Cardiovascular Research Center (J.E.H., R.M.), Massachusetts General Hospital, Boston.
Cardiology Division, Department of Medicine (J.E.H., L.W., C.S.B., T.C., A.S.E., K.M.H., P.P.P., R.M., M.N., G.D.L.), Massachusetts General Hospital, Boston.
Circulation. 2019 Jul 30;140(5):353-365. doi: 10.1161/CIRCULATIONAHA.118.039136. Epub 2019 May 28.
Heart failure with preserved ejection fraction (HFpEF) is common, yet there is currently no consensus on how to define HFpEF according to various society and clinical trial criteria. How clinical and hemodynamic profiles of patients vary across definitions is unclear. We sought to determine clinical characteristics, as well as physiologic and prognostic implications of applying various criteria to define HFpEF.
We examined consecutive patients with chronic exertional dyspnea (New York Heart Association class II to IV) and ejection fraction ≥50% referred for comprehensive cardiopulmonary exercise testing with invasive hemodynamic monitoring. We applied societal and clinical trial HFpEF definitions and compared clinical profiles, exercise responses, and cardiovascular outcomes.
Of 461 patients (age 58±15 years, 62% women), 416 met American College of Cardiology/American Heart Association (ACC/AHA), 205 met European Society of Cardiology (ESC), and 55 met Heart Failure Society of America (HFSA) criteria for HFpEF. Clinical profiles and exercise capacity varied across definitions, with peak oxygen uptake of 16.2±5.2 (ACC/AHA), 14.1±4.2 (ESC), and 12.7±3.1 mL·kg·min (HFSA). A total of 243 patients had hemodynamic evidence of HFpEF (abnormal rest or exercise filling pressures), of whom 222 met ACC/AHA, 161 met ESC, and 41 met HFSA criteria. Over a mean follow-up of 3.8 years, the incidence of cardiovascular outcomes ranged from 75 (ACC/AHA) to 298 events per 1000 person-years (HFSA). Application of clinical trial definitions of HFpEF similarly resulted in distinct patient classification and prognostication.
Use of different HFpEF classifications variably enriches for future cardiovascular events, but at the expense of not including up to 85% of individuals with physiologic evidence of HFpEF. Comprehensive phenotyping of patients with suspected heart failure highlights the limitations and heterogeneity of current HFpEF definitions and may help to refine HFpEF subgrouping to test therapeutic interventions.
射血分数保留的心力衰竭（HFpEF）很常见，但目前尚无共识如何根据各种协会和临床试验标准来定义 HFpEF。不同定义下患者的临床和血液动力学特征如何变化尚不清楚。我们旨在确定应用各种标准定义 HFpEF 对患者的临床特征以及生理和预后的影响。
我们检查了连续因慢性运动性呼吸困难（纽约心脏协会 II 至 IV 级）和射血分数≥50%而接受综合心肺运动试验和有创血液动力学监测的患者。我们应用了协会和临床试验 HFpEF 定义，并比较了临床特征、运动反应和心血管结局。
在 461 例患者（年龄 58±15 岁，62%为女性）中，416 例符合美国心脏病学会/美国心脏协会（ACC/AHA）标准，205 例符合欧洲心脏病学会（ESC）标准，55 例符合美国心力衰竭学会（HFSA）标准。临床特征和运动能力因定义而异，峰值摄氧量分别为 16.2±5.2（ACC/AHA）、14.1±4.2（ESC）和 12.7±3.1mL·kg·min（HFSA）。共有 243 例患者存在 HFpEF 的血液动力学证据（静息或运动充盈压异常），其中 222 例符合 ACC/AHA 标准，161 例符合 ESC 标准，41 例符合 HFSA 标准。平均随访 3.8 年后，心血管结局的发生率范围为每 1000 人年 75 例（ACC/AHA）至 298 例事件（HFSA）。应用临床试验 HFpEF 定义同样导致了患者分类和预后的明显差异。
不同 HFpEF 分类的应用不同程度地增加了未来心血管事件的风险，但代价是不包括多达 85%的存在 HFpEF 生理证据的个体。疑似心力衰竭患者的综合表型突出了当前 HFpEF 定义的局限性和异质性，并可能有助于细化 HFpEF 亚组以测试治疗干预措施。
