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Yuasa N, Obokata M, Harada T, Kagami K, Sorimachi H, Saito Y, Naito A, Kato T, Wada N, Ishii H. Characterization and prognostic importance of chronotropic incompetence in heart failure with preserved ejection fraction. J Cardiol 2024; 83:113-120. [PMID: 37419310 DOI: 10.1016/j.jjcc.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/22/2023] [Accepted: 06/30/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Exercise intolerance is the primary symptom of patients with heart failure with preserved ejection fraction (HFpEF). Chronotropic incompetence has been considered to be common and contribute to poor exercise capacity in HFpEF. However, clinical characteristics, pathophysiology, and outcomes of chronotropic incompetence in HFpEF remain poorly understood. METHODS Patients with HFpEF (n = 246) underwent ergometry exercise stress echocardiography with simultaneous expired gas analysis. The patients were divided into two groups based on the presence of chronotropic incompetence, which was defined by heart rate reserve <0.80. RESULTS Chronotropic incompetence was common in HFpEF (n = 112, 41 %). Compared to HFpEF patients with a normal chronotropic response (n = 134), those with chronotropic incompetence had higher body mass index, a higher prevalence of diabetes, more frequent β-blocker use, and worse New York Heart Association class. During peak exercise, patients with chronotropic incompetence demonstrated less increase in cardiac output and arterial oxygen delivery (cardiac output × saturation × hemoglobin × 1.34 × 10), higher metabolic work (peak oxygen consumption [VO2]/watt), an inability to increase arteriovenous oxygen difference, and poorer exercise capacity (lower peak VO2) than those without. Chronotropic incompetence was associated with higher rates of a composite of all-cause mortality or worsening HF events (hazard ratio, 2.66, 95 % confidence intervals, 1.16-6.09, p = 0.02). CONCLUSION Chronotropic incompetence is common in HFpEF, and is associated with unique pathophysiologic characteristics during exercise and clinical outcomes.
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Affiliation(s)
- Naoki Yuasa
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
| | - Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Kazuki Kagami
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yuki Saito
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Ayami Naito
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Naoki Wada
- Department of Rehabilitation Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Lopez-Candales A, Asif T, Sawalha K, Norgard NB. Heart Failure with Preserved Left Ventricular Ejection Fraction: A Complex Conundrum Simply Not Limited to Diastolic Dysfunction. Cardiovasc Ther 2023; 2023:1552826. [PMID: 37496726 PMCID: PMC10368509 DOI: 10.1155/2023/1552826] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 05/25/2023] [Accepted: 06/06/2023] [Indexed: 07/28/2023] Open
Abstract
Over the last two decades, the changing paradigm of heart failure with preserved ejection fraction (HFpEF) has transformed our understanding not only of the pathophysiology of this clinical entity but also the diagnostic and therapeutic approaches aimed at treating this complex patient population. No longer HFpEF should be seen as simply left ventricular diastolic dysfunction but as a group of that in addition of having small and thick left ventricles with abnormal diastolic filling patterns as their main pathophysiologic abnormality; they also have whole host of different abnormalities. In fact, this heterogeneous clinical entity embodies numerous mechanisms and is linked to multiorgan dysfunction, with hypertension and obesity playing a major role. Although we have gained an enormous amount of understanding not only on the causes but also the downstream effects of HFpEF, there is still much to be learned before we can fully comprehend this complex clinical entity. It is the main intention of this review to synthesize the most recent attributes, mechanism, diagnostic tools, and most useful therapeutic alternatives to be considered when evaluating patients either complaining of dyspnea on exertion as well as exercise intolerance or those recently admitted with HF symptoms but with normal LVEF in the absence of any other valvular abnormalities.
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Affiliation(s)
- Angel Lopez-Candales
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, USA
| | - Talal Asif
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, USA
| | - Khalid Sawalha
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, USA
| | - Nicholas B. Norgard
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, USA
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Yuyun MF, Kinlay S, Singh JP, Joseph J. Are arrhythmias the drivers of sudden cardiac death in heart failure with preserved ejection fraction? A review. ESC Heart Fail 2022; 10:1555-1569. [PMID: 36495033 DOI: 10.1002/ehf2.14248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/16/2022] [Accepted: 11/08/2022] [Indexed: 12/14/2022] Open
Abstract
In patients with heart failure with preserved ejection fraction (HFpEF), sudden cardiac death (SCD) accounts for approximately 25-30% of all-cause mortality and 40% of cardiovascular mortality in properly adjudicated large clinical trials. The mechanism of SCD in HFpEF remains unknown but thought to be driven by arrhythmic events. Apart from atrial fibrillation, which is prevalent in approximately 45% of HFpEF patients, the true burden of other cardiac arrhythmias in HFpEF remains undetermined. The incidence and risk of clinically significant advanced cardiac conduction disease with bradyarrhythmias and ventricular arrhythmias remain less known. Recommendations have been made for long-term cardiac rhythm monitoring to determine the incidence of arrhythmias and clarify mechanisms and mode of death in HFpEF patients. In animal studies, spontaneous ventricular arrhythmias and SCD are significantly elevated in HFpEF animals compared with controls without heart failure. In humans, these studies are scant, with a few published small-size studies suggesting an increased incidence of ventricular arrhythmias in HFpEF. Higher rates of clinically significant conduction disease and cardiac pacing are seen in HFpEF compared with the general population. Excepting atrial fibrillation, the predictive effect of other arrhythmias on heart failure hospitalization, all-cause mortality, and precisely SCD remains unknown. Given the high occurrence of SCD in the HFpEF population, it could potentially become a target for therapeutic interventions if driven by arrhythmias. Studies to address these knowledge gaps are urgently warranted. In this review, we have summarized data on arrhythmias and SCD in HFpEF while highlighting avenues for future research in this area.
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Affiliation(s)
- Matthew F. Yuyun
- VA Boston Healthcare System Boston MA USA
- Harvard Medical School Boston MA USA
- Boston University School of Medicine Boston MA USA
- Brigham and Women's Hospital Boston MA USA
| | - Scott Kinlay
- VA Boston Healthcare System Boston MA USA
- Harvard Medical School Boston MA USA
- Boston University School of Medicine Boston MA USA
- Brigham and Women's Hospital Boston MA USA
| | - Jagmeet P. Singh
- Harvard Medical School Boston MA USA
- Massachusetts General Hospital Boston MA USA
| | - Jacob Joseph
- VA Boston Healthcare System Boston MA USA
- Harvard Medical School Boston MA USA
- Brigham and Women's Hospital Boston MA USA
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Palau P, Seller J, Domínguez E, Sastre C, Ramón JM, de La Espriella R, Santas E, Miñana G, Bodí V, Sanchis J, Valle A, Chorro FJ, Llácer P, Bayés-Genís A, Núñez J. Effect of β-Blocker Withdrawal on Functional Capacity in Heart Failure and Preserved Ejection Fraction. J Am Coll Cardiol 2021; 78:2042-2056. [PMID: 34794685 DOI: 10.1016/j.jacc.2021.08.073] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Chronotropic incompetence has shown to be associated with a decrease in exercise capacity in heart failure with preserved ejection fraction (HFpEF), yet β-blockers are commonly used in HFpEF despite the lack of robust evidence. OBJECTIVES This study aimed to evaluate the effect of β-blocker withdrawal on peak oxygen consumption (peak Vo2) in patients with HFpEF and chronotropic incompetence. METHODS This is a multicenter, randomized, investigator-blinded, crossover clinical trial consisting of 2 treatment periods of 2 weeks separated by a washout period of 2 weeks. Patients with stable HFpEF, New York Heart Association functional classes II and III, previous treatment with β-blockers, and chronotropic incompetence were first randomized to withdrawing from (arm A: n = 26) versus continuing (arm B: n = 26) β-blocker treatment and were then crossed over to receive the opposite intervention. Changes in peak Vo2 and percentage of predicted peak Vo2 (peak Vo2%) measured at the end of the trial were the primary outcome measures. To account for the paired-data nature of this crossover trial, linear mixed regression analysis was used. RESULTS The mean age was 72.6 ± 13.1 years, and most of the patients were women (59.6%) in New York Heart Association functional class II (66.7%). The mean peakVo2 and peak Vo2% were 12.4 ± 2.9 mL/kg/min, and 72.4 ± 17.8%, respectively. No significant baseline differences were found across treatment arms. Peak Vo2 and peak Vo2% increased significantly after β-blocker withdrawal (14.3 vs 12.2 mL/kg/min [Δ +2.1 mL/kg/min]; P < 0.001 and 81.1 vs 69.4% [Δ +11.7%]; P < 0.001, respectively). CONCLUSIONS β-blocker withdrawal improved maximal functional capacity in patients with HFpEF and chronotropic incompetence. β-blocker use in HFpEF deserves profound re-evaluation. (β-blockers Withdrawal in Patients With HFpEF and Chronotropic Incompetence: Effect on Functional Capacity [PRESERVE-HR]; NCT03871803; 2017-005077-39).
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Affiliation(s)
- Patricia Palau
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Julia Seller
- Cardiology Department, Hospital de Denia, Alicante, Spain
| | | | - Clara Sastre
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Jose María Ramón
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Rafael de La Espriella
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Enrique Santas
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain
| | - Gema Miñana
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain
| | - Vicent Bodí
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain
| | - Alfonso Valle
- Cardiology Department, Hospital de Denia, Alicante, Spain
| | - F Javier Chorro
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain
| | - Pau Llácer
- Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain; Internal Medicine Department, Hospital Ramón y Cajal, Madrid, Spain
| | - Antoni Bayés-Genís
- Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain; Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria del Hospital Clínico Universitario de Valencia, Universitat de València, Valencia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovascular, Madrid, Spain.
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