Global constructive myocardial work predicts reduction of ejection fraction in patients with heart failure with preserved ejection fraction
Authors: Chilingaryan A , Tunyan L G , Tumasyan L R , Asatryan A A , Sisakyan J G , Kzhdryan H K , Adamyan K G , Zelveyan P H 
Published: October 2022

Abstract

Background
Despite advances in treatment of heart failure with preserved ejection fraction (HFpEF) its management remains challenging. SGLT2 inhibitors benefits across the full range of ejection fraction, and sacubitril/valsartan benefits up to the lower end of preserved EF &lt;57% implies that in some patients with HFpEF some pathophysiological mechanisms of HFrEF might co-exist, and some subset of HFpEF patients might benefit from proven treatment of HFrEF, particularly those with EF deterioration over time. We aimed to found out predictors of EF deterioration in HFpEF patients assuming that we can start treating them earlier with therapies of HFrEF, preventing further deterioration.

Methods
We studied 215 patients (63% women) 73±8 years with HFpEF. All patients had records of comorbidity Charlson index (CI), glomerular filtration rate (GFR). Echocardiography (EchoCG) was performed with offline analysis, including calculations of myocardial work (MW), global longitudinal (LS), radial (RS), circumferential (SS) and area strain (AS) by one experienced specialist. GW index was obtained from pressure-strain loops derived from speckle tracking analysis multiplied by brachial systolic blood pressure. Global constructive work (GCW) as the sum of positive work due to myocardial shortening during systole and negative work due to lengthening during isovolumic relaxation, global wasted work as energy loss by myocardial lengthening in systole and shortening in isovolumic relaxation, and GW efficiency as the percentage ratio of constructive work to the sum of constructive work and wasted work were obtained. RS, SS and AS were calculated in 3D by dedicated software. Patients followed up for 3 years.

Results
5 patients developed myocardial infarction and were excluded from the study. Baseline EF was higher in women (61,2±3,1 vs 56,4±2,7; P&lt;0.002), in patients &gt;70 years (62,4±2,1 vs 57,1±2,3; p&lt;0.005), and with end-diastolic volume index &lt;60 ml/m2 (56,1±3,2 vs 63,4±2,3; p&lt;0.001). Overall decline in EF compare to baseline was −7.3±1.6%, p&lt;0.01. Reduction in EF was more prominent in patients &gt;70 years (−6,9±1,8 vs −5,7±1,7; P&lt;0,002), and in patients with coronary artery disease (CAD) (−7,2±1,9 vs −5,8±1,6; P&lt;0,001) and did not relate to sex, LV size, CI, and GFR. During follow up 58 (27%) patients had EF &lt;50%. We observed significant worsening in AS (−27.9±8.5% vs −24.7±5.3%, p&lt;0.003), LS (−19.7±2.4% vs −17.1±1.6%, p&lt;0.005), and GCW (GCW 2378±117 vs 2107±102 mmHg%, p&lt;0.002). Patients with EF &lt;50% at the end of the study had significantly less AS and GCW baseline values compared with patients with EF&gt;50% (22.4±7.2% vs −27.6±8.1%, p&lt;0.002; 2081±92 vs 2489±127 mmHg%, p&lt;0.001). GCW was the predictor of EF deterioration (area under curve 0,875).

Conclusion
GCW predicts reduction of EF in patients with HFpEF which may help earlier identify the subset of HFpEF patients who may benefit from proven therapies for HFrEF and prevent upcoming deterioration.

Funding Acknowledgement
Type of funding sources: None.