One case of severe obesity with preserved ejection fraction heart failure treated by permanent cardiac pacemaker

A 54 year old male, with multiple diseases(such as severe obesity, severe edema, atrial fibrillation, high atrioventricular block, global enlargement (lA55mm LV 62mm RA 69*55mm RV 46mm)), was diagnosed as heart failure with preserved ejection fraction (HFpEF). After treatment with drugs and implanting permanent cardiac pacemaker, the patient’s edema completely disappeared, weight loss of 42kg, heart failure symptoms disappeared left ventricular shrinkage (LV 59mm).

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Using A 21-Year Real-World Database from a Private Cardiologist's Practice to Test the Hypothesis that Combining Pharmacological Therapies (Carvedilol, Spironolactone and Statins) with Weight Loss May Benefit Patients with HFpEF

Journal of Cardiology Research ◽

10.36879/jcr.20.000133 ◽

2020 ◽

pp. 1-9

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Weight Loss ◽

Clinical Trials ◽

Endothelial Dysfunction ◽

Combination Therapy ◽

Ejection Fraction ◽

Diastolic Dysfunction ◽

Left Ventricular ◽

Lv Diastolic Dysfunction

Heart Failure with preserved Ejection Fraction (HFpEF) is a clinical syndrome in which patients have symptoms of Heart Failure (HF), such as dyspnea and fatigue, a Left Ventricular Ejection Fraction (LVEF) ≥ 50% and evidence of cardiac dysfunction as a cause of symptoms, such as abnormal Left Ventricular (LV) diastolic dysfunction with elevated filling pressures. Besides LV diastolic dysfunction, recent investigations suggest a more complex and heterogeneous pathophysiology, including systolic reserve abnormalities, chronotropic incompetence, stiffening of ventricular tissue, atrial dysfunction, secondary Pulmonary Arterial Hypertension (PAH), impaired vasodilatation and endothelial dysfunction. Unlike Heart Failure with Reduced Ejection Fraction (HFrEF), clinical trials over the years have not yet identified effective treatments that reduce mortality in patients with HFpEF. A database on use of carvedilol in a private cardiologist's practice was begun in 1997 and concluded at the end of 2018. We used this database to test the hypothesis that combining pharmacological interventions to address diastolic dysfunction (carvedilol), volume overload (spironolactone/eplerenone) and endothelial dysfunction (statins) with weight loss may benefit patients with HFpEF. We report analysis of 335 patients with HFpEF comprised of 61% female (mean age 74 ± 8) and 39% males (mean age 72 ± 7). Initial EF ranged between 50 and 77% with mean EF of 57 ± 6%. Only 15 patients were changed to metoprolol succinate, verapamil or diltiazem because of adverse side effects. Two hundred and twenty of the patients were in normal sinus rhythm when started on carvedilol, spironolactone/eplerenone and statin therapy with weight loss counseling. After 5 years, 191 patients were still on combination therapy, and only 31 (17%) had developed Atrial Fibrillation (AF). Compared to previous HFpEF trials reporting a 32% risk of developing atrial fibrillation after 4 years, our combination therapy significantly (p < 0.05) reduced the risk of developing AF over 5 years. Thus, irrespective of age and sex with comorbidities of type 2 Diabetes Mellitus (DM) and Chronic Kidney Disease (CKD), patients with HFpEF can be managed successfully with carvedilol, spironolactone/eplerenone and statins with a clinical benefit being a reduced risk of developing AF. We consider these data hypothesis-generating and hope these results will be tested further in database analyses and clinical trials.

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Application of the current HFA-ESC consensus guidelines on diagnosis of heart failure with preserved ejection fraction to a population referred for echocardiography

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa356.038 ◽

2021 ◽

Vol 22 (Supplement_1) ◽

Author(s):

K Liang ◽

R Hearse-Morgan ◽

S Fairbairn ◽

Y Ismail ◽

AK Nightingale

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Ejection Fraction ◽

Diastolic Function ◽

Global Longitudinal Strain ◽

Diagnostic Algorithm ◽

Left Ventricular ◽

Lv Function ◽

Preserved Ejection Fraction ◽

Consensus Guidelines

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND The recent Heart Failure Association (HFA) of the European Society of Cardiology (ESC) consensus guidelines on diagnosis of heart failure with preserved ejection fraction (HFpEF) have developed a simple diagnostic algorithm for clinical use. PURPOSE To assess whether echocardiogram (echo) parameters needed to assess diastolic function are routinely collected in patients referred for assessment of heart failure symptoms. METHODS Retrospective analysis of echo referrals in January 2020 were assessed for parameters of diastolic function as per step 2 of the HF-PEFF diagnostic algorithm. Echo images and clinical reports were reviewed. Electronic records were utilised to obtain clinical history, blood results (NT-proBNP) and demographic data. RESULTS 1330 patients underwent an echo in our department during January 2020. 83 patients were referred with symptoms of heart failure without prior history of cardiac disease; 20 patients found to have impaired left ventricular (LV) function were excluded from analysis. Of the 63 patients with possible HFpEF, HF-PEFF score was low in 18, intermediate in 33 and high in 12. Median age was 68 years (range 32 to 97 years); 25% had a BMI >30. There was a high prevalence of hypertension (52%), diabetes (19%) and atrial fibrillation (40%) (cf. Table 1). Body surface area (BSA) was documented in 65% of echo reports. Most echo parameters were recorded with the exception of global longitudinal strain (GLS) and indexed LV mass (cf. image 1). NT-proBNP was recorded in only 20 patients (31.7%). 12 patients with an intermediate HF-PEFF score could have been re-categorised to a high score depending on GLS and NT-proBNP (which were not recorded). CONCLUSION More than three quarters of echoes acquired in our department obtained the relevant parameters to assess diastolic function. The addition of BSA, and inclusion of NT-proBNP, and GLS would have been additive to a third of ‘intermediate’ patients to determine definite HFpEF. Our study demonstrates that the current HFA-ESC diagnostic algorithm and HF-PEFF scoring system are easy to use, highly relevant and applicable to current clinical practice. Age >70 years 29 (46.0%) Obesity (BMI >30) 16 (25.4%) Diabetes 12 (19%) Hypertension 33 (52.4%) Atrial Fibrillation 25 (39.7%) ECG abnormalities 18 (28.5%) Table 1. Prevalence of Clinical Risk Factors Abstract Figure. Image 1. HFPEFF score & echo parameters

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Prevalence and correlates of coronary microvascular dysfunction in heart failure with preserved ejection fraction: PROMIS-HFpEF

European Heart Journal ◽

10.1093/eurheartj/ehy531 ◽

2018 ◽

Vol 39 (37) ◽

pp. 3439-3450 ◽

Cited By ~ 108

Author(s):

Sanjiv J Shah ◽

Carolyn S P Lam ◽

Sara Svedlund ◽

Antti Saraste ◽

Camilla Hage ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Endothelial Dysfunction ◽

Ejection Fraction ◽

Microvascular Dysfunction ◽

Left Ventricular ◽

Coronary Microvascular Dysfunction ◽

Preserved Ejection Fraction ◽

Transthoracic Doppler Echocardiography ◽

Flow Reserve

Abstract Aims To date, clinical evidence of microvascular dysfunction in patients with heart failure (HF) with preserved ejection fraction (HFpEF) has been limited. We aimed to investigate the prevalence of coronary microvascular dysfunction (CMD) and its association with systemic endothelial dysfunction, HF severity, and myocardial dysfunction in a well defined, multi-centre HFpEF population. Methods and results This prospective multinational multi-centre observational study enrolled patients fulfilling strict criteria for HFpEF according to current guidelines. Those with known unrevascularized macrovascular coronary artery disease (CAD) were excluded. Coronary flow reserve (CFR) was measured with adenosine stress transthoracic Doppler echocardiography. Systemic endothelial function [reactive hyperaemia index (RHI)] was measured by peripheral arterial tonometry. Among 202 patients with HFpEF, 151 [75% (95% confidence interval 69–81%)] had CMD (defined as CFR <2.5). Patients with CMD had a higher prevalence of current or prior smoking (70% vs. 43%; P = 0.0006) and atrial fibrillation (58% vs. 25%; P = 0.004) compared with those without CMD. Worse CFR was associated with higher urinary albumin-to-creatinine ratio (UACR) and NTproBNP, and lower RHI, tricuspid annular plane systolic excursion, and right ventricular (RV) free wall strain after adjustment for age, sex, body mass index, atrial fibrillation, diabetes, revascularized CAD, smoking, left ventricular mass, and study site (P < 0.05 for all associations). Conclusions PROMIS-HFpEF is the first prospective multi-centre, multinational study to demonstrate a high prevalence of CMD in HFpEF in the absence of unrevascularized macrovascular CAD, and to show its association with systemic endothelial dysfunction (RHI, UACR) as well as markers of HF severity (NTproBNP and RV dysfunction). Microvascular dysfunction may be a promising therapeutic target in HFpEF.

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P1369Predictors of atrial fibrillation recurrence after radiofrequency ablation in patients with chronic heart failure with preserved ejection fraction

EP Europace ◽

10.1093/europace/euaa162.331 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

T Zolotarova

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Radiofrequency Ablation ◽

Chronic Heart Failure ◽

Ejection Fraction ◽

Left Atrium ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Preserved Ejection Fraction ◽

Af Recurrence

Abstract Introduction. Randomized controlled trials and meta-analyzes have shown high efficacy of the radiofrequency ablation (RFA) for both initial and secondary strategies after unsuccessful drug therapy (DT) to maintain sinus rhythm (SR) and improve functional and morphological quality of life; in patients with chronic heart failure (CHF), RFA were associated with a significant relative reduction in the risk of overall mortality, atrial fibrillation (AF) recurrence, and hospitalization for cardiac pathology (compared with DT). High risk of arrhythmia recurrence (up to 45% within 6 - 12 months after intervention) remains a major RFA problem. Purpose. to evaluate predictive properties of demographic, hemodynamic and electrocardiographic parameters for recurrence after atrial fibrillation ablation in patients with chronic heart failure with preserved ejection fraction. Methods. We included 120 patients, aged 59.80 ± 10.08 years with CHF with preserved ejection fraction (EF) of left ventricle (LV) who underwent first time RFA for AF with LV EF(> 40%) I-III FC NYHA. Baseline clinical data, ECG before and after the procedure, ECHO parameters were collected Results Thirty-two patients had AF recurrence after a mean follow-up of twelve months. Those experiencing recurrence were more female (50% vs.39%, p <0,01), had a longer QTc interval before ablation than those without recurrence (387,23 ± 2,31 vs. 341,22 ± 8,91 ms, p < 0,01) and after ablation (439,01 ± 4,73 vs. 373,21 ± 7,92 ms, p < 0,001), lower LV EF (59% vs. 63%, p < 0,05), higher left atrium diameter (4,59 ± 0,45 vs. 4,08 ± 0,61 cm, p < 0,001) and higher mean pulmonary artery gradient (32,86 ± 9,67 vs. 25,15 ± 9,73, p < 0,01). Conclusions. QTc duration to radiofrequency ablation and its prolongation after intervention are independent predictors of arrhythmia recurrence in patients with chronic heart failure with a preserved left ventricular ejection fraction. The size of the left atrium before ablation is a highly sensitive predictor of recurrence of arrhythmia

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P1088Effect of coronary artery disease on patients with atrial fibrillation and heart failure with preserved ejection fraction - from vicious twins to vicious triplets?

EP Europace ◽

10.1093/europace/euaa162.017 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

T Stephan ◽

A Kuehberger ◽

M Baumhardt ◽

K Weinmann ◽

D Felbel ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Coronary Artery Disease ◽

Catheter Ablation ◽

Clinical Outcome ◽

Ejection Fraction ◽

Left Ventricular ◽

Preserved Ejection Fraction ◽

Multivariate Logistic Regression ◽

Artery Disease

Abstract Background Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) are common diseases and associated with increased morbidity and mortality, which even aggravates if both conditions are coexisting. Coronary artery disease (CAD) is highly prevalent in both, patients with AF (17-46%) and HFpEF (50-80%). Notably, all three entities share several common risk factors. While it is well established that the emergence of the vicious twins HFpEF and AF is mechanistically linked, CAD can also be pathophysiological related to HFpEF, as well as AF by several mechanisms. Aim The study aimed to evaluate the influence of CAD on patients with concomitant AF and HFpEF and to identify parameters affecting the patients clinical outcome. Methods We retrospectively screened patients with AF and HFpEF for CAD. Patients with and without CAD were compared by relevant patient characteristics and echocardiographic parameters at baseline and at the end of follow-up. Additionally, we assessed hospitalization rates and performed multivariate logistic regression to analyze parameters influencing the clinical outcome. Results Between January 2013 and December 2016 6.114 patients with atrial fibrillation and 2.187 patients with echocardiographic diastolic dysfunction were treated at our university hospital department. Of those, 127 patients had concomitant diagnosis of HFpEF according to current guidelines and AF. In 77 patients (61%) CAD had been diagnosed by coronary angiography. At baseline, CAD patients had significantly more myocardial infarction, dyslipidemia, use of aspirin, lower left ventricular ejection fraction, larger left ventricular diastolic diameter and a higher CHA2DS2-VAsc score. Moreover, CAD patients had significantly higher rates of all-cause and cardiovascular hospitalizations. Interestingly, NYHA-class and left ventricular mass index improved significantly in the group without CAD, whereas there was no change in the CAD-group. Multivariate logistic regression only associated catheter ablation for AF significantly with NYHA improvement in the total cohort. Assessment of all-cause and cardiovascular hospitalization in CAD patients undergoing either catheter ablation or medical therapy revealed, that catheter ablation significantly decreased event rates. Moreover, catheter ablation for AF was associated with echocardiographic signs of reverse remodelling, whereas conservative treatment resulted in progression of remodelling. Conclusion This is the first study to evaluate the effect of CAD on patients with concomitant AF and HFpEF. As expected, presence of CAD was related to a worse clinical outcome. Interestingly, in CAD patients catheter ablation was significantly associated with functional and clinical improvement. In conclusion, catheter ablation for AF might display an effective therapeutic approach in this vulnerable population.

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P6356Comparisons of clinical outcomes in patients with heart failure with preserved ejection fraction with and without atrial fibrillation: results from a multicenter PURSUIT-HFpEF registry

European Heart Journal ◽

10.1093/eurheartj/ehz746.0952 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

M Masuda ◽

T Kanda ◽

M Asai ◽

T Mano ◽

T Yamada ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Ejection Fraction ◽

Clinical Outcomes ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Preserved Ejection Fraction ◽

Reduced Ejection Fraction ◽

Heart Failure Patients ◽

Patients With Heart Failure

Abstract Background The presence of atrial fibrillation (AF) has been demonstrated to be associated with poor clinical outcomes in heart failure patients with reduced ejection fraction. Objective This study aimed to elucidate the impact of the presence of atrial fibrillation (AF) on the clinical characteristics, therapeutics, and outcomes in patients with heart failure and preserved ejection fraction (HFpEF). Methods PURSUIT-HFpEF is a multicenter prospective observational study including patients hospitalized for acute heart failure with left ventricular ejection fraction of >50%. Patients with acute coronary syndrome or severe valvular disease were excluded. Results Of 486 HFpEF patients (age, 80.8±9.0 years old; male, 47%) from 24 cardiovascular centers, 199 (41%) had AF on admission. Patients with AF had lower systolic blood pressures (142±27 vs. 155±35mmHg, p<0.0001) and higher heart rates (91±29 vs. 82±26bpm, p<0.0001) than those without. There was no difference in the usage of inotropes or mechanical ventilation between the 2 groups. A higher quality of life score (EQ5D, 0.72±0.27 vs. 0.63±0.30, p=0.002) was observed at discharge in patients with than without AF. In addition, AF patients tended to demonstrate lower in-hospital mortality rates (0.5% vs. 2.4%, p=0.09) and shorter hospital stays (20.3±12.1 vs. 22.6±18.4 days, p=0.09) than those without. During a mean follow up of 360±111 days, mortality (14.1% vs. 15.3) and heart failure re-hospitalization rates (13.1% vs. 13.9%) were comparable between the 2 groups. Conclusion In contrast to heart failure patients with reduced ejection fraction, AF on admission was not associated with poor long-term clinical outcomes among HFpEF patients. Several in-hospital outcomes were better in patients with AF than in those without. Acknowledgement/Funding None

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P1272 Echocardiographic evaluation of left ventricular filling pressure in patients with heart failure with preserved ejection fraction : usefulness of inferior vena cava measurement

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.722 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

J Motiejunaite ◽

P Jourdain ◽

B Gellen ◽

M T Bailly ◽

A A Bouchachi ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Ejection Fraction ◽

Inferior Vena ◽

Vena Cava ◽

Left Ventricular ◽

Filling Pressure ◽

Preserved Ejection Fraction ◽

Ventricular Filling Pressure ◽

Ventricular Filling

Abstract Context Echocardiography is an essential tool for evaluation of left ventricular filling pressure (LVFP). We aimed to assess the usefulness of inferior vena cava (IVC) measurement and the 2016 ESC recommendations in patients with suspected heart failure with preserved ejection fraction (HFpEF). Methods Invasive hemodynamics and echocardiographic measurements were documented in 132 consecutive patients referred to our centre with dyspnea, left ventricular ejection fraction (LVEF) ≥50%, and suspected pulmonary hypertension on a previous echocardiogram. Echocardiographic measurements of mitral flow (E and A wave velocities), the E/e’ratio, indexed left atrial volume (LAV), tricuspid regurgitation velocity (TRV) and the IVC size and collapsibility were obtained. Increased LVFP was defined by an invasive pulmonary artery wedge pressure (PAWP) > 15 mmHg. Results In sinus rhythm patients, the sum of the criteria (E/e’ ratio > 14, TRV > 2.8 m/s and indexed LAV > 34 ml/m²) ≥ 2 had a positive predictive value (PPV) of 63% for PAWP > 15 mmHg, whereas a dilated (> 2.1 cm) and/or non collapsible (≤ 50%) IVC had a PPV of 83%. In atrial fibrillation (AF), a dilated and/or non collapsible IVC had an 86% PPV for increased LVFP. We found that 16% of patients with elevated LVFP were more accurately classified using IVC evaluation than using the current guidelines criteria (net reclassification improvement = 0.25, p <0.05). Conclusion Echographic measurements of the IVC size and collapsibility outperformed the classic 2016 recommendations algorithm to evaluate LVFP in sinus rhythm patients with suspected HFpEF. The IVC study was also valuable in patients with atrial fibrillation.

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Atrial fibrillation and risk of incident heart failure with reduced versus preserved ejection fraction

Heart ◽

10.1136/heartjnl-2021-319122 ◽

2021 ◽

pp. heartjnl-2021-319122

Author(s):

Charles D Nicoli ◽

Wesley T O’Neal ◽

Emily B Levitan ◽

Matthew J Singleton ◽

Suzanne E Judd ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Ejection Fraction ◽

Racial Differences ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Preserved Ejection Fraction ◽

Ventricular Ejection Fraction ◽

Increased Risk ◽

Significant Difference

ObjectiveAssociations between atrial fibrillation (AF) and heart failure (HF) have been established. We compared the extent to which AF is associated with each primary subtype of HF, with reduced (HFrEF) versus preserved ejection fraction (HFpEF).MethodsWe included 25 787 participants free of baseline HF from the REGARDS (REasons for Geographic And Racial Differences in Stroke) cohort. Baseline AF was ascertained from ECG and self-reported history of physician diagnosis. Incident HF events were determined from physician-adjudicated review of hospitalisation medical records and HF deaths. Based on left ventricular ejection fraction (LVEF) at the time of HF event, HFrEF, HFpEF, and mid-range HF were defined as LVEF <40%, ≥50% and 40%–49%, respectively. Multivariable Cox proportional-hazards models examined the association between AF and HF. The Lunn-McNeil method was used to compare associations of AF with incident HFrEF versus HFpEF.ResultsOver a median of 9 years of follow-up, 1109 HF events occurred (356 HFpEF, 388 HFrEF, 77 mid-range and 288 unclassified). In a model adjusted for sociodemographics, cardiovascular risk factors, and incident coronary heart disease, AF was associated with increased risk of all HF events (HR 1.67, 95% CI 1.38 to 2.01). The associations of AF with HFrEF versus HFpEF events did not differ significantly (HR 1.87 (95% CI 1.38 to 2.54) and HR 1.65 (95% CI 1.20 to 2.28), respectively; p value for difference=0.581). These associations were consistent in sex and race subgroups.ConclusionsAF is associated with both HFrEF and HFpEF events, with no significant difference in the strength of association among these subtypes.

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