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Bramblett T, Teleb M, Albaghdadi A, Agrawal H, Mukherjee D. Heart Failure with Preserved Ejection Fraction: Entresto a Possible Option. Cardiovasc Hematol Disord Drug Targets 2018; 17:80-85. [PMID: 28676030 DOI: 10.2174/1871529x17666170703120237] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 05/11/2017] [Accepted: 06/06/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) makes up half of diagnosed heart failure (HF) cases and has similar outcomes compared to heart failure with reduced ejection fraction (HFrEF) but a discrepancy in knowledge and approach to treatment. HFpEF is diagnosed using the following criteria: symptoms, preserved ejection fraction (greater than 50%), and evidence of abnormal left ventricular filling or relaxation, or diastolic distensibility or stiffness. Studies conducted to examine the efficacy of angiotensin receptor blockers (ARB) (irbesartan and candesartan), thiazide diuretics (chlorthalidone), and angiotensin converting enzyme inhibitors (ACEI) (perindopril) in the treatment of HFpEF, showed moderate efficacy but no clear benefit. Recently, the FDA has approved a novel drug, which combines an angiotensin receptor neprilysin inhibitor and ARB (valsartan) named LCZ696 (entresto) for possible treatment of HFrEF. CONCLUSION In this article, we will discuss the failure of previous treatment modalities and the promise that LCZ696 (entresto) may hold for treating patients with HFpEF.
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O'Neal WT, Sandesara P, Patel N, Venkatesh S, Samman-Tahhan A, Hammadah M, Kelli HM, Soliman EZ. Echocardiographic predictors of atrial fibrillation in patients with heart failure with preserved ejection fraction. Eur Heart J Cardiovasc Imaging 2018; 18:725-729. [PMID: 28379310 DOI: 10.1093/ehjci/jex038] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 02/17/2017] [Indexed: 11/14/2022] Open
Abstract
Aims To determine if markers of diastolic dysfunction are associated with atrial fibrillation (AF) development among patients with heart failure with preserved ejection fraction (HFpEF). Methods and Results We examined the association of several echocardiographic measures of diastolic dysfunction with incident AF in 573 patients (mean age = 68 ± 9.5 years; 48% men; 79% white) with HFpEF from the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial (TOPCAT) who were free of baseline AF. Echocardiograms were analysed at a core laboratory. Incident AF cases were identified by follow-up study electrocardiograms and review of relevant medical records through May of 2013. Over a median follow-up of 3 years, 40 patients developed AF (incidence rate = 2.2 per 100 person years). Increasing values of the E/A ratio [per 0.1 increase: hazard ratio (HR) = 1.11, 95% confidence interval (CI) = 1.06-1.17], left atrial volume (per 5 mL increase: HR = 1.13, 95% CI = 1.03-1.23), and left atrial area (per 5 cm2 increase: HR = 1.51, 95% CI = 1.03-2.22) were associated with greater risk of AF. The risk of AF decreased with increasing peak A wave velocities (per 10 cm/s increase: HR = 0.83, 95% CI = 0.72-0.96). The risk of AF was not materially altered when peak A wave velocity was further adjusted for left atrial volume (HR = 0.83, 95% CI = 0.71-0.96) and area (HR = 0.83, 95% CI = 0.71-0.96). However, the associations of left atrial volume (HR = 1.10, 95% CI = 0.99-1.22) and area (HR = 1.48, 95% CI = 0.96-2.28) were no longer significant when accounting for peak A wave velocity. Conclusion Diastolic parameters of left atrial function possibly are more important markers of AF risk than left atrial dilation in HFpEF.
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Eriksson B, Wändell P, Dahlström U, Näsman P, Lund LH, Edner M. Comorbidities, risk factors and outcomes in patients with heart failure and an ejection fraction of more than or equal to 40% in primary care- and hospital care-based outpatient clinics. Scand J Prim Health Care 2018; 36:207-215. [PMID: 29633886 PMCID: PMC6066291 DOI: 10.1080/02813432.2018.1459654] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE The aim of this study is to describe patients with heart failure and an ejection fraction (EF) of more than or equal to 40%, managed in both Primary- and Hospital based outpatient clinics separately with their prognosis, comorbidities and risk factors. Further to compare the heart failure medication in the two groups. DESIGN We used the prospective Swedish Heart Failure Registry to include 9654 out-patients who had HF and EF ≥40%, 1802 patients were registered in primary care and 7852 in hospital care. Descriptive statistical tests were used to analyze base line characteristics in the two groups and multivariate logistic regression analysis to assess mortality rate in the groups separately. SETTING The prospective Swedish Heart Failure Registry. SUBJECTS Patients with heart failure and an ejection fraction (EF) of more than or equal to 40%. MAIN OUTCOME MEASURES Comorbidities, risk factors and mortality. RESULTS Mean-age was 77.5 (primary care) and 70.3 years (hospital care) p < 0.0001, 46.7 vs. 36.3% women respectively (p < 0.0001) and EF ≥50% 26.1 vs. 13.4% (p < 0.0001). Co-morbidities were common in both groups (97.2% vs. 92.3%), the primary care group having more atrial fibrillation, hypertension, ischemic heart disease and COPD. According to the multivariate logistic regression analysis smoking, COPD and diabetes were the most important independent risk factors in the primary care group and valvular disease in the hospital care group. All-cause mortality during mean follow-up of almost 4 years was 31.5% in primary care and 27.8% in hospital care. One year-mortality rates were 7.8%, and 7.0% respectively. CONCLUSION Any co-morbidity was noted in 97% of the HF-patients with an EF of more than or equal to 40% managed at primary care based out-patient clinics and these patients had partly other independent risk factors than those patients managed in hospital care based outpatients clinics. Our results indicate that more attention should be payed to manage COPD in the primary care group. KEY POINTS 97% of heart failure patients with an ejection fraction of more than or equal to 40% managed at primary care based out-patient clinics had any comorbidity. Patients in primary care had partly other independent risk factors than those in hospital care. All-cause mortality during mean follow-up of almost 4 years was higher in primary care compared to hospital care. In matched HF-patients RAS-antagonists, beta-blockers as well as the combination of the two drugs were more seldom prescribed when managed in primary care compared with hospital care.
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López-Candales A, Hernández Burgos PM, Vargas PE. New heart failure reclassification: are we left with more questions than answers? Postgrad Med 2018; 130:449-451. [PMID: 29846126 DOI: 10.1080/00325481.2018.1481715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Nagy AI, Hage C, Merkely B, Donal E, Daubert JC, Linde C, Lund LH, Manouras A. Left atrial rather than left ventricular impaired mechanics are associated with the pro-fibrotic ST2 marker and outcomes in heart failure with preserved ejection fraction. J Intern Med 2018; 283:380-391. [PMID: 29430747 DOI: 10.1111/joim.12723] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIMS Left ventricular (LV) mechanics have been extensively investigated in heart failure with preserved ejection fraction (HFpEF) overshadowing for a long time the potential role of left atrium (LA) in that setting. Soluble suppression of tumorigenicity-2 receptor (ST2) is a novel biomarker of pro-fibrotic burden in HF. We hypothesized that due to the thinner LA wall, the fibrotic myocardial changes in HFpEF as indicated by elevated ST2 levels might more readily be reflected by impairments in the LA rather than the LV performance. METHODS AND RESULTS In 86 patients with HFpEF, enrolled in the Karolinska Rennes (KaRen) biomarker prospective substudy, global LA strain (GL-LS) along with other echocardiographic as well as haemodynamic parameters and ST2 levels were measured. ST2 levels were inversely associated with LA-GS (r = -0.30, P = 0.009), but not with LA size, LV geometry, systolic or diastolic LV function (P > 0.05 for all). Furthermore, symptom severity correlated with ST2 and LA-GS, but not with LV structural or functional indices. Finally, during a median 18-month follow-up, LA-GS independently predicted the composite endpoint of HF hospitalization and all-cause mortality, even after adjustment for potential clinical and cardiac mechanical confounders, including LV global longitudinal strain and filling pressures (odds ratio: 4.15; confidence interval: 1.2-14, P = 0.023). CONCLUSIONS Reduced LA-GS but not LV functional systolic and diastolic parameters were associated with the pro-fibrotic ST2 marker, HF symptoms and outcome in HFpEF.
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Anand IS, Claggett B, Liu J, Shah AM, Rector TS, Shah SJ, Desai AS, O'Meara E, Fleg JL, Pfeffer MA, Pitt B, Solomon SD. Interaction Between Spironolactone and Natriuretic Peptides in Patients With Heart Failure and Preserved Ejection Fraction: From the TOPCAT Trial. JACC-HEART FAILURE 2018; 5:241-252. [PMID: 28359411 DOI: 10.1016/j.jchf.2016.11.015] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 11/23/2016] [Accepted: 11/28/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The aims of this study were to explore the relationship of baseline levels of natriuretic peptides (NPs) with outcomes and to test for an interaction between baseline levels of NPs and the effects spironolactone. BACKGROUND Plasma NPs are considered to be helpful in the diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF), and elevated levels are associated with adverse outcomes. Levels of NPs higher than certain cutoffs are often used as inclusion criteria in clinical trials of HFpEF to increase the likelihood that patients have HF and to select patients at higher risk for events. Whether treatments have a differential effect on outcomes across the spectrum of NP levels is unclear. METHODS The TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial) trial randomized patients with HFpEF and either prior hospitalization for HF or elevated natriuretic peptide levels (B-type NP [BNP] ≥100 pg/ml or N-terminal proBNP ≥360 pg/ml) to spironolactone or placebo. Baseline BNP (n = 430) or N-terminal proBNP (n = 257) levels were available in 687 patients enrolled from the Americas in the elevated-NP stratum of TOPCAT. RESULTS Higher levels of NPs were independently associated with an increased risk for TOPCAT's primary endpoint of cardiovascular mortality, aborted cardiac arrest, or hospitalization for HF when analyzed either continuously or grouped by terciles, adjusting for region of enrollment, age, sex, atrial fibrillation, diabetes, renal function, body mass index, and heart rate. There was a significant interaction between the effect of spironolactone and baseline NP terciles for the primary outcome (p = 0.017), with greater benefit of the drug in the lower compared with higher NP terciles. CONCLUSIONS Similar to the effects of irbesartan in the I-PRESERVE (Irbesartan in Heart Failure With Preserved Ejection Fraction) trial, a greater benefit of spironolactone was observed in the group with lower levels of NPs and overall risk in TOPCAT. Elevated NPs in HFpEF identify patients at higher risk for events but who may be less responsive to treatment. The mechanism of this apparent interaction between disease severity and response to therapy requires further exploration. (Aldosterone Antagonist Therapy for Adults With Heart Failure and Preserved Systolic Function [TOPCAT]; NCT00094302).
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Zoppini G, Bergamini C, Bonapace S, Trombetta M, Mantovani A, Toffalini A, Lanzoni L, Bertolini L, Zenari L, Bonora E, Targher G, Rossi A. Left ventricular chamber dilation and filling pressure may help to categorise patients with type 2 diabetes. BMJ Open Diabetes Res Care 2018; 6:e000529. [PMID: 29942525 PMCID: PMC6014226 DOI: 10.1136/bmjdrc-2018-000529] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 05/11/2018] [Accepted: 05/20/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Type 2 diabetes may alter cardiac structure and function. Many patients with type 2 diabetes have diastolic dysfunction with preserved ejection fraction (EF). Recently, this latter measure was criticised. Thus, this research looked at the impact of left ventricular end-diastolic volume and E/e' ratio variations in patients with type 2 diabetes and preserved EF with the aim to recognise different clinical phenotypes. METHODS In this cross-sectional study, we evaluated 176 men affected by type 2 diabetes with transthoracic echocardiography. All subjects have preserved EF (>50%). Patients were stratified into four groups based on the median value of both left ventricular end-diastolic volume and E/e' ratio, and the clinical variables were registered. The independent predictors associated with the groups were analysed by a multinomial logistic regression model. RESULTS Diabetes duration, age, estimated glomerular filtration rate and antihypertensive treatments were significantly different among the groups as were EF, left atrial volume index (LAVI), E/A, septum thickness and s' mean wave. Multinomial regression analysis showed that the groups significantly differed for age, diabetes duration, EF, LAVI, septum thickness and s' mean wave. The main result of this study was that patients with higher left ventricular volume and higher E/e' ratio (group 2) showed the worse clinical profile. CONCLUSIONS Our study might suggest that variations of left ventricular end-diastolic volume along with E/e' ratio variations, even in the normal range, may allow to recognise phenotypes of patients with type 2 diabetes with worse clinical characteristics. This finding should be tested in prospective studies to assess the predictive roles of these phenotypes.
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Abstract
The newly defined category of heart failure (HF) with mid-range ejection fraction (HFmrEF; EF 40-49 %) is beginning to be characterised but little is known about the potential for treating it. Trials and observational studies suggest that standard therapy for HF with reduced ejection fraction (HFrEF; EF <40 %) may also offer some benefit to patients with EF ≥40 %; however, any difference between its effects on HFmrEF and true HF with preserved ejection fraction (HFpEF) have until now not been explored. This study summarises randomised trial data from the CHARM programme that suggest that candesartan may improve outcomes in HFmrEF.
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Upadhya B, Pisani B, Kitzman DW. Evolution of a Geriatric Syndrome: Pathophysiology and Treatment of Heart Failure with Preserved Ejection Fraction. J Am Geriatr Soc 2017; 65:2431-2440. [PMID: 29124734 DOI: 10.1111/jgs.15141] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The majority of older adults who develop heart failure (HF), particularly older women, have a preserved left ventricular ejection fraction (HFpEF). The prevalence of this syndrome is increasing, and the prognosis is not improving, unlike that of HF with reduced ejection fraction (HFrEF). Individuals with HFpEF have severe symptoms of effort intolerance, poor quality of life, frequent hospitalizations, and greater likelihood of death. Despite the importance of HFpEF, there are numerous major gaps in our understanding of its pathophysiology and management. Although it was originally viewed as a disorder due solely to abnormalities in left ventricular diastolic function, our understanding has evolved such that HFpEF is now understood as a systemic syndrome involving multiple organ systems, and it is likely that it is triggered by inflammation and other as-yet-unidentified circulating factors, with important contributions of aging and multiple comorbidities, features generally typical of other geriatric syndromes. We present an update on the pathophysiology, diagnosis, management, and future directions in this disorder in older persons.
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Nadruz W, West E, Sengeløv M, Santos M, Groarke JD, Forman DE, Claggett B, Skali H, Shah AM. Prognostic Value of Cardiopulmonary Exercise Testing in Heart Failure With Reduced, Midrange, and Preserved Ejection Fraction. J Am Heart Assoc 2017; 6:JAHA.117.006000. [PMID: 29089342 PMCID: PMC5721737 DOI: 10.1161/jaha.117.006000] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background This study aimed to compare the independent and incremental prognostic value of peak oxygen consumption (VO2) and minute ventilation/carbon dioxide production (VE/VCO2) in heart failure (HF) with preserved (HFpEF), midrange (HFmEF), and reduced (HFrEF) ejection fraction (LVEF). Methods and Results In 195 HFpEF (LVEF ≥50%), 144 HFmEF (LVEF 40–49%), and 630 HFrEF (LVEF <40%) patients, we assessed the association of cardiopulmonary exercise testing variables with the composite outcome of death, left ventricular assist device implantation, or heart transplantation (256 events; median follow‐up of 4.2 years), and 2‐year incident HF hospitalization (244 events). In multivariable Cox regression analysis, greater association with outcomes in HFpEF than HFrEF were noted with peak VO2 (HR [95% confidence interval]: 0.76 [0.67–0.87] versus 0.87 [0.83–0.90] for the composite outcome, Pinteraction=0.052; 0.77 [0.69–0.86] versus 0.92 [0.88–0.95], respectively for HF hospitalization, Pinteraction=0.003) and VE/VCO2 slope (1.11 [1.06–1.17] versus 1.04 [1.03–1.06], respectively for the composite outcome, Pinteraction=0.012; 1.10 [1.05–1.15] versus 1.04 [1.03–1.06], respectively for HF hospitalization, Pinteraction=0.019). In HFmEF, peak VO2 and VE/VCO2 slope were associated with the composite outcome (0.79 [0.70–0.90] and 1.12 [1.05–1.19], respectively), while only peak VO2 was related to HF hospitalization (0.81 [0.72–0.92]). In HFpEF and HFrEF, peak VO2 and VE/VCO2 slope provided incremental prognostic value beyond clinical variables based on the C‐statistic, net reclassification improvement, and integrated diagnostic improvement, with models containing both measures demonstrating the greatest incremental value. Conclusions Both peak VO2 and VE/VCO2 slope provided incremental value beyond clinical characteristics and LVEF for predicting outcomes in HFpEF. Cardiopulmonary exercise testing variables provided greater risk discrimination in HFpEF than HFrEF.
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Bjugstad KB, Lalama J, Rael LT, Salottolo K, Dauber I, Bar-Or D. Poor acute outcome in congestive heart failure is associated with increases in the plasma static oxidation-reduction potentials (sORP) in men but not in women. Redox Rep 2017; 22:534-541. [PMID: 28845739 DOI: 10.1080/13510002.2017.1369644] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES In congestive heart failure (CHF), men are younger, more likely to have reduced ejection fraction (HF-rEF), and to be diabetic compared to women. Despite this, sex differences in oxidative stress have yet to be explored in CHF. METHODS Data from 67 males and 63 females hospitalized for CHF were collected. Static oxidation-reduction potential (sORP), a relative indicator of oxidative stress, and capacity ORP (icORP), a relative indicator of antioxidant capacity, were measured from plasma samples. We examined whether sex modified the relationship between ORP and hospital discharge disposition (poor outcome: death, hospice), along with other demographics, medications, and diagnostic parameters. RESULTS Males with poor outcomes had higher sORP and icORP values than females (P < 0.05). For those with a good outcome, there were no differences between the sexes (P > 0.05). Males were younger and more likely to have HF-rEF and diabetes. Controlling for these variables did not account for the sex differences in ORP measures. Regardless of sex, higher creatinine was related to higher sORP and icORP, while lower magnesium and potassium were related to higher sORP and icORP, respectively. DISCUSSION Increases in sORP during CHF are partially affected by sex and acute outcomes, but are also related to variables without sexual biases.
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Zheng SL, Chan FT, Nabeebaccus AA, Shah AM, McDonagh T, Okonko DO, Ayis S. Drug treatment effects on outcomes in heart failure with preserved ejection fraction: a systematic review and meta-analysis. Heart 2017; 104:407-415. [PMID: 28780577 PMCID: PMC5861385 DOI: 10.1136/heartjnl-2017-311652] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 06/19/2017] [Accepted: 07/05/2017] [Indexed: 02/06/2023] Open
Abstract
Background Clinical drug trials in patients with heart failure and preserved ejection fraction have failed to demonstrate improvements in mortality. Methods We systematically searched Medline, Embase and the Cochrane Central Register of Controlled Trials for randomised controlled trials (RCT) assessing pharmacological treatments in patients with heart failure with left ventricular (LV) ejection fraction≥40% from January 1996 to May 2016. The primary efficacy outcome was all-cause mortality. Secondary outcomes were cardiovascular mortality, heart failure hospitalisation, exercise capacity (6-min walk distance, exercise duration, VO2 max), quality of life and biomarkers (B-type natriuretic peptide, N-terminal pro-B-type natriuretic peptide). Random-effects models were used to estimate pooled relative risks (RR) for the binary outcomes, and weighted mean differences for continuous outcomes, with 95% CI. Results We included data from 25 RCTs comprising data for 18101 patients. All-cause mortality was reduced with beta-blocker therapy compared with placebo (RR: 0.78, 95%CI 0.65 to 0.94, p=0.008). There was no effect seen with ACE inhibitors, aldosterone receptor blockers, mineralocorticoid receptor antagonists and other drug classes, compared with placebo. Similar results were observed for cardiovascular mortality. No single drug class reduced heart failure hospitalisation compared with placebo. Conclusion The efficacy of treatments in patients with heart failure and an LV ejection fraction≥40% differ depending on the type of therapy, with beta-blockers demonstrating reductions in all-cause and cardiovascular mortality. Further trials are warranted to confirm treatment effects of beta-blockers in this patient group.
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Kosowski M, Kübler P, Kołodziej A, Krakowiak B, Kustrzycka-Kratochwil D, Sławin J, Sokolski M, Biegus J, Zymliński R, Banasiak W, Ponikowski P, Reczuch K. InterAtrial Shunt Device (IASD®) implantation - a novel treatment method for heart failure with preserved ejection fraction. Kardiol Pol 2017; 75:736-741. [PMID: 28541594 DOI: 10.5603/kp.a2017.0096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 03/27/2017] [Accepted: 04/10/2017] [Indexed: 11/25/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a condition with complex pathophysiology and clinical profile. No treatment has been proven to reduce mortality or reduce morbidity in a meaningful way. In the era of percutaneous cardiac interventions, a novel method of reducing left atrial pressure by creating an iatrogenic interatrial shunt has been introduced. We present a report of implantation of InterAtrial Shunt Device (IASD®) in three consecutive patients.
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O'Neal WT, Sandesara PB, Samman-Tahhan A, Kelli HM, Hammadah M, Soliman EZ. Heart rate and the risk of adverse outcomes in patients with heart failure with preserved ejection fraction. Eur J Prev Cardiol 2017; 24:1212-1219. [PMID: 28482692 DOI: 10.1177/2047487317708676] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Although high resting heart rates are associated with adverse outcomes in heart failure with reduced ejection, the reports for heart failure with preserved ejection fraction (HFpEF) are conflicting. Design A secondary analysis was conducted in order to examine the relationship between resting heart rate and adverse outcomes in 2705 patients (mean age = 68 ± 10 years; 47% men; 88% white) with HFpEF who were in sinus rhythm from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial (TOPCAT). Methods Baseline heart rate was obtained from baseline electrocardiogram data. Outcomes were adjudicated by a clinical end-point committee and included the following factors: hospitalisation, hospitalisation for heart failure, death and cardiovascular death. Results Over a median follow-up of 3.4 years (25th-75th percentiles = 2.0-4.9 years), a total of 1157 hospitalisations, 311 hospitalizations for heart failure, 369 deaths and 233 cardiovascular deaths occurred. An increased risk (per 5-beats per minute [bpm] increase) for hospitalisation (hazard ratio [HR] = 1.03, 95% confidence interval [CI] = 1.004-1.060), hospitalisation for heart failure (HR = 1.10, 95% CI = 1.05-1.15), death (HR = 1.10, 95% CI = 1.06-1.16) and cardiovascular death (HR = 1.13, 95% CI = 1.07-1.19) was observed. When the analysis was limited to those who did not report the use of β-blockers, the magnitude of the association for each outcome (per 5-bpm increase) was not materially altered (hospitalisation: HR = 1.03, 95% CI = 0.97-1.09; hospitalisation for heart failure: HR = 1.12, 95% CI = 0.98-1.27; death: HR = 1.16, 95% CI = 1.05-1.28; cardiovascular death: HR = 1.12, 95% CI = 0.99-1.27). Conclusion High resting heart rate is a risk factor for adverse outcomes in patients with HFpEF, and future studies are needed in order to determine whether reducing heart rate improves outcomes in HFpEF.
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Gatzoulis KA, Antoniou CK, Dilaveris P, Chrysohoou C, Arsenos P, Trachanas K, Tousoulis D. Ventricular arrhythmogenic potential assessment in an asymptomatic ischemic cardiomyopathy patient with a normal ejection fraction. Hellenic J Cardiol 2017; 58:443-445. [PMID: 28351656 DOI: 10.1016/j.hjc.2017.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 03/14/2017] [Accepted: 03/15/2017] [Indexed: 11/17/2022] Open
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Bezgin T, Elveran A, Karagoz A, Canga Y, Dogan C. Parathyroid hormone is associated with heart failure with preserved ejection fraction. ACTA ACUST UNITED AC 2017; 117:442-7. [PMID: 27546695 DOI: 10.4149/bll_2016_086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Parathyroid hormone (PTH) is a novel promising biomarker that can predict hospitalization, functional status and mortality in patients who suffered heart failure with preserved ejection fraction (HFpEF). OBJECTIVE We aimed to investigate the association of serum PTH levels and measures of disease severity (NYHA functional class, NT-proBNP, CRP, EF, Troponin I) in patients with HFpEF. METHODS A total of consecutive 58 outpatients with HFpEF and 30 controls were prospectively studied. All patients underwent laboratory tests, including NT-proBNP and PTH analyses. RESULTS PTH, NT-proBNP, troponin I, and CRP levels were significantly higher in patients with HFpEF when compared with control group (54.61 ± 31.02 vs 40.40 ± 14.22 pg/ml, p < 0.05; 126.05 ± 162.94 vs 44.57 ± 14.95 pg/ml, p < 0.01; 0.011 ± 0.013 vs 0.004 ± 0.001 ug/L, p < 0.01; 4.65 ± 4.24 vs 1.63 ± 0.97 mg/L, p < 0.01, respectively). Left atrium was found to be more enlarged in HFpEF patients (LAVI = 36 ± 18 vs 28 ± 11 ml/m², p < 0.01). Most indices of left ventricular diastolic function were more severely impaired compared to controls (p < 0.05). There was no correlation between PTH and CRP, troponin I, LVMI, LV volumes, LV diameters, E/E', age, and BMI in both groups (p = NS). There was strong positive correlation between PTH and NT-proBNP levels in all study participants (r = 0.359; p < 0.01). CONCLUSION PTH together with other markers of heart failure may provide valuable information both in the diagnosis and staging of heart failure syndromes (Tab. 4, Fig. 1, Ref. 40).
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Kanorskii SG, Sereda AF. [Comparison of Verapamil and Amlodipine for Treatment of Chronic Heart Failure With Preserved Left Ventricular Ejection Fraction in Patients With Hypertensive Disease]. KARDIOLOGIIA 2016; 56:27-32. [PMID: 28290801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE to compare efficacy of verapamil and amlodipine in treatment of chronic heart failure (CHF) with preserved left ventricular (LV) ejection fraction (EF) in patients with hypertensive disease (HD). MATERIAL AND METHODS Patients with stage III HD, class II-III CHF, and LVEF more or equal 50% (n=167, age 48-70 years) underwent complex examination before and after 12 months of treatment with perindopril combined either with verapamil SR (n=85) or amlodipine (n=82). RESULTS Average 6-minute walk distance increased after both verapamil and amlodipine containing treatment (by 15.1 and 18.2%, respectively). Administration of both drugs was associated with improvement of clinical state and quality of life. But only treatment containing amlodipine was associated with lowering of N-terminal probrain natriuretic peptide and improvement of echocardiographic parameters of LV diastolic function. CONCLUSION In treatment of CHF in patients with HD amlodipine is at least not inferior to verapamil for elevation of exercise tolerance and superior to verapamil for improvement of LV diastolic function. Amlodipine might be perspective for use in patients with chronotropic incompetence.
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Integration of Flow-Gradient Patterns Into Clinical Decision Making for Patients With Suspected Severe Aortic Stenosis and Preserved LVEF: A Systematic Review of Evidence and Meta-Analysis. JACC Cardiovasc Imaging 2016; 9:1255-1263. [PMID: 27544900 DOI: 10.1016/j.jcmg.2016.01.035] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 01/25/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This study was designed to evaluate the evidence base for the 2014 American Heart Association/American College of Cardiology (AHA/ACC) guidelines for severe aortic stenosis (SAS) and preserved left ventricular ejection fraction by comparing the natural history of the disease in subgroups of low-gradient (LG) aortic stenosis patients with high-gradient (HG) patients. BACKGROUND The 2014 AHA/ACC valvular disease guidelines recommend estimation of stroke volume index by echocardiography in patients with suspected LG SAS and preserved left ventricular ejection fraction. METHODS PubMed, Embase, and Scopus databases were searched for all studies that have compared the natural history of SAS with preserved ejection fraction in flow-gradient patterns. We studied the following 3 subgroups: HG, low-flow low-gradient (LFLG), and normal-flow low-gradient (NFLG). The random effects model was used to pool individual study results. The end-point was long-term all-cause mortality. RESULTS A total of 9 studies with 3,065 patients fulfilled the criteria. Compared to HG SAS, both LFLG and NFLG patients had a higher burden of comorbidities such as coronary artery disease and hypertension. Atrial fibrillation was more prevalent in LFLG patients. Moreover, end-diastolic volume index was smaller for LFLG patients and indexed aortic valve area was larger for NFLG patients. All-cause mortality was similar between HG and LFLG subgroups (relative risk: 1.07; 95% confidence interval: 0.83 to 1.38; p = 0.60), whereas patients with NFLG had a significantly lower all-cause mortality compared to the HG subgroup (relative risk: 0.64; 95% confidence interval: 0.47 to 0.86; p = 0.004). CONCLUSIONS Patients with LFLG SAS have similar outcomes compared to HG SAS but worse compared to NFLG SAS. These findings support estimating stroke volume index in patients with suspected LG SAS. All analyses revealed high heterogeneity and further high-quality studies are necessary.
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Prevalence and Risk Factors of Heart Failure with Preserved Ejection Fraction: A Population-Based Study in Northeast China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13080770. [PMID: 27483300 PMCID: PMC4997456 DOI: 10.3390/ijerph13080770] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/22/2016] [Accepted: 07/25/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) has attracted increasing attention worldwide. We aimed to estimate the prevalence of HFpEF and analyze its correlates in a sample of residents of northeast China; METHODS A population-based study of 2230 participants ≥35 years old was conducted in rural areas of Liaoning Province from January 2012 through August 2013. Information about lifestyle and other potential risk factors was obtained. HFpEF was diagnosed according to the recommendations of European Society of Cardiology; RESULTS The overall prevalence of HFpEF was 3.5% (1.8% in men and 4.9% in women). The prevalence of HFpEF increased with age in both genders and was greater in women than in men for every age group. Multivariable logistic regression analysis found that female gender (OR, 3.575; 95% CI, 1.761-7.256), hypertension (OR, 3.711; 95% CI, 2.064-6.674), and history of heart disease (2.086; 95% CI, 1.243-3.498) were associated factors for prevalent HFpEF; CONCLUSIONS In a general population from rural northeast China, we found that female gender, hypertension, and history of heart disease were risk factors for prevalent HFpEF.
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Lewis EF, Kim HY, Claggett B, Spertus J, Heitner JF, Assmann SF, Kenwood CT, Solomon SD, Desai AS, Fang JC, McKinlay SA, Pitt BA, Pfeffer MA. Impact of Spironolactone on Longitudinal Changes in Health-Related Quality of Life in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial. Circ Heart Fail 2016; 9:e001937. [PMID: 26962133 DOI: 10.1161/circheartfailure.114.001937] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Heart failure (HF) with preserved ejection fraction patients have equally impaired health-related quality of life (HRQL) compared with those with HF with reduced ejection fraction, but limited studies have evaluated the impact of therapies on changes in HRQL. METHODS AND RESULTS Patients ≥50 years of age, with symptomatic HF and left ventricular ejection fraction ≥45%, were enrolled in Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) and randomized to spironolactone or placebo. Patients completed the Kansas City Cardiomyopathy Questionnaire (KCCQ), which was the primary HRQL instrument, and EQ5D visual analog scale at baseline, 4 months, 12 months, and annually thereafter. McMaster Overall Treatment Evaluation was assessed at 4 and 12 months to assess global change scores. Change scores (+SD) were calculated to determine between-group differences, and multivariable repeated-measures models were created to identify other factors associated with change scores. Paired KCCQ data were available for 91.7% of 3445 TOPCAT patients. By 4 months, the mean change in KCCQ was 7.7±16 and mean change in EQ5D visual analog scale was 4.7±16. Adjusted mean changes in KCCQ for the spironolactone group were significantly better than those for the placebo group at 4-month (1.54 better; P=0.002), 12-month (1.35 better; P=0.02), and 36-month (1.86 better; P=0.02) visits. No between-group differences in EQ5D visual analog scale change scores or McMaster Overall Treatment Evaluation were noted. Older age, obesity, current smoking, New York Heart Association class III/IV, and comorbid illnesses were associated with declines in KCCQ scores. Use of spironolactone was an independent predictor of improved KCCQ scores. CONCLUSIONS In symptomatic HF with preserved ejection fraction patients, use of spironolactone was associated with an improvement in HF-specific HRQL. Several modifiable risk factors were associated with HRQL deterioration. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00094302.
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Molina AJA, Bharadwaj MS, Van Horn C, Nicklas BJ, Lyles MF, Eggebeen J, Haykowsky MJ, Brubaker PH, Kitzman DW. Skeletal Muscle Mitochondrial Content, Oxidative Capacity, and Mfn2 Expression Are Reduced in Older Patients With Heart Failure and Preserved Ejection Fraction and Are Related to Exercise Intolerance. JACC-HEART FAILURE 2016; 4:636-45. [PMID: 27179829 DOI: 10.1016/j.jchf.2016.03.011] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 03/03/2016] [Accepted: 03/16/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to examine skeletal muscle mitochondria content, oxidative capacity, and the expression of key mitochondrial dynamics proteins in patients with heart failure with preserved ejection fraction (HFpEF), as well as to determine potential relationships with measures of exercise performance. BACKGROUND Multiple lines of evidence indicate that severely reduced peak exercise oxygen uptake (peak VO2) in older patients with HFpEF is related to abnormal skeletal muscle oxygen utilization. Mitochondria are key regulators of skeletal muscle metabolism; however, little is known about how these organelles are affected in HFpEF. METHODS Both vastus lateralis skeletal muscle citrate synthase activity and the expression of porin and regulators of mitochondrial fusion were examined in older patients with HFpEF (n = 20) and healthy, age-matched control subjects (n = 17). RESULTS Compared with age-matched healthy control subjects, mitochondrial content assessed by porin expression was 46% lower (p = 0.01), citrate synthase activity was 29% lower (p = 0.01), and Mfn2 (mitofusin 2) expression was 54% lower (p <0.001) in patients with HFpEF. Expression of porin was significantly positively correlated with both peak VO2 and 6-min walk distance (r = 0.48, p = 0.003 and r = 0.33, p = 0.05, respectively). Expression of Mfn2 was also significantly positively correlated with both peak VO2 and 6-min walk distance (r = 0.40, p = 0.02 and r = 0.37, p = 0.03 respectively). CONCLUSIONS These findings suggest that skeletal muscle oxidative capacity, mitochondrial content, and mitochondrial fusion are abnormal in older patients with HFpEF and might contribute to their severe exercise intolerance.
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Samson R, Jaiswal A, Ennezat PV, Cassidy M, Le Jemtel TH. Clinical Phenotypes in Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2016; 5:e002477. [PMID: 26811159 PMCID: PMC4859363 DOI: 10.1161/jaha.115.002477] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Golwala H, Pandey A, Ju C, Butler J, Yancy C, Bhatt DL, Hernandez AF, Fonarow GC. Temporal Trends and Factors Associated With Cardiac Rehabilitation Referral Among Patients Hospitalized With Heart Failure: Findings From Get With The Guidelines-Heart Failure Registry. J Am Coll Cardiol 2015; 66:917-26. [PMID: 26293762 DOI: 10.1016/j.jacc.2015.06.1089] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 05/26/2015] [Accepted: 06/15/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Current guidelines recommend cardiac rehabilitation (CR) in medically stable outpatients with heart failure (HF); however, temporal trends and factors associated with CR referral among these patients in real-world practice are not entirely known. OBJECTIVES The purpose of this study was to assess proportional use, temporal trends, and factors associated with CR referral at discharge among patients admitted with decompensated HF. METHODS Using data from a national Get With the Guidelines-Heart Failure registry, we assessed the temporal trends in CR referral among eligible patients with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF) at discharge after HF hospitalization between 2005 and 2014. On multivariable analysis, we also assessed patient- and hospital-level characteristics that are associated with CR referral. RESULTS Among 105,619 HF patients (48% with HFrEF, 52% with HFpEF), 10.4% (12.2% with HFrEF, 8.8% with HFpEF) received CR referral at discharge. A significant increase in CR referral rates was observed among both HFpEF and HFrEF patients over the study period (ptrend <0.0001 for HFrEF, HFpEF, and overall). Compared with patients discharged without CR referral, patients referred for CR were younger, predominantly men, and more likely to receive evidence-based HF therapies at discharge. On multivariable analysis, younger age, fewer comorbid conditions, and in-hospital procedures such as coronary artery bypass grafting, percutaneous coronary intervention, and cardiac valve surgery were most strongly associated with CR referral. CONCLUSIONS Only one-tenth of eligible HF patients received CR referral at discharge after hospitalization for HF. The proportional use of CR referral is increasing over time among both HFrEF and HFpEF patients. Further strategies to improve physician and patient awareness in regard to the benefit of CR should be used to increase CR referral among patients with HF.
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How B-Type Natriuretic Peptide (BNP) and Body Weight Changes Vary in Heart Failure With Preserved Ejection Fraction Compared With Reduced Ejection Fraction: Secondary Results of the HABIT (HF Assessment With BNP in the Home) Trial. J Card Fail 2015; 22:283-93. [PMID: 26433086 DOI: 10.1016/j.cardfail.2015.09.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 09/17/2015] [Accepted: 09/22/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Heart failure is a common cause of hospitalization and can be divided into types with preserved and reduced ejection fraction (HFpEF and HFrEF, respectively). In this subanalysis of the HABIT (Heart Failure Assessment With BNP in the Home) trial, we examined the differences between home B-type natriuretic peptide (BNP) testing and weight monitoring in patients with HFpEF and with HFrEF before decompensation. METHODS AND RESULTS This was a retrospective review of patients with HFpEF and HFrEF from the HABIT trial. The HFpEF patients compared with HFrEF patients were older and more obese and had lower baseline BNP values. Intra-individual BNP dispersion (spread of distribution over time) was greater in HFpEF than in HFrEF owing to rapid fluctuations (within 3 days). Slowly varying changes in BNP (estimated by a moving average) were equally predictive of ADHF risk in both HFpEF and HFrEF. However, in HFpEF, a rapid rise in BNP >200 pg/mL within 3 days was associated with an increased risk of acute decompensated heart failure (ADHF; hazard ratio 4.0), whereas a similar association was not observed in HFrEF. Weight gain ≥5 lb in 3 days had a high specificity but low sensitivity for ADHF in both HFpEF and HFrEF, whereas a lower threshold of ≥2 lb weight gain over 3 days in patients with HFpEF (but not HFrEF) was a moderately sensitive cutoff associated with decompensation (60% sensitivity). CONCLUSIONS Patients with HFpEF and HFrEF have variations in their BNP and weight before decompensation. The rapid time scale behaves differently between the groups. In those with HFpEF, a 3-day period characterized by ≥2 lb weight gain and/or >200 pg/mL BNP rise was significantly associated with decompensation. Future prospective studies investigating different weight and BNP cutoffs for home monitoring of HFpEF and HFrEF patients should be performed to fully learn the value of BNP changes before clinical deompensation.
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Nanayakkara S, Kaye DM. Management of heart failure with preserved ejection fraction: a review. Clin Ther 2015; 37:2186-98. [PMID: 26385583 DOI: 10.1016/j.clinthera.2015.08.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 08/05/2015] [Accepted: 08/09/2015] [Indexed: 01/14/2023]
Abstract
PURPOSE The purpose of this article was to review the clinical management of patients with heart failure with preserved ejection fraction (HFPEF). METHODS For this critical review, electronic databases (MEDLINE, EMBASE, PubMed) were searched for relevant basic research studies and randomized clinical trials recently published or presented at major meetings. Details of in-progress or planned studies were obtained from the ClinicalTrials.gov website. The range of publication dates was the year 2000 to 2015. Search terms included HFPEF, heart failure with preserved ejection fraction, HFPSF, heart failure with preserved systolic function, diastolic heart failure, diastolic dysfunction, HFNEF, heart failure with normal ejection fraction, treatment, management, therapy. FINDINGS Patients with HFPEF account for up to half of all patients with a clinical diagnosis of HF. Key contributing factors include hypertension, obesity, and atrial fibrillation, and other chronic diseases, including diabetes, chronic obstructive pulmonary disease, and anemia, frequently coexist. To date, large-scale clinical trials, particularly those focused on antagonism of the renin-angiotensin-aldosterone system, have provided limited evidence of clinical benefit. IMPLICATIONS The aggressive management of contributing factors, including hypertension, atrial fibrillation, and myocardial ischemia, is key in the management of HFPEF. New insights into the mechanisms and thus the identification of potential therapeutic strategies are urgently required.
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