RESUMEN
Aims: Extracellular vesicles (EVs) were investigated as potential biomarkers associated with heart failure (HF) pathophysiology in patients undergoing elective coronary artery bypass surgery characterized by HF phenotype. Materials and methods: Patients with preoperative proxy-diagnoses of HF types i.e., preserved (HFpEF; n = 19) or reduced ejection fraction (HFrEF; n = 20) were studied and compared to patients with normal left ventricular function (n = 42). EVs in plasma samples collected from the coronary sinus, an arterial line, and from the right atrium were analyzed by flow cytometry. We studied EVs of presumed cardiomyocyte origin [EVs exposing Connexin-43 + Caveolin-3 (Con43 + Cav3) and Connexin-43 + Troponin T (Con43 + TnT)], of endothelial origin [EVs exposing VE-Cadherin (VE-Cad)] and EVs exposing inflammatory markers [myeloperoxidase (MPO) or pentraxin3 (PTX3)]. Results: Median concentrations of EVs exposing Con43 + TnT and Con43 + Cav3 were approximately five to six times higher in coronary sinus compared to radial artery indicative of cardiac release. Patients with HFrEF had high trans-coronary gradients of both Con43 + TnT and Con43 + Cav3 EVs, whereas HFpEF had elevated gradients of Con43 + Cav3 EVs but lower gradients of Con43 + TnT. Coronary sinus concentrations of both Con43 + TnT and Con43 + Cav3 correlated significantly with echocardiographic and laboratory measures of HF. MPO-EV concentrations were around two times higher in the right atrium compared to the coronary sinus, and slightly higher in HFpEF than in HFrEF. EV concentrations of endothelial origin (VE-Cad) were similar in all three patient groups. Conclusion: Con43 + TnT and Con43 + Cav3 EVs are released over the heart indicating cardiomyocyte origin. In HFrEF the EV release profile is indicative of myocardial injury and myocardial stress with elevated trans-coronary gradients of both Con43 + TnT and Con43 + Cav3 EVs, whereas in HFpEF the profile indicates myocardial stress with less myocardial injury.
RESUMEN
OBJECTIVES: Heart failure (HF) management is suboptimal in Sweden despite available evidence-based guidelines. To improve HF treatment, a comprehensive HF management program (4D project) was implemented in the Stockholm County (>2.1 million inhabitants). Design. A standardized care program centralized at five hospital-based HF clinics was implemented in 2014-2017. We registered from 2012 to 2017: (1) numbers of referrals and visits to HF clinics, (2) numbers of hospital admitted patients per million inhabitants, (3) dispensed HF medications after admission, and (4) covariate-adjusted 1-year all-cause mortality or HF readmission. Results. Yearly visits to the five HF outpatient clinics increased 3.4 times from 3,372 to 11,527. Dispensed HF drug prescriptions increased, in particular, for readmitted patients, compared to 2012 (p<.0001). Total number of hospital admitted HF patients as well as new-onset or readmitted HF patients decreased by 16, 13, and 20%, respectively (p < .0001). The combined 1-year mortality or HF readmission over the period was 48% (n = 17,124/35,880) and improved per year (HR 0.98 [0.97-0.99], p < .001) from 2012. Conclusion. A comprehensive standardized care HF management program including expanded HF clinics was associated with improved evidence-based medication, reduced HF hospitalization, and improvement of the combined outcome of 1-year mortality or HF readmission in Stockholm.
Asunto(s)
Insuficiencia Cardíaca , Insuficiencia Cardíaca/terapia , Humanos , Suecia , Resultado del TratamientoRESUMEN
AIMS: To study prevalence and prognostic importance of diagnostic echocardiographic variables in patients with suspected heart failure with preserved ejection fraction (HFpEF) in the prospective KaRen register study. METHODS AND RESULTS: KaRen patients were included following an acute HF-presentation, using Framingham criteria, B-type natriuretic peptide (BNP) >100â¯ng/L or N-terminal pro-BNP (NT-pro-BNP) >300â¯ng/L, and left ventricular (LV) ejection fraction ≥45%. Echocardiography was performed after 4-8â¯weeks and analyzed at a core laboratory. In this substudy HFpEF was diagnosed according to the ESC guidelines for heart failure 2016. A total of 539 patients were included with a follow-up after 4-8â¯weeks in 438 patients. Complete echocardiography and ECG were available in 356 patients. At least two abnormal echocardiographic criteria for HFpEF were found in 94% (nâ¯=â¯333). Echocardiographic signs of structural heart disease and diastolic dysfunction according to 4 criteria by ESC were found in 76% (nâ¯=â¯270). Diastolic dysfunction was graded as mild in 30% (nâ¯=â¯107), moderate in 27% (nâ¯=â¯97) or severe in 35% (nâ¯=â¯124). After multivariate analyses with adjustment for age, gender, EF and natriuretic peptides we found two independent predictors of worse prognosis: presence of moderate and severe diastolic dysfunction (HR 1.8, CI 1.2-2.7, pâ¯=â¯0.0037) and presence of a high number (≥4) of abnormal diastolic parameters (HR 2.0, CI 1.3-3.1, pâ¯=â¯0.0033). CONCLUSION: The majority of KaRen patients with suspected HFpEF had diagnostic echocardiographic criteria for HFpEF according to ESC Guidelines. Our findings support using 2016 ESC HF guidelines for risk prediction in HFpEF.