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Published on: February 18, 2022
Echocardiographic predictors of cardiovascular outcome in heart failure with preserved ejection fraction
Nelson Wang1,2,3, Phidias Rueter2,3, Melvin Ng4
1The George Institute for Global Health UNSW, Sydney, Australia.
Insights
Key echocardiographic measures like left ventricular global longitudinal strain, left atrial reservoir strain, and the tricuspid annular plane systolic excursion to pulmonary artery systolic pressure ratio are independent predictors of cardiovascular outcomes in heart failure with preserved ejection fraction (HFpEF). These findings can improve risk prediction models.
Area of Science:
- Cardiology
- Echocardiography
- Heart Failure Research
Background:
- Heart failure with preserved ejection fraction (HFpEF) poses a significant clinical challenge.
- Optimal echocardiographic predictors for cardiovascular outcomes in HFpEF remain incompletely defined.
- Identifying reliable prognostic markers is crucial for managing HFpEF patients.
Purpose of the Study:
- To identify independent echocardiographic predictors of cardiovascular outcomes in patients with HFpEF.
- To determine which echocardiographic parameters robustly predict major adverse cardiovascular events in HFpEF.
Main Methods:
- A systematic literature search of electronic databases was performed up to November 2022.
- A random effects meta-analysis pooled hazard ratios from multivariate prediction models of 46 studies (20,056 patients).
- Subgroup analyses assessed predictors in acute vs. chronic HF and considered clinical variables like E/e', PASP, renal function, and natriuretic peptides.
Main Results:
- Decreased left ventricular (LV) global longitudinal strain, decreased left atrial (LA) reservoir strain, and a lower tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) ratio were independent predictors across all subgroups.
- Higher E/e', moderate-to-severe tricuspid regurgitation, LV mass index, and LA ejection fraction were also predictors but less robust.
- These key parameters remained significant predictors independent of filling pressures, clinical characteristics, and natriuretic peptides.
Conclusions:
- Impaired LV global longitudinal strain, lower LA reservoir strain, and a lower TAPSE/PASP ratio are robust predictors of cardiovascular death and HF hospitalization in HFpEF.
- These echocardiographic findings reflect critical functional changes in HFpEF.
- These parameters should be integrated into future prospective risk prediction models for HFpEF.
Aims:
The optimal echocardiographic predictors of cardiovascular outcome in heart failure (HF) with preserved ejection fraction (HFpEF) are unknown. We aimed to identify independent echocardiographic predictors of cardiovascular outcome in patients with HFpEF.
Methods And Results:
Systematic literature search of three electronic databases was conducted from date of inception until November 2022. Hazard ratios (HRs) and their 95% confidence intervals (CIs) for echocardiographic variables from multivariate prediction models for the composite primary endpoint of cardiovascular death and HF hospitalization were pooled using a random effects meta-analysis. Specific subgroup analyses were conducted for studies that enrolled patients with acute versus chronic HF, and for those studies that included E/e', pulmonary artery systolic pressure (PASP), renal function, natriuretic peptides and diuretic use in multivariate models. Forty-six studies totalling 20 056 patients with HFpEF were included. Three echocardiographic parameters emerged as independent predictors in all subgroup analyses: decreased left ventricular (LV) global longitudinal strain (HR 1.24, 95% CI 1.10-1.39 per 5% decrease), decreased left atrial (LA) reservoir strain (HR 1.30, 95% CI 1.13-1.1.50 per 5% decrease) and lower tricuspid annular plane systolic excursion (TAPSE) to PASP ratio (HR 1.17, 95% CI 1.07-1.25 per 0.1 unit decrease). Other independent echocardiographic predictors of the primary endpoint were a higher E/e', moderate to severe tricuspid regurgitation, LV mass index and LA ejection fraction, although these variables were less robust.
Conclusions:
Impaired LV global longitudinal strain, lower LA reservoir strain and lower TAPSE/PASP ratio predict cardiovascular death and HF hospitalization in HFpEF and are independent of filling pressures, clinical characteristics and natriuretic peptides. These echocardiographic parameters reflect key functional changes in HFpEF, and should be incorporated in future prospective risk prediction models.
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