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Heart failure with preserved ejection fraction in outpatients with unexplained dyspnea: a pressure-volume loop analysis.
J Am Coll Cardiol. 2010 Apr 20; 55(16):1701-10.JACC

Abstract

OBJECTIVES

The aim of the present study was to diagnose heart failure with preserved ejection fraction (HFPEF) in outpatients with unexplained chronic dyspnea and to elucidate its underlying mechanisms in this population using invasive pressure-volume loop analysis.

BACKGROUND

The diagnosis of HFPEF in stable outpatients with unexplained dyspnea is difficult.

METHODS

Thirty patients (age 67 +/- 8.6 years, 27% males) with preserved left ventricular (LV) ejection fraction (>50%) and unexplained chronic New York Heart Association functional class II to III dyspnea underwent heart catheterization. Patients with significant coronary artery stenosis (>50%) were excluded. Pressure-volume loops were assessed using a conductance catheter at rest, hand-grip exercise, leg lifting, and nitroprusside and dobutamine infusion.

RESULTS

Twenty (66%) patients showed LV end-diastolic pressure >16 mm Hg (HFPEF), whereas the remaining 10 patients served as controls. Patients with HFPEF had significantly higher end-diastolic stiffness (0.205 +/- 0.074 vs. 0.102 +/- 0.017, p < 0.001) at rest, and their end-diastolic pressure-volume relationship showed a consistent upward and leftward shift during all hemodynamic interventions compared with controls. Regarding the underlying mechanism of HFPEF, 14 (70%) patients had markedly increased end-diastolic stiffness, which was considered a sufficient single pathology to induce increased LV end-diastolic pressure. Four (20%) patients showed a concomitant presence of moderately increased stiffness and severe LV dyssynchrony, and the remaining 2 (10%) patients, with normal stiffness, showed significant exercise-induced mitral regurgitation at hand-grip exercise. If the invasive pressure measurements were absent, only 5 (25%) of the outpatients with HFPEF fulfilled the European Society of Cardiology definition of HFPEF.

CONCLUSIONS

A significant proportion of stable outpatients with unexplained chronic dyspnea may have HFPEF. In the patients whom we studied, increased LV stiffness, dyssynchrony, and dynamic mitral regurgitation were the major mechanisms underlying development of HFPEF.

Authors+Show Affiliations

Cardiovascular Center Aalst, Aalst, Belgium. martin.penicka@olvz-aalst.beNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

20394874

Citation

Penicka, Martin, et al. "Heart Failure With Preserved Ejection Fraction in Outpatients With Unexplained Dyspnea: a Pressure-volume Loop Analysis." Journal of the American College of Cardiology, vol. 55, no. 16, 2010, pp. 1701-10.
Penicka M, Bartunek J, Trakalova H, et al. Heart failure with preserved ejection fraction in outpatients with unexplained dyspnea: a pressure-volume loop analysis. J Am Coll Cardiol. 2010;55(16):1701-10.
Penicka, M., Bartunek, J., Trakalova, H., Hrabakova, H., Maruskova, M., Karasek, J., & Kocka, V. (2010). Heart failure with preserved ejection fraction in outpatients with unexplained dyspnea: a pressure-volume loop analysis. Journal of the American College of Cardiology, 55(16), 1701-10. https://doi.org/10.1016/j.jacc.2009.11.076
Penicka M, et al. Heart Failure With Preserved Ejection Fraction in Outpatients With Unexplained Dyspnea: a Pressure-volume Loop Analysis. J Am Coll Cardiol. 2010 Apr 20;55(16):1701-10. PubMed PMID: 20394874.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Heart failure with preserved ejection fraction in outpatients with unexplained dyspnea: a pressure-volume loop analysis. AU - Penicka,Martin, AU - Bartunek,Jozef, AU - Trakalova,Helena, AU - Hrabakova,Hana, AU - Maruskova,Michaela, AU - Karasek,Jiri, AU - Kocka,Viktor, PY - 2009/10/05/received PY - 2009/11/13/revised PY - 2009/11/19/accepted PY - 2010/4/17/entrez PY - 2010/4/17/pubmed PY - 2010/6/16/medline SP - 1701 EP - 10 JF - Journal of the American College of Cardiology JO - J. Am. Coll. Cardiol. VL - 55 IS - 16 N2 - OBJECTIVES: The aim of the present study was to diagnose heart failure with preserved ejection fraction (HFPEF) in outpatients with unexplained chronic dyspnea and to elucidate its underlying mechanisms in this population using invasive pressure-volume loop analysis. BACKGROUND: The diagnosis of HFPEF in stable outpatients with unexplained dyspnea is difficult. METHODS: Thirty patients (age 67 +/- 8.6 years, 27% males) with preserved left ventricular (LV) ejection fraction (>50%) and unexplained chronic New York Heart Association functional class II to III dyspnea underwent heart catheterization. Patients with significant coronary artery stenosis (>50%) were excluded. Pressure-volume loops were assessed using a conductance catheter at rest, hand-grip exercise, leg lifting, and nitroprusside and dobutamine infusion. RESULTS: Twenty (66%) patients showed LV end-diastolic pressure >16 mm Hg (HFPEF), whereas the remaining 10 patients served as controls. Patients with HFPEF had significantly higher end-diastolic stiffness (0.205 +/- 0.074 vs. 0.102 +/- 0.017, p < 0.001) at rest, and their end-diastolic pressure-volume relationship showed a consistent upward and leftward shift during all hemodynamic interventions compared with controls. Regarding the underlying mechanism of HFPEF, 14 (70%) patients had markedly increased end-diastolic stiffness, which was considered a sufficient single pathology to induce increased LV end-diastolic pressure. Four (20%) patients showed a concomitant presence of moderately increased stiffness and severe LV dyssynchrony, and the remaining 2 (10%) patients, with normal stiffness, showed significant exercise-induced mitral regurgitation at hand-grip exercise. If the invasive pressure measurements were absent, only 5 (25%) of the outpatients with HFPEF fulfilled the European Society of Cardiology definition of HFPEF. CONCLUSIONS: A significant proportion of stable outpatients with unexplained chronic dyspnea may have HFPEF. In the patients whom we studied, increased LV stiffness, dyssynchrony, and dynamic mitral regurgitation were the major mechanisms underlying development of HFPEF. SN - 1558-3597 UR - https://www.unboundmedicine.com/medline/citation/20394874/Heart_failure_with_preserved_ejection_fraction_in_outpatients_with_unexplained_dyspnea:_a_pressure_volume_loop_analysis_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0735-1097(10)00585-1 DB - PRIME DP - Unbound Medicine ER -