Prof. Dragos Vinereanu,
Heart failure with preserved ejection fraction (HFpEF) is a common condition (more than 50% of cases of HF), with a poor prognosis, similar to that of HFrEF. Although EF is preserved, longitudinal systolic function is impaired, with an augmentation of the circumferential function. This can be assessed by measuring the global longitudinal strain (GLS) by speckle tracking echocardiography. Impaired GLS is also a prognostic marker, better than EF: abnormal GLS (less than 15.8%) was associated with a more than 2 fold increase in a composite of cardiovascular death, HF hospitalization or aborted cardiac arrest, as reported by A. Klein.
Geometric changes of the left ventricle (LV) are fundamental to the pathophysiologic abnormalities in HFpEF, being part of its diagnostic algorithm. Thus, LV stiffness is associated with LV concentric remodeling, LV (mainly concentric) hypertrophy, lack of LV dilatation, and left atrial enlargement and stiffness (likely leading to more atrial fibrillation). Meanwhile, these abnormalities have also been associated with adverse outcomes in HFpEF, as outlined by H. Dokainish.
Exercise stress echocardiography is a practical and reproducible non-invasive diagnostic modality in HFpEF, since it can unmask or worsen diastolic functional abnormalities. Thus, during exercise, patients with HFpEF develop increased LV filling pressure, increase in chamber stiffness, and inability to enhance myocardial relaxation. Consequently, diastolic functional reserve (Δe’) is reduced. Meanwhile, prognosis of exercise-induced pulmonary hypertension is poor when it is associated with exercise-induced increase in E/e’. Arterial stiffening contributes to the development of HFpEF, and also becomes more prominent during exercise, explained J.W. Ha.
Finally, R Wassmuth reported that myocardial fibrosis by CMR has functional and prognostic repercussions in HFpEF. Thus, diffuse fibrosis is related to the severity of diastolic dysfunction. Meanwhile, focal fibrosis is reportedly associated with all-cause mortality (OR 3.3), HF hospitalization (OR 2.9), and sudden cardiac death (OR 5.3) in non-ischemic cardiomyopathy. Similarly, fibrosis has prognostic implications in HCM, diabetes, aortic stenosis, and amyloidosis.
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