Epicardial Adipose Tissue Thickness and Preserved Ejection Fraction Heart Failure.

PURPOSE OF THE REVIEW: Preserved ejection fraction heart failure and obesity frequently coexist. Whether obesity plays a consistent role in the pathogenesis of preserved ejection fraction heart failure is unclear. Accumulation of visceral adiposity underlies the pathogenic aftermaths of obesity. However, visceral adiposity imaging is assessed by computed tomography or magnetic resonance and thus not routinely available. In contrast, epicardial adiposity thickness is assessed by echocardiography and thus routinely available. We review the rationale for assessing epicardial adiposity thickness in patients with preserved ejection fraction heart failure and elevated body mass index. RECENT FINDINGS: Body mass index correlates poorly with visceral, and epicardial adiposity. Visceral and epicardial adiposity enlarges as preserved ejection fraction heart failure progresses. Epicardial adiposity may hasten the progression of coronary artery disease and impairs left ventricular sub-endocardial perfusion and diastolic function. Epicardial adiposity thickness may help monitor the therapeutic response in patients with preserved ejection failure heart failure and elevated body mass index.

Patient-Centered Heart Failure Therapy.

Simultaneous initiation of quadruple therapy with angiotensin receptor-neprilysin inhibitor, beta-adrenergic receptor blocker, mineralocorticoid receptor antagonist, and sodium glucose cotransporter 2 inhibitor aims at prompt improvement and prevention of readmission in patients hospitalized for heart failure with reduced ejection fraction. However, titration of quadruple therapy is time consuming. Lengthy up-titration of quadruple therapy may negate the benefit of early initiation. Quadruple therapy should start with a sodium glucose cotransporter 2 inhibition and a mineralocorticoid antagonist, as both enable safe decongestion and require minimal or no titration. Depending on the level of decongestion and clinical characteristics, patients receive an angiotensin receptor-neprilysin inhibitor or a beta-adrenergic receptor blocker to be titrated after hospital discharge. Outpatient addition of an angiotensin receptor-neprilysin inhibitor to a beta-adrenergic receptor blocker or vice versa completes the quadruple therapy scheme. By focusing on decongestion and matching intervention to patients' profile, the present therapeutic sequence allows rapid implementation of quadruple therapy at fully recommended doses.

Myocardial recovery following left ventricular assist device implantation.

Durable left ventricular assist devices (LVADs) have consistently shown improved mortality and morbidity in patients with end-stage heart failure. Select patients with LVADs may experience significant enough myocardial recovery after device implantation to allow for explantation or decommissioning. While earlier trials suggested a high incidence of recovery, real-world clinical data have demonstrated this to be a much rarer phenomenon. Whether or not patients experience recovery, practices such as speed optimization and usage of guideline-directed medical therapy can improve patient outcomes.

Integrated Care Model of Adiposity-Related Chronic Diseases.

PURPOSE OF REVIEW: Although obesity is a disease, most patients with obesity do not undergo effective treatment nor adhere to long-term care. We examine the barriers that patients with obesity confront when searching for effective treatment and propose an integrated care model of adiposity-related chronic diseases in a cardio-renal metabolic unit. RECENT FINDINGS: The current care of obesity is fragmented between primary care providers, medical specialists and metabolic bariatric surgeons with little or no coordination of care between these providers. The current care of obesity heavily focuses on weight loss as the primary aim of treatment thereby reenforcing the weight stigma and turning patients away from effective therapy like metabolic bariatric surgery. An interdisciplinary cardio-renal metabolic unit that, besides weight loss, emphasizes prevention/remission of adiposity-related chronic diseases may deliver thorough and rewarding care to most patients with obesity.

Comprehensive and Safe Decongestion in Acutely Decompensated Heart Failure.

PURPOSE OF THE REVIEW: Progressive intravascular, interstitial, and alveolar fluid overload underlies the transition from compensated to acutely decompensated heart failure and loop diuretics are the mainstay of treatment. Adverse effects and resistance to loop diuretics received much attention while the contribution of a depressed cardiac output to diuretic resistance was downplayed. RECENT FINDINGS: Analysis of experience with positive inotropic agents, especially dobutamine, indicates that enhancement of cardiac output is not consistently associated with increased renal blood flow. However, urinary output and renal sodium excretion increase likely due to dobutamine-mediated decrease in renal and systemic reduced activation of sympathetic nervous- and renin-angiotensin-aldosterone system. Mechanical circulatory support with left ventricular assist devices ascertained the contribution of low cardiac output to diuretic resistance and the pathogenesis and progression of kidney disease in acutely decompensated heart failure. Diuretic resistance commonly occurs in acutely decompensated heart failure. However, failure to resolve fluid overload despite high doses of loop diuretics should alert to the presence of a low cardiac output state.

Cardiovascular Disease Risk Reduction and Body Mass Index.

PURPOSE OF REVIEW: Anti-hypertensive and lipid lowering therapy addresses only half of the cardiovascular disease risk in patients with body mass index > 30 kg/m2, i.e., obesity. We examine newer aspects of obesity pathobiology that underlie the partial effectiveness of anti-hypertensive lipid lowering therapy for the reduction of cardiovascular disease risk in obesity. RECENT FINDINGS: Obesity-related insulin resistance, vascular endothelium dysfunction, increased sympathetic nervous system/renin-angiotensin-aldosterone system activity, and glomerulopathy lead to type 2 diabetes, coronary atherosclerosis, and chronic disease kidney disease that besides hypertension and dyslipidemia increase cardiovascular disease risk. Obesity increases cardiovascular disease risk through multiple pathways. Optimal reduction of cardiovascular disease risk in patients with obesity is likely to require therapy targeted at both obesity and obesity-associated conditions.

COVID 19 in-hospital mortality, body mass index and obesity related conditions.

OBJECTIVE: Obese patients with respiratory failure need more intensive care and invasive mechanical ventilation than their non-obese counterparts. We aimed to evaluate the impact of body mass index and obesity related conditions on fatal outcome during a hospitalization for COVID-19. METHODS: From March 1 to April 30, 2020, 425 consecutive patients with severe acute respiratory syndrome coronavirus 2 were hospitalized at University Medical Center, in New Orleans. Clinical variables, comorbidities, and hospital course were extracted from electronic medical records. Special attention was given to obesity related conditions like hypertension, type 2 diabetes, and dyslipidemia. Severe obesity was defined as a body mass index ≥35-<40 kg/m2 and morbid obesity as body mass index ≥40 kg/m2. Risk of mortality was determined by applying multivariate binary logistic regression modeling to risk factor variables (age, sex, race, and Charlson comorbid score). RESULTS: Patients were mostly African American (77.9%) and 51.0% were women. Age and Charlson comorbidity index scores averaged 60 (50-71 years) and 3.0 (1.25-5), respectively. In-hospital mortality was greater in morbidly obese than non-morbidly obese patients. Of the 64 severely obese patients, 16 had no obesity related conditions, and 48 had at least one obesity related condition: hypertension (60%), type 2 diabetes mellitus (28%), and dyslipidemia (20%). In-hospital mortality was greater in severely obese patients with than without at least one obesity related condition. CONCLUSION: During a hospitalization for COVID-19, severely obese patients with at least one obesity related condition and morbidly obese patients have a high mortality.

Therapeutic Stalemate in Heart Failure With Preserved Ejection Fraction.

The findings of randomized trials of neurohormonal modulation have been neutral in heart failure with preserved ejection fraction and consistently positive in heart failure with reduced ejection. Left ventricular remodeling promotes the development and progression of heart failure with preserved and reduced ejection fraction. However, different stimuli mediate left ventricular remodeling that is commonly concentric in heart failure with preserved ejection fraction and eccentric in heart failure with reduced ejection. The stimuli that promote concentric left ventricular remodeling may account for the neutral findings of neuhormonal modulation in heart failure with preserved ejection fraction. Low-grade systemic inflammation-induced microvascular endothelial dysfunction is currently the leading hypothesis behind the development and progression of heart failure with preserved ejection fraction. The hypothesis provided the rationale for several randomized controlled trials that have led to neutral findings. The trials and their limitations are reviewed.

Roux-en-Y gastric bypass and sleeve gastrectomy for obesity-associated hypertension.

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) reduce blood pressure (BP) in obese patients with hypertension (HTN). We compared the effect of RYGB and SG on BP in obese patients with HTN at a large-volume, private bariatric surgery center using a propensity score analysis. The measurement and management of BP were exclusively left to the patient's provider without any involvement of Tulane investigators. At month 1, RYGB and SG equally decreased: (1) mean body weight: 12.7 vs 13.2 kg (p=not significant (NS)) (2) systolic/diastolic BP: 8.5/5.3 vs 8.0/4.2 mm Hg (p=NS) and (3) average number of antihypertensive medications from 1.5 to 0.8 and from 1.6 to 0.6 per patient (p=NS). From month 1 to 12, BP remained unchanged after RYGB but tended to increase from month 6 to 12 after SG. Remission of HTN occurred in 52% and 44% of patients after RYGB and SG. In contrast to the full effect of RYGB and SG on BP at 1 month, body weight decreases steadily over 12 months after RYGB and SG. In conclusion, early after surgery, RYGB and SG equally reduce BP in obese patients with HTN. Thereafter, RYGB has a more sustained effect on BP than SG.

Diabetes Mellitus and Heart Failure With Preserved Ejection Fraction: Role of Obesity.

Heart failure with preserved ejection fraction is a growing epidemic and accounts for half of all patients with heart failure. Increasing prevalence, morbidity, and clinical inertia have spurred a rethinking of the pathophysiology of heart failure with preserved ejection fraction. Unlike heart failure with reduced ejection fraction, heart failure with preserved ejection fraction has distinct clinical phenotypes. The obese-diabetic phenotype is the most often encountered phenotype in clinical practice and shares the greatest burden of morbidity and mortality. Left ventricular remodeling plays a major role in its pathophysiology. Understanding the interplay of obesity, diabetes mellitus, and inflammation in the pathophysiology of left ventricular remodeling may help in the discovery of new therapeutic targets to improve clinical outcomes in heart failure with preserved ejection fraction. Anti-diabetic agents like glucagon-like-peptide 1 analogs and sodium-glucose co-transporter 2 are promising therapeutic modalities for the obese-diabetic phenotype of heart failure with preserved ejection fraction and aggressive weight loss via lifestyle or bariatric surgery is still key to reverse adverse left ventricular remodeling. This review focuses on the obese-diabetic phenotype of heart failure with preserved ejection fraction highlighting the interaction between obesity, diabetes, and coronary microvascular dysfunction in the development and progression of left ventricular remodeling. Recent therapeutic advances are reviewed.

Bariatric Surgery and Hospitalization for Heart Failure in Morbidly Obese Patients.

BACKGROUND: Bariatric surgery may improve heart failure outcome in morbidly obese patients. However, the safety of bariatric surgery has not been investigated in morbidly obese patients hospitalized for heart failure. We evaluated the effects of bariatric surgery on parameters of hospitalization for heart failure in morbidly obese patients. METHODS: We analyzed administrative discharge data of morbidly obese patients with heart failure as a primary diagnosis. Propensity score matching was performed to assess parameters of hospitalization in morbidly obese patients with and without a history of bariatric surgery. The discharges with diastolic heart failure codes were analyzed separately. RESULTS: Morbid obesity was coded in 4.4% of all discharges. Heart failure was the primary diagnosis in 6.0% of discharges with morbid obesity codes. Only 1% of discharges with morbid obesity and heart failure as primary diagnosis codes were coded for bariatric surgery. Length of stay (p < 0.001), in-hospital mortality (p < 0.001), and the estimated cost of hospitalizations (p < 0.007) were lower in discharges with than without bariatric surgery codes. Length of stay was shorter and in-hospital mortality was lower in discharges with codes for diastolic heart failure and bariatric surgery than with codes for only diastolic heart failure (p < 0.042 and p < 0.001 respectively). CONCLUSION: When hospitalized for heart failure, morbidly obese patients who underwent bariatric surgery fare as well as or slightly better than their counterparts who did not.

Weight Reduction for Obesity-Induced Heart Failure with Preserved Ejection Fraction.

PURPOSE OF REVIEW: Heart failure with preserved ejection fraction mainly affects the elderly. The obesity phenotype of heart failure with preserved ejection fraction reflects the coexistence of two highly prevalent conditions in the elderly. Obesity may also lead to heart failure with preserved ejection fraction in middle-aged persons, especially in African American women. RECENT FINDINGS: Obesity is twice as common in middle-aged than in elderly persons with heart failure with preserved ejection fraction. Obese middle-aged persons with heart failure with preserved ejection fraction are less likely to be Caucasian and to have atrial fibrillation or chronic kidney disease as comorbidities than elderly patients with heart failure with preserved ejection fraction. Obesity-associated low-grade systemic inflammation may induce/heighten inflammatory activation of the coronary microvascular endothelium, leading to cardiomyocyte hypertrophy/ stiffness, myocardial fibrosis, and left ventricular diastolic dysfunction. Both substantial weight reduction with bariatric surgery and lesser levels of weight reduction with caloric restriction are promising therapeutic approaches to obesity-induced heart failure with preserved ejection fraction.

Obesity, Hypertension, and Bariatric Surgery.

PURPOSE OF REVIEW: Obesity increases the risk of hypertension. However, blood pressure decreases before any significant loss of body weight after bariatric surgery. We review the mechanisms of the temporal dissociation between blood pressure and body weight after bariatric surgery. RECENT FINDINGS: Restrictive and bypass bariatric surgery lower blood pressure and plasma leptin levels within days of the procedure in both hypertensive and normotensive morbidly obese patients. Rapidly decreasing plasma leptin levels and minimal loss of body weight point to reduced sympathetic nervous system activity as the underlying mechanism of rapid blood pressure decline after bariatric surgery. After the early rapid decline, blood pressure does not decrease further in patients who, while still obese, experience a steady loss of body weight for the subsequent 12 months. The divergent effects of bariatric surgery on blood pressure and body weight query the role of excess body weight in the pathobiology of the obesity phenotype of hypertension. The decrease in blood pressure after bariatric surgery is moderate and independent of body weight. The lack of temporal relationship between blood pressure reduction and loss of body weight for 12 months after sleeve gastrectomy questions the nature of the mechanisms underlying obesity-associated hypertension.

Precardiogenic Shock: A New Clinical Entity.

The pathogenesis of cardiogenic shock (CS) has evolved from an acute event due to a large myocardial infarction to a semiacute event due to rapid hemodynamic deterioration on a background of preexisting left ventricular systolic dysfunction. Pre-CS refers to the period of rapid hemodynamic deterioration that precedes overt CS with hypotension, inflammatory response, and end-organ failure. Mortality remains extremely high in CS and has not improved over the past decades. Pre-CS offers a unique opportunity to initiate early treatment that may result in better clinical outcomes. The present review addresses the definition, recognition, and management of pre-CS with the pharmacologic or mechanical support of the failing left ventricle.

Epicardial Adipose Tissue and Cardiovascular Disease.

PURPOSE OF REVIEW: Epicardial adipose tissue has been associated with the development/progression of cardiovascular disease. We appraise the strength of the association between epicardial adipose tissue and development/progression of cardiovascular diseases like coronary artery disease, atrial fibrillation, and heart failure with preserved ejection fraction. RECENT FINDINGS: Cross-sectional clinical and translational correlative studies have established an association between epicardial adipose tissue and progression of coronary artery disease. Recent studies question this association and underline the need for longitudinal studies. Epicardial adipose tissue also plays a definite role in the pathobiology of atrial fibrillation and its recurrence after ablation. In contrast to an early paradigm, epicardial adipose tissue does not appear to play a key role in the pathogenesis of heart failure with preserved ejection fraction in obese patients. The association of epicardial adipose tissue with atrial fibrillation is robust. In contrast, the association of epicardial adipose tissue with coronary artery disease and heart failure with preserved ejection fraction is tenuous. Additional research, including longitudinal studies, is needed to confirm or refute these proposed associations.

Effect of sleeve gastrectomy on hypertension.

The objective of this study was to determine the effect of laparoscopic sleeve gastrectomy (LSG) on blood pressure in private practice settings. This study involved a retrospective review of 870 consecutive adult patients >18 y of age who underwent LSG over a period of 12 mo in a private bariatric surgery center. Data were collected from the preoperative and postoperative follow-up visits at 1, 3, 6, and 12 mo. The study population consists of 694 hypertensive and 176 normotensive patients. From the baseline to 12 mo after LSG, (1) mean body weight/body mass index decreased from 123 kg/44 kg/m2 to 94 kg/34 kg/m2 (P < .001); (2) mean systolic/diastolic blood pressure in hypertensive patients decreased from 131.9/79.9 to 127.6/77.1 mm Hg (P < .001); 3) only mean systolic blood pressure decreased in normotensive patients from 117.5 to 114.0 mm Hg (P < .001). One month after LSG, mean systolic blood pressure had decreased from 131.9 to 126.2 mm Hg (P < 0. 001) and the average number of antihypertensive medications per patient declined from 1.5 at the baseline to 0.6 (P < .001). Over the following 11 mo, blood pressure remained stable despite reduced antihypertensive therapy. Patients requiring more than two antihypertensive agents fell from 49% at the baseline to 22% at 12 mo. Hypertension resolved in 34% of patients. Linear regression analysis showed no association between change in body weight and change in systolic blood pressure. Within 1 mo of LSG, hypertensive patients experienced a significant decline in systolic blood pressure and antihypertensive therapy that remains unchanged at 12 mo in the face of major reductions in antihypertensive medications. Weight loss and blood pressure reduction may not be directly related.

Physiologic assessment of moderate coronary lesions: a step towards complete revascularization in coronary artery bypass grafting.

BACKGROUND: An accurate diagnostic assessment of coronary artery disease is crucial for patients undergoing coronary artery bypass grafting (CABG). Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) to guide complete revascularization have not been adequately studied in patients prior to CABG. We compared an anatomic to a physiologic assessment of moderate coronary lesions (40-70% stenosis) in patients referred for CABG. METHODS: We retrospectively reviewed 109 medical records of patients who underwent CABG at Tulane Medical Center from 2014 to 2016. Patients were divided into an FFR/iFR-guided and an angiography-guided group. Clinical characteristics, procedural outcomes, and clinical outcomes for the two groups were compared over an 18-month follow-up period. RESULTS: There were significantly higher rates of three-vessel anastomoses (85.7% vs. 74.7%, P<0.05) and venous grafting (85.7% vs. 76.8%, P<0.05) in the FFR/iFR group. The FFR/iFR group had a lower rate of grafts placed to the left anterior descending artery (LAD) distribution than the angiography group (7.1% vs. 29.5%, P<0.05). The FFR/iFR group had a higher rate of grafts placed to the left circumflex (LCx) artery distribution than the angiography group (28.6% vs. 9.5%, P<0.05). We observed a trend toward reduction in major adverse cardiac events (MACEs) (7.1% vs. 11.6%, P=0.369) and angina (0.0% vs. 6.3%, P=0.429) in the FFR/iFR group compared to the angiography group over 18 months. CONCLUSIONS: Physiologic assessment of coronary lesions can effectively guide complete revascularization in patients undergoing CABG. Moreover, FFR/iFR-guided CABG was associated with significantly higher rates of three-vessel anastomoses, venous grafting, and graft distribution to the circumflex system.