P1447New diastolic dysfunction grade and clinical outcomes in heart failure with preserved ejection fraction

Abstract Funding Acknowledgements British Heart Foundation Aims First-phase ejection fraction (EF1), the ejection fraction up to the time of maximal ventricular contraction may be impaired in heart failure with preserved ejection fraction (HFpEF), with homeostatic mechanisms preserving the overall ejection fraction. We examined whether EF1 is impaired and whether it predicts adverse outcomes in patients with HFpEF. Methods and Results We examined EF1 in patients with HFpEF diagnosed according to European Society of Cardiology guidelines, in subjects with pre-clinical diastolic dysfunction and in control subjects with no evidence of heart failure. The predictive value of EF1 for a combined end-point of re-hospitalisation for heart failure and death from any cause was compared to that of conventional echocardiographic and other indices. There was a progressive impairment of EF1 in patients with diastolic dysfunction and HFpEF compared to those without evidence of heart failure (P < 0.001). In 180 HFpEF patients followed for a median of 14.7 months, 101 patients reached the primary endpoint (61 deaths and 40 hospitalisations). EF1 was the most powerful predictor of events (table 1). A cut-off value of 19.4% gave hazard ratios (for EF1 < 19.4% compared to ≥19.4%) of 3.04 (figure 1), (95% confidence interval 2.014 – 4.604, P < 0.001) unadjusted, and 2.976 (1.887 – 4.695, P < 0.001) adjusted for age, gender, other echocardiographic indices (including EF, E/e’ ratio, stroke volume and left atrial volume index) and N-terminal pro-brain natriuretic peptide. Conclusion Early systolic function is impaired in HFpEF and is a powerful predictor of clinical outcomes. Therapies targeted at improving early systolic function may improve outcomes in HFpEF. Table 1 HR CI (95%) P value Age 1.020 1.001 - 1.039 0.042 Female Gender 1.989 1.254 - 3.156 0.003 ln NT-proBNP 1.354 1.096 - 1.672 0.005 Haemoglobin 0.992 0.980 - 1.005 0.225 eGFR 0.997 0.988 - 1.006 0.568 Structural Heart Disease 0.748 0.439 - 1.274 0.285 Diastolic Dysfunction 0.694 0.445 - 1.082 0.107 Ejection Fraction 1.031 0.996 - 1.068 0.082 Stroke Volume index 0.963 0.940 - 0.986 0.002 TPAVF 0.995 0.980 - 1.005 0.230 EF1 0.900 0.869 - 0.932 <0.001 Multivariate analysis of predictors of events Abstract 563 Figure 1 Kaplan-Meier Curve

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Sex Differences in Heart Failure With Preserved Ejection Fraction

Journal of the American Heart Association ◽

10.1161/jaha.120.018574 ◽

2021 ◽

Author(s):

Yohei Sotomi ◽

Shungo Hikoso ◽

Daisaku Nakatani ◽

Hiroya Mizuno ◽

Katsuki Okada ◽

...

Keyword(s):

Heart Failure ◽

Observational Study ◽

Ejection Fraction ◽

Diastolic Dysfunction ◽

Clinical Outcomes ◽

Preserved Ejection Fraction ◽

Multicenter Observational Study ◽

Female Sex ◽

End Point ◽

Prospective Multicenter Observational Study

Background The female preponderance in heart failure with preserved ejection fraction (HFpEF) is a distinguishing feature of this disorder, but the association of sex with degree of diastolic dysfunction and clinical outcomes among individuals with HFpEF remains unclear. Methods and Results We conducted a prospective, multicenter, observational study of patients with HFpEF (PURSUIT‐HFpEF [Prospective Multicenter Observational Study of Patients with Heart Failure with Preserved Ejection Fraction]: UMIN000021831). Between 2016 and 2019, 871 patients were enrolled from 26 hospitals (follow‐up: 399±349 days). We investigated sex‐related differences in diastolic dysfunction and postdischarge clinical outcomes in patients with HFpEF. The echocardiographic end point was diastolic dysfunction according to American Society of Echocardiography/European Association of Cardiovascular Imaging criteria. The clinical end point was a composite of all‐cause death and heart failure readmission. Women accounted for 55.2% (481 patients) of the overall cohort. Compared with men, women were older and had lower prevalence rates of hypertension, coronary artery disease, and chronic kidney disease. Women had diastolic dysfunction more frequently than men (52.8% versus 32.0%, P <0.001). The incidence of the clinical end point did not differ between women and men (women 36.1/100 person‐years versus men 30.5/100 person‐years, P =0.336). Female sex was independently associated with the echocardiographic end point (adjusted odds ratio, 2.839; 95% CI, 1.884–4.278; P <0.001) and the clinical end point (adjusted hazard ratio, 1.538; 95% CI, 1.143–2.070; P =0.004). Conclusions Female sex was independently associated with the presence of diastolic dysfunction and worse clinical outcomes in a cohort of elderly patients with HFpEF. Our results suggest that a sex‐specific approach is key to investigating the pathophysiology of HFpEF. Registration URL: https://upload.umin.ac.jp ; Unique identifier: UMIN000021831.

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Faculty Opinions recommendation of Prior pacemaker implantation and clinical outcomes in patients with heart failure and preserved ejection fraction.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.735524857.793559886 ◽

2019 ◽

Author(s):

Gad Cotter ◽

Olga Milo

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Clinical Outcomes ◽

Pacemaker Implantation ◽

Preserved Ejection Fraction ◽

Patients With Heart Failure

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Major depression and clinical outcomes in patients with heart failure with preserved ejection fraction

European Journal of Clinical Investigation ◽

10.1111/eci.13401 ◽

2020 ◽

Author(s):

Jian Liu ◽

Zejun Guo ◽

Meida Fan ◽

Weihao Liang ◽

Xin He ◽

...

Keyword(s):

Heart Failure ◽

Major Depression ◽

Ejection Fraction ◽

Clinical Outcomes ◽

Preserved Ejection Fraction ◽

Patients With Heart Failure

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Opportunistic screening models for high-risk men and women to detect diastolic dysfunction and heart failure with preserved ejection fraction in the community

European Journal of Preventive Cardiology ◽

10.1177/2047487318816774 ◽

2018 ◽

Vol 26 (6) ◽

pp. 613-623 ◽

Cited By ~ 8

Author(s):

Aisha Gohar ◽

Rogier F Kievit ◽

Gideon B Valstar ◽

Arno W Hoes ◽

Evelien E Van Riet ◽

...

Keyword(s):

Heart Failure ◽

High Risk ◽

Ejection Fraction ◽

Diastolic Dysfunction ◽

Left Ventricular Diastolic Dysfunction ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Preserved Ejection Fraction ◽

Men And Women ◽

Ventricular Diastolic Dysfunction

Background The prevalence of undetected left ventricular diastolic dysfunction is high, especially in the elderly with comorbidities. Left ventricular diastolic dysfunction is a prognostic indicator of heart failure, in particularly of heart failure with preserved ejection fraction and of future cardiovascular and all-cause mortality. Therefore we aimed to develop sex-specific diagnostic models to enable the early identification of men and women at high-risk of left ventricular diastolic dysfunction with or without symptoms of heart failure who require more aggressive preventative strategies. Design Individual patient data from four primary care heart failure-screening studies were analysed (1371 participants, excluding patients classified as heart failure and left ventricular ejection fraction <50%). Methods Eleven candidate predictors were entered into logistic regression models to be associated with the presence of left ventricular diastolic dysfunction/heart failure with preserved ejection fraction in men and women separately. Internal-external cross-validation was performed to develop and validate the models. Results Increased age and β-blocker therapy remained as predictors in both the models for men and women. The model for men additionally consisted of increased body mass index, moderate to severe shortness of breath, increased pulse pressure and history of ischaemic heart disease. The models performed moderately and similarly well in men (c-statistics range 0.60–0.75) and women (c-statistics range 0.51–0.76) and the performance improved significantly following the addition of N-terminal pro b-type natriuretic peptide (c-statistics range 0.61–0.80 in women and 0.68–0.80 in men). Conclusions We provide an easy-to-use screening tool for use in the community, which can improve the early detection of left ventricular diastolic dysfunction/heart failure with preserved ejection fraction in high-risk men and women and optimise tailoring of preventive interventions.

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Features of heart failure with preserved ejection fraction (HFpEF) in diabetic patients with resistant hypertension

Diabetes Mellitus ◽

10.14341/dm12732 ◽

2021 ◽

Vol 24 (4) ◽

pp. 304-314

Author(s):

M. A. Manukyan ◽

A. Y. Falkovskaya ◽

V. F. Mordovin ◽

T. R. Ryabova ◽

I. V. Zyubanova ◽

...

Keyword(s):

Diabetes Mellitus ◽

Heart Failure ◽

Blood Pressure ◽

Blood Flow ◽

Ejection Fraction ◽

Diastolic Dysfunction ◽

Diastolic Function ◽

Resistant Hypertension ◽

Diabetic Patients ◽

Preserved Ejection Fraction

BACKGROUND: It is expected that a steady increase in the incidence of diabetes and resistant hypertension (RHTN), along with an increase in life expectancy, will lead to a noticeable increase in the proportion of patients with heart failure with preserved ejection fraction (HFpEF). At the same time, data on the frequency of HFpEF in a selective group of patients with RHTN in combination with diabetes are still lacking, and the pathophysiological and molecular mechanisms of its formation have not been yet studied sufficiently.AIM: To assess the features of the development HFpEF in diabetic and non-diabetic patients with RHTN, as well as to determine the factors associated with HFpEF.MATERIALS AND METHODS: In the study were included 36 patients with RHTN and type 2 diabetes mellitus (DM) (mean age 61.4 ± 6.4 years, 14 men) and 33 patients with RHTN without diabetes, matched by sex, age and level of systolic blood pressure (BP). All patients underwent baseline office and 24-hour BP measurement, echocardiography with assess diastolic function, lab tests (basal glycemia, HbA1c, creatinine, aldosterone, TNF-alpha, hsCRP, brain naturetic peptide, metalloproteinases of types 2, 9 (MMP-2, MMP-9) and tissue inhibitor of MMP type 1 (TIMP-1)). HFpEF was diagnosed according to the 2019 AHA/ESC guidelines.RESULTS: The frequency of HFpEF was significantly higher in patients with RHTN with DM than those without DM (89% and 70%, respectively, p=0.045). This difference was due to a higher frequency of such major functional criterion of HFpEF as E/e’≥15 (p=0.042), as well as a tendency towards a higher frequency of an increase in left atrial volumes (p=0.081) and an increase in BNP (p=0.110). Despite the comparable frequency of diastolic dysfunction in patients with and without diabetes (100% and 97%, respectively), disturbance of the transmitral blood flow in patients with DM were more pronounced than in those without diabetes. Deterioration of transmitral blood flow and pseudo-normalization of diastolic function in diabetic patients with RHTN have relationship not only with signs of carbohydrate metabolism disturbance, but also with level of pulse blood pressure, TNF-alfa, TIMP-1 and TIMP-1 / MMP-2 ratio, which, along with the incidence of atherosclerosis, were higher in patients with DM than in those without diabetes.CONCLUSIONS: Thus, HFpEF occurs in the majority of diabetic patients with RHTN. The frequency of HFpEF in patients with DN is significantly higher than in patients without it, which is associated with more pronounced impairments of diastolic function. The progressive development of diastolic dysfunction in patients with diabetes mellitus is associated not only with metabolic disorders, but also with increased activity of chronic subclinical inflammation, profibrotic state and high severity of vascular changes.

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Preload-corrected dynamic Starling mechanism in patients with heart failure with preserved ejection fraction

Journal of Applied Physiology ◽

10.1152/japplphysiol.00718.2017 ◽

2018 ◽

Vol 124 (1) ◽

pp. 76-82 ◽

Cited By ~ 3

Author(s):

Michinari Hieda ◽

Erin Howden ◽

Shigeki Shibata ◽

Takashi Tarumi ◽

Justin Lawley ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Diastolic Dysfunction ◽

Diastolic Pressure ◽

Left Ventricular Diastolic Dysfunction ◽

Left Ventricular ◽

Preserved Ejection Fraction ◽

Dynamic Modulation ◽

Power Spectral ◽

Ventricular Diastolic Dysfunction

The beat-to-beat dynamic Starling mechanism (DSM), the dynamic modulation of stroke volume (SV) because of breath-by-breath changes in left-ventricular end-diastolic pressure (LVEDP), reflects ventricular-arterial coupling. The purpose of this study was to test whether the LVEDP-SV relationship remained impaired in heart failure with preserved ejection fraction (HFpEF) patients after normalization of LVEDP. Right heart catheterization and model-flow analysis of the arterial pressure waveform were performed while preload was manipulated using lower-body negative pressure to alter LVEDP. The DSM was compared at similar levels of LVEDP between HFpEF patients ( n = 10) and age-matched healthy controls ( n = 12) (HFpEF vs. controls: 10.9 ± 3.8 vs. 11.2 ± 1.3 mmHg, P = 1.00). Transfer function analysis between diastolic pulmonary artery pressure (PAD) representing dynamic changes in LVEDP vs. SV index was applied to obtain gain and coherence of the DSM. The DSM gain was significantly lower in HFpEF patients than in the controls, even at a similar level of LVEDP (0.46 ± 0.19 vs. 0.99 ± 0.39 ml·m−2·mmHg−1, P = 0.0018). Moreover, the power spectral density of PAD, the input variability, was greater in the HFpEF group than the controls (0.75 ± 0.38 vs. 0.28 ± 0.26 mmHg2, P = 0.01). Conversely, the power spectral density of SV index, the output variability, was not different between the groups ( P = 0.97). There was no difference in the coherence, which confirms the reliability of the linear transfer function between the two groups (0.71 ± 0.13 vs. 0.77 ± 0.19, P = 0.87). The DSM gain in HFpEF patients is impaired compared with age-matched controls even at a similar level of LVEDP, which may reflect intrinsic LV diastolic dysfunction and incompetence of ventricular-arterial coupling. NEW & NOTEWORTHY The beat-to-beat dynamic Starling mechanism (DSM), the dynamic modulation of stroke volume because of breath-by-breath changes in left-ventricular end-diastolic pressure (LVEDP), reflects ventricular-arterial coupling. Although the DSM gain is impaired in heart failure with preserved ejection fraction (HFpEF) patients, it is not clear whether this is because of higher LVEDP or left-ventricular diastolic dysfunction. The DSM gain in HFpEF patients is severely impaired, even at a similar level of LVEDP, which may reflect intrinsic left-ventricular diastolic dysfunction.

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