Cerebral Hypoperfusion Is Exaggerated With an Upright Posture in Heart Failure

Fraser, Katelyn S.; Heckman, George A.; McKelvie, Robert S.; Harkness, Karen; Middleton, Laura; Hughson, Richard L.

doi:10.1016/j.jchf.2014.07.017

Cited by 43 publications

(56 citation statements)

References 36 publications

(23 reference statements)

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“…In addition, gait speed was lower in the HFrEF subjects than in the healthy control subjects in the study of Frazer et al (11). However, it is difficult to attribute this finding solely to a lower supine CI, because it has been shown that flow to the cerebellar vermis increases from supine to standing (23) and, as previously noted, posterior flow was not assessed in the present study.…”

contrasting

confidence: 46%

“…Thus, cerebral inflow pressure in the upright position is less than the inflow pressure in the supine position. Because height and MAP between control subjects and HFrEF patients were similar, this effect is likely to be modest in the present experiment (11). However, HFrEF patients had a greater reduction in CI from supine to upright than control subjects (-12% vs. -0.44%; p ¼ 0.065), which would promote sympathoexcitation through a baroreceptormediated pathway with an increase in cerebrovascular resistance.…”

mentioning

confidence: 70%

“…In this issue of JACC: Heart Failure, Fraser et al (11) hypothesized that patients with HFrEF would be more susceptible than healthy control subjects to cerebral hypoperfusion during postural change from supine to upright due to a lower resting Qc. To test this hypothesis, 22 HFrEF patients (mean left ventricular ejection fraction, 33 AE 11%) and 22 age-and sexmatched healthy control subjects underwent hemodynamic assessment during a transition from supine to an upright, seated position.…”

mentioning

confidence: 99%

“…Among the overall cohort (HFrEF patients plus control subjects), there was a nonlinear relationship between supine CI and the change in CBF from the supine to upright position, such that subjects with the lowest resting CI had the greatest decrement in CBF. Fraser et al interpret their data to suggest a "threshold effect" of CI on CBF, such that subjects with a resting CI of <3 l/min/m 2 had greater reductions in CBF than subjects whose resting CI was >3 l/min/m 2 (Figure 3 in their article [11]). However, it should be noted that this relationship was driven almost entirely by 2 subjects with extremely low Qc, both of whom had large decreases in CBF.…”

mentioning

confidence: 99%

“…Fraser et al (11) hypothesized that exaggerated reductions in CBF may contribute to the CD observed in patients with HFrEF, an argument that has been previously advanced. For example, Zuccala et al (20) reported that cognitive performance declines sharply among HFrEF patients at a left ventricular ejection fraction cutoff of 30%, and CD is related to stroke volume and CI in these patients (21).…”

mentioning

confidence: 99%

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Patients With Heart Failure With Reduced Ejection Fraction Have Exaggerated Reductions in Cerebral Blood Flow During Upright Posture ∗

Cornwell

Levine

2015

JACC: Heart Failure

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C ognitive dysfunction (CD) is a major and often underappreciated complication among patients with heart failure (HF). Memory and attention deficits are the most common manifestations, with a prevalence of 30% to 80% depending on patient age (1). However, up to 25% of patients with HF may have moderate to severe impairments in cognition, which increase the risk of medication nonadherence and HF hospitalizations, physical disability, and mortality (2). Although the association between HF and CD is based on multiple shared risk factors such as hypertension (3), atherosclerosis (4), and diabetes mellitus (5), cerebral hypoperfusion in its own right has been advanced as a primary contributor to CD (6). Indeed, hypoperfusive lesions have been observed in the form of white matter hyperintensities (7) and, in the Framingham Heart Study, cardiac index (CI) was positively related to total brain volume and information-processing speed (8).In this regard, patients with heart failure with a reduced ejection fraction (HFrEF) represent a substrate of subjects at particularly increased risk for CD due to the combination of a low output state and multiple comorbidities. Furthermore, the majority of activities of daily living occur in an upright posture, which might lead to further reductions in cerebral perfusion due to a gravitational displacement of blood below the brain on both the arterial and venous sides of the circulation. In healthy young adults, upright positioning (without muscle tensing) reduces cardiac output (Qc) by w 2 l/min, with concomitant reductions in mean arterial pressure (MAP) at the level of the middle cerebral artery by w10 mm Hg and cerebral oxygenation by w7% (9). In addition, reductions in cerebral blood flow (CBF) have previously been shown to impair attention tasks (10). In this issue of JACC: Heart Failure, Fraser et al. (11) hypothesized that patients with HFrEF would be more susceptible than healthy control subjects to cerebral hypoperfusion during postural change from supine to upright due to a lower resting Qc. To test this hypothesis, 22 HFrEF patients (mean left ventricular ejection fraction, 33 AE 11%) and 22 age-and sexmatched healthy control subjects underwent hemodynamic assessment during a transition from supine to an upright, seated position. Supine CI, estimated from pulse contour analysis (12), was lower among HFrEF patients compared with the healthy control subjects (3.2 AE 1.5 l/min/m 2 vs. 5.2 AE 1.3 l/min/m 2 ; p < 0.05).Supine CBF, estimated by using a Doppler ultrasound of the right and left internal carotid arteries (ICAs), was also lower in HFrEF patients than in the control subjects. Among HFrEF subjects, upright positioning led to a 12% and 15% reduction in CI and CBF, respectively.Among the control subjects, heart rate increased and, as a result, CI was minimally affected (although, as noted earlier, this finding is unusual in the literature using other techniques to assess CI);

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confidence: 46%

mentioning

confidence: 70%

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confidence: 99%

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confidence: 99%

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confidence: 99%

See 3 more Smart Citations

Patients With Heart Failure With Reduced Ejection Fraction Have Exaggerated Reductions in Cerebral Blood Flow During Upright Posture ∗

Cornwell

Levine

2015

JACC: Heart Failure

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Rationale and design of the FELICITAR registry (Frailty Evaluation After List Inclusion, Characteristics and Influence on Transplantation and Results)

Ayesta

Astiz

Masa

et al. 2018

Clinical Cardiology

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Frailty reflects a state of decreased physiological reserve and vulnerability to stressors. Its prevalence among patients with cardiovascular disease is as high as 60%. Frailty is associated with a poor prognosis for patients with heart failure, increasingly frequent hospitalization, and death. The recent published listing criteria for heart transplantation of the International Society for Heart and Lung Transplantation recommend assessing frailty (class IIb recommendation, level of evidence C). However, this recommendation is not based on prospective studies, and frailty scores have only been validated in patients age > 65 years. The aim of the FELICITAR registry (Frailty Evaluation After List Inclusion, Characteristics and Influence on Transplantation and Results) is to assess the impact of frailty on prognosis before and after heart transplantation. A series of 100 patients from 3 Spanish centers will be included as soon as they are added to the national heart transplantation waiting list. Frailty will be evaluated again every 3 months until heart transplantation and at 3, 6, and 12 months thereafter. Depression, cognitive assessment, and quality of life also will be analyzed. The 2 primary endpoints are all-cause mortality and prevalence of frailty assessed using the Fried frailty index. Results from this study may show that frailty is frequent in patients with advanced heart failure listed for heart transplantation and is associated with a poor prognosis both before and after surgery. The findings may contribute to a better understanding of the characteristics of the optimal candidate for heart transplantation.

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Impaired cerebral oxygenation in heart failure patients at rest and during head‐up tilt testing

et al. 2020

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Aims Heart failure (HF) confers potentially negative effects on the brain and autonomic nervous system. The measurement cerebral tissue oxygen saturation (SctO 2) may aid in understanding such effects. We aimed to investigate if compensated HF affects SctO 2 at rest and during orthostatic challenge. Methods and results Non-invasive haemodynamic monitoring and near-infrared spectroscopy were applied during head-up tilt (HUT) in 61 HF patients [mean (SD) 71 (11) years, 82% male, New York Heart Association (NYHA) class I-III] and 60 controls [60 (12) years, 42% male). Group differences in continuous variables were compared using Student's t-test. Associations between HF and SctO 2 were studied using multivariable linear regression models adjusted for age, sex, diabetes, smoking, systolic blood pressure (SBP), and heart rate in supine position and after 10 min of HUT. Mean SctO 2 was lower in HF patients compared with controls both in the supine position (67 vs. 71%; P < 0.001) and after 10 min of HUT (64 vs. 69%; P < 0.001). The HUT-induced SctO 2 decrease was greater in HF patients compared with controls (P = 0.026). SBP did not change in neither HF patients nor controls during HUT, whereas diastolic blood pressure and heart rate increased in both groups. HF was associated with lower SctO 2 in supine (B = À2.5%, P = 0.023) and after 10 min of HUT (B = À2.6%, P = 0.007) after multivariable adjustments. Conclusions Cerebral tissue oxygenation is lower in HF patients both at rest and during orthostasis compared with subjects without HF. Future studies should test if the lower cerebral oxygenation associates with negative prognosis and with impaired cognitive function.

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Cerebral Hypoperfusion Is Exaggerated With an Upright Posture in Heart Failure

Abstract: The reduction in CBF was exaggerated in the upright posture in HF patients and may increase the risk for subsequent cognitive impairment.

Cited by 43 publications

References 36 publications

Patients With Heart Failure With Reduced Ejection Fraction Have Exaggerated Reductions in Cerebral Blood Flow During Upright Posture ∗

Patients With Heart Failure With Reduced Ejection Fraction Have Exaggerated Reductions in Cerebral Blood Flow During Upright Posture ∗

Rationale and design of the FELICITAR registry (Frailty Evaluation After List Inclusion, Characteristics and Influence on Transplantation and Results)

Impaired cerebral oxygenation in heart failure patients at rest and during head‐up tilt testing

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