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The potential value of integrated natriuretic peptide and echo-guided heart failure management
Full text linkThere is increasing interest in guiding Heart Failure (HF) therapy with Brain Natriuretic Peptide (BNP) or N-terminal prohormone of Brain Natriuretic Peptide (NT-proBNP), with the goal of lowering concentrations of these markers (and maintaining their suppression) as part of the therapeutic approach in HF. However, recent European Society of Cardiology (ESC) and American Heart Association/American College of Cardiology (AHA/ACC) guidelines did not recommend biomarker-guided therapy in the management of HF patients. This has likely to do with the conceptual, methodological, and practical limitations of the Natriuretic Peptides (NP)-based approach, including biological variability, slow time-course, poor specificity, cost and venipuncture, as well as to the lack of conclusive scientific evidence after 15 years of intensive scientific work and industry investment in the field. An increase in NP can be associated with accumulation of extra-vascular lung water, which is a sign of impending acute heart failure. If this is the case, an higher dose of loop diuretics will improve symptoms. However, if no lung congestion is present, diuretics will show no benefit and even harm. It is only a combined clinical, bio-humoral (for instance with evaluation of renal function) and echocardiographic assessment which may unmask the pathophysiological (and possibly therapeutic) heterogeneity underlying the same clinical and NP picture. Increase in B-lines will trigger increase of loop diuretics (or dialysis); the marked increase in mitral insufficiency (at baseline or during exercise) will lead to increase in vasodilators and to consider mitral valve repair; the presence of substantial inotropic reserve during stress will give a substantially higher chance of benefit to beta-blocker or Cardiac Resynchronization Therapy (CRT). To each patient its own therapy, not with a "blind date" with symptoms and NP and carpet bombing with drugs, but with an open-eye targeted approach on the mechanism predominant in that individual patient. A monocular, specialistic, unidimensional approach to HF can miss its pathogenetic and clinical complexity, which only can be overcome with an integrated, versatile and tailored approach
Asymmetrical myocardial expression of natriuretic peptides in pacing-induced heart failure.
No full textHigh-frequency pacing of the left ventricle (LV) free wall causes a dyssynchronous pattern of contraction that leads to progressive heart failure (HF) with pronounced differences in regional contractility. Aim of this study was to evaluate possible changes in brain natriuretic peptide (BNP) and C-type natriuretic peptide (CNP) mRNA expression in the anterior/anterior lateral region (pacing site, PS) as compared to the infero-septal region (opposite site, OS) and to explore possible association between the contractiling pattern and biomarker expression. Cardiac tissue was collected from minipigs with pacing-induced HF (n=8) and without (control, n=6). The samples were selectively harvested from the anterior left ventricular (LV) wall, PS, and from an area remote to the pacing-site, OS. BNP and CNP mRNA expression was evaluated by semi-quantitative polymerase chain reaction (PCR). A significant difference in BNP expression was found in the PS between HF animals and controls (BNP/GAPDH: 0.65+/-0.11 vs. 0.35+/-0.04, p=0.02), but not in the OS (BNP/GAPDH: 0.36+/-0.05, ns vs. controls). CNP expression was not different compared to controls, although higher levels were observed in the PS and in the OS with respect to the controls (CNP/GAPDH: controls 0.089+/-0.036, PS 0.289+/-0.23, OS 0.54+/-0.16). This finding was in tune with an increase of CNP tissue concentration (controls: 0.69+/-0.13; PS=1.56+/-0.19; OS=1.70+/-0.42 pg/mg protein; p=0.039 controls vs. OS). Higher BNP mRNA expression in the PS is consistent with a reduction in contractile function in this region, while higher CNP mRNA expression in the OS suggests the presence of concomitant endothelial dysfunction in the remote region
Resting heart rate is an independent predictor of left ventricular diastolic dysfunction in obese patients with or without arterial hypertension
No full textResting heart rate is an independent predictor of left ventricular diastolic dysfunction in obese patients with or without arterial hypertensio
Prognostic value of cardiac power output to left ventricular mass in patients with left ventricular dysfunction and dobutamine stress echo negative by wall motion criteria
No full textCardiac power output to left ventricular mass (power/mass) is an index of myocardial efficiency reflecting the rate at which cardiac work is delivered with respect to the potential energy stored in the left ventricular mass. In the present study, we sought to investigate the capability of power/mass assessed at peak of dobutamine stress echocardiography to predict mortality in patients with ischaemic cardiomyopathy and no inducible ischaemia
Low HDL - high inflammatory markers in heart failure induced by high frequency pacing in minipigs.
No full textPatterns of left ventricular remodeling in chronic heart failure: Prevalence and prognostic implications
No full textAbstract
BACKGROUND AND AIM:
Many descriptors of left ventricular (LV) remodeling have important prognostic implications in patients with chronic systolic heart failure (HF). We sought to assess the prognostic value of the combination of increased LV mass with a disproportion between wall thickness and internal diameter.
METHODS AND PATIENTS:
Patients (n = 536) with chronic HF, ejection fraction 91 mL/m(2), classified according to LV mass index and relative wall thickness (RWT), were followed up for 33 ± 21 months. Ventricular mass was determined using a standard M-mode echocardiographic method. Relative wall thickness was defined as the ratio of (sum of interventricular septum thickness in diastole + posterior wall thickness in diastole)/LV end-diastolic diameter.
RESULTS:
Prevalence of the pattern of increased LV mass index, defined as LV mass index >148 g/m(2) in men and >122 g/m(2) in women, and decreased RWT (70 years (P 2 (P < .0001), increased LV mass index, and decreased RWT (P = .003), E wave deceleration time ≤140 ms (P = .005), and male gender (P = .025). Patients with increased LV mass index and decreased RWT had a worse survival (33%) than patients with less LV mass index and normal to reduced RWT (log-rank 23.92; P < .0001). Comparisons of Cox models showed that the combination of increased mass index and decreased RWT added prognostic value to a model that included ejection fraction and end-systolic volume index.
CONCLUSION:
In patients with systolic HF, an independent and incremental risk of adverse outcome was associated with increased mass index and decreased RWT
Prognostic Value of Pulsed Tissue Doppler Imaging for the Assessment of Left Ventricular Systolic Function in Patients with Nonischemic Dilated Cardiomyopathy
No full textAbstract
There is still some debate regarding the prognostic significance of left ventricular longitudinal systolic dysfunction as assessed by tissue Doppler (TD) imaging in patients with chronic heart failure (HF), since previous studies have included patients with postischemic wall motion abnormalities. Thus, this study was designed to ascertain whether TD-derived longitudinal systolic dysfunction may influence the outcome of patients with nonischemic chronic HF. In 200 consecutive patients with chronic HF secondary to dilated cardiomyopathy and no history of ischemic heart disease, peak systolic mitral annular velocity (S(m) ) was measured by pulsed TD at the septal and lateral annular sites. The end points were cardiac death or hospitalization for worsening HF. Mean follow-up duration was 30 months. In a time independent analysis, averaged S(m) calculated as the average of septal and lateral S(m) , resulted to be a significant predictor of outcome in the study population (area under receiver-operator characteristic curve: cardiovascular death, 0.69, P < 0.0001; cardiovascular events, 0.64, P = 0.0005). In a time-dependent analysis, average S(m) was associated with both cardiovascular death (hazard ratio 0.832, P = 0.0019) and cardiovascular events (hazard ratio 0.904, P = 0.039), independently of other clinical risk factors and echocardiographic parameters of systolic function. Septal S(m) but not lateral S(m) was independently associated with the outcome measures. In conclusion, the assessment of systolic mitral annular velocity by pulsed TD is a useful indicator for prognostic stratification of patients with nonischemic dilated cardiomyopathy and chronic HF. (Echocardiography ****;**:1-7)
Independent and incremental prognostic value of increased left ventricular mass and reduced relative wall thickness in patients with chronic systolic heart failure and left ventricular remodeling
No full textIndependent and incremental prognostic value of increased left ventricular mass and reduced relative wall thickness in patients with chronic systolic heart failure and left ventricular remodelin
Pre-treatment of human mesenchymal stem cells with a chemical inductor of cardiogenesis increases their effects on regional myocardial function in a swine model of myocardial infarction.
No full textThe role of natriuretic peptides and echocardiography in the management and follow up of patients with chronic heart failure
No full textBackground. The concept of echo and natriuretic peptide (NP) guided therapy is appealing since currently there is no objective guide to optimal dosing of therapy and loop diuretics in particular in patients with chronic heart failure (CHF).
Aim. To assess whether echo and NP guided therapy may be useful for the management of patients with CHF due to left ventricular systolic dysfunction.
Materials and methods. We retrospectively analyzed the multicentric individual data of 414 patients with CHF with reduced ejection fraction; during ambulatory follow-up, the therapy (including loop diuretics) was titrated according to the presence of echocardiographic signs of elevated left ventricular filling pressures and NP serum levels. Mortality rate, changes in renal function, NP levels, cardiac function and medication doses were analyzed.
Results. The median follow-up duration was 1030 days. The mortality rate was 3,7% per year. During the observation period, the dose of loop diuretics increased by 20%. An increase of ≥ 0.3 mg/dL in serum creatinine was reported in 15% of the patients. Newly diagnosed renal dysfunction (eGFR <60 ml/min/1.73m2) occurred in 10% of patients. There was a significant decrease in NP levels and an improvement in LV filling pressures and systolic function. Regarding other therapies, significantly more patients were using beta blockers at follow up and the doses were increased. Non significant changes in the percentage of patients treated and in the medication dose was noted for Angiotensin Converting Enzyme Inhibitors/ Angiotensin Type 1 Receptor Blockers (ACEi/ARB) and for Mineralocorticoid Receptor Antagonists (MRA).
Conclusion. Our study suggests that the outcome of patients with CHF might be improved by the integrative use of clinical examination, biochemical and echocardiographic parameters. These effects are likely to be mediated by an appropriate use of loop diuretics and kidney function preservation
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