CONTEXT Perioperative red blood cell transfusion is commonly used to address anemia, an independent risk factor for morbidity and mortality after cardiac operations; however, evidence regarding ...optimal blood transfusion practice in patients undergoing cardiac surgery is lacking. OBJECTIVE To define whether a restrictive perioperative red blood cell transfusion strategy is as safe as a liberal strategy in patients undergoing elective cardiac surgery. DESIGN, SETTING, AND PATIENTS The Transfusion Requirements After Cardiac Surgery (TRACS) study, a prospective, randomized, controlled clinical noninferiority trial conducted between February 2009 and February 2010 in an intensive care unit at a university hospital cardiac surgery referral center in Brazil. Consecutive adult patients (n = 502) who underwent cardiac surgery with cardiopulmonary bypass were eligible; analysis was by intention-to-treat. INTERVENTION Patients were randomly assigned to a liberal strategy of blood transfusion (to maintain a hematocrit ≥30%) or to a restrictive strategy (hematocrit ≥24%). MAIN OUTCOME MEASURE Composite end point of 30-day all-cause mortality and severe morbidity (cardiogenic shock, acute respiratory distress syndrome, or acute renal injury requiring dialysis or hemofiltration) occurring during the hospital stay. The noninferiority margin was predefined at −8% (ie, 8% minimal clinically important increase in occurrence of the composite end point). RESULTS Hemoglobin concentrations were maintained at a mean of 10.5 g/dL (95% confidence interval CI, 10.4-10.6) in the liberal-strategy group and 9.1 g/dL (95% CI, 9.0-9.2) in the restrictive-strategy group (P < .001). A total of 198 of 253 patients (78%) in the liberal-strategy group and 118 of 249 (47%) in the restrictive-strategy group received a blood transfusion (P < .001). Occurrence of the primary end point was similar between groups (10% liberal vs 11% restrictive; between-group difference, 1% 95% CI, −6% to 4%; P = .85). Independent of transfusion strategy, the number of transfused red blood cell units was an independent risk factor for clinical complications or death at 30 days (hazard ratio for each additional unit transfused, 1.2 95% CI, 1.1-1.4; P = .002). CONCLUSION Among patients undergoing cardiac surgery, the use of a restrictive perioperative transfusion strategy compared with a more liberal strategy resulted in noninferior rates of the combined outcome of 30-day all-cause mortality and severe morbidity. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01021631
Patients with heart failure with reduced ejection fraction related to anthracycline-based chemotherapy have increased sympathetic nerve activity and decreased exercise capacity. These alterations in ...autonomic control and physical capacity are similar to those observed in patients with heart failure due to other etiologies. These findings highlight the importance of special care of oncological patients treated with chemotherapy.
Cardiotoxicity is the most worrying cardiovascular alteration in patients treated with chemotherapy. To improve the understanding regarding the cardiotoxicity, we studied whether 1) patients with cardiac dysfunction related to anthracycline-based chemotherapy have augmented sympathetic nerve activity and decreased exercise capacity and 2) these responses are similar to those observed in patients with heart failure caused by other etiologies. Sixteen patients with heart failure with reduced ejection fraction related to anthracycline-based chemotherapy with or without chest radiation (HFrEFCA), 10 patients with heart failure with reduced ejection not related to cancer therapy (HFrEF), and 16 age- and body mass index (BMI)-matched healthy control subjects were studied. Left ventricular ejection fraction (LVEF, echocardiography), peak oxygen consumption (peak V̇o
2
, cardiopulmonary exercise test), muscle sympathetic nerve activity (MSNA, microneurography), and forearm blood flow (FBF, venous occlusion plethysmography) were measured. We found that peak oxygen consumption peak V̇o
2
and LVEF were significantly reduced in patients with HFrEFCA compared with that of control subjects ( P < 0.0001) but similar to those found in patients with HFrEFCA. The sympathetic nerve activity burst frequency and incidence were significantly higher in patients with HFrEFCA than that in control subjects ( P < 0.0001). No differences were found between patients with HFrEF and HFrEFCA. Peak V̇o
2
was inversely associated with MSNA burst frequency ( r = −0.53, P = 0.002) and burst incidence ( r = −0.38, P = 0.01) and directly associated with LVEF ( r = 0.71, P < 0.0001). Taken together, we conclude that patients who develop heart failure due to anthracycline-based chemotherapy have sympathetic neural overdrive and reduced exercise capacity. In addition, these physiological changes are similar to those observed in patients with HFrEF.
NEW & NOTEWORTHY Patients with heart failure with reduced ejection fraction related to anthracycline-based chemotherapy have increased sympathetic nerve activity and decreased exercise capacity. These alterations in autonomic control and physical capacity are similar to those observed in patients with heart failure due to other etiologies. These findings highlight the importance of special care of oncological patients treated with chemotherapy.
In recent years, the field of cardio-oncology has grown worldwide, bringing benefits to cancer patients in terms of survival and quality of life. This study reports the experience of a pioneer ...cardio-oncology programme at University Cancer Hospital in Brazil over a period of 10 years, describing the clinical profile of patients and the clinical outcomes.
A retrospective study was conducted on a cohort of patients treated at the cardio-oncology programme from April 2009 to February 2019. We analysed the characteristics of patients and outcomes, including mortality, according to the type of clinical indication for outpatient care (general cardiology, perioperative evaluation and follow-up and treatment cardiotoxicity).
From a total of 26,435 medical consultations, we obtained the data of 4535 individuals among the medical care outpatients. When we analysed the clinical characteristics of patients considering the clinical indication - general cardiology, perioperative evaluation and cardiotoxicity outpatient clinics, differences were observed with respect to age (59 48-66, 66 58-74 and 69 62-76, p < 0.001), diabetes (67 15%, 635 22.6% and 379 29.8%; p < 0.001), hypertension (196 43.8%, 1649 58.7% and 890 70.1%, p < 0.001) and dyslipidaemia (87 19.7%), 735 26.2% and 459 36.2%, p < 0.001). A similar overall mortality rate was observed in the groups (47.5% vs. 45.7% vs. 44.9% p = 0.650).
The number of oncologic patients in the Cardio-Oncology Programme has grown in the last decade. A well-structured cardio-oncology programme is the key to achieving the true essence of this area, namely, ongoing care for cancer patients throughout the disease treatment process, optimizing their cardiovascular status to ensure they can receive the best therapy against cancer.
Cardiotoxicity is associated with the chronic use of doxorubicin leading to cardiomyopathy and heart failure. Identification of cardiotoxicity-specific miRNA biomarkers could provide clinicians with ...a valuable prognostic tool. The aim of the study was to evaluate circulating levels of miRNAs in breast cancer patients receiving doxorubicin treatment and to correlate with cardiac function. This is an ancillary study from "Carvedilol Effect on Chemotherapy-induced Cardiotoxicity" (CECCY trial), which included 56 female patients (49.9±3.3 years of age) from the placebo arm. Enrolled patients were treated with doxorubicin followed by taxanes. cTnI, LVEF, and miRNAs were measured periodically. Circulating levels of miR-1, -133b, -146a, and -423-5p increased during the treatment whereas miR-208a and -208b were undetectable. cTnI increased from 6.6±0.3 to 46.7±5.5 pg/mL (p<0.001), while overall LVEF tended to decrease from 65.3±0.5 to 63.8±0.9 (p=0.053) over 12 months. Ten patients (17.9%) developed cardiotoxicity showing a decrease in LVEF from 67.2±1.0 to 58.8±2.7 (p=0.005). miR-1 was associated with changes in LVEF (r=-0.531, p<0.001). In a ROC curve analysis miR-1 showed an AUC greater than cTnI to discriminate between patients who did and did not develop cardiotoxicity (AUC = 0.851 and 0.544, p= 0.0016). Our data suggest that circulating miR-1 might be a potential new biomarker of doxorubicin-induced cardiotoxicity in breast cancer patients.
Archaeal genes present in
may represent symbionts that would explain development of heart failure in 30% of Chagas disease patients. Extracellular vesicles in peripheral blood, called exosomes (< 0.1 ...μm) or microvesicles (>0.1 μm), present in larger numbers in heart failure, were analyzed to determine whether they are derived from archaea in heart failure Chagas disease.
Exosomes and microvesicles in serum supernatant from 3 groups were analyzed: heart failure Chagas disease (
= 26), asymptomatic indeterminate form (
= 21) and healthy non-chagasic control (
= 16). Samples were quantified with transmission electron microscopy, flow cytometer immunolabeled with anti-archaemetzincin-1 antibody (AMZ 1, archaea collagenase) and probe anti-archaeal DNA and zymography to determine AMZ1 (Archaeal metalloproteinase) activity.
Indeterminate form patients had higher median numbers of exosomes/case vs. heart failure patients (58.5 vs. 25.5,
< 0.001), higher exosome content of AMZ1 antigens (2.0 vs. 0.0;
< 0.001), and lower archaeal DNA content (0.2 vs. 1.5,
= 0.02). A positive correlation between exosomes and AMZ1 content was seen in indeterminate form (
= 0.5,
< 0.001), but not in heart failure patients (r = 0.002,
= 0.98). Higher free archaeal DNA (63.0 vs. 11.1,
< 0.001) in correlation with exosome numbers (
= 0.66,
= 0.01) was seen in heart failure but not in indeterminate form (
= 0.29,
= 0.10). Flow cytometer showed higher numbers of AMZ1 microvesicles in indeterminate form (64 vs. 36,
= 0.02) and higher archaeal DNA microvesicles in heart failure (8.1 vs. 0.9,
< 0.001). Zymography showed strong% collagenase activity in HF group, mild activity in IF compared to non-chagasic healthy group (121 ± 14, 106 ± 13 and 100;
< 0.001).
Numerous exosomes, possibly removing and degrading abnormal AMZ1 collagenase, are associated with indeterminate form. Archaeal microvesicles and their exosomes, possibly associated with release of archaeal AMZ1 in heart failure, are future candidates of heart failure biomarkers if confirmed in larger series, and the therapeutic focus in the treatment of Chagas disease.
► Combinations of eNOS polymorphisms (haplotypes) affect endogenous NO formation. ► Lower NO formation may increase the cardiovascular risk. ► We showed that tagSNPs (neighboring polymorphisms) ...affect endogenous NO formation. ► TagSNPs may lower endogenous NO formation.
Haplotypes formed by clinically relevant polymorphisms in the endothelial nitric oxide synthase (eNOS) gene have been associated with variations in endogenous nitric oxide (NO) formation in white and black subjects. We examined whether further genetic variation and haplotypes of the eNOS gene, represented by the rs3918188, rs743506 and rs7830 tagSNPs (polymorphisms that represent the information of neighboring SNPs in linkage disequilibrium) affect endogenous NO formation in 181 healthy black subjects. We measured whole blood nitrite concentration as a marker of endogenous NO formation for each subject. We found that the heterozygotes CA for the tagSNP rs7830 (P=0.0278, OR=0.4839, CI 95% 0.2567–0.9121), as well as the haplotype “C–G–A” (P=0.0068), were more common in subjects with low circulating whole blood nitrite concentrations compared with subjects with high circulating whole blood nitrite concentrations, although the genotype finding is not significant after correction for multiple comparisons. These findings suggest that these tagSNPs of the eNOS gene and haplotypes are associated with low levels of nitric oxide production in blacks, and could be used as a marker of cardiovascular risk.
The environmental dioxin 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) is classified as a Group 1 human carcinogen and teratogenic agent. We hypothesize that TCDD-induced oxidative stress may also ...interfere with mitochondrial ATP-sensitive potassium channels (mitoKATP), which are known to regulate and to be regulated by mitochondrial redox state. We investigated the effects of an acute treatment of male Wistar rats with TCDD (50 μg/kg i.p.) and measured the regulation of cardiac mitoKATP. While the function of cardiac mitochondria was slightly depressed, mitoKATP activity was 52% higher in animals treated with TCDD. The same effects were not observed in liver mitochondria isolated from the same animals. Our data also shows that regulation of mitochondrial ROS production by mitoKATP activity is different in both groups. To our knowledge, this is the first report to show that TCDD increases mitoKATP activity in the heart, which may counteract the increased oxidative stress caused by the dioxin during acute exposure.
•Acute TCDD treatment of Wistar rats causes cardiac oxidative stress.•Acute TCDD treatment causes cardiac mitochondrial alterations.•Mitochondrial liver vs. heart alterations are distinct.•TCDD treatment resulted in altered activity of cardiac mitochondrial K-ATP channels.
Dioxin alters the regulation of cardiac mitochondrial ATP-sensitive potassium channels and disturbs mitochondrial physiology.
Myocardial hypertrophy and dysfunction occur in response to excessive catecholaminergic drive. Adverse cardiac remodelling is associated with activation of proinflammatory cytokines in the ...myocardium. To test the hypothesis that exercise training can prevent myocardial dysfunction and production of proinflammatory cytokines induced by β‐adrenergic hyperactivity, male Wistar rats were assigned to one of the following four groups: sedentary non‐treated (Con); sedentary isoprenaline treated (Iso); exercised non‐treated (Ex); and exercised plus isoprenaline (Iso+Ex). Echocardiography, haemodynamic measurements and isolated papillary muscle were used for functional evaluations. Real‐time RT‐PCR and Western blot were used to quantify tumour necrosis factor α, interleukin‐6, interleukin‐10 and transforming growth factor β1 (TGF‐β1) in the tissue. NF‐κB expression in the nucleus was evaluated by immunohistochemical staining. The Iso rats showed a concentric hypertrophy of the left ventricle (LV). These animals exhibited marked increases in LV end‐diastolic pressure and impaired myocardial performance in vitro, with a reduction in the developed tension and maximal rate of tension increase and decrease, as well as worsened recruitment of the Frank–Starling mechanism. Both gene and protein levels of tumour necrosis factor α and interleukin‐6, as well as TGF‐β1 mRNA, were increased. In addition, the NF‐κB expression in the Iso group was significantly raised. In the Iso+Ex group, the exercise training had the following effects: (1) it prevented LV hypertrophy; (ii) it improved myocardial contractility; (3) it avoided the increase of proinflammatory cytokines and improved interleukin‐10 levels; and (4) it attenuated the increase of TGF‐β1 mRNA. Thus, exercise training in a model of β‐adrenergic hyperactivity can avoid the adverse remodelling of the LV and inhibit inflammatory cytokines. Moreover, the cardioprotection is related to beneficial effects on myocardial performance.
Pathological left ventricular hypertrophy is a powerfulpredictor of heart failure and mortality. Substantial evidence has demonstrated that sustained β‐adrenergic cardiac stimulation is often associated with myocardial hypertrophy. We show that an exercise training programme was suitable to inhibit the myocardial hypertrophy induced in rats by β‐adrenergic hyperactivity. Prevention of hypertrophy was accompanied by inhibition of proinflammatory substances (cytokines) in the myocardium. Surprisingly, there was an improvement of myocardial function even in the presence of β‐adrenergic hyperactivity. These results show that exercise training is very effective in promoting heart protection against β‐adrenergic hyperactivity. This is particularly interesting for cardiovascular diseases, since in these conditions (e.g. hypertension and heart failure) there is an excessive adrenergic drive.
Abstract Objective Esterified cholesterol is the storage form of cholesterol in the organism. High-density lipoprotein (HDL), where free cholesterol is transferred from other lipoproteins and ...tissues, is the main esterification site in plasma. The aim of this study was to investigate how high cholesterol intake changes free/esterified ratios of cholesterol in the plasma, aorta, liver and lipid transfers to HDL. Methods Twenty male Golden Syrian hamsters fed 0.5% cholesterol for 15 wk and 19 controls without cholesterol feeding were sacrificed to determine serum lipids, transfer proteins (cholesteryl ester transfer protein and phospholipid transfer protein), and amount of free and esterified cholesterol in the aorta and liver. In vitro transfer of radioactive free and esterified cholesterol, phospholipids, and triacylglycerols to HDL was performed by incubating whole plasma with an artificial nanoemulsion used as a lipid donor and measuring radioactivity in the HDL fraction after chemical precipitation of non-HDL fractions and of the nanoemulsion. Results Compared with controls, cholesterol-fed animals showed a 137% increase in non-HDL plasma fraction and a 61% increase in HDL ( P < 0.001). The esterified/free cholesterol ratio in non-HDL and HDL fractions did not change. In the aorta, free cholesterol increased 55% and the esterified/free ratio (0.2) decreased. Cholesterol accumulation in the liver was several-fold greater and esterified/free increased (1.3). Cholesterol feeding pronouncedly increased the transfer of free and esterified cholesterol, phospholipids, and triacylglycerols to HDL and cholesteryl ester transfer protein and phospholipid transfer protein activities. Conclusions Free cholesterol is cytotoxic and less stable than esterified cholesterol, and the present data on how the organism responds to high cholesterol intake with respect to esterified/free ratios in the plasma, aorta, liver, and lipid transfers to HDL may have physiopathologic implications.
During embryonic development, mouse female germ cells enter meiosis in an anterior-to-posterior wave believed to be driven by retinoic acid. It has been proposed that ovarian follicle formation and ...activation follow the same general wave of meiotic progression; however, the precise anatomic specification of these processes has not been delineated. Here, we created a mouse line using Mvh, Gdf9, and Zp3 promoters to drive distinct temporal expression of three fluorescent proteins in the oocytes and to identify where the first follicle cohort develops. The fluorescent profile revealed that the first growing follicles consistently appeared in a specific region of the ovary, the anterior-dorsal region, which led us to analyze if meiotic onset occurred earlier in the dorsal ovarian region. Surprisingly, in addition to the anterior-to-posterior wave, we observed an early meiotic entry in the ventral region of the ovary. This additional anatomic stratification of meiosis contrasts with the localization of the initial follicle formation and activation in the dorsal region of the ovary. Therefore, our study suggests that the specification of cortical and medullar areas in the ventral and dorsal regions on the ovary, rather than the onset of meiosis, impacts where the first follicle activation event occurs.
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