Real-time cardiovascular magnetic resonance imaging for non-invasive characterisation of heart failure with preserved ejection fraction: final outcomes of the HFpEF stress trial

Abstract

Background The diagnosis of heart failure with preserved ejection fraction (HFpEF) remains challenging. Recently, the HFpEF Stress Trial demonstrated feasibility and accuracy of non-invasive cardiovascular magnetic resonance (CMR) real-time (RT) exercise-stress atrial function imaging for early identification of HFpEF. However, no outcome data have yet been presented. Methods The HFpEF Stress Trial (DZHK-17) prospectively recruited 75 patients with dyspnea on exertion and echocardiographic preserved EF and signs of diastolic dysfunction (E/eʹ > 8). 68 patients entered the final study cohort and were characterized as HFpEF (n = 34) or non-cardiac dyspnea (n = 34) according to pulmonary capillary wedge pressure (HFpEF: PCWP rest: ≥ 15 mmHg stress: ≥ 25 mmHg). These patients were contacted by telephone and hospital charts were reviewed. The clinical endpoint was cardiovascular events (CVE). Results Follow-up was performed after 48 months; 1 patient was lost to follow-up. HFpEF patients were more frequently compared to non-cardiac dyspnea (15 vs. 8, p = 0.059). Hospitalised patients during follow-up had higher H2FPEF scores (5 vs. 3, p < 0.001), and impaired left atrial (LA) function at rest (p ≤ 0.002) and stress (p ≤ 0.006). Impairment of CMR-derived atrial function parameters at rest and during exercise-stress (p ≤ 0.003) was associated with increased likelihood for CVE. CMR-Feature Tracking LA Es/Ee (p = 0.016/0.017) and RT-CMR derived LA long axis strain (p = 0.003) were predictors of CVE independent of the presence of atrial fibrillation. Conclusions Left atrial function emerged as the strongest predictor for 4-year outcome in the HFpEF Stress Trial. A combination of rest and exercise-stress LA function quantification allows accurate diagnostic and prognostic stratification in HFpEF. Clinicaltrials.gov: NCT03260621. Graphical abstract

Assessment of the cardiac output at rest and during exercise stress using real-time cardiovascular magnetic resonance imaging in HFpEF-patients

“…While the need for invasive measurements of the CO can be dismissed using CMR, it might not necessarily become the standard of care, as the effort for the calculation of a simple parameter does not justify the conduction of a whole CMR scan. However, especially in HFpEF patients, CMR can provide important additional information for diagnosis and prognostication [ 9 , 29 , 30 , 31 ] and is being recommended for further evaluation diseases pathogenesis [ 32 ]. In these specific clinical indications, real-time rest and exercise stress calculation of the cardiac index can now provide additional reliable, and clinically useful information while avoiding unnecessary invasive procedures at the same time.…”

Rest and exercise-stress estimated pulmonary capillary wedge pressure using real-time free-breathing cardiovascular magnetic resonance imaging

“…The HFpEF-Stress trial identified changes in atrial longitudinal deformation, a functional parameter for atrial dysfunction, as highly predictive of LVFP and out-of-proportion increases in response to exercise-stress [15] . Indeed, atrial longitudinal deformation as a diagnostic and prognostic marker has come to the fore in an array of cardiovascular disease [15] , [24] , [25] , [26] , [27] . Hence, atrial function rather than size might more dynamically reflect changes in PCWP caused by exercise-stress induced congestion.…”

Impact of epicardial adipose tissue on cardiac function and morphology in patients with diastolic dysfunction

“…Epicardial adipose tissue (EAT) has emerged as an important risk factor in multiple diseases, while it seems to accelerate cardiac functional deterioration and increase the probability of adverse events. 1 , 2 , 3 , 4 Studies revealed that patients with increased EAT show haemodynamic alterations with functional impairment of both ventricles, as well as increased cardiac filling pressures at rest and during exercise stress with concomitantly reduced exercise capacity. 5 , 6 , 7 , 8 Furthermore, EAT directly impacts local cardiac structure 4 and is suspected to cause inflammation and remodelling, both playing a role in the development and progression of cardiovascular disease.…”