Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, Rochester, Minnesota 55905, USA.
J Am Coll Cardiol. 2012 Jan 31;59(5):442-51. doi: 10.1016/j.jacc.2011.09.062.
The purpose of this study was to compare hemodynamic responses to vasodilator therapy in patients with heart failure (HF) and preserved ejection fraction (HFpEF) versus HF and reduced ejection fraction (HFrEF).
There is no proven therapy for HFpEF. In the absence of data, medicines with established benefit in HFrEF such as vasodilators are frequently prescribed for HFpEF.
We compared baseline hemodynamics and acute responses to vasodilation with intravenous sodium nitroprusside in patients with HFrEF (n = 174) and HFpEF (n = 83), determined invasively by cardiac catheterization.
Baseline blood pressure, stroke volume, and cardiac output were greater in HFpEF than HFrEF, while pulmonary artery mean and pulmonary wedge pressures were similar. Left ventricular filling pressures were reduced to a similar extent in each group with nitroprusside, but the drop in systemic arterial pressure was 2.6-fold greater in HFpEF (p < 0.0001), and improvements in stroke volume and cardiac output were each ∼60% lower in HFpEF compared to HFrEF (p < 0.0001). Despite similarly elevated filling pressures, HFpEF patients were fourfold more likely than HFrEF to experience a reduction in stroke volume with nitroprusside (p < 0.0001), suggesting greater vulnerability to preload reduction. Pulmonary artery systolic pressure dropped more in HFpEF than in HFrEF despite similar reduction in pulmonary mean pressure and resistance, suggesting higher right ventricular systolic elastance in HFpEF.
As compared to patients with HFrEF, patients with HFpEF experience greater blood pressure reduction, less enhancement in cardiac output, and greater likelihood of stroke volume drop with vasodilators. These findings emphasize fundamental differences in the 2 HF phenotypes and suggest that more pathophysiologically targeted therapies are needed for HFpEF.
本研究旨在比较射血分数保留的心力衰竭（HFpEF）与射血分数降低的心力衰竭（HFrEF）患者对血管扩张剂治疗的血液动力学反应。
目前尚无针对 HFpEF 的有效治疗方法。在缺乏数据的情况下，经常为 HFpEF 患者开具血管扩张剂等在 HFrEF 中已证实有效的药物。
我们比较了通过心导管术确定的 HFrEF（n = 174）和 HFpEF（n = 83）患者的基线血液动力学和静脉注射硝普钠的急性血管扩张反应。
HFpEF 患者的基线血压、每搏量和心输出量大于 HFrEF，而肺动脉平均压和肺楔压相似。硝普钠可使左心室充盈压降低到相似程度，但 HFpEF 组的全身动脉压下降幅度大 2.6 倍（p < 0.0001），并且 HFpEF 患者的每搏量和心输出量改善程度分别比 HFrEF 低 60%（p < 0.0001）。尽管充盈压同样升高，但 HFpEF 患者发生硝普钠引起的每搏量降低的可能性是 HFrEF 的四倍（p < 0.0001），表明对前负荷降低的易感性更高。尽管肺动脉收缩压下降幅度大于 HFrEF，但肺动脉平均压和阻力下降相似，提示 HFpEF 患者的右心室收缩弹性更高。
与 HFrEF 患者相比，HFpEF 患者接受血管扩张剂治疗时血压降低更大、心输出量增强更少且更有可能发生每搏量降低。这些发现强调了这两种心力衰竭表型的根本差异，并表明 HFpEF 需要更具病理生理靶向的治疗方法。
