Abstract 15161: Increased Right Atrial Stiffness in Patients With Heart Failure With Preserved Ejection Fraction and Pulmonary Hypertension

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Jessie van Wezenbeek ◽  
Arno van der Bovenkamp ◽  
Jeroen N Wessels ◽  
Sophia-Anastasia Mouratoglou ◽  
Marie Jose Goumans ◽  
...  
Keyword(s):  
Heart Failure ◽  
Pulmonary Hypertension ◽  
Ejection Fraction ◽  
Right Heart Catheterization ◽  
Right Atrial ◽  
Heart Catheterization ◽  
Preserved Ejection Fraction ◽  
Chamber View ◽  
Patients With Heart Failure ◽  
Pulmonary Arterial

Background: Patients with Heart Failure with preserved Ejection Fraction (HFpEF) and Pulmonary Hypertension (PH) have increased right atrial (RA) pressures. Whether the higher RA pressures are related to increased afterload or overall stiffening of the heart is unknown. The aim of this study is to gain further insight into the right atrium in HFpEF-PH. Methods: This is a retrospective analysis of patients with HFpEF (no PH), HFpEF-PH and Pulmonary Arterial Hypertension (PAH) that underwent right heart catheterization and cardiac magnetic resonance (CMR) imaging. CMR was used to determine RA function by quantifying volume and strain on the 4-chamber view. Total, passive and active RA emptying fraction (RAEF) were calculated. RA stiffness was calculated by determining the slope of maximum and minimum pressure during v-wave and minimal and maximal RA volumes. Groups were compared with ANOVA and post-hoc comparison with Bonferroni correction. Results: 176 patients were included: 13 HFpEF, 33 HFpEF-PH and 130 PAH patients. Although afterload was lower in PAH and higher in HFpEF patients, as shown by mean pulmonary arterial pressure (mPAP) (41 ± 2 mmHg in HFpEF-PH vs 53 ± 21 mmHg in PAH vs 19 ± 1 mmHg in HFpEF, p<0.001) and pulmonary vascular resistance (PVR) (2.3 ± 0.3 wu/m 2 in HFpEF-PH vs 5.7 ± 0.2 wu/m 2 in PAH vs 0.4 ± 0.06 wu/m 2 in HFpEF, p<0.001), mean RA pressure was significantly higher in HFpEF-PH patients compared to both groups (Figure 1A). HFpEF-PH patients had significantly increased RA stiffness compared to HFpEF and PAH patients (Figure 1B). Total RAEF was reduced in HFpEF-PH compared to PAH and HFpEF patients: passive RAEF was similar, but active RAEF was slightly reduced in HFpEF-PH (Figure 1C). This was in line with measurements of RA longitudinal strain (Figure 1D). Conclusions: Despite lower afterload, HFpEF-PH patients have worse RA function and increased RA stiffness compared to PAH. Higher RA pressures in HFpEF-PH may reflect additional stiffening of the heart.

Abstract 19944: Targeted Therapy of Pulmonary Hypertension in Patients With Heart Failure and Preserved Ejection Fraction: Safety and Efficacy in Comparison to IPAH in Compera

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Stephan Rosenkranz ◽  
Marius M Hoeper ◽  
Doerte Huscher ◽  
David Pittrow ◽  
Christian F Opitz
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Pulmonary Hypertension ◽  
Ejection Fraction ◽  
Preserved Ejection Fraction ◽  
Evidence Based Treatment ◽  
Patients With Heart Failure ◽  
Venous Oxygen Saturation ◽  
Initial Ph ◽  
Pulmonary Arterial

Background: While targeted therapies are available for idiopathic pulmonary arterial hypertension (IPAH), evidence based treatment recommendations for pulmonary hypertension (PH) associated with heart failure and preserved ejection fraction (HFpEF) are lacking. Methods and Results: Out of 5,935 patients in the prospective COMPERA registry, we analyzed patients with “typical” IPAH (n=421, ≤2 of the following risk factors: BMI >30 kg/m2, hypertension, CAD, diabetes and atrial fibrillation at the time of diagnosis), “atypical” IPAH (n=139, >2 risk factors) or PH-HFpEF (n=226) who received targeted PH therapies. Patients with PH-HFpEF, when compared to “typical” and “atypical” IPAH were older (73±8 vs. 62±17 and 71±9 years), had a higher BMI (30 vs. 26 and 32 kg/m2), and more comorbidities (98% vs. 73% and 100%, all p<0.001), respectively. However, mean PAP (46±9 vs. 47±13 and 44±11 mmHg), cardiac index (2.2±0.7 vs. 2,3±0,8 and 2,2±0,8 l/min), and mixed venous oxygen saturation (62±7 vs. 62±10 and 63±9%, all ns) were almost identical. As compared to “typical” and “atypical” IPAH, PH-HFpEF patients had a higher PAWP (20±4 vs. 9±3 and 10±4 mmHg), resulting in a lower calculated PVR (559±270 vs. 861±477 and 784±844 dyn.s.cm-5). Survival at 1, 2 and 3 years post diagnosis was not different between groups. PDE-5 inhibitors were the most common form of initial PH treatment in PH-HFpEF (94%), and combination therapy was less common compared to “typical” or “atypical” IPAH at 1 year (7% vs. 44% and 26%). All 3 groups responded to targeted PH therapies at 12 months, while treatment effects were less pronounced in PH-HFpEF: Compared to baseline, the median increase of the 6MWD at 1 year was 29, 50, and 60 m, respectively. Treatment discontinuations occurred more frequently in patients with PH-HFpEF than in IPAH, either because of side effects or lack of improvement. Conclusions: Despite almost identical alterations of pulmonary artery pressure and cardiac output, patients with PH-HFpEF differed with respect to age, comorbidities and certain hemodynamic features when compared to “typical” or “atypical” IPAH. All groups responded to targeted PH therapy, however tolerability and efficacy of PH drugs were reduced in patients with PH-HFpEF while survival was not different.

scholarly journals 138 Exercise haemodynamics in heart failure with preserved ejection fraction: a systematic review and meta-analysis

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Claudia Baratto ◽  
Sergio Caravita ◽  
Davide Soranna ◽  
Céline Dewachter ◽  
Antoine Bondue ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Body Position ◽  
Meta Analysis ◽  
Right Heart Catheterization ◽  
Standard Test ◽  
Right Atrial ◽  
Peak Exercise ◽  
Heart Catheterization ◽  
Preserved Ejection Fraction

Abstract Aims Exercise right heart catheterization (RHC) is considered the gold-standard test to diagnose heart failure with preserved ejection fraction (HFpEF). However, exercise RHC is an insufficiently standardized technique, and current haemodynamic thresholds to define HFpEF are not universally accepted. We sought to describe the exercise haemodynamics profile of HFpEF cohorts reported in literature, as compared with control subjects. Methods and results We performed a systematic literature review until December 2020. Studies reporting pulmonary artery wedge pressure (PAWP) at rest and peak exercise were extracted. Summary estimates of all haemodynamic variables were evaluated, stratified according to body position (supine/upright exercise), and the PAWP/cardiac output (CO) slope during exercise was extrapolated. Twenty-eight studies were identified, providing data for 2230 HFpEF patients and 706 controls. At peak exercise, patients with HFpEF achieved higher PAWP [30 (29–31) vs. 16 (15–17) mmHg, P &lt; 0.001] and mean right atrial pressure (P &lt; 0.001) than controls. These differences persisted after adjustment for age, sex, body mass index, body position. However, peak PAWP values were highly heterogeneous among the cohorts, with a relative overlap with controls. PAWP/CO slope was steeper in HFpEF than in controls [3.81 (3.24–4.38) vs. 0.91 (0.24–1.58) mmHg/l/min, P &lt; 0.001], even after adjustment for covariates (P = 0.020) (Figure). Conclusions The haemodynamic profile of HFpEF patients is consistent across studies and characterized by a higher left and right filling pressure at rest, magnified by physical exercise. Our analysis strongly suggests that PAWP/CO slope might allow for a more consistent identification of HFpEF, irrespective of body position. This variable likely overcomes the shortcomings of an isolated peak PAWP measurement, allowing for a more univocal identification of HFpEF in patients with unexplained dyspnoea.

scholarly journals Right Ventricular and Right Atrial Function Are Less Compromised in Pulmonary Hypertension Secondary to Heart Failure With Preserved Ejection Fraction: A Comparison With Pulmonary Arterial Hypertension With Similar Pressure Overload

2021 ◽  
Author(s):  
Jessie van Wezenbeek ◽  
Azar Kianzad ◽  
Arno van de Bovenkamp ◽  
Jeroen Wessels ◽  
Sophia A. Mouratoglou ◽  
...  
Keyword(s):  
Heart Failure ◽  
Pulmonary Hypertension ◽  
Pulmonary Arterial Hypertension ◽  
Ejection Fraction ◽  
Arterial Hypertension ◽  
Vena Cava ◽  
Pressure Overload ◽  
Right Atrial ◽  
Preserved Ejection Fraction ◽  
Pulmonary Arterial

Background: Heart failure with preserved ejection fraction (HFpEF) is a prevalent disorder for which no effective treatment yet exists. Pulmonary hypertension (PH) and right atrial (RA) and ventricular (RV) dysfunction are frequently observed. The question remains whether the PH with the associated RV/RA dysfunction in HFpEF are markers of disease severity. Methods: To obtain insight in the relative importance of pressure-overload and left-to-right interaction, we compared RA and RV function in 3 groups: 1. HFpEF (n=13); 2. HFpEF-PH (n=33), and; 3. pulmonary arterial hypertension (PAH) matched to pulmonary artery pressures of HFpEF-PH (PH limited to mPAP ≥30 and ≤50 mmHg) (n=47). Patients underwent right heart catheterization and cardiac magnetic resonance imaging. Results: The right ventricle in HFpEF-PH was less dilated and hypertrophied than in PAH. In addition, RV ejection fraction was more preserved (HFpEF-PH: 52±11 versus PAH: 36±12%). RV filling patterns differed: vena cava backflow during RA contraction was observed in PAH only. In HFpEF-PH, RA pressure was elevated throughout the cardiac cycle (HFpEF-PH: 10 [8–14] versus PAH: 7 [5–10] mm Hg), while RA volume was smaller, reflecting excessive RA stiffness (HFpEF-PH: 0.14 [0.10–0.17] versus PAH: 0.08 [0.06–0.11] mm Hg/mL). RA stiffness was associated with an increased eccentricity index (HFpEF-PH: 1.3±0.2 versus PAH: 1.2±0.1) and interatrial pressure gradient (9 [5 to 12] versus 2 [−2 to 5] mm Hg). Conclusions: RV/RA function was less compromised in HFpEF-PH than in PAH, despite similar pressure-overload. Increased RA pressure and stiffness in HFpEF-PH were explained by left atrial/RA-interaction. Therefore, our results indicate that increased RA pressure is not a sign of overt RV failure but rather a reflection of HFpEF-severity.

Clinical characteristics and prognostic impact of pulmonary hypertension in heart failure with preserved ejection fraction: the PURSUIT HFpEF study

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
F Sera ◽  
T Ohtani ◽  
K Nakamoto ◽  
T Yamada ◽  
Y Yasumura ◽  
...  
Keyword(s):  
Heart Failure ◽  
Pulmonary Hypertension ◽  
Ejection Fraction ◽  
Right Atrial ◽  
Rank Test ◽  
Heart Catheterization ◽  
Funding Source ◽  
Prognostic Impact ◽  
Preserved Ejection Fraction ◽  
Private Company

Abstract Background Heart failure (HF) with preserved ejection fraction (HFpEF) can develop pulmonary hypertension (PH), which can result from pre-capillary PH as well as post-capillary PH. However, the prevalence and clinical significance of pre-capillary component of PH in HFpEF remain unknown. Purpose We aimed to investigate prevalence, clinical features, and prognostic impact of pre-capillary and/or post capillary PH associated with HFpEF. Methods From the PURSUIT-HFpEF (Prospective Multicenter Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) registry, 204 patients (men: 46%, age: 79±9 years) who were hospitalized with HF and underwent right heart catheterization were divided into 4 groups according to the PH guidelines: non-PH, isolated post-capillary PH (Ipc-PH), pre-capillary PH, and combined pre- and post-capillary PH (Cpc-PH). Patients who had been diagnosed with idiopathic pulmonary arterial hypertension were excluded from the analysis. Results The prevalence of PH was 31% (Ipc-PH: 22%, pre-capillary PH: 3%, Cpc-PH: 6%). The prevalence of subcategories of PH was significantly different depending on mean right atrial pressure (RAP) (figure). Echocardiography at discharge showed no significant differences in RV diameter or TAPSE, but smaller LV diameter and higher E/e' in pre-capillary PH and Cpc-PH, which resulted in a higher operant diastolic elastance (Ed). Composite endpoint of all-cause mortality and HF hospitalization at 1 year occurred 13% in non-PH, 25% in Ipc-PH, 49% in pre-capillary PH, and 63% in Cpc-PH, respectively (p=0.001 by log-rank test). Conclusions Distinct prevalence of PH was observed in the groups with different RAP levels. Pre-capillary component of PH was associated with impaired LV diastolic function and worse outcomes in HFpEF. Figure 1 Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd

scholarly journals Echocardiographic and Hemodynamic Parameters Associated with Diminishing Renal Filtration among Patients with Heart Failure with Preserved Ejection Fraction

2018 ◽  
Vol 9 (2) ◽  
pp. 83-91 ◽  
Author(s):  
Kevin Bryan Lo ◽  
Kene Mezue ◽  
Pradhum Ram ◽  
Abhinav Goyal ◽  
Mahek Shah ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Renal Dysfunction ◽  
Pressure Ratio ◽  
Left Ventricular ◽  
Right Atrial ◽  
Heart Catheterization ◽  
Preserved Ejection Fraction ◽  
Patients With Heart Failure

Background: Renal dysfunction is an important predictor of poor outcomes in patients with heart failure with preserved ejection fraction (HFpEF). Right ventricular (RV) dysfunction is implicated as one of the explanations for worsening renal function in cardiorenal syndrome. Novel right heart catheterization (RHC) parameters such as pulmonary artery pulsatility index (PAPi) and right atrial to pulmonary capillary wedge pressure ratio (RA:PCWP) have been found as predictors of RV dysfunction. However, most studies investigating these parameters have been done in the setting of myocardial infarction or left ventricular assist device implantation, with limited data on these metrics in patients with HFpEF. Objective: The purpose of this study was to determine whether novel RHC parameters such as RA:PCWP and PAPi correlate with long-term renal outcomes among patients with HFpEF. Methods: A retrospective single-center study of adult patients with a documented diagnosis of heart failure who had RHC was performed between January 2006 and December 2010 at Einstein Med ical Center Philadelphia. Selected patients also had a serum B-type natriuretic peptide level ≥100 pg/mL and a PCWP ≥15 mm Hg. Patients with an ejection fraction < 50%, including those with recovered ejection fraction, and end-stage renal disease were excluded. Results: A total of 81 patients with a clinical diagnosis of HFpEF were identified who met the inclusion criteria. On multivariate analysis, after adjusting for age, sex, race, diabetes, hypertension, and cardiac index, PAPi was associated with long-term estimated glomerular filtration rate (eGFR) (β = 3.43, 95% CI = 0.635–6.23, p = 0.017), and RA:PCWP showed a trend towards significance (β = 14.81, 95% CI = –0.096–29.73, p = 0.051). The results were unchanged after further adjustment for eGFR at the time of RHC. Conclusion: Novel hemodynamic indices obtained by RHC may have predictive value for long-term renal dysfunction in patients with HFpEF.

scholarly journals Diagnostic utility of sub-maximum cardiopulmonary exercise testing in the ambulatory setting for heart failure with preserved ejection fraction

2020 ◽  
Vol 10 (4) ◽  
pp. 204589402097227
Author(s):  
Hannah T. Oakland ◽  
Phillip Joseph ◽  
Ahmed Elassal ◽  
Marjorie Cullinan ◽  
Paul M. Heerdt ◽  
...  
Keyword(s):  
Heart Failure ◽  
Pulmonary Hypertension ◽  
Gas Exchange ◽  
Ejection Fraction ◽  
Exercise Test ◽  
Cardiopulmonary Exercise Test ◽  
Right Heart Catheterization ◽  
Heart Catheterization ◽  
Preserved Ejection Fraction ◽  
Cardiopulmonary Exercise

Pulmonary hypertension is commonly associated with heart failure with preserved ejection fraction. In heart failure with preserved ejection fraction, the elevated left-sided filling pressures result in isolated post-capillary pulmonary hypertension or combined pre- and post-capillary pulmonary hypertension. Although right heart catheterization is the gold standard for diagnosis, it is an invasive test with associated risks. The ability of sub-maximum cardiopulmonary exercise test as an adjunct diagnostic tool in pulmonary hypertension-associated heart failure with preserved ejection fraction is not known. Forty-six patients with heart failure with preserved ejection fraction and pulmonary hypertension (27 patients with combined pre- and post-capillary pulmonary hypertension and 19 patients with isolated post-capillary pulmonary hypertension) underwent sub-maximum cardiopulmonary exercise test followed by right heart catheterization. The study also included 18 age- and gender-matched control subjects. Several sub-maximum gas exchange parameters were examined to determine the ability of sub-maximum cardiopulmonary exercise test to distinguish between isolated post-capillary pulmonary hypertension and combined pre- and post-capillary pulmonary hypertension. Conventional echocardiogram measures did not distinguish between isolated post-capillary pulmonary hypertension and combined pre- and post-capillary pulmonary hypertension. Compared to isolated post-capillary pulmonary hypertension, combined pre- and post-capillary pulmonary hypertension had greater ventilatory equivalent for carbon dioxide (VE/VCO2) slope, reduced delta end-tidal CO2 change during exercise, reduced oxygen uptake efficiency slope, and reduced gas exchange determined pulmonary vascular capacitance. The latter was significantly associated with right heart catheterization determined pulmonary artery compliance ( r = 0.5; p = 0.0004). On univariate analysis, sub-maximum VE/VCO2, delta end-tidal carbon dioxide, and gas exchange determined pulmonary vascular capacitance emerged as independent predictors of the extrapolated maximum oxygen uptake (%predicted) (β-coefficient values of –7.32, 95% CI: –13.3 – (–1.32), p = 0.01; 8.01, 95% CI: 1.96–14.05, p = 0.01; 8.78, 95% CI: 2.26–15.29, p = 0.01, respectively). Sub-maximum gas exchange parameters obtained during cardiopulmonary exercise test in an ambulatory setting allows for discrimination between isolated post-capillary pulmonary hypertension and combined pre- and post-capillary pulmonary hypertension. Additionally, sub-maximum cardiopulmonary exercise test derived VE/VCO2, delta end-tidal carbon dioxide, and gas exchange determined pulmonary vascular capacitance influences aerobic capacity in heart failure with preserved ejection fraction.

scholarly journals Prognostic Importance of Pulmonary Arterial Capacitance in Acute Decompensated Heart Failure With Preserved Ejection Fraction

2021 ◽  
Author(s):  
Akito Nakagawa ◽  
Yoshio Yasumura ◽  
Chikako Yoshida ◽  
Takahiro Okumura ◽  
Jun Tateishi ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Cox Regression ◽  
Right Heart Catheterization ◽  
Heart Catheterization ◽  
Preserved Ejection Fraction ◽  
Right Heart ◽  
End Point ◽  
Prognostic Importance ◽  
Pulmonary Arterial

Background Although the prognostic importance of pulmonary arterial capacitance (PAC; stroke volume/pulmonary arterial pulse pressure) has been elucidated in heart failure with reduced ejection fraction, whether its significance in patients suffering from heart failure with preserved ejection fraction is not known. We aimed to examine the association of PAC with outcomes in inpatients with heart failure with preserved ejection fraction. Methods and Results We prospectively studied 705 patients (median age, 83 years; 55% women) registered in PURSUIT‐HFpEF (Prospective Multicenter Observational Study of Patients With Heart Failure With Preserved Ejection Fraction). We investigated the association of echocardiographic PAC at discharge with the primary end point of all‐cause death or heart failure rehospitalization with a mean follow‐up of 384 days. We further tested the acceptability of the prognostic significance of PAC in a subgroup of patients (167/705 patients; median age, 81 years; 53% women) in whom PAC was assessed by right heart catheterization. The median echocardiographic PAC was 2.52 mL/mm Hg, with a quartile range of 1.78 to 3.32 mL/mm Hg. Univariable and multivariable Cox regression testing revealed that echocardiographic PAC was associated with the primary end point (unadjusted hazard ratio, 0.82; 95% CI, 0.72–0.92; P =0.001; adjusted hazard ratio, 0.86; 95% CI, 0.74–0.99; P =0.035, respectively). Univariable Cox regression testing revealed that PAC assessed by right heart catheterization (median calculated PAC, 2.82 mL/mm Hg) was also associated with the primary end point (unadjusted HR, 0.70; 95% CI, 0.52–0.91; P =0.005). Conclusions A prospective cohort study revealed that impaired PAC diagnosed with both echocardiography and right heart catheterization was associated with adverse outcomes in inpatients with heart failure with preserved ejection fraction. Registration URL: https://upload.umin.ac.jp/cgi‐open‐bin/ctr_e/ctr_view.cgi?recptno=R000024414. Unique identifier: UMIN000021831.

scholarly journals Pulmonary Hypertension Due to Heart Failure With Preserved Ejection Fraction: Clinical Relevance, Management, and Future Directions

2015 ◽  
Vol 14 (2) ◽  
pp. 88-94
Author(s):  
Rebecca Cogswell ◽  
Thenappan Thenappan
Keyword(s):  
Heart Failure ◽  
Pulmonary Hypertension ◽  
Ejection Fraction ◽  
Treatment Options ◽  
Preserved Ejection Fraction ◽  
Specific Patient ◽  
Disease Trajectory ◽  
Patients With Heart Failure ◽  
Secondary Pulmonary Hypertension ◽  
Pulmonary Arterial

There are currently 6 million Americans with heart failure, and this number is projected to increase to 8.5 million by 2030. One-half of patients with heart failure have preserved ejection fraction (HFpEF), and the prevalence is increasing. HFpEF can lead to secondary pulmonary hypertension (PH-HFpEF) and is associated with a worsened disease trajectory when present. It is unclear, however, whether PH is a marker of disease severity or a target of treatment in HFpEF. As PH-HFpEF and pulmonary arterial hypertension share several clinical characteristics, the distinction between these 2 syndromes can be difficult. New classification schemes have been proposed to separate those with passive elevations in pulmonary artery pressures from those with more significant pulmonary vascular remodeling. While these classifications have limitations, they are necessary such that pathophysiology, disease trajectory, and pharmacologic therapies can be studied in specific patient subgroups. In this article, we will review the epidemiology of HFpEF, current definitions for both HFpEF and PH in HFpEF, treatment options, and ongoing clinical trials.

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