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Coronary Artery Disease and Heart Failure With Preserved Ejection Fraction: The ARIC Study
Jenine E John1,2, Brian Claggett2, Hicham Skali1,2
1Noninvasive Cardiovascular Imaging Program Departments of Medicine and Radiology Brigham and Women's Hospital Boston MA.
Insights
Coronary artery disease (CAD) significantly increases the risk of developing heart failure with preserved ejection fraction (HFpEF). Echocardiographic changes, especially impaired diastolic function, partially explain this link.
Area of Science:
- Cardiology
- Cardiovascular Disease Research
- Heart Failure Etiology
Background:
- The role of coronary artery disease (CAD) as a risk factor for heart failure with preserved ejection fraction (HFpEF) remains incompletely understood.
- Investigating the association between CAD and HFpEF is crucial for understanding heart failure pathogenesis.
Purpose of the Study:
- To assess the association between incident coronary artery disease (CAD) and subsequent incident heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF).
- To determine the extent to which echocardiographic markers of prevalent CAD explain the relationship between CAD and incident HFpEF.
Main Methods:
- Utilized survival models with time-updated variables in 9902 participants from the Atherosclerosis Risk in Communities (ARIC) study over a 13-year follow-up.
- Assessed echocardiographic correlates of prevalent CAD and their impact on the association with incident HFpEF.
Main Results:
- Incident CAD was associated with increased risk for both HFrEF and HFpEF, with the highest risk observed early after the CAD event.
- After adjusting for demographics and comorbidities, CAD remained a significant predictor of both HFrEF and HFpEF.
- Prevalent CAD was linked to echocardiographic changes including lower ejection fraction and increased left ventricular mass, E/e', and left atrial volume.
- The association between prevalent CAD and incident HFpEF was attenuated after accounting for echocardiographic measures, particularly left ventricular diastolic function.
Conclusions:
- Coronary artery disease is identified as a significant risk factor for developing heart failure with preserved ejection fraction, even after accounting for common comorbidities.
- Echocardiographic alterations, specifically impaired left ventricular diastolic function, partially mediate the relationship between CAD and HFpEF.
Abstract:
Background Whether coronary artery disease (CAD) is a significant risk factor for heart failure (HF) with preserved ejection fraction (HFpEF) is unclear. Methods and Results Among 9902 participants in the ARIC (Atherosclerosis Risk in Communities) study, we assessed the association of incident CAD with subsequent incident HFpEF (left ventricular ejection fraction [≥50%]) and HF with reduced ejection fraction (HFrEF; left ventricular ejection fraction <50%) using survival models with time-updated variables. We also assessed the extent to which echocardiographic correlates of prevalent CAD account for the relationship between CAD and incident HFpEF. Over 13-year follow-up, incident CAD developed in 892 participants and 178 subsequently developed HF (86 HFrEF, 71 HFpEF). Incident HFrEF and HFpEF risk were both greatest early after the CAD event. At >1 year post-CAD event, adjusted incidence of HFrEF and HFpEF were similar (7.2 [95% CI, 5.2-10.0] and 6.7 [4.8-9.2] per 1000 person-years, respectively) and CAD remained predictive of both (HFrEF: hazard ratio, 2.76 [95% CI, 1.99-3.84]; HFpEF: 1.85 [1.35-2.54]) after adjusting for demographics and common comorbidities. Among 4779 HF-free participants at Visit 5 (2011-2013), the 490 with prevalent CAD had lower left ventricular ejection fraction and higher left ventricular mass index, E/e', and left atrial volume index (all P<0.01). The association of prevalent CAD with incident HFpEF post-Visit 5 was not significant after adjusting for echocardiographic measures, with the greatest attenuation observed for left ventricular diastolic function. Conclusions CAD is a significant risk factor for incident HFpEF after adjustment for demographics and common comorbidities. This relationship is partially accounted for by echocardiographic alterations, particularly left ventricular diastolic function.
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