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Sudden death in heart failure with preserved ejection fraction and beyond: an elusive target

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Abstract

Heart failure (HF) with preserved ejection fraction (HFpEF) represents half of HF patients, who are more likely older, women, and hypertensive. Mortality rates in HFpEF are higher compared with age- and comorbidity-matched non-HF controls and lower than in HF with reduced ejection fraction (HFrEF); the majority (50–70%) are cardiovascular (CV) deaths. Among CV deaths, sudden death (SD) (~ 35%) and HF-death (~ 20%) are the leading cardiac modes of death; however, proportionally, CV deaths, SD, and HF-deaths are lower in HFpEF, while non-CV deaths constitute a higher proportion of deaths in HFpEF (30–40%) than in HFrEF (~ 15%). Importantly, the underlying mechanism of SD has not been clearly elucidated and non-arrhythmic SD may be more prominent in HFpEF than in HFrEF. Furthermore, there is no specific strategy for identifying high-risk patients, probably due to wide heterogeneity in presentation and pathophysiology of HFpEF and a plethora of comorbidities in this population. Thus, the management of HFpEF remains problematic due to paucity of data on the clinical benefits of current therapies, which focus on symptom relief and reduction of HF-hospitalization by controlling fluid retention and managing risk-factors and comorbidities. Matching a specific pathophysiology or mode of death with available and novel therapies may improve outcomes in HFpEF. However, this still remains an elusive target, as we need more information on determinants of SD. Implantable cardioverter-defibrillators (ICDs) have changed the landscape of SD prevention in HFrEF; if ICDs are to be applied to HFpEF, there must be a coordinated effort to identify and select high-risk patients.

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Abbreviations

ACEI:

Angiotensin converting enzyme inhibitor

AF:

Atrial fibrillation

ARB:

Angiotensin receptor blocker

BNP:

Brain natriuretic peptide

CAD:

Coronary artery disease

CKD:

Chronic kidney disease

CMR:

Cardiac magnetic resonance (imaging)

CV:

Cardiovascular

DM:

Diabetes mellitus

ECG:

Electrocardiogram

EP:

Electrophysiology

HF:

Heart failure

HFmrEF:

Heart failure with mid-range ejection fraction

HFpEF:

Heart failure with preserved ejection fraction

HFrEF:

Heart failure with reduced ejection fraction

ICD:

Implantable cardioverter defibrillator

LGE:

Late gadolinium enhancement

LV:

Left ventricle(−ular)

LVEF:

Left ventricular ejection fraction

LVH:

Left ventricular hypertrophy

MI:

Myocardial infarction

MRA:

Mineralocorticoid receptor antagonist

NICM:

Non-ischemic cardiomyopathy

PCI:

Percutaneous coronary intervention

RCT:

Randomized controlled trial

RV:

Right ventricular

SCD:

Sudden cardiac death

SD:

Sudden death

STEMI:

ST elevation myocardial infarction

VF:

Ventricular fibrillation

VT:

Ventricular tachycardia

VTA:

Ventricular tachyarrhythmia

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  1. Third Department of Cardiology, Athens University School of Medicine, Vas. Sofias 114, 115 27, Athens, Greece

    Antonis S. Manolis

  2. Patras University School of Medicine, Patras, Greece

    Antonis A. Manolis

  3. Red Cross Hospital, Athens, Greece

    Theodora A. Manolis

  4. Onassis Cardiac Surgery Center, Athens, Greece

    Helen Melita

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Manolis, A.S., Manolis, A.A., Manolis, T.A. et al. Sudden death in heart failure with preserved ejection fraction and beyond: an elusive target. Heart Fail Rev 24, 847–866 (2019). https://doi.org/10.1007/s10741-019-09804-2

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