Cardiac Performance In Patients Research Articles

Hemodynamic effects of vericiguat in symptomaticHFrEF patients: insights from right heart catheterization study

Abstract Background Vericiguat is recommended in the guidelines as Class IIb for patients with heart failure with reduced ejection fraction (HFrEF) who continue to have persistent symptoms despite receiving standard therapy. However, the precise effects of vericiguat on pulmonary and systemic hemodynamics and cardiac performance remain unclear. Purpose This study aimed to investigate the hemodynamic impact of vericiguat in 12 symptomatic HFrEF patients who experienced worsening HF despite receiving standard therapy with the four foundational heart failure medications, using right heart catheterization (RHC). Methods On day 1, RHC was performed via the right internal jugular vein and a balloon-tripped pulmonary artery thermodilution catheter was placed. On day 2 and 3, RHC data were measured at 15min before and 30min, 1hr, 2hr, 3hr and 5hr after intake of 2.5mg vericiguat. RHC data on day 2 and 3 were averaged and the catheter was removed after the RHC measurements on day 3. RHC was repeated on a median day of 105(quartiles 37,168). The acute hemodynamic effects of vericiguat were assessed using a comparison of six RHC measures, including pulmonary artery wedge pressure (PAWP), mean pulmonary artery pressure (MPAP), mean arterial blood pressures (MABP), pulmonary (PVR) and systemic vascular resistances (SVR) and cardiac index (CI), at 15minutes before intake of vericiguat 2.5mg with those at 30minutes to 5hours after that. The chronic hemodynamic effects of vericiguat were evaluated by comparing the six RHC measures on day 1 with those on day 105(37,168). Results Participant characteristics on day 1 were age 63.5(53.5,70)yrs., 16.7%(N=2) women, height 164.3(155,171.3)cm, weight 64.6(54.8,75.1)kg, body mass index 23.8(20,26.3), systolic 101.5(90.5,111.5)mmHg and diastolic blood pressures 60.2(53.5,65)mmHg, heart rate 65.5(56,72)bpm, New York Heart Association functional class Ⅱ 50%(N=6), Ⅲ 16.7%(N=2) and Ⅳ 33.3%(N=4), estimated glomerular filtration rate 44.5(34.5,53.5)mL/min/1.73m2, left-ventricular ejection fraction 19.9(14.5,24.5)% and diastolic diameter 68(60.5,72.5)mm, left-atrial diameter 45(36.5,50.5)mm and brain natriuretic peptide level 419(254,479)pg/mL. Oral intake of vericiguat 2.5mg decreased PAWP (11[7.5,15]mmHg) and MPAP (19.3[14.3,26.8]mmHg) before the intake to PAWP (9.3[6.8,14]mmHg) and MPAP (17.5[12.5,24]mmHg) at 30min after that (both P<0.05[crude P<0.0017])(Figure A) while comparable changes in MABP, PVR, SVR and CI and the other timepoints (all P>0.05[crude P<0.0017]). Vericiguat was titrated to 2.5mg 25% (N=3), 5mg 50% (N=6) and 10mg 25% (N=3) on day 105 (37,168), in which PAWP (9.5[6.5,12.5]mmHg) was decreased from PAWP (14.5[9.5,19.5]mmHg) on day 1 (P<0.05[crude P<0.0083])(Figure B) while comparable changes in the other RHC parameters (all P>0.05[crude P<0.0083]). Conclusions The consistent reduction in PAWP underscores vericiguat's well-tolerated nature and potential to enhance cardiac performance in patients with HFrEF.

Evaluating haemodynamic changes: vericiguat in patients with heart failure with reduced ejection fraction.

Vericiguat has been used to treat patients with heart failure with reduced ejection fraction (HFrEF) who demonstrated worsening heart failure despite treatment with other guideline-directed medical therapies. The haemodynamic effects of vericiguat remain unclear. This study enrolled 12 patients (median age, 63 [quartiles 53.5, 70] years; 16.7%(N=2) women) with symptomatic HFrEF (New York Heart Association functional class II-IV) who demonstrated worsening heart failure despite treatment with the four foundational guideline-recommended therapies between March and December 2022, with follow-ups completed in June 2023. A balloon-tipped pulmonary artery thermodilution catheter was placed in the right internal jugular vein to perform right heart catheterisation (RHC) on day 1. Haemodynamic data were acquired before and after vericiguat intake (2.5mg) on days 2 and 3. The data on days 2 and 3 were averaged. RHC was repeated on day 105 (37, 168). Oral intake of vericiguat 2.5mg decreased mean pulmonary artery pressure (19.3 [14.3, 26.8] mmHg) and pulmonary artery wedge pressure (PAWP) (11 [7.5, 15] mmHg) before the intake to mean pulmonary artery pressure (17.5 [12.5, 24] mmHg) and PAWP (9.3 [6.8, 14] mmHg) at 30min after (both P<0.05). Reduction in PAWP was also found from 14.5 [9.5, 19.5] mmHg on day 1 to 9.5 [6.5, 12.5] mmHg on day 105 (37, 168) (P<0.05), when vericiguat was titrated to 2.5mg 25% (N=3), 5mg 50% (N=6), and 10mg 25% (N=3). The consistent reduction in PAWP underscores the well-tolerated nature of vericiguat and its potential to enhance cardiac performance in patients with HFrEF.

Strategic noninvasive multimodal assessment of cardiac performance in patients with heart failure

Abstract Aims We sought to evaluate whether a noninvasive combination assay targeting left ventricular filling pressure (LVFP) would be useful for risk stratification of patients with heart failure (HF). Although abnormal LVFP is inevitably related to HF outcomes, its noninvasive application remains difficult in daily practice. Methods This prospective observational study enrolled consecutive hospitalized HF patients. According to the baseline N-terminal pro-B-type natriuretic peptide (NT-proBNP) and Doppler echocardiographic diastolic assessments, patients were classified into three groups: normal range of both LVFP and NT-proBNP (Group 1), normal range of LVFP but elevated NT-proBNP (Group 2), and elevated LVFP and NT-proBNP (Group 3). The primary endpoints were the composite adverse cardiovascular events. Results Event-free survival in Group 2 (n = 56, mean age of 65.4±12.4) was better than that in Group 3 (n = 45, mean age of 68.5±11.5) but worse than that in Group 1 (n = 123, mean age of 61.4±10.5) (log-rank p &amp;lt;0.001). Cardiopulmonary exercise test (CPET) findings were compatible with these findings. Left atrial strain showed better risk stratification than left atrial volume index. Serial addition of left atrial assessment and CPET in the model incrementally enhanced the predictive power of LVFP-based stratification for adverse events. Conclusions The strategic combination of NT-proBNP, echocardiographic LVFP and left atrial function, and CPET is helpful to predict adverse clinical outcomes in patients with HF. The larger the number of combined cardiac performance indicators, the better the noninvasive risk-stratification was.

Serial echocardiographic evaluation of COVID-19 patients without prior history of structural heart disease: a 1-year follow-up CRACoV-HHS study.

It is a well-known fact that COVID-19 affects the cardiovascular system by exacerbating heart failure in patients with preexisting conditions. However, there is a poor insight into the cardiovascular involvement and sequelae in patients without preexisting conditions. The aim of the study is to analyse the influence of COVID-19 on cardiac performance in patients without prior history of structural heart disease. The study is part of the CRACoV project, which includes a prospective design and a 12-month follow-up period. The study included 229 patients hospitalised with a diagnosis of COVID-19 (median age of 59 years, 81 were women). A standard clinical assessment and laboratory tests were performed in all participants. An extended echocardiographic image acquisition was performed at baseline and at a 3-, 6-, and 12-month follow-up. All analyses were performed off-line. A series of echocardiographic parameters was compared using repeated measures or Friedman analysis of variance. In all subjects, the left ventricular (LV) ejection fraction at baseline was preserved [63.0%; Q1:Q3 (60.0-66.0)]. Elevated levels of high-sensitivity cardiac troponin T were detected in 21.3% of the patients, and elevated NT-proBNP levels were detected in 55.8%. At the 1-year follow-up, no significant changes were observed in the LV diameter and volume (LV 48.0 ± 5.2 vs. 47.8 ± 4.8 mm, p = 0.08), while a significant improvement of the parameters in the biventricular strain was observed (LV -19.1 ± 3.3% vs. -19.7 ± 2.5%, p = 0.01, and right ventricular -19.9 ± 4.5% vs. -23.2 ± 4.9%, p = 0.002). In addition, a decrease in the LV wall thickness was also observed (interventricular septum 10.4 ± 1.6 vs. 9.7 ± 2.0 mm, p < 0.001; LV posterior wall 9.8 ± 1.4 vs. 9.1 ± 1.5 mm, p < 0.001). In an acute phase of COVID-19, the elevation of cardiac biomarkers in patients with normal left ventricular ejection fraction is a frequent occurrence; however, it does not translate into clinically significant cardiac dysfunction after 1 year. The serial echocardiographic evaluations conducted in patients without preexisting structural heart disease demonstrate an overall trend towards an improved cardiac function and a reduced myocardial thickening at 1-year follow-up. This suggests that the acute cardiac consequences of COVID-19 are associated with systemic inflammation and haemodynamic stress in patients without preexisting conditions.

The moderating role of depressive symptoms in the association between heart rate variability and cognitive performance in cardiac patients

IntroductionCoronary heart disease (CHD) is strongly associated with cognitive impairment, which is a core feature of depression, highly prevalent in patients with CHD. Interestingly, patients with CHD and individuals with depression display reduced heart rate variability (HRV), which proxies a complex network integrating autonomic and attentional systems. This study investigated the moderating role of depressive symptoms in the relation between reduced HRV and cognitive performance in patients with CHD. MethodThe sample included 274 patients with CHD (mean [standard deviation] age = 62 [9.5] years; 13 % women) admitted to cardiac rehabilitation units. Visual attention and task switching were assessed through the Trail Making Test (TMT). Depressive symptoms were assessed with the Beck Depression Inventory-II (BDI-II). Resting electrocardiographic recordings were collected to compute HRV indices. ResultsPatients with more severe depressive symptoms displayed an inverse association between HRV and cognitive performance (TMT-A: b = −0.08, p = .022; TMTB: b = −0.07, p = .042), whereas patients with milder depressive symptoms showed no significant association (TMT-A: b = −0.00, p = .90; TMTB: b = −0.02, p = .44). ConclusionsDepressive symptoms may strengthen the relation between reduced HRV and poorer cognitive performance in cardiac patients. The presence of depressive symptoms may signal the dysfunction of a network subserving autonomic and cognitive function.

Outcomes of Atrioventricular Node Ablation and Pacing in Patients with Heart Failure and Atrial Fibrillation: From Cardiac Resynchronization Therapy to His Bundle Pacing.

Objective: To review the relevant literature on the use of atrioventricular node ablation and pacing in patients with heart failure and atrial fibrillation. Methods: APubMed/MEDLINE and SCOPUS search was performed in order to assess the clinical outcomes of atrioventricular node ablation and pacemaker implantation, as well as the complications that may occur. Results: Several clinical trials, observational analyses and meta-analyses have shown that the "pace and ablate" strategy not only improves symptoms but also can enhance cardiac performance in patients with heart failure and atrial fibrillation. Although this procedure is effective and safe, some complications may occur including worsening of heart failure, permanent fibrillation, arrhythmias and sudden death. Regarding pacemaker implantation, cardiac resynchronization therapy is shown to be the optimal choice compared to right ventricle apical pacing. His bundle pacing is a promising alternative to cardiac resynchronization therapy and has shown beneficial effects, while left bundle branch pacing is an innovative modality. Conclusions: Atrioventricular node ablation and pacemaker implantation is shown to have beneficial effects on clinical outcomes of patients with atrial fibrillation ± heart failure who do not respond or are intolerant to medical treatment. Cardiac resynchronization therapy is the treatment of choice and His bundle pacing seems to be an effective alternative way of pacing in these patients.

Abstract 10196: Reducing Symptom Burden Using Ubiquinol And/Or D-Ribose in Patients With Heart Failure With Preserved Ejection Fraction

Introduction: Mitochondrial dysfunction has been implicated in the development of HFpEF, particularly a decrease in the production of adenosine triphosphate (ATP). Ubiquinol is produced in the mitochondria and is required for oxidative phosphorylation and D-ribose is an essential component of ATP. Thus, supplementing with ubiquinol and/or D-ribose could be useful to improve mitochondrial biomechanics and patient symptoms. Hypothesis: To determine if ubiquinol and/or D-ribose would reduce the symptoms and improve cardiac performance in patients with HFpEF. Methods: This study was a randomized, double-blind, placebo-controlled trial of 216 patients with HFpEF. Four study groups received various supplements over 12 weeks: Group 1 - placebo capsules and placebo powder (placebo group); Group 2 - ubiquinol (600 mg/day) and placebo D-ribose; Group 3 - placebo ubiquinol with D-ribose (15 g/day); Group 4 - ubiquinol (600 mg/day) and D-ribose (15 g/day). There were seven outcome measures for this study: Kansas City Cardiomyopathy Questionnaire (KCCQ) clinical summary score (CSS), level of vigor using a subscale from the Profile of Mood States (POMS), ejection fraction (EF), the ratio of mitral peak velocity of early filling (E) to early diastolic mitral annular velocity (eꞌ) (septal E/eꞌ ratio), B-type natriuretic peptides (BNP), lactate/ATP ratio, and the 6-minute walk test (6MWT). Results: Using ubiquinol and/or D-ribose significantly increased the KCCQ clinical summary score (17.30 to 25.82 points [compared to Group 1, p = 0.0001 (Group 2); p &lt; 0.0001 (Group 3); p=0.0116 (Group 4)], vigor score (7.65 to 8.15 points [all p &lt; 0.0001]), EF (7.08 to 8.03% [p = 0.0006; p &lt; 0.0001; p = 0.0002]), and decreased BNP (-72.02 to -47.51 pg/mL [p = 0.0002; p = 0.0024; p = 0.0415]) and lactate/ATP ratio (-4.32x10 -4 to -3.35x10 -4 mmol/L/RLU) [p &lt; 0.0001; p &lt; 0.0001; p = 0.0006]). We found no significant improvement in septal E/e’ or 6MWT. Conclusions: The use of ubiquinol and/or D-ribose significantly decreased the patients’ symptoms of HFpEF and improved EF. This suggests that the ubiquinol and/or D-ribose increased mitochondrial function by increasing cellular ATP &amp; may help reduce symptom burden and improve cardiac function. NIH: 1R01AG054486-01A1, NCT03133793, IND: 134633

REDUCTION OF HEART RATE VIA P2X4 RECEPTOR ACTIVATION AS A PROMISING TREATMENT STRATEGY IN PULMONARY ARTERIAL HYPERTENSION

Objective: Mounting evidence suggest that the ATP-sensitive ionotropic P2X4 receptor (P2X4R) improves cardiac performance and optimizes myocardial energy demand by reducing chronotropy. Here, we set to investigate whether the digitalis-like effect of the P2X4R in the sinus node was preserved in rats with right heart failure due to pulmonary arterial hypertension (PAH). Design and method: Male Wistar rats received a single subcutaneous injection of either monocrotaline (MCT; PAH group) or vehicle (CTRL group). Right heart failure associated to PAH normally occurs in Wistar rats 21 to 25 days after MCT administration. Myographic recordings were performed in spontaneously beating atria (chronotropic effect) isolated from both animal groups. Results: Baseline spontaneous atrial rate was 250 ± 5 (n = 26) bpm in CTRL and 237 ± 7 bpm (n = 23) in PAH group (p &gt; 0.05). ATP (0.01–1 mM) concentration-dependently reduced the spontaneous atrial rate of both animal groups. The negative chronotropic effect of ATP (100 M) was smaller in PAH rats (-9 ± 2%; n = 14 vs. -22 ± 4%; n = 25, p &lt; 0.05), but this divergence was attenuated upon increasing the concentration of ATP to 1 mM (CTRL: -54 ± 5%; n = 15 vs. MCT: -50 ± 7%; n = 8; p &gt; 0.05). The P2X4R antagonist, 5-BDBD (10 M), attenuated the negative chronotropic action of ATP (100 M) in CTRL (from -19 ± 5% to -13 ± 3%; n = 5, p &gt; 0.05) and PAH (from -8 ± 3% to 1 ± 8%; n = 4, p &gt; 0.05) rats. The positive allosteric modulator of P2X4R, ivermectin (30 M), potentiated the negative chronotropic effect of ATP (100 M) in CTRL (from -31 ± 5% to -56 ± 14%; n = 5, p &gt; 0.05) and PAH (from -12 ± 6% to -24 ± 9%; n = 4, p &lt; 0.05). The non-selective P2XR agonist, CTP (1 mM), which contrary to ATP does not breakdown into adenosine, also decreased atrial chronotropy in CTRL (-24.31 ± 6.73%; n = 6) and PAH (-11.82 ± 1.98%; n = 6) rats. Conclusions: Data suggest that the negative chronotropic effect of P2X4R activation is preserved in atria of rats with heart failure associated to PAH, thus strengthening the hypothesis that heart rate reductions using this ATP-sensitive receptor may increase cardiac performance in patients with PAH-induced heart failure.

Effects of Ubiquinol and/or D-ribose in Patients With Heart Failure With Preserved Ejection Fraction

Patients with heart failure with preserved ejection fraction (HFpEF) have few pharmacologic therapies, and it is not known if supplementing with ubiquinol and/or d-ribose could improve outcomes. The overall objective of this study was to determine if ubiquinol and/or d-ribose would reduce the symptoms and improve cardiac performance in patients with HFpEF. This was a phase 2 randomized, double-blind, placebo-controlled trial of 216 patients with HFpEF who were ≥ 50 years old with a left ventricular ejection fraction (EF) ≥ 50%. A total of 4 study groups received various supplements over 12 weeks: Group 1 received placebo ubiquinol capsules and d-ribose powder, Group 2 received ubiquinol capsules (600 mg/d) and placebo d-ribose powder, Group 3 received placebo ubiquinol capsules with d-ribose powder (15 g/d), and Group 4 received ubiquinol capsules and d-ribose powder. There were 7 outcome measures for this study: Kansas City Cardiomyopathy Questionnaire (KCCQ) clinical summary score, level of vigor using a subscale from the Profile of Mood States, EF, the ratio of mitral peak velocity of early filling to early diastolic mitral annular velocity (septal E/e' ratio), B-type natriuretic peptides, lactate/adenosine triphosphate ratio, and the 6-minute walk test. Treatment with ubiquinol and/or d-ribose significantly improved the KCCQ clinical summary score (17.30 to 25.82 points), vigor score (7.65 to 8.15 points), and EF (7.08% to 8.03%) and reduced B-type natriuretic peptides (-72.02 to -47.51) and lactate/adenosine triphosphate ratio (-4.32 to -3.35 × 10-4). There were no significant increases in the septal E/e' or the 6-minute walk test. In conclusion, ubiquinol and d-ribose reduced the symptoms of HFpEF and increased the EF. These findings support the use of these supplements in addition to standard therapeutic treatments for patients with HFpEF.

A four-month follow-up study of Cardiac performance in patients hospitalized with COVID-19 in a Tertiary Care Government Medical Hospital

PurposeMyocardial injury is one of the most frequently observed injury in patients hospitalized with coronavirus disease 2019 (COVID-19) pneumonia. Cardiac abnormalities ranging from elevations of cardiac necrosis biomarkers to cardiac dysfunction associated with myocarditis has been reported during the acute COVID-19 phase. Not much information is available on late cardiac manifestations in patients who have recovered from the cute COVID-19 illness. Our purpose is to present and quantify the extent of alterations in cardiac function in patients hospitalized 4 months earlier for COVID-19 infection.Methods & MaterialsA prospective echocardiographic evaluation was conducted of 39 patients hospitalized 4±1 month earlier for a laboratory-confirmed and symptomatic COVID-19. Thorough analysis of risk-factors was noted using a pre-prepared questionnaire. Echocardiographic measurements and respective cardiac investigations were analyzed using inferential and sensitivity analysis.ResultsOf the 39 patients (mean age 54 ± 11 years, 73% male), twenty-seven (69%) had pre-existing cardiovascular risks factors (systemic hypertension, diabetes, or dyslipidemia), and four patients (10.3%) had a known prior myocardial infarction (MI). Seventeen patients (43.6%) experienced myocardial injury during the index COVID-19 hospitalization as identified by a rise in cardiac troponin levels. Four months later, 71.8% of patients still reported clinical symptoms including exertional dyspnea for 69%. Under resting condition, echocardiographic measurements were indifferent between patients with versus without myocardial injury during the acute phase of COVID-19 infection. On the contrary, low-level exercise (25W for 3 min) showed a significant increase in the average E/e' ratio (P < 0.01) and the systolic pulmonary artery pressure (P < 0.05) in patients with myocardial injury during the acute COVID-19 phase. Sensitivity analyses showed that these left ventricular diastolic markers changes were observed irrespective of pre-existing cardiovascular risk factors or established cardiac diseases further cementing that the SARS-CoV-2 infection was the primary cause.ConclusionFour months after the acute COVID-19 phase, statistically significant cardiac diastolic abnormalities were observed in patients who experienced myocardial injury but not in patients without cardiac involvement.

Heart Failure Due to High-Degree Atrioventricular Block: How Frequent Is It and What Is the Cause?

The causes of heart failure (HF) during high-grade atrioventricular block (AVB) are poorly understood. This study assessed the mechanisms of HF in patients with AVB. We studied patients presenting (between 2012 and 2016) with high-grade AVB not related to acute myocardial infarction. Patients with preexisting significant valvular heart disease were excluded. All patients underwent comprehensive echocardiographic evaluation during AVB, before pacemaker implantation. The diagnosis of HF was based on the Framingham criteria. A total of 122 patients were included in the study, 50% male, average age 76 ± 13 years. Twenty-eight patients (23%) with AVB presented with HF. Univariate correlates associated with HF were decrease in cardiac output (CO) (odds ratio [OR] 0.68 [95% confidence interval 0.49-0.9] per L/min; P=0.007), measures of impaired left ventricular (LV) compliance, and increase in diastolic mitral regurgitation (MR) volume (OR 1.04 [1.01-1.07] per cc; P=0.0016). Ventricular rate during AVB and LV ejection fraction were not significantly associated with the presence of HF. By multivariate nominal logistic analysis, the best model associated with HF included diastolic MR volume (OR 1.04 [1.001-1.09]; P=0.02), A-wave deceleration time (OR 0.96 [0.94-0.9]; P=0.001), and CO (OR 0.92 [0.4-1.00]; P=0.005) (χ2=30.6; area under the receiver operating characteristic curve=0.84; P < 0.0001 for the entire model). In the setting of high-degree AVB, clinical HF occurrence correlates with impaired LV compliance and diastolic MR volume, but not with heart rate or LV ejection fraction. The cardiac performance of patients with poor LV compliance and high-volume diastolic MR may show maladjustment to slow heart rates, manifesting as low CO and HF.

Cardiac performance in patients hospitalized with COVID-19: A 6-month follow-up study

IntroductionMyocardial injury is frequently observed in patients hospitalized with Coronavirus disease 2019 (COVID-19) pneumonia. Different cardiac abnormalities have been reported during the acute COVID-19 phase but there is limited information on late cardiac sequelae in patients who have recovered from acute COVID-19 illness.ObjectiveTo document the presence and quantify the extent of myocardial functional alterations in patients hospitalized 6 months earlier for COVID-19 infection.Methods and resultsWe conducted a prospective echocardiographic evaluation of 48 patients (58 ± 13 years, 69% male) hospitalized 6 ± 1 month earlier for a laboratory-confirmed and symptomatic COVID-19. Thirty-two (66.6%) had pre-existing cardiovascular risks factors (hypertension, T2DM or dyslipidemia) and three patients (6.2%) had a known prior myocardial infarction. Sixteen patients (33.3%) experienced myocardial injury during the index COVID-19 hospitalization as identified by a rise in cardiac troponin levels. Six months later, 60.4% of patients still reported clinical symptoms including exercise dyspnea for 56%. Echocardiographic measurements under resting conditions were not different between patients with vs. without myocardial injury during the acute COVID-19 phase. In contrast, low-level exercise (25 W for 3 minutes) induced a significant increase in the average E/e’ ratio (10.1 ± 4.3 vs. 7.3 ± 11.5, P = 0.01) and the systolic pulmonary artery pressure (33.4 ± 7.8 vs. 25.6 ± 5.3 mmHg, P = 0.02) in patients with myocardial injury during the acute COVID-19 phase. Sensitivity analyses showed that these alterations of left ventricular diastolic markers were observed regardless of cardiovascular disorders indicating SARS-CoV-2 infection as a primary cause.ConclusionsSix months after the acute COVID-19 phase, significant cardiac diastolic abnormalities are observed in patients who experienced myocardial injury but not in patients without cardiac involvement.

Cardiac performance in patients hospitalized with COVID-19: a 6month follow-up study.

AimsMyocardial injury is frequently observed in patients hospitalized with coronavirus disease 2019 (COVID‐19) pneumonia. Different cardiac abnormalities have been reported during the acute COVID‐19 phase, ranging from infra‐clinic elevations of myocardial necrosis biomarkers to acute cardiac dysfunction and myocarditis. There is limited information on late cardiac sequelae in patients who have recovered from acute COVID‐19 illness. We aimed to document the presence and quantify the extent of myocardial functional alterations in patients hospitalized 6 months earlier for COVID‐19 infection.Methods and resultsWe conducted a prospective echocardiographic evaluation of 48 patients (mean age 58 ± 13 years, 69% male) hospitalized 6 ± 1 month earlier for a laboratory‐confirmed and symptomatic COVID‐19. Thirty‐two (66.6%) had pre‐existing cardiovascular risks factors (systemic hypertension, diabetes, or dyslipidaemia), and three patients (6.2%) had a known prior myocardial infarction. Sixteen patients (33.3%) experienced myocardial injury during the index COVID‐19 hospitalization as identified by a rise in cardiac troponin levels. Six months later, 60.4% of patients still reported clinical symptoms including exercise dyspnoea for 56%. Echocardiographic measurements under resting conditions were not different between patients with versus without myocardial injury during the acute COVID‐19 phase. In contrast, low‐level exercise (25W for 3 min) induced a significant increase in the average E/e′ ratio (10.1 ± 4.3 vs. 7.3 ± 11.5, P = 0.01) and the systolic pulmonary artery pressure (33.4 ± 7.8 vs. 25.6 ± 5.3 mmHg, P = 0.02) in patients with myocardial injury during the acute COVID‐19 phase. Sensitivity analyses showed that these alterations of left ventricular diastolic markers were observed regardless of whether of cardiovascular risk factors or established cardiac diseases indicating SARS‐CoV‐2 infection as a primary cause.ConclusionsSix months after the acute COVID‐19 phase, significant cardiac diastolic abnormalities are observed in patients who experienced myocardial injury but not in patients without cardiac involvement.

HEMODYNAMIC EFFECTS OF NITROXYL DONOR BMS-986231 COMPARED TO NITROGLYCERIN OR PLACEBO IN PATIENTS WITH CHRONIC HEART FAILURE-A RANDOMIZED DOUBLE-BLIND CROSSOVER TRIAL

Nitroxyl (HNO) causes post-translational modification of thiol proteins. In animal models, the HNO donor BMS-986231 causes vasodilation and has inotropic and lusitropic actions. We compared the effects of BMS-986231 to nitroglycerin (NTG) or placebo on cardiac performance in patients with chronic

Considerable scatter in the relationship between left atrial volume and pressure in heart failure with preserved left ventricular ejection fraction

The index for a target that can lead to improved prognoses and more reliable therapy in each heterogeneous patient with heart failure with preserved ejection fraction (HFpEF) remains to be defined. We examined the heterogeneity in the cardiac performance of patients with HFpEF by clarifying the relationship between the indices of left atrial (LA) volume (LAV) overload and pressure overload with echocardiography. We enrolled patients with HFpEF (N = 105) who underwent transthoracic echocardiography during stable sinus rhythm. Relative LAV overload was evaluated using the LAV index or stroke volume (SV)/LAV ratio. Relative LA pressure overload was estimated using E/e’ or the afterload-integrated index of left ventricular (LV) diastolic function: diastolic elastance (Ed)/arterial elastance (Ea) ratio = (E/e’)/(0.9 × systolic blood pressure). The logarithmic value of the N-terminal pro-brain natriuretic peptide was associated with SV/LAV (r = −0.214, p = 0.033). The pulmonary capillary wedge pressure was positively correlated to Ed/Ea (r = 0.403, p = 0.005). SV/LAV was negatively correlated to Ed/Ea (r = −0.292, p = 0.002), with no observed between-sex differences. The correlations between the LAV index and E/e’ and Ed/Ea and between SV/LAV and E/e’ were less prominent than the abovementioned relationships. SV/LAV and Ed/Ea, showing relative LAV and LA pressure respectively, were significantly but modestly correlated in patients with HFpEF. There may be considerable scatter in the relationships between these indices, which could possibly affect the selection of medications or efforts to improve the prognoses of patients with HFpEF.

The application value of afterload-related cardiac performance in patients with sepsis-induced cardiomyopathy

Objective To investigate the application value of afterload-related cardiac performance(ACP) in patients with sepsis-induced cardiomyopathy. Methods A total of 148 patients with septic shock admitted by the department of critical care of Wuhan fourth hospital from April 2013 to March 2018 were retrospectively included, all included patients were divided into LVEF 80%), mild heart function impairment group (60% < ACP≤80%), moderate heart function impairment group (40% < ACP≤60%), and severe heart function impairment group (ACP≤40%) according to ACP value, the mortality rate at 28 days was compared in the 4 groups. The measurement data were compared by grouped t test, the rates were compared by chi-square test. Results The mortality rate was 58.2% in the LVEF < 50% group, and 30.9% in the LVEF≥50% group, with statistically significant differences (χ2=11.171, P<0.01). The values of ACP in the LVEF < 50% group were (39.3±16.4) %, and those in the LVEF≥50% group were (69.1±14.9) %, with statistically significant differences (t=11.571, P<0.01).The mortality rate was 14.81% in the normal group, 44.00% in the mild, 58.82% in the moderate and 90.00% in the severe group. The differences between the normal group and the mild and moderate groups were statistically significant, while those between the severe group and the mild and moderate groups were statistically significant. Conclusion Afterload-related cardiac performance is of great value for the diagnosis and prognosis in patients with sepsis-induced cardiomyopathy. Key words: Sepsis-induced cardiomyopathy; Septic shock; Afterload-related cardiac performance; Cardiac output; Systemic vascular resistance

Impact of cardiac function, refractory ascites and beta blockers on the outcome of patients with cirrhosis listed for liver transplantation

Whether non-selective beta blockers (NSBBs) are deleterious in patients with end-stage cirrhosis and refractory ascites has been widely debated. We hypothesized that only the subset of patients on the liver transplant waiting list who had impaired cardiac performance would be at increased risk of mortality if receiving NSBBs. This study included 584 consecutive patients with cirrhosis evaluated for transplantation between 1999 and 2014. All patients had right heart catheterization with hemodynamic measurements at evaluation. Fifty percent received NSBBs. Refractory ascites was present in 33%. Cardiac performance was assessed by left ventricular stroke work index (LVSWI). Waiting list mortality without liver transplantation was explored using competing risk analysis. LVSWI was significantly lower in patients with refractory ascites. In multivariate analysis using competing risk, refractory ascites, NSBBs and LVSWI were associated with waiting list mortality in the whole population, with a statistically significant interaction between NSBBs and LVSWI. The most discriminant value of LVSWI was 64.1g-m/m2. In the final model, refractory ascites (subdistribution hazard ratio 1.52; 95% CI1.01-2.28; p=0.0083) and treatment by NSBBs with LVSWI <64.1g-m/m2 (subdistribution hazard ratio 1.96; 95% CI 1.32-2.90; p=0.0009) were significantly associated with waiting list mortality, taking into account serum sodium and the model for end-stage liver disease score. This study suggests that compromised cardiac performance is more common in patients with refractory ascites and that NSBBs are deleterious in cirrhotic patients with compromised cardiac performance. These results highlight the prognostic value of cardiac function in patients with end-stage cirrhosis. There are still controversies concerning the impact of non-selective beta blockers on outcomes in patients with decompensated cirrhosis, especially in those with refractory ascites. In this study of 584 cirrhotic patients evaluated for liver transplantation, who underwent right heart catheterization, we have shown that global cardiac performance measured by left ventricular stroke work index is lower in patients with refractory ascites. Administration of non-selective beta blockers in patients with compromised cardiac performance may increase waiting list mortality. These results highlight the prognostic value of global cardiac performance in patients with end-stage cirrhosis.

Ghrelin Preserves Ischemia-Induced Vasodilation of Male Rat Coronary Vessels Following β-Adrenergic Receptor Blockade.

Acute myocardial infarction (MI) triggers an adverse increase in cardiac sympathetic nerve activity (SNA). Whereas β-adrenergic receptor (β-AR) blockers are routinely used for the management of MI, they may also counter β-AR-mediated vasodilation of coronary vessels. We have reported that ghrelin prevents sympathetic activation following MI. Whether ghrelin modulates coronary vascular tone following MI, either through the modulation of SNA or directly as a vasoactive mediator, has never been addressed. We used synchrotron microangiography to image coronary perfusion and vessel internal diameter (ID) in anesthetized Sprague-Dawley rats, before and then again 30 minutes after induction of an MI (left coronary artery ligation). Rats were injected with either saline or ghrelin (150 µg/kg, subcutaneously), immediately following the MI or sham surgery. Coronary angiograms were also recorded following β-AR blockade (propranolol, 2 mg/kg, intravenously). Finally, wire myography was used to assess the effect of ghrelin on vascular tone in isolated human internal mammary arteries (IMAs). Acute MI enhanced coronary perfusion to nonischemicregions through dilation of small arterioles (ID 50 to 250 µm) and microvessel recruitment, irrespective of ghrelin treatment. In ghrelin-treated rats, β-AR blockade did not alter the ischemia-induced vasodilation, yet in saline-treated rats, β-AR blockade abolished the vasodilation of small arterioles. Finally, ghrelin caused a dose-dependent vasodilation of IMA rings (preconstricted with phenylephrine). In summary, this study highlights ghrelin as a promising adjunct therapy that can be used in combination with routine β-AR blockade treatment for preserving coronary blood flow and cardiac performance in patients who suffer an acute MI.

Abnormal Coronary Flow Velocity Reserve and Decreased Myocardial Contractile Reserve Are Main Factors in Relation to Physical Exercise Capacity in Cardiac Amyloidosis

The aim of the present study was to evaluate the clinical importance of echocardiographic coronary flow velocity reserve (CFVR), resting and exercise left ventricular global longitudinal strain (LVGLS), and myocardial work efficiency (MWE) in patients with cardiac amyloidosis (CA). The study population comprised 69 subjects: group A, 27 patients with CA confirmed by endomyocardial biopsy (CA positive); group B, 42 healthy control subjects. The amyloid phenotype in group A was as follows: patients with wild-type transthyretin-related amyloidosis (n=10), carriers of the Danish familial transthyretin amyloidosis mutation with cardiac involvement (n=5), and patients with amyloid light chain amyloidosis with cardiac involvement (n=12). All subjects underwent comprehensive echocardiographic evaluation during rest and during symptom-limited, semisupine exercise testing. Furthermore, CFVR was assessed using Doppler echocardiography. Patients with CA had significantly lower CFVR (1.7±0.6 vs 3.9±0.8, P<.0001), MWE (1.9±1.0 vs 3.0±0.7, P<.0001), and LVGLS magnitude (11% [10%-14%] vs 20% [18%-21%], P<.0001) than control subjects. Patients with CA showed severely reduced deformation and efficiency reserve compared with control subjects (ΔLVGLS 0.9±2.8% vs 5.6±2.3%, P<.0001; ΔMWE 2.5±2.8 vs 8.8±2.6, P<.0001). In patients with CA, a strong relation was seen between physical capacity by the metabolic equivalent of tasks test and CFVR (r=0.55, P<.01), peak exercise LVGLS (r=0.64, P<.0001), and peak exercise MWE (r=0.60, P<.01). Patients with CA had a profound lack of CFVR and longitudinal myocardial deformation reserve compared with healthy control subjects. Both parameters were significantly associated with exercise capacity and may prove useful for evaluating cardiac performance in patients with CA.

Non-Invasive Ventilation in Patients with Heart Failure: A Systematic Review and Meta-Analysis.

Non-invasive ventilation (NIV) may perfect respiratory and cardiac performance in patients with heart failure (HF).The objective of the study to establish, through systematic review and meta-analysis, NIV influence on functional capacity of HF patients.A systematic review with meta-analysis of randomized studies was carried out through research of databases of Cochrane Library, SciELO, Pubmed and PEDro, using the key-words: heart failure, non-invasive ventilation, exercise tolerance; and the free terms: bi-level positive airway pressure (BIPAP), continuous positive airway pressure (CPAP), and functional capacity (terms were searched for in English and Portuguese) using the Boolean operators AND and OR. Methodological quality was ensured through PEDro scale. Weighted averages and a 95% confidence interval (CI) were calculated. The meta-analysis was done thorugh the software Review Manager, version 5.3 (Cochrane Collaboration).Four randomized clinical trials were included. Individual studies suggest NIV improved functional capacity. NIV resulted in improvement in the distance of the six-minute walk test (6MWT) (68.7m 95%CI: 52.6 to 84.9) in comparison to the control group.We conclude that the NIV is an intervention that promotes important effects in the improvement of functional capacity of HF patients. However, there is a gap in literature on which are the most adequate parameters for the application of this technique.