Fluctuation of Dynamic Diastolic Function Relative to Static Cardiac Structure - New Insights Into the Underlying Mechanism of Heart Failure With Preserved Ejection Fraction in Elderly Patients

Time-sensitive prognostic performance of an afterload-integrated diastolic index in heart failure with preserved ejection fraction: a prospective multicentre observational study

OBJECTIVES

The prognostic significance of an afterload-integrated diastolic index, the ratio of diastolic elastance (Ed) to arterial elastance (Ea) (Ed/Ea=[E/e']/[0.9×systolic blood pressure]), is valid for 1 year after discharge in older patients with heart failure with preserved ejection fraction (HFpEF). We aimed to clarify the association with changes in Ed/Ea from enrolment to 1 year and prognosis thereafter in patients with HFpEF.

SETTING

A prospective, multicentre observational registry of collaborating hospitals in Osaka, Japan.

PARTICIPANTS

We enrolled 659 patients with HFpEF hospitalised for acute decompensated heart failure (men/women: 296/363). Blood tests and transthoracic echocardiography were performed before discharge and at 1 year after.

PRIMARY OUTCOME MEASURES

All-cause mortality and/or re-admission for heart failure were evaluated after discharge.

RESULTS

High Ed/Ea assessed before discharge was a significant prognostic factor during the first, but not the second, year after discharge in all-cause mortality or all-cause mortality and/or re-admission for heart failure. When re-analysis was performed using the value of Ed/Ea at 1 year after discharge, high Ed/Ea was significant for the prognosis during the second year for both end points (p=0.012 and p=0.033, respectively). The poorest mortality during 1‒2 years after enrolment was observed in those who showed a worsening Ed/Ea during the first year associated with larger left ventricular mass index and reduced left ventricular ejection fraction. In all-cause mortality and/or re-admission for heart failure, the event rate during 1‒2 years was highest in those with persistently high Ed/Ea even after 1 year.

CONCLUSIONS

Time-sensitive prognostic performance of Ed/Ea, an afterload-integrated diastolic index, was observed in older patients with HFpEF.

TRIAL REGISTRATION NUMBER

UMIN000021831.

Impact of Afterload-Integrated Diastolic Indexon Prognosis in Elderly Patients with Heart Failure with Preserved Ejection Fraction with and without Atrial Fibrillation

Objects

We aimed to clarify the differences in the of the ratio of diastolic elastance (Ed) to arterial elastance (Ea), [Ed/Ea=(E/e')/(0.9×systolic blood pressure)], anafterload-integrateddiastolic index that reflects left atrial pressure overload, on prognosis between patients with heart failure with preserved ejection fraction (HFpEF) with and without atrial fibrillation (AF).

Methods

We studied 552 HFpEF patients hospitalized for acute decompensated heart failure (sinus rhythm/AF:352/200).Blood testing and transthoracic echocardiography were performed before discharge. Primary endpoint was all-cause mortality after discharge.

Results

During a median follow-up of 508 days, 88 patients (sinus rhythm/AF: 54/34) had all-cause mortality. In the subgroup with sinus rhythm, but not AF, Ed/Ea was significantly higher in patients with than without all-cause mortality. In a multivariate Cox hazard analysis, Ed/Ea was significantly associated with all-cause mortality independent of N-terminal pro-brain natriuretic peptide level in patients with sinus rhythm, but not with AF.

Conclusions

Ed/Ea providedlesser important information for predicting all-cause mortality in HFpEF patients with AF than with sinus rhythm. The prognostic risk factors may differ between elderly HFpEF patients with and without AF.

Left atrial pressure overload and prognosis in elderly patients with heart failure and preserved ejection fraction: a prospective multicenter observational study

OBJECTIVES

The severity of diastolic dysfunction is assessed using a combination of several indices of left atrial (LA) volume overload and LA pressure overload. We aimed to clarify which overload is more associated with the prognosis in patients with heart failure and preserved ejection fraction (HFpEF).

SETTING

A prospective, multicenter observational registry of collaborating hospitals in Osaka, Japan.

PARTICIPANTS

We enrolled hospitalised patients with HFpEF showing sinus rhythm (men, 79; women, 113). Blood tests and transthoracic echocardiography were performed before discharge. The ratio of diastolic elastance (Ed) to arterial elastance (Ea) was used as a relative index of LA pressure overload.

PRIMARY OUTCOME MEASURES

All-cause mortality and admission for heart failure were evaluated at >1 year after discharge.

RESULTS

In the multivariable Cox regression analysis, Ed/Ea, but not LA volume index, was significantly associated with all-cause mortality or admission for heart failure (HR 2.034, 95% CI 1.059 to 3.907, p=0.032), independent of age, sex, and the serum N-terminal pro-brain natriuretic peptide (NT-proBNP) level. In patients with a higher NT-proBNP level, the effect of higher Ed/Ea on prognosis was prominent (p=0.015).

CONCLUSIONS

Ed/Ea, an index of LA pressure overload, was significantly associated with the prognosis in elderly patients with HFpEF showing sinus rhythm.

TRIAL REGISTRATION NUMBER

UMIN000021831.

Considerable scatter in the relationship between left atrial volume and pressure in heart failure with preserved left ventricular ejection fraction

The index for a target that can lead to improved prognoses and more reliable therapy in each heterogeneous patient with heart failure with preserved ejection fraction (HFpEF) remains to be defined. We examined the heterogeneity in the cardiac performance of patients with HFpEF by clarifying the relationship between the indices of left atrial (LA) volume (LAV) overload and pressure overload with echocardiography. We enrolled patients with HFpEF (N = 105) who underwent transthoracic echocardiography during stable sinus rhythm. Relative LAV overload was evaluated using the LAV index or stroke volume (SV)/LAV ratio. Relative LA pressure overload was estimated using E/e' or the afterload-integrated index of left ventricular (LV) diastolic function: diastolic elastance (Ed)/arterial elastance (Ea) ratio = (E/e')/(0.9 × systolic blood pressure). The logarithmic value of the N-terminal pro-brain natriuretic peptide was associated with SV/LAV (r = -0.214, p = 0.033). The pulmonary capillary wedge pressure was positively correlated to Ed/Ea (r = 0.403, p = 0.005). SV/LAV was negatively correlated to Ed/Ea (r = -0.292, p = 0.002), with no observed between-sex differences. The correlations between the LAV index and E/e' and Ed/Ea and between SV/LAV and E/e' were less prominent than the abovementioned relationships. SV/LAV and Ed/Ea, showing relative LAV and LA pressure respectively, were significantly but modestly correlated in patients with HFpEF. There may be considerable scatter in the relationships between these indices, which could possibly affect the selection of medications or efforts to improve the prognoses of patients with HFpEF.

Sex-related differences in left ventricular diastolic function and arterial elastance during admission in patients with heart failure with preserved ejection fraction: The PURSUIT HFpEF study

BACKGROUND

We previously reported that an index of afterload-related left ventricular diastolic function, operant diastolic elastance (Ed)/effective arterial elastance (Ea) = E/e'/(0.9 × systolic blood pressure), was significantly higher in elderly hypertensive women. We aimed to determine sex-related differences in the E/e'-related indices for left ventricular diastolic function and their related factors during admission in patients with heart failure with preserved ejection fraction (HFpEF).

HYPOTHESIS

Elderly HFpEF women exhibit severe left ventricular diastolic dysfunction associated with different left atrioventricular volume ratio.

METHODS

We divided 267 patients with HFpEF (men/women, 116/151) into two groups by age (≥75 years, n = 212; <75 years, n = 55). We examined the alterations of E/e', E/e'/stroke volume index = Ed, and Ed/Ea, and cardiac structure during admission.

RESULTS

Ed and Ea were significantly higher in women than in men, at admission, especially in patients ≥75 years. Before discharge, not only Ed and Ea but also Ed/Ea was significantly higher in women than in men, especially in patients ≥75 years. Elderly female patients had larger left atrial than left ventricular volume.

CONCLUSIONS

Higher afterload-related left ventricular diastolic elastance, Ed/Ea, in association with higher arterial elastance, Ea, accompanied by left atrioventricular volume mismatch was observed in elderly HFpEF women.

Transient manifestation of left ventricular diastolic dysfunction following ablation in patients with paroxysmal atrial fibrillation

BACKGROUND

In patients with atrial fibrillation, ablation decreases left atrial (LA) compliance, which may lead to left ventricular (LV) diastolic dysfunction. We aimed to examine serial changes in LV diastolic function after 2 ablation procedures and their related factors in patients with paroxysmal atrial fibrillation (PAF).

HYPOTHESIS

LV diastolic function is different after 2 ablation procedures.

METHODS

We enrolled 132 patients with PAF (76 males, mean age 67 years; cryoballoon [CB] ablation/radiofrequency [RF] ablation 60/72) who underwent a single ablation procedure. The transthoracic echocardiographic parameters were obtained before, 3 days after, and 6 months after ablation.

RESULTS

The afterload-related index of LV diastolic function, Ed/Ea = E/e' / (0.9 × systolic blood pressure), increased significantly at 3 days after ablation, especially after CB ablation (P <0.05), although no differences were observed in age, sex, LA size, LV size, and E/e' before ablation between CB ablation and RF ablation. Creatine kinase release after ablation was significantly higher in CB ablation than in RF ablation (P <0.001). The increment of Ed/Ea after CB ablation was positively correlated with LV ejection fraction (LVEF) before ablation (r =0.416; P <0.05). The elderly (age ≥ 75 years), females, and patients with hypertension were more likely to show impaired LV diastolic function transiently after 3 days of ablation, but the diastolic index was restored to baseline level after 6 months.

CONCLUSIONS

The increased Ed/Ea after CB ablation represented transient manifestation of underlying LV diastolic dysfunction in PAF patients with preserved LVEF with older age, female sex, and a history of hypertension.

Prognostic impact of reducing myocardial ischemia identified using ECG-gated myocardial perfusion SPECT in Japanese patients with coronary artery disease: J-ACCESS 4 study

AIM

Whether myocardial ischemia identified using myocardial perfusion imaging (MPI) can be an alternative target of coronary revascularization to reduce the incidence of cardiac events remains unclear.

METHODS AND RESULTS

This multicenter, prospective cohort study aimed to clarify the prognostic impact of reducing myocardial ischemia. Among 494 registered patients with possible or definite coronary artery disease (CAD), 298 underwent initial pharmacological stress ^99mTc-tetrofosmin MPI before, and eight months after revascularization or medical therapy, and were followed up for at least one year. Among these, 114 with at least 5% ischemia at initial MPI were investigated. The primary endpoints were cardiac death, non-fatal myocardial infarction and hospitalization for heart failure. Ischemia was reduced ≥5% in 92 patients. Coronary revascularization reduced ischemia (n = 89) more effectively than medical therapy (n = 25). Post-stress cardiac function also improved after coronary revascularization. Ejection fraction significantly improved at stress (61.0% ± 10.7% vs. 65.4% ± 11.3%; p < 0.001) but not at rest (67.1% ± 11.3% vs. 68.3% ± 11.6%; p = 0.144), among patients who underwent revascularization. Rates of coronary revascularization and cardiac events among the 114 patients were significantly higher (13.6%, p = 0.035) and lower (1.1% p = 0.0053), respectively, in patients with, than without ≥5% ischemia reduction. Moreover, patients with complete resolution of ischemia at the time of the second MPI had a significantly better prognosis.

CONCLUSIONS

Reducing ischemia by ≥5% and the complete resolution of ischemia could improve the prognosis of patients with stable CAD.