Metabolic syndrome may play role in HFpEF risk
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CHICAGO — Patients with metabolic syndrome are at risk for developing HF with preserved ejection fraction, although the mechanisms behind this risk are speculative at the moment, according to a presentation at the Cardiometabolic Health Congress.
As HFpEF becomes more understood, cardiologists see that several comorbid conditions are involved in the development of HFpEF such as systemic microvascular endothelial inflammation, vascular oxidative stress and secondary fibrosis.
“It doesn’t explain everything that happens in HFpEF, but it felt a little bit better,” Mariell Jessup, MD, FAHA, FACC, FESC, emeritus professor of medicine at the University of Pennsylvania and chief science and medical officer for the American Heart Association, said during the presentation.
Most patients with HFpEF are elderly, as shown in the Atherosclerosis Risk in Communities (ARIC) study published in Circulation in 2017. This study previously developed a prediction model for HFpEF in a study published in Circulation: Heart Failure in 2012, which included race, age, sex, prevalent CHD, diabetes, systolic BP, heart rate, BP medication use, smoking status and BMI. These researchers also developed a simplified risk score that was restricted to a patient’s race, age, sex and N-terminal pro-B-type natriuretic peptide.
Although findings from the ARIC study did not incorporate many components of metabolic syndrome, the AHA developed “Life’s Simple 7,” which include several elements of the syndrome. A study published in the American Journal of Medicine found that patients at middle age with greater achievement of Life’s Simple 7 had a greater preservation of cardiac function and structure and a lower lifetime occurrence of HF. This remained true when assessed in other ethnic groups, as shown in the MESA study published in the Journal of the American Heart Association in 2017.
“If we can stay on target with maintaining a healthy lifestyle, we will be immortal, but the problem with HFpEF is that it is associated with multiple comorbidities,” Jessup said during the presentation.
In a study published in Circulation: Heart Failure in 2016, researchers found that obesity stood out as a significant risk factor for HFpEF. Other studies found that the risk for HFpEF in patients with obesity who were metabolically healthy may not be nearly as high as in those with obesity who were metabolically unhealthy.
“It’s not enough to say HFpEF is a disease of women — notice that I didn’t say anything about it, but sex keeps coming out as a predictor — and it’s not just about obesity because we have a lot of that in this country; it has got to be something else besides that, we think,” Jessup said during the presentation.
Physical activity may also play a role, as the risk for HFpEF decreases the more a patient exercises, according to the presentation.
HF, especially HFpEF can be prevented with BP control. According to the SPRINT trial published in The New England Journal of Medicine in 2015, targeting a systolic BP of less than 120 mm Hg in patients at high risk for CV events resulted in lower rates of fatal and nonfatal major CV events and all-cause death compared with a target of less than 140 mm Hg.
“If we went home and we dedicated ourselves to making sure that every single one of our patients had normal blood pressure, however we want to define it. ... But if we just got it within shooting level of being normal, we would probably prevent easily 60% to 70% of HFpEF,” Jessup said during the presentation. “That’s what I think, and I’d love to do a trial to prove that.”
There are no good studies on whether BP control is as important once a patient develops HFpEF, but it probably does not hurt, Jessup said.
“We know that there’s been drugs given in HFpEF that normally lower blood pressure, and in fact, it lower blood pressure a bit, but it didn’t help the syndrome and it didn’t help people live longer,” Jessup said. “There’s a real disconnect between those two.” – by Darlene Dobkowski
References:
Jessup M. Role of Metabolic Syndrome in HFpEF. Presented at: Cardiometabolic Health Congress; Oct. 10-13, 2019; Chicago.
Agarwal SK, et al. Circ Heart Fail. 2012;doi:10.1161/CIRCHEARTFAILURE.111.964841.
Eaton CB, et al. Circ Heart Fail. 2016;doi:10.1161/CIRCHEARTFAILURE.115.002883.
Folsom AR, et al. Am J Med. 2015;doi:10.1016/j.amjmed.2015.03.027.
Ogunmoroti O, et al. J Am Heart Assoc. 2017;doi:10.1161/JAHA.116.005180.
Shah AM, et al. Circulation. 2017;doi:10.1161/CIRCULATIONAHA.116.023361.
SPRINT Research Group. N Engl J Med. 2015;doi:10.1056/NEJMoa1511939.
Disclosure: Jessup reports no relevant financial disclosures.