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Advances in Heart Failure

Pulmonary Hypertension in Heart Failure Preserved Ejection Fraction

Prevalence, Pathophysiology, and Clinical Perspectives

Marco Guazzi
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https://doi.org/10.1161/CIRCHEARTFAILURE.113.000823
Circulation: Heart Failure. 2014;7:367-377
Originally published March 18, 2014
Marco Guazzi
From the Heart Failure Unit and Cardiopulmonary Laboratory, Cardiology, IRCCS, Policlinico San Donato University Hospital, Milan, Italy.
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  • heart failure preserved ejection fraction
  • pulmonary hypertension
  • right ventricular function

Introduction

An elevation of left ventricular diastolic and pulmonary venous pressure is typical of heart failure (HF) regardless of left ventricular (LV) ejection fraction. Normal left ventricular diastolic function keeps both pressures low (<12 mm Hg), although some increase may be observed during stress conditions, such as volume overload1 and exercise.2 When these changes occur within a range of transient periods and in a normal heart, they are well tolerated because of the pulmonary vasculature ability to recruit and distend the capillary network.3

Heart failure with preserved ejection fraction (HFpEF) is a condition presenting, by definition, with an impaired relaxation and stiffened myocardium, which is in part consequence of an increased load to the left ventricle attributable to the stiff arterial system and resulting in a well-defined ventricular–vascular uncoupling. These main hemodynamic alterations expose the lung vasculature to pressure-induced challenges whose most immediate acute threat is pulmonary edema.4 In the long term, the sustained backward hemodynamic transmission, along with the potential contribution of mitral insufficiency, increases the pulsatile loading on the right ventricle (RV)5 and triggers pulmonary hypertension (PH) development and symptom exacerbation.6 Thus, as a consequence of hemodynamic and functional perturbations, PH-HFpEF develops as a more advanced corollary of diastolic HF, leading to abnormal phenotypes of the lung microcirculation,7,8 the arterial system, and right heart function9–11 (Figure 1).

Figure 1.

From heart failure with preserved ejection fraction (HFpEF) to pulmonary hypertension (PH) HFpEF: hemodynamic components and pathophysiological correlates. In HFpEF, the central pathophysiological role is played by an impaired left ventricle (LV) filling mechanics that can arise both from intrinsic structural and molecular alterations in the LV (stiff heart) secondary to myocite hypertrophy, fibrosis, and impaired coronary reserve and as a consequence of an increased load to the heart …

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Circulation: Heart Failure
March 2014, Volume 7, Issue 2
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    Pulmonary Hypertension in Heart Failure Preserved Ejection Fraction
    Marco Guazzi
    Circulation: Heart Failure. 2014;7:367-377, originally published March 18, 2014
    https://doi.org/10.1161/CIRCHEARTFAILURE.113.000823

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    Pulmonary Hypertension in Heart Failure Preserved Ejection Fraction
    Marco Guazzi
    Circulation: Heart Failure. 2014;7:367-377, originally published March 18, 2014
    https://doi.org/10.1161/CIRCHEARTFAILURE.113.000823
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