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Review
. 2019 Jun;132(6):692-697.
doi: 10.1016/j.amjmed.2018.12.038. Epub 2019 Jan 23.

Heart Failure With Preserved Ejection Fraction: Is Ischemia Due to Coronary Microvascular Dysfunction a Mechanistic Factor?

Islam Y Elgendy  1 , Carl J Pepine  2
Affiliations
Review

Heart Failure With Preserved Ejection Fraction: Is Ischemia Due to Coronary Microvascular Dysfunction a Mechanistic Factor?

Islam Y Elgendy et al. Am J Med. 2019 Jun.

Abstract

Heart failure with preserved ejection fraction (HFpEF) is increasing in prevalence and has no guideline-recommended therapy, related in part to a lack of mechanism. Traditionally, HFpEF was thought to be secondary to afterload overload due to systemic hypertension; however, accumulating evidence suggests that HFpEF continues to worsen despite adequate control of blood pressure. Emerging data support the suggestion that myocardial ischemia secondary to coronary microvascular dysfunction could be the new paradigm pathophysiology. Several prospective, observational cohort studies indicate that the outcomes of patients with microvascular dysfunction, after an interval of several years, are dominated by HFpEF hospitalizations. Further, the most prevalent clinical phenotype (eg older women with multiple comorbidities) of patients with HFpEF resembles those with coronary microvascular dysfunction, albeit older. In this review, we provide in-depth insight about this emerging HFpEF paradigm, discuss potential therapeutic implications of this pathophysiology, and summarize some important knowledge gaps.

Keywords: Coronary artery disease; Heart failure; Ischemia; Microvascular dysfunction; Preserved ejection fraction.

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Conflict of interest statement

Conflicts of Interest: None.

Figures

Figure 1
Figure 1
Pathogenic processes in HFpEF: Central role for microvascular ischemia. CMD = coronary microvascular disease; HFpEF = heart failure with preserved ejection fraction; VSM = vascular smooth muscle
Figure 2
Figure 2
Variable clinical course in coronary microvascular disease and heart failure with preserved function. Patients with multiple comorbidities, such as obesity and hypertension, develop progressive loss of coronary microvascular reserve secondary to the release of pro-inflammatory markers, which gradually worsens with years, until this reaches the threshold for ischemia, and then there will be gradual loss of the left ventricular diastolic reserve, which manifests later on with overt heart failure with preserved ejection fraction. HF = heart failure; IHD = ischemic heart disease; LV = left ventricular.
See this image and copyright information in PMC

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