolic volume, EDV, and end-systolic volume, ESV, to EDV. In analogy, pressure ejection fraction, EF(P), may be defined by the ratio of the difference of systolic arterial pressure, SBP, and diastolic arterial pressure, DBP, to SBP. The pressure-heart rate (heart rate: HR) is given by the product of systolic pressure and heart rate, SBP × HR. EF(P) and SBP × HR data were derived for all patients (n = 824) who were admitted in 2008 to the ICU of a university hospital at the specific time 30 min prior to leaving the ICU whether as survivors or non-survivors. The results are displayed in an efficiency/pressure-heart rate diagram. The efficiency/pressure-heart rate diagram reveals one subarea populated exclusively by survivors, another subarea populated statistically significant by non-survivors, and a third area shared by survivors and non-survivors. The efficiency/pressure-heart rate product relationship may be used as an outcome criterion to assess survival and to noninvasively monitor improvement or deterioration in real time to improve safety in patients with diverse dysfunctions.

  17. The easier, the better: age, creatinine, ejection fraction score for operative mortality risk stratification in a series of 29,659 patients undergoing elective cardiac surgery.

    PubMed

    Ranucci, Marco; Castelvecchio, Serenella; Conte, Massimiliano; Megliola, Gianluigi; Speziale, Giuseppe; Fiore, Flavio; Guarracino, Fabio; Scolletta, Sabino; Escobar, Ricardo Martinez; Falco, Mauro; Bignami, Elena; Landoni, Giovanni

    2011-09-01

    Age, preoperative creatinine value, and ejection fraction are easily arranged in the age, creatinine, ejection fraction score to predict operative mortality in elective cardiac operations, as recently shown. We validate the age, creatinine, ejection fraction score in a large multicentric study. We analyzed 29,659 consecutive patients who underwent elective cardiac operations in 14 Italian institutions during the period from 2004 to 2009. The operative (30-day) mortality rate was recorded for the entire population and for subgroups of patients based on the risk distribution. The predicted mortality was assessed using the additive and logistic European System for Cardiac Operative Risk Evaluations, and the age, creatinine, ejection fraction score. Accuracy and clinical performance of the different models were tested. The observed mortality rate was 2.77% (95% confidence interval, 2.59-2.96). The predicted mortality rate was 2.84% (95% confidence interval, 2.79-2.88) for the age, creatinine, ejection fraction score (not significantly different from the observed rate), 6.26% for the additive European System for Cardiac Operative Risk Evaluation, and 9.67% for the logistic European System for Cardiac Operative Risk Evaluation (both significantly overestimated). For all deciles of risk distribution, the European System for Cardiac Operative Risk Evaluation significantly overestimated mortality risk; the age, creatinine, ejection fraction score slightly overestimated the mortality risk in very low-risk patients and significantly underestimated the mortality risk in very high-risk patients, correctly estimating the risk in 7 of 10 deciles. The accuracy of the age, creatinine, ejection fraction score was acceptable (area under the curve of 0.702). In a separate analysis, this value increased to 0.74 by excluding centers that reported no operative mortality. These values were similar or worse for the European System for Cardiac Operative Risk Evaluation. The age, creatinine

  18. Associations of anemia and renal dysfunction with outcomes among patients hospitalized for acute decompensated heart failure with preserved or reduced ejection fraction.

    PubMed

    Kajimoto, Katsuya; Sato, Naoki; Keida, Takehiko; Sakata, Yasushi; Takano, Teruo

    2014-11-07

    The relationship among anemia, renal dysfunction, left ventricular ejection fraction, and outcomes of patients hospitalized for acute decompensated heart failure is unclear. The aim of this study was to evaluate the association between cardiorenal anemia syndrome and postdischarge outcomes in patients hospitalized for heart failure with a preserved or reduced ejection fraction. Of 4842 patients enrolled in the Acute Decompensated Heart Failure Syndromes Registry between April 1, 2007 and December 31, 2011, 4393 patients were evaluated to investigate the association among anemia, renal dysfunction, preserved or reduced ejection fraction, and the primary end point (mortality and readmission for heart failure since discharge). The patients were divided into four groups on the basis of eGFR and hemoglobin at discharge. The median follow-up period after discharge was 432 (range=253-659) days. The primary end point was reached in 37.6% and 34.8% of the preserved and reduced ejection fraction groups, respectively. After adjustment for multiple comorbidities, there was no significant association of either renal dysfunction or anemia alone with the primary end point in patients with preserved ejection fraction, but the combination of renal dysfunction and anemia was associated with a significantly higher risk than that without either condition (hazard ratio, 1.54; 95% confidence interval, 1.12 to 2.12; P<0.01). In patients with reduced ejection fraction, adjusted analysis showed that a significantly higher risk of the primary end point was associated with renal dysfunction alone (hazard ratio, 1.65; 95% confidence interval, 1.21 to 2.25; P=0.002) and also, renal dysfunction plus anemia relative to the risk without either condition (hazard ratio, 2.19; 95% confidence interval, 1.62 to 2.96; P<0.001). The findings show that renal dysfunction combined with anemia is associated with an increased risk of adverse postdischarge outcomes in patients with preserved ejection fraction

  19. A Multiphysics Modeling Approach to Develop Right Ventricle Pulmonary Valve Replacement Surgical Procedures with a Contracting Band to Improve Ventricle Ejection Fraction

    PubMed Central

    Tang, Dalin; Yang, Chun; Geva, Tal; Rathod, Rahul; Yamauchi, Haruo; Gooty, Vasu; Tang, Alexander; Kural, Mehmet H.; Billiar, Kristen L.; Gaudette, Glenn; del Nido, Pedro J.

    2012-01-01

    Patients with repaired tetralogy of Fallot account for the majority of cases with late onset right ventricle (RV) failure. A new surgical procedure placing an elastic band in the right ventricle is proposed to improve RV function measured by ejection fraction. A multiphysics modeling approach is developed to combine cardiac magnetic resonance imaging, modeling, tissue engineering and mechanical testing to demonstrate feasibility of the new surgical procedure. Our modeling results indicated that the new surgical procedure has the potential to improve right ventricle ejection fraction by 2–7% which compared favorably with recently published drug trials to treat LV heart failure. PMID:23667272

  20. Associations of Anemia and Renal Dysfunction with Outcomes among Patients Hospitalized for Acute Decompensated Heart Failure with Preserved or Reduced Ejection Fraction

    PubMed Central

    Sato, Naoki; Keida, Takehiko; Sakata, Yasushi; Takano, Teruo

    2014-01-01

    Background and objectives The relationship among anemia, renal dysfunction, left ventricular ejection fraction, and outcomes of patients hospitalized for acute decompensated heart failure is unclear. The aim of this study was to evaluate the association between cardiorenal anemia syndrome and postdischarge outcomes in patients hospitalized for heart failure with a preserved or reduced ejection fraction. Design, setting, participants, & measurements Of 4842 patients enrolled in the Acute Decompensated Heart Failure Syndromes Registry between April 1, 2007 and December 31, 2011, 4393 patients were evaluated to investigate the association among anemia, renal dysfunction, preserved or reduced ejection fraction, and the primary end point (mortality and readmission for heart failure since discharge). The patients were divided into four groups on the basis of eGFR and hemoglobin at discharge. The median follow-up period after discharge was 432 (range=253–659) days. Results The primary end point was reached in 37.6% and 34.8% of the preserved and reduced ejection fraction groups, respectively. After adjustment for multiple comorbidities, there was no significant association of either renal dysfunction or anemia alone with the primary end point in patients with preserved ejection fraction, but the combination of renal dysfunction and anemia was associated with a significantly higher risk than that without either condition (hazard ratio, 1.54; 95% confidence interval, 1.12 to 2.12; P<0.01). In patients with reduced ejection fraction, adjusted analysis showed that a significantly higher risk of the primary end point was associated with renal dysfunction alone (hazard ratio, 1.65; 95% confidence interval, 1.21 to 2.25; P=0.002) and also, renal dysfunction plus anemia relative to the risk without either condition (hazard ratio, 2.19; 95% confidence interval, 1.62 to 2.96; P<0.001). Conclusions The findings show that renal dysfunction combined with anemia is associated with an

  1. Effect of ivabradine in patients with heart failure with preserved ejection fraction: the EDIFY randomized placebo-controlled trial.

    PubMed

    Komajda, Michel; Isnard, Richard; Cohen-Solal, Alain; Metra, Marco; Pieske, Burkert; Ponikowski, Piotr; Voors, Adriaan A; Dominjon, Fabienne; Henon-Goburdhun, Cécile; Pannaux, Matthieu; Böhm, Michael

    2017-04-30

    This randomized, double-blind, placebo-controlled trial assessed whether heart rate (HR) reduction with ivabradine improves cardiac function in heart failure with preserved ejection fraction (HFpEF). The prEserveD left ventricular ejectIon fraction chronic heart Failure with ivabradine studY (EDIFY) included 179 patients in New York Heart Association (NYHA) classes II and III, in sinus rhythm, with HR of ≥70 b.p.m., NT-proBNP of ≥220 pg/mL (BNP ≥80 pg/mL) and left ventricular ejection fraction of ≥45%. Ivabradine (or placebo) was titrated to 7.5 mg b.i.d. Patients were followed for 8 months on the change and assessed for three co-primary endpoints: echo-Doppler E/e' ratio, distance on the 6-min walking test (6MWT), and plasma NT-proBNP concentration. At baseline, median E/e' was 12.8 [interquartile range (IQR): 9.9-16.3], median distance on the 6MWT was 320 m (IQR: 247-375 m), and median NT-proBNP was 375 pg/mL (IQR: 253-701 pg/mL). Baseline median HR was 75 b.p.m. (IQR: 70-107 b.p.m.). A total of 171 patients (87 in the ivabradine group, 84 in the placebo group) were evaluated for treatment efficacy. After 8 months of treatment, findings showed a median change in HR of -13.0 b.p.m. (IQR: -18.0 to -6.0 b.p.m.) in the ivabradine group and -3.5 b.p.m. (IQR: -11.5 to 3.0 b.p.m.) in the placebo group [estimated between-group difference: 7.7 b.p.m.; 90% confidence interval (CI) -10 to -5.4; P < 0.0001]. No evidence of improvement was found in any of the three co-primary endpoints. There was almost no change in median E/e' in either of the two groups [median change: +1.0 (IQR: -0.8 to 2.9) in the ivabradine group; -0.6 (IQR: -2.2 to 1.4) in the placebo group; estimated between-group difference: 1.4, 90% CI 0.3-2.5; P = 0.135]. There were no meaningful changes in the other co-primary endpoints and no apparent trends. There was no significant safety concern. In patients with HFpEF, HR reduction with ivabradine did not

  2. Evaluation of biventricular ejection fraction with ECG-gated 16-slice CT: preliminary findings in acute pulmonary embolism in comparison with radionuclide ventriculography.

    PubMed

    Coche, Emmanuel; Vlassenbroek, Alain; Roelants, Véronique; D'Hoore, William; Verschuren, Franck; Goncette, Louis; Maldague, Baudouin

    2005-07-01

    This study aimed to assess the feasibility of cardiac global function evaluation during a whole-chest multi-slice CT (MSCT) acquisition in patients referred for suspicion of pulmonary embolism (PE), and to compare the results with planar equilibrium radionuclide ventriculography (ERNA). Ten consecutive haemodynamically stable patients (six female, four male; mean age 69.7 years; heart rate 65-99 bpm) with suspicion of PE underwent an MSCT and ERNA within a 6 h period. CT acquisition was performed after contrast medium injection by using 16x1.5 mm collimation and retrospective ECG gating. Left ventricular (LVEF) and right ventricular (RVEF) ejection fractions were calculated using dedicated three-dimensional software. Relationships between measurements obtained with MSCT and ERNA were assessed using linear regression analysis and reliability of MSCT was assessed with intra-class correlation coefficient. Bland-Altman analysis was performed to calculate limits of agreement between MSCT and ERNA. MSCT was performed successfully in ten patients with a mean acquisition time of 16.5+/-2.8 s. Functional cardiac evaluation was possible on CT for all patients except for one due to poor opacification of right ventricle. Linear regression analysis showed a good correlation between MSCT and ERNA for the LVEF (R=0.91) and the RVEF (R=0.89) measurements. Intra-class correlation was superior for LVEF (0.92) than for the RVEF (0.68). Bland-Altman plots demonstrated that MSCT substantially overestimated the ERNA RVEF. Morphological CT data demonstrated PE in four of ten of patients and alternative diagnoses in five of ten patients. Our study reveals that MSCT with retrospective ECG gating may provide in one modality a morphological and a functional cardiopulmonary evaluation. Comparison with ERNA demonstrated a good correlation for both ventricular ejection fractions.

  3. Peak oxygen uptake and left ventricular ejection fraction, but not depressive symptoms, are associated with cognitive impairment in patients with chronic heart failure

    PubMed Central

    Steinberg, Gerrit; Lossnitzer, Nicole; Schellberg, Dieter; Mueller-Tasch, Thomas; Krueger, Carsten; Haass, Markus; Ladwig, Karl Heinz; Herzog, Wolfgang; Juenger, Jana

    2011-01-01

    Background The aim of the present study was to assess cognitive impairment in patients with chronic heart failure (CHF) and its associations with depressive symptoms and somatic indicators of illness severity, which is a matter of controversy. Methods and results Fifty-five patients with CHF (mean age 55.3 ± 7.8 years; 80% male; New York Heart Association functional class I–III) underwent assessment with an expanded neuropsychological test battery (eg, memory, complex attention, mental flexibility, psychomotor speed) to evaluate objective and subjective cognitive impairment. Depressive symptoms were assessed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID) and a self-report inventory (Hospital Anxiety and Depression Scale [HADS]). A comprehensive clinical dataset, including left ventricular ejection fraction, peak oxygen uptake, and a 6-minute walk test, was obtained for all patients. Neuropsychological functioning revealed impairment in 56% of patients in at least one measure of our neuropsychological test battery. However, the Mini Mental State Examination (MMSE) could only detect cognitive impairment in 1.8% of all patients, 24% had HADS scores indicating depressive symptoms, and 11.1% met SCID criteria for a depressive disorder. No significant association was found between depressive symptoms and cognitive impairment. Left ventricular ejection fraction was related to subjective cognitive impairment, and peak oxygen uptake was related to objective cognitive impairment. Conclusion Cognitive functioning was substantially reduced in patients with CHF and should therefore be diagnosed and treated in routine clinical practice. Caution is advised when the MMSE is used to identify cognitive impairment in patients with CHF. PMID:22267941

  4. Comparison of ejection fraction and Goldman risk factor analysis to dipyridamole-thallium 201 studies in the evaluation of cardiac morbidity after aortic aneurysm surgery

    SciTech Connect

    McEnroe, C.S.; O'Donnell, T.F. Jr.; Yeager, A.; Konstam, M.; Mackey, W.C. )

    1990-04-01

    Associated coronary artery disease is the critical factor that influences early and late mortality after abdominal aortic aneurysm surgery. Dipyridamole-thallium 201 scintigraphy, left ventricular ejection fraction, and Goldman risk factor analysis have been suggested as preoperative noninvasive screening methods to detect significant coronary artery disease. In this series of 95 elective abdominal aortic aneurysm repairs dipyridamole-thallium 201 scintigraphy was highly predictive of the absence of perioperative cardiac morbidity (96% specificity, 44/46 normal scans, no cardiac morbidity), whereas ejection fraction (73% specificity, 31/42 normal ejection fraction, no cardiac morbidity) and Goldman risk factor analysis (84% specificity, 44/51 class I, no cardiac morbidity) were less. Furthermore, thallium redistribution on dipyridamole-thallium 201 scintigraphy leading to coronary angiography identified a significant number of patients with occult coronary artery disease who required preoperative coronary revascularization (8%, 8/95) and might have remained undetected on the basis of left ventricular ejection fraction or Goldman risk factor analysis. Finally, fixed thallium deficit, which some investigators have interpreted as a low probability finding for cardiac morbidity, was associated with a higher than expected incidence of cardiac complications. Forty-six percent (7/15) of all postoperative cardiac complications (three myocardial infarctions, three ischemic events, one death) occurred in patients with abdominal aortic aneurysms with fixed deficits. This suggests that patients with fixed deficits on dipyridamole-thallium 201 scintigraphy should be considered for later delayed (4 hours) thallium images or coronary angiography or both.

  5. Challenging aspects of treatment strategies in heart failure with preserved ejection fraction: “Why did recent clinical trials fail?”

    PubMed Central

    Becher, Peter Moritz; Fluschnik, Nina; Blankenberg, Stefan; Westermann, Dirk

    2015-01-01

    Heart failure (HF) is the leading cause of hospitalization among older adults and the prevalence is growing with the aging populations in the Western countries. Epidemiologic reports suggest that approximately 50% of patients who have signs or symptoms of HF have preserved left ventricular ejection fraction. This HF type predominantly affects women and the elderly with other co-morbidities, such as diabetes, hypertension, and overt volume status. Most of the current treatment strategies are based on morbidity benefits such as quality of life and reduction of clinical HF symptoms. Treatment of patients with HF with preserved ejection fraction displayed disappointing results from several large randomized controlled trials. The heterogeneity of HF with preserved ejection fraction, understood as complex syndrome, seems to be one of the primary reasons. Here, we present an overview of the current management strategies with available evidence and new therapeutic approach from drugs currently in clinical trials, which target diastolic dysfunction, chronotropic incompetence, and risk factor management. We provide an outline and interpretation of recent clinical trials that failed to improve outcome and survival in patients with HF with preserved ejection fraction. PMID:26413231

  6. Fractionation of elements by particle size of ashes ejected from Copahue Volcano, Argentina.

    PubMed

    Gómez, Dario; Smichowski, Patricia; Polla, Griselda; Ledesma, Ariel; Resnizky, Sara; Rosa, Susana

    2002-12-01

    The volcano Copahue, Neuquén province, Argentina has shown infrequent explosive eruptions since the 18th century. Recently, eruptive activity and seismicity were registered in the period July-October, 2000. As a consequence, ash clouds were dispersed by winds and affected Caviahue village located at about 9 km east of the volcano. Samples of deposited particles from this area were collected during this episode for their chemical analysis to determine elements of concern with respect to the health of the local population and its environment. Different techniques were used to evaluate the distribution of elements in four particle size ranges from 36 to 300 microm. X-ray powder diffraction (XRD) was selected to detect major components namely, minerals, silicate glass, fragments of rocks and sulfurs. Major and minor elements (Al, Ca, Cl, Fe, K, Mg, Mn, Na, S, Si and Ti), were detected by energy dispersive X ray analysis (EDAX). Trace element (As, Cd, Cr, Cu, Hg, Ni, Pb, Sb, U, V and Zn) content was quantified by inductively coupled plasma-mass spectrometry (ICP-MS). Nuclear activation analysis (NAA) was employed for the determination of Ce, Co, Cs, Eu, Hf, La, Lu, Rb, Sc, Sm, Ta and Yb. An enrichment was observed in the smallest size fraction of volcanic ashes for four elements (As, Cd, Cu and Sb) of particular interest from the environmental and human health point of view.

  7. Two-Dimensional Speckle Tracking Echocardiography Predict Left Ventricular Remodeling after Acute Myocardial Infarction in Patients with Preserved Ejection Fraction

    PubMed Central

    Hsiao, Ju-Feng; Chung, Chang-Min; Chu, Chi-Ming; Lin, Yu-Shen; Pan, Kuo-Li; Chang, Shih-Tai

    2016-01-01

    Objectives Left ventricular remodeling after acute myocardial infarction increases cardiovascular events and mortality. But few study was done in patients with preserved ejection fraction (EF > 40%). We investigate whether the strain and strain rate by 2D speckle tracking echocardiography could predict left ventricular remodeling after acute myocardial infarction in this cohort. Methods The 83 patients (average age 60.7 ± 12.3 y, 75 [90.4%] male) with new-onset acute myocardial infarction receiving echocardiography immediately, and 6 months after admission were grouped by the presence or absence of left ventricular remodeling. Strain and strain rate including longitudinal, circumferential, and radial direction were calculated. The average of strain and strain rate of which segmental longitudinal strains > – 15% were defined as the injury longitudinal strain (InjLS). Results Left ventricular remodeling occurred in 24 of 83 patients (28.9%). In univariate logistic regression analyses, gender, peak CK-MB, log BNP, use of statin before discharge, wall motion score index, and InjLS were significantly associated with left ventricular remodeling (p < 0.05). In multivariate analysis using the forward stepwise method, gender, CK-MB, and InjLS were independent predictors. The hazard ratio for InjLS was 1.48 (p = 0.04). Receiver operating characteristic curve (ROC) analyses showed the area under the curve (AUC) of InjLS was largest (AUC = 0.75, cut-off value = –11.7%, sensitivity = 81%, specificity = 71%, p < 0.01). In ST-segment elevation myocardial infarction subgroup, InjLS was the only predictor according to ROC analysis (AUC = 0.79, p < 0.01, cut-off value = –11.4%, sensitivity = 88%, specificity = 77%) and multivariate logistic regression analysis (hazard ratio = 1.88, 95% CI: 1.22–2.88, p < 0.01). Conclusions InjLS was an excellent predictor for left ventricular remodeling after acute myocardial infarction in patient with preserved ejection fraction. PMID

  8. Strain Echocardiography and Functional Capacity in Asymptomatic Primary Mitral Regurgitation With Preserved Ejection Fraction.

    PubMed

    Mentias, Amgad; Naji, Peyman; Gillinov, A Marc; Rodriguez, L Leonardo; Reed, Grant; Mihaljevic, Tomislav; Suri, Rakesh M; Sabik, Joseph F; Svensson, Lars G; Grimm, Richard A; Griffin, Brian P; Desai, Milind Y

    2016-11-01

    The potential additive utility of baseline resting left ventricular global longitudinal strain (LV-GLS) and exercise stress testing in risk stratification of patients with significant mitral regurgitation (MR) has not been studied. The goal of this study was to determine whether resting LV-GLS and exercise testing provide incremental prognostic utility in asymptomatic patients with ≥3+ primary MR and preserved left ventricular ejection fraction. Between 2000 and 2011, resting and exercise echocardiography data, Society of Thoracic Surgeons (STS) scores, and death were recorded in 737 patients (mean age 58 ± 13 years; 68% men). Coronary artery disease and flail leaflet were seen in 10% and 28% of patients, respectively. STS score, resting left ventricular ejection fraction, mitral effective regurgitant orifice, resting right ventricular systolic pressure (RVSP), exercise metabolic equivalents (METs), and percentage of age-/sex-predicted METs were 1.5 ± 1%, 62 ± 2%, 0.45 ± 0.2 cm(2), 31 ± 12 mm Hg, 9.8 ± 3, and 115 ± 27, respectively. Median LV-GLS was -21.7%. Within 3 months (interquartile range: 1 to 15 months), 65% underwent mitral valve surgery. At 8.3 ± 3 years, 64 (9%) patients died (0% 30-day post-operative deaths). On multivariable Cox survival analysis, higher STS score (hazard ratio [HR]: 1.14), more abnormal resting LV-GLS (HR: 1.60), higher baseline RVSP (HR: 1.35), and lower percentage of age-/sex-predicted METs (HR: 1.13) were associated with higher mortality, whereas mitral valve surgery (HR: 0.82) was associated with improved survival (all p < 0.01). Addition of predicted METs and resting LV-GLS to STS, resting RVSP, left ventricular end-systolic dimension, and mitral effective regurgitant orifice increased the C-statistic for longer-term mortality from 0.61 to 0.69 and 0.78, respectively (all p < 0.01). On quadratic spline analysis, the risk of death progressively increased as resting LV-GLS worsened below -21%. Reduced exercise

  9. Mineralocorticoid receptor antagonist use in hospitalized patients with heart failure, reduced ejection fraction, and diabetes mellitus (from the EVEREST Trial).

    PubMed

    Vaduganathan, Muthiah; Dei Cas, Alessandra; Mentz, Robert J; Greene, Stephen J; Khan, Sadiya; Subacius, Haris P; Chioncel, Ovidiu; Maggioni, Aldo P; Konstam, Marvin A; Senni, Michele; Fonarow, Gregg C; Butler, Javed; Gheorghiade, Mihai

    2014-09-01

    Despite the well-established benefits of mineralocorticoid receptor agonists (MRAs) in heart failure with reduced ejection fraction, safety concerns remain in patients with concomitant diabetes mellitus (DM) because of common renal and electrolyte abnormalities in this population. We analyzed all-cause mortality and composite cardiovascular mortality and HF hospitalization over a median 9.9 months among 1,998 patients in the placebo arm of the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) trial by DM status and discharge MRA use. Of the 750 patients with DM, 59.2% were receiving MRAs compared with 62.5% in the non-DM patients. DM patients not receiving MRAs were older, more likely to be men, with an ischemic heart failure etiology and slightly worse renal function compared with those receiving MRAs. After adjustment for baseline risk factors, among DM patients, MRA use was not associated with either mortality (hazard ratio [HR] 0.93; 95% confidence interval [CI] 0.75 to 1.15) or the composite end point (HR 0.94; 95% CI 0.80 to 1.10). Similar findings were seen in non-DM patients (mortality [HR 1.01; 95% CI 0.84 to 1.22] or the composite end point [HR 0.98; 95% CI 0.85 to 1.13] [p >0.43 for DM interaction]). In conclusion, in-hospital initiation of MRA therapy was low (15% to 20%), and overall discharge MRA use was only 60% (with regional variation), regardless of DM status. There does not appear to be clear, clinically significant in-hospital hemodynamic or even renal differences between those on and off MRA. Discharge MRA use was not associated with postdischarge end points in patients hospitalized for worsening heart failure with reduced ejection fraction and co-morbid DM. DM does not appear to influence the effectiveness of MRA therapy. Copyright © 2014 Elsevier Inc. All rights reserved.

  10. Copeptin in patients with heart failure and preserved ejection fraction: a report from the prospective KaRen-study

    PubMed Central

    Hage, Camilla; Lund, Lars H; Donal, Erwan; Daubert, Jean-Claude; Linde, Cecilia; Mellbin, Linda

    2015-01-01

    Introduction Underlying mechanisms of heart failure (HF) with preserved ejection fraction (HFPEF) remain unknown. We explored copeptin, a biomarker of the arginine vasopressin system, hypothesising that copeptin in HFPEF is elevated, associated with diastolic dysfunction and N-terminal pro-brain natriuretic peptide (NT-proBNP) and predictive of HF hospitalisation and mortality. Methods and analysis In a prospective observational substudy of the The Karolinska Rennes (KaRen) 86 patients with symptoms of acute HF and ejection fraction (EF) ≥45% were enrolled. After 4–8 weeks, blood sampling and echocardiography was performed. Plasma-copeptin was analysed in 86 patients and 62 healthy controls. Patients were followed in median 579 days (quartile 1; quartile 3 (Q1;Q3) 276;1178) regarding the composite end point all-cause mortality or HF hospitalisation. Ethics and dissemination The patients with HFPEF had higher copeptin levels, median 13.56 pmol/L (Q1;Q3 8.56;20.55) than controls 5.98 pmol/L (4.15;9.42; p<0.001). Diastolic dysfunction, assessable in 75/86 patients, was present in 45 and absent in 30 patients. Copeptin did not differ regarding diastolic dysfunction and did not correlate with cardiac function but with NT-proBNP (r=0.223; p value=0.040). In univariate Cox regression analysis log copeptin predicted the composite end point (HR 1.56 (95% CI 1.03 to 2.38; p value=0.037)) but not after adjusting for NT-proBNP (HR 1.39 (95% CI 0.91 to 2.12; p value=0.125)). Conclusions In the present patients with HFPEF, copeptin is elevated, correlates with NT-proBNP but not markers of diastolic dysfunction, and has prognostic implications, however blunted after adjustment for NT-proBNP. The HFPEF pathophysiology may be better reflected by markers of neurohormonal activation than by diastolic dysfunction. Trial registration number ClinicalTrials.gov NCT00774709. PMID:26568833

  11. Differing prognostic value of pulse pressure in patients with heart failure with reduced or preserved ejection fraction: results from the MAGGIC individual patient meta-analysis.

    PubMed

    Jackson, Colette E; Castagno, Davide; Maggioni, Aldo P; Køber, Lars; Squire, Iain B; Swedberg, Karl; Andersson, Bert; Richards, A Mark; Bayes-Genis, Antoni; Tribouilloy, Christophe; Dobson, Joanna; Ariti, Cono A; Poppe, Katrina K; Earle, Nikki; Whalley, Gillian; Pocock, Stuart J; Doughty, Robert N; McMurray, John J V

    2015-05-07

    Low pulse pressure is a marker of adverse outcome in patients with heart failure (HF) and reduced ejection fraction (HF-REF) but the prognostic value of pulse pressure in patients with HF and preserved ejection fraction (HF-PEF) is unknown. We examined the prognostic value of pulse pressure in patients with HF-PEF [ejection fraction (EF) ≥ 50%] and HF-REF. Data from 22 HF studies were examined. Preserved left ventricular ejection fraction (LVEF) was defined as LVEF ≥ 50%. All-cause mortality at 3 years was evaluated in 27 046 patients: 22 038 with HF-REF (4980 deaths) and 5008 with HF-PEF (828 deaths). Pulse pressure was analysed in quintiles in a multivariable model adjusted for the previously reported Meta-Analysis Global Group in Chronic Heart Failure prognostic variables. Heart failure and reduced ejection fraction patients in the lowest pulse pressure quintile had the highest crude and adjusted mortality risk (adjusted hazard ratio 1.68, 95% confidence interval 1.53-1.84) compared with all other pulse pressure groups. For patients with HF-PEF, higher pulse pressure was associated with the highest crude mortality, a gradient that was eliminated after adjustment for other prognostic variables. Lower pulse pressure (especially <53 mmHg) was an independent predictor of mortality in patients with HF-REF, particularly in those with an LVEF < 30% and systolic blood pressure <140 mmHg. Overall, this relationship between pulse pressure and outcome was not consistently observed among patients with HF-PEF. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

  12. Clinical benefit of cardiac resynchronization therapy with a defibrillator in patients with an ejection fraction > 35% estimated by cardiac magnetic resonance.

    PubMed

    Fabregat-Andrés, Oscar; García-González, Pilar; Valle-Muñoz, Alfonso; Estornell-Erill, Jordi; Pérez-Boscá, Leandro; Palanca-Gil, Victor; Payá-Serrano, Rafael; Quesada-Dorador, Aurelio; Morell, Salvador; Ridocci-Soriano, Francisco

    2014-02-01

    Cardiac resynchronization therapy with a defibrillator prolongs survival and improves quality of life in advanced heart failure. Traditionally, patients with ejection fraction > 35 estimated by echocardiography have been excluded. We assessed the prognostic impact of this therapy in a group of patients with severely depressed systolic function as assessed by echocardiography but with an ejection fraction > 35% as assessed by cardiac magnetic resonance. We analyzed consecutive patients admitted for decompensated heart failure between 2004 and 2011. The patients were in functional class II-IV, with a QRS ≥ to 120 ms, ejection fraction ≤ 35% estimated by echocardiography, and a cardiac magnetic resonance study. We included all patients (n=103) who underwent device implantation for primary prevention. Ventricular arrhythmia, all-cause mortality and readmission for heart failure were considered major cardiac events. The patients were divided into 2 groups according to systolic function assessed by magnetic resonance. The 2 groups showed similar improvements in functional class and ejection fraction at 6 months. We found a nonsignificant trend toward a higher risk of all-cause mortality in patients with systolic function ≤ 35% at long-term follow-up. The presence of a pattern of necrosis identified patients with a worse prognosis for ventricular arrhythmias and mortality in both groups. We conclude that cardiac resynchronization therapy with a defibrillator leads to a similar clinical benefit in patients with an ejection fraction ≤ 35% or > 35% estimated by cardiac magnetic resonance. Analysis of the pattern of late gadolinium enhancement provides additional information on arrhythmic risk and long-term prognosis. Copyright © 2013 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.

  13. Functional iron deficiency and diastolic function in heart failure with preserved ejection fraction.

    PubMed

    Kasner, Mario; Aleksandrov, Aleksandar S; Westermann, Dirk; Lassner, Dirk; Gross, Michael; von Haehling, Stephan; Anker, Stefan D; Schultheiss, Heinz-Peter; Tschöpe, Carsten

    2013-10-12

    Functional iron deficiency (FID) is an independent risk factor for poor outcome in advanced heart failure with reduced EF, but its role in heart failure with preserved EF (HFPEF) remains unclear. We aimed to investigate the impact of FID on cardiac performance determined by pressure-volume loop analysis in HFPEF. 26 HFPEF patients who showed an increase in LV stiffness by pressure-volume (PV) loop analysis obtained by conductance-catheterization, performed exercise testing, echocardiographic examination including tissue Doppler and determination of iron metabolism: serum iron, ferritin and transferrin saturation. HFPEF patients who provided ferritin <100 μg/l or ferritin of 100-299 μg/l in combination with transferrin saturation <20% were defined as having FID. In 14 patients the expression of transferrin receptor was determined from available endomyocardial biopsies. Fifteen out of 26 HFPEF patients showed FID without anemia. Compared to control subjects and HFPEF patients without FID, HFPEF patients with FID showed an up-regulation of the myocardial transferrin receptor expression (p<0.05). No differences between HFPEF patients with and without iron deficiency were found in heart dimensions, systolic and diastolic function obtained by PV-loop and echocardiography analysis. According to the linear regression analysis, LV stiffness was correlated with peak oxygen uptake (r=-0.636, p<0.001) but not with the ferritin level or transferrin saturation. No relation was found between FID and exercise capacity. The association of LV stiffness with exercise performance was independent from the level of iron deficiency. In non-anemic HFPEF patients, cardiac dysfunction and impaired exercise capacity occur independently of FID. © 2013.

  14. Diagnostic and Prognostic Value of CMR T1-Mapping in Patients With Heart Failure and Preserved Ejection Fraction.

    PubMed

    Rommel, Karl-Philipp; Lücke, Christian; Lurz, Philipp

    2017-03-14

    Heart failure with preserved ejection fraction (HFpEF) presents a major challenge in modern cardiology. Although this syndrome is of increasing prevalence and is associated with unfavorable outcomes, treatment trials have failed to establish effective therapies. Currently, solutions to this dilemma are being investigated, including categorizing and characterizing patients more diversely to individualize treatment. In this regard, new imaging techniques might provide important information. Diastolic dysfunction is a diagnostic and pathophysiological cornerstone in HFpEF and is believed to be caused by systemic inflammation with the development of interstitial myocardial fibrosis and myocardial stiffening. Cardiac magnetic resonance (CMR) T1-mapping is a novel tool, which allows noninvasive quantification of the extracellular space and diffuse myocardial fibrosis. This review provides an overview of the potential of myocardial tissue characterization with CMR T1 mapping in HFpEF patients, outlining its diagnostic and prognostic implications and discussing future directions. We conclude that CMR T1 mapping is potentially an effective tool for patient characterization in large-scale epidemiological, diagnostic, and therapeutic HFpEF trials beyond traditional imaging parameters.

  15. Challenges in the Management of Patients with Chronic Obstructive Pulmonary Disease and Heart Failure With Reduced Ejection Fraction.

    PubMed

    Jaiswal, Abhishek; Chichra, Astha; Nguyen, Vinh Q; Gadiraju, Taraka V; Le Jemtel, Thierry H

    2016-02-01

    Chronic obstructive pulmonary disease (COPD) and heart failure with reduced ejection fraction (HFrEF) commonly coexist in clinical practice. The prevalence of COPD among HFrEF patients ranges from 20 to 32 %. On the other hand; HFrEF is prevalent in more than 20 % of COPD patients. With an aging population, the number of patients with coexisting COPD and HFrEF is on rise. Coexisting COPD and HFrEF presents a unique diagnostic and therapeutic clinical conundrum. Common symptoms shared by both conditions mask the early referral and detection of the other. Beta blockers (BB), angiotensin-converting enzyme inhibitors, and aldosterone antagonists have been shown to reduce hospitalizations, morbidity, and mortality in HFrEF while long-acting inhaled bronchodilators (beta-2-agonists and anticholinergics) and corticosteroids have been endorsed for COPD treatment. The opposing pharmacotherapy of BBs and beta-2-agonists highlight the conflict in prescribing BBs in COPD and beta-2-agonists in HFrEF. This has resulted in underutilization of evidence-based therapy for HFrEF in COPD patients owing to fear of adverse effects. This review aims to provide an update and current perspective on diagnostic and therapeutic management of patients with coexisting COPD and HFrEF.

  16. Phenomapping for the Identification of Hypertensive Patients with the Myocardial Substrate for Heart Failure with Preserved Ejection Fraction.

    PubMed

    Katz, Daniel H; Deo, Rahul C; Aguilar, Frank G; Selvaraj, Senthil; Martinez, Eva E; Beussink-Nelson, Lauren; Kim, Kwang-Youn A; Peng, Jie; Irvin, Marguerite R; Tiwari, Hemant; Rao, D C; Arnett, Donna K; Shah, Sanjiv J

    2017-03-03

    We sought to evaluate whether unbiased machine learning of dense phenotypic data ("phenomapping") could identify distinct hypertension subgroups that are associated with the myocardial substrate (i.e., abnormal cardiac mechanics) for heart failure with preserved ejection fraction (HFpEF). In the HyperGEN study, a population- and family-based study of hypertension, we studied 1273 hypertensive patients utilizing clinical, laboratory, and conventional echocardiographic phenotyping of the study participants. We used machine learning analysis of 47 continuous phenotypic variables to identify mutually exclusive groups constituting a novel classification of hypertension. The phenomapping analysis classified study participants into 2 distinct groups that differed markedly in clinical characteristics, cardiac structure/function, and indices of cardiac mechanics (e.g., phenogroup #2 had a decreased absolute longitudinal strain [12.8 ± 4.1 vs. 14.6 ± 3.5%] even after adjustment for traditional comorbidities [p < 0.001]). The 2 hypertension phenogroups may represent distinct subtypes that may benefit from targeted therapies for the prevention of HFpEF.

  17. Effects of renal denervation on vascular remodelling in patients with heart failure and preserved ejection fraction: A randomised control trial

    PubMed Central

    Hayward, Carl; Keegan, Jennifer; Gatehouse, Peter D; Rajani, Ronak; Khattar, Rajdeep S; Mohiaddin, Raad H; Rosen, Stuart D; Lyon, Alexander R; di Mario, Carlo

    2017-01-01

    Objective To assess the effect of renal denervation (RDT) on micro- and macro-vascular function in patients with heart failure with preserved ejection fraction (HFpEF). Design A prospective, randomised, open-controlled trial with blinded end-point analysis. Setting A single-centre London teaching hospital. Participants Twenty-five patients with HFpEF who were recruited into the RDT-PEF trial. Main outcome measures Macro-vascular: 24-h ambulatory pulse pressure, aorta distensibilty (from cardiac magnetic resonance imaging (CMR), aorta pulse wave velocity (CMR), augmentation index (peripheral tonometry) and renal artery blood flow indices (renal MR). Micro-vascular: endothelial function (peripheral tonometry) and urine microalbuminuria. Results At baseline, 15 patients were normotensive, 9 were hypertensive and 1 was hypotensive. RDT did not lower any of the blood pressure indices. Though there was evidence of abnormal vascular function at rest, RDT did not affect these at 3 or 12 months follow-up. Conclusions RDT did not improve markers of macro- and micro-vascular function. PMID:28228942

  18. Role of biomarkers in cardiac structure phenotyping in heart failure with preserved ejection fraction: critical appraisal and practical use.

    PubMed

    D'Elia, Emilia; Vaduganathan, Muthiah; Gori, Mauro; Gavazzi, Antonello; Butler, Javed; Senni, Michele

    2015-12-01

    Heart failure (HF) with preserved ejection fraction (HFpEF) is a heterogeneous clinical syndrome characterized by cardiovascular, metabolic, and pro-inflammatory diseases associated with advanced age and extracardiac comorbidities. All of these conditions finally lead to impairment of myocardial structure and function. The large phenotypic heterogeneity of HFpEF from pathophysiological underpinnings presents a major hurdle to HFpEF therapy. The new therapeutic approach in HFpEF should be targeted to each HF phenotype, instead of the 'one-size-fits-all' approach, which has not been successful in clinical trials. Unless the structural and biological determinants of the failing heart are deeply understood, it will be impossible to appropriately differentiate HFpEF patients, identify subtle myocardial abnormalities, and finally reverse abnormal cardiac function. Based on evidence from endomyocardial biopsies, some of the specific cardiac structural phenotypes to be targeted in HFpEF may be represented by myocyte hypertrophy, interstitial fibrosis, myocardial inflammation associated with oxidative stress, and coronary disease. Once the diagnosis of HFpEF has been established, a potential approach could be to use a panel of biomarkers to identify the main cardiac structural HFpEF phenotypes, guiding towards more appropriate therapeutic strategies. Accordingly, the purpose of this review is to investigate the potential role of biomarkers in identifying different cardiac structural HFpEF phenotypes and to discuss the merits of a biomarker-guided strategy in HFpEF.

  19. Reproducibility of ejection-fraction determinations by equilibrium radionuclide angiography in response to supine bicycle exercise: concise communication.

    PubMed

    Pfisterer, M E; Battler, A; Swanson, S M; Slutsky, R; Froelicher, V; Ashburn, W L

    1979-06-01

    Sixteen patients with stable, chronic coronary artery disease were studied twice within and average of 15 days to evaluate the reproducibility of ejection fraction (EF) determined by equilibrium radionuclide angiography (EQ) at rest, during supine bicycle exercise (ex), and in the recovery period (rec). Following injection of 20--25 mCi of Tc-99m-tagged human serum albumin, data were analyzed for 2-min periods at rest, during several stages of exercise (submax, max), and during recovery (rec1 = minutes 2 + 3, rec2 = minutes 9 + 10). Each patient reached similar (heart rate) X (blood pressure) products in the two studies: 21280 +/- 5200 compared with 20390 +/- 4140 mmHg/min. Mean EFs for the first and second studies were: at rest (53.0 +/- 10.8)%, 52.5 +/- 10.4)% (r = 0.95; submax ex (51.4 +/- 12.0)%, (52.1 +/- 12.8)%, (r = 0.91); max ex (50.6 +/- 12.6)%, (51.6 +/- 12.9)% (r = 0.97); rec1 (62.7 +/- 11.6)%, (62.4 +/- 12.2)% (r = 0.95); rec2 (55.5 %/- 10.8)%, (57.2 +/- 11.7)% (r = 0.91). In stable patients, the reproducibility of EF determined by EQ is excellent during rest, supine bicycle exercise, and recovery from exercise.

  20. Evolution of left ventricular ejection fraction after acute myocardial infarction: implications for implantable cardioverter-defibrillator eligibility.

    PubMed

    Sjöblom, Johanna; Muhrbeck, Josephine; Witt, Nils; Alam, Mahbubul; Frykman-Kull, Viveka

    2014-08-26

    Implantable cardioverter-defibrillator therapy improves survival in patients with reduced left ventricular ejection fraction (LVEF) after acute myocardial infarction (AMI). Although the risk of sudden cardiac death is highest in the first month after AMI, there is no survival benefit of early implantable cardioverter-defibrillator implantation, and the optimal time frame has yet to be established. Thus, the aim of this study was to investigate what proportion of post-AMI patients had improved LV function to such an extent that the indication for implantable cardioverter-defibrillator was no longer present. Patients admitted for AMI with reduced LVEF (≤40%) were eligible for inclusion. Repeat echocardiographic examinations were performed 5 days, 1 month, and 3 months after the AMI. We prospectively included 100 patients with LVEF of 31±5.8% after AMI. At the 1-month follow-up, 55% had an LVEF >35%. The main improvement in LVEF had occurred by 1 month. The mean difference in LVEF over the next 2 months was small, 1.9 percentage units. During the first 9 weeks, 10% of the patients suffered from life-threatening arrhythmias. Most patients have improved LVEF after AMI, and in the majority, the improvement can be confirmed after 1 month, implying that further delay of implantable cardioverter-defibrillator implantation may not be warranted. Life-threatening arrhythmias occurred in 10% of the patients, illustrating the high risk for sudden cardiac death in this population. © 2014 American Heart Association, Inc.

  1. Quantification of left ventricular volumes, mass, and ejection fraction using cine displacement encoding with stimulated echoes (DENSE) MRI.

    PubMed

    Haggerty, Christopher M; Kramer, Sage P; Skrinjar, Oskar; Binkley, Cassi M; Powell, David K; Mattingly, Andrea C; Epstein, Frederick H; Fornwalt, Brandon K

    2014-08-01

    To test the hypothesis that magnitude images from cine displacement encoding with stimulated echoes (DENSE) magnetic resonance imaging (MRI) can accurately quantify left ventricular (LV) volumes, mass, and ejection fraction (EF). Thirteen mice (C57BL/6J) were imaged using a 7T ClinScan MRI. A short-axis stack of cine T2-weighted black blood (BB) images was acquired for calculation of LV volumes, mass, and EF using the gold standard sum-of-slices methodology. DENSE images were acquired during the same imaging session in three short-axis (basal, mid, apical) and two long-axis orientations. A custom surface fitting algorithm was applied to epicardial and endocardial borders from the DENSE magnitude images to calculate volumes, mass, and EF. Agreement between the DENSE-derived measures and BB-derived measures was assessed via coefficient of variation (CoV). 3D surface reconstruction was completed on the order of seconds from segmented images, and required fewer slices to be segmented. Volumes, mass, and EF from DENSE-derived surfaces matched well with BB data (CoVs ≤11%). LV mass, volumes, and EF in mice can be quantified through sparse (five slices) sampling with DENSE. This consolidation significantly reduces the time required to assess both mass/volume-based measures of cardiac function and advanced cardiac mechanics. © 2013 Wiley Periodicals, Inc.

  2. A Systematic Review Concerning the Relation between the Sympathetic Nervous System and Heart Failure with Preserved Left Ventricular Ejection Fraction

    PubMed Central

    Verloop, Willemien L.; Beeftink, Martine M. A.; Santema, Bernadet T.; Bots, Michiel L.; Blankestijn, Peter J.; Cramer, Maarten J.; Doevendans, Pieter A.; Voskuil, Michiel

    2015-01-01

    Background Heart failure with preserved left ventricular ejection fraction (HFPEF) affects about half of all patients diagnosed with heart failure. The pathophysiological aspect of this complex disease state has been extensively explored, yet it is still not fully understood. Since the sympathetic nervous system is related to the development of systolic HF, we hypothesized that an increased sympathetic nerve activation (SNA) is also related to the development of HFPEF. This review summarizes the available literature regarding the relation between HFPEF and SNA. Methods and Results Electronic databases and reference lists through April 2014 were searched resulting in 7722 unique articles. Three authors independently evaluated citation titles and abstracts, resulting in 77 articles reporting about the role of the sympathetic nervous system and HFPEF. Of these 77 articles, 15 were included for critical appraisal: 6 animal and 9 human studies. Based on the critical appraisal, we selected 9 articles (3 animal, 6 human) for further analysis. In all the animal studies, isoproterenol was administered to mimic an increased sympathetic activity. In human studies, different modalities for assessment of sympathetic activity were used. The studies selected for further evaluation reported a clear relation between HFPEF and SNA. Conclusion Current literature confirms a relation between increased SNA and HFPEF. However, current literature is not able to distinguish whether enhanced SNA results in HFPEF, or HFPEF results in enhanced SNA. The most likely setting is a vicious circle in which HFPEF and SNA sustain each other. PMID:25658630

  3. Determination of left ventricular ejection fraction by visual estimation during real-time two-dimensional echocardiography

    SciTech Connect

    Rich, S.; Sheikh, A.; Gallastegui, J.; Kondos, G.T.; Mason, T.; Lam, W.

    1982-09-01

    It has been shown that the measured reduction in the cross-sectional area of the left ventricle (LV), as viewed in the short axis, closely approximates its ejection fraction (EF). We assessed the reliability of using two-dimensional echocardiography (2DE) to visually estimate the EF during real-time viewing, without the need of digitizers, planimetry, or calculations. Twenty-five adult hospitalized patients with either suspected or known cardiac disease were evaluated prospectively. Each patient also had gated nuclear angiography during the same admission, and 14 had cardiac catheterization with left ventriculography. The EF was determined by 2DE using a visual estimate of the percent area reduction of the LV cavity in the short-axis view at the level of the papillary muscles. All 2 DE studies were read by two or more blinded reviewers, with a value for the EF to the nearest 2.5% determined by consensus. These values correlated closely to the values determined in all 25 patients with gated nuclear angiography (r . 0.927) and the 14 patients who had left ventriculography (r . 0.935). We believe that this method of visually estimating the LVEF will enable echocardiographers to easily use 2 DE for a reliable and instantaneous assessment of ventricular function, without the need of sophisticated analytical equipment.

  4. Development of Left Ventricular Diastolic Dysfunction with Preservation of Ejection Fraction during Progression of Infant Right Ventricular Hypertrophy

    PubMed Central

    Kitahori, Kazuo; He, Huamei; Kawata, Mitsuhiro; Cowan, Douglas B.; Friehs, Ingeborg; del Nido, Pedro J.; McGowan, Francis X.

    2011-01-01

    Background Progressive left ventricular (LV) dysfunction can be a major late complication in patients with chronic right ventricular (RV) pressure overload (e.g., tetralogy of Fallot). We therefore examined LV function (serial echocardiography and ex vivo Langendorff) and histology in a model of infant pressure-load RV hypertrophy (RVH). Methods and Results Ten-day-old rabbits (N=6 per time point, total = 48) that underwent pulmonary artery banding (PAB) were sacrificed at 2–8 weeks after PAB, and comparisons were made with age-matched sham controls. LV performance (myocardial performance index, MPI) decreased during the progression of RVH although the LV ejection fraction (EF) was maintained. In addition, RVH caused significant septal displacement, reduced septal contractility, and decreased LV end-systolic (LVDs) and diastolic (LVDd) dimensions, resulting in LV diastolic dysfunction with the appearance of preserved EF. Significant septal and LV free wall apoptosis (myocyte-specific TUNEL and activated caspase-3), fibrosis (Masson’s trichrome stain), and reduced capillary density (CD31 immunostaining) occurred in the PAB group after 6–8 wks (all p<0.05). Conclusion This is the first study showing that pressure overload of the RV resulting in RVH causes LV diastolic dysfunction while preserving EF through mechanical and molecular effects upon the septum and LV myocardium. In particular, the development of RVH is associated with septal and LV apoptosis and reduced LV capillary density. PMID:19919985

  5. Risk of ventricular arrhythmia in patients with myocardial infarction and non-obstructive coronary arteries and normal ejection fraction

    PubMed Central

    Bière, Loïc; Niro, Marjorie; Pouliquen, Hervé; Gourraud, Jean-Baptiste; Prunier, Fabrice; Furber, Alain; Probst, Vincent

    2017-01-01

    AIM To assess the arrhythmic determinants and prognosis of patients presenting with myocardial infarction and non-obstructive coronary arteries (MINOCA) with normal ejection fraction (EF). METHODS This is an observational analysis of 131 MINOCA patients with normal EF. Three cardiac magnetic resonance (CMR) diagnosis classes were recognized according to the late gadolinium enhancement (LGE) pattern: Myocardial infarction (MI) (n = 34), myocarditis (n = 47), and “no LGE” (n = 50). Ventricular events occurring during hospitalization were recorded and the entire population was followed-up at 1 year. RESULTS Ventricular arrhythmia was observed in 18 (13.8%) patients during hospitalization. The “no LGE” patients experienced fewer ventricular events than the MI and myocarditis patients [4.0% vs 26.5% and 14.9%, respectively (P = 0.013)]. There was no significant difference between the MI and myocarditis groups. On multivariate analysis, LGE transmural extent [OR = 1.52 (1.08-2.15), P = 0.017] and ST-segment elevation [OR = 4.65 (1.61-13.40), P = 0.004] were independent predictors of ventricular arrhythmic events, irrespective of the diagnosis class. Finally, no patient experienced sudden cardiac death or ventricular arrhythmia recurrence at 1-year. CONCLUSION MINOCA patients with normal EF presented no 1-year cardiovascular events, irrespective of the CMR diagnosis class. LGE transmural extent and ST segment elevation at admission are risk markers of ventricular arrhythmia during hospitalization. PMID:28400924

  6. Correlation of right ventricular ejection fraction and tricuspid annular plane systolic excursion in tetralogy of Fallot by magnetic resonance imaging.

    PubMed

    Morcos, Peter; Vick, G Wesley; Sahn, David J; Jerosch-Herold, Michael; Shurman, Alan; Sheehan, Florence H

    2009-03-01

    The correlation between right ventricular ejection fraction (RVEF) and tricuspid annular plane systolic excursion (TAPSE) by two-dimensional (2-D) echo has been repeatedly validated, but not by magnetic resonance imaging (MRI) nor in patients with congenital heart disease. We tested whether TAPSE measurements by MRI correlate with RVEF in surgically repaired tetralogy of Fallot (TOF) patients. TAPSE was measured from systolic displacement of the RV-freewall/tricuspid annular plane junction in the apical 4-chamber view in 7 normal subjects and 14 TOF patients. The RV was reconstructed in 3-D from manually traced borders on MR images to compute true EF. Because we previously observed discrepancy between TAPSE and RVEF in the presence of regional dysfunction, we also analyzed RV wall motion in terms of regional stroke volume at 20 short axis slices from apex to tricuspid annulus. RVEF was 52 +/- 3% in normal subjects and 41 +/- 9% in TOF (P < 0.01). TAPSE correlated weakly (r = 0.50, P < 0.05) with RVEF. TOF patients exhibited increased regional stroke volume from apical portions of the RV and decreased regional stroke volume at the base compared to normal (P < 0.05 at 15 of 20 slices). Regional stroke volume in apical slices correlated inversely with RVEF such that patients with higher apical stroke volume had lower RVEF (P < 0.05). TAPSE is not a reliable measure of RVEF in TOF by MRI. TAPSE may be of limited use in conditions that exhibit abnormal regional contraction.

  7. Prognostic significance of myocardial energy expenditure and myocardial efficiency in patients with heart failure with reduced ejection fraction.

    PubMed

    Cetin, Mehmet S; Ozcan Cetin, Elif H; Canpolat, Ugur; Sasmaz, Hatice; Temizhan, Ahmet; Aydogdu, Sinan

    2017-08-14

    In heart failure with reduced ejection fraction (HFrEF) patients, myocardial blood flow (MBF), myocardial energy expenditure (MEE), myocardial efficiency has been poorly evaluated because of the necessity of invasive procedures in the determination of these parameters. Transthoracic echocardiography (TTE) can provide reliable data for MEE, MBF (via coronary sinus (CS) flows). Also, myocardial efficiency can be evaluated by the MEE to MBF ratio. We aim to assess MBF, MEE and energy efficiency and the prognostic value of these parameters in HFrEF. In this prospective study, a total of 80 patients with HFrEF due to either ischemic or non-ischemic etiology and 20 healthy control subjects were included. Median follow-up duration was 901 (27-1004) days. MBF was calculated via coronary sinus blood flow. MEE was measured from circumferential end-systolic stress, stroke volume and left ventricular ejection time. MEE to MBF ratio was determined as MEf. Primary composite end-point (CEP) was cardiovascular mortality, heart transplantation or mechanical circulatory support. MEE and MEf were lower and MBF per minute was higher in HF group compared to control subjects whereas MBF per 100 g left ventricular mass was not different. MEE and MEf have significantly negative correlation with troponin I, BNP, uric acid and positive correlation with epicardial fat thickness. In Cox regression analysis, per one calorie decrease of MEE was associated 4.3 times increased risk [HR 4.396 (95% CI 1.230-15.716)] and per one percent decrease of MEf was associated 3.3 times increased risk of CEP [HR 3.343 (95% CI 1.025-10.905)]. Our study demonstrated that while MEE and MEf diminished in HFrEF, MBF preserved with the symptomatic progression of HF. MEE and MEf were found to be associated with important prognostic markers and independent predictors of CEP in HFrEF. Evaluation of MEE, MBF and MEf with echocardiography may provide an additional data regarding prognostic assessment of HFr

  8. Extracellular Volume Fraction Is More Closely Associated With Altered Regional Left Ventricular Velocities Than Left Ventricular Ejection Fraction in Non-Ischemic Cardiomyopathy

    PubMed Central

    Collins, Jeremy; Sommerville, Cort; Magrath, Patrick; Spottiswoode, Bruce; Freed, Benjamin H; Benzuly, Keith H; Gordon, Robert; Vidula, Himabindu; Lee, Dan C; Yancy, Clyde; Carr, James; Markl, Michael

    2014-01-01

    Background Non-ischemic cardiomyopathy (NICM) is a common cause of left ventricular (LV) dysfunction and myocardial fibrosis. The purpose of this study was to non-invasively evaluate changes in segmental LV extracellular volume fraction (ECV), LV velocities, myocardial scar, and wall motion in NICM patients. Methods and Results Cardiac MRI including pre- and post-contrast myocardial T1-mapping and velocity quantification (tissue phase mapping, TPM) of the LV (basal, mid-ventricular, apical short axis) was applied in 31 patients with NICM (50±18years). Analysis based on the 16-segment AHA model was employed to evaluate the segmental distribution of ECV, peak systolic and diastolic myocardial velocities, scar determined by late gadolinium enhancement (LGE), and wall motion abnormalities. LV segments with scar or impaired wall motion were significantly associated with elevated ECV (r=0.26, p<0.001) and reduced peak systolic radial velocities (r=−0.43, p<0.001). Regional myocardial velocities and ECV were similar for patients with reduced (n=12, ECV=0.28±0.06) and preserved LV ejection fraction (LVEF) (n=19, ECV=0.30±0.09). Patients with preserved LVEF showed significant relationships between increasing ECV and reduced systolic (r=−0.19, r=−0.30) and diastolic (r=0.34, r=0.26) radial and long-axis peak velocities (p<0.001). Even after excluding myocardial segments with LGE, significant relationships between ECV and segmental LV velocities were maintained indicating the potential of elevated ECV to identify regional diffuse fibrosis not visible by LGE which was associated with impaired regional LV function Conclusions Regionally elevated ECV negatively impacted myocardial velocities. The association of elevated regional ECV with reduced myocardial velocities independent of LVEF suggests a structure-function relationship between altered ECV and segmental myocardial function in NICM. PMID:25552491

  9. Surgical Experience and Long-term Results of Baroreflex Activation Therapy for Heart Failure With Reduced Ejection Fraction.

    PubMed

    Weaver, Fred A; Abraham, William T; Little, William C; Butter, Christian; Ducharme, Anique; Halbach, Marcel; Klug, Didier; Lovett, Eric G; Madershahian, Navid; Müller-Ehmsen, Jochen; Schafer, Jill E; Senni, Michele; Swarup, Vijay; Wachter, Rolf; Zile, Michael R

    2016-01-01

    The purpose of this publication is to describe the intraoperative experience along with long-term safety and efficacy of the second-generation baroreflex activation therapy (BAT) system in patients with heart failure (HF) and reduced ejection fraction HF (HFrEF). In a randomized trial of New York Heart Association Class III HFrEF, 140 patients were assigned 1:1 to receive BAT plus medical therapy or medical therapy alone. Procedural information along with safety and efficacy data were collected and analyzed over 12 months. Within the cohort of 71 patients randomized to BAT, implant procedure time decreased with experience, from 106 ± 37 minutes on the first case to 83 ± 32 minutes on the third case. The rate of freedom from system- and procedure-related complications was 86% through 12 months, with the percentage of days alive without a complication related to system, procedure, or underlying cardiovascular condition identical to the control group. The complications that did occur were generally mild and short-lived. Overall, 12 months therapeutic benefit from BAT was consistent with previously reported efficacy through 6 months: there was a significant and sustained beneficial treatment effect on New York Heart Association functional Class, quality of life, 6-minute hall walk distance, plasma N-terminal pro-brain natriuretic peptide, and systolic blood pressure. This was true for the full trial cohort and a predefined subset not receiving cardiac resynchronization therapy. There is a rapid learning curve for the specialized procedures entailed in a BAT system implant. BAT system implantation is safe with the therapeutic benefits of BAT in patients with HFrEF being substantial and maintained for at least 1 year.

  10. Prognostic power of global 2D strain according to left ventricular ejection fraction in patients with ST elevation myocardial infarction

    PubMed Central

    Cha, Myung-Jin; Kim, Hyun-Sook; Kim, Seong Hwan; Park, Jae-Hyeong

    2017-01-01

    Backgrounds We aimed to evaluate the predictive power of longitudinal and circumferential fibers according to left ventricular ejection fraction (LVEF) in successfully reperfused acute ST elevation myocardial infarction (STEMI) patients. Methods Total 691 patients (age 59±13, 20% female) underwent clinical evaluation and conventional and strain echocardiography (Global longitudinal strain (GLS), global circumferential strain (GCS)). The clinical outcome was defined as the composite of death, hospitalization for heart failure, non-fatal myocardial infarction, and ventricular arrhythmia. Results During a follow-up of 39±19 months, there were 47 (6.8%) clinical events. In multivariate Cox models adjusted clinical risk factors, age (HR 1.08, p = 0.001) and GLS (HR 1.37, p = 0.001) were independent predictors. The addition of GLS resulted in significant incremental improvement in the predictive value on LVEF (χ2 = 31.8→45.8, p<0.001), although GCS offers no additional benefit. In the subgroup analysis according to LVEF, adjusted with clinical factors, GLS was significant predictive for outcome for the patients with mildly depressed (LVEF 40–50%, HR 2.25, p<0.001) and significantly depressed (LVEF<40%, HR 1.28, p = 0.016) systolic function, although GCS and LVEF lost their power with LVEF<40%. For the patients with preserved LVEF (>50%), GLS, GCS and LVEF did not show significant predictive power. Conclusions GLS is a most powerful predictor of outcome in successfully reperfused STEMI patients, especially with depressed LV dysfunction, although GCS and LVEF lost their predictive power for the patients with significantly depressed LV function. However, GLS did not predict outcome for the patients with preserved LVEF (>50%). PMID:28334029

  11. Characteristics and Outcomes of Concurrently Diagnosed New Rapid Atrial Fibrillation or Flutter and New Reduced Ejection Fraction.

    PubMed

    Rodriguez, Yasser; Althouse, Andrew D; Adelstein, Evan C; Jain, Sandeep K; Mendenhall, George Stuart; Saba, Samir; Shalaby, Alaa A; Voigt, Andrew H; Wang, Norman C

    2016-12-01

    Characteristics and outcomes of concurrently diagnosed new rapid atrial fibrillation (AF) or atrial flutter (AFL) and new heart failure with reduced left ventricular ejection fraction (LVEF) are not well described. A retrospective cohort study of subjects referred for expedited transesophageal echocardiography-guided rhythm-control strategies for concurrent new rapid AF/AFL and new LVEF ≤ 40% diagnosed during the same admission was analyzed. Twenty-five subjects (median age 57 years; 96% male; 96% Caucasian; median CHA2 DS2 -VASc = 2) presented with new AF (n = 18) or AFL (n = 7) with rapid ventricular rate (median 135 beats/min) and new reduced LVEF (median 27%; range, 10-37.5%). Seven (28%) subjects had left atrial appendage thrombi (LAAT) and five (20%) subjects had heavy or binge alcohol use. Baseline characteristics were similar between those with and without LAAT. Thirteen subjects with AF and without LAAT underwent direct-current cardioversion (DCCV) and 10 (77%) had AF recurrence within 90 days. Improvement of long-term LVEF to >40% was comparable for subjects with and without initial LAAT (83% vs 94%; P = 0.46). Three of four subjects who received primary prophylaxis implantable cardioverter-defibrillators improved their LVEF to >35% after sinus rhythm maintenance. The median long-term follow-up time was 3.0 years. Subjects with concurrently diagnosed new rapid AF/AFL and new reduced LVEF are characterized by a high prevalence of LAAT and significant alcohol use. AF subjects without initial LAAT who underwent DCCV had a high 90-day AF recurrence rate. The presence of LAAT did not have a prognosticative effect on eventual LVEF improvement, which was observed in almost all subjects. © 2016 Wiley Periodicals, Inc.

  12. Simplifying contrast-induced acute kidney injury prediction after primary percutaneous coronary intervention: the age, creatinine and ejection fraction score.

    PubMed

    Araujo, Gustavo N; Pivatto Junior, Fernando; Fuhr, Bruno; Cassol, Elvis P; Machado, Guilherme P; Valle, Felipe H; Bergoli, Luiz C; Wainstein, Rodrigo V; Polanczyk, Carisi A; Wainstein, Marco V

    2017-05-24

    Contrast-induced acute kidney injury (CI-AKI) is a common event after percutaneous coronary intervention (PCI). Presently, the main strategy to avoid CI-AKI lies in saline hydration, since to date none pharmacologic prophylaxis proved beneficial. Our aim was to determine if a low complexity mortality risk model is able to predict CI-AKI in patients undergoing PCI after ST elevation myocardial infarction (STEMI). We have included patients with STEMI submitted to primary PCI in a tertiary hospital. The definition of CI-AKI was a raise of 0.3 mg/dL or 50% in post procedure (24-72 h) serum creatinine compared to baseline. Age, glomerular filtration and ejection fraction were used to calculate ACEF-MDRD score. We have included 347 patients with mean age of 60 years. In univariate analysis, age, diabetes, previous ASA use, Killip 3 or 4 at admission, ACEF-MDRD and Mehran scores were predictors of CI-AKI. After multivariate adjustment, only ACEF-MDRD score and diabetes remained CI-AKI predictors. Areas under the ROC curve of ACEF-MDRD and Mehran scores were 0.733 (0.68-0.78) and 0.649 (0.59-0.70), respectively. When we compared both scores with DeLong test ACEF-MDRDs AUC was greater than Mehran's (P = 0.03). An ACEF-MDRD score of 2.33 or lower has a negative predictive value of 92.6% for development of CI-AKI. ACEF-MDRD score is a user-friendly tool that has an excellent CI-AKI predictive accuracy in patients undergoing primary percutaneous coronary intervention. Moreover, a low ACEF-MDRD score has a very good negative predictive value for CI-AKI, which makes this complication unlikely in patients with an ACEF-MDRD score of <2.33.

  13. Cardiac output response to exercise in relation to metabolic demand in heart failure with preserved ejection fraction

    PubMed Central

    Abudiab, Muaz M.; Redfield, Margaret M.; Melenovsky, Vojtech; Olson, Thomas P.; Kass, David A.; Johnson, Bruce D.; Borlaug, Barry A.

    2013-01-01

    Aims Exercise intolerance is a hallmark of heart failure with preserved ejection fraction (HFpEF), yet its mechanisms remain unclear. The current study sought to determine whether increases in cardiac output (CO) during exercise are appropriately matched to metabolic demands in HFpEF. Methods and results Patients with HFpEF (n = 109) and controls (n = 73) exercised to volitional fatigue with simultaneous invasive (n = 96) or non-invasive (n = 86) haemodynamic assessment and expired gas analysis to determine oxygen consumption (VO2) during upright or supine exercise. At rest, HFpEF patients had higher LV filling pressures but similar heart rate, stroke volume, EF, and CO. During supine and upright exercise, HFpEF patients displayed lower peak VO2 coupled with blunted increases in heart rate, stroke volume, EF, and CO compared with controls. LV filling pressures increased dramatically in HFpEF patients, with secondary elevation in pulmonary artery pressures. Reduced peak VO2 in HFpEF patients was predominantly attributable to CO limitation, as the slope of the increase in CO relative to VO2 was 20% lower in HFpEF patients (5.9 ± 2.5 vs. 7.4 ± 2.6 L blood/L O2, P = 0.0005). While absolute increases in arterial–venous O2 difference with exercise were similar in HFpEF patients and controls, augmentation in arterial–venous O2 difference relative to VO2 was greater in HFpEF patients (8.9 ± 3.4 vs. 5.5 ± 2.0 min/dL, P < 0.0001). These differences were observed in the total cohort and when upright and supine exercise modalities were examined individually. Conclusion While diastolic dysfunction promotes congestion and pulmonary hypertension with stress in HFpEF, reduction in exercise capacity is predominantly related to inadequate CO relative to metabolic needs. PMID:23426022

  14. Sarcopenia in patients with heart failure with preserved ejection fraction: Impact on muscle strength, exercise capacity and quality of life.

    PubMed

    Bekfani, Tarek; Pellicori, Pierpaolo; Morris, Daniel A; Ebner, Nicole; Valentova, Miroslava; Steinbeck, Lisa; Wachter, Rolf; Elsner, Sebastian; Sliziuk, Veronika; Schefold, Joerg C; Sandek, Anja; Doehner, Wolfram; Cleland, John G; Lainscak, Mitja; Anker, Stefan D; von Haehling, Stephan

    2016-11-01

    To describe the prevalence of sarcopenia in ambulatory patients with heart failure with preserved ejection fraction (HFpEF) and its relation to reduced exercise capacity, muscle strength, and quality of life (QoL). A total of 117 symptomatic outpatients with HFpEF were prospectively enrolled in Germany, England, and Slovenia as part of the Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF). Appendicular skeletal muscle (ASM) mass (the sum of muscle mass in both arms and legs) was assessed by DEXA. Echocardiography, 6-minute walk testing (6-MWT), muscle strength assessment, spiroergometry and QoL evaluation using EQ-5D Questionnaire were performed. Sarcopenia was defined as ASM 2 standard deviations below the mean of a healthy reference group aged 18-40years. Patients were divided into 3 groups according to the E/e' value: ≤8, 9-14, and ≥15. Sarcopenia was detected in 19.7% of all patients. These patients performed worse during 6-MWT (404±116 vs. 307±145m, p=0.003) and showed lower absolute peak oxygen consumption (1579±474 vs. 1211±442mL/min, p<0.05). Both ASM and muscle strength were lowest in patients with E/e' >15 (p<0.05). Higher values of muscle strength/ASM were associated with a better QoL (r=0.5, p<0.0005). Logistic regression showed ASM to be independently associated with reduced distance walked during the 6-MWT adjusted for NYHA, height, left atrium diameter, ferritin and forced expiratory volume in 1s (FEV1) (odds ratio 1.2, p=0.02). Sarcopenia affects a clinically relevant proportion of patients with HFpEF. Low ASM is strongly linked to reduced muscle strength, exercise capacity and QoL in these patients. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  15. Measures of Ventricular-Arterial Coupling and Incident Heart Failure With Preserved Ejection Fraction: A Matched Case-Control Analysis.

    PubMed

    Lekavich, Carolyn L; Barksdale, Debra J; Wu, Jia-Rong; Neelon, Virginia; Crandell, Jamie; Velazquez, Eric J

    2017-09-01

    Evidence continues to demonstrate increasing prevalence, cost, and mortality implications of heart failure with preserved ejection fraction (HFpEF), but clearly defined parameters that distinguish between control subjects and HFpEF have not been established. This study was designed to detect differences in markers associated with Ventricular-arterial coupling and HFpEF when comparing matched case and control groups. A study cohort of case (incident patients with HFpEF; n = 155) and matched control (patients with no prior heart failure; n = 155) groups was retrospectively identified. Matching criteria included race, sex, age, and date of echocardiography (within 1 year). Physiologic and echocardiographic markers were collected from previously acquired transthoracic echocardiograms. These echocardiographic images were reanalyzed, and measures of ventricular-arterial coupling were calculated. Using conditional logistic regression and controlling for covariates, models were fitted to detect differences in HFpEF markers between case and control subjects. Statistically significant differences in markers that reflect ventricular elastance (Ees; P = .007) and left atrial diameter (LAdiam; P = .04) were detected when comparing the case and control groups. Conditional logistic regression analyses suggested a 40% higher odds of being in the case group with every 1-unit increase in Ees (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.10-1.79) and a 2.92 times higher odds of being in the case group for every 1 cm increase in LAdiam (OR 2.92, 95% CI 1.064-7.994). Ees and LAdiam are easily measurable echocardiographic markers that may have a role in identifying and tracking the progression toward incident HFpEF without increasing cost or risk to the patient. Prospective studies are indicated to explore the use of Ees and LAdiam as predictors of impending HFpEF. Copyright © 2017 Elsevier Inc. All rights reserved.

  16. Improved detection of myocardial damage in sarcoidosis using longitudinal strain in patients with preserved left ventricular ejection fraction.

    PubMed

    Murtagh, Gillian; Laffin, Luke J; Patel, Kershaw V; Patel, Amit V; Bonham, Catherine A; Yu, Zoe; Addetia, Karima; El-Hangouche, Nadia; Maffesanti, Francesco; Mor-Avi, Victor; Hogarth, D Kyle; Sweiss, Nadera J; Beshai, John F; Lang, Roberto M; Patel, Amit R

    2016-09-01

    Cardiac infiltration is an important cause of death in sarcoidosis. Transthoracic echocardiography (TTE) has limited sensitivity for the detection of cardiac sarcoidosis (CS). Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is used to diagnose CS but has limitations of cost and availability. We sought to determine whether TTE-derived global longitudinal strain (GLS) may be used to identify individuals with CS, despite preserved left ventricular ejection fraction (LVEF), and whether abnormal GLS is associated with major cardiovascular events (MCE). We studied 31 patients with biopsy-proven extra-cardiac sarcoidosis, LVEF>50% and LGE on CMR (CS+ group), and 31 patients without LGE (CS- group), matched by age, sex, and severity of lung disease. GLS was measured using vendor-independent speckle tracking software. Parameters of left and right ventricular systolic and diastolic function were also studied. Receiver-operating characteristic curves were used to identify GLS cutoff for CS detection, and Kaplan-Meier plots to determine the ability of GLS to predict MCE. LGE was associated with reduced GLS (-19.6±1.9% in CS- vs -14.7±2.4% in CS+, P<.01) and with reduced E/A ratio (1.1±0.3 vs 0.9±0.3, respectively, P =.01). No differences were noted in other TTE parameters. GLS magnitude inversely correlated with LGE burden (r=-.59). GLS cutoff of -17% showed sensitivity and specificity 94% for detecting CS. Patients who experienced MCE had worse GLS than those who did not (-13.4±0.9% vs -17.7±0.4%, P=.0003). CS is associated with significantly reduced GLS in the presence of preserved LVEF. GLS measurements may become part of the TTE study performed to screen for CS. © 2016, Wiley Periodicals, Inc.

  17. A pilot study of angiogenin in heart failure with preserved ejection fraction: a novel potential biomarker for diagnosis and prognosis?

    PubMed

    Jiang, Hong; Zhang, Lei; Yu, Ying; Liu, Ming; Jin, Xuejuan; Zhang, Peipei; Yu, Peng; Zhang, Shuning; Zhu, Hongmin; Chen, Ruizhen; Zou, Yunzeng; Ge, Junbo

    2014-11-01

    Characteristics of heart failure with preserved ejection fraction (HFPEF) have not yet been fully understood. The objectives of this pilot study are to detect protein expression profile in the sera of HFPEF patients, and to identify potential biomarkers for the disease. Five hundred and seven proteins were detected in the sera of healthy volunteers and patients with either HFPEF or hypertension using antibody microarrays (three in each group). The results showed that the serum concentrations of 17 proteins (e.g. angiogenin, activin A and artemin) differed considerably between HFPEF and non-HFPEF patients (hypertensive patients and healthy controls), while a protein expression pattern distinct from that in non-HFPEF patients was associated with HFPEF patients. The up-regulation of angiogenin in both HFPEF patients with LVEF ≥50% (P = 0.004) and a subset of HFPEF patients with LVEF = 41-49% (P < 0.001) was further validated in 16 HFPEF patients and 16 healthy controls. Meanwhile, angiogenin distinguished HFPEF patients from controls with a mean area under the receiver operating characteristic curve of 0.88 (P < 0.001) and a diagnostic cut-off point of 426 ng/ml. Moreover, the angiogenin levels in HFPEF patients were positively correlated with Lg(N-terminal pro-B-type natriuretic peptide, NT-proBNP) (P < 0.001). In addition, high angiogenin level (≥426 ng/ml) was a predictor of all-cause death within a short-term follow-up duration, but not in the longer term of 36 months. This pilot study indicates that the aforementioned 17 potential biomarkers, such as angiogenin, may hold great promise for both diagnosis and prognosis assessment of HFPEF.

  18. Prognostic significance of tPA/PAI-1 complex in patients with heart failure and preserved ejection fraction.

    PubMed

    Winter, Max-Paul; Kleber, Marcus E; Koller, Lorenz; Sulzgruber, Patrick; Scharnagl, Hubert; Delgado, Graciela; Goliasch, Georg; März, Winfried; Niessner, Alexander

    2017-02-28

    Heart failure with preserved ejection fraction (HFpEF) represents a major epidemic, clinical and public health problem with rising patient numbers every year. Traditional markers for heart failure have been shown to be of limited sensitivity in patients with HFpEF, as those do not reflect pathophysiology of the disease properly. Dysregulation of haemostasis is thought to be central for the initiation and progression of HFpEF. For this reason, we aimed to assess markers of fibrinolytic activity as potential biomarkers for risk assessment in patients with HFpEF. We evaluated blood coagulation parameters in 370 patients with HFpEF included in the LUdwigshafen Risk and Cardiovascular Health (LURIC) study. Within an observation period of 9.7 years, 40 percent of these patients died from any cause. tPA/PAI-1 complex significantly predicted all-cause mortality with a hazard ratio (HR) of 1.24 (95 % confidence interval [CI] 1.04-1.47) per increase of 1 SD and cardiovascular mortality with a HR 1.26 (95 % CI 1.02-1.56) per increase of 1 SD. Both associations remained significant after adjustment for cardiovascular risk factors, N-terminal pro-B-type natriuretic peptide (NT-proBNP) and frequent HFpEF- related comorbidities. Importantly, tPA/PAI-1 complex had additional prognostic value above and beyond NT-proBNP as indicated by integrated discrimination improvement (0.0157, p=0.017). In conclusion, the concentration of tPA/PAI-1 complex is an independent predictor of mortality from all causes and from cardiovascular causes in patients with HFpEF. The concomitant measurement of tPA/PAI-1 complex might be useful in clinical practice to add prognostic value to traditional markers of heart failure.

  19. Comparison of Causes of Death After Heart Transplantation in Patients With Left Ventricular Ejection Fractions ≤35% Versus >35.

    PubMed

    Birati, Edo Y; Mathelier, Hansie; Molina, Maria; Hanff, Thomas C; Mazurek, Jeremy A; Atluri, Pavan; Acker, Michael A; Rame, J Eduardo; Margulies, Kenneth B; Goldberg, Lee R; Jessup, Mariell

    2016-04-15

    Sudden cardiac death (SCD) is a common cause of death in the general population, occurring in 300,000 to 350,000 people in the United States alone. Currently, there are no data supporting implantable cardioverter-defibrillator therapy in patients who underwent orthotopic heart transplant (OHT) with low left ventricular ejection fraction (LVEF). In this retrospective study, we included all patients who underwent primary OHT at our institution from 2007 to 2013. We compared the cause of death in patients who underwent OHT and evaluated the correlation of the cause of death and the patients' LVEF. Our objectives were to determine whether patients who underwent OHT with LVEF <35% are at increased risk for SCD compared with those who underwent OHT with normal LVEF. To summarize our results, a total of 345 patients were included in our study (mean age 50 ± 14 years, 68% men). The mean follow-up was 1,260 ± 698 days. Forty patients (11.5%) died >6 months after OHT. Surviving patients had higher LVEF compared with deceased patients (64 ± 7% and 50 ± 24%, respectively, p ≤0.001). In all, 10 (25%) of the deceased patients died suddenly, 9 (23%) from sepsis, and 8 (20%) from malignancy. Of the 11 deceased patients with LVEF ≤35%, 2 patients (18%) died suddenly compared with 9 SCDs among the 29 deceased patients (31%) with LVEF >35% (p = 0.54). In conclusion, patients who underwent OHT who died were more likely to have LVEF <35%, and a quarter of the deceased patients who underwent OHT died suddenly. A reduced LVEF was not associated with an increased risk of SCD.

  20. Treating Heart Failure with Preserved Ejection Fraction Related to Arterial Stiffness. Can we Kill Two Birds With One Stone?

    PubMed

    Athyros, Vasilios G; Pagourelias, Efstathios D; Gossios, Thomas D; Vasilikos, Vasilios G

    2015-01-01

    Heart failure with preserved ejection fraction (HFpEF). Arterial hypertension (AH), arterial stiffness (AS), older age, and female gender are the main determinants of HFpEF, but several cardiac or extra-cardiac pathologies are also possible causes. The combined ventricular-vascular stiffening (abnormal left atrium-left ventricle coupling related to AS) is the main contributor of the increased prevalence of HFpEF in elderly persons, particularly elderly women, and in younger persons with AH. The hospitalization and mortality rates of HFpEF are similar to those of heart failure with reduced EF (HFrEF). However, although the prognosis of HFrEF has been substantially improved during the last 2 decades, the effective treatment of HFpEF remains an unmet need. Regimens effective in HFrEF have no substantial effect on HFpEF, because of different pathophysiologies of the 2 syndromes. Pipeline drugs seem promising, but it will take some years before they are commercially available. Aggressive treatment of noncardiac comorbidities seems to be the only option at hand. Treatment of anaemia, sleep disorders, chronic kidney disease (CKD), non-alcoholic fatty liver (NAFLD), atrial fibrillation, diabetes, and careful use of diuretics to reduce preload are effective to some degree. Statin treatment, despite the presence of dyslipidaemia, deserves special attention because it has been proven, mainly in small studies or post hoc analyses of trials, that it offers a substantial improvement in quality of life and a reduction in mortality rates. We need to urgently utilize these recourses to relieve a considerable part of the general population suffering from HFpEF, a deadly disease.

  1. Exercise training in patients with heart failure and preserved ejection fraction: meta-analysis of randomized control trials.

    PubMed

    Pandey, Ambarish; Parashar, Akhil; Kumbhani, Dharam; Agarwal, Sunil; Garg, Jalaj; Kitzman, Dalane; Levine, Benjamin; Drazner, Mark; Berry, Jarett

    2015-01-01

    Heart failure with preserved ejection fraction (HFPEF) is common and characterized by exercise intolerance and lack of proven effective therapies. Exercise training has been shown to be effective in improving cardiorespiratory fitness (CRF) in patients with systolic heart failure. In this meta-analysis, we aim to evaluate the effects of exercise training on CRF, quality of life, and diastolic function in patients with HFPEF. Randomized controlled clinical trials that evaluated the efficacy of exercise training in patients with HFPEF were included in this meta-analysis. Primary outcome of the study was change in CRF (measured as change in peak oxygen uptake). Effect of exercise training on quality of life (estimated using Minnesota living with heart failure score), and left ventricular systolic and diastolic function was also assessed. The study included 276 patients who were enrolled in 6 randomized controlled trials. In the pooled data analysis, patients with HFPEF undergoing exercise training had significantly improved CRF (mL/kg per min; weighted mean difference, 2.72; 95% confidence interval, 1.79-3.65) and quality of life (weighted mean difference, -3.97; 95% confidence interval, -7.21 to -0.72) when compared with the control group. However, no significant change was observed in the systolic function (EF-weighted mean difference, 1.26; 95% confidence interval, -0.13% to 2.66%) or diastolic function (E/A-weighted mean difference, 0.08; 95% confidence interval, -0.01 to 0.16) with exercise training in patients with HFPEF. Exercise training in patients with HFPEF is associated with an improvement in CRF and quality of life without significant changes in left ventricular systolic or diastolic function. © 2014 American Heart Association, Inc.

  2. Development of a Mouse Model of Metabolic Syndrome, Pulmonary Hypertension, and Heart Failure with Preserved Ejection Fraction.

    PubMed

    Meng, Qingqing; Lai, Yen-Chun; Kelly, Neil J; Bueno, Marta; Baust, Jeffrey J; Bachman, Timothy N; Goncharov, Dmitry; Vanderpool, Rebecca R; Radder, Josiah E; Hu, Jian; Goncharova, Elena; Morris, Alison M; Mora, Ana L; Shapiro, Steven D; Gladwin, Mark T

    2017-04-01

    Pulmonary hypertension (PH) associated with heart failure with preserved ejection fraction (PH-HFpEF; World Health Organization Group II) secondary to left ventricular (LV) diastolic dysfunction is the most frequent cause of PH. It is an increasingly recognized clinical complication of the metabolic syndrome. To date, no effective treatment has been identified, and no genetically modifiable mouse model is available for advancing our understanding for PH-HFpEF. To develop a mouse model of PH-HFpEF, we exposed 36 mouse strains to 20 weeks of high-fat diet (HFD), followed by systematic evaluation of right ventricular (RV) and LV pressure-volume analysis. The HFD induces obesity, glucose intolerance, insulin resistance, hyperlipidemia, as well as PH, in susceptible strains. We observed that certain mouse strains, such as AKR/J, NON/shiLtJ, and WSB/EiJ, developed hemodynamic signs of PH-HFpEF. Of the strains that develop PH-HFpEF, we selected AKR/J for further model validation, as it is known to be prone to HFD-induced metabolic syndrome and had low variability in hemodynamics. HFD-treated AKR/J mice demonstrate reproducibly higher RV systolic pressure compared with mice fed with regular diet, along with increased LV end-diastolic pressure, both RV and LV hypertrophy, glucose intolerance, and elevated HbA1c levels. Time course assessments showed that HFD significantly increased body weight, RV systolic pressure, LV end-diastolic pressure, biventricular hypertrophy, and HbA1c throughout the treatment period. Moreover, we also identified and validated 129S1/SvlmJ as a resistant mouse strain to HFD-induced PH-HFpEF. These studies validate an HFD/AKR/J mouse model of PH-HFpEF, which may offer a new avenue for testing potential mechanisms and treatments for this disease.

  3. Dual Endothelin-A/Endothelin-B Receptor Blockade and Cardiac Remodeling in Heart Failure With Preserved Ejection Fraction.

    PubMed

    Valero-Munoz, Maria; Li, Shanpeng; Wilson, Richard M; Boldbaatar, Batbold; Iglarz, Marc; Sam, Flora

    2016-11-01

    Despite the increasing prevalence of heart failure with preserved ejection fraction (HFpEF) in humans, there remains no evidence-based therapies for HFpEF. Endothelin-1 (ET-1) antagonists are a possibility because elevated ET-1 levels are associated with adverse cardiovascular effects, such as arterial and pulmonary vasoconstriction, impaired left ventricular (LV) relaxation, and stimulation of LV hypertrophy. LV hypertrophy is a common phenotype in HFpEF, particularly when associated with hypertension. In the present study, we found that ET-1 levels were significantly elevated in patients with chronic stable HFpEF. We then sought to investigate the effects of chronic macitentan, a dual ET-A/ET-B receptor antagonist, on cardiac structure and function in a murine model of HFpEF induced by chronic aldosterone infusion. Macitentan caused LV hypertrophy regression independent of blood pressure changes in HFpEF. Although macitentan did not modulate diastolic dysfunction in HFpEF, it significantly reduced wall thickness and relative wall thickness after 2 weeks of therapy. In vitro studies showed that macitentan decreased the aldosterone-induced cardiomyocyte hypertrophy. These changes were mediated by a reduction in the expression of cardiac myocyte enhancer factor 2a. Moreover, macitentan improved adverse cardiac remodeling, by reducing the stiffer cardiac collagen I and titin n2b expression in the left ventricle of mice with HFpEF. These findings indicate that dual ET-A/ET-B receptor inhibition improves HFpEF by abrogating adverse cardiac remodeling via antihypertrophic mechanisms and by reducing stiffness. Additional studies are needed to explore the role of dual ET-1 receptor antagonists in patients with HFpEF. © 2016 American Heart Association, Inc.

  4. Characteristics of sleep-disordered breathing in patients with atrial fibrillation and preserved left ventricular ejection fraction.

    PubMed

    Strotmann, Johanna; Fox, Henrik; Bitter, Thomas; Sauzet, Odile; Horstkotte, Dieter; Oldenburg, Olaf

    2017-09-23

    Sleep-disordered breathing (SDB) represents a common and highly relevant co-morbidity in patients with atrial fibrillation (Afib). Obstructive sleep apnea (OSA) has been identified as an independent risk factor for developing Afib and for Afib recurrence after treatment, but the role of central sleep apnea (CSA) is less clear. This study investigated characteristics of SDB in Afib patients with preserved left ventricular ejection fraction (PEF). Consecutive patients (07/2007 to 03/2016) with documented Afib at hospital admission and PEF undergoing 6-channel cardiorespiratory polygraphy (PG) screening were retrospectively analyzed. A total of 211 patients were included (146 men; age 68.7 ± 8.5 years). Only 6.6% of patients had no SDB (apnea-hypopnea index [AHI] < 5/h). When moderate-to-severe SDB (AHI ≥ 15/h) was classified based on the predominant type of apneas and hypopneas, OSA (≥ 80% obstructive events) was found in 15% of patients, CSA (≥ 80% central events) in 10%, and 36% had mixed sleep apnea. For patients with Cheyne-Stokes respiration (CSR; 34%), time spent in CSR increased significantly as total AHI increased (p < 0.001); total CSR duration was 20, 50, and 117 min, respectively, in patients with mild, moderate, and severe SDB. SDB was highly prevalent in this cohort of patients with Afib and PEF. The proportion of patients with moderate-to-severe OSA, for whom treatment is recommended by current guidelines, was about 15%. With 36% of patients presenting with moderate-to-severe mixed sleep apnea and almost 10% of patients having CSA, treatment guidelines for these types of SDB in the setting of Afib are needed.

  5. Screening for Cardiac Magnetic Resonance Scar Features by 12-lead ECG, in Patients with Preserved Ejection Fraction

    PubMed Central

    Mewton, Nathan; Strauss, David G.; Rizzi, Patricia; Verrier, Richard L.; Liu, Chia Ying; Tereshchenko, Larisa G.; Nearing, Bruce; Volpe, Gustavo J.; Marchlinski, Francis E.; Moxley, John; Killian, Tony; Wu, Katherine C.; Spooner, Peter; Lima, João A.C.

    2015-01-01

    Background Increased QRS score and wide spatial QRS-T angle are independent predictors of cardiovascular mortality in the general population. Our main objective was to assess whether a QRS score ≥5 and/or QRS-T angle ≥105° enable screening of patients for myocardial scar features. Methods 77 patients age ≤70 years with QRS score ≥5 AND/OR spatial QRS-T angle ≥105° as well as left ventricular ejection fraction (LVEF) >35% were enrolled in the study. All participants underwent complete clinical examination, signal averaged ECG (SAECG), 30-minute ambulatory ECG recording for T wave alternans (TWA), and late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Relationship between QRS score, QRS-T angle with scar presence and pattern, as well as gray zone, core, and total scar size by LGE-CMR were assessed. Results Myocardial scar was present in 41 (53%) patients, of whom 19 (46%) exhibited a typical ischemic pattern. QRS score but not QRS-T angle was related to total scar size and gray zone size (R2=0.12, P=0.002; R2=0.17; P ≤0.0001 respectively). Patients with QRS scores ≥6 had significantly greater myocardial scar and gray zone size, increased QRS duration and QRS-T angle, a higher prevalence of late potentials (LP) presence, increased LV end-diastolic volume and decreased LVEF. There was a significant independent and positive association between TWA value and total scar (P=0.001) and gray zone size (P=0.01). Conclusion Patients with preserved LVEF and myocardial scar by CMR also have electrocardiographic features that could be involved in ventricular arrhythmogenesis. PMID:26806840

  6. Screening for Cardiac Magnetic Resonance Scar Features by 12-Lead ECG, in Patients with Preserved Ejection Fraction.

    PubMed

    Mewton, Nathan; Strauss, David G; Rizzi, Patricia; Verrier, Richard L; Liu, Chia Ying; Tereshchenko, Larisa G; Nearing, Bruce; Volpe, Gustavo J; Marchlinski, Francis E; Moxley, John; Killian, Tony; Wu, Katherine C; Spooner, Peter; Lima, João A C

    2016-01-01

    Increased QRS score and wide spatial QRS-T angle are independent predictors of cardiovascular mortality in the general population. Our main objective was to assess whether a QRS score ≥ 5 and/or QRS-T angle ≥ 105° enable screening of patients for myocardial scar features. Seventy-seven patients of age ≤ 70 years with QRS score ≥ 5 and/or spatial QRS-T angle ≥ 105° as well as left ventricular ejection fraction (LVEF) >35% were enrolled in the study. All participants underwent complete clinical examination, signal-averaged ECG (SAECG), 30-minute ambulatory ECG recording for T-wave alternans (TWA), and late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Relationship between QRS score, QRS-T angle with scar presence and pattern, as well as gray zone, core, and total scar size by LGE-CMR were assessed. Myocardial scar was present in 41 (53%) patients, of whom 19 (46%) exhibited a typical ischemic pattern. QRS score but not QRS-T angle was related to total scar size and gray zone size (R(2) = 0.12, P = 0.002; R(2) = 0.17; P ≤ 0.0001, respectively). Patients with QRS scores ≥ 6 had significantly greater myocardial scar and gray zone size, increased QRS duration and QRS-T angle, a higher prevalence of late potentials (LPs) presence, increased LV end-diastolic volume and decreased LVEF. There was a significant independent and positive association between TWA value and total scar (P = 0.001) and gray zone size (P = 0.01). Patients with preserved LVEF and myocardial scar by CMR also have electrocardiographic features that could be involved in ventricular arrhythmogenesis. © 2016 Wiley Periodicals, Inc.

  7. Left ventricular abnormal response during dynamic exercise in patients with heart failure and preserved left ventricular ejection fraction at rest.

    PubMed

    Ennezat, Pierre V; Lefetz, Yann; Maréchaux, Sylvestre; Six-Carpentier, Marie; Deklunder, Ghislaine; Montaigne, David; Bauchart, Jean Jacques; Mounier-Véhier, Claire; Jude, Brigitte; Nevière, Rémi; Bauters, Christophe; Asseman, Philippe; de Groote, Pascal; Lejemtel, Thierry H

    2008-08-01

    The mechanisms that contribute to limit functional capacity are incompletely understood in patients with preserved resting ejection fraction (HFpREF). We assessed left ventricular (LV) systolic response to dynamic exercise in patients with HFpREF and in patients with similar comorbidities to HFpREF patients but without history or evidence of heart failure. Twenty-five HFpREF patients in steady-state clinical condition without significant coronary artery disease and 25 hypertensive controls underwent exercise echocardiography. At rest, systolic pulmonary artery pressure, left atrial area, E/A and E/e' ratios were greater in patients with HFpREF than in control patients, whereas peak systolic mitral annular velocity was lower in HFpREF patients. The exercise-induced changes in LVEF, forward stroke volume, and cardiac output were significantly lower in HFpREF compared with control patients (-4 +/- 8 vs. +6 +/- 6 %, P = .001; -4 +/- 9 vs. +10 +/- 10 mL, P < .0001, and 1.6 +/- 1.2 vs. 3.5 +/- 1.8 L/min, P < .0001, respectively). Exercise-induced changes in effective arterial elastance significantly differed in HFpREF and control patients (0.5 +/- 0.6 vs. -0.2 +/- 0.5 mm Hg/mL, P < .0001). In addition, 7 of the 25 HFpREF patients developed functional mitral regurgitation during exercise and none in controls. When compared with patients with similar comorbidities but without history or evidence of heart failure, patients with HFpREF experience greater arterial stiffening and thereby a deterioration of global LV systolic performance during dynamic exercise.

  8. The Relationships between Body Mass Index and Left Ventricular Diastolic Function in a Structurally Normal Heart with Normal Ejection Fraction

    PubMed Central

    Jin, Han-Young; Jang, Jae-Sik; Yang, Tae-Hyun; Kim, Dae-Kyeong; Kim, Dong-Soo

    2017-01-01

    Background We conducted research to determine the effect of the weight on left ventricular (LV) diastolic function in Asians, who are at greater risk of cardiovascular events compared to individuals from Western countries with similar body mass indices (BMIs). Methods We studied 543 participants with structurally normal hearts and normal ejection fractions. Participants were classified as normal-weight (BMI < 23.0 kg/m2), overweight (BMI 23.0–27.4 kg/m2), or obese (BMI ≥ 27.5 kg/m2). Peak E velocity, peak A velocity, and E′ velocity were measured and E/E′ was calculated. Results Overweight participants had lower E than normal-weight participants (p = 0.001). E′ velocities in overweight and obese participants were less than those in normal weight participants (both p < 0.001). The E/E′ ratio in obese participants was higher compared to the value in normal-weight participants (p < 0.001) and overweight participants (p = 0.025). BMI was associated with E (R = −0.108), A (R = 0.123), E′ (R = −0.229), and E/E′ ratio (R = 0.138) (all p < 0.05). In multivariate analyses, BMI was independently associated with higher A, lower E′, and higher E/E′. The risk of diastolic dysfunction was significantly higher among overweight [adjusted odds ratio: 2.088; 95% confidence interval (CI): 1.348–3.235; p = 0.001] and obese participants (adjusted odds ratio: 5.910; 95% CI: 2.871–12.162; p < 0.001) compared to normal-weight participants. Conclusion Obesity and overweight independently predicted diastolic dysfunction. An optimal body weight lower than the universal cut-off is reasonable for preventing LV heart failure in Asians. PMID:28400930

  9. Sitagliptin reduces inflammation, fibrosis and preserves diastolic function in a rat model of heart failure with preserved ejection fraction.

    PubMed

    Esposito, Grazia; Cappetta, Donato; Russo, Rosa; Rivellino, Alessia; Ciuffreda, Loreta Pia; Roviezzo, Fiorentina; Piegari, Elena; Berrino, Liberato; Rossi, Francesco; De Angelis, Antonella; Urbanek, Konrad

    2016-12-06

    Heart failure with preserved ejection fraction (HFpEF) is a systemic syndrome driven by co-morbidities, and its pathophysiology is poorly understood. Several studies suggesting that dipeptidyl peptidase 4 (DPP4) might be involved in the pathophysiology of heart failure have prompted experimental and clinical investigations of DPP4 inhibitors in the cardiovascular system. Here we have investigated whether the DPP4 inhibitor sitagliptin affected the progression of HFpEF independently of its effects on glycaemia. Seven-week-old Dahl salt-sensitive rats were fed a high-salt diet for 5 weeks to induce hypertension. Then the rats continued with the high-salt diet and were treated with either sitagliptin (10 mg·kg(-1) ) or vehicle for the following 8 weeks. Blood pressure and cardiac function were measured in vivo. Histochemical and molecular biology analyses of myocardium were used to assay cytokines, fibrotic markers, DPP4 and glucagon-like peptide-1 (GLP-1)/GLP-1 receptor. Treatment with sitagliptin attenuated diastolic dysfunction, reduced mortality and reduced cardiac DPP4 activity, along with increased circulating GLP-1 and myocardial expression of GLP-1 receptors. Myocardial levels of pro-inflammatory cytokines (TNF-α, IL-6 and CCL2) were reduced. Sitagliptin treatment decreased the levels of endothelial NOS monomer, responsible for generation of ROS, while the amount of NO-producing dimeric form increased. Markers of oxidative and nitrosative stress were decreased. Moreover, increased collagen deposition and activation of pro-fibrotic signalling, inducing elevated myocardial stiffness, were attenuated by sitagliptin treatment. Sitagliptin positively modulated active relaxation and passive diastolic compliance by decreasing inflammation-related endothelial dysfunction and fibrosis, associated with HFpEF. © 2016 The British Pharmacological Society.

  10. Exercise-induced torsional dyssynchrony relates to impaired functional capacity in patients with heart failure and normal ejection fraction.

    PubMed

    Tan, Yu Ting; Wenzelburger, Frauke Wg; Sanderson, John E; Leyva, Francisco

    2013-02-01

    Left ventricular (LV) systole and diastole are intimately dependent on myocardial torsion, which involves coupling between myocardial rotation (twisting in systole and untwisting in diastole) and longitudinal motion. Heart failure with normal ejection fraction (HFNEF) is known to involve exercise-induced wall motion abnormalities, but torsion on exercise has not been explored. We hypothesised that torsional dyssynchrony may also be involved and be exaggerated by exercise. 67 patients (age 73±7 years, 45 female) with HFNEF and 38 controls underwent cardiopulmonary exercise testing and echocardiography at rest and on supine exercise. Analysis of three plane motions was performed using speckle tracking and tissue Doppler imaging. Torsional dyssynchrony was quantified as the SD of the time to peak systolic motion (SDSM) (basal and apical rotation, longitudinal and radial displacement); the time difference between peak twist and peak longitudinal displacement (twist-longitudinal motion delay, TLMD) and the ratio of untwist to longitudinal extension (UT:LE). At rest, HFNEF patients had similar SDSM, TLMD and UT:LE compared with controls. Exercise was associated with significantly more dyssynchrony in the HFNEF patients (SDSM 38.8±27.6 ms vs 25.9±15.5 ms, p=0.02; TLMD 28.4±46.2 ms vs 2.9±31.2 ms, p=0.005 and UT:LE 10.4±15.3 vs 3.3±3.8, p=0.022). The SDSM correlated positively with LV wall thickness (r=0.31, p=0.015) and negatively with peak oxygen consumption (r=-0.299, p=0.01) and changes in stroke volume on exercise (r=-0.371, p=0.001). HFNEF involves exercise-induced torsional dyssynchrony in systole and diastole, which relates to LV hypertrophy as well as exercise capacity.

  11. Prognostic value of monocyte count in patients hospitalized for heart failure with reduced ejection fraction (from the EVEREST Trial).

    PubMed

    Greene, Stephen J; Harinstein, Matthew E; Vaduganathan, Muthiah; Subačius, Haris; Konstam, Marvin A; Zannad, Faiez; Maggioni, Aldo P; Swedberg, Karl; Butler, Javed; Gheorghiade, Mihai

    2012-12-01

    Monocytes play a critical role in the pathophysiology of heart failure (HF), but few studies have evaluated the prognostic implications of an increased monocyte count in patients with HF and reduced ejection fraction (EF). The Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) examined the effects of tolvaptan in patients with worsening HF and EF ≤40%. This post hoc analysis evaluated the primary end points of all-cause mortality and cardiovascular mortality or HF hospitalization in 3,717 patients. At baseline, 265 (7.1%) had an increased monocyte count defined by ≥800/μl. Patients with increased monocyte count tended to have an increased EF and were less likely to have a history of diabetes mellitus, hypercholesterolemia, or coronary revascularization but were more likely to have higher HF functional class and to be taking HF therapies such as diuretics, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, and digoxin (p <0.05 for all comparisons). At median follow-up of 9.9 months, increased monocyte count was predictive of all-cause mortality (hazard ratio 1.27, 95% confidence interval 1.003 to 1.60, p = 0.047) but was not associated with cardiovascular mortality or HF hospitalization (hazard ratio 1.06, 95% confidence interval 0.87 to 1.30, p = 0.55). Similar results were seen when monocyte count was analyzed as a continuous variable. However, after adjustment for baseline clinical risk factors, monocyte count was not predictive of either primary end point. In conclusion, increased monocyte count occurs in a minority of patients hospitalized with HF and is associated with poor postdischarge prognosis. However, it does not contribute prognostic value above other more traditional risk factors. Copyright © 2012. Published by Elsevier Inc.

  12. Prognostic value of three-dimensional echocardiographic right ventricular ejection fraction in patients with pulmonary arterial hypertension

    PubMed Central

    Murata, Mitsushige; Tsugu, Toshimitsu; Kawakami, Takashi; Kataoka, Masaharu; Minakata, Yugo; Endo, Jin; Tsuruta, Hikaru; Itabashi, Yuji; Maekawa, Yuichiro; Murata, Mitsuru; Fukuda, Keiichi

    2016-01-01

    Background Right ventricular (RV) function is an independent predictor of clinical outcomes in patients with pulmonary arterial hypertension (PAH). However, it remains controversial which RV parameter should be measured as an appropriate index for the treatment of PAH. The aim of this study was to identify the most useful parameter that correlates with hemodynamics and predicts clinical outcomes in PAH. Results Most of the clinical and echocardiographic RV parameters were significantly correlated with pulmonary vascular resistance (PVR) as well as mean pulmonary arterial pressure (mPAP). Among these, three dimensional right ventricular ejection fraction (3DRVEF) showed the strongest hemodynamic correlation, followed by 6-minute walk distance. Receiver operating characteristic analysis of association with cardiac events including death, hospitalization, and intervention revealed a greater area under the curve for 3DRVEF than for mPAP (0.78 vs. 0.74). Kaplan-Meier analysis showed that patients with 3DRVEF less than 38% had significantly shorter event-free survival than those with greater than 38% (P = 0.0007). Finally, the Cox proportional hazards analysis revealed that 3DRVEF, but not mPAP, was an independent predictor of clinical events in PAH. Materials and Methods Eighty-six consecutive patients were enrolled in this study. RV hemodynamic parameters were measured by right heart catheterization (RHC). RV function was assessed using two-dimensional speckle-tracking echocardiography and three-dimensional transthoracic echocardiography (3DTTE) to evaluate RV free wall global strain (RVFS) and RVEF. Conclusions RVEF measured by 3DTTE could be a useful parameter for noninvasively assessing RV hemodynamics and predicting the clinical outcomes in PAH patients. PMID:27893420

  13. Directed bedside transthoracic echocardiography: preferred cardiac window for left ventricular ejection fraction estimation in critically ill patients.

    PubMed

    Mark, Dustin G; Ku, Bon S; Carr, Brendan G; Everett, Worth W; Okusanya, Olugbenga; Horan, Annamarie; Gracias, Vicente H; Dean, Anthony J

    2007-10-01

    Bedside transthoracic echocardiography (TTE) performed by emergency physicians (EPs) is valuable in the rapid assessment and treatment of critically ill patients. We sought to determine the preferred cardiac window for left ventricular ejection fraction (LVEF) estimation by EP sonographers in a critically ill patient population. Prospective investigator-blinded study of focused bedside TTE in a convenience sample of surgical intensive care patients. Investigators were faculty, fellows, or residents from an academic emergency medicine department. Five standard cardiac views were performed: parasternal long axis (PSLA), parasternal short axis (PSSA), subxiphoid 4-chamber, subxiphoid short axis, and apical 4-chamber (AFC). LVEF was determined using at least 1 cardiac view. Investigators rated their preference for each cardiac view on a 5-point Likert scale. A total of 70 studies were performed on 70 patients during a 6-month period. Users rated the PSLA as the most useful view for estimation of LVEF (mean 4.23; 95% confidence interval, 3.95-4.51). Pairwise comparisons of cardiac ultrasound views revealed PSLA was preferred over all other views (P < .05) except PSSA (P = .23). Complete 5 view examinations were not achieved in all patients (PSLA in 98%, PSSA in 96%, apical 4-chamber in 74%, subxiphoid 4-chamber in 35%, and subxiphoid short axis in 18%). Interobserver correlation of LVEF estimation was good (r = 0.86, r2 = 0.74, P < .0001). Parasternal long axis and PSSA are the preferred echocardiographic windows for EP estimation of LVEF using focused bedside TTE in critical care patients. This may be an important consideration in patients who often have physical barriers to optimal echocardiographic evaluation, are relatively immobile, and have unstable conditions requiring rapid assessment and intervention.

  14. Association between cardiovascular vs. non-cardiovascular co-morbidities and outcomes in heart failure with preserved ejection fraction.

    PubMed

    Lund, Lars H; Donal, Erwan; Oger, Emmanuel; Hage, Camilla; Persson, Hans; Haugen-Löfman, Ida; Ennezat, Pierre-Vladimir; Sportouch-Dukhan, Catherine; Drouet, Elodie; Daubert, Jean-Claude; Linde, Cecilia

    2014-09-01

    The prevalence of cardiovascular and non-cardiovascular co-morbidities and their relative importance for outcomes in heart failure with preserved ejection fraction (HFPEF) remain poorly characterized. This study aimed to investigate this. The Karolinska-Rennes (KaRen) Study was a multinational prospective observational study designed to characterize HFPEF. Inclusion required acute HF, defined by the Framingham criteria, LVEF ≥ 45%, and NT-pro-BNP ≥ 300 ng/L or BNP ≥ 100 ng/L. Detailed clinical data were collected at baseline and patients were followed prospectively for 18 months. Predictors of the primary (HF hospitalization or all-cause mortality) and secondary (all-cause mortality) outcomes were assessed with multivariable Cox regression. A total of 539 patients [56% women; median (interquartile range) age 79 (72-84) years; NT-pro-BNP/BNP 2448 (1290-4790)/429 (229-805) ng/L] were included. Known history of HF was present in 40%. Co-morbidities included hypertension (78%), atrial fibrillation/flutter (65%), anaemia (51%), renal dysfunction (46%), CAD (33%), diabetes (30%), lung disease (25%), and cancer (16%). The primary outcome occurred in 268 patients [50%; 106 deaths (20%) and 162 HF hospitalizations (30%)]. Important independent predictors of the primary and/or secondary outcomes were age, history of non-cardiovascular syncope, valve disease, anaemia, lower sodium, and higher potassium, but no cardiovascular co-morbidities. Renin-angiotensin system antagonist and mineralocorticoid receptor antagonist use predicted improved prognosis. HFPEF was associated with higher age, female gender, hypertension, atrial fibrillation/flutter, and numerous non-cardiovascular co-morbidities. Prognosis was determined by non-cardiovascular co-morbidities, but use of conventional heart failure medications may still be associated with improved outcomes. © 2014 The Authors. European Journal of Heart Failure © 2014 European Society of Cardiology.

  15. The Association between Platelet/Lymphocyte Ratio and Coronary Artery Disease Severity in Asymptomatic Low Ejection Fraction Patients

    PubMed Central

    Açar, Burak; Gul, Murat; Özeke, Özcan; Aydogdu, Sinan

    2016-01-01

    Background and Objectives Coronary angiography (CAG) is generally needed in the setting of systolic heart failure (HF) with an unidentified etiology as a part of diagnostic strategy. On the other hand, the clinical value of this invasive strategy is largely unknown. Platelet-lymphocyte ratio (PLR) has recently emerged as a novel inflammatory index that may serve as an important predictor of inflammatory state and overall mortality. The present study aimed to search the predictive value of PLR in determining the extent of coronary atherosclerosis in asymptomatic low ejection fraction (EF) patients. Subjects and Methods 156 asymptomatic heart failure (HF) subjects (without angina or HF symptoms, mean age: 58 years; to male: 71.2%) were enrolled, and thereafter a CAG was performed. Gensini Score was used to determine the severity of coronary artery disease (CAD) on CAG. According to this scoring system, the overall study group was categorized into three distinct subgroups: control group with the score 0, mild atherosclerosis group with the score 0 to 20 and severe atherosclerosis group with the score of >20. Thereafter, a comparison was made among groups with regard to mean values of PLR. Results The severe atherosclerosis group had a substantially higher level of mean PLR in comparison to other groups (p<0.001). Pre-CAG PLR levels as well as a variety of clinical variables including age, low density lipoprotein (LDL)-cholesterol demonstrated an independent correlation with Gensini score through a multivariate analysis. Conclusion These findings suggest the potential association of high PLR levels with severe atherosclerosis in the setting of asymptomatic systolic HF. A simple measurement of PLR helps to identify the severity of coronary atherosclerosis prior to conducting coronary angiography. PMID:27826341

  16. Myocardial Stiffness in Patients with Heart Failure and a Preserved Ejection Fraction: Contributions of Collagen and Titin

    PubMed Central

    Zile, Michael R.; Baicu, Catalin F.; Ikonomidis, John; Stroud, Robert E.; Nietert, Paul J.; Bradshaw, Amy D.; Slater, Rebecca; Palmer, Bradley M.; Van Buren, Peter; Meyer, Markus; Redfield, Margaret; Bull, David; Granzier, Henk; LeWinter, Martin M.

    2015-01-01

    Background The purpose of this study was to determine whether patients with heart failure and a preserved ejection fraction (HFpEF) have an increase in passive myocardial stiffness and the extent to which discovered changes are dependent on changes in extracellular matrix fibrillar collagen and/or cardiomyocyte titin. Methods and Results Seventy patients undergoing coronary artery bypass grafting underwent an echocardiogram, plasma biomarker determination, and intra-operative left ventricular (LV) epicardial anterior wall biopsy. Patients were divided into 3 groups: referent control (n=17, no hypertension or diabetes), hypertension (HTN) without(-) HFpEF (n=31), and HTN with(+) HFpEF (n=22). One or more of the following studies were performed on the biopsies: passive stiffness measurements to determine total, collagen-dependent and titin-dependent stiffness (differential extraction assay), collagen assays (biochemistry or histology), or titin isoform and phosphorylation assays. Compared with controls, patients with HTN(-)HFpEF had no change in LV end diastolic pressure (LVEDP), myocardial passive stiffness, collagen, or titin phosphorylation but had an increase in biomarkers of inflammation (CRP, sST2, TIMP-1). Compared with both control and HTN(-)HFpEF, patients with HTN(+)HFpEF had increased LVEDP, left atrial volume, NT-proBNP, total, collagen-dependent and titin-dependent stiffness, insoluble collagen, increased titin phosphorylation on PEVK S11878(S26), reduced phosphorylation on N2B S4185(S469), and increased biomarkers of inflammation. Conclusions Hypertension in the absence of HFpEF, did not alter passive myocardial stiffness. Patients with HTN(+)HFpEF had a significant increase in passive myocardial stiffness; collagen-dependent and titin-dependent stiffness were increased. These data suggest that the development of HFpEF is dependent on changes in both collagen and titin homeostasis. PMID:25637629

  17. Acute hemodynamic effects of inhaled sodium nitrite in pulmonary hypertension associated with heart failure with preserved ejection fraction

    PubMed Central

    Simon, Marc A.; Vanderpool, Rebecca R.; Nouraie, Mehdi; Bachman, Timothy N.; White, Pamela M.; Sugahara, Masataka; Gorcsan, John; Parsley, Ed L.; Gladwin, Mark T.

    2016-01-01

    BACKGROUND. Pulmonary hypertension (PH) is associated with poor outcomes, yet specific treatments only exist for a small subset of patients. The most common form of PH is that associated with left heart disease (Group 2), for which there is no approved therapy. Nitrite has shown efficacy in preclinical animal models of Group 1 and 2 PH, as well as in patients with left heart failure with preserved ejection fraction (HFpEF). We evaluated the safety and efficacy of a potentially novel inhaled formulation of nitrite in PH-HFpEF patients as compared with Group 1 and 3 PH. METHODS. Cardiopulmonary hemodynamics were recorded after acute administration of inhaled nitrite at 2 doses, 45 and 90 mg. Safety endpoints included change in systemic blood pressure and methemoglobin levels. Responses were also compared with those administered inhaled nitric oxide. RESULTS. Thirty-six patients were enrolled (10 PH-HFpEF, 20 Group 1 pulmonary arterial hypertension patients on background PH-specific therapy, and 6 Group 3 PH). Drug administration was well tolerated. Nitrite inhalation significantly lowered pulmonary, right atrial, and pulmonary capillary wedge pressures, most pronounced in patients with PH-HFpEF. There was a modest decrease in cardiac output and systemic blood pressure. Pulmonary vascular resistance decreased only in Group 3 PH patients. There was substantial increase in pulmonary artery compliance, most pronounced in patients with PH-HFpEF. CONCLUSIONS. Inhaled nitrite is safe in PH patients and may be efficacious in PH-HFpEF and Group 3 PH primarily via improvements in left and right ventricular filling pressures and pulmonary artery compliance. The lack of change in pulmonary vascular resistance likely may limit efficacy for Group 1 patients. TRIAL REGISTRATION. ClinicalTrials.gov NCT01431313 FUNDING. This work was supported in part by the NIH grants P01HL103455 (to MAS and MTG), R01HL098032 (to MTG), and R01HL096973 (to MTG), and Mast Therapeutics, Inc. PMID

  18. Presence of ´isolated´ tricuspid regurgitation should prompt the suspicion of heart failure with preserved ejection fraction

    PubMed Central

    Mascherbauer, Julia; Kammerlander, Andreas A.; Zotter-Tufaro, Caroline; Aschauer, Stefan; Duca, Franz; Dalos, Daniel; Winkler, Susanne; Schneider, Matthias; Bergler-Klein, Jutta; Bonderman, Diana

    2017-01-01

    Background Diastolic dysfunction of the left ventricle is common but frequently under-diagnosed. Particularly in advanced stages affected patients may present with significant functional tricuspid regurgitation (TR) as the most prominent sign on echocardiography. The underlying left ventricular pathology may eventually be missed and symptoms of heart failure are attributed to TR, with respective therapeutic consequences. The aim of the present study was to determine prevalence and mechanisms underlying TR evolution in heart failure with preserved ejection fraction (HFpEF). Methods and results Consecutive HFpEF patients were enrolled in this prospective, observational study. Confirmatory diagnostic tests including echocardiography and invasive hemodynamic assessments were performed. Of the 175 patients registered between 2010 and 2014, 51% had significant (moderate or severe) TR without structural abnormalities of the tricuspid valve. Significant hemodynamic differences between patients with and without relevant TR were encountered. These included elevated pulmonary vascular resistance (p = 0.038), reduced pulmonary arterial compliance (PAC, p = 0.005), and elevated left ventricular filling pressures (p = 0.039) in the TR group. Multivariable binary logistic regression analysis revealed diastolic pulmonary artery pressure (p = 0.029) and PAC (p = 0.048) as independent determinants of TR. Patients were followed for 18.1±14.1 months, during which 32% had a cardiac event. While TR was associated with outcome in the univariable analysis, it failed to predict event-free survival in the multivariable model. Conclusions The presence of ´isolated´ functional TR should prompt the suspicion of HFpEF. Our data show that significant TR is a marker of advanced HFpEF but neither an isolated entity nor independently associated with event-free survival. PMID:28199339

  19. Dual Endothelin-A/Endothelin-B Receptor Blockade and Cardiac Remodeling in Heart Failure With Preserved Ejection Fraction

    PubMed Central

    Valero-Munoz, Maria; Li, Shanpeng; Wilson, Richard M.; Boldbaatar, Batbold; Iglarz, Marc; Sam, Flora

    2017-01-01

    Background Despite the increasing prevalence of heart failure with preserved ejection fraction (HFpEF) in humans, there remains no evidence-based therapies for HFpEF. Endothelin-1 (ET-1) antagonists are a possibility because elevated ET-1 levels are associated with adverse cardiovascular effects, such as arterial and pulmonary vasoconstriction, impaired left ventricular (LV) relaxation, and stimulation of LV hypertrophy. LV hypertrophy is a common phenotype in HFpEF, particularly when associated with hypertension. Methods and Results In the present study, we found that ET-1 levels were significantly elevated in patients with chronic stable HFpEF. We then sought to investigate the effects of chronic macitentan, a dual ET-A/ET-B receptor antagonist, on cardiac structure and function in a murine model of HFpEF induced by chronic aldosterone infusion. Macitentan caused LV hypertrophy regression independent of blood pressure changes in HFpEF. Although macitentan did not modulate diastolic dysfunction in HFpEF, it significantly reduced wall thickness and relative wall thickness after 2 weeks of therapy. In vitro studies showed that macitentan decreased the aldosterone-induced cardiomyocyte hypertrophy. These changes were mediated by a reduction in the expression of cardiac myocyte enhancer factor 2a. Moreover, macitentan improved adverse cardiac remodeling, by reducing the stiffer cardiac collagen I and titin n2b expression in the left ventricle of mice with HFpEF. Conclusions These findings indicate that dual ET-A/ET-B receptor inhibition improves HFpEF by abrogating adverse cardiac remodeling via antihypertrophic mechanisms and by reducing stiffness. Additional studies are needed to explore the role of dual ET-1 receptor antagonists in patients with HFpEF. PMID:27810862

  20. Prevalence, Clinical Characteristics, and Outcomes Associated with Eccentric versus Concentric Left Ventricular Hypertrophy In Heart Failure with Preserved Ejection Fraction

    PubMed Central

    Katz, Daniel H.; Beussink, Lauren; Sauer, Andrew J.; Freed, Benjamin H.; Burke, Michael A.; Shah, Sanjiv J.

    2013-01-01

    While concentric remodeling (CR) and concentric hypertrophy (CH) are common forms of left ventricular (LV) remodeling in heart failure with preserved ejection fraction (HFpEF), eccentric hypertrophy (EH) can also occur in these patients. However, clinical characteristics and outcomes of EH have not been well described in HFpEF. We prospectively studied 402 patients with HFpEF, divided into 4 groups based on LV structure: normal geometry (no LV hypertrophy [LVH] and relative wall thickness [RWT] < 0.42); CR (no LVH and RWT > 0.42); CH (LVH and RWT > 0.42); and EH (LVH and RWT < 0.42). We compared clinical, laboratory, echocardiographic, invasive hemodynamic, and outcome data among groups. Of 402 patients, 48 (12%) had EH. Compared to CH, patients with EH had lower systolic blood pressure and less renal impairment despite similar rates of hypertension. After adjustment for covariates, EH was associated with reduced LV contractility compared to CH (lower LVEF [β-coefficient = −3.2; 95% confidence interval (CI) −5.4, −1.1%] and ratio of systolic blood pressure to end-systolic volume [β-coefficient = −1.0; 95% CI −1.5, −0.5 mmHg/ml]). EH was also associated with increased LV compliance compared to CH (LV end-diastolic volume at an idealized LV end-diastolic pressure of 20 mmHg [EDV20] β-coefficient = 14.2;95% CI 9.4, 19.1 ml). Despite these differences, EH and CH had similarly elevated cardiac filling pressures and equivalent adverse outcomes. In conclusion, the presence of EH denotes a distinct subset of HFpEF that is pathophysiologically similar to HF with reduced EF (HFrEF), and may benefit from HFrEF therapy. PMID:23810323

  1. Clinical utility of automated assessment of left ventricular ejection fraction using artificial intelligence-assisted border detection.

    PubMed

    Rahmouni, Hind W; Ky, Bonnie; Plappert, Ted; Duffy, Kevin; Wiegers, Susan E; Ferrari, Victor A; Keane, Martin G; Kirkpatrick, James N; Silvestry, Frank E; St John Sutton, Martin

    2008-03-01

    Ejection fraction (EF) calculated from 2-dimensional echocardiography provides important prognostic and therapeutic information in patients with heart disease. However, quantification of EF requires planimetry and is time-consuming. As a result, visual assessment is frequently used but is subjective and requires extensive experience. New computer software to assess EF automatically is now available and could be used routinely in busy digital laboratories (>15,000 studies per year) and in core laboratories running large clinical trials. We tested Siemens AutoEF software (Siemens Medical Solutions, Erlangen, Germany) to determine whether it correlated with visual estimates of EF, manual planimetry, and cardiac magnetic resonance (CMR). Siemens AutoEF is based on learned patterns and artificial intelligence. An expert and a novice reader assessed EF visually by reviewing transthoracic echocardiograms from consecutive patients. An experienced sonographer quantified EF in all studies using Simpson's method of disks. AutoEF results were compared to CMR. Ninety-two echocardiograms were analyzed. Visual assessment by the expert (R = 0.86) and the novice reader (R = 0.80) correlated more closely with manual planimetry using Simpson's method than did AutoEF (R = 0.64). The correlation between AutoEF and CMR was 0.63, 0.28, and 0.51 for EF, end-diastolic and end-systolic volumes, respectively. The discrepancies in EF estimates between AutoEF and manual tracing using Simpson's method and between AutoEF and CMR preclude routine clinical use of AutoEF until it has been validated in a number of large, busy echocardiographic laboratories. Visual assessment of EF, with its strong correlation with quantitative EF, underscores its continued clinical utility.

  2. Potential clinical impact of cardiovascular magnetic resonance assessment of ejection fraction on eligibility for cardioverter defibrillator implantation

    PubMed Central

    2012-01-01

    Background For the primary prevention of sudden cardiac death, guidelines provide left ventricular ejection fraction (EF) criteria for implantable cardioverter defibrillator (ICD) placement without specifying the technique by which it should be measured. We sought to investigate the potential impact of performing cardiovascular magnetic resonance (CMR) for EF on ICD eligibility. Methods The study population consisted of patients being considered for ICD implantation who were referred for EF assessment by CMR. Patients who underwent CMR within 30 days of echocardiography were included. Echocardiographic EF was determined by Simpson’s biplane method and CMR EF was measured by Simpson’s summation of discs method. Results Fifty-two patients (age 62±15 years, 81% male) had a mean EF of 38 ± 14% by echocardiography and 35 ± 14% by CMR. CMR had greater reproducibility than echocardiography for both intra-observer (ICC, 0.98 vs 0.94) and inter-observer comparisons (ICC 0.99 vs 0.93). The limits of agreement comparing CMR and echocardiographic EF were – 16 to +10 percentage points. CMR resulted in 11 of 52 (21%) and 5 of 52 (10%) of patients being reclassified regarding ICD eligibility at the EF thresholds of 35 and 30% respectively. Among patients with an echocardiographic EF of between 25 and 40%, 9 of 22 (41%) were reclassified by CMR at either the 35 or 30% threshold. Echocardiography identified only 1 of the 6 patients with left ventricular thrombus noted incidentally on CMR. Conclusions CMR resulted in 21% of patients being reclassified regarding ICD eligibility when strict EF criteria were used. In addition, CMR detected unexpected left ventricular thrombus in almost 10% of patients. Our findings suggest that the use of CMR for EF assessment may have a substantial impact on management in patients being considered for ICD implantation. PMID:23043729

  3. The Prognostic Importance of Impaired Systolic Function in Heart Failure with Preserved Ejection Fraction and the Impact of Spironolactone

    PubMed Central

    Shah, Amil M.; Claggett, Brian; Sweitzer, Nancy K.; Shah, Sanjiv J.; Anand, Inder S.; Liu, Li; Pitt, Bertram; Pfeffer, Marc A.; Solomon, Scott D.

    2015-01-01

    Background Impairment in left ventricular (LV) systolic function has been described in heart failure with preserved ejection fraction (HFpEF), but its prognostic relevance is not known. We determined whether LV longitudinal strain (LS) is predictive of cardiovascular (CV) outcomes in HFpEF beyond clinical and conventional echocardiographic measures. Methods and Results LS was assessed by 2D speckle-tracking echocardiography at baseline in 447 HFpEF patients enrolled in the Treatment Of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial. At a median follow-up of 2.6 (IQR 1.5–3.9) years, 115 patients experienced the primary composite outcome of CV death, HF hospitalization, or aborted cardiac arrest. Impaired LS, defined as an absolute LS<15.8%, was present in 52% of patients and was predictive of the composite outcome (adjusted HR 2.14, 95% CI 1.26–3.66; p=0.005), CV death alone (adjusted HR 3.20, 95% CI 1.44–7.12; p=0.004), and HF hospitalization alone (adjusted HR 2.23, 95% CI 1.16–4.28; p=0.016) after adjusting for clinical and conventional echocardiographic variables. LS was the strongest echocardiographic predictor of the composite outcome. Exploratory analysis in a subset of 131 patients with follow-up LS assessed after 12–18 months demonstrated a trend towards improvement in LS associated with spironolactone in patients enrolled in the Americas but not in Russia or Georgia. Conclusions Impaired LV systolic function is a powerful predictor of HF hospitalization, CV death, or aborted cardiac arrest in HFpEF, independent of clinical predictors. Impaired LS represents a novel imaging biomarker to identify HFpEF patients at particularly high risk for CV morbidity and mortality. Clinical Trial Registration Information Clinicaltrials.gov. Identifier NCT00094302. PMID:26130119

  4. Acute hemodynamic effects of inhaled sodium nitrite in pulmonary hypertension associated with heart failure with preserved ejection fraction.

    PubMed

    Simon, Marc A; Vanderpool, Rebecca R; Nouraie, Mehdi; Bachman, Timothy N; White, Pamela M; Sugahara, Masataka; Gorcsan, John; Parsley, Ed L; Gladwin, Mark T

    2016-11-03

    Pulmonary hypertension (PH) is associated with poor outcomes, yet specific treatments only exist for a small subset of patients. The most common form of PH is that associated with left heart disease (Group 2), for which there is no approved therapy. Nitrite has shown efficacy in preclinical animal models of Group 1 and 2 PH, as well as in patients with left heart failure with preserved ejection fraction (HFpEF). We evaluated the safety and efficacy of a potentially novel inhaled formulation of nitrite in PH-HFpEF patients as compared with Group 1 and 3 PH. Cardiopulmonary hemodynamics were recorded after acute administration of inhaled nitrite at 2 doses, 45 and 90 mg. Safety endpoints included change in systemic blood pressure and methemoglobin levels. Responses were also compared with those administered inhaled nitric oxide. Thirty-six patients were enrolled (10 PH-HFpEF, 20 Group 1 pulmonary arterial hypertension patients on background PH-specific therapy, and 6 Group 3 PH). Drug administration was well tolerated. Nitrite inhalation significantly lowered pulmonary, right atrial, and pulmonary capillary wedge pressures, most pronounced in patients with PH-HFpEF. There was a modest decrease in cardiac output and systemic blood pressure. Pulmonary vascular resistance decreased only in Group 3 PH patients. There was substantial increase in pulmonary artery compliance, most pronounced in patients with PH-HFpEF. Inhaled nitrite is safe in PH patients and may be efficacious in PH-HFpEF and Group 3 PH primarily via improvements in left and right ventricular filling pressures and pulmonary artery compliance. The lack of change in pulmonary vascular resistance likely may limit efficacy for Group 1 patients. ClinicalTrials.gov NCT01431313 FUNDING. This work was supported in part by the NIH grants P01HL103455 (to MAS and MTG), R01HL098032 (to MTG), and R01HL096973 (to MTG), and Mast Therapeutics, Inc.

  5. Left ventricular ejection fraction: Single-plane and multiplanar transesophageal echocardiography versus equilibrium gated-pool scintigraphy

    SciTech Connect

    Nessly, M.L.; Bashein, G.; Detmer, P.R.; Graham, M.M.; Kao, R.; Martin, R.W. )

    1991-02-01

    The relative accuracy and precision of estimating left ventricular ejection fraction (EF) in dogs were assessed by two-dimensional transesophageal echocardiography (2D-TEE) and by three-dimensional transesophageal echocardiographic (3D-TEE) imaging and reconstruction. This assessment was accomplished by comparing each echocardiographic method to a gated equilibrium blood pool radionuclide (RN) standard. By using both correlation and regression analysis, 2D-TEE performed reasonably well in estimating RNEF (correlation coefficient (r) = 0.80, slope = 1.01, intercept = 6.37, standard error of the estimate (SEE), 8.98), but not as well as 3D-TEE (r = 0.86, slope = 0.83, intercept = 3.38, SEE, 5.74). Using Altman and Bland's methods of comparison analysis, it was found that 2D-TEE overestimated RNEF by 7% (standard deviation (SD), 8.8). This degree of overestimation was not consistent across the range of measurement. In contrast, 3D-TEE slightly underestimated RNEF by less than 3% and showed less variability (SD, 6.0). The accuracy of the 3D-TEE determinations was not dependent on the magnitude of EF. Additionally, a significantly higher proportion of the 2D-TEE measurements (0.30) compared with the 3D-TEE measurements (0.10) differed from RN values by more than 10% (P = 0.009, McNemar's test). At the clinically important low end of the EF range (RNEF less than or equal to 35%), 2D-TEE may be expected (with 95% confidence) to be within -15% to +28% EF of reference values, whereas 3D-TEE can be expected to be within -8% to +5% EF relative to RN.

  6. Alterations in myostatin expression are associated with changes in cardiac left ventricular mass but not ejection fraction in the mouse.

    PubMed

    Artaza, Jorge N; Reisz-Porszasz, Suzanne; Dow, Joan S; Kloner, Robert A; Tsao, James; Bhasin, Shalender; Gonzalez-Cadavid, Nestor F

    2007-07-01

    Myostatin (Mst) is a negative regulator of skeletal muscle in humans and animals. It is moderately expressed in the heart of sheep and cattle, increasing considerably after infarction. Genetic blockade of Mst expression increases cardiomyocyte growth. We determined whether Mst overexpression in the heart of transgenic mice reduces left ventricular size and function, and inhibits in vitro cardiomyocyte proliferation. Young transgenic mice overexpressing Mst in the heart (Mst transgenic mice (TG) under a muscle creatine kinase (MCK) promoter active in cardiac and skeletal muscle, and Mst knockout (Mst (-/-)) mice were used. Xiscan angiography revealed that the left ventricular ejection fraction did not differ between the Mst TG and the Mst (-/-) mice, when compared with their respective wild-type strains, despite the decrease in whole heart and left ventricular size in Mst TG mice, and their increase in Mst (-/-) animals. The expected changes in cardiac Mst were measured by RT-PCR and western blot. Mst and its receptor (ActRIIb) were detected by RT-PCR in rat H9c2 cardiomyocytes. Transfection of H9c2 with plasmids expressing Mst under muscle-specific creatine kinase promoter, or cytomegalovirus promoter, enhanced p21 and reduced cdk2 expression, when assessed by western blot. A decrease in cell number occurred by incubation with recombinant Mst (formazan assay), without affecting apoptosis or cardiomyocyte size. Anti-Mst antibody increased cardiomyocyte replication, whereas transfection with the Mst-expressing plasmids inhibited it. In conclusion, Mst does not affect cardiac systolic function in mice overexpressing or lacking the active protein, but it reduces cardiac mass and cardiomyocyte proliferation.

  7. Low level exercise echocardiography helps diagnose early stage heart failure with preserved ejection fraction: a study of echocardiography versus catheterization.

    PubMed

    Hammoudi, Nadjib; Laveau, Florent; Helft, Gérard; Cozic, Nathalie; Barthelemy, Olivier; Ceccaldi, Alexandre; Petroni, Thibaut; Berman, Emmanuel; Komajda, Michel; Michel, Pierre-Louis; Mallet, Alain; Le Feuvre, Claude; Isnard, Richard

    2017-03-01

    Increased left ventricular end-diastolic pressure (LVEDP) with exercise is an early sign of heart failure with preserved left ventricular ejection fraction (LVEF). The abnormal exercise increase in LVEDP is nonlinear, with most change occurring at low-level exercise. Data on non-invasive approach of this condition are scarce. Our objective was assessing E/e' to estimate low level exercise LVEDP using a direct invasive measurement as the reference method. Sixty patients with LVEF >50 % prospectively underwent both exercise cardiac catheterization and echocardiography. E/e' was measured at rest and during low-level exercise. Abnormal LVEDP was defined as >16 mmHg. Patients with a history of coronary artery disease and/or abnormal LV morphology were classified as having apparent cardiac disease (CD). Thirty-four (57 %) patients had elevated LVEDP only during exercise. Most of the change in LVEDP occurred since the first exercise level (25 W). There was a correlation between LVEDP and septal E/e' at rest and during exercise. Lateral E/e' and E/average e' ratio had worse correlations with LVEDP. In the whole population, exercise septal E/e' at 25 W had the best accuracy for abnormal exercise LVEDP, area under curve (AUC) = 0.79. However, while low-level exercise septal E/e' had a high accuracy in CD patients (n = 26, AUC = 0.96), E/e' was not linked to LVEDP in patients without CD (n = 34). Low-level exercise septal E/e' is valuable for predicting abnormal exercise LVEDP in patients with preserved LVEF and apparent CD. However, this new diagnosis approach appears not reliable in patients with normal LV morphology and without coronary artery disease. https://clinicaltrials.gov . Unique identifier: NCT01714752.

  8. Echocardiography and invasive hemodynamics during stress testing for diagnosis of heart failure with preserved ejection fraction: an experimental study.

    PubMed

    Leite, Sara; Oliveira-Pinto, José; Tavares-Silva, Marta; Abdellatif, Mahmoud; Fontoura, Dulce; Falcão-Pires, Inês; Leite-Moreira, Adelino F; Lourenço, André P

    2015-06-15

    Inclusion of exercise testing in diagnostic guidelines for heart failure with preserved ejection fraction (HFpEF) has been advocated, but the target population, technical challenges, and underlying pathophysiological complexity raise difficulties to implementation. Hemodynamic stress tests may be feasible alternatives. Our aim was to test Trendelenburg positioning, phenylephrine, and dobutamine in the ZSF1 obese rat model to find echocardiographic surrogates for end-diastolic pressure (EDP) elevation and HFpEF. Seventeen-week-old Wistar-Kyoto, ZSF1 lean, and obese rats (n = 7 each) randomly and sequentially underwent (crossover) Trendelenburg (30°), 5 μg·Kg(-1)·min(-1) dobutamine, and 7.5 μg·Kg(-1)·min(-1) phenylephrine with simultaneous left ventricular (LV) pressure-volume loop and echocardiography evaluation under halogenate anesthesia. Effort testing with maximum O2 consumption (V̇o 2 max) determination was performed 1 wk later. Obese ZSF1 showed lower effort tolerance and V̇o 2 max along with higher resting EDP. Both Trendelenburg and phenylephrine increased EDP, whereas dobutamine decreased it. Significant correlations were found between EDP and 1) peak early filling Doppler velocity of transmitral flow (E) to corresponding myocardial tissue Doppler velocity (E') ratio, 2) E to E-wave deceleration time (E/DT) ratio, and 3) left atrial area (LAA). Diagnostic efficiency of E/DT*LAA by receiver-operating characteristic curve analysis for elevation of EDP above a cut-off of 13 mmHg during hemodynamic stress was high (area under curve, AUC = 0.95) but not higher than that of E/E' (AUC = 0.77, P = 0.15). Results in ZSF1 obese rats suggest that noninvasive echocardiography after hemodynamic stress induced by phenylephrine or Trendelenburg can enhance diagnosis of stable HFpEF and constitute an alternative to effort testing.

  9. Evaluation of myocardial deformation in patients with sickle cell disease and preserved ejection fraction using three-dimensional speckle tracking echocardiography.

    PubMed

    Ahmad, Homaa; Gayat, Etienne; Yodwut, Chattanong; Abduch, M Cristina; Patel, Amit R; Weinert, Lynn; Desai, Ankit; Tsang, Wendy; Garcia, Joe G N; Lang, Roberto M; Mor-Avi, Victor

    2012-09-01

    Sickle cell disease (SCD) is a hemoglobinopathy that affects one in 500 African Americans. Although it is well established that patients with SCD have left ventricular (LV) diastolic dysfunction, it is not clear whether they have subtle LV systolic dysfunction despite preserved ejection fraction (EF). We used three-dimensional speckle tracking echocardiography (3DSTE) to assess changes in both systolic and diastolic LV function in SCD. Transthoracic real time 3D images were obtained (Philips iE33) in 56 subjects, including 28 stable outpatients with SCD (age 33 ± 7 years) and 28 normal controls (age 35 ± 9 years). 3DSTE was performed using prototype software (4DLV Analysis, TomTec) to obtain LV volume and deformation time curves, from which indices of systolic and diastolic LV function were calculated. In SCD patients, 3DSTE-derived LV filling parameters were significantly different from normal controls, reflecting an increase in both rapid and atrial filling volumes and prolonged active relaxation, depicted by a decrease in filling volume fractions at fixed times and an increase in rapid filling duration. Global LV systolic function was not only preserved but increased compared to controls, as reflected by significantly increased global longitudinal strain. Importantly, twist angle and torsion as well as radial and circumferential components of 3D strain were similar in both groups. 3DSTE was able to confirm diastolic dysfunction, as expected in some patients with SCD. However, 3DSTE strain analysis did not reveal any changes in LV systolic function. These findings provide novel insight into the pathophysiology of the cardiovascular complications of SCD. © 2012, Wiley Periodicals, Inc.

  10. [Antiinflammatory activity of extracts and fractions obtained from Physalis peruviana L. calyces].

    PubMed

    Franco, Luis A; Matiz, Germán E; Calle, Jairo; Pinzón, Roberto; Ospina, Luis F

    2007-03-01

    Cape gooseberry calyces (Physalis peruviana) have been used in folk medicine for their medicinal properties including anticancer, antimycobacterial, antipyretic, diuretic, immunomodulatory and antiinflammatory properties. The antiinflammatory effect was evaluated for extracts and fractions obtained from Physalis peruviana calyces in a mice model of acute inflammation. The fractions responsible for antiinflammatory activity were extracted for possible identification. The Physalis peruviana calyces were extracted by percolation with organic solvents. The primary hydroalcoholic fraction was purified by column chromatography. The antiinflammatory effect of extracts and fractions was evaluated using the 12-O-tetradecanoylphorbol-13-acetate-induced mouse model of ear edema. Thirty-eight secondary fractions were obtained by column chromatography of primary hydroalcoholic fraction. Six fractions, evaluated in 12-O-tetradecanoylphorbol-13-acetate-induced inflammation assay, showed significant antiinflammatory activity (p<0.05). The major fraction, Pp-D28-LF, showed a significant dose-dependent response at doses over 250 microg/ear. The antiinflammatory activity attributed to Physalis peruviana calyces was confirmed and validated its use in folk medicine. Fractions responsible for the antiinflammatory action were identified and seem promising for phytomedicinal development. Further studies are needed to isolate and identify the active constituents of these fractions as well as to ascertain the mechanisms involved in the antiinflammatory effect.

  11. One-Year Outcomes After Transcatheter Insertion of an Interatrial Shunt Device for the Management of Heart Failure With Preserved Ejection Fraction

    PubMed Central

    Hasenfuß, Gerd; Neuzil, Petr; Post, Martijn C.; Doughty, Robert; Trochu, Jean-Noël; Kolodziej, Adam; Westenfeld, Ralf; Penicka, Martin; Rosenberg, Mark; Walton, Antony; Muller, David; Walters, Darren; Hausleiter, Jorg; Raake, Philip; Petrie, Mark C.; Bergmann, Martin; Jondeau, Guillaume; Feldman, Ted; van Veldhuisen, Dirk J.; Ponikowski, Piotr; Silvestry, Frank E.; Burkhoff, Dan; Hayward, Christopher

    2016-01-01

    Background— Heart failure with preserved ejection fraction has a complex pathophysiology and remains a therapeutic challenge. Elevated left atrial pressure, particularly during exercise, is a key contributor to morbidity and mortality. Preliminary analyses have demonstrated that a novel interatrial septal shunt device that allows shunting to reduce the left atrial pressure provides clinical and hemodynamic benefit at 6 months. Given the chronicity of heart failure with preserved ejection fraction, evidence of longer-term benefit is required. Methods and Results— Patients (n=64) with left ventricular ejection fraction ≥40%, New York Heart Association class II–IV, elevated pulmonary capillary wedge pressure (≥15 mm Hg at rest or ≥25 mm Hg during supine bicycle exercise) participated in the open-label study of the interatrial septal shunt device. One year after interatrial septal shunt device implantation, there were sustained improvements in New York Heart Association class (P<0.001), quality of life (Minnesota Living with Heart Failure score, P<0.001), and 6-minute walk distance (P<0.01). Echocardiography showed a small, stable reduction in left ventricular end-diastolic volume index (P<0.001), with a concomitant small stable increase in the right ventricular end-diastolic volume index (P<0.001). Invasive hemodynamic studies performed in a subset of patients demonstrated a sustained reduction in the workload corrected exercise pulmonary capillary wedge pressure (P<0.01). Survival at 1 year was 95%, and there was no evidence of device-related complications. Conclusions— These results provide evidence of safety and sustained clinical benefit in heart failure with preserved ejection fraction patients 1 year after interatrial septal shunt device implantation. Randomized, blinded studies are underway to confirm these observations. Clinical Trial Registration— URL: https://www.clinicaltrials.gov. Unique identifier: NCT01913613. PMID:27852653

  12. Assessment of the Relationship between Galectin-3 and Ejection Fraction and Functional Capacity in the Patients with Compensated Systolic Heart Failure

    PubMed Central

    Atabakhshian, Roya; Kazerouni, Faranak; Raygan, Fariba; Amirrasouli, Hushang; Rahimipour, Ali; Shakeri, Nezhat

    2014-01-01

    Background: Galectin-3 is a soluble ß-galactoside–binding lectin released by activated cardiac macrophages. Galectin-3 has been proposed for diagnosis and prognosis of HF patients. Objectives: The present study aimed to investigate the relationship between galectin-3 as a biomarker and ejection fraction and functional capacity in the patients with compensated systolic heart failure. Patients and Methods: In this study, serum levels of Galectin-3 were measured in 76 patients with compensated heart failure with New York Heart Association class I–IV and left ventricular ejection fraction < 45%. Galectin-3 was measured by an ELISA kit. Besides, echocardiography was used to evaluate left ventricular ejection fraction. Additionally, functional capacity was determined based on the patients’ ability to perform a set of activities. After all, the data were analyzed used t-test, Kruskal-Wallis, one–way ANOVA, and chi-square test. P < 0.05 was considered as statistically significant. Results: The patients’ age ranged from 45 to 75 years, with the mean age of 63.85 ± 9 years. In addition 57.9% of the patients were male. The results revealed no significant correlation between Galectin-3 and age, body mass index, and estimated glomerular filtration rate. Also, no significant correlation was observed between Galectin-3 levels and left ventricular ejection fraction (P = 0.166) and functional capacity (P = 0.420). Yet, a significant difference was found between males and females regarding the mean of Galectin-3 (P = 0.039). Conclusions: The study results suggested that Galectin-3 could not be used as a marker of disease progression in the patients under treatment, which could probably be the result of medication use in these patients. PMID:25614856

  13. Assessment of vasodilator therapy in patients with severe congestive heart failure: limitations of measurements of left ventricular ejection fraction and volumes

    SciTech Connect

    Firth, B.G.; Dehmer, G.J.; Markham, R.V. Jr.; Willerson, J.T.; Hillis, L.D.

    1982-11-01

    Although noninvasive techniques are often used to assess the effect of vasodilator therapy in patients with congestive heart failure, it is unknown whether changes in noninvasively determined left ventricular ejection fraction, volume, or dimension reliably reflect alterations in intracardiac pressure and flow. Accordingly, we compared the acute effect of sodium nitroprusside on left ventricular volume and ejection fraction (determined scintigraphically) with its effect on intracardiac pressure and forward cardiac index (determined by thermodilution) in 12 patients with severe, chronic congestive heart failure and a markedly dilated left ventricle. Nitroprusside (infused at 1.3 +/- 1.1 (mean +/- standard deviation) microgram/kg/min) caused a decrease in mean systemic arterial, mean pulmonary arterial, and mean pulmonary capillary wedge pressure as well as a concomitant increase in forward cardiac index. Simultaneously, left ventricular end-diastolic and end-systolic volume indexes decreased, but the scintigraphically determined cardiac index did not change significantly. Left ventricular ejection fraction averaged 0.19 +/- 0.05 before nitroprusside administration and increased by less than 0.05 units in response to nitroprusside in 11 of 12 patients. The only significant correlation between scintigraphically and invasively determined variables was that between the percent change in end-diastolic volume index and the percent change in pulmonary capillary wedge pressure (r . 0.68, p . 0.01). Although nitroprusside produced changes in scintigraphically determined left ventricular ejection fraction, end-systolic volume index, and cardiac index, these alterations bore no predictable relation to changes in intracardiac pressure, forward cardiac index, or vascular resistance. Furthermore, nitroprusside produced a considerably greater percent change in the invasively measured variables than in the scintigraphically determined ones.

  14. Cytostatic activity of some compounds from the unsaponifiable fraction obtained from virgin olive oil.

    PubMed

    Saenz, M T; Garcia, M D; Ahumada, M C; Ruiz, V

    1998-06-30

    Oleuropein, tyrosol, squalene and the fraction of sterols and triterpenoid dialcohols from the unsaponifiable fraction obtained from virgin olive oil have been tested for possible cytostatic activity against McCoy cells, using 6-mercaptopurine as a positive control. The samples of sterols and triterpenic dialcohols showed a strong activity.

  15. In situ expression of Bcl-2 in pulmonary artery endothelial cells associates with pulmonary arterial hypertension relative to heart failure with preserved ejection fraction

    PubMed Central

    Benza, Raymond L.; Williams, Gretchen; Wu, Changgong; Shields, Kelly J.; Raina, Amresh; Murali, Srinivas

    2016-01-01

    Abstract We have previously reported that pulmonary artery endothelial cells (PAECs) can be harvested from the tips of discarded Swan-Ganz catheters after right heart catheterization (RHC). In this study, we tested the hypothesis that the existence of an antiapoptotic phenotype in PAECs obtained during RHC is a distinctive feature of pulmonary arterial hypertension (PAH; World Health Organization group 1) and might be used to differentiate PAH from other etiologies of pulmonary hypertension. Specifically, we developed a flow cytometry-based measure of Bcl-2 activity, referred to as the normalized endothelial Bcl-2 index (NEBI). We report that higher NEBI values are associated with PAH to the exclusion of heart failure with preserved ejection fraction (HFpEF) and that this simple diagnostic measurement is capable of differentiating PAH from HFpEF without presenting addition risk to the patient. If validated in a larger, multicenter study, the NEBI has the potential to assist physicians in the selection of appropriate therapeutic interventions in the common and dangerous scenario wherein patients present a clinical and hemodynamic phenotype that makes it difficult to confidently differentiate between PAH and HFpEF. PMID:28090298

  16. Survival Benefits of Invasive Versus Conservative Strategies in Heart Failure in Patients With Reduced Ejection Fraction and Coronary Artery Disease: A Meta-Analysis.

    PubMed

    Wolff, Georg; Dimitroulis, Dimitrios; Andreotti, Felicita; Kołodziejczak, Michalina; Jung, Christian; Scicchitano, Pietro; Devito, Fiorella; Zito, Annapaola; Occhipinti, Michele; Castiglioni, Battistina; Calveri, Giuseppe; Maisano, Francesco; Ciccone, Marco M; De Servi, Stefano; Navarese, Eliano P

    2017-01-01

    Heart failure with reduced ejection fraction caused by ischemic heart disease is associated with increased morbidity and mortality. It remains unclear whether revascularization by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) carries benefits or risks in this group of stable patients compared with medical treatment. We performed a meta-analysis of available studies comparing different methods of revascularization (PCI or CABG) against each other or medical treatment in patients with coronary artery disease and left ventricular ejection fraction ≤40%. The primary outcome was all-cause mortality; myocardial infarction, revascularization, and stroke were also analyzed. Twenty-one studies involving a total of 16 191 patients were included. Compared with medical treatment, there was a significant mortality reduction with CABG (hazard ratio, 0.66; 95% confidence interval, 0.61-0.72; P<0.001) and PCI (hazard ratio, 0.73; 95% confidence interval, 0.62-0.85; P<0.001). When compared with PCI, CABG still showed a survival benefit (hazard ratio, 0.82; 95% confidence interval, 0.75-0.90; P<0.001). The present meta-analysis indicates that revascularization strategies are superior to medical treatment in improving survival in patients with ischemic heart disease and reduced ejection fraction. Between the 2 revascularization strategies, CABG seems more favorable compared with PCI in this particular clinical setting. © 2017 American Heart Association, Inc.

  17. Patient barriers to implantable cardioverter defibrillator implantation for the primary prevention of sudden cardiac death in patients with heart failure and reduced ejection fraction

    PubMed Central

    Chan, Laura Lihua; Lim, Choon Pin; Aung, Soe Tin; Quetua, Paul; Ho, Kah Leng; Chong, Daniel; Teo, Wee Siong; Sim, David; Ching, Chi Keong

    2016-01-01

    INTRODUCTION Device therapy is efficacious in preventing sudden cardiac death (SCD) in patients with reduced ejection fraction. However, few who need the device eventually opt to undergo implantation and even fewer reconsider their decisions after deliberation. This is due to many factors, including unresolved patient barriers. This study identified the factors that influenced patients’ decision to decline implantable cardioverter defibrillator (ICD) implantation, and those that influenced patients who initially declined an implant to reconsider having one. METHODS A single-centre survey was conducted among 240 patients who had heart failure with reduced ejection fraction and met the ICD implantation criteria, but had declined ICD implantation. RESULTS Participants who refused ICD implantation were mostly male (84%), Chinese (71%), married (72%), currently employed (54%), and had up to primary or secondary education (78%) and monthly income of < SGD 3,000 (51%). Those who were more likely to reconsider their decision were aware that SCD was a consequence of heart failure with reduced ejection fraction, knowledgeable of the preventive role of ICDs, currently employed and aware that their doctor strongly recommended the implant. Based on multivariate analysis, knowledge of the role of ICDs for primary prophylaxis was the most important factor influencing patient decision. CONCLUSION This study identified the demographic and social factors of patients who refused ICD therapy. Knowledge of the role of ICDs in preventing SCD was found to be the strongest marker for reconsidering ICD implantation. Measures to address this information gap may lead to higher rates of ICD implantation. PMID:27075476

  18. Material ejection

    NASA Technical Reports Server (NTRS)

    Webb, David F.; Forbes, Terry G.; Aurass, Henry; Chen, James; Martens, Piet; Rompolt, Bogdan; Rusin, Vojtech; Martin, Sara F.

    1994-01-01

    This paper reviews the major discussions and conclusions of the Flares 22 Workshop concerning the physical processes involved in mass ejecta events, with an emphasis on large-scale phenomena, especially Coronal Mass Ejections (CMEs). New insights have been gained from recent data obtained from the Solar Maximum Mission (SMM) and Yohkoh spacecraft and from several new ground-based radio and optical instruments, as well as from theoretical advances concerning the origins, driving mechanisms and long-term evolution of CMEs.

  19. Material ejection

    NASA Astrophysics Data System (ADS)

    Webb, David F.; Forbes, Terry G.; Aurass, Henry; Chen, James; Martens, Piet; Rompolt, Bogdan; Rusin, Vojtech; Martin, Sara F.

    1994-08-01

    This paper reviews the major discussions and conclusions of the Flares 22 Workshop concerning the physical processes involved in mass ejecta events, with an emphasis on large-scale phenomena, especially Coronal Mass Ejections (CMEs). New insights have been gained from recent data obtained from the Solar Maximum Mission (SMM) and Yohkoh spacecraft and from several new ground-based radio and optical instruments, as well as from theoretical advances concerning the origins, driving mechanisms and long-term evolution of CMEs.

  20. Material ejection

    NASA Technical Reports Server (NTRS)

    Webb, David F.; Forbes, Terry G.; Aurass, Henry; Chen, James; Martens, Piet; Rompolt, Bogdan; Rusin, Vojtech; Martin, Sara F.

    1994-01-01

    This paper reviews the major discussions and conclusions of the Flares 22 Workshop concerning the physical processes involved in mass ejecta events, with an emphasis on large-scale phenomena, especially Coronal Mass Ejections (CMEs). New insights have been gained from recent data obtained from the Solar Maximum Mission (SMM) and Yohkoh spacecraft and from several new ground-based radio and optical instruments, as well as from theoretical advances concerning the origins, driving mechanisms and long-term evolution of CMEs.

  1. Clinical outcomes and cardiovascular responses to exercise training in heart failure patients with preserved ejection fraction: a systematic review and meta-analysis.

    PubMed

    Dieberg, Gudrun; Ismail, Hashbullah; Giallauria, Francesco; Smart, Neil A

    2015-09-15

    Exercise training induces physical adaptations for heart failure patients with systolic dysfunction, but less is known about those patients with preserved ejection fraction. To establish whether exercise training produces changes in peak V̇o2 and related measures, quality of life, general health, and diastolic function in heart failure patients with preserved ejection fraction. We conducted a MEDLINE search (1985 to October 10, 2014), for exercise-based rehabilitation trials in heart failure, using search terms "exercise training, heart failure with preserved ejection fraction, heart failure with normal ejection fraction, peak V̇o₂, and diastolic heart dysfunction". Seven intervention studies were included providing a total of 144 exercising subjects and 114 control subjects, a total of 258 participants. Peak V̇o₂ increased by a mean difference (MD) 2.13 ml·kg(-1)·min(-1) [95% confidence interval (CI) 1.54 to 2.71, P < 0.00001] in exercise training vs. sedentary control, equating to a 17% improvement from baseline. The corresponding data are provided for the following exercise test variables: V̇e/V̇co₂ slope, MD 0.85 ml·kg(-1)·min(-1) (95% CI 0.05 to 1.65, P = 0.04); maximum heart rate, MD 5.60 beats per minute (95% CI 3.95 to 7.25, P < 0.00001); Six-Minute Walk Test, MD 32.1 m (95% CI 17.2 to 47.1, P < 0.0001); and indices of diastolic function: E/A ratio, MD 0.07 (95% CI 0.02 to 0.12, P = 0.005); E/E' ratio MD -2.31 (95% CI -3.44 to -1.19, P < 0.0001); deceleration time (DT), MD -13.2 ms (95% CI -19.8 to -6.5, P = 0.0001); and quality of life: Minnesota Living with Heart Failure Questionnaire, MD -6.50 (95% CI -9.47 to -3.53, P < 0.0001); and short form-36 health survey (physical dimension), MD 15.6 (95% CI 7.4 to 23.8, P = 0.0002). In 3,744 h patient-hours of training, not one death was directly attributable to exercise. Exercise training appears to effect several health-related improvements in people with heart failure and preserved ejection

  2. Relation of Carotid Artery Diameter With Cardiac Geometry and Mechanics in Heart Failure With Preserved Ejection Fraction

    PubMed Central

    Liao, Zhen‐Yu; Peng, Ming‐Cheng; Yun, Chun‐Ho; Lai, Yau‐Huei; Po, Helen L.; Hou, Charles Jia‐Yin; Kuo, Jen‐Yuan; Hung, Chung‐Lieh; Wu, Yih‐Jer; Bulwer, Bernard E.; Yeh, Hung‐I; Tsai, Cheng‐Ho

    2012-01-01

    Background Central artery dilation and remodeling are associated with higher heart failure and cardiovascular risks. However, data regarding carotid artery diameter from hypertension to heart failure have remained elusive. We sought to investigate this issue by examining the association between carotid artery diameter and surrogates of ventricular dysfunction. Methods and Results Two hundred thirteen consecutive patients including 49 with heart failure and preserved ejection fraction (HFpEF), 116 with hypertension, and an additional 48 healthy participants underwent comprehensive echocardiography and tissue Doppler imaging. Ultrasonography of the common carotid arteries was performed for measurement of intima‐media thickness and diameter (CCAD). Cardiac mechanics, including LV twist, were assessed by novel speckle‐tracking software. A substantial graded enlargement of CCAD was observed across all 3 groups (6.8±0.6, 7.7±0.73, and 8.7±0.95 mm for normal, hypertension, and HFpEF groups, respectively; ANOVA P<0.001) and correlated with serum brain natriuretic peptide level (R2=0.31, P<0.001). Multivariable models showed that CCAD was associated with increased LV mass, LV mass‐to‐volume ratio (β‐coefficient=10.9 and 0.11, both P<0.001), reduced LV longitudinal and radial strain (β‐coeffficient=0.81 and −3.1, both P<0.05), and twist (β‐coefficient=−0.84, P<0.05). CCAD set at 8.07 mm as a cut‐off had a 77.6% sensitivity, 82.3% specificity, and area under the receiver operating characteristic curves (AUROC) of 0.86 (95% CI 0.80 to 0.92) in discriminating HFpEF. In addition, CCAD superimposed on myocardial deformation significantly expanded AUROC (for longitudinal strain, from 0.84 to 0.90, P of ΔAUROC=0.02) in heart failure discrimination models. Conclusions Increased carotid artery diameter is associated with worse LV geometry, higher brain natriuretic peptide level, and reduced contractile mechanics in individuals with HFpEF. PMID:23316319

  3. Skeletal muscle composition and its relation to exercise intolerance in older patients with heart failure and preserved ejection fraction.

    PubMed

    Haykowsky, Mark J; Kouba, Erik J; Brubaker, Peter H; Nicklas, Barbara J; Eggebeen, Joel; Kitzman, Dalane W

    2014-04-01

    Exercise intolerance is the primary chronic symptom in heart failure with preserved ejection fraction (HFpEF), the most common form of heart failure in older patients; however its pathophysiology is not well understood. Recent data suggest that peripheral factors such as skeletal muscle (SM) dysfunction may be important contributors. Therefore, 38 participants, 23 patients with HFpEF (69±7 years) and 15 age-matched healthy controls (HCs), underwent magnetic resonance imaging and cardiopulmonary exercise testing to assess for SM, intermuscular fat (IMF), subcutaneous fat, total thigh, and thigh compartment (TC) areas and peak exercise oxygen consumption (peak VO2). There were no significant intergroup differences in total thigh area, TC, subcutaneous fat, or SM. However, in the HFpEF versus HC group, IMF area (35.6±11.5 vs 22.3±7.6 cm2, p=0.01), percent IMF/TC (26±5 vs 20±5%, p=0.005), and the ratio of IMF/SM (0.38±0.10 vs 0.28±0.09, p=0.007) were significantly increased, whereas percent SM/TC was significantly reduced (70±5 vs 75±5, p=0.009). In multivariate analyses, IMF area (partial r=-0.51, p=0.002) and IMF/SM ratio (partial r=-0.45, p=0.006) were independent predictors of peak VO2 whereas SM area was not (partial r = -0.14, p=0.43). Thus, older patients with HFpEF have greater thigh IMF and IMF/SM ratio compared with HCs, and these are significantly related to their severely reduced peak VO2. These data suggest that abnormalities in SM composition may contribute to the severely reduced exercise capacity in older patients with HFpEF. This implicates potential targets for novel therapeutic strategies in this common debilitating disorder of older persons. Copyright © 2014 Elsevier Inc. All rights reserved.

  4. Impaired relaxation despite upregulated calcium-handling protein atrial myocardium from type 2 diabetic patients with preserved ejection fraction.

    PubMed

    Lamberts, Regis R; Lingam, Shivanjali J; Wang, Heng-Yu; Bollen, Ilse A E; Hughes, Gillian; Galvin, Ivor F; Bunton, Richard W; Bahn, Andrew; Katare, Rajesh; Baldi, J Chris; Williams, Michael J A; Saxena, Pankaj; Coffey, Sean; Jones, Peter P

    2014-04-05

    Diastolic dysfunction is a key factor in the development and pathology of cardiac dysfunction in diabetes, however the exact underlying mechanism remains unknown, especially in humans. We aimed to measure contraction, relaxation, expression of calcium-handling proteins and fibrosis in myocardium of diabetic patients with preserved systolic function. Right atrial appendages from patients with type 2 diabetes mellitus (DM, n = 20) and non-diabetic patients (non-DM, n = 36), all with preserved ejection fraction and undergoing coronary artery bypass grafting (CABG), were collected. From appendages, small cardiac muscles, trabeculae, were isolated to measure basal and β-adrenergic stimulated myocardial function. Expression levels of calcium-handling proteins, sarcoplasmic reticulum Ca2+ ATPase (SERCA2a) and phospholamban (PLB), and of β1-adrenoreceptors were determined in tissue samples by Western blot. Collagen deposition was determined by picro-sirius red staining. In trabeculae from diabetic samples, contractile function was preserved, but relaxation was prolonged (Tau: 74 ± 13 ms vs. 93 ± 16 ms, non-DM vs. DM, p = 0.03). The expression of SERCA2a was increased in diabetic myocardial tissue (0.75 ± 0.09 vs. 1.23 ± 0.15, non-DM vs. DM, p = 0.007), whereas its endogenous inhibitor PLB was reduced (2.21 ± 0.45 vs. 0.42 ± 0.11, non-DM vs. DM, p = 0.01). Collagen deposition was increased in diabetic samples. Moreover, trabeculae from diabetic patients were unresponsive to β-adrenergic stimulation, despite no change in β1-adrenoreceptor expression levels. Human type 2 diabetic atrial myocardium showed increased fibrosis without systolic dysfunction but with impaired relaxation, especially during β-adrenergic challenge. Interestingly, changes in calcium-handling protein expression suggests accelerated active calcium re-uptake, thus improved relaxation, indicating a compensatory calcium-handling mechanism in diabetes

  5. Impaired relaxation despite upregulated calcium-handling protein atrial myocardium from type 2 diabetic patients with preserved ejection fraction

    PubMed Central

    2014-01-01

    Background Diastolic dysfunction is a key factor in the development and pathology of cardiac dysfunction in diabetes, however the exact underlying mechanism remains unknown, especially in humans. We aimed to measure contraction, relaxation, expression of calcium-handling proteins and fibrosis in myocardium of diabetic patients with preserved systolic function. Methods Right atrial appendages from patients with type 2 diabetes mellitus (DM, n = 20) and non-diabetic patients (non-DM, n = 36), all with preserved ejection fraction and undergoing coronary artery bypass grafting (CABG), were collected. From appendages, small cardiac muscles, trabeculae, were isolated to measure basal and β-adrenergic stimulated myocardial function. Expression levels of calcium-handling proteins, sarcoplasmic reticulum Ca2+ ATPase (SERCA2a) and phospholamban (PLB), and of β1-adrenoreceptors were determined in tissue samples by Western blot. Collagen deposition was determined by picro-sirius red staining. Results In trabeculae from diabetic samples, contractile function was preserved, but relaxation was prolonged (Tau: 74 ± 13 ms vs. 93 ± 16 ms, non-DM vs. DM, p = 0.03). The expression of SERCA2a was increased in diabetic myocardial tissue (0.75 ± 0.09 vs. 1.23 ± 0.15, non-DM vs. DM, p = 0.007), whereas its endogenous inhibitor PLB was reduced (2.21 ± 0.45 vs. 0.42 ± 0.11, non-DM vs. DM, p = 0.01). Collagen deposition was increased in diabetic samples. Moreover, trabeculae from diabetic patients were unresponsive to β-adrenergic stimulation, despite no change in β1-adrenoreceptor expression levels. Conclusions Human type 2 diabetic atrial myocardium showed increased fibrosis without systolic dysfunction but with impaired relaxation, especially during β-adrenergic challenge. Interestingly, changes in calcium-handling protein expression suggests accelerated active calcium re-uptake, thus improved relaxation, indicating a compensatory

  6. Risk of Heart Failure With Preserved Ejection Fraction in Older Women After Contemporary Radiotherapy for Breast Cancer.

    PubMed

    Saiki, Hirofumi; Petersen, Ivy A; Scott, Christopher G; Bailey, Kent R; Dunlay, Shannon M; Finley, Randi R; Ruddy, Kathryn J; Yan, Elizabeth; Redfield, Margaret M

    2017-04-11

    Cardiomyocytes are resistant to radiation. However, cardiac radiation exposure causes coronary microvascular endothelial inflammation, a perturbation implicated in the pathogenesis of heart failure (HF) and particularly HF with preserved ejection fraction (HFpEF). Radiotherapy for breast cancer results in variable cardiac radiation exposure and may increase the risk of HF. We conducted a population-based case-control study of incident HF in 170 female residents of Olmsted County, Minnesota (59 cases and 111 controls), who underwent contemporary (1998-2013) radiotherapy for breast cancer with computed tomography-assisted radiotherapy planning. Controls were matched to cases for age, tumor side, chemotherapy use, diabetes mellitus, and hypertension. Mean cardiac radiation dose (MCRD) in each patient was calculated from the patient's computed tomography images and radiotherapy plan. Mean age at radiotherapy was 69±9 years. Of HF cases, 38 (64%) had EF≥50% (HFpEF), 18 (31%) had EF<50% (HF with reduced EF), and 3 (5%) did not have EF measured. The EF was ≥40% in 50 of the 56 HF cases (89%) with an EF measurement. The mean interval from radiotherapy to HF was 5.8±3.4 years. The odds of HF was higher in patients with a history of ischemic heart disease or atrial fibrillation. The MCRD was 2.5 Gy (range, 0.2-13.1 Gy) and higher in cases (3.3±2.7 Gy) than controls (2.1±2.0 Gy; P=0.004). The odds ratio (95% confidence interval) for HF per log MCRD was 9.1 (3.4-24.4) for any HF, 16.9 (3.9-73.7) for HFpEF, and 3.17 (0.8-13.0) for HF with reduced EF. The increased odds of any HF or HFpEF with increasing MCRD remained significant after adjustment for HF risk factors and in sensitivity analyses matching by cancer stage rather than tumor side. Only 18.6% of patients experienced new or recurrent ischemic events between radiotherapy and the onset of HF. The relative risk of HFpEF increases with increasing cardiac radiation exposure during contemporary conformal breast cancer

  7. Cost-effectiveness of sacubitril/valsartan versus enalapril in patients with heart failure and reduced ejection fraction.

    PubMed

    Lin, Liang; Bin-Chia Wu, David; Aziz, Mohamed Ismail Abdul; Wong, Raymond; Sim, David; Leong, Kui Toh Gerard; Wei, Yong Quek; Tan, Doreen; Ng, Kwong

    2017-09-29

    Sacubitril/valsartan reduces cardiovascular death and hospitalisations for heart failure (HF). However, decision-makers need to determine whether its benefits are worth the additional costs, given the low-cost generic status of traditional standard of care. To evaluate the cost-effectiveness of sacubitril/valsartan compared to enalapril in patients with HF and reduced ejection fraction, from the Singapore healthcare payer perspective. A Markov model was developed to project clinical and economic outcomes of sacubitril/valsartan versus enalapril for 66-year-old patients with HF over 10 years. Key health states included New York Heart Association classes I to IV and deaths; patients in each state incurred a monthly risk of hospitalisation for HF and cardiovascular death. Sacubitril/valsartan benefits were modelled by applying the hazard ratios (HRs) in PARADIGM-HF trial to baseline probabilities. Primary model outcomes were total and incremental costs and quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio (ICER) for sacubitril/valsartan relative to enalapril Results: Compared to enalapril, sacubitril/valsartan was associated with an ICER of SGD 74,592 (USD 55,198) per QALY gained. A major driver of cost-effectiveness was the cardiovascular mortality benefit of sacubitril/valsartan. The uncertainty of this treatment benefit in Asian subgroup was tested in sensitivity analyses using a HR of 1 as upper limit, where the ICERs ranged from SGD 41,019 (USD 30,354) to SGD 1,447,103 (USD 1,070,856) per QALY gained. Probabilistic sensitivity analyses showed the probability of sacubitril/valsartan being cost-effective was below 1%, 12%, and 71% at SGD 20,000, SGD 50,000, and SGD 100,000 per QALY gained, respectively. At current daily price of SGD 9.00, sacubitril/valsartan may not represent good value for limited healthcare dollars compared to enalapril in reducing cardiovascular morbidity and mortality in HF in Singapore healthcare setting. This

  8. Pharmacodynamic and Pharmacokinetic Profiles of Sacubitril/Valsartan (LCZ696) in Patients with Heart Failure and Reduced Ejection Fraction.

    PubMed

    Kobalava, Zhanna; Kotovskaya, Yulia; Averkov, Oleg; Pavlikova, Elena; Moiseev, Valentine; Albrecht, Diego; Chandra, Priya; Ayalasomayajula, Surya; Prescott, Margaret F; Pal, Parasar; Langenickel, Thomas H; Jordaan, Pierre; Rajman, Iris

    2016-08-01

    Concomitant renin-angiotensin-aldosterone system blockade and natriuretic peptide system enhancement may provide unique therapeutic benefits to patients with heart failure and reduced ejection fraction (HFrEF). This study assessed the pharmacodynamics and pharmacokinetics of LCZ696 in patients with HFrEF. This was an open-label, noncontrolled single-sequence study. After a 24-h run-in period, patients (n = 30) with HFrEF (EF ≤ 40%; NYHA class II-IV) received LCZ696 100 mg twice daily (bid) for 7 days and 200 mg bid for 14 days, along with standard treatment for heart failure (HF) (except angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers [ARBs]). On Day 21, significant increases were observed in the plasma biomarkers indicative of neprilysin and RAAS inhibition (ratio-to-baseline: cyclic guanosine monophosphate [cGMP], 1.38; renin concentration and activity, 3.50 and 2.27, respectively; all, P < 0.05). Plasma NT-proBNP levels significantly decreased at all the time points on Days 7 and 21; plasma aldosterone and endothelin-1 levels significantly decreased on Day 21 (all, P < 0.05). Following administration of LCZ696, the Cmax of sacubitril (neprilysin inhibitor prodrug), LBQ657 (active neprilysin inhibitor), and valsartan were reached within 0.5, 2.5, and 2 h. Between 100- and 200-mg doses, the Cmax and AUC0-12 h for sacubitril and LBQ657 were approximately dose-proportional while that of valsartan was less than dose-proportional. Treatment with LCZ696 for 21 days was well tolerated and resulted in plasma biomarker changes indicative of neprilysin and RAAS inhibition in patients with HF. The pharmacokinetic exposure of the LCZ696 analytes in patients with HF observed in this study is comparable to that observed in the pivotal Phase III study. © 2016 John Wiley & Sons Ltd.

  9. Response to Endurance Exercise Training in Older Adults with Heart Failure with Preserved or Reduced Ejection Fraction.

    PubMed

    Pandey, Ambarish; Kitzman, Dalane W; Brubaker, Peter; Haykowsky, Mark J; Morgan, Timothy; Becton, J Thomas; Berry, Jarett D

    2017-08-01

    To systematically examine the relative magnitude and predictors of responses to exercise training in older adult with heart failure (HF) with reduced ejection fraction (HFrEF), and preserved EF (HFpEF). Secondary analysis of a randomized controlled trial. Outpatient cardiac rehabilitation program. Individuals with HF (24 HFrEF, 24 HFpEF) who underwent supervised exercise training. The study included individual-level data from the exercise training arms of a randomized controlled trial that evaluated the effect of 16 weeks of supervised moderate-intensity endurance exercise training in older adults with chronic, stable HFpEF and HFrEF. Changes in peak oxygen uptake (VO2peak ) in response to supervised training in individuals with HFpEF were compared with that of individuals with HFrEF. The significant clinical predictors of changes in VO2peak with exercise training were assessed using univariate and multivariate regression models. Training-related improvement in VO2peak was higher in participants with HFpEF than in those with HFrEF (change: 18.7 ± 17.6% vs -0.3 ± 15.4%, P < .001). In univariate analysis, echocardiographic abnormalities in left ventricular structure and function and lower body mass index were associated with blunted response of VO2peak with exercise training. In multivariate regression analysis using stepwise selection, submaximal exercise systolic blood pressure, and resting early deceleration time were independent predictors of change in VO2peak . The change in VO2peak in response to endurance exercise training in older adults with HF differs significantly according to HF subtype, with greater VO2peak improvement in HFpEF than HFrEF. These results suggest that the current Centers for Medicare and Medicaid Services policy excluding individuals with HFpEF from reimbursement from cardiac rehabilitation may need to be revisited. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

  10. The Effect of Cardiac Rehabilitation Exercise Training on Cardiopulmonary Function in Ischemic Cardiomyopathy With Reduced Left Ventricular Ejection Fraction

    PubMed Central

    2016-01-01

    Objective To observe the effect and safety of cardiac rehabilitation (CR) exercise in ischemic cardiomyopathy and to compare the results between patients with preserved left ventricular ejection fraction (LVEF) and reduced LVEF. Methods Patients with ischemic cardiomyopathy with LVEF <50% were included as subjects. The patients were classified into the preserved LVEF (pLVEF; LVEF 41%–49%) group and the reduced LVEF (rLVEF; LVEF ≤40%) group. Patients underwent hourly aerobic exercise training sessions with an intensity of 60%–85% of heart rate reserve, three times a week for 6 weeks. Graded exercise test and transthoracic echocardiogram were performed in all study patients before and after completion of the CR exercise program. Results After completion of the CR exercise program, both groups (pLVEF, n=30; rLVEF, n=18) showed significant increases in LVEF and VO2max. In the pLVEF group, LVEF and VO2max increased from 45.1%±4.8% to 52.5%±9.6% (p<0.001) and from 24.1±6.3 to 28.1±8.8 mL/kg/min (p=0.002), respectively. In the rLVEF group, LVEF and VO2max increased from 29.7%±7.7% to 37.6%±10.3% (p<0.001) and from 17.6±4.7 to 21.2±5.1 mL/kg/min (p<0.001), respectively. Both groups completed their exercise program safely. Conclusion In both groups, patients with ischemic cardiomyopathy who completed a 6-week supervised CR exercise program demonstrated remarkable improvements in cardiopulmonary function. This result implies that neither of the two groups showed higher efficacy in comparison to each other, but we can conclude that CR exercise in the rLVEF group was as effective and safe as that in the pLVEF group. PMID:27606271

  11. Comparisons of Noninvasive Methods Used to Assess Exercise Stroke Volume in Heart Failure with Preserved Ejection Fraction.

    PubMed

    VAN Iterson, Erik H; Olson, Thomas P; Borlaug, Barry A; Johnson, Bruce D; Snyder, Eric M

    2017-09-01

    Cardiopulmonary exercise testing (CPET) plays an important role in properly phenotyping signs and symptoms of heart failure with preserved ejection fraction (HFpEF). The prognostic value of CPET is strengthened when accompanied by cardiac hemodynamic measurements. Although recognized as the "gold" standard, cardiac catheterization is impractical for routine CPET. Thus, advancing the scientific/methodologic understanding of noninvasive techniques for exercise cardiac hemodynamic assessment is clinically impactful in HFpEF. This study tested the concurrent validity of noninvasive acetylene gas (C2H2) uptake, echocardiography (ECHO), and oxygen pulse (O2pulse) for measuring/predicting exercise stroke volume (SV) in HFpEF. Eighteen white HFpEF and 18 age-/sex-matched healthy controls participated in upright CPET (ages, 69 ± 9 yr vs 63 ± 9 yr). At rest, 20 W, and peak exercise, SV was measured at steady-state via C2H2 rebreathe (SVACET) and ECHO (SVECHO), whereas O2pulse was derived (=V˙O2/HR). Resting relationships between SVACET and SVECHO, SVECHO and O2pulse, or SVACET and O2pulse were significant in HFpEF (R = 0.30, 0.36, 0.67), but not controls (R = 0.07, 0.01, 0.09), respectively. Resting relationships persisted to 20 W in HFpEF (R = 0.70, 0.53, 0.70) and controls (R = 0.05, 0.07, 0.21), respectively. Peak exercise relationships were significant in HFpEF (R = 0.62, 0.24, 0.64), but only for SVACET versus O2pulse in controls (R = 0.07, 0.04, 0.33), respectively. Standardized standard error of estimate between techniques was strongest in HFpEF at 20 W: SVACET versus SVECHO = 0.57 ± 0.22; SVECHO versus O2pulse = 0.71 ± 0.28; SVACET versus O2pulse = 0.56 ± 0.22. Constituting a clinically impactful step towards construct validation testing, these data suggest SVACET, SVECHO, and O2pulse demonstrate moderate-to-strong concurrent validity for measuring/predicting exercise SV in HFpEF.

  12. Aldosterone Antagonists and Outcomes in Real-World Older Patients with Heart Failure and Preserved Ejection Fraction

    PubMed Central

    Patel, Kanan; Fonarow, Gregg C.; Kitzman, Dalane W.; Aban, Inmaculada B.; Love, Thomas E.; Allman, Richard M.; Gheorghiade, Mihai; Ahmed, Ali

    2013-01-01

    Objectives The purpose of this study was to examine the clinical effectiveness of aldosterone antagonists in older patients with heart failure and preserved ejection fraction (HF-PEF). Background Aldosterone antagonists improve outcomes in HF and reduced EF. However, their role in HF-PEF remains unclear. Methods Of the 10,570 hospitalized older (age ≥65 years) HF-PEF (EF ≥40%) patients in Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) trial, 8013 had no prior aldosterone antagonist use and no current contraindications, of whom 492 (6% of 8013) received new prescriptions for aldosterone antagonists. We assembled a matched cohort of 487 pairs of patients receiving and not receiving aldosterone antagonists, who had similar propensity to receive these drugs, and were balanced on 116 baseline characteristics. Results Patients had a mean age of 80 years, a mean EF of 54%, 59% were women, and 8% were African American. During 2.4 year of mean follow-up (through December, 2008), the primary composite endpoint of all-cause mortality or HF hospitalization occurred in 392 (81%) and 393 (81%) patients receiving and not receiving aldosterone antagonists, respectively (hazard ratio {HR}, 0.97; 95% confidence interval {CI}, 0.84–1.11; p=0.628). Aldosterone antagonists had no association with all-cause mortality (HR, 1.03; 95% CI, 0.89–1.20; p=0.693) or HF hospitalization (HR, 0.88; 95% CI, 0.73–1.07; p=0.188). Among 8013 pre-match patients, multivariable-adjusted HR for primary composite endpoint associated with aldosterone antagonist use was 0.93 (95% CI, 0.83–1.03; p=0.144). Conclusions In older HF-PEF patients, aldosterone antagonists had no association with clinical outcomes. Findings from the ongoing randomized controlled TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) trial will provide further insights into their effect in HF-PEF. PMID

  13. Impact of Ejection Fraction and Aortic Valve Gradient on Outcomes of Transcatheter Aortic Valve Replacement.

    PubMed

    Baron, Suzanne J; Arnold, Suzanne V; Herrmann, Howard C; Holmes, David R; Szeto, Wilson Y; Allen, Keith B; Chhatriwalla, Adnan K; Vemulapali, Sreekaanth; O'Brien, Sean; Dai, Dadi; Cohen, David J

    2016-05-24

    In patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), studies have suggested that reduced left ventricular (LV) ejection fraction (LVEF) and low aortic valve gradient (AVG) are associated with worse long-term outcomes. Because these conditions commonly coexist, the extent to which they are independently associated with outcomes after TAVR is unknown. The purpose of this study was to evaluate the impact of LVEF and AVG on clinical outcomes after TAVR and to determine whether the effect of AVG on outcomes is modified by LVEF. Using data from 11,292 patients who underwent TAVR as part of the Transcatheter Valve Therapies Registry, we examined rates of 1-year mortality and recurrent heart failure in patients with varying levels of LV dysfunction (LVEF <30% vs. 30% to 50% vs. >50%) and AVG (<40 mm Hg vs. ≥40 mm Hg). Multivariable models were used to estimate the independent effect of AVG and LVEF on outcomes. During the first year of follow-up after TAVR, patients with LV dysfunction and low AVG had higher rates of death and recurrent heart failure. After adjustment for other clinical factors, only low AVG was associated with higher mortality (hazard ratio: 1.21; 95% confidence interval: 1.11 to 1.32; p < 0.001) and higher rates of heart failure (hazard ratio: 1.52; 95% confidence interval: 1.36 to 1.69; p <0.001), whereas the effect of LVEF was no longer significant. There was no evidence of effect modification between AVG and LVEF with respect to either endpoint. In this series of real-world patients undergoing TAVR, low AVG, but not LV dysfunction, was associated with higher rates of mortality and recurrent heart failure. Although these findings suggest that AVG should be considered when evaluating the risks and benefits of TAVR for individual patients, neither severe LV dysfunction nor low AVG alone or in combination provide sufficient prognostic discrimination to preclude treatment with TAVR. Copyright © 2016 American

  14. Dementia-related adverse events in PARADIGM-HF and other trials in heart failure with reduced ejection fraction.

    PubMed

    Cannon, Jane A; Shen, Li; Jhund, Pardeep S; Kristensen, Søren L; Køber, Lars; Chen, Fabian; Gong, Jianjian; Lefkowitz, Martin P; Rouleau, Jean L; Shi, Victor C; Swedberg, Karl; Zile, Michael R; Solomon, Scott D; Packer, Milton; McMurray, John J V

    2017-01-01

    Inhibition of neprilysin, an enzyme degrading natriuretic and other vasoactive peptides, is beneficial in heart failure with reduced ejection fraction (HFrEF), as shown in PARADIGM-HF which compared the angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril/valsartan with enalapril. As neprilysin is also one of many enzymes clearing amyloid-β peptides from the brain, there is a theoretical concern about the long-term effects of sacubitril/valsartan on cognition. Therefore, we have examined dementia-related adverse effects (AEs) in PARADIGM-HF and placed these findings in the context of other recently conducted HFrEF trials. In PARADIGM-HF, patients with symptomatic HFrEF were randomized to sacubitril/valsartan 97/103 mg b.i.d. or enalapril 10 mg b.i.d. in a 1:1 ratio. We systematically searched AE reports, coded using the Medical Dictionary for Regulatory Activities (MedDRA), using Standardized MedDRA Queries (SMQs) with 'broad' and 'narrow' preferred terms related to dementia. In PARADIGM-HF, 8399 patients aged 18-96 years were randomized and followed for a median of 2.25 years (up to 4.3 years). The narrow SMQ search identified 27 dementia-related AEs: 15 (0.36%) on enalapril and 12 (0.29%) on sacubitril/valsartan [hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.33-1.59]. The broad search identified 97 (2.30%) and 104 (2.48%) AEs (HR 1.01, 95% CI 0.75-1.37), respectively. The rates of dementia-related AEs in both treatment groups in PARADIGM-HF were similar to those in three other recent trials in HFrEF. We found no evidence that sacubitril/valsartan, compared with enalapril, increased dementia-related AEs, although longer follow-up may be necessary to detect such a signal and more sensitive tools are needed to detect lesser degrees of cognitive impairment. Further studies to address this question are warranted. © 2016 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of

  15. Adenosine receptor expression in an experimental animal model of myocardial infarction with preserved left ventricular ejection fraction.

    PubMed

    Cabiati, Manuela; Martino, Alessandro; Mattii, Letizia; Caselli, Chiara; Prescimone, Tommaso; Lionetti, Vincenzo; Morales, Maria-Aurora; Del Ry, Silvia

    2014-07-01

    Adenosine, a purine nucleoside and a "retaliatory metabolite" in ischemia, is ubiquitous in the body and increases 100-fold during ischemia. Its biological actions are mediated by four adenosine receptors (ARs): A(1), A(2A), A(2B) and A(3). The aim of this study was to determine possible myocardial alterations in AR expression in an experimental animal model of myocardial infarction (MI) with a preserved left ventricular (LV) ejection fraction. LV tissue was collected from sexually mature male farm pigs with MI (n = 6) induced by permanent surgical ligation of the left anterior descending coronary artery and from five healthy pigs (C). mRNA expression of A(1)R, A(2A)R, A(2B)R, A(3)R and TNF-α was determined by real-time PCR in tissue collected from border (BZ) and remote zones (RZ) of the infarcted area and from LV of C. BZ, RZ and samples of C were stained immunohistochemically to investigate A(3)R immunoreaction. After 4 weeks a different regulation of ARs was observed. A(1)R mRNA expression was significantly lower in the infarct regions than in controls (C = 0.75 ± 0.2, BZ = 0.05 ± 0.2, RZ = 0.07 ± 0.02 p = 0.0025, p = 0.0016, C vs. BZ and RZ, respectively). Conversely A(3)R was higher in infarct areas (C = 0.94 ± 0.2, BZ = 2.85 ± 0.5, RZ = 3.48 ± 1.0, p = 0.048 C vs. RZ). No significant differences were observed for A(2A)R (C = 1.58 ± 0.6, BZ = 0.42 ± 0.1, RZ = 1.37 ± 0.6) and A(2B)R (C = 1.66 ± 0.2, BZ = 1.54 ± 0.5, RZ = 1.25 ± 0.4). A(3)R expression was confirmed by immunohistochemical analysis and was principally localized in cardiomyocytes. TNF-α mRNA results were: C 0.41 ± 0.25; BZ 1.60 ± 0.19; RZ 0.17 ± 0.04. The balance between A(1)R and A(3)R as well as between A(2A)R and A(2B)R was consistent with adaptative retaliatory anti-ischemic adenosinergic changes in the infarcted heart with preserved LV function.

  16. Assessment of Left Ventricular Ejection Fraction Calculation on Long-axis Views From Cardiac Magnetic Resonance Imaging in Patients With Acute Myocardial Infarction

    PubMed Central

    Huttin, Olivier; Petit, Marie-Anaïs; Bozec, Erwan; Eschalier, Romain; Juillière, Yves; Moulin, Frédéric; Lemoine, Simon; Selton-Suty, Christine; Sadoul, Nicolas; Mandry, Damien; Beaumont, Marine; Felblinger, Jacques; Girerd, Nicolas; Marie, Pierre-Yves

    2015-01-01

    Abstract To assess left ventricular ejection fraction (LVEF) accurately, cardiac magnetic resonance (CMR) can be indicated and lays on the evaluation of multiple slices of the left ventricle in short axis (CMRSAX). The objective of this study was to assess another method consisting of the evaluation of 2 long-axis slices (CMRLAX) for LVEF determination in acute myocardial infarction. One hundred patients underwent CMR 2 to 4 days after acute myocardial infarction. LVEF was computed by the area-length method on horizontal and vertical CMRLAX images. Those results were compared to reference values obtained on contiguous CMRSAX images in one hand, and to values obtained from transthoracic echocardiography (TTE) in the other hand. For CMRSAX and TTE, LVEF was computed with Simpson method. Reproducibility of LVEF measurements was additionally determined. The accuracy of volume measurements was assessed against reference aortic stroke volumes obtained by phase-contrast MR imaging. LVEF from CMRLAX had a mean value of 47 ± 8% and were on average 5% higher than reference LVEF from CMRSAX (42 ± 8%), closer to routine values from TTELAX (49 ± 8%), much better correlated with the reference LVEF from CMRSAX (R = 0.88) than that from TTE (R = 0.58), obtained with a higher reproducibility than with the 2 other techniques (% of interobserver variability: CMRLAX 5%, CMRSAX 11%, and TTE 13%), and obtained with 4-fold lower recording and calculation times than for CMRSAX. Apart from this, CMRLAX stroke volume was well correlated with phase-contrast values (R = 0.81). In patients with predominantly regional contractility abnormalities, the determination of LVEF by CMRLAX is twice more reproducible than the reference CMRSAX method, even though the LVEF is consistently overestimated compared with CMRSAX. However, the CMRLAX LVEF determination provides values closer to TTE measurements, the most available and commonly used method in clinical practice, clinical

  17. microRNA-21 promotes cardiac fibrosis and development of heart failure with preserved left ventricular ejection fraction by up-regulating Bcl-2.

    PubMed

    Dong, Shuguang; Ma, Wenhan; Hao, Bohan; Hu, Fen; Yan, Lianhua; Yan, Xiaofei; Wang, Ya; Chen, Zhijian; Wang, Zhaohui

    2014-01-01

    The morbidity and mortality of heart failure with preserved left ventricular ejection fraction (HFpEF) were similar to those of systolic heart failure, but the pathogenesis of HFpEF remains poorly understood. It was demonstrated that, in systolic heart failure, microRNA-21 (miR-21) could inhibit the apoptosis of cardiac fibroblasts, leading to cardiac hypertrophy and myocardial fibrosis, but the role of miR-21 in HFpEF remains unknown. By employing cell culture technique, rat myocardiocytes and cardiac fibroblasts were obtained. The expression of miR-21 in the two cell types under different conditions was compared and we found that the miR-21 expression was significantly higher in cardiac fibroblasts than in myocardiocytes. We established a rat HFpEF model and harvested the tissues of cardiac apex for pathological examination, Northern blotting and so forth. We found that miR-21 expression was significantly higher in model rats than in sham-operated rats, and the model rats developed the cardiac atrophy and cardiac fibrosis. After injection of miR-21 antagonist, the the cardiac atrophy and cardiac fibrosis were conspicuously ameliorated. Both in vivo and in vitro, inhibition of miR-21 expression resulted in reduced Bcl-2 expression while over-expression of miR-21 led to elevation of Bcl-2 expression. Our study suggested that miR-21 promoted the development of HFpEF by up-regulating the expression of anti-apoptotic gene Bcl-2 and thereby suppressing the apoptosis of cardiac fibrosis.

  18. Evaluation of right ventricular function after cardiac surgery: The importance of tricuspid annular plane systolic excursion and right ventricular ejection fraction.

    PubMed

    Garcia Gigorro, Renata; Renes Carreño, Emilio; Mayordomo, Sandra; Marín, Helena; Perez Vela, Jose Luis; Corres Peiretti, María Angélica; Montejo González, Juan Carlos

    2016-08-01

    The evaluation of right ventricular systolic function is essential to the hemodynamic management of critically ill cardiac patients. Nevertheless, assessment of right ventricular function remains problematic. We sought to analyze the correlation between tricuspid annular plane systolic excursion (TAPSE) and right ventricular ejection fraction (RVEF) in the assessment of global and regional right ventricular function, respectively. This was a prospective study of 61 cardiac surgical patients. TAPSE was measured with transthoracic echocardiography and RVEF was obtained by a thermodilution pulmonary artery catheter. Both measurements were estimated simultaneously during the early postoperative period. Patients with previously identified severe tricuspid insufficiency were excluded from the study to avoid confounding results. The etiologies for cardiac surgery were surgical pulmonary thromboendarterectomy in 19 patients, valve replacement in 17 patients, heart transplant in 13 patients, and coronary artery bypass graft in 9 patients. Mean RVEF and TAPSE were 26.2% ± 9.7% and 11.4 ± 4 mm, respectively. RVEF and TAPSE showed a significant correlation (r = 0.73, P < .001). Weak reverse relationships between TAPSE or RVEF with afterload hemodynamic parameters, mean pulmonary artery pressure, or pulmonary vascular resistance were elucidated. TAPSE is a robust measure of right ventricular function that correlates with RVEF assessed by pulmonary artery catheter. A noninvasive method such as echocardiography can guide and support invasive monitoring of right ventricular function in cardiac surgical patients. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

  19. Relation between coronary arterial dominance and left ventricular ejection fraction after ST-segment elevation acute myocardial infarction in patients having percutaneous coronary intervention.

    PubMed

    Veltman, Caroline E; Hoogslag, Georgette E; Kharbanda, Rohit K; de Graaf, Michiel A; van Zwet, Erik W; van der Hoeven, Bas L; Delgado, Victoria; Bax, Jeroen J; Scholte, Arthur J H A

    2014-12-01

    The presence of a left dominant coronary artery system is associated with worse outcome after ST-segment elevation myocardial infarction (STEMI) compared with right dominance or a balanced coronary artery system. However, the association between coronary arterial dominance and left ventricular (LV) function at follow-up after STEMI is unclear. The present study aimed at evaluating the relation between coronary arterial dominance and LV ejection fraction (LVEF) shortly after STEMI and at 12-month follow-up. A total of 741 patients with STEMI (mean age 60 ± 11 years and 77% men) were evaluated with 2-dimentional echocardiography within 48 hours of admission (baseline) and at 12-month follow-up after STEMI. Coronary arterial dominance was assessed on the angiographic images obtained during primary percutaneous coronary intervention. A right, left, and balanced dominant coronary artery system was noted in 640 (86%), 58 (8%), and 43 (6%) patients, respectively. At baseline, significant difference in LV function was observed, with slightly lower LVEF in patients with a left dominant coronary artery system (LVEF 45 ± 8% vs 48 ± 9% and 50 ± 9%, for left dominant, right dominant, and balanced coronary artery system respectively, p = 0.03). However, at 12-month follow-up no differences in LV function or volumes were observed among the different coronary arterial dominance groups. In conclusion, patients with a left dominant coronary artery system had lower LVEF early after STEMI. At 12-month follow-up, differences in LVEF were no longer present among the different coronary arterial dominance groups. Copyright © 2014 Elsevier Inc. All rights reserved.

  20. Left ventricular outflow tract velocity time integral outperforms ejection fraction and Doppler-derived cardiac output for predicting outcomes in a select advanced heart failure cohort.

    PubMed

    Tan, Christina; Rubenson, David; Srivastava, Ajay; Mohan, Rajeev; Smith, Michael R; Billick, Kristen; Bardarian, Samuel; Thomas Heywood, J

    2017-07-03

    Left ventricular outflow tract velocity time integral (LVOT VTI) is a measure of cardiac systolic function and cardiac output. Heart failure patients with low cardiac output are known to have poor cardiovascular outcomes. Thus, extremely low LVOT VTI may predict heart failure patients at highest risk for mortality. Patients with heart failure and extremely low LVOT VTI were identified from a single-center database. Baseline characteristics and heart failure related clinical outcomes (death, LVAD) were obtained at 12 months. Correlation between clinical endpoints and the following variables were analyzed: ejection fraction (EF), pulmonary artery systolic pressure (PASP), NYHA class, renal function, Doppler cardiac output (CO), and LVOT VTI. Study cohort consisted of 100 patients. At the 12-month follow up period, 30 events (28 deaths, 2 LVADs) were identified. Occurrence of death and LVAD implantation was statistically associated with a lower LVOT VTI (p = 0.039) but not EF (p = 0.169) or CO (p = 0.217). In multivariate analysis, LVOT VTI (p = 0.003) remained statistically significant, other significant variables were age (p = 0.033) and PASP (p = 0.022). Survival analysis by LVOT VTI tertile demonstrated an unadjusted hazard ratio of 4.755 (CI 1.576-14.348, p = 0.006) for combined LVAD and mortality at one year. Extremely low LVOT VTI strongly predicts adverse outcomes and identifies patients who may benefit most from advanced heart failure therapies.

  1. Measurement of aortic valve calcification using multislice computed tomography: correlation with haemodynamic severity of aortic stenosis and clinical implication for patients with low ejection fraction.

    PubMed

    Cueff, Caroline; Serfaty, Jean-Michel; Cimadevilla, Claire; Laissy, Jean-Pierre; Himbert, Dominique; Tubach, Florence; Duval, Xavier; Iung, Bernard; Enriquez-Sarano, Maurice; Vahanian, Alec; Messika-Zeitoun, David

    2011-05-01

    Measurement of the degree of aortic valve calcification (AVC) using electron beam computed tomography (EBCT) is an accurate and complementary method to transthoracic echocardiography (TTE) for assessment of the severity of aortic stenosis (AS). Whether threshold values of AVC obtained with EBCT could be extrapolated to multislice computed tomography (MSCT) was unclear and AVC diagnostic value in patients with low ejection fraction (EF) has never been specifically evaluated. Patients with mild to severe AS underwent prospectively within 1 week MSCT and TTE. Severe AS was defined as an aortic valve area (AVA) of less than 1 cm(2). In 179 patients with EF greater than 40% (validation set), the relationship between AVC and AVA was evaluated. The best threshold of AVC for the diagnosis of severe AS was then evaluated in a second subset (testing set) of 49 patients with low EF (≤40%). In this subgroup, AS severity was defined based on mean gradient, natural history or dobutamine stress echocardiography. Correlation between AVC and AVA was good (r=-0.63, p<0.0001). A threshold of 1651 arbitrary units (AU) provided 82% sensitivity, 80% specificity, 88% negative-predictive value and 70% positive-predictive value. In the testing set (patients with low EF), this threshold correctly differentiated patients with severe AS from non-severe AS in all but three cases. These three patients had an AVC score close to the threshold (1206, 1436 and 1797 AU). In this large series of patients with a wide range of AS, AVC was shown to be well correlated to AVA and may be a useful adjunct for the evaluation of AS severity especially in difficult cases such as patients with low EF.

  2. The relationship between mitral annular systolic velocity and ejection fraction in patients with preserved global systolic function of the left ventricle

    PubMed Central

    2013-01-01

    Background The aim of the study was to investigate the relationship between the ejection fraction (EF) and the mitral annular systolic velocity (Sm) in patients with preserved left ventricular systolic function (EF>55%). The study task was to evaluate whether the assessment of Sm(avg) can be used as an alternative to the Simpson’s method in assessment of the EF. The expected benefit was that Sm could be used to predict EF, when EF is difficult to assess due to poor image quality (IQ). Method Sm was obtained by spectral pulse wave Tissue Doppler Imaging (pwTDI) from the lateral and septal sites of the mitral annulus (MA) and an averaged value was calculated - Sm(avg). EF was assessed using Simpson’s rule. Participants were divided into controls (n=70), hypertensive (HTN, n=56), HTN with diastolic dysfunction (HTN/DD, n=65), HTN with diabetes mellitus (HTN/DM, n=52) and HTN with DD and DM (HTN/DD/DM, n=65). Results Sm(avg) showed strong correlation with EF (r=0.978; p<0.0001). There were no significant differences between the correlation coefficients between the subgroups and the controls. The mathematical model that the study recommended to assess the EF is: EF=45.0 + 2 × Sm(avg). Conclusion The assessment of Sm(avg) could be used as an alternative to EF. This approach may be useful especially when the IQ is poor. The method maintains high accuracy and reproducibility in prediction of the EF. PMID:24160570

  3. Sudden Cardiac Death in Women With Suspected Ischemic Heart Disease, Preserved Ejection Fraction, and No Obstructive Coronary Artery Disease: A Report From the Women's Ischemia Syndrome Evaluation Study.

    PubMed

    Mehta, Puja K; Johnson, B Delia; Kenkre, Tanya S; Eteiba, Wafia; Sharaf, Barry; Pepine, Carl J; Reis, Steven E; Rogers, William J; Kelsey, Sheryl F; Thompson, Diane V; Bittner, Vera; Sopko, George; Shaw, Leslee J; Bairey Merz, C Noel

    2017-08-21

    Sudden cardiac death (SCD) is often the first presentation of ischemic heart disease; however, there is limited information on SCD among women with and without obstructive coronary artery disease (CAD). We evaluated SCD incidence in the WISE (Women's Ischemia Syndrome Evaluation) study. Overall, 904 women with suspected ischemic heart disease with preserved ejection fraction and core laboratory coronary angiography were followed for outcomes. In case of death, a death certificate and/or a physician or family narrative of the circumstances of death was obtained. A clinical events committee rated all deaths as cardiovascular or noncardiovascular and as SCD or non-SCD. In total, 96 women (11%) died over a median of 6 years (maximum: 8 years). Among 65 cardiovascular deaths, 42% were SCD. Mortality per 1000 person-hours increased linearly with CAD severity (no CAD: 5.8; minimal: 15.9; obstructive: 38.6; P<0.0001). However, the proportion of SCD was similar across CAD severity: 40%, 58%, and 38% for no, minimal, and obstructive CAD subgroups, respectively (P value not significant). In addition to traditional risk factors (age, diabetes mellitus, smoking), a history of depression (P=0.018) and longer corrected QT interval (P=0.023) were independent SCD predictors in the entire cohort. Corrected QT interval was an independent predictor of SCD in women without obstructive CAD (P=0.033). SCD contributes substantially to mortality in women with and without obstructive CAD. Corrected QT interval is the single independent SCD risk factor in women without obstructive CAD. In addition to management of traditional risk factors, these data indicate that further investigation should address mechanistic understanding and interventions targeting depression and corrected QT interval in women. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

  4. Normal limits for left ventricular ejection fraction and volumes determined by gated single photon emission computed tomography--a comparison between two quantification methods.

    PubMed

    Lomsky, Milan; Johansson, Lena; Gjertsson, Peter; Björk, Jonas; Edenbrandt, Lars

    2008-05-01

    To compare gender-related normal limits for left ventricular (LV) ejection fraction (EF), end-diastolic and end-systolic volumes (EDV and ESV), obtained using two myocardial perfusion-gated single photon emission computed tomography (SPECT) quantification methods. A total of 185 patients were retrospectively selected from a consecutive series of patients examined for coronary artery disease (CAD) or for management of known CAD. Patients were included in the study group if they had normal or probably normal results with stress and rest perfusion imaging and if the combined interpretation of perfusion studies and gated rest studies showed no signs or suspicion of myocardial infarction. The gated SPECT studies were performed using a 2-day stress/gated rest Tc-99m sestamibi protocol. All patient studies were processed using CAFU and quantitative-gated SPECT (QGS), the two software packages for quantification of gated SPECT images. The lower normal limits for EF were higher for CAFU compared with QGS for both women (59% versus 53%) and men (54% versus 47%). The upper normal limits for EDV were also higher for CAFU compared with QGS for both women (133 versus 107 ml) and men (182 versus 161 ml). The differences between the software packages were small for ESV (women 44 versus 44 ml; men 69 versus 74 ml). Gender-specific normal limits need to be applied for LV EF and volumes determined by gated SPECT. Separate criteria for abnormal LV EF and EDV need to be used for women and men depending on the software package used.

  5. A quantitative analysis of left ventricular filling pressures in patients with a reduced ejection fraction, with or without concomitant left bundle branch block.

    PubMed

    Daskalov, Ivaylo Rilkov; Gotchev, Dobromir Tenev

    2011-05-01

    This study aimed to prove that a mathematical model can be used to quantify the relationship between the left ventricular filling pressure (LVFP) determined as the E/e' ratio and the pulmonary capillary wedge pressure (PCWP) assessed by right heart catheterization (RHC) in patients with reduced ejection fractions (EF), with or without a left bundle branch block (LBBB). We hypothesize that such an approach will be clinically beneficial, especially for patients in the so-called "gray area," for whom E/e' is not a reliable index for assessment of the LVFP. We enrolled 64 patients in sinus rhythm and with a reduced EF, 31 of whom exhibited a LBBB on an ECG. The e' was obtained from the septal (e'(sept)) and lateral sites (e'(lat)) of the mitral annulus. The averaged e' (e'(aver)) was also calculated (e'(sept) + e'(lat)/2). Although we found a good correlation (r = 0.641; e'(lat)/0.641; e'(sept)/0.607; e'(aver)) between E/e' and the mean PCWP in patients without LBBB, regardless of the e' used, the equation only yielded significance (P = 0.03) when the e'(aver) was used (PCWP = 6.7 + E/e'(aver)). In patients with LBBB, we found a moderate correlation between the LVFP and the mean PCWP (r = 0.451; e'(lat)/r = 0.413; e'(sept)/r = 0.454; e'(aver)), although all of the used e' positions lacked significance (P = 0.065 e'(lat)/0.075 e'(sept)/0.082 e'(aver)). Our results suggest that in patients with reduced EF and without LBBB, it is possible to quantify the LVFP using an equation. These results are of great clinical benefit, especially for "gray area" patients. © 2011, Wiley Periodicals, Inc.

  6. A study of the dependence of protocol optimization on the left ventricular ejection fraction (LVEF) in coronary CT angiography (CCTA) examination

    NASA Astrophysics Data System (ADS)

    Yu, Dong-Su; Cho, Jae-Hwan; Park, Cheol-Soo; Yoo, Heung-Joon; Choi, Cheon-Woong; Kim, Dae-Hyun

    2013-10-01

    The purpose of this study is to obtain a good quality image and to minimize patient doses and re-examination rates through an optimization of the protocol for coronary computed tomography angiography (CCTA) examination based on a comparison and an analysis of the heart rates (HRs) of patients who had left ventricular ejection fraction (LVEF) values of less than 40% and the HRs of ordinary patients. This study targeted 16 patients who received thallium single-photon emission computed tomography (SPECT) or echocardiography simultaneously among the patients who took the CCTA examinations. Depending on the LVEF value (30 ˜ 39, 40 ˜ 49, 50 ˜ 59, and 60% or above), the patients were divided into groups of four based on HR (50 ˜ 59, 60 ˜ 69, 70 ˜ 79, and 80 or above). DynEva software was used to set the region of interest (ROI) on the ascending aorta and for a measurement of the threshold value. Comparisons and analyses were made based on the LVEF values and the HRs, after which the results were compared with the ones from the existing examination protocols and contrast medium protocols. According to the study results, the relation between the HR and the LVEF demonstrated that it took a long time to reach the true 100 hounsfield unit (HU) when the LVEF was 40% or below. Contrasting media showed significant differences, except in the case where the HR was 80 or above, and/or the LVEF was less than 40%. Moreover, for an LVEF of less than 40%, time differences were significant when contrasting media reached the true 100 HU to begin the scanning process. Therefore, it was possible to predict that the contrasting media were already being washed out from the left ventricle.

  7. Obtaining the Grobner Initialization for the Ground Flash Fraction Retrieval Algorithm

    NASA Technical Reports Server (NTRS)

    Solakiewicz, R.; Attele, R.; Koshak, W.

    2011-01-01

    At optical wavelengths and from the vantage point of space, the multiple scattering cloud medium obscures one's view and prevents one from easily determining what flashes strike the ground. However, recent investigations have made some progress examining the (easier, but still difficult) problem of estimating the ground flash fraction in a set of N flashes observed from space In the study by Koshak, a Bayesian inversion method was introduced for retrieving the fraction of ground flashes in a set of flashes observed from a (low earth orbiting or geostationary) satellite lightning imager. The method employed a constrained mixed exponential distribution model to describe the lightning optical measurements. To obtain the optimum model parameters, a scalar function of three variables (one of which is the ground flash fraction) was minimized by a numerical method. This method has formed the basis of a Ground Flash Fraction Retrieval Algorithm (GoFFRA) that is being tested as part of GOES-R GLM risk reduction.

  8. Validation of Noninvasive Measurement of Cardiac Output Using Inert Gas Rebreathing in a Cohort of Patients With Heart Failure and Reduced Ejection Fraction.

    PubMed

    Hassan, Mohamed; Wagdy, Kerolos; Kharabish, Ahmed; Selwanos, Peter Philip; Nabil, Ahmed; Elguindy, Ahmed; ElFaramawy, Amr; Elmahdy, Mahmoud F; Mahmoud, Hani; Yacoub, Magdi H

    2017-03-01

    Cardiac output (CO) is a key indicator of cardiac function in patients with heart failure. No completely accurate method is available for measuring CO in all patients. The objective of this study was to validate CO measurement using the inert gas rebreathing (IGR) method against other noninvasive and invasive methods of CO quantification in a cohort of patients with heart failure and reduced ejection fraction. The study included 97 patients with heart failure and reduced ejection fraction (age 42±15.5 years; 64 patients (65.9%) had idiopathic dilated cardiomyopathy and 21 patients (21.6%) had ischemic heart disease). Median left ventricle ejection fraction was 24% (10%-36%). Patients with atrial fibrillation were excluded. CO was measured using 4 methods (IGR, cardiac magnetic resonance imaging, cardiac catheterization, and echocardiography) and indexed to body surface area (cardiac index [CI]). All studies were performed within 48 hours. Median CI measured by IGR was 1.75, by cardiac magnetic resonance imaging was 1.82, by cardiac catheterization was 1.65, and by echo was 1.7 L·min(-1)·m(-2). There were significant modest linear correlations between IGR-derived CI and cardiac magnetic resonance imaging-derived CI (r=0.7; P<0.001), as well as cardiac catheterization-derived CI (r=0.6; P<0.001). Using Bland-Altman analysis, the agreement between the IGR method and the other methods was as good as the agreement between any 2 other methods with each other. The IGR method is a simple, accurate, and reproducible noninvasive method for quantification of CO in patients with advanced heart failure. The prognostic value of this simple measurement needs to be studied prospectively. © 2017 American Heart Association, Inc.

  9. Effect of fluid and dietary sodium restriction in the management of patients with heart failure and preserved ejection fraction: study protocol for a randomized controlled trial.

    PubMed

    d'Almeida, Karina S M; Rabelo-Silva, Eneida R; Souza, Gabriela C; Trojahn, Melina M; Barilli, Sofia L S; Mansson, Jessica V; Biolo, Andreia; Rohde, Luis E P; Clausell, Nadine; Beck-da-Silva, Luís

    2014-09-04

    Although half of all patients with heart failure (HF) have a normal or near-normal ejection fraction and their prognosis differs little from that of patients with a reduced ejection fraction, the pathophysiology of HF with preserved ejection fraction (HF-PEF) is still poorly understood, and its management poorly supported by clinical trials. Sodium and fluid restriction is the most common self-care measure prescribed to HF patients for management of congestive episodes. However, its role in the treatment of HF-PEF remains unclear. This trial seeks to compare the effects of a sodium- and fluid-restricted diet versus an unrestricted diet on weight loss, neurohormonal activation, and clinical stability in patients admitted for decompensated HF-PEF. This is a randomized, parallel trial with blinded outcome assessment. The sample will include adult patients (aged ≥18 years) with a diagnosis of HF-PEF admitted for HF decompensation. The patients will be randomized to receive a diet with sodium and fluid intake restricted to 0.8 g/day and 800 mL/day respectively (intervention group) or an unrestricted diet, with 4 g/day sodium and unlimited fluid intake (control group), and followed for 7 days or until hospital discharge. The primary outcome shall consist of weight loss at 7 days or discharge. The secondary outcome includes assessment of clinical stability, neuroho