MONTREAL — In patients with heart failure with preserved ejection fraction (diastolic heart failure), coronary artery disease is common and is associated with worse echocardiographic findings and clinical outcomes, researchers found.
Overall, 38% of such patients at a large urban medical center had coronary artery disease, according to Deepak Gupta, MD, of Northwestern University in Chicago.
Echocardiography revealed poorer left and right ventricular function and increased filling pressures, he reported at the American Society of Echocardiography meeting here.
In addition, patients with coronary artery disease had a greater likelihood of being hospitalized for heart failure and of dying during 18 months of follow-up (HR 1.7 and 3.2, respectively).
“Together, these data suggest that patients with [coronary artery disease] represent a discrete pathophysiologic subset within [heart failure with preserved ejection fraction],” Gupta said.
Although the patients with coronary artery disease were taking more medications specifically for the condition than the other patients with heart failure with preserved ejection fraction, Gupta and his colleagues have not yet looked at whether those treatments impact clinical outcomes.
Numerous previous studies have shown that coronary artery disease is common in patients with heart failure with preserved ejection fraction, with prevalence ranging from 15% to 65%.
But those studies were limited, Gupta said, in that they preceded contemporary management of coronary disease; lacked systematic evaluation and definition of coronary disease; used various definitions for heart failure with preserved ejection fraction; and had variable use of echocardiography.
None of the studies, however, has directly compared echocardiographic characteristics of those patients with and without coronary disease, Gupta said.
So he and his colleagues conducted a prospective, observational study of 354 patients who had been hospitalized previously for heart failure, and who had an ejection fraction greater than 50% (the average was 61%).
Patients with prior heart failure with an ejection fraction lower than 40%, constrictive pericarditis, severe valvular disease, or prior cardiac transplant were excluded.
The researchers diagnosed coronary artery disease using a predefined algorithm that included medical history, angiography, and stress testing (for those who could not undergo angiography).
The 38% of patients who had coronary artery disease were older (mean 70 versus 62), more likely to be male, and more likely to have comorbidities, including diabetes, hypertension, dyslipidemia, and chronic kidney disease (P<0.05 for all). They were less likely to be obese, however.
Pulse pressure was higher in those with coronary disease (68 versus 62 mm Hg, P<0.003).
In terms of the echocardiographic findings, there was no difference in left ventricular ejection fraction and diastolic function grade, but there were higher filling pressures — indicated by higher septal and lateral E/E’ — and reduced systolic S’ and diastolic A’ velocities in patients with coronary disease (P<0.05 for all).
Those with coronary disease also had lower right ventricular function as shown by reduced TAPSE or tricuspid annular plane systolic excursion, which is a measure of right ventricular ejection fraction and right ventricular fractional area change (P<0.01 for both).
In a multivariate analysis, coronary artery disease was independently associated with reduced S’ velocity, TAPSE, right ventricular fractional area change, and higher septal E/E’ (P<0.05 for all).
Coronary disease was also associated with significantly higher rates of heart failure hospitalization (34% versus 22%) and all-cause death (21% versus 10%) during follow-up (P<0.05 for both).
Gupta acknowledged some limitations of the study, including the use of patients from a single center; the fact that not all of the patients underwent coronary angiography; and the use of patients with a prior hospitalization for heart failure.
Although that excluded some ambulatory patients, Gupta said, the goal was to include the highest-risk patients.