101
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Pagel PS, Tawil JN, Boettcher BT, Izquierdo DA, Lazicki TJ, Crystal GJ, Freed JK. Heart Failure With Preserved Ejection Fraction: A Comprehensive Review and Update of Diagnosis, Pathophysiology, Treatment, and Perioperative Implications. J Cardiothorac Vasc Anesth 2020; 35:1839-1859. [PMID: 32747202 DOI: 10.1053/j.jvca.2020.07.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/15/2020] [Accepted: 07/02/2020] [Indexed: 02/07/2023]
Abstract
Almost three-quarters of all heart failure patients who are older than 65 have heart failure with preserved ejection fraction (HFpEF). The proportion and hospitalization rate of patients with HFpEF are increasing steadily relative to patients in whom heart failure occurs as result of reduced ejection fraction. The predominance of the HFpEF phenotype most likely is explained by the prevalence of medical conditions associated with an aging population. A multitude of age-related, medical, and lifestyle risk factors for HFpEF have been identified as potential causes for the sustained low-grade proinflammatory state that accelerates disease progression. Profound left ventricular (LV) systolic and diastolic stiffening, elevated LV filling pressures, reduced arterial compliance, left atrial hypertension, pulmonary venous congestion, and microvascular dysfunction characterize HFpEF, but pulmonary arterial hypertension, right ventricular dilation and dysfunction, and atrial fibrillation also frequently occur. These cardiovascular features make patients with HFpEF exquisitely sensitive to the development of hypotension in response to acute declines in LV preload or afterload that may occur during or after surgery. With the exception of symptom mitigation, lifestyle modifications, and rigorous control of comorbid conditions, few long-term treatment options exist for these unfortunate individuals. Patients with HFpEF present for surgery on a regular basis, and anesthesiologists need to be familiar with this heterogeneous and complex clinical syndrome to provide successful care. In this article, the authors review the diagnosis, pathophysiology, and treatment of HFpEF and also discuss its perioperative implications.
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Affiliation(s)
- Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
| | - Justin N Tawil
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Brent T Boettcher
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - David A Izquierdo
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Timothy J Lazicki
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - George J Crystal
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, IL
| | - Julie K Freed
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
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102
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Parcha V, Patel N, Kalra R, Bhargava A, Prabhu SD, Arora G, Arora P. Clinical, Demographic, and Imaging Correlates of Anemia in Heart Failure With Preserved Ejection Fraction (from the RELAX Trial). Am J Cardiol 2020; 125:1870-1878. [PMID: 32307089 DOI: 10.1016/j.amjcard.2020.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/01/2020] [Accepted: 03/03/2020] [Indexed: 01/14/2023]
Abstract
Anemia is a commonly occurring comorbidity among patients of heart failure with preserved ejection fraction (HFpEF) but limited data exists on the cardiovascular phenotype of anemia in HFpEF. We sought to characterize the clinical features, exercise capacity, and outcomes in patients with HFpEF to elucidate the phenotype and pathophysiology of anemia in HFpEF. Post hoc analyses of participants enrolled in the RELAX (Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in Diastolic Heart Failure) trial was performed. Anemia was defined as hemoglobin <13 g/dL in men and <12 g/dL in women. Multivariate adjusted regression modeling was done to assess for differences in peak oxygen uptake. Adjusted hazard ratios were generated to assess difference in hospitalization events using a Cox proportional hazards model. Anemic HFpEF patients were more likely to be older, male, and have worse renal function (p <0.05 for all). N-terminal pro-B-type natriuretic peptide, troponin I, pro-collagen III N-terminal peptide, C-telopeptide for type I collagen, uric acid, cystatin-c, and galectin-3 (p <0.05 for all) levels were higher in anemic HFpEF patients. In adjusted models, anemic HFpEF patients had worse exercise capacity (peak oxygen uptake: 11.3 vs 12.1 mL/kg/min; p = 0.004). The hazard for cardiac or renal cause of hospitalization in those with anemia was 2.0 (95% confidence interval: 0.9 to 4.3). Anemic HFpEF patients have worse exercise capacity and are more likely to be hospitalized. A better understanding of the physiologic phenotypes of HFpEF patients may allow for greater personalization of treatment and prognostication in HFpEF patients.
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Affiliation(s)
- Vibhu Parcha
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nirav Patel
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rajat Kalra
- Cardiovascular Division, University of Minnesota, Minneapolis, Michigan
| | - Anirudh Bhargava
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sumanth D Prabhu
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama; Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Garima Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama; Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.
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103
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Jain CC, Borlaug BA. Performance and Interpretation of Invasive Hemodynamic Exercise Testing. Chest 2020; 158:2119-2129. [PMID: 32473950 DOI: 10.1016/j.chest.2020.05.552] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/15/2020] [Accepted: 05/22/2020] [Indexed: 01/06/2023] Open
Abstract
Exertional dyspnea is a common complaint for patients seen in pulmonary, cardiac, and general medicine clinics, and elucidating the cause is often challenging, particularly when physical examination, echocardiography, radiography, and pulmonary function test results are inconclusive. Invasive cardiopulmonary exercise testing has emerged as the gold standard test to define causes of dyspnea and exertional limitation in this population. In this review, we describe the methods for performing and interpreting invasive cardiopulmonary exercise testing, with particular attention to the hemodynamic and blood sampling data as they apply to patients being evaluated for heart failure and pulmonary hypertension.
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104
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Gui Y, Chen J, Hu J, Ouyang M, Deng L, Liu L, Sun K, Tang Y, Xiang Q, Xu J, Zhu L, Peng Z, Zou P, Li B, Zheng Z, Xu D. Efficacy and Safety of Inorganic Nitrate Versus Placebo Treatment in Heart Failure with Preserved Ejection Fraction. Cardiovasc Drugs Ther 2020; 34:503-513. [DOI: 10.1007/s10557-020-06980-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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105
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Borlaug BA. Evaluation and management of heart failure with preserved ejection fraction. Nat Rev Cardiol 2020; 17:559-573. [DOI: 10.1038/s41569-020-0363-2] [Citation(s) in RCA: 168] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2020] [Indexed: 01/19/2023]
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106
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Gaborit FS, Kistorp C, Kümler T, Hassager C, Tønder N, Iversen K, Kamstrup PR, Faber J, Køber L, Schou M. Early Stages of Obesity-related Heart Failure Are Associated with Natriuretic Peptide Deficiency and an Overall Lack of Neurohormonal Activation: The Copenhagen Heart Failure Risk Study. Glob Heart 2020; 15:25. [PMID: 32489798 PMCID: PMC7218759 DOI: 10.5334/gh.776] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 02/18/2020] [Indexed: 12/27/2022] Open
Abstract
Objective This study evaluated the associations between the natriuretic peptide activity and the neurohormonal response in non-obese and obese outpatients with and without heart failure (HF). Background Obesity-related HF may be a distinct subtype of HF. Obesity is associated with lower plasma concentrations of natriuretic peptides. The associations between obesity and neurohormonal activation estimated by mid-regional pro-adrenomedullin (MR-proADM) and copeptin in patients with HF is not elucidated. Methods This prospective cohort-study included 392 outpatients ≥60years, plus ≥1 risk-factor(-s) for HF (hypertension, ischemic heart disease, atrial fibrillation, diabetes, chronic kidney disease), and without known HF. Patients were categorized 'non-obese' BMI = 18.5-29.9 kg/m2 (n = 273) and 'obese' BMI ≥ 30 kg/m2 (n = 119). The diagnosis of HF required signs, symptoms, and abnormal echocardiography. NT-proBNP, MR-proANP, MR-proADM, and copeptin were analyzed. Results Obese patients were younger, had a higher prevalence of diabetes and chronic kidney disease, but a lower prevalence of atrial fibrillation. A total of 39 (14.3%) non-obese and 26 (21.8%) obese patients were diagnosed with HF. In obese patients, HF was not associated with higher plasma concentrations of NT-proBNP (Estimate: 0.063; 95%CI: -0.037-1.300; P = 0.064), MR-proANP (Estimate: 0.207; 95%CI: -0.101-0.515; P = 0.187), MR-proADM (Estimate: 0.112; 95%CI: -0.047-0.271; P = 0.168), or copeptin (Estimate: 0.093; 95%CI: -0.333-0.518; P = 0.669). Additionally, obese patients with HF had lower plasma concentrations of NT-proBNP (Estimate: -0.998; 95%CI: -1.778-0.218; P = 0.012), and MR-proANP (Estimate: -0.488; 95%CI: -0.845-0.132; P = 0.007) compared to non-obese patients with HF, whereas plasma concentrations of MR-proADM (Estimate: 0.066; 95%CI: -0.119-0.250; P = 0.484) and copeptin (Estimate: 0.140; 95%CI: -0.354-0.633; P = 0.578) were comparable. Conclusions Patients with obesity-related HF have natriuretic peptide deficiency and lack of increased plasma concentrations of MR-proADM and copeptin suggesting that patients with obesity-related HF have a blunted overall neurohormonal activity.
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Affiliation(s)
- Freja Stoltze Gaborit
- Department of Cardiology, Herlev Gentofte University Hospital, DK
- Faculty of Health and Medical Science, University of Copenhagen, DK
| | - Caroline Kistorp
- Department Endocrinology, Rigshospitalet, Copenhagen, DK
- Department of Clinical Medicine, University of Copenhagen, DK
| | - Thomas Kümler
- Department of Cardiology, Herlev Gentofte University Hospital, DK
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, Copenhagen, DK
- Department of Clinical Medicine, University of Copenhagen, DK
| | - Niels Tønder
- Department of Cardiology, North Zealand University Hospital, DK
| | - Kasper Iversen
- Department of Cardiology, Herlev Gentofte University Hospital, DK
- Department of Clinical Medicine, University of Copenhagen, DK
| | - Pia R. Kamstrup
- Department of Clinical Biochemistry, Herlev Gentofte University Hospital, DK
| | - Jens Faber
- Department Endocrinology, Rigshospitalet, Copenhagen, DK
- Department Endocrinology, Herlev Gentofte University Hospital, DK
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, DK
- Department of Clinical Medicine, University of Copenhagen, DK
| | - Morten Schou
- Department of Cardiology, Herlev Gentofte University Hospital, DK
- Department of Clinical Medicine, University of Copenhagen, DK
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107
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Zamani P, Proto EA, Mazurek JA, Prenner SB, Margulies KB, Townsend RR, Kelly DP, Arany Z, Poole DC, Wagner PD, Chirinos JA. Peripheral Determinants of Oxygen Utilization in Heart Failure With Preserved Ejection Fraction: Central Role of Adiposity. ACTA ACUST UNITED AC 2020; 5:211-225. [PMID: 32215346 PMCID: PMC7091498 DOI: 10.1016/j.jacbts.2020.01.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 12/27/2019] [Accepted: 01/02/2020] [Indexed: 01/04/2023]
Abstract
ΔAVo2 during exercise is a complex metric that incorporates into its calculation skeletal muscle blood flow and DmO2 across the skeletal muscle capillary membrane. Although ΔAVo2 was reduced in patients with HFpEF during both systemic and local (forearm) exercise, there was no difference in forearm DmO2 among subjects with HFpEF, those with hypertension, and healthy control subjects; therefore, abnormalities in forearm DmO2 cannot explain the reduced forearm ΔAVo2 seen in subjects with HFpEF. Local forearm exercise performance predicted about one-third of the variability in systemic aerobic capacity, demonstrating that peripheral factors are important in determining whole-body exercise tolerance. Degree of adiposity strongly correlated with ΔAVo2 during both local and whole-body exercise, suggesting that adipose tissue may play an active role in limiting exercise capacity in subjects with HFpEF.
The aim of this study was to determine the arteriovenous oxygen content difference (ΔAVo2) in adult subjects with and without heart failure with preserved ejection fraction (HFpEF) during systemic and forearm exercise. Subjects with HFpEF had reduced ΔAVo2. Forearm diffusional conductance for oxygen, a lumped conductance parameter that incorporates all impediments to the movement of oxygen from red blood cells in skeletal muscle capillaries into the mitochondria within myocytes, was estimated. Forearm diffusional conductance for oxygen was not different among adults with HFpEF, those with hypertension, and healthy control subjects; therefore, diffusional conductance cannot explain the reduced forearm ΔAVo2. Instead, adiposity was strongly associated with ΔAVo2, suggesting an active role for adipose tissue in reducing exercise capacity in patients with HFpEF.
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Key Words
- CO, cardiac output
- DEXA, dual-energy x-ray absorptiometry
- DmO2, skeletal muscle diffusional conductance for oxygen
- FIo2, fraction of inspired oxygen
- HFpEF
- HFpEF, heart failure with preserved ejection fraction
- MVC, maximal voluntary contraction force
- NT-proBNP, N-terminal pro–brain natriuretic peptide
- Po2, partial pressure of oxygen
- Vo2, oxygen consumption
- adiposity
- aerobic capacity
- exercise
- oxygen transport
- ΔAVo2, arteriovenous oxygen content difference
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Affiliation(s)
- Payman Zamani
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth A Proto
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy A Mazurek
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stuart B Prenner
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kenneth B Margulies
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raymond R Townsend
- Division of Nephrology/Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel P Kelly
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zoltan Arany
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David C Poole
- Departments of Kinesiology, Anatomy, and Physiology, Kansas State University, Manhattan, Kansas
| | - Peter D Wagner
- Division of Pulmonary Medicine, University of California-San Diego, San Diego, California
| | - Julio A Chirinos
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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108
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Reddy YN, Rikhi A, Obokata M, Shah SJ, Lewis GD, AbouEzzedine OF, Dunlay S, McNulty S, Chakraborty H, Stevenson LW, Redfield MM, Borlaug BA. Quality of life in heart failure with preserved ejection fraction: importance of obesity, functional capacity, and physical inactivity. Eur J Heart Fail 2020; 22:1009-1018. [DOI: 10.1002/ejhf.1788] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 12/12/2019] [Accepted: 12/14/2019] [Indexed: 12/28/2022] Open
Affiliation(s)
| | - Aruna Rikhi
- Division of CardiologyDuke University Durham NC USA
| | - Masaru Obokata
- Division of Cardiovascular DiseasesMayo Clinic Rochester MN USA
| | - Sanjiv J. Shah
- Division of CardiologyNorthwestern University Chicago IL USA
| | | | | | - Shannon Dunlay
- Division of Cardiovascular DiseasesMayo Clinic Rochester MN USA
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109
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Pieske B, Tschöpe C, de Boer RA, Fraser AG, Anker SD, Donal E, Edelmann F, Fu M, Guazzi M, Lam CSP, Lancellotti P, Melenovsky V, Morris DA, Nagel E, Pieske-Kraigher E, Ponikowski P, Solomon SD, Vasan RS, Rutten FH, Voors AA, Ruschitzka F, Paulus WJ, Seferovic P, Filippatos G. How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2020; 22:391-412. [PMID: 32133741 DOI: 10.1002/ejhf.1741] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 10/30/2018] [Accepted: 08/26/2019] [Indexed: 12/11/2022] Open
Abstract
Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for heart failure symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular (LV) ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), LV filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1 : Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2 : Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.
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Affiliation(s)
- Burkert Pieske
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany.,Department of Internal Medicine and Cardiology, German Heart Institute, Berlin, Germany.,Berlin Institute of Health (BIH), Germany
| | - Carsten Tschöpe
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany.,Berlin Institute of Health (BIH) Center for Regenerative Therapies (BCRT), Charite, Berlin, Germany
| | - Rudolf A de Boer
- University Medical Centre Groningen, University of Groningen, Department of Cardiology, Groningen, the Netherlands
| | | | - Stefan D Anker
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany.,Berlin Institute of Health (BIH) Center for Regenerative Therapies (BCRT), Charite, Berlin, Germany.,Department of Cardiology and Pneumology, University Medicine Göttingen (UMG), Germany
| | - Erwan Donal
- Cardiology and CIC, IT1414, CHU de Rennes LTSI, Université Rennes-1, INSERM 1099, Rennes, France
| | - Frank Edelmann
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany
| | - Michael Fu
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hosptal/Ostra, Göteborg, Sweden
| | - Marco Guazzi
- Department of Biomedical Sciences for Health, University of Milan, IRCCS, Milan, Italy.,Department of Cardiology, IRCCS Policlinico, San Donato Milanese, Milan, Italy
| | - Carolyn S P Lam
- National Heart Centre, Singapore & Duke-National University of Singapore.,University Medical Centre Groningen, The Netherlands
| | - Patrizio Lancellotti
- Department of Cardiology, Heart Valve Clinic, University of Liège Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Liège, Belgium
| | - Vojtech Melenovsky
- Institute for Clinical and Experimental Medicine - IKEM, Prague, Czech Republic
| | - Daniel A Morris
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum
| | - Eike Nagel
- Institute for Experimental and Translational Cardiovascular Imaging, University Hospital Frankfurt.,German Centre for Cardiovascular Research (DZHK), Partner Site Frankfurt, Germany
| | - Elisabeth Pieske-Kraigher
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ramachandran S Vasan
- Section of Preventive Medicine and Epidemiology and Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Adriaan A Voors
- University Medical Centre Groningen, University of Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Frank Ruschitzka
- University Heart Centre, University Hospital Zurich, Switzerland
| | - Walter J Paulus
- Department of Physiology and Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, The Netherlands
| | - Petar Seferovic
- University of Belgrade School of Medicine, Belgrade University Medical Center, Serbia
| | - Gerasimos Filippatos
- Department of Cardiology, National and Kapodistrian University of Athens Medical School; University Hospital "Attikon", Athens, Greece.,University of Cyprus, School of Medicine, Nicosia, Cyprus
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110
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Tang WHW, Wilcox JD, Jacob MS, Rosenzweig EB, Borlaug BA, Frantz RP, Hassoun PM, Hemnes AR, Hill NS, Horn EM, Singh HS, Systrom DM, Tedford RJ, Vanderpool RR, Waxman AB, Xiao L, Leopold JA, Rischard FP. Comprehensive Diagnostic Evaluation of Cardiovascular Physiology in Patients With Pulmonary Vascular Disease: Insights From the PVDOMICS Program. Circ Heart Fail 2020; 13:e006363. [PMID: 32088984 DOI: 10.1161/circheartfailure.119.006363] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Invasive hemodynamic evaluation through right heart catheterization plays an essential role in the diagnosis, categorization, and risk stratification of patients with pulmonary hypertension. METHODS Subjects enrolled in the PVDOMICS (Redefining Pulmonary Hypertension through Pulmonary Vascular Disease Phenomics) program undergo an extensive invasive hemodynamic evaluation that includes repeated measurements at rest and during several provocative physiological challenges. It is a National Institutes of Health/National Heart, Lung, and Blood Institute initiative to reclassify pulmonary hypertension groups based on clustered phenotypic and phenomic characteristics. At a subset of centers, participants also undergo an invasive cardiopulmonary exercise test to assess changes in hemodynamics and gas exchange during exercise. CONCLUSIONS When coupled with other physiological testing and blood -omic analyses involved in the PVDOMICS study, the comprehensive right heart catheterization protocol described here holds promise to clarify the diagnosis and clustering of pulmonary hypertension patients into cohorts beyond the traditional 5 World Symposium on Pulmonary Hypertension groups. This article will describe the methods applied for invasive hemodynamic characterization in the PVDOMICS program. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02980887.
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Affiliation(s)
- W H Wilson Tang
- Division of Heart Failure & Transplant Medicine, Department of Cardiovascular Medicine (W.H.W.T., M.S.J.), Cleveland Clinic, Cleveland, OH.,Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute (W.H.W.T., J.D.W.), Cleveland Clinic, Cleveland, OH
| | - Jennifer D Wilcox
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute (W.H.W.T., J.D.W.), Cleveland Clinic, Cleveland, OH
| | - Miriam S Jacob
- Division of Heart Failure & Transplant Medicine, Department of Cardiovascular Medicine (W.H.W.T., M.S.J.), Cleveland Clinic, Cleveland, OH
| | - Erika B Rosenzweig
- Division of Pediatric Cardiology, Department of Pediatrics and Medicine, Columbia University Medical Center, New York, NY (E.B.R.)
| | - Barry A Borlaug
- Division of Circulatory Failure, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (B.A.B., R.P.F.)
| | - Robert P Frantz
- Division of Circulatory Failure, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (B.A.B., R.P.F.)
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD (P.M.H.)
| | - Anna R Hemnes
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (A.R.H.)
| | - Nicholas S Hill
- Department of Pulmonary, Critical Care and Sleep Medicine, Tufts University Medical Center, Boston MA (N.S.H.)
| | - Evelyn M Horn
- Division of Cardiology, Department of Medicine, Cornell University Medical Center, New York, NY (E.M.H., H.S.S.)
| | - Harsimran S Singh
- Division of Cardiology, Department of Medicine, Cornell University Medical Center, New York, NY (E.M.H., H.S.S.)
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA (D.M.S., A.B.W.)
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (R.J.T.)
| | - Rebecca R Vanderpool
- Division of Translational and Regenerative Medicine, (R.R.V.).,University of Arizona College of Medicine, Tucson, AZ (R.R.V.)
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA (D.M.S., A.B.W.)
| | - Lei Xiao
- National Heart, Lung and Blood Institute, Bethesda MD (L.X.)
| | - Jane A Leopold
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston MA (J.A.L.)
| | - Franz P Rischard
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine (F.P.R.)
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111
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Jain CC, Borlaug BA. Hemodynamic assessment in heart failure. Catheter Cardiovasc Interv 2020; 95:420-428. [PMID: 31507065 DOI: 10.1002/ccd.28490] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 08/25/2019] [Indexed: 12/28/2022]
Abstract
Hemodynamics play a central role in the pathophysiology of heart failure (HF), yet their proper assessment and optimization remains challenging. Heart failure is defined as the inability of the heart to deliver adequate perfusion (cardiac output) to the body at rest or exercise, or to require an elevation in cardiac filling pressures in order to do this. This bedrock definition is important because it relies on measurable quantities (filling pressures and output) that are readily assessed in the cardiac catheterization laboratory. Here we present three cases to illustrate how better understanding of the determinants of cardiac output and stroke volume: preload, afterload, contractility, and lusitropy, as well as the determinants of congestion (high filling pressures) may be used to guide optimization of hemodynamic status. The goal is that the readers will be able to think more critically when evaluating the hemodynamics of their patient in HF and recognize the complex interplay that determines the complex balance between cardiac ejection and filling capabilities, and how this alters symptoms and outcomes for patients with HF. KEY POINTS: Careful assessment of hemodynamics in the catheterization laboratory allows for actionable insight to a patient's volume status, cardiac function and can help prognosticate outcomes. Exercise hemodynamics in heart failure is a powerful tool to better understand the cause of symptoms and predict outcomes. Clinicians should aim to decrease biventricular filling pressures to normal values to improve morbidity and reduce risk for readmission. In patients with heart failure and reduced ejection fraction, clinicians should aim to decrease afterload as much as can be tolerated by the renal function and patient's symptoms. Low cardiac output can often be improved by optimizing preload and afterload rather than initiating inotropes, which should be reserved until needed. In advanced heart failure, the right heart function becomes a key determinant of symptoms and outcomes.
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Affiliation(s)
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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112
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Pugliese NR, Mazzola M, Fabiani I, Gargani L, De Biase N, Pedrinelli R, Natali A, Dini FL. Haemodynamic and metabolic phenotyping of hypertensive patients with and without heart failure by combining cardiopulmonary and echocardiographic stress test. Eur J Heart Fail 2020; 22:458-468. [PMID: 31950651 DOI: 10.1002/ejhf.1739] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/02/2019] [Accepted: 12/09/2019] [Indexed: 12/14/2022] Open
Abstract
AIM We combined cardiopulmonary exercise test (CPET) and exercise stress echocardiography (ESE) to identify early haemodynamic and metabolic alterations in patients with hypertension (HT) with and without heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS Fifty stable HFpEF-HT outpatients (mean age 68 ± 14 years) on optimal medical therapy, 63 well-controlled HT subjects (mean age 63 ± 11 years) and 32 age and sex-matched healthy controls (mean age 59 ± 15 years) underwent a symptom-limited graded ramp bicycle CPET-ESE. The acquisition protocol included left ventricular cardiac output, global longitudinal strain, E/e', peak oxygen consumption (VO2 ), non-invasive arterial-venous oxygen content difference (AVO2 diff) and lung ultrasound B-lines. There was a decline in peak VO2 from controls (24.4 ± 3 mL/min/kg) to HFpEF-HT (15.2 ± 2 mL/min/kg), passing through HT (18.7 ± 2 mL/min/kg; P < 0.0001). HFpEF-HT displayed a lower peak cardiac output (9.8 ± 0.9 L/min) compared to HT (12.6 ± 1.0 L/min; P = 0.02) and controls (13.3 ± 1.0 L/min; P = 0.01). Peak AVO2 diff was reduced in HFpEF-HT and HT (13.3 ± 2 and 13.5 ± 2 mL/dL vs. controls: 16.9 ± 2 mL/dL; P < 0.0001). A different left ventricular contractility was observed among groups, expressed as low-load global longitudinal strain (-16.8 ± 5% in HFpEF-HT, -18.2 ± 3% in HT, and 20.9 ± 3% in controls; P < 0.0001), and distribution of E/e' and B-lines [HFpEF-HT: 13.7 ± 3 and 16, interquartile range (IQR) 10-22; HT: 9.5 ± 2 and 8, IQR 4-10; controls: 6.2 ± 2 and 0, IQR 0-2; P < 0.0001]. CONCLUSIONS Reduced peak VO2 values in HT with and without HFpEF may be the result of decreased AVO2 diff. CPET-ESE can also identify mild signs of left ventricular systo-diastolic dysfunction and pulmonary congestion, promoting advances in personalized therapy.
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Affiliation(s)
- Nicola R Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Matteo Mazzola
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Iacopo Fabiani
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Luna Gargani
- Institute of Clinical Physiology - CNR, Pisa, Italy
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Roberto Pedrinelli
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Andrea Natali
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Frank L Dini
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy
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113
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HUANG CHENYU, LEE JENKUANG, CHEN ZHENGWEI, CHENG JENFANG, CHEN SSUYUAN, LIN LIANYU, WU CHOKAI. Inhaled Prostacyclin on Exercise Echocardiographic Cardiac Function in Preserved Ejection Fraction Heart Failure. Med Sci Sports Exerc 2020; 52:269-277. [DOI: 10.1249/mss.0000000000002145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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114
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Obokata M, Reddy YNV, Borlaug BA. Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction: Understanding Mechanisms by Using Noninvasive Methods. JACC Cardiovasc Imaging 2020; 13:245-257. [PMID: 31202759 PMCID: PMC6899218 DOI: 10.1016/j.jcmg.2018.12.034] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 12/16/2022]
Abstract
Research in the last decade has substantially advanced our understanding of the pathophysiology of heart failure with preserved ejection fraction (HFpEF). However, treatment options remain limited as clinical trials have largely failed to identify effective therapies. Part of this failure may be related to mechanistic heterogeneity. It is speculated that categorizing HFpEF patients based upon underlying pathophysiological phenotypes may represent the key next step in delivering the right therapies to the right patients. Echocardiography may provide valuable insight into both the pathophysiology and underlying phenotypes in HFpEF. Echocardiography also plays a key role in the evaluation of patients with unexplained dyspnea, where HFpEF is suspected but the diagnosis remains unknown. The combination of the E/e' ratio and right ventricular systolic pressure has recently been shown to add independent value to the diagnostic evaluation of patients suspected of having HFpEF. Finally, echocardiography enables identification of the different causes that mimic HFpEF but are treated differently, such as valvular heart disease, pericardial constriction, and high-output heart failure or infiltrative myopathies such as cardiac amyloid. This review summarizes the current understanding of the pathophysiology and phenotyping of HFpEF with particular attention to the role of echocardiography in this context.
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Affiliation(s)
- Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota.
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115
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Chen ZW, Huang CY, Cheng JF, Chen SY, Lin LY, Wu CK. Stress Echocardiography-Derived E/e' Predicts Abnormal Exercise Hemodynamics in Heart Failure With Preserved Ejection Fraction. Front Physiol 2019; 10:1470. [PMID: 31849715 PMCID: PMC6901703 DOI: 10.3389/fphys.2019.01470] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 11/14/2019] [Indexed: 12/18/2022] Open
Abstract
Background The correlation between echocardiographic parameters and hemodynamics data in patients with heart failure with preserved ejection fraction (HFpEF) is unclear. It is important to find a non-invasive echocardiographic parameter for predicting exercise pulmonary capillary wedge pressure (PCWP). Aim This study sought to determine the correlation between echocardiographic parameters and hemodynamics data at rest and during exercise in HFpEF patients. Methods and Results This study was a cross-sectional cohort exploratory analysis of baseline data from the ILO-HOPE trial. A total of 34 HFpEF patients were enrolled. The average age was 70 ± 12 years, and most (74%) were women. The patients underwent invasive cardiac catheterization and expired gas analysis at rest and during exercise. Echocardiography including tissue Doppler imaging was performed, and global longitudinal strain and other novel diastolic function indexes were analyzed at rest and during exercise. At rest, no significant correlation was noted between resting PCWP and echocardiographic parameters. However, a significant correlation was observed between post-exercise PCWP and stress E/e′ (septal, lateral, and mean) ratio (p = 0.003, 0.031, 0.012). Moreover, post-exercise ΔPCWP showed a good correlation with stress E/e′ (septal, lateral, and mean; all p ≤ 0.001) and global longitudinal strain (GLS) during exercise (p = 0.03). After multivariate regression analysis with adjustment for possible confounding factors including age and sex, there was still a significant correlation between post-exercise ΔPCWP and E/e′ (r = 0.62, p < 0.001 for E/e′mean). Conclusion Only stress echocardiography derived tissue Doppler E/e′ ratio is closely correlated with abnormal exercise hemodynamics (PCWP and post-exercise ΔPCWP) in HFpEF. This echocardiographic marker is substantially more sensitive than other novel echocardiographic parameters during exercise, and may have significant diagnostic utility for ambulatory HFpEF patients with dyspnea. Clinical Trial Registration https://www.clinicaltrials.gov, identifier NCT03620526.
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Affiliation(s)
- Zheng-Wei Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Yun-Lin Branch, Yun-Lin, Taiwan
| | - Chen-Yu Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan
| | - Jen-Fang Cheng
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, Pingtung Hospital, Pingtung, Taiwan
| | - Ssu-Yuan Chen
- Department of Physical Medicine and Rehabilitation, Fu Jen Catholic University Hospital and Fu Jen Catholic University School of Medicine, New Taipei City, Taiwan.,Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Cho-Kai Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.,Cardiovascular Institute, Stanford University, Stanford, CA, United States
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116
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Reddy YNV, Obokata M, Koepp KE, Egbe AC, Wiley B, Borlaug BA. The β-Adrenergic Agonist Albuterol Improves Pulmonary Vascular Reserve in Heart Failure With Preserved Ejection Fraction. Circ Res 2019; 124:306-314. [PMID: 30582447 DOI: 10.1161/circresaha.118.313832] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
RATIONALE Pulmonary vascular resistance fails to decrease appropriately during exercise in patients with heart failure with preserved ejection fraction (HFpEF). Interventions that enhance pulmonary vasodilation might be beneficial in this cohort but could also worsen left atrial hypertension, exacerbating lung congestion. Intravenous β-agonists reduce pulmonary vascular resistance but are not suitable for chronic use. OBJECTIVE We hypothesized that the inhaled β-adrenergic agonist albuterol would improve pulmonary vasodilation during exercise in patients with HFpEF, without increasing left heart filling pressures. METHODS AND RESULTS We performed a randomized, double-blind, placebo-controlled trial testing the effects of inhaled albuterol on resting and exercise hemodynamics in subjects with HFpEF using high-fidelity micromanometer catheters and expired gas analysis. The primary end point was pulmonary vascular resistance during exercise. Subjects with HFpEF (n=30) underwent resting and exercise hemodynamic assessment and were then randomized 1:1 to inhaled, nebulized albuterol or placebo. Rest and exercise hemodynamic testing was then repeated. Albuterol improved the primary end point of exercise pulmonary vascular resistance as compared with placebo (-0.6±0.5 versus +0.1±0.7 WU; P=0.003). Albuterol enhanced cardiac output reserve and right ventricular pulmonary artery coupling, reduced right atrial and pulmonary artery pressures, improved pulmonary artery compliance, and enhanced left ventricular transmural distending pressure (all P <0.01), with no increase in pulmonary capillary hydrostatic pressures. CONCLUSIONS Albuterol improves pulmonary vascular reserve in patients with HFpEF without worsening left heart congestion. Further study is warranted to evaluate the chronic efficacy of β-agonists in HFpEF and other forms of pulmonary hypertension. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov . Unique identifier: NCT02885636.
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Affiliation(s)
- Yogesh N V Reddy
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Masaru Obokata
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Katlyn E Koepp
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Alexander C Egbe
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Brandon Wiley
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Barry A Borlaug
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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117
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Takahari K, Hidaka T, Ueda Y, Izumi K, Harada Y, Susawa H, Kinoshita M, Itakura K, Utsunomiya H, Kihara Y. H 2FPEF Score for the Prediction of Exercise Intolerance and Abnormal Hemodynamics in Japanese - Evaluation by Exercise Stress Echocardiography Combined With Cardiopulmonary Exercise Testing. Circ J 2019; 83:2487-2493. [PMID: 31708523 DOI: 10.1253/circj.cj-19-0699] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Both the H2FPEF-score and nomogram-score, which consist of simple clinical parameters, can assist in diagnosing "early" heart failure with preserved ejection fraction (HFpEF) and only exertional dyspnea, but their these usefulness in Japanese remains unclear. We sought to investigate the correlation between these scores and exercise response, including the peak oxygen uptake (V̇O2), the pulmonary artery systolic pressure (PASP), the ratio of early diastolic transmitral flow velocity to early diastolic mitral annular velocity (E/e') and stroke volume (SV) using exercise stress echocardiography (ESE) combined with cardiopulmonary exercise testing (CPET).Methods and Results:In this single-center, retrospective cross-sectional study the H2FPEF-score and nomogram-score were calculated in a total of 139 patients who underwent ESE combined with CPET. The scores correlated with peak V̇O2(r=-0.48, r=-0.44), PASP (r=0.23, r=0.29) and SV (r=-0.32, r=-0.19) at peak exercise. The nomogram-score correlated with E/e' (r=0.24). The prevalence of exercise intolerance (percent predicted peak V̇O2<75% and <50%) increased as the H2FPEF-score increased and reached 88.9% and 22.2% among the patients with high H2FPEF-score (6-9 points). CONCLUSIONS The H2FPEF-score may be useful as the initial step to diagnosing 'early' HFpEF. The nomogram-score may be more useful in Japanese because of its more universal association with exercise response than the H2FPEF-score.
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Affiliation(s)
- Kosuke Takahari
- Shobara-city Soryo Clinic.,Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Takayuki Hidaka
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Yusuke Ueda
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kanako Izumi
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Yu Harada
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Hitoshi Susawa
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Mirai Kinoshita
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences.,Department of Cardiovascular Medicine, Shobara Red Cross Hospital
| | - Kiho Itakura
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Hiroto Utsunomiya
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
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118
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Borlaug BA, Schaff HV, Pochettino A, Pedrotty DM, Asirvatham SJ, Abel MD, Carter RE, Mauermann WJ. Pericardiotomy Enhances Left Ventricular Diastolic Reserve With Volume Loading in Humans. Circulation 2019; 138:2295-2297. [PMID: 30571519 DOI: 10.1161/circulationaha.118.036006] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Barry A Borlaug
- Departments of Cardiovascular Medicine (B.A.B., D.M.P., S.J.A.), Mayo Clinic, Rochester, MN
| | | | | | - Dawn M Pedrotty
- Departments of Cardiovascular Medicine (B.A.B., D.M.P., S.J.A.), Mayo Clinic, Rochester, MN
| | - Samuel J Asirvatham
- Departments of Cardiovascular Medicine (B.A.B., D.M.P., S.J.A.), Mayo Clinic, Rochester, MN
| | - Martin D Abel
- Anesthesiology (M.D.A., W.J.M.), Mayo Clinic, Rochester, MN
| | - Rickey E Carter
- Health Sciences Research (R.E.C.), Mayo Clinic, Rochester, MN
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119
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Caravita S, Yerly P, Baratto C, Dewachter C, Faini A, Rimouche A, Branzi G, Perego GB, Bondue A, Parati G, Vachiéry JL. Noninvasive versus invasive pressure–flow relationship of the pulmonary circulation: bias and error. Eur Respir J 2019; 54:13993003.00881-2019. [DOI: 10.1183/13993003.00881-2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 08/12/2019] [Indexed: 11/05/2022]
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120
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Hemodynamic Effects of Weight Loss in Obesity: A Systematic Review and Meta-Analysis. JACC-HEART FAILURE 2019; 7:678-687. [PMID: 31302042 DOI: 10.1016/j.jchf.2019.04.019] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 04/25/2019] [Accepted: 04/25/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVES The authors aimed to explore whether weight loss may improve central hemodynamics in obesity. BACKGROUND Hemodynamic abnormalities in obese heart failure with preserved ejection fraction patients are correlated with the amount of excess body mass, suggesting a possible causal relationship. METHODS Relevant databases were systematically searched from inception to May 2018, without language restriction. Studies reporting invasive hemodynamic measures before and following therapeutic weight loss interventions in patients with obesity but no clinically overt heart failure were extracted. RESULTS A total of 9 studies were identified, providing data for 110 patients. Six studies tested dietary intervention and 3 studies tested bariatric surgery. Over a median duration of 9.7 months (range 0.75 to 23.0 months), a median weight loss of 43 kg (range 10 to 58 kg) was associated with significant reductions in heart rate (-9 beats/min, 95% confidence interval [CI]: -12 to -6; p < 0.001), mean arterial pressure (-7 mm Hg, 95% CI: -11 to -3; p < 0.001), and resting oxygen consumption (-85 ml/min, 95% CI: -111 to -60; p < 0.001). Central cardiac hemodynamics improved, manifested by reductions in pulmonary capillary wedge pressure (-3 mm Hg, 95% CI: -5 to -1; p < 0.001) and mean pulmonary artery pressure (-5 mm Hg, 95% CI: -8 to -2; p = 0.001). Exercise hemodynamics were assessed in a subset of patients (n = 49) in which there was significant reduction in exercise pulmonary artery pressure (p = 0.02). CONCLUSIONS Therapeutic weight loss in obese patients without HF is associated with favorable hemodynamic effects. Randomized controlled trials evaluating strategies for weight loss in obese patients with heart failure such as the obese phenotype of heart failure with preserved ejection fraction are needed.
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121
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Abstract
Approximately half of the patients with signs and symptoms of heart failure have a left ventricular ejection fraction that is not markedly abnormal. Despite the historically initial surprise, heightened risks for heart failure specific major adverse events occur across the broad range of ejection fraction, including normal. The recognition of the magnitude of the problem of heart failure with preserved ejection fraction in the past 20 years has spurred an explosion of clinical investigation and growing intensity of informative outcome trials. This article addresses the historic development of this component of the heart failure syndrome, including the epidemiology, pathophysiology, and existing and planned therapeutic studies. Looking forward, more specific phenotyping and even genotyping of subpopulations should lead to improvements in outcomes from future trials.
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Affiliation(s)
- Marc A. Pfeffer
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amil M. Shah
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Barry A. Borlaug
- Cardiovascular Medicine Division, Mayo Clinic, Rochester, Minnesota
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122
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Levine AR, Simon MA, Gladwin MT. Pulmonary vascular disease in the setting of heart failure with preserved ejection fraction. Trends Cardiovasc Med 2019; 29:207-217. [PMID: 30177249 PMCID: PMC6378124 DOI: 10.1016/j.tcm.2018.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 12/12/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is defined as clinical features of heart failure, ideally with biomarker evidence such as elevated plasma natriuretic peptide levels, in the setting of an ejection fraction (EF) greater than 50% and imaging evidence of diastolic left ventricular dysfunction [1,2]. In the absence of cardiac imaging or invasive hemodynamics, this is a clinical syndrome that is often indistinguishable from heart failure with reduced ejection fraction (HFrEF). HFpEF and HFrEF present with a cadre of comparable signs and symptoms including jugular venous distention, pulmonary rales on auscultation, breathlessness, orthopnea, exercise intolerance, exertional dyspnea, fatigue and peripheral edema. HFpEF accounts for at least half of all diagnoses of heart failure [1,2]. Pulmonary hypertension (PH) is a common complication of HFpEF that is linked to worse disease morbidity and mortality. In fact, mortality has been linked to increases in the intrinsic pulmonary vascular resistance in the setting of increased left ventricular end diastolic pressure, characterized hemodynamically by rises in the transpulmonary pressure gradient, pulmonary vascular resistance or diastolic pressure gradient. Despite being the most common form of PH, there are no approved therapies for the treatment of PH secondary to HFpEF. This review will summarize the hemodynamic classifications of PH in the setting of HFpEF, mechanisms of disease, the potential contribution of pulmonary vascular disease to poor outcomes in patients with HFpEF, and new approaches to therapy.
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Affiliation(s)
- Andrea R Levine
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, United States; Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Marc A Simon
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, United States; University of Pittsburgh Medical Center Heart and Vascular Institute Pittsburgh, Pittsburgh, PA 15213, United States; University of Pittsburgh Department of Bioengineering Pittsburgh, Pittsburgh, PA 15213, United States
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, United States; Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, United States.
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123
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Stokes MB, Sanders P. Does Left Ventricular Systolic Function Matter? Treating Atrial Fibrillation in HFrEF Versus HFpEF. Cardiol Clin 2019; 37:157-166. [PMID: 30926017 DOI: 10.1016/j.ccl.2019.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Atrial fibrillation (AF) and heart failure (HF) pose international health care challenges that contribute significantly to hospitalizations, morbidity, mortality, and significant health care costs. Both AF and HF contribute to the development of each other and both are associated with a worsened prognosis when they occur together. Assessment of systolic function via transthoracic echocardiography is essential in the investigation of the AF patient. Clinical and echocardiographic assessment may classify AF patients with HF into HF with reduced ejection fraction (HF-rEF) and HF with preserved ejection fraction (HF-pEF). Such classification can assist in numerous important management decisions in AF.
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Affiliation(s)
- Michael B Stokes
- Department of Cardiology, South Australian Health and Medical Research Institute, University of Adelaide, Royal Adelaide Hospital, Port Road, Adelaide, South Australia 5000, Australia
| | - Prashanthan Sanders
- Department of Cardiology, Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide, Royal Adelaide Hospital, Port Road, Adelaide, South Australia 5000, Australia.
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124
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Smith JR, Borlaug BA, Olson TP. Exercise Ventilatory Efficiency in Older and Younger Heart Failure Patients With Preserved Ejection Fraction. J Card Fail 2019; 25:278-285. [PMID: 30822511 DOI: 10.1016/j.cardfail.2019.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 01/31/2019] [Accepted: 02/20/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with heart failure with preserved ejection fraction (HFpEF) exhibit pulmonary abnormalities, but the studies to date have reported wide variability in the ventilatory equivalent for carbon dioxide (V̇E/V̇CO2) slope. It is possible that aging may contribute to that variability. We sought to compare ventilatory efficiency and its components in older and younger HFpEF patients during exercise. METHODS AND RESULTS Eighteen older (O; 80 ± 4 y) and 19 younger (Y; 59 ± 7 y) HFpEF patients performed cardiopulmonary exercise testing to volitional fatigue. Measurements of arterial blood gases were used to derive VD/VT, dead space ventilation, and alveolar ventilation. V̇E/V̇CO2 slope was greater in older compared with younger HFpEF patients (O 36 ± 7vs Y 31 ± 7; P = .04). At peak exercise, older HFpEF exhibited greater VD/VT compared with younger HFpEF (O 0.37 ± 0.10vs Y 0.28 ± 0.10; P < .01), whereas PaCO2 was not different between groups (P = .58). V̇E and alveolar ventilation were similar (P > .23), but dead space ventilation was greater in older compared with younger HFpEF at peak exercise (P = .04). CONCLUSIONS Older HFpEF patients exhibit greater ventilatory inefficiency resulting from elevated physiologic dead space during peak exercise compared with younger HFpEF patients. These results suggest that aging can worsen the pathophysiologic mechanisms underlying ventilatory efficiency during exercise in HFpEF.
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Affiliation(s)
- Joshua R Smith
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota.
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
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Obokata M, Reddy YNV, Borlaug BA. The Role of Echocardiography in Heart Failure with Preserved Ejection Fraction: What Do We Want from Imaging? Heart Fail Clin 2019; 15:241-256. [PMID: 30832815 DOI: 10.1016/j.hfc.2018.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Noninvasive imaging, particularly echocardiography, plays a central role in the evaluation for heart failure with preserved ejection fraction (HFpEF). Echocardiography helps to rule in HFpEF among patients with unexplained dyspnea when the diagnosis is uncertain. In established HFpEF, echocardiography provides important insights into pathophysiology and phenotyping, such as isolated left ventricular diastolic dysfunction, left atrial dysfunction, abnormal right ventricular-pulmonary artery coupling, ischemia, or obesity phenotypes. In addition, imaging enables risk stratification for HFpEF. This article provides a critical appraisal of the role of echocardiography in the diagnosis and evaluation of HFpEF.
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Affiliation(s)
- Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street Southwest, Rochester, MN 55906, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street Southwest, Rochester, MN 55906, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street Southwest, Rochester, MN 55906, USA.
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Lai YC, Wang L, Gladwin MT. Insights into the pulmonary vascular complications of heart failure with preserved ejection fraction. J Physiol 2018; 597:1143-1156. [PMID: 30549058 DOI: 10.1113/jp275858] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 11/19/2018] [Indexed: 12/21/2022] Open
Abstract
Pulmonary hypertension in the setting of heart failure with preserved ejection fraction (PH-HFpEF) is a growing public health problem that is increasing in prevalence. While PH-HFpEF is defined by a high mean pulmonary artery pressure, high left ventricular end-diastolic pressure and a normal ejection fraction, some HFpEF patients develop PH in the presence of pulmonary vascular remodelling with a high transpulmonary pressure gradient or pulmonary vascular resistance. Ageing, increased left atrial pressure and stiffness, mitral regurgitation, as well as features of metabolic syndrome, which include obesity, diabetes and hypertension, are recognized as risk factors for PH-HFpEF. Qualitative studies have documented that patients with PH-HFpEF develop more severe symptoms than those with HFpEF and are associated with more significant exercise intolerance, frequent hospitalizations, right heart failure and reduced survival. Currently, there are no effective therapies for PH-HFpEF, although a number of candidate drugs are being evaluated, including soluble guanylate cyclase stimulators, phosphodiesterase type 5 inhibitors, sodium nitrite and endothelin receptor antagonists. In this review we attempt to provide an updated overview of recent findings pertaining to the pulmonary vascular complications in HFpEF in terms of clinical definitions, epidemiology and pathophysiology. Mechanisms leading to pulmonary vascular remodelling in HFpEF, a summary of pre-clinical models of HFpEF and PH-HFpEF, and new candidate therapeutic strategies for the treatment of PH-HFpEF are summarized.
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Affiliation(s)
- Yen-Chun Lai
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Longfei Wang
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA.,The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Borlaug BA, Anstrom KJ, Lewis GD, Shah SJ, Levine JA, Koepp GA, Givertz MM, Felker GM, LeWinter MM, Mann DL, Margulies KB, Smith AL, Tang WHW, Whellan DJ, Chen HH, Davila-Roman VG, McNulty S, Desvigne-Nickens P, Hernandez AF, Braunwald E, Redfield MM. Effect of Inorganic Nitrite vs Placebo on Exercise Capacity Among Patients With Heart Failure With Preserved Ejection Fraction: The INDIE-HFpEF Randomized Clinical Trial. JAMA 2018; 320:1764-1773. [PMID: 30398602 PMCID: PMC6248105 DOI: 10.1001/jama.2018.14852] [Citation(s) in RCA: 181] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE There are few effective treatments for heart failure with preserved ejection fraction (HFpEF). Short-term administration of inorganic nitrite or nitrate preparations has been shown to enhance nitric oxide signaling, which may improve aerobic capacity in HFpEF. OBJECTIVE To determine the effect of 4 weeks' administration of inhaled, nebulized inorganic nitrite on exercise capacity in HFpEF. DESIGN, SETTING, AND PARTICIPANTS Multicenter, double-blind, placebo-controlled, 2-treatment, crossover trial of 105 patients with HFpEF. Participants were enrolled from July 22, 2016, to September 12, 2017, at 17 US sites, with final date of follow-up of January 2, 2018. INTERVENTIONS Inorganic nitrite or placebo administered via micronebulizer device. During each 6-week phase of the crossover study, participants received no study drug for 2 weeks (baseline/washout) followed by study drug (nitrite or placebo) at 46 mg 3 times a day for 1 week followed by 80 mg 3 times a day for 3 weeks. MAIN OUTCOMES AND MEASURES The primary end point was peak oxygen consumption (mL/kg/min). Secondary end points included daily activity levels assessed by accelerometry, health status as assessed by the Kansas City Cardiomyopathy Questionnaire (score range, 0-100, with higher scores reflecting better quality of life), functional class, cardiac filling pressures assessed by echocardiography, N-terminal fragment of the prohormone brain natriuretic peptide levels, other exercise indices, adverse events, and tolerability. Outcomes were assessed after treatment for 4 weeks. RESULTS Among 105 patients who were randomized (median age, 68 years; 56% women), 98 (93%) completed the trial. During the nitrite phase, there was no significant difference in mean peak oxygen consumption as compared with the placebo phase (13.5 vs 13.7 mL/kg/min; difference, -0.20 [95% CI, -0.56 to 0.16]; P = .27). There were no significant between-treatment phase differences in daily activity levels (5497 vs 5503 accelerometry units; difference, -15 [95% CI, -264 to 234]; P = .91), Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (62.6 vs 61.9; difference, 1.1 [95% CI, -1.4 to 3.5]; P = .39), functional class (2.5 vs 2.5; difference, 0.1 [95% CI, -0.1 to 0.2]; P = .43), echocardiographic E/e' ratio (16.4 vs 16.6; difference, 0.1 [95% CI, -1.2 to 1.3]; P = .93), or N-terminal fragment of the prohormone brain natriuretic peptide levels (520 vs 533 pg/mL; difference, 11 [95% CI, -53 to 75]; P = .74). Worsening heart failure occurred in 3 participants (2.9%) during the nitrite phase and 8 (7.6%) during the placebo phase. CONCLUSIONS AND RELEVANCE Among patients with HFpEF, administration of inhaled inorganic nitrite for 4 weeks, compared with placebo, did not result in significant improvement in exercise capacity. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02742129.
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Affiliation(s)
| | - Kevin J. Anstrom
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Sanjiv J. Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Michael M. Givertz
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - G. Michael Felker
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Andrew L. Smith
- Emory School of Medicine, Emory University, Atlanta, Georgia
| | | | - David J. Whellan
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | | | - Steven McNulty
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Eugene Braunwald
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Obokata M, Borlaug BA. The strengths and limitations of E/e' in heart failure with preserved ejection fraction. Eur J Heart Fail 2018; 20:1312-1314. [PMID: 29932475 DOI: 10.1002/ejhf.1250] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, USA
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Affiliation(s)
- Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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