- Email: [email protected]
Blood ketone bodies in congestive heart failure
665
-
-
Objtxtives.The present study was designedto assesswilether blood ketonebodiesare elevatedin cungestiveheart failure \CHF) and whether ketonemir is related to tbe hemodynanri~and neurohumoral abnormalitiesof CHF, &e&ground.In CHF, consumptionof the body’sfat storesmay become abnormally high, contributing to the development of cardiaccachexia.Increasedmobilizationof free fatty acidscould, in theory, augment k&genesis, but vvhetherpatients with CHF are prone to ketosisremainsunknown. MefMs. Forty-five patients with chronic GMF (mean age [ +SD] 57 & 13 years)and 14 control subjectsfree of CHF (mean age 53 + 13 years) underwent invasiveand noninvasivecardiac studies and determination of biood ketone Mies (acetoacetste plus beta-hydroxybutyrate),circulating free fatty acids,glucose, lactate,k&in, glucagon,growth hormone, cortisol,norepinephrine, N-terminal proatrial natriuretic peptide, tumor necrosis factor-alpha and interleukin-6 after aa overnight fast. ResuflsPatientswith (IHF had elevatedblood ketone bodies (median 267 ~mot/liter. range 44 to Y52)comparedwith controrol .----.
1-^1_-_---.---
Il.-l---.-l-~
fJ Am Coli &r&o1 ~~Y~;2~:~~5-72)
-------
Congestive heart failure (GE) is a clinical syndrome that resultsfrom systolic or diristoliccardiacpump dysfunction ml is accompaniedby a number of neurohumoral and metabolic alterations in the l30Cly (I,?. Im chrcmic CM?, WiE4ing of subcutaneousfat and skeletalmusclejs relatively common and suggests augmented consumption of noncarbohydrate substratesfor energy production (1,3). Regarding the mechanisms leading to lossof the body’sfat stores,elevatedconcentrations of stresshormones, including norepinephrine (4,5j, may play a role by enhancing lipolysis,and increasedbasall~l~.tab~lis~~~ [cjf with insufficient food intake or absorption (1,7&l may ako contribute. It has also been shown recently that fat oxidation during exerciseis increased in patients with C&IF compared with healthy persons (9). These changes in lipid metabolism --
..--- --_----
fDq~artmenr of Medicine)and Deprinent of fllnimi Chemisty Helsinki University Central Hospitsl, Helsinki; and *Department Of Clin~d Chemistry, ‘Turku University Central Hospit& Turks, Finland. This work was supported ky grants from the Pinnisk Heart Researck Foundation (Dr. Lommi), the Kesea~ck Institute of Helsinki University C~lntral Hospital (Dr. Lammi), the Finnish Heart Disuse Association (19tk I;ebruav Fund) (Rr- Kupari) and the Finnish Academy (Gmnt SA 7135 to Dr. Kupxij. Helsinki, Finland. From tke Oivisitrn of Cardblogy
subjects(medianWI fimol/Kter,range31 to 2YY,p < OAIS). In the total study gtoirp, blood ketonebodieswererelated to puilmonmy artery wedge pressure (rs = 0.45, p c O&M), left vestrictdar ejectionfr&iun (rS= -0.37, p < Q.Ol),rigbt atria1pressore(r, = 036, p < 0.01) and circula;ingconcentrationsof free fatty acids @S= 0.52, p C Q.QQl),&close (r, = -0.3Y, p < O.Ol),norepinephrine (r, = 0.45,p C QAMl),growth hormone (l; = 0.30, p < 0.W) and interhWin-6 (r, = 0.27, p < 8.05). In multivariate amdysis,left ventricularejectionfraction, serum free fatty acids and serumglucosewereindependentpredictorsof ketnnemia. Conclusions.Bhod ketone bodies are elevated in CHF in proportion to the severityof cardiac dysfunctionand neorohormonal Mivation. This may be at least partly attributable to increasedfree fatty acid rnobi~~~t~oo in resp+mscto augmented neurohormonai stimulation. Additional studies are needed to identifythe detailedmechanismsand clinicalimplicationsof CIIF ketnsis.
could boost hqntic ketone body production, atrd we have rtxently shown that fastiug breath acetone concentrations are often elevated io patients with CHF (IQ). This study was designed to assesswhether blood ketone bodies are etevated after an overnig,ht fast in patients with clinical CHF and whether the degree of ketonemia depends on the hemodynamic abnormahties or the prevailing nemoi~ul~~~rai milieu, incloding circula.tingstresshormone and cy?Jkineooncentrations.
1Pa+ipn)r “s.ll.*Yi The studs included 59 patients with cardiac diseaseadmitted to Helsihki UniversityCentral Hospital between ,immaxyand October 1994 for treatment or diagnasriz cvaluation. CMthe patients, 45 (28 men; mean age (ESDJ 57 +- 13 yearsj had definite clinical cH1-’and 14 (,9men; mean age53 -t: 13 years), constituting the contra? group, were free of CRF. The diagnosisof CRF required that the patient had a cardiovascular diseaseand at !east three of the following four signs: 1) dyspneaor fatigue on ordinary et%rt; 2j audibIti third heart som~dor heart rate >9lI beatsimin at rest; 3:).enlarged heart vo1n11xc per body area on chest radkgnph f3500 ml/m’ in WO!llW,
XT50 ml/m” in men) (II);
or 4) plmotwy
wnous
congestion on chest radiograph or abnormal neck vein disten-
tion. Patientswith diabetes or other ,endocrine,chronic infectious, hepatic, renal9gastrointestinal or connectivetissue diseases or malignancy were excluded. Acute infectious or ~~~~a~nrnat~~ diseasesand recent myocardiai infarction also led to exclusion, as did the use of drugs with a possible influence on the synthesisor metabolism of the ketone bodies (beta-adrcnergicblocking agents, rorticoskroidsj. Eventually, the most common reasonsfor exclusionwere diabetes, recent myocardial infarction and use of beta-blockers. In the CHF group, the underlying condition was vaivuiar heart diseasein 15 patients, coronary artery diseasein IO, idioparhic dilated cardiomyopathy in IO, embolic or primary pulmonary hypertensionin 6: constrictivepericarditis in 2 and congenital heart diseasein 2, Twenty-eight patients were in sinus rhythm, 41 had chronic atrial fibrillation and 6 had pacemaker rhythm for most of the time. Functionally, 8 patients were in New York Hear! Associationfunctional class IV? 21 were in classIII and 16 in classII. Fcrty-one patients were using furosemide (mean daily dose 135 mg, range 40 to 500), which was combined with spironolactone in 12 patients acd metolazone in 4 patients. Three patients were taking hydrochiorothiazide. Thirty& patients were taking digoxin, 26 were using angiotensin-convertingenzymeinhibitors and 21 itiere u&g long-acting nitrates. In the control group, eight patients had valvular disease (six aortic, two mitral), four had congenitalheart disease(ail septal defects; two atria], two ventricular) and two had coronary artery disease.They underwent cardiac catheterization either for assessmentof the hemodynamicsignificanceof their structural heart diseaseor for preoperative evaluation. Twelve of rhem were in sinusrhythm and two had chronic atria1 fibriilation. Functionally, eight control patients were in functional classII and sixwere in classI. None fulfilled our definition of CHF (presence of three or four of the four clinical signs specified previously), but two signs were identified in four patients and one sign in five patients. Two patients were taking angiotensin-converting enzyme inhibitors and diuretics; digoxin and nitrates were used by three patients each. Study design. All studies were performed while the patients were in the hospital for treatment or examinations. Eligible patients with CI-IF who hrd been admitted for worsening congestionwere studied afte: removal of fluid retention and restoration of earlier symptomatic status. Throughout their hospital stay,the patients were on a nonreducing hospital diet with an averagetotal energycontent of 2,030 kcal/dayand with a minimum of 200 dday of carbohydrates.The patients underwent clinical examination and echocardiography followed, within 1 to 2 days, by indirect calorimetry and blood sampling after a 12-h fast for the determination of circulating energy substrates,metaboiites, hormones and cytokines.Cardiac catheterization was performed within 2 days after the blood tests, The patients continued their regular medication during the examinations.The study protocol was approved by the Institutional Ethics Committee. The nature and potential risks of the study were explained in detail to each patient before asking for their consent to participate.
Clinical ~xa~i~~ti~~. The patients were examined clinically, paying special attention to the history of exerciseintolerance and ?o the signs of CHF specified in the diagnostic criteria (see previous discussion).The neck veinswere studied by estimating the supraclavicularheight of the blood column ir; the right internal jugdiar vein with the patient breathing quietly in the sitting position. Any venous bulging above the clavicle was considered abnormal. Brachiaf artery blood pressurewas measured by the sphygnlomanometriccuff method. Posteroanterior and lateral &est radiographs were obtained and the heart volume per body area was calculated (II). All participants, except ol\e man with filncrionai class IV symptoms, undenvent a standardized 6-m;.rstilwaikmg test (12) supervised by one of the investigators(J.L.). Body height and weight were measured and body massindex was determined asweight (kg) divided by the square of height (m). The triceps, infracapular and suprailiacskinfold thicknesseswere measuredby a caliper, and the percent body fat was calculated using standard tables (13). Lean body mass was derived as body weight minus calculated fat mass. Determination of circulating substrates, metabolites, hermanes and cytokines. After a 12-h overnight fast (from 8 PM to 8 AM), while the patients were still in supine rest, blood was sampled from an antecubital vein cannulated 30 min in advance for the determination of glucose, free fatty acids, beta-hydroxybutyrate, acetoacetate,lactate, insulin, proinsulin C-peptide, giucagon, cortisol, growth hormone, norepinephrine, epinephrine, N-terminal proatrial natriuretic peptide (pro-ANP), tumor necrosisfactor-alpha (TNF-alpha) soluble TNF-alpha receptor II and interleukin-6. The blood samples for ketone bodies, lactate, norepinephrine and epinephrine were frozen immediately and stored at --70°Cuntil the assays. Other blood sampleswere collected on ice and centrifuged at 4°C; the serum was stored at -20°C until the determinations. Blood acetoacetate,beta-hydroxybutyrate and lactate were determined in perchloric acid extractsby a Transcon 102 FM Auoronephelometer (Elomit, Transcon Instruments Ltd., Helsinki, Finland) using nicotinamide adenine dinucieotidelinked enzymatic methods (14,15). Acetoacetate and betahydroxybutyrate were summed to give the concentration of blood ketone bodies, which was used asan index of ketonemia in all analyses.Serum free fatty acids were measured by the microfluorometric technique described by Miles et al. (16). Plasma glucosewas measnred enzymaticallyusing an Eppendad EPOS 5060 analyzer (Eppendorf, Hamburg, Germany), and serum insulin was measured using a double-antibody radioimmunoassay kit (Pharmacia, Uppsala, Sweden); the interassaycoefficient of variation for insulin was Y,O%at the concentration of 20 mU/iiter. Serum proinsulin C-peptide was determined using a competitive radioimmunologic kit (3ykSangtecDiagnostica, Dietzenbach, Germany) with a coefficient of variation of 30.0% at the concentration of 0.11 nmol/Iiter and 4.5% at 1.8 nmolfliter. Serum glucagon was measured using a double-antibody radioimmunoassay kit (Diagnostic Produds Corporation) from blood samplescontaining 1 mg of aprotinin; the interassaycoeiliieientof variation was 15.7% at
of 10.6 pmdfiter acd 57% at 153 pmoI/Iiter. Serum growth hormone was measured using an immunoradiometric assay(ClS Bio International, Paris, France), with a coefficient of variation of 4.2% at the concentration of 3.3 pgliter and 4.4% at 16.4 pgiliter. Serum o~tisol was determined by a rad~o~~l~lunoass~y kit (Orion Diagnostica, Espoo, Finland), with a coefficient of variation of 5.2% at the concentration of 31.2 nmoI/?iter and 4.3% at 542 nmoliliter. Plasma norepinephrine was determined by high performance liquid chromatography with electrochemical detection after alumina adsorption and elution with 2% acetic acid (17); the interassay coefficient of variation was 5.5% at 2.01 nmol/liter. Plasma pro&VP was determined using a radioimmunoassay kit (Biotop, Zulu and Medix Biochmica, Kauniainen, Finland), with an interassaycoeflicient
The concentration
trunk and pulmonary artery wedge positions using a Siatham P23 transducer with the zero reference 1eveIset at the midaxillary line. Mean pressureswere electronically integrated. Cardiac output was determined by the Fick principie; the Deltatrac monitor was used to measure oxygen consumption simultaneouslywith blood sampling for oxygen content in the pulmonary and femoral arteries. If clinically indicated, left heart catheterization with selectivecoronary angiography was performed thereafter. Statistical methods. The KoIInogorov-Smi~iovnnc-sample test was used to assessthe normality of data distribution. The concentrationsof blood ketone bodies,free fatty acids,cytokines and most hormoneswere skewedtoward high ~&es. A!1 differencesbetween the CHF and control groupswere then anatyzed by the Mann-Whitney Utest, Associationsof blood ketone bodies with the clinical,hemodynamicand echocardiographicvariables, and with Lhe IaboratorJrdata, were analyzedby calculating the Spearman(distribution-free)rank correlationco&k&its (rJ or% after logarithmic data transformation, the Pearson productmoment coefficients.Statisticallysign&ant univariatecorrelates of blood ketone bodies were subjectedto a stepwise,multiple linear regressionanalysisto identik the independentpredictors01 ketonemia. Ketode body concentrationand the explanato~ variables showing skewed data distribution were log trit~s~~r~n~d bcfon regressionanaIysis;p < O,i).F was consideredst~lt~sti~~Ily significant.The data aresummarizedasmean I: SD or asmedian and range.dAI41: analyseswere made usinga tommerciallyavailable statisticalpackagefor mi~~ompute~s (@y&t 5.03 for Windows, SYSTATInc.).
esullts ~~h~~~~~~~~~ and ~~~~~~~~c~~a~ ~~~~~~~~~~~~ and cdurimetyy. On average:patients with CHF weighe.d somewhat lessand had a slightlysmaller body massindex and fat percentage than the control subjects, even thnngh :he diilerenceswere not statisticat!ysignificant (TabIc 1), Men had a higher body wigtit and height and a higher letanbody mass> hut lower fat percentage, than women (datn t1ot ShCBVJl); indirect
668
LOMMI BLOOD
ET .AL. KE?ONE
BODIES IN CHF
Tabte2. Noninvasive and Invasive Characteristics of Cardiac
and Function irt the Study Groups With and Without Heart Failure ChIti Patients With CHF Patients (n = 14) (n = 45) Characteristic (Wed11 i fii? (mean 2 SD) ____-___---~~ Noninvasive data 84 2 IS‘ 67 2 10 HR (beatsimin) 115 _f 25,; 13s t 22 HA SBP (mm I&) 73 2 I1 75 ? 8 BA DBP (mm I&) 0.39 It ll.21§ c.54 2 0.12 LVER 83 + 273” SOS f 10s Heart voIume.body area, (mlim’)~/ (i-min walking distance (m) 309 t 139 464 I 131 Invasive data CI (litersi’min per m’) 2.4 i- 0.6 2.5 i- 0.4 923 PAWP (mm Hg) ‘1 f 9* 1624 PAP (mm Hg) 30 It 13” it3 10 It fi+ a-. RAP (mm Hg) ---. -_-‘p < O.@Ol, fp < 0.01, $p < 0.05YZISUS CGnirOi group.$Determined by two-dimensional ecbocxdiography. jlMeasn:cd from chest radiographs. BA = brachial arteq; DBP = diastolic b!ood pressure; CHF = congestive heart failure; CI = cardiac index; HR = heart rate; LVEF = left ventricular ejection fiaction; PAP = pulmonary artery pressure; PAWP = pulmonary artery wedge pressure; RAP = right atria1 pressure: SBP = qstolic blood pressure. Circulatory Congestive --
the proportion of male patients was similar in the CHF and control groups (62% and 64%, respectively). Table 2 shows that patients with CHF had an increased mean rest heart rate, a decreased left ventricular ejection fraction, a shortened B-min walking distance and elevated cardiacfilling pressurescompared with the control group. The overlap of the hemodynamicmeasurementswas not negligible, however. Because of the heterogeneity of the underlying diseases,some patients with CHP had fully normal or even high left ventricular ejection fractions, whereas three control patients (two with valvularregurgitation and one with coronary artery disease)had an abnsrmally low ejection fraction despite the absenceof definite clinica; CHF (Fig. I). Fmthermore, as Figure 1 shows,even after exclusionof patients with precapillary pulmonary hypertension, a few patients with CHF had a normal pulmonary wedge pressure,although an elevate6value was observedin one control patient with mitral valve disease. Reliable evaluation of tricuspid regurgitation was possible in 48 patients. fn the CHF group (n = 3h), 6 patients had no regurgitation, 5 had jet areas<4 cm’, 13 had jet areasbetween 4 and 10 cm” and 12 had jet areas 110 cm’. In the controi group (n -il 1^L)? 9 patien$ had no regurgitation, 2 had jet areas ~3 cm” and 1 patient had a jet area >I0 cm’. The basalmetabolic rate couid be determined in 38 patients with CHF and in ! 1 control subjects.Expressedper kilogram of lean body mass, basal metabolism averaged 77.8 i 12.4 J+.g--‘amin-” in the CHF group versus 75.7 rt 14.1 J*kg-“*min”’ in the control group (p - NS). The rate of lipid oxidation averaged49.1 z 112.3J-kg-‘wmin-’ in patients with CHF and 42.1 5 13.7I+kg‘-‘&il ’ in the control subjects(p = NS). fio~~?vq
0
to
20
30
Left ventriwlar
40
50
ejectian
60
90
fraclhi.
80
WI
Figure 1. Relation of blood ketone hodics to pdmonaq artery wedge
pressure,ri&htatria1pressureend Ml ventriculHrejectionfmction. SuXidand upen clrciesrepresentheart failure:p-tients and control patients,rcsprctivcly.Note that the scaleof the y axisis logarithmic. Vui:regressionlinesrepresentthe leastsquaresfitsandthe correlation coefficientsare Pearson’s.Six patientswith pure right-sidedheart failure(precapillary pulmonaryhypertension) wereomittedfrom plots of ketonebodiesagainstpulmonaryarterywedgepressureand left ventricularejectionfraction.Whenthesepatientswereindudizd,the torretation of log ketone bodies with pulmonary,wedge pressure decreased to 0.44 (p = NOI) andwith ejectionfrzrton to -0X (p = 0.007).
JACC
Vol. 28, No. 3
September 19X565-72
BLOOD
Table 3. Circuirrting Concentratioas of Substrates, Metabolites, HrJrmones and Cytokines in the Study Groups With and Without Congestive Heart Failtire Patients With CIiF Variable B-ketone bodies (~moliliter)” B-lactate (mmofihterj P.-glucose (~o~~~iter) S-free fatty acids (pmohliter\, S-insulin (muiliter) S-glucagon ipmoliliter) S-giucagoniinsulin ratio (pmol/mU)
S-C-pcptide jnmol/liter) §-growth hormone (&liter) S-cortisol (nmoliliter) P-norepinephrine (nmol,‘liter)O P-epinephrine
(mnolilitcrji~
P-pro-ANP (nmolilitcr)
II! = 45) 0.74t 0.23
0.66rt 0.18
5.2 2 0.7
53 5 0.3 469 i 143
603 It:254$ 6.1 (2.3-53)
37.3 I 5.1 6.123.2 1.1 (U.27-4.8)i
2.0(0.1~IS)!: 462 -e 121: 1.9 (0%YS)$
0.31(0.13~0.54) ?.JG(0.12-4.43)Il
6.7(3.2-B) 34.5 5 4.6 5.12 2.7 0.72(0.25-1.7) 0.35(0.1-2) 326 %:sJ 1.2 (0.448)
0.23(O.OY-3.50) 0.44(0.14-2.7s)
P-TNF-alpha (ng,Qiter)# 19 (0.8-68) 14 (S-63) lSW(l,OlO-5,225)¶ i336(87S-1,596) P-TNF-alpha receptor II (ngiliter)** P-interleukin-6 (ngJites)*5.3(0.2-39) 2.7 (0.3-41) -. ‘Acetoacetate plus b-;a-hydro~~butyrate. ,i-p < O.Uj> Sp i O.UUl. $ < 0.01. versus control group. In = 45 (34 + 11). j/n = 37 (29 -t 8). #n = 48 (37 + 11).
:%I = 54 (40 + 14). Data are mean t SD or median (range).ANP = atrial natriuretic peptitie;B J blood; CHF = congestive heart failure; P =: plasma; S = serum; TNF = tumor necrosisfactor.
Substrates, metabolites, hormones aad cy%okioes.Table 3 compares the laboratory data between the two study groups. Blood ketone bodies were elevated in patients with CIIF (Fig. 2), aswere setnm free fatty acidsand C-peptide, but there were no statisticallysignificant dithzrencesin the concentrations of glucose, lactate, insulin or glucagon or in the glucagon-toFigure 2. Blood ketone body concentration (acetoacetate plus betahydroxybutyrate) in 45 patients with congestive heart failure (CHF) and in 14 control subjects. 1 I I 0
1
CHF -
669
ET .4f,. IN CHF
Cardiovascular Variables in the Total Study Group and in the Congestive Heart FaiailnreCroup -
m = 14) 150 (31499)
LOMMI BODIES
Table4. Correlation of Blood Ketone Body Concentration With
Control P@ienEs
267 (44-9s2)‘i
KETONE
Variabie lll.--l--l.~~_ NYHA futctional class S-minute walking distance LVFF PAWP Mean PAP Mean RAP
CI Tricuspid
-
(!l
=
regurgitant jet area
48)
Ail Pztients (n = 59) iis)
0.35": -0.19 -P.Z7$2
O.dlIj 0.4@
0.36s -0.91 U.:iBf
CHF Group (n = 4s) Cd
0.22 0.03 -0.36”~
u.45f 0.37* 0.34" 0.01
0.27
-~~I~
‘;p i 0.05 ip < 0.01, #p < O.OUi. @earoxm rank correlatiou coefficient (rs) was -0.51 {p C U.UUl) when the six patients with precapillary puhnonaty
hypertensionwere excludedfrom the analysis.//Speannanrank correlation coeificient (rJ was 0.X (p < O.&Gl) when patients with ptecapilla~ pulmonary hypertensionwere Lscluded. NYHA = PJew York Heart Association; other abbreviations as in TaPles 1 and 2.
insulin ratio. The stresshormones (cortisol, growth hormone and norepinephrine, and proAMP were also clearly higher in the patients with CEF than in the control group. The patients with CEIF, likewise. had elevated concentrations of soluble T&IF-alphareceptor II in the circulation, but the trends toward higher TNF-alpha and interieukin-6 were not statistically significant. Comiatcs d’ blood ketone body concentration. The concentration of ketone bodies was independent of age, gender, body weight, body massindex anti lean body massin the total study group, but correlated inverselywith the calcu1ate.lirody fat mass(rS= -0.27, p < MS). Correlations of ketone bodies with the rates of basalmetabolism and lipid oxidation were not statisticallysignificant. The associationsof blood ketone bodies v:ith the cardiovascular and laboratory data are shown in Tables 4 and 5, respectively.In the total study group, blood ketone bodies rose with decreasingejection fraction and with higher tilling pressures and increasingtricuspid regurgitation (Table 4, Fig. 1). Ketone bodies correlated inverselywith plasma glucose and directly ~vithfree fatty acids,norepinephrine?growth hormone, pro-ANP and interleu’kin-6 (Table 5, Fig. 3) Comparable analjrsesrestricted ta the patients with CIIF gave basically similar findings, Jthoogh some correlation coetlicientswere mot statistically significant owing to the smaller number of sub.jec&(Tables 3 and 5). Multiple linear regressionanalysisin the total study group showed that log blood ketone bodies correlated independently with log serum free fatty acids (Sandardized beta coethcient 0.51, p s: MXll), piasmaglucose{beta -if,29, p i: 0,ol j and left ni:lrictdlar ejection fractior (beta -0.38, p Cr: tl.01). The squared multiple correlation coet%cient(R’, the explanatory pwex of the model) was0.51. The samethree firctorswere the indqendent predictors of log ketone bodies: also in analysis res&ioted to t:hc CHF group (I? = O.Qrl)an? in analysis
GO
LOMMI ET AZ.. BLOOD
KETOMZ
BODIES
IN CHF
‘Fable 5. Corre!ation of Blood Ketone Body Concentration With Circulating Substrates, Hormones and Cytokines in the Total Study Group and in the Congstive Heart Failure Group __II____ All P&ems CHF Group in = 59) (3-i= 45) Variabk ;1;1 !I;) -----__l P-g10c0se -0.33” -0.34f S-free ralty acids 0.52: 0.49’ r3-1;mie 0.01 0.07 S-insulin -0.15 -0.25 S-giocagon 11.15 0.05 0.18 S-glucagoniinsulinratio 0.25 S-cortisol 0.07 -0.13 S-growth hormone (i.mt 0.20 P-norepinephrine (II = 4.5) 0.45’ 0.36t P-prw4NP 0.36’ 0.3OP 0.05 -0.13 P-TNF-alpha (11= 48) P-soIobIeTNF-a!phareceptorII 0,UI --0.21 (II = 54) F-imerieiikin-G(n = 54) 0.27t 0.16 .--_l_-;p c F.01,.fp i O.US.$p < 4J.001.Data xesented are Spcarnan rank c rxlation coeWciems(r,). Abbreviationsas in Table 4.
la I-,. 5.1
P-Worepine$rinr
nmal/L
10.0
inva’?i&~ the taai study group lesssi):patients with CHF due
to purl right heart failure fR2 = 0.52).
I
We found tE;at blood ketone bodies were elevated in patients with CHI-: ii: proportion to the severityof symptoms and to the degree of venous congestion, left ventricular dysfunction and neurcG!ormonaIaswell as cytokine activation, Left ventricular systolicdysfunction, elevated circulating free fatty acids and low plasma glucosewere independent predictors of high ketone body concentration. These findings suggest that CHF is a ketosis-pronestate and that the susceptibilityto ketosisincreaseswith the severityof CHF. Determinants cf blood ketone bodies: the roie of stress hormones and free fatty acids. In general, ketone bodies accumulatein blood if their synthesisin the liver is augmented or if their distribution volume, utilization or excretion is decreased (20). Augmented production, in turn, may result either from a rising supplyof ketogenic substratesor from the activation of the hepatic ketogenic mechanism. In our work, circulating free fatty acids,the main ketogenic substrate,were elevated in the patients with CHF compared with control subjects, suggestingthat increasedproduction probably contributed to the higher level of blood ketone bodies in CHF. In the background, hormonally stimulated lipolysis may have been instrumental because norepinephrine, cortisol and growth hormone were all elevated in the patients with CHF, and these hormones can augment lipolysis and fatty acid supply>particularly if the antilipolytic effects of insulin are suppressed(20-25). In addition to boosting lipolysis,norepinephrine may have direct ketogenic action in the liver and can reduce the clearanceof ketone bodies in the periphery (24)” Norepinephrine and sympathetic stimulation also promote
I
J 0.1 1.0 10.0 P-pro-atriarlnatriuretio peptide, mnol/L t
I
Figure 3. Relationof blood ketclnebodiesto the concentrations of
norepinephrine,proatrialnatriureticpeptideand interjeukin-6in the circubtion. Solid circles representpatients with congestiveheart failiire,and opencirclesrepresentconirolpatients.Both the y and x axesa;e in a logarithmicscale.The re@ession lines representthe least squaresfits and the correlaticincoefficientsare Fearson’s.
glycogendepletion (20), which favors fatty acid oxidation and ketogenesis(21,26,2’7! Role of nutrition. Another factor that theoretically could potent&e kerogenesisin CHF is an imbalance between the supplyof and need for calories.Malnutrition is not uncommon
Sepiember
196:665-X!
in chronic CIIF and is thought to reflect reduced food intake and absorption, in addition to increasedbasalmetabolism and cellular hypoxia (1,7,8,28,29), Increased secretion of TNFalpha may also contribute (30,31). Like simple fasting, mahmtrition depletes the body af its glycogen stores, le,+dingTVfat utilization and ketogenesis.Our patients with CHF were not overtly malnourisiled~but many of them had markedlv elevated right atria1pressure,which predicts nutritional problems in CHF (8). Although we found that blood ketone bodieswere inverselyrelated to the body’sfat mass,supporting the role of nutrition, neither the other characteristicspertinent to the nutritional status nor the basal metabolic rate 2redieted the degree of ketonemia. Role of’glucagon and insulin. An increasein the glucagonto-insulin ratio in serum has been raised as the key initiating factor in most ketotic states, including simple fasting (20,273. When glucagon increasesrelative to insulin, fatty acids taken up in the liver are rerouted from the synthesisof triglycerides and phospholipids to oxidation and ketogenesis-that is, the ketogeaic machinery is switched to a higher activity. Surprisingly, the glucagon-to-insulin ratio was not elevated in our patients with CHF, nor was the degree of ketonemia associated with either serum glucagon or insulin concentration or their ratio. Therefore, these hormones seemunlikely to play a major role in the genesis of CHF ketosis. It is well known that increased free fatty acid supply can augment ketone bodl production, even if the activity of the hepatocytes’ ketogenic mechanism is unaltered (27). There are reports suggestingthat CHF is accompanied by insulin resistance(32,33), and we initially thought chat insulin resistancewith impaired suppressionof lipolysiscould contribute to the development of CHF ketosis.However, our patients with CHF had no hyperinsulinemia suggestiveof insulin resistance, compared with the control group, not even when the insulin concentrations were adjusted to plasma glucose {data not shown). Yet we admit that a precise assessmentof the body’s insulin sensitivitydepends on the use of a euglycemic insuhn clamp and that there was some discrepancyin our data because C-peptide levelswere slightly but statisticallysignificantly elevated in U-IF. Earlier reports (32,33) associating insulin resistancewith CHF included healthy control groups, whereasour control patients had a heart diseasebut no CHF, This is a crucial difference because insulin resistance may accompany such common conditions as atherosrierosis and hypertension, even in the absenceof CHF (34). Role a$ cytakines, Cytotines arc low molecular weight proteins secreted by cells in responseto stimuli varying from bacterial infections to myocardial injury (35). In addition to autocrine effects, cytokines have. paracrine and endocrine actions on tissues as well as heart and blood vessels.We measured plasma cytokine concentrations in our pa&h% primarily becauseincreasedconcentrations of TNFqalpba ac,! interleukins have been reported in CHF (30,31,36) and in par&mar becauseTN&alpha has been linked with the devet-, opment of malnutrition and cardiac cachexia (30,31). We found that blood ketone bodies were not associated with
TNF-alpha but showed a direct relation to interleo& 6. IIowever, there was: also a linear relation between ~nterleukin-~and right atria1pressure (rs = 0.53, p < Q.Mll), and the associationof blood ketone bodies with interleukin-6 may simply have reflected the link between ketonemia and the severityof CHF. In multivariate analysis,interleukin-6 wasnot an independent predictor of ketonemia. The significanceof interleukin-6 in CHF is still unknown, although experi~~en~al~,; it promotes cardiac dysfmrction (37,383. Possibleclinical implications. Whether mcasming the degree of ketonemia in patients with CNF has clinical relevance cannot be answeredfrom our study.We believe,howeve;, that the degree of ketosis proneness could give insight into the severityof CHF and that elevatedblond ket~e bodiesafter an overnight fast could be taken as a warning of incipient problems with the maintenance of the body’s energy stores. Whether susceptihihtyto ketosiscould have progncst%value, suchas nemohormonal activation or serum sod& concemration convey (I), deservesattention in future studio-. Study limitations. Our CHF group may net represent t% general CHF population well, aecause exclusion of patients taking beta-blockers led to underrepresentation of ischemic heart diseaseend h*l=+G ,,,,L,.nsion. In the control group, several patients had one or two of the four diagnosticcriteria of G-IF, and some also had abnormal hemodynamic measurements (Fig. 2) even though none fulfilled 01:: definition of clinical CHF. If we had included in the control group only patients with none of the four CHF criteria, the metabolic differences between the groups rizighthave been more significant. Yet we have observed prevIo&y that cardiac patients free of clirrical CHF by our criteria do not d&r from healthy personswith regard to breath acetone concentration, which correlates linearly with blood acetone (Kl), The lack of a more detailed characterization of the patients’ nutritional status and diet is another limitation. Although none of our patients with CHF was grosslyedematous, some fluid retention was possibleand may have biased the anthropometric measurements, apart from body height and percent body fat. Our study ma): also be criticized for not discontinuing drug therapy before the exam.. inations. However, many of the patients with CHF were severelysymptomatic, which made interruption of therapy for several drug half-lives an impractical alternative. Moreover, diuretics, angiotensin~convert~ng enzyme inhibitors and digoxin have no known diiect influence on the turnover of ketone bodies. Finally, we acknowledgeFhat our inferencesof altered ketcgenesisare indirect becausethe production, utihzation and excretion of ketone bodies were not separately quantified. It is My possible that the clearance of ketone bodies (utilization and excretion) can be altered in patients with CHF having marked syst’emiccongestion, low cardiac output and renal dysfunction. Future studies using isotope techniqueswith or without hepatic vein catheter~at~o~for the measurement of liver blood flow and net output of kctcne bodies are needed to evaluate in detail how the elemeats of ketone body kinetics are altered in CIIF.
672
LOMMI BLOOD
ET AL. KETONE
BODJES
IN CHF
Conclusions. Mild elevation of blood ketone bodies is common in patients with CHF. The degree of ketonemia is related to the severity of hemodynamic abnormalities and to the degree of neurohormonal and cytokine (interleukind) activation. Increased supply of free fatty acids from stress hormone-stimulated lipolysisis likely to be one of the mechanisms leading to ketonemia in CHF; insulin and glucagon appear to be relatively unimportant. Additional studies are needed, however, to detail the mechanismsof CHF ketosisand to assessits clinical significance.
18. 19.
20.
21.
22.
23. 1. Fittman JG, Cohen P. The pdthogenesis of cardiac cachexia. N EngI J ivied 1964;271:403-9. 2. Packer hi. Pathophysiology of chronic heart failure. Lancet 1992;340:88-92. 3. Neely JR, Rovetto MJ, Oram JF. h4yocardiul utilization of carbohydrate and lipids. Frog Cardiovasc Dis 1972;15:2SY-329. 4. Cohn JN, Levine TB, Olivari MT, et al. Plasma norepinephrine as a guide to prognosis in patients with chronic congestive heart failure. N Engt J Med 1984;311:819-23. 5. Anand IS, Ferrari R, Kalra GS, Wahi PL, Poole-Wilson PA, Harris PC. Edema of cardiac origin. Studies of body water and sodium, renal function, hemodynamic indexes, and plasma hormones in untreated congestive heart failure. Circulation 1989;80:299-303. 6. Poehlman ET, Scheffers J. Gottlieb SS, Fisher ML, Vaitekevicius I’. Increased resting .metabolic rate in patients with congestive heart failure. Ann Intern Med 199~i;121:860-2. 7. Ansari A. Syndromes of cardiac cachcxia and the each&c heart: current perspective. Prog Cardiovasc Dis 1937;30:45-60. 8. Carr JG, Stevenson LW, WalJen JA, Heber D. Prevalence and hemodynamic correlates of malnutrition in severe congestive heart failure secondary to ischemic or idiopathic uilated cardiomyopathy. Am J Cardiol 1989;63: 709-13. 9. Riley M, Bell N, Elborn JS, Stanford CF, Buchanar KD, Nicholls DP. Metabolic responses to graded exercise in chronic heart failure. Eur Heart J 1993;14:1484-8. 10. Kupari M, Lommi J, Ventilii M, Kajalainen U. Breath acetone in congestive hear1 failure. Am J Cardiol 1995;76:1076-8. il. Keats TE, Enge IP. Cardiac mensuration by the cardiac voiume mrthod. Radiology 1965;85:850-9. 12. Lipkin DP, Striven AJ, Crake T, Poole-Wilson PA. Six minute walking test for assessing exercise capacity in chronic heart faiiure. BMJ 19Yh;292%53-5. 13. Durin JVG& Womersley J. Body fat assessed from total body density and its estimation from skinfold thickness: measurements on 481 men and women aged Iron1 16 to 72 years, Br J Nutr 1974;31:77-97. 14. Williamson DH, Mellano, J, Krebs HA. Enzymatic determination of D-p hydroqbutyric acid and acetoacetic acid in blood. Biochem J 1962$2:YO-6. 15. Lowry OH, Passoneau JV. A Flexible Sysem of Enzymlrtic Analysis. New York Academic Press, 1932:193-21. 16. Miles JR, Glasscock J, Aikens J, Gerich J, Haymond M. A microfluorome’ric method for the determination of free fatty acids in plasma. 3 Lipid Kes 1983;:!4:96-9. 17. Scheinin M, Koulu M: Latirikainen E, 4llonen II. Hypokalcmia and other non-bronchial chects of inhaled fenotcrol and salbutamok a placebo-
24.
25. 26.
27. 28. 29. 30.
31.
32.
33. 34. 35. 36.
37.
38.
controlled dose-response siudy in healthy volunteers. Br J Clin Pharmecol 1987;24:645-53. Ferrsnnini E. The theoretical basis of indirect calorimetry. Metaho!ism 1988:37:287-301, Schillcr NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left venfric!e by two-dimensional ecbocardiograpby. J Am Sot Echocardiogr 1989;2:358-67, Baiasse EO, Fcry F. Ketone body production and disposal elIerts of fasting. diabetes and exercise. Diabetes Metab Rev 1989:5:247-70. Johnston DG, Pernet A, McCulloch A; B&a-Malpica G, Burrin JM, Alberti KGMh4. Some hormonal influences on glucose and ketone body metabolism in normal human subjects. In: Metabolic Acidosis. London: Pttman Books (Ciba Foundation symposium 87): 1982~165-91. Metcalfe F, Johnston DG, Nosadini R, Orksov H, Alberti KGMM. Metabolic effects of acute and prolonged growth hormone excess in normal and insulin-deficient man. Diabetologia 1981;20:!23-8. Scbsdc DS, Eaton RP. The regulation of plasma ketone body concentration by counter-regulatory hormones in man: III. Effects of norcpinephrme in normal man. Diabetes 1979;28:5-10. Schade DS, Eaton RP, Standefer J. Glucocorticoid regulation of plasma ketone body concentration in insulin deficient man. J Clin Endocrinol Metab 1977;44:1069-79. Keller U. Gerber PPG. Stauffacher W. Stimulatorv effect of noreuineohrine on ketogenesis in normal and insulin-deficient humans. Am’ J Physiol l%+k247:E732-E739. Keller U, Weiss h4; Stauffacher W. Contribution of n- and P-receptors to ketogenic and lipolytic effects of norepinephrine in humans. Diabetes 1959;3s:454-9. Foster DW. From glycogen to ketones-and hack. Diabetes 39X4133:31% 99. Schwengel RH, Gottlieb SS, Fisher ML. Protein-energy malnutrition in patients with ischemic and nonischemic dilated cardiomyopathy and congestive heart failure. Am J Cardiol 1994;73:908-10. Morrison WL, Edwards RHT. Cardiac cachexia. Br Heart J 1991;302:301-2. Levine B, Kalman J, Mayer L, Fillit H, Packer M. Elevated circulating levels of tumor necrosis factor in severe chronic heart failure. N Engl J Med 1990:323:236-41. McMurray J, Abdullah 1. Dargie HJ, Shapiro D. Increased concentrations of tumor necrosis factor in “cachectic” patients with severe chronic heart failure. Br Hedri J 1991;66:356-8. Paolisso G, De Riu S, Marrazzo 6, Verza M, Varriccbio M; D’Onofrio F. Insulin resistance and hyperinsulinemia in patients with chronic congestive heart failure. Metabolism 1991;40:972-7. Swan JW, Walton C, Godsland IF, Clark AL, Coats JS, Oliver MF. Insulin resistance in chronic heart failure. Em Heart J 1994;15:1528-32. Williams W. Insulin resistance: shape of things to come. Lancct 1994;244: 521-4. Mann DL, Young JB. Basic mechanisms in congestive heart failure. Recognizing the role of proinflammatory cytokines. Chest 1994;105:897-904, Wiedermann CJ, Beimpold II, Herold M, Knapp E, Eraunsteiner H. Increased levels of serum neopterin and decreased production of neutrophil superoxide anions in chronic heart failure with elevated levels of tumor necrosis factor-alpha. J Am Coil Cardiol 1993;22:1597-1901. Finkcl MS, Oddis CV, Jacob TD, Watkins SC, Hauler BG, Simmons RI... Negative inotropic effects of cytokines on heart mediated by nitric oxide. Science 1992;257:367-9, Finkei MS, Hoffman RA, Shea L, Oddis CV, Simmons RL, Hattler BG. Intcrlcukin-6 (!I,-61 as a mediator of stunned myocardiam. Am J Cardiol 1993;71:1231-2.
-
-
Objtxtives.The present study was designedto assesswilether blood ketonebodiesare elevatedin cungestiveheart failure \CHF) and whether ketonemir is related to tbe hemodynanri~and neurohumoral abnormalitiesof CHF, &e&ground.In CHF, consumptionof the body’sfat storesmay become abnormally high, contributing to the development of cardiaccachexia.Increasedmobilizationof free fatty acidscould, in theory, augment k&genesis, but vvhetherpatients with CHF are prone to ketosisremainsunknown. MefMs. Forty-five patients with chronic GMF (mean age [ +SD] 57 & 13 years)and 14 control subjectsfree of CHF (mean age 53 + 13 years) underwent invasiveand noninvasivecardiac studies and determination of biood ketone Mies (acetoacetste plus beta-hydroxybutyrate),circulating free fatty acids,glucose, lactate,k&in, glucagon,growth hormone, cortisol,norepinephrine, N-terminal proatrial natriuretic peptide, tumor necrosis factor-alpha and interleukin-6 after aa overnight fast. ResuflsPatientswith (IHF had elevatedblood ketone bodies (median 267 ~mot/liter. range 44 to Y52)comparedwith controrol .----.
1-^1_-_---.---
Il.-l---.-l-~
fJ Am Coli &r&o1 ~~Y~;2~:~~5-72)
-------
Congestive heart failure (GE) is a clinical syndrome that resultsfrom systolic or diristoliccardiacpump dysfunction ml is accompaniedby a number of neurohumoral and metabolic alterations in the l30Cly (I,?. Im chrcmic CM?, WiE4ing of subcutaneousfat and skeletalmusclejs relatively common and suggests augmented consumption of noncarbohydrate substratesfor energy production (1,3). Regarding the mechanisms leading to lossof the body’sfat stores,elevatedconcentrations of stresshormones, including norepinephrine (4,5j, may play a role by enhancing lipolysis,and increasedbasall~l~.tab~lis~~~ [cjf with insufficient food intake or absorption (1,7&l may ako contribute. It has also been shown recently that fat oxidation during exerciseis increased in patients with C&IF compared with healthy persons (9). These changes in lipid metabolism --
..--- --_----
fDq~artmenr of Medicine)and Deprinent of fllnimi Chemisty Helsinki University Central Hospitsl, Helsinki; and *Department Of Clin~d Chemistry, ‘Turku University Central Hospit& Turks, Finland. This work was supported ky grants from the Pinnisk Heart Researck Foundation (Dr. Lommi), the Kesea~ck Institute of Helsinki University C~lntral Hospital (Dr. Lammi), the Finnish Heart Disuse Association (19tk I;ebruav Fund) (Rr- Kupari) and the Finnish Academy (Gmnt SA 7135 to Dr. Kupxij. Helsinki, Finland. From tke Oivisitrn of Cardblogy
subjects(medianWI fimol/Kter,range31 to 2YY,p < OAIS). In the total study gtoirp, blood ketonebodieswererelated to puilmonmy artery wedge pressure (rs = 0.45, p c O&M), left vestrictdar ejectionfr&iun (rS= -0.37, p < Q.Ol),rigbt atria1pressore(r, = 036, p < 0.01) and circula;ingconcentrationsof free fatty acids @S= 0.52, p C Q.QQl),&close (r, = -0.3Y, p < O.Ol),norepinephrine (r, = 0.45,p C QAMl),growth hormone (l; = 0.30, p < 0.W) and interhWin-6 (r, = 0.27, p < 8.05). In multivariate amdysis,left ventricularejectionfraction, serum free fatty acids and serumglucosewereindependentpredictorsof ketnnemia. Conclusions.Bhod ketone bodies are elevated in CHF in proportion to the severityof cardiac dysfunctionand neorohormonal Mivation. This may be at least partly attributable to increasedfree fatty acid rnobi~~~t~oo in resp+mscto augmented neurohormonai stimulation. Additional studies are needed to identifythe detailedmechanismsand clinicalimplicationsof CIIF ketnsis.
could boost hqntic ketone body production, atrd we have rtxently shown that fastiug breath acetone concentrations are often elevated io patients with CHF (IQ). This study was designed to assesswhether blood ketone bodies are etevated after an overnig,ht fast in patients with clinical CHF and whether the degree of ketonemia depends on the hemodynamic abnormahties or the prevailing nemoi~ul~~~rai milieu, incloding circula.tingstresshormone and cy?Jkineooncentrations.
1Pa+ipn)r “s.ll.*Yi The studs included 59 patients with cardiac diseaseadmitted to Helsihki UniversityCentral Hospital between ,immaxyand October 1994 for treatment or diagnasriz cvaluation. CMthe patients, 45 (28 men; mean age (ESDJ 57 +- 13 yearsj had definite clinical cH1-’and 14 (,9men; mean age53 -t: 13 years), constituting the contra? group, were free of CRF. The diagnosisof CRF required that the patient had a cardiovascular diseaseand at !east three of the following four signs: 1) dyspneaor fatigue on ordinary et%rt; 2j audibIti third heart som~dor heart rate >9lI beatsimin at rest; 3:).enlarged heart vo1n11xc per body area on chest radkgnph f3500 ml/m’ in WO!llW,
XT50 ml/m” in men) (II);
or 4) plmotwy
wnous
congestion on chest radiograph or abnormal neck vein disten-
tion. Patientswith diabetes or other ,endocrine,chronic infectious, hepatic, renal9gastrointestinal or connectivetissue diseases or malignancy were excluded. Acute infectious or ~~~~a~nrnat~~ diseasesand recent myocardiai infarction also led to exclusion, as did the use of drugs with a possible influence on the synthesisor metabolism of the ketone bodies (beta-adrcnergicblocking agents, rorticoskroidsj. Eventually, the most common reasonsfor exclusionwere diabetes, recent myocardial infarction and use of beta-blockers. In the CHF group, the underlying condition was vaivuiar heart diseasein 15 patients, coronary artery diseasein IO, idioparhic dilated cardiomyopathy in IO, embolic or primary pulmonary hypertensionin 6: constrictivepericarditis in 2 and congenital heart diseasein 2, Twenty-eight patients were in sinus rhythm, 41 had chronic atrial fibrillation and 6 had pacemaker rhythm for most of the time. Functionally, 8 patients were in New York Hear! Associationfunctional class IV? 21 were in classIII and 16 in classII. Fcrty-one patients were using furosemide (mean daily dose 135 mg, range 40 to 500), which was combined with spironolactone in 12 patients acd metolazone in 4 patients. Three patients were taking hydrochiorothiazide. Thirty& patients were taking digoxin, 26 were using angiotensin-convertingenzymeinhibitors and 21 itiere u&g long-acting nitrates. In the control group, eight patients had valvular disease (six aortic, two mitral), four had congenitalheart disease(ail septal defects; two atria], two ventricular) and two had coronary artery disease.They underwent cardiac catheterization either for assessmentof the hemodynamicsignificanceof their structural heart diseaseor for preoperative evaluation. Twelve of rhem were in sinusrhythm and two had chronic atria1 fibriilation. Functionally, eight control patients were in functional classII and sixwere in classI. None fulfilled our definition of CHF (presence of three or four of the four clinical signs specified previously), but two signs were identified in four patients and one sign in five patients. Two patients were taking angiotensin-converting enzyme inhibitors and diuretics; digoxin and nitrates were used by three patients each. Study design. All studies were performed while the patients were in the hospital for treatment or examinations. Eligible patients with CI-IF who hrd been admitted for worsening congestionwere studied afte: removal of fluid retention and restoration of earlier symptomatic status. Throughout their hospital stay,the patients were on a nonreducing hospital diet with an averagetotal energycontent of 2,030 kcal/dayand with a minimum of 200 dday of carbohydrates.The patients underwent clinical examination and echocardiography followed, within 1 to 2 days, by indirect calorimetry and blood sampling after a 12-h fast for the determination of circulating energy substrates,metaboiites, hormones and cytokines.Cardiac catheterization was performed within 2 days after the blood tests, The patients continued their regular medication during the examinations.The study protocol was approved by the Institutional Ethics Committee. The nature and potential risks of the study were explained in detail to each patient before asking for their consent to participate.
Clinical ~xa~i~~ti~~. The patients were examined clinically, paying special attention to the history of exerciseintolerance and ?o the signs of CHF specified in the diagnostic criteria (see previous discussion).The neck veinswere studied by estimating the supraclavicularheight of the blood column ir; the right internal jugdiar vein with the patient breathing quietly in the sitting position. Any venous bulging above the clavicle was considered abnormal. Brachiaf artery blood pressurewas measured by the sphygnlomanometriccuff method. Posteroanterior and lateral &est radiographs were obtained and the heart volume per body area was calculated (II). All participants, except ol\e man with filncrionai class IV symptoms, undenvent a standardized 6-m;.rstilwaikmg test (12) supervised by one of the investigators(J.L.). Body height and weight were measured and body massindex was determined asweight (kg) divided by the square of height (m). The triceps, infracapular and suprailiacskinfold thicknesseswere measuredby a caliper, and the percent body fat was calculated using standard tables (13). Lean body mass was derived as body weight minus calculated fat mass. Determination of circulating substrates, metabolites, hermanes and cytokines. After a 12-h overnight fast (from 8 PM to 8 AM), while the patients were still in supine rest, blood was sampled from an antecubital vein cannulated 30 min in advance for the determination of glucose, free fatty acids, beta-hydroxybutyrate, acetoacetate,lactate, insulin, proinsulin C-peptide, giucagon, cortisol, growth hormone, norepinephrine, epinephrine, N-terminal proatrial natriuretic peptide (pro-ANP), tumor necrosisfactor-alpha (TNF-alpha) soluble TNF-alpha receptor II and interleukin-6. The blood samples for ketone bodies, lactate, norepinephrine and epinephrine were frozen immediately and stored at --70°Cuntil the assays. Other blood sampleswere collected on ice and centrifuged at 4°C; the serum was stored at -20°C until the determinations. Blood acetoacetate,beta-hydroxybutyrate and lactate were determined in perchloric acid extractsby a Transcon 102 FM Auoronephelometer (Elomit, Transcon Instruments Ltd., Helsinki, Finland) using nicotinamide adenine dinucieotidelinked enzymatic methods (14,15). Acetoacetate and betahydroxybutyrate were summed to give the concentration of blood ketone bodies, which was used asan index of ketonemia in all analyses.Serum free fatty acids were measured by the microfluorometric technique described by Miles et al. (16). Plasma glucosewas measnred enzymaticallyusing an Eppendad EPOS 5060 analyzer (Eppendorf, Hamburg, Germany), and serum insulin was measured using a double-antibody radioimmunoassay kit (Pharmacia, Uppsala, Sweden); the interassaycoefficient of variation for insulin was Y,O%at the concentration of 20 mU/iiter. Serum proinsulin C-peptide was determined using a competitive radioimmunologic kit (3ykSangtecDiagnostica, Dietzenbach, Germany) with a coefficient of variation of 30.0% at the concentration of 0.11 nmol/Iiter and 4.5% at 1.8 nmolfliter. Serum glucagon was measured using a double-antibody radioimmunoassay kit (Diagnostic Produds Corporation) from blood samplescontaining 1 mg of aprotinin; the interassaycoeiliieientof variation was 15.7% at
of 10.6 pmdfiter acd 57% at 153 pmoI/Iiter. Serum growth hormone was measured using an immunoradiometric assay(ClS Bio International, Paris, France), with a coefficient of variation of 4.2% at the concentration of 3.3 pgliter and 4.4% at 16.4 pgiliter. Serum o~tisol was determined by a rad~o~~l~lunoass~y kit (Orion Diagnostica, Espoo, Finland), with a coefficient of variation of 5.2% at the concentration of 31.2 nmoI/?iter and 4.3% at 542 nmoliliter. Plasma norepinephrine was determined by high performance liquid chromatography with electrochemical detection after alumina adsorption and elution with 2% acetic acid (17); the interassay coefficient of variation was 5.5% at 2.01 nmol/liter. Plasma pro&VP was determined using a radioimmunoassay kit (Biotop, Zulu and Medix Biochmica, Kauniainen, Finland), with an interassaycoeflicient
The concentration
trunk and pulmonary artery wedge positions using a Siatham P23 transducer with the zero reference 1eveIset at the midaxillary line. Mean pressureswere electronically integrated. Cardiac output was determined by the Fick principie; the Deltatrac monitor was used to measure oxygen consumption simultaneouslywith blood sampling for oxygen content in the pulmonary and femoral arteries. If clinically indicated, left heart catheterization with selectivecoronary angiography was performed thereafter. Statistical methods. The KoIInogorov-Smi~iovnnc-sample test was used to assessthe normality of data distribution. The concentrationsof blood ketone bodies,free fatty acids,cytokines and most hormoneswere skewedtoward high ~&es. A!1 differencesbetween the CHF and control groupswere then anatyzed by the Mann-Whitney Utest, Associationsof blood ketone bodies with the clinical,hemodynamicand echocardiographicvariables, and with Lhe IaboratorJrdata, were analyzedby calculating the Spearman(distribution-free)rank correlationco&k&its (rJ or% after logarithmic data transformation, the Pearson productmoment coefficients.Statisticallysign&ant univariatecorrelates of blood ketone bodies were subjectedto a stepwise,multiple linear regressionanalysisto identik the independentpredictors01 ketonemia. Ketode body concentrationand the explanato~ variables showing skewed data distribution were log trit~s~~r~n~d bcfon regressionanaIysis;p < O,i).F was consideredst~lt~sti~~Ily significant.The data aresummarizedasmean I: SD or asmedian and range.dAI41: analyseswere made usinga tommerciallyavailable statisticalpackagefor mi~~ompute~s (@y&t 5.03 for Windows, SYSTATInc.).
esullts ~~h~~~~~~~~~ and ~~~~~~~~c~~a~ ~~~~~~~~~~~~ and cdurimetyy. On average:patients with CHF weighe.d somewhat lessand had a slightlysmaller body massindex and fat percentage than the control subjects, even thnngh :he diilerenceswere not statisticat!ysignificant (TabIc 1), Men had a higher body wigtit and height and a higher letanbody mass> hut lower fat percentage, than women (datn t1ot ShCBVJl); indirect
668
LOMMI BLOOD
ET .AL. KE?ONE
BODIES IN CHF
Tabte2. Noninvasive and Invasive Characteristics of Cardiac
and Function irt the Study Groups With and Without Heart Failure ChIti Patients With CHF Patients (n = 14) (n = 45) Characteristic (Wed11 i fii? (mean 2 SD) ____-___---~~ Noninvasive data 84 2 IS‘ 67 2 10 HR (beatsimin) 115 _f 25,; 13s t 22 HA SBP (mm I&) 73 2 I1 75 ? 8 BA DBP (mm I&) 0.39 It ll.21§ c.54 2 0.12 LVER 83 + 273” SOS f 10s Heart voIume.body area, (mlim’)~/ (i-min walking distance (m) 309 t 139 464 I 131 Invasive data CI (litersi’min per m’) 2.4 i- 0.6 2.5 i- 0.4 923 PAWP (mm Hg) ‘1 f 9* 1624 PAP (mm Hg) 30 It 13” it3 10 It fi+ a-. RAP (mm Hg) ---. -_-‘p < O.@Ol, fp < 0.01, $p < 0.05YZISUS CGnirOi group.$Determined by two-dimensional ecbocxdiography. jlMeasn:cd from chest radiographs. BA = brachial arteq; DBP = diastolic b!ood pressure; CHF = congestive heart failure; CI = cardiac index; HR = heart rate; LVEF = left ventricular ejection fiaction; PAP = pulmonary artery pressure; PAWP = pulmonary artery wedge pressure; RAP = right atria1 pressure: SBP = qstolic blood pressure. Circulatory Congestive --
the proportion of male patients was similar in the CHF and control groups (62% and 64%, respectively). Table 2 shows that patients with CHF had an increased mean rest heart rate, a decreased left ventricular ejection fraction, a shortened B-min walking distance and elevated cardiacfilling pressurescompared with the control group. The overlap of the hemodynamicmeasurementswas not negligible, however. Because of the heterogeneity of the underlying diseases,some patients with CHP had fully normal or even high left ventricular ejection fractions, whereas three control patients (two with valvularregurgitation and one with coronary artery disease)had an abnsrmally low ejection fraction despite the absenceof definite clinica; CHF (Fig. I). Fmthermore, as Figure 1 shows,even after exclusionof patients with precapillary pulmonary hypertension, a few patients with CHF had a normal pulmonary wedge pressure,although an elevate6value was observedin one control patient with mitral valve disease. Reliable evaluation of tricuspid regurgitation was possible in 48 patients. fn the CHF group (n = 3h), 6 patients had no regurgitation, 5 had jet areas<4 cm’, 13 had jet areasbetween 4 and 10 cm” and 12 had jet areas 110 cm’. In the controi group (n -il 1^L)? 9 patien$ had no regurgitation, 2 had jet areas ~3 cm” and 1 patient had a jet area >I0 cm’. The basalmetabolic rate couid be determined in 38 patients with CHF and in ! 1 control subjects.Expressedper kilogram of lean body mass, basal metabolism averaged 77.8 i 12.4 J+.g--‘amin-” in the CHF group versus 75.7 rt 14.1 J*kg-“*min”’ in the control group (p - NS). The rate of lipid oxidation averaged49.1 z 112.3J-kg-‘wmin-’ in patients with CHF and 42.1 5 13.7I+kg‘-‘&il ’ in the control subjects(p = NS). fio~~?vq
0
to
20
30
Left ventriwlar
40
50
ejectian
60
90
fraclhi.
80
WI
Figure 1. Relation of blood ketone hodics to pdmonaq artery wedge
pressure,ri&htatria1pressureend Ml ventriculHrejectionfmction. SuXidand upen clrciesrepresentheart failure:p-tients and control patients,rcsprctivcly.Note that the scaleof the y axisis logarithmic. Vui:regressionlinesrepresentthe leastsquaresfitsandthe correlation coefficientsare Pearson’s.Six patientswith pure right-sidedheart failure(precapillary pulmonaryhypertension) wereomittedfrom plots of ketonebodiesagainstpulmonaryarterywedgepressureand left ventricularejectionfraction.Whenthesepatientswereindudizd,the torretation of log ketone bodies with pulmonary,wedge pressure decreased to 0.44 (p = NOI) andwith ejectionfrzrton to -0X (p = 0.007).
JACC
Vol. 28, No. 3
September 19X565-72
BLOOD
Table 3. Circuirrting Concentratioas of Substrates, Metabolites, HrJrmones and Cytokines in the Study Groups With and Without Congestive Heart Failtire Patients With CIiF Variable B-ketone bodies (~moliliter)” B-lactate (mmofihterj P.-glucose (~o~~~iter) S-free fatty acids (pmohliter\, S-insulin (muiliter) S-glucagon ipmoliliter) S-giucagoniinsulin ratio (pmol/mU)
S-C-pcptide jnmol/liter) §-growth hormone (&liter) S-cortisol (nmoliliter) P-norepinephrine (nmol,‘liter)O P-epinephrine
(mnolilitcrji~
P-pro-ANP (nmolilitcr)
II! = 45) 0.74t 0.23
0.66rt 0.18
5.2 2 0.7
53 5 0.3 469 i 143
603 It:254$ 6.1 (2.3-53)
37.3 I 5.1 6.123.2 1.1 (U.27-4.8)i
2.0(0.1~IS)!: 462 -e 121: 1.9 (0%YS)$
0.31(0.13~0.54) ?.JG(0.12-4.43)Il
6.7(3.2-B) 34.5 5 4.6 5.12 2.7 0.72(0.25-1.7) 0.35(0.1-2) 326 %:sJ 1.2 (0.448)
0.23(O.OY-3.50) 0.44(0.14-2.7s)
P-TNF-alpha (ng,Qiter)# 19 (0.8-68) 14 (S-63) lSW(l,OlO-5,225)¶ i336(87S-1,596) P-TNF-alpha receptor II (ngiliter)** P-interleukin-6 (ngJites)*5.3(0.2-39) 2.7 (0.3-41) -. ‘Acetoacetate plus b-;a-hydro~~butyrate. ,i-p < O.Uj> Sp i O.UUl. $ < 0.01. versus control group. In = 45 (34 + 11). j/n = 37 (29 -t 8). #n = 48 (37 + 11).
:%I = 54 (40 + 14). Data are mean t SD or median (range).ANP = atrial natriuretic peptitie;B J blood; CHF = congestive heart failure; P =: plasma; S = serum; TNF = tumor necrosisfactor.
Substrates, metabolites, hormones aad cy%okioes.Table 3 compares the laboratory data between the two study groups. Blood ketone bodies were elevated in patients with CIIF (Fig. 2), aswere setnm free fatty acidsand C-peptide, but there were no statisticallysignificant dithzrencesin the concentrations of glucose, lactate, insulin or glucagon or in the glucagon-toFigure 2. Blood ketone body concentration (acetoacetate plus betahydroxybutyrate) in 45 patients with congestive heart failure (CHF) and in 14 control subjects. 1 I I 0
1
CHF -
669
ET .4f,. IN CHF
Cardiovascular Variables in the Total Study Group and in the Congestive Heart FaiailnreCroup -
m = 14) 150 (31499)
LOMMI BODIES
Table4. Correlation of Blood Ketone Body Concentration With
Control P@ienEs
267 (44-9s2)‘i
KETONE
Variabie lll.--l--l.~~_ NYHA futctional class S-minute walking distance LVFF PAWP Mean PAP Mean RAP
CI Tricuspid
-
(!l
=
regurgitant jet area
48)
Ail Pztients (n = 59) iis)
0.35": -0.19 -P.Z7$2
O.dlIj 0.4@
0.36s -0.91 U.:iBf
CHF Group (n = 4s) Cd
0.22 0.03 -0.36”~
u.45f 0.37* 0.34" 0.01
0.27
-~~I~
‘;p i 0.05 ip < 0.01, #p < O.OUi. @earoxm rank correlatiou coefficient (rs) was -0.51 {p C U.UUl) when the six patients with precapillary puhnonaty
hypertensionwere excludedfrom the analysis.//Speannanrank correlation coeificient (rJ was 0.X (p < O.&Gl) when patients with ptecapilla~ pulmonary hypertensionwere Lscluded. NYHA = PJew York Heart Association; other abbreviations as in TaPles 1 and 2.
insulin ratio. The stresshormones (cortisol, growth hormone and norepinephrine, and proAMP were also clearly higher in the patients with CEF than in the control group. The patients with CEIF, likewise. had elevated concentrations of soluble T&IF-alphareceptor II in the circulation, but the trends toward higher TNF-alpha and interieukin-6 were not statistically significant. Comiatcs d’ blood ketone body concentration. The concentration of ketone bodies was independent of age, gender, body weight, body massindex anti lean body massin the total study group, but correlated inverselywith the calcu1ate.lirody fat mass(rS= -0.27, p < MS). Correlations of ketone bodies with the rates of basalmetabolism and lipid oxidation were not statisticallysignificant. The associationsof blood ketone bodies v:ith the cardiovascular and laboratory data are shown in Tables 4 and 5, respectively.In the total study group, blood ketone bodies rose with decreasingejection fraction and with higher tilling pressures and increasingtricuspid regurgitation (Table 4, Fig. 1). Ketone bodies correlated inverselywith plasma glucose and directly ~vithfree fatty acids,norepinephrine?growth hormone, pro-ANP and interleu’kin-6 (Table 5, Fig. 3) Comparable analjrsesrestricted ta the patients with CIIF gave basically similar findings, Jthoogh some correlation coetlicientswere mot statistically significant owing to the smaller number of sub.jec&(Tables 3 and 5). Multiple linear regressionanalysisin the total study group showed that log blood ketone bodies correlated independently with log serum free fatty acids (Sandardized beta coethcient 0.51, p s: MXll), piasmaglucose{beta -if,29, p i: 0,ol j and left ni:lrictdlar ejection fractior (beta -0.38, p Cr: tl.01). The squared multiple correlation coet%cient(R’, the explanatory pwex of the model) was0.51. The samethree firctorswere the indqendent predictors of log ketone bodies: also in analysis res&ioted to t:hc CHF group (I? = O.Qrl)an? in analysis
GO
LOMMI ET AZ.. BLOOD
KETOMZ
BODIES
IN CHF
‘Fable 5. Corre!ation of Blood Ketone Body Concentration With Circulating Substrates, Hormones and Cytokines in the Total Study Group and in the Congstive Heart Failure Group __II____ All P&ems CHF Group in = 59) (3-i= 45) Variabk ;1;1 !I;) -----__l P-g10c0se -0.33” -0.34f S-free ralty acids 0.52: 0.49’ r3-1;mie 0.01 0.07 S-insulin -0.15 -0.25 S-giocagon 11.15 0.05 0.18 S-glucagoniinsulinratio 0.25 S-cortisol 0.07 -0.13 S-growth hormone (i.mt 0.20 P-norepinephrine (II = 4.5) 0.45’ 0.36t P-prw4NP 0.36’ 0.3OP 0.05 -0.13 P-TNF-alpha (11= 48) P-soIobIeTNF-a!phareceptorII 0,UI --0.21 (II = 54) F-imerieiikin-G(n = 54) 0.27t 0.16 .--_l_-;p c F.01,.fp i O.US.$p < 4J.001.Data xesented are Spcarnan rank c rxlation coeWciems(r,). Abbreviationsas in Table 4.
la I-,. 5.1
P-Worepine$rinr
nmal/L
10.0
inva’?i&~ the taai study group lesssi):patients with CHF due
to purl right heart failure fR2 = 0.52).
I
We found tE;at blood ketone bodies were elevated in patients with CHI-: ii: proportion to the severityof symptoms and to the degree of venous congestion, left ventricular dysfunction and neurcG!ormonaIaswell as cytokine activation, Left ventricular systolicdysfunction, elevated circulating free fatty acids and low plasma glucosewere independent predictors of high ketone body concentration. These findings suggest that CHF is a ketosis-pronestate and that the susceptibilityto ketosisincreaseswith the severityof CHF. Determinants cf blood ketone bodies: the roie of stress hormones and free fatty acids. In general, ketone bodies accumulatein blood if their synthesisin the liver is augmented or if their distribution volume, utilization or excretion is decreased (20). Augmented production, in turn, may result either from a rising supplyof ketogenic substratesor from the activation of the hepatic ketogenic mechanism. In our work, circulating free fatty acids,the main ketogenic substrate,were elevated in the patients with CHF compared with control subjects, suggestingthat increasedproduction probably contributed to the higher level of blood ketone bodies in CHF. In the background, hormonally stimulated lipolysis may have been instrumental because norepinephrine, cortisol and growth hormone were all elevated in the patients with CHF, and these hormones can augment lipolysis and fatty acid supply>particularly if the antilipolytic effects of insulin are suppressed(20-25). In addition to boosting lipolysis,norepinephrine may have direct ketogenic action in the liver and can reduce the clearanceof ketone bodies in the periphery (24)” Norepinephrine and sympathetic stimulation also promote
I
J 0.1 1.0 10.0 P-pro-atriarlnatriuretio peptide, mnol/L t
I
Figure 3. Relationof blood ketclnebodiesto the concentrations of
norepinephrine,proatrialnatriureticpeptideand interjeukin-6in the circubtion. Solid circles representpatients with congestiveheart failiire,and opencirclesrepresentconirolpatients.Both the y and x axesa;e in a logarithmicscale.The re@ession lines representthe least squaresfits and the correlaticincoefficientsare Fearson’s.
glycogendepletion (20), which favors fatty acid oxidation and ketogenesis(21,26,2’7! Role of nutrition. Another factor that theoretically could potent&e kerogenesisin CHF is an imbalance between the supplyof and need for calories.Malnutrition is not uncommon
Sepiember
196:665-X!
in chronic CIIF and is thought to reflect reduced food intake and absorption, in addition to increasedbasalmetabolism and cellular hypoxia (1,7,8,28,29), Increased secretion of TNFalpha may also contribute (30,31). Like simple fasting, mahmtrition depletes the body af its glycogen stores, le,+dingTVfat utilization and ketogenesis.Our patients with CHF were not overtly malnourisiled~but many of them had markedlv elevated right atria1pressure,which predicts nutritional problems in CHF (8). Although we found that blood ketone bodieswere inverselyrelated to the body’sfat mass,supporting the role of nutrition, neither the other characteristicspertinent to the nutritional status nor the basal metabolic rate 2redieted the degree of ketonemia. Role of’glucagon and insulin. An increasein the glucagonto-insulin ratio in serum has been raised as the key initiating factor in most ketotic states, including simple fasting (20,273. When glucagon increasesrelative to insulin, fatty acids taken up in the liver are rerouted from the synthesisof triglycerides and phospholipids to oxidation and ketogenesis-that is, the ketogeaic machinery is switched to a higher activity. Surprisingly, the glucagon-to-insulin ratio was not elevated in our patients with CHF, nor was the degree of ketonemia associated with either serum glucagon or insulin concentration or their ratio. Therefore, these hormones seemunlikely to play a major role in the genesis of CHF ketosis. It is well known that increased free fatty acid supply can augment ketone bodl production, even if the activity of the hepatocytes’ ketogenic mechanism is unaltered (27). There are reports suggestingthat CHF is accompanied by insulin resistance(32,33), and we initially thought chat insulin resistancewith impaired suppressionof lipolysiscould contribute to the development of CHF ketosis.However, our patients with CHF had no hyperinsulinemia suggestiveof insulin resistance, compared with the control group, not even when the insulin concentrations were adjusted to plasma glucose {data not shown). Yet we admit that a precise assessmentof the body’s insulin sensitivitydepends on the use of a euglycemic insuhn clamp and that there was some discrepancyin our data because C-peptide levelswere slightly but statisticallysignificantly elevated in U-IF. Earlier reports (32,33) associating insulin resistancewith CHF included healthy control groups, whereasour control patients had a heart diseasebut no CHF, This is a crucial difference because insulin resistance may accompany such common conditions as atherosrierosis and hypertension, even in the absenceof CHF (34). Role a$ cytakines, Cytotines arc low molecular weight proteins secreted by cells in responseto stimuli varying from bacterial infections to myocardial injury (35). In addition to autocrine effects, cytokines have. paracrine and endocrine actions on tissues as well as heart and blood vessels.We measured plasma cytokine concentrations in our pa&h% primarily becauseincreasedconcentrations of TNFqalpba ac,! interleukins have been reported in CHF (30,31,36) and in par&mar becauseTN&alpha has been linked with the devet-, opment of malnutrition and cardiac cachexia (30,31). We found that blood ketone bodies were not associated with
TNF-alpha but showed a direct relation to interleo& 6. IIowever, there was: also a linear relation between ~nterleukin-~and right atria1pressure (rs = 0.53, p < Q.Mll), and the associationof blood ketone bodies with interleukin-6 may simply have reflected the link between ketonemia and the severityof CHF. In multivariate analysis,interleukin-6 wasnot an independent predictor of ketonemia. The significanceof interleukin-6 in CHF is still unknown, although experi~~en~al~,; it promotes cardiac dysfmrction (37,383. Possibleclinical implications. Whether mcasming the degree of ketonemia in patients with CNF has clinical relevance cannot be answeredfrom our study.We believe,howeve;, that the degree of ketosis proneness could give insight into the severityof CHF and that elevatedblond ket~e bodiesafter an overnight fast could be taken as a warning of incipient problems with the maintenance of the body’s energy stores. Whether susceptihihtyto ketosiscould have progncst%value, suchas nemohormonal activation or serum sod& concemration convey (I), deservesattention in future studio-. Study limitations. Our CHF group may net represent t% general CHF population well, aecause exclusion of patients taking beta-blockers led to underrepresentation of ischemic heart diseaseend h*l=+G ,,,,L,.nsion. In the control group, several patients had one or two of the four diagnosticcriteria of G-IF, and some also had abnormal hemodynamic measurements (Fig. 2) even though none fulfilled 01:: definition of clinical CHF. If we had included in the control group only patients with none of the four CHF criteria, the metabolic differences between the groups rizighthave been more significant. Yet we have observed prevIo&y that cardiac patients free of clirrical CHF by our criteria do not d&r from healthy personswith regard to breath acetone concentration, which correlates linearly with blood acetone (Kl), The lack of a more detailed characterization of the patients’ nutritional status and diet is another limitation. Although none of our patients with CHF was grosslyedematous, some fluid retention was possibleand may have biased the anthropometric measurements, apart from body height and percent body fat. Our study ma): also be criticized for not discontinuing drug therapy before the exam.. inations. However, many of the patients with CHF were severelysymptomatic, which made interruption of therapy for several drug half-lives an impractical alternative. Moreover, diuretics, angiotensin~convert~ng enzyme inhibitors and digoxin have no known diiect influence on the turnover of ketone bodies. Finally, we acknowledgeFhat our inferencesof altered ketcgenesisare indirect becausethe production, utihzation and excretion of ketone bodies were not separately quantified. It is My possible that the clearance of ketone bodies (utilization and excretion) can be altered in patients with CHF having marked syst’emiccongestion, low cardiac output and renal dysfunction. Future studies using isotope techniqueswith or without hepatic vein catheter~at~o~for the measurement of liver blood flow and net output of kctcne bodies are needed to evaluate in detail how the elemeats of ketone body kinetics are altered in CIIF.
672
LOMMI BLOOD
ET AL. KETONE
BODJES
IN CHF
Conclusions. Mild elevation of blood ketone bodies is common in patients with CHF. The degree of ketonemia is related to the severity of hemodynamic abnormalities and to the degree of neurohormonal and cytokine (interleukind) activation. Increased supply of free fatty acids from stress hormone-stimulated lipolysisis likely to be one of the mechanisms leading to ketonemia in CHF; insulin and glucagon appear to be relatively unimportant. Additional studies are needed, however, to detail the mechanismsof CHF ketosisand to assessits clinical significance.
18. 19.
20.
21.
22.
23. 1. Fittman JG, Cohen P. The pdthogenesis of cardiac cachexia. N EngI J ivied 1964;271:403-9. 2. Packer hi. Pathophysiology of chronic heart failure. Lancet 1992;340:88-92. 3. Neely JR, Rovetto MJ, Oram JF. h4yocardiul utilization of carbohydrate and lipids. Frog Cardiovasc Dis 1972;15:2SY-329. 4. Cohn JN, Levine TB, Olivari MT, et al. Plasma norepinephrine as a guide to prognosis in patients with chronic congestive heart failure. N Engt J Med 1984;311:819-23. 5. Anand IS, Ferrari R, Kalra GS, Wahi PL, Poole-Wilson PA, Harris PC. Edema of cardiac origin. Studies of body water and sodium, renal function, hemodynamic indexes, and plasma hormones in untreated congestive heart failure. Circulation 1989;80:299-303. 6. Poehlman ET, Scheffers J. Gottlieb SS, Fisher ML, Vaitekevicius I’. Increased resting .metabolic rate in patients with congestive heart failure. Ann Intern Med 199~i;121:860-2. 7. Ansari A. Syndromes of cardiac cachcxia and the each&c heart: current perspective. Prog Cardiovasc Dis 1937;30:45-60. 8. Carr JG, Stevenson LW, WalJen JA, Heber D. Prevalence and hemodynamic correlates of malnutrition in severe congestive heart failure secondary to ischemic or idiopathic uilated cardiomyopathy. Am J Cardiol 1989;63: 709-13. 9. Riley M, Bell N, Elborn JS, Stanford CF, Buchanar KD, Nicholls DP. Metabolic responses to graded exercise in chronic heart failure. Eur Heart J 1993;14:1484-8. 10. Kupari M, Lommi J, Ventilii M, Kajalainen U. Breath acetone in congestive hear1 failure. Am J Cardiol 1995;76:1076-8. il. Keats TE, Enge IP. Cardiac mensuration by the cardiac voiume mrthod. Radiology 1965;85:850-9. 12. Lipkin DP, Striven AJ, Crake T, Poole-Wilson PA. Six minute walking test for assessing exercise capacity in chronic heart faiiure. BMJ 19Yh;292%53-5. 13. Durin JVG& Womersley J. Body fat assessed from total body density and its estimation from skinfold thickness: measurements on 481 men and women aged Iron1 16 to 72 years, Br J Nutr 1974;31:77-97. 14. Williamson DH, Mellano, J, Krebs HA. Enzymatic determination of D-p hydroqbutyric acid and acetoacetic acid in blood. Biochem J 1962$2:YO-6. 15. Lowry OH, Passoneau JV. A Flexible Sysem of Enzymlrtic Analysis. New York Academic Press, 1932:193-21. 16. Miles JR, Glasscock J, Aikens J, Gerich J, Haymond M. A microfluorome’ric method for the determination of free fatty acids in plasma. 3 Lipid Kes 1983;:!4:96-9. 17. Scheinin M, Koulu M: Latirikainen E, 4llonen II. Hypokalcmia and other non-bronchial chects of inhaled fenotcrol and salbutamok a placebo-
24.
25. 26.
27. 28. 29. 30.
31.
32.
33. 34. 35. 36.
37.
38.
controlled dose-response siudy in healthy volunteers. Br J Clin Pharmecol 1987;24:645-53. Ferrsnnini E. The theoretical basis of indirect calorimetry. Metaho!ism 1988:37:287-301, Schillcr NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left venfric!e by two-dimensional ecbocardiograpby. J Am Sot Echocardiogr 1989;2:358-67, Baiasse EO, Fcry F. Ketone body production and disposal elIerts of fasting. diabetes and exercise. Diabetes Metab Rev 1989:5:247-70. Johnston DG, Pernet A, McCulloch A; B&a-Malpica G, Burrin JM, Alberti KGMh4. Some hormonal influences on glucose and ketone body metabolism in normal human subjects. In: Metabolic Acidosis. London: Pttman Books (Ciba Foundation symposium 87): 1982~165-91. Metcalfe F, Johnston DG, Nosadini R, Orksov H, Alberti KGMM. Metabolic effects of acute and prolonged growth hormone excess in normal and insulin-deficient man. Diabetologia 1981;20:!23-8. Scbsdc DS, Eaton RP. The regulation of plasma ketone body concentration by counter-regulatory hormones in man: III. Effects of norcpinephrme in normal man. Diabetes 1979;28:5-10. Schade DS, Eaton RP, Standefer J. Glucocorticoid regulation of plasma ketone body concentration in insulin deficient man. J Clin Endocrinol Metab 1977;44:1069-79. Keller U. Gerber PPG. Stauffacher W. Stimulatorv effect of noreuineohrine on ketogenesis in normal and insulin-deficient humans. Am’ J Physiol l%+k247:E732-E739. Keller U, Weiss h4; Stauffacher W. Contribution of n- and P-receptors to ketogenic and lipolytic effects of norepinephrine in humans. Diabetes 1959;3s:454-9. Foster DW. From glycogen to ketones-and hack. Diabetes 39X4133:31% 99. Schwengel RH, Gottlieb SS, Fisher ML. Protein-energy malnutrition in patients with ischemic and nonischemic dilated cardiomyopathy and congestive heart failure. Am J Cardiol 1994;73:908-10. Morrison WL, Edwards RHT. Cardiac cachexia. Br Heart J 1991;302:301-2. Levine B, Kalman J, Mayer L, Fillit H, Packer M. Elevated circulating levels of tumor necrosis factor in severe chronic heart failure. N Engl J Med 1990:323:236-41. McMurray J, Abdullah 1. Dargie HJ, Shapiro D. Increased concentrations of tumor necrosis factor in “cachectic” patients with severe chronic heart failure. Br Hedri J 1991;66:356-8. Paolisso G, De Riu S, Marrazzo 6, Verza M, Varriccbio M; D’Onofrio F. Insulin resistance and hyperinsulinemia in patients with chronic congestive heart failure. Metabolism 1991;40:972-7. Swan JW, Walton C, Godsland IF, Clark AL, Coats JS, Oliver MF. Insulin resistance in chronic heart failure. Em Heart J 1994;15:1528-32. Williams W. Insulin resistance: shape of things to come. Lancct 1994;244: 521-4. Mann DL, Young JB. Basic mechanisms in congestive heart failure. Recognizing the role of proinflammatory cytokines. Chest 1994;105:897-904, Wiedermann CJ, Beimpold II, Herold M, Knapp E, Eraunsteiner H. Increased levels of serum neopterin and decreased production of neutrophil superoxide anions in chronic heart failure with elevated levels of tumor necrosis factor-alpha. J Am Coil Cardiol 1993;22:1597-1901. Finkcl MS, Oddis CV, Jacob TD, Watkins SC, Hauler BG, Simmons RI... Negative inotropic effects of cytokines on heart mediated by nitric oxide. Science 1992;257:367-9, Finkei MS, Hoffman RA, Shea L, Oddis CV, Simmons RL, Hattler BG. Intcrlcukin-6 (!I,-61 as a mediator of stunned myocardiam. Am J Cardiol 1993;71:1231-2.