Echocardiographic estimation of left ventricular and pulmonary pressures in patients with heart failure and preserved ejection fraction: a study utilizing simultaneous echocardiography and invasive measurements

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Aims Left atrial (LA) mechanical function may play a significant role in the development and progression of heart failure with preserved ejection fraction (HFpEF). We performed a systematic review and meta‐analysis to evaluate association of impaired LA function with outcomes in HFpEF. Methods and results Multiple databases were searched for original studies measuring different phases of LA function in HFpEF patients. Comparative LA function between HFpEF patients and healthy controls was assessed by pooling weighted mean differences (WMD). Adjusted hazard ratios (HRs) with 95% confidence intervals were pooled to evaluate the prognostic utility of LA function. Twenty‐two studies (2 trials, 20 observational) comprising 1974 HFpEF patients and 751 healthy controls were included. HFpEF patients had decreased LA reservoir [WMD = −12.21% (−15.47, −8.95); P < 0.001], LA conduit [WMD = −5.68% (−8.56, −2.79); P < 0.001], and pump [WMD = −11.07% (−14.81, −7.34); P < 0.001] emptying fractions compared with controls. LA reservoir [WMD = −13.38% (−16.07, −10.68); P < 0.001], conduit [WMD = −4.09% (−6.77, −1.42); P = 0.003], and pump [WMD = −3.53% (−4.47, −2.59); P < 0.001] strains were also significantly lower in HFpEF patients. Decreased LA reservoir strain [HR 1.24 (1.02, 1.50); P = 0.03] was significantly associated with risk of composite all‐cause mortality or heart failure hospitalization. Conclusions Impaired LA function appears to have diagnostic and prognostic value in HFpEF, but whether indices of LA function truly refine discrimination for diagnosis or prognosis remains to be fully determined. Larger studies are needed to better evaluate associations between LA function and clinical outcomes and the role of LA function as a target for novel HFpEF therapies.

Section: Discussionmentioning

confidence: 86%

Left atrial function in heart failure with preserved ejection fraction: a systematic review and meta‐analysis

Khan

Memon

Murad

et al. 2020

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“…There is controversy about the best non‐invasive indicators of elevated LV filling pressures and mPCWP 287 . The E / e ′ index has gained a supremacy in clinical practice that is not fully supported by all clinical investigations 288 , 289 . The diagnostic utility of alternative indices such as retrograde pulmonary venous flow, 290 , 291 estimated LV stiffness (diastolic pressure–volume quotient), 284 and LA strain rate during atrial contraction 74 , 161 , 276 , 292 in patients in SR, and the L wave of mitral inflow 293 and LA strain during reservoir function 160 , 294 in patients in AF, merit further investigation.…”

Section: Calculating and Interpreting The Hfa–peff Scorementioning

confidence: 99%

How to diagnose heart failure with preserved ejection fraction: the HFA–PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Pieske

Tschöpe

Boer

et al. 2020

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418

643

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the ‘HFA–PEFF diagnostic algorithm’. Step 1 (P=Pre‐test assessment) is typically performed in the ambulatory setting and includes assessment for heart failure symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non‐cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular (LV) ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e′), LV filling pressure estimated using E/e′, left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2–4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

“…Clinical history such as recurrent heart failure hospitalizations, and the physician's impression from the patient encounter are critical. An expanding spectrum of parameters are available from echocardiography and other imaging modalities, and they may serve not only for prognostication but also to guide patient management, gradually taking the place of right heart catheterization, though with some limitations . Invasive haemodynamic assessment does not improve the accuracy of heart failure prognostication, but it is a critical component of the work‐up for potential heart transplantation or long‐term MCS recipients.…”

Section: Prognostic Stratificationmentioning

confidence: 99%

“…An expanding spectrum of parameters are available from echocardiography and other imaging modalities, and they may serve not only for prognostication but also to guide patient management, gradually taking the place of right heart catheterization, though with some limitations. 128,129 Invasive haemodynamic assessment does not improve the accuracy of heart failure prognostication, but it is a critical component of the work-up for potential heart transplantation or long-term MCS recipients. It allows an accurate estimate of important parameters, such as the pulmonary capillary wedge pressure, pulmonary vascular resistance, transpulmonary gradient, and adds to the assessment of right ventricular function.…”

Section: Prognostic Stratificationmentioning

confidence: 99%

Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology

Crespo-Leiro

Metra

Lund

et al. 2018

680

605

This article updates the Heart Failure Association of the European Society of Cardiology (ESC) 2007 classification of advanced heart failure and describes new diagnostic and treatment options for these patients. Recognizing the patient with advanced heart failure is critical to facilitate timely referral to advanced heart failure centres. Unplanned visits for heart failure decompensation, malignant arrhythmias, co-morbidities, and the 2016 ESC guidelines criteria for the diagnosis of heart failure with preserved ejection fraction are included in this updated definition. Standard treatment is, by definition, insufficient in these patients. Inotropic therapy may be used as a bridge strategy, but it is only a palliative measure when used on its own, because of the lack of outcomes data. Major progress has occurred with short-term mechanical circulatory support devices for immediate management of cardiogenic shock and long-term mechanical circulatory support for either a bridge to transplantation or as destination therapy. Heart transplantation remains the treatment of choice for patients without contraindications. Some patients will not be candidates for advanced heart failure therapies. For these patients, who are often elderly with multiple co-morbidities, management of advanced heart failure to reduce symptoms and improve quality of life should be emphasized. Robust evidence from prospective studies is lacking for most therapies for advanced heart failure. There is an urgent need to develop evidence-based treatment algorithms to prolong life when possible and in accordance with patient preferences, increase life quality, and reduce the burden of hospitalization in this vulnerable patient population.