Focus issue on heart failure with preserved left ventricular ejection fraction

Contemporary Prevalence and Correlates of Incident Heart Failure with Preserved Ejection Fraction

Clinical Characteristics and Predictors of In-Hospital Mortality in Acute Heart Failure With Preserved Left Ventricular Ejection Fraction

Additional risk stratification may provide more aggressive and focalized preventive treatment to high-risk hypertensive patients according to the Japanese hypertension guidelines. We prospectively investigated the predictive value of high-sensitivity troponin I (hsTnI), both independently and in combination with N-terminal pro-B-type natriuretic peptide (NT-proBNP), for incident heart failure (HF) in high-risk hypertensive patients with preserved left ventricular ejection fraction (LVEF). Baseline hsTnI and NT-proBNP levels and echocardiography data were obtained for 493 Japanese hypertensive outpatients (mean age, 68.5 years) with LVEF ≥ 50%, no symptomatic HF, and at least one of the following comorbidities: stage 3-4 chronic kidney disease, diabetes mellitus, and stable coronary artery disease. During a mean follow-up period of 86.1 months, 44 HF admissions occurred, including 31 for HF with preserved ejection fraction (HFpEF) and 13 for HF with reduced ejection fraction (HFrEF; LVEF <50%). Both hsTnI (p < 0.01) and NT-proBNP (p < 0.005) levels were significant independent predictors of HF admission. Furthermore, when the patients were stratified into 4 groups according to increased hsTnI (≥highest tertile value of 10.6pg/ml) and/or increased NT-proBNP (≥highest tertile value of 239.7pg/ml), the adjusted relative risks for patients with increased levels of both biomarkers versus neither biomarker were 13.5 for HF admission (p < 0.0001), 9.45 for HFpEF (p = 0.0009), and 23.2 for HFrEF (p = 0.003). Finally, the combined use of hsTnI and NT-proBNP enhanced the C-index (p < 0.05), net reclassification improvement (p = 0.0001), and integrated discrimination improvement (p < 0.05) to a greater extent than that of any single biomarker. The combination of hsTnI and NT-proBNP, which are individually independently predictive of HF admission, could improve predictions of incident HF in high-risk hypertensive patients but could not predict future HF phenotypes.

BackgroundThe prevalence and clinical outcomes of heart failure with preserved leftventricular ejection fraction after acute myocardial infarction have notbeen well elucidated.ObjectiveTo analyze the prevalence of heart failure with preserved left ventricularejection fraction in acute myocardial infarction and its association withmortality.MethodsPatients with acute myocardial infarction (n = 1,474) were prospectivelyincluded. Patients without heart failure (Killip score = 1), with heartfailure with preserved left ventricular ejection fraction (Killip score >1 and left ventricle ejection fraction ≥ 50%), and with systolic dysfunction(Killip score > 1 and left ventricle ejection fraction < 50%) onadmission were compared. The association between systolic dysfunction withpreserved left ventricular ejection fraction and in-hospital mortality wastested in adjusted models.ResultsAmong the patients included, 1,256 (85.2%) were admitted without heartfailure (72% men, 67 ± 15 years), 78 (5.3%) with heart failure withpreserved left ventricular ejection fraction (59% men, 76 ± 14 years), and140 (9.5%) with systolic dysfunction (69% men, 76 ± 14 years), withmortality rates of 4.3%, 17.9%, and 27.1%, respectively (p < 0.001).Logistic regression (adjusted for sex, age, troponin, diabetes, and bodymass index) demonstrated that heart failure with preserved left ventricularejection fraction (OR 2.91; 95% CI 1.35–6.27; p = 0.006) and systolicdysfunction (OR 5.38; 95% CI 3.10 to 9.32; p < 0.001) were associatedwith in-hospital mortality.ConclusionOne-third of patients with acute myocardial infarction admitted with heartfailure had preserved left ventricular ejection fraction. Although thissubgroup exhibited more favorable outcomes than those with systolicdysfunction, this condition presented a three-fold higher risk of death thanthe group without heart failure. Patients with acute myocardial infarctionand heart failure with preserved left ventricular ejection fractionencounter elevated short-term risk and require special attention andmonitoring during hospitalization.

The aim: to study the effect of add-on pentoxifylline therapy on the structural and functional indicators of the heart state, endothelial function, quality of life and physical abilities in patients with chronic heart failure with preserved left ventricular ejection fraction. Materials and methods. The indicators of the structural and functional state of the heart, endothelial function, quality of life and physical abilities of patients older than 60 years, who were followed-up in the Department of Cardiology of the State Institution “D. F. Chebotarev Institute of Gerontology of the NAMS of Ukraine”, based on 67 case histories, 37 of them were prescribed pentoxifylline as add-on therapy to the standard therapeutic regimen. Statistical data were calculated using modern application packages, in particular SPSS v.22, Statistica 7.0, MedCalc statical software v.11.5.0.0. The significance level was assessed using paired and unpaired Student's t-test with Bonferroni corrections, and the correlation and two-way analysis of variance were performed. Results. A significant additional effect of pentoxifylline treatment on the indicators of maximum blood flow in the forearm microvessels in response to the reactive hyperemia test, which characterizes the ability of the microvessel endothelium to synthesize relaxation factors, was detected. Patients who additionally received pentoxifylline showed significantly better indicators of left ventricular myocardial relaxation and reduction of hypertrophy than those on the standard therapy. There was a significant increase in walking distance in the third year of treatment in the patients who additionally received pentoxifylline. There was no difference in the impact on the quality of life of the patients. Conclusions. The addition of pentoxifylline to the standard therapy in patients with chronic heart failure with preserved left ventricular ejection fraction significantly reduces myocardial hypertrophy, improves diastolic relaxation, increases volumetric blood flow velocity in microvessels mediating reactive hyperemia, which may contribute to further stabilizing the clinical course of the disease and increasing 6-minute walking distance. The presented data are an additional evidence of pathogenetically reasonable therapy with pentoxifylline in patients with chronic heart failure with preserved left ventricular ejection fraction, which allows us to consider this drug as potentially promising for the routine treatment of such patients.

Chronic heart failure (CHF) is actual medical problem around the world and in Ukraine. Almost 50% of these patients have heart failure with preserved ejection fraction. CHF is the result of many complications and cardiovascular disease, such as coronary heart disease, including myocardial infarction and hypertension. Despite the prevalence of heart failure with preserved ejection fraction a common strategy for the treatment of this disease has not yet been developed. This is due to the limited number of controlled studies in these patients. One of the most effective drugs in the treatment of heart failure with preserved ejection fraction after myocardial infarction are candesartan and ramipril. Determining the dynamics of GDF 15 and NTproBNP along with those of echocardiography is promising for evaluating the effectiveness of treatment of patients with heart failure with preserved ejection fraction after myocardial infarction in the background of arterial hypertension.The aim of research. To determine the dynamics of structural and functional changes of the heart and the levels of GDF 15 and NTproBNP on the ramipril and candesartan therapy in patients with heart failure and preserved ejection fraction after myocardial infarction on the background of arterial hypertension.Materials and methods. 38 patients with heart failure with preserved left ventricular ejection fraction (EF&gt;45%) after myocardial infarction with comorbidity arterial hypertension were included into the study. Dynamics of structural and functional changes of the heart and the levels of GDF 15 and NTproBNP on the ramipril and candesartan therapy for 12 weeks (mean age 64,3 ± 1,3 years) were investigated. Prescription myocardial infarction ranged from 2 months to 3 years. Patients were divided into 2 groups. The first group in addition to the basic treatment received candesartan (KASARK "Arterium", Ukraine) at a mean dose 18,5 ± 2,1 mg daily. Patients of the second group received ramipril (RAMIMED, «Medochemie Ltd.», Iceland/Cyprus) at a mean dose 5,8±0,6 mg daily.Results. In patients receiving candesartan was observed decreased hypertrophy with significant thinning left ventricular walls, decreased left ventricular mass index (5,4%, p&lt;0,05), MVA (11,0%, p&lt;0,05), increase E' (12,5%, p&lt;0,05), reduction ratio E/E' (10,9%, p&lt;0,05) and decreased left atrium volume index (12,0%, p&lt;0,05). Patients with ramipril therapy have significant thinning posterior left ventricular wall (6,7%, p&lt;0,05), decreased left ventricular mass index (5,9%, p&lt;0,05) and left atrium volume index (10,1%, p&lt;0,05). On the candesartan therapy for 12 weeks was observed a significant reduction the levels of GDF 15 (Δ (%)=-27±4,65) and NTproBNP (Δ(%)=-22±12,7) in serum. Patients with ramipril therapy also contributed to a significant decrease levels of GDF 15 (Δ (%)=-25±3,48) and NTproBNP (Δ(%)=-16±12,6). On the background of candesartan therapy was a significant increased the distance of the 6-minute walking test (26,1%; p&lt;0,05). Ramipril therapy also led to a significant increased the distance of the 6-minute walking test (13,1%; p&lt;0,05).Conclusion. Intaking of the candesartan and ramipril contributed to decreasing LV. On the background of candesartan therapy was observed more substantial improvement of LV diastolic function with decreasing E/E' compared with ramipril. Candesartan and ramipril therapy led to a lowering of GDF 15 and NTproBNP, while the dynamics of NTproBNP in patients receiving candesartan was more significant. Candesartan and ramipril therapy provided to improve the clinical condition of patients.

Is left bundle branch area pacing the optimal pacing strategy for bradyarrhythmia with preserved ejection fraction? A network meta-analysis.

Women are approximately two times more likely than men to develop heart failure in the setting of preserved left ventricular ejection fraction [i.e. heart failure with preserved left ventricular ejection fraction (HFpEF)], but the reasons for this disparity are unknown. HFpEF is caused by changes in ventricular-vascular properties that are associated with aging and hypertensive cardiac remodeling. These changes lead to diastolic and systolic dysfunction and impaired reserve capacity. Many of the cardiovascular alterations seen in HFpEF are also noted to greater extent in women compared with men. Women demonstrate more concentric left ventricular remodeling and less ventricular dilatation in response to arterial hypertension. Ventricular and arterial stiffness increases with age in both sexes, but the increase is more dramatic in women. Recently, age-sex interactions have also been observed in the manner in which left ventricular function changes across the lifespan, wherein systolic and diastolic function and functional reserve become more compromised in women as compared with men in the postmenopausal years, despite similar or enhanced function in women during youth. The prevalence of HFpEF is increasing and women outnumber men by a 2 : 1 ratio. Recent data have identified striking parallels between structure-function alterations observed in HFpEF and sex differences in cardiovascular function across the adult lifespan. These data suggest that sex-specific maladaptations to hypertensive aging in women may underlie greater risk of HFpEF.

Effects of candesartan on cardiac sympathetic nerve activity in patients with congestive heart failure and preserved left ventricular ejection fraction

Background Patients who have progressed to chronic atrial fibrillation (AF) usually presented both atrial remodeling coexisting elevated pulmonary arterial pressure without other secondary causes. Purpose The aim of our study was to assessed the impact of progression to chronic structural remodeling in AF patients with preserved left ventricular ejection fraction (LVEF) on long-term clinical outcome including all-cause mortality or hospital admission. Methods We enrolled 5,585 consecutive AF patients (≥19 years, mean age 66±13 years, 41.1% female) in a tertiary hospital from 2007 to January 2017. Chronic AF structural remodeling (CAFR) was defined as both atrial enlargements including left atrial antero-posterior diameter ≥50mm, pulmonary arterial pressure ≥35mmHg and LVEF ≥50% on transthoracic echocardiography. AF patients with preserved LVEF were divided into two groups: group 1 (1,102 patients with CAFR) and group 2 (1,661 patients without CAFR). Results There were no significant differences in age (p=0.330), female (p=0.609), LVEF (p=0.607) and the proportions of comorbidities including hypertension (p=0.226), diabetes mellitus (p=0.751) and heart failure (HF) (p=0.054) between two groups. Mean follow-up durations were 77.6±42.2 (group 1) and 65.6±35.7 (group 2) months, respectively. Kaplan-Meier estimates showed a significant difference in hospitalization for HF (Log-rank p&amp;lt;0.001), but there was a significant difference in any cause death (Log-rank p=0.182) between two groups. In Cox proportional-hazards models, after adjusting relevant risk factors, chronic kidney disease (hazards ratio [HR] 1.89, 95% CI 1.48–2.41, p&amp;lt;0.001) and CAFR (HR 1.33, 95% CI 1.11–1.59, p=0.001) with admission for HF. Conclusion This study suggests that progressive structural atrial remodeling in AF patients with preserved LVEF is independently associated long-term clinical worse outcome of hospitalization for HF. Funding Acknowledgement Type of funding source: None

Background Atrial fibrillation (AF) is the most common cardiac arrhythmia and presents significant management challenges due to its potential complications. Catheter ablation (CA) is a standard treatment for symptomatic patients, particularly those unresponsive to medical therapy. However, long-term population studies report that nearly 50% of patients require hospitalization for AF or atrial flutter within 10 years post-ablation. Additionally, the hospitalization rate for heart failure is 1.1 per 100 person-years—relatively low but not negligible. AF patients often have a high prevalence of heart failure with preserved ejection fraction (HFpEF), contributing to heart failure progression. The H₂FPEF and HFA-PEFF scores are validated HFpEF risk stratification tools; however, their predictive value for heart failure outcomes after CA in AF patients remains unclear. Purpose To evaluate the predictive value of the H₂FPEF and HFA-PEFF scores for worsening heart failure in AF patients undergoing primary CA. Method This retrospective, single-center observational study was conducted at Niigata University Medical and Dental Hospital. A total of 338 AF patients with preserved left ventricular ejection fraction (LVEF &amp;gt; 50%) who underwent primary CA between February 2017 and September 2022 were included. Patients were classified as high-risk if they had an H₂FPEF score ≥6 or an HFA-PEFF score ≥5. The primary endpoint was worsening heart failure, while the secondary endpoint was AF recurrence. Kaplan-Meier survival analysis and Cox proportional hazards models were used to examine associations between the scores and outcomes. Sensitivity and specificity analyses assessed predictive accuracy. Statistical analyses were conducted using JMP Pro 17. Results Among 338 patients, 97 (28.7%) were high-risk. The mean age was 66 ± 10 years, 68.0% were men, and median LVEF was 64.9%. High-risk patients were older (71 vs. 65 years, P &amp;lt; 0.001) and included fewer males (50.5% vs. 75.1%, P &amp;lt; 0.001). LVEF and AF pattern (paroxysmal or persistent) did not differ between groups. High-risk group had a significantly higher incidence of worsening heart failure than low-risk group (Log-rank P &amp;lt; 0.001), but AF recurrence did not differ between groups (Log-rank P = 0.186). Worsening heart failure was more common in the high-risk group regardless of AF recurrence (AF recurrence group: Log-rank P = 0.037, Non-AF recurrence group: Log-rank P &amp;lt; 0.001). Cox proportional hazards analysis identified a high H₂FPEF and HFA-PEFF score as an independent predictor of worsening heart failure (HR 4.78, 95% CI 1.94–11.76, P &amp;lt; 0.001). H₂FPEF score ≥6 predicted worsening heart failure with an AUC of 0.745, sensitivity of 71%, and specificity of 64%. HFA-PEFF score ≥5 had an AUC of 0.798, sensitivity of 75%, and specificity of 75%. Conclusions The H₂FPEF and HFA-PEFF scores effectively predict worsening heart failure in AF after primary CA, regardless of AF recurrence.Freedom from worsening heart failure

Rheumatoid arthritis (RA) is characterized by a twofold increase in morbidity and mortality due to chronic heart failure (CHF). At the same time, the prevalence of CHF among RA patients is significantly underestimated. The aim of the review was to analyze the results of the main studies on the features of the clinical presentation of heart failure (HF) in RA patients, the role of visualization techniques and biomarkers in the diagnosis of HF and preclinical dysfunction of the myocardium. HF in patients with RA is characterized by a predominance of HF with a preserved left ventricular ejection fraction (LVEF). The use of clinical diagnostic criteria in RA patients can lead to both over- or underdiagnosis of CHF. Systolic dysfunction estimated by LVEF is rare in RA and does not reflect the real frequency of myocardial dysfunction. Echocardiography (ECHO-CG) with tissue Doppler echocardiography (TDE) and visualization of myocardial deformation, magnetic resonance imaging (MRI) of the heart in RA patients revealed a high frequency of HF with preserved ejection fraction, left ventricular remodeling and hypertrophy, pre-clinical systolic and diastolic dysfunction. Determination of natriuretic peptides is useful for verifying the diagnosis of HF and estimating the prognosis in this cohort, despite the possible decrease in the sensitivity and specificity of these indicators in RA patients. The review discusses the advantages of MRI of the heart, including quantitative T1 and T2 regimens, in the diagnosis of myocarditis, myocardial fibrosis, and myocardial perfusion disorders in RA patients. In order to verify the diagnosis of heart failure and detect pre-clinical myocardial dysfunction in RA patients, the determination of natriuretic peptides concentration should become part of the routine examination, beginning with the debut of the disease, along with the collection of a cardiological history, physical examination, ECHO-CT with TDE, and visualization of myocardial deformation. Evaluation of the quantitative characteristics of tissue according to MRI of the heart could improve the diagnosis of myocardial damage.

Non-invasive imaging plays an increasingly important role in emergency medicine, given the trend towards smaller, portable ultrasound devices, the integration of ultrasound imaging across diverse medical disciplines, and the growing evidence supporting its clinical benefits for the patient. Heart failure with preserved ejection fraction (HFpEF) provides a compelling illustration of the impactful role that imaging plays in distinguishing diverse clinical presentations of heart failure with numerous associated comorbidities, including pulmonary, renal, or hepatic diseases. While a preserved left ventricular ejection fraction might misguide the clinician away from diagnosing cardiac disease, there are several clues provided by cardiac, vascular, and lung ultrasonography, as well as other imaging modalities, to rapidly identify (decompensated) HFpEF. Congestion remains the primary reason why patients with heart failure (irrespective of ejection fraction) seek emergency care. Furthermore, comprehensive phenotyping is becoming increasingly important, considering the development of targeted treatments for conditions exhibiting HFpEF physiology, such as cardiac amyloidosis. Timely recognition in such cases has lasting implications for long-term outcomes.

The purpose of the study was to evaluate the radiofrequency ablation impact on the morpho-functional state of the heart in patients with atrial fibrillation and chronic heart failure with preserved ejection fraction based on 2-year follow-up. Materials and methods. The study included 194 patients with an average age of 59.3±8.5 years with atrial fibrillation and concomitant heart failure with preserved left ventricular ejection fraction of I-III functional class of New York Heart Association. Patients were divided into 2 groups: 136 patients who underwent radiofrequency catheter ablation and 58 patients in the control group who did not undergo intervention and continued antiarrhythmic pharmacotherapy. Patients were comparable in terms of basic clinical and demographic indicators. In order to assess the morpho-functional state of the heart, transthoracic echocardiography was performed at the stage of inclusion in the study and 2 years after. Results and discussion. According to the results of the analysis in the radiofrequency catheter ablation group 2 years after the intervention revealed: a statistically significant decrease in the mean end-systolic diameter of the left ventricle (3.3±0.48 cm versus 3.2±0.41cm, p &lt;0.001); decreased size of the left atrium (4.3±0.71 cm versus 4.2±0.30 cm, p &lt;0.001); left ventricular ejection fraction increased significantly (61.9±7.14% versus 63.9±5.65%, p &lt;0.001); the E/e' ratio decreased statistically significantly (11.9±1.65 versus 9.4±1.48; p &lt;0.001) and the left ventricular myocardial mass index (118.3±25.04 g/m2 versus 116.4±18.04 g/m2; p=0.045). In the pharmacotherapy group there were: a statistically significant increase in the average end-systolic size of the left ventricle (3.61±0.45 cm versus 3.63±0.41, p=0.007); statistically significant increased left atrium (4.3±0.61 cm versus 4.4±0.36; p &lt;0.001) and the right atrium (4.1±0.52 cm versus 4.2±0.26; p &lt;0.001); decreased left ventricular ejection fraction (58.1±6.12% versus 56.6±6.11; p &lt;0.001); increased values of the ratio E/e' (12.1±1.63 versus 12.7±1.27; p=0.002) and decreased level of the left ventricular myocardial mass index (120.5±24.05 g/m2 versus 118.3±20.13 g/m2; p=0.044). Conclusion. Radiofrequency ablation of atrial fibrillation in patients with heart failure with preserved left ventricular ejection fraction to control sinus rhythm is associated with improved morpho-functional state of the heart at the 2-year follow-up compared with antiarrhythmic pharmacotherapy strategy: the left ventricular ejection fraction increases, the left ventricular diastolic function improves according to the E/e' value, the size of the left atrium decreases

Background Risk stratification of patients with low-gradient (LG) severe aortic stenosis (AS) despite preserved left ventricular ejection fraction remains challenging. We sought to evaluate the relationship between the dimensionless index (DI)-the ratio of the left ventricular outflow tract time-velocity integral to that of the aortic valve jet-and mortality in these patients. Methods Seven hundred fifty-five patients with LG severe AS (defined by aortic valve area ≤1 cm2 or aortic valve area indexed to body surface area ≤0.6 cm2/m2 and mean aortic pressure gradient <40 mm Hg) and preserved left ventricular ejection fraction ≥50% were studied. Flow status was defined according to stroke volume index <35 mL/m2 (low flow, LF) or ≥35 mL/m2 (normal flow, NF). Results After adjustment for age, sex, body mass index, Charlson comorbidity index, history of hypertension, history of atrial fibrillation, AS-related symptoms, left ventricular ejection fraction, indexed left ventricular ventricular mass, aortic valve area, and aortic valve replacement as a time-dependent covariate, patients with LG-LF and DI<0.25 exhibited a considerable increased risk of death compared with patients with LG-NF and DI≥0.25 (adjusted hazard ratio, 2.41 [95% CI, 1.61-3.62]; P<0.001), LG-NF and DI<0.25 (adjusted hazard ratio, 1.84 [95% CI, 1.24-2.73]; P=0.003), and LG-LF and D≥0.25 (adjusted hazard ratio, 2.27 [95% CI, 1.42-3.63]; P<0.001). In contrast, patients with LG-LF and DI≥0.25, LG-NF and DI<0.25, and LG-NF and DI≥0.25 had similar outcome. DI<0.25 showed incremental prognostic value in patients with LG-LF severe AS but not in patients with LG-NF severe AS. Conclusions Among patients with LG severe AS and preserved left ventricular ejection fraction, decreased DI<0.25 is a reliable parameter in patients with LF to identify a subgroup of patients at higher risk of death who may derive benefit from aortic valve replacement.