[Renal insufficiency in the context of cardio-pulmonary-renal pathophysiology]. / Niereninsuffizienz im Kontext der kardiopulmorenalen Pathophysiologie.

Heart failure and renal insufficiency as well as pulmonary hypertension are pathophysiologically closely associated as a cardio-renal or cardio-pulmonary-renal syndrome. Due to the frequent hospitalization of patients affected by this syndrome, it is of high medical and also health economic relevance. Besides the inhibition of the renin-angiotensin-aldosterone system (RAAS), multimodal treatment options are available with mineralocorticoid receptor antagonists, angiotensin receptor-neprilysin inhibitors and sodium-glucose transporter 2 (SGLT-2) inhibitors. Profound knowledge of the pathophysiology and the therapeutic options is as necessary for an optimized medical care as patient-oriented, transdisciplinary and cross-sectoral care.

[Heart failure with preserved ejection fraction as a model disease for the cardio-pulmonary-renal syndrome : Importance of visceral fat expansion as central pathomechanism]. / Herzinsuffizienz mit erhaltener Ejektionsfraktion als Modellerkrankung für das kardio-pulmo-renale Syndrom : Bedeutung der viszeralen Fettexpansion als zentraler Pathomechanismus.

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome with diverse underlying etiologies and pathophysiological factors. Obesity and type 2 diabetes mellitus (T2DM), diseases which frequently coexist, induce a cluster of metabolic and nonmetabolic signaling derangements, which promote induction of inflammation, fibrosis and myocyte stiffness, all representing hallmarks of HFpEF. In contrast to other HFpEF risk factors, obesity and T2DM are often associated with the formation of an enlarged visceral adipose tissue (VAT), which is a highly active endocrine organ that can sustainably exacerbate inflammation and fibrotic remodeling of myocardial, renal, and vascular tissues via various paracrine and vasocrine signals. An abnormally large epicardial adipose tissue (EAT) thus not only causes a mechanical constriction of the diastolic filling procedure of the heart but is also associated with an increased release of proinflammatory adipokines that trigger atrial fibrillation and impaired left ventricular contraction parameters. Obese patients with HFpEF therefore belong to a unique HFpEF phenotype with a particularly poor prognosis that could benefit from an EAT-oriented phenotype-specific intervention. In addition to statins and antidiabetic drugs such as metformin, glucagon-like peptide­1 (GLP-1) receptor agonists and sodium-glucose transporter 2 (SGLT-2) inhibitors could also play an important role.

[Heart failure care in a digitalized future : A discourse on resource-sparing structures and self-determined patients]. / Herzinsuffizienzversorgung in einer digitalisierten Zukunft : Ein Diskurs zu ressourcenschonenden Strukturen und selbstbestimmten Patienten.

Digital health solutions, applications of artificial intelligence (AI) and new technologies, such as cardiac magnetic resonance imaging and cardiac human genetics are currently being validated in cardiac healthcare pathways. They show promising approaches for improving existing healthcare structures in the future by strengthening the focus on predictive, preventive and personalized medicine. In addition, the accompanying use of digital health applications will become increasingly more important in the future healthcare, especially in patients with chronic diseases. In this article, the authors describe a case of chronic heart failure (HF) as an example to provide an overview of how digitalized healthcare can be efficiently designed across sectors and disciplines in the future. Moreover, the importance of a self-determined patient management for the treatment process itself is underlined. Since HF is frequently accompanied by various comorbidities during the course of the disease that are often recognized only after a delay, the necessity for a timely simultaneous and preventive treatment of multiple comorbidities in cardiovascular diseases is emphasized. Against this background the currently separately applied disease management programs (DMP) are critically questioned. The development of a holistic DMP encompassing all indications for the treatment of chronic diseases may pave the way to a more efficient medical care system.

Benefits of peritoneal ultrafiltration in HFpEF and HFrEF patients.

BACKGROUND: Peritoneal ultrafiltration (pUF) in refractory heart failure (HF) reduces the incidence of decompensation episodes, which is of particular significance as each episode incrementally adds to mortality. Nevertheless, there are insufficient data about which patient cohort benefits the most. The objective of this study was to compare pUF in HFrEF and HFpEF, focusing on functional status, hospitalizations, surrogate endpoints and mortality. METHODS: This study involves 143 patients, who could be classified as either HFpEF (n = 37, 25.9%) or HFrEF (n = 106, 74.1%) and who received pUF due to refractory HF. RESULTS: Baseline eGFR was similar in HFrEF (23.1 ± 10.6 mg/dl) and HFpEF (27.8 ± 13.2 mg/dl). Significant improvements in NYHA class were found in HFpEF (3.19 ± 0.61 to 2.72 ± 0.58, P <  0.001) and HFrEF (3.45 ± 0.52 to 2.71 ± 0.72, P <  0.001). CRP decreased in HFrEF (19.4 ± 17.6 mg/l to 13.7 ± 21.4 mg/l, P = 0.018) and HFpEF (33.7 ± 52.6 mg/l to 17.1 ± 26.3 mg/l, P = 0.004). Body weight was significantly reduced in HFrEF (81.1 ± 14.6 kg to 77.2 ± 15.6 kg, P = 0.003) and HFpEF (86.9 ± 15.8 kg to 83.1 ± 15.9 kg, P = 0.005). LVEF improved only in HFrEF (25.9 ± 6.82% to 30.4 ± 12.2%, P = 0.046). BCR decreased significantly in HFrEF and HFpEF (55.7 ± 21.9 to 34.3 ± 17.9 P > 0.001 and 50.5 ± 68.9 to 37.6 ± 21.9, P = 0.006). Number of hospitalization episodes as well as number of hospitalization days decreased significantly only in HFpEF (total number 2.88 ± 1.62 to 1.25 ± 1.45, P <  0.001, days 40.4 ± 31.7 to 18.3 ± 22.5 days, P = 0.005). CONCLUSIONS: pUF offers various benefits in HFpEF and HFrEF, but there are also substantial differences. In particular, hospitalization rates were found to be significantly reduced in HFpEF patients, indicating a greater medical and economical advantage. However, LVEF was only found to be improved in HFrEF patients. While pUF can now be regarded as an option to supplement classical HF therapy, further studies are desirable to obtain specifications about pUF in HFpEF, HFmEF and HFrEF patients.

Local impedance drop-guided versus lesion size index-guided pulmonary vein isolation.

BACKGROUND: Local tissue impedance drop (LID) and lesion size index (LSI) technologies are valuable for predicting effective lesion formation. This study compares the acute and long-term efficacy of LID-guided versus LSI-guided pulmonary vein isolation (PVI) for atrial fibrillation treatment. METHODS: We retrospectively analyzed two patient groups undergoing radiofrequency PVI. In the LID-guided group (n = 35), ablation was performed without contact force monitoring, stopping at the LID plateau (target LID 12 Ohm posterior, 16 Ohm anterior). In the LSI-guided group (n = 31), ablation used contact force information with target LSI (5 anterior, 4 posterior). Both groups utilized a power of 40 W anterior and 30 W posterior, with < 6 mm inter-lesion distance. Gap mapping and touch-up ablation were done if necessary. RESULTS: PVI was achieved with a significantly shorter ablation time in the LSI-guided group (25 min [21;31] vs 30 [27;35], p = 0.035). PV gaps were more frequent in the LID-guided group (74% vs 42%, p = 0.016). Over 11.5 ± 2.9 months follow-up, arrhythmia recurrence was higher in the LID-guided group (34.3% vs 16.1%, p = 0.037). A redo procedure performed in 10 (28.6%) patients in the LID-guided group and 3 (9.7%) in the LSI-guided group showed chronic PV reconnections in 7 out of 10 (70%) and 2 out of 3 (67%) patients, respectively. CONCLUSIONS: LSI-guided ablation results in shorter ablation time and fewer PV gaps compared to LID-guided ablation. Despite initial success, LID-guided ablation had higher arrhythmia recurrence and PV reconnections during long-term follow-up compared to LSI-guided ablation.

[Artificial intelligence in cardiology : Relevance, current applications, and future developments]. / Künstliche Intelligenz in der Kardiologie : Relevanz, aktuelle Anwendungen und nächste Schritte.

Big data and applications of artificial intelligence (AI), such as machine learning or deep learning, will enrich healthcare in the future and become increasingly important. Among other things, they have the potential to avoid unnecessary examinations as well as diagnostic and therapeutic errors. They could enable improved, early and accelerated decision-making. In the article, the authors provide an overview of current AI-based applications in cardiology. The examples describe innovative solutions for risk assessment, diagnosis and therapy support up to patient self-management. Big data and AI serve as a basis for efficient, predictive, preventive and personalised medicine. However, the examples also show that research is needed to further develop the solutions for the benefit of the patient and the medical profession, to demonstrate the effectiveness and benefits in health care and to establish legal and ethical standards.

Kidney injury as post-interventional complication of TAVI.

Transcatheter aortic valve implantation (TAVI) is an accepted treatment approach of aortic stenosis. In the beginning, this technique was executed in high-risk patients only. Today, intermediate-risk patients are also amenable for TAVI, as long as the transfemoral approach is chosen. Numerous predictors have been identified that could lead to periprocedural complications and are defined by patient co-morbidities as well as being inherent to the technical approach. Although vascular complications and postinterventional paravalvular regurgitation have been minimized over the past years by revised technologies and techniques, there is a prevailing individual risk brought about by the specific pathophysiology of the cardiorenal syndrome.

HMGB1: the missing link between diabetes mellitus and heart failure.

Diabetes mellitus (DM) is a major independent risk factor for cardiovascular disease, but also leads to cardiomyopathy. However, the etiology of the cardiac disease is unknown. Therefore, the aim of this study was to identify molecular mechanisms underlying diabetic heart disease. High glucose treatment of isolated cardiac fibroblasts, macrophages and cardiomyocytes led to a sustained induction of HMGB1 on the RNA and protein level followed by increased NF-κB binding activity with consecutively sustained TNF-α and IL-6 expression. Short interference (si) RNA knock-down for HMGB1 and RAGE in vitro confirmed the importance of this axis in diabetes-driven chronic inflammation. In a murine model of post-myocardial infarction remodeling in type 1 diabetes, cardiac HMGB1 expression was significantly elevated both on RNA and protein level paralleled by increased expression of pro-inflammatory cytokines up to 10 weeks. HMGB1-specific blockage via box A treatment significantly reduced post-myocardial infarction remodeling and markers of tissue damage in vivo. The protective effects of box A indicated an involvement of the mitogen-activated protein-kinases jun N-terminal kinase and extracellular signal-regulated kinase 1/2, as well as the transcription factor nuclear factor-kappaB. Interestingly, remodeling and tissue damage were not affected by administration of box A in RAGE(-/-) mice. In conclusion, HMGB1 plays a major role in DM and post-I/R remodeling by binding to RAGE, resulting in activation of sustained pro-inflammatory pathways and enhanced myocardial injury. Therefore, blockage of HMGB1 might represent a therapeutic strategy to reduce post-ischemic remodeling in DM.

Endothelial S100A1 modulates vascular function via nitric oxide.

S100A1, a Ca(2+)-binding protein of the EF-hand type, is known to modulate sarcoplasmic reticulum Ca(2+) handling in skeletal muscle and cardiomyocytes. Recently, S100A1 has been shown to be expressed in endothelial cells (ECs). Because intracellular Ca(2+) ([Ca(2+)](i)) transients can be involved in important EC functions and endothelial NO synthase activity, we sought to investigate the impact of endothelial S100A1 on the regulation of endothelial and vascular function. Thoracic aortas from S100A1 knockout mice (SKO) showed significantly reduced relaxation in response to acetylcholine compared with wild-type vessels, whereas direct vessel relaxation using sodium nitroprusside was unaltered. Endothelial dysfunction attributable to the lack of S100A1 expression could also be demonstrated in vivo and translated into hypertension of SKO. Mechanistically, both basal and acetylcholine-induced endothelial NO release of SKO aortas was significantly reduced compared with wild type. Impaired endothelial NO production in SKO could be attributed, at least in part, to diminished agonist-induced [Ca(2+)](i) transients in ECs. Consistently, silencing endothelial S100A1 expression in wild type also reduced [Ca(2+)](i) and NO generation. Moreover, S100A1 overexpression in ECs further increased NO generation that was blocked by the inositol-1,4,5-triphosphate receptor blocker 2-aminoethoxydiphenylborate. Finally, cardiac endothelial S100A1 expression was shown to be downregulated in heart failure in vivo. Collectively, endothelial S100A1 critically modulates vascular function because lack of S100A1 expression leads to decreased [Ca(2+)](i) and endothelial NO release, which contributes, at least partially, to impaired endothelium-dependent vascular relaxation and hypertension in SKO mice. Targeting endothelial S100A1 expression may, therefore, be a novel therapeutic means to improve endothelial function in vascular disease or heart failure.

Rhizoma Coptidis inhibits LPS-induced MCP-1/CCL2 production in murine macrophages via an AP-1 and NFkappaB-dependent pathway.

INTRODUCTION: The Chinese extract Rhizoma coptidis is well known for its anti-inflammatory, antioxidative, antiviral, and antimicrobial activity. The exact mechanisms of action are not fully understood. METHODS: We examined the effect of the extract and its main compound, berberine, on LPS-induced inflammatory activity in a murine macrophage cell line. RAW 264.7 cells were stimulated with LPS and incubated with either Rhizoma coptidis extract or berberine. Activation of AP-1 and NFkappaB was analyzed in nuclear extracts, secretion of MCP-1/CCL2 was measured in supernatants. RESULTS: Incubation with Rhizoma coptidis and berberine strongly inhibited LPS-induced monocyte chemoattractant protein (MCP)-1 production in RAW cells. Activation of the transcription factors AP-1 and NFkappaB was inhibited by Rhizoma coptidis in a dose- and time-dependent fashion. CONCLUSIONS: Rhizoma coptidis extract inhibits LPS-induced MCP-1/CCL2 production in vitro via an AP-1 and NFkappaB-dependent pathway. Anti-inflammatory action of the extract is mediated mainly by its alkaloid compound berberine.

S100A1 in cardiovascular health and disease: closing the gap between basic science and clinical therapy.

Calcium (Ca(2+)) signaling plays a major role in a wide range of physiological functions including control and regulation of cardiac and skeletal muscle performance and vascular tone. As all Ca(2+) signals require proteins to relay intracellular Ca(2+) oscillations downstream to different signaling networks, a specific toolkit of Ca(2+)-sensor proteins involving members of the EF-hand S100 Ca(2+) binding protein superfamily maintains the integrity of the Ca(2+) signaling in a variety of cardiac and vascular cells, transmitting the message with great precision and in a temporally and spatially coordinated manner. Indeed, the possibility that S100 proteins might contribute to heart and vascular diseases was first suggested by the discovery of distinctive patterns of S100 expression in healthy and diseased hearts and vasculature from humans and animal heart failure (HF) models. Based on more elaborate genetic studies in mice and strategies to manipulate S100 protein expression in human cardiac, skeletal muscle and vascular cells, it is now apparent that the integrity of distinct S100 protein isoforms in striated muscle and vascular cells such as S100A1, S100A4, S100A6, S100A8/A9 or S100B is a basic requirement for normal cardiovascular and muscular development and function; loss of integrity would naturally lead to profound deregulation of the implicated Ca(2+) signaling systems with detrimental consequences to cardiac, skeletal muscle, and vascular function. The brief debate and discussion here are confined by design to the biological actions and pathophysiological relevance of the EF-hand Ca(2+)-sensor protein S100A1 in the heart, vasculature and skeletal muscle with a particular focus on current translational therapeutic strategies. By virtue of its ability to modulate the activity of numerous key effector proteins that are essentially involved in the control of Ca(2+) and NO homeostasis in cardiac, skeletal muscle and vascular cells, S100A1 has been proven to play a critical role both in cardiac performance, blood pressure regulation and skeletal muscle function. Given that deregulated S100A1 expression in cardiomyocytes and endothelial cells has recently been linked to heart failure and hypertension, it is arguably a molecular target of considerable clinical interest as S100A1 targeted therapies have already been successfully investigated in preclinical translational studies.

High-mobility group box-1 in ischemia-reperfusion injury of the heart.

BACKGROUND: High-mobility group box-1 (HMGB1) is a nuclear factor released by necrotic cells and by activated immune cells. HMGB1 signals via members of the toll-like receptor family and the receptor for advanced glycation end products (RAGE). Although HMGB1 has been implicated in ischemia/reperfusion (I/R) injury of the liver and lung, its role in I/R injury of the heart remains unclear. METHODS AND RESULTS: Here, we demonstrate that HMGB1 acts as an early mediator of inflammation and organ damage in I/R injury of the heart. HMGB1 levels were already elevated 30 minutes after hypoxia in vitro and in ischemic injury of the heart in vivo. Treatment of mice with recombinant HMGB1 worsened I/R injury, whereas treatment with HMGB1 box A significantly reduced infarct size and markers of tissue damage. In addition, HMGB1 inhibition with recombinant HMGB1 box A suggested an involvement of the mitogen-activated protein kinases jun N-terminal kinase and extracellular signal-regulated kinase 1/2, as well as the nuclear transcription factor nuclear factor-kappaB in I/R injury. Interestingly, infarct size and markers of tissue damage were not affected by administration of recombinant HMGB1 or HMGB1 antagonists in RAGE(-/-) mice, which demonstrated significantly reduced damage in reperfused hearts compared with wild-type mice. Coincubation studies using recombinant HMGB1 in vitro induced an inflammatory response in isolated macrophages from wild-type mice but not in macrophages from RAGE(-/-) mice. CONCLUSIONS: HMGB1 plays a major role in the early event of I/R injury by binding to RAGE, resulting in the activation of proinflammatory pathways and enhanced myocardial injury. Therefore, blockage of HMGB1 might represent a novel therapeutic strategy in I/R injury.

Reference change values and determinants of variability of NT-proANP and GDF15 in stable chronic heart failure.

Biovariability, reference change values (RCV), and index of individuality (IOI) have not been previously described for NT-proANP or GDF15. Also, the relation of changes of these markers to other clinical variables or biomarkers is unknown. In 41 patients with stable chronic systolic dysfunction, NT-proANP and GDF15 were measured alongside with clinical variables/markers comprising NT-proBNP, hsTnT, and hsCRP at four sampling intervals (2 weeks, 1-, 2-, 3-month intervals). At 2 weeks, 1-, 2-, and 3-month-follow-up, individual NT-proANP variations were 27.1, 22.5, 28.9, 15.6%, respectively, corresponding to RCVs of 53.2, 62.4, 80.2, and 43.2%, respectively. For GDF15, the respective individual variations were 6.8, 4.1, 5.5, 6.8%, corresponding to RCVs of 18.8, 11.5, 15.3 and 18.8%. Neither changes of NT-proANP or GDF15 correlated with changes in any of the clinical variables or biomarkers examined except for GDF15 with renal function. Baseline hormonal levels and clinical variables did not consistently influence the extent of change. The IOI was 0.19-0.35 according to interval for NT-proANP and 0.06-0.09 for GDF 15. In patients with CHF preselected for clinical stability changes of NT-proANP at intermediate follow-up do not correlate with changes in other variables; changes of GDF15 inversely correlate with renal function. The extent of change in both markers is not related to baseline hormonal levels or other baseline variables. RCVs are high for NT-proANP and low for GDF15, while inter-individual variation is high in GDF15 and intermediate in NT-proANP.

Variability of N-terminal probrain natriuretic peptide in stable chronic heart failure and its relation to changes in clinical variables.

BACKGROUND: We investigated the variability of N-terminal probrain natriuretic peptide (NT-proBNP) and its relation to known confounding variables in patients with stable chronic heart failure who were on a stable optimized medication regimen. METHODS: At 4 sampling intervals (14-day, 1-month, 2-month, and 3-month) the results for NT-proBNP measurements and several clinical variables were measured in samples from 41 patients with chronic systolic dysfunction who met 21 prespecified criteria for stability. RESULTS: Mean within-person NT-proBNP variabilities expressed as percentage CV were 17.6%, 18.9%, 15.5%, and 16.2% at 14-day, 1-month, 2-month, and 3-month follow-up, respectively, and the corresponding reference change values were 34.6%, 52.5%, 43.1%, and 45.0%, respectively. Within-person variability of NT-proBNP was not found to be associated with renal function, weight, or waist circumference. Likewise, age, sex, baseline NT-proBNP, New York Heart Association functional class, and ejection fraction did not influence variability of NT-proBNP. The index of individuality ranged from 0.07-0.15 depending on the time interval between test results. CONCLUSIONS: Although other reported studies have revealed variations in the range of 80%, in this prespecified stable heart-failure population variation of NT-proBNP at 14-day, 1-month, 2-month, and 3-month follow-up was lower and was not related to renal function or weight. In view of the low index of individuality we observed, within-person variation is quite low compared to between-person variation. Consideration of these facts is important for the interpretation of clinical trials and the use of NT-proBNP in monitoring patients with heart failure.

Prevalence and prognostic significance of adrenergic escape during chronic beta-blocker therapy in chronic heart failure.

AIMS: Like aldosterone escape to ACE-inhibitors, adrenergic escape (AE) to beta-blockers appears conceivable in chronic heart failure (CHF), as generalized systemic neurohumoral activation has been described as the pathophysiological basis of this syndrome. The aim of this study was to examine the prevalence and prognostic value of AE with respect to different beta-blocker agents and doses. METHODS AND RESULTS: This was a prospective, observational study of 415 patients with systolic CHF receiving chronic stable beta-blocker therapy. AE was defined by norepinephrine levels above the upper limit of normal. Irrespective of the individual beta-blocker agents used and the dose equivalent taken, the prevalence of AE was 31-39%. Norepinephrine levels neither correlated with heart rate (r=0.02; 95% CI: -0.08-0.11; P=0.74) nor were they related to underlying rhythm (P=0.09) or the individual beta-blocker agent used (P=0.87). The presence of AE was a strong and independent indicator of mortality (adjusted HR: 1.915; 95% CI: 1.387-2.645; chi2: 15.60). CONCLUSION: We verified the presence of AE in CHF patients on chronic stable beta-blocker therapy, irrespective of the individual beta-blocker agent and the dose equivalent. As AE might indicate therapeutic failure, the determination of AE could help to identify those patients with CHF that might benefit from more aggressive treatment modalities. Heart rate, however, is not a surrogate for adrenergic escape.

Exploring potential associations of suicidal ideation and ideas of self-harm in patients with congestive heart failure.

OBJECTIVE: To determine the factors, which are associated with suicidal ideation and ideas of self-harm in patients with congestive heart failure (CHF). METHODS: We examined 294 patients with documented CHF, New York Heart Association (NYHA) functional class II-IV, in a cross sectional study at three cardiac outpatient departments. Measures included self-reports of suicidal ideation and self-harm (PHQ-9), depression (SCID), health-related quality of life (SF-36), multimorbidity (CIRS-G), consumption of alcoholic beverages, as well as comprehensive clinical status. Data were analyzed using logistic regression analyses. RESULTS: 50 patients (17.1%) reported experiencing suicidal ideation and/or ideas of self-harm on at least several days over the past two weeks. The final regression model revealed significant associations with health-related quality of life, physical component (odds ratio [OR] 0.56; 95% confidence interval [CI]: 0.35-0.91), and mental component (OR 0.50; 95% CI: 0.31-0.82), consumption of alcoholic beverages (OR 1.27; 95% CI: 1.05-1.54), first-episode depression (OR 3.92; 95% CI: 1.16-13.22), and lifetime depression (OR 10.89; 95% CI: 2.49-47.72). Age was only significant in the univariable (P=.03) regression analysis. NYHA functional class, left ventricular ejection fraction (LVEF), etiology of CHF, medication, cardiovascular interventions, multimorbidity, gender, and living situation were not significantly associated with suicidal ideation or ideas of self-harm. CONCLUSIONS: Lifetime depression, in particular, increases the risk of suicidal ideation and ideas of self-harm in CHF patients. Furthermore, the findings of our study underline the necessity of differentiating between first-episode and lifetime depression in CHF-patients in future research and clinical practice.

Relation of N-terminal pro-brain natriuretic peptide levels and their prognostic power in chronic stable heart failure to obesity status.

AIMS: To investigate the relationship between body mass index (BMI) and N-terminal pro-brain natriuretic peptide (NTproBNP) level and resultant prognostic capacity in chronic heart failure (CHF) controlled for known confounders. METHODS AND RESULTS: We formed 206 triplets of patients (n = 618) with stable systolic CHF matched with respect to age, sex, renal function (MDRD, modification of diet in renal disease formula), and NYHA class, each with a BMI >30 kg/m(2) (group 3), 20-24.9 kg/m(2) (group 1), and 25-29.9 kg/m(2) (group 2). BMI conveys a 4% drop in NTproBNP per unit increase. This influence remained significant after correction for age, sex, MDRD, NYHA, heart rate, rhythm, and ejection fraction. NTproBNP remained an independent predictor of adverse outcome after correction for age, sex, BMI, NYHA, MDRD, and ejection fraction. Despite numerical differences, prognostic power was comparable between BMI groups (log-transformed NTproBNP; group 1: hazard ratio (HR) 1.435, 95% CI 1.046-1.967, chi(2) 5.02, P = 0.03; group 2: HR 1.604, 95% CI 1.203-2.138, chi(2) 10.36, P = 0.001; group 3: HR 1.735, 95% CI 1.302-2.313, chi(2) 14.12, P = 0.0002) (P = NS, all). An NTproBNP correction factor was calculated. CONCLUSION: Even matched for NYHA, age, sex, and renal function, BMI exerts a significant and independent inverse influence on NTproBNP in patients with stable CHF. NTproBNP retained equal statistical power in all three BMI groups.

Absence of auto-antibodies against cardiac troponin I predicts improvement of left ventricular function after acute myocardial infarction.

AIMS: Application of antibodies against cardiac troponin I (cTnI-Ab) can induce dilation and dysfunction of the heart in mice. Recently, we demonstrated that immunization with cTnI induces inflammation and fibrosis in myocardium of mice. Others have shown that auto-antibodies to cTnI are present in patients with acute coronary syndrome, but little is known about the clinical relevance of detected cTnI-Ab. METHODS AND RESULTS: First, anti-cTnI and anti-cTnT antibody titres were measured in sera from 272 patients with dilated- (DCM) and 185 with ischaemic- (ICM) cardiomyopathy. Secondly, 108 patients with acute myocardial infarction (AMI) were included for a follow-up study. Heart characteristics were determined by magnetic resonance imaging 4 days and 6-9 months after AMI. Altogether in 7.0% of patients with DCM and in 9.2% with ICM, an anti-cTnI IgG antibody titre >/=1:160 was measured. In contrast, only in 1.7% of patients with DCM and in 0.5% with ICM, an anti-cTnT IgG antibody titre >/=1:160 was detected. Ten out of 108 patients included in the follow-up study were tested positive for cTnI-Ab with IgG Ab titres >/=1:160. TnI-Ab negative patients showed a significant increase in left ventricular ejection fraction (LVEF) and stroke volume 6-9 months after AMI. In contrast, there was no significant increase in LVEF and stroke volume in TnI-Ab positive patients. CONCLUSION: We demonstrate for the first time that the prevalence of cTnI-Abs in patients with AMI has an impact on the improvement of the LVEF over a study period of 6-9 months.

Peritoneal dialysis as therapeutic option in heart failure patients.

AIMS: Each episode of acute decompensated heart failure (HF) incrementally adds to mortality. Peritoneal dialysis (PD) offers an alternative therapeutic option in refractory HF and reduces the incidence of decompensation episodes. The objective of this study was to determine the efficacy of PD, in terms of functional status, surrogate endpoints, rate of hospitalizations, and mortality. METHODS AND RESULTS: This study is based on the registry of the German Society of Nephrology, involving 159 patients receiving PD treatment due to refractory HF between January 2010 and December 2014. Body weight was reduced by PD (82.2 ± 14.9 to 78.4 ± 14.8 kg, P < 0.001), and significant improvements in New York Heart Association functional class (3.38 ± 0.55 to 2.85 ± 0.49, P < 0.001) were found already after 3 months. Left ventricular ejection fraction did not change (31.5 ± 13.8 to 34.0 ± 15.7%, P = 0.175). C-reactive protein improved with PD treatment (33.7 ± 52.6 to 17.1 ± 26.3 mg/L, P = 0.004). Blood urea nitrogen/creatinine ratio decreased significantly (148.7 ± 68.3 to 106.7 ± 44.8 mg/dL, P < 0.001). Hospitalization rates decreased significantly (total number 2.86 ± 1.88 to 1.90 ± 1.78, P = 0.001, and 39.2 ± 30.7 to 27.1 ± 25.2 days, P = 0.004). One year mortality was 39.6% in end-stage HF patients treated with PD. CONCLUSIONS: Peritoneal dialysis offers an additional therapeutic option in end-stage HF and is associated with improved New York Heart Association classification and reduced hospitalization. Although PD treatment was associated with various benefits, further studies are necessary to identify which patients benefit the most from PD.