Clinical Research
Heart Failure
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

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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 VO2max.

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.

Key Words

diastolic
heart failure
rotation
strain
untwist

Abbreviations and Acronyms

A′
peak late diastolic myocardial mitral annular velocity by pulse wave Doppler imaging
Am
peak late diastolic myocardial mitral annular velocity by color tissue Doppler imaging
DT
deceleration time
E′
peak early diastolic myocardial mitral annular velocity by pulse wave Doppler imaging
Em
peak early diastolic myocardial mitral annular velocity by color tissue Doppler imaging
LV
left ventricle/ventricular
NT-proBNP
N-terminal pro-brain natriuretic peptide
S′
peak systolic myocardial mitral annular velocity by pulse wave Doppler imaging
Sm
peak systolic myocardial mitral annular velocity by color tissue Doppler imaging
VO2max
maximum oxygen consumption
Vp
mitral flow propagation velocity

Cited by (0)

The project was funded by a project grant from the British Heart Foundation and an equipment grant from the North Staffs Heart Committee. Dr. Sanderson has received travel grants from Sanofi-Aventis, Boehringer-Ingelheim, and Pfizer, and lecture fees from Pfizer. Dr. Frenneaux is a consultant to Medtronic and St. Jude and has a method-of-use patent for perhexiline in heart failure (no current financial value).