Prevalence and Prognostic Significance of Microvascular Dysfunction in Heart Failure With Preserved Ejection Fraction,JACC: Cardiovascular Imaging

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Prevalence and Prognostic Significance of Microvascular Dysfunction in Heart Failure With Preserved Ejection Fraction
JACC: Cardiovascular Imaging ( IF 12.8 ) Pub Date : 2022-01-12 , DOI: 10.1016/j.jcmg.2021.11.022
J Ranjit Arnold ₁ , Prathap Kanagala ₂ , Charley A Budgeon ₃ , Michael Jerosch-Herold ₄ , Gaurav S Gulsin ₁ , Anvesha Singh ₁ , Jamal N Khan ₅ , Daniel C S Chan ₁ , Iain B Squire ₁ , Leong L Ng ₁ , Gerry P McCann ₁

Affiliation

Background

The pathophysiological and clinical significance of microvascular dysfunction (MVD) in patients with heart failure with preserved ejection fraction (HFpEF) remains uncertain.

Objectives

The aim of this study was to use cardiovascular magnetic resonance to: 1) quantify coronary microvascular function; 2) examine the relationship between perfusion and fibrosis; and 3) evaluate the impact of MVD and fibrosis on long-term clinical outcomes.

Methods

In a prospective, observational study, patients with HFpEF and control subjects underwent multiparametric cardiovascular magnetic resonance (comprising assessment of left ventricular volumetry, perfusion, and fibrosis [focal by late gadolinium enhancement and diffuse by extracellular volume]). The primary endpoint was the composite of death or hospitalization with heart failure.

Results

One hundred and one patients with HFpEF (mean age 73 ± 9 years, mean ejection fraction 56% ± 5%) and 43 control subjects (mean age 73 ± 5 years, mean ejection fraction 58% ± 5%) were studied. Myocardial perfusion reserve (MPR) was lower in patients with HFpEF versus control subjects (1.74 ± 0.76 vs 2.22 ± 0.76; P = 0.001). MVD (defined as MPR <2.0) was present in 70% of patients with HFpEF (vs 48% of control subjects; P = 0.014). There was no significant linear correlation between MPR and diffuse fibrosis (r = −0.10; P = 0.473) and no difference in MPR between those with and without focal fibrosis (mean difference −0.03; 95% CI: −0.37 to 0.30). In the HFpEF group, during median follow-up of 3.1 years, there were 45 composite events. MPR was independently predictive of clinical outcome following adjustment for clinical, blood, and imaging parameters (1 SD increase: HR: 0.673 [95% CI: 0.463 to 0.978; P = 0.038]; HR: 0.694 [95% CI: 0.491 to 0.982; P = 0.039]; and HR: 0.690 [95% CI: 0.489 to 0.973; P = 0.034], respectively).

Conclusions

MVD is highly prevalent among patients with HFpEF and is an independent predictor of prognosis. The lack of correlation between MVD and fibrosis may challenge the assertion of a direct causal link between these entities. (Developing Imaging and Plasma Biomarkers in Describing Heart Failure With Preserved Ejection Fraction [DIAMONDHFpEF]; NCT03050593)

中文翻译：

保留射血分数的心力衰竭中微血管功能障碍的患病率和预后意义

背景

射血分数保留型心力衰竭（HFpEF）患者微血管功能障碍（MVD）的病理生理学和临床意义仍不确定。

目标

本研究的目的是利用心血管磁共振：1）量化冠状动脉微血管功能；2）检查灌注与纤维化的关系；3) 评估 MVD 和纤维化对长期临床结果的影响。

方法

在一项前瞻性观察性研究中，HFpEF 患者和对照受试者接受了多参数心血管磁共振检查（包括对左心室容积、灌注和纤维化的评估 [通过晚期钆增强聚焦和通过细胞外体积扩散]）。主要终点是死亡或住院合并心力衰竭的复合终点。

结果

研究了 101 名 HFpEF 患者（平均年龄 73 ± 9 岁，平均射血分数 56% ± 5%）和 43 名对照受试者（平均年龄 73 ± 5 岁，平均射血分数 58% ± 5%）。HFpEF 患者的心肌灌注储备 (MPR) 低于对照组 (1.74 ± 0.76 vs 2.22 ± 0.76; P = 0.001)。70% 的 HFpEF 患者存在 MVD（定义为 MPR <2.0）（与对照组的 48%；P = 0.014）。MPR与弥漫性纤维化之间没有显着的线性相关性（r = -0.10; P =0.473），有和没有局灶性纤维化的患者的 MPR 无差异（平均差 -0.03；95% CI：-0.37 至 0.30）。在 HFpEF 组中，在 3.1 年的中位随访期间，发生了 45 起复合事件。MPR 可独立预测临床、血液和影像学参数调整后的临床结果（1 SD 增加：HR：0.673 [95% CI：0.463 至 0.978；P = 0.038]；HR：0.694 [95% CI：0.491 至 0.982 ；P = 0.039]；和 HR：0.690 [95% CI：0.489 至 0.973；P = 0.034]）。