Soluble lymphocyte activation gene 3 (sLAG3) may be used for diagnosis or prognosis in various diseases. However, the relationship between sLAG3 and coronary artery disease (CAD) are still unclear. This study aimed to investigate the levels of sLAG3 in patients with CAD, and its potential clinical association with the disease.A total of 66 subjects (49 patients with CAD and 17 control subjects without CAD) were enrolled. The sLAG3 level was measured using enzyme-linked immunosorbent assay (ELISA) kits. Clinical variables included demographics, biochemical markers, coronary angiography status, and ejection fraction of the heart (EF) were collected, and Gensini scores were calculated. LAG3 gene data was extracted from three datasets  in Gene Expression Omnibus (GEO) to compare differential expression between CAD and control subjects.P < 0.05), and negatively associated with CAD . Furthermore, the area under the curve (AUC) of sLAG3 level was significant (P < 0.05). The sLAG3 level in subjects with body mass index (BMI) ≥ 24 kg/m2 was lower compared to those with BMI < 24 kg/m2 (P < 0.05). The sLAG3 level was also negatively associated with BMI and diabetes mellitus (P < 0.05), though not associated with the Gensini scores or EF (P > 0.05). Lastly, the LAG3 gene expression in peripheral whole blood of patients with CAD were down-regulated compared to healthy controls (P < 0.05).The sLAG3 level was significantly lower in the CAD vs. the controls (The sLAG3 level was negatively associated with the occurrence but not severity of CAD. Meanwhile, the sLAG3 was negatively associated with BMI and diabetes mellitus, suggesting the reduced sLAG3 might be a novel risk factor for developing CAD. Coronary artery disease (CAD), a chronic inflammatory immune disease, is one of the leading causes of heart failure and death globally , 2. It iLymphocyte activation gene 3 (LAG3) is an immune checkpoint and transmembrane protein, which binds to major histocompatibility complex class II (MHC-II) and fibrinogen-like protein-1 (FGL1) as ligands for LAG3 –13. As aTo date, the use of sLAG3 has been confirmed in the diagnosis or prognosis of a variety of diseases including cancer –24. Goldn = 49; 38 men and 11 women, mean age 63.61 ± 11.42 years) and control . The diagnostic criteria of CAD were based on literature  kits according to the manufacturer’s instruction. The ejection fraction of the heart (EF) and clinical baseline characteristics were collected during hospitalization. The clinical baseline characteristics included age, gender, body mass index (BMI), lipids levels, the history of smoking, hypertension, and diabetes mellitus.Whole blood without anticoagulants was left for 2 h at room temperature or overnight at 41 were retrieved. The raw data were downloaded as MINiML files. The microarray data were normalized by the normalize quantiles function of the preprocessCore package in R software. Box plots were drawn using the “boxplot” R package, and the “ggord” package was used to draw the principal component analysis (PCA) plot. We extracted the LAG3 gene data from the three datasets and compared the difference in LAG3 gene expression in peripheral whole blood between the CAD and healthy control groups through the Wilcox test.Three datasets  from the Gene Expression Omnibus (GEO) databaset-tests between the two groups. Non-normally distributed variables were compared by Mann-Whitney U-tests between the two groups. The categorical variables were expressed as percentages and compared by the chi-square test or Fisher’s exact test. Logistic regression analyses were performed to identify associations of sLAG3 with CAD in different regression models. The receiver operating characteristic (ROC) curve analysis was used to evaluate the area under the curve (AUC) of sLAG3 for discriminating CAD.Normally distributed variables are presented as mean ± standard deviation (SD), whereas non-normally distributed variables were expressed as medians with the interquartile range (IQR). Normally distributed variables were compared by student’s P < 0.05 was considered statistically significant.Spearman’s correlation analysis was applied to determine the correlation between sLAG3 and the variables. Multiple line regression analysis was applied to assess the independent association between sLAG3 and clinical variables. Statistical analysis was performed by SPSS v26.0. P < 0.05). The BMI of patients with CAD was higher compared to the control group (P < 0.05). There were no significant differences in age, gender, or history of diabetes between the patient with CAD and control groups (P > 0.05). The levels of triglyceride (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were comparable between patients with CAD and the control group (P > 0.05).Baseline clinical characteristics of the CAD and control groups are presented in P < 0.05]. Moreover, we divided patients with CAD into acute and CCS groups, and found no significant differences in sLAG3 protein level between the two groups . After adjusting for hypertension and BMI, the sLAG3 was inversely associated with CAD . Additionally, after controlling for other variables including hypertension, diabetes, age, smoking, LDL-C, and HDL-C in different models, a lower sLAG3 level was also related to an increased risk of CAD  = 0.212, k of CAD .P < 0.05), the cut-off value for sLAG3 was 280 ng/mL, whereas the corresponding sensitivity and specificity were 0.941 and 0.490, respectively.The ROC curve was used to evaluate the diagnostic value of the sLAG3 level for CAD. As presented in P > 0.05). Spearman’s correlation analysis was used to determine the correlation between sLAG3 and EF from the ultrasound data of 43 subjects. There was no significant correlation between the sLAG3 level and EF (P > 0.05).We used Gensini scores to evaluate the severity of coronary artery lesions. Spearman’ s correlation analysis showed that the sLAG3 level did not correlate with the Gensini scores  and healthy controls (n = 26). We found that LAG3 gene expression in the peripheral blood of patients with CAD was down-regulated compared to the control group  can be found below: The studies involving human participants were reviewed and approved by the Ethics Committee of Guizhou Medical University Affiliated Hospital. The patients/participants provided their written informed consent to participate in this study.XX and HZ draft the manuscript. XX and ZD carried out the statistical analysis. LN, XX, and ZD participated in data collection and interpretation of results. ZL and WL contributed to discussion, edited the manuscript, designed, and supervised the project. All authors contributed to the article and approved the submitted version.


Reduced renal perfusion has been implicated in the development of septic AKI. However, the relative contributions of macro- and microcirculatory blood flow and the extent to which impaired perfusion is an intrinsic renal phenomenon or part of a wider systemic shock state remains unclear.Single-centre prospective longitudinal observational study was carried out. Assessments were made at Day 0, 1, 2 and 4 after ICU admission of renal cortical perfusion in 50 patients with septic shock and ten healthy volunteers using contrast-enhanced ultrasound (CEUS). Contemporaneous measurements were made using transthoracic echocardiography of cardiac output. Renal artery blood flow was calculated using velocity time integral and vessel diameter. Assessment of the sublingual microcirculation was made using handheld video microscopy. Patients were classified based on the degree of AKI: severe = KDIGO 3 v non-severe = KDIGO 0–2.p < 0.05), and reduced wash-in rate (WiR)  and perfusion index (PI) ; differences persisted throughout the entire study. Conversely, there were no differences in either cardiac index, renal blood flow or renal resistive index. Sublingual microcirculatory variables were not significantly different between groups at study enrolment or at any subsequent time point. Although lactate was higher in the severe AKI group at study enrolment, these differences did not persist, and there were no differences in either ScvO2 or ScvCO2-SaCO2 between groups. Patients with severe AKI received higher doses of noradrenaline . Linear regression analysis showed no correlation between mTT and cardiac index (R-0.18) or microcirculatory flow index (R-0.16).At study enrolment, patients with severe AKI (37/50) had prolonged CEUS mean transit time (mTT) (10.2 vs. 5.5 s, Renal cortical hypoperfusion is a persistent feature in critically ill septic patients who develop AKI and does not appear to be caused by reductions in macrovascular renal blood flow or cardiac output. Cortical hypoperfusion appears not be associated with changes in the sublingual microcirculation, raising the possibility of a specific renal pathogenesis that may be amenable to therapeutic intervention.Trial Registration Clinical Trials.gov NCT03713307, 19 Oct 2018. Septic shock is one of the commonest causes of acute kidney injury (AKI) in critically ill patients and is associated with a mortality of approximately 50% , 2. SeptContrast-enhanced ultrasound (CEUS) is an emerging imaging technique in the field of critical illness using highly echogenic but inert microbubbles to delineate areas of microvessel perfusion within organs. When given by infusion, high-frequency ultrasound pulses destroy the microbubbles allowing the creation of time intensity curves during subsequent reperfusion. Both experimental data  and clinThe aim of the current study is to examine renal cortical perfusion using CEUS in a larger cohort of patients with septic shock, alongside detailed measurement of cardiac output, renal blood flow and flow in the sublingual microcirculation in order to further develop our understanding of the pathogenesis of this important condition.A single-centre prospective longitudinal observational study is carried out at a tertiary critical care centre in the United Kingdom. Serial assessments were made of the renal and systemic macro- and microcirculatory state using CEUS, transthoracic echocardiography and sublingual video microscopy at 4 time points: Day zero (D0) within 24 h of ICU admission, D0 + 24 h (D1), D0 + 48 h (D2) and D0 + 96 h (D4). The study protocol was published prior to data analysis .Ethical approval was granted by Yorkshire and the Humber, Leeds West Research Ethics Committee (18/YH/0371).AKI was staged using KDIGO criteria . Common Only adult patients (> 18 years) were included. Patients were also required to have met all of the following criteria: To be within 24 h of admission to the ICU, have evidence of suspected or confirmed infection a Serial Organ Failure Assessment (SOFA) score increase of 2 or more a vasopressor requirement to maintain a mean arterial blood pressure of 65 mmHg and an arterial blood lactate of > 2 mmol/L after initial fluid resuscitation.Patients were excluded from the study if they had stage four chronic kidney disease or worse, a renal transplant, contraindication to SonoVue™  contrast or if the intent of treatment was primarily palliative. Pulmonary hypertension, a relative contraindication to SonoVue, was measured with transthoracic echo prior to administration of contrast and withheld if the pulmonary artery systolic pressure was > 90 mmHg.. Based on an estimated difference in perfusion index of 1000 au between groups (AKI present and AKI absent) and on a standard deviation (SD) of 1000 au and assuming a power of 90% and alpha of 0.05, 22 patients in each group (n = 44) were estimated to detect a difference in perfusion index, assuming approximately 50% of patients with septic shock develop AKI. In order to address potential for missing data, unequal groupings or refusal of retrospective consent, the population size was set at 50.The sample size was derived from a power calculation, although the published CEUS data from critically ill patients was limitedRenal ultrasound was performed using an Affiniti ultrasound system . After conventional grayscale US imaging using the Philips C5-1 transducer at the patient’s flank, any patient with ultrasonographic evidence of CKD was excluded and the most accessible kidney chosen to perform the study provided both kidneys appeared normal . Baseline greyscale and colour Doppler sonographic images were acquired and the renal resistive index measured in an intralobular artery as described elsewhere . For CEUImages of the entire examination were digitally recorded. When delivered centrally, contrast typically arrives in the kidney at approximately 45 s, after which the kidney continues to enhance until approximately 1 min to 1 min 30 s. By 2 min a steady state of contrast enhancement was reliably achieved and the kidney was not further enhancing. Five high-frequency pulses were subsequently delivered, one every 30 s. Microbubbles are destroyed immediately on pulsing, followed by reperfusion of bubble contrast and these destruction-replenishment cycles were used to model perfusion-based indices.Post-processing was performed offline using VueBox™ . Cortical regions lying in proximity to the probe with good views and reliably visible reperfusion were identified as regions of interest. Time intensity curves (TIC) were produced with several key components as shown in Fig. The plateau of peak intensity minus the background signal is termed the Relative Blood Volume (RBV) and is reflective of the total volume of the vascular space within the ROI. The maximal gradient of the wash-in slope is termed the wash-in rate (WiR) and the time taken to reach half-maximum signal intensity the mean transit time (mTT). Perfusion index (PI) is a composite variable produced by the division of RBV by mTT and aims to provide a single number representing tissue perfusion.Following completion of the CEUS protocol the contrast infusion rate was reduced to 0.5 mL/min to provide more time and reduced intensity, which provided optimal images of the renal artery. The diameter of the renal artery was measured on a magnified contrast-enhanced view. Pulsed wave Doppler was then used to quantify time-averaged velocity (TAV) within the renal artery at the same location as the diameter measurement. TAV is the area under the Doppler time curve per pulsed waveform. Quantification of renal blood flow was calculated using the following equation:entclass1pt{minimaVideos of sublingual microcirculation were acquired using an Incident Dark Field (IDF) video-microscope . Acquisition and analysis of video sequences were carried out by a single operator in accordance with the most recent international consensus criteria .A comprehensive transthoracic echocardiogram study was performed in order to gather the minimum dataset required by the British Society of Echocardiography (BSE) . A singlThe original intent, outlined in the published protocol was to analyse patients according to the presence or absence of AKI. However, the vast majority of the cohort exhibited at least some degree of AKI (KDIGO stage ≥ 1) ,and we therefore changed our primary outcome from that published in the protocol, prior to data analysis, based on the presence or absence of severe AKI (KDIGO 3 v KDIGO 0–2).p values were two-sided and considered significant at < 0.05.Continuous data were examined for normality using the Shapiro Wilk test and parametric data reported as mean ± standard deviation (SD) and compared using the non-paired t test. Nonparametric data are reported as median and inter-quartile range (Q1–Q3) and compared using the Wilcoxon rank-sum test. Ordinal data was reported as number and percentage and compared using Chi-squared test. Longitudinal data were compared between individual days using analysis of variance and post hoc testing undertaken by Tukey’s Honest Significant Differences if normal or Kruskal–Wallis test if nonparametric. Longitudinal trends over time were assessed using regression analysis, either linear or local regression, stated within the results. Data were normalised by log or Cox-Box transformation where appropriate. All data were assessed using R version 4.0.3. All Fifty-one patients were recruited, but one subsequently withheld consent for data analysis. Thirty-seven (74%) were classified as KDIGO stage 3, four (8%) stage 2, 2(4%) stage 1, and seven (14%) did not develop AKI. Provided the patients remained alive for the study duration, CEUS imaging was achieved in all and at all time points. There were no adverse events from contrast administration. In the severe AKI group, five patients had died by D1, six by D2 and ten by D4. In the non-severe group, no patients died. All conducted observations were included in the final analysis. Baseline characteristics of the study patients are shown in Table Thirty-three patients (89%) in the severe AKI group were diagnosed as such within the first 24 h of admission, the remaining four patients were diagnosed over the following four days of the study period. Thirty (81%) of the severe AKI group received renal replacement therapy within the first 24 h of admission and of those 30 patients, 26 could also have been classified as stage 3 AKI by either urinary or biochemical measurements taken within in the day of ICU admission.The suspected site of infection was predominantly from gastrointestinal perforation or infarction (31%); other causes included lower respiratory tract infection (26%) and urological sepsis (8%). No site was identified in 13%. No causative organisms were grown in 35% of cases. In the remainder, gram negative bacteria predominated (33%), followed by gram positive bacteria (20%) and fungal infection (8%).Cortical CEUS parameters for healthy volunteers and patients with and without severe AKI are shown in Fig. Systemic and regional haemodynamic measurements for patients with and without severe AKI are shown in Table 2 gap) are shown in Table Sublingual microcirculatory variables and surrogate markers of tissue perfusion  and markers of macro- and micro-circulation and surrogates of tissue perfusion are shown in Table p = 0.06) and 0.03 (p = 0.334), respectively.Correlation coefficients were calculated for both MFI and cardiac index and PVD and cardiac index. Neither demonstrated a significant correlation, correlation coefficient (R) 0.07 (For the first time, in a clinical setting, we report an assessment of blood flow and perfusion in the kidney and in a separate microcirculatory bed, alongside measurements of regional and systemic macrovascular blood flow. The principal finding of the current study is that in patients with septic shock the severity of acute kidney injury was related to the degree of renal cortical hypoperfusion and that this hypoperfusion did not appear to be associated with alterations in regional or systemic blood flow.Our findings build on previous experimental and clinical studies. Lima and colleagues, using a porcine model of induced sepsis, demonstrated that both renal and sublingual microcirculatory impairment persisted after normalisation of cardiac output . However2 differences normalised rapidly and did not differentiate between AKI severity suggest that the principal mechanism driving cortical hypoperfusion may be, at least partially, intrinsic to the renal circulation. These findings, alongside those showing no correlation between renal cortical perfusion and either cardiac output or renal blood flow, are clinically important suggesting that any attempt at preventing or ameliorating the effects of AKI in septic patients' needs to focus on blood flow within the renal cortex itself, as therapies directed at other endpoints may prove ineffective. We also noted marked heterogeneity of cortical blood flow, even in patients with similar degrees of AKI, suggesting that therapeutic interventions would be best targeted on an individual patient basis rather than in a “one size fits all” approach.Our findings suggest that although microcirculatory impairment was initially apparent in both the renal and sublingual microcirculations, those in the kidney were both more severe and persistent. The finding that other clinically utilised markers of systemic hypoperfusion, such as lactate, central venous oxygen saturations and venous—arterial COThe apparent lack of correlation between alterations in renal cortical blood flow and changes in the sublingual microcirculation circulation further suggest that the mechanism of cortical hypoperfusion observed in septic AKI may be at least partially caused by factors intrinsic to the kidney rather than a feature of a more generalised endotheliopathy. Histopathological changes reported in septic AKI are also less than expected, particularly given the severe clinical phenotype often observed, which further suggests a predominately functional cause , 19. TheIn addition to the afferent and efferent arteriolar tone, renal perfusion pressure could contribute to alterations in cortical perfusion. In the present study, patients with severe AKI were on higher doses of noradrenaline than those in whom it did not develop. Whether noradrenaline reduces cortical perfusion is unclear. Schneider et al. studied the renal effects of noradrenaline using CEUS and demonstrated marked heterogeneity, some patients demonstrated improved perfusion, while others worsened . NoradreCEUS for the assessment of renal perfusion in critically ill patients is a new and emerging technique which has the potential to allow investigators a real-time window on renal perfusion, allowing rapid assessment of the efficacy of therapeutic interventions in individual patients. Perfusion CEUS has been adapted from a technique used to delineate vascular structures in solid organs and as such the variables reported in the present study are relatively novel. As perfusion CEUS becomes increasingly used as a research tool investigators should seek consensus on the standardisation of image acquisition and analysis.We suggest that infusion with destruction-replenishment kinetics should become the standard technique in the assessment of tissue perfusion, as opposed to bolus administration of contrast which generates indicator dilution curves with significant confounding influences from global and regional blood flow. Of the CEUS variables recorded in the current study those based on intensity such as relative blood volume are limited by multiple patient and technical factors and have previously performed poorly in reliability studies, with intra and inter-individual variability . In the Perfusion index and wash-in rate demonstrated extreme collinearity in the present study, and we suggest that one variable would therefore suffice in future studies. Mean transit time is less dependent on factors such as organ depth and gain settings . As expeWe were unable to demonstrate associations between macrovascular variables such as cardiac index and microcirculatory flow in either the renal or sublingual microcirculation. To our knowledge, this is the first clinical study to demonstrate haemodynamic incoherence of two separate regions and strengthens the argument supporting independence of large vessel flow and tissue oxygen delivery in shocked states .Our study has several limitations. Although the sample size was larger than any previous clinical study, it was conducted at a single site on a relatively small number of patients. We had to change our a priori outcome from AKI or no AKI after the vast majority of patients developed at least KDIGO stage 1 AKI. Furthermore, our study cohort was heavily skewed towards those with KDIGO 3 AKI, principally due to the early commencement of renal replacement therapy following admission to critical care. We included healthy controls but did not include data from non-septic critically ill patients. The healthy control data were essential to define normal values with this exploratory method, and we accept the results are therefore specific to septic AKI. Measurement of medullary blood flow is inherently difficult due to the complex nature of large vessels in the vicinity of regions with critical perfusion. As such we could not confidently report medullary perfusion alterations and the study of this important tissue bed requires further work. The variables we have used to measure cortical perfusion are relatively exploratory and correlation to a gold standard, such as functional MRI would help validate this technique. Finally, the use of ultrasound, as opposed to direct invasive measurement, to assess renal blood flow has been criticised; we attempted to overcome this limitation by utilising the presence of contrast medium to more accurately measure the diameter of the renal artery. In addition, we calibrated our method using healthy volunteers; the mean measured RBF in the volunteer cohort and the assumed normal value for RBF of 1.2 l/min were used to generate a constant. The constant was then multiplied by the measured RBF in the patient cohorts; however, we accept that this is an unproven technique.Renal cortical hypoperfusion is a persistent feature in critically ill septic patients who develop AKI and does not appear to be caused by reductions in macrovascular renal blood flow or cardiac output. Cortical hypoperfusion appears not be associated with changes in the sublingual microcirculation, raising the possibility of a specific renal pathogenesis that may be amenable to therapeutic intervention.


Ankle-brachial index (ABI) is commonly used for screening lower extremity peripheral artery disease (PAD) according to the international guidelines. Arterial Doppler waveform recordings is a tool to diagnose and assess PAD severity. We hypothesized that ABI measurement could be simplified by measuring only the pressure where the best arterial flow is recorded. The aim of this study was to evaluate the concordance between ABI performed according to the American Heart Association guidelines (AHA-ABI) and ABI measured according to best arterial waveform (FLOW-ABI).This was a monocentric cross-sectional study.We included patients with exertional limb symptoms suspected of PAD. Arterial Doppler waveforms and ABI were acquired on both lower extremities at the pedis and tibial posterior arteries. Each arterial waveform was classified using the Saint-Bonnet classification. Concordances were analyzed with the kappa coefficient . Exercise PAD study was registered n° NCT03186391.2) with exertional limb symptoms were included from May 2016 to June 2019. On each extremity, FLOW-ABI had excellent concordance for the diagnosis of PAD with the AHA-ABI with a kappa of 0.95  in the right extremity and 0.91  in the left extremity.In total, one hundred and eighty-eight patients (62+/−12 years and 26.8+/−4.5 kg/mThere is almost perfect concordance between AHA-ABI and FLOW-ABI. Thus, ABI can be simplified into five pressure measurements instead of seven in patient suspected of PAD with exertional limb symptoms. The question remains in patients with chronic limb ischemia. Lower extremity peripheral artery disease (PAD) is one of the most common diseases with a major cardiovascular morbi-mortality, particularly in developed countries . Its preAmerican Heart Association to standardize the procedure  at rest by dividing the highest of the two arterial pressures of the two ankle arteries by the highest brachial pressure between both arms –8. To berocedure . The ABIrocedure . Indeed,rocedure  whereas rocedure –16. A siThe arterial flow analysis of the Doppler waveform is as well an interesting tool for the arterial hemodynamic evaluation , 17, 18,We hypothesized that the highest arterial pressure in each extremity is located on the distal artery with the best arterial Doppler waveform; thus, ABI measurement might be simplified by measuring only five pressures instead of the seven as proposed by the AHA and other international guidelines , 11, 21.The main objective of this study was to analyze the concordance for the diagnosis of PAD between the ABI measured with the AHA method (AHA-ABI) and ABI measured considering the pressure in the artery with the best Doppler waveform (FLOW-ABI) to simplify the measurement in clinical practice.This is a retrospective study on consecutive patients suspected of PAD with exertional limb pain referred between May 2016 and June 2019 to our vascular center in the University Hospital of Rennes, France .The study was approved by an institutional review board from the University Hospital of Rennes , 17. AllPatients were included if they had full data available including arterial Doppler waveform and ABI measurements available for both extremities.We collected all the medical history including age, sex, body mass index, comorbidities, and medications .Patients were at rest in a comfortable temperature room (20–22°C) for at least 20 min, in a supine position prior to testing . ArteriaThe AHA-ABI was calculated as proposed by AHA guidelines: “During the sequence of measurement, the first measurement should be repeated at the end of the sequence and both results averaged to temper the white coat effect of the first measurement, except if the difference between the 2 measurements of the first arm exceeds 10 mmHg. In that case, the first measurement should be disregarded and only the second measurement should be considered. For example, when the counterclockwise sequence — right arm, right posterior tibial artery (RPTA), right dorsalis pedis artery (RDPA), left posterior tibial artery (LPTA), left dorsalis pedis artery (LDPA), left brachial artery — is used, the measurement of the right arm should be repeated at the end of the sequence and both results obtained at the right arm should be averaged unless the difference between the 2 measurements of the right arm exceeds 10 mm Hg. In this case, only the second measurement of right arm pressure should be considered” , 12.The FLOW-ABI was obtained by dividing the pressure of the lower extremity artery with the best Doppler waveforms by the highest brachial pressure between both arms. In the case of similar Doppler waveform between the posterior tibial artery (PTA) and the dorsalis pedis artery (DPA), we used the posterior tibial artery by default.The last three types  were grouped together due to their small numbers to have a significantly large group for comparison.® .The results are expressed as mean ± standard deviation in the case of normal distribution (Shapiro–Wilk test) or in median [25th centile and 75th centile] in the other cases. The Kruskal– Wallis test (KW) was used for the comparisons between the ankle blood pressures and the Saint-Bonnet Doppler waveform types, analyzing independently each limb. The concordance between the AHA-ABI and the FLOW-ABI for the diagnosis of PAD was assessed using the Kappa coefficient expressed with a confidence interval of 95% for the right and left limbs. A second analysis was performed in a subgroup of limbs that had different Doppler waveform types. The Landis and Koch interpretation of kappa values was used: 0.21–0.40: fair; 0.41–0.60: moderate, 0.61–0.80: substantial; >0.80: almost perfect . Correlan = 71).Among 259 patients suspected of PAD with exertional limb symptoms, 188 patients were included as shown in Baseline characteristics are presented in The Doppler waveforms were the same between ipsilateral limbs arteries in 138/188 in the right limb (73.4%) and 143/188 in the left limb (76.1%).p-value < 0.05 for each artery of each limb. However, no statistical difference appears between the arteries classified N and A (p > 0.05). When the N pressures are compared with the ones classified B, only the two tibial posterior arteries are significantly different.Significant difference between the best Doppler waveform type (N according to the Saint-Bonnet classification) and the pressures from the arteries classed in the three last types of the classification  was found with a The analysis of the concordance between the AHA-ABI and the FLOW-ABI shows an excellent concordance rating PAD/no PAD with a kappa value equal to 0.95  for the right limb and 0.91  for the left limb. The contingency tables are reported in Medians of differences of ABI value between the two methods were 0.09  for the right limb and 0.13  for the left limb excluding one patient with outlier values. Indeed, one patient with diabetes had different values according to the two methods (0.45 vs. 1.57). The discordant patients' values are available in . For the limbs with different waveforms, coefficients of correlation between AHA-ABI and FLOW-ABI were 0.99 and 0.99 for the right and leftlimbs, respectively.We found a high correlation between AHA-ABI and FLOW-ABI on both lower extremities  with a SAnkle-brachial index is an important diagnostic tool for PAD, but it is a time-consuming method with seven measures of pressure to perform when clinicians follow the AHA guidelines . To our This result may have a strong impact in clinical practice by permitting the measurement of only one artery on each limb, the one with the best Doppler waveform, saving time and allowing the increased use of ABI, in particular among general practitioners. Indeed, physicians from various countries have not adopted, in common practice, this measurement in primary care practices , 31. TheThe other interest of simplifying the ABI measurement might be about the education of medical students and residents. Indeed, studies have demonstrated that learning how to measure ABI is challenging  and not Moreover, this study confirms that the best pressure matches with the best Doppler waveform and conversely. This supports the importance of harmonization and definition of the arterial Doppler waveforms using a standardized classification. Indeed, various papers from different countries  found heterogeneity in Doppler waveform descriptions if no classification was used , 36–38. Our study has several limitations. First, the present results were found in patients with exertional limb symptoms and suspected of PAD. Thus, we cannot ascertain that similar results will be found in asymptomatic patients or in patients with critical limb ischemia. Second, the use of the posterior tibial artery by default in case of similar waveform categorization may be a bias. However, there is a trend in clinical practice to measure more pressure on the posterior tibial artery than on dorsalis pedis artery. Furthermore, although the artery caliber between both arteries does not appear significantly different in several studies , 40, theOur study shows that ABI measurement using FLOW-ABI is as accurate as the AHA-ABI method for the diagnosis of PAD. The FLOW-ABI might replace the AHA-ABI in patients with exertional limb symptoms and suspected of PAD. Further studies with an external validation of these criteria seem useful to confirm our findings in a global population and the benefit in practice.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Institutional Review Board from the University Hospital of Rennes , 17. TheStudy design: AM, GM, and ALF. Data collection: AM, QT, GM, and LO. Data analysis: AM, ELP, DL, and GM. Writing: AM and GM. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Hemodynamic instability is frequently present in critically ill patients, primarily caused by a decreased preload, contractility, and/or afterload. We hypothesized that peripheral arterial blood pressure waveforms allow to differentiate between these underlying causes. In this in‐silico experimental study, a computational cardiovascular model was used to simulate hemodynamic instability by decreasing blood volume, left ventricular contractility or systemic vascular resistance, and additionally adaptive and compensatory mechanisms. From the arterial pressure waveforms, 45 features describing the morphology were discerned and a sensitivity analysis and principal component analysis were performed, to quantitatively investigate their discriminative power. During hemodynamic instability, the arterial waveform morphology changed distinctively, for example, the slope of the systolic upstroke having a sensitivity of 2.02 for reduced preload, 0.80 for reduced contractility, and −0.02 for reduced afterload. It was possible to differentiate between the three underlying causes based on the derived features, as demonstrated by the first two principal components explaining 99% of the variance in waveforms. The features with a high correlation coefficient (>0.25) to these principal components are describing the systolic up‐ and downstroke, and the anacrotic and dicrotic notches of the waveforms. In this study, characteristic peripheral arterial waveform morphologies were identified that allow differentiation between deficits in preload, contractility, and afterload causing hemodynamic instability. These findings are confined to an in silico simulation and warrant further experimental and clinical research in order to prove clinical usability in daily practice. In this in‐silico simulation study, characteristic peripheral arterial pressure waveform morphologies were identified that allow differentiation between deficits in preload, contractility, and afterload causing hemodynamic instability. As a starting point, a hemodynamically unstable 60‐year‐old adult with a MAP of 60 mmHg was chosen, either caused by a reduced preload, contractility, or afterload. Next, per underlying cause the input variables HR, LVC, and SVR were gradually increased, and VC decreased, separately until recovery from hemodynamic instability. Recovery was defined as a MAP of 70 mmHg; when blood pressure did not increase to this level, a maximum increase or reduction of 100% of the baroreflex variable was used. For obvious reasons, LVC was not increased in the scenario of reduced contractility, since this simply removes the underlying cause, and the same holds for SVR in the reduced afterload scenario and VC in the reduced preload case.Additionally, the effect of spontaneous ventilation on the arterial waveforms was studied by performing the same initial simulations of a 60‐year‐old adult with hemodynamic instability, but now breathing with a respiratory rate of 11/min and a tidal volume of 0.5 liter.2.2® software . First, a single heartbeat from the pressure waveform was selected and five fiducial points to specify waveform morphology were detected  and flow waveforms (in ml/s) generated by Aplysia with a sample frequency of 400 Hz were analyzed using MATLABThe systolic peak was defined as the maximum pressure during a heartbeat, diastolic end as the minimum pressure after the systolic peak. The dicrotic notch marks the end of systole and the beginning of the diastolic phase  was performed to investigate whether it is possible to distinguish the three main underlying causes of hemodynamic instability based on arterial waveforms. The raw waveforms of the 60‐year‐old adult with stepwise decrease of BV, LVC, and SVR were used as input for the PCA. The correlation coefficient plotted against time shows which phases of the waveform are most important for differentiation. Next, the calculated arterial waveform features were used as input for the PCA. The correlation coefficient then shows the most important features. The same PCA was performed with all simulated adult cases with different ages and stepwise decrease of BV, LVC, and SVR.33.1In total, 212 waveforms were generated; as examples, the absolute and normalized waveforms of the three scenarios  with a MAP of 60 mmHg are shown in Figure In Figure The results of the addition of baroreflex compensatory mechanism to the 60‐year‐old adult case with MAP of 60 mmHg can be seen in Figure 3.2A selection of the results of the sensitivity analysis are displayed in Table Respiratory variation did not significantly affect the waveform features. The relative standard deviation of the features during 60 s of spontaneous breathing did not exceed 5% of the mean.3.3The first PCA was performed only on the waveforms of the control 60‐year‐old adult, with stepwise reduction of BV, LVC, and SVR. The PCA of the raw signals resulted in a first principal component (PC) explaining 97.5% and a second PC explaining 2.4% of the variation between the arterial waveforms. The correlation coefficient of the first PC is the highest in the systolic downstroke and the second PC is maximal during the systolic upstroke and systolic peak pressure physiological underpinning. In addition, it can be inferred from the sensitivity analysis that several waveform features are sensitive for hemodynamic instability, with reducing blood volume having the greatest impact on the waveform. Even with the imposed respiratory variation of spontaneous breathing, the waveform features of a single heartbeat are sufficiently stable as based on the proposed analysis. While other experimental studies only investigated a single facet of HD instability, data from this study allow to identify those features discriminating between preload, contractility, and afterload deficiency. As clearly reflected in the PCA, a combination of the features with the highest correlation coefficients enable the differentiation between underlying causes. Importantly, the more severe the HD instability, the more the principal components diverge from each other, thus the clearer the differentiation.Our novel approach of peripheral arterial waveform analysis allows to discriminate underlying causes of HD instability within one simulated individual, but is limited when comparing individuals. PCs of simulations of varying ages are not unique for elements of HD instability in different individuals. In addition, differentiation between the three primary causes of HD instability is less clear in young patients, since they have more compliant vessels and therefore less wave reflection. This is also noted by the results from the Framingham heart study, showing a more prevalent dicrotic notch in younger individuals . Besides, in septic shock a complex combination of pathophysiological mechanisms is often present, causing a dynamic combination of relative hypovolemia, vasoplegia, and septic cardiomyopathy. Nevertheless, when the effect of distinct single causes of hemodynamic instability on the arterial waveform is well known, the contribution of these pathological elements to complex real‐life cases could more easily be unraveled.The Aplysia CardioVascular Lab was used in this study, which realistically simulates peripheral pressure waveforms, though there are some inherent shortcomings. It is a comprehensive and complex model of the human cardiovascular system, therefore, it is virtually impossible to determine all its parameters with clinically available measurements. Several assumptions, model simplifications, and non‐modelled parameters are used, so Aplysia only approaches real human hemodynamics. However, some specific (patho)physiological states were validated using clinical and experimental data, showing comparable results (Broomé et al., 4.3There is a demand for more personalized and pathophysiology based medicine in the ICU (Vincent et al., In combination with focused bedside echocardiography, arterial waveform analysis can be a powerful tool to continuously assess ventriculo‐arterial coupling. Additionally, specific waveform features can be used to set individual hemodynamic targets in conjunction with information on, for example, right ventricular function and interventricular dependency as readily assessable by echocardiography.Importantly, the algorithms used in this study include well‐defined, straightforward analyses and could thus possibly be automated and included into existing modern monitoring devices, including HD monitors and echocardiography devices. Such a comprehensive HD monitoring strategy may lead to a more insightful, patient‐specific management and it is tempting to speculate whether this approach will also translate into an improvement of clinical outcome measures related to the ICU stay.5The proposed approach allows identifying distinct peripheral arterial waveform morphologies and differentiate between preload, contractility, and afterload deficits as causes of hemodynamic instability. These findings set the stage for improved, individualized strategies towards easily‐accessible, continuous, and comprehensive hemodynamic monitoring at the bedside. Further experimental and clinical research is warranted to advance the proposed algorithms and ultimately prove their usability in clinical practice to optimize daily management in critically ill patients.MB is the founder and owner of the company Aplysia Medical AB, Stockholm, Sweden, having the commercial rights of the simulation model and software used in this work. The other authors have no conflicts of interest to declare.MM and BW conceived the idea and designed the study. MB developed and improved the model. MM performed the simulations, analyzed the data, and wrote the manuscript. All authors discussed the results and drafted, reviewed and accepted the manuscript.


Cardiovascular diseases (CVDs) are the leading cause of mortality globally with almost a third of all annual deaths worldwide. Low- and middle-income countries (LMICs) are disproportionately highly affected covering 80% of these deaths. For CVD, hypertension (HTN) is the leading modifiable risk factor. The comparative impact of diagnostic interventions that improve either the accuracy, the reach, or the completion of HTN screening in comparison to the current standard of care has not been estimated.This microsimulation study estimated the impact on HTN-induced morbidity and mortality in LMICs for four different scenarios: (S1) lower HTN diagnostic accuracy; (S2) improved HTN diagnostic accuracy; (S3) better implementation strategies to reach more persons with existing tools; and, lastly, (S4) the wider use of easy-to-use tools, such as validated, automated digital blood pressure measurement devices to enhance screening completion, in comparison to the current standard of care (S0). Our hypothetical population was parametrized using nationally representative, individual-level HPACC data and the global burden of disease data. The prevalence of HTN in the population was 31% out of which 60% remained undiagnosed. We investigated how the alteration of a yearly blood pressure screening event impacts morbidity and mortality in the population over a period of 10 years.The study showed that while improving test accuracy avoids 0.6% of HTN-induced deaths over 10 years , almost 40 million  are the leading cause of mortality globally, affecting low- and middle-income countries (LMICs) disproportionally highly.Hypertension (HTN) is the leading modifiable risk factor for CVDs.The diagnosis of HTN and thus the access to treatment is hampered by the necessity of at least one repeated measurement for a final diagnosis and the operator-dependent variability of blood pressure measurement.It is unclear which strategies would be the most impactful to close the diagnostic gap: more accurate, easy-to-use and/or more scalable tools or better implementation strategies to reach more persons with existing tools.We developed a stochastic microsimulation model that examines the impact of possible diagnostic interventions and implementation strategies on HTN-induced morbidity and mortality in LMICs.The different scenarios were applied over a period of 10 years and affected the individual risk of experiencing a CVD event.While improving test accuracy avoids only 0.6% of HTN-induced deaths over 10 years, scaling up test coverage and completion can avoid almost 40 million HTN-induced CVD events and 14 million (13.7%) related deaths.This simulation demonstrates the importance of increasing the coverage of testing for HTN and the improvement of screening completion over diagnostic accuracy of HTN testing.Strategies to narrow the diagnostic gap in HTN should put more emphasis on screening completion. Cardiovascular diseases (CVDs) are the leading cause of mortality globally; an estimated 17.9 million people die each year, which makes up about 32% of all annual deaths worldwide . The ageThese limitations contribute to the diagnostic gap (approximately 61%), denoting the percentage of people with HTN not having completed their second measurement and being diagnosed . To imprThis simulation study aims to estimate impact on morbidity and mortality from HTN through altering the diagnostic accuracy of HTN tools or increasing the coverage of screening for hypertension to achieve more active outreach and follow-up compared to the current standard of care.This study is reported as per the “Strengthening the reporting of empirical simulation studies (STRESS)”  10]..10].In this simulation study, we followed an artificial population representative for LMICs with respect to incidence of HTN and CVD over a period of 10 years. Every person has individual characteristics, e.g., sex or blood pressure; thus, using a microsimulation model, we were able to track each individual’s health status independently. We investigated the effect of blood pressure screening on the total number of CVD events and the resulting deaths within the population. We considered different scenarios that assumed improved accuracy or improved coverage and/or completion of screening for HTN, which is two consecutive blood pressure measurements, and compared them to the status quo. We describe the flow through the model in In this microsimulation, we aimed at simulating an artificial LMIC population aged 30 years and older, accounting for the fact that HTN is less prevalent in the younger generation.Stratified by gross national income class, this would result in a population size of 3.15 billion (low-income countries (LICs): 167,113,750; lower-middle-income countries (LoMICs): 1,360,371,000; upper-middle-income countries (UMICs): 1,621,405,000). See Section A in The characteristics of the individuals composing the LMICs population were sampled from a cross-sectional study of nationally representative, individual-level data in LMICs , in the We further assigned each individual a systolic blood pressure, as the systolic blood pressure was shown to be the better determinant of CVD risk than the diastolic blood pressure ,14. The Every individual was also assigned a date of death independent of CVD events. These time points were sampled by means of a Weibull distribution with mean set to the life expectancy in the respective income group  and a pThe mathematical risk function for experiencing a CVD event was calculated from a sex-specific Cox proportional-hazard regression  blood pressure measurement for final diagnosis. Each year the proportion of the coverage was selected randomly from the population to undergo a first blood pressure measurement. From this subgroup, a proportion was enabled to complete the screening event by a second blood pressure measurement and get diagnosed with probability depending on the different screening scenarios modeled (see below). Individuals with a higher CVD risk were more likely to complete their screening event  and then performed the simulation cycle 10 times for the specific scenarios (S0 to S4). A person may experience at most one CVD event within a year. At the end of the simulation period, we investigate endpoints to compare the impact of different screening scenarios over the period of 10 years . The resWe assumed that the sensitivity and the specificity of the HTN blood pressure measurement was 87% and 85%, respectively, for the baseline case . The covThe percentage of the population not having received a diagnosis is denoted as diagnostic gap and was estimated by Geldsetzter and colleagues to be 60.8% in the population with HTN . Thus, 3This scenario was supposed to model the current performance of the HTN screening event under routine implementation conditions. We chose the lower bound of the confidence interval of the blood pressure measurement accuracy  represeFor increased accuracy of the screening event, we chose a sensitivity and specificity of 93% and 95%, respectively. This is likely to require wider use of automated, digital devices or improved measurement techniques, although this increased accuracy is in line with the upper bound of the confidence interval of the blood pressure measurement accuracy from Irving and colleagues . The remThe increased coverage represents a scale-up in the number of people screened once. This scenario assumed using already existing tests with their accuracy as outlined in the base case and would be accomplished through more accessible tools as well as programmatic improvements that translate into better implementation strategies. In this simulation, we assumed a doubling of the coverage (8.18% versus 4.09% per year in the base case), yet the percentage of having completed the confirmatory blood pressure measurement remained the same as in the base case.Analogously to S3, we doubled the coverage to enable more people access to a first screen. On top of that, we modeled an improvement in the number of screening events completed. In the best case, all persons with a positive test result in the first screen will have completed their screen. This will require more accessible tools or innovation in programmatic scale-up to ensure complete follow-up.We obtained a population size of over 3 billion  individuals comprising about 5% of individuals from LICs, 43% from LoMICs, and more than half (51.5%) from UMICs , which iIn The same findings are reflected when assessing the differences of the scenarios for the number of CVD events in the population with hypertension per year. Similar trends can be observed in the numbers of deaths resulting from a CVD event within the persons with HTN . WhereasWhen performing a subset analysis and comparing the differences of impact on the countries of same income, we observe similar patterns. Any diagnostic intervention has the most impact in UMICs, followed by LoMICs and LICs , by doubling of the coverage of a first screen, 6.6% of HTN-induced deaths could be avoided over a period of 10 years, and by increasing screen completion in addition, even 13.7% of deaths would not occur.The base case of our model was calibrated in such a way that the HTN prevalence and the increase in HTN prevalence over time is in line with the recent Global Burden of Disease (GBD) study report . MoreoveThese findings have implications on policy development and resource allocation. First of all, it shows that diagnosis and early identification plays a critical role in mitigating long-term mortality of CVD. Further, based on our data, programmatic expansion of screening interventions to scale up testing capacity might have a greater benefit than improving diagnostic accuracy. Models for scaling up testing could draw on successfully implemented community based mass screenings as implemented in Northern California  or annuaAlthough all efforts were made to mimic reality, our model also has several limitations. Due to the simplification of the population initialization, our model does not consider differences that arise from local heterogeneities. Moreover, genetic predisposition, ethnic background, family history of HTN, and dietary and exercise habits were not included in the model. Further, smoking and diabetes, which may contribute to HTN and CVD risk and their evolution over time were not included in the model due to lack of data on the direct relationship to parameterize the model. Furthermore, we acknowledge that blood pressure levels depend on more variables than what we can consider in the model, e.g., diet or lifestyle. The parametrization of the development of HTN was inferred from a logistic regression of the HPACC dataset and thus estimated prevalent and not incident hypertension. Also, we did not take into account adverse events accrued from putting false positively diagnosed individuals on treatment.The model parameters  are assuFor the probability of being screened, we utilize numbers from Geldsetzer and colleagues  Click here for additional data file.S1 Text(DOCX)Click here for additional data file.S1 HPACC Consortium(DOCX)Click here for additional data file.


Hypertension is highly prevalent and a major contributor to cardiovascular mortality and morbidity. In spite of the availability of efficacious, safe and affordable anti-hypertensive drugs, hypertension remains poorly controlled in the majority of hypertensive patients. Various reasons including non-adherence to the anti-hypertensive drugs, account for the poor control. Resistant hypertension is also one of the reasons for poor control of blood pressure (BP). The sympathetic nervous system (SNS) has long been recognized as one of the determinants in the pathophysiology of a raised BP. Overactivity of the SNS is a contributor to sustained arterial hypertension. Renal denervation (RDN) is increasingly recognized as a safe and effective adjunctive therapy to control BP with or without pharmacotherapy. Hence for patients who remain uncontrolled despite all efforts, renal denervation (RDN) is a novel treatment that can potentially improve BP control, hence reducing the major adverse cardiovascular events (MACE). More recent randomized, sham control trials of RDN have shown that RDN produces a sustained lowering of BP. To date, this lowering of BP through RDN is maintained for at least 3 years. Furthermore, this procedure has been found to be safe. Hence this consensus summarises the science behind RDN and the available clinical data to support the use of this therapy. It is hoped that this consensus will offer guidance on the importance of identifying patients who will benefit most from this therapy. A multidisciplinary team approach in the management of the patient undergoing RDN is recommended.  The latest Malaysian National Health and Morbidity Survey 2019 showed that 30% of Malaysians above the age of 18 years suffer from hypertension [Despite their limitations, lifestyle modification combined with pharmacotherapy are the mainstay of hypertension management. Patient counselling should be aggressively pursued to ensure or improve adherence and control of BP.More than half of Malaysian hypertensive patients have a BP that remained uncontrolled despite the best possible pharmacological intervention . For theVarious guidelines define slightly different BP targets –4. This Reasons for uncontrolled hypertension abound—from patient, physician-related as well as system-related factors.There is also a subset of patients in whom BP remains uncontrolled despite earnest adherence to guideline directed therapies. The categorization as resistant hypertension requires a failure to achieve BP goal despite treatment with at least 3 medications (inclusive of a diuretic). All 3 drugs should have been given at maximally tolerated doses and the patients had been adherent to medications, as well as pseudo-resistance and secondary causes of hypertension have been excluded –4, 6.The prevalence of resistant hypertension has been consistently reported as 10–20% of all persons with hypertension , 8. In MThe sympathetic nervous system of the kidneys plays an important role in the pathophysiology of hypertension. In patients with hypertension, chronic activation of the efferent and afferent pathways produces pathological changes such as increased renin secretion, salt and water retention, peripheral vasoconstriction, left ventricular hypertrophy and cardiac arrhythmias. RDN can potentially reverse some of the pathological changes associated with hypertension  and may The efficacy and safety of RDN have been demonstrated in many clinical trials. Overall, current clinical evidence especially from recently concluded randomized controlled trials show that RDN does work in selected hypertensive individuals. The quantum of BP lowering is at least equivalent to that achievable with a single anti-hypertensive medication. In fact, the Global SYMPLICITY Registry (GSR), the sub-study of the GSR in South Korea and several other studies with longer durations of follow-up suggested that there is a potential for further BP reductions over time –18.Point of viewClinical relevancePositioning the role of RDN in Asian hypertensive patientsFuture directionTo determine the role of RDN in the management of young moderate hypertensive patients in addition to pharmacotherapy in AsiaYoung hypertensives with overactive sympathetic drive as main mechanism for high BPPatients with comorbiditiesPatients with target organ damagePatients on polypharmacy for multiple comorbiditiesPatients who are non-adherent/non-compliantConsideration of RDN for the Asian populationMedication adherence is low amongst younger hypertensives, those on polypharmacy especially without the use of fixed-dose combinations and patients who develop medication-related side effects , 20.Patients’ regard for RDN often differs from their physicians’ perspective. This preference for RDN need not necessarily happen only for those with high pill burden or very severe hypertension –23.The preference for RDN to improve blood pressure control without having to resort to medications needs to be discussed with considerations of anticipated benefits, safety, cost, and procedural acceptance.Pseudo-resistant hypertension is a term used to describe a situation where uncontrolled BP is not truly resistant to anti-hypertensive medications but results from factors that may influence BP readings independent of pharmacological treatment of hypertension .A significant proportion of uncontrolled resistant hypertension is due to factors that can cause a falsely elevated BP in patients already taking three or more types of anti-hypertensive medications. These include improper BP measurement techniques, medication non-adherence, white coat hypertension, undertreatment and clinical inertia , 25–29.A poor BP measurement technique is common in a busy clinical setting. Common mistakes include a single measurement of BP, an inappropriate BP cuff size, placement of BP cuff over thick clothing, patient not adequately rested, talking during BP measurement and incorrect body position.A prospective study in a hypertension specialty clinic, patients with apparent resistant hypertension who were referred for further management were analysed. BP measurements taken during triage were compared with BP measurements taken by a trained physician under more controlled situations and with appropriate BP measurement techniques. The systolic and diastolic BP readings were 33/21 mmHg higher during triage compared with standardized measurement with a median difference of 23/13 mmHg. This study demonstrated that 33% of patients who were referred would have been misdiagnosed as having resistant hypertension based solely on their initial triage assessment .Poor adherence to anti-hypertensive medications is one of the major causes of uncontrolled BP and is a common phenomenon in patients with chronic diseases. The World Health Organization had reported that the medication adherence rate in hypertensive patients was only 50% in developed countries and even lower in developing countries due to poor accessibility to medication and health care services , 29. A lWhite coat hypertension is another important cause of pseudo-resistant hypertension. In this condition, office or clinic BP is uncontrolled but out-of-office BP measurement shows controlled BP in patients on ≥ 3 anti-hypertensive agents. This condition is illustrated in a study where 8295 cases of apparent resistant hypertension were included in an ambulatory BP monitoring registry. The study demonstrated that only 62.5% of patients had sustained uncontrolled hypertension both during clinic visit and during ambulatory BP monitoring. The other 37.5% had white coat hypertension . Thus, tClinical inertia or failure of health care providers to initiate or intensify the treatment regime when indicated may lead to suboptimal control of BP , 28. In A comprehensive review of patient’s medications including over the counter drugs, supplements and herbs is important in the assessment of uncontrolled resistant hypertension. Medications that are known to cause BP elevation include NSAIDS, combined hormonal contraceptives, corticosteroids, antineoplastic agents, anti-depressant (venlafaxine hydrochloride), liquorice, immunosuppressive agents , erythropoietin, antiretroviral treatment, alcohol, caffeine, cocaine and salt-containing medications .It is important to identify and select the appropriate patients who will benefit most from RDN. RDN can be considered for particular patients or patient situations Table  ParticulRenal denervation (RDN), initially with radiofrequency ablation, as a treatment for hypertension was initially explored in the 1990s, and early clinical data was published just over a decade ago, followed by many other studies and reviews done more recently –42. InitThe SPYRAL OFF-MED proof-of-concept study was a single-blind (participant) multicentre randomised, sham-controlled study, of 80 patients with mild to moderate hypertension, off anti-hypertensive medications, using radiofrequency ablation delivered by the SYMPLICITY SPYRAL catheter. The primary endpoint was a change in ambulatory (systolic) BP measurement (ABPM) after 3 months. A statistically significant 5 mmHg drop in 24-hour ABPM and a 7.7 mmHg drop in office systolic BP, in favour of RDN was seen . SubsequThe RADIANCE-HTN SOLO was also a single-blind (participant) multicentre randomised, sham-controlled study, of 146 patients with mild to moderate hypertension, off anti-hypertensive medications, using ultrasound emissions from the PARADISE balloon cooled ultrasound catheter. The primary endpoint was a change in systolic daytime 24-h ABPM after 2 months. Again, a statistically significant 6.3 mmHg drop of daytime ABPM and 6.5 mmHg drop in office systolic BP, in favour of RDN was seen .n = 30) and –8·6 mmHg (14·6) for the sham control group (n = 32); adjusted treatment difference was –10·0 mmHg, 95% CI –16·6 to –3·3; (p = 0·0039) and there were no short-term or long-term safety issues associated with renal denervation [The SPYRAL ON-MED proof-of-concept trial was, again, a single-blind (participant) multicentre randomised, sham-controlled study, of 80 patients with mild to moderate hypertension, on 1–3 anti-hypertensive medications, using radiofrequency ablation delivered by the SYMPLICITY SPYRAL catheter. The primary endpoint was a change in 24-h ABPM after 6 months. A statistically significant 7.4 mmHg drop in 24-hour ABPM and a 6.8 mmHg drop in office systolic BP, in favour of RDN was seen . Since tAnother study of similar design, using a VESSIX catheter, the REDUCE-HTN: REINFORCE, in a similar patient group of mild to moderate hypertension, was inconclusive . ReassurMore recently, the RADIANCE-HTN TRIO, a single-blind (participant) multicentre randomised sham-controlled study, of 136 patients with hypertension resistant to a standardised triple pill combination, demonstrated that using the PARADISE balloon cooled ultrasound catheter could significantly reduce daytime ambulatory systolic BP by 4.5 mmHg .Finally, the magnitude of BP reductions, including that demonstrated by RDN therapy, at both ABPM and office systolic blood pressure readings, translates to improved cardiovascular outcomes , 56. TheThe concept of ‘always-on’ effect is certainly an attractive proposal to consider RDN as it could circumvent many of the afore-mentioned impediments to good BP control –63. The Multiplying the consistent BP-lowering effect with durability of RDN effects of up to 3 years in the Global Symplicity Registry , the potImpact of medication burdenThe majority of patients with resistant or uncontrolled hypertension would be on multiple anti-hypertensive medications. Whilst the likelihood of ‘cure’ with total abolition of need for continued medication is rare, if not impossible, there is a potential reduction of pill burden following RDN.Analysis of the SPYRAL-HTN ON-MED pilot trial data using the novel ‘win-ratio method’ clearly showed a reduction in the prescribed medication burden from baseline to follow-up at 6 months . The RADThe theoretical considerations to offer RDN for uncontrolled hypertension include:Pre-procedure assessmentPre-procedure investigationsRenal function testFull blood countCoagulation profile Crossmatch blood group Renal ultrasound and doppler studies (recommended)CTA renal artery MRA renal artery Pre-procedure planningObtain informed consent Discontinue agents that could affect renal function  for at least 48 hours before the procedure.Special care on the doses of prescribed diureticsAppropriate hydration prior to the procedureDual anti-platelet therapy (DAPT) interruption not requiredWithhold anticoagulation 48-72 h prior to the procedureContinue anti-hypertensive medications as usual or withhold some at physician’s discretionPercutaneous renal sympathetic denervation is not technically challenging. However, under specific clinical circumstances  or when faced with more complex abdominal aortic anatomy  some procedural tips may be useful. For further information regarding the procedure, refer to supplementary Appendix Prevalence of hypertension is higher in most of the Asian countries compared to the west. , 66–70. However, the bigger problem is not only the higher prevalence but also the poor control rates in most of the Asian countries compared to the west. , 66, 67 With the availability of more recent data since the publication of the last round of hypertension guidelines worldwide, a paradigm shift is expected in the coming guidelines as regards to RDN. The latest WHO guidelines released last year however did not make any mention of RDN except for stating that patients not controlled on 3 drugs  inhibitors, calcium channel blockers (CCB) and diuretics) should be referred to a specialist. However, what is expected is that the recommendation for RDN will be upgraded from the previous Class II recommendation Grade B level of Evidence to Class 1 recommendation with Grade A Level of evidence . As for patients who are young or obese, with or without, obstructive sleep apnoea, and those with high sympathetic overdrive, a Class II recommendation with Grade C Level of Evidence will be appropriate for the time being until more definitive data from appropriately designed RCTs are available.which may be inadequately controlled in some groups). This needs to be recognized and appropriately addressed.Hypertension is a prevalent, largely asymptomatic, and potentially dangerous disease , undertreatment, poor medication adherence and clinical inertia) –31, 33Resistant hypertension , 85, 86Secondary causes of hypertension. Patients with secondary causes of hypertension might benefit from specific therapy to treat underlying causes rather than RDNHyperactive renal-sympathetic system  –89This consensus statement takes into consideration the current available data on RDN as a adjunctive treatment modality in poorly controlled/resistant  hypertension RDN can be considered for the following patients. Particular emphasis is made with regard to patient selection which is a key determinant of RDN suitability and successThe possible indicators of successful blood pressure lowering after RDN:Patients with baseline office heart rate ≥70 per min, not on anti-hypertensive medications showed greater reduction in mean office, 24-hour, daytime, and night-time SBP for RDN at 3 months .Younger patients with younger vascular age and low abdominal aortic calcification burden, as repoUncomplicated hypertension.The ongoing SPYRAL ON-MED trial expected to be announced in 2022 is hoped, will provide more data on the promising role of RDN in lowering blood pressure for a selected group of patients continued on concomitant blood pressure medications.Managing patient expectationsHypertensive medications will most likely be continued at current levels for a few monthsBlood pressure medications usually cannot be stopped and most probably not be reduced. In some cases, these can be reduced. However, blood pressure levels will be better controlled in the longer term.Reduction of blood pressure after post renal denervation will be gradual over a few months to a yearBenefits of renal denervation are principally for the reduction of end-organ damage and cardiovascular risk reduction due to better blood pressure controlIn conclusion, this consensus recommends that for better blood pressure control and reduction of CV risk:effective adjunctive treatment for sustained lowering of blood pressure in hypertensive patients who fulfil the criteria for RDNSuccessful denervation can be an early in the management of hypertensionRenal denervation should be considered offered to patient during consultation in selected group of individualsShould be Reassurance of the RDN procedure should be emphasizedexpectations should be addressed when discussing RDNPatient patient preference in shared decision making and should be considered for renal denervation consideration.Informed Patient preference may be considered in the following:Young patients who prefer to be on minimal medicationPatients who are on multiple medications resulting in high tablet countPatients well motivated to have good and sustained blood pressure controlIt is hoped that this consensus will enable health care providers to understand the science and rationale behind RDN to enable them to identify patients for consideration of this treatment.RDN should not be considered as a therapy of last resort but as an initial treatment option.Lifestyle modification and pharmacological intervention should remain the mainstay of hypertension management.Patient medication adherence should be continually assessed and adjusted as necessary even after successful RDNSupplementary Appendix 1


Background: An exaggerated blood pressure response (EBPR) during exercise testing is not well defined, and several blood pressure thresholds are used in different studies and recommended in different guidelines. Methods: Competitive athletes of any age without known arterial hypertension who presented for preparticipation screening were included in the present study and categorized for EBPR according to American Heart Association (AHA), European Society of Cardiology (ESC), and American College of Sports Medicine (ACSM) guidelines as well as the systolic blood pressure/MET slope method. Results: Overall, 1137 athletes  without known arterial hypertension were included April 2020–October 2021. Among them, 19.6%, 15.0%, and 6.8% were diagnosed EBPR according to ESC, AHA, and ACSM guidelines, respectively. Left ventricular hypertrophy (LVH) was detected in 20.5% of the athletes and was approximately two-fold more frequent in athletes with EBPR than in those without. While EBPR according to AHA  and ACSM guidelines  was independently (of age and sex) associated with LVH, EBPR defined according to ESC guidelines  was not. In adult athletes, only AHA guidelines  and systolic blood pressure/MET slope method  were independently predictive for LVH. Conclusions: Diverging guidelines exist for the screening regarding EBPR. In competitive athletes, the prevalence of EBPR was highest when applying the ESC (19.6%) and lowest using the ACSM guidelines (6.8%). An association of EBPR with LVH in adult athletes, independently of age and sex, was only found when the AHA guideline or the systolic blood pressure/MET slope method was applied. Arterial hypertension is the most important and most common cardiovascular risk factor (CVRF) for morbidity and mortality worldwide ,2,3,4. TDiagnosis of arterial hypertension by resting blood pressure is well defined. In Europe, a systolic blood pressure (BP) value of ≥140 mmHg and a diastolic BP value of ≥90 mmHg are the defined thresholds of arterial hypertension ,13,14,15However, for arterial-hypertension-naïve individuals with EBPR during the exercise testing, it was shown that these individuals are at increased risk of developing both arterial hypertension as well as cardiovascular events in the future, underlining the importance of this phenomenon ,35,36,37In the context of arterial hypertension, it is well known that an increase in left ventricular mass and left ventricular hypertrophy (LVH) are associated with cardiovascular disease (CVD) as well as an elevated number of cardiovascular events and mortality ,38. DespThus, the objectives of the present study were to evaluate (I) how prevalent EBPR is in athletes and (II) which definition of an EBPR during exercise testing was best associated with LVH in athletes without known arterial hypertension.We performed a retrospective analysis of athletes of any age without known arterial hypertension who presented at the Department of Sports Medicine  of the University Hospital Heidelberg (Germany) for their preparticipation screening examination between April 2020 and October 2021.Athletes were eligible for this study if they performed regular training for competition, were able to perform an exercise test at our department, had no contraindications for exercise testing, and had no known diagnosis of arterial hypertension. Exclusion criteria were a known diagnosis of arterial hypertension and contraindications regarding performing exercise testing ,23.The requirement for informed consent was waived as we used only anonymized retrospective data routinely collected during the health screening process. Studies in Germany involving a retrospective analysis of diagnostic standard data of anonymized patients do not require an ethics statement.Arterial hypertension at rest was defined according to the ESC guidelines . In all 3 − (LV end-diastolic diameter)3]) + 0.6 g [LVH was defined as (I) septal or posterior left ventricular (LV) wall diameter ≥13 mm ,40 or (I + 0.6 g . LVH wasAmerican Heart Association (AHA) guidelines : systoliEuropean Society of Cardiology (ESC) guidelines ,24: systThe American College of Sports Medicine (ACSM) guidelines ,21: syst2 maximum values during exercise testing as recommended by the ACSM guideline (MET = VO2max/3.5 mL·kg−1·min−1) [The systolic BP/MET slope method ,45,46,471·min−1) .Exercise testing was performed according to current guidelines with electrocardiogram (ECG) and BP measurements at the end of every load level. The exercise test was stopped if the athlete was at their maximum capacity or stopping criteria according to current guidelines ,23.EBPR was defined on the basis of the peak BP values during exercise testing according to three different guidelines and the systolic BP/MET slope method:2 according to the World Health Organization.Obesity was defined as body mass index (BMI) ≥30 kg/m2 test for categorical variables, as appropriate. Data of continuous variables were presented as median and interquartile range and categorical variables as absolute numbers with related percentages.Athletes categorized as athletes with EBPR according to the three aforementioned guidelines and the systolic BP/MET slope method were compared to those athletes not categorized as EBPR  with the help of the Wilcoxon–Mann–Whitney U test for continuous variables and Fisher’s exact or chiWe performed univariate and multivariate logistic regression models to investigate the association between EBPR (defined according to the three guidelines) as well as BP values at rest and maximum values during exercise on the one hand and LVH on the other hand. Multivariate regression models were adjusted for age and sex in order to prove the independence of the statistical results of athletes’ age and sex. Results of the logistic regressions are presented as odds ratio (OR) and 95% Confidence interval (CI).p values < 0.05 (two-sided) were considered to be statistically significant. No adjustment for multiple testing was applied to the present analysis.All statistical analyses were carried out with the use of SPSS software . Only the Overall, 1137 athletes ; 395 (34.7%) females) without known arterial hypertension were included in the present study between April 2020 and October 2021. Most included athletes were in the second or third decade of life A. Among Overall, 223 athletes ; 149 male athletes (20.1%)) had a diagnosis of EBPR according to AHA guidelines , 171 re, and 77 While the proportions of female athletes with and without EBPR according to ESC and AHA guidelines were widely balanced, comprising approximately 1/3 of the athletes with EBPR, the proportion of male athletes with EBPR according to ACSM was distinctly higher, with 85.7% of all individuals with EBPR . CVRF niThe proportion of athletes with EBPR increased with inclining age regardless of the chosen definition. Notably, EBPR was more often diagnosed due to maximum systolic in comparison to maximum diastolic blood pressure values during exercise B–D.LVH was approximately two-fold more frequent in athletes with EBPR than in those without (risk ratios (RR) 2.2, 1.8, and 2.0 when using the definitions of AHA guidelines, ESC guidelines, and ACSM guidelines, respectively).Interestingly, aortic valve regurgitation and mitral valve regurgitation were both more prevalent in athletes with EBPR .p < 0.001) and the ACSM guidelines (OR 1.81 (95%CI 1.05–3.09), p = 0.031) were independently (of age and sex) associated with LVH, EBPR defined according to the ESC guidelines (OR 1.49 (95%CI 1.00–2.23), p = 0.051) was not independently associated with LVH , with LVH .In addition, LVH was associated with systolic BP at rest and maximum systolic BP during exercise, but not with diastolic BP values .When focusing on the adult athletes only, 598 athletes  years) aged 18 years or older remained in the analysis. Among these, 180 (30.1%) had an LVH.According to the guideline definitions, 170 ; 116 male athletes (29.0%)) athletes were classified as EBPR according to AHA guidelines, 137 ; 83 male athletes (20.8%)) according to ESC guidelines, and 65 ; 54 male athletes (13.5%)) according to ACSM guidelines.p = 0.001; multivariate: OR 1.96 (95% CI 1.32–2.90), p = 0.001). EBPR according to the ESC (univariate: OR 1.40 (95% CI 0.94–2.10), p = 0.100; multivariate: OR 1.44 (95%CI 0.93–2.22), p = 0.104) as well as ACSM guidelines (univariate: OR 1.64 (95% CI 0.97–2.79), p = 0.067; multivariate: OR 1.73 (95% CI 0.98–3.07), p = 0.060) were not associated with LVH independently of age and sex.In adult athletes, only the definition of EBPR according to AHA guidelines was independently predictive for LVH (univariate: OR 1.88 (95%CI 1.29–2.74), p < 0.001).When using the systolic BP/MET slope method with a cutoff value > 6.2 mmHg/MET to define an EBPR in those 639 athletes, who underwent spiroergometric testing, we detected 386 athletes (60.4%) with normal BP response and 253 athletes with EBPR ; 173 male athletes (41.2%)) . LVH wasp < 0.001), but this association remained not significant after adjustment for age and sex (OR 2.26 (95% CI 0.40–12.66), p = 0.355). Sex-specific analyses revealed a significant association of systolic BP/MET slope > 6.2 mmHg/MET with LVH in male (OR 2.348 (95%CI 1.472–3.746), p < 0.001) in contrast to female athletes (OR 1.706 (95%CI 0.878–3.315), p = 0.115).Systolic BP/MET slope > 6.2 mmHg/MET was associated with LVH in the univariate regression analysis (OR 2.12 (95% CI 1.45–3.10), p = 0.023) as well as multivariate logistic regression analysis adjusted for age and sex (OR 1.73 (95% CI 1.08–2.78), p = 0.023). However, sex-specific analyses also revealed sex-specific differences in adult athletes. While systolic BP/MET slope > 6.2 mmHg/MET was associated with LVH in male adult athletes (OR 1.848 (95% CI 1.079–3.166), p = 0.025), in females, no association was seen (OR 1.325 (95% CI 0.603–2.913), p = 0.484).In contrast, in the 398 adult athletes with spiroergometric evaluation, systolic BP/MET slope > 6.2 mmHg/MET was associated with LVH in both, the univariate (OR 1.67 (95% CI 1.07–2.60), Arterial hypertension is accompanied by substantially increased cardiovascular morbidity and mortality ,49,50,51Among individuals who were not categorized as patients with arterial hypertension ,13,14,15Thus, the objectives of our present study were to evaluate the prevalence of EBPR in athletes and which definition regarding EBPR during exercise testing was best/strongest associated with LVH in athletes without known arterial hypertension.(I)EBPR was diagnosed between 6.8% and 19.6% of all athletes in our study according to the different guideline recommendations. Prevalence was highest when categorized according to the ESC guidelines (19.6%) and lowest according to the ACSM guidelines (6.8%).(II)CVRF, such as nicotine abuse and obesity, were more prevalent in athletes with EBPR.(III)The proportion of athletes with EBPR increased with inclining age regardless of the chosen definition.(IV)EBPR was more often diagnosed due to maximum systolic in comparison to maximum diastolic BP values during exercise.(V)Only the EBPR definition of the AHA guideline was able to predict LVH independently of age and sex in both the overall sample as well as in adult athletes as the only guideline recommended threshold.(VI)In addition, the recently implemented systolic BP/MET slope method with a cutoff value > 6.2 mmHg/MET to define an EBPR, was able to predict LVH in adult athletes independently of age and sex.The main results of the study can be summarized as follows:Our study results reveal a large variation regarding the prevalence of EBPR according to the different guideline definitions in athletes without known arterial hypertension (variation of 12.8% according to different guideline recommendations). The prevalence was highest when categorized according to the ESC guidelines ,24 , an identified EBPR and especially a prolonged and delayed decline in blood pressure after exercise testing could provide clues regarding a masked arterial hypertension or development of a manifest arterial hypertension in the future ,63.In athletes with EBPR and/or a prolonged and delayed decline in blood pressure after exercise testing, a 24 h blood pressure measurement could give important and valuable additional diagnostic information . Where tEBPR was diagnosed in between 6.8% and 19.6% of all athletes without known arterial hypertension. Prevalence was highest when athletes were categorized according to ESC guidelines (19.6%) and lowest when categorized according to ACSM guidelines (6.8%). The proportion of athletes with EBPR increased with inclining age regardless of the chosen definition. Only the EBPR definition of the AHA guidelines and the systolic blood pressure/MET slope method were associated with LVH independently of age and sex in adult athletes. However, the prognostic value of this association remains to be elucidated by sufficiently powered in-depth long-term studies. Such studies are also necessary to further evaluate the importance of the identification of EBPR in athletes and the significance of actual EBPR guidelines as diagnostic tools in young athletes.


Cardiorespiratory fitness was tested with a bicycle test, and adherence to the Mediterranean diet (MedDiet) was assessed with the MDS questionnaire. Our data strengthened previous results confirming that the higher a person’s adherence to MedDiet, the higher the cardiorespiratory fitness and the lower the body fat. Furthermore, our results showed that anemia in patients with CHF has an impact in terms of cardiorespiratory fitness, and functional outcomes by questionnaire. Since our data revealed gaps in iron supply (37.9% with iron deficiency), malnutrition (only 7.8% with high adherence to MedDiet), and both symptomatic and non-symptomatic study participants failed to meet reference values for physical performance, we encourage the enforcement of the guidelines in the treatment of CHF more strongly.In addition to drug therapy, lifestyle modification, including physical activity, and nutrition management are an integral part of current guidelines for patients with chronic heart failure (CHF). However, evidence on which clinical parameters are most influenced by nutritional behaviour, exercise capacity, or iron status is scarce. For a multicenter intervention study, we included participants with diagnosed CHF ( Chronic heart failure (CHF) is one of the most common diseases with a prevalence of 1–2% in adults in developed countries, disproportionately affecting the elderly . The cauDamage of the heart and chronic pressure and/or volume overload triggers cellular, structural, and neurohumoral adaptions . This caN-terminal natriuretic pro-B peptide (NT-proBNP) has emerged as an important diagnostic laboratory marker of cellular damage and CHF because blood concentrations increase as heart failure develops or worsens ,6,7. AccThe clinical severity of CHF is graded according to the New York Heart Association (NYHA) on the basis of clinical symptoms at various degrees of patients’ physical activity (PA) .Therapy of CHF is primarily based on consistent drug intervention to reduce the cardiac workload and improve comorbidities . FurtherA significant advantage of a specific diet for patients with CHF could not be proven so far, which is why the dietary recommendations for the general population of the German Society for Nutritional Medicine also apply to patients with CHF ,14. AlthExercise capacity in cardiopulmonary exercise tests correlates strongly with the degree of heart failure according to NYHA stages . So far,Heart failure, Individual exercise training, Telemonitoring, Selfmanagement”) at the study center Hannover Medical School, Germany. HITS is a partially ongoing multicenter, prospective, both therapeutic and diagnostic, randomized, and parallel-group study done as a collaborative project between Leipzig University, Hannover Medical School, Leipzig Heart Center, AOKplus health insurances, IGES institute, Diaventions GmbH, and the Clinical Centers in Wolfsburg, Chemnitz and Dresden (Germany). The study is registered under DRKS00019022 in the German Clinical Trials Register. The institutional review boards of Hannover Medical School (No. 8786) and medical faculty of Leipzig University (479/19-ek) approved the study’s ethics, and written informed consent was obtained prior to the inclusion of study participants.The objective of the presented data set refers to the baseline data from the “HITS” study  and control group (CG). The allocation to the NYHA stages I, II, or III was taken from existing diagnoses or was determined by the study physicians based on the severity of symptoms during PA  which were collected via a venous blood sample, further laboratory parameters were collected at Hannover Medical School .Anthropometric data  were assessed based on defined standard operation procedures (SOP), after a general medical examination by a physician . Body-mass index (BMI) was calculated with the formula bodyweight (kg) ÷ height (mn = 216), participants were divided into one of the following three groups: ID according to ESC guidelines included participants (n = 82) with a ferritin level < 100 ng/mL or a ferritin level < 300 ng/mL in conjunction with a transferrin saturation < 20% , the carbon dioxide production [VCO2(mL/min)], and ventilation. All parameters were continuously measured breath-by-breath [Exercise capacity (measured as peak power output in watts [W]) and maximum heart rate  . Scores The 23-item Kansas City Cardiomyopathy Questionnaire (KCCQ) was used to quantify physical limitations, symptoms, self-efficacy, social interference, and HrQoL in patients with CHF ). A one-way analysis of variance (ANOVA) was used to test for group differences between normal iron status, ID, and anemia. The effect size is given by η². Significant differences were corrected with the Bonferoni post hoc test. The type-I-error was set to 5% (two-sided).A stepwise backward multivariate linear regression was performed to identify parameters associated with relative oxygen uptake . A priory case number calculation was performed to detect group differences of 10% in exercise capacity with the given number of cases with a statistical power of 0.85 and the mentioned significance.The combined data set consisted of 239 participants, 74 participants with NYHA 1 classification, and 165 participants with NYHA 2 & 3 classifications.In addition to the primary diagnoses according to the inclusion criteria of the study, the most frequent secondary diagnoses are listed in p = 0.005), TSF% , KCCQ total score , ferritin , waist-to-hip-ratio , wattmax , VO2max , FFM , hematocrit , but not with sTFR . In all participants, hemoglobin correlated with BMI , FFM  and by trend with wattmax/kg  and VO2max/kg . The sTFR correlated with BMI , KCCQ symptom scale , KCCQ functional score , clinical summery score  and KCCQ total score , wattmax/kg , and VO2max/kg .Ferritin correlates with BMI , NYHA level , KCCQ symptom scale , individual aerobic lactate threshold , and MDS total score  predicted VO2max/kg. The model explained 31.1% of the total variation in VO2max/kg.In a multivariate linear regression model including age, sex, WHR, NT-proBNP, ferritin, sTFR, tTSF(%), hemoglobin, hematocrit, VOn = 109), ID (n = 82), and anemia (n = 25). 2max,VO2max/kg, KCCQ scores, and CRP  and VO2max/kg (p = 0.043). The MDS correlated with BMI , body fat , wattmax/kg , VO2max/kg , and WHR , but no correlation with the KCCQ subscores and the KCCQ overall score were found. A total of 154 participants completed the MDS questionnaire; 67 showed a low adherence to MedDiet and 87 showed a medium/high adherence. By this division, there are significant differences for body fat (n = 36) and 47.1% of the participants with anemia showed at least medium adherence to MedDiet. When comparing low adherence with medium/high adherence to MedDiet and ID and anemia classification, the chi2 test showed no significant differences (p = 0.476). In all, 62.1% of the participants with ID (n = 11) had increased sTFR. There were no significant differences between participants with increased sTFR and normal sTFR in physical performance, laboratory parameters, body composition, and MedDiet.Only 4.8% of all participants  and medium/high (≥6 points) adherence to MedDiet. This goes in line with the findings of a 12-month intervention study, in which, besides some positive effects on biomarkers of iron status, no overall effect on iron status was found . With reTuttolomondo et al. describe that there has been no review of evidence base assessing the impact of dietary intake on functional indices that impact HrQoL in persons over 65 years of age . To inve2max and endurance performance, due to the reduction of the oxygen-carrying capacity of blood [Iron deficiency is prevalent in up to 50% of patients with CHF, which is associated with reduced exercise capacity, impaired HrQoL, and increased risk of hospitalization and mortality, regardless of the presence or absence of anemia ,36. Thisof blood .2max and significant group differences between the three iron status groups  in terms of VO2max and VO2max/kg and KCCQ questionnaire as an expression of functional outcomes.Indeed, our analyses showed significant differences between anemic and non-anemic participants in terms of VOThe presence of ID or anemia are frequent co-occurrences in patients with CHF whereby an absolute ID with depleted iron stores can be distinguished from a functional ID caused by impaired iron utilization or misdistribution ,39. ThatThe current definition of ID for CHF patients is a ferritin level < 100 ng/mL, or ferritin levels from 100–299 ng/mL in the presence of TSF level < 20%, irrespectively of present anemia . These hAn alternative to ferritin determination could be the combined evaluation of low hepcidin and increased sTfR values. The sTfR value is expressed more abundantly in intracellular ID and indicates increased tissue demand even before low hemoglobin levels occur. Unlike ferritin and transferrin, it is not affected by inflammation or vigorous physical exercise . Jankowsn = 239) instead of the whole study population (n = 679), which would have resulted in a greater statistical power. Overall, not all of the study data collected, including medications or nutritional supplement, is yet available, as the examinations are still ongoing in some study centers.Our study has strengths and limitations. One limitation of our multicenter study that we have to state is that the technologies used to determine the body compositions, the exercise capacity, and the consulted laboratories were not the same for all study centers. In addition, not every parameter on which this analysis is based has been collected in every study center, which is why the present analysis included only participants of Hannover Medical School (For the diagnosis of ID, the current diagnostic criteria for clinical heart failure were also applied to NYHA 1 patients. Since these were often just patients at risk for developing heart failure, too many patients may have been diagnosed with ID, which could also explain the relatively good exercise performance in the group of patients with ID.Our results show that anemia in patients with CHF has an impact on both maximum oxygen uptake as a vital sign for cardiorespiratory fitness, and functional outcomes by questionnaire. Furthermore, our results show the higher a person’s adherence to MedDiet, the higher the relative cardiorespiratory fitness. The analysis of our baseline data show, that 10.9% of study participants are anemic and 37.9% showed an ID. In further studies, we suggest investigating whether or not the combined evaluation of low hepcidin and increased sTfR values could be an alternative to ferritin determination.Only 7.8% have stated a high adherence to the MedDiet. Both symptomatic and non-symptomatic study participants failed to meet reference values for physical performance during exercise testing . With ou