Abstract
This study aimed to determine the prognostic value of cardiovascular magnetic resonance (CMR) in patients with heart failure with preserved ejection fraction and associated pulmonary hypertension (pulmonary hypertension-HFpEF). Patients with pulmonary hypertension-HFpEF were recruited from the ASPIRE registry and underwent right heart catheterisation (RHC) and CMR. On RHC, the inclusion criteria was a mean pulmonary artery pressure (MPAP) ≥ 25 mmHg and pulmonary arterial wedge pressure > 15 mmHg and, on CMR, a left atrial volume > 41 ml/m2 with left ventricular ejection fraction > 50%. Cox regression was performed to evaluate CMR against all-cause mortality. In this study, 116 patients with pulmonary hypertension-HFpEF were identified. Over a mean follow-up period of 3 ± 2 years, 61 patients with pulmonary hypertension-HFpEF died (53%). In univariate regression, 11 variables demonstrated association to mortality: indexed right ventricular (RV) volumes and stroke volume, right ventricular ejection fraction (RVEF), indexed RV mass, septal angle, pulmonary artery systolic/diastolic area and its relative area change. In multivariate regression, only three variables were independently associated with mortality: RVEF (HR 0.64, P < 0.001), indexed RV mass (HR 1.46, P < 0.001) and IV septal angle (HR 1.48, P < 0.001). Our CMR model had 0.76 area under the curve (P < 0.001) to predict mortality. This study confirms that pulmonary hypertension in patients with HFpEF is associated with a poor prognosis and we observe that CMR can risk stratify these patients and predict all-cause mortality. When patients with HFpEF develop pulmonary hypertension, CMR measures that reflect right ventricular afterload and function predict all-cause mortality.
Highlights
Heart failure with preserved ejection fraction (HFpEF) constitutes approximately half of all heart failure (HF) diagnoses [1]
In this study we have shown that a cardiovascular magnetic resonance (CMR) based volumetric and functional assessment of the right ventricle can risk stratify patients with pulmonary hypertension-HFpEF
It is worth noting that the majority of echocardiographybased studies have demonstrated that it is mainly right ventricular (RV) function and remodelling that are associated with a poor prognosis in pulmonary hypertension-HFpEF
Summary
Heart failure with preserved ejection fraction (HFpEF) constitutes approximately half of all heart failure (HF) diagnoses [1]. It is estimated that approximately 50% of patients with HFpEF develop pulmonary hypertension [2, 3]. The. Cardiovascular magnetic resonance (CMR) is the imaging reference standard for volumetric assessment and is emerging as one of the key non-invasive imaging methods to diagnose, and temporally monitor patients with pulmonary hypertension [5, 6] and phenotype patients with HFpEF [7]. The guidelines for the diagnosis and treatment of pulmonary hypertension highlight the potential of CMR in the assessment of disease severity and follow-up [8,9,10]. In HFpEF, CMR can sub-phenotype myocardial diseases that lead to the development of myocardial stiffness [13], including cardiac amyloidosis, hypertensive cardiomyopathy, hypertrophic cardiomyopathy and cardiac sarcoidosis
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