We assessed the effect of blood pressure (BP) control on left ventricular mass index (LVMI) and left ventricular hypertrophy (LVH).Ninety-six patients  ≥9 months post–kidney transplantation from the 4C-T (Cardiovascular Comorbidity in Children with Chronic Kidney Disease and Transplantation) study were analyzed longitudinally . Cumulative systolic blood pressure (SBP)/diastolic BP exposure was calculated as a time-averaged area under the curve and categorized: ≤50th, 50th to ≤75th, 75th to ≤90th, and >90th percentile (pct). We performed adjusted linear and logistic mixed models for LVMI and LVH, respectively.2.16 with 64% (n=61) kidney transplantation recipients displaying LVH. Compared with patients with cumulative SBP exposure >90th pct, patients with cumulative SBP of 50th to ≤75th showed a significant LVMI reduction of −5.24g/m2.16 (P=0.007). A similar tendency was seen for cumulative SBP≤50th , but patients with cumulative SBP of 75th to ≤90th pct showed no reduction. A post hoc analysis in patients with cumulative SBP≤75th revealed that median SBP exposure was at 57.5th pct. For cumulative diastolic BP, a significant LVMI reduction was seen in all 3 categories ≤90th pct compared with patients >90th pct. Patients with cumulative SBP of ≤50th or 50th to ≤75th pct showed 79% or 83% lower odds of developing LVH, respectively. Patients with cumulative diastolic BP ≤50th showed a tendency of 82% lower odds for LVH .At baseline, LVMI was 49.7±12.7g/mStricter BP control led to regression of LVMI and LVH. Our data suggest a BP target below the 60th pct, which needs to be substantiated in a randomized controlled trial. This study demonstrates the effect of stricter blood pressure (BP) control on left ventricular mass index and left ventricular hypertrophy based on prospectively collected data from pediatric kidney transplantation (KTx) recipients.Maintaining systolic BP values at ≤75th pct is significantly associated with left ventricular mass index regression and lower odds of developing left ventricular hypertrophy.A post hoc analysis mirroring the eligibility criteria of a possible randomized controlled trial in pediatric KTx recipients indicates that the protective effect is achieved by maintaining BP values below the 60th pct.Left ventricular hypertrophy is a strong predictor for cardiovascular mortality and affects about 40% of children 1 year after KTx.BP is the main determinant of left ventricular mass early after KTx.This analysis offers first evidence supporting lower BP targets in pediatric KTx recipients.The results of this study underscore the necessity of conducting a randomized controlled trial to validate its findings. This will allow for specific recommendations on BP targets in children and adolescents after KTx.1 Therefore, factors affecting long-term health, especially cardiovascular disease, carry increased relevance as cardiovascular events are among the most common causes of death in pediatric KTx recipients.4 Cardiovascular morbidity is caused by a variety of cardiovascular risk factors: arterial hypertension is of particular importance and strongly correlated with cardiovascular organ damage.6 Registry studies demonstrate a high prevalence of arterial hypertension in pediatric KTx recipients8 with >70% requiring antihypertensive medication9 and more than one-third showing actual blood pressure (BP) levels higher than the 95th percentile (pct).8 We recently extended this finding, demonstrating sharply increased odds for arterial hypertension for patients after pediatric KTx  when compared with healthy age- and sex-matched children from the German Health Interview and Examination Survey for Children and Adolescents in a case-control study.10Life expectancy in children with chronic kidney disease (CKD) after kidney transplantation (KTx) has increased steadily.11 This led to the implementation of BP goals for patients before kidney replacement therapy. However, currently, no specific recommendations exist on BP management in pediatric patients after KTx that are based on prospective data. This is a major shortcoming as several studies have demonstrated the negative impact of arterial hypertension on cardiovascular health and transplant survival in children after KTx.14 Left ventricular hypertrophy (LVH), that is, pathologically increased left ventricular mass (LVM), reflects asymptomatic cardiovascular disease15 and is the most prominent manifestation of cardiovascular organ damage due to arterial hypertension.16 In adults, LVH is associated with death due to major cardiovascular events.17 It affects approximately 40% of children 1 year after KTx.19 We have previously shown that the left ventricular mass index (LVMI) increases in the early course after preemptive KTx and is mainly determined by BP and not by the mode of kidney replacement therapy.20In children with CKD not yet requiring kidney replacement therapy, the randomized controlled ESCAPE (The Effect of Strict Blood Pressure Control and ACE Inhibition on the Progression of CKD in Pediatric Patients) trial demonstrated that intensified BP control using ACE (angiotensin-converting enzyme) inhibition reduces CKD disease progression.21 In addition, we simulated the effect of intensified versus regular BP control on LVMI in a subgroup of patients resembling potential inclusion criteria of a randomized controlled trial.Our main objective was to decipher the range of BP control that can regress or prevent the development of LVH using longitudinal data. We assessed the cumulative exposure of BP on the dynamics of LVMI as well as LVH in a prospective cohort of children from the 4C-T (Cardiovascular Comorbidity in Children with Chronic Kidney Disease and Transplantation) study.The data that support the findings of this study are available from the corresponding author upon reasonable request.21) who were transplanted ≥9 months ago and had at least 2 BP and LVMI measurements . After obtaining written informed consent, the 4C study prospectively enrolled 704 patients with CKD (age 6–17 years) with an estimated glomerular filtration rate below 60 mL/min/1.73 m2 between 2009 and 2011; 238 received kidney replacement therapy during follow-up. Details on the 4C study set-up, inclusion and exclusion criteria, and data acquisition have been described in detail.21 In brief, patients were investigated annually with a full cardiovascular assessment including echocardiography. Seven regional coordinators visited the 55 participating centers in 12 European countries. In addition to annual assessments, blood and urine samples, anthropometric and casual BP measurements, as well as updates of the clinical and medication history were obtained every 6 months. The study fully applies to the Declaration of Helsinki and was approved by institutional review boards of each center as described previously.21 The clinical and research activities being reported are consistent with the Principles of the Declaration of Istanbul as outlined in the Declaration of Istanbul on Organ Trafficking and Transplant Tourism.We included children after KTx from the 4C-T study =0.80×+0.6.23 As our primary end point, LVMI was calculated by dividing LVM in grams by height in meters to the 2.16th with a correction factor of 0.09.24 As secondary end point, LVH was defined as an LVMI of ≥45 g/m2.16.24Echocardiography was performed following a standardized operating procedure in accordance with the guidelines of the American Society of Echocardiography.25Table S1 provides the prevalence of hypertension at baseline and the 1st follow-up visit.Systolic BP (SBP) and diastolic BP (DBP) were measured using locally available oscillometric devices and defined as the median of 3 measurements.z-scores were calculated, normalized for sex, age, and height.26 In patients with an age of >17 years, BP z-scores were calculated using the formula for 17 years of age. The cumulative BP exposure at each LVMI follow-up visit  was calculated as the cumulative BP area under the curve (AUC) from baseline  to each follow-up visit (vn) averaged by time since v0 to vn (in months).SBP and DBP z-score AUC, a z-score of 0 was set as the baseline for the AUC, that is, the area under 0 was calculated as the area of reduction (as minus). Figure S2 provides further details on the calculation of the cumulative BP exposure.For the BP z-scores were classified into 4 categories: ≤50th pct, >50th to ≤75th pct, >75th to ≤90th pct, and >90th pct.Cumulative SBP and DBP exposures according to AUC 27 body mass index z-score normalized for age and sex.28Our main objective was to define the range of cumulative BP exposure that can regress the LVMI or prevent the development of LVH regardless of the potential causes of BP changes, for example, immunosuppressive or antihypertensive treatment. We considered the following parameters as fixed covariates: time since baseline visit, age, sex, estimated glomerular filtration rate,t-tests were performed to test differences between patients with the presence and absence of LVH at baseline visits. Chi-squared test was used to compare proportions between variables with 2 or more categories. We performed 2 multivariable linear mixed effect models (linear mixed models) for LVMI at follow-up visits  to investigate the effect of the cumulative exposure to either SBP or DBP. Models were adjusted for LVMI at baseline and the fixed covariates at the respective follow-up visits. Another 2 multivariable logistic mixed effect models (logistic mixed models) were performed for LVH at follow-up visits to investigate the effect of cumulative exposure to either SBP or DBP. Models were adjusted for LVH at baseline and the fixed covariates at the respective follow-up visits. Due to missing values of fixed covariates, 3 patients were excluded from the mixed model analyses resulting in 215 observations from 93 patients. We included random slopes to account for interindividual variation and time since the baseline visit as a repeated effect to account for intraindividual variation. Unadjusted spline regression was fitted for the LVMI and either cumulative exposure of SBP or DBP. A 2-tailed P<0.05 was considered as statistically significant. Statistical analysis was performed using SAS 9.4 . This article was written according to the STROBE  guidelines.29Continuous values are presented as mean±SD, and categories as absolute and relative frequencies. Unpaired 2.730 using similar linear and logistic mixed models for the cumulative exposure of SBP and DBP on LVMI (g/m2.7) and LVH, as previously explained in the statistical analysis. In the sensitivity analysis for LVH,31 we used the cutoff of >40 g/m2.7 in girls and >45 g/m2.7 in boys as the definition of LVH.We performed sensitivity analyses for the LVM indexed to the height (m)Table S2 provides the details on this analysis.Based on our findings, we then performed a post hoc analysis on a subgroup of patients. This analysis was performed to plan a randomized controlled trial on the effect of intensified versus regular BP control on LVMI. Therefore, the inclusion criteria resemble exactly those of the trial: patients ≤16 years of age who presented with arterial hypertension (defined as SBP or DBP >95th pct or treated with antihypertensive medication) at the baseline visit. Corrected means for LVMI depending on the cumulative SBP category in a total of 94 observations from 37 patients were calculated. Figure S1). This resulted in a total of 324 observations for this analysis.Detailed characteristics of the study population are given in Table 2. We identified 61 patients with LVH , who showed significantly higher body mass index, body mass index z-score, and DBP z-score compared with those without LVH.At baseline, patients were 15.3±3 years old and had been transplanted 1.3±0.6 years ago. Patients were followed for 2.6±1.3 years, with a maximum follow-up of 6.9 years. Twenty-nine patients (30%) were transplanted after prior dialysis. The mean estimated glomerular filtration rate at the baseline visit was 64.4±24.6 mL/min/1.73 mFigure [A] shows the proportion of patients exposed to the 4 different BP categories differentiated by the presence/absence of LVH for the first follow-up visit. While 43% of patients presenting with LVH had been exposed to SBP >90th pct, this was only the case in 21% of patients without LVH. This difference was even more pronounced for the proportion of patients exposed to DBP >90th pct: this applied to 15% with LVH and only to 2% without LVH.Figure S3) with an effect for SBP towards an LVMI increase seen already at a lower pct than for DBP. We therefore performed separate analyses for the adjusted models.We already saw a differential effect of the cumulative exposure of either SBP or DBP on LVMI in the unadjusted analysis . A similar tendency was seen in patients with a cumulative exposure below the <50th pct ]. No significant changes were observed in patients who experienced a cumulative SBP between >75th to ≤90th pct , >50th to ≤75th pct , and >75th to ≤90th pct  showed a significant reduction when compared with those with a cumulative DBP exposure >90th pct .To estimate the risk of developing LVH, a logistic mixed model was employed. Compared with patients with a cumulative SBP of >90th pct, patients with a cumulative SBP exposure of either ≤50th or >50th to ≤75th pct showed significantly lower odds for developing LVH of 79%  and 83% , respectively. For the cumulative DBP exposure, only those with cumulative DBP of ≤50th pct showed a tendency of an 82% lower odds of LVH 2.7. The results were similar to our main findings showing a cumulative exposure SBP of ≤75th percentile was associated with a lower LVMI and lower odds of developing LVH. The use of LVMI g/m2.7 revealed a stronger association of cumulative exposure of DBP with LVMI and LVH.Table S2A). We identified 37 patients  from the study cohort, who fulfilled the inclusion criteria of our proposed trial at the baseline visit (Table S2B).To simulate the conditions for an urgently needed randomized controlled trial on the effect of intensified versus regular BP control, we conducted a post hoc analysis in a subgroup of patients to estimate the achievable LVMI mean values after 2 years (2.16]) and between >75th and ≤90th pct. , those who were exposed to cumulative SBP of ≤75th pct. showed the lowest LVMI values . Multiple comparisons between the categories in both classifications did not reveal significance highlighting that a larger sample size is needed for an interventional trial.We focused on the cumulative SBP exposure as our analyses had shown that SBP was of greater importance for LVMI. When compared with patients with cumulative SBP exposure of >90th pct.  trial including 21 pediatric transplant recipients could not demonstrate an effect of lowering the BP target on graft function.33 A large intervention study including 8164 adult participants from the SPRINT  showed that intensified SBP lowering to <120 mm Hg versus standard SBP of <140 mm Hg reduced the risk of developing LVH by 46% among participants without LVH at baseline, as well as a 66% lower risk among those with the presence of LVH at baseline.34 A recent ancillary analysis from the same trial extended these findings: intensified SBP control reduced the incidence of malignant LVH  by 66% and the risk of acute decompensated heart failure by 4.4% in participants with the presence of malignant LVH at baseline.35 The HOT-KID  Study, a randomized controlled trial in children with CKD, recently showed a significant reduction of relative wall thickness and a sustained but not significantly different annual reduction of LVMI in children with intensified SBP lowering to <40th pct compared with children with SBP lowering to the 50th to 75th pct. The authors suggest that a target of SBP close to 50th pct optimally regresses LVM.36Mitigating cardiovascular risk in the pediatric KTx population through better BP control is particularly challenging. For the pediatric CKD population an intensified BP control has been shown to delay the progression of kidney disease, a target BP in the low range of normal was associated with a 35% lower risk of progression to end-stage kidney disease within 5 years after initiation.37 a meta-analysis in adults showed that lowering DBP was more effective than lowering SBP on LVM regression.38 We show that both, SBP and DBP reduction, have an effect on LVM, but that a lower SBP than DBP target is necessary to control LVM. Still, the effect of diastolic pressure on the myocardium is detectable. Effects are most likely exerted during end-diastole, when the left ventricular end-diastolic pressure has to increase to open the aortic valve.LVH induced by arterial hypertension is the consequence of pressure overload. Whether SBP or DBP is more important remains a matter of debate. While most studies consider SBP as the underlying force,10 Our data strongly suggest that an intensified BP control may reduce cardiovascular organ damage most likely resulting in less long-term morbidity, improved quality of life, and higher life expectancy. Still, we must acknowledge that our results are derived from a prospective observational study thus being subject to potential residual confounding. LVMI might have been influenced by factors, which were not part of our prespecified model building, such as dialysis vintage, anemia, secondary hyperparathyroidism, the immunosuppressive, and antihypertensive therapy. A rather large number of patients remained on steroids in our study. We can assume that BP control might be easier achieved in patients without steroids and on low-dose calcineurin inhibitors because these patients may require fewer antihypertensive drugs.Our data mirror the evidence from adult and pediatric trials that a stricter BP control reduces cardiovascular risk. Pediatric KTx recipients are a particularly high-risk group demonstrating cardiovascular morbidity and mortality.Certain limitations are inherent to data coming from an observational study. First of all, the data describe an association and cannot infer causality. Longitudinal studies are subject to attrition bias, older participants in our cohort tended to have fewer follow-up visits due to their transition to adult care. The calculated cumulative exposure of BP was based on the standardized office BP measurement. Patients with high BP values only at nighttime would not have been recognized as such and therefore may have diluted the overall positive effect of better BP control on LVMI. Our study has several strengths. All participants were followed longitudinally with standardized cardiovascular measurements. Our pediatric cohort is not confounded by comorbidities related to aging; therefore, the structural changes of the heart are most likely exclusively driven by BP.39Taken together, our findings call for an interventional trial that is designed to define BP targets in children after KTx. The majority of observations in the category ≤75th pct lie below the 60th pct and therefore suggests a BP target ≤60th pct for the intervention group. This would also assure the necessary separation of patients with intensified BP from controls, which most likely will have BP values between the 75th and 90th pct. The type of evidence coming from such a randomized controlled trial would close a major gap of knowledge and address the urgent request made by KDIGO  in the current recommendations.A cumulative exposure to SBP values ≤75th pct was significantly associated with a reduction of LVMI and a risk reduction of around 80% for the development of LVH. Moreover, the post hoc analysis simulating a potential randomized controlled trial confirmed our findings by demonstrating that an SBP exposure below the 60th pct was associated with the lowest LVMI values.Our data call for stricter BP control in pediatric KTx recipients. Ideally, this should be substantiated by a randomized controlled trial addressing the question, which BP target should be achieved in this particularly vulnerable patient group.www.era-edta.org to F. Schaefer); and Roche Organ Transplant Research Foundation (N365520785 to B.M.W. Schmidt). R.I. Sugianto was supported by a fellowship grant from Women in Transplantation .This study was supported by the German Federal Ministry of Education and Research (No. 01EO0802 to A. Melk); the European Renal Association—European Dialysis and Transplant Association (None.


Allium sativum) for treating arterial hypertension has been recognized as effective for several decades. However, tolerance to treatment is low, and several technological modifications have been developed to improve its tolerability, such as the aging process at controlled temperature and humidity. This study aims to validate the antihypertensive effects of an optimized extract of aged black garlic with low doses of s-allyl-cysteine (SAC) in a Grade I hypertensive population with drug treatment. A randomized, triple-blind, placebo-controlled parallel trial was developed, where a daily supplementation with 0.25 mg/day of SAC for 12 weeks was performed. A reduction in systolic and diastolic blood pressure of 1.8 mmHg (0.7 to 4.1 95% CI) and 1.5 mmHg (0.3 to 3.0 95% CI), respectively, was observed. Similarly, an increase in blood nitric oxide  and antioxidant capacity  and a reduction in uric acid levels  and ACE activity  were observed. No changes in endothelial function and inflammatory cytokines were observed. It was concluded that low-dose SAC supplementation in an optimized black-garlic extract allows for an extra-significant reduction in blood pressure in a Grade I hypertensive population receiving drug treatment. The use of garlic ( A wealth of evidence exists to demonstrate that lowering blood pressure can substantially reduce premature morbidity and mortality . HoweverSeveral studies have shown that garlic can help lower blood pressure in individuals with hypertension . A mean Aged black garlic (ABG) is a type of modified garlic that contains a unique composition of organosulfur compounds and polyphenols compared to fresh garlic . During In this sense, this study aimed to evaluate the antihypertensive effects of a daily intake of a low-dose SAC-optimized ABG extract for 12 weeks in individuals with Grade I hypertension following blood-pressure-reducing drug therapy. For that purpose, a randomized, triple-blind, placebo-controlled parallel trial was developed, where the primary outcome was the reduction in office and home blood pressure. Secondary outcomes such as endothelial function, nitric oxide, inflammatory cytokines, angiotensin-converting enzyme activity, and antioxidant capacity levels in blood were determined to explain the antihypertensive effect of ABG.The study was designed as a triple-blind, placebo-controlled, randomized parallel study to determine whether an optimized aged black garlic (ABG) extract could reduce systolic and diastolic blood pressure in subjects with Grade I hypertension. The study consisted of two periods. An initial period called the “Run-in phase”, two weeks in duration, involved all volunteers being treated with a placebo, and blood pressure was monitored daily and served as the basis for the evaluation of future changes in blood pressure. At least five consecutive days of home blood pressure monitoring are required for a reliable diagnosis of home hypertension . TherefoVolunteers were randomly assigned to each group by sequential number assignment, and they were divided by sex after their acceptance to participate in the study. The study was carried out under the ethical principles established in the latest version of the Declaration of Helsinki and Tokyo for human investigation and following Regulation (EU) 2016/679 of the European Parliament of the Council of 27 April 2016 on Data Protection (RGPD); Law 14/2007 on biomedical research; and Organic Law 3/2018 on the Protection of Personal Data and Guarantee of Digital Rights. Participants provided informed consent before they participated in the study. The study protocol was approved by Hospital Universitari Arnau de Vilanova (CEIC-2435), Lleida, Spain, and the trial is registered at ClinicalTrials.gov NCT04915053. No changes to methods after trial commencement were introduced.The intervention consisted of a daily intake of one tablet after wake-up and before breakfast. Group L received an optimized ABG10+ -extract tablet manufactured by Pharmactive Biotech Products, S.L.U. , according to a proprietary process. The extract was from garlic harvested in the area of Las Pedroñeras , and the tablets were manufactured at Instant Procès . Each ABG tablet contained 250 mg of ABG extract, which provided 0.25 mg of SAC per tablet plus 300 mg of the excipients shown in 2), serum LDL-cholesterol levels < 115 mg/dL (set point of low or moderate SCORE risk of cardiovascular events), fasting serum glucose levels > 126 mg/dL (cut-off parameter among the criteria of diabetes), anemia (hemoglobin < 13 g/dL in mean and <12 g/dL in women), chronic gastrointestinal disease, being pregnant or intending to become pregnant, lactation, intending to participate or have participated in a clinical trial or nutritional intervention study in the last 30 days before study enrolment, and allergy to garlic.Volunteers were recruited in collaboration with the Atherothrombotic Disease Detection and Treatment Unit (UDETMA) of the Hospital Universitari Arnau de Vilanova  from the database of patients with Grade I hypertension. The inclusion criteria included: men and women over 18 years of age with diagnosed hypertension that were under treatment with one or more antihypertensive drugs, excluding ACE inhibitors. Exclusion criteria included suffering from morbid obesity , with a maximum error tolerance for static pressure of ±3 mmHg. Volunteers were seated comfortably in a quiet environment for 5 min before blood pressure measurements. Office and home blood pressure were determined by the average of three recordings of systolic and diastolic blood pressure, obtained at 3 min intervals after subjects had been seated on a chair with their feet on the floor and arms supported at the heart level. For home blood pressure measurements, volunteers were instructed to take measurements in the morning, 15 min after getting up and urinating (if applicable); to sit comfortably; and to take blood pressure three times at 5 min intervals. They were provided with a notebook where they had to record the measurements daily, including the exact time. Additionally, at the time of the appointments, the measurements provided by the volunteer were verified by consulting the memory of the sphygmomanometer and, if necessary, corrected in their notebook based on the time and date of measurement.75) were assessed to evaluate endothelial function during the experimental period . Briefly, the thermoneutral room temperature was always maintained (24 °C) during the analysis. Any restrictive clothing, watches, or rings that could interfere with blood flow to the arms and fingers were removed from the volunteer. Further, the upper-arm blood pressure cuff was applied snuggly. The volunteer was comfortably lying in the study room and relaxed for at least 15 min before the analysis. The measurement protocol consisted of 1 min of reading, where the correct placement of the sensors and the perceived signal were verified, followed by 5 min of basal conditions, 5 min of occlusion, and 5 min of post-occlusion recording. Occlusion was performed by increasing the blood pressure cuff to a supra-systolic level of at least 60 mmHg above systolic blood pressure and no less than 200 mmHg. A total absence of signal from the occluded hand verified blood-flow cessation. When the appearance of any movement was noted, cuff pressure was increased by an additional 50 mmHg, up to 300 mmHg. RHI and AI75 values were automatically calculated by EndoPAT™ 2000 software. Occlusion borders were verified in all measurements, and manual corrections were performed when necessary.The EndoPAT™ parameters reactive hyperemia index (RHI) and augmentation index  following manufacturer instructions. Serum samples were filtered with a 10 kDa Spin column  to deproteinize the samples before the analysis. The analysis consisted of a two-step process: first, nitrate is converted to nitrite by nitrate reductase, and then nitrite reacts with the fluorescent probe 2,3 diaminonaphthalene. A nitrite standard calibration curve was used to compare the fluorescence intensity of samples. The analysis was performed in triplicate in each sample.3, and acetate buffer  was mixed with 90 μL of distilled water and 30 μL of plasma, or sodium phosphate buffer for the blank. Maximum absorbance values of this solution at 595 nm were taken every minute for 30 min at 37 °C, using a Beckman DU640 spectrophotometer . Antioxidant capacity was referenced to standards containing known concentrations of 6-hydroxy-2,5,7,8-tetramethyl chroman-2-carboxylic acid (Trolox) and expressed as μM Trolox Equivalents (TE). Total antioxidant capacity was defined as the slope of the increase in absorbance.Antioxidant capacity was measured by the FRAP (ferric reducing antioxidant power) assay. Briefly, 900 μL of the FRAP reagent containing 2,4,6-tri(2-pyridyl)-s-triazine, FeClThe simultaneous assessment of serum concentrations of IL-2, IL-4, IL-5, IL-8, INF-γ, inducible protein 10 (IP-10), and soluble CD40 ligand (sCD40L) was performed using commercially available multiplex bead-based immunoassay kits  following manufacturer’s instructions. Briefly, plasma samples (25 μL/well) or standards (25 μL well) were incubated with 25 μL of the pre-mixed bead sets in pre-wetted 96-well microtiter plates at 4 °C overnight. After washing, 25 μL of the fluorescent detection antibody mixture was added for 30 min, and 25 μL of streptavidin-phycoerythrin was added to each well for 30 min at room temperature. A range of 3.2–10,000 pg/mL recombinant cytokines was used to establish standard curves and maximize the assay’s sensitivity and dynamic range. Cytokine levels were determined using a Luminex IS 100 .N-[3-(2-furyl)-acryloyl]-Lphenylalanylglyclglycine (FAPGG) is hydrolyzed to FAP and glycylglycine. The hydrolysis of FAPGG by volunteer serum ACE results in a decrease in absorbance at 340 nm. A standardized calibrator  was employed to estimate ACE activity in samples.ACE activity was determined following the manufacturer’s instruction of Spinreact’s  quantitative determination kit. Briefly, in this method, the direct substrate p-value below 0.05. Statistical analyses and graphs were achieved with GraphPad Prism v6.Statistical analysis was performed as per protocol. Primary and secondary parameters were measured at baseline and after 12 weeks of intervention. Data are presented as mean ± standard deviation of the mean. Two-way ANOVA and multiple comparisons, used to analyze the treatment effect, were performed using Sidak’s test. A statistical analysis of initial differences between Groups A and L was performed by a two-tailed unpaired Student’s t-test. A Chi-square test was performed for categorical variables. Correlation analysis between the change in blood pressure and confounding variables was performed by Pearson’s correlation analysis. To determine the evolution in home blood pressure measurements, linear regressions were conducted between the days of treatment (0–84 days) and the mean of the blood pressure taken daily. Differences in slopes were monitored by a two-tailed t-test analysis. In all cases, the cut-off to determine significant differences between groups was set at a The recruitment phase included creating a database of potential volunteers according to the inclusion and exclusion criteria. Of the 303 patients in the database, 89 volunteers showed interest in participating in the study and entered the run-in phase. Eight volunteers did not complete the run-in phase due to placebo intolerances, personal issues, and non-response to the next appointment. Eighty-one volunteers were randomized to participate in one of the two groups of the present study (Group A: Placebo and Group L: Active compound) and started the experimental phase. Finally, 38 and 39 volunteers from Groups A and L completed the experimental phase. The leading causes of withdrawal from the study were non-response to appointments in Groups A and L and intolerance to treatment in Group L, mainly due to gastroesophageal reflux. A flowchart of the study is depicted in p = 0.4396). No data were excluded from the study.Treatment compliance was determined from the number of pills taken divided by the total days of the treatment period. Some volunteers took extra treatment days due to volunteer availability adjustments in appointments. The mean treatment days in both groups were 87 ± 5 and 88 ± 5 for groups L and A, respectively. The mean compliance in both groups was above 96%, where no difference in compliance was observed between groups (Four volunteers reported treatment adverse events. Two volunteers from Group L (active compound) and one from Group A (placebo group) reported mild gastric discomfort, while one volunteer from Group A reported muscular cramps.The treatment blinding of volunteers was executed by asking each participant in the last appointment if they believed there where in the active or placebo group. Moreover, 23% and 45% of volunteers in Groups L and A, respectively, thought they were in the active group. Therefore, it was determined that volunteer treatment blinding was appropriately conducted. Regarding the researcher blinding, none of the researchers were aware of which group the active compound belonged to until the finalization of the statistical analysis.Changes in blood pressure were determined through two methods: the measurements in the office at baseline and 12 weeks and the daily measurement performed by the volunteers at home. The results of the office pressure measurements are shown in 75 values) were observed in either group. Similarly, no significant differences in the blood lipid profile were observed  or the intake of blood pressure-lowering drugs . Nevertheless, it was observed that the volunteers with lower basal values of RHI  and higher basal levels of the cytokine IP10  in Group L where the ones with a lower response to the treatment.No differences in response to the treatment were observed due to sex , induces significant effects on blood pressure control. This last point is critical to highlight since it demonstrates garlic extracts at low doses that are effective without inducing commonly reported side effects  or otherThe reduction in blood pressure measured at home is considered even more relevant than the measurement in the office since recent meta-analyses have indicated that home blood pressure monitoring better predicts cardiovascular morbidity and mortality than office blood pressure . In this2S [75 indexes in this study. A similar finding is reported with other garlic extracts [The changes in blood pressure observed in this study are consistent with previous observations of the effect of the same ABG extract on cardiovascular physiology. A clinical trial in subjects with moderate hypercholesterolemia reported reduced diastolic blood pressure, particularly in men with diastolic blood pressure above 75 mmHg , without2S . Neverthextracts . InteresRegarding inflammation markers, previous studies suggest that components of ABG extract present anti-inflammatory properties in models of lipopolysaccharide toxin inflammation induction . In this2S-regulating and NO-stimulating properties [p = 0.6656 and p = 0.2638 for garlic and onion, respectively; and for the difference in diastolic blood pressure p = 0.6392 and p = 0.5370 for garlic and onion, respectively).It is suggested that combination therapy is more effective than increasing doses of a single blood-pressure-reducing drug . ABG-extoperties . The resThis study has some limitations. Although a significant reduction in blood pressure was observed, the time of the day of administration can be optimized. Treatment-time differences affect the beneficial and adverse effects of different blood pressure-reducing drugs . For exaBased on the results obtained in this study, it can be concluded that daily supplementation with ABG extracts with low doses of SAC (0.25 mg/day) can induce significant reductions in blood pressure in individuals with Grade I hypertension and antihypertensive drug therapy.


Although the proportion of EGDs spared by ST+PLT was less than SSM+PLT (SSM < 29.89 kPa + PLT > 113.5 × 109/L) (35.7% vs. 44.1%), it was higher than that of the Baveno VI criteria (B6) (35.7% vs. 28.2%). We did not validate SSM+PLT in VC considering our aims. ST+PLT safely spared 24.6% of EGDs in VC, identical to B6. Conclusions: The ability of ST+PLT to exclude HRVs was superior to B6 but slightly inferior to SSM+PLT. When SSM cannot be routinely performed, ST+PLT provides an extra option for patients to exclude HRVs as a more convenient model.Currently, most primary hospitals cannot routinely perform liver stiffness measurements (LSMs) and spleen stiffness measurements (SSMs), which are recommended by guidelines to exclude high-risk varices (HRVs). We tried to find more convenient indicators for HRV screening. We enrolled 213 cirrhosis patients as the training cohort (TC) and 65 primary biliary cirrhosis patients as the validation cohort (VC). We included indicators such as SSM by two-dimensional shear wave elastography, LSM by transient elastography, and other imaging and laboratory tests. Variable analysis revealed SSM, platelets (PLT), and spleen thickness (ST) as independent risk indicators for HRV. In TC, ST+PLT (ST < 42.2 mm and PLT > 113.5 × 10 Portal hypertension (PH) is a common clinical syndrome characterized by an elevated hepatic vein pressure gradient . Based on the location of the etiology, PH can be categorized into pre-hepatic, intra-hepatic, and post-hepatic types . The mos9/L can further avoid EGD screening based on a spleen stiffness measurement (SSM) ≤ 40 kPa [Esophagogastroduodenoscopy (EGD), known as the gold standard for diagnosing GEVs, is still recommended in guidelines. For patients with decompensated cirrhosis and HRVs, EGD should be performed annually or every six months, depending on their condition . However≤ 40 kPa . However≤ 40 kPa ,9,10,11.This study aims to obtain more easily measurable indicators and validate their abilities to exclude HRVs. Simultaneously, we will analyze these indicators in comparison with LSMs and SSMs. We retrospectively collected relevant clinical data from all patients admitted to Tianjin Second People’s Hospital from September 2020 to April 2023 who obtained LSMs and SSMs to form the training cohort (TC). Additionally, we enrolled all patients diagnosed with primary biliary cholangitis (PBC) from January 2016 to April 2023 as the validation cohort (VC). All PBC patients in the VC were also clinically diagnosed with cirrhosis.Inclusion criteria: (1) Age ≥ 18 years; (2) SSM was obtained by two-dimensional shear wave elastography (2D-SWE) in the TC, and LSM was obtained by transient elastography (TE) in all patients; (3) patients with data records  that were updated within three months of our study; and (4) patients diagnosed with compensated and decompensated cirrhosis  were confirmed based on clinical symptoms, laboratory tests, and imaging examinations ,13. Exclusion criteria: (1) Decompensated patients with a history of varix bleeding; (2) splenectomy or congenital absence of the spleen; (3) splenic lesions due to hematological disorders; (4) portal vein or splenic vein thrombosis; (5) benign or malignant spleen tumors; (6) patients who have received transjugular intrahepatic portosystemic shunt (TIPS) surgery; (7) non-cirrhotic PH; (8) use of non-selective β-blockers in the last two weeks; (9) patients with liver cancer; (10) liver transplantation; and (11) patients with missing data.The ethics committee approved all these studies. Moreover, informed consent materials were available for all examinations.The laboratory data we collected encompassed PLT, ALB, creatinine (CR), alanine aminotransferase (ALT), aspartate transaminase (AST), total bilirubin (TBIL), prothrombin time (PT), and international normalized ratio (INR).For this study, EGD was conducted using Olympus CV-260SL equipment . The findings were recorded following guidelines, mainly including the location, size, and presence of red signs in varices . HRVs weSSMs were performed using an Aixplorer ultrasound system  in the TC. LSMs were performed using a FibroScan502  in all patients. Patients were required to be fasting before the examinations. For LSMs, the patient lay supine on the bed with the right arm extended to expose the liver region fully. For SSMs, the patient was in a right lateral position on the bed with the left arm extended to expose the spleen region fully. The physicians were unaware of the patients’ other clinical data. The units of the LSMs and SSMs are kilopascals (kPa). Each LSM or SSM value was the median of ten measurements. The results were considered valid if the interquartile range/median ≤ 30% for the ten measurements. Patients with ascites performed abdominocentesis before undergoing LSMs and SSMs (no or trace ascites on ultrasound).Abdominal ultrasonography was conducted using a Toshiba SSH-140A Doppler ultrasound . Patients fasted and rested for at least ten minutes before the examination. During the examination, the patient was lying supine on the bed with arms raised, fully exposing the abdomen. We measured the SD, ST, PVD, and SVD as candidate indicators.P values less than 0.05 were considered significant.We used the R language  for the statistical analyses. Continuous variables are expressed as median ; categorical variables are expressed as number (proportions). The Mann–Whitney U test was utilized to compare samples of continuous variables, while the chi-square test was employed for categorical variable comparisons. The stepwise logistic regression was applied for multivariable screening. We plotted the receiver operating characteristic curve (ROC) for each indicator and calculated the area under the curve (AUC) to evaluate the diagnostic accuracy of each model. The maximum Youden index determined the optimal cutoff value. Comparisons of paired AUCs were performed using the Delong test. The primary outcomes of interest for evaluating indicators and models were the proportion of spared EGDs and the missed HRV rate. Other statistical indicators to evaluate the diagnostic value included sensitivity (Sen), specificity (Spe), positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and accuracy (ACU). The simplified model derived from the TC was validated in the VC. Calculation formulas: (1) Proportion of spared EGDs = patients eligible for non-invasive models/total patients; (2) missed HRV rate = patients who fit the non-invasive models but had HRVs/total patients with HRVs.The details of the participant selection are shown in p < 0.05) between the HRV and non-HRV groups in the multivariate analysis. According to p < 0.001, p = 0.001, p = 0.011). Based on the ROC, the optimal cutoff values for SSM, PLT, and ST were 29.89 kPa, 113.5 × 109/L, and 42.2 mm, respectively.Firstly, we conducted a univariate analysis for all variables and included those with a statistical difference , the proportions of spared EGDs were 58.2%, 54.2%, and 45.5%, respectively. However, the missed HRV rates in each model were 7.3% (3/41), 9.8% (4/41), and 9.8% (4/41), respectively , 0.868 (95% CI: 0.817–0.918), 0.852 (95% CI: 0.795–0.909), and 0.782 (95% CI: 0.707–0.856), respectively . SSM andectively . The mis9/L) spared 35.7% of EGDs, with a 2.4% missed HRV rate, 97.6% Sen, 43.6% Spe, 98.7% NPV, and 0.06 NLR. ST+PLT could correctly classify 54% of patients with HRVs  spared 28.2% of EGDs, with a 0% missed HRV rate, 100% Sen, 34.9% Spe, 100% NPV, and 0 NLR (9/L) spared 44.1% of EGDs, with a 2.4% missed HRV rate, 97.6% Sen, 54.1% Spe, 98.9% NPV, and 0.05 NLR , 0.859 (95% CI: 0.805–0.913), and 0.853 (95% CI: 0.797–0.910), all of which had improved over the single-indicator model . SSM+ PLp = 0.005), and ST+PLT exhibited a similar superiority over B6 in AUC , 0.835 (95% CI: 0.730–0.940), and 0.884 (95% CI: 0.801–0.967), respectively . Both B6In our study, the prevalence of HRVs in the TC was 19.2% (41/213), including 12.9% 22/170) in patients with compensated cirrhosis. According to previous studies, the prevalence of HRVs in patients with compensated cirrhosis was about 10–20% ,17, high0 in patiIn the TC, from an array of candidate indicators, we found that SSMs, PLT, and ST were most significantly associated with the occurrence of HRVs. Moreover, we concluded that single-indicator models, while sparing a more significant number of EGDs, had higher missed HRV rates . However, the combined models could exclude HRVs well, with all Sen values greater than 95%, all NLR values less than 0.1, all NPVs greater than 95%, and all missed HRV rates less than 5%. Similar to our findings, past research has indicated that PLT is more effective when combined with other non-invasive indicators ,15,20,21Compared with SSMs and LSMs, ST and PLT are indicators that are more readily monitored and accessible in the clinic. Therefore, we recommend the ST+PLT model to exclude HRVs, and its results are promising. In the TC, ST+PLT was superior to B6 but slightly inferior to SSM+PLT. To date, the majority of hospitals do not perform SSMs, and the cutoff value is not standardized. LSMs have been more widely used, making the cutoff value more mature. Therefore, in the VC, we only compared ST+PLT with B6. Several studies have demonstrated that B6 could exclude HRVs equally well in patients with PBC with a low missed rate (<5%) ,23. AlthIn our study, the AUCs for ST in predicting HRVs were 0.782 in the TC and 0.884 in the VC. Liang et al. concluded that ST was the crucial factor in identifying HRVs, and its AUCs in the two cohorts were 0.808 (95% CI: 0.760–0.857) and 0.858 (95% CI: 0.816–0.894), similar to our results , which wFurthermore, we determined a new cutoff value for SSMs by 2D-SWE (Aixplorer ultrasound system) of 29.89 kPa. There are several advantages offered by 2D-SWE ,29,30,31In this study, we included some biochemical indicators for the variable analysis. In the past, numerous experts have also designed algorithms using biochemical indicators to exclude varices or HRVs. Tan et al. validated the feasibility of the VariScreen  . Chen etOur article has three main features. On the one hand, we enrolled PBC patients as the VC to find a new non-invasive model to exclude HRVs for them, considering there were few relevant studies. Patanwala et al. proposed the NVP score for predicting varices in PBC patients but failed to carry out the clinical application due to the complicated calculations . AlthougOf course, our study had some limitations. First, our data came from a single center and were collected retrospectively, inevitably resulting in selection bias. Next, our sample size was relatively small due to rigorous screening, necessitating further validation with a larger dataset, which is also the direction of our future efforts.9/L) could exempt a significant number of patients from EGD screening with a low missed HRV rate (<5%).ST demonstrated a favorable capacity in excluding HRVs and could replace LSMs, offering a new option for primary hospitals. Although a better non-invasive indicator, SSMs are not currently applicable to primary hospitals. At present, ST+PLT (ST < 42.2 mm + PLT > 113.5 × 10


BackgroundThe cornerstone of pharmaceutical therapy for obstructive airway illnesses involves inhalation of bronchodilators, such as ipratropium bromide (IP) and salbutamol (SB). The heart rate regulation may be changed by β-2 agonists and anticholinergic medications. Investigating the impact of inhaled SB and IP on the heart rate was the goal of this study.MethodsA total of 304 patients were enrolled in this investigation. Baseline demographic characteristics, medical history, and adverse events were documented. Their heart rates were monitored before and after bronchodilator administration. SB and IP were selected based on historical usage. Blood pressure readings were also taken before and after each session.ResultsThere was a significant increase in heart rates after SB from a mean of 106.69 to 117.20. Similarly, the heart rate of the patients in the IP group increased to a mean of 106.95 from 93.44, with a statistically significant p-value. Moreover, tremors were the most common adverse effect, accounting for 85.3% of the patients in the IP group and 75% in the SB group. In contrast, palpitation was more common in the SB group 25% vs. 14.7% with a significant p-value.ConclusionFrequently administered dosages of SB and IP caused a considerable increase in heart rates, as well as tremors and palpitation. Chronic obstructive pulmonary disease (COPD) is a common, preventable, and manageable condition. Asthma, among the most common major non-communicable diseases, significantly reduces many people's quality of life. Asthma already affects 300 million individuals worldwide, and another hundred million individuals could contract it by 2025 . ReactivWhile these drugs have demonstrated local bronchodilating effects, there have been concerns about their potential adverse systemic effects, particularly in individuals with cardiac comorbidities . The higTherefore, considering that these medicines constitute a cornerstone of COPD exacerbation care, taking into account potential benefits and risks, there is a need to synthesize current data for their usage. IP and SB can have adverse systemic effects in addition to their local broncho-dilating effects. Although the overall mortality in asthma is low, it is on the rise . There aFollowing absorption into the bloodstream, SB shortens the duration of diastole, raising heart rates and causing myocardial oxygen demand . AdditioNevertheless, it is not thought that people with coronary artery disease, COPD, or asthma usually develop angina pectoris, which is made worse by inhaling SB . DespiteSubjects The study was conducted as a prospective cohort study at Dr. Ziauddin University Hospital, Karachi, Pakistan, for a period of six months from January 01, 2023, till June 30, 2023, which included patients between the ages of 18 and 65 years, of any gender, with obstructive airway disease. Patients who met the inclusion criteria were enrolled in the study after obtaining ethical review committee approval from the Dr. Ziauddin University Hospital Ethical Review Committee.Patient selectionIn our study, we included patients aged between 18 and 65 years of any gender, who were diagnosed with obstructive airway disease (asthma or chronic obstructive pulmonary disease), presenting to Dr. Ziauddin University Hospital. Participants who provided informed consent were enrolled.We excluded patients with thyroid problems, a history of cardiac arrhythmias, pacemakers, other significant cardiac comorbidities , and pregnant women. Patients with cancer, psychiatric illnesses, and chronic liver and kidney diseases were also excluded. Participants who consumed alcohol or beverages with caffeine within 24 hours before the study were not included. Patients who were unable to provide informed consent were also excluded.Sample size calculationThe sample size was calculated based on the anticipated effect size, significance level (α), and power (1-β) using the following formula:n=(d)22(Zα/2+Zβ)2⋅(σ)2where n is the required sample size; /2Zα/2 and Zβ are the critical values corresponding to the desired level of significance and power, respectively; σ is the estimated standard deviation; and d is the desired effect size.Study designFollowing the recruitment of eligible participants, heart rate measurements were manually recorded, using a heart rate monitor, by a trained attending nurse or duty doctor. Heart rate data were collected after the patient was made to sit or lie for a minimum of 10 minutes. Subsequently, the heart rate was measured 10 minutes after nebulization with either IP (250 mcg) or SB (2.5 mg). The choice of medication was based on the patient's previous history of bronchodilator use. Patients who had been previously taking short-acting β-agonists (SABA) or long-acting β-agonists (LABA) were administered SB, while those previously on short-acting muscarinic antagonists (SAMA) or long-acting muscarinic antagonists (LAMA) received IP. Patients who were taking bronchodilators from both groups were given SB or IP alternatively. Blood pressure readings were taken by a qualified clinician from the left arm held at heart level using a sphygmomanometer before and after each nebulization session.Statistical analysis All statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) . Categorical variables were compared using Fisher's exact test or the chi-square test, depending on the context. The Kolmogorov-Smirnov test was employed to assess the normal distribution of continuous variables before applying Student’s t-test to compare them. A paired sample t-test was used to analyze the mean heart rate before and after administering the medication. A p-value of 0.05 or less was considered statistically significant.A total of 304 patients were included in this prospective cohort study. Table Additionally, bronchiectasis and biomass exposure were more predominant in the IP group . Patients in the IP group had a longer history of bronchodilator use (7.68 years) compared to those in the SB group (6.30 years), although the difference was not statistically significant (P = 0.105).The effects of the medications on heart rate are presented in Table Other adverse effects are listed in Table The current study aimed to investigate the cardiovascular effects of two commonly used bronchodilators, SB, and IP, in patients with obstructive airway disease. The findings revealed several important insights into the impact of these medications on heart rates and other adverse effects, which have significant implications for clinical practice.When evaluating the cardiovascular effects of these medicines, prior research has typically concentrated on changes in pulse and blood pressure changes . The maiThe present study investigated the cardiovascular effects of SB and IP in patients with obstructive airway disease. Our findings revealed a significant increase in heart rates after the inhalation of both medications, which has important clinical implications. These results are consistent with previous research on the cardiovascular impact of these bronchodilators, highlighting the need for careful consideration of their use in patients with underlying cardiac comorbidities.One notable finding in our study was the dose-dependent effect of SB on heart rates. A previous investigation demonstrated that a dose of 1.5 mg of SB increased heart rates by 14 beats per minute in one case and an average of seven beats per minute in three patients after 200 μg of the medication . AnotherOur results are comparable with other studies that reported a rise in heart rates following the inhalation of SB . HoweverIn contrast to SB, IP has been suggested as a preferable aerosol therapy option due to its lack of association with an increase in heart rates . Our stuThe parasympathetic regulation of the heart is of utmost importance, and disturbances in parasympathetic activity can lead to arrhythmias and cardiac mortality . PatientThis study provides valuable insights into the cardiovascular effects of two commonly used bronchodilators, SB, and IP, in patients with obstructive airway disease. The results highlight the need for careful consideration of potential adverse effects, particularly in patients with pre-existing cardiovascular comorbidities. Clinicians should weigh the benefits and risks of each medication based on individual patient characteristics to ensure safe and effective management of obstructive airway disease. Future research should continue to explore the cardiovascular effects of bronchodilators, aiming to improve treatment strategies and patient outcomes.


In the whole study cohort, FABP3 was independently associated with all-cause death, and both FABP3 and FABP4 concentrations were associated with CV mortality. The predictive values of these two molecules for all-cause  and CV mortality  were only statistically significant in the subgroup of subjects with T2D. Notably, FABP4 , but not FABP3, also predicted the occurrence of the composite endpoint  only in subjects with T2D. All these associations were not found in CHF subjects without T2D. Our findings support the usefulness of serum FABP3 and FABP4 concentrations as independent predictors for the occurrence of all-cause and CV mortality in ambulatory subjects with CHF with T2D.Subjects with type 2 diabetes mellitus (T2D) are at increased risk for heart failure (HF). The cardiac-specific (FABP3) and adipose-tissue-specific (FABP4) types of the fatty acid binding proteins have been associated with both all-cause and cardiovascular (CV) mortality. The aim of this study was to explore the prognosis value of FABP3 and FABP4 in ambulatory subjects with chronic HF (CHF), with and without T2D. A prospective study involving 240 ambulatory CHF subjects was performed. Patients were followed-up for a mean of 5.78 ± 3.30 years and cause of death (if any) was recorded. Primary endpoints were defined as all-cause and CV death, and a composite endpoint that included CV death or hospitalization for HF was included as a secondary endpoint. Baseline serum samples were obtained and the serum FABP3 and FABP4 concentrations were assessed by sandwich enzyme-linked immunosorbent assay. Survival analysis was performed with multivariable Cox regressions, using Fine and Gray competing risks models when needed, to explore the prognostic value of FABP3 and FABP4 concentrations, adjusting for potential confounders. Type 2 diabetes mellitus was highly prevalent, accounting for 47.5% for total subjects with CHF. Subjects with T2D showed higher mortality rates (T2D: 69.30%; non-T2D: 50.79%,  Increasing evidence has shown a greater risk for heart failure (HF) associated with the presence of type 2 diabetes mellitus (T2D) . Indeed,Metabolic disturbances, including impaired glucose and fatty acid metabolism, have been related to increased risk for HF independently of coronary artery disease . EnhanceBoth FABP3 and FABP4 have been linked to oxidative stress. For instance, circulating FABP3 has been positively related to oxidative stress biomarkers, including malondialdehyde (MDA) and asymmetric dimethylarginine (ADMA), and inversely associated with the total antioxidant capacity (TAC) in patients with carbon-monoxide-induced cardiotoxicity . On the An increasing body of evidence supports the notion that both FABP3 and FABP4 serum concentrations can predict both all-cause ,40,41,42The current research was performed in a subset of a well-characterized ambulatory cohort of subjects with CHF, prospectively admitted in a structured ambulatory multidisciplinary HF unit ,60. SpecAll participants provided written informed consent. The study was approved by Local Ethics Committee of the Hospital Universitari Germans Trias i Pujol (code: EO 10-076) and was performed according to the ethical standards outlined in the Declaration of Helsinki .Anthropometric and clinical data were obtained at the point of study inclusion and were described elsewhere .Serum concentrations of FABP3 and FABP4  were determined in duplicate using commercial sandwich enzyme-linked immunosorbent assay kits (intra- and inter-assay coefficients of variation were estimated <5%).A diagnosis of T2D was made when one of the following criteria were met: (1) a diagnosis of T2D was previously established and recorded in the patient’s electronic history, (2) fasting plasma glucose ≥ 126 mg/dL or HbA1c ≥ 6.5% identified by laboratory testing  or (3) tt test and Mann–Whitney U test, as required.The Kolmogorov–Smirnov test was used to determine the normality of the continuous variables. Continuous variables were expressed as median and interquartile range, unless otherwise indicated. Categorical variables are expressed as numbers with percentages. Differences between patients were analyzed by the Chi-squared test, Student’s p < 0.05.The association of FABP3 and FABP4 with all-cause and CV mortality, or the composite endpoint , was evaluated using a multivariable Cox regression analysis approach. The primary endpoints were considered as the dependent variables and the selected relevant clinical variables  functional class, time of evolution, FEECO (ejection fraction on echocardiography) NT-ProBNP and obesity) plus FABP3 or FABP4 as independent covariables. Competing risks models using the Fine and Gray method were realized with CV mortality and the composite endpoint . FABP3 and FABP4 analyses were performed for each 1 ng/mL or 1 ng/dL increase, respectively. Statistical analyses were performed using STATA V.16.0 . Differences were considered statistically significant with a two-sided p-value = 0.002; 80.7% vs. 49.2%, p-value < 0.001, respectively). Upon inclusion, 73.7% of subjects with CHF and T2D were receiving oral antidiabetic drugs and 62.3% were under insulin treatment. The percentage of subjects with NYHA functional classes III-IV was higher in subjects with T2D compared with those without T2D . Subjects with T2D showed lower serum concentrations of total-, HDL- and LDL-cholesterol and increased serum concentrations of creatinine and NT-proBNP, compared with subjects without T2D. Additionally, subjects with T2D also showed increased serum concentrations of FABP3  and FABP4  compared with subjects without T2D. No significant correlations were found between lipid parameters  with FABP3 and FABP4 in T2D patients , non-significant correlations were found in T2D patients  . During a mean follow-up period of 5.78 ± 3.30 years, 143 patients died. The average years of follow-up until death (5.22 (2.02–8.17) vs. 7.13 (3.27–8.90), p-value = 0.009) or the composite endpoint (death or readmission) (2.57 (0.61–6.81) vs. 5.72 (0.90–8.31), p-value = 0.006) were lower in T2D than in non-T2D subjects.The baseline characteristics of the study population and a comparison of the clinical and biochemical parameters of patients with CHF with and without T2D are shown in patients . Urate w< 0.692) . The morThe rate of all-cause mortality increased along with FABP3 A and FABp-value = 0.002; FABP4: HR 2.21, 95% CI 1.12–4.36, p-value = 0.023, respectively)  , but not FABP3, predicted the occurrence of the composite endpoint  in subjects with CHF and T2D   and CV dctively) . Neverthctively)  and CV (ctively)  mortalit and T2D , but not and T2D . Indeed, and T2D A and FAB and T2D B tertile and T2D  death we and T2D  was pred and T2D .Multivariable models were adjusted for clinically relevant variables. AUC for FABP3 = 0.8644. AUC for FABP4 = 0.8657. FABP3: fatty acid binding protein 3; FABP4: fatty acid binding protein 4; HF: heart failure; NYHA: New York heart association; LVEF: left ventricular ejection fraction; NTproBNP: pro-B-type natriuretic peptide; eGFR estimated glomerular filtration rate (CKD-EPI equation).Multivariable models were adjusted for clinically relevant variables. AUC for FABP3 model = 0.7532. AUC for FABP4 model = 0.7428. FABP3: fatty acid binding protein 3; FABP4: fatty acid binding protein 4; HF: heart failure; NYHA: New York heart association; LVEF: left ventricular ejection fraction; NTproBNP: pro-B-type natriuretic peptide; eGFR estimated glomerular filtration rate (CKD-EPI equation); SHR: Subdistribution Hazard Ratio.Multivariable models were adjusted for clinically relevant variables. AUC for FABP3 model = 0.7131. AUC for FABP4 model = 0.7188. FABP3: fatty acid binding protein 3; FABP4: fatty acid binding protein 4; HF: heart failure; NYHA: New York heart association; LVEF: left ventricular ejection fraction; NTproBNP: pro-B-type natriuretic peptide; eGFR estimated glomerular filtration rate (CKD-EPI equation); SHR: Subdistribution Hazard Ratio.Subjects with CHF and T2D frequently display a poor prognosis . In thesThe role of FABP3 and FABP4 as independent predictors of mortality has been reported in subjects with pulmonary embolism ,47 and aIn the present study, a comprehensive Cox regression model was built in order to further analyze the potential role of both FABP3 and FABP4 as all-cause mortality predictors in a cohort of ambulatory patients with CHF. Serum concentrations of both molecules were higher in patients with CHF and T2D compared with patients with CHF without T2D. In our models, FABP3, but not FABP4, was identified as an independent predictor of the all-cause death in the whole study cohort. Remarkably, when only CHF subjects with T2D were considered, both FABP3 and FABP4 predicted the occurrence of all-cause mortality but were unable to predict the all-cause mortality in the subgroup of subjects without T2D.Focusing on CV mortality prediction, previous studies identified that low concentrations of FABP3 may predict CV death in combination with high BNP concentrations in patients with non-ischemic dilated cardiomyopathy . MoreoveIn the metabolic context of T2D, the energy substrates of cardiomyocytes to produce metabolic energy switch from glucose to fatty acid. The increased use of fatty acids for energy production in mitochondria is frequently associated with increased reactive oxygen species (ROS) production, which leads to enhanced oxidative stress in diabetic cardiomyocytes. The accumulation of ROS profoundly affects normal cardiomyocyte physiology and function, leading to reduced cardiac contractibility and maladaptive cardiac response . In thisOur study has some limitations. First, it was performed in a subset of the general population attending a single-center HF unit in a tertiary hospital, and it is not possible to rule out the possibility of bias due to selection. The relatively small sample size attenuated the impact of the results. Unfortunately, data on insulin, as well as oxidative parameters other than urate were unavailable in our cohort data sets. Additionally, the retrospective nature of our study precludes the extrapolation of causal relationships from our data. Nevertheless, our data are in line with increasing evidence suggesting a prognosis value of both FABP3 and FABP4 in a wide range of pathologies. Finally, although several adjusted multivariate models were performed, additional confounders may have had an impact on the results.Overall, our findings strongly support the role of both serum FABP3 and FABP4 as independent predictors for the occurrence of all-cause and CV mortality in ambulatory subjects with T2D and CHF.


Forty matched haemodialysis (HD) patients and thirty healthy subjects served as controls for MBG measurements. Patients were then prospectively followed up to 12 months and the occurrence of an established cardio-renal endpoint  was recorded. Results: Median MBG plasma levels were lower in Ktx as compared with HD patients (p = 0.02), but higher as compared with healthy controls (p = 0.0005). Urinary sodium  and eGFR  were the sole independent predictors of MBG in this cohort, while a strong correlation with left ventricular mass index (LVMi), found in univariate analyses , gained significance only in multivariate models not including eGFR. Logistic regression analyses indicated MBG as a significant predictor of the combined endpoint , as well as eGFR, LVMi, serum phosphate and proteinuria. Conclusions: Ktx recipients display altered MBG levels which are influenced by sodium balance, renal impairment and the severity of LVH. Thus, MBG might represent an important missing link between reduced graft function and pathological cardiac remodelling and may hold important prognostic value for improving cardio-renal risk assessment.Background: Left ventricular hypertrophy (LVH), which is a pervasive complication of end-stage kidney disease (ESKD), persists in some uremic individuals even after kidney transplantation (Ktx), contributing to worsening CV outcomes. Marinobufagenin (MBG), an endogenous steroid cardiotonic hormone endowed with natriuretic and vasoconstrictive properties, is an acknowledged trigger of uremic cardiomyopathy. However, its clinical significance in the setting of Ktx remains undefined. Methods: In a cohort of chronic Ktx recipients ( Kidney transplantation (Ktx) is the renal replacement therapy of choice for end-stage kidney disease (ESKD). Progressive renal recovery by the functional graft ameliorates various aspects of chronic uremia, such as blood pressure control, electrolytic imbalance, inflammation, oxidative stress and toxins overload, with a following improvement in the patients’ overall wellbeing and quality of life.Yet, despite such tangible benefits, mortality remains remarkably higher in Ktx recipients as compared with the general population  and, in Pathological left ventricular hypertrophy (LVH), which is largely prevalent among ESKD patients on chronic dialysis, persists in up to 50% of Ktx patients, representing an important prognostic factor for mortality, also among normotensive individuals . LVH priMarinobufagenin (MBG) is a recently discovered endogenous cardiotonic steroid hormone, which binds the ubiquitous Na+/K+-ATPase cellular pump, triggering the activation of specific ionic intracellular signalling pathways . Acute eCirculating MBG levels are increased in chronic kidney disease (CKD) patients, indicating that an impaired renal function may somewhat alter the balance of this hormone . AdditioThe possible role of this hormone in the setting of kidney transplantation, however, remains, thus far, undetermined.Keeping this background in mind, we therefore aimed at running a pilot, observational, cross-sectional analysis to evaluate the clinical predictors of MBG in a small cohort of Ktx recipients, with a particular focus on a possible relationship with cardiac morpho-functional abnormalities and reduced graft function. In a following, exploratory prospective phase, we also tested the prognostic value of MBG as a risk biomarker for the occurrence of adverse cardio-renal events in the short–midterm.2, according to the CKD-Epi formula), evidence of chronic rejection, severe peripheral vasculopathy and recent transplantation (<3 months) represented the main exclusion criteria. The study was approved by the Local Institutional Review Board and all participating subjects provided written informed consent.Fifty-eight adult kidney transplant recipients (age > 18 years) referred to the outpatient clinic of the University Hospital of Catanzaro, Italy, from November 2021 to February 2022 were screened to participate into this pilot, observational, prospective study. Infections, cancer, recent cardiovascular events requiring hospitalization, active inflammatory states, unstable renal function, severe renal impairment , according to the manufacturer’s instructions. Measurements were made blind and in duplicate and levels were expressed as nmol/L. Circulating MBG levels were also quantified in a convenience sample of 30 healthy individuals and in 30 patients undergoing chronic renal replacement therapy by haemodialysis (HD) who were matched with Ktx recipients for age and gender.A complete baseline assessment was performed in every participant upon hospital admission, before starting a planned outpatients visit. Clinical, demographic, and anthropometric parameters were recorded using a standardized, electronic case report form. Additionally, patients underwent blood pressure measurement at rest by a manual sphygmomanometer and a thorough echocardiographic examination. Left ventricular mass index (LVMi) was measured together with other cardiac morpho-functional parameters, as elsewhere recommended . Blood sAfter the baseline evaluation, patients entered an exploratory 12-month follow-up with an established cardio-renal endpoint of all-cause and CV mortality, non-fatal CV events , acute worsening in renal function  or chronic graft rejection.t-test for normally distributed values, the Mann–Whitney U test for non-parametric values and the chi-square followed by a Fisher’s exact test for frequency distributions. The Pearson (R) and the Spearman (Rho) correlation coefficients were employed to test correlations between variables, as appropriate. Univariate correlations were displayed graphically as linear regression. Before testing correlations, all values showing a skewed distribution were log-transformed to better approximate normal distributions. Multiple regression analyses were performed by building two separate models including all univariate correlates of MBG and LVMi values, respectively, in order to assess independent relationships. Data were expressed as partial correlation coefficients (β) and p-value. Univariate logistic regression analyses were performed to establish significant associations of clinical variables with the exploratory cardio-renal endpoint.The statistical analysis was performed using the SPSS package , the MedCalc Statistical Software  and the GraphPad prism package . Data were shown as mean ± SD, median (IQ range) or frequency percentage as appropriate. Differences between groups were assessed by the unpaired p-values ≤ 0.05.All results were considered significant for 2 (IQR 32.7–66.1). All patients had no or negligible proteinuria . Serum calcium, phosphate and alkaline phosphatase levels were within the normal range in most individuals, as well as the lipid blood parameters and inflammatory profile. Echocardiography data indicated, on average, a preserved LV function (Ejection Fraction 59.3 ± 3.6%), mildly increased left atrial volume (35.1 ± 13 mL/m2) and minimal evidence of diastolic dysfunction (E/e’ 9.4 ± 3.9). LVMi was on average 104 ± 33 g/m2, with 15 individuals (37.5%) displaying pathologically increased values with respect to gender-adjusted cut-offs.The final study population included 40 Ktx recipients. Mean age was 56.6 ± 12.5 years and 26 (65%) were male. Median transplantation vintage was 9 years (IQR 3–18), while the median dialysis duration before the transplant was 33.5 months (IQR 13–65). Most patients (85%) received a kidney from deceased donors. Only 10 patients (25%) were diabetics while the majority (65%) were hypertensive under pharmacological control, with 12 of them (30% of the whole population) being on RAAS blockers. Combined immunosuppressive therapy included calcineurin inhibitors in 37 patients (92.5%), corticosteroids in 33 (82.5%), mycophenolate mofetil in 29 (72.5%) and m-TOR inhibitors in only 4 patients (10%). Prevalence of other cardiovascular diseases was marginal. The median estimated GFR was 54.8 mL/min/mp = 0.0005) but lower as compared with matched individuals on chronic HD treatment . Conversely, robust direct correlations were found with urinary sodium excretion , LVMi  and age  (p = 0.04). In a multivariate model including all the univariate predictors of MBG, only the correlations with urinary sodium  and eGFR  were revealed as independent, while those with LVMi, age and gender were lost. This model was rather robust, explaining about 70% of the overall variation of MBG in this study cohort (p < 0.0001). Interestingly, LVMi re-emerged as a significant predictor of MBG after excluding eGFR from this model . From the univariate analysis, a strong inverse correlation was found between circulating MBG levels and eGFR values  , while ap < 0.0001), MBG , proteinuria  and, marginally, with age , while an inverse correlation was found with eGFR  (p = 0.01) and eGFR  were maintained as independent, while those with proteinuria and age disappeared. Of note, in this fully adjusted model, the correlation with MBG remained statistically borderline , attaining overt significance only if eGFR was excluded from the model . Likewise, in this latter case, also the association with age re-appeared . Results from uni- and multivariate analyses of LVMi are depicted in At univariate analysis, LVMi was directly correlated with systolic BP  . As revep = 0.02. 2 increase; p < 0.0001), serum phosphate levels , LVMi  and MBG plasma levels .During the follow-up , nine Ktx patients (22.5%) reached the composite cardio-renal endpoint. In further detail, two patients died, two patients had a non-fatal CV event, while the remaining five had a renal event. Baseline MBG plasma levels were significantly higher in Ktx individuals experiencing the endpoint as compared with others (1.38 [0.84–3.12] vs. 0.66 [0.57–0.92] nmol/L; In the present study, we have investigated, for the first time, the possible clinical significance of circulating MBG in a homogeneous cohort of Ktx recipients. Although preliminary, various findings from our study deserve, in our opinion, a focussed discussion.First, circulating MBG levels in Ktx recipients were, on average, lower as compared with chronic haemodialysis patients but higher with respect to healthy individuals.Under physiological conditions, MBG is produced and released from adrenocortical glands in response to high plasma sodium, volume overload and angiotensin-2 increase, despite additional, yet unknown mechanisms having been postulated. Acute peripheral effects of MBG include vasoconstriction and natriuresis. MBG is freely filtered in urine but the excretion mechanism, overall clearance and peripheral metabolism still remain largely undefined .A sustained MBG accumulation in uremic patients is a well-acknowledged issue and may portend serious detrimental effects in the long term. In fact, a persistent activation of the Na+/K+-ATPase elicits pathological vascular and cardiac remodelling and aberrant fibrosis, thereby causing or worsening existing CV damage . For theAnother important aim of our study was to investigate possible relationships between MBG and cardiac remodelling in Ktx recipients. As alluded to before, a plethora of observations pointed at MBG as an important factor eliciting myocardial hypertrophy and, lately, fibrosis in experimental models of uremia . LikewisIn renal patients, the prevalence of left ventricular hypertrophy parallels the severity of renal function impairment, resulting in affecting roughly 70–80% of uremic patients on chronic dialysis .Although the recovery in renal function driven by Ktx may ameliorate cardiac remodelling, LVMi remains increased in some Ktx recipients . Indeed,In previous studies, MBG has proven to be useful as a prognostic biomarker in predicting mortality among HD patients , CV evenHence, apart from its involvement in the pathophysiology of cardio-renal damage, MBG is now attracting increasing attention as a potential additive tool for risk stratification.Accordingly, an exploratory logistic regression analysis made in our Ktx recipients revealed a significant association between MBG plasma levels and the occurrence of a combined cardio-renal endpoint within a 12-month follow-up. Of note, such an association was evident despite the very low number of participants and the few events recorded. Unfortunately, the study was not sufficiently powered to answer this particular research question in a proper manner, either in terms of population size or follow-up length: this prevented us to perform more complex survival analyses to verify whether the prognostic value of MBG would have been fully independent from other acknowledged risk predictors such as, for instance, eGFR and LVMi.In this pilot study, we have described for the first time altered MBG levels in Ktx recipients which are strictly influenced by sodium balance and, above all, by the entity of renal function impairment and the severity of left ventricular hypertrophy. MBG might thus be placed at the crossroad of pathological cardiac remodelling and residual graft function, although its biological significance as a causal factor or a simple epiphenomenon cannot be clarified in the absence of proper mechanistic evidence. In this latter regard, future prospective investigations on larger and more heterogeneous cohorts are desirable to confirm the prognostic usefulness of this substance for improving cardio-renal risk assessment, thus extending to Ktx recipients the promising observations made in other disease settings.


Circulatory shock is a common and important diagnosis in the critical care environment. Hemodynamic monitoring is quintessential in the management of shock. The currently used hemodynamic monitoring devices not only measure cardiac output but also provide data related to the prediction of fluid responsiveness, extravascular lung water, and also pulmonary vascular permeability. Additionally, these devices are minimally invasive and associated with fewer complications. The area of hemodynamic monitoring is progressively evolving with a trend toward the use of minimally invasive devices in this area. The critical care physician should be well-versed with current hemodynamic monitoring limitations and stay updated with the upcoming advances in this field so that optimal therapy can be delivered to patients in circulatory shock. Hemodynamic monitoring is an essential tool to understand the etiology and pathophysiology underlying various shock states, and thereby, administer life support therapies  in an appropriate and timely manner.Fluid resuscitation is usually the first step in the management of circulatory shock. Fluid responsiveness has been defined as > 15% increase in stroke volume (SV) within 15 minutes of 250 to 500 mL or 6 mL/kg crystalloid over 20 to 30 minutes.Frank-Starling principle: As per the Frank-Starling principle, the heart adjusts its SV on the basis of its sarcomere length (end-diastolic volume or preload). This relationship between SV and preload is curvilinear. As preload increases, SV increases until a point beyond which SV shows no further change to increasing preload. So, a favorable hemodynamic response to fluids can be expected only if the heart is operating in the steep part of the curve .Fluid challengeIn the 2000s, Marik et alTo understand the physiologic rationale behind group A and B indices, it is important to recapitulate the concept of heart-lung interaction within a closed thoracic cavity. During inspiratory phase of controlled positive pressure ventilation, there is increased intrathoracic pressure (ITP) causing decrease in preload to right ventricle (RV) and as a result of decreased venous return. Thus, the blood volume being ejected in that cardiac cycle from RV decreases, which leads to decreased PA blood flow, left ventricle (LV) filling, and hence, fall in LV SV, which manifests in expiration due to a delay caused by pulmonary circuit transit time. Simultaneously, in the same inspiratory cycle LV SV increases due to decreased LV afterload and squeezing of the alveolar vessels into the left atrium. Therefore, phasic variations are noticed in positive pressure ventilation, which gets exaggerated in hypovolemia. Larger changes are noticed when patient is lying on steep portion of the Frank-Starling curve.Systolic pressure variation (SPV) is calculated directly from arterial pressure waveform as SPV = maximum systolic pressure (SPmax) – minimum systolic pressure (SPmin) or as a percentage, SPV% = [(SPmax – SPmin)/ ½ (SPmax + SPmin)] × 100 . SPV caStroke volume variation (SVV) calculates the difference between SV during the inspiratory and expiratory phases of respiration . It wasPulse pressure is the difference between arterial systolic and diastolic pressures. It is influenced by SV and aortic compliance. As comparison of pulse pressures is done over a single respiratory cycle, change in arterial compliance is considered to be minimal. Pulse pressure variation (PPV) can be calculated either directly from the arterial waveform or it can be directly recorded by PiCCO . PPV% =Two large multicenter studies  have recently evaluated the utility of PPV and observed that PPV is suitable in 1 to 2% ICU patients only.Inferior vena cava (IVC) and superior vena cava (SVC) are distensible blood vessels. Their diameter and flow vary with respiration and the changes in size are exaggerated by hypovolemia.Unlike IVC, SVC has mainly an intrathoracic course. Positive pressure ventilation decreases its transmural pressure, and hence, SVC gets collapsed. SVC collapsibility index can be calculated using transesophageal echocardiography or esophageal Doppler and as cSVC = [(Dmax – Dmin)/(Dmax)] × 100. cSVC > 36% has been found to have AUC of 0.99 for predicting fluid responsiveness.However, there are some limitations of group A and B indices which restrict their applicability in critically ill patients, as mentioned belowPositive pressure, controlled ventilation, sinus rhythm, and large tidal volume ≥ 8 mL/kg are needed to ensure sufficient change in ITP for correct assessment of these indices.Further studies are needed to validate these indices in the setting of vasoactive drugs and in open chest or abdomen conditions.In scenarios like cardiac tamponade, RV failure, raised IAP, and arrhythmias.Morbid obesity and postlaparotomy conditions, assessment of IVC/SVC changes is difficult.Lifting legs in circulatory collapse has been used by first aid rescuers for many years. In passive leg raising (PLR), there is a gravitational transfer of around 300 mL blood from the lower part of the body toward the central circulatory compartment which acts as a fluid challenge. Moreover, any change in CO vanishes completely once the legs are returned back to horizontal position. Thus, PLR acts as a “self and reversible” volume challenge. PLR-induced change in aortic blood flow of 8 to 10% has been found to have AUC of 0.91 to 0.96 for predicting fluid responsiveness. Studies have shown that PLR-induced change in CO (PLR-cCO) is at least as accurate as PPV and is better than SVV and SPV for predicting fluid responsiveness.There are certain essential points that need to be kept in mind while doing PLR:PLR should start from semirecumbent position (and not from supine position).PLR effects must be assessed by direct measurement of CO (and not by simple measurement of BP).Technique used to measure CO must be able to detect the short and transient changes induced by PLR as effects of PLR may disappear after 1 minute.CO should be measured not only before and during PLR but also when patient is moved back to semirecumbent position to check return of CO to baseline.Avoid pain, cough, discomfort, and awakening-induced adrenergic stimulation .An algorithmic approach to assessment of fluid responsiveness has been shown inAdolf Fick described about CO estimation in 1870 for the first time. Until the introduction of PAC, Fick's principle was the reference standard for CO determination. Since the last decade, many noninvasive CO monitors have been introduced which do not require the introduction of PAC, as shown in the classification of CO monitoring devices inPAC is still the reference gold standard method which calculates CO using intermittent (or semicontinuous) bolus thermodilution (TD) method. Five to 10 mL cold saline (≤ 25°C) is injected into the RA which mixes with venous blood and cools down. Change in temperature is recorded in PA by a thermistor near the tip of the PAC. Thus, a TD curve is generated which calculates CO by Stewart-Hamilton equation. An average of three values is finally taken as CO. PAC also provides data regarding right atrial pressure, PA pressures, PAOP, and mixed venous oxygen saturation (SvO2). It has certain limitations, including invasiveness, possibility of complications while insertion, difficulty in data interpretation, and lack of evidence in favor of PAC. PAC still has limited use in the management and diagnosis of pulmonary hypertension, undifferentiated shock, cardiogenic shock, heart failure, and obscure hemodynamics .Esophageal Doppler monitors CO by measuring blood flow in the descending thoracic aorta. In sedated and MV patients, esophageal Doppler probe is introduced either by oral or by nasal route and fixed at 35 to 40 cm from teeth. The tip of the probe is then rotated to face the descending aorta. The characteristic velocity signal from the descending aorta appears as a swoosh sound. D-shaped piezoelectric crystal is present at the tip of the probe which acts as Doppler transducer and transmits sound waves either as 4 MHz continuous wave or as 5 MHz pulsed wave. Signals reflected back by red blood cells (RBCs) are then recorded to calculate Doppler shift.Estimation of aortic blood flow is done by measurement of velocity time integral (VTI). SV is then calculated by the formula, SV = VTI × cross-sectional area .There are certain assumptions in esophageal Doppler monitoring system which limits its applicability:Proportion of blood flow in ascending and descending aorta is assumed to be fixed and “flat” (same RBC speed).Aortic diameter is considered to be fixed during systole.Angle between ultrasound beam and blood flow is assumed to be fixed (45–60 degrees).A fixed proportion of 30% blood flow is thought to be diverted to the heart, brain, and limbs before reaching the descending thoracic aorta.Two different proprietary devices use transpulmonary TD (TPTD) techniques, namely: PiCCO  and VolumeView . These devices come in the category of minimally invasive devices as they are less invasive than PAC, which traverses through the pulmonary vasculature and calculates intermittent CO using thermistor lodged in the PA.TPTD is done for external calibration of system. Both central venous  cannulation and femoral/axillary artery cannulation are required. A known volume of ice cold saline injection is injected into the central vein and changes in blood temperature are recorded in femoral or axillary artery. TD curve is generated and CO is estimated from the curve using Stewart-Hamilton equation similar to PAC . Other important variables recorded are GEDV (preload), cardiac function index (contractility), extravascular lung water (EVLW), SVV, PPV and pulmonary vascular permeability index.After calibration by TPTD, pulse contour analysis is done which is based on the Windkessel model. This model states that the volume of blood entering a vessel of infinite length is equal to the volume of blood leaving that vessel over the period of cardiac contraction. During systole, vessels expand while during diastole, they contract. The aorta acts as a capacitor and systemic arterioles act as resistors.Z) of the aorta.Based on the relationship among BP, SV, arterial compliance, and systemic vascular resistance, SV is calculated as the area under systolic portion of arterial waveform as an integral of change in pressure (P) from end-diastole (t0) to end-systole (t1) over time and is inversely proportional to impedance  curve is generated from which CO is analyzed by Stewart-Hamilton equation. This method is as reliable as other TD methods but is unable to predict CO accurately in patients on neuromuscular blockers and those taking therapeutic lithium, and also, there are chances of anemia due to frequent blood sampling and overall lithium is costly.FloTrac system is also a pulse contour analysis method which includes FloTrac sensor and Vigileo monitor and requires only a peripheral arterial catheter  for CO estimation. It does not require any external calibration. A proprietary algorithm analyzes the arterial pressure waveform and samples it at 100 Hz and updates it every 20 seconds. Characteristics of the arterial waveform are then coupled with patient's demographics to calculate CO. This algorithm operates on the principle that pulse pressure is proportional to SV and inversely proportional to vascular compliance. Continuous self-calibration goes on by an automatic vascular tone adjustment property of software algorithm which eliminates the need for any external calibration.But FloTrac does not track changes in SV accurately and has poor agreement with PAC. This device is a noncalibrated device and may not be very suitable for prolonged use in critical care environment than for short-term use in operating rooms.2rebreathing system is used which consists of CO2infrared sensor, airflow/pressure pneumotachometer, pulse oximeter, and a disposable partial rebreathing loop. According to the Fick principle, CO is calculated by the following formula:Partial CO2/Change in CaCO2CO = Change in VCO2 = CO2clearance, and CaCO2 = arterial CO2content .where VCOHowever, this system measures only pulmonary capillary blood flow and is inaccurate in high shunt conditions. It is not applicable in low minute ventilation conditions and for spontaneously breathing patients.A high-frequency, low-magnitude electric current of known frequency and amplitude is applied across thorax and changes in voltage are measured. The ratio between voltage and current amplitude is then calculated to determine impedance (Zo). SV is proportional to product of maximal rate of change of Zo and ventricular ejection time (VET) . Electrical resistance of thorax is assumed to be directly related to intrathoracic blood volume.It is inaccurate in ICU settings . Moreover, Zo depends on electrode placement, body size, temperature, and humidity.Pulse wave analysis by finger-cuff  and pulse wave velocity (based on pulse wave transit time) are other noninvasive techniques to monitor CO but they have not been validated for clinical usage.Echocardiography is an important, noninvasive, repeatable, bedside tool to examine and monitor cardiac structure and functionPreload estimation (end-diastolic volumes)Fluid responsiveness indices: IVC/SVC assessment, left ventricular outflow tract VTI variation, and ascending aortic blood velocity/flow variation by pulsed wave DopplerSystolic and diastolic function of LV and RVOthers: Regional wall motion abnormality, valves, thrombus, and pericardial effusionTwo-dimensional echocardiography along with critical care ultrasonography is increasingly gaining importance in emergency and ICU settings for timely diagnosis and management of shock as shown by Kanji et al in 2014Normal CO is frequently mistaken to represent normal flow of oxygen to vital organs. However, both are not the same. To assess the balance between oxygen delivery and metabolic demand of tissues, indicators of tissue oxygenation like venous oximetry, blood lactates, and capillary refill time (CRT) are commonly used.Lactates are produced as an end product of glycolysis and are normally cleared out from the body by liver and kidneys. Hyperlactatemia is defined as serum lactate > 2 mmol/L and lactic acidosis is hyperlactatemia associated with metabolic acidosis (pH < 7.35).There may be various causes of hyperlactatemia besides tissue hypoperfusion. Therefore, it is essential to approach and manage hyperlactatemia in the appropriate clinical scenario.2) measured from central venous catheter with its tip at the junction of SVC and RA or mixed venous oxygen saturation (SvO2)  assesses the balance between oxygen delivery and consumption.2closely parallel that of SvO2in critically ill patients.2 < 70% indicates poor oxygen delivery to tissues. In 2001, the early goal-directed trial (EGDT) by Rivers et al showed a mortality benefit if ScVO2 > 70% was targeted as resuscitation endpoint.2 > 70% failed to show a mortality benefit pointing more toward the benefit of an individualized or personalized resuscitation strategy (focusing on early antibiotics and judicious fluid resuscitation) rather than focusing on a predefined and fixed target.Central venous oxygen saturation  and arterial blood (PaCO2). PCO2gap (PvCO2–PaCO2) > 6 mm Hg reflects poor regional blood flow.An example of COThe compensatory sympathetic activation in shock diverts blood flow away from skin to vital structures like brain and heart. Moreover, there is no autoregulation in blood vessels of skin. So, skin perfusion assessment in the form of skin mottling (around the knee)The recently conducted ANDROMEDA-SHOCK trialCirculatory shock often involves disturbances of microcirculation, which comprises of vessels < 100 μm in diameter including arterioles, capillaries, and venules. Derangements of microcirculation include heterogeneity of blood flow , reduced perfused vascular density, and impaired oxygen diffusion.Hemodynamic indices described above assess the macrocirculation  and failed to assess microcirculation. Some of the important tools for assessing microcirculatory markers of perfusion include laser Doppler to measure RBC velocity in small tissues, near-infrared spectroscopy, orthogonal polarization spectral, and side-stream dark field imaging and assessment of sublingual microcirculation (hand-held video-microscopy). However, these tools are still under research.Hemodynamic monitoring is an integral part of critical care. Its major role is to optimize administration of fluids and vasoactive drugs at the right time in the right dose titrated as per personal needs of the patient. Since the last couple of years, our awareness about fluid responsiveness is improving. Many advanced CO monitors have turned up for optimally evaluating a patient's hemodynamics and the field is continuously evolving. As such, there is no monitoring device which is ideal for all patients and a good physician should embrace a combination of bedside clinical examination and corroborate it with data obtained from all these hemodynamic monitoring methods for judicious management of critically ill patients.