THE PROGNOSTIC ROLE OF CARDIAC HEMODYNAMIC RESERVES IN HEART FAILURE WITH PRESERVED EJECTION FRACTION

Objective: Reduced cardiac reserves play an important role in poor exercise tolerance in heart failure with preserved ejection fraction (HFpEF). However, their prognostic role in HFpEF is not well defined. We aimed to evaluate the prognostic significance of key cardiac reserves in patients with HFpEF. Design and method: 348 patients (164 men, median age 68 years) with stable heart failure in NYHA functional class II-III, preserved left ventricular (LV) ejection fraction (>=50%), and increased LV filling pressure at rest and/or during exercise (determined by echocardiography) were included in retrospective cohort analysis. The median follow-up period between the initial visit and the follow-up call was 5.4 (3.5-7.0) years. Primary outcome included a composite of all-cause mortality and hospitalizations for congestive heart failure (HF). Primary outcome occurred in 166 patients (73 patients died and 93 patients were hospitalized for exacerbation of HF); 182 patients survived without hospitalizations. The event-free survival rate between groups were analysed using the Kaplan-Meier method, and the significance was evaluated using log-rank tests. Results: Patients who experienced primary endpoint had a greater enhancement in the early mitral inflow to mitral annulus relaxation velocity ratio (E/e’ ratio) on exercise (reflecting LV filling pressure and diastolic reserve), as well as a lesser enhancement in left atrial reservoir strain (LA reserve) and tricuspid annular plane systolic excursion (right ventricular [RV] reserve) on exercise. There were no differences in global longitudinal strain enhancement on exercise (LV contractility reserve) between groups. Reserve dysfunction showed a strong association with poor HFpEF prognosis: LA reserve (RR 1.81 [95% CI 1.28-2.56], P<0.001), LV diastolic reserve (RR 1.62 (95% CI 1.25-2.27, P<0.01), and RV reserve (RR 1.47 (95% CI 1.05-2.05), P<0.05). Conclusions: Here, we demonstrated for the first time the high predictive accuracy of cardiac reserves (LV diastolic, LA, RV) in HFpEF.