Search

sNicotinamide adenine dinucleotide (NAD) is a critical metabolite and coenzyme for multiple metabolic pathways and cellular processes (1-4). In this study, we identified Singheart, SGHRT as a nuclear genome-encoded NAD+-binding mitochondrial micropeptide. SGHRT, present in both monomeric and dimeric forms, binds directly to NAD, but not NADH or flavin adenine dinucleotide (FAD). Localized to the inner mitochondrial membrane and mitochondrial matrix, SGHRT interacts with the mitochondrial enzymes Succinate-CoA Ligase and Succinate Dehydrogenase. SGHRT deletion in human embryonic stem cell derived cardiomyocytes disrupted mitochondria morphology, decreased total NAD and ATP abundance, and resulted in defective TCA cycle metabolism, the electron transport chain and in Ox-Phos processes. These results comprise the first report of an NAD+-binding micropeptide, SGHRT, required for mitochondrial function and metabolism.

Background:Asian representation in sport is increasing, yet there remains a lack of reference values for the Asian athlete's heart. Consequently, current guidelines for cardiovascular screening recommend using Caucasian athletes' norms to evaluate Asian athletes. This study aims to outline electrocardiographic and echocardiographic characteristics of the Asian athlete's heart using a Singaporean prospective registry of Southeast (SE) Asian athletes.Methods and Results:One hundred and fifty elite athletes, mean age of 26.1 ± 5.7 years (50% males, 88% Chinese), were evaluated using a questionnaire, 12-lead electrocardiogram (ECG) and transthoracic echocardiogram. All ECGs were analyzed using the 2017 International Recommendations. Echocardiographic data were presented by gender and sporting discipline. The prevalence of abnormal ECGs among SE Asian athletes was 6.7%—higher than reported figures for Caucasian athletes. The abnormal ECGs comprised mainly anterior T wave inversions (ATWI) beyond lead V2, predominantly in female athletes from mixed/endurance sport (9.3% prevalence amongst females). None had echocardiographic structural abnormalities. Male athletes had reduced global longitudinal strain compared to females (−18.7 ± 1.6 vs. −20.7 ± 2.1%,p< 0.001). Overall, SE Asian athletes had smaller left ventricular cavity sizes and wall thickness compared to non-Asian athletes.Conclusion:SE Asian athletes have higher abnormal ECG rates compared to Caucasian athletes, and also demonstrate structural differences that should be accounted for when interpreting their echocardiograms compared to athletes of other ethnicities.

Background Soluble suppression of tumorigenesis-2 (sST2) is released in response to inflammation and vascular injury, and holds prognostic value in heart failure (HF). Type 2 diabetes (T2D) is characterized by a pro-inflammatory status and is highly prevalent among HF patients, with adverse impact on outcomes. The clinical value of sST2 in HF patients with T2D has never been characterized. Purpose We aimed to assess sST2 clinical correlates and prognostic value in HF patients with T2D. Methods Individual data of 3476 patients with stable chronic HF from 5 cohorts from the BIOS (Biomarkers In Heart Failure Outpatient Study) dataset were analysed, with available N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin T (hs-TnT), and sST2 levels. Results Mean age was 65±12 years (75% males). T2D was present in 1386 patients (40%), who had higher body mass index (BMI, 27 [24–30] vs. 26 [23–29] kg/m2, p Conclusions sST2 is higher in HF patients with T2D and likely linked to a pro-inflammatory status. sST2 maintains its prognostic value both in diabetic and non-diabetic HF patients, independently of NT-proBNP, hs-TnT and hs-CRP. Funding Acknowledgement Type of funding sources: None. Figure 1

Background B-type natriuretic peptide (BNP) and mid-regional pro-atrial natriuretic peptide (MRproANP) testing are recommended to aid in the diagnosis of acute heart failure. However, the application of these biomarkers for optimal diagnostic performance is uncertain. Methods We performed a systematic review and harmonised individual patient-level data to evaluate the diagnostic performance of BNP and MRproANP for the diagnosis of acute heart failure using random-effects meta-analysis. We subsequently developed and externally validated a decision-support tool called CoDE-HF for both BNP and MRproANP that combines the natriuretic peptide concentrations with clinical variables using machine learning to report the probability of acute heart failure for an individual patient. Results Fourteen studies from 12 countries provided individual patient-level data in 8,493 patients for BNP and 3,847 patients for MRproANP, in whom, 48.3% (4,105/8,493) and 41.3% (1,611/3899) had an adjudicated diagnosis of acute heart failure, respectively. The negative and positive predictive values of guideline-recommended thresholds for BNP (100 pg/mL) and MR-proANP (120 pg/mL) were 93.6% (95% confidence interval 88.4–96.6%) and 68.8% (62.9–74.2%), and 95.6% (92.2–97.6%) and 64.8% (56.3–72.5%), respectively. However, we observed significant heterogeneity in the diagnostic performance across important patient subgroups (Figure 1). In the external validation cohort, CoDE-HF was well calibrated with excellent discrimination in those without prior acute heart failure for both BNP and MRproANP (area under the curve of 0.946 [0.933–0.958] and 0.943 [0.921–0.964], and Brier scores of 0.105 and 0.073, respectively). CoDE-HF performed consistently across all subgroups for both BNP and MRproANP, and identified 30% and 65.7% at low-probability (negative predictive value of 99.1% [98.8–99.3%] and 99.1% [98.8–99.4%]), and 30% and 17.3% at high-probability (positive predictive value of 91.3% [90.7–91.9%] and 70.0% [68.5–71.4%]) in those without prior heart failure, respectively (Figure 2). Conclusion In an international collaborative analysis, we observed that guideline-recommended thresholds for BNP and MRproANP to diagnose acute heart failure varied significantly across patient subgroups. A decision-support tool using machine learning to combine natriuretic peptides as a continuous measure and other clinical variables provides a more accurate and individualised approach. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Medical Research Council and British Heart Foundation Figure 1. NPV of BNP threshold (100 pg/mL)Figure 2. NPV of the CoDE-HF rule-out score

Background Left ventricular global longitudinal strain (LV-GLS) by speckle tracking echocardiography (STE) reflects intrinsic myocardial function, influenced by interstitial abnormalities. Cardiovascular magnetic resonance (CMR) detects myocardial fibrosis non-invasively, but it is limited for widespread use. We aim to establish LV-GLS as a marker of replacement myocardial fibrosis on CMR and validate the prognostic value of LV-GLS thresholds associated with fibrosis. Methods LV-GLS thresholds of replacement fibrosis were established in the derivation cohort: 151 patients (57±10 years; 58% males) with hypertension who underwent STE to measure LV-GLS and CMR for replacement myocardial fibrosis. Prognostic value of the thresholds was validated in a separate outcome cohort: 261 patients with moderate-severe aortic stenosis (AS; 71±12 years; 58% males; NYHA functional class I-II) and preserved LVEF ≥50%. Primary outcome was a composite of cardiovascular mortality, heart failure hospitalization, myocardial infarction and cerebrovascular events. Results In the derivation cohort, LV-GLS demonstrated good discrimination (c-statistics 0.74; 95% confidence interval: 0.66–0.83; P−15.0% (corresponding to 95% specificity to rule-in myocardial fibrosis) had the worst outcomes compared to patients with LV-GLS Conclusions LV-GLS thresholds associated with replacement myocardial fibrosis is a novel approach to risk-stratify patients with AS and preserved LVEF (Figure 2). Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council Figure 1Figure 2

BACKGROUND Acute decompensated heart failure (ADHF) is associated with deterioration in renal function—an important risk factor for poor outcomes. Whether ADHF results in permanent kidney damage/dysfunction is unknown. METHODS AND RESULTS We investigated for the first time the renal responses to the development of, and recovery from, ADHF using an ovine model. ADHF development induced pronounced hemodynamic changes, neurohormonal activation, and decline in renal function, including decreased urine, sodium and urea excretion, and creatinine clearance. Following ADHF recovery (25 days), creatinine clearance reductions persisted. Kidney biopsies taken during ADHF and following recovery showed widespread mesangial cell prominence, early mild acute tubular injury, and medullary/interstitial fibrosis. Renal transcriptomes identified altered expression of 270 genes following ADHF development and 631 genes following recovery. A total of 47 genes remained altered post‐recovery. Pathway analysis suggested gene expression changes, driven by a network of inflammatory cytokines centered on IL‐1β (interleukin 1β), lead to repression of reno‐protective eNOS (endothelial nitric oxide synthase) signaling during ADHF development, and following recovery, activation of glomerulosclerosis and reno‐protective pathways and repression of proinflammatory/fibrotic pathways. A total of 31 dysregulated genes encoding proteins detectable in urine, serum, and plasma identified potential candidate markers for kidney repair (including CNGA3 [cyclic nucleotide gated channel subunit alpha 3] and OIT3 [oncoprotein induced transcript 3]) or long‐term renal impairment in ADHF (including ACTG2 [actin gamma 2, smooth muscle] and ANGPTL4 [angiopoietin like 4]). CONCLUSIONS In an ovine model, we provide the first direct evidence that an episode of ADHF leads to an immediate decline in kidney function that failed to fully resolve after ≈4 weeks and is associated with persistent functional/structural kidney injury. We identified molecular pathways underlying kidney injury and repair in ADHF and highlighted 31 novel candidate biomarkers for acute kidney injury in this setting.

Background: Patients with cancer are at increased risk of acute myocardial infarction (AMI). It is unclear if the Atherosclerotic Cardiovascular Disease (ASCVD) risk score at incident AMI is reflective of this higher risk in patients with prior cancer than those without. Methods: We linked nationwide AMI and cancer registries from 2008 to 2019. A total of 18,200 eligible patients with ASCVD risk score calculated at incident AMI were identified (1086 prior cancer; 17,114 no cancer). Results: At incident AMI, age-standardized mean ASCVD risk was lower in the prior cancer group (18.6%) than no cancer group (20.9%) (p < 0.001). Prior to incident AMI, smoking, hypertension, hyperlipidemia and diabetes mellitus were better controlled in the prior cancer group. However post-AMI, prior cancer was associated with lower guideline-directed medical therapy usage and higher all-cause mortality (adjusted hazard ratio 1.85, 95% confidence interval 1.66–2.07). Conclusions: AMI occurred despite better control of cardiovascular risk factors and lower age-standardized estimated mean 10-year ASCVD risk among patients with prior cancer than no cancer. Prior cancer was associated with lower guideline-directed medical therapy post-AMI and higher mortality.

This chapter discusses issues relating to the sale of new properties. It covers acting for a developer or buyer, road and sewer agreements, structural defects insurance, and synchronizing completion of a related sale when acting for the buyer of new property.

The purchase deed transfers the legal estate in the property from the seller to the buyer. Whereas the contract sets out what the parties have agreed, the purchase deed actually puts those agreed terms into effect. This chapter discusses drafting and approving the deed; forms of purchase deed; the plan in a purchase; execution of purchase deed; and advising the client.

This chapter first examines some of the more commonly encountered elements or clauses in most leases. Essentially, it sets out what one might expect to see in a lease of either residential or commercial property. The discussions then turn to the Council of Mortgage Lenders’ Handbook for Solicitors and Licensed Conveyancers England and Wales; defective leases; liability on covenants in leases: enforcement; granting new leases; existing leases; and enfranchisement.

Conveyancing practitioners, whether they are acting for the seller or the buyer, still have much to do once completion has taken place. However, the buyer’s solicitor will have more work to do, as in most transactions acting on behalf of the buyer means after completion dealing with the possible payment of stamp duty land tax and then registration of the title and/or transfer. So far as the seller is concerned, if there is a mortgage, paying off any lender is required, as well as accounting to the client for the net proceeds of sale. This chapter considers all these post-completion procedures.

Exchange of contracts is the most critical stage in the conveyancing process as it represents the point at which the parties become legally bound to proceed. This chapter examines pre-exchange matters; the process by which contracts are actually exchanged; and matters that should be attended to immediately after exchange has taken place. It also considers the risk and responsibility for buildings insurance, and the consequences of the buyer occupying the property before completion.

This chapter considers the provisions of the Landlord and Tenant Act 1954, Part II, which provides security of tenure for the majority of business tenants by giving them a statutory right to renew their lease or tenancy. It explains the need for ‘tenancy’; need for ‘occupation’; need for ‘the purposes of a business’; key methods of termination under the Act; section 40 notices; interim rent applications; landlord’s statutory grounds of opposition; tenant’s right to compensation; and the terms of the new tenancy.

This chapter considers issues relating to the drafting the contract for the seller. These include occupiers and tenancies; seller’s duty of disclosure; formalities; contents of the contract; deposit; completion; title guarantee; indemnity covenants; sales of part; option agreements; and conditional contracts.

Deducing title is the process by which the seller demonstrates to the buyer that the seller owns the property and can convey it. In a modern conveyancing transaction the parties will deduce and investigate title before contracts are exchanged. This chapter explains the process of deducing title; investigating title; and some special title situations.

This chapter examines pre-contract searches and enquiries. Searches are requests for information about the subject property made by conveyancers that are sent to various agencies that hold that information, like local authorities. Enquiries are questions about the subject property that are sent to a seller to answer. These are interesting and important subjects within the conveyancing process and cover a lot of points that can be of considerable consequence to a buyer.

Commercial conveyancing services support the market in and for commercial property. This chapter focuses on several different topics that relate to commercial property and involve specialist knowledge of commercial conveyancing. These include commercial leases; buying and selling commercial freeholds; and commercial property and some elements of revenue law.

Property Law and Practice (PLP) covers all aspects of the process that is otherwise called conveyancing. It is how practitioners arrange the transmission of property ownership from seller to buyer. This introductory chapter provides an overview of PLP. Specifically, it explains the three foundations upon which PLP rests: land law, contract law, and trusts.

This chapter discusses initial activities in the conveyancing process including advising joint buyers on co-ownership; advising buyers to have a survey of the property carried out before exchange of contracts; estate agents; capital gains tax; stamp duty land tax; client care and advice on costs; professional conduct; the Law Society’s National Conveyancing Protocol; and advising on finance.

This chapter considers what can be done if a conveyancing contract is delayed, disputed or denied. A practitioner must be able to advise a client when a transaction goes wrong and remedies are sought to correct that wrong. The discussions cover late completion; conditions when time is of the essence for a conveyancing contract; consequences of delay; notices to complete; and remedies.

This chapter deals with important issues arising in relation to a mortgage taken out by a client to assist in financing the purchase of a property. It looks at the most popular types of mortgage, the impact of the Financial Services and Markets Act 2000, and other matters, including important professional conduct issues. It also considers mortgages of leasehold property and mortgages of commercial property.

Completion is the moment in time when the buyer pays over the balance of the purchase price to the seller in exchange for the deeds (if any), executed purchase deed, keys, and, if the contract so provides, vacant possession. This chapter discusses the how, where, and when for completion; deeds and unregistered land; postal completions; dealing with the discharge of the seller’s mortgage; the Land Registry’s electronic discharge (e-DS1) scheme; and the outcome of completion.

This chapter considers the process by which students are required to demonstrate their knowledge and abilities on property law and practice-the subject assessment or examination itself. It presents some hints and tips to enhance and improve examination technique.

Town and country planning legislation aims to control the development of land and buildings. Section 57(1) of the Town and Country Planning Act 1990 stipulates that ‘planning permission is required for the carrying out of any development of land’. This chapter first discusses the two main elements of town and country planning: (1) obtaining planning permission for new developments; and (2) the change of use of existing properties. It then explains breaches of planning control and enforcement; building regulations; and typical planning enquiries. A town and country planning decision tree is also presented.

Frailty is associated with future cardiovascular events in older adults. This cross-sectional study examined the relationship between subclinical vasculopathy with measures of skeletal muscle mass and function. Asymptomatic community-dwelling Asians ≥55 years underwent assessments for subclinical vasculopathy (carotid intima-media thickness (cIMT), aortic and carotid stiffness, and endothelial function), muscle mass (calf circumference adjusted for body mass index) and function (knee extension strength, 6-meter fast gait speed). Multivariable regression analyses for associates of muscle mass/function controlled for demographics and cardiometabolic risk factors. Among 336 participants (median age 62 years, 55.1% male, 3.6% sarcopenia), cIMT, aortic and carotid stiffness inversely correlated with muscle mass, strength and gait speed; cIMT remained independently associated with gait speed (β=-0.26) in multivariable analyses. Age and sex significantly modified the relationship between subclinical vasculopathy and muscle mass/function. Associations, only found in those aged ≥70, included cIMT with gait speed (β=-0.48) and knee strength (β=-9.33), and aortic augmentation index and aortic stiffness composite z-score with gait speed (β=-0.11 and β=-0.19 respectively). Among males, cIMT correlated with gait speed (β=-0.31). The association of subclinical vasculopathy with skeletal muscle mass and function in asymptomatic adults ≥55 years is best reflected by cIMT. The roles of mediating pathways deserve further evaluation.

Background Ejection Fraction (EF) has been an important parameter describing cardiac function, because of earlier work demonstrating its correlation with outcomes. However, during conditions such as Heart Failure preserved ejection fraction (HFpEF), EF fails to distinguish HFpEF from healthy patients. There are further reports that EF can be skewed by the geometry of the heart, and Heart Failure (HF) can present a wide variety of cardiac morphologies due to remodelling. The reason for the poor performance of EF and its dependency on geometry is unclear, and it is further unclear if such geometric changes from HF remodelling affects cardiac function. We strive to address this here, and derive an improve and simple EF parameter to resolve this. Methods We developed a simple discretized numerical model to relate incompressible myocardial strains to stroke volume. We used data from two porcine animal models of heart failure, one for HFpEF and one for HF reduced EF (HFrEF), and literature clinical measurements to inform our model. We used the model to test the effects of geometric changes relevant to HF on the ability of the heart to convert myocardial strains to flow function. Results Our animal models showed that cardiac dilation and wall thickening are primary features relevant to HF. Further investigation via our numerical model showed that wall thickening with no change to strain artificially increased EF, while cardiac dilation with no change to strain artificially decreased EF, demonstrating that EF can be skewed by geometric changes during HF remodelling, and is an inaccurate representation of cardiac function. We further showed that this is because EF is calculated using the endocardial boundary rather than the mid-wall layer, because a corrected EF parameter (CEF) that uses the mid-wall layer for quantification resolves this shortcoming. This CEF became independent of cardiac geometry, and could successfully distinguish HFpEF and healthy heart in our animal models, where EF could not. The CEF can be calculated easily with measurements of EF, wall thickness, and LV inner diameter. We further showed that the myocardial strains at the endocardial and epicardial boundary deviated significantly from each other and from the strains at the mid-wall layer, and this magnitude of deviation depended on the cardiac geometry, suggesting that any quantification of cardiac function using the epi- or endo- boundaries can be skewed by geometric changes to the heart, and will be ineffective. Finally, we tested specific types of HF morphologies, namely, eccentric hypertrophy, concentric hypertrophy, and concentric remodelling with our numerical model. We found that the concentric remodelling morphology is the most inefficient in converting myocardial strains to stroke volume, while eccentric hypertrophy is the most efficient. This may explain why HFpEF hearts, which are likely have wall thickening similar to concentric remodelling, have exercise intolerant, and our results suggest that cardiac dilation during HFrEF is providing advantages to help with flow function. Conclusion We demonstrated that geometric changes during HF remodeling can significantly impact cardiac function, and can skews functional parameters like EF. We further showed that the reason for EF’s shortcoming is due to a flawed reliance on quantification using the endocardial boundary of the heart rather than the mid-wall layer. We proposed a new CEF parameter to replace EF that can resolve the shortcoming, and that can distinguish HFpEF from healthy hearts. Conflict of Interest None to declare

There are important efforts being made to revitalise Aboriginal languages in Australia, which are both pedagogically and culturally appropriate. This research seeks to expand the current knowledge of the effectiveness of gesturing as a teaching strategy for young children learning the Gathang language. An experimental method was used to investigate the effectiveness of gesture by employing a context in which other variables (e.g., other teaching pedagogies) could be held constant. Participants, age range 4–5.2 years, were taught Gathang nouns with gesture and without gesture, alongside verbal and pictorial instruction. After the teaching sessions, each child was assessed for their receptive and expressive knowledge of the Gathang nouns, at two time points, two days after instruction (post-test 1) and one week after (post-test 2). At post-test 2, children had stronger receptive knowledge for words they had learned with gesture than without. These findings contribute to a growing body of research attesting to the effectiveness of gesture for improving knowledge acquisition amongst learners. In the context of Aboriginal language revitalisation, gesture also aligns with traditional teaching practices and offers a relatively low-cost strategy for helping teachers assist their students in acquiring Aboriginal languages.

Aims Cardiac specificity provides an advantage in correlating heart failure (HF) biomarker plasma levels with indices of cardiac function and remodelling, as shown for natriuretic peptides. Using bioinformatics, we explored the cardiac specificity of secreted proteins and investigated in more detail the relationship of Dickkopf‐3 (DKK3) gene expression and DKK3 plasma concentrations with cardiac function and remodelling in (pre)clinical studies. Methods and results The cardiac specificity of secreted proteins was determined using RNAseq data for a large panel of organs and tissues. This showed that natriuretic peptides (NPPA and NPPB) are highly cardiac‐specific (>99%), whereas other HF biomarkers, including galectin‐3 (Gal‐3, LGALS3) and growth differentiation factor‐15 (GDF‐15), lack cardiac specificity (

BACKGROUND: Guideline-recommended doses of angiotensin-converting-enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs), and β blockers are similar for men and women with heart failure with reduced ejection fraction (HFrEF), even though there are known sex differences in pharmacokinetics of these drugs. We hypothesised that there might be sex differences in the optimal dose of ACE inhibitors or ARBs and β blockers in patients with HFrEF.METHODS: We did a post-hoc analysis of BIOSTAT-CHF, a prospective study in 11 European countries of patients with heart failure in whom initiation and up-titration of ACE inhibitors or ARBs and β blockers was encouraged by protocol. We included only patients with left ventricular ejection fraction less than 40%, and excluded those who died within the first 3 months. Primary outcome was a composite of time to all-cause mortality or hospitalisation for heart failure. Findings were validated in ASIAN-HF, an independent cohort of 3539 men and 961 women with HFrEF.FINDINGS: Among 1308 men and 402 women with HFrEF from BIOSTAT-CHF, women were older (74 [12] years vs 70 [12] years, pINTERPRETATION: This study suggests that women with HFrEF might need lower doses of ACE inhibitors or ARBs and β blockers than men, and brings into question what the true optimal medical therapy is for women versus men.FUNDING: European Commission.

New contingency policy plans are expected to be published by the United Kingdom government to set out urgent actions, such as carbon capture and storage, greenhouse gas removal and the use of sustainable bioenergy to meet the greenhouse gas reduction targets of the 4th and 5th Carbon Budgets. In this study, we identify two plausible bioenergy production pathways for bioenergy with carbon capture and storage (BECCS) based on centralized and distributed energy systems to show what BECCS could look like if deployed by 2050 in Great Britain. The extent of agricultural land available to sustainably produce biomass feedstock in the centralized and distributed energy systems is about 0.39 and 0.5 Mha, providing approximately 5.7 and 7.3 MtDM/year of biomass respectively. If this land‐use change occurred, bioenergy crops would contribute to reduced agricultural soil GHG emission by 9 and 11 urn:x-wiley:17571693:media:gcbb12630:gcbb12630-math-0001/year in the centralized and distributed energy systems respectively. In addition, bioenergy crops can contribute to reduce agricultural soil ammonia emissions and water pollution from soil nitrate leaching, and to increase soil organic carbon stocks. The technical mitigation potentials from BECCS lead to projected CO2 reductions of approximately 18 and 23 urn:x-wiley:17571693:media:gcbb12630:gcbb12630-math-0002/year from the centralized and distributed energy systems respectively. This suggests that the domestic supply of sustainable biomass would not allow the emission reduction target of 50 urn:x-wiley:17571693:media:gcbb12630:gcbb12630-math-0003/year from BECCS to be met. To meet that target, it would be necessary to produce solid biomass from forest systems on 0.59 or 0.49 Mha, or alternatively to import 8 or 6.6 MtDM/year of biomass for the centralized and distributed energy system respectively. The spatially explicit results of this study can serve to identify the regional differences in the potential capture of CO2 from BECCS, providing the basis for the development of onshore CO2 transport infrastructures.

OBJECTIVEMicrovascular complications are common among patients with diabetes mellitus (DM). The presence of heart failure (HF) is presumed to be due to macrovascular disease (typically HF with reduced ejection fraction [HFrEF] following myocardial infarction). We hypothesized that HF with preserved ejection fraction (HFpEF) in patients with DM may be a manifestation of microvascular disease compared with HFrEF. The objective of this study was to examine the prevalence and association with clinical outcome of microvascular complications in patients with HF and DM.RESEARCH DESIGN AND METHODSWe investigated the prevalence, association with clinical outcome, and cardiac structure and function of microvascular (neuropathy, nephropathy, and retinopathy) complications of DM in 2,800 prospectively enrolled participants with HF and DM (561 with HFpEF) from the Asian Sudden Cardiac Death In Heart Failure (ASIAN-HF) registry.RESULTSA total of 601 (21.5%) participants with DM had microvascular complications. Participants with DM and any (one or more) microvascular complications were more likely to have HFpEF (odds ratio 1.70 [95% CI 1.15–2.50]; P = 0.008). Furthermore, the likelihood of having HFpEF increased with an increasing number of microvascular complications (Ptrend < 0.001). Microvascular complications were associated with more left ventricular (LV) hypertrophy and a greater reduction in quality of life in HFpEF than HFrEF (Pinteraction < 0.001 for all). Compared with participants with DM and without microvascular complications, the adjusted hazard ratio for the composite outcome of all-cause death or HF hospitalization was 1.35 (95% CI 1.04–1.76) for participants with DM and microvascular complications regardless of HF type (Pinteraction = 0.112).CONCLUSIONSDiabetic microvascular disease is more common, and related to greater LV remodeling, more impairment of quality in life, and similar adverse outcomes, in participants with HFpEF compared with HFrEF. HFpEF may be a clinical manifestation of microvascular disease in DM.

BACKGROUND Heart failure (HF) is a leading cause of morbidity and mortality worldwide. Plasma concentrations of B-type natriuretic peptide (BNP) or its amino terminal congener (NT-proBNP) are used for HF diagnosis and risk stratification. Because BNP concentrations are inexplicably lowered in obese patients, we investigated the relationship between proBNP glycosylation, plasma NT-proBNP, and body mass index (BMI) in HF patients. METHODS Three assays were developed to distinguish between total proBNP (glycosylated plus nonglycosylated proBNP), proBNP not glycosylated at threonine 71 (NG-T71), and proBNP not glycosylated in the central region (NG-C). Intraassay and interassay CVs were RESULT Applying these assays and an NT-proBNP assay to plasma samples from 106 healthy volunteers and 238 HF patients determined that concentrations [median (interquartile range)] of proBNP, NG-T71, and NT-proBNP were greater in HF patients compared with controls [300 (44–664), 114 (18–254), and 179 (880–3459) ng/L vs 36 (18–229), 36 (18–175), and 40 (17–68) ng/L, respectively; all P < 0.012]. NG-C was undetectable in most samples. ProBNP concentrations in HF patients with BMI more or less than 30 kg/m2 were not different (P = 0.85), whereas HF patients with BMI >30 kg/m2 had lower NT-proBNP and NG-T71 concentrations (P < 0.003) and higher proBNP/NT-proBNP and proBNP/NG-T71 ratios (P = 0.001 and P = 0.02, respectively) than those with BMI CONCLUSIONS Increased BMI is associated with decreased concentrations of proBNP not glycosylated at T71. Decreased proBNP substrate amenable to processing could partially explain the lower NT-proBNP and BNP concentrations observed in obese individuals, including those presenting with HF.

Reduced myocardial miR-221 expression is associated with severe cardiac fibrosis in heart failure patients. We aimed to demonstrate its mechanisms in cardioprotection and remodeling following myocardial infarction (MI). Using in vitro hypoxia and reoxygenation (H/R) of H9c2 and rat cardiac fibroblast (cFB) models, we found that miR-221 protects H9c2 through combined anti-apoptotic and anti-autophagic effects and cFB via anti-autophagic effects alone in H/R. It inhibits myofibroblast (myoFB) activation as indicated by lowering α-smooth muscle actin (α-SMA) expression, gel contraction, and collagen synthesis (Sircol assay). In vivo, following left coronary artery ligation (MI), rats were treated with miR-221 mimics (intravenous [i.v.], 1 mg/kg). With treatment, miR-221 increased by ∼15-fold in infarct and peri-infarct zones at day 2 post-MI. At days 7 and 30 post-MI, miR-221 reduced infarct size, fibrosis, and α-SMA+ cells in both infarct and remote myocardium. Left ventricle (LV) function was preserved as indicated by ejection fraction, infarct thickness, LV developed pressure, ±dP/dt, and end diastolic pressure. We demonstrated the anti-apoptotic and anti-autophagic effects were due to combined mechanisms of direct targeting on Bak1 and P53 and inhibition of phosphorylation at Ser46 and direct targeting on Ddit4, respectively. miR-221 enhances cardiomyocyte survival and protects cardiac function post-MI. It enhances cFB survival yet inhibits their activation, thus reducing adverse cardiac fibrosis., Graphical Abstract

Introduction Subclinical atrial fibrillation (AF), in the form of cardiac implantable device‐detected atrial high rate episodes (AHREs), has been associated with increased thromboembolism. An implantable cardioverter‐defibrillator (ICD) lead with a floating atrial dipole may permit a single lead (DX) ICD system to detect AHREs. We sought to assess the utility of the DX ICD system for subclinical AF detection in patients, with a prospective multicenter, cohort‐controlled trial. Methods and Results One hundred fifty patients without prior history of AF (age 59 ± 13 years; 108 [72%] male) were enrolled into the DX cohort and implanted with a Biotronik DX ICD system at eight centers. Age‐, sex‐, and left ventricular ejection fraction‐matched single‐ and dual‐chamber ICD cohorts were derived from a Cornell database and from the IMPACT trial, respectively. The primary endpoint were AHRE detection at 12 months. During median 12 months follow‐up, AHREs were detected in 19 (13%) patients in the DX, 8 (5.3%) in the single‐chamber, and 19 (13%) in the dual‐chamber cohorts. The rate of AHRE detection was significantly higher in the DX cohort compared to the single‐chamber cohort (P = .026), but not significantly different compared to the dual‐chamber cohort. There were no inappropriate ICD therapies in the DX cohort. At 12 months, only 3.0% of patients in the DX cohort had sensed atrial amplitudes less than 1.0 mV. Conclusion Use of a DX ICD lead allows subclinical AF detection with a single lead DX system that is superior to that of a conventional single‐chamber ICD system.

Background Soluble urokinase plasminogen activator receptor (suPAR) is an emerging marker of cardiovascular disease burden. Appropriate assessment of assay performance and reference interval are required to enable interpretation of results to facilitate its clinical application. Methods suPAR was measured using the suPARnostic® ELISA in 155 healthy volunteers. Assay performance was assessed for anticoagulant effect, recovery, interference, linearity and cross-reactivity. The identity of immunoreactive suPAR was confirmed by size-exclusion HPLC . To establish anatomical sites of release and uptake, we measured suPAR in regional samples from subjects undergoing cardiac catheterization . Results The median concentration of suPAR was 2.1 ng/mL (IQR:1.7–2.3) in health. In comparison with EDTA , suPAR measurements were affected by lithium heparin (>10% change) and increased with serum usage. suPAR reactivity also increased in the presence of haemolysis (10 g/L), but was suppressed with urokinase and lipids (4 g/L). In multiple regression analyses, suPAR associated independently with body weight, NT-proBNP and MR-proADM (P = .03) for healthy individuals. Regional plasma sampling showed lower suPAR concentrations in the coronary sinus and renal vein compared with concentrations in femoral arterial samples. Immunoreactive circulating suPAR species had Mr of 10–39 kDa. Conclusion The suPARnostic® assay performs acceptably for a clinical assay but is limited in the presence of high levels of hemolysis, lipids and urokinase. We provide the first evidence for the heart and kidneys as organs of suPAR clearance in humans. Additional investigations are warranted to determine whether there is a need to compare the marker performance of differing circulating forms of suPAR.

Background: Human mesenchymal stem cell-derived exosomes (hMSC-Exo) have been shown to reduce ischemia/reperfusion injury (I/R) in multiple models. I/R-induced apoptosis or autophagy play important roles in cell death. However, little or no reports demonstrate any roles of hMSC-Exo in this regards. Objective: To test the hypothesis that the inhibition of I/R-induced apoptosis and autophagy play a pivotal role in the cardioprotection of hMSC-Exo. Methods: Myoblast H9c2 cells and isolated rat hearts underwent hypoxia/re-oxygenate (H/R) or ischemia/ reperfusion (I/R) respectively. H9c2 were treated with 1.0 μg/ml Exo, in comparison with 3-MA or rapamycin (Rapa), a known anti- or pro-autophagic agent respectively. Hearts were treated with 0.5, 1.0 and 2.0 μg/ml Exo for 20 min in the beginning of reperfusion. Cell viability, WST assay, LDH release, Annexin-V staining apoptosis assay and GFP-LC3 labeled autophagosomes formation, cardiac function and Western blot were measured. Results: Exo significantly reduced H/R injury as indicated by increased cell viability and reduced LDH and apoptosis. 3-MA, while Rapa, showed increased or decreased protective effects. Rapa-induced injury was partially blocked by Exo. Exo decreased LC3-II/I ratio and increased p62, inhibited autophagosome formation, an indication of autophagy inhibition. In isolated heart, Exo increased cardiac functional recovery and reduced LDH release in I/R. Bcl-2 was significantly upregulated by Exo but not 3-MA. Exo downregulated Traf6 and upregulated mTORC1/p-4eBP1. Conclusion: Exo reduce I/R-induced apoptosis and autophagy. Up-regulation of Bcl-2 is the cross-talk between these two processes. The down-regulation of Traf6 and activation of mTORC1 are additional mechanisms in the inhibition of apoptosis and autophagy.

Aims To examine sex differences in clinical characteristics, echocardiographic features, quality of life and 1-year death or heart failure (HF) hospitalization outcomes in patients with/without diabetes mellitus (DM).Methods and results Utilizing the Asian Sudden Cardiac Death in HF (ASIAN-HF) registry, 5255 patients (mean age 59.6 +/- 13.1, 78% men) with symptomatic HF with reduced ejection fraction (HFrEF) were stratified by DM status to address the research aims. Despite similar prevalence of DM between Asian men (43%) and women (42%), the odds of DM increased at lower body mass index in women vs. men (>= 23 vs. >= 27.5 kg/m(2), P-interaction = 0.014). DM was more strongly related to chronic kidney disease in women vs. men [adjusted odds ratio (OR) 1.85, 95% confidence interval (CI) 1.33-2.57 vs. OR 1.32, 95% CI 1.11-1.56, P-interaction = 0.009]. Sex also modified the relationship between DM and left ventricular geometry (P-interaction = 0.003), whereby DM was associated with amore concentric left ventricular geometry in women than men. Women had lower quality of life than men (P Conclusions Asian women with HFrEF were more likely to have DM despite a lean body mass index, a greater burden of chronic kidney disease and more concentric left ventricular geometry, compared to men. Furthermore, DM confers worse quality of life, irrespective of sex, and a greater risk of adverse outcomes in women than men. These data underscore the need for sex-specific approaches to diabetes in patients with HF.

Background Clinicians need improved tools to better identify nonacute heart failure with preserved ejection fraction (HFpEF). Objectives The purpose of this study was to derive and validate circulating microRNA signatures for nonacute heart failure (HF). Methods Discovery and validation cohorts (N = 1,710), comprised 903 HF and 807 non-HF patients from Singapore and New Zealand (NZ). MicroRNA biomarker panel discovery in a Singapore cohort (n = 546) was independently validated in a second Singapore cohort (Validation 1; n = 448) and a NZ cohort (Validation 2; n = 716). Results In discovery, an 8-microRNA panel identified HF with an area under the curve (AUC) 0.96, specificity 0.88, and accuracy 0.89. Corresponding metrics were 0.88, 0.66, and 0.77 in Validation 1, and 0.87, 0.58, and 0.74 in Validation 2. Combining microRNA panels with N-terminal pro–B-type natriuretic peptide (NT-proBNP) clearly improved specificity and accuracy from AUC 0.96, specificity 0.91, and accuracy 0.90 for NT-proBNP alone to corresponding metrics of 0.99, 0.99, and 0.93 in the discovery and 0.97, 0.96, and 0.93 in Validation 1. The 8-microRNA discovery panel distinguished HFpEF from HF with reduced ejection fraction with AUC 0.81, specificity 0.66, and accuracy 0.72. Corresponding metrics were 0.65, 0.41, and 0.56 in Validation 1 and 0.65, 0.41, and 0.62 in Validation 2. For phenotype categorization, combined markers achieved AUC 0.87, specificity 0.75, and accuracy 0.77 in the discovery with corresponding metrics of 0.74, 0.59, and 0.67 in Validation 1 and 0.72, 0.52, and 0.68 in Validation 2, as compared with NT-proBNP alone of AUC 0.71, specificity 0.46, and accuracy 0.62 in the discovery; with corresponding metrics of 0.72, 0.44, and 0.57 in Validation 1 and 0.69, 0.48, and 0.66 in Validation 2. Accordingly, false negative (FN) (81% Singapore and all NZ FN cases were HFpEF) as classified by a guideline-endorsed NT-proBNP ruleout threshold, were correctly reclassified by the 8-microRNA panel in the majority (72% and 88% of FN in Singapore and NZ, respectively) of cases. Conclusions Multi-microRNA panels in combination with NT-proBNP are highly discriminatory and improved specificity and accuracy in identifying nonacute HF. These findings suggest potential utility in the identification of nonacute HF, where clinical assessment, imaging, and NT-proBNP may not be definitive, especially in HFpEF.

INTRODUCTION Insertable cardiac monitors (ICMs) provide a minimally invasive method of continuous monitoring for abnormal heart rhythms. While the benefits of ICMs are clear, current algorithm performance can be improved. The objective of this study is to assess the performance of a novel adaptive atrial fibrillation (AF) detection algorithm and separately programmable atrial tachycardia (AT) algorithm. METHODS A dual-stage detect-and-verify AF algorithm and separately programmable AT algorithm were developed. Sensitivity and PPV across a range of settings were determined in silico by comparison with an adjudicated Holter data set (n = 1966 with 229 patient days). Finally, the ability to improve performance through simulated remote programming was assessed. RESULTS The dual-stage algorithm detected AF in all true AF patients (76/76) resulting in a patient-level sensitivity of 100%. Episode-level sensitivity and PPV ranged from 97.6% to 100% and 79.1% to 98.5%, respectively. Thirty-six false-positive episodes were observed and 32 (88.9%) of these were corrected with programming changes. Decoupling of AF and AT durations improved PPV from a range of 10%-22% to a range of 95%-100%. CONCLUSIONS AF and AT algorithms were designed with novel features including an adaptive morphology assessment for AF detection and separately programmable durations for AT detection. In silico performance yielded improved PPVs while maintaining high sensitivity across a range of settings. Importantly, programming changes that may be made remotely with this system reduced false positives. These algorithms allow clinicians to individualize arrhythmia detection settings thereby improving data management and reducing clinic burden.

No real-world large database associates lower rate limit (LRL) programming and survival of subjects with cardiac resynchronization therapy-defibrillators (CRT-Ds).The purpose of this study was to test the hypothesis that lower LRL programming is independently associated with survival, and that LRL and heart rate score (HrSc) are associated.All dual-chamber CRT-D devices in the Remote Patient Monitoring (RPM) ALTITUDE database (2006-2011) were queried. Baseline HrSc was defined as the percentage of all atrial sensed and paced beats in the tallest 10-beat histogram bin postimplant. LRL was assessed during repeated RPM uploads. Using a Cox model multivariable analysis, relationships between LRL, survival, HrSc, and other variables were evaluated. Survival was determined by query of death indices.Data analyzed included 61,881 subjects (mean follow-up 2.9 years). LRL ranged from 40 to 85 bpm. Baseline lower LRL was associated with younger age, less atrial fibrillation, female sex, and lower HrSc (P.001 for all covariates). Lower LRL was associated with improved survival, with LRL 40 associated with the largest survival benefit. This was significant for all 3 HrSc subgroups (P .001). An interaction between HrSc and LRL was observed, with the largest survival difference between HrSc groups observed at LRL-40 (P.001).LRL programming and HrSc were associated, and lower values of both were associated with improved survival in a large database of CRT-D subjects. Relationships between survival, LRL programming, and HrSc merit further study.

Background and Purpose: Cardiac biomarkers, NT-proBNP (N-terminal probrain natriuretic peptide), hs-cTnT (high-sensitivity-cardiac troponin T), and GDF-15 (growth differentiation factor-15) have been proposed as important biomarkers of early vascular pathology. However, little is known of the longitudinal associations of these cardiac biomarkers with cerebrovascular disease and clinical events. We examine the association of blood-based cardiac biomarkers (NT-proBNP, hs-cTnT, and GDF-15) with cognitive decline, incident cerebrovascular disease, vascular events, and mortality. Methods: Four hundred thirty-four memory-clinic patients provided blood samples at baseline, underwent 3 annual neuropsychological assessments and brain magnetic resonance imaging scans at baseline and follow-up. NT-proBNP and hs-cTnT concentrations were measured by electrochemiluminescence immunoassay and GDF-15 by quantitative sandwich immunoassay. Baseline and follow-up magnetic resonance imagings were graded for white matter hyperintensities, lacunes, cerebral microbleeds, cortical infarcts, and intracranial stenosis. Data on incident vascular events and mortality were obtained. Results: Patients with higher levels of NT-proBNP, hs-cTnT, and GDF-15 showed greater decline in memory domain. Additionally, hs-cTnT was associated with decline in global cognition, executive function, and visuomotor speed. Higher levels of NT-proBNP were associated with incident cerebral microbleeds and hs-cTnT with incident cortical infarcts. During a mean follow-up of 3 years, 26 (5.9%) patients died and 35 (8.1%) developed vascular events. Patients with higher levels of NTpro-BNP and hs-cTnT were at increased risk of vascular events whereas those with higher levels of NT-proBNP and GDF-15 were at risk of mortality. Conclusions: Higher levels of blood-based cardiac biomarkers were associated with decline in memory and risk of vascular events and mortality. Moreover, NT-proBNP and hs-cTnT were associated with incident cerebral microbleeds and cortical infarcts. Thus, these biomarkers are potentially useful in identifying patients at risk of adverse vascular events and death.

Aims Inflammation plays an important role in cardiovascular disease (CVD) development. The NOD-like receptor protein-3 (NLRP3) inflammasome contributes to the development of atherosclerosis in animal models. Components of the NLRP3 inflammasome pathway such as interleukin-1β can therapeutically be targeted. Associations of genetically determined inflammasome-mediated systemic inflammation with CVD and mortality in humans are unknown. Methods and results We explored the association of genetic NLRP3 variants with prevalent CVD and cardiovascular mortality in 538 167 subjects on the individual participant level in an explorative gene-centric approach without performing multiple testing. Functional relevance of single-nucleotide polymorphisms on NLRP3 inflammasome activation has been evaluated in monocyte-enriched peripheral blood mononuclear cells (PBMCs). Genetic analyses identified the highly prevalent (minor allele frequency 39.9%) intronic NLRP3 variant rs10754555 to affect NLRP3 gene expression. rs10754555 carriers showed significantly higher C-reactive protein and serum amyloid A plasma levels. Carriers of the G allele showed higher NLRP3 inflammasome activation in isolated human PBMCs. In carriers of the rs10754555 variant, the prevalence of coronary artery disease was significantly higher as compared to non-carriers with a significant interaction between rs10754555 and age. Importantly, rs10754555 carriers had significantly higher risk for cardiovascular mortality during follow-up. Inflammasome inducers (e.g. urate, triglycerides, apolipoprotein C3) modulated the association between rs10754555 and mortality. Conclusion The NLRP3 intronic variant rs10754555 is associated with increased systemic inflammation, inflammasome activation, prevalent coronary artery disease, and mortality. This study provides evidence for a substantial role of genetically driven systemic inflammation in CVD and highlights the NLRP3 inflammasome as a therapeutic target.

High quality, well-validated antibodies are needed to mitigate irreproducibility and clarify conflicting data in science. We describe an epitope-directed monoclonal antibody (mAb) production method that addresses issues of antibody quality, validation and utility. The workflow is illustrated by generating mAbs against multiple in silico-predicted epitopes on human ankyrin repeat domain 1 (hANKRD1) in a single hybridoma production cycle. Antigenic peptides (13-24 residues long) presented as three-copy inserts on the surface exposed loop of a thioredoxin carrier produced high affinity mAbs that are reactive to native and denatured hANKRD1. ELISA assay miniaturization afforded by novel DEXT microplates allowed rapid hybridoma screening with concomitant epitope identification. Antibodies against spatially distant sites on hANKRD1 facilitated validation schemes applicable to two-site ELISA, western blotting and immunocytochemistry. The use of short antigenic peptides of known sequence facilitated direct epitope mapping crucial for antibody characterization. This robust method motivates its ready adoption for other protein targets.

Omeprazole is commonly co-prescribed with clopidogrel. Clopidogrel requires bio-activation by cytochrome P450 CYP2C19. Omeprazole may reduce clopidogrel's antithrombotic efficacy by inhibiting CYP2C19. Studies in Caucasians receiving omeprazole with clopidogrel showed no significant increase in death and myocardial infarction with this drug-drug interaction. There are limited large-scale studies in Asians, who may have a greater prevalence of CYP2C19 loss-of-function polymorphisms. A single centre retrospective cohort study was undertaken based on a review of medication records and prescription data. Patients prescribed clopidogrel from 2009 to 2012 were followed-up with until December 2012 (median:29 months). The primary outcome was all-cause mortality and secondary outcomes were myocardial infarction (MI), cerebrovascular accidents, and subsequent coronary interventions. Of 12,440 patients prescribed clopidogrel, 62%(n = 7714) were on omeprazole (63.8% Chinese, 13.9% Malay, 12.4% Indian, 10.0% others), and 38%(n = 4726) were not on omeprazole or other proton pump inhibitors (62.6% Chinese, 13.5% Malay, 10.7% Indian, 13.2% others). Mortality after co-prescription occurred in 14.3%(n = 1101) of patients, compared to 6.3%(n = 300) of patients prescribed clopidogrel only. Multivariate analysis using propensity score adjusted analysis showed no significant increase in all-cause mortality with co-prescription (adjusted hazards ratio [AHR] 1.13, [95%CI 0.95-1.35]). Patients on co-prescription had a higher risk of subsequent MI (16% vs 3.8%; AHR 2.03 [95%CI 1.70-2.44]), but not of cerebrovascular accidents (5.0% vs 2.0%; AHR 0.98 [95%CI 0.76-1.27]) or coronary interventions (1.7% vs 0.7%; AHR 1.28 [95%CI 0.83-1.96]). The risk of a subsequent MI was higher in the Malay (AHR 2.43 [95%CI 1.68-3.52]) and Chinese (AHR 2.06 [95%CI 1.63-2.60]) population as compared to the Indian (AHR 1.56 [95%CI 1.06-2.31]) population. In conclusion, the use of clopidogrel with omeprazole is associated with an increased risk of MI, but not mortality or stroke, in this multi-ethnic Asian population. These risks appear to vary among different ethnic groups.