Prevalence of CAD, coronary microvascular disease high in patients with HFpEF
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In a prospective cohort study of patients hospitalized with HF with preserved ejection fraction, a majority of participants had evidence of epicardial CAD, coronary microvascular disease or both.
“Half of the patients with invasively documented CAD in this study had no history of CAD, highlighting the high burden of unrecognized CAD in HFpEF, consistent with other studies,” Christopher J. Rush, MB, ChB, PhD, of the British Heart Foundation Cardiovascular Research Centre at the University of Glasgow, United Kingdom, and colleagues wrote. “In addition, we found that neither semiquantitative CMR perfusion imaging (using myocardial perfusion reserve index) nor the presence of a visual perfusion defect predicted obstructive epicardial CAD on invasive investigation, suggesting that angiography may be necessary to diagnose CAD in patients with HFpEF. This finding is consistent with the results of one retrospective study that reported poor diagnostic accuracy of noninvasive ischemia testing in detecting epicardial CAD.”
For this prospective, multicenter, cohort study, researchers evaluated 106 consecutive patients hospitalized with HFpEF (mean age, 72 years; 50% women) between Jan. 2, 2017, and Aug. 1, 2018, to determine the prevalence of obstructive epicardial CAD, coronary microvascular dysfunction and myocardial ischemia, MI and myocardial fibrosis.
Within this cohort, 75 patients had coronary angiography; 62 had assessment of coronary microvascular function; 41 underwent coronary vasoreactivity testing; and 52 received cardiac MRI.
Researchers reported that obstructive epicardial CAD was present in 51% of patients with HFpEF who underwent coronary angiography (95% CI, 39-62) of whom half had no history of CAD (50%; 95% CI, 34-66).
Among participants with assessed microvascular function, 66% had endothelium-independent coronary microvascular dysfunction (95% CI, 53-77). Among those who underwent coronary vasoreactivity testing, 24% had endothelium-dependent coronary microvascular disease (95% CI, 13-40).
Cardiac MRI findings among hospitalized patients with HFpEF included:
- impaired global myocardial perfusion in 71% of patients (95% CI, 54-83);
- visual perfusion defect in 30% of patients (95% CI, 19-46);
- ischemic late gadolinium enhancement in 27% of patients (95% CI, 16-41); and
- extracellular volume greater than 30% in 42% of patients (95% CI, 28-56)
Moreover, patients with obstructive CAD experienced more adverse events during follow-up compared with patients without obstructive CAD (74% vs. 46%).
“The suggestion that invasive angiography may be necessary to diagnose CAD in patients with HFpEF should be taken with caution, because many alternative noninvasive testing modalities for detection of flow-limiting CAD are widely available,” Viviany R. Taqueti, MD, MPH, FACC, FASNC, director of the cardiac stress laboratory at Brigham and Women’s Hospital and Harvard Medical School, wrote in a related editorial. “Despite these limitations, and taking care not to overinterpret the study results, these are welcome and much-needed supportive data in 2 key clinical cardiovascular areas (HFpEF and coronary microvascular dysfunction) that have proven both diagnostically and therapeutically challenging.”
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