Abstract 17712: Reverse Epidemiology in Heart Failure With Preserved Ejection Fraction: Is the Association Between Total Cholesterol and Worse Outcomes Driven by Right Heart Failure?
Background: “Reverse epidemiology” is a term used to describe the association between low total cholesterol (TC) and worse outcomes in systolic heart failure (HF). We hypothesized: (1) the reverse epidemiology phenomenon is present in HF with preserved EF (HFpEF); and (2) elevated right-sided pressures and right ventricular (RV) dysfunction may contribute to this association.
Methods: We prospectively studied the association between lipid levels, cardiac structure/function, and outcomes in 370 outpatients with confirmed, symptomatic HFpEF. Fasting lipid panel and echocardiography were performed on all patients, who were followed every 3 months for the composite outcome of HF hospitalization, cardiovascular hospitalization, and death. Cox proportional hazards analyses were used to determine the prognostic significance of lipid markers.
Results: The mean age was 65±13 y, 63% female. Comorbidities were common, 52% were on statins, and there was objective evidence of HFpEF (LVEF 61±7%; 81% had grade 2 or 3 diastolic dysfunction; left atrial volume index 34±14 ml/m2; PCWP 23±9 mmHg). Lipid levels were: TC 153±43 mg/dl, LDL 89±34 mg/dl, HDL 44±19 mg/dl, triglycerides 105±68. TC correlated with multiple right heart parameters (R=-0.21 [P=0.0006] for PA systolic pressure; R=-0.31 [P<0.0001] for RA pressure; R=0.22 [P<0.0001] for RV fractional area change (Figure); and R=0.14 [P=0.009] for TAPSE). Low TC and LDL levels (especially TC<110 and LDL<70 mg/dl) were both associated with worse outcomes (Figure) even in patients not taking statins (P<0.05 for all associations). The associations were partially attenuated by adjustment for right heart parameters.
Conclusions: In HFpEF, reduced levels of TC and LDL are: (1) associated with increased right-heart pressures and RV dysfunction; and (2) worse outcomes. THe "reverse epidemiology" phenomenon in HF may be partially explained by right heart failure causing hepatic congestion and decreased cholesterol synthesis.
- © 2013 by American Heart Association, Inc.