151 The pre-HFpEF entity: a window of opportunity to prevent and halt the progression to HF with preserved ejection fraction (HFpEF). (4th June 2021) - Tran, Patrick
Abstract : Background: Before the emergence of HFpEF, there is an insidious phase of progressive myocardial fibrosis, arterial stiffness, and rising left ventricular end-diastolic pressures (LVEDP) driven by amassing cardio-metabolic comorbidities. This phase is characterized by incipient structural cardiac abnormalities but without the manifestation of HF. We hence propose the term 'pre-HFpEF'. ( Figure 1 ) We hypothesize that pre-HFpEF is associated with high morbidity (e.g. hospitalization rate) similar to HFpEF but without the increased mortality, presuming the ventricle is 'fatigued' but remains compensated. Expanding on preventive cardiology, we believe that early identification of this cohort with aggressive comorbidity control may potentially halt its progression to HFpEF which has a dismal prognosis and disappointing therapies. Our study therefore aims to demonstrate that this seemingly subclinical entity is clinically diagnosable and depending on the degree of LVEDP, is associated with adverse clinical outcomes. Methods: 1294 consecutive patients with NYHA II-IV breathlessness referred to the community HF clinic were screened and included if LVEF >45% and LV diastolic dysfunction (LVDD) were present but without clinical and radiological evidence of HF. Echocardiographic assessment of diastology was based on 2016 EACVI guidelines. 175 patients were included and divided into two groups: rising LVEDP (E/e' <14) versus raised LVEDP (E/e'≥14). Clinical demographics and events (deaths, unplanned hospitalization and length of hospital stay) were retrospectively compared at 12 and 36 months. Results: 55 patients had E/e' ≥14 and 120 had E/e'<14 with the former group having significantly higher NT-proBNP and proportion of hypertension. There were no significant differences in the other comorbidities usually associated with HFpEF. ( Table 1 ) This may support the concept that pre-HFpEF is at the early stages of disease but has the potential to progress to HFpEF through additional comorbidity burden. The E/e'≥14 group had a significantly higher number of cardiovascular-related admissions and twice the average length of hospital stay compared with the E/e' <14 group. At 3 years, the high E/e' cohort had 285 all-cause hospital admissions and 54 all-cause deaths. There was no significant difference in mortality between the two groups at 12 or 36 months, reflecting the notion that pre-HFpEF is at the beginning of the spectrum of both disease and prognosis. Conclusion: A high E/e ≥14 cut-off with raised NT-proBNP may be used as a screening tool to identify high-risk pre-HFpEF group which is associated with adverse clinical outcomes. Without increased mortality so far, it is crucial to promptly identify this population that may be more amenable to risk factor modification than HFpEF. Close monitoring in a dedicated HFpEF clinic with vigorous management of comorbidities is therefore recommended. Conflict of Interest: None