Cardiovascular Features of Heart Failure With Preserved Ejection Fraction Versus Nonfailing Hypertensive Left Ventricular Hypertrophy in the Urban Baltimore Community
The Role of Atrial Remodeling/Dysfunction
Vojtech Melenovsky, MD*, , ,1,
Barry A. Borlaug, MD*,
Boaz Rosen, MD*,
Ilan Hay, MD*,
Luigi Ferruci, MD, PhD ,
Christopher H. Morell, PhD,
Edward G. Lakatta, MD,
Samer S. Najjar, MD and
David A. Kass, MD*,*
* Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
Laboratory of Cardiovascular Science, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
Clinical Research Branch, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, Maryland
Department of Mathematical Sciences, Loyola College in Maryland, Baltimore, Maryland.
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Figure 1 The Prevalence of DD Grades in Each Subject Group
Patients unclassifiable by the scheme are noted as indeterminate. There was substantial overlap in the prevalence of diastolic dysfunction (DD) in symptomatic heart failure with preserved ejection fraction (HFpEF) and asymptomatic hypertensive left ventricular hypertrophy (HLVH) subjects.
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Figure 2 Comparison of LA Volumes and Emptying Fractions Adjusted for LV Mass Body Surface Area and Estimated Pulmonary Artery Wedge Pressure for Each Subject Group
Plots show the adjusted mean and 95% confidence interval. HFpEF subjects had significantly greater atrial size and reduced function. *p < 0.05 HFpEF versus LVH. LA = left atrial; LV = left ventricular; other abbreviations as in Figure 1.
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Figure 3 Total Epicardial Versus Left Ventricular End-Diastolic Chamber Volumes
Increase in total (epicardial) heart volume with similar end-diastolic volume (EDV) in HFpEF versus HLVH, and both versus control subjects. *p < 0.01 versus HLVH; p < 0.001 versus control subjects. Abbreviations as in Figure 1.
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Figure 4 Reduced Atrial Systolic Reserve in HFpEF Patients
The effect of isometric handgrip exercise on late diastolic (A') annular tissue velocity in patients with HFpEF (n = 21) and asymptomatic HLVH subjects (n = 25). Unlike HLVH subjects, HFpEF patients had minimal increases in A' with handgrip-exercise. Data shown are mean ± SEM. *Between group ANOVA. Abbreviations as in Figure 1.
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Figure 5 LV Mass and Atrial Volumes Better Distinguish HFpEF From HLVH Subjects Than Indexes of Diastolic Dysfunction
Histograms for group distributions of E/E' ratio and diastolic dysfunction (DD) grade (A) versus LVMI and LAVmax
(B). The latter show better separation between HFpEF and HLVH subjects. (C) LA enlargement was weakly correlated to LVMI, particularly in the HFpEF subjects. (D) Product of LVMI and LAVmax provides the best separation among study groups. (E) Receiver-operating curves for discriminating between HFpEF and HLVH. The most optimal characteristic was found for LVMI x LAVmax (AUC = 0.85), followed by LVMI (AUC = 0.79) and LAVmax (AUC = 0.77). E/E' ratio (AUC = 0.69) and DD grade (AUC = 0.68) were poorer discriminators. The optimal cut-off value (4,418 ml x g/m2.7) of LVMI x LAVmax
(arrow) separated the groups with a sensitivity 0.838 and specificity 0.825. AUC = area under the curve; E = early diastolic tissue velocity; E' = longitudinal early tissue velocity; LAV = left atrial volume; LVMI = left ventricular mass index; other abbreviations as in Figures 1 and 2.
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