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Tesi etd-07132018-102416


Thesis type
Tesi di specializzazione (5 anni)
Author
ROVAI, ILARIA
URN
etd-07132018-102416
Title
Diastolic Dysfunction and Left Ventricular Remodeling: classification and prognostic impact of a combined structural and functional echocardiographic analysis in a cohort of patients with Stage A and B Heart Failure with preserved Ejection Fraction (HFpEF)
Struttura
PATOLOGIA CHIRURGICA, MEDICA, MOLECOLARE E DELL'AREA CRITICA
Corso di studi
MALATTIE DELL'APPARATO CARDIOVASCOLARE
Commissione
relatore Dott. Dini, Frank L.
correlatore Prof. Pedrinelli, Roberto
Parole chiave
  • diastolic dysfunction
  • Heart failure
  • preserved ejection fraction
  • cardiac remodeling
  • prognosis
Data inizio appello
08/08/2018;
Consultabilità
completa
Riassunto analitico
Background. Patients with Heart failure with preserved ejection fraction (HFpEF) are<br>characterized by diastolic dysfunction (DD) and adverse left ventricular (LV)<br>remodeling.<br>Objectives. To assess the prognostic impact of different diastolic function algorithms<br>and a complex remodeling classification (CRC, including relative wall thickness, LV<br>mass index and end-diastolic volume index) in stage A and B HFpEF.<br>Methods. We selected 1923 stage A and B HFpEF patients (male 43%; age 57, 33-76<br>years) from a multicenter study, using three algorithms for LV diastolic function<br>(Paulus 2007, Nagueh 2009, Nagueh 2016), with classic and CRC. We considered a<br>composite end-point: all-cause death, hospitalization for worsening HF and acute<br>pulmonary edema.<br>Results. DD was observed in a minority of the population according to the three<br>different algorithms. The highest presence of DD was diagnosed by Nagueh 2009 (211<br>patients, 11%), while the prevalence according to Nagueh 2016 (63 patients, 3.3%)<br>turned out to be the lowest (p&lt;0.001 vs the other two algorithms). The proportion of<br>patients with undetermined diastolic function was similar across the 3 algorithms,<br>with a non-significant higher prevalence in Nagueh 2016 (n=154, 8%). According to<br>CRC, 486 (25,3%) patients had adverse hypertrophic remodeling: 294 (15,3%)<br>concentric hypertrophy, 73 (3.8%) eccentric hypertrophy, 80 (4.2%) dilated<br>hypertrophy and 39 (2%) mixed hypertrophy. 294 (15.3%) were unclassifiable. After<br>a median follow-up of 29 months, multivariate Cox-regression (adjusted for age,<br>gender, history of stable ischemic heart disease, classic remodeling classification)<br>identified CRC (p=0.01) and Nagueh 2016 (p&lt;0.001) as independent predictors of<br>end-point. Hypertrophic remodeling patterns (in particular concentric and eccentric<br>hypertrophy) showed the worst prognosis in the survival analysis. The coexistence of<br>an adverse LV remodeling by CRC and DD by Nagueh 2016 was associated with the<br>worst prognosis. CRC succeeded in stratifying also the subgroup with undetermined<br>diastole, proving the coexistence of an adverse hypertrophy pattern is associated<br>with a worse prognosis in these patients.<br>Conclusions. A concurrent structural (CRC) and functional (Nagueh 2016) analysis<br>improves prognostic stratification in stage A and B HFpEF patients.
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