Author + information
- Pierpaolo Pellicori, MD∗ (, )
- Kate Hutchinson, MBChB, BSc,
- Andrew L. Clark, MA, MD and
- John G.F. Cleland, MD
- ↵∗Department of Academic Cardiology, Hull and East Yorkshire Medical Research and Teaching Centre, MRTDS (Daisy) Building, Entrance 2, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, United Kingdom
The pathophysiology of heart failure (HF) with normal ejection fraction (EF) is complex; echocardiography may add further confusion, especially when it focuses on one aspect of cardiac function to the exclusion of all others. Among 219 patients with a LVEF >45% and plasma N-terminal pro–B-type natriuretic peptide (NT-proBNP) >400 ng/l who were randomized in PARAMOUNT (The Prospective comparison of ARNI with ARB on Management Of heart failUre with preserved ejectioN fraction Trial), Kraigher-Krainer et al. (1) showed that most of these patients had reduced longitudinal or circumferential LV systolic function measured by 2-dimensional speckle tracking compared with control subjects or patients with hypertension. The severity of systolic dysfunction was closely related to plasma NT-proBNP, which is a powerful prognostic marker (2). Neither E′ nor left atrial volume (LAVI), which are popular measurements of diastolic dysfunction, were strongly associated with NT-proBNP.
We found a broadly similar association between global longitudinal strain (GLS) by speckle tracking and NT-proBNP among 313 outpatients with suspected heart failure who had a LVEF >50% (3). However, in our study, GLS was a weak predictor of outcomes using univariable analysis; only inferior vena cava dimension, serum urea, and NT-proBNP were independent predictors on multivariable analysis.
The PARAMOUNT and TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) studies have begun to establish raised plasma concentrations of natriuretic peptides as a key selection criterion for clinical trials of HF with normal LVEF and as an integral part of its diagnosis.
Similar to echocardiography, NT-proBNP alone is insufficient for a diagnosis of heart failure; it is merely a measure of the severity of cardiac dysfunction. However, the activation of this counter-regulatory system, which is designed to correct congestion, is powerful evidence of disease.
Should echocardiography now be relegated purely to excluding low LVEF or valve disease as the cause of heart failure, with the diagnosis of heart failure made by clinical evaluation informed by NT-proBNP and with knowledge of the patient’s body mass index, heart rhythm and renal function? Although the answer is probably “yes,” more experience and training in the use of both natriuretic peptides and echocardiography are still required.
A deeper understanding of echocardiographic phenotyping, especially of right heart function (4), will provide much greater diversity of therapeutic targets than the current crude separation into HF with reduced EF, preserved EF, and valve disease. Echocardiography will continue to have an essential role in diagnosing the cause of HF, although it is no longer required to confirm its presence.
- American College of Cardiology Foundation
- Kraigher-Krainer E.,
- Shah A.M.,
- Gupta D.K.,
- et al.
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