Elsevier

Journal of Cardiac Failure

Volume 27, Issue 9, September 2021, Pages 942-948
Journal of Cardiac Failure

Early Identification of Patients at Risk for Incident Heart Failure With Preserved Ejection Fraction: Novel Approach to Echocardiographic Trends

https://doi.org/10.1016/j.cardfail.2021.03.013Get rights and content

Highlights

  • Echocardiography may provide a signal to identify patients at risk for developing acute decompensated incident heart failure with preserved ejection fraction, up to 10 to 20 years before diagnosis.

  • Significant and progressive increases were detected in (a) arterial elastance, (b) left atrial diameter, (c) left ventricular filling pressure, (d) ventricular elastance, (e) right atrial pressure estimate, (f) right ventricular systolic pressure, and (g) ventricular-arterial coupling at specific time intervals before acute incident heart failure with preserved ejection fraction.

  • Some of the echocardiographic markers in this article are not reported routinely, but all are feasibly measured and available in clinical practice.

Abstract

Background

Heart failure with preserved ejection fraction (HFpEF) continues to increase in prevalence with a 50% mortality rate within 3 years of diagnosis, but lacking effective evidence-based therapies. Specific echocardiographic markers are not typically used to trigger alarm before acute HFpEF decompensation. The goal of this study was to retrospectively track changes in echocardiographic markers leading to the time of incident HFpEF hospitalization.

Methods and Results

In a single-center, retrospective analysis, patients with HFpEF admitted between 2007 and 2014 were identified using the International Classification of Diseases, 9th Revision with search refined using the European Society of Cardiology HFpEF guidelines. Using linear mixed effects models, changes in echocardiographic markers preceding acute HF decompensation owing to incident HFpEF were analyzed. We report on an incident HFpEF cohort of 242 patients, extending 18 years retrospectively, and including 675 echocardiograms analyzed from the overall sample at 14 distinct time intervals before acute decompensation. The regression models demonstrated 3 echocardiographic markers with statistically significant increases across multiple time intervals including, arterial elastance (P = .006), right atrial pressure estimate (P < .001), and right ventricular systolic pressure (P = .006). Other echocardiographic markers had individual time intervals with significant increases before acute decompensation, including (a) left atrial diameter, 8 to 10 years before HFpEF diagnosis, (b) left ventricular filling pressure 2 to 6 years before HFpEF diagnosis, (c) ventricular elastance 3 to 6 months before HFpEF diagnosis, and (d) ventricular elastance/arterial elastance as early as 10 to 20 years and as late as 3 to 6 months before HFpEF diagnosis. Furthermore, African Americans presented with incident HFpEF at an average younger age than White patients (65.6 ± 15.2 years vs. 76.7 years ± 11.7, P < .001).

Conclusions

Noninvasive echocardiographic markers associated with incident HFpEF diagnosis showed long, mid, and acute range, significant changes as far back as 10 to 20 years and as close as 3 to 6 months before acute HFpEF decompensation. Including a diverse study cohort is critical to understanding the phenotypic differences of HFpEF. This hypothesis-generating study identified a novel approach to identifying trends in echocardiographic markers that may be used as a signal of impending incident HFpEF.

Section snippets

Design and Study Population

In this single-center retrospective cohort study, patients were identified by International Classification of Diseases, 9th Revision, codes and further screened and confirmed to have HFpEF by applying the European Society of Cardiology definition for HFpEF.16 Patients were selected by a primary diagnosis of incident (first episode) HFpEF as identified by the International Classification of Diseases, 9th revision, Clinical Modification, code book with codes for 428.30 (diastolic heart failure,

Study Population

The longest interval of echocardiography availability before incident HFpEF admission was 19.9 years (median 2.6, Q1–Q3 0.05–6.40 years). The potential sample for this study included 876 patients whose charts were screened and 634 patients who were excluded, leaving 242 patients in the incident HFpEF cohort. The most common reasons for exclusion were (a) history of an echocardiographic EF of less than 50% (n = 296 [47%]), (b) no HFpEF (did not meet European Society of Cardiology diagnostic

Discussion

Unique and clinically relevant increases were detected in echocardiographic markers trends at time intervals well before acute incident HFpEF decompensation. For the echocardiographic markers Ea, RAest, and RVSP, increases were noted across multiple time intervals, whereas E/e’, Ees, Ees/Ea, and left atrial diameter demonstrated progressive increases at individual clinically relevant time intervals leading to HFpEF. RAest increases were noted up to 10 to 20 years before HFpEF and continued to

Limitations

A control group would have strengthened our study results; however, prior studies have demonstrated the usefulness of Ees as an early marker for incident HFpEF within a case-control analysis showing the control group had a 40% higher odds of being in the case group (incident HFpEF) with every 1-unit increase in the Ees.19 In addition, other studies report on the normal progression of echocardiographic markers with aging, but our results suggest that interval increases in echocardiographic

Conclusions

This study illustrates that significant increases in echocardiographic markers (Ea, E/e’, Ees, Ees/Ea, left atrial diameter, RAest, and RVSP) are detectable well before patients develop acute HFpEF decompensation and coincide with trackable physiologic changes that have been proven to be associated with HFpEF. Granted not all of the echocardiographic markers in this study are routinely reported; however, all of the echocardiographic markers analyzed in this study are measurable from routinely

Lay Summary

Heart failure with preserved ejection fraction is a common type of heart failure, in which the heart muscle is strong, but too stiff, not allowing for enough relaxation to fill the heart.

We may be able to identify this condition early, and this may be especially helpful to patients with high blood pressure, overweight, or diabetes.

An echocardiogram may provide information to identify who is at risk for developing heart failure with preserved ejection fraction and provide us a window of

Acknowledgments

The authors thank Melissa LeFevre, BA, RDCS, for her contributions with echocardiography image measurement for arterial and Ees calculations.

References (32)

  • GC Fonarow et al.

    Characteristics, treatment, and outcomes of patients with preserved systolic function hospitalized for heart failure

    J Am Coll Cardiol

    (2007)
  • DW Armstrong et al.

    Factors influencing the echocardiographic estimate of right ventricular systolic pressure in normal patients and clinically relevant ranges according to age

    Can J Cardiol

    (2010)
  • EJ Benjamin et al.

    Heart disease and stroke statistics-2017 update: a report from the American Heart Association

    Circulation

    (2017)
  • D Mozaffarian et al.

    Heart disease and stroke statistics-2016 update: a report from the American Heart Association

    . Circulation

    (2016)
  • SJ. Shah

    Precision medicine for heart failure with preserved ejection fraction: an overview

    J Cardiovasc Transl Res

    (2017)
  • BA. Borlaug

    The pathophysiology of heart failure with preserved ejection fraction

    Nat Rev Cardiol

    (2014)
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