Prevalence, clinical characteristics, and outcomes associated with eccentric versus concentric left ventricular hypertrophy in heart failure with preserved ejection fraction

Abstract

Although concentric remodeling (CR) and concentric hypertrophy (CH) are common forms of left ventricular (LV) remodeling in heart failure with preserved ejection fraction (HFpEF), eccentric hypertrophy (EH) can also occur in these patients. However, clinical characteristics and outcomes of EH have not been well described in HFpEF. We prospectively studied 402 patients with HFpEF, divided into 4 groups based on LV structure: normal geometry (no LV hypertrophy [LVH] and relative wall thickness [RWT] ≤0.42); CR (no LVH and RWT >0.42); CH (LVH and RWT >0.42); and EH (LVH and RWT ≤0.42). We compared clinical, laboratory, echocardiographic, invasive hemodynamic, and outcome data among groups. Of 402 patients, 48 (12%) had EH. Compared with CH, patients with EH had lower systolic blood pressure and less renal impairment despite similar rates of hypertension. After adjustment for covariates, EH was associated with reduced LV contractility compared with CH: lower LVEF (β coefficient = -3.2; 95% confidence interval [CI] -5.4 to -1.1%) and ratio of systolic blood pressure to end-systolic volume (β coefficient = -1.0; 95% CI -1.5 to -0.5 mm Hg/ml). EH was also associated with increased LV compliance compared with CH (LV end-diastolic volume at an idealized LV end-diastolic pressure of 20 mm Hg β coefficient = 14.2; 95% CI 9.4 to 19.1 ml). Despite these differences, EH and CH had similarly elevated cardiac filling pressures and equivalent adverse outcomes. In conclusion, the presence of EH denotes a distinct subset of HFpEF that is pathophysiologically similar to HF with reduced EF (HFrEF) and may benefit from HFrEF therapy.

Figure 1. Distribution of Left Ventricular Geometries in Heart Failure with Preserved Ejection Fraction

Left ventricular hypertrophy was defined as left ventricular mass/height^2.7>44g/m^2.7 in women and >48 g/m^2.7 in men. Concentric geometry defined as RWT > 0.42.CR = concentric remodeling; CH = concentric hypertrophy; EH = eccentric hypertrophy.

Figure 2. Pressure-Volume Relationships in Heart Failure with Preserved Ejection Fraction: Eccentric Hypertrophy versus Concentric Hypertrophy

Patients with eccentric hypertrophy have downward and rightward shifted end-systolic and end-diastolic pressure volume relationships, as indicated by larger ESV₁₂₀ and EDV₂₀ values.

Figure 3. Kaplan-Meier Survival Curves for the Combined Outcome of Heart Failure Hospitalization, Cardiovascular Hospitalization, or Death, Stratified by Left Ventricular Geometry Group

Patients with eccentric hypertrophy had outcomes that were similar to patients with concentric hypertrophy (Log-rank P=0.33).Patients with left ventricular hypertrophy (either eccentric or concentric hypertrophy) had worse outcomes compared to those without left ventricular hypertrophy (Log-rank P=0.0005).