Effect of renin angiotensin blockers on angiotensin converting enzyme 2 level in cardiovascular patients.

BACKGROUND: Renin-angiotensin-aldosterone system (RAAS) is hypothesized to be in the center of COVID pathophysiology as the angiotensin converting enzyme 2 (ACE2) represents the main entrance of the virus, thus there is a need to address the effect of chronic use of RAAS blockers, as in case of treatment of cardiovascular diseases, on the expression of ACE2. Accordingly, this study aimed to clarify the effect of ACE inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) on ACE2 and to assess the correlation between ACE2 and several anthropometric and clinic-pathological factors. METHODS: A total of 40 healthy controls and 60 Egyptian patients suffering from chronic cardiovascular diseases were enrolled in this study. Patients were divided into 40 patients treated with ACEIs and 20 patients treated with ARBs. Serum ACE2 levels were assessed by ELISA. RESULTS: Assessment of serum ACE2 level in different groups showed a significant difference between ACEIs and healthy groups and ACEIs and ARBs group, while there was no difference between ARBs and healthy. Multivariate analysis using ACE2 level as constant and age, female sex, ACEIs use and myocardial infarction (MI) showed that there was a significant effect of female sex and ACEIs use on ACE2 level with no effect of age, MI and diabetes. CONCLUSION: ACE2 levels varied between ACEIs and ARBs. It tends to be lower in ACEIs group and there is a strong positive association between ACE2 level and the female sex. This needs to be considered in Future studies to further understand the relationship between gender, sex hormones and ACE2 level. TRIAL REGISTRATION: Retrospectively registered ClinicalTrials.gov ID: NCT05418361 (June 2022).

Impact of exercise training on myocardial contractile functions assessed by cardiac magnetic resonance in post-myocardial infarction patients.

BACKGROUND: Improvement of functional capacity and mortality reduction in post-MI patients were found to be associated with regular exercise training. The cardiac magnetic resonance (CMR) is considered the most accurate non-invasive modality in quantitative assessment of left ventricular (LV) volumes and systolic functions. Our main objective was to investigate the impact of exercise training on LV systolic functions in patients post anterior MI using CMR. 32 patients on recommended medical treatment 4 week after having a successful primary PCI for an anterior MI were recruited, between May 2018 and May 2019. They were divided into two groups, training group (TG): 16 assigned to a 12 week exercise training program and control group (CG): 16 who received medical treatment without participating in the exercise training program. Treadmill exercise using modified Bruce protocol was done to TG before and after the training program in order to record the resting and maximum HR, metabolic equivalent (MET), and calculate HR reserve. CMR was performed for all patients 4 weeks after PCI and was repeated after completion of the study period to calculate ejection fraction (EF), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV), and wall motion score index (WMSI). RESULTS: 100% were males. 6 patients from CG dropped during follow-up, no statistically significant difference between the two groups regarding age, BMI, smoking status, hypertension, diabetes mellitus and dyslipidemia. Using the CMR, the TG showed significant improvement in EF (36.6 ± 14.2% to 43.1 ± 12.4%; P < 0.001) and WMSI (2.03 ± 0.57 to 1.7 ± 0.49; P < 0.001), without statistically significant change in LV volumes. Regarding CG no significant changes in EF, WMSI, LV volumes were found. There was significant improvement in EF and WMSI change before and after study in TG vs. CG [6.5 (2.3-9.0) vs. - 2.0 (- 6.8 to 1.3), P value < 0.001] and [- 0.3 (- 0.5 to 0.1) vs. 0.1 (- 0.1 to - 0.5), P value 0.001] respectively. CONCLUSIONS: 12 weeks of exercise training program in post-MI patients have a favorable impact on LV global and regional systolic functions without adversely affecting LV remodeling (as assessed by CMR).

Impact of lipophilic vs hydrophilic statins on the clinical outcome and biomarkers of remodelling in heart failure patients: A prospective comparative randomized study.

AIMS: There are insufficient direct comparative studies addressing the impact of the type of statin on their respective efficacy in heart failure (HF). The aim of the current study was to compare the effects of lipophilic (atorvastatin) vs hydrophilic (rosuvastatin) on left ventricular function, inflammatory and fibrosis biomarkers in patients with chronic HF. METHODS: This was a prospective, randomized, comparative, parallel study. A total of 85 patients with chronic HF optimized on guideline directed therapy were randomized to receive either atorvastatin 40 mg (n = 42) or rosuvastatin 20 mg (n = 43) for 6 months. Baseline and follow-up assessment included 2D echocardiography, measurement of N-terminal pro-brain natriuretic peptide, interleukin-6 and soluble suppression of tumorigenicity 2 (sST2) levels, liver enzymes and lipid profile. RESULTS: The increase in left ventricular ejection fraction was significantly higher in the atorvastatin group compared to the rosuvastatin group (6.5% [3-11] vs 4% [2-5], P = .006). The reduction in left ventricular end diastolic and end systolic volume was comparable between the 2 groups. The decrease in sST2 levels in pg/mL was significantly higher in the atorvastatin compared to the rosuvastatin group (-255 [-383 to -109.8 vs - 151 [-216 to -69], P = .003). There was a significant reduction in N-terminal pro-brain natriuretic peptide and interleukin-6 levels in both groups, yet the reduction was comparable in both groups. CONCLUSION: The study results suggest that lipophilic atorvastatin is superior to hydrophilic rosuvastatin in increasing left ventricular ejection fraction and reducing fibrosis marker sST2 in HF patients. Trial registration ID: NCT03255044, registered on 21 August 2017.

Impact of Ramadan Fasting on Biochemical and Exercise Parameters Among Patients Undergoing Exercise-Based Cardiac Rehabilitation.

BACKGROUND: Ramadan fasting is an important worship activity for Muslims. It is not known if fasting could have deleterious effect on cardiac patients joining cardiac rehabilitation (CR) program, especially during summer season. AIM: To assess the effect of Ramadan fasting on biochemical and exercise parameters among patients undergoing 12-week exercise-based CR program. PATIENTS AND METHODS: 53 patients joining CR program in university hospital were included in the study. The patients were divided into two groups according to their Ramadan fasting status. Fasting group included 32 patients, while non-fasting group included 21 patients. All patients underwent supervised exercise-based CR during the month of Ramadan. Plasma osmolality, blood urea and serum creatinine were assessed before CR and during the last week of Ramadan. Lipid profile, echocardiography and exercise parameters were assessed before and after CR program. RESULTS: The two groups were similar in baseline characteristics including: risk factors, osmolality, urea, creatinine, lipid profile and hemoglobin values, as well as ejection fraction and exercise parameters. After the program, both groups showed significant improvement in ejection fraction, total cholesterol, LDL and HDL levels. There was also improvement in duration of exercise reached and achieved METs before and after CR program in both groups. An important notice was that fasting did not significantly influence plasma osmolality in either group. CONCLUSION: Ramadan fasting did not change serum osmolality or negatively affect the results of CR among cardiac patients. It appears to be safe to undergo exercise-based CR during Ramadan even in summer season.

Effect of Genetic and Nongenetic Factors on the Clinical Response to Mineralocorticoid Receptor Antagonist Therapy in Egyptians with Heart Failure.

This prospective cohort study evaluated the association between the renin angiotensin aldosterone system genotypes and response to spironolactone in 155 Egyptian patients with heart failure with reduced ejection fraction (HFrEF). Genotype frequencies for AGT rs699 were: CC = 16%, CT = 48%, and TT = 36%. Frequencies for CYP11B2 rs1799998 were: TT = 33%, TC = 50%, and CC = 17%. After 6 months of spironolactone treatment, change in the left ventricular ejection fraction (LVEF) differed by AGT rs699 (CC, 14.6%; TC, 7.9%; TT, 2.7%; P = 2.1E-26), and CYP11B2 rs1799998 (TT, 9.1%; TC, 8.7%; CC, 1.4%; P = 0.0006) genotypes. Multivariate linear regression showed that the AGT rs699 and CYP11B2 rs1799998 polymorphisms plus baseline serum potassium explained 71% of variability in LVEF improvement (P = 0.001), 63% of variability in serum potassium increase (P = 2.25E-08), and 39% of the variability in improvement in quality of life (P = 2.3E-04) with spironolactone therapy. These data suggest that AGT and CYP11B2 genotypes as well as baseline serum K are predictors of spironolactone response in HFrEF.

Effect of exercise training on heart rate recovery in patients post anterior myocardial infarction.

BACKGROUND: Regular exercise training has been shown to reduce mortality, improve functional capacity; and control the risk factors in myocardial infarction (MI) patients. Heart rate recovery (HRR) is a strong independent mortality predictor in patients with previous MI. AIM: The main objective of this study was to investigate the impact of exercise training on heart rate recovery in patients post anterior myocardial infarction. METHODS: We recruited patients one month after having anterior MI who were referred to cardiac rehabilitation (CR) clinic in Ain Shams University hospital between October 2016 and July 2017. All the patients participated in exercise training sessions 3 times a week for 12 weeks. Symptom limited treadmill exercise test was done before and after exercise training program to calculate heart rate recovery in 1st minute (HRR1) and 2nd minute (HRR2). RESULTS: A total of 50 patients, including 44 (88%) males, completed the exercise training program. The mean age was 51 years. Statistically significant improvement in HRR1 and HRR2 was observed (p value <0.001) after completion of exercise based cardiac rehabilitation program. Significant improvement in resting heart rate was also observed (p value <0.001). Moreover, metabolic equivalent (METs) and HR reserve were improved significantly (p value <0.001). No statistically significant changes were observed in resting systolic and diastolic blood pressures and maximum HR (p value = 0.95, 0.76 and 0.31 respectively). CONCLUSION: Exercise training improves HRR, resting HR, METs and HR reserve in post anterior MI patients.

Cardiac rehabilitation improves the ischemic burden in patients with ischemic heart disease who are not suitable for revascularization.

BACKGROUND: Ischemic heart diseases including stable angina & acute events, represent a huge burden on both the individual & the society and represent an important source of disability. AIM: We aimed to identify the effect of cardiac rehabilitation program (CRP) on the ischemic burden in patients with ischemic heart disease (IHD) unsuitable for coronary revascularization. METHODS: The study included 40 patients with IHD who were not suitable for coronary revascularization either by PCI or CABG (due to unsuitable coronary anatomy, co morbidities, high surgical/procedural risk or patient preference). All patients were subjected to sophisticated CRP protocols, including patient education, nutritional, medical, psychological and sexual counseling and group smoking cessation. All patients participated in low intensity exercise program twice weekly. The patient's symptoms, vitals and medications were evaluated at each visit and clinical and laboratory data, echocardiography and stress myocardial perfusion imaging (SPECT) were evaluated before and 3months after the end of the study. RESULTS: The mean age was 56.8±3.1years and only 2 patients (5%) were females. 22 (55%) patients were diabetic, 21 (53%) were hypertensive and 30 (75%) were smokers. It was found that 3months after completion of CRP, there was a significant decrease in BMI (30.3±2.9 vs. 31.2±1.9, p<0.001), and mean blood pressure (93.4±11 vs. 105±10.6mmHg, p<0.001). There was also a favorable effect on lipid profile and a significant improvement of the functional capacity in terms of NYHA functional class (2.1±0.62 vs. 1.4±0.6, p<0.001). Despite that wall motion score index did not significantly change after CRP, there was a strong trend toward a better ejection fraction (53.7±7.8 vs. 54.5±6.3 %, p=0.06) and significant improvement of Canadian cardiovascular class (1.42±0.6 vs. 1.95±0.5, p<0.001) post CRP. Importantly, the difference between the SPECT-derived summed segmental scores at peak stress and at rest (SDS) was significantly lower after CRP (4.4±3 vs. 7.2±3, p<0.001). CONCLUSION: Participation in cardiac rehabilitation program improves ischemic burden in patients with IHD who are unfit or not suitable for conventional cardiac revascularization. In addition the decreased ischemic burden, functional capacity, hemodynamic and metabolic profiles also improve for this group of patients and thus, cardiac rehabilitation should be implemented for routine management of those patients.

Tissue Doppler-Derived Myocardial Acceleration during Isovolumetric Contraction Predicts Pulmonary Capillary Wedge Pressure in Patients with Significant Mitral Regurgitation.

The aim of this study was to determine whether isovolumic contraction velocity (IVV) and acceleration (IVA) predict pulmonary capillary wedge pressure (PCWP) in mitral regurgitation. Forty-four patients with mitral regurgitation were studied. PCWP was invasively measured. IVV, IVA and the ratio IVRT/Te'-E (where IVRT = isovolumic relaxation time, and Te'-E = time difference between the onset of mitral annular e' and mitral flow E waves) were measured. Mean age was 59.2 ± 13.3 y. Twenty-six patients had an ejection fraction ≥55%, and 18 patients had an ejection fraction <55%. IVRT/Te'-E was impossible in 11 patients because Te'-E = zero. PCWP correlated with IVV, IVA and IVRT/Te'-E; overall (r = -0.714, -0.892 and, -0.752, all p < 0.001), ejection fraction ≥55 (r = -0.467, -0.749, -0.639, p = 0.016, <0.001, 0.003) and ejection fraction <55% (r = -0.761, -0.911 and -0.833, all p < 0.001). Similar correlations were found for sinus and atrial fibrillation. Our study suggests that IVV and IVA correlate with PCWP in patients with mitral regurgitation irrespective of systolic function or rhythms and, thus, can be alternatives to the tedious IVRT/Te'-E, especially when impossible because Te'-E = 0.