Heart failure with preserved ejection fraction (HFpEF) is frequently accompanied by
co-morbidities and a systemic proinflammatory state, resulting in coronary microvascular
dysfunction (CMD), as well as myocardial fibrosis. The purpose of this study is to
examine the relation between myocardial perfusion reserve (MPR) and diffuse myocardial
fibrosis in patients with HFpEF using cardiovascular magnetic resonance. A single
center study was performed in 19 patients with clinical HFpEF and 15 healthy control
subjects who underwent quantitative first-pass perfusion imaging to calculate global
MPR. T1 mapping was used to assess fibrosis and to calculate extracellular volume.
Spiral cine displacement encoded stimulated echo was used to calculate myocardial
strain. Comprehensive 2D echocardiograms with speckle tracking, cardiopulmonary exercise
testing, and brain natriuretic peptide levels were also obtained. In patients with
HFpEF, mean left ventricular EF was 61% ± 9% and left ventricular mass index 45 ±
12 g/m2. Compared with controls, HFpEF patients had reduced global MPR (2.29 ± 0.64 vs 3.38
± 0.76, p = 0.002) and VO2 max (16.5 ± 6.8 vs 30.9 ± 7.7 ml/kg min, p <0.001) whereas extracellular volume (0.29
± 0.04 vs 0.25 ± 0.04, p = 0.02), pulmonary artery systolic pressure (35.4 ± 13.7
vs 22.3 ± 5.4 mm Hg, p = 0.004), and average E/e’ (15.0 ± 7.6 vs 8.6 ± 2.0, p = 0.005)
were increased. Displacement encoded stimulated echo peak systolic circumferential
strain (p = 0.60) as well as echocardiographic derived global longitudinal strain
(p = 0.07) were similar between both groups. The prevalence of CMD, defined as global
MPR <2.5, in the HFpEF group was 69%. In conclusion, HFpEF patients have a high prevalence
of CMD and diffuse fibrosis. These parameters may be useful clinical end points for
future therapeutic trials.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of CardiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Prevalence and correlates of coronary microvascular dysfunction in heart failure with preserved ejection fraction: PROMIS-HFpEF.Eur Heart J. 2018; 39: 3439-3450
- A novel paradigm for heart failure with preserved ejection fraction: comorbidities drive myocardial dysfunction and remodeling through coronary microvascular endothelial inflammation.J Am Coll Cardiol. 2013; 62: 263-271
- Angiographic evaluation of coronary microvascular dysfunction in patients with heart failure and preserved ejection fraction.Microcirculation. 2015; 22: 528-533
- Coronary microvascular dysfunction in patients with heart failure with preserved ejection fraction.Am J Physiol Heart Circ Physiol. 2018; 314: H1033-H1042
- Reduced myocardial flow in heart failure patients with preserved ejection fraction.Circ Heart Fail. 2016; 9e002562
- Impairment of coronary flow reserve evaluated by phase contrast cine-magnetic resonance imaging in patients with heart failure with preserved ejection fraction.J Am Heart Assoc. 2016; 5e002649
- Coronary microvascular rarefaction and myocardial fibrosis in heart failure with preserved ejection fraction.Circulation. 2015; 131: 550-559
- High-resolution magnetic resonance myocardial perfusion imaging at 3.0-Tesla to detect hemodynamically significant coronary stenoses as determined by fractional flow reserve.J Am Coll Cardiol. 2011; 57: 70-75
- Quantification of absolute myocardial perfusion in patients with coronary artery disease: comparison between cardiovascular magnetic resonance and positron emission tomography.J Am Coll Cardiol. 2012; 60: 1546-1555
- New concepts in diastolic dysfunction and diastolic heart failure: Part I: diagnosis, prognosis, and measurements of diastolic function.Circulation. 2002; 105: 1387-1393
- Evaluation of diffuse myocardial fibrosis in heart failure with cardiac magnetic resonance contrast-enhanced T1 mapping.J Am Coll Cardiol. 2008; 52: 1574-1580
- Equilibrium contrast cardiovascular magnetic resonance for the measurement of diffuse myocardial fibrosis: preliminary validation in humans.Circulation. 2010; 122: 138-144
- Interstitial Fibrosis, functional status, and outcomes in heart failure with preserved ejection fraction: insights from a prospective cardiac magnetic resonance imaging study.Circ Cardiovasc Imaging. 2016; 9e005277
- Myocardial extracellular volume: unifying form and function in heart failure with preserved ejection fraction.J Am Coll Cardiol. 2016; 67: 1826-1828
- Seeing the unseen fibrosis in heart failure with preserved ejection fraction.JACC Cardiovasc Imaging. 2014; 7: 998-1000
- Myocardial tissue tracking with two-dimensional cine displacement-encoded MR imaging: development and initial evaluation.Radiology. 2004; 230: 862-871
- Imaging three-dimensional myocardial mechanics using navigator-gated volumetric spiral cine DENSE MRI.Magn Reson Med. 2010; 64: 1089-1097
- Increased extracellular volume and altered mechanics are associated with LVH in hypertensive heart disease, not hypertension alone.JACC Cardiovasc Imaging. 2015; 8: 172-180
- Diagnostic performance of fully automated pixel-wise quantitative myocardial perfusion imaging by cardiovascular magnetic resonance.JACC Cardiovasc Imaging. 2018; 11: 697-707
- Theory-based signal calibration with single-point T1 measurements for first-pass quantitative perfusion MRI studies.Acad Radiol. 2006; 13: 686-693
- Society for cardiovascular magnetic resonance board of trustees task force on standardized protocols. Standardized cardiovascular magnetic resonance (CMR) protocols 2013 update.J Cardiovasc Magn Reson. 2013; 15 (91-429X-15-91)
- Quantitative cardiovascular magnetic resonance perfusion imaging identifies reduced flow reserve in microvascular coronary artery disease.J Cardiovasc Magn Reson. 2018; 20 (018-0435-1): 14
- Extracellular volume fraction mapping in the myocardium, part 1: evaluation of an automated method.J Cardiovasc Magn Reson. 2012; 14 (63-429X-14-63)
- Advances in parametric mapping with CMR imaging.JACC Cardiovasc Imaging. 2013; 6: 806-822
- Motion-guided segmentation for cine DENSE MRI.Med Image Anal. 2009; 13: 105-115
- Tracking myocardial motion from cine DENSE images using spatiotemporal phase unwrapping and temporal fitting.IEEE Trans Med Imaging. 2007; 26: 15-30
- Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.J Am Soc Echocardiogr. 2015; 28 (e14): 1-39
- Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.J Am Soc Echocardiogr. 2016; 29: 277-314
- Coronary microvascular dysfunction, microvascular angina, and treatment strategies.JACC Cardiovasc Imaging. 2015; 8: 210-220
- Comprehensive echocardiographic and cardiac magnetic resonance evaluation differentiates among heart failure with preserved ejection fraction patients, hypertensive patients, and healthy control subjects.JACC Cardiovasc Imaging. 2018; 11: 577-585
Article info
Publication history
Published online: August 22, 2019
Received in revised form:
August 5,
2019
Received:
May 30,
2019
Footnotes
Funding: Drs. Löffler, Balfour, and Shaw were supported by NIH 5T32EB003841. Dr. Salerno was funded by NIH R01 HL131919. This work was funded by the UVA-AstraZeneca Alliance.
Identification
Copyright
© 2019 Elsevier Inc. All rights reserved.
