Author + information
- Received May 12, 2016
- Revision received December 12, 2016
- Accepted December 21, 2016
- Published online October 9, 2017.
- Marco Guazzi, MD, PhDa,b,∗ (, )
- Debra Dixon, BSc,
- Valentina Labate, MDa,b,
- Lauren Beussink-Nelson, RDCS, MHSc,
- Francesco Bandera, MDa,b,
- Michael J. Cuttica, MDd and
- Sanijv J. Shah, MDc,e
- aDepartment of Cardiology University, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
- bDepartment of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
- cDivision of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- dDivision of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- eFeinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- ↵∗Address for correspondence:
Dr. Marco Guazzi, Department of Biomedical Sciences for Health, University of Milan, Heart Failure Unit, University Cardiology Department, IRCCS Policlinico San Donato, Piazza E. Malan 2, 20097, San Donato Milanese, Milan, Italy.
Objectives This study sought to investigate how right ventricular (RV) contractile function and its coupling with pulmonary circulation (PC) stratify clinical phenotypes and outcome in heart failure preserved ejection fraction (HFpEF) patients.
Background Pulmonary hypertension and RV dysfunction are key hemodynamic abnormalities in HFpEF.
Methods Three hundred eighty seven HFpEF patients (mean age 64 ± 12 years, 59% females, left ventricular ejection fraction 59 ± 7%) underwent RV and pulmonary hemodynamic evaluation by echocardiography (entire population) and right heart catheterization (219 patients). Patients were investigated by tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) relationship and stratified according to TAPSE/PASP ratio tertiles (1: <0.35; 2: 0.35 to 0.57; 3: >0.57). Specifically, TAPSE/PASP ratio was taken as a noninvasive index of RV to PC coupling based on the correlation with invasively evaluated RV systolic elastance/arterial elastance (r = 0.35; p < 0.0001).
Results Groups had similar prevalence of comorbidities except for a higher prevalence of atrial fibrillation and kidney dysfunction in tertile 1. Progressively increasing levels of natriuretic peptides, worse systemic and pulmonary hemodynamics, abnormal exercise aerobic capacity and ventilatory inefficiency were observed from the highest to lowest TAPSE/PASP tertile. TASPE/PASP correlated with pulmonary artery compliance (r = 0.69; p < 0.0001). Remarkably, the tertile 1 group distributed along the worse portion of the curve at lower pulmonary artery compliance and higher pulmonary vascular resistances. In addition, the TAPSE/PASP ratio emerged as an independent predictor of worse outcomes.
Conclusions A thorough assessment of RV-PC coupling and RV contractile function stratify HFpEF phenotypes at different level of risk. These observations shift the interest toward therapeutic strategies that may benefit the right heart as primary unmet need in the complex pathophysiology of the HFpEF syndrome.
Supported by a Grant of the Monzino Foundation (MG), Milano, Italy. Dr. Cuttica is on the Speakers Bureau and Advisory Board for Actelion Pharmaceuticals, United Therapeutics, and Gilead. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 12, 2016.
- Revision received December 12, 2016.
- Accepted December 21, 2016.
- 2017 American College of Cardiology Foundation