Preclinical data suggest that coronary microvascular dysfunction (CMD) contributes to the development of heart failure with preserved ejection fraction (HFpEF), through various mechanisms including the reduction of endothelial nitric oxide bioavailability and cyclic guanosine monophosphate production, resulting in increased cardiomyocyte stiffening, hypertrophy, and fibrosis [1-3]. Clinical evidence supporting this hypothesis, is, however, scarce, and the prevalence of CMD in HFpEF is unknown.
The prospective PROMIS-HFpEF (PRevalence Of Microvascular dySfunction in Heart Failure with Preserved Ejection Fraction) study assessed the prevalence of impaired coronary flow reserve (CFR) in HFpEF, and explored possible correlates, such as systemic endothelial dysfunction (reactive hyperemia index: RHI, urinary albumin-to-creatinine ratio: UACR), clinical factors, laboratory markers, and echocardiographic indices. For this purpose, detailed echocardiography and adenosine-based transthoracic Doppler echocardiography-assessed CFR measurements were combined in HFpEF patients. CMD was defined as a coronary flow velocity ratio of <2.5 [4].
Eligible patients had a prior history of symptomatic HF, NYHA Class II–IV symptoms, an EF ≥40%, and at least one of the following:
Patients with known unrevascularized macrovascular coronary artery disease were excluded.
Impaired coronary microvascular function is highly prevalent in HFpEF patients and is associated with systemic endothelial dysfunction, as well as with markers of HF severity such as elevated NTproBNP and cardiac dysfunction.
1. Lee JF, Barrett-O’Keefe Z, Garten RS, et al. Evidence of microvascular dysfunction in heart failure with preserved ejection fraction. Heart 2016;102:278–284.
2. Marechaux S, Samson R, van Belle E, et al. Vascular and microvascular endothelial function in heart failure with preserved ejection fraction. J Card Fail 2016;22:3–11.
3. Narang N, Medvedofsky D, Dryer K, et al. Microvascular dysfunction and cardiac fibrosis in heart failure with preserved ejection fraction: a case report. ESC Heart Fail 2017;4:645–648.
4. Gan LM, Svedlund S, Wittfeldt A, et al. Incremental value of transthoracic Doppler echocardiography-assessed coronary flow reserve in patients with suspected myocardial ischemia undergoing myocardial perfusion scintigraphy. J Am Heart Assoc 2017;6:e004875.
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