Background:Recent trial data suggest that stratification of patients with heart failure with preserved ejection fraction (HFpEF) according to left ventricular ejection fraction (LVEF) provides a means for dissecting different treatment responses. However, the differential pathophysiologic considerations have rarely been described.Methods:This prospective, single-center study analyzed consecutive symptomatic patients with HFpEF diagnosed according to the 2016 European Society of Cardiology heart failure guidelines. Patients were grouped into LVEF 50% to 60% and LVEF >60% cohorts. All patients underwent cardiac magnetic resonance imaging. Transfemoral cardiac catheterization was performed to derive load-dependent and load-independent left ventricular (LV) properties on pressure–volume loop analyses.Results:Fifty-six patients with HFpEF were enrolled and divided into LVEF 50% to 60% (n=21) and LVEF >60% (n=35) cohorts. On cardiac magnetic resonance imaging, the LVEF >60% cohort showed lower LV end-diastolic volumes (P=0.019) and end-systolic volumes (P=0.001) than the LVEF 50% to 60% cohort; stroke volume (P=0.821) did not differ between the cohorts. Extracellular volume fraction was higher in the LVEF 50% to 60% cohort than in the LVEF >60% cohort (0.332 versus 0.309; P=0.018). Pressure-volume loop analyses demonstrated higher baseline LV contractility (end-systolic elastance, 1.85 vs 1.33 mm Hg/mL; P<0.001) and passive diastolic stiffness (β constant, 0.032 versus 0.018; P=0.004) in the LVEF >60% cohort. Ventriculo-arterial coupling (end-systolic elastance/arterial elastance) at rest was in the range of optimized stroke work in the LVEF >60% cohort but was impaired in the LVEF 50% to 60% cohort (1.01 versus 0.80; P=0.005). During handgrip exercise, patients with LVEF >60% had higher increases in end-systolic elastance (1.85 versus 0.82 mm Hg/mL; P=0.023), attenuated increases in indexed end-systolic volume (−1 versus 7 mL/m²; P<0.004), and more exaggerated increases in LV filling pressures (8 vs 5 mm Hg; P=0.023). LV stroke volume decreased in the LVEF >60% cohort (P=0.007) under exertion.Conclusions:Patients with HFpEF in whom LVEF ranged from 50% to 60% demonstrated reduced contractility, impaired ventriculo-arterial coupling, and higher extracellular volume fraction. In contrast, patients with HFpEF and a LVEF >60% demonstrated a hypercontractile state with excessive LV afterload and diminished preload reserve. A LVEF-based stratification of patients with HFpEF identified distinct morphologic and pathophysiologic subphenotypes.

中文翻译：

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左心室射血分数范围内保留射血分数心力衰竭的特征

背景：最近的试验数据表明，根据左心室射血分数 (LVEF) 对射血分数保留的心力衰竭 (HFpEF) 患者进行分层提供了一种剖析不同治疗反应的方法。然而，差异性病理生理因素很少被描述。方法：这项前瞻性单中心研究分析了根据 2016 年欧洲心脏病学会心力衰竭指南诊断为 HFpEF 的连续有症状患者。患者被分为 LVEF 50% 至 60% 和 LVEF >60% 的队列。所有患者均接受了心脏磁共振成像。进行经股心脏导管插入术以在压力-容积环分析中推导负荷依赖性和负荷无关的左心室 (LV) 特性。结果：56 名 HFpEF 患者被纳入并分为 LVEF 50% 至 60% (n=21) 和 LVEF >60% (n=35) 队列。在心脏磁共振成像中，LVEF >60% 的队列显示较低的 LV 舒张末期容积（P =0.019) 和收缩末期容积 ( P =0.001) 高于 LVEF 50% 至 60% 的队列；每搏输出量 ( P =0.821) 在队列之间没有差异。LVEF 50% 至 60% 队列的细胞外体积分数高于 LVEF >60% 队列（0.332 对 0.309；P = 0.018）。压力-容积环分析表明基线 LV 收缩力（收缩末期弹性，1.85 对 1.33 mm Hg/mL；P <0.001）和被动舒张刚度（β 常数，0.032 对 0.018；P=0.004) 在 LVEF >60% 队列中。在 LVEF >60% 的队列中，静息时的脑室-动脉耦合（收缩末期弹性/动脉弹性）在优化的卒中工作范围内，但在 LVEF 50% 至 60% 的队列中受损（1.01 对 0.80；P =0.005 ). 在握力运动期间，LVEF >60% 的患者收缩末期弹力增加较多（1.85 对 0.82 mm Hg/mL；P =0.023），索引的收缩末期容积增加减弱（-1 对 7 mL/m²；P <0.004)，并且 LV 充盈压增加更夸张（8 对 5 mm Hg；P =0.023）。LVEF >60% 队列中的 LV 每搏量减少（P=0.007) 在劳累下。结论：LVEF 范围为 50% 至 60% 的 HFpEF 患者表现出收缩力降低、心室-动脉耦合受损和细胞外体积分数升高。相反，HFpEF 和 LVEF >60% 的患者表现出过度收缩状态，伴有过度的 LV 后负荷和减少的前负荷储备。基于 LVEF 的 HFpEF 患者分层确定了不同的形态学和病理生理学亚表型。