Heart Failure And Normal Ejection Fraction Research Articles

The prognostic impact of specialist cardiology input in patients admitted for heart failure and normal ejection fraction.

Specialist cardiology care is associated with a prognostic benefit in patients with heart failure (HF) with reduced ejection fraction (HFrEF) admitted with decompensated HF. However, up to one third of patients admitted with HF and normal ejection fraction (HFnEF) do not receive specialist cardiology input. Whether this has prognostic implications is unknown. Data on patients hospitalized with HFnEF from two tertiary centres were analysed. The primary outcome measure was all-cause mortality during follow-up. The secondary outcome was in-hospital mortality. A total of 1413 patients were included in the study. Of these, 23% (n=322) did not receive in-hospital specialist cardiology input. Patients seen by a cardiologist were less likely to have hypertension (73% vs. 79%, P=0.03) and respiratory co-morbidities (25% vs. 31%, P=0.02) compared with those who did not receive specialist input. Similarly, clinical presentation was more severe for those who received specialist input (New York Heart Association III/IV 83% vs. 75% respectively, P=0.003; moderate-to-severe peripheral oedema 65% vs. 54%, P<0.001). Medical management was similar, except for a higher use of diuretics (90% vs. 86%, P=0.04) and a longer length of stay for patients who received specialist input (9 vs. 4days, P<0.001). Long-term outcomes were comparable between patients who received specialist input and those who did not. However, specialist input was independently associated with lower in-hospital mortality (hazard ratio 0.19, confidence interval 0.09-0.43, P<0.001). In-hospital cardiology specialist input has no long-term prognostic advantage in patients with HFnEF but is independently associated with reduced in-hospital mortality.

522 THE IMPACT OF SPECIALIST CARDIOLOGY INPUT ON OUTCOMES IN PATIENTS ADMITTED FOR HEART FAILURE WITH NORMAL EJECTION FRACTION. A MULTICENTRE STUDY

Abstract Aims Specialist cardiology care is associated with a prognostic benefit in patients with HF with reduced ejection fraction (HFrEF) admitted with decompensated heart failure (HF). However, up to one third of patients admitted with HF and normal ejection fraction (HFnEF) do not receive specialist cardiology input. Whether this has prognostic implications is unknown. Methods Data on patients hospitalised with HFnEF from two tertiary centres were analysed. The primary outcome measure was all-cause mortality during follow-up. The secondary outcome was in-hospital mortality. Results A total of 1,413 patients were included in the study. Of these, 23% (n=322) did not receive in-hospital specialist cardiology input. Patients seen by a cardiologist were less likely to have hypertension (73% vs 79%, p=0.03) and respiratory comorbidities (25% vs 31%, p=0.02) compared to those who did not receive specialist input. Similarly, clinical presentation was more severe for those who received specialist input (NYHA III/IV 83% vs 75% respectively, p=0.003; moderate-to-severe peripheral oedema 65% vs 54%, p&amp;lt;0.001). Medical management was similar, except for a higher use of diuretics (90% vs 86%, p=0.04) and a longer length of stay for patients who received specialist input (9 vs 4 days, p&amp;lt;0.001). Long-term outcomes were comparable between patients who received specialist input and those who did not. However, specialist input was independently associated with lower in-hospital mortality (HR 0.19, CI 0.09-0.43, p&amp;lt;0.001). Conclusion In-hospital cardiology specialist input has no long-term prognostic advantage in patients with HFnEF but it is independently associated with reduced in-hospital mortality.

Electrocardiographic characteristics in patients with heart failure and normal ejection fraction: A systematic review and meta-analysis.

BackgroundLittle is known about ECG abnormalities in patients with heart failure and normal ejection fraction (HeFNEF) and how they relate to different etiologies or outcomes.Methods and ResultsWe searched the literature for peer‐reviewed studies describing ECG abnormalities in HeFNEF other than heart rhythm alone. Thirty five studies were identified and 32,006 participants. ECG abnormalities reported in patients with HeFNEF include atrial fibrillation (prevalence 12%–46%), long PR interval (11%–20%), left ventricular hypertrophy (LVH, 10%–30%), pathological Q waves (11%–18%), RBBB (6%–16%), LBBB (0%–8%), and long JTc (3%–4%). Atrial fibrillation is more common in patients with HeFNEF compared to those with heart failure and reduced ejection fraction (HeFREF). In contrast, long PR interval, LVH, Q waves, LBBB, and long JTc are more common in patients with HeFREF. A pooled effect estimate analysis showed that QRS duration ≥120 ms, although uncommon (13%–19%), is associated with worse outcomes in patients with HeFNEF.ConclusionsThere is high variability in the prevalence of ECG abnormalities in patients with HeFNEF. Atrial fibrillation is more common in patients with HeFNEF compared to those with HeFREF. QRS duration ≥120 ms is associated with worse outcomes in patients with HeFNEF. Further studies are needed to address whether ECG abnormalities correlate with different phenotypes in HeFNEF.

Effect of increased inspired oxygen on exercise performance in patients with heart failure and normal ejection fraction

IntroductionWe investigated whether increased concentrations of inspired oxygen (Fio2) affects exercise tolerance in patients with heart failure and normal ejection fraction (HeFNEF). Methods46 patients (mean age 75 years (63% male) and median NTproBNP 1432 (interquartile range: 543–2378 ng/l)) with HeFNEF (defined as signs or symptoms of heart failure requiring treatment with diuretics, with a left ventricular ejection fraction of >45% by echocardiography and amino terminal pro brain natriuretic peptide (NTproBNP) >220 ng/l) completed three maximal incremental exercise tests with different Fio2 (21%, 28% and 40%) in random order. Fio2 was controlled by investigator but blinded to patients. The primary outcome was exercise time (ET). ResultsIncreasing Fio2 significantly increased exercise time (522 ± 180 seconds for 21% to 543 ± 176 seconds, and 542 ± 177 seconds, for 28% and 40%, respectively, P = 0.04) with no difference in peak workload (57 ± 25 W, 58 ± 25 W and 57 ± 25 W, for 21%, 28% and 40%, respectively, P = 0.50). There was an increase in oxygen saturation but no change in peak heart rate with increasing Fio2. Compared to patients with LVEF ≥50%, patients with LVEF between 45 and 49% had a significantly greater exercise time and peak workload. There was a correlation between the difference in exercise time between Fio2 21% and 40% and age; but not with BMI, haemoglobin, creatinine or NTproBNP. ConclusionIncreasing Fio2 during exertion leads to a small increase in exercise time in patients with HeFNEF.

Study with a Portable Gas Analyzer of the 6-Minute Walk Test in Heart Failure with Normal Ejection Fraction

Abstract Background: Few studies have used portable gas analyzers during the 6-minute walk test (6MWT) in patients with heart failure and normal ejection fraction (HFNEF). Objectives: To analyze the kinetics of hemodynamic, ventilatory, and metabolic variables in patients with HFNEF during the T6m using a portable gas analyzer. Methods: Prospective, analytical study with an intentional, non-probabilistic, convenience sample. In total, 24 patients with HFNEF and past hospital admissions due to a clinical diagnosis of heart failure (HF) were included using the 2007 criteria established by the European Society of Cardiology. Three assessments were performed: 6MWT familiarization, 6MWT with the portable gas analyzer, and cardiopulmonary exercise test (CPET). Results: The heart rates (HRs) and the peak VO2 at the end of the 6MWT corresponded to 85.7% and 86.45% of the values obtained during the CPET. The final HRs after the T6m were equivalent to those obtained at the CPET anaerobic threshold (AT), with relative VO2 values at the end of the 6MWT above the VO2 of the CPET AT. There was no difference between the maximum respiratory quotient (RQ) values in these two tests, which were both above 1.0. The VE/VO2 slope descended initially and then ascended significantly after the fifth minute of the test, estimating the identification of the AT. Conclusions: In patients with HFNEF, the 6MWT represents an almost maximum effort, and is performed above the CPET AT and 85% above the maximum HR and the CPET peak VO2, with a maximum RQ similar to that in the CPET.

Prevalence, predictors, and prognostic implications of PR interval prolongation in patients with heart failure

AimsTo determine the prevalence, incidence, predictors, and prognostic implications of PR interval prolongation in patients referred with suspected heart failure.Methods and resultsConsecutive patients referred with suspected heart failure were prospectively enrolled. After excluding patients with implantable cardiac devices and atrial fibrillation, 1420 patients with heart failure and reduced ejection fraction (HeFREF) [age: median 71 (interquartile range IQR 63–78) years; men: 71%; NT-ProBNP: 1319 (583–3378) ng/L], 1094 with heart failure and normal ejection fraction (HeFNEF) [age: 76 (70–82) years; men: 47%; NT-ProBNP: 547 (321–1171) ng/L], and 1150 without heart failure [age: 68 (60–75) years; men: 51%; NT-ProBNP: 86 (46–140) ng/L] were included. The prevalence of first-degree heart block [heart rate corrected PR interval (PRc) > 200 ms] was higher in patients with heart failure (21% HeFREF, 20% HeFNEF, 9% without heart failure). In patients with HeFREF or HeFNEF, longer baseline PRc was associated with greater age, male sex, and longer QRS duration, and, in those with HeFREF, treatment with amiodarone or digoxin. Patients with heart failure in the longest PRc quartile had worse survival compared to shorter PRc quartiles, but PRc was not independently associated with survival in multivariable analysis. For patients without heart failure, shorter baseline PRc was independently associated with worse survival.ConclusionPRc prolongation is common in patients with HeFREF or HeFNEF and associated with worse survival, although not an independent predictor of outcome. The results of clinical trials investigating the therapeutic potential of shortening the PR interval by pacing are awaited.

Left ventricular performance and dyssynchrony in heart failure and normal ejection fraction: assessment by stress echocardiography

Purpose: We evaluated the left ventricular (LV) performance and dyssynchrony in patients with heart failure and normal ejection fraction (HFNEF) during exercise as compared to those with heart failure and reduced ejection fraction (HFREF) and healthy subjects. Methods: All subjects received echocardiographic (Vivid7) examination with symptom-limited (fatigue or dyspnea) exercise testing on a semi-recumbent and tilting bicycle ergometer. The exercise images for two-dimensional (2D) speckle tracking were acquired with submaximal heart rate of 90-100bpm, while M-mode and tissue Doppler Imaging (TDI) exercise images were stored with attainment of >85% of maximal age-predicted heart rate response. Results: Stress echocardiography exams were performed in 40 HFNEF (aged 65±9 years; 53% male), 40 HFREF (aged 62±9 years; 90% male) and 30 normals (aged 56±5 years; 33% male). Trends of progressive decline in 2D global circumferential and radial strains (GCS & GRS), global longitudinal strains (2D GLS & GLS_TDI), pulsed-wave TDI systolic velocity (septal S') and M-mode mitral annular plane systolic excursion (MAPSE) were observed from control, HFNEF to HFREF groups (all p<0.05). LV twist was preserved in HFNEF but reduced in HFREF patients as compared to normals (p<0.001). Diastolic function measured by spetal e' progressively decreased from controls to HFNEF followed by HFREF (all p<0.05). LV filling pressure (septal E/e'), stroke volume and cardiac indices (LVSI & LVCI) were preserved in HFNEF but deteriorated in HFREF than controls. LV dyssynchrony parameters (standard deviation of time to peak systolic velocity, Ts-SD) were similar in all groups. Conclusions: This study provides the reference values of LV performance and dyssynchrony during exercise in HFNEF and knowledge about these changes provide important insights for future clinical studies.

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Advantages of deformation indices over systolic velocities in assessment of longitudinal systolic function in patients with heart failure and normal ejection fraction

Tissue Doppler imaging (TDI) systolic velocities have been used to detect impaired systolic function in patients with heart failure and normal ejection fraction (HFnEF). However, many patients do not show alterations by this technique, and furthermore, myocardial systolic velocities can be affected by tethering, translation, and loading conditions. Thus, uncertainties remain about the detection of abnormal systolic function in HFnEF patients. The aim of this study was, therefore, to compare systolic velocities vs. TDI-derived deformation indices for detection of possible abnormalities of systolic function in HFnEF patients, taking into account loading conditions. We studied 40 patients with systolic heart failure (SHF: EF ≤ 40%), 47 HFnEF patients, and 50 controls (C). Systolic velocities of the mitral annulus (pulsed-wave TDI) were measured at four sites and averaged; concomitantly, peak negative TDI-derived strain and strain rate of the four walls were measured in apical, four-, and two-chamber views. Ejection fraction was 65 ± 6% in C, 62 ± 7% in HFnEF, and 29 ± 7% in SHF (P< 0.001 vs. both). In HFnEF patients, systolic velocities and peak negative global longitudinal strain rate and strain were higher than in SHF (P< 0.0001 for all), but lower than in C (P< 0.0001 for all). After controlling for age, left ventricular mass index, end-diastolic volume index, and circumferential end-systolic stress, differences between groups remained significant for deformation indices but not for TDI velocities. By velocity/strain-stress relationship analysis, peak global longitudinal strain was more sensitive than peak systolic motion in detecting systolic dysfunction in HFnEF patients (64 vs. 40%, P< 0.05). In patients with HFnEF, TDI-derived deformation indices may more accurately detect abnormal systolic function than myocardial velocities.

Resting global and regional left ventricular contractility in patients with heart failure and normal ejection fraction: insights from speckle-tracking echocardiography

ObejctiveTo compare left ventricular (LV) systolic performance and contractility in patients with heart failure and normal ejection fraction (HFNEF), compared with patients with heart failure and reduced ejection fraction (HFREF)...

RESTING GLOBAL AND REGIONAL LEFT VENTRICULAR CONTRACTILITY IN PATIENTS WITH HEART FAILURE AND NORMAL EJECTION FRACTION - INSIGHTS FROM SPECKLE-TRACKING ECHOCARDIOGRAPHY

Obejctive To compare left ventricular (LV) systolic performance and contractility in patients with heart failure and normal ejection fraction (HFNEF), compared with patients with heart failure and reduced ejection fraction (HFREF) and healthy subjects using newer echocardiographic techniques. Design A case–control trial. Setting University teaching hospital (tertiary referral centre). Patients Sixty healthy control subjects (53±10 years), 112 patients with HFNEF (74±12 years) and 175 patients with HFREF (67±13 years). Interventions All underwent standard two-dimensional, Doppler and speckle-tracking echocardiography. Main outcome measures Effective arterial (Ea) and LV end-systolic elastance (Ees), stress-corrected mid-wall shortening, preload recruitable stroke work, two-dimensional strain and torsion. Comparisons were adjusted for age, gender and body size. Results Besides diastolic dysfunction, patients with HFNEF had impaired load-independent ventricular contractility with a progressive decrease of the corrected Ees from controls (2.9±0.8 mm Hg/g) to HFNEF (2.2±0.9 mm Hg/g) followed by HFREF (0.8±0.3 mm Hg/g; all p 85% falling below their corresponding stress-corrected mean. Conclusions Impaired myocardial contractility is evident in many patients with HFNEF and this may contribute towards pathophysiology of HFNEF more than previously thought.

Disfunção renal e anemia em pacientes com insuficiência cardíaca com fração de ejeção reduzida versus normal

The presence of anemia and renal dysfunction grants a bad prognosis for patients with heart failure and reduced ejection fraction (HFREF). The impact on patients with heart failure and normal ejection fraction (HFNEF) is not widely studied. To study the prevalence and the prognosis of anemia and renal dysfunction (RD) in patients with heart failure according to the type of ventricular dysfunction. A total of 209 patients with chronic and stable heart failure were prospectively studied. Individuals with ejection fraction <50% were considered as HFREF patients. Anemia was defined, based on WHO criteria, as hemoglobin <13 g/dl for men and <12 g/dl for women. Renal function was calculated by means of the Simplified Modified Diet Renal Disease (sMDRD) formula. Hospitalizations, emergency admittances and obit by cardiac causes were considered as cardiac events. Ninety patients had HFREF and 119 had HFNEF. The glomerular filtration rate (GFR) was smaller in HFREF group (57.6 +/- 66.2 versus 94.8 +/- 36.6 ml/min/1.73m(2); p=0.01). There was no difference in the prevalence of anemia between groups (23.3% versus 18.5%; p=0.34). Moderate to severe RD prevalence was higher in HFREF group (32.2% versus 16.8%; p=0.01). RD was the only factor associated with anemia that was independently associated with cardiac events (HR 2.52; 95%CI=1.27-5.2; p=0.01). RD was less prevalent in HFNEF, while the prevalence of anemia did not differ between groups. RD was predictor of cardiac events independently on ejection fraction.

Lack of Diastolic Reserve in Patients With Heart Failure and Normal Ejection Fraction

The genesis of symptoms in patients with heart failure (HF) and normal ejection fraction (HFNEF) is unclear. Most investigations of HFNEF have focused on cardiac function at rest although most of these patients are breathless only on exercise. Stress-induced impairment in systolic or diastolic function could result in these symptoms. Method and Result- Forty-one patients with HFNEF and 29 controls underwent dobutamine stress echocardiography with color tissue Doppler imaging. Wall motion score index and regional myocardial systolic velocity (Sm) were measured at and peak stress. Systolic (Sa), early diastolic (Ea), and late diastolic (Aa) mitral annular velocities were averaged over the 6 periannular sites. Mitral annular long-axis velocity was lower in the HFNEF than controls at rest. Global, regional, and long-axis systolic function did not worsen with stress in the HFNEF group. The Ea decreased and the E/Ea increased with stress in the HFNEF but not in controls. The 6-minute walk distance was shorter and negatively correlated to the E/EA ratio at rest and stress in the HFNEF group. Impaired diastolic reserve results in stress-induced increase in the left ventricular end-diastolic pressure in patients with HFNEF giving rise to exercise intolerance.

Response to Letter Regarding Article, “Role of Left Ventricular Stiffness in Heart Failure With Normal Ejection Fraction”

We would like to thank Dr Kass for his interest in our study, which investigated hemodynamic characteristics of patients with heart failure and normal ejection fraction (HFNEF).1 An important finding in our study was that with increased paced heart rates the patients in the HFNEF group showed a decrease in end-diastolic volume leading to reduced stroke volume, which limited their ability to increase cardiac output and may explain their exertional limitations. These results were in contrast to those in the control group where end-diastolic volumes and stroke …

ASYMPTOMATIC LEFT VENTRICULAR DIASTOLIC DYSFUNCTION AND RISK OF DEATH IN THE COMMUNITY

LV to untwist in diastole is dependent on systolic twist. We hypothesise that patients with heart failure and normal ejection fraction (HFNEF) have reduced LV untwist to facilitate rapid early diastolic filling particularly during exercise thus symptoms of exertional dyspnoea. Methods: 34 clinically diagnosed HFNEF patients with proven cardiac limitation (72± 7 years, 23 females, LVEF 60± 7%, VO2max 17.9± 3.0ml/(min kg)) and 23 agematched healthy controls (70± 8 years, 15 females, LVEF 63± 8%, VO2max 30.9± 4.6ml/(min kg)) were recruited. Rest and submaximal supine exercise echocardiography were performed to comparable heart rate and blood pressure. Apical rotation and untwist were studied by speckle tracking. The mitral flow propagation velocity (Vp) was derived from colour M-mode Doppler. Results: LV apical systolic rotation and early diastolic untwist are significantly less at rest and on exercise in patients. Vp at rest is comparable between the two groups. However, the increase in Vp on exercise is significantly less in patients hence Vp is significantly lower than controls. LV early untwist correlates significantly with the increase in Vp (r= 0.43, p= 0.005) and VO2max (r= 0.526, p= 0.007). Exercise Vp also correlates with VO2max (r= 0.347, p= 0.03). Patients Controls p-Value Rotation rest (◦) 10.7 ± 4.1 13.9 ± 3.2 0.002 Rotation exercise (◦) 13.5 ± 4.8 17.6 ± 4.0 0.006 Untwist rest (◦) 24.3 ± 9.4 30.9 ± 9.7 0.013 Untwist exercise (◦) 22.1 ± 8.9 29.5 ± 7.8 0.008 Vp rest (m/s) 40.2 ± 10.8 39.8 ± 7.3 0.875 Vp exercise (m/s) 52.6 ± 12.0 62.4 ± 13.8 0.012 Conclusion: LV rotation and untwist mechanics are impaired in HFNEF. This is associated with reduced LV suction in early diastole and reduced exercise tolerance. The efficiency of LV rotation and untwist is crucial to aid rapid early diastolic filling particularly on exercise when heart rate is increased and diastole shortens. doi:10.1016/j.hlc.2009.03.042 Tuesday Young Investigators ASYMPTOMATIC LEFT VENTRICULAR DIASTOLIC DYSFUNCTION AND RISK OF DEATH IN THE COMMUNITY Walter Abhayaratna, Katrina Hayes, Christine O’Reilly, Satoru Sakuragi, Niels Becker Australian National University, Canberra, ACT, Australia Background: There is limited information regarding the risk of death in asymptomatic individuals with left ventricular (LV) diastolic dysfunction (LVDD) and ejection fraction (EF) >50%. In this population-based study, we assessed mortality rates of subjects with LVDD without a history or clinical evidence of congestive heart failure. Methods and results:Weassessed diastolic function using comprehensive Doppler echocardiography in 1275 Canberra Heart Study participants (mean age 69 years; 50% men). Diastolic dysfunction was classified as mild or advanced (with elevated LV filling pressure). Prevalence rates of mild and advanced preclinical LVDD were 26% and 7.5% in women, respectively; and 24% and 6.9% in men, respectively. During a mean follow-up of 4.8 years, there were 61 deaths in preclinical subjects with EF> 50%. Death rates among individuals with normal LV diastolic function and mild LVDD were similar (0.8 vs. 1.1 per 100 person-years, respectively; p= 0.24). However, the rate of death among those with advanced LVDD (3.0 per 100 person-years)was higherwhen compared to subjectswith normal diastolic function and mild LVDD (p< 0.01 for both). After adjustment for age, sex, EF and cardiovascular risk factors, preclinical advanced LVDDwas associated with an increased mortality risk (adjusted Hazards Ratio 2.2, CI 1.1–4.2). Conclusion: Community-based adults with preclinical LVDD are at increased risk of death only when the condition is advanced and is associatedwith increased LVfilling pressures. doi:10.1016/j.hlc.2009.03.043 LEFT VENTRICULAR DYSSYNCHRONY EARLY AFTER NON-ST ELEVATION MYOCARDIAL INFARCTION INDEPENDENTLY PREDICTED LONG-TERM LEFT VENTRICULAR REMODELLING A. Ng, J. Vidiac, D.Y. Leung Liverpool Hospital, Sydney, NSW, Australia We evaluated the prognostic significance of LV dyssynchrony early after non-ST elevation myocardial infarction (NSTEMI). Methods: LV dyssynchrony was measured as standard deviation of times to 12 regional peak Smvelocities (SDTs) in 100 NSTEMI patients (age 60.0± 11.8 years, 71 men) prior to angiography, at 6 and 12 months. Significant dyssynchrony was defined as SDTs≥ 32.6ms. Results: LV end-diastolic volume (EDV) index decreased with time (47.1± 14.2mL/m2 vs. 46.4± 13.6mL/m2 vs. 43.1± 12.8mL/m2, p< 0.001) and was independently predicted by lower number of diseased vessels (p= 0.001) and revascularization (p= 0.041). LV end-systolic volume (ESV)

Arterial Stiffness and Arterial Wave Reflections Are Associated With Systolic and Diastolic Function in Patients With Normal Ejection Fraction

Increased arterial stiffness and early wave reflections have been observed in patients with heart failure and normal ejection fraction (HFNEF). We investigated, whether impaired arterial function is associated with impaired systolic and diastolic function and symptomatic status. We prospectively enrolled 336 patients (mean age 63.5 years) undergoing coronary angiography, and assessed pulse wave velocity (PWV) invasively, arterial wave reflections (augmentation index (AIx); pressure augmentation (AP)) noninvasively using radial applanation tonometry and a validated transfer function, and characteristic impedance (Zc) using echocardiography with tonometry. In addition, echocardiography including tissue Doppler of the mitral annulus was performed. Peak systolic velocity (S') varied inversely with AIx (R = -0.38, P < 0.001), AP (R = -0.48, P < 0.0001), PWV (R = -0.39, P < 0.001), and Zc (R = -0.29, P < 0.01). Likewise, early diastolic velocity (E') showed a strong, negative correlation with AP (R = -0.32, P < 0.01), PWV (R = -0.64, P < 0.0001), and Zc (R = -0.50, P < 0.0001). Higher filling pressures were associated with increased wave reflections (AIx, AP) and arterial stiffness (PWV, Zc). All associations were independent of age and gender. Patients suffering from exertional dyspnea had increased AIx, AP, and PWV. In middle-aged and elderly patients, increased arterial stiffness and wave reflections are consistently and independently associated with impaired systolic and diastolic function and with functional limitations.

Angiographic coronary artery disease associated with hypertensive heart failure and normal ejection fraction. Insights from a prospective monocenter study

The prevalence of underlying coronary artery disease (CAD) was examined in 23 consecutive hypertensive patients presenting with acute onset of heart failure and normal ejection fraction (HFnlEF) without clinical, electrocardiographic and biochemical evidence of myocardial ischemia. By coronary angiography, 2 patients had 1-vessel disease, 5 patients had 2-vessels disease and 1 patient had 3-vessels disease. 26% of patients was classified as having ischemic heart disease. Underlying CAD is not an uncommon finding in hypertensive HFnlEF and must be checked with the aim to enhance the therapeutic management.