Division of Cardiology (L.B.K., E.E.L., J.K.W., J.K.P., J.M.R., R.E.G., J.E.H.), Beth Israel Deaconess Medical Center, Boston, MA.
Division of Cardiology, Massachusetts General Hospital, Boston (L.M., G.D.L., R.M., E.S.L.).
Circ Heart Fail. 2024 May;17(5):e011366. doi: 10.1161/CIRCHEARTFAILURE.123.011366. Epub 2024 May 14.
Although heart failure with preserved ejection fraction (HFpEF) has become the predominant heart failure subtype, it remains clinically under-recognized. HFpEF diagnosis is particularly challenging in the setting of obesity given the limitations of natriuretic peptides and resting echocardiography. We examined invasive and noninvasive HFpEF diagnostic criteria among individuals with obesity and dyspnea without known cardiovascular disease to determine the prevalence of hemodynamic HFpEF in the community.
Research volunteers with dyspnea and obesity underwent resting echocardiography; participants with possible pulmonary hypertension qualified for invasive cardiopulmonary exercise testing. HFpEF was defined using rest or exercise pulmonary capillary wedge pressure criteria (≥15 mm Hg or Δpulmonary capillary wedge pressure/Δcardiac output slope, >2.0 mm Hg·L·min1).
Among n=78 participants (age, 53±13 years; 65% women; body mass index, 37.3±6.8 kg/m), 40 (51%) met echocardiographic criteria to undergo invasive cardiopulmonary exercise testing. In total, 24 participants (60% among the cardiopulmonary exercise testing group, 31% among the total sample) were diagnosed with HFpEF by rest or exercise pulmonary capillary wedge pressure (n=12) or exercise criteria (n=12). There were no differences in NT-proBNP (N-terminal pro-B-type natriuretic peptide; 79 [62-104] versus 73 [57-121] pg/mL) or resting echocardiography (mitral E/e' ratio, 9.1±3.1 versus 8.0±2.7) among those with versus without HFpEF (>0.05 for all). Distributions of HFpEF diagnostic scores were similar, with the majority classified as intermediate risk (100% versus 93.75% [HFPEF] and 87.5% versus 68.75% [HFA-PEFF (Heart Failure Association Pretest assessment, echocardiography and natriuretic peptide, functional testing, and final etiology)] in those with versus without HFpEF).
Among adults with obesity and dyspnea without known cardiovascular disease, at least a third had clinically unrecognized HFpEF uncovered on invasive cardiopulmonary exercise testing. Clinical, biomarker, resting echocardiography, and diagnostic scores were similar among those with and without HFpEF. These results suggest clinical underdiagnosis of HFpEF among individuals with obesity and dyspnea and highlight limitations of noninvasive testing in the identification of HFpEF.
尽管射血分数保留型心力衰竭（HFpEF）已成为主要的心衰亚型，但临床上仍未得到充分认识。鉴于利钠肽和静息超声心动图的局限性，肥胖患者 HFpEF 的诊断尤其具有挑战性。我们在没有已知心血管疾病的肥胖伴呼吸困难患者中检查了 HFpEF 的有创和无创诊断标准，以确定社区中血流动力学 HFpEF 的患病率。
呼吸困难和肥胖的研究志愿者接受静息超声心动图检查；可能患有肺动脉高压的参与者有资格接受有创心肺运动测试。HFpEF 使用静息或运动肺毛细血管楔压标准定义（≥15mmHg 或Δ肺毛细血管楔压/Δ心输出量斜率>2.0mmHg·L·min1）。
在 n=78 名参与者中（年龄 53±13 岁；65%为女性；体重指数 37.3±6.8kg/m2），40 名（51%）符合超声心动图标准进行有创心肺运动测试。总共有 24 名参与者（心肺运动测试组的 60%，总样本的 31%）通过静息或运动肺毛细血管楔压（n=12）或运动标准（n=12）诊断为 HFpEF。HFpEF 患者的 NT-proBNP（N 末端脑利钠肽前体）差异无统计学意义（79[62-104]与 73[57-121]pg/mL）或静息超声心动图（二尖瓣 E/e' 比值，9.1±3.1 与 8.0±2.7）（均>0.05）。HFpEF 诊断评分的分布相似，大多数被归类为中危（100%与 93.75%[HFPEF]和 87.5%与 68.75%[HFA-PEFF（心力衰竭协会预测试评估、超声心动图和利钠肽、功能测试和最终病因）]在有和无 HFpEF 的患者中）。
在没有已知心血管疾病的肥胖伴呼吸困难的成年人中，至少有三分之一的患者通过有创心肺运动测试发现了临床上未被识别的 HFpEF。有和无 HFpEF 的患者之间，临床、生物标志物、静息超声心动图和诊断评分相似。这些结果表明肥胖伴呼吸困难的个体中 HFpEF 的临床漏诊率较高，并突出了非侵入性检查在识别 HFpEF 方面的局限性。
