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Rao VN, Cyr DD, Wruck LM, Sanders G, Hofmann P, Rössig L, Siedentop H, Evers T, Meyer M, Paraschin K, Nkulikiyinka R, Parikh K, Felker GM. Electronic health record characterization and outcomes of heart failure with preserved ejection fraction. Am Heart J 2023; 263:1-14. [PMID: 37116604 DOI: 10.1016/j.ahj.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 04/20/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Electronic health record (EHR)-based identification of heart failure with preserved ejection fraction (HFpEF) in the clinical setting may facilitate screening for clinical trials by improving the understanding of its epidemiology and outcomes; yet, previous data have yielded variable results. We sought to characterize groups identified with HFpEF by different EHR screening strategies and their associated long-term outcomes across a large and diverse population. METHODS We retrospectively analyzed 116,499 consecutive patients from an academic referral center who underwent echocardiography, and 9,263 patients who underwent echocardiography within 6 months of right heart catheterization (RHC), between 2008 and 2018. EHR-based screening strategies identified patients with HFpEF using 1) International Classification of Diseases (ICD)-9/10 codes, 2) H2FpEF score ≥6 and ejection fraction (EF) ≥50%, or 3) RHC wedge pressure ≥15 mmHg and EF ≥50%, when available. Primary outcomes were 1) cumulative incident heart failure hospitalization (HFH), and 2) death, over 10 years. RESULTS There were 33,461 (29%) patients who met either ICD or H2FpEF-HFpEF definition, of whom 5,310 (16%) met both criteria. Compared to ICD-HFpEF, patients with H2FpEF-HFpEF were more likely older (median age 72 vs 67), White (78% vs 64%), and had atrial fibrillation (97% vs 41%). Among those also with RHC, 6,353 (69%) patients met any HFpEF criteria, of whom only 783 (12%) satisfied all three criteria. Female sex was more common among RHC-HFpEF (55%) compared to other methods (H2FpEF-HFpEF, 47%; ICD-HFpEF, 43%). Atrial fibrillation was substantially higher among HFpEF identified by the H2FpEF score (97%) compared to other methods (49% for ICD and 47% for RHC). Across HFpEF screening methods, 10-year cumulative incidence rates for HFH was 32% to 45% for echocardiography only and 43% to 52% for echocardiography and RHC populations; 10-year risk of death was 54% to 56% for echocardiography only and 52% to 57% for echocardiography and RHC populations. CONCLUSIONS Different EHR-based HFpEF definitions identified cohorts with modest overlap and varying baseline characteristics. Yet, long-term risk for HFH and death were similarly high for cohorts identified among both populations undergoing echocardiography only or echocardiography and RHC. These data aid in identifying relevant subgroups in clinical trials of HFpEF.
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Affiliation(s)
- Vishal N Rao
- Division of Cardiology, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Derek D Cyr
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Lisa M Wruck
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Gretchen Sanders
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Paul Hofmann
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | | | | | | | | | - Kishan Parikh
- Division of Cardiology, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - G Michael Felker
- Division of Cardiology, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
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Nanayakkara S, Kaye DM. Device therapy with interatrial shunt devices for heart failure with preserved ejection fraction. Heart Fail Rev 2023; 28:281-286. [PMID: 35438418 PMCID: PMC9941219 DOI: 10.1007/s10741-022-10236-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/24/2022]
Abstract
Heart failure with preserved ejection fraction is responsible for half of all heart failure and confers substantial morbidity and mortality, and yet to date, there have been no effective pharmacologic interventions. Although the pathophysiology is complex, the primary aetiology of exercise intolerance is due to an elevated left atrial pressure, particularly with exercise. In this context, device-based therapy has become a focus. Several companies have developed techniques to percutaneously create an iatrogenic left to right shunt at the atrial level, thereby reducing left atrial pressure and reducing transmitted pressures to the pulmonary circulation and reducing pulmonary congestion. In this review, we explore the pathophysiology, evidence base, benefits, and considerations of these devices and their place in the therapeutic landscape of heart failure with preserved ejection fraction.
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Affiliation(s)
- Shane Nanayakkara
- Alfred Hospital and Baker Heart & Diabetes Institute, Commercial Rd, Melbourne, 3004 Australia
| | - David M. Kaye
- Alfred Hospital and Baker Heart & Diabetes Institute, Commercial Rd, Melbourne, 3004 Australia
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Hsu S, Fang JC, Borlaug BA. Hemodynamics for the Heart Failure Clinician: A State-of-the-Art Review. J Card Fail 2022; 28:133-148. [PMID: 34389460 PMCID: PMC8748277 DOI: 10.1016/j.cardfail.2021.07.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 01/03/2023]
Abstract
Heart failure (HF) fundamentally reflects an inability of the heart to provide adequate blood flow to the body without incurring the cost of increased cardiac filling pressures. This failure occurs first during the stressed state, but progresses until hemodynamic derangements become apparent at rest. As such, the measurement and interpretation of both resting and stressed hemodynamics serve an integral role in the practice of the HF clinician. In this review, we discuss conceptual and technical best practices in the performance and interpretation of both resting and invasive exercise hemodynamic catheterization, relate important pathophysiologic concepts to clinical care, and discuss updated, evidence-based applications of hemodynamics as they pertain to the full spectrum of HF conditions.
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Affiliation(s)
- Steven Hsu
- Division of Cardiology, Dept. of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - James C Fang
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, Utah.
| | - Barry A Borlaug
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
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Huang WM, Cheng HM, Yu WC, Guo CY, Chiang CE, Chen CH, Sung SH. The ventilatory abnormalities and prognostic values of H 2 FPEF score in dyspnoeic patients with preserved left ventricle systolic function. ESC Heart Fail 2020; 7:1872-1879. [PMID: 32488965 PMCID: PMC7373923 DOI: 10.1002/ehf2.12754] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 04/24/2020] [Accepted: 04/26/2020] [Indexed: 12/13/2022] Open
Abstract
AIMS Heart failure with preserved ejection fraction (HFpEF) is one of the major diagnoses in dyspnoeic subjects, and H2 FPEF score enables robust differentiation of HFpEF. Given ventilatory abnormalities prevail in subjects with HFpEF, the associations between H2 FPEF score and pulmonary function remain to be elucidated. METHODS AND RESULTS Subjects who presented with exertional dyspnoea and had left ventricular ejection fraction of >50% were eligible for this study. Total lung capacity, forced expiratory volume in the 1 s, and forced vital capacity (FVC) were obtained by pulmonary function tests. Pulmonary artery systolic pressure (PASP), the ratio of early ventricular filling flow velocity to the septal mitral annulus tissue velocity (E/e'), and left ventricular mass (LVM) were measured by echocardiogram. Among a total of 5849 participants (65.6 ± 6.4 years, 54% men), 2453 (41.9%) had low H2 FPEF score (0 ~ 1) and 160 (2.7%) had high H2 FPEF score,6~9 respectively. Subjects with high H2 FPEF score were older and had higher proportion of restrictive and obstructive defect, more morbidities, poorer renal function, lower haemoglobin, higher LVM, E/e' ratio, and PASP. During a mean follow-up duration of 30.0 ± 20.5 months, the H2 FPEF score was significantly associated with mortality [hazard ratio and 95% confidence intervals, 1.063(1.010-1.18)], independent of sex, haemoglobin, renal function, LVM, and comorbidities. CONCLUSIONS Either obstructive or restrictive ventilation defects prevail in subjects with high H2 FPEF score, indicating chronic obstructive pulmonary disease (COPD) is commonly associated with HFpEF. In addition, H2 FPEF score was correlated with long-term survival in dyspnoeic subjects with or without concomitant diseases of HFpEF and COPD.
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Affiliation(s)
- Wei-Ming Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hao-Min Cheng
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan.,General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Department of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Chung Yu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Department of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chao-Yu Guo
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Department of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chen-Huan Chen
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Department of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Hsien Sung
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
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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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Esfandiari S, Wolsk E, Granton D, Azevedo L, Valle FH, Gustafsson F, Mak S. Pulmonary Arterial Wedge Pressure at Rest and During Exercise in Healthy Adults: A Systematic Review and Meta-analysis. J Card Fail 2019; 25:114-122. [DOI: 10.1016/j.cardfail.2018.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/28/2018] [Accepted: 10/16/2018] [Indexed: 12/28/2022]
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Reddy YNV, Carter RE, Obokata M, Redfield MM, Borlaug BA. A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure With Preserved Ejection Fraction. Circulation 2018; 138:861-870. [PMID: 29792299 PMCID: PMC6202181 DOI: 10.1161/circulationaha.118.034646] [Citation(s) in RCA: 647] [Impact Index Per Article: 107.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/02/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Diagnosis of heart failure with preserved ejection fraction (HFpEF) is challenging in euvolemic patients with dyspnea, and no evidence-based criteria are available. We sought to develop and then validate noninvasive diagnostic criteria that could be used to estimate the likelihood that HFpEF is present among patients with unexplained dyspnea to guide further testing. METHODS Consecutive patients with unexplained dyspnea referred for invasive hemodynamic exercise testing were retrospectively evaluated. Diagnosis of HFpEF (case) or noncardiac dyspnea (control) was ascertained by invasive hemodynamic exercise testing. Logistic regression was performed to evaluate the ability of clinical findings to discriminate cases from controls. A scoring system was developed and then validated in a separate test cohort. RESULTS The derivation cohort included 414 consecutive patients (267 cases with HFpEF and 147 controls; HFpEF prevalence, 64%). The test cohort included 100 consecutive patients (61 with HFpEF; prevalence, 61%). Obesity, atrial fibrillation, age >60 years, treatment with ≥2 antihypertensives, echocardiographic E/e' ratio >9, and echocardiographic pulmonary artery systolic pressure >35 mm Hg were selected as the final set of predictive variables. A weighted score based on these 6 variables was used to create a composite score (H2FPEF score) ranging from 0 to 9. The odds of HFpEF doubled for each 1-unit score increase (odds ratio, 1.98; 95% CI, 1.74-2.30; P<0.0001), with an area under the curve of 0.841 ( P<0.0001). The H2FPEF score was superior to a currently used algorithm based on expert consensus (increase in area under the curve of 0.169; 95% CI, 0.120-0.217; P<0.0001). Performance in the independent test cohort was maintained (area under the curve, 0.886; P<0.0001). CONCLUSIONS The H2FPEF score, which relies on simple clinical characteristics and echocardiography, enables discrimination of HFpEF from noncardiac causes of dyspnea and can assist in determination of the need for further diagnostic testing in the evaluation of patients with unexplained exertional dyspnea.
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Affiliation(s)
- Yogesh N. V. Reddy
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rickey E. Carter
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Masaru Obokata
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Barry A. Borlaug
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Reddy YNV, Olson TP, Obokata M, Melenovsky V, Borlaug BA. Hemodynamic Correlates and Diagnostic Role of Cardiopulmonary Exercise Testing in Heart Failure With Preserved Ejection Fraction. JACC. HEART FAILURE 2018; 6:665-675. [PMID: 29803552 PMCID: PMC6076329 DOI: 10.1016/j.jchf.2018.03.003] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 02/23/2018] [Accepted: 03/06/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This study sought to define the invasive hemodynamic correlates of peak oxygen consumption (Vo2) in both supine and upright exercise in heart failure with preserved ejection fraction (HFpEF) and evaluate its diagnostic role as a method to discriminate HFpEF from noncardiac etiologies of dyspnea (NCD). BACKGROUND Peak Vo2 is depressed in patients with HFpEF. The hemodynamic correlates of reduced peak Vo2 and its role in the clinical evaluation of HFpEF are unclear. METHODS Consecutive patients with dyspnea and normal EF (N = 206) undergoing both noninvasive upright and invasive supine cardiopulmonary exercise testing were examined. Patients with invasively verified HFpEF were compared with those with NCD. RESULTS Compared with NCD (n = 72), HFpEF patients (n = 134) displayed lower peak Vo2 during upright and supine exercise. Left heart filling pressures during exercise were inversely correlated with peak Vo2 in HFpEF, even after accounting for known determinants of O2 transport according to the Fick principle. Very low upright peak Vo2 (<14 ml/kg/min) discriminated HFpEF from NCD with excellent specificity (91%) but poor sensitivity (50%). Preserved peak Vo2 (>20 ml/kg/min) excluded HFpEF with high sensitivity (90%) but had poor specificity (49%). Intermediate peak Vo2 cutoff points were associated with substantial overlap between cases and NCD. CONCLUSIONS Elevated cardiac filling pressure during exercise is independently correlated with reduced exercise capacity in HFpEF, irrespective of body position, emphasizing its importance as a novel therapeutic target. Noninvasive cardiopulmonary testing discriminates HFpEF and NCD at high and low values, but additional testing is required for patients with intermediate peak Vo2.
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Affiliation(s)
- Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Thomas P Olson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vojtech Melenovsky
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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