Ventricular-Arterial Coupling, Remodeling, and Prognosis in Chronic Heart Failure

• Published in: Journal of the American College of Cardiology 2013-09, Vol.62 (13), p.1165-1172
• Main Authors: Ky, Bonnie, MD, MSCE, French, Benjamin, PhD, May Khan, Abigail, MD, Plappert, Ted, CVT, Wang, Andrew, BA, Chirinos, Julio A., MD, Fang, James C., MD, Sweitzer, Nancy K., MD, PhD, Borlaug, Barry A., MD, Kass, David A., MD, St. John Sutton, Martin, MBBS, Cappola, Thomas P., MD, ScM
• Format: Article
• Language: English
• Subjects: Aged; Biological and medical sciences; Blood pressure; Cardiology; Cardiology. Vascular system; Cardiovascular; Echocardiography; ejection fraction; Female; Heart; Heart attacks; heart failure; Heart Failure - diagnosis; Heart Failure - mortality; Heart Failure - physiopathology; Heart failure, cardiogenic pulmonary edema, cardiac enlargement; Heart Transplantation; Heart-Assist Devices; Hospitalization; Humans; Internal Medicine; Laboratories; Male; mechanics; Medical sciences; Middle Aged; Mortality; Myocardial Contraction; Myocardium - pathology; Organ Size; Prognosis; Prospective Studies; Stroke Volume; United States - epidemiology
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2013.03.085

Objectives The objective of this study was to compare the physiological determinants of ejection fraction (EF)—ventricular size, contractile function, and ventricular-arterial (VA) interaction—and their associations with clinical outcomes in chronic heart failure (HF). Background EF is a potent predictor of HF outcomes, but represents a complex summary measure that integrates several components including left ventricular size, contractile function, and VA coupling. The relative importance of each of these parameters in determining prognosis is unknown. Methods In 466 participants with chronic systolic HF, we derived quantitative echocardiographic measures of EF: cardiac size (end-diastolic volume [EDV]); contractile function (the end-systolic pressure volume relationship slope [Eessb ] and intercept [V0 ]); and VA coupling (arterial elastance [Ea]/Eessb ). We determined the association between these parameters and the following adverse outcomes: 1) the combined endpoint of death, cardiac transplantation, or ventricular assist device (VAD) placement; and 2) cardiac hospitalization. Results Over a median follow-up of 3.4 years, there were 76 deaths, 52 transplantations, 14 VAD placements, and 684 cardiac hospitalizations. EF was independently associated with death, transplantation, and VAD placement (adjusted hazard ratio [HR]: 3.0; 95% confidence interval [CI]: 1.8 to 5.0 comparing third and first tertiles), as were EDV (HR: 2.6; 95% CI: 1.5 to 4.2); V0 (HR: 3.6; 95% CI: 2.1 to 6.1); and Ea/Eessb (HR: 2.1; 95% CI: 1.3 to 3.3). EDV, V0 , and Ea/Eessb were also associated with risk of cardiac hospitalization. Eessb was not significantly associated with any adverse outcomes in adjusted analyses. Conclusions Left ventricular size, V0 , and VA coupling are associated with prognosis in systolic HF, but end-systolic elastance (Eessb ) is not. Assessment of VA coupling via Ea/Eessb is an additional noninvasively derived metric that can be used to gauge prognosis in human HF.