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Maeder MT, Weber L, Buser M, Brenner R, Joerg L, Rickli H. Pulmonary Hypertension in Patients With Heart Failure With Mid-Range Ejection Fraction. Front Cardiovasc Med 2021; 8:694240. [PMID: 34307506 PMCID: PMC8298862 DOI: 10.3389/fcvm.2021.694240] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/15/2021] [Indexed: 12/12/2022] Open
Abstract
Pulmonary hypertension (PH) is common in patients with heart failure (HF). The role of PH in patients with HF with reduced (HFrEF) and preserved (HFpEF) left ventricular ejection fraction (LVEF) has been extensively characterized during the last years. In contrast, the pathophysiology of HF with mid-range LVEF (HFmrEF), and in particular the role of PH in this context, are largely unknown. There is a paucity of data in this field, and the prevalence of PH, the underlying mechanisms, and the optimal therapy are not well-defined. Although often studied together there is increasing evidence that despite similarities with both HFrEF and HFpEF, HFmrEF also differs from both entities. The present review provides a summary of the current concepts of the mechanisms and clinical impact of PH in patients with HFmrEF, a proposal for the non-invasive and invasive diagnostic approach required to define the pathophysiology of PH and its management, and a discussion of future directions based on insights from mechanistic studies and randomized trials. We also provide an outlook regarding gaps in evidence, future clinical challenges, and research opportunities.
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Affiliation(s)
- Micha T Maeder
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Lukas Weber
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marc Buser
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Roman Brenner
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Lucas Joerg
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Hans Rickli
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
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Maeder MT, Weber L, Ammann P, Buser M, Ehl NF, Gerhard M, Brenner R, Haager PK, Maisano F, Rickli H. Relationship between B-type natriuretic peptide and invasive haemodynamics in patients with severe aortic valve stenosis. ESC Heart Fail 2020; 7:577-587. [PMID: 31994357 PMCID: PMC7160488 DOI: 10.1002/ehf2.12614] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/22/2019] [Accepted: 12/23/2019] [Indexed: 11/08/2022] Open
Abstract
AIMS In patients with aortic stenosis (AS), B-type natriuretic peptide (BNP) is a prognostic marker. However, there is little information on the association between BNP and invasive haemodynamics in AS. The aim of the present study was to assess the hitherto not well-defined relationship between BNP and invasive haemodynamics in patients with severe AS undergoing aortic valve replacement (AVR) with a view to understand the link between high BNP and poor prognosis in these patients. In particular, we were interested in the association between BNP and combined pre-capillary and post-capillary pulmonary hypertension (CpcPH). METHODS AND RESULTS BNP was measured in 252 patients (age 74 ± 10 years, 58% male patients) with severe AS [indexed aortic valve area 0.4 ± 0.1 cm2 /m2 and left ventricular ejection fraction (LVEF) 57 ± 12%] the day before cardiac catheterization. Patients were followed for a median (interquartile range) period of 3.1 (2.3-4.3) years after surgical (n = 157) or transcatheter (n = 95) AVR. The prevalence of CpcPH (mean pulmonary artery pressure ≥ 25 mmHg, mean pulmonary artery wedge pressure > 15 mmHg, and pulmonary vascular resistance > 3 Wood units) was 13%. The median BNP plasma concentration was 188 (78-452) ng/L. The indexed aortic valve area was similar across BNP quartiles (P = 0.21). Independent predictors of higher BNP (ln transformed) included lower haemoglobin (beta = -0.18; P < 0.001), lower LVEF (beta = -0.20; P < 0.001), more severe mitral regurgitation (beta = 0.20; P < 0.001), higher mean pulmonary artery wedge pressure (beta = -0.37; P < 0.001), and higher pulmonary vascular resistance (beta = 0.21; P < 0.001). In a multivariate model with CpcPH rather than its haemodynamic components, CpcPH was independently associated with higher BNP (0.21; P < 0.001). Higher ln BNP was associated with higher mortality [hazard ratio 1.90 (95% confidence interval 1.33-2.71); P < 0.001] in the univariate analysis. Patients in the third and fourth BNP quartiles had a more than six-fold risk of death compared with patients in the first and second quartiles [hazard ratio 6.29 (95% confidence interval 1.86-21.27); P = 0.003]. In the multivariate analysis, lower LVEF [hazard ratio 0.96 (95% confidence interval 0.94-0.99) per 1% increase; P = 0.01] and CpcPH [hazard ratio 4.58 (95% confidence interval 1.89-11.09); P = 0.001] but not BNP were independently associated with mortality. The areas under the receiver operator characteristics curve for BNP for the prediction of CpcPH and mortality were 0.88 and 0.74, respectively. CONCLUSIONS In patients with severe AS, higher BNP is a marker of the presence of CpcPH and its contributors. The association between BNP and such an adverse haemodynamic profile at least in part explains the ability of BNP to predict long-term post-AVR mortality.
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Affiliation(s)
- Micha T Maeder
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, St. Gallen, 9007, Switzerland
| | - Lukas Weber
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, St. Gallen, 9007, Switzerland.,Department of Internal Medicine, Spital Rorschach, St. Gallen, Switzerland
| | - Peter Ammann
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, St. Gallen, 9007, Switzerland
| | - Marc Buser
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, St. Gallen, 9007, Switzerland
| | - Niklas F Ehl
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, St. Gallen, 9007, Switzerland
| | - Marc Gerhard
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, St. Gallen, 9007, Switzerland
| | - Roman Brenner
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, St. Gallen, 9007, Switzerland
| | - Philipp K Haager
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, St. Gallen, 9007, Switzerland
| | - Francesco Maisano
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Hans Rickli
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, St. Gallen, 9007, Switzerland
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Kaye DM, Silvestry FE, Gustafsson F, Cleland JG, van Veldhuisen DJ, Ponikowski P, Komtebedde J, Nanayakkara S, Burkhoff D, Shah SJ. Impact of atrial fibrillation on rest and exercise haemodynamics in heart failure with mid-range and preserved ejection fraction. Eur J Heart Fail 2017; 19:1690-1697. [DOI: 10.1002/ejhf.930] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/01/2017] [Accepted: 06/04/2017] [Indexed: 11/09/2022] Open
Affiliation(s)
- David M. Kaye
- Alfred Hospital and Baker IDI Heart & Diabetes Institute; Melbourne Australia
| | | | | | - John G. Cleland
- National Heart & Lung Institute; Royal Brompton and Harefield Hospitals, Imperial College; London UK
| | | | | | | | - Shane Nanayakkara
- Alfred Hospital and Baker IDI Heart & Diabetes Institute; Melbourne Australia
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