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Prevalence of Coronary Artery Disease and Coronary Microvascular Dysfunction in Patients With Heart Failure With
Christopher J Rush1,2, Colin Berry1,2, Keith G Oldroyd1,2
1British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
Insights
Coronary artery disease (CAD) and coronary microvascular dysfunction (CMD) are highly prevalent in heart failure with preserved ejection fraction (HFpEF) patients, often unrecognized. These conditions may represent key therapeutic targets for improving HFpEF outcomes.
Area of Science:
- Cardiology
- Heart Failure Research
- Vascular Biology
Background:
- Coronary artery disease (CAD) and coronary microvascular dysfunction (CMD) are implicated in heart failure with preserved ejection fraction (HFpEF).
- The prevalence of CAD and CMD in HFpEF patients remains understudied.
Purpose of the Study:
- To determine the prevalence of obstructive epicardial CAD and CMD in hospitalized patients diagnosed with HFpEF.
- To investigate the association between these conditions and clinical outcomes.
Main Methods:
- Prospective, multicenter cohort study of 106 HFpEF patients.
- Coronary angiography with fractional flow reserve and coronary flow reserve assessment.
- Cardiac magnetic resonance imaging for myocardial perfusion and fibrosis evaluation.
Main Results:
- Obstructive epicardial CAD was found in 51% of patients; 50% of these had no prior CAD diagnosis.
- Coronary microvascular dysfunction (CMD) was present in 66% (endothelium-independent) and 24% (endothelium-dependent).
- 81% of patients without obstructive CAD had CMD, and 91% of all patients had evidence of either CAD, CMD, or both.
Conclusions:
- Obstructive epicardial CAD and CMD are highly prevalent and frequently undiagnosed in hospitalized HFpEF patients.
- CMD is common even in the absence of obstructive epicardial CAD.
- These findings suggest that CAD and CMD are significant contributors to HFpEF pathophysiology and potential therapeutic targets.
Importance:
Coronary artery disease (CAD) and coronary microvascular dysfunction (CMD) may contribute to the pathophysiologic characteristics of heart failure with preserved ejection fraction (HFpEF). However, the prevalence of CAD and CMD have not been systematically studied.
Objective:
To examine the prevalence of CAD and CMD in hospitalized patients with HFpEF.
Design, Setting, And Participants:
A total of 106 consecutive patients hospitalized with HFpEF were evaluated in this prospective, multicenter, cohort study conducted between January 2, 2017, and August 1, 2018; data analysis was performed from March 4 to September 6, 2019. Participants underwent coronary angiography with guidewire-based assessment of coronary flow reserve, index of microvascular resistance, and fractional flow reserve, followed by coronary vasoreactivity testing. Cardiac magnetic resonance imaging was performed with late gadolinium enhancement and assessment of extracellular volume. Myocardial perfusion was assessed qualitatively and semiquantitatively using the myocardial-perfusion reserve index.
Main Outcomes And Measures:
The prevalence of obstructive epicardial CAD, CMD, and myocardial ischemia, infarction, and fibrosis.
Results:
Of 106 participants enrolled (53 [50%] women; mean [SD] age, 72 [9] years), 75 had coronary angiography, 62 had assessment of coronary microvascular function, 41 underwent coronary vasoreactivity testing, and 52 received cardiac magnetic resonance imaging. Obstructive epicardial CAD was present in 38 of 75 participants (51%, 95% CI, 39%-62%); 19 of 38 (50%; 95% CI, 34%-66%) had no history of CAD. Endothelium-independent CMD (ie, coronary flow reserve <2.0 and/or index of microvascular resistance ≥25) was identified in 41 of 62 participants (66%; 95% CI, 53%-77%). Endothelium-dependent CMD (ie, abnormal coronary vasoreactivity) was identified in 10 of 41 participants (24%; 95% CI, 13%-40%). Overall, 45 of 53 participants (85%; 95% CI, 72%-92%) had evidence of CMD and 29 of 36 (81%; 95% CI, 64%-91%) of those without obstructive epicardial CAD had CMD. Cardiac magnetic resonance imaging findings included myocardial-perfusion reserve index less than or equal to 1.84 (ie, impaired global myocardial perfusion) in 29 of 41 patients (71%; 95% CI, 54%-83%), visual perfusion defect in 14 of 46 patients (30%; 95% CI, 19%-46%), ischemic late gadolinium enhancement (ie, myocardial infarction) in 14 of 52 patients (27%; 95% CI, 16%-41%), and extracellular volume greater than 30% (ie, diffuse myocardial fibrosis) in 20 of 48 patients (42%; 95% CI, 28%-56%). Patients with obstructive CAD had more adverse events during follow-up (28 [74%]) than those without obstructive CAD (17 [46%]).
Conclusions And Relevance:
In this cohort study, 91% of patients with HFpEF had evidence of epicardial CAD, CMD, or both. Of those without obstructive CAD, 81% had CMD. Obstructive epicardial CAD and CMD appear to be common and often unrecognized in hospitalized patients with HFpEF and may be therapeutic targets.
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