Heart failure with preserved ejection fraction: a forest of a variety of trees.

Abstract

This editorial refers to ‘Right heart dysfunction in heart failure with preserved ejection fraction’, by V. Melenovsky et al. , on page doi:10.1093/eurheartj/ehu193 In heart failure (HF) with reduced ejection fraction (HFrEF), the magnitude of left ventricular (LV) contractile dysfunction which defines this group has proven an important prognostic marker and effective target for therapy. Measures of right ventricular (RV) contraction are not commonly quantified, but when they are they provide additional prognostic information. It is now well recognized that up to half of HF patients have more preserved contractile function as measured by LVEF (HFpEF),1 demonstrate rates of HF re-hospitalization and functional decline similar to HFrEF,2 and have a higher risk of death compared with age-matched controls.3 While abnormal cardiac performance is implied in the HF diagnosis, the mechanisms underlying HFpEF are clearly multifactorial, with contributions of age, arterial stiffening, renal dysfunction, atrial fibrillation, and obesity, among others ( Figure 1 ). Even within the heart, while LV diastolic dysfunction is an important underlying cardiac perturbation, additional abnormalities of cardiac function may contribute, including subtle abnormalities of LV systolic function, dyssynchronous ventricular contraction and/or relaxation, impaired left atrial (LA) function, pulmonary vascular dysfunction, chronotropic incompetence, and impaired peripheral oxygen extraction.4 In addition to aetiological heterogeneity, phenotypic heterogeneity and the prominent contribution of co-morbidities make understanding this syndrome particularly challenging. Melenovsky et al . now appropriately call our attention to the importance of RV dysfunction as a contributing mechanism.5 Operating in parallel with the left ventricle, the right ventricle is also intimately coupled to the left ventricle via the interventricular septum and pericardium. The right ventricle normally …