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Heart failure with preserved ejection fraction – state of the art

EuroEcho-Imaging 2014 session report

Discussion of diagnosis, assessment and treatment of heart failure with preserved ejection fraction underlines the need for further clinical research in this area.

Alex Pui-Wai Lee described how left ventricular long-axis systolic function is reduced in patients with HFPEF. This was first reported from the Chinese University of Hong Kong in 2002 and it has recently been reconfirmed using global longitudinal strain. HFPEF patients also develop dyssynchrony during stress. Other recent studies have reported that in patients with HFPEF, LV ejection fraction declines over time, by about 6% per year. Using ejection fraction to dichotomise patients with heart failure is artificial.

Dragos Vinereanu from Bucharest reviewed some of the pitfalls and limitations of current echocardiographic criteria for diagnosing HFPEF. For example, the NORRE collaboration organised by the EACVI has reported from a large number of healthy subjects that the lower limit for normal ejection fraction should be 56%. Mitral annular early diastolic velocity (e’) cannot be used in patients with conduction defects or significant mitral regurgitation, and 3D imaging is the most accurate method for determining LA volume.

Jesús Peteiro from La Coruña showed some examples of stress echocardiography during upright exercise on a treadmill. He assesses diastolic function during the recovery period, whereas other investigators now try to assess diastolic function during low-level dynamic exercise. In discussion, the need for reproducible techniques and control data from age-matched populations was stressed.

Finally, Wojciech Kosmala from Wroclaw described how patients with HFPEF most commonly have diffuse interstitial fibrosis, but this is the most difficult pattern to quantify by gadolinium hyper-enhancement during a cardiac magnetic resonance study. The extracellular collagen volume correlates with myocardial stiffness and is inversely related to the peak filling rate during early diastole. It is increased in hypertensive and diabetic subjects and may be amenable to treatment with aldosterone antagonists.

This was a useful session that reinforced the need for further clinical research, the revision of diagnostic criteria, and the development of common methods for testing diastolic functional reserve.




Heart failure with preserved ejection fraction – state of the art

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.