Coronary Microvascular Rarefaction and Myocardial Fibrosis in Heart Failure with Preserved Ejection Fraction
Background—Characterization of myocardial structural changes in heart failure (HF) with preserved ejection fraction (HFpEF) has been hindered by limited availability of human cardiac tissue. Cardiac hypertrophy, coronary artery disease (CAD), coronary microvascular rarefaction and myocardial fibrosis may contribute to HFpEF pathophysiology.
Methods and Results—We identified HFpEF patients (n=124) and age-appropriate control patients (non-cardiac death, no HF diagnosis; n=104) who underwent autopsy. Heart weight and CAD severity were obtained from the autopsy reports. Using whole field digital microscopy and automated analysis algorithms in full thickness left ventricular (LV) sections, microvascular density (MVD), myocardial fibrosis and their relationship were quantified. Subjects with HFpEF had heavier hearts (median 538 g; 169% of age/sex/body size expected heart weight vs. 335 g; 112% in controls), more severe CAD (65% with ≥ one vessel with >50% diameter stenosis in HFpEF vs 13% in controls), more LV fibrosis (median % area fibrosis, 9.6 vs. 7.1) and lower MVD (median 961 vs. 1316 vessels per mm2) than control (p <0.0001 for all). Myocardial fibrosis increased with decreasing MVD in controls (r = - 0.28, p=0.004) and HFpEF (r = - 0.26, p=0.004). Adjusting for MVD attenuated the group differences in fibrosis. Heart weight, fibrosis and MVD were similar in HFpEF patients with vs without CAD.
Conclusions—In this study, patients with HFpEF had more cardiac hypertrophy, epicardial CAD, coronary microvascular rarefaction and myocardial fibrosis than controls. Each of these findings may contribute to the LV diastolic dysfunction and cardiac reserve function impairment characteristic of HFpEF.
- Received February 21, 2014.
- Revision received October 26, 2014.
- Accepted November 3, 2014.