Thesis etd-07132018-102416 |
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Thesis type
Tesi di specializzazione (5 anni)
Author
ROVAI, ILARIA
URN
etd-07132018-102416
Thesis 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)
Department
PATOLOGIA CHIRURGICA, MEDICA, MOLECOLARE E DELL'AREA CRITICA
Course of study
MALATTIE DELL'APPARATO CARDIOVASCOLARE
Supervisors
relatore Dott. Dini, Frank L.
correlatore Prof. Pedrinelli, Roberto
correlatore Prof. Pedrinelli, Roberto
Keywords
- cardiac remodeling
- diastolic dysfunction
- Heart failure
- preserved ejection fraction
- prognosis
Graduation session start date
08/08/2018
Availability
Withheld
Release date
08/08/2088
Summary
Background. Patients with Heart failure with preserved ejection fraction (HFpEF) are characterized by diastolic dysfunction (DD) and adverse left ventricular (LV) remodeling.
Objectives. To assess the prognostic impact of different diastolic function algorithms and a complex remodeling classification (CRC, including relative wall thickness, LV mass index and end-diastolic volume index) in stage A and B HFpEF.
Methods. We selected 1923 stage A and B HFpEF patients (male 43%; age 57, 33-76 years) from a multicenter study, using three algorithms for LV diastolic function (Paulus 2007, Nagueh 2009, Nagueh 2016), with classic and CRC. We considered a composite end-point: all-cause death, hospitalization for worsening HF and acute pulmonary edema.
Results. DD was observed in a minority of the population according to the three different algorithms. The highest presence of DD was diagnosed by Nagueh 2009 (211 patients, 11%), while the prevalence according to Nagueh 2016 (63 patients, 3.3%) turned out to be the lowest (p<0.001 vs the other two algorithms). The proportion of patients with undetermined diastolic function was similar across the 3 algorithms, with a non-significant higher prevalence in Nagueh 2016 (n=154, 8%). According to CRC, 486 (25,3%) patients had adverse hypertrophic remodeling: 294 (15,3%) concentric hypertrophy, 73 (3.8%) eccentric hypertrophy, 80 (4.2%) dilated hypertrophy and 39 (2%) mixed hypertrophy. 294 (15.3%) were unclassifiable. After a median follow-up of 29 months, multivariate Cox-regression (adjusted for age, gender, history of stable ischemic heart disease, classic remodeling classification) identified CRC (p=0.01) and Nagueh 2016 (p<0.001) as independent predictors of end-point. Hypertrophic remodeling patterns (in particular concentric and eccentric hypertrophy) showed the worst prognosis in the survival analysis. The coexistence of an adverse LV remodeling by CRC and DD by Nagueh 2016 was associated with the worst prognosis. CRC succeeded in stratifying also the subgroup with undetermined diastole, proving the coexistence of an adverse hypertrophy pattern is associated with a worse prognosis in these patients.
Conclusions. A concurrent structural (CRC) and functional (Nagueh 2016) analysis improves prognostic stratification in stage A and B HFpEF patients.
Objectives. To assess the prognostic impact of different diastolic function algorithms and a complex remodeling classification (CRC, including relative wall thickness, LV mass index and end-diastolic volume index) in stage A and B HFpEF.
Methods. We selected 1923 stage A and B HFpEF patients (male 43%; age 57, 33-76 years) from a multicenter study, using three algorithms for LV diastolic function (Paulus 2007, Nagueh 2009, Nagueh 2016), with classic and CRC. We considered a composite end-point: all-cause death, hospitalization for worsening HF and acute pulmonary edema.
Results. DD was observed in a minority of the population according to the three different algorithms. The highest presence of DD was diagnosed by Nagueh 2009 (211 patients, 11%), while the prevalence according to Nagueh 2016 (63 patients, 3.3%) turned out to be the lowest (p<0.001 vs the other two algorithms). The proportion of patients with undetermined diastolic function was similar across the 3 algorithms, with a non-significant higher prevalence in Nagueh 2016 (n=154, 8%). According to CRC, 486 (25,3%) patients had adverse hypertrophic remodeling: 294 (15,3%) concentric hypertrophy, 73 (3.8%) eccentric hypertrophy, 80 (4.2%) dilated hypertrophy and 39 (2%) mixed hypertrophy. 294 (15.3%) were unclassifiable. After a median follow-up of 29 months, multivariate Cox-regression (adjusted for age, gender, history of stable ischemic heart disease, classic remodeling classification) identified CRC (p=0.01) and Nagueh 2016 (p<0.001) as independent predictors of end-point. Hypertrophic remodeling patterns (in particular concentric and eccentric hypertrophy) showed the worst prognosis in the survival analysis. The coexistence of an adverse LV remodeling by CRC and DD by Nagueh 2016 was associated with the worst prognosis. CRC succeeded in stratifying also the subgroup with undetermined diastole, proving the coexistence of an adverse hypertrophy pattern is associated with a worse prognosis in these patients.
Conclusions. A concurrent structural (CRC) and functional (Nagueh 2016) analysis improves prognostic stratification in stage A and B HFpEF patients.
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