Coronary microvascular dysfunction and future risk of heart failure with preserved ejection fraction
Coronary microvascular dysfunction and future risk of heart failure with preserved ejection fraction
复制标题
DOI：
10.1093/eurheartj/ehx721
复制
发表时间：
2018-03-07
影响因子：
39.3
通讯作者：
Di Carli, Marcelo F.
中科院分区：
文献类型：
--
作者：
Taqueti, Viviany R.;Solomon, Scott D.;Di Carli, Marcelo F.
目的 冠状动脉微血管缺血、心肌细胞损伤和僵硬可能在射血分数保留的心力衰竭（HFpEF）的病理生理学中发挥重要作用。迄今为止，冠状动脉血流储备 (CFR)、心肌损伤、舒张功能障碍和未来 HFpEF 风险之间的关系尚不清楚。 方法和结果 连续接受疑似冠状动脉疾病 (CAD) 评估的患者 (n = 201)，通过负荷心肌灌注正电子发射断层扫描、血清肌钙蛋白和经胸超声心动图进行评估，但没有出现血流限制性 CAD 或左心室射血分数降低。患者因心血管死亡和非致命性心肌梗塞或心力衰竭住院治疗进行随访（中位 4.1 年）。冠状动脉血流储备被量化为应激/静息心肌血流量。分别通过二脉多普勒和组织多普勒获得早期舒张血流（E）和舒张（e'）速度。 CFR 受损的患者（< 2，n = 108）表现出 e' 线性下降和 E/e' 增加与舒张功能恶化一致（趋势 P < 0.0001）。仅当 CFR 受损时，可检测到的肌钙蛋白才与舒张功能障碍相关（交互作用 P = 0.002）。在调整分析中，CFR 受损与舒张功能障碍（E/e'（间隔）> 15，调整后 OR 2.58，95% CI 1.22-5.48）和复合心血管结局或单独 HFpEF 住院（调整后 HR 2.47，95% CI 1.09-5.62）独立相关。 CFR 受损和舒张功能障碍的患者 HFpEF 住院风险增加了五倍以上 (P < 0.001)。 结论 在无明显 CAD 的有症状患者中，CFR 受损与舒张功能障碍和不良事件（尤其是 HFpEF 住院）独立相关。冠状动脉微血管和舒张功能障碍的存在与 HFpEF 事件的风险显着增加相关。
Aims Coronary microvascular ischaemia, cardiomyocyte injury and stiffness may play an important role in the pathophysiology of heart failure with preserved ejection fraction (HFpEF). To date, the relationship between coronary flow reserve (CFR), myocardial injury, diastolic dysfunction, and future HFpEF risk is unknown.Methods and results Consecutive patients (n = 201) undergoing evaluation for suspected coronary artery disease (CAD) with stress myocardial perfusion positron emission tomography, serum troponin, and transthoracic echocardiography who did not have flow-limiting CAD or reduced left ventricular ejection fraction were identified. Patients were followed up (median 4.1 years) for cardiovascular death and hospitalization for non-fatal myocardial infarction or heart failure. Coronary flow reserve was quantified as stress/rest myocardial blood flow. Early diastolic flow (E) and relaxation (e') velocities were obtained via transmitral and tissue Doppler, respectively. Patients with impaired CFR (< 2, n = 108) demonstrated linearly decreasing e' and increasing E/e' consistent with worsening diastolic function (P for trend < 0.0001). A detectable troponin was associated with diastolic dysfunction only in the presence of impaired CFR (interaction P = 0.002). In adjusted analyses, impaired CFR was independently associated with diastolic dysfunction (E/e'(septal) > 15, adjusted OR 2.58, 95% CI 1.22-5.48) and composite cardiovascular outcomes or HFpEF hospitalization alone (adjusted HR 2.47, 95% CI 1.09-5.62). Patients with both impaired CFR and diastolic dysfunction demonstrated > five-fold increased risk of HFpEF hospitalization (P < 0.001).Conclusion In symptomatic patients without overt CAD, impaired CFR was independently associated with diastolic dysfunction and adverse events, especially HFpEF hospitalization. The presence of both coronary microvascular and diastolic dysfunctions was associated with a markedly increased risk of HFpEF events.