CAD and Microvascular Dysfunction in HFpEF

Jun 24, 2021
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Authors:
Rush CJ, Berry C, Oldroyd KG, et al.
Citation:
Prevalence of Coronary Artery Disease and Coronary Microvascular Dysfunction in Patients With Heart Failure With Preserved Ejection Fraction. JAMA Cardiol 2021;Jun 23:[Epub ahead of print].
Summary By:
Marty Tam, MD, FACC

Quick Takes

  • Epicardial coronary artery disease and coronary microvascular dysfunction are very prevalent in patients hospitalized with HFpEF.
  • Disease is often unrecognized in this population.

Study Questions:

In patients hospitalized with heart failure with preserved ejection fraction (HFpEF), what is the prevalence of coronary artery disease (CAD) and coronary microvascular dysfunction (CMD)?

Methods:

This was a prospective, multicenter, cohort study that enrolled consecutive patients hospitalized with HFpEF between January 2017 and August 2018. Notably, patients with an estimated glomerular filtration rate <30 ml/min/1.73 m2 or severe frailty were excluded from the study. Patients underwent invasive coronary angiography with physiologic + vasoreactivity testing and cardiac magnetic resonance imaging (CMRI) with vasodilator stress testing.

Based on invasive coronary angiography, three main conditions were identified: 1) obstructive epicardial CAD, 2) endothelium-independent CMD (by physiologic testing), and 3) endothelium-dependent CMD (by vasoreactivity testing). Based on CMRI, three main conditions were identified: 1) impaired myocardial perfusion, 2) myocardial infarction, and 3) diffuse myocardial fibrosis.

Endpoints were assessed for all-cause death or hospitalization for: 1) any reason, 2) a cardiovascular cause, 3) HF, and 4) a noncardiovascular cause.

Results:

Overall, 106 patients were enrolled in the study (2,285 screened). The following testing was completed in this cohort:

  • Did not undergo testing (changes in clinical status), 23/106 (22%).
  • Invasive angiography, 75 (71%): physiologic testing, 62/75 (83%); vasoreactivity testing, 41/75 (55%).
  • CMRI, 52/106 (49%).
  • Both invasive angiography and CMRI, 44/106 (42%).

The following prevalence of disease was identified by invasive coronary angiography:

  • Obstructive epicardial CAD, 38/75 (51%); no prior history, 19/38 (50%).
  • Endothelium-independent CMD, 41/62 (66%).
  • Endothelium-dependent CMD, 10/41 (24%).
  • Any CMD, 45/53 (85%).
  • Any CMD in patients without obstructive epicardial CAD, 29/36 (81%).
  • Any CAD or CMD, 91%.

The following prevalence of disease was identified by CMRI:

  • Impaired myocardial perfusion: low myocardial-perfusion reserve index, 29/41 (71%); inducible perfusion defect, 14/46 (30%).
  • Myocardial infarction, 14/52 (27%); no prior history, 8/14 (57%).
  • Diffuse myocardial fibrosis, 20/48 (42%).

Exploratory clinical outcomes summary, median follow-up 18 months:

  • Small number of events limiting analysis.
  • Higher rate of events in patients with obstructive epicardial CAD vs. without (74% vs. 46%).
  • No significant difference in outcomes-based CMD status.
  • Higher rate of events based on undesirable CMRI findings.

Conclusions:

Obstructive epicardial CAD and CMD are common in hospitalized patients with HFpEF, with some patients not having a previous diagnosis.

Perspective:

Management of comorbid conditions, including epicardial CAD and CMD, that contribute to the pathophysiology and systemic mediators of HFpEF is important. The authors aim in this study to prospectively and systematically describe the prevalence of CAD and CMD in hospitalized patients with HFpEF. The results were striking in that 91% of patients had some form of obstructive epicardial CAD (51%) or CMD (81%). Notably, many of these patients did not carry a prior diagnosis and many had CMD without epicardial CAD. Obstructive epicardial CAD was associated with higher rates of adverse events in exploratory analysis, while there was no clear association with CMD (in the context of a small number of events). CMRI data were available for some patients demonstrating similar high prevalence of abnormal findings as well as unrecognized disease. The study was limited by many patients being excluded from enrollment and lack of testing in some enrolled patients. Applicability to ambulatory HFpEF populations is also unclear.

These results are certainly intriguing and help to broaden our clinical decision making in this patient population. It will be important in the future to assess how this knowledge should be translated into clinical practice and if outcomes will change as a result. The role for intensification of medical therapy or targeted therapy is still unclear.

Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Magnetic Resonance Imaging, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Cardiomyopathies, Coronary Angiography, Coronary Artery Disease, Diagnostic Imaging, Dyslipidemias, Endothelium, Exercise Test, Fibrosis, Geriatrics, Glomerular Filtration Rate, Heart Failure, Magnetic Resonance Imaging, Metabolic Syndrome, Myocardial Infarction, Myocardial Ischemia, Perfusion, Prevalence, Stroke Volume, Vasodilator Agents


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