Updates 4 July 2016
Multiple Phenotypes for HFpEF and Novel Therapeutic Strategies.
Heart failure with preserved ejection fraction (HFpEF) poses an increasing burden of disease with an older population and is associated with adverse prognosis. Management can be problematic and new initiatives have been limited by our understanding of its pathogenesis.
In a State-of-the-Art review, published in this week’s Circulation, Shah et al examine the pathogenesis of HFpEF and explore new therapeutic options. A central tenet is that HFpEF is a multisystem inflammatory disorder affecting not just the heart, but also the lungs, kidneys and skeletal muscle. The origins of this disorder lie in obesity, systemic hypertension and impaired glucose tolerance, which in turn result in abnormal endothelial-myocyte signaling, a pro-inflammatory and pro-fibrotic state.
The authors explore the key roles of diuretic therapy, potential anti-inflammatory benefit of statins and novel approaches to limiting myocardial fibrosis. The importance of improving skeletal muscle efficiency through weight-loss and exercise training is highlighted. Although nitrates are widely used in HFpEF, the authors argue that the use of nitrates may actually be self-defeating and that the real benefit lies with nitrites.
As the authors note, many new clinical studies will be required, however we should be moving towards more individualized management of HFpEF, taking into account more detailed patient phenotype and precipitating/contributing pathologies.
Plasma Ceramides – A New Risk Predictor in Coronary Artery Disease
Among patients with coronary artery disease, the risk of future adverse events can be estimated for groups according to well-established risk-factors, but at the individual patient level, prediction of risk can be more problematic. In particular, it is desirable to identify those individuals at increased risk of plaque rupture and an acute event, who may benefit from intensive therapy.
Ceramide species are produced by six fatty acyl selective ceramide synthases and ceramides are known to associate with many central processes of atherosclerosis development including lipoprotein uptake, inflammation, and apoptosis. Thus, ceramides may be markers of atherosclerotic plaque vulnerability. As plasma LDL levels are not closely correlated with risk of acute coronary events in individuals, Laaksonen et al examined the potential predictive value of plasma ceramide levels. Their findings are reported in this week’s European Heart Journal.
When plasma ceramides were used to estimate relative risk for adverse events in three separate studies, the authors found that plasma ceramide ratios were significant predictors of CV death both in patients with stable CAD and ACS, over and above currently used lipid markers.
The authors concluded that plasma ceramide ratios may improve the identification of high-risk patients in need of more aggressive therapeutic interventions.
Clinical Practice Quality – Performance and Quality Measures for Adults with Atrial Fibrillation and Atrial Flutter
Atrial fibrillation and atrial flutter are a major source of cardiovascular morbidity and mortality and are frequently associated with significant co-morbidities, which can complicate management.
Comprehensive management guidelines are available, however key issues of clinical practice quality are how widely and completely these management guidelines are applied. The issue of under-use of anticoagulation in patients with atrial fibrillation, particularly in elderly patients, has been well publicized.
Practitioners seeking to improve their clinical care through audit and performance review can be assisted by peer-reviewed performance measures, which can serve as a benchmark of best-quality practice.
The ACC/AHA has just published such clinical performance and quality measures for management of adults with atrial fibrillation and atrial flutter. The performance measures address both the hospital inpatient and ambulatory care settings. Measures were developed for care domains that were not previously addressed, including patient safety, effective clinical care, communication, and care coordination
The new document provides clear tabular documentation of performance metrics, relevant inclusion and exclusion criteria and reference to standards of care. This document is recommended to all practitioners seeking to review their performance and quality of care in this domain.