HFpEF, CAD, and Revascularization: Worse than We Thought | CardioSource WorldNews Interventions

JACC in a Flash | Coronary artery disease (CAD) commonly occurs in patients with heart failure and preserved ejection fraction (HFpEF), but the relationship is not fully understood. Though associated with common risk factors, it is also possible that CAD and HFpEF simply coexist without any mechanistic relationship. Current studies and guidelines endorse treatment of commonly observed comorbidities, but it has also recently been proposed that HFpEF embodies a heterogeneous group of diseases that may respond differently to treatments. So, should HFpEF patients with CAD be diagnostically grouped separately from those without CAD, and how should CAD be managed in these patients once it is identified?

To investigate the characteristics, evaluation, prognostic impact, and treatment of CAD in HFpEF patients, Hwang et al. examined 376 HFpEF patients, 255 (86%) of whom had angiographically-proven CAD. Compared with HFpEF patients without CAD, patients with CAD were more likely to be male, have CAD risk factors, and be treated with anti-ischemic medications. Symptoms of angina and HF, however, were similar in patients with and without CAD, as were measures of cardiovascular structure, function, and hemodynamics.

During a median 4-year follow-up, HFpEF patients with CAD displayed greater deterioration in left ventricular ejection fraction (LVEF) and increased mortality compared to those without CAD—independent of other predictors (HR = 1.71; 95% CI 1.03-2.98; p = 0.04). In terms of therapeutics, revascularization—particularly complete revascularization—appeared to be associated with the preservation of cardiac function and improved outcomes in patients with CAD. Eighty percent of the 255 HFpEF patients with significant CAD underwent revascularization:

  • complete revascularization was performed in 102 patients
  • partial revascularization in 103 patients
  • no revascularization in 50 patients

On average, LVEF decreased in HFpEF patients with CAD, although patients who did not undergo complete revascularization experienced a 2-fold greater decline in EF compared with those who underwent complete revascularization. This relationship was, again, independent of other predictors (HR = 0.56; 95% CI 0.33-0.93; p = 0.03). Those who underwent complete revascularization also demonstrated greater survival rates—similar to those of HFpEF patients without CAD. This relationship strengthened in patients with more severe CAD.

One key issue according to the authors: effectively determining who does or does not have CAD. Barry Greenberg, MD, who wrote an accompanying editorial, seconded that conclusion, noting that CAD "appears to alter the clinical course and it presents a therapeutic target for a disease for which no currently available treatments are known to affect long-term outcome."

When it comes to CAD in these patients, the differences appear to trump the similarities "to justify the diagnostic separation of HFpEF patients according to the presence or absence of CAD," Dr. Hwang and colleagues concluded. "Although prospective trials are needed, the current exploratory data support the hypothesis that revascularization of CAD in patients with HFpEF might be effective to improve both ventricular function and survival in this population."

Hwang S-J, Melenovsky V, Borlaug BA. J Am Coll Cardiol. 2014;63:2817-27.
Greenberg B. J Am Coll Cardiol. 2014;63:2828-30.

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