PROJECT CODE PN-III-P1-1.1-TE-2016-0669

Grant number 49/02/05/2018

Title: MULTIMODALITY APPROACH OF HEART FAILURE WITH PRESERVED EJECTION FRACTION BY BIOMARKERS AND IMAGING ANALYSIS

ACRONIM: HEART-PRESERVED

Project Leader: RIMBAS ROXANA CRISTINA

FUNDING AUTHORITY - THE NATIONAL AUTHORITY FOR SCIENTIFIC RESEARCH OF ROMANIA – UEFISCDI

Budget: 449.385 lei

PROJECT SUMMARY

ISSUES. Heart failure with preserved ejection fraction (HFpEF) is now recognized as a major and growing public health problem worldwide. From 23 million people worldwide with HF1, more than half of them have HFpEF. Hospitalization and mortality risks in HFpEF are similar with HF with reduced ejection fraction (HFrEF). Moreover, hospitalizations for HFpEF have increased over time, whereas those for HFrEF have declined2. Despite the high prevalence, mortality, and costs of HFpEF, its clinical phenotype and natural history remains poorly defined3. Furthermore, clinical trials investigating different treatment strategies have had disappointing results. Potential contributors for these negative results include a pathophysiology incompletely understood, heterogeneity of aetiologies of HFpEF (obesity, diabetes, hypertension, coronary artery disease, renal disease, etc.), and poor matching of therapeutic mechanisms to primary pathophysiological processes4-6.

A new mechanism involved in the pathophysiology of HFpEF has been proposed recently. It is represented by a sequence of events, leading to myocardial stiffness, one of the key mechanisms of HFpEF. In summary, common comorbidities induce an inflammatory state. This systemic inflammatory state causes the coronary microvascular endothelium to increase production of reactive oxygen species, which reduces NO bioavailability, generating reduction in cGMP and causing remodelling, impaired relaxation, and myocardial stiffness8, 9. Several biomarkers from this chain, including biomarkers of myocyte stress, inflammation, endothelial dysfunction, extracellular matrix remodelling, appeared to be promising diagnostic and prognostic tools in patients with HFpEF (Figure 1) 10-16. Specific MicroARNs reflecting inflammation, endothelial dysfunction, and myocardial fibrosis, such as MiRNA-126, MiRNA-21; 29a, may also be involved (17, 18)

New imaging modalities have emerged recently for the diagnosis of HFpEF. 2D echocardiography (2DE) is still the most used technique for the assessment of heart function. However, it has poor agreement with cardiac magnetic resonance (CMR)19, considered the “gold standard” for the quantification of systolic function. CMR is also the preferred imaging method to assess myocardial fibrosis, using late gadolinium enhancement (LGE), which allows differentiation between ischaemic and non-ischaemic origins of HFpEF. 3D echocardiography (3DE) has better agreement and reproducibility with CMR for the measurement of EF than 2DE. However, its diagnostic and prognostic performance in HFpEF is not well established. Integrated backscatter (IBS) has been used also in order to assess myocardial fibrosis by 2DE, but its role in HFpEF is not clearly clarified. A more detailed assessment of LV performance can now be made using deformation analysis by 2D/3D speckle tracking echocardiography (STE). Significant correlations between regional deformation and myocardial fibrosis were described in animal studies20. Meanwhile, parameters of STE were proved recently to have good correlations with plasma biomarkers, Doppler 2DE measurements, and severity of HFpEF21-23. A new STE software, which allows myocardial layer by layer analysis, is now available, but its potential utility in diagnosis of myocardial fibrosis has not been established yet.

Our project (HEART-PRESERVED) will assess the incremental diagnostic and prognostic value of specific biomarkers and new imaging measurements, derived from 3DE, IBS, and STE, over established clinical and imaging parameters, in order to define a new protocol for the management of HFpEF. CMR will serve as a gold standard for the evaluation of the cardiac function.

OBJECTIVES

HEART-PRESERVED will assess specific biomarkers (systemic inflamation, endotelial dysfunction, oxidative stress, and myocardial fibrosis) and new imaging parameters, by 3DE, IBS, and STE (2D and 3D). Vascular ultrasound will be used to assess endothelial dysfunction. CMR will evaluate cardiac function and myocardial fibrosis. All these biological, echocardiographic, vascular, and CMR parameters will be used in order to create a multimodality algorhythm for diagnosis and prognosis of HFpEF. This new approach might support a stratified therapeutic management of different stages of HFpEF.

Principal objective is to define a new algorhythm for staging patients with HFpEF, by integrating biomarkers and new echo parameters, validated by CMR.

Secondary objectives are: (1) to analyse different pathophysiological mechanisms involved in cardiac dysfunction (inflammation, cardiac fibrosis, oxidative stress); (2) to identify high-risk patients, for developing a rapid progression to HF with mid-range/reduced EF or reduction of LVEF with more than 10%, assessed by 3DE; (3) to define the best predictors for mid- and long-term survival; (4) to describe sex-specific changes in biomarkers and cardiovascular function in HFpEF; (5) to validate against CMR the new echo parameters, derived from 3DE, IBS, and STE, potentially useful in diagnosis and prognosis of HFpEF. Our long-term objective is to initiate the first longitudinal Romanian registry, focused on collecting biological, imaging, and treatment characteristics of patients with HFpEF, and to correlate them with long-term outcomes.

METHODOLOGY

Study population. HEART-PRESERVED will include prospectively 100 patients with HFpEF based on the criteria described by the 2016 HF guidelines24, after excluding other non-cardiac causes of symptoms of HF. The protocol will be sent for approval to the Local Ethic Committee. It will include clear specifications about the blood sample prelevation and storage, ecocardiographic and vascular assessment, and CMR evaluation.

Inclusion criteria: (1) Patients with certified diagnosis of stable HFpEF, based on the current guidelines24; (2) sinus rhythm; (3) age over 18 years; and (4) informed consent signed.

Exclusion criteria: recent hospitalization for acute HF (<4weeks), hypertrophic cardiomyopathy, severe valvular heart disease, pericardial disease, previous history of myocarditis, permanent atrial fibrillation, any systemic inflamatory disease or vasculitis, active cancer in the last year, renal failure with haemodialysis, pulmonary causes of dyspnoea, moderate to severe anaemia, inappropriate quality of echocardiographic images for 3DE and STE, and any contraindication for CMR evaluation.

Anticipated duration of recruitment: 12 months (8-9 patients/month);

Duration of participation of each patient: minumum 1 year, optimum of 5 years. Recruiment will be performed by screening potential patients referred to our Cardiology Department

Methods. At baseline, all patients will be assessed by:

1. Clinical characteristics
2. Electrocardiogram (12 leads):
3. Routine blood tests: HLG, lipid profile, hepatic and renal function, uric acid, Na+, K+, glycaemia, HbA1c, NT-proBNP;
4. 6 min walk test;
5. Biomarkers: A comprehensive biomarkers approach will be used. They will be determined in serum/plasma of all patients. Figure 1 display most relevant proteins for detection of systemic inflammation, endothelial dysfunction, NO availability, and fibrosis.
6. Specific microRNAs (miRNAs) reflecting systemic inflammation, endothelial dysfunction, and myocardial fibrosis. Total RNA (including mature miRNA) will be revers-transcribed, then miRNA 126, 21 and 29a will be quantified using specific primers in a qPCR assay.
7. Echocardiography (VIVID 9 GE with dedicated software for post-processing):

• Conventional 2DE
• Tissue Doppler
• 3DE for cardiac chamber anatomy and volume, and LV mass30;
• STE (2D and 3D) for myocardial deformation (strain and strain rate) in radial, longitudinal, and circumferential directions, in order to assess LV/RV systolic and diastolic function, LV torsion, and left and right atrial function
• IBS with evaluation of myocardial fibrosis.

8. Measurement of endothelial function, arterial remodelling, and arterial stiffness
9. Cardiac magnetic resonance

Follow-up will be performed at 1, 2, and 5 years in order to assess:

• Reduction of LVEF with at least 10% by 3DE or progression to HF with mid-range or reduced EF;
• Clinical outcomes: all-cause, sudden, and cardiovascular death; worsening of HF; all-cause and HF hospitalization; acute coronary syndromes; stroke; development of atrial fibrillation.

Patients will be followed after the grant finishes, in order to design long-term prognosis models. All biological data suggesting pro-inflammatory status, microvascular endothelial dysfunction, reduced NO and cGMP bioavailability, and fibrosis will be correlated with new echocardiographic parameters, vascular changes, parameters from CMR evaluation, in order to create a stage related multimodality protocol, for a better assessment of HFpEF. In the follow-up stage, all biological and imaging markers will be used for new prognostic models.

I. Accepted paper for presentation at European Echocardiography Congress

1. Multilayer analysis of ventricular myocardial deformation by speckle tracking: a potential new tool for a better characterization of heart failure continuum. Rimbas, S. Mihaila-Baldea, AA. Andronic, ML. Luchian, AM. Chitroceanu, H. Memis, A. Velcea, SI. Visoiu, D. Vinereanu. Euroecho 2018 Rapid Fire Abstract oral presentation
2. An atypical case of Fabry disease with obstructive hypertrophic cardiomyopathy: a multimodality imaging based diagnosis. S. Visoiu, Rimbas, AO. Ciobanu, AI. Nicula, M. Iascone, R. Jurcut, M. Cinteza, D. Vinereanu. Euroecho 2018 Poster Presentation.
3. Two year echocardiographic follow-up in systemic sclerosis patients on standard therapy. Magda, AM. Gheorghiu, T. Constantinescu, C. Mihai, M. Cinteza, D. Vinereanu. Euroecho 2018 Poster Presentation.
4. Diagnosis and prediction of late cardiovascular toxicity induced by RCHOP chemotherapy in non-Hodgkin lymphoma through 3D myocardial deformation and arterial stiffness. D Mihalcea, R Bruja, AE Balinisteanu, AM Vladareanu, D Vinereanu. Euroecho 2018 Poster Presentation.

II. Oral presentation at the National Cardiology Congress 2018 Sinaia

1. Modele noi de prognostic pentru mortalitatea în spital şi pe termen lung la pacienţii cu insuficienţă cardiacă acută şi fracţie de ejecţie conservată. R.C. Rimbaș, M. Ștefan, L.F. Trasca, I.S. Visoiu, A.A. Andronic, A. Velcea, D. Vinereanu.- first prize for the best heart failure study
2. Analiza de deformare miocardică ventriculară prin ecografie multilayer speckle tracking – un nou instrument potențial pentru o caracterizare mai bună a continuumului insuficienței cardiace. R.C. Rimbaș, S. Mihăilă-Baldea, A.A. Andronic, L.M. Luchian, A.M. Chitroceanu, H. Memis, S.I. Vișoiu, A. Velcea, D. Vinereanu - first prize for the best rapid fire abstract

III.Submited paper under review

1. ECOCARDIOGRAPHIC PREDICTORS OF A WORSE OUTCOME IN PATIENTS WITH LIVER CIRROSIS: WHAT SHOULD WE ASSESS?- HEPATOLOGY - HEP-18-2149 (ISI IF=079);
2. LEFT VENTRICULAR MYOCARDIAL CLEFT IN A COMPLICATED ACUTE MYOCARDIAL INFARCTION: A CHALLENGING DIFFERENTIAL DIAGNOSIS" Echocardiography: A Journal of Cardiovascular Ultrasound and Allied Techniques- ECHO-2018-0790 ISI IF=1.197;

Scientific results 2019 HEART-PRESERVED

I. Presented papers at the European Society of Cardiology Congress 2019 Paris

1. Analysis of myocardial work: a potential new tool for a better assessment of left ventricular function. Rimbas, AM. Chitroceanu, ML. Luchian, SI. Visoiu, S. Mihaila-Baldea, LS. Magda, H. Memis, L. Lungeanu-Juravle, A. Velcea, A. Balinisteanu, AA. Andronic, D. Vinereanu. Abstract 86239. poster presentation

II. Presented papers at the National Cardiology Congress 2019 Sinaia

1. Non-invasive myocardial work analysis – a potential novel echocardiographic tool for a better characterization of heart failure with preserved ejection fraction. C. Rimbaș, A. Chitroceanu, M.L. Luchian, L.Ș. Magda, A. Velcea, S.I. Vișoiu, A. Balinisteanu, H. Memis, D. Vinereanu,- - oral presentation - third prize for the best heart failure study
2. Analysis of myocardial work by Speckle Tracking echocardiography in cirrhotic cardiomyopathy – a potential novel method for a better assessment of left ventricular function. M. Chitroceanu, R.C. Rimbaș, I.S. Vișoiu, A.E. Balinișteanu, M.L. Luchian, M. Rimbaș, C.S. Pop, D. Vinereanu – oral presentation - first prize for the best rapid fire abstract
3. Late onset of arrhytmogenic cardiomyopathy, unmasked by a myocarditis episode: when multimodality imaging solves the puzzle. L. Luchian, C.R. Rimbaș, C.I. Stoicescu, A.V. Marinescu, A.I. Nicula, D. Vinereanu – oral presentation - second prize rapid fire abstract
4. Left atrial volumes by 3-dimensional but not 2-dimensional echocardiography predict cardiac death and events in patients with heart failure with reduced ejection fraction. A.E. Velcea, A.A. Andronic, R.C. Rimbaș, L.M. Luchian, A. Chitroceanu, E. Șerban, S. Stoica, Mihăilă-Baldea, D. Vinereanu

III. Accepted for presentation at European Congress of Echocardiography EuroECHO Viena 4-7 dec. 2019

1. Myocardial work in a cohort of systemic sclerosis patients. Magda, EC. Popa, R. Rimbas, AM. Gheorghiu, AC. Ciobanu, D. Vinereanu – poster presentation 91199
2. Left atrial pump function assessed by speckle tracking echocardiography adds important value for the diagnosis of heart failure with preserved ejection fraction. Rimbas, DJ. Mihalcea, LM. Luchian, S. Mihaila Baldea, LS. Magda, SI. Visoiu, AA. Andronic, A. Velcea, L. Lungeanu Juravle, A. Balinisteanu, A. Nicula, D. Vinereanu^. Abstract 90832 rapid fire abstract – oral presentation
3. Left atrial deformation analysis by 2D speckle tracking echocardiography in liver cirrhosis is a potential new tool for a better characterization of cirrhotic cardiomyopathy. Rimbas, LM. Luchian, AM. Chitroceanu, M. Rimbas, SI. Visoiu, C. Pop, D. Vinereanu ^- Abstract 90839. poster presentation
4. Myocardial work analysis is a potential novel tool to diagnose subclinical cardiac dysfunction in cirrhotic cardiomyopathy. AM. Chitroceanu, Rimbas, SI. Visoiu, AE. Balinisteanu, ML. Luchian, M. Rimbas, C. Pop, D. Vinereanu^. Abstract 91021. poster presentation
5. Diagnosis and prediction of late cardiotoxicity in non Hodgkin's lymphoma by 3D echocardiography, vascular ultrasound, and cardiac biomarkers. Mihalcea, A. Balinisteanu, G. Cosmulescu, AM. Vladareanu, D. Vinereanu^. Abstract 91170 poster presentation

IV. Accepted and published papers derived from TE grant:

1. Echocardiographic Predictors of a Worse Outcome in Patients With Liver Cirrhosis: What Should We Assess? Rimbas RC, Rimbas M, Vinereanu D. Hepatology 2019 69(6):2714-2715. https://doi.org/10.1002/hep.30584 (ISI IF=079);
2. Severe Late-Onset Fabry Cardiomyopathy Unmasked by a Multimodality Imaging Approach. Ionela-Simona Visoiu, Andrea Olivia Ciobanu, Alina Ioana Nicula, Maria Iascone, Ruxandra Jurcut, Dragos Vinereanu, Roxana Cristina Rimbas. Circ Cardiovasc Imaging. 2019;12:e009709. DOI: 10.1161/CIRCIMAGING.119.009709 (ISI IF=6.803)
3. Extensive cardiac involvement in a young woman with polymyositis - the devil behind the curtain unmasked by a multimodality imaging approach. Maria Luiza Luchian, Claudiu Ionut Stoicescu, Alina Ioana Nicula, Dragos Vinereanu, Roxana Cristina Rimbas – in press - Circ Cardiovasc Imaging CIRCCVIM/2019/009758R2 ((ISI IF=6.803)
4. New myocardial deformation by 2D multi-layer speckle-tracking analysis in healthy subjects - normal reference values and their physiological determinants – conditionally accepted under review Ultrasound Biology and Medicine- Ms. Ref. No.:  UMB-D-19-00413R1 (ISI IF = 2.205)

Scientific results 2018-2020 HEART-PRESERVED

I. Presented at European Echocardiography Congress 2018

1. Multilayer analysis of ventricular myocardial deformation by speckle tracking: a potential new tool for a better characterization of heart failure continuum. RC. Rimbas, S. Mihaila-Baldea, AA. Andronic, ML. Luchian, AM. Chitroceanu, H. Memis, A. Velcea, SI. Visoiu, D. Vinereanu. – oral presentation – rapid fire abstract
2. An atypical case of Fabry disease with obstructive hypertrophic cardiomyopathy: a multimodality imaging based diagnosis. S. Visoiu, RC. Rimbas, AO. Ciobanu, AI. Nicula, M. Iascone, R. Jurcut, M. Cinteza, D. Vinereanu - Poster Presentation.
3. Two-year echocardiographic follow-up in systemic sclerosis patients on standard therapy. SL. Magda, AM. Gheorghiu, T. Constantinescu, C. Mihai, M. Cinteza, D. Vinereanu - Poster Presentation.
4. Diagnosis and prediction of late cardiovascular toxicity induced by RCHOP chemotherapy in non-Hodgkin lymphoma through 3D myocardial deformation and arterial stiffness. D Mihalcea, R Bruja, AE Balinisteanu, AM Vladareanu, D Vinereanu - Poster Presentation.

II. Presented at National Congress of Cardiology 2018

1. Modele noi de prognostic pentru mortalitatea în spital şi pe termen lung la pacienţii cu insuficienţă cardiacă acută şi fracţie de ejecţie conservată. R.C. Rimbaș, Ștefan, L.F. Trasca, I.S. Visoiu, A.A. Andronic, A. Velcea, D. Vinereanu – First prize at SRC Congress 2018 for the best heart failure study
2. Analiza de deformare miocardică ventriculară prin ecografie multilayer speckle tracking – un nou instrument potențial pentru o caracterizare mai bună a continuumului insuficienței cardiace. R.C. Rimbaș, S. Mihăilă-Baldea, A.A. Andronic, L.M. Luchian, A.M. Chitroceanu, H. Memis, S.I. Vișoiu, A. Velcea, D. Vinereanu – First prize at SRC Congress 2018 for the best oral rapid-fire abstract

III. Presented papers at the European Society of Cardiology Congress 2019 Paris

1. Analysis of myocardial work: a potential new tool for a better assessment of left ventricular function. RC Rimbas, AM. Chitroceanu, ML. Luchian, SI. Visoiu, Mihaila-Baldea, LS Magda, H. Memis, L. Lungeanu-Juravle, A Velcea, A. Balinisteanu, AA. Andronic, D. Vinereanu - poster presentation

IV. Presented papers at the National Cardiology Congress 2019 Sinaia

1. Non-invasive myocardial work analysis – a potential novel echocardiographic tool for a better characterization of heart failure with preserved ejection fraction. RC Rimbaș, A Chitroceanu, ML Luchian, Ș. Magda, A. Velcea, S.I. Vișoiu, A. Balinisteanu, H. Memis, D. Vinereanu - oral presentation - third prize for the best heart failure study
2. Analysis of myocardial work by Speckle Tracking echocardiography in cirrhotic cardiomyopathy – a potential novel method for a better assessment of left ventricular function. AM Chitroceanu, RC Rimbaș, IS Vișoiu, AE Balinișteanu, ML Luchian, M Rimbaș, CS Pop, D. Vinereanu – oral presentation - first prize for the best rapid fire abstract
3. Late onset of arrhytmogenic cardiomyopathy, unmasked by a myocarditis episode: when multimodality imaging solves the puzzle. ML Luchian, RC Rimbaș, CI Stoicescu, A.V. Marinescu, AI Nicula, D. Vinereanu – oral presentation - second prize rapid fire abstract
4. Left atrial volumes by 3-dimensional but not 2-dimensional echocardiography predict cardiac death and events in patients with heart failure with reduced ejection fraction. AE Velcea, AA Andronic, RC Rimbaș, L.M. Luchian, A. Chitroceanu, E. Șerban, S. Stoica, Mihăilă-Baldea, D. Vinereanu

V. Presented at European Congress of Cardiovascular Imaging EACVI Viena 2019

1. Myocardial work in a cohort of systemic sclerosis patients. Magda, EC. Popa, R. Rimbas, AM. Gheorghiu, AC. Ciobanu, D. Vinereanu – poster presentation
2. Left atrial pump function assessed by speckle tracking echocardiography adds important value for the diagnosis of heart failure with preserved ejection fraction. Rimbas, DJ. Mihalcea, LM. Luchian, S. Mihaila Baldea, LS. Magda, SI. Visoiu, AA. Andronic, A. Velcea, L. Lungeanu Juravle, A. Balinisteanu, A. Nicula, D. Vinereanu^. rapid fire abstract – oral presentation
3. Left atrial deformation analysis by 2D speckle tracking echocardiography in liver cirrhosis is a potential new tool for a better characterization of cirrhotic cardiomyopathy. RC Rimbas, LM Luchian, AM Chitroceanu, M Rimbas, SI Visoiu, C Pop, D Vinereanu - poster presentation
4. Myocardial work analysis is a potential novel tool to diagnose subclinical cardiac dysfunction in cirrhotic cardiomyopathy. Chitroceanu, RC Rimbas, SI Visoiu, AE Balinisteanu, ML Luchian, M Rimbas, C. Pop, D Vinereanu - poster presentation
5. Diagnosis and prediction of late cardiotoxicity in non Hodgkin's lymphoma by 3D echocardiography, vascular ultrasound, and cardiac biomarkers. D Mihalcea, A. Balinisteanu, G. Cosmulescu, AM. Vladareanu, D. Vinereanu - poster presentation

VI. Submitted under evaluation

1. MYOCARDIAL CLEFT IN A PATIENT WITH DILATED CARDIOMYOPATHY AND ACUTE MYOCARDIAL INFARCTION: A CHALLENGING DIFFERENTIAL DIAGNOSIS ASSESSED MY MULTIMODALITY IMAGING – AM Chitroceanu, RC Rimbas, AI Nicula, D Vinereanu - Kardiologia Polska (Polish Heart Journal)- ISI IF 1.674
2. 3D is a feasible and more reproducible method than 2D echocardiography for in-training echocardiographers to follow-up patients with heart failure with reduced ejection fraction. S Mihaila Baldea, AE. Velcea, RC. Rimbas, A. Andronic, L. Matei, SI. Calin, D. Muraru, LP. Badano, D. Vinereanu^.  - CARDIOVASCULAR ULTRASOUND – ISI IF 2.043

VII. Published papers

1. Echocardiographic Predictors of a Worse Outcome in Patients With Liver Cirrhosis: What Should We Assess? Rimbas RC, Rimbas M, Vinereanu D. Hepatology 2019 69(6):2714-2715. https://doi.org/10.1002/hep.30584 (ISI IF=14.079);
2. Severe Late-Onset Fabry Cardiomyopathy Unmasked by a Multimodality Imaging Approach. Ionela-Simona Visoiu, Andrea Olivia Ciobanu, Alina Ioana Nicula, Maria Iascone, Ruxandra Jurcut, Dragos Vinereanu, Roxana Cristina Rimbas. Circ Cardiovasc Imaging. 2019;12:e009709. DOI: 10.1161/CIRCIMAGING.119.009709 (ISI IF=6.803);
3. Extensive cardiac involvement in a young woman with polymyositis - the devil behind the curtain unmasked by a multimodality imaging approach. Maria Luiza Luchian, Claudiu Ionut Stoicescu, Alina Ioana Nicula, Dragos Vinereanu, Roxana Cristina Rimbas. Circ Cardiovasc Imaging. 2019;12:e009758. DOI: 10.1161/CIRCIMAGING.119.009758 (ISI IF=6.803);
4. The added value of three-dimensional echocardiography in the late diagnosis of a pacemaker complication in a patient with severe congestive heart failure: a case report S Mihaila Baldea, AE Velcea, C Siliste, D Vinereanu. European Heart Journal - Case Reports 2019; 3:1–6. doi:10.1093/ehjcr/ytz004; Online ISSN 2514-2119
5. New myocardial deformation by 2D multi-layer speckle-tracking analysis in healthy subjects - normal reference values and their physiological determinants. Ultrasound Biology and Medicine 2020; 46(3):818-827 (ISI IF = 2.205)