Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT.
Division of Respiratory Diseases, Federal University of São Paulo-UNIFESP, São Paulo, Brazil.
Chest. 2021 Jun;159(6):2402-2416. doi: 10.1016/j.chest.2020.12.028. Epub 2021 Jan 1.
Right ventricular (RV) dysfunction is associated with poorer outcomes in heart failure with preserved ejection fraction (HFpEF). Although female subjects are more likely to have HFpEF, male subjects have worse prognosis and resting RV function. The contribution of dynamic RV-pulmonary arterial (RV-PA) coupling between sex and its impact on peak exercise capacity (VO) in HFpEF is not known.
The goal of this study was to investigate the differential effects of sex on RV-PA coupling during maximum incremental exercise in patients with HFpEF.
This study examined rest and exercise invasive pulmonary hemodynamics in 22 male patients with HFpEF and 27 female patients with HFpEF. To further investigate the discrepancy in RV-PA response between sex, 26 age-matched control subjects (11 male subjects and 15 female subjects) were included. Single beat analysis of RV pressure waveforms was used to determine the end-systolic elastance (Ees) and pulmonary arterial elastance. RV-PA coupling was determined as the ratio of end-systolic elastance/PA elastance.
Both HFpEF groups experienced decreased peak VO (% predicted). However, male patients with HFpEF experienced a greater decrement in peak VO compared with female patients (58 ± 16% vs 70 ± 15%; P < .05). Male patients with HFpEF had a more pronounced increase in RV afterload, Ea (1.8 ± 0.6 mm Hg/mL/m vs 1.3 ± 0.4 mm Hg/mL/m; P < .05) and failed to increase RV contractility during exercise, resulting in dynamic RV-PA uncoupling (0.9 ± 0.4 vs 1.2 ± 0.4; P < .05) and subsequent reduced stroke volume index augmentation. In contrast, female patients with HFpEF were able to augment RV contractility in the face of increasing afterload, preserving RV-PA coupling during exercise.
Male patients with HFpEF were more compromised regarding dynamic RV-PA uncoupling and reduced peak VO compared with female patients. This finding was driven by both RV contractile impairment and afterload mismatch. In contrast, female patients with HFpEF had preserved RV-PA coupling during exercise and better peak exercise VO compared with male patients with HFpEF.
右心室（RV）功能障碍与射血分数保留的心力衰竭（HFpEF）患者的预后较差有关。尽管女性患者更容易出现 HFpEF，但男性患者的预后更差，静息 RV 功能更差。性别的 RV-肺动脉（RV-PA）偶联及其对 HFpEF 患者峰值运动能力（VO）的影响的贡献尚不清楚。
本研究的目的是探讨在 HFpEF 患者最大递增运动过程中，性别的不同对 RV-PA 偶联的影响。
本研究检查了 22 名男性 HFpEF 患者和 27 名女性 HFpEF 患者的静息和运动性肺血管内血流动力学。为了进一步研究性别之间 RV-PA 反应的差异，纳入了 26 名年龄匹配的对照者（11 名男性和 15 名女性）。使用 RV 压力波形的单次搏动分析来确定收缩末期弹性（Ees）和肺动脉弹性。RV-PA 偶联被定义为收缩末期弹性/PA 弹性的比值。
HFpEF 两组患者的峰值 VO（%预测值）均下降。然而，与女性 HFpEF 患者相比，男性 HFpEF 患者的峰值 VO 下降更为明显（58 ± 16%vs 70 ± 15%；P<.05）。HFpEF 的男性患者 RV 后负荷（Ea）增加更为明显（1.8 ± 0.6mm Hg/mL/m 与 1.3 ± 0.4mm Hg/mL/m；P<.05），且在运动过程中无法增加 RV 收缩性，导致 RV-PA 解偶联（0.9 ± 0.4 与 1.2 ± 0.4；P<.05）和随后的 stroke volume index 增强减少。相比之下，HFpEF 的女性患者能够在增加后负荷的情况下增强 RV 收缩性，在运动过程中保持 RV-PA 偶联。
与女性 HFpEF 患者相比，HFpEF 的男性患者在动态 RV-PA 解偶联和峰值 VO 降低方面的情况更差。这一发现是由 RV 收缩功能障碍和后负荷不匹配共同驱动的。相比之下，HFpEF 的女性患者在运动过程中保持了 RV-PA 偶联，并且峰值运动能力 VO 优于 HFpEF 的男性患者。
