Zooming in on the Microvasculature in Heart Failure With Preserved Ejection Fraction

Mohammed, Selma F.; Majure, David T.; Redfield, Margaret M.

doi:10.1161/circheartfailure.116.003272

Cited by 29 publications

(21 citation statements)

References 23 publications

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“…Recent studies, editorial commentaries and reviews have begun to embrace the potential importance of CMD in the pathophysiology of HFpEF . In an autopsy study, patients with HFpEF displayed a higher prevalence of microscopic hypertrophy, coronary microvascular rarefaction, and fibrosis than age‐matched controls .…”

Section: Discussionmentioning

confidence: 99%

“…Recent studies, editorial commentaries and reviews have begun to embrace the potential importance of CMD in the pathophysiology Table 4 Cardiac structure, function, and intracoronary haemodynamics in heart failure with preserved ejection fraction patients with and without endothelium-independent coronary microvascular dysfunction 2.81, 95% CI 0.94-8.34, P=0. 3.56, 95% CI 1.14-11.12, P=0 of HFpEF. 1,2,[4][5][6][7][8][9]11,14,26 In an autopsy study, patients with HFpEF displayed a higher prevalence of microscopic hypertrophy, coronary microvascular rarefaction, and fibrosis than age-matched controls. 2 In patients with HFpEF but no significant epicardial coronary disease, plasma high-sensitivity troponins, markers of cardiac injury, were found to be more than twofold higher in subjects with HFpEF at rest, with even greater separation during exercise compared with control subjects.…”

Section: Coronary Microvascular Dysfunction and Hfpefmentioning

confidence: 99%

“…While clinical cardiology originally focused on diseases of the large epicardial conduit arteries, myocardial perfusion is importantly determined by structure and function of the coronary microvasculature and capillaries . An increasing number of studies have shown that coronary microvascular dysfunction (CMD) plays an important role in many cardiovascular diseases, including heart failure with preserved ejection fraction (HFpEF) . In this patient cohort, CMD has been demonstrated histologically, via imaging techniques, and invasively .…”

Section: Introductionmentioning

confidence: 96%

“…1 An increasing number of studies have shown that coronary microvascular dysfunction (CMD) plays an important role in many cardiovascular diseases, including heart failure with preserved ejection fraction (HFpEF). [1][2][3][4][5][6][7][8][9][10][11][12] In this patient cohort, CMD has been demonstrated histologically, 2,3 via imaging techniques, [4][5][6] and invasively. 7 By impairing myocardial blood supply, CMD may promote cardiomyocyte injury, leading to impairments in cardiac functional reserve and adverse haemodynamics that promote symptoms and disability in HFpEF, 12 while increasing interstitial fibrosis when blood supply is impaired chronically.…”

Section: Introductionmentioning

confidence: 99%

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Endothelium‐dependent and independent coronary microvascular dysfunction in patients with heart failure with preserved ejection fraction

Yang

Obokata

Reddy

et al. 2019

European J of Heart Fail

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115

103

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Background Coronary microvascular inflammation is hypothesized to play a fundamental role in the pathophysiology of heart failure with preserved ejection fraction (HFpEF). No study has directly evaluated both endothelium‐dependent and independent coronary microvascular function in HFpEF. Methods and results Consecutive patients with HFpEF undergoing invasive coronary physiologic testing and echocardiography were examined. Endothelial function was quantified by the increase in coronary blood flow in response to intracoronary infusion of acetylcholine (10−6–10−4 mol/L) using a Doppler flow wire with quantitative angiography. Endothelium‐independent coronary microvascular function was assessed by the hyperaemic increase in coronary flow reserve in response to adenosine infusion. Among 162 HFpEF patients (67% women), coronary microvascular function was abnormal in 117 (72%). Isolated endothelium‐dependent microvascular dysfunction was present in 47 patients (29%), isolated endothelium‐independent microvascular dysfunction in 53 patients (33%), and combined microvascular dysfunction in 17 patients (10%). The presence of coronary microvascular dysfunction was not identifiable from medical co‐morbidities or other clinical characteristics. As compared to patients with normal endothelium‐independent function, HFpEF patients with endothelium‐independent coronary microvascular dysfunction displayed lower diastolic relaxation velocities (7.0 ± 1.8 vs. 8.4 ± 2.9 cm/s, P = 0.002) and higher estimated filling pressures (E/e' 13.1 ± 4.1 vs. 9.6 ± 3.4, P < 0.001). There were no relationships between left ventricular structure, function, or haemodynamics and endothelium‐dependent coronary vasodilatation. Endothelium‐independent microvascular dysfunction was associated with increased mortality. Conclusions Coronary microvascular dysfunction is common in patients with HFpEF and is caused equally by endothelium‐dependent and independent mechanisms, but the presence of microvascular dysfunction cannot be identified from clinical markers and co‐morbidities alone. Patients with HFpEF and endothelium‐independent microvascular dysfunction display worse diastolic dysfunction and outcomes.

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Section: Discussionmentioning

confidence: 99%

Section: Coronary Microvascular Dysfunction and Hfpefmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 96%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Endothelium‐dependent and independent coronary microvascular dysfunction in patients with heart failure with preserved ejection fraction

Yang

Obokata

Reddy

et al. 2019

European J of Heart Fail

Self Cite

115

103

View full text Add to dashboard Cite

show abstract

“…18 This patient displayed evidence for coronary microvascular dysfunction, which has increasingly been recognized as an important contributor to HFpEF. 19,20 Even with anatomically normal epicardial coronary arteries on angiography, microvascular dysfunction may lead to subendocardial ischemia, which is associated with the severity of diastolic dysfunction, elevation in filling pressures, and impairments in functional capacity in patients with HFpEF. 21…”

Section: Interpretation and Discussionmentioning

confidence: 99%

Hemodynamic assessment in heart failure

Jain

Borlaug

2019

Cathet Cardio Intervent

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Hemodynamics play a central role in the pathophysiology of heart failure (HF), yet their proper assessment and optimization remains challenging. Heart failure is defined as the inability of the heart to deliver adequate perfusion (cardiac output) to the body at rest or exercise, or to require an elevation in cardiac filling pressures in order to do this. This bedrock definition is important because it relies on measurable quantities (filling pressures and output) that are readily assessed in the cardiac catheterization laboratory. Here we present three cases to illustrate how better understanding of the determinants of cardiac output and stroke volume: preload, afterload, contractility, and lusitropy, as well as the determinants of congestion (high filling pressures) may be used to guide optimization of hemodynamic status. The goal is that the readers will be able to think more critically when evaluating the hemodynamics of their patient in HF and recognize the complex interplay that determines the complex balance between cardiac ejection and filling capabilities, and how this alters symptoms and outcomes for patients with HF. Key Points Careful assessment of hemodynamics in the catheterization laboratory allows for actionable insight to a patient's volume status, cardiac function and can help prognosticate outcomes. Exercise hemodynamics in heart failure is a powerful tool to better understand the cause of symptoms and predict outcomes. Clinicians should aim to decrease biventricular filling pressures to normal values to improve morbidity and reduce risk for readmission. In patients with heart failure and reduced ejection fraction, clinicians should aim to decrease afterload as much as can be tolerated by the renal function and patient's symptoms. Low cardiac output can often be improved by optimizing preload and afterload rather than initiating inotropes, which should be reserved until needed. In advanced heart failure, the right heart function becomes a key determinant of symptoms and outcomes.

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Prognostic significance of high-sensitivity cardiac troponin in patients with heart failure with preserved ejection fraction

et al. 2019

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The aim of this study was to investigate the prognostic significance of high-sensitivity troponin T (hs-TnT) in patients with heart failure (HF) with preserved ejection fraction (HFpEF). We enrolled consecutive patients admitted to Shinshu University Hospital for HF treatment between July 2014 and March 2017 and stratified them into HF with reduced ejection fraction and HFpEF groups (left ventricular ejection fraction, < 50% and ≥ 50%, respectively). Hs-TnT was evaluated at discharge, and patients were prospectively monitored for all-cause mortality, non-fatal myocardial infarction, stroke, and HF hospitalization. In 155 enrolled patients (median age 76 years), during a median follow-up of 449 days, 60 experienced an adverse event. Hs-TnT was significantly higher in patients with adverse events than in those without in HFpEF ( p = 0.003). Hs-TnT did not significantly correlate with age, sex, hemoglobin, albumin, eGFR, or BNP. In Kaplan–Meier analysis, high hs-TnT predicted a poor prognosis in HFpEF ( p = 0.003). In multivariate Cox regression analysis, hs-TnT levels independently predicted adverse events in HFpEF ( p = 0.003) after adjusting for age and eGFR [HR, 1.015 (95% CI, 1.005–1.025), p = 0.004], and age and BNP [HR 1.016 (95% CI 1.005–1.027), p = 0.005]. Elevated hs-TnT at discharge predicted adverse events in HFpEF.

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Zooming in on the Microvasculature in Heart Failure With Preserved Ejection Fraction

Cited by 29 publications

References 23 publications

Endothelium‐dependent and independent coronary microvascular dysfunction in patients with heart failure with preserved ejection fraction

Endothelium‐dependent and independent coronary microvascular dysfunction in patients with heart failure with preserved ejection fraction

Hemodynamic assessment in heart failure

Prognostic significance of high-sensitivity cardiac troponin in patients with heart failure with preserved ejection fraction

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