Impaired systolic function by strain imaging in heart failure with preserved ejection fraction

Abstract

Objectives: This study sought to determine the frequency and magnitude of impaired systolic deformation in heart failure with preserved ejection fraction (HFpEF).

Background: Although diastolic dysfunction is widely considered a key pathophysiologic mediator of HFpEF, the prevalence of concomitant systolic dysfunction has not been clearly defined.

Methods: We assessed myocardial systolic and diastolic function in 219 HFpEF patients from a contemporary HFpEF clinical trial. Myocardial deformation was assessed using a vendor-independent 2-dimensional speckle-tracking software. The frequency and severity of impaired deformation was assessed in HFpEF, and compared to 50 normal controls free of cardiovascular disease and to 44 age- and sex-matched hypertensive patients with diastolic dysfunction (hypertensive heart disease) but no HF. Among HFpEF patients, clinical, echocardiographic, and biomarker correlates of left ventricular strain were determined.

Results: The HFpEF patients had preserved left ventricular ejection fraction and evidence of diastolic dysfunction. Compared to both normal controls and hypertensive heart disease patients, the HFpEF patients demonstrated significantly lower longitudinal strain (LS) (-20.0 ± 2.1 and -17.07 ± 2.04 vs. -14.6 ± 3.3, respectively, p < 0.0001 for both) and circumferential strain (CS) (-27.1 ± 3.1 and -30.1 ± 3.5 vs. -22.9 ± 5.9, respectively; p < 0.0001 for both). In HFpEF, both LS and CS were related to LVEF (LS, R = -0.46; p < 0.0001; CS, R = -0.51; p < 0.0001) but not to standard echocardiographic measures of diastolic function (E' or E/E'). Lower LS was modestly associated with higher NT-proBNP, even after adjustment for 10 baseline covariates including LVEF, measures of diastolic function, and LV filling pressure (multivariable adjusted p = 0.001).

Conclusions: Strain imaging detects impaired systolic function despite preserved global LVEF in HFpEF that may contribute to the pathophysiology of the HFpEF syndrome. (LCZ696 Compared to Valsartan in Patients With Chronic Heart Failure and Preserved Left-ventricular Ejection Fraction; NCT00887588).

Keywords: CS; HF; HFpEF; HHD; LA; LAVi; LS; LV; LVEF; N-terminal pro-brain natriuretic peptide; NT-proBNP; RWT; cardiac biomarkers; circumferential strain; diastolic heart failure; echocardiography; heart failure; heart failure with preserved ejection fraction; hypertensive heart disease; left atrial; left atrial volume index; left ventricular; left ventricular ejection fraction; longitudinal strain; mechanics; relative wall thickness; systolic strain.

Figure 1. Average Longitudinal and Circumferential Systolic Strain

Average longitudinal strain (red bars) and circumferential systolic strain (green bars) among normal controls (n = 50), hypertensive heart disease (HHD) patients (n = 44), heart failure with preserved ejection fraction (HFpEF) patients overall (n = 219), and in 3 categories HFpEF based on left ventricular ejection fraction (LVEF). *p < 0.0001 compared to controls and between HHD and HFpEF overall for longitudinal strain and circumferential strain. #p = 0.0002 compared to controls. †LVEF-adjusted p < 0.001 compared to controls.

Figure 2. Association of Longitudinal Systolic Strain and NT-proBNP

Association of longitudinal systolic strain (quartiles) and N-terminal pro-brain natriuretic peptide (NT-proBNP), geometric means and 95% confidence intervals. *Trend test performed using log-transformed NT-proBNP data. †Analysis adjusted for age, sex, systolic and diastolic blood pressure, body mass index, E/E’, left ventricular ejection fraction, left atrial volume index, atrial fibrillation, and estimated glomerular filtration rate.