Aim

Left ventricular diastolic dysfunction (DD) is a common finding in the general population. DD plays a distinguished role in the genesis of heart failure with preserved ejection faction (HFpEF). Nevertheless, it remains unclear which mechanisms prompt a transition from asymptomatic left ventricular diastolic dysfunction (ALVDD) to overt HFpEF. We aimed to evaluate the prevalence and correlates of DD in subjects with and without HFpEF at the population level. 

Methods and Results

In 5,821 subjects (mean age 61.3 ± 8.3 years, range 46-78, 51.4 % females) prospectively enrolled between 2016 and 2019 in the population-based Hamburg City Health Study (HCHS) standardised 2-dimensional transthoracic echocardiography was performed. DD was identified if at least two of the three echocardiographic parameters (1) left atrial volume index (LAVI) >34ml/m², (2) E/e’ >10, and (3) e’lateral <10cm/s or septal <7cm/s were fulfilled. DD was present in 12.4%. Of those in the DD group, 11.2% showed no symptoms (ALVDD) while 1.2% suffered from HFpEF. 

In logistic regression analysis, DD and HFpEF were associated with an odds ratio (OR) of 14.9 (95% Confidence Interval (CI) 9.6-22.7, p<0.001). In multivariable regression analysis adjusted for age, sex, body mass index (BMI), arterial hypertension, diabetes, current smoking, and coronary artery disease (CAD), major associations of both ALVDD and HFpEF were age (OR 1.8,  95% CI 1.6-2.0, p<0.001; OR 3.3, 95% CI 2.3-5.0, p<0.001 ), BMI (OR 1.1, 95% CI 1.0-1.3, p=0.003; OR 1.6, 95% CI 1.3-2.0, p<0.001), current smoking (OR 1.3, 95% CI 1.0-1.6, p=0.033; OR 2.4, 95% CI 1.2-4.4, p=0.007), E/e’ (OR 5.1, 95% CI 4.5-5.8, p<0.001; OR 2.5, 95% CI 2.1-3.1, p<0.001), left ventricular mass index (LVMI) (OR 1.5, 95% CI 1.4-1.7, p<0.001; OR 2.0, 95% CI 1.6-2.5, p<0.001), and LAVI (OR 2.2, 95% CI 2.0-2.4, p<0.001; OR 2.2, 95% CI 1.7-2.7, p<0.001). Several comorbidities were related to HFpEF but not to ALVDD: atrial fibrillation (OR 2.6, 95% CI 1.2-5.5, p=0.015), CAD (OR 6.0, 95% CI 3.1-11.0, p<0.001), chronic obstructive pulmonary disease (OR 4.3, 95% CI 2.2-7.9, p<0.001), female sex (OR 3.3, 95% CI 1.9-5.9, p<0.001), QRS duration (OR 1.4, 95% CI 1.1-1.7, p=0.005), and hsCRP (OR 1.2, 95% CI 1.0-1.3, p=0.024).

Conclusion

DD is a common finding in the community. DD is highly associated with prevalent heart failure in subjects with preserved ejection fraction. DD and HFpEF both show significant associations to major cardiovascular risk factors.  

Central illustration. Pertinent associated factors for ALVDD and HFpEF. The figure visualizes ORs derived from adjusted logistic regression analysis. The size of the circles correlate with the size of the OR. Adjustment was performed for age, sex, body-mass-index (BMI), arterial hypertension, diabetes, coronary artery disease (CAD) and smoking. All displayed ORs showed statistical significance. Abbreviations: AAD = Abdominal aorta diameter, AF = atrial fibrillation, AH = arterial hypertension, ALVDD = asymptomatic left ventricular diastolic dysfunction, BMI = body mass index, CAD = coronary artery disease, GFR = glomerular filtration rate, HFpEF = heart failure with preserved ejection fraction, hsCRP = high sensitivity C-reactive protein, LASV = left atrial end-systolic volume, LVEDV = left ventricular end-diastolic volume, LV mass = left ventricular mass, QRS = QRS duration, QoL = quality of life.