Left bundle branch pacing vs biventricular pacing in heart failure patients with left bundle branch block:A systematic review and meta-analysis

BACKGROUND Left bundle branch pacing(LBBP)is a novel pacing modality of cardiac resynchronization therapy(CRT)that achieves more physiologic native ventricular activation than biventricular pacing(BiVP).AIM To explore the validity of electromechanical resynchronization,clinical and echocardiographic response of LBBP-CRT.METHODS Systematic review and Meta-analysis were conducted in accordance with the standard guidelines as mentioned in detail in the methodology section.RESULTS In our analysis,the success rate of LBBP-CRT was determined to be 91.1%.LBBP CRT significantly shortened QRS duration,with significant improvement in echocardiographic parameters,including left ventricular ejection fraction,left ventricular end-diastolic diameter and left ventricular end-systolic diameter in comparison with BiVP-CRT.CONCLUSION A significant reduction in New York Heart Association class and B-type natriuretic peptide levels was also observed in the LBBP-CRT group vs BiVP-CRT group.Lastly,the LBBP-CRT cohort had a reduced pacing threshold at follow-up as compared to BiVP-CRT.

The influence of pressure injury risk on the association between left ventricular ejection fraction and all-cause mortality in patients with acute myocardial infarction 80 years or older

BACKGROUND: We aimed to investigate whether the pressure injury risk mediates the association of left ventricular ejection fraction(LVEF) with all-cause death in patients with acute myocardial infarction(AMI) aged 80 years or older.METHODS: This retrospective cohort study included 677 patients with AMI aged 80 years or older from a tertiary-level hospital. Pressure injury risk was assessed using the Braden scale at admission, and three risk groups(low/minimal, intermediate, high) were defined according to the overall score of six different variables. LVEF was measured during the index hospitalization for AMI. All-cause death after hospital discharge was the primary outcome.RESULTS: Over a median follow-up period of 1,176 d(interquartile range [IQR], 722–1,900 d), 226(33.4%) patients died. Multivariate Cox regression analysis showed that reduced LVEF was associated with an increased risk of all-cause death only in the high-risk group of pressure injury(adjusted hazard ratios [HR]=1.81, 95% confidence interval [CI]: 1.03–3.20;P=0.040), but not in the low/minimal-(adjusted HR=1.29, 95%CI: 0.80–2.11;P=0.299) or intermediate-risk groups(adjusted HR=1.14, 95%CI: 0.65–2.02;P=0.651). Significant interactions were detected between pressure injury risk and LVEF(adjusted P=0.003). The cubic spline with hazard ratio plot revealed a distinct shaped curve relation between LVEF and all-cause death among different pressure injury risk groups.CONCLUSIONS: In older patients with AMI, the risk of pressure injury mediated the association between LVEF and all-cause death. The classification of older patients for both therapy and prognosis assessment appears to be improved by the incorporation of pressure injury risk assessment into AMI care management.

Interaction between the left ventricular ejection fraction and left ventricular strain and its relationship with coronary stenosis

BACKGROUND Coronary artery stenosis(CAS)is the most common type of heart disease and the leading cause of death in both men and women globally.CAS occurs when the arteries that supply blood to the heart muscle harden and become narrower due to plaque buildup-cholesterol and other material-on their inner walls.As a result,the heart muscle cannot receive the blood or oxygen it needs.Most heart attacks happen when a blood clot suddenly cuts off the hearts'blood supply,causing permanent heart damage.AIM To analyze the relationship between the left ventricular ejection fraction(LVEF),left ventricular strain(LVS),and coronary stenosis.METHODS A total of 190 participants were enrolled in this trail.The control group comprised 93 healthy individuals,and observation group comprised 97 patients with coronary heart disease who were hospitalized between July 2020 and September 2021.Coronary lesions were assessed using the Gensini score,and the LVEF and LVS were measured using magnetic resonance imaging(MRI).The interaction between the LVEF and LVS was examined using a linear regression model.The relationship between LVEF and coronary stenosis was examined using Spearman’s correlation.RESULTS The LVEF of the observation group was lower than that of the control group.The left ventricular end-systolic volume(LVESV)and left ventricular end-diastolic volume(LVEDV)of the observation group were significantly higher than those of the control group(P<0.05).The longitudinal and circumferential strains(LS,CS)of the observation group were significantly higher than those of the control group;however,the radial strain(RS)of the observation group was significantly lower than that of the control group(P<0.05).LVS,LS,and CS were significantly negatively correlated with the LVEF,and RS was positively correlated with the LVEF.There were significant differences in the LVEF,LVESV,and LVEDV of patients with different Gensini scores;the LVEF significantly decreased and the LVESV and LVEDV increased with increasing Gensini scores(P<0.05).In the observation group,the LVEF was negatively correlated and the LVESV and LVEDV were positively correlated with coronary stenosis(P<0.05).CONCLUSION The LVEF measured using MRI is significantly linearly correlated with LVS and negatively correlated with coronary stenosis.

The Clinical Association of Left Atrial Function with Left Ventricular Ejection Fraction

The left atrium (LA) has been recognized as a morphophysiological barometer of left ventricular (LV) diastolic dysfunction. Because in the myocardial ischemia cascade where LV diastolic dysfunction often precedes LV systolic dysfunction, the LA which fashions as an early marker of diastolic anomaly, could equally reflect a declining LV function and/or be a good predictor of potential sequelae. We assessed this association of LA function with reduced LV systolic function among hospitalized patients. Among patients with reduced LV ejection fraction, LA passive ejection fraction was lower (0.172 ± 0.12 vs. 0.232 ± 0.14, p = 0.013) whereas LA kinetic energy was higher (6.48 ± 6.3 vs. 4.57 ± 3.5, p = 0.005). Echocardiographic assessment of LA function, therefore, appears correlated with LVEF and could be important when risk stratifying hospitalized patients.

Heart failure with reduced,mildly reduced,or preserved left ventricular ejection fraction:Has reasoning been lost?

Left ventricular(LV)ejection fraction(LVEF),defined as LV stroke volume divided by end-diastolic volume,has been systematically used for the diagnosis,classification,and management of heart failure(HF)over the last three decades.HF is classified as HF with reduced LVEF,HF with midrange or mildly reduced LVEF,and HF with preserved LVEF using arbitrary,continuously changing LVEF cutoffs.A prerequisite for using this LVEF-based terminology is knowledge of the LVEF normal range,which is lacking and may lead to erroneous conclusions in HF,especially at the higher end of the LVEF spectrum.

Heart failure with preserved ejection fraction: A distinct heart failure phenotype?

The present work discusses the serious confusion resulting from the arbitrary nomenclature of heart failure with preserved ejection fraction(HFpEF),the presumed underlying pathophysiology,and the supposed features.A consequence of this misconception is that HFpEF trials have recruited patients with entirely different characteristics rendering the extrapolation of the results of one study to the other infeasible and dramatically affecting diagnosis and treatment.

The Prevalence and Short-Term Outcomes of Ventricular Dyssynchrony after Right Ventricular Pacing

Objective: Long-term right ventricular pacing has been associated with an increased risk of heart failure and cardiomyopathy. The pathophysiology of cardiomyopathy associated with right ventricular pacing remains unclear. We aim to evaluate the burden and short-term outcomes of ventricular dyssynchrony after immediate permanent pacemaker implantation. Materials and Methods: This prospective cohort study examined consecutive patients who had permanent pacemaker implantation at Vajira Hospital in 2019. Left ventricular systolic function, specifically left ventricular ejection fraction (LVEF) and echocardiographic ventricular dyssynchrony parameters were assessed. The endpoints included the prevalence of ventricular dyssynchrony, new-onset cardiomyopathy, heart failure, and death. The correlation between QRS complex duration, the burden of ventricular pacing, and echocardiographic ventricular dyssynchrony was measured. Results: Thirty-six consecutive patients underwent pacemaker implantation. The prevalence of mechanical ventricular dyssynchrony was 22.2% using the interventricular conduction delay method, 41.7% using LV pre-ejection period method, and 11.1% using the septal posterior wall motion abnormality method. Electrical ventricular dyssynchrony was 86.1% and new-onset cardiomyopathy was 17.1% after 3 months of permanent pacemaker implantation. The right ventricular pacing of more than 20% was significantly associated with cardiomyopathy (p < 0.022) and heart failure (log-rank, p = 0.049) within 3 months. But heart failure was not associated with mechanical ventricular dyssynchrony parameters (log-rank, p = 0.610;hazard ratio [HR], 1.53;95% confidence interval [CI], 0.29 - 7.96;p = 0.613 for IVMD and log-rank, p = 0.398;HR, 0.04;95% CI, 0.01 - 3316.7 for SPWMD). Conclusion: Mechanical and electrical ventricular dyssynchrony are common findings in right ventricular pacing. High-burden right ventricular pacing after 3 months of permanent pacemaker implantation is often associated with cardiomyopathy and heart failure, but mechanical and electrical ventricular dyssynchrony does not predict a short-term decline in left ventricular systolic function and heart failure.

Clinical characteristics and prognosis of heart failure with normal left ventricular ejection fraction in elderly patients

Background The term heart failure with normal ejection fraction （HFNEF） is often used to describe the syndrome of heart failure with normal ejection fraction. Based on the previous studies, HFNEF has a significant morbidity and mortality and is associated with a similar prognosis to heart failure with reduced ejection fraction （HFREF）. The present study aimed to investigate the clinical characteristics and prognosis of HFNEF in elderly patients. Methods Consecutive elderly patients （〉60 years old） hospitalized for the first episode of heart failure （HF） in Beijing Hospital from January 2003 to December 2009 were retrospectively recruited. Three hundred and ten patients with HF were eligible for our study. As recently recommended, a cut-off value of 50% was used to distinguish HFNEF （LVEF〉50%） from HFREF （LVEF〈50%）. Data were retrospectively obtained from hospital records and databases. Follow-up data were obtained by telephone and from hospital records. For every eligible patient, the clinical characteristics and prognosis were collected and compared between the HFNEF and HFREF groups. Results Patients with HFNEF accounted for 54.5% of all cases of elderly patients with HF. Compared with HFREF, the elderly patients with HFNEF had a higher proportion of females （62.1% vs. 32.6%, P 〈0.001）, higher body mass index （BMI） （（24.9±4.7） vs. （23.5±4.0） kg/m2, P=0.011）, higher systolic blood pressure at admission （（141.5±22.6） vs. （134.3±18.6） mmHg, P=0.002）, but lower hemoglobin levels （（118.3±22.7） vs. （125.8±23.8） g/L, P=0.005）. The incidence of coronary heart disease （43.2% vs. 65.2%, P 〈0.001） and myocardial infarction （16.6% vs. 46.1%, P 〈0.001） were significantly lower in elderly patients with HFNEF than in those with HFREF （P 〈0.001）. With a mean follow-up of 33.5 （0.5-93） months, 120 patients （38.7%） died, including 94 （30.3%） cardiac deaths. The HFNEF group had fewer deaths than the HFREF group at the end of the first follow-up （46/169 （27.2%） vs. 58/141 （41.1%）） and at the end of the second follow-up （56/169 （33.1%） vs. 64/141 （45.4%））. Kaplan-Meier survival analysis showed a significantly higher survival rate in elderly patients with HFNEF than those with HFREF （P=0.021 for total mortality and P 〈0.001 for cardiac mortality）. Multiple Logistic regression analysis showed that LVEF 〈50% was an independent risk factor for death in elderly patients with HF. Conclusions More than half of elderly patients with HF have a normal LVEF. The prognosis of the elderly patients with HFNEF is poor, though slightly better than the elderly patients with HFREF.

Baseline left ventricular ejection fraction associated with symptom improvements in both children and adolescents with postural tachycardia syndrome under metoprolol therapy

Background:Postural tachycardia syndrome(POTS)is a common childhood disease that seriously affects the patient’s physical and mental health.This study aimed to investigate whether pre-treatment baseline left ventricular ejection fraction(LVEF)and left ventricular fractional shortening(LVFS)values were associated with symptom improvement after metoprolol therapy for children and adolescents with POTS.Methods:This retrospective study evaluated 51 children and adolescents with POTS who received metoprolol therapy at the Peking University First Hospital between November 2010 and July 2019.All patients had completed a standing test or basic head-up tilt test and cardiac echocardiography before treatment.Treatment response was evaluated 3 months after starting metoprolol therapy.The pre-treatment baseline LVEF and LVFS values were evaluated for correlations with decreases in the symptom score after treatment(DSS).Multivariable analysis was performed using factors with a P value of<0.100 in the univariate analyses and the demographic characteristics.Results:A comparison of responders and non-responders revealed no significant differences in demographic,hemodynamic characteristics,and urine specific gravity(all P>0.050).However,responders had significantly higher baseline LVEF(71.09%±4.44%vs.67.17%±4.88%,t=2.789,P=0.008)and LVFS values(40.00[38.00,42.00]%vs.36.79%±4.11%,Z=2.542,P=0.010)than the non-responders.The baseline LVEF and LVFS were positively correlated with DSS(r=0.378,P=0.006;r=0.363,P=0.009),respectively.Logistic regression analysis revealed that LVEF was independently associated with the response to metoprolol therapy in children and adolescents with POTS(odds ratio:1.201,95%confidence interval:1.039–1.387,P=0.013).Conclusions:Pre-treatment baseline LVEF was associated with symptom improvement after metoprolol treatment for children and adolescents with POTS.

Long Term Follow-Up of Cardiotoxicity in Breast Cancer Treatment: A Case Report

Background: Cardiac toxicity is currently defined as a symptomatic decrease in Left Ventricular Ejection Fraction (LVEF) of more than 5% or an asymptomatic decrease of at least 10% to a value of under 50% in repeated evaluations on conventional transthoracic echocardiogram (TTE), as well as a Global Longitudinal Strain (GLS) value Aims: To highlight using GLS rather than modified Simpson 2D-LVEF for the evaluation of long-term cardiotoxicity. Case Presentation: The case concerns a 73-year-old female patient with a history of breast cancer chemotherapy and anthracyclines-based therapy who presented symptoms of late cardiac toxicity related to the chemotherapeutic treatment. In the following years, the patient remained asymptomatic with a 2D-LVEF of 48%, dilation of the left atrium was found, and the reservoir phase strain was severely decreased. Conclusion: The preferred method for evaluating cardiovascular complications associated with chemotherapy is the TTE, which is performed prior to the start of treatment, during therapy, and in the follow-up. Myocardial deformation as a predictor of cardiotoxicity allows the identification of subclinical heart failure.

Low gradient aortic stenosis with preserved left ventricular ejection fraction and the role of valve replacement

Background Aortic valve replacement （AVR） improves survival in severe symptomatic aortic stenosis （AS）. Yet, in many patients with severe AS, the timing of AVR remains poorly defined. In particular, it is challenging in patients with low mean pressure gradient （〈 40 mmHg） and severe AS （aortic valve area （AVA）≤1.0 cm^2） with preserved left ventricular （LV） ejection fraction.

Left bundle branch area pacing:A new era of cardiac resynchronization therapy?

The recent systematic review and meta-analysis provided a comprehensive focus on the current state of cardiac resynchronization therapy(CRT).The authors determined the feasibility of physiological left bundle branch area pacing(LBBAP)in patients indicated for CRT through a careful analysis of trials.They found that LBBAP was associated with significant reductions in QRS duration,New York Heart Association functional class,B-type natriuretic peptide levels,and pacing thresholds as well as improvements in echocardiographic parameters compared to biventricular pacing.

Changes of Plasma Levels of Brain Natriuretic Peptide in Patients with Chronic Heart Failure

To investigate the changes of plasma brain natriuretic peptide （BNF） levels inpatients with chronic heart failure （CHF）. Methods Plasma BNP concentrations in patients with CHF （n=56） and in normal controls （n=60） were measured with specific radioimmunoassay. Left ventricular ejection fraction in patients with chronic heart failure was measured with 99mTc gated cardiac blood pool scintigraphy. Results The results showed that Plasma BNP concentrations in patients with CHF were significantly higher than normal controls （223±79 ng/L vs 40±15 ng/L, P 〈 0.01）. Plasma BNP concentrations had a significant negative correlation with left ventricular ejection fractions（r=-0.68, P 〈 0.01 ）. Conclusions These results indicates that Plasma BNP levels are increased in patients with CHF, and they markedly increased according to the severity of heart failure classified by NYHA classifi- cation. The plasma BNP levels may be a biochemical parameter for evaluating the left ventricular function.

Clinical and angiographic correlates of left ventricular dysfunction in patients with three vessel coronary disease

Background Among patients with advanced multivessel coronary disease, left ventricular （LV） function is widely variable, and clinical and angiographic correlates of ventricular dysfunction remain to be defined. Methods Among 73 339 patients undergoing diagnostic cardiac catheterization at a single center in China, patients with left ventriculographic assessment were identified with three-vessel coronary disease with or without left main involvement. Clinical and angiographic characteristics were examined among patients with normal or varying extent of LV dysfunction, and predictors of LV impairment （ejection fraction （EF）： 〈25%, 25%-40% or 〉40%） were determined. Results Among 11 950 patients identified with three-vessel coronary disease, the sample distribution of LVEF was 〉40%, n=10 776; 25%-40%, n=948; 〈25%, n=226. Patients with reduced LV function （〈40%） more commonly were male and had a history of myocardial infarction （MI）, diabetes or unstable angina. Hypertension was more frequent in those with LVEF 〉40%. In a multivariate Logistic regression analysis, prior MI （odds ratio （OR）, 3.37; 95% confidence interval （CI）, 2.96-3.84） was most predictive of LVEF 〈40%, followed by male gender, diabetes, and presentation with unstable angina. For LVEF 〈25%, only prior MI was identified as a significant correlate of severe LV dysfunction （OR 4.06, 95% CI 3.06-5.39）. Following exclusion of patients with previous MI （n=7416）, male gender and diabetes were predictive of LVEF 〈40%, yet presentation with unstable angina was the only factor significantly associated with LVEF 〈25%. Conclusion Among individuals identified with three-vessel coronary disease with or without left main involvement, previous MI was the most significant risk factor of LV dysfunction.

Arrhythmia and its risk factors post myocardial infarction:A prospective study

Objectives:To determine the occurrence of arrhythmia and its associated risk factors in the first week after acute myocardial infarction(MI).Methods:A total of 100 patients with acute MI were recruited,who were followed up for one week to determine the occurrence of arrhythmia and its association with electrolyte disturbances,left ventricular ejection fraction(LVEF),and demographic factors.Univariate and multivariate logistic regression was used to identify significant risk factors of arrhythmia.Results:Among 100 cases,arrhythmia was seen in 27 patients.Sinus tachycardia was the commonest,followed by ventricular premature beats and sinus bradycardia.Ejection fraction,serum calcium and magnesium were significantly different between non-arrhythmia and arrhythmia patients(P<0.05).Multivariate logistic regression analysis showed that ejection fraction was an independent significant risk factor of arrhythmia.Patients with ejection fraction>40%had a significantly lower risk of arrhythmia with an adjusted odds ratio of 0.22(95%CI:0.08 to 0.64).Conclusions:Arrhythmia is common in the first week after myocardial infarction.The type of arrhythmia and the type of block may depend on the heart muscles involved during myocardial infarction.Ejection fraction is a risk factor that may affect the occurrence of arrhythmia.

Dengue hemorrhagic fever and cardiac involvement

Dengue viral infection(DVI)is one of the world’s most significant viral infections spreading.Most of the patients have been asymptomatic,with relatively benign clinical manifestations and outcomes.However,a small number of patients have progressed to severe dengue diseases,including hemorrhage,multi-organ impairment,and increased vascular leakage causing hypovolemic shock,which can cause cardiovascular collapse and death.Numerous lines of evidence have demonstrated that DVI could also cause cardiac dysfunction,arrhythmias,and severe myocarditis.The treatment for dengue hemorrhagic fever(DHF)patients remains symptomatic and supportive,with close monitoring of hemodynamic status.The contributory role of cardiac dysfunction in DHF patients has potentially critical implications on the management.This review will address the current knowledge of cardiac involvement in DHF patients and the management strategy to reduce the fatality outcome.

A Systematic Review Incorporating Meta-Analysis on the Effectiveness of Intravenous Immunoglobulin Versus Corticosteroids in the Treatment of Pediatric Myocarditis

Background:Concerns have been raised about the efficacy of intravenous immunoglobulin and corticosteroids in pediatric myocarditis;however,the relationship between the risk and efficacy of these two therapies in children with myocarditis varies.Methods:A systematic review on seventeen studies was conducted in July 2020,which included 1,960 subjects at the baseline,with 788 receiving intravenous immunoglobulin and 142 receiving corticosteroids.The mean difference(MD)or odds ratio(OR)with 95%confidence intervals(Cis)was calculated to assess the prognostic role of both treatments using dichotomous and continuous methods with random or fixed-effect models.Results:The use of intravenous immunoglobulin was significantly associated with a lower mortality rate or heart transplantation in children with myocarditis(OR,0.55;95%CI,0.40-0.77,^<0.001)compared with the control group.However,corticosteroids were not significantly associated with the same parameters(OR,0.72;95% CI,0.31-1.63,p=0.43).The use of intravenous immunoglobulin was not significantly related to improving left ventricular ejection in children with myocarditis(OR,2.30;95% CI,-9.65-14.25,p=0.71)and so were corticosteroids(MD,5.17;95% CI,-0.26-10.60,p=0.06).Conclusion:The use of intravenous immunoglobulin might have an independent risk relationship with a lower mortality rate or heart transplantation and is recommended in children with myocarditis to prevent complications.

Effect of Different Styles of Coronary Heart Disease and Its Risk Factors on Cardiac Remodeling and Dysfunction

Objectives To evaluate the effect of different styles of coronary heart disease （CHD）, different regions of acute myocardial infarction （AMI）, its risk factors and branches of coronary stenosis on left ventricular remodeling and dysfunction by applying echocardiography. Methods 251 patients with CHD and 96 patients without CHD （NoCHD） were verified by selective coronary angiography. CHD patients were divided into stable angina pectoris （SAP） 26, unstable angina pectoris（UAP） 53, acute myocardial infarction （AMI） 140 and old myocardial infarction （OMI） 30 based on clinical situation, cTnT, cardiac enzyme and ECG. AMI patients were further divided into subgroups including acute anterior myocardial infarct （Aa,n = 53）, acute inferior myocardial infarction （Ai, n=54） and Aa＋Ai （n=33） based on ECG. Cardiac parameters： end-diastolic interventricular septum thickness（IVSd）, end-diastolic left ventricular internal diameter （LVd）, left ventricular mass （LM）, end-diastolic left ventricular volume （EDV）, end-systolic left ventricular volume （ESV） and left ventricular ejection fraction（LVEF） were measured by ACUSON 128XP/10 echocardiography. Multiples linear regression analyses were performed to test statistical associations between LVEF and the involved branches of coronary stenosis, blood pressure, lipids, glucose and etc after onset of myocardial infarction. Results EDV and ESV were increased and LVEF decreased on patients with AMI,OMI and UAP （P〈0.05-0.0001）. LM was mainly increased in patients with OMI （P〈0.01） and LVd was mainly enlarged in patients with AMI. EF was significantly decreased and EDV, ESV, LM and LVd were remarkably increased in AMI patients with Aa and Aa＋Ai. With the multiple linear regression analyses by SPSS software, we found that LVEF was negatively correlated to the involved branches of coronary stenosis as well as to systolic blood pressure after onset of myocardial infarction while there was no significant correlation between LVEF and other factors. LVEF was significantly decreased, and LVd and LM increased in AMI patients with antecedent hypertension, compared to patients without hypertension （P〈0.001）. Conclusions Effects of different styles of CHD and different regions of AMI on left ventricular remodeling and cardiac function are different. Myocardial infarction, especially Aa and Aa＋Ai, is one of the most important causes of left ventricular remodeling and cardiac dysfunction. Multiple vessel stenosis and systolic blood pressure at the onset of myocardial infarction reduce LVEF in AMI patients. Antecedent hypertension may accelerate the effect of AMI on cardiac remodeling and dysfunction. Therefore primary and secondary preventions of CHD are critical for protecting heart from remodeling and dysfunction.

Attenuation of tumor necrosis factor-a elevation and improved heart function by postconditioning for 60 seconds in patients with acute myocardial infarction

Background Postconditioning has been shown to reduce infarct size, ischemic/reperfusion injury and myocardial injury in patients with acute myocardial infarction （AMI） undergoing percutaneous coronary intervention （PCI）. This study tested the hypothesis that postconditioning attenuates the elevation of tumor necrosis factor-a （TNF-a） and improves heart function in patients with AMI after PCI. Methods A total of 75 patients were randomly assigned to 1 of 3 groups： the routine group （n=-26）, in which no intervention was given at the onset of reperfusion; and the Postcon-30s （n=25） or Postcon-60 s （n=24） groups, in which 3 cycles of 30- or 60-second balloon deflation and inflation were repetitively performed. TNF-a serum concentration was measured by ELISA. Global and regional left ventricular systolic function was determined by echocardiography at 1 year. Thirty-four normal controls （NC） were enrolled in the study. Results The TNF-a concentration in patients with AMI was significantly elevated at baseline compared to controls （P 〈0.01）. Concentration levels increased in the routine and Postcon-30s, but not in Postcon-60s group at 7 days （P 〈0.05）. As for linear associations among the three groups, left ventricular ejection fraction （LVEF） and wall motion score index （WMSI） were ranked as follows： Postcon-60s 〉Postcon-30s〉routine （P values all 〈0.05, 65% vs. 57% vs. 52% and 1.10 vs. 1.27 vs. 1.53） after 1 year. More importantly, there was a significant relevance between the soluble TNF-a serum concentration at 7 days and LVEF or WMSI after 1 year （Pvalues all 〈0.0001）. Conclusions Postconditioning, in particular Postcon-60s was associated with long-term cardioprotective effects for inhibition of the inflammatory response and reperfusion injury. The soluble TNF-a serum concentration provided powerful prognostic information of global and regional left ventricular systolic function in patients with AMI.

Emerging Treatment Approaches to Improve Outcomes in Patients with Heart Failure

Heart failure(HF)is a major public health problem around the world.Although currently available therapies have improved outcomes,morbidity and mortality in patients with HF remain unacceptably high.Most guideline-recommended therapies for HF are indicated for patients with a reduced left ventricular ejection fraction(HFrEF).Until recently,treatment options that improved outcomes in patients with HF and preserved left ventricular ejection fraction or mildly reduced ejection fraction were limited.Over the past several years,however,several new drugs including angiotensin receptor neprilysin inhibitors(ARNIs),sodium glucose cotransporter 2 inhibitors(SGLT2 inhibitors),soluble guanylate cyclase stimulators,and a cardiac myotrope,omecamtiv mecarbil have all reported positive results in pivotal phase III clinical trials.Moreover,the results of these studies have provided evidence that both ARNIs and SGLT2 inhibitors can improve clinical outcomes in patients with HF across a broad spectrum of LVEF,not just in HFrEF.This article presents the rationale for the use of each of these 4 new classes of drugs,reviews the results from pivotal clinical trials showing their safety and efficacy,and provides a framework for how each drug has begun to be integrated into new HF management guidelines.Collectively,these new drugs provide hope for the millions of patients around the world who suffer from HF.