Redfield, M

Background Patients with atrial fibrillation (AF) often complain of dyspnea, raising the question that symptoms could be related to unrecognized heart failure (HF) with preserved ejection fraction (HFpEF). Methods We used the HFpEF‐age, body mass index and history of AF algorithm to estimate the probability of undiagnosed HFpEF in CABANA (Catheter Ablation vs. Antiarrhythmic Drug Therapy), and its interaction with catheter ablation on quality of life (QOL). Probable HFpEF was defined as patient‐reported dyspnea with HFpEF‐age, body mass index and history of AF probability≥75%. Absence of dyspnea or HFpEF‐age, body mass index and history of AF probability<75% was considered to reflect patients without HFpEF. The effect of randomization to catheter ablation on QOL (Mayo Atrial Fibrillation‐Specific Symptom Inventory questionnaire and EuroQol‐5 Dimension‐3 Level score) was assessed using mixed models. Results Of participants without known HF, 70% (n=1225) had probable HFpEF and the remaining 30% (n=522) did not. Those with probable HFpEF had worse New York Heart Association class, EuroQol‐5 Dimension‐3 Level score, Mayo Atrial Fibrillation‐Specific Symptom Inventory severity, and Mayo Atrial Fibrillation‐Specific Symptom Inventory frequency scores ( P <0.0001 for all), with higher risk of HF hospitalization (hazard ratio [HR], 2.19 [95% CI, 1.11–4.31], P =0.01). Ablation resulted in greater improvement in EuroQol‐5 Dimension‐3 Level and Mayo Atrial Fibrillation‐Specific Symptom Inventory severity/frequency scores in probable HFpEF (interactions P =0.005, P =0.05, and P =0.04 respectively). In probable HFpEF, catheter ablation was associated with lower risk of cardiovascular hospitalization (HR, 0.78 [95% CI, 0.66–0.92], P =0.003, interaction P =0.03) but not HF hospitalization (HR, 0.94 [95% CI, 0.55–1.64], P =0.84). Conclusions Nearly three quarters of CABANA participants had potentially undiagnosed HFpEF, with worse QOL and risk of HF hospitalization. Catheter ablation in probable HFpEF resulted in greater improvement in QOL, but residual QOL impairment and HF risk remained elevated despite ablation. These data reinforce the importance of diligent consideration of HFpEF among patients with symptomatic AF to ensure optimal use of foundational treatments for HF.

Abstract Background Left atrial pressure (LAP) is clinically estimated by the occluded pulmonary artery (PA) pressure (PA wedge pressure, PAWP), which should equalize with downstream LAP. Early studies reported the potential for PAWP to exceed LAP, but the frequency and clinical significance of this finding is unclear. Purpose This study aimed to investigate the hemodynamic characteristics, physiologic determinants, and prognostic impact of patients with PAWP exceeding LAP. Method Patients who underwent right heart catheterization (RHC) for diagnosis or treatment with PAWP and simultaneous measurement of LAP were identified. Patients were divided into two groups based on differences in PAWP and LAP. Pulmonary capillary pressure (Pc) was measured using the PA occlusion technique. Pulmonary vascular resistance (PVR) was then partitioned into upstream PVRa ([mean PA pressure (PAP)-Pc]/cardiac output [CO]) and downstream PVRv ([Pc-PAWP]/CO), with each expressed as a percentage of PVR. Results 675 patients underwent RHC with transseptal puncture allowing measurement of both PAWP and LAP simultaneously. A strong correlation and agreement between PAWP and LAP were demonstrated (r=0.92, P&lt;0.001; bias +0.5 mmHg), but 310 patients (46%) displayed PAWP exceeding LAP by at least 1 mmHg (mean difference 3±2 mmHg). Patients with PAWP exceeding LAP displayed higher mean PAP (Figure 1A) and PVR calculated using LAP as the downstream pressure (PVR-LA: 2.10 [1.13-3.53] vs 3.38 [2.19-5.66] WU, P&lt;0.001). PAWP was significantly higher in patients with PAWP exceeding LAP, although there was no significant difference in LAP between the groups (Figure 1B-C). PA compliance, which does not rely on either PAWP or LAP for calculation, was significantly lower in patients with PAWP exceeding LAP (2.7 [1.8-4.0] vs 2.1 [1.5-3.0] mL/mmHg, P&lt;0.001, Figure 1D). The difference between PAWP and LAP was significantly correlated with mean PAP (r=0.32, P&lt;0.001, Figure 1E). In 63 patients where Pc could be measured, those with PAWP exceeding LAP showed a higher Pc and greater pulmonary venous (vs arterial) distribution of PVR (Figure 1F-H). Over 5.4 (IQR 1.7-10.2) years, the composite outcome of all-cause death or heart failure hospitalization occurred in 326 patients (48%). Patients with PAWP exceeding LAP had a higher risk of the composite outcome than those without (log-rank P&lt;0.001, Figure 2). Patients with PAWP exceeding LAP had 37% greater risk of composite outcome than those without (hazard ratio 1.37, 95% CI 1.09-1.73; P=0.008) after adjusting for age, sex, hemoglobin, moderate or greater mitral regurgitation, and tricuspid regurgitation, LAP, and mean PAP. Conclusions While PAWP is a robust surrogate for LAP, the former commonly exceeds the latter, and patients with PAWP exceeding LAP have more severe pulmonary vascular disease, greater capillary hypertension and venous involvement, and a higher risk for adverse outcomes.