Implications of Coronary Artery Disease in Heart Failure With Preserved Ejection Fraction
What are the characteristics, evaluation, and prognostic impact of coronary artery disease (CAD) in patients with heart failure and preserved ejection fraction (HFpEF), and how does revascularization impact outcomes in patients with HFpEF and CAD?
This was a retrospective analysis of patients hospitalized for HFpEF and who underwent coronary angiography within 1 year of hospital discharge and echocardiography within 6 months prior to angiography. HFpEF patients were categorized into those with and without significant anatomic CAD (defined by an angiographic stenosis of at least 50% in one or more epicardial coronary arteries). Clinical, hemodynamic, echocardiographic, treatment, and outcome characteristics were examined in the analytic sample of patients.
The analytic sample included 376 patients with HFpEF, of which 255 (68%) had CAD. Over one-half of HFpEF patients underwent stress testing prior to angiography; however, only 70% of patients with angiographically proven CAD were found to demonstrate ischemia at the time of stress testing, with a 30% false-negative rate. Repeat echocardiography was performed in 218 patients after angiography; compared to patients without CAD, those with CAD experienced a fourfold greater decline in EF over time (median interval for repeat echocardiography was 1,314 days). In adjusted analyses, CAD was a significant predictor of mortality (hazard ratio [HR], 1.71; 95% confidence interval [CI], 1.03-2.98; p = 0.04). In those with CAD, complete revascularization was associated with lower mortality (HR, 0.56; 95% CI, 0.33-0.93; p = 0.03).
While CAD is common in patients with HFpEF and associated with increased mortality and greater deterioration in ventricular function, revascularization may be associated with improved outcomes and survival.
There are paucity of data to inform the prognostic import and optimal treatment of CAD in patients with HFpEF. Furthermore, no treatment has been shown to decrease mortality in HFpEF. CAD, which is plausibly associated with both diastolic and systolic dysfunction, may be a treatment target in those with HFpEF. The current analysis establishes the following important points: 1) CAD is common in patients with HFpEF (two thirds of patients had angiographically proven CAD), 2) detection of ischemia in patients with HFpEF may be less accurate (there was a 30% false-negative rate on stress testing in patients with angiographically proven CAD), 3) CAD is independently associated with adverse outcomes in patients with HFpEF, and 4) complete revascularization may be an opportunity to independently improve survival in patients with HFpEF. As the authors suggest, prospective trials are clearly and urgently needed to clarify optimal treatment in patients with concomitant HFpEF and CAD.
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