The Role of Echocardiography in Heart Failure with Preserved Ejection Fraction: What Do We Want from Imaging?

Radiomics features of the cardiac blood pool to indicate hemodynamic changes in pulmonary hypertension (PH) due to heart failure with preserved ejection fraction (PH-HFpEF)

To test the hypothesis that cine MRI-derived radiomics features of the cardiac blood pool can represent hemodynamic characteristics of pulmonary hypertension-heart failure with preserved ejection fraction (PH-HFpEF). Nineteen PH-HFpEF patients (9 male, 57.8 ± 14.7 years) and 19 healthy controls (13 male, 50.3 ± 13.6 years) were enrolled. All participants underwent a cardiac MRI scan. One hundred and seven radiomics features (7 classes) of the blood pool in the left and right ventricles/atrium (LV/RV/LA/RA) were extracted from 4-chamber cine (2D images) at the stages of systole, rapid filling, diastasis, and atrial contraction within a cardiac cycle. For PH-HFpEF patients, features acquired from LV/LA were related to the pulmonary capillary wedge pressure (PCWP); features acquired from RV/RA were related to the mean pulmonary artery pressure (mPAP) using the Pearson correlation coefficient (r). Logistic regression, receiver operating characteristic (ROC) curve and the area under the curve (AUC) were used to test the capability of radiomics features in discriminating 2 subject groups. Features acquired from different chambers at various periods present diverse properties in representing hemodynamic indices of PH-HFpEF. Multiple radiomics features blood pool were significantly related to PCWP and/or mPAP (r: 0.4-0.679, p < 0.05). In addition, multiple features of blood pools acquired at various time points within a cardiac cycle can efficiently discriminate PH-HFpEF from controls (individual AUC: 0.7-0.864). Cine MRI-derived radiomics features of the cardiac blood pool have the potential to characterize hemodynamic abnormalities in the context of PH-HFpEF.

The roles of exercise stress echocardiography for the evaluation of heart failure with preserved ejection fraction in the heart failure pandemic era

Heart failure with preserved ejection fraction (HFpEF) accounts for nearly 70% of all HF and has become the dominant form of HF. The increased prevalence of HFpEF has contributed to a rise in the number of HF patients, known as the "heart failure pandemic". In addition to the fact that HF is a progressive disease and a delayed diagnosis may worsen clinical outcomes, the emergence of disease-modifying treatments such as sodium-glucose transporter 2 inhibitors and glucagon-like peptide-1 receptor agonists has made appropriate and timely identification of HFpEF even more important. However, diagnosis of HFpEF remains challenging in patients with a lower degree of congestion. In addition to normal EF, this is related to the fact that left ventricular (LV) filling pressures are often normal at rest but become abnormal during exercise. Exercise stress echocardiography can identify such exercise-induced elevations in LV filling pressures and facilitate the diagnosis of HFpEF. Exercise stress echocardiography may also be useful for risk stratification and assessment of exercise tolerance as well as cardiovascular responses to exercise. Recent attention has focused on dedicated dyspnea clinics to identify early HFpEF among patients with unexplained dyspnea and to investigate the causes of dyspnea. This review discusses the role of exercise stress echocardiography in the diagnosis and evaluation of HFpEF.

NT-proBNP cardiac value in COVID-19: a focus on the paediatric population

NT-proBNP is a peptide related to brain natriuretic peptide, a cardiac biomarker and a member of the natriuretic family of peptides. NT-proBNP has demonstrated its clinical utility in the assessment of a wide spectrum of cardiac manifestations. It is also considered a more precise diagnostic and prognostic cardiac biomarker than brain natriuretic peptide. With the appearance of the Severe Acute Respiratory Syndrome Coronavirus 2 virus and the subsequent COVID-19 pandemic, diagnosis of heart implications began to pose an increasing struggle for the physician. Echocardiography is considered a central means of evaluating cardiac disorders like heart failure, and it is considered a reliable method. However, other diagnostic methods are currently being explored, one of which involves the assessment of NT-proBNP levels. In the literature that involves the adult population, significant positive correlations were drawn between the levels of NT-proBNP and COVID-19 outcomes such as high severity and fatality. In the paediatric population, however, the literature is scarce, and most of the investigations assess NT-proBNP in the context of Multiple Inflammatory Syndrome in Children, where studies have shown that cohorts with this syndrome had elevated levels of NT-proBNP when compared to non-syndromic cohorts. Thus, more large-scale studies on existing COVID-19 data should be carried out in the paediatric population to further understand the prognostic and diagnostic roles of NT-proBNP.

Diagnostic accuracy of plasma brain natriuretic peptide for evaluation of dyspnea NYHA-III and NYHA-IV in emergency department of tertiary care hospital

Objective

To determine the diagnostic accuracy of breathing not properly (BNP) for evaluation of dyspnea NYHA III and IV due to systolic heart failure in emergency department patients keeping echocardiography as the gold standard.

Study design

Cross-sectional validation study. Setting: Department of Accident and Emergency Duration of Study: 25 July 2022-25 January 2023.

Subjects and methods

A total of 115 of both sexes presenting with acute onset of dyspnea and having NYHA Class III and IV were included. Emergency nursing staff had immediately taken a single venous blood sample for BNP and creatinine levels and a 2D echo was performed. Ejection fraction was recorded, and the diagnosis of systolic heart failure on the basis of an ejection fraction, that is less than or equal to 45% was documented.

Results

The age range in this study was from 18 to 65 years, with a mean age of 49.147±8.73 years. Mean BNP levels were 139.452±84.04 pg/ml. Patients with NYHA class III was 67.8 and 32.2% belongs to NYHA class IV. BNP levels greater than or equal to 100 pg/ml diagnosed 76 (66.1%) and echocardiography has diagnosed 68 (59.1%) patients with heart failure. BNP levels greater than or equal to 100 pg/ml had shown sensitivity 94.1%, specificity 74.5%, and diagnostic accuracy 86%, positive predictive value 84.21%, negative prediction value 89.74%, likelihood positive ratio 3.68 and likelihood negative ratio was 0.08 in diagnosis of heart failure.

Conclusion

BNP estimation is a sensible and particular procedure for diagnosing CHF in patients who present to the emergency department with acute dyspnea and may add extra advantages to the administration of patients with congestive heart failure (CHF) in our population.

Imaging in Heart Failure with Preserved Ejection Fraction: A Multimodality Imaging Point of View

Heart failure with preserved ejection fraction (HFpEF) is an important global health problem. Despite increased prevalence due to improved diagnostic options, limited improvement has been achieved in cardiac outcomes. HFpEF is an extremely complex syndrome and multimodality imaging is important for diagnosis, identifying its different phenotypes and determining prognosis. Evaluation of left ventricular filling pressures using echocardiographic diastolic function parameters is the first step of imaging in clinical practice. The role of echocardiography is becoming more popular and with the recent developments in deformation imaging, cardiac MRI is extremely important as it can provide tissue characterisation, identify fibrosis and optimal volume measurements of cardiac chambers. Nuclear imaging methods can also be used in the diagnosis of specific diseases, such as cardiac amyloidosis.

Few geriatric heart failure patients investigated according to clinical guidelines: a retrospective review of patient records

BACKGROUND

Research on heart failure (HF) has often focused on younger patients. The aim of this study was to analyze extent of investigation and treatment among older patients prior to referral to inpatient geriatric care for worsening of HF.

METHODS

Data on etiology, ejection fraction (EF) by echocardiography (ECHO), level of functioning according to New York Heart Association (NYHA), analysis of N-terminal-pro-brain natriuretic peptide (NT-Pro-BNP), ongoing treatment, adherence to guidelines, and information from previous caregiver were collected from patient records prior to admission from a sample of 134 patients.

RESULTS

Few patients had been examined by a cardiologist (14%) during the year prior to referral. EF assessment had been performed in 78% (n = 105). The patients were categorized as having HF with reduced (HFrEF 28%), preserved (HFpEF 53%) or mid-range (HFmrEF 19%) EF. HFpEF patients had older EF assessments (mean 517 days) than those with HFrEF (385 days). In 61% (n = 82) at least one assessment with NT-Pro-BNP had been performed, being older among patients with HFpEF (290 days vs 16 days). There was a strong positive correlation (OR 4.9, p = 0.001) between having recent assessments of EF and NT-Pro-BNP (n = 30, 21%) and being presented with etiology in the referral, adjusted for EF, age, sex, and comorbidity. Among the HFrEF patients, 78% were treated with ACEI/ARB and BB according to ESC guidelines but reaching only half of target doses. In the HFpEF group the corresponding treatment was 46%. Among patients with EF ≤ 35% only 14% were treated with mineral receptor antagonists, ie low adherence to guidelines.

CONCLUSIONS

HF care in this population of older individuals showed deficiencies. There was little contact with cardiologists, lack of information of etiology in referrals and low adherence to treatment guidelines. Improving adherence to HF guidelines regarding investigation and treatment for HF in older people is therefore urgent and calls for more collaboration between specialists in cardiology and geriatric medicine.

Diagnostic value of expired gas analysis in heart failure with preserved ejection fraction

Cardiopulmonary exercise testing (CPET) may potentially differentiate heart failure (HF) with preserved ejection fraction (HFpEF) from noncardiac causes of dyspnea (NCD). While contemporary guidelines for HF recommend using CPET for identifying causes of unexplained dyspnea, data supporting this practice are limited. This study aimed to determine the diagnostic value of expired gas analysis to distinguish HFpEF from NCD. Exercise stress echocardiography with simultaneous expired gas analysis was performed in patients with HFpEF (n = 116) and those with NCD (n = 112). Participants without dyspnea symptoms were also enrolled as controls (n = 26). Exercise capacity was impaired in patients with HFpEF than in controls and those with NCD, evidenced by lower oxygen consumption (VO₂), but there was a substantial overlap between HFpEF and NCD. Receiver operating characteristic curve analyses showed modest diagnostic abilities of expired gas analysis data in differentiating individuals with HFpEF from the controls; however, none of these variables clearly differentiated between HFpEF and NCD (all areas under the curve < 0.61). Expired gas analysis provided objective assessments of exercise capacity; however, its diagnostic value in identifying HFpEF among patients with symptoms of exertional dyspnea was modest.

Epidemiology, Pathophysiology, Diagnosis, and Therapy of Heart Failure With Preserved Ejection Fraction in Japan

Heart failure (HF) with preserved ejection fraction (HFpEF) is a global health care problem, with diagnostic difficulty, limited treatment options and high morbidity and mortality rates. The prevalence of HFpEF is increasing because of the aging population and the increasing burden of cardiac and metabolic comorbidities, such as systemic hypertension, diabetes, chronic kidney disease, and obesity. The knowledge base is derived primarily from the United States and Europe, and data from Asian countries, including Japan, remain limited. Given that phenotypic differences may exist between Japanese and Western patients with HFpEF, careful characterization may hold promise to deliver new therapy specific to the Japanese population. In this review, we summarize the current knowledge regarding the epidemiology, pathophysiology and diagnosis of and the potential therapies for HFpEF in Japan.

Expert proposal to characterize cardiac diseases with normal or preserved left ventricular ejection fraction and symptoms of heart failure by comprehensive echocardiography

Currently, the term "heart failure with preserved left ventricular ejection fraction (HFpEF)" is based on echocardiographic parameters and clinical symptoms combined with elevated or normal levels of natriuretic peptides. Thus, "HFpEF" as a diagnosis subsumes multiple pathophysiological entities making a uniform management plan for "HFpEF" impossible. Therefore, a more specific characterization of the underlying cardiac pathologies in patients with preserved ejection fraction and symptoms of heart failure is mandatory. The present proposal seeks to offer practical support by a standardized echocardiographic workflow to characterize specific diagnostic entities associated with "HFpEF". It focuses on morphological and functional cardiac phenotypes characterized by echocardiography in patients with normal or preserved left ventricular ejection fraction (LVEF). The proposal discusses methodological issues to clarify why and when echocardiography is helpful to improve the diagnosis. Thus, the proposal addresses a systematic echocardiographic approach using a feasible algorithm with weighting criteria for interpretation of echocardiographic parameters related to patients with preserved ejection fraction and symptoms of heart failure. The authors consciously do not use the diagnosis "HFpEF" to avoid misunderstandings. Central illustration: Scheme illustrating the characteristic echocardiographic phenotypes and their combinations in patients with "HFpEF" symptoms with respect to the respective cardiac pathology and pathophysiology as well as the underlying typical disease.

New Opportunities in Heart Failure with Preserved Ejection Fraction: From Bench to Bedside… and Back

Heart failure with preserved ejection fraction (HFpEF) is a growing public health problem in nearly 50% of patients with heart failure. Therefore, research on new strategies for its diagnosis and management has become imperative in recent years. Few drugs have successfully improved clinical outcomes in this population. Therefore, numerous attempts are being made to find new pharmacological interventions that target the main mechanisms responsible for this disease. In recent years, pathological mechanisms such as cardiac fibrosis and inflammation, alterations in calcium handling, NO pathway disturbance, and neurohumoral or mechanic impairment have been evaluated as new pharmacological targets showing promising results in preliminary studies. This review aims to analyze the new strategies and mechanical devices, along with their initial results in pre-clinical and different phases of ongoing clinical trials for HFpEF patients. Understanding new mechanisms to generate interventions will allow us to create methods to prevent the adverse outcomes of this silent pandemic.

Left ventricular dysfunction with preserved ejection fraction: the most common left ventricular disorder in chronic kidney disease patients

Chronic kidney disease (CKD) is a risk factor for premature cardiovascular disease. As kidney function declines, the presence of left ventricular abnormalities increases such that by the time kidney replacement therapy is required with dialysis or kidney transplantation, more than two-thirds of patients have left ventricular hypertrophy. Historically, much research in nephrology has focussed on the structural and functional aspects of cardiac disease in CKD, particularly using echocardiography to describe these abnormalities. There is a need to translate knowledge around these imaging findings to clinical outcomes such as unplanned hospital admission with heart failure and premature cardiovascular death. Left ventricular hypertrophy and cardiac fibrosis, which are common in CKD, predispose to the clinical syndrome of heart failure with preserved left ventricular ejection fraction (HFpEF). There is a bidirectional relationship between CKD and HFpEF, whereby CKD is a risk factor for HFpEF and CKD impacts outcomes for patients with HFpEF. There have been major improvements in outcomes for patients with heart failure and reduced left ventricular ejection fraction as a result of several large randomized controlled trials. Finding therapy for HFpEF has been more elusive, although recent data suggest that sodium-glucose cotransporter 2 inhibition offers a novel evidence-based class of therapy that improves outcomes in HFpEF. These observations have emerged as this class of drugs has also become the standard of care for many patients with proteinuric CKD, suggesting that there is now hope for addressing the combination of HFpEF and CKD in parallel. In this review we summarize the epidemiology, pathophysiology, diagnostic strategies and treatment of HFpEF with a focus on patients with CKD.

Diagnostic role of echocardiography for patients with heart failure symptoms and preserved left ventricular ejection fraction

The syndrome heart failure with preserved ejection fraction (HFpEF) represents patients with different comorbidities and specific etiologies, but with a key and common alteration: an elevation in left ventricular (LV) filling pressure or pulmonary capillary wedge pressure (PCWP). Expert consensuses, society guidelines, and diagnostic scores have been stated to diagnose HFpEF syndrome based mainly on the determination of elevated LV filling pressure or PCWP by transthoracic echocardiography (TTE). Echocardiographic parameters such as early (E) and late diastolic mitral inflow velocity (mitral E/A ratio), septal and lateral mitral annular early diastolic velocity (E'), ratio of the early diastolic mitral inflow and annular velocity (E/E'-ratio), maximal left atrial volume index (LAVI_max), and tricuspid regurgitation peak velocity (V_TR) constitute the pivotal parameters for determining elevated LV filling pressure or PCWP in patients with suspected HFpEF symptoms. Notwithstanding this, taking into consideration the heterogeneity of patients with HFpEF symptoms, the term "HFpEF" should be considered as a syndrome rather than an entity since HFpEF results from different pathological entities that should and can be characterized by echocardiography and multimodality imaging. Comprehensive TTE might help diagnose specific diseases and etiologies by characterization of specific cardiac phenotypes.

From Left Atrial Dimension to Curved M-Mode Speckle-Tracking Images: Role of Echocardiography in Evaluating Patients with Atrial Fibrillation

Left atrial (LA) enlargement and dysfunction increase the risk of atrial fibrillation (AF). Traditional echocardiographic evaluation of the left atrium has been limited to dimensional and semi-quantification measurement of the atrial component of ventricular filling, with routine measurement of LA function not yet implemented. However, functional parameters, such as LA emptying fraction (LAEF), may be more sensitive markers for detecting AF-related changes than LA enlargement. Speckle-tracking echocardiography has proven to be a feasible and reproducible technology for the direct evaluation of LA function. The clinical application, advantages, and limitations of LA strain and strain rate need to be fully understood. Furthermore, the prognostic value and utility of this technique in making therapeutic decisions for patients with AF need further elucidation. Deep learning neural networks have been successfully adapted to specific tasks in echocardiographic image analysis, and fully automated measurements based on artificial intelligence could facilitate the clinical diagnostic use of LA speckle-tracking images for classification of AF ablation outcome. This review describes the fundamental concepts and a brief overview of the prognostic utility of LA size, LAEF, LA strain and strain rate analyses, and the clinical implications of the use of these measures.

Exercise Stress Echocardiography in the Diagnostic Evaluation of Heart Failure with Preserved Ejection Fraction

More than half of patients with heart failure have a preserved ejection fraction (HFpEF). The prevalence of HFpEF has been increasing worldwide and is expected to increase further, making it an important health-care problem. The diagnosis of HFpEF is straightforward in the presence of obvious objective signs of congestion; however, it is challenging in patients presenting with a low degree of congestion because abnormal elevation in intracardiac pressures may occur only during physiological stress conditions, such as during exercise. On the basis of this hemodynamic background, current consensus guidelines have emphasized the importance of exercise stress testing to reveal abnormalities during exercise, and exercise stress echocardiography (i.e., diastolic stress echocardiography) may be used as an initial diagnostic approach to HFpEF owing to its noninvasive nature and wide availability. However, evidence supporting the use of this method remains limited and many knowledge gaps exist with respect to diastolic stress echocardiography. This review summarizes the current understanding of the use of diastolic stress echocardiography in the diagnostic evaluation of HFpEF and discusses its strengths and limitations to encourage future studies on this subject.

Right atrial pressure represents cumulative cardiac burden in heart failure with preserved ejection fraction

AIMS

Right-sided filling pressure is elevated in some patients with heart failure (HF) and preserved ejection fraction (HFpEF). We hypothesized that right atrial pressure (RAP) would represent the cumulative burden of abnormalities in the left heart, pulmonary vasculature, and the right heart.

METHODS AND RESULTS

Echocardiography was performed in 399 patients with HFpEF. RAP was estimated from inferior vena cava morphology and its respiratory change [estimated right atrial pressure (eRAP)], and patients were divided according to eRAP (3 or ≥8 mmHg). Patients with higher eRAP displayed more severe abnormalities in LV diastolic function as well as right heart structure and function than those with normal eRAP. Cardiac deaths or HF hospitalization occurred in 84 patients over a median follow-up of 19.0 months (interquartile range 6.7-36.9). The presence of higher eRAP was independently associated with an increased risk of the composite outcome (adjusted hazard ratio 2.20 vs. normal eRAP group, 95% confidence interval 1.34-3.62, P = 0.002). Kaplan-Meier curves separating the patients into four groups based on eRAP and E/e' ratio showed that event-free survival varied among the groups, providing an incremental prognostic value of eRAP over E/e' ratio. The classification and regression tree analysis demonstrated that eRAP was the strongest predictor of the outcome followed by right ventricular dimension, E/e' ratio, and estimated right ventricular systolic pressure, stratifying the patients into four risk groups (incident rate 8.8-72.2%).

CONCLUSIONS

These data may provide new insights into the prognostic role of RAP in the complex pathophysiology of HFpEF and suggest the utility of eRAP for the risk stratification in patients with HFpEF.

The roles of global longitudinal strain imaging in contemporary clinical cardiology

Myocardial deformation imaging is now readily available during routine echocardiography and plays an important role in the advanced care of cardiovascular diseases. Its clinical value in detecting subtle myocardial dysfunction, by helping diagnose disease and allowing prediction of disease progression and earlier pharmacological intervention, has been demonstrated. Strain imaging has been the most studied and clinically used technique in the field of cardio-oncology. A relative percent reduction in left ventricular (LV) global longitudinal strain > 15% from baseline is considered a marker of early subclinical LV dysfunction and may have the potential to guide early initiation of cardioprotective therapy. The role of strain imaging is expanding to other fields, such as cardiac amyloidosis, other cardiomyopathies, valvular heart diseases, pulmonary hypertension, and heart failure with preserved ejection fraction. It is also used for the evaluation of the right ventricle and atria. This review aims to provide a current understanding of the roles of strain imaging in the evaluation and management of patients with cardiovascular diseases in clinical practice.

The H2FPEF and HFA-PEFF algorithms for predicting exercise intolerance and abnormal hemodynamics in heart failure with preserved ejection fraction

Exercise intolerance is a primary manifestation in patients with heart failure with preserved ejection fraction (HFpEF) and is associated with abnormal hemodynamics and a poor quality of life. Two multiparametric scoring systems have been proposed to diagnose HFpEF. This study sought to determine the performance of the H₂FPEF and HFA-PEFF scores for predicting exercise capacity and echocardiographic findings of intracardiac pressures during exercise in subjects with dyspnea on exertion referred for bicycle stress echocardiography. In a subset, simultaneous expired gas analysis was performed to measure the peak oxygen consumption (VO₂). Patients with HFpEF (n = 83) and controls without HF (n = 104) were enrolled. The H₂FPEF score was obtainable for all patients while the HFA-PEFF score could not be calculated for 23 patients (feasibility 88%). Both H₂FPEF and HFA-PEFF scores correlated with a higher E/e' ratio (r = 0.49 and r = 0.46), lower systolic tricuspid annular velocity (r =  - 0.44 and =  - 0.24), and lower cardiac output (r =  - 0.28 and r =  - 0.24) during peak exercise. Peak VO₂ and exercise duration decreased with an increase in H₂FPEF scores (r =  - 0.40 and r =  - 0.32). The H₂FPEF score predicted a reduced aerobic capacity (AUC 0.71, p = 0.0005), but the HFA-PEFF score did not (p = 0.07). These data provide insights into the role of the H₂FPEF and HFA-PEFF scores for predicting exercise intolerance and abnormal hemodynamics in patients presenting with exertional dyspnea.

Echocardiography in the diagnostic evaluation and phenotyping of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) represents one of the greatest unmet needs in modern cardiology given its diagnostic difficulty and limited therapeutic options. Echocardiography provides valuable information on cardiac structure, function, and hemodynamics and plays a central role in the evaluation of HFpEF. Echocardiography is crucial in identifying HFpEF among patients with dyspnea, especially when overt congestion is absent. The combination of echocardiographic indices of diastolic function, clinical characteristics, and natriuretic peptide tests has been proposed in the diagnostic evaluation of patients with suspected HFpEF. Echocardiography also provides valuable insight into the pathophysiology and underlying phenotypes of HFpEF. Exercise stress echocardiography can also detect abnormalities that develop only during exercise. This may enhance the diagnosis of HFpEF by demonstrating elevation in the left ventricular filling pressure and may have potential for better pathophysiological characterization. This review focuses on the role of echocardiography in the diagnostic evaluation and phenotyping of HFpEF. We also discuss the potential role of exercise stress echocardiography for the diagnosis and disease phenotyping of HFpEF.

Unilateral Lung Congestion During Exercise in a Patient With a Single Pulmonary Vein Stenosis

A 55-year-old man underwent exercise stress echocardiography for evaluation of left inferior pulmonary vein stenosis. During exercise, ultrasound B-lines developed in the left lung only. Unilateral pulmonary congestion did not lead to forward or backward failure. The patient was followed up conservatively. (Level of Difficulty: Beginner.).

Invasive validation of the left ventricular global longitudinal strain for estimating left ventricular filling pressure

PURPOSE

An elevated left ventricular (LV) filling pressure is the main finding in heart failure patients with preserved ejection fraction, which is estimated with an algorithm using echocardiographic parameters recommended by the recent American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines. In this study, we sought to determine the efficacy of the LV global longitudinal strain (GLS) in predicting an elevated LV filling pressure.

METHODS AND RESULTS

A total of 73 prospectively selected patients undergoing LV catheterization (mean age 63.19 ± 9.64, 69% male) participated in this study. Using the algorithm, the LV filling pressure was estimated using the echocardiographic parameters obtained within 24 hours before catheterization. The LV GLS was measured using an automated functional imaging system (GE, Vivid E9 USA). Invasive LV pre-A pressure corresponding to the mean left atrial pressure (LAP) was used as a reference, and a LAP of >12 mm Hg was defined as elevated. Invasive LV filling pressure was elevated in 43 patients (59%) and normal in 30 patients (41%). Nine of 73 (12%) patients were defined as indeterminate based on the 2016 algorithm. Using the ROC method, -18.1% of LV GLS determined the elevated LAP (AUC =0.79; specificity, 73%; sensitivity, 84%) with better sensitivity compared to that by the algorithm (AUC =0.76; specificity, 77%; sensitivity, 72%).

CONCLUSIONS

We demonstrated that LV GLS was an independent predictor of elevated LAP as the E/e' ratio and TR jet velocity and may be used as a major criterion for the diagnosis of HFpEF.

LA reservoir strain: a sensitive parameter for estimating LV filling pressure in patients with preserved EF

An elevated left ventricular (LV) filling pressure is the main finding in patients with heart failure with preserved ejection fraction (HFpEF), and LV filling pressure is estimated with an algorithm in the recent American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guideline. In this study, we sought to determine the efficacy of LA global longitudinal strain to estimate elevated LV filling pressure. Seventy-one consecutive patients (mean age of 63.2  ±  9.75, 70% male) who underwent left ventricular catheterization were included. Transthoracic echocardiography was performed within 24 h before catheterization. The LV filling pressure was estimated using echo parameters based on the 2016 ASE/EACVI algorithm. LA GLS was measured using 2D speckle tracking echocardiography in a four-chamber view (GE, Vivid E9 USA). Invasive LV pre-A pressure corresponding to the mean left atrial pressure (LAP) was used as a reference, and > 12 mm Hg was defined as elevated. Invasive LV filling pressure was defined as elevated in 41 (58%) and normal in 30 patients (42%). The LV filling pressure of 9 (13%) of 71 patients was defined as indeterminate based on the 2016 algorithm. Using the ROC method, 25.5% of LA reservoir strain (LASr) had a higher sensitivity (AUC = 0.79, specificity 77%, sensitivity 80%) in estimating LV filling pressure than the 2016 ASE/EACVI algorithm (AUC = 0.75, specificity 77%, sensitivity 70%). LASr, with higher sensitivity than 2016 ASE/EACVI algorithm, may be used as a single parameter to estimate LV filling pressure and hence may add incremental value toHFpEF diagnosis.

Hemodynamic and Clinical Implications of Impaired Pulmonary Vascular Reserve in the Fontan Circulation

BACKGROUND

Pulmonary vascular disease, pulmonary endothelial dysfunction, liver fibrosis, renal disease, and exercise intolerance are common in adults with Fontan physiology. Although the pathophysiologic mechanisms linking these phenomena have been studied, certain aspects are not well understood.

OBJECTIVES

This study hypothesized that impaired pulmonary vascular reserve (VR) plays a central role linking these abnormalities, and that patients with abnormal pulmonary VR with exercise, compared with patients with normal VR, would display poorer pulmonary endothelial function, greater liver stiffness, more renal dysfunction, and poorer exercise capacity.

METHODS

Symptomatic adults with the Fontan palliation (n = 29) underwent invasive cardiopulmonary exercise testing, echocardiography, and assessment of microvascular function. Abnormal pulmonary VR was defined by the slope of increase in pulmonary pressure relative to cardiac output with exercise >3 mm Hg/l/min. Pulmonary endothelial function was assessed using reactive hyperemia index. End-organ function was assessed using magnetic resonance elastography-derived liver stiffness, glomerular filtration rate, N-terminal pro-B-type natriuretic peptide, and peak oxygen consumption (Vo₂).

RESULTS

Compared with individuals with normal VR (n = 8), those with abnormal VR (n = 21) displayed higher central and pulmonary venous pressures, and more severely impaired cardiac output and stroke volume responses to exertion, but similar pulmonary vascular resistance at rest. Patients with abnormal VR displayed more severely impaired reactive hyperemia index, increased liver stiffness, lower glomerular filtration rate, higher N-terminal pro-B-type natriuretic peptide, and lower peak Vo₂. As compared to pulmonary vascular resistance at rest, slope of increase in pulmonary pressure relative to cardiac output displayed stronger correlations with reactive hyperemia index (r = -0.63 vs. r = -0.31; Meng test p = 0.009), magnetic resonance elastography-derived liver stiffness (r = 0.47 vs. r = 0.29; Meng test p = 0.07), glomerular filtration rate (r = -0.52 vs. r = -0.24; Meng test p = 0.03), N-terminal pro-B-type natriuretic peptide (r = 0.56 vs. r = 0.17; Meng test p = 0.02), and peak Vo₂ (r = -0.63 vs. r = -0.26; Meng test p = 0.02).

CONCLUSIONS

Pulmonary vascular limitations in Fontan physiology are related to pulmonary endothelial and end-organ dysfunction, suggesting a mechanistic link between these commonly observed findings, and these abnormalities are more apparent during exercise testing, with little relationship at rest.

Diagnosis and Management of Patients with Heart Failure with Preserved Ejection Fraction (HFpEF): Current Perspectives and Recommendations

Heart failure with preserved ejection fraction (HFpEF) is a major global public health problem. Diagnosis of HFpEF is still challenging and built based on the comprehensive echocardiographic analysis. Currently, there are no universally accepted therapies that alter the clinical course of HFpEF. This review attempts to summarize the current advances in the diagnosis of HFpEF and provide future directions of the patients´ management with this very widespread, heterogeneous clinical syndrome.

Tissue Doppler indices of diastolic function as prognosticator in patients without heart failure in primary care

BACKGROUND

Tissue Doppler imaging (TDI) indices of left ventricular (LV) diastolic function provide incremental prognostic information on mortality and morbidity in the general population and in several clinical scenarios. Their independent, additional role in outpatients with normal LV ejection fraction (LVEF) and without heart failure (HF) is undefined.

METHODS

We reviewed clinical and echocardiographic records of 2628 consecutive outpatients 52.8% male, median age 71 years) with LVEF > 50% without concurrent or prior HF, from the Cardiovascular Center of Trieste. We analyzed septal early mitral annular velocity (e') and its combination with mitral peak early filling velocity (E/e') in relation to the composite end-point of death and cardiovascular hospitalizations.

RESULTS

During follow-up of 26 months (interquartile range: 12-41), 392 (15%) patients experienced the endpoint (88 deaths). Increasing E/e' showed an overall association with the clinical end-point (log rank p < 0.02), but with no prognostic difference between the middle and upper tertile. Decreasing e' also showed an association with the end-point, with a more balanced stepwise risk increase for increasing tertiles (log rank p < 0.01 for all contrasts). At multivariable analysis, E/e' (either in tertiles or dichotomized according to the threshold of 15) was no longer associated with clinical outcome, whereas e' independently predicted the combined endpoint [hazard ratio 0.73 (0.53-0.94), p = 0.04]. The prognostic value of e' was incremental to that of other clinical and echocardiographic variables (p = 0.04).

CONCLUSIONS

In outpatients with normal LVEF and without HF, e' and E/e' are both associated with clinical end-points, though only e' is an independent and incremental predictor of outcome. These findings suggest a potential role for e' as a prognosticator, and spread a cautionary word about the utilization of septal E/e' alone as a surrogate for a comprehensive assessment of diastolic function in this context.

Use of speckle tracking to assess heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) currently represents approximately 50% of heart failure (HF) cases in the USA and is increasingly recognized as a leading cause of morbidity and mortality. Recent data suggest that the prevalence of HFpEF relative to HF with reduced ejection fraction (HFrEF) is increasing at a rate of 1% per year. With an aging population and increasing risk factors such as hypertension, obesity, and diabetes mellitus, HFpEF will soon be the most prevalent HF phenotype. Two-dimensional speckle-tracking echocardiography (STE) has been used to diagnose HFpEF specifically by focusing on the longitudinal systolic function of the left ventricle (LV). Yet there are many patients with HFpEF in whom there are no differences in LV global longitudinal systolic strain, but there are changes in left atrial function and structure. There are several proposed pathophysiological mechanisms for HFpEF such as endothelial dysfunction, interactions among proteins, signaling pathways, and myocardial bioenergetics. Yet only one specific therapy, mineralocorticoid receptor antagonist, spironolactone, is recommended as a treatment for patients with HFpEF. However, spironolactone does not address many of the pathophysiologic changes that occur in HFpEF, thus new novel therapeutic agents are needed. With the limited available therapies, clinicians should use STE to assess for the presence of this syndrome in their patients to provide effective diagnosis and management.

Heart failure prevalence in the general population: SOBOTA-HF study rationale and design

Aims

Epidemiological heart failure (HF) data in the era of natriuretic peptides and echocardiography are scarce. The primary aim of this study is to evaluate the HF prevalence in the general population. We will also investigate natriuretic peptide cut‐off for diagnosis of HF. Finally, we will be able to identify left ventricular function phenotypes and study relations between cardiac function, clinical presentation, and health‐related quality of life.

Methods and results

Screening Of adult urBan pOpulation To diAgnose Heart Failure (SOBOTA‐HF) is a cross‐sectional prevalence study in a representative sample of Murska Sobota residents aged 55 years or more. Individuals will be invited to attend screening visit with point‐of‐care N‐terminal pro‐b‐type natriuretic peptide (NT‐proBNP) testing. All subjects with NT‐proBNP ≥ 125 pg/mL will be invited for a diagnostic visit that will include history and physical examination, electrocardiogram, echocardiography, blood and urine sampling, ankle brachial index, pulmonary function tests, body composition measurement, physical performance tests, and questionnaires. To validate the screening procedure, a control group (NT‐proBNP < 125 pg/mL) will undergo the same diagnostic evaluation. An external centre will validate echocardiography results, and the HF diagnosis will be adjudicated within an international HF expert panel. Overall and age‐specific HF prevalence will be calculated in individuals ≥ 55 years and extrapolated to the whole population.

Conclusions

The SOBOTA‐HF study will test the latest HF guideline diagnostic criteria in the general population sample. Next to HF prevalence, it will provide insight into left ventricular function and general patient phenotype; we will also extend current understanding of natriuretic peptides for HF screening.