Relação entre a Razão Nitrogênio Ureico/Creatinina e Prognóstico de Insuficiência Cardíaca em Todo o Espectro da Fração de Ejeção / Relationship between BUN/Cr and Prognosis of HF Across the Full Spectrum of Ejection Fraction

Resumo Fundamento Em pacientes com insuficiência cardíaca (IC), devido à relativa deficiência do volume sanguíneo, a ativação do sistema neuro-hormonal leva à vasoconstrição renal, que afeta o teor de nitrogênio ureico (NU) e creatinina (C) no organismo, sendo que NU e C são facilmente afetados por outros fatores. Portanto, a razão NU/C pode ser utilizada como mais um marcador para o prognóstico da IC. Objetivo Explorar o prognóstico do desfecho adverso da IC no grupo NU/C alta em comparação com o grupo NU/C baixa em todo o espectro da fração de ejeção. Métodos De 2014 a 2016, pacientes sintomáticos hospitalizados com IC foram recrutados e acompanhados para observar desfechos cardiovasculares adversos. Foram realizadas análise logística e a análise COX para determinar a significância. Valores de p<0,05 foram considerados estatisticamente significativos. Resultados Na análise de regressão logística univariada, o grupo NU/C alta apresentou maior risco de desfecho adverso na insuficiência cardíaca com fração de ejeção reduzida (ICFEr) e insuficiência cardíaca com fração de ejeção preservada (ICFEp). A análise de regressão logística multivariada mostrou que o risco de morte cardíaca no grupo ICFEr foi maior do que no grupo NU/C baixa, enquanto o risco de morte por todas as causas foi significativo apenas em 3 meses (p<0,05) (Ilustração Central). O risco de morte por todas as causas no grupo NU/C alta no grupo ICFEP foi significativamente maior do que no grupo NU/C baixa em dois anos. Conclusão O grupo NU/C alta está relacionado ao risco de mau prognóstico da ICFEP, não sendo inferior ao valor preditivo da fração de ejeção do ventrículo esquerdo (FEVE).

Abstract Background In patients with heart failure (HF), due to the relative deficiency of blood volume, neurohormone system activation leads to renal vasoconstriction, which affects the content of blood urea nitrogen (BUN) and creatinine (Cr) in the body, while BUN and Cr are easily affected by other factors. Therefore, BUN/Cr can be used as another marker for the prognosis of HF. Objective Explore the prognosis of adverse outcome of HF in the high BUN/Cr group compared with the low BUN/Cr group across the full spectrum of ejection fraction. Methods From 2014 to 2016, symptomatic hospitalized HF patients were recruited and followed up to observe adverse cardiovascular outcomes. Logistic analysis and COX analysis were performed to determine significance. p-values <0.05 were considered statistically significant. Results In the univariate logistic regression analysis, the high BUN/Cr group had a higher risk of adverse outcome in heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Multivariate logistic regression analysis showed that the risk of cardiac death in the HFrEF group was higher than that in the low BUN/Cr group, while the risk of all-cause death was significant only in 3 months (p<0.05) (Central Illustration). The risk of all-cause death in the high BUN/Cr in the HFpEF group was significantly higher than that in the low BUN/Cr group at two years. Conclusion The high BUN/Cr group is related to the risk of poor prognosis of HFpEF, and is not lower than the predictive value of left ventricular ejection fraction (LVEF).

Application of extracorporeal membrane oxygenation in early allograft dysfunction after heart transplantation / 器官移植

Objective To evaluate the effect of extracorporeal membrane oxygenation (ECMO) on early allograft dysfunction (EAD) after heart transplantation. Methods Clinical data of 614 heart transplant recipients were retrospectively analyzed. All recipients were divided into the ECMO group (n=43) and non-ECMO group (n=571) according to postoperative application of ECMO. In the ECMO group, the conditions of recipients undergoing ECMO after heart transplantation were summarized. Perioperative status and long-term prognosis of recipients were compared between two groups. Results Among 43 recipients undergoing ECMO, 17 cases underwent thoracotomy due to bleeding, 10 cases of infection, 4 cases of venous thrombosis of the lower limbs, and 1 case of stroke, respectively. Twenty-six recipients were recovered and discharged after successful weaning from ECMO, six died during ECMO support, six died after weaning from ECMO, five received retransplantation due to unsuccessful weaning from ECMO, and only one survived after retransplantation. Compared with the non-ECMO group, intraoperative cardiopulmonary bypass duration was significantly longer, the proportion of recipients requiring postoperative intra-aortic balloon pump (IABP), dialysis due to renal insufficiency, reoperation for hemostasis, infection, mechanical ventilation time≥96 h and tracheotomy was significantly higher, and the length of postoperative intensive care unit (ICU) stay was significantly longer in the ECMO group (all P < 0.05). The survival rate after discharge and 90-d survival rate in the ECMO group were 63% and 96%, significantly lower than 97% and 100% in the non-ECMO group (both P < 0.05). Survival analysis showed that the long-term survival rate in the ECMO group was significantly lower than that in the non-ECMO group (P < 0.05). After excluding the recipients who died within 90 d after heart transplantation, no significant difference was observed in the long-term survival rate (P > 0.05). Conclusions ECMO is an effective treatment of EAD after heart transplantation. The short-term survival rate of recipients using ECMO after heart transplantation is lower than that of those who do not use ECMO, and there is no significant difference in long-term survival of recipients surviving 90 d after heart transplantation.

Papel de la ecocardiografía speckle-tracking (rastreo de marcas) y la resonancia magnética cardíaca-feature tracking en la circulación de Fontan. Diferencias entre los ventrículos derecho e izquierdo / Speckle-tracking echocardiography and MCR-feature tracking in Fontan circulation. Differences between right and left ventricles

Resumen Introducción: En los pacientes con DCPT, la disfunción ventricular es inevitable, y más temprana en VU derechos. La deformación miocárdica por STE y RMC-FT parece promisoria. Objetivo: Analizar la función ventricular mediante STE y RMC-FT en pacientes con DCPT, en comparación con RMC convencional según la morfología del VU y la posible implicación en su diagnóstico temprano. Método: Se recogieron medidas del strain longitudinal y circunferencial por STE y RMC-FT, volúmenes ventriculares y FE por RMC en 64 pacientes con DCPT. Resultados: La morfología ventricular no se relacionó con disfunción por RMC. Los VU derechos tuvieron valores por STE y RMC-FT disminuidos respecto de los VU izquierdos, con FE similares. Existe correlación entre STE y RMC-FT, no equivalentes, con buena factibilidad y reproducibilidad. Conclusiones: La RMC-FT y el STE son técnicas útiles en el diagnóstico temprano y la vigilancia de la función ventricular en VU derechos con FE preservada.

Abstract Introduction: In patients with TCPC, the development of ventricular dysfunction is inevitable and is more precocious in SRVs. Myocardial deformation by STE and CMR-FT is promising. Objective: To analize ventricular function in patients with TCPC using STE and CMR-FT compared with conventional cMRI, depending on SV morphology, to determine their role in early diagnosis of ventricular dysfunction. Method: Sixty-four patients with TCPC were included. Longitudinal and circumferential strain by STE and CMR-FT and ventricular volume and EF were obtained. Results: Dysfunction analyzed by cMRI showed no association with ventricular morphology. SRVs had lower values in STE and CMR-FT compared with SLVs, with similar EF. While not equivalent, correlation was observed between the STE and the CMR-FT values, demonstrating good feasibility and reproducibility. Conclusion: The strain data in CMR-FT and STE could be useful for diagnosis and monitoring of ventricular function and as markers of early SRV dysfunction with preserved EF.

Dilemas de la insuficiencia cardíaca con fracción de eyección preservada / Dilemmas of heart failure with preserved ejection fraction / Dilemas da insuficiência cardíaca com fração de ejeção preservada

La insuficiencia cardíaca con fracción de eyección preservada (ICFEp) y reducida presentan marcadas diferencias. Mientras que la última tiene un algoritmo diagnóstico y terapéutico desde hace años, con guías y fármacos que mejoran su pronóstico, la ICFEp no solo presenta dificultades para llegar al diagnóstico, sino que tampoco hay fármacos que hayan demostrado disminuir la mortalidad. En esta revisión se hace un abordaje amplio de la ICFEp, comenzando por definirla y distinguirla de la disfunción diastólica. Se describe el gold standard para su diagnóstico invasivo y se analizan los scores no invasivos recientemente desarrollados que estiman la probabilidad de tener la enfermedad. A través del análisis de las comorbilidades frecuentemente asociadas, se describen los mecanismos fisiopatológicos implicados. Asimismo, se detallan los fenotipos propuestos para agrupar pacientes y diseñar ensayos clínicos con fármacos que prueben disminuir la mortalidad. Por último, se reseñan las medidas terapéuticas no farmacológicas y farmacológicas recomendadas.

Heart failure with preserved and reduced ejection fraction have significant differences. While the latter has had a diagnostic and therapeutic algorithm for years, with guidelines and drugs that improve its prognosis, heart failure with preserved ejection fraction (HFpEF) not only presents difficulties in reaching a diagnosis, but also there are no drugs that have been proven to be effective in reducing mortality. In this review, a broad approach to HFpEF is made, beginning by defining it and distinguishing it from diastolic dysfunction. The gold standard for its invasive diagnosis is described and recently developed non-invasive scores that estimate the probability of having the disease are analyzed. Through the analysis of the frequently associated comorbidities, the pathophysiological mechanisms involved are described. Likewise, the phenotypes proposed to group patients and design clinical trials with drugs that try to reduce mortality are detailed. Finally, the recommended non-pharmacological and pharmacological therapeutic measures are outlined.

A insuficiência cardíaca com fração de ejeção preservada (ICFEp) e reduzida apresentam diferenças marcantes. Enquanto esta última conta com um algoritmo diagnóstico e terapêutico há anos, com diretrizes e medicamentos que melhoram seu prognóstico, a ICFEp não só apresenta dificuldades no diagnóstico, mas nenhum há medicamentos que tenham demonstrado reduzir a mortalidade. Nesta revisão, é feita uma abordagem ampla da ICFEp, começando por defini-la e distinguindo-a da disfunção diastólica. O padrão ouro para seu diagnóstico invasivo é descrito e são analisados os escores não invasivos recentemente desenvolvidos que estimam a probabilidade de ter a doença. Através da análise de comorbidades frequentemente associadas, são descritos os mecanismos fisiopatológicos envolvidos. Da mesma forma, são detalhados os fenótipos propostos para agrupar pacientes e desenhar ensaios clínicos com medicamentos que podem ser mostradas para reduzir a mortalidade. Por fim, são delineadas as medidas terapêuticas não farmacológicas e farmacológicas recomendadas.

Obesidad en la mortalidad de pacientes con insuficiencia cardiaca y fracción de eyección reducida / Obesity in the mortality of patients with heart failure and reduced ejection fraction

Introducción: La asociación entre obesidad y menor mortalidad en pacientes con insuficiencia cardiaca y fracción de eyección del ventrículo izquierdo es controversial. Objetivo: Evaluar la asociación entre obesidad y mortalidad en pacientes con insuficiencia cardiaca y fracción de eyección reducida. Métodos: Se realizó un estudio observacional de cohorte prospectivo en pacientes con insuficiencia cardiaca y fracción de eyección reducida en el período comprendido entre enero del 2010 y diciembre de 2020. La muestra quedó conformada por 173 pacientes. Se evaluó la supervivencia mediante el método de Kaplan-Meier, para estimar el efecto del pronóstico de la variable obesidad sobre la mortalidad. Se utilizó el modelo de regresión de Cox. Resultados: Se observó que los pacientes obesos al año de seguimiento tuvieron mejor supervivencia que los que presentaron normopeso (0,6 versus 0,8) a los cinco años presentaron similar supervivencia los tres subgrupos de índice masa corporal (0,6), la mayor mortalidad la presentaron los pacientes bajo peso. La curva de éstos últimos, se distancia del resto de las categorías de IMC, Log Rank p= 0,001. En el modelo de regresión de Cox la obesidad presentó un odd ration OR=´1,159 p=0,648 (intervalo de confianza de 0,615-2,181). Conclusiones: En los pacientes con insuficiencia cardiaca con fracción de eyección reducida no se observó el fenómeno de obesidad paradójica en relación a la mortalidad(AU)

Introduction: The association between obesity and lower mortality in patients with heart failure and left ventricular ejection fraction is controversial. Objective: To evaluate the association between obesity and mortality in patients with heart failure and reduced ejection fraction. Methods: An observational prospective cohort study was carried out, from January 2010 to December 2020, in patients with heart failure and reduced ejection fraction. The sample was made up of 173 patients. Survival was evaluated using Kaplan-Meier method to estimate the prognostic effect of the obesity variable on mortality. Cox regression model was used. Results: It was observed that obese patients at one year of follow-up had better survival than those with normal weight (0.6 versus 0.8). At five years, the three subgroups of body mass index (0.6) showed similar survival and the highest mortality was observed by low weight patients. The curve of the latter differs from the rest of the BMI categories, Log Rank p=0.001. In the Cox regression model, obesity had an odds ratio OR=´1.159 p=0.648 (confidence interval 0.615-2.181). Conclusions: In patients with heart failure with reduced ejection fraction, the phenomenon of paradoxical obesity was not observed in relation to mortality(AU)

La tercera cara de la moneda en el manejo de la falla cardíaca / The third side of the coin in the management of heart failure

Resumen En las últimas décadas, el manejo de la insuficiencia cardíaca ha tenido avances significativos nunca antes vistos en la historia de la cardiología, lo cual ha elevado el pronóstico de vida de los pacientes con falla cardíaca, a niveles cercanos a los de un individuo sano. Para ello se han empleado múltiples alternativas farmacológicas, como los inhibidores de la enzima convertidora de angiotensina (IECA), los antagonistas de los receptores de angiotensina (ARA II), los bloqueadores de los receptores mineralocorticoides, los bloqueadores de los receptores IF I, los inhibidores de la neprilisina y los betabloqueadores, asociadas al desarrollo de la cardiología intervencionista y la cirugía cardiovascular a nivel coronario, valvular, remodelado cardíaco y dispositivos de estimulación, asistencia, resincronización y cardioversión miocárdica. Sin embargo, hay un importante escenario en el manejo de la falla cardíaca que, en ocasiones, por diversas circunstancias, se deja de lado o se pospone como terapia de primera línea concomitante a las ya expuestas. Este artículo intenta describir la importancia que tienen dichas terapias -a las que hemos llamado la tercera cara de la moneda en el manejo de la falla cardíaca- a la luz de la evidencia actual.

Abstract In the last decades the management of heart failure has seen significant advance as never before in the history of cardiology, raising the life expectancy of patients with heart failure to levels close to those of healthy individuals. For such a task, multiple pharmacological alternatives have been employed: angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (ARB), mineralocorticoid receptor antagonists, I-F channel antagonists, neprilysin inhibitors, beta blockers, associated to the development of interventionist cardiology and cardiac surgery at coronary level, valvular level, cardiac remodeling, and devices for stimulation, assistance, resynchronization and myocardial cardioversion. However, there is an important stage in the management of heart failure that occasionally, due to varied circumstances, is set aside or put off as a front-line therapy accompanying the ones already mentioned. This article attempts to describe the importance that said therapies have in light of current evidence, which we have called: the third side of the coin in the management of heart failure.

Mortalidade por Insuficiência Cardíaca com Fração de Ejeção Intermediária / Mortality from Heart Failure with Mid-Range Ejection Fraction

Resumo Fundamento A importância prognóstica da classificação 'insuficiência cardíaca (IC) com fração de ejeção (FE) intermediária' permanece incerta. Objetivo Analisar as características clínicas, comorbidades, complicações e mortalidade hospitalar e tardia de pacientes classificados em IC com FE intermediária (ICFEi - FE: 40%-49%) e comparar às daqueles em IC com FE preservada (ICFEp - FE > 50%) e IC com FE reduzida (ICFEr - FE < 40%) na internação por IC descompensada. Métodos Coorte ambispectiva de pacientes internados por IC descompensada em unidade cardiointensiva. Foram avaliadas características clínicas, comorbidades, complicações e mortalidade hospitalar e tardia. Utilizou-se o software R, com significância de 5%, para a realização dos testes qui-quadrado, análises de variância, multivariada de Cox e curva de sobrevida de Kaplan Meier, além de técnicas de machine learning (Elastic Net, árvore de sobrevida). Resultados Foram incluídos 519 indivíduos entre setembro de 2011 e junho de 2019, com média da idade de 74,87±13,56 anos, sendo 57,6% homens. Observou-se frequência de ICFEp, ICFEi e ICFEr de 25,4%, 27% e 47,6%, respectivamente. O infarto prévio foi mais frequente na ICFEi. O tempo médio de seguimento foi 2,94±2,55 anos, sem diferença estatística da mortalidade entre os grupos (53,8%, 52,1% e 57,9%). Na curva de sobrevida, não houve diferença entre os grupos ICFEp e ICFEi, nem entre ICFEp e ICFEr, mas houve entre os grupos ICFEi e ICFEr. Idade maior que 77 anos, IC prévia, história de readmissão, demência e necessidade de vasopressores foram associadas com maior mortalidade tardia na árvore de sobrevida. Conclusão A FE não foi selecionada como variável associada a mortalidade nos pacientes com IC descompensada.

Abstract Background The prognostic importance of the classification 'heart failure (HF) with mid-range ejection fraction (EF)' remains uncertain. Objective To analyze the clinical characteristics, comorbidities, complications, and in-hospital and late mortality of patients classified as having HF with mid-range EF (HFmrEF - EF: 40%-49%), and to compare them to those of patients with HF with preserved EF (HFpEF - EF > 50%) and with HF with reduced EF (HFrEF - EF < 40%) on admission for decompensated HF. Methods Ambispective cohort of patients admitted to the cardiac intensive care unit due to decompensated HF. Clinical characteristics, comorbidities, complications, and in-hospital and late mortality were assessed. The software R was used, with a 5% significance, for the tests chi-square, analysis of variance, Cox multivariate, and Kaplan-Meier survival curve, in addition to machine-learning techniques (Elastic Net and survival tree). Results 519 individuals were included between September 2011 and June 2019 (mean age, 74.87 ± 13.56 years; 57.6% were men). The frequencies of HFpEF, HFmrEF and HFrEF were 25.4%, 27% and 47.6%, respectively. Previous infarction was more frequent in HFmrEF. The mean follow-up time was 2.94 ± 2.55 years, with no statistical difference in mortality between the groups (53.8%, 52.1%, 57.9%). In the survival curve, there was difference between neither the HFpEF and HFmrEF groups, nor the HFpEF and HFrEF groups, but between the HFmrEF and HFrEF groups. Age over 77 years, previous HF, history of readmission, dementia and need for vasopressors were associated with higher late mortality in the survival tree. Conclusion The EF was not selected as a variable associated with mortality in patients with decompensated HF.

Contribución del acortamiento longitudinal y circunferencial al volumen sistólico y fracción de eyección en la estenosis aórtica grave / Contribution of Longitudinal and Circumferential Shortening to Stroke Volume and Ejection Fraction in Severe Aortic Stenosis

RESUMEN Introducción: El volumen sistólico (VS) del ventrículo izquierdo (VI) es eyectado por una combinación de acortamiento longitudinal (AL), circunferencial (AC) y giro ventricular. El AL se produce por el movimiento del anillo mitral hacia el ápex, lo que ocasiona engrosamiento de la pared (AC y radial), reducción de la cavidad ventricular y eyección del VS. No está definido el rol del AL en la estenosis aórtica (EAo). Objetivo: Analizar la contribución del AL y AC al VS y la fracción de eyección ventricular izquierda (FEVI) en la EAo grave. Materiales y métodos: Se estudiaron 152 pacientes (70 ± 12 años, 64 mujeres) con EAo grave (área valvular <1 cm2) con ecoDoppler cardíaco. La contribución del AL al VS se evalúo considerando a la base del corazón como un cilindro., con volumen = base × altura; la base, un círculo con radio igual a (espesor septal en sístole + espesor pared posterior en sístole + diámetro de fin de sístole)/2; y la altura, el promedio de la excursión sistólica del anillo lateral, septal, anterior e inferior. La contribución del AC al VS se estimó como: VS - contribución del AL al VS. Ambas contribuciones se expresaron en forma absoluta y como porcentajes del VS (% VS-AL y % VS-AC). Resultados: El AL contribuyó con 2 tercios aproximadamente al VS (68 ± 18 %) y el AC con el resto. El VS-AL correlacionó inversamente con el VS (r = - 0,45 p <0,001) y el VS-AC tuvo correlación directa (r = 0,45 p <0,001). La contribución del % VS-AL fue mayor en los pacientes con FEVI <50%. El % VS-AL correlacionó inversamente con el EPR (r = - 0,32 , p <0,01). Conclusión: La contribución del AL al VS es mayor que la del AC, y correlaciona inversamente con el VS. Es mayor el % VS-AL en los pacientes con FEVI <50%. Los hallazgos mencionados podrían tener implicancias al considerar puntos de corte para los índices de función longitudinal (strain) sin considerar la FEVI y/o geometría ventricular.

ABSTRACT Background: Left ventricular (LV) stroke volume (SV) is ejected by a combination of longitudinal shortening (LS), circumferential shortening (CS) and ventricular twist. Longitudinal shortening is caused by the motion of the mitral annulus towards the apex, causing wall thickening (CS and radial thickening), reduction of the ventricular cavity and LV ejection. The role of LS in aortic stenosis (AS) is not defined. Objective: The aim of this study was to analyze the contribution of LS and CS to SV and left ventricular ejection fraction (LVEF) in severe AS. Methods: The study included 152 patients (70 ± 12 years, 64 women) with severe AS (valve area <1 cm2) studied by cardiac Doppler echocardiography. The contribution of LS to SV was evaluated by considering the base of the heart as a cylinder, with volume = base x height; the base was assumed as a circle with radius equal to (systolic septal thickness + systolic posterior wall thickness + end-systolic diameter)/2; and height, as an average of the mitral lateral, septal, anterior and inferior annulus systolic excursion. The contribution of CS to SV was estimated as: SV - contribution of LS to SV. Both contributions were expressed in absolute form and as SV percentages (%SV-LS and %SV-CS). Results: Longitudinal shortening contributed with approximately 2 thirds of SV (68 ± 18 %) and CS with the rest. SV-LS correlated inversely with SV (r = - 0.45 p <0.001) and SV-CS had direct correlation (r = 0.45 p <0.001). The contribution of %SV-LS was greater in patients with LVEF <50%. Percent SV-LS correlated inversely with relative wall thickness (RWT) (r = 0.32, p <0.01). Conclusion: The contribution of LS to SV is greater than that of CS, and correlates inversely with SV. Percent SV-LS is higher in patients with EF <50%. The aforementioned findings could have implications when considering cut-off points for longitudinal function indices (strain) without considering LVEF and/or ventricular geometry.

Clinical Efficacy of Dapagliflozin Combined with Shexiang Baoxinwan in Treatment of Acute Heart Failure with Reduced Ejection Fraction / 中国实验方剂学杂志

ObjectiveTo study the clinical efficacy of dapagliflozin combined with Shexiang Baoxinwan （SXBXW） in the treatment of acute heart failure with reduced ejection fraction （HFrEF） and syndrome of Qi deficiency and blood stasis. MethodA total of 176 patients hospitalized due to acute HFrEF （syndrome of Qi deficiency and blood stasis） were selected and randomized into control group， SXBXW group， dapagliflozin group， and SXBXW + dapagliflozin group （the latter three groups were called the intervention groups）. The New York Heart Association （NYHA） class， 6-minute walk test （6MWT） score， Kansas City Cardiomyopathy Questionnaire （KCCQ） score， traditional Chinese medicine （TCM） syndrome score， N-terminal pro-brain natriuretic peptide （NT-proBNP）， soluble suppression of tumorigenicity 2 （sST2）， interleukin-6 （IL-6）， and hypersensitive C-reactive protein （hs-CRP） of the patients were evaluated and measured at the time of admission， 1 week after treatment， and 2 weeks of treatment. Furthermore， the hospital stay， in-hospital mortality， and 30-day re-admission rate were recorded. Statistical analysis was performed to evaluate the efficacy of each group. ResultAfter 1 week of treatment， the SXBXW group exhibited superior NYHA class， KCCQ score， TCM syndrome score and curative effect， IL-6， and hs-CRP to the control group （P<0.05， P<0.01）. After 2 weeks of treatment， the SXBXW group showed superior TCM syndrome score， TCM curative effect， and hs-CRP （P<0.05， P<0.01） to the control group. The dapagliflozin group was superior to the control group in terms of TCM syndrome score， NT-proBNP， and sST2 （P<0.05， P<0.01） after 1 week of treatment and in terms of NYHA class， KCCQ score， NT-proBNP， sST2， and hospital stay （P<0.05， P<0.01） after 2 weeks of treatment. The SXBXW + dapagliflozin group exhibited better efficacy than the control group in terms of NYHA class， 6MWT score， KCCQ score， TCM syndrome score and curative effect， NT-proBNP， sST2， IL-6， and hs-CRP （P=0.014） after 1 week of treatment and in terms of NYHA class， KCCQ score， TCM syndrome score and curative effect， NT-proBNP， sST2， IL-6， hs-CRP， and hospital stay （P<0.01） after 2 weeks of treatment. ConclusionSXBXW and dapagliflozin have good therapeutic effect on acute HFrEF and syndrome of Qi deficiency and blood stasis， and their combination demonstrated better therapeutic effect， with good safety and tolerability.

A Data Mining-Based Study on Medication Rules of Chinese Herbs to Treat Heart Failure with Preserved Ejection Fraction / 中国结合医学杂志

OBJECTIVE@#To summarize the medication rules of Chinese herbs to treat heart failure with preserved ejection fraction (HFPEF) based on data mining and to provide references for clinical utilization.@*METHODS@#The China National Knowledge Infrastructure (CNKI), Wanfang database (Wanfang), VIP database (VIP), Chinese Biomedical Literature (CBM), PubMed, Embase, and Cochrane Library databases were searched from inception to October 2021 to identify relevant literature on treating HFPEF with Chinese herbs. Microsoft Excel 2019 was used to set up a database, and then, association rule analysis and hierarchical cluster analysis were performed by using apriori algorithm and hclust function respectively in R-Studio (Version 4.0.3).@*RESULTS@#A total of 182 qualified papers were included, involving a total of 92 prescriptions, 130 Chinese herbs, and 872 individual herbs prescribed, with an average of 9.5 herbs per prescription. The six most frequently prescribed herbs were Astragali Radix (Huangqi), Salviae Miltiorrhizae Radix Et Rhizoma (Danshen), Poria (Fuling), Glycyrrhizae Radix Et Rhizoma (Gancao), Cinnamomi Ramulus (Guizhi), and Ginseng Radix Et Rhizoma (Renshen). There were 35 herbs used more than 5 times, involving 11 efficacy categories. The top three categories were deficiency-tonifying herbs, blood-activating and stasis-removing herbs, and dampness-draining diuretic herbs. The most commonly used herbs were mainly warm and sweet. The primary meridian tropisms were Lung Meridian, Heart Meridian and Spleen Meridian. Association rule analysis yielded 26 association rules, such as Astragali Radix (Huangqi) & Salviae Miltiorrhizae Radix Et Rhizoma (Danshen), Poria (Fuling), Cinnamomi Ramulus (Guizhi) & Atractylodis Macrocephalae Rhizoma (Baizhu). Hierarchical cluster analysis yielded four herb classes, and their functions were mainly qi-replenishing and yang-warming, blood-activating and diuresis-inducing.@*CONCLUSIONS@#HFPEF is the syndrome of root vacuity and tip repletion, and its core pathogenesis is "deficiency", "stasis", and "water", with "deficiency" being the most principal, which is closely related to Xin (heart), Fei (Lung), and Pi (Spleen). The treatment of this disease occurs by improving qi, warming yang, activating blood and inducing diuresis. Astragali Radix (Huangqi) with Salviae Miltiorrhizae Radix Et Rhizoma (Danshen) is the basic combination of herbs applied.

An Autopsy Case of Transthyretin-Related Cardiac Amyloidosis (TTR-CA), Which Fell into Low-Output Syndrome after Cardiac Surgery / 日本心臓血管外科学会雑誌

We present the case of 83-year-old male patient. He was under observation as an outpatient with mild to moderate aortic stenosis and regurgitation since 75 years old. He underwent surgery because of repeated hospitalization by heart failure due to progressive aortic valve stenosis and regurgitation, mitral valve stenosis and regurgitation, and tricuspid regurgitation. Elective aortic valve replacement, mitral valve replacement and tricuspid valve repair was performed. Even though his condition after surgery was stable, suddenly feature like low output syndrome appeared on day 6, and led to a mortality on day 8 after operation. Ejection fraction was kept above 50 percent before and after surgery, which indicated to Heart Failure with preserved Ejection Fraction (HFpEF). After autopsy examination, by immunohistochemical staining identified transthyretin, we demonstrated previously undiagnosed transthyretin-related cardiac amyloidosis (TTR-CA).

Pharmacoeconomic evaluation of empagliflozin in the treatment of heart failure with reduced ejection fraction / 中国药房

OBJECTIVE To conduct the pharmacoeconomic evaluation of empagliflozin in the treatment of heart failure with reduced ejection fraction （HFrEF），and to provide evidence-based reference for rational drug use and medical and healthy decision-making. METHODS A Markov model was used to perform a cost-effectiveness analysis of the regimen of empagliflozin in the treatment of HFrEF ，and to evaluate the cost and effectiveness of standard treatment plan plus empagliflozin （empagliflozin group）vs. standard treatment plan （standard treatment group ）. Clinical parameters were obtained from the EMPEROR-Reduced study；cost and utility data came from the published literatures. The cycle of the model was 1 month and the simulation time was 20 years. Single-factor sensitivity analysis and probability sensitivity analysis were performed to validate the results of cost-effectiveness analysis. RESULTS Compared with the standard treatment group ，each additional quality-adjusted life year in the empagliflozin group cost 37 995.94 yuan more ，which was less than China ’s 1 time GDP per capita in 2020（72 447 yuan）. The results of single factor sensitivity analysis showed that steady-state hospitalization rate of 2 groups was the most important factor affecting the incremental cost-effectiveness ratio . The results of probability sensitivity analysis showed that when the willingness-to-pay threshold （WTP）was 1 time GDP per capita in 2020（72 447 yuan），the probability of empagliflozin group with cost-effectiveness advantage was 58.8％；when the WTP was 3 times GDP per capita in 2020（217 341 yuan），the probability of empagliflozin group with cost-effectiveness advantage was 63.8％. CONCLUSIONS Compared with standard treatment plan alone，standard treatment plan plus empagliflozin is more cost-effective in the treatment of HFrEF. However ，the economic probability is not high.

The relationship and significance of echocardiographic indexes of acute myocardial infarction with serum heart-type fatty acid binding protein and chitinase-3 like protein-1 / 中国医师进修杂志

Objective:To investigate the relationship between left ventricular ejection fraction (LVEF), left ventricular end diastolic diameter (LVEDD), wall motion score (WMS) of echocardiographic indexes and serum heart type fatty acid binding protein (h-FABP), chitinase-3 like protein-1 (YKL-40) and their predictive value for prognosis in patients with acute myocardial infarction (AMI).Methods:A retrospective selection of 130 AMI patients admitted from January 2020 to March 2021 in the University of Hong Kong Shenzhen Hospital were selected as the research objects. According to whether major adverse cardiovascular events or death occurred within 30 d, they were divided into a good prognosis group (85 cases) and a poor prognosis group (45 cases). The echocardiographic indexes, serum h-FABP and YKL-40 levels were compared between the two groups, the correlation between serum indexes and color Doppler ultrasound indexes and the value of echocardiographic indexes for prognosis were also analyzed.Results:When the poor prognosis group was admitted to the hospital and after 1 week of treatment, the LVEF was lower than that in good prognosis group: (40.12±4.10)% vs. (44.37±5.06)% and (47.62±4.83)% vs. (53.29±5.31)%; the LVEDD, WMS, serum h-FABP and YKL-40 level were higher than those in good prognosis group: (52.78±3.67) mm vs. (49.16±3.14) mm and (48.35±4.08) mm vs. (44.20±3.72) mm, (23.42±3.11) scores vs. (20.09±2.87) scores and (20.07±3.70) scores vs. (15.20±2.34) scores, (28.76±4.22) mg/L vs. (22.35±3.19) mg/L and (20.04±3.33) mg/L vs. (14.20±2.76) mg/L, (40.17±5.10) μg/L vs. (34.83±3.25) μg/L and (32.09±4.38) μg/L vs. (27.20±3.07) μg/L, and there were statistical differences ( P<0.05). LVEF was negatively correlated with serum h-FABP and YKL-40 neither at admission nor 1 week after treatment, and LVEDD and WMS were positively correlated with serum h-FABP and YKL-40 ( P<0.05). The areas under the curve for combined prediction of prognosis by LVEF, LVEDD, and WMS was the largest at 0.873. The survival rates of high-risk patients indicated with LVEF, LVEDD, and WMS were lower than that of low-risk patients: 56.52% vs. 90.91%, 52.38% vs. 91.67%, and 54.17% vs. 95.24%, and there were statistical differences ( P<0.05). Conclusions:The echocardiographic parameters LVEF, LVEDD and WMS in patients with AMI are closely related to serum h-FABP and YKL-40, which can provide an objective basis for the evaluation of myocardial pathophysiological changes. Moreover, the combined detection of LVEF, LVEDD, and WMS can be used to further assess the prognostic survival status, with a positive significance for guiding clinical treatment plans.

Short-term and medium-term changes of the left ventricular ejection fraction in children with dilated cardiomyopathy complicated with complete left bundle branch block and the predictive value of relevant electrocardiogram indexes / 中华实用儿科临床杂志

Objective:To investigate the short-term and medium-term changes of the left ventricular ejection fraction (LVEF) and the predictive value of relevant electrocardiogram (ECG) indexes in children with dilated cardiomyopathy (DCM) complicated with complete left bundle branch block (CLBBB).Methods:Children clinically diagnosed with DCM in the Department of Heart Center, Women and Children′s Hospital, Qingdao University and Beijing Anzhen Hospital, Capital Medical University between November 2011 and August 2020 were retrospectively recruited.According to the combination of CLBBB, they were divided into CLBBB group and non-CLBBB group.Echocardiogram and ECG were regularly performed.Short-term and medium-term changes of LVEF based on the 1-5-year follow-up data were compared between groups.COX proportional hazards model and Kaplan-Meier multiplicative limit method were used to analyze the predictive value of ECG indexes of LVEF changes in children with DCM combined with CLBBB.Results:Ninety-four children with DCM were enrolled, including 35 cases in CLBBB group and 59 cases in non-CLBBB group.There was no difference in baseline LVEF between groups.However, significant differences were found in QRS duration, corre-cted QT interval(QTc), R peak time in lead V 5 (T V5R) and QRS notching or slurring between groups ( P<0.05). LVEF of all children showed an upward trend within one year after onset, while the Z value of eft ventricular end diastolic diameter(LVEDd) showed a downward trend, and the two indexes tended to be stable within 1 - 5 years.The Z value of LVEDd in CLBBB group was significantly higher than that of non-CLBBB group, while LVEF was significantly lower (all P<0.05). The mean LVEF of CLBBB group slightly fluctuated around 50%, that of LVEF in non-CLBBB group was 60%.The multivariate COX regression analysis showed that QRS duration ( HR=0.979; 95% CI: 0.960-0.999, P<0.05) and QTc ( HR=0.988; 95% CI: 0.979-0.998, P<0.05) were independent predictors of LVEF recovery in children with DCM.Kaplan-Meier method showed a significant difference of LVEF normalization between DCM children with different QRS durations ( P<0.05), which was also detected in those with QTc interval ( P<0.05). Conclusions:LVEF of children with DCM combined with CLBBB increases in the short term after standard treatment, and then being stable.CLBBB can affect the recovery of left ventricular systolic function in children with DCM.Moreover, QRS duration and QTc interval are independent predictors of LVEF recovery in DCM children.

Determinantes de la fracción de eyección ventricular izquierda en pacientes con estenosis aórtica grave / Determinants of left ventricular ejection fraction in severe aortic stenosis

RESUMEN Introducción: En la estenosis aórtica (EAo) grave la fracción de eyección ventricular izquierda (FEVI) reducida (<50%) puede deberse a una disminución de la contractilidad, exceso de poscarga (EP) o a una combinación de ambos mecanismos. Sin embargo, cuando la FEVI es ≥50% algunos pacientes pueden tener la contractilidad disminuida. Objetivo: Evaluar el nivel de contractilidad (NC), EP y geometría ventricular como determinantes de la FEVI en pacientes con EAo grave. Material y métodos: Se estudiaron 184 pacientes con EAo grave y 71 individuos normales (N) mediante eco-Doppler cardíaco. El NC se determinó mediante la diferencia entre la fracción de acortamiento mesoparietal (FAm) medida (EAo) y la FAm predicha (N) menos 2 errores estándar para un valor determinado de estrés meridional de fin de sístole (EFS). Los pac con EAo fueron divididos en 4 grupos: FEVI <50% (n = 78), FEVI 50-59% (n = 27), FEVI 60-69% (n = 45) y FEVI ≥70% (n = 34). Resultados: El NC estuvo disminuido aproximadamente en la mitad de los pac. con FEVI <60% y en menor grado en los pacientes con FEVI ≥60%. El EP se observó en los pacientes con FEVI <50% con NC disminuido (34%) como así también con NC conservado (45%) Conclusiones: La mitad de los pacientes con FEVI <60% presentó NC disminuido y en menor proporción ello ocurrió en el resto de los pacientes, incluso hasta con FEVI ≥70%. La sobrestimación de la función sistólica utilizando la FEVI parece estar relacionada con el grado de hipertrofia concéntrica

ABSTRACT Background: In severe aortic stenosis (AS), reduced left ventricular ejection fraction (LVEF) (<50%) may be attributed to decreased contractility, afterload mismatch (AM) or a combination of both mechanisms. However, when LVEF is ≥50% some patients may have decreased contractility. Objective: The aim of this study was to assess contractility level (CL), AM and ventricular geometry as determinants of LVEF in patients with severe AS. Methods: Doppler echocardiography was used to study 184 patients with severe AS and 71 normal individuals (N). Contractility was assessed as the difference between measured and predicted midwall fractional shortening (mFS) minus 2 standard errors for an established meridional end-systolic stress (ESS). Patients with AS were divided into 4 groups: LVEF <50% (n = 78), LVEF 50-59% (n = 27), LVEF 60-69% (n = 45), and LVEF ≥70% (n = 34). Results: Decreased CL was observed in approximately half of the patients with LVEF <60% and in a lesser degree in patients with LVEF ≥60%. Afterload mismatch was found in patients with LVEF <50% with decreased (34%) as well as preserved (45%) CL. Conclusions: Half of the patients with LVEF <60% presented decreased CL and to a lesser extent this occurred in the rest of the patients, even with LVEF ≥70%. The overestimation of systolic function using LVEF seems to be related to the degree of concentric hypertrophy..

Comparing cardiac CT angiography and MR angiography in evaluating left ventricular function and volumes / Comparación de la angiografía por TC y la angiografía por RM para evaluar la función y los volúmenes del ventrículo izquierdo

Abstract Background: cardiovascular diseases are among the principal causes of mortality and morbidity worldwide. Prevention, early diagnosis and treatment can play an important role in reducing complication of cardiovascular diseases. Objectives: Considering increasing popularity of cardiac computed tomography CT angiography (CTA) in one side and also magnetic esonance angiography (MRA) as gold standard modality on the other side, we decided to perform this meta-analysis study to compare cardiac CTA and MRA in evaluating left ventricular volumes. Method: this study is a systematic review in which we included all studies with inclusion criteria and without exclusion criteria up to 30 December, 2019. Studies were selected after searching on different databases and articles in bibliography of included studies. Obtained studies were screened for quality. Required data were extracted and were then analyzed via STATA 11 statistical package. Results: among 90 articles obtained in primary search, finally 19 studies entered data extraction and synthesis. Based on our meta-analysis, standardized mean difference was -0.09 (95% CI -0.2, 0.02) for end systolic volume (ESV), -0.10 (95% CI -0.22, 0.01) for end diastolic volume (EDV), 0.10 (95% CI -0.01, 0.22) for ejection fraction (EF) and -0.09 (95% CI -0.23, 0.04) for stroke volume (SV). Conclusion: Results of this systematic review and meta-analysis showed that there is no statistically significant difference between CTA and MRA in evaluating ESV, EDV, EF and SV. Based on our findings, it can be interpreted that CTA has similar accuracy with MRA in evaluating ventricular volumes.

Resumen Introducción: Las enfermedades cardiovasculares están entre las principales causas de morbimortalidad global. La prevención, el diagnóstico precoz y el tratamiento pueden desempeñar un papel importante en la reducción de las complicaciones de las enfermedades cardiovasculares. Objetivo: Teniendo en cuenta la creciente popularidad de la angiografía por tomografía computarizada (ATC) cardiaca, por un lado, y también la angiografía por resonancia magnética (ARM) como el método de referencia, por el otro, decidimos llevar a cabo un metaanálisis para comparar la ATC y la ARM cardiaca en la evaluación de los volúmenes del ventrículo izquierdo. Método: Revisión sistemática en la cual incluimos todos los estudios con criterios de inclusión y sin criterios de exclusión hasta el 30 de diciembre de 2019. Los estudios se seleccionaron de diferentes bases de datos y artículos de las bibliografías de los estudios incluidos. Los estudios obtenidos se examinaron para evaluar su calidad. Los datos requeridos fueron extraídos y luego analizados utilizando el paquete estadístico STATA 11. Resultados: De los 90 artículos obtenidos en la búsqueda primaria, finalmente 19 estudios entraron a extracción de datos y síntesis. Según nuestro metaanálisis, la diferencia de medias estandarizada fue de −0.09 (intervalo de confianza del 95% [IC95%] −0.2 a 0.02) para el volumen sistólico final (VSF), −0.10 (IC95%: −0.22 a 0.01) para el volumen diastólico final (VDF), 0.10 (IC95%: −0.01 a 0.22) para la fracción de eyección (FE) y − 0.09 (IC95%: −0.23 a 0.04) para el volumen sistólico (VS). Conclusiones: Los resultados de esta revisión sistemática y metaanálisis mostraron que no existe una diferencia estadísticamente significativa entre la ATC y la ARM en la evaluación del VSF, el VDF, la FE y el VS. Basado en nuestros hallazgos, se puede interpretar que la ATC tiene una precisión parecida a la ARM en la evaluación de los volúmenes ventriculares.

Three-dimensional speckle tracking imaging for quantitative evaluation of left ventricular global strain in renal transplant recipients / 器官移植

Objective To evaluate the application value of three-dimensional speckle tracking imaging (3D-STI) in quantitatively evaluating the left ventricular global strain in recipients within 3 months after renal transplantation. Methods Clinical data including blood pressure, serum creatinine and tacrolimus blood concentration of 34 renal transplant recipients were collected before operation, 7 d, 1 month and 3 months after operation, respectively. Meanwhile, conventional echocardiography and 3D-STI examination were performed. Echocardiographic parameters [left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV) and left ventricular ejection fraction (LVEF)] and 3D-STI parameters [left ventricular global peak longitudinal strain (GPLS), global peak circumferential strain (GPCS), global peak radial strain (GPRS) and global peak area strain (GPAS)] of recipients were collected. The changes of these parameters before operation, 7 d, 1 month and 3 months after operation were statistically compared. The changing characteristic and application value of 3D-STI in quantitatively evaluating the left ventricular global strain in recipients within 3 months after renal transplantation were evaluated. Results LVEF and GPCS did not significantly differ at different time points (all P > 0.05), whereas LVEDV, LVESV, GPLS, GPAS and GPRS significantly differed at different time points from preoperative to within postoperative 3 months (all P < 0.001). GPLS, GPAS and GPRS trended to decline within postoperative 1 month, and slightly increased at 3 months after operation, which was still lower than the preoperative levels. Conclusions Application of 3D-STI may sensitively detect the changes of left ventricular global strain in recipients after renal transplantation when no significant variations are observed in postoperative LVEF. Compared with conventional echocardiography, 3D-STI may more accurately evaluate the changes of left ventricular global strain in recipients after renal transplantation.

Heart failure with Normal and Reduced Ejection Fraction – Assessment and Shared Care Management

@#Non-alcoholic fatty liver disease (NAFLD) has become the commonest chronic liver disease in the world. Overall improvement in public health, active screening of blood products, and universal vaccination of hepatitis B have led to a drop in incidence of hepatitis B and C worldwide. NAFLD is strongly associated with metabolic syndrome. With the rise in overweight status and obesity worldwide, it is not surprising that NAFLD is on the rise. Diagnosis of NAFLD requires confirmation of fatty infiltration in liver, as well as liver damage such as elevated liver enzymes and presence of fibrosis. Currently, the best treatment for NAFLD is weight loss, and the proven method would be dieting with regular exercises. Vitamin E and pioglitazoles are promising medications for treating NAFLD, but each medication has their shortcomings. Until more studies are conducted, lifestyle modification remains the only reliable way to treat NAFLD. Family physicians ought to look out for cardiovascular diseases, as well as being vigilant in cancer screening, as NAFLD is associated with higher risks of ischemic heart disease and cancer.

Assessment of left ventricular function in heart failure with preserved ejection fraction patients by speckle tracking layer-specific strain combined with myocardial work technique / 中华超声影像学杂志

Objective:To assess the changes of left ventricular systolic function and global myocardial work in heart failure with preserved ejection fraction (HFpEF) patients by speckle tracking layer-specific strain combined with myocardial work technique and explore the diagnostic value of each parameter for HFpEF.Methods:From December 2019 to December 2020, 38 HFpEF patients (HFpEF group) and 38 healthy individuals with age- and sex-matched (control group) were enrolled consecutively in the Fourth Affiliated Hospital of Harbin Medical University. Conventional ultrasound parameters were collected. Layer-specific strain and myocardial work techniques were used to obtain the global longitudinal strain (GLS) of the left ventricular endocardium, mid-myocardium, and epicardium (GLSendo, GLSmid, GLSepi), global myocardial work index (GWI), global myocardial work efficiency (GWE), global constructive work (GCW), and global wasted work (GWW). The absolute difference of GLS(ΔGLS) between endocardium and epicardium were calculate.All parameters were analyzed statistically. ROC curves were plotted to compare the effectiveness of layer-specific strain and myocardial work parameters in predicting left ventricular systolic function impairment in HFpEF patients.Results:①Left atrial diameter, interventricular septum at end-diastole, left ventricular posterior wall at end-diastole, relative wall thickness, left ventricular mass index, and average early diastolic peak velocity (E)/early diastolic tissue velocity (e′) in HFpEF group were significantly higher compared with control subjects, while late diastolic peak velocity (A), E/A, and e′ were significantly lower (all P<0.05); E, left ventricular end-diastolic diameter, left ventricular end-diastolic volume, left ventricular end-systolic volume, fraction shortening, and left ventricular ejection fraction were not different between HFpEF and control groups (all P>0.05). ②The global longitudinal strain of the left ventricule was highest in the endocardium and lowest in the epicardium. ③Compared with control subjects, HFpEF patients demonstrated significantly decreased GLSendo, GLSmid, GLSepi, ΔGLS, GWI, GWE, GCW and increased GWW (all P<0.01). ④The ROC results showed that the area under the curve of ΔGLS and GWE for predicting left ventricular contractile function impairment in HFpEF group, was 0.884 and 0.882, respectively; The cutoff values were -5.8% and 95%; The sensitivity were 84.2% and 71.1%, and the specificity was 84.2% and 89.5%, respectively. ⑤The ROC curve of combining the two technologies showed that the maximum area under the curve of the ΔGLS in tandem with GWE was 0.944, the sensitivity was 81.6%, and the specificity was 97.4%. Conclusions:Both speckle tracking layer-specific strain and myocardial work techniques can sensitively detect left ventricular myocardial function impairment in HFpEF patients at an early stage. ΔGLS and GWE are more reliable indexes for predicting left ventricular systolic function damage in HFpEF patients. Combining the two techniques can improve the diagnostic performance in HFpEF patients.