The pathophysiology of heart failure with normal ejection fraction

exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion

Yu Ting Tan, Frauke Wenzelburger, Eveline Lee, Grant Heatlie, Francisco Leyva, Kiran Patel, Michael Frenneaux, John E. Sanderson

Research output: Contribution to journalArticle

311 Citations (Scopus)

Abstract

Objectives The purpose of this study was to test the hypothesis that in heart failure with normal ejection fraction (HFNEF) exercise limitation is due to combined systolic and diastolic abnormalities, particularly involving ventricular twist and deformation (strain) leading to reduced ventricular suction, delayed untwisting, and impaired early diastolic filling.

Background A substantial proportion of patients with heart failure have a normal left ventricular ejection fraction. Currently the pathophysiology is considered to be due to abnormal myocardial stiffness and relaxation.

Methods Patients with a diagnosis of HFNEF and proven cardiac limitation by cardiopulmonary exercise testing were studied by standard, tissue Doppler, and speckle tracking echocardiography at rest and on submaximal exercise.

Results Fifty-six patients (39 women; mean age 72 +/- 7 years) with a clinical diagnosis of HFNEF and 27 age-matched healthy control subjects (19 women; mean age 70 +/- 7 years) had rest and exercise images of sufficient quality for analysis. At rest, systolic longitudinal and radial strain, systolic mitral annular velocities, and apical rotation were lower in patients, and all failed to rise normally on exercise. Systolic longitudinal functional reserve was also significantly lower in patients (p < 0.001). In diastole, patients had reduced and delayed untwisting, reduced left ventricular suction at rest and on exercise, and higher end-diastolic pressures. Mitral annular systolic and diastolic velocities, systolic left ventricular rotation, and early diastolic untwist on exercise correlated with peak VO(2)max.

Conclusions In HFNEF there are widespread abnormalities of both systolic and diastolic function that become more apparent on exercise. HFNEF is not an isolated disorder of diastole. (J Am Coll Cardiol 2009; 54: 36-46) (C) 2009 by the American College of Cardiology Foundation

Original languageEnglish
Pages (from-to)36-46
Number of pages11
JournalJournal of the American College of Cardiology
Volume54
Issue number1
DOIs
Publication statusPublished - 30 Jun 2009

Keywords

  • diastolic
  • heart failure
  • rotation
  • strain
  • untwist
  • speckle tracking echocardiography
  • incremental prognostic value
  • mitral annulus velocity
  • long axis function
  • myocardial-infarction
  • natriuretic peptide
  • chamber stiffness
  • index
  • dysfunction
  • hypertrophy

Cite this

The pathophysiology of heart failure with normal ejection fraction : exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion. / Tan, Yu Ting; Wenzelburger, Frauke; Lee, Eveline; Heatlie, Grant; Leyva, Francisco; Patel, Kiran; Frenneaux, Michael; Sanderson, John E.

In: Journal of the American College of Cardiology, Vol. 54, No. 1, 30.06.2009, p. 36-46.

Research output: Contribution to journalArticle

Tan, Yu Ting ; Wenzelburger, Frauke ; Lee, Eveline ; Heatlie, Grant ; Leyva, Francisco ; Patel, Kiran ; Frenneaux, Michael ; Sanderson, John E. / The pathophysiology of heart failure with normal ejection fraction : exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion. In: Journal of the American College of Cardiology. 2009 ; Vol. 54, No. 1. pp. 36-46.
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abstract = "Objectives The purpose of this study was to test the hypothesis that in heart failure with normal ejection fraction (HFNEF) exercise limitation is due to combined systolic and diastolic abnormalities, particularly involving ventricular twist and deformation (strain) leading to reduced ventricular suction, delayed untwisting, and impaired early diastolic filling.Background A substantial proportion of patients with heart failure have a normal left ventricular ejection fraction. Currently the pathophysiology is considered to be due to abnormal myocardial stiffness and relaxation.Methods Patients with a diagnosis of HFNEF and proven cardiac limitation by cardiopulmonary exercise testing were studied by standard, tissue Doppler, and speckle tracking echocardiography at rest and on submaximal exercise.Results Fifty-six patients (39 women; mean age 72 +/- 7 years) with a clinical diagnosis of HFNEF and 27 age-matched healthy control subjects (19 women; mean age 70 +/- 7 years) had rest and exercise images of sufficient quality for analysis. At rest, systolic longitudinal and radial strain, systolic mitral annular velocities, and apical rotation were lower in patients, and all failed to rise normally on exercise. Systolic longitudinal functional reserve was also significantly lower in patients (p < 0.001). In diastole, patients had reduced and delayed untwisting, reduced left ventricular suction at rest and on exercise, and higher end-diastolic pressures. Mitral annular systolic and diastolic velocities, systolic left ventricular rotation, and early diastolic untwist on exercise correlated with peak VO(2)max.Conclusions In HFNEF there are widespread abnormalities of both systolic and diastolic function that become more apparent on exercise. HFNEF is not an isolated disorder of diastole. (J Am Coll Cardiol 2009; 54: 36-46) (C) 2009 by the American College of Cardiology Foundation",
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T1 - The pathophysiology of heart failure with normal ejection fraction

T2 - exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion

AU - Tan, Yu Ting

AU - Wenzelburger, Frauke

AU - Lee, Eveline

AU - Heatlie, Grant

AU - Leyva, Francisco

AU - Patel, Kiran

AU - Frenneaux, Michael

AU - Sanderson, John E.

PY - 2009/6/30

Y1 - 2009/6/30

N2 - Objectives The purpose of this study was to test the hypothesis that in heart failure with normal ejection fraction (HFNEF) exercise limitation is due to combined systolic and diastolic abnormalities, particularly involving ventricular twist and deformation (strain) leading to reduced ventricular suction, delayed untwisting, and impaired early diastolic filling.Background A substantial proportion of patients with heart failure have a normal left ventricular ejection fraction. Currently the pathophysiology is considered to be due to abnormal myocardial stiffness and relaxation.Methods Patients with a diagnosis of HFNEF and proven cardiac limitation by cardiopulmonary exercise testing were studied by standard, tissue Doppler, and speckle tracking echocardiography at rest and on submaximal exercise.Results Fifty-six patients (39 women; mean age 72 +/- 7 years) with a clinical diagnosis of HFNEF and 27 age-matched healthy control subjects (19 women; mean age 70 +/- 7 years) had rest and exercise images of sufficient quality for analysis. At rest, systolic longitudinal and radial strain, systolic mitral annular velocities, and apical rotation were lower in patients, and all failed to rise normally on exercise. Systolic longitudinal functional reserve was also significantly lower in patients (p < 0.001). In diastole, patients had reduced and delayed untwisting, reduced left ventricular suction at rest and on exercise, and higher end-diastolic pressures. Mitral annular systolic and diastolic velocities, systolic left ventricular rotation, and early diastolic untwist on exercise correlated with peak VO(2)max.Conclusions In HFNEF there are widespread abnormalities of both systolic and diastolic function that become more apparent on exercise. HFNEF is not an isolated disorder of diastole. (J Am Coll Cardiol 2009; 54: 36-46) (C) 2009 by the American College of Cardiology Foundation

AB - Objectives The purpose of this study was to test the hypothesis that in heart failure with normal ejection fraction (HFNEF) exercise limitation is due to combined systolic and diastolic abnormalities, particularly involving ventricular twist and deformation (strain) leading to reduced ventricular suction, delayed untwisting, and impaired early diastolic filling.Background A substantial proportion of patients with heart failure have a normal left ventricular ejection fraction. Currently the pathophysiology is considered to be due to abnormal myocardial stiffness and relaxation.Methods Patients with a diagnosis of HFNEF and proven cardiac limitation by cardiopulmonary exercise testing were studied by standard, tissue Doppler, and speckle tracking echocardiography at rest and on submaximal exercise.Results Fifty-six patients (39 women; mean age 72 +/- 7 years) with a clinical diagnosis of HFNEF and 27 age-matched healthy control subjects (19 women; mean age 70 +/- 7 years) had rest and exercise images of sufficient quality for analysis. At rest, systolic longitudinal and radial strain, systolic mitral annular velocities, and apical rotation were lower in patients, and all failed to rise normally on exercise. Systolic longitudinal functional reserve was also significantly lower in patients (p < 0.001). In diastole, patients had reduced and delayed untwisting, reduced left ventricular suction at rest and on exercise, and higher end-diastolic pressures. Mitral annular systolic and diastolic velocities, systolic left ventricular rotation, and early diastolic untwist on exercise correlated with peak VO(2)max.Conclusions In HFNEF there are widespread abnormalities of both systolic and diastolic function that become more apparent on exercise. HFNEF is not an isolated disorder of diastole. (J Am Coll Cardiol 2009; 54: 36-46) (C) 2009 by the American College of Cardiology Foundation

KW - diastolic

KW - heart failure

KW - rotation

KW - strain

KW - untwist

KW - speckle tracking echocardiography

KW - incremental prognostic value

KW - mitral annulus velocity

KW - long axis function

KW - myocardial-infarction

KW - natriuretic peptide

KW - chamber stiffness

KW - index

KW - dysfunction

KW - hypertrophy

U2 - 10.1016/j.jacc.2009.03.037

DO - 10.1016/j.jacc.2009.03.037

M3 - Article

VL - 54

SP - 36

EP - 46

JO - Journal of the American College of Cardiology

JF - Journal of the American College of Cardiology

SN - 0735-1097

IS - 1

ER -