Right ventricle;

What’s the significance of atrial fibrillation in my patient with heart failure with preserved ejection fraction (HFpEF)?

FA Manian MD, MPH, , , , , , Leave a comment

Although HFpEF alone may be associated with high pulmonary artery pressures, coexisting atrial fibrillation (AF) further increases the risk of right ventricular (RV) dysfunction independent from pulmonary artery pressures.1

A 2018 observational cohort study involving patients with symptomatic HFpEF (LVEF≥45%) found a significantly higher rate of RV dysfunction among those with current AF (63%) than those without a history of AF (20%) vs earlier AF but in normal sinus rhythm at the time of assessment (43%) (P=0.001).1 What’s fascinating is that AF was associated with RV dysfunction (O.R. 4.7 [95% C.I. 1.8-12.1]) even when adjusted for the mean pulmonary artery pressure.  

Another intriguing finding of the study was that earlier AF patients who were in normal sinus rhythm at the time of the study, tended to have more RV dysfunction that those who did not have a history of AF (O.R.3.1 [0.8-11.6], P=0.09).  These findings suggest that factors other than heart rhythm play a role in the development of RV remodeling in patients with HFpEF and AF. Several other studies support the strong association between AF and RV dysfunction in HFpEF.2-5  

What are some ramifications of AF-associated RV dysfunction in HFpEF? For one, the presence of RV dysfunction in heart failure (HFpEF or HFrEF) has been strongly associated with higher all-cause mortality and heart failure hospitalization.2,4 Another is a potential explanation for why some patients with heart failure and AF have disproportionate amount of lower extremity edema compared to the severity of their pulmonary edema.  Could coexisting RV dysfunction be contributing?

Bonus Pearl: Did you know that 65%-73% of patients with HFpEF and RV dysfunction have AF vs 31%-53% of those with HFpEF without RV dysfunction?1  

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References

  1. Gorter TM, Van Melle JP, Rienstra M, et al. Right hert dysfunction in heart failue with preserved ejection fraction: the impact of atrial fibrillation. J Cardiac Fail 2018;24:177-185. Right Heart Dysfunction in Heart Failure With Preserved Ejection Fraction: The Impact of Atrial Fibrillation – PubMed (nih.gov)
  2. Bosch L, Lam CSP, Gong L, et al. Right ventricular dysfunction in left-sided heart failure with preserved versus reduced ejection fraction. Eur J Heart Fail 2017;19:1664-71. Right ventricular dysfunction in left-sided heart failure with preserved versus reduced ejection fraction – PubMed (nih.gov)
  3. Melenovsky V, Hwang SJ, Lin G, et al. Right heart dysfunction in heart failure with preserved ejection fraction. Eur Heart J 2014;35:3452-62. Right heart dysfunction in heart failure with preserved ejection fraction – PubMed (nih.gov)
  4. Mohammed SF, Hussain I, Abou Ezzeddine OF, et al. Right ventricular function in heart failure with preserved ejection fraction: a community-based study. Circulation 2014;130:2310-20. Right ventricular function in heart failure with preserved ejection fraction: a community-based study – PubMed (nih.gov)
  5. Ghio S, Guazzi M, Scardovi AB, et al. Different correlates but similar prognostic implications for right ventricular dysfunction in heart failure patients with reduced or preserved ejection fraction. Eur J Heart Fail 2016;19:873-9. Different correlates but similar prognostic implications for right ventricular dysfunction in heart failure patients with reduced or preserved ejection fraction – PubMed (nih.gov)

Disclosures/Disclaimers: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

 

What’s the significance of atrial fibrillation in my patient with heart failure with preserved ejection fraction (HFpEF)?

Can syncope be related to acute pulmonary embolism in the absence of hemodynamic instability or right ventricular failure?

FA Manian MD, MPH, , , , , , , , , Leave a comment

Although we often think of syncope caused by acute pulmonary embolism (APE) in the setting of submassive or massive APE and right ventricular failure or shock (1,2), less massive APE may potentially cause syncope as well by triggering a vaso-vagal reflex (3).

For sure, a significant association between submassive or massive APE and syncope has been reported (1,2).  More specifically, patients with syncope and APE may be more likely to have systolic blood pressure <90 mmHg, right ventricular dilation and right ventricular hypokinesis (1). Another study reported a higher rate of central embolism (83% vs 43%), right ventricular dysfunction (91% vs 68%) and troponin positivity (80% vs 39%), but not 30 day mortality (2).

In contrast, 1 study found that patients with syncope as a presenting symptom of APE did not show a more serious clinical picture (e.g. shock) than those without syncope (3), while another found EKG signs of acute right ventricle overload in only 25% of patients with syncope (4).  

So while massive APEs may be associated with syncope, they don’t seem to be a prerequisite for this condition.

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References

1.  Omar HR, Mirsaeidi M, Weinstock MB, et al. Syncope on presentation is a surrogate for submassive and massive acute pulmonary embolism. Am J Emerg Med 2018;36:297-300. https://www.ncbi.nlm.nih.gov/pubmed/29146419

2. Altinsoy B, Erboy F, Tanriverdi H, et al. Syncope as a presentation of acute pulmonary embolism. Ther Clin Risk Manag 2016;12:1023-28. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4930221/

3. Castelli R, Tarsia P, Tantardini G et al. Syncope in patients with pulmonary embolism: comparison between patients with syncope as the presenting symptom of pulmonary embolism and patients with pulmonary embolism without syncope. Vascular Medicine 2003;8:257-261. https://journals.sagepub.com/doi/abs/10.1191/1358863x03vm510oa

4. Miniati M, Cenci, Monti S, et al. Clinical presentation of acute pulmonary embolism: survey of 800 cases. PloS One 2012;7:e30891.

 

 

Can syncope be related to acute pulmonary embolism in the absence of hemodynamic instability or right ventricular failure?