Severe Chronic Heart Failure Patients Research Articles

Galectin -3: an independent cardiac marker of left ventricular (LV) remodeling in chronic heart failure

Introduction and Aim: Heart failure (HF) with increased morbidity and mortality is a critical condition where the cardiac pumping capacity fails to meet up with the body’s demand. Its development is silent due to slow, progressive remodeling presenting with symptoms later. Brain Natriuretic peptides (BNP) denotes ventricular loading status which do not reveal other mechanisms whereas a novel marker Galectin-3 (Gal-3) provides information about cardiac structural changes which includes inflammation, fibrosis, remodeling for guiding treatment. Research studies demonstrated that there is upregulation of Galectin- 3 in both acute and chronic heart failure (CHF) individuals. The objectives of our study were to compare Galectin- 3 levels in moderate and severe LVD CHF patients and determine whether serum Galectin -3 can be used as an independent cardiac marker of ventricular structural remodeling in such HF individuals. Materials and Methods: 80 patients between 20 - 80 years diagnosed with CHF using Framingham criteria with ejection fraction (EF) of 45% and classified into two groups:(i) moderate LVD and (ii) severe LVD. Those with abnormal kidney functions were excluded. Comparison was done between serum Galectin - 3 and BNP; Gal- 3 was determined to be an independent marker of structural remodeling of LV between the two categories. Results: Galectin-3 and BNP were significantly increased in HF with severe LVD than moderate LVD. Multivariate linear regression showed Galectin-3 as an independent predictor of LV remodeling with respect to changes in LV end- diastolic dimension with statistically significant p 0.001 whereas BNP did not show any such significance. Conclusion: Galectin -3 and BNP levels were elevated in severe LV dysfunction than moderate LVD and concluded that Gal-3 is an independent cardiac biomarker of LV remodeling in Chronic heart failure.

Alterations of the Gut Microbiota in Patients With Severe Chronic Heart Failure.

Chronic heart failure (CHF) is the final outcome of almost all forms of cardiovascular diseases, remaining the main cause of mortality worldwide. Accumulating evidence is focused on the roles of gut microbial community in cardiovascular disease, but few studies have unveiled the alterations and further directions of gut microbiota in severe CHF patients. Aimed to investigate this deficiency, fecal samples from 29 CHF patients diagnosed with NYHA Class III-IV and 30 healthy controls were collected and then analyzed using bacterial 16S rRNA gene sequencing. As a result, there were many significant differences between the two groups. Firstly, the phylum Firmicutes was found to be remarkably decreased in severe CHF patients, and the phylum Proteobacteria was the second most abundant phyla in severe CHF patients instead of phylum Bacteroides strangely. Secondly, the α diversity indices such as chao1, PD-whole-tree and Shannon indices were significantly decreased in the severe CHF versus the control group, as well as the notable difference in β-diversity between the two groups. Thirdly, our result revealed a remarkable decrease in the abundance of the short-chain fatty acids (SCFA)-producing bacteria including genera Ruminococcaceae UCG-004, Ruminococcaceae UCG-002, Lachnospiraceae FCS020 group, Dialister and the increased abundance of the genera in Enterococcus and Enterococcaceae with an increased production of lactic acid. Finally, the alternation of the gut microbiota was presumably associated with the function including Cell cycle control, cell division, chromosome partitioning, Amino acid transport and metabolism and Carbohydrate transport and metabolism through SCFA pathway. Our findings provide the direction and theoretical knowledge for the regulation of gut flora in the treatment of severe CHF.

Effects of WeChat platform-based health management on health and self-management effectiveness of patients with severe chronic heart failure.

BACKGROUNDEpidemiological studies have found that the prevalence of chronic heart failure in China is 0.9%, the number of people affected is more than 4 million, and the 5-year survival rate is even lower than that of malignant tumors.AIMTo determine the impact of WeChat platform-based health management on severe chronic heart failure patients’ health and self-management efficacy.METHODSA total of 120 patients suffering from chronic heart failure with cardiac function grade III-IV, under the classification of the New York Heart Association, were admitted to our hospital in May 2017. In January 2020, they were divided into two groups: A control group (with routine nursing intervention) and an observation group (with WeChat platform-based health management intervention). Changes in cardiac function, 6-min walking distance (6MWD), high-sensitivity cardiac troponin (hs-cTnT), and N-terminal pro B-type natriuretic peptide (NT-proBNP) were detected in both groups. The Self-Care Ability Scale (ESCA) score, Minnesota Living with Heart Failure Questionnaire score, and compliance score were used to evaluate self-management ability, quality of life, and compliance of the two groups. During a follow-up period of 12 mo, the occurrence of cardiovascular adverse events in both the groups was counted.RESULTSThe left ventricular ejection fraction, stroke output, and 6MWD increased, and the hs-cTnT and NT-proBNP decreased in both the groups, as compared to those before the intervention. Further, cardiac function during the 6MWD, hs-cTnT, and NT-proBNP improved significantly in the observation group after intervention (P < 0.05). The scores of self-care responsibility, self-concept, self-care skills, and self-care health knowledge in the observation group were higher than those of the control group before intervention, and their ESCA scores were significantly improved after intervention (P < 0.05). The Minnesota heart failure quality of life (LiHFe) scores of physical restriction, disease symptoms, psychological emotion, social relations, and other items were decreased compared to those of the control group before intervention, and the LiHFe scores of the observation group were significantly improved compared to those of the control group (P < 0.05). With intervention, the compliance scores of rational diet, regular medication, healthy behavior, and timely reexamination were increased, thereby leading to the compliance scores of the observation group being significantly improved compared to those of the control group (P < 0.05). During the 12 mo follow-up, the incidence rates of acute myocardial infarction and cardiogenic rehospitalization in the observation group were lower than those of the control group, and the hospitalization time in the observation group was shorter than that of the control group, but there was no significant difference between the two groups (P > 0.05).CONCLUSIONWeChat platform-based health management can improve the self-care ability and compliance of patients with severe chronic heart failure, improve the cardiac function and related indexes, reduce the occurrence of cardiovascular adverse events, and enable the avoidance of rehospitalization.

Interrelationship between renin-angiotensin-aldosterone system and oxidative stress in chronic heart failure patients with or without renal impairment

We investigated oxidative stress and RAAS biomarkers, as well as their association, in chronic heart failure (CHF) patients on optimized medical therapy, stratified by disease severity or by renal function. Since vitamin D has been shown to attenuate RAAS activation and oxidative stress, we further evaluated the relationship between vitamin D, RAAS and oxidative stress in CHF patients with or without renal impairment. Sixty CHF outpatients were included and stratified by disease severity or by renal function. We quantified urinary hydrogen peroxide, plasma and urinary isoprostanes, plasma total antioxidant status, urinary angiotensinogen (intrarenal RAAS activation biomarker) and plasma angiotensinogen, plasma renin and aldosterone concentration, serum angiotensin-converting enzyme (ACE) activity, plasma angiotensin peptides, and serum total 25-hydroxyvitamin D (S-total 25(OH)D). Severe CHF patients had higher urinary isoprostanes (p = 0.002) and lower S-total 25(OH)D (p = 0.006) compared to mild-to-moderate patients, but no differences were observed for other redox or RAAS biomarkers. Patients with impaired renal function (iRF) had higher urinary angiotensinogen (p = 0.003) and lower S-total 25(OH)D (p = 0.028) compared to those with normal renal function (nRF), while no differences were observed for the remaining RAAS and redox parameters. Several positive correlations between oxidative stress and RAAS biomarkers were detected in iRF patients, while in patients with nRF these correlations were primarily inverse. In CHF-iRF patients, S-25(OD)D was inversely associated with urinary isoprostanes, which in turn were positively associated with plasma angiotensinogen and serum ACE. In conclusion, CHF patients with renal function impairment have increased intrarenal RAAS activation and lower vitamin D values and might benefit from the combination of RAAS blockers with vitamin D and/or antioxidants.

Integrated approach of yoga, meditation and enhanced external counter pulsation with pharmacological therapy in severe chronic heart failure patients

Integrated approach of yoga, meditation and enhanced external counter pulsation with pharmacological therapy in severe chronic heart failure patients

Palliative care needs in patients with severe and chronic heart failure and their influencing factors

Objective To explore the palliative care needs in patients with severe and chronic heart failure (CHF) and their influencing factors. Methods Totally 110 severe CHF patients hospitalized in the Department of Cardiovascular Medicine of a ClassⅢ Grade A hospital in Harbin from June 2016 to October 2017 were selected by convenient sampling, and investigated with the general information questionnaire, Palliative Care Outcome Scale (POS) , Hospital Anxiety and Depression Scale (HADS) and Karnofsky Performance Status (KPS) . Multiple linear regression analysis was used to analyze the influencing factors to the palliative care needs in severe CHF patients. Results The POS score of the 110 severe CHF patients was (19.01±4.20) . Multiple linear regression analysis showed that the patient's course of disease, cardiac function, number of comorbidities, anxiety and depression were the influencing factors to the palliative care needs in severe CHF patients (P<0.05) . Conclusions Severe CHF patients have higher palliative care needs. Medical and nursing workers should take palliative care measures as early as possible according to the actual situation of patients to improve the patient's quality of life. Key words: Heart failure; Anxiety; Depression; Palliative care; Influencing factors

FACTORS OF LIFE QUALITY IMPROVEMENT AFTER HEART TRANSPLANTATION: PREDICTIVE SIGNIFICANCE OF CARDIOPULMONARY EXERCISE TEST

Aim . Evaluation of prognostic significance of the parameters of cardiopulmonary exercise test in life quality improvement for the post-cardiac transplantation patients. Material and methods. Into the study, 40 patients included, with severe chronic heart failure (CHF), included in the waiting list for cardiac transplantation. Before and after orthotopic heart transplantation (OHT), clinical status was evaluated, cardiopulmonary exercise testing parameters (CET) and life quality by SF-36. Results . After OHT the significant life quality improvement noted, by the scale “Physical health” from 36 (32-45) points before surgery to 52 (49-55) points (p&lt;0,05) and “Psychological health” from 38 (34-50) to 51 (50-56) points. In 13% cases life quality improvement was not noted. Among the CET parameters, significant relation with life quality improvement by “Physical” scale showed the preoperation level of exercise tolerance (ОR 2,10 (1,08-9,80), p=0,001), peak of oxygen consumption (OR 1,20 (0,97-2,61), p=0,037), efficacy of oxygen consumption in exertion (OR 0,68 (0,36-1,27), p=0,047). Also, it was shown that life quality increase after OHT depends on efficacy of oxygen consumption baseline return in first minute (OR 1,13 (1,02-1,27), p=0,024). Any relations of CET with “Psychological” life quality by SF-36 were not noted. Conclusion. Exercise tolerance, peak oxygen consumption, exertion ventilatory efficacy, efficacy of oxygen consumption baseline return after exercise, by CET in severe CHF patients, have high predictive value in evaluation of probability of life quality improvement by the scale “Physical health” of SF-36 after cardiac transplantation.

RIGHT VENTRICLE MYOCARDIUM CONTRACTILITY AS PARAMETER OF CARDIAC RESYNCHRONIZATION EFFICACY

Aim. To evaluate the significance of the right ventricle (RV) myocardium contractility in assessment of cardiac resynchronization therapy (CRT). Material and methods. Totally, 80 patients included, with dilation cardiomyopathy (49 males, 31 females), mean age 54±10,5 y.o.), heart failure (HF) of III functional class (FC) by NYHA, ejection fraction (EF) of the left ventricle (LV) was 30,1±3,8%, 6-minute walking distance — 290,5±64,3 m, end-diastolic volume (EDV) — 220,7±50,9 mL. Stable sinus rhythm was found in 45 patients, and chronic medication resistant atrial fibrillation — in35. In patients, the disorders of intraventricular conduction were found as the His left bundle branch block with QRS width from 146 ms to 240 ms (183±32 ms). Implanting of the resynchronization device was done by standard method for biventricular electrocardiostimulation. Permanent atrial fibrillation patients, as 2nd step, underwent complete atrioventricular block formation. In all patients, by radionuclide equal tomoventriculography, the contractility was studied, of the left and right ventricle myocardium, before CRT and 12 moths post-procedure. Results. Control study was conducted in 1 year; positive clinical dynamics was noticed: FC of HF decreased from III to II. Clinical responders were 69 patients (86,25%), did not respond 11 (13,75%). As the criteria of the “respond” on CRT we used increased 15% and more EF during 12 months. Among the responders, there was positive clinical dynamics: EF of LV increased from 30,1±3,8% to 42,8±4,8% (p≤0,001), LV EDV decreased from 220,7±50,9 to 197,9±47,8 mL (p≤0,005), in nonresponders EF LV remained almost unchanged: from 30,1±3,8% to 33,8±3,8% (p≤0,001), and EDV of LV increased: 220,7±50,9 to 227,8±27,8 mL (p≤0,001). All participants were retrospectively selected into 2 groups: responders and nonresponders on CRT. Radionuclide tomoventriculography was used for the changes for 12 months ofLV and RV contractility investigation. Maximum filling rate and the mean filling velocity during 1/3 of diastole were significantly worse in the 2nd group patients, by 30% and 60%, respectively. Other parameters in the groups did not differ significantly. Conclusion. Hence, the data points on the relation of RV contractility improvement by CRT with positive cardiac resynchronization, together with the improvement of theLV contractility. Resynchronization in severe chronic HF patients, with saved contractility of the right chambers, is more effective, and higher scintigraphical values of maximum filling rate and the mean filling velocity during 1/3 of diastole might be prognosis criteria of positive response on CRT.

0087: Sleep apneas treatment during cardiac rehabilitation can improve heart failure prognosis? SATELIT-HF study: sleep apnea treatment during cardiac rehabilitation of CHF patients

Sleep-disordered breathing (SDB) is commonly in chronic heart failure (CHF) patients. Exercise training (ET) improves exercise tolerance and reduces cardiac decompensations in CHF population. Otherwise, ventilation therapy (VT) improves prognosis and exercise capacity in CHF patients with SDB. However, the effect of the combination therapy: ET and VT is still unexplored. The aim of our study is to evaluate the effects on hemodynamic status (cardiac decompensations) of ET and VT in stable CHF patients referred to cardiac rehabilitation (CR). We included 118 stable CHF patients with an apnea-hypopnea index (AHI) >15/h diagnosed by polygraphy. They were randomized into exercise training (ET group n=58) or combined exercise and ventilation (ET+VT group n=60). The follow up period was the 8 weeks during which 20 exercise training sessions were scheduled. Severe episodes of cardiac decompensations were recorded. The mean age was 62.6±10.3 years, 89% were males, 50% NYHA class II and 50% in class III, mean LVEF was 30%. 40% and 60% of patients had respectively obstructive and central and/or mixed apneas, with a mean AHI 34.4±14.3/h. Patients of ET+VT group had significantly fewer acute cardiovascular events than those of ET group (2/60 vs. 7/58; 3.3% vs. 15.5%, p<0.05). Ventilation therapy combined with ET in severe CHF patients seems to reinforce benefits of ET alone. Screening of SDB in CR could be proposed in order to optimize the global management of the heart disease.

Sleep apneas treatment during cardiac rehabilitation can improve heart failure prognosis? SATELIT-HF

Introduction Sleep-disordered breathing (SDB) is commonly in chronic heart failure (CHF) patients. Exercise training (ET) improves exercise tolerance and reduces cardiac decompensations in CHF population. Otherwise, ventilation therapy (VT) improves prognosis and exercise capacity in CHF patients with SDB. However, the effect of the combination therapy: ET and VT is still unexplored. The aim of our study is to evaluate the effects on hemodynamic status (cardiac decompensations) of ET and VT in stable CHF patients referred to cardiac rehabilitation (CR). Methods We included 118 stable CHF patients with an apnea-hypopnea index (AHI) > 15/h diagnosed by polygraphy. They were randomized into exercise training (ET group n = 58) or combined exercise and ventilation (ET + VT group n = 60). The follow up period was the 8 weeks during which 20 exercise training sessions were scheduled. Severe episodes of cardiac decompensations were recorded. Results The mean age was 62.6 ± 10.3 years, 89% were males, 50% NYHA class II and 50% in class III, mean LVEF was 30%. 40% and 60% of patients had respectively obstructive and central and/or mixed apneas, with a mean AHI 34.4 ± 14.3/h. Patients of ET + VT group had significantly fewer acute cardiovascular events than those of ET group (2/60 vs. 9/58; 3.3% vs. 15.5%, P Conclusion Ventilation therapy combined with ET in severe CHF patients seems to reinforce benefits of ET alone. Screening of SDB in CR could be proposed in order to optimize the global management of the heart disease.

A physiologically based pharmacokinetic drug-disease model to predict carvedilol exposure in adult and paediatric heart failure patients by incorporating pathophysiological changes in hepatic and renal blood flows.

Background and ObjectiveChronic diseases are associated with pathophysiological changes that could have profound impacts on drug pharmacokinetic behaviour, with a potential need to modify the administered drug therapy. It is important to acknowledge that most patients with chronic illnesses do not have a single, predominant condition but suffer from multiple comorbidities. The rapid advancement in physiologically based pharmacokinetic (PBPK) modelling, as well as the increasing quantitative knowledge of disease-related pathophysiological changes, facilitate building of drug–disease models. However, there are only a few published examples of PBPK models incorporating the pathophysiological changes that occur with chronic diseases. The objective of this study was to develop PBPK models that incorporate the haemodynamic changes in hepatic and renal blood flows occurring in chronic heart failure (CHF) and to evaluate these changes in adults and children, using carvedilol as a model drug.MethodsAfter a comprehensive literature search to select the model input parameters, two PBPK models were developed. Model 1 was based on human liver and intestinal microsome clearances, and model 2 was based on clearance by specific cytochrome P450 enzymes. After evaluation of both models in healthy adults, the reduced hepatic and renal blood flows were incorporated into the developed models to predict carvedilol exposure in the adult CHF population. The adult carvedilol models were scaled down to children by using Simcyp® (Simcyp Ltd, Sheffield, UK). In order to show the impact of reduced organ blood flows on carvedilol disposition, the predictions in the CHF population were made with and without reductions in organ blood flows.ResultsThe predictions made by both models in healthy adults were comparable and within the 2-fold error range. In adults with CHF, the mean observed/predicted ratio [ratio(Obs/Pred)] for oral clearance (CL/F) without reductions in organ blood flows was outside the 2-fold error range, i.e. 0.34 (95 % confidence interval [CI] 0.31–0.37), with use of both models. The mean CL/F ratio(Obs/Pred) values after incorporation of reduced organ blood flows were 1.0 (95 % CI 0.92–1.08) and 0.95 (95 % CI 0.88–1.03) with use of models 1 and 2, respectively. The mean ratio(Obs/Pred) values for the pharmacokinetic parameters were not improved after incorporation of reduced blood flows in paediatric patients, except in those above 17 years of age, who were categorized according to the New York Heart Association classification of CHF, where the CL/F ratio(Obs/Pred) values in two patients were closer to unity.ConclusionThere was a strong connection between a decrease in hepatic clearance of carvedilol and an increase in the severity of CHF, especially in adults and in paediatric patients above 17 years of age. The incorporated reductions in hepatic and renal blood flows occurring in moderate and severe CHF patients resulted in improved predictions of carvedilol exposure. The developed models can be extended to predict exposures of drugs with high hepatic extraction in the CHF population.Electronic supplementary materialThe online version of this article (doi:10.1007/s40262-015-0253-7) contains supplementary material, which is available to authorized users.

Optimisation of cardiac resynchronisation therapy during exercise

The benefits of cardiac resynchronisation therapy (CRT) in selected cohorts with systolic dysfunction and congestive heart failure are well established [1–3]. CRT reduces heart failure hospitalisations, decreases mortality, and improves the quality of life and cardiac function, described as left ventricular (LV) reverse remodelling. CRT improves inter-, intra- and atrio-ventricular dyssynchrony. It is important to stress that there is only a moderate correlation between clinical and echocardiographic response; i.e. patients with improvement in their clinical status might not always show significant reverse remodelling. Nevertheless, the number of patients who do not respond to this therapy remain as high as 30 % to 40 %. The reasons for not responding to CRT are probably complex and multifactorial. Patient selection, accurate assessment of dyssynchrony, LV lead placement and optimal position and device programming are of importance. This necessitates a comprehensive evaluation of baseline and post-implant clinical, electrocardiographic and echocardiographic data. Moreover, LV lead position optimisation and device interrogation are useful for optimising CRT and should be considered to maximise the therapeutic response to CRT. It is recommended to perform AV-delay optimisation in all patients, guided either by the device or by echocardiography. However, the role of AV and VV optimisation regarding long-term outcome remain debatable. The SMART AV trial [4] showed that patients with normal AV delay did not derive benefit from echo-guided or device-guided AV optimisation compared with the empiric settings. However, patients with prolonged AV conduction were not included in this prospective, randomised trial. Moreover, in the Freedom trial [5] the authors concluded that routine AV and VV optimisation, by echo or the QuickOpt algorithm in unselected CRT recipients, did not appear to contribute significantly to further improving responsiveness to CRT. A variety of techniques, including echocardiography-guided methods, have been described to determine the optimal AV and VV delays. Many of these techniques have poor reproducibility and are time-consuming [6, 7]. None of these techniques have been shown to be superior and long-term benefits are lacking. Most device-based algorithms allow a rapid, simplified approach to CRT optimisation. However, their clinical value has also been called into question. Only the CLEAR study [8, 9] results suggest the clinical value of frequent CRT optimisation by SonRTM algorithm or echocardiography in severe chronic heart failure patients in the long-term.

Survey on the anaemia and renal function of the hospitalised severe chronic heart failure patients

ObjectiveTo investigate the incidence of anaemia and renal dysfunction in severe chronic heart failure (CHF) patients and analyse the relationship among anaemia, RF and CHF and assess the impact of...

Changes in Cardiac Denervation Independent of Changes in Systolic Function During Follow-up in CHF Patients

Introduction: Regional cardiac denervation in chronic heart failure (CHF) is associated with propensity towards arrhythmogenesis and with increased cardiac effects of catecholamines. The objectives of the study were to evaluate relationships between the extent of denervation utilising metaiodobenzylguanidine (123I-MIBG) myocardial scintigraphy and markers of LV systolic dysfunction in severe CHF patients, and to assess the progression of sympathetic nervous dysfunction. Methods: 123I-MIBG was performed in 41 CHF patients (mean LVEF 30 ± 7%) and was repeated in a subgroup of 14 patients after one year. The early and delayed heart to mediastinum ratio (EHMR and DHMR) and washout rate were calculated. Echocardiographic LVDs, LVDd and LVEF as well as NT-proBNP concentrations were determined at the same time points. Results: CHF was infarct-related in 68% of the patients. At baseline, EHMR and DHMR (1.7 ± 0.18 and 1.59 ± 0.18) were significantly lower than population norms (2.42 ± 0.27 and 2.60 ± 0.15, respectively). There was a weak inverse relationship between EHMR and LVDd (r = −0.37, p = 0.025) and LVDs (r = −0.30, p = 0.086), but not with LVEF. NT-proBNP concentrations also inversely correlated with DHMR (r = −0.33, p = 0.04). As regards the progression of myocardial denervation, there was a significant decrease in DHMR (1.55 ± 0.25 vs.1.26 ± 0.3, p = 0.0002), with no significant change in LV functional parameters or NT-pro-BNP levels. Conclusions: CHF is associated with marked myocardial sympathetic dysfunction, which is weakly correlated with LVD and NT-proBNP concentrations. Sympathetic nervous activity deteriorated significantly during 12 months follow-up, independently of changes in systolic function.

Functional Electrical Stimulation is More Effective in Severe Symptomatic Heart Failure Patients and Improves Their Adherence to Rehabilitation Programs

BackgroundFunctional electrical stimulation (FES) improves exercise capacity and quality of life in chronic heart failure (CHF) patients. However, there is no evidence regarding the effectiveness of this treatment modality according to the severity of CHF. This study compares the effectiveness of FES on exercise capacity, endothelial function, neurohormonal status, and emotional stress in New York Heart Association (NYHA) III-IV versus NYHA II patients. Methods and ResultsEighteen NYHA II and 13 age- and sex-matched NYHA III-IV patients with stable CHF (left ventricular ejection fraction <35%) underwent a 6-week FES training program. Questionnaires addressing quality of life (Kansas City Cardiomyopathy Questionnaire, functional and overall), and emotional stress (Zung self-rating depression scale, Beck Depression Inventory), as well as plasma B-type natriuretic peptide (BNP), 6-minute walking distance test (6MWT), and endothelial function (flow-mediated dilatation [FMD]) were assessed at baseline and after completion of training protocol. 6MWT and plasma BNP improved significantly in 2 patient groups (both P < .001) after training program. The improvement of BNP was statistically greater in NYHA III-IV patients posttreatment than in those with NYHA II class (F=315.342, P < .001). Similarly, the improvement of 6MWT was statistically greater in NYHA III-IV group than in NYHA II patients (F=79.818, P < .001). Finally, an FES-induced greater improvement of FMD (F=9.517, P=.004) and emotional stress scores was observed in NYHA III-IV patients in comparison to NYHA II patients. There was a higher proportion of NYHA III-IV patients adhering to the FES training program for additional 3 months compared with the NYHA II group of patients (76.9% vs. 55.6%, P < .001). ConclusionFES might exert a greater beneficial effect on clinical and neurohormonal status of NYHA III-IV patients in comparison to NYHA II patients. This effect may have important clinical relevance leading to increased adherence of severe CHF patients to exercise rehabilitation programs.

Six-minute walking test predicts long-term cardiac death in patients who received cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) has been proven to be effective in patients suffering from chronic heart failure (CHF) associated with electrical dyssynchrony. However, long-term predictors of mortality in that subset have not been extensively investigated. The aim of this study was to establish baseline long-term predictors of cardiovascular mortality in CHF patients treated with CRT. A total of 188 consecutive patients with moderate to severe CHF who had undergone a successful CRT implant were evaluated. Baseline measurements included clinical history, a 6-min walking test (6MWT), and echocardiographic parameters. Patients with cardiac or non-cardiac diseases limiting their ability to perform a 6MWT were excluded, with the final count totalling 155 patients [82% men, mean age 69 +/- 8 years, New York Heart Association (NYHA) functional class: II 22%, III 73.5%, IV 4.5%]. A total of 24 patients (15.5%) died of cardiovascular causes and one patient underwent heart transplantation during a mean follow-up of 24.4 +/- 18.1 months. Univariate analysis showed that NYHA class, distance walked in the 6MWT, left atrial diameter, digoxine and left ventricle (LV) ejection fraction were all significantly related to rates of mortality. Multivariate Cox regression after adjustment for the presence of a defibrillator showed that the LV ejection fraction [HR 0.91 (95% CI: 0.84-0.98) P = 0.008] and 6MWT distance <225 m [HR 5.6 (95% CI: 1.2-25.3) P = 0.026] were independent predictors of cardiovascular mortality. Baseline functional capacity, measured by the 6MWT distance, and LV ejection fraction are independent predictors of mortality in moderate to severe CHF patients, despite CRT. A 6MWT distance walked of <225 m identifies patients at high risk of cardiovascular death at mid-long term.

Assessment of cardiac resynchronization therapy response

The present study was performed to evaluate how to assess cardiac resynchronization therapy (CRT) efficacy in chronic heart failure (CHF) through clinical, echocardiographic and exercise analysis. We analyzed 41 stable CHF (NYHA III) patients with: left bundle-branch-block, ejection fraction < 35%, left-ventricular dissynchrony (by tissue-Doppler), peak oxygen consumption (VO2) < 16 ml/kg/min, suitable cardiac vein (by multislice computed tomography) and no anemia or kidney failure. Patients were evaluated before and after (7 ± 3 months) CRT. Two patients died. CRT responders to none of the evaluated criteria were 19.5%. The best agreement (90%) with clinical response was obtained using the presence/absence of either left-ventricular systolic volume (LVSV) or peakVO2 response. In less severe CHF (peakVO2 12–16 ml/kg/min), peakVO2 and work-load didn't change after CRT, despite echocardiographic, ventilation/carbon dioxide relationship and clinical improvement. Echocardiography and CPET are complementary for the evaluation of CRT, but not in less severe CHF patients, where the role of CPET remain uncertain.

Heart-Type Fatty Acid-Binding Protein Is More Sensitive Than Troponin T to Detect the Ongoing Myocardial Damage in Chronic Heart Failure Patients

Heart-type fatty acid-binding protein (H-FABP) is a small cytosolic protein and released into the circulation when the myocardium is injured. Previous studies have demonstrated that both H-FABP and troponin T (TnT) are detectable in venous blood samples in chronic heart failure (CHF) patients, suggesting the presence of ongoing myocardial damage (OMD). We hypothesized that a cytosolic marker (H-FABP) is more sensitive than a myofibrillar component (TnT) in the detection of OMD in CHF. We measured serum H-FABP and TnT levels in 126 consecutive CHF patients at admission, and patients were followed-up with a mean period of 474 +/- 328 days. Cutoff values for H-FABP (4.3 ng/mL) and TnT (0.01 ng/mL) were determined from previous studies. Positive rate of H-FABP was higher than that of TnT in all CHF patients (46% [58/126] versus 26% [33/126], P < .0001), and in severe CHF (New York Heart Association III/IV) patients (69% [34/49] versus 47% [23/49], P = .0121). There were 27 cardiac events during a follow-up period. In patients with cardiac events, H-FABP was more frequently detected than TnT (88% [24/27] versus 44% [12/27], P = .0103). There were 33 patients with positive H-FABP among 93 patients with negative TnT. Those patients had more severe New York Heart Association class, higher levels of brain natriuretic peptide, and higher rates of cardiac events (36% versus 5%, P < .0001) compared with those both H-FABP and TnT were negative. Kaplan-Meier analysis demonstrated that in patients with negative TnT, positive H-FABP group had higher risk for cardiac events than negative H-FABP group (P < .0001). A multivariate analysis with Cox proportional hazard model showed that H-FABP was the only independent predictor of cardiac events (hazard ratio 15.677, P = .0001). The area under the receiver operating characteristic curve was larger for H-FABP than for TnT (0.779 versus 0.581; P = .009), suggesting that H-FABP had greater predictive capacity for cardiac events than TnT. H-FABP was more sensitive to detect OMD and could identify patients at high risk more effectively than TnT.

Improved exercise tolerance and cardiac function in severe chronic heart failure patients undergoing a supervised exercise program

Background Exercise intolerance is a widespread and serious problem in chronic heart failure (CHF) patients. However, the impact of a supervised exercise and rehabilitation program on exercise tolerance and cardiac performance in severe CHF patients has not yet been fully investigated. Methods Of 56 consecutive patients with severe CHF (New York Heart Association functional class III, Stage D) 44 underwent a hospital-based supervised 18-week, cardiac exercise and rehabilitation program (exercise group), and 12 did not (control group). Cardiac performance was assessed by a 6-minute walk test, peak exercise VO 2, exercise duration time, resting and immediate post peak exercise stroke index (SI), cardiac index (CI) and systemic vascular resistance (SVR), before and after exercise. Results Both groups were comparable regarding baseline clinical characteristics. Post exercise training, functional and hemodynamic parameters improved significantly in the exercise group compared to controls. A highly significant interaction between the groups and change was found in the 6-minute walk test ( p < 0.001), exercise test duration ( p < 0.001), METs during exercise ( p < 0.001), immediate post peak exercise CI (0.016), delta peak VO 2 ( p = 0.028), and immediate post peak exercise SVR ( p = 0.045). Conclusions A hospital-based supervised exercise and rehabilitation program significantly improves functional and hemodynamic parameters in severe CHF patients, and may partially contribute to better physical conditioning detected in these patients after exercise training.

Increased endothelial monocyte adhesiveness is related to clinical outcomes in chronic heart failure

Background Vascular inflammation and endothelial dysfunction are evident in patients with chronic heart failure (CHF). We hypothesized that circulating peripheral blood mononuclear cells (PBMCs) may be activated and the resultant increased endothelial monocyte adhesion may be functionally and pathophysiologically relevant in CHF. In the present study, we investigated the clinical significance of the activity of PBMCs in patients with CHF. Methods PBMCs were isolated from 34 CHF patients, from 10 healthy volunteers (normal control group) and from 17 patients admitted for investigation of suspected coronary artery disease (disease control group). In each patient, the adhesiveness of PBMCs to cultured human aortic endothelial cells (HAECs) with or without tumor necrosis factor-alpha (TNF-α) stimulation was determined. Major adverse cardiac events (death, heart transplantation or hospitalization with worsening heart failure) were determined in the 34 CHF patients during a median follow-up period of 182 days. Results Compared with those from both control groups and from mild CHF patients, PBMCs isolated from severe CHF patients adhered more to the HAECs. The endothelial adhesiveness of PBMCs correlated positively with the circulating levels of CAMs and can supply prognostic information in CHF patients. The difference between event-free curves based on the median levels of endothelial-PBMC adhesion was significant (log rank test, p = 0.0139). Conclusions Endothelial adhesiveness of PBMCs is increased and correlated to clinical outcomes, and may be pathophysiologically relevant to the progression of CHF.