High Prevalence of Occult Heart Failure With Preserved Ejection Fraction Among Patients With Atrial Fibrillation and Dyspnea
Authors: Yogesh N.V. Reddy, Masaru Obokata, Bernard J. Gersh, Barry A. Borlaug
Journal: Circulation (2018)

◼ dyspnea ◼ exercise ◼ heart failure A trial fibrillation (AF) is common in patients with heart failure and preserved ejection fraction (HFpEF). 1,2Like people with HFpEF, patients with AF commonly describe exertional dyspnea.Treatments directed at AF are often undertaken by using antiarrhythmic drugs, rate control, or AF ablation with the ultimate goal of improving these symptoms.However, recent data indicate that some patients with apparently lone AF display myocardial abnormalities that persist even when sinus rhythm has been restored, suggesting the coexistence of an underlying cardiomyopathic process. 3Viewed in this light, AF might be conceptualized as a consequence rather than a cause of symptoms of heart failure.There is little information available regarding the prevalence of HFpEF among patients presenting with dyspnea, normal ejection fraction (EF), and AF.Because history, physical examination, and echocardiography are insensitive to the diagnosis of HFpEF, the only method to accurately determine whether HFpEF is present or absent in this group is to ascertain disease status by using the gold standard of invasive hemodynamic cardiopulmonary exercise testing. 4,5e examined the relationships between AF and HFpEF among consecutive patients presenting with unexplained exertional dyspnea, normal EF (>50%), and no prior diagnosis of heart failure referred for invasive exercise testing between 2000 and 2014.Patients were diagnosed with HFpEF based on an increase in pulmonary capillary wedge pressure to ≥25 mm Hg during exercise. 4,5Patients with no demonstrable cardiac pathology and an exercise pulmonary capillary wedge pressure <25 mm Hg during exercise were diagnosed as having noncardiac etiologies of dyspnea.Patients with alternative causes of heart failure, a prior history of tachycardia-mediated cardiomyopathy, or any history of low EF (<50%) were excluded.The study was approved by the Mayo Clinic institutional review committee, and all subjects gave informed consent.Among 429 consecutive patients meeting these criteria, 154 (36%) were diagnosed with noncardiac etiologies of dyspnea, and 275 (64%) were diagnosed with HFpEF (Table ).In comparison with patients with noncardiac etiologies of dyspnea, patients with HFpEF were older, heavier, and more likely to have diabetes mellitus and hypertension.The majority of patients with noncardiac etiologies of dyspnea (96.1%) were in sinus rhythm, with only 3.3% and 0.7% documented to have paroxysmal and persistent/permanent AF, respectively.Conversely, 17.5% and 17.1% of subjects with HFpEF had paroxysmal or persistent/permanent AF, respectively (P<0.0001).HFpEF was highly prevalent among patients with AF and dyspnea, diagnosed in 98% of individuals with persistent/permanent AF and 91% of those with paroxysmal AF.With the use of logistic regression, the odds ratio (OR) for HFpEF associated with permanent AF was 38.6 (95% confidence interval [CI], 8.3-688.0;P=0.0003), and the OR for HFpEF with paroxysmal AF was 7.9 (95% CI, 3.4-23.2;P<0.0001).After adjusting for baseline characteristics, the presence of permanent AF (OR, 22.1; 95% CI, 4.4-401) and paroxysmal AF (OR, 4.86; 95% CI, 1.90-15.1)remained a highly significant predictor of HFpEF (both P<0.001).The prevalence rate ratio of HFpEF among patients with