Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in women in developed societies. Unfavorable structural and functional adaptations within the heart and central blood ...vessels with sedentary aging in women can act as the substrate for the development of debilitating CVD conditions such as heart failure with preserved ejection fraction (HFpEF). The large decline in cardiorespiratory fitness, as indicated by maximal or peak oxygen uptake (V̇o
and V̇o
, respectively), that occurs in women as they age significantly affects their health and chronic disease status, as well as the risk of cardiovascular and all-cause mortality. Midlife and older women who have performed structured endurance exercise training for several years or decades of their adult lives exhibit a V̇o
and cardiac and vascular structure and function that are on par or even superior to much younger sedentary women. Therefore, regular endurance exercise training appears to be an effective preventative strategy for mitigating the adverse physiological cardiovascular adaptations associated with sedentary aging in women. Herein, we narratively describe the aging and short- and long-term endurance exercise training adaptations in V̇o
, cardiac structure, and left ventricular systolic and diastolic function at rest and exercise in midlife and older women. The role of circulating estrogens on cardiac structure and function is described for consideration in the timing of exercise interventions to maximize beneficial adaptations. Current research gaps and potential areas for future investigation to advance our understanding in this critical knowledge area are highlighted.
Despite advances in medical and cardiac resynchronization therapy (CRT), individuals with chronic congestive heart failure (CHF) have persistent symptoms, including exercise intolerance. Optimizing ...cardio-locomotor coupling may increase stroke volume and skeletal muscle perfusion as previously shown in healthy runners. Therefore, we tested the hypothesis that exercise stroke volume and cardiac output would be higher during fixed-paced walking when steps were synchronized with the diastolic compared with systolic portion of the cardiac cycle in patients with CHF and CRT.
Ten participants (58±17 years of age; 40% female) with CHF and previously implanted CRT pacemakers completed 5-minute bouts of walking on a treadmill (range, 1.5-3 mph). Participants were randomly assigned to first walking to an auditory tone to synchronize their foot strike to either the systolic (0% or 100±15% of the R-R interval) or diastolic phase (45±15% of the R-R interval) of their cardiac cycle and underwent assessments of oxygen uptake (V̇o
; indirect calorimetry) and cardiac output (acetylene rebreathing). Data were compared through paired-samples
tests.
V̇o
was similar between conditions (diastolic 1.02±0.44 versus systolic 1.05±0.42 L/min;
=0.299). Compared with systolic walking, stroke volume (diastolic 80±28 versus systolic 74±26 mL;
=0.003) and cardiac output (8.3±3.5 versus 7.9±3.4 L/min;
=0.004) were higher during diastolic walking; heart rate (paced) was not different between conditions. Mean arterial pressure was significantly lower during diastolic walking (85±12 versus 98±20 mm Hg;
=0.007).
In patients with CHF who have received CRT, diastolic stepping increases stroke volume and oxygen delivery and decreases afterload. We speculate that, if added to pacemakers, this cardio-locomotor coupling technology may maximize CRT efficiency and increase exercise participation and quality of life in patients with CHF.
Measuring visual attention to faces with cleft deformity Boonipat, Thanapoom; Brazile, Tiffany L.; Darwish, Oliver A. ...
Journal of plastic, reconstructive & aesthetic surgery,
June 2019, 2019-Jun, 2019-06-00, 20190601, Letnik:
72, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Limited data are available regarding observers' visual attention to faces with congenital difference. We implemented eye tracking technology to examine this issue, as it pertains particularly to ...faces with cleft deformity.
Four hundred three observers assessed 273 clinical images, while their eye movements were unobtrusively tracked using an infrared sensor. Forty-one facial images of the repaired cleft lip, 137 images of other facial conditions, and 95 images of matched controls were assessed. Twenty facial regions of interest ("lookzones") were considered for all images observed. A separate cohort of 720 raters evaluated the images for attractiveness. Observer and image demographic information was collected. Visual fixation counts and durations were computed across all 20 lookzones for all images.
The effect of a variety of variables on lookzone fixation was analyzed using factorial ANOVA testing.
Cleft-repaired faces were rated as less attractive and drew observers' attention preferentially to the affected upper lip lookzone (p<.001). Images rated as less attractive garnered greater visual attention in the cleft-affected lookzones (p<.001). The eye tracking methodology demonstrated exquisite sensitivity to laterality of cleft deformity (p<.001). Individuals reporting a personal or a family history of facial deformity fixated more on the perioral region of cleft-repaired faces than did naïve observers (p<.001).
These findings highlight the utility of eye tracking measures for understanding critical variables that influence the visual processing of faces with cleft deformity. The data may provide analytical tools for assessing surgical outcome and direct priority setting during surgeons' conversations with patients.
Sarcoidosis is a multiorgan system granulomatous disease of unknown etiology. It is hypothesized that a combination of environmental, occupational, and/or infectious factors provoke an immunological ...response in genetically susceptible individuals, resulting in a diversity of manifestations throughout the body. In the United States, cardiac sarcoidosis (CS) is diagnosed in 5% of patients with systemic sarcoidosis, however, autopsy results suggest that cardiac involvement may be present in > 50% of patients. CS is debilitating and significantly decreases quality of life and survival. Currently, there are no gold-standard clinical diagnostic or monitoring criteria for CS.
We identified patients with a diagnosis of sarcoidosis who were seen at the Simmons Center from 2007 to 2020 who had a positive finding of CS documented with cardiovascular magnetic resonance (CMR) and/or endomyocardial biopsy as found in the electronic health record. Medical records were independently reviewed for interpretation and diagnostic features of CS including late gadolinium enhancement (LGE) patterns, increased signal on T2-weighted imaging, and non-caseating granulomas, respectively. Extracardiac organ involvement, cardiac manifestations, comorbid conditions, treatment history, and vital status were also abstracted.
We identified 44 unique patients with evidence of CS out of 246 CMR reports and 9 endomyocardial biopsy pathology reports. The first eligible case was diagnosed in 2007. The majority of patients (73%) had pulmonary manifestations, followed by hepatic manifestations (23%), cutaneous involvement (23%), and urolithiasis (20%). Heart failure was the most common cardiac manifestation affecting 59% of patients. Of these, 39% had a documented left ventricular ejection fraction of < 50% on CMR. Fifty eight percent of patients had a conduction disease and 44% of patients had documented ventricular arrhythmias. Pharmacotherapy was usually initiated for extracardiac manifestations and 93% of patients had been prescribed prednisone. ICD implantation occurred in 43% of patients. Patients were followed up for a median of 5.4 (IQR: 2.4-8.5) years. The 10-year survival was 70%. In addition to age, cutaneous involvement was associated with an increased risk of death (age-adjusted OR 8.47, 95% CI = 1.11-64.73).
CMR is an important tool in the non-invasive diagnosis of CS. The presence of LGE on CMR in a pattern consistent with CS has been shown to be a predictor of mortality and likely contributed to a high proportion of patients undergoing ICD implantation to decrease risk of sudden cardiac death.
Additional studies are necessary to develop robust criteria for the diagnosis of CS with CMR, assess the benefit of serial imaging for disease monitoring, and evaluate the effect of immunosuppression on disease progression.
We investigated whether central or peripheral limitations to oxygen uptake elicit different respiratory sensations and whether dyspnea on exertion (DOE) provokes unpleasantness and negative emotions ...in patients with heart failure with preserved ejection fraction (HFpEF). 48 patients were categorized based on their cardiac output (Q̇c)/oxygen uptake (V̇O2) slope and stroke volume (SV) reserve during an incremental cycling test. 15 were classified as centrally limited and 33 were classified as peripherally limited. Ratings of perceived breathlessness (RPB) and unpleasantness (RPU) were assessed (Borg 0–10 scale) during a 20 W cycling test. 15 respiratory sensations statements (1–10 scale) and 5 negative emotions statements (1−10) were subsequently rated. RPB (Central: 3.5±2.0 vs. Peripheral: 3.4±2.0, p=0.86), respiratory sensations, or negative emotions were not different between groups (p>0.05). RPB correlated (p<0.05) with RPU (r=0.925), “anxious” (r=0.610), and “afraid” (r=0.383). While DOE provokes elevated levels of negative emotions, DOE and respiratory sensations seem more related to a common mechanism rather than central and/or peripheral limitations in HFpEF.
•Respiratory sensations did not differ between patient groups.•Unpleasantness and negative emotions did not differ between patients.•%body fat correlated with FVC and V̇E, which were also correlated with RPB•VD/VT correlated with the V̇E/V̇CO2 slope, which was also correlated with RPB.•DOE is more related to pulmonary limitations than central/peripheral limitations.
BACKGROUND: We identified peripherally limited patients using cardiopulmonary exercise testing and measured skeletal muscle oxygen transport and utilization during invasive single leg exercise ...testing to identify the mechanisms of the peripheral limitation. METHODS: Forty-five patients with heart failure with preserved ejection fraction (70±7 years, 27 females) completed seated upright cardiopulmonary exercise testing and were defined as having a (1) peripheral limitation to exercise if cardiac output/oxygen consumption (VO 2 ) was elevated (≥6) or 5 to 6 with a stroke volume reserve >50% (n=31) or (2) a central limitation to exercise if cardiac output/VO 2 slope was ≤5 or 5 to 6 with stroke volume reserve <50% (n=14). Single leg knee extension exercise was used to quantify peak leg blood flow (Doppler ultrasound), arterial-to-venous oxygen content difference (femoral venous catheter), leg VO 2 , and muscle oxygen diffusive conductance. In a subset of participants (n=36), phosphocreatine recovery time was measured by magnetic resonance spectroscopy to determine skeletal muscle oxidative capacity. RESULTS: Peak VO 2 during cardiopulmonary exercise testing was not different between groups (central: 13.9±5.7 versus peripheral: 12.0±3.1 mL/min per kg; P =0.135); however, the peripheral group had a lower peak arterial-to-venous oxygen content difference (central: 13.5±2.0 versus peripheral: 11.1±1.6 mLO 2 /dL blood; P <0.001). During single leg knee extension, there was no difference in peak leg VO 2 ( P =0.306), but the peripherally limited group had greater blood flow/VO 2 ratio ( P =0.024), lower arterial-to-venous oxygen content difference (central: 12.3±2.5 versus peripheral: 10.3±2.2 mLO 2 /dL blood; P =0.013), and lower muscle oxygen diffusive conductance ( P =0.021). A difference in magnetic resonance spectroscopy–derived phosphocreatine recovery time was not detected ( P =0.199). CONCLUSIONS: Peripherally limited patients with heart failure with preserved ejection fraction identified by cardiopulmonary exercise testing have impairments in oxygen transport and utilization at the level of the skeletal muscle quantified by invasive knee extension exercise testing, which includes an increased blood flow/V̇O 2 ratio and poor muscle diffusive capacity. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04068844.
Background
In patients with hypertrophic cardiomyopathy (HCM), impaired augmentation of stroke volume and diastolic dysfunction contribute to exercise intolerance. Systolic–diastolic (S‐D) coupling ...characterizes how systolic contraction of the left ventricle (LV) primes efficient elastic recoil during early diastole. Impaired S‐D coupling may contribute to the impaired cardiac response to exercise in patients with HCM.
Methods
Patients with HCM (n = 25, age = 47 ± 9 years) and healthy adults (n = 115, age = 49 ± 10 years) underwent a cardiopulmonary exercise testing (CPET) and echocardiogram. S‐D coupling was defined as the ratio of LV longitudinal excursion of the mitral annulus during early diastole (EDexc) and systole (Sexc) and compared between groups. Peak oxygen uptake (peak V̇O2) (Douglas bags), cardiac index (C2H2 rebreathe), and stroke volume index (SVi) were assessed during CPET. Linear regression was performed between S‐D coupling and peak V̇O2, peak cardiac index, and peak SVi.
Results
S‐D coupling was lower in HCM (Controls: 0.63 ± 0.08, HCM: 0.56 ± 0.10, p < 0.001). Peak V̇O2 and stroke volume reserve were lower in patients with HCM (Peak VO2 Controls: 28.5 ± 5.5, HCM: 23.7 ± 7.2 mL/kg/min, p < 0.001, SV reserve: Controls 39 ± 16, HCM 30 ± 18 mL, p = 0.008). In patients with HCM, S‐D coupling was associated with peak V̇O2 (r = 0.47, p = 0.018), peak cardiac index (r = 0.60, p = 0.002), and peak SVi (r = 0.63, p < 0.001).
Conclusion
Systolic–diastolic coupling was impaired in patients with HCM and was associated with fitness and the cardiac response to exercise. Inefficient S‐D coupling may link insufficient stroke volume generation, diastolic dysfunction, and exercise intolerance in HCM.
Systolic Diastolic Coupling represents the portion of systolic excursion (Sexc) recovered during early diastole (EDexc)(Left) and can be measured using Tissue Doppler Imaging of the mitral annulus (Top, Right). S‐D Coupling is significantly lower in patients with Hypertrophic Cardiomyopathy compared to healthy controls (Bottom, Right).
ASCVD/CVD in Women
As women age, structural and functional changes occur in the cardiovascular system that may predispose them to specific cardiovascular diseases. Heart failure with preserved ...ejection fraction (HFpEF) affects more women than men for reasons that are incompletely understood. A leading hypothesis suggests that increased vascular stiffness, left ventricular (LV) concentric hypertrophy, and decreased LV compliance after menopause contribute to the development of HFpEF. This study aimed to assess whether vascular stiffness, myocardial stiffness, and diastolic function differ between healthy premenopausal and postmenopausal women.
Sixty-nine healthy, sedentary women (44% premenopausal, patient reported) underwent upright cardiopulmonary testing on a cycle ergometer and supine resting right heart catheterization (RHC). During exercise, we measured cardiac output (Q̇c; acetylene rebreathing) and oxygen uptake (V̇O2; Douglas bags); stroke volume (SV) was calculated from Q̇c and heart rate. At rest, we measured right atrial pressure (RAP), pulmonary capillary wedge pressure (PCWP), and transmural pressure (TMP = PCWP – RAP) from RHC. Furthermore, we assessed body composition (hydrodensitometry), aortic stiffness (carotid-femoral pulse wave velocity aPWV), and cardiac structure/function (echocardiography). Myocardial stiffness was assessed during LV loading and unloading to construct individual pressure-volume curves using the equation TMP=P∞(expa(v-v0)-1). Groups were compared using an independent-samples (Welch's) t-tests. Data are reported as mean ± standard deviation.
There were no statistically significant differences in V̇O2, Q̇c, or a-vO2 difference at rest or with exercise between the groups (Table 1). Postmenopausal women exhibited lower mitral annular systolic and diastolic excursion velocities and decreased systolic-diastolic coupling (e'VTI/s'VTI; Table 1). There were no statistically significant differences in PCWP, TMP, LVEDV, LV mass (Figure 1A & 1B) and resting and maximal exercise SV (Table 1) between groups. aPWV and SBP with maximal exercise was higher in postmenopausal women (Figure 1C), whereas myocardial stiffness did not differ between the groups (Figure 1D & 1E).
Healthy, sedentary postmenopausal women demonstrate higher aortic stiffness, SBP response to exercise, and decreased systolic-diastolic coupling compared to premenopausal women. However, there were no significant differences in LV structure. Further studies are needed to understand the independent effects of aging and hormonal changes on vascular stiffening, diastolic function, and HFpEF risk in postmenopausal women.
Abstract only Introduction: Mechanisms mediating the disproportionate risk for heart failure with preserved ejection fraction (HFpEF) in women are poorly understood. Impaired stroke volume (SV) ...reserve, increased afterload, arterial and left ventricular (LV) stiffness contribute to exercise intolerance in HFpEF. It is unknown whether subclinical changes in these measures predispose women to HFpEF; therefore, we compared resting and exercise cardiovascular structure and function across age in healthy men and women. Methods: We studied 192 sedentary normotensive, non-obese adults (53% female; age: 58 ± 13 20-90 years) at rest, during sub- and maximal exercise. We measured systolic blood pressure (SBP; electrosphygmomanometry) and aortic stiffness (carotid-femoral pulse wave velocity; aPWV). Myocardial stiffness was assessed as the slope of individual pressure-volume (right heart catheterization-echocardiography) curves generated by graded LV loading and unloading. SV was calculated from cardiac output (Q˙c; C 2 H 2 rebreathe)/heart rate to assess afterload (Ea; SBP/SV) and SV reserve (% change from rest) during exercise. Data were compared via two-way ANOVA (age*sex). Results: There was no significant age*sex interaction for aPWV, SV reserve, resting or maximal SBP, or myocardial stiffness; however, there was a main effect for sex with higher myocardial stiffness in women (Figure). aPWV and SV reserve were not different between sexes (p=0.349, p=0.940). Maximal exercise SBP was lower in women, but a similar proportion of each sex had an exaggerated maximal exercise SBP (Men: >210; Women: >190 mmHg; 28% vs 35%, χ 2 =0.290). Peak exercise afterload was higher in women (Figure) due to lower SV. Conclusions: Increased risk for HFpEF in women may be driven in part by greater myocardial stiffness throughout the aging process. Sex related abnormalities in afterload were most prominent with exercise in women, which may predispose to LV hypertrophy and increased stiffness.
Abstract only
Introduction:
Heart failure with preserved ejection fraction (HFpEF) is a disease of advanced aging that disproportionately affects women. Diastolic function changes with age and it is ...unknown if gender-related differences in progression exist. Understanding ages at which parameters of vascular and diastolic function diverge may provide insight into the differential risk of HFpEF between genders.
Methods:
Sedentary but healthy non-obese subjects aged 20-90 (n=178, 58% female; avg age 56 ± 13 yrs) underwent measures of pulmonary capillary wedge pressure (PCWP; right heart catheterization), blood pressure and cardiac output (acetylene rebreathe). Diastolic function was assessed by Doppler echocardiogram. A generalized linear model was used to estimate effects of age for each measured hemodynamic parameter as a function of gender.
Results:
Across age, women had higher systolic blood pressure (SBP) (age*gender p=0.025, age p<0.001) and total peripheral resistance (TPR) (age*gender p=0.053, age p<0.001). Changes in TPR were apparent at age 26 while SBP diverged at age 55. (Figure) Women had slower early diastolic recoil (e’) (age*gender p<0.001) starting at age 55. While E wave velocity was lower in women, age-related decline was similar to men. E/e’ was higher in women (age*gender p=0.007) and diverged at a young age (28). PCWP declined with age similarly in both men and women. Systolic velocity (s’) declined in early middle age (42) in women (age*gender p=0.007, age p=0.002).
Conclusions:
Women experience greater changes in cardiac and vascular function with age than men. The age at which these parameters diverge differs, with evidence for decline in vascular function and cardiac contractility occurring at young ages in women while changes in SBP and diastolic recoil occur after age 55. Understanding lifestyle and hormonal factors that influence these differences may help elucidate HFpEF risk factors that are modifiable and serve as a target for therapy.
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