Iranian Heart Journal

Iranian Heart Journal

Heart Failure With Preserved Left Ventricular Ejection Fraction in Chronic Kidney Disease

Document Type : Original Article

Authors
Tarief Sallam 1
Salah Eldin Hamdy El-Demerdash 1
Wael Elkilany 1
Mohamed Saeed Hassan 2
Islam Bastawy 1
1 Ain Shams University, Faculty of Medicine, Cardiology Department, Egypt.
2 Ain Shams University, Faculty of Medicine, Internal Medicine, And Nephrology Department. Cairo, Egypt.
Abstract
Background: Chronic kidney disease (CKD) can lead to left ventricular (LV) systolic and diastolic dysfunction. Cardiovascular disease is a primary cause of mortality in this patient population. This study aimed to use the H2FPEF score to identify patients with CKD who have a high probability of heart failure with preserved ejection fraction (HFpEF).
 
Methods: We included 100 patients with CKD stages III through V and dyspnea suggestive of heart failure with an ejection fraction greater than 50%. All patients were evaluated for demographic data, CKD, and cardiovascular disease risk factors. Comprehensive echocardiography was performed, and LV global longitudinal strain (GLS) was assessed in patients in sinus rhythm. The H2FPEF score was calculated to predict the probability of HFpEF, with scores interpreted as follows: less than 2, unlikely; 2 to 5, intermediate; and 6 or greater, high.
 
Results: The probability of HFpEF was high in 29% of patients, intermediate in 66%, and low in 5%. Patients with a high probability of HFpEF had significantly worse LV GLS (–14.08 ± 1.084 vs –15.07 ± 1.24%; P = 0.01) and lower hemoglobin levels (9.71 ± 0.66 vs 10.7 ± 1.33 g/dL; P < 0.001). The H2FPEF score correlated positively with LV GLS (r = 0.406; P < 0.001). A hemoglobin level of 9.7 g/dL or less predicted a high H2FPEF score with an overall accuracy of 72.6%.
 
Conclusions: Using the simple, noninvasive H2FPEF score, we found that nearly one-third of patients with CKD had a high probability of HFpEF. LV systolic function declined as the H2FPEF score increased. Hemoglobin level was an independent predictor of a high probability of HFpEF. (Iranian Heart Journal 2025; 26(4): 34-45)
Keywords
Cardio-renal syndrome
Heart failure
Left ventricular diastolic dysfunction
Renal anemia
Systolic dysfunction
  1. Bhandari SK, Zhou H, Shaw SF, Shi J, Tilluckdharry NS, Rhee CM, et al. Causes of Death in End-Stage Kidney Disease: Comparison between the United States Renal Data System and a Large Integrated Health Care System. Am J Nephrol. 2022; 53(1):32-40. doi: 10.1159/000520466.
  2. Thompson S, James M, Wiebe N, Hemmelgarn B, Manns B, Klarenbach S, et al. Cause of Death in Patients with Reduced Kidney Function. J Am Soc Nephrol. 2015 Oct; 26(10):2504-11. doi: 10.1681/ASN.2014070714. Epub 2015 Mar 2.
  3. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004 Sep 23; 351(13):1296-305. doi:10.1056/NEJMoa041031. Erratum in: N Engl J Med. 2008; 18(4):4.
  4. Tomey MI, Winston JA. Cardiovascular pathophysiology in chronic kidney disease: opportunities to transition from disease to health. Ann Glob Health. 2014 Jan-Feb; 80(1):69-76. doi:10.1016/j.aogh.2013.12.007.
  5. Rangaswami J, Bhalla V, Blair JEA, Chang TI, Costa S, Lentine KL, et al. Cardiorenal Syndrome: Classification, Pathophysiology, Diagnosis, and Treatment Strategies: A Scientific Statement From the American Heart Association. Circulation. 2019 Apr 16; 139(16):e840-e878. doi:10.1161/CIR.0000000000000664.
  6. van de Wouw J, Broekhuizen M, Sorop O, Joles JA, Verhaar MC, Duncker DJ, et al. Chronic Kidney Disease as a Risk Factor for Heart Failure With Preserved Ejection Fraction: A Focus on Microcirculatory Factors and Therapeutic Targets. Front Physiol. 2019 Sep 4; 10:1108. doi:10.3389/fphys.2019.01108.
  7. Paulus WJ, Tschöpe C, Sanderson JE, Rusconi C, Flachskampf FA, Rademakers FE, et al. How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology. Eur Heart J. 2007 Oct; 28(20):2539-50. doi:10.1093/eurheartj/ehm037.
  8. Reddy YNV, Carter RE, Obokata M, Redfield MM, Borlaug BA. A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure With Preserved Ejection Fraction. Circulation. 2018 Aug 28; 138(9):861-870. doi: 10.1161/CIRCULATIONAHA.118.034646.
  9. Pieske B, Tschöpe C, de Boer RA, Fraser AG, Anker SD, Donal E, et al. How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail. 2020 Mar; 22(3):391-412. doi: 10.1002/ejhf.1741.
  10. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009 May 5; 150(9):604-12. doi: 10.7326/0003-4819-150-9-200905050-00006. Erratum in: Ann Intern Med. 2011 Sep 20; 155(6):408.
  11. Stevens PE, Levin A; Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group Members. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med. 2013 Jun 4; 158(11):825-30. doi: 10.7326/0003-4819-158-11-201306040-00007.
  12. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015 Jan; 28(1):1-39.e14. doi: 10.1016/j.echo.2014.10.003.
  13. Nagueh SF, Smiseth OA, Appleton CP, Byrd BF 3rd, Dokainish H, Edvardsen T, et al. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2016 Dec; 17(12):1321-1360. doi: 10.1093/ehjci/jew082.
  14. Yang H, Wright L, Negishi T, Negishi K, Liu J, Marwick TH. Research to Practice: Assessment of Left Ventricular Global Longitudinal Strain for Surveillance of Cancer Chemotherapeutic-Related Cardiac Dysfunction. JACC Cardiovasc Imaging. 2018 Aug; 11(8):1196-1201. doi: 10.1016/j.jcmg.2018.07.005.
  15. Tsutamoto T, Sakai H, Yamamoto T, Nakagawa Y. Renal Clearance of N-Terminal pro-Brain Natriuretic Peptide Is Markedly Decreased in Chronic Kidney Disease. Circ Rep. 2019 Aug 1; 1(8):326-332. doi: 10.1253/circrep.CR-19-0063.
  16. Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024 Aug 30:ehae176. doi: 10.1093/eurheartj/ehae176.
  17. Ananthram MG, Gottlieb SS. Renal Dysfunction and Heart Failure with Preserved Ejection Fraction. Heart Fail Clin. 2021 Jul; 17(3):357-367. doi: 10.1016/j.hfc.2021.03.005.
  18. Patel RN, Sharma A, Prasad A, Bansal S. Heart Failure With Preserved Ejection Fraction With CKD: A Narrative Review of a Multispecialty Disorder. Kidney Med. 2023 Sep 27; 5(12):100705. doi: 10.1016/j.xkme.2023.100705.
  19. Mikhail A, Brown C, Williams JA, Mathrani V, Shrivastava R, Evans J, et al. Renal association clinical practice guideline on Anaemia of Chronic Kidney Disease. BMC Nephrol. 2017 Nov 30; 18(1):345. doi: 10.1186/s12882-017-0688-1.
  20. Loncar G, Obradovic D, Thiele H, von Haehling S, Lainscak M. Iron deficiency in heart failure. ESC Heart Fail. 2021 Aug; 8(4):2368-2379. doi: 10.1002/ehf2.13265.
  21. Pfeffer MA, Shah AM, Borlaug BA. Heart Failure With Preserved Ejection Fraction In Perspective. Circ Res. 2019 May 24; 124(11):1598-1617. doi:10.1161/CIRCRESAHA.119.313572.
  22. Sîrbu O, Floria M, Dascalita P, Stoica A, Adascalitei P, Sorodoc V, et al. Anemia in heart failure - from guidelines to controversies and challenges. Anatol J Cardiol. 2018 Jul; 20(1):52-59. doi:10.14744/AnatolJCardiol.2018.08634.
  23. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-3726. doi: 10.1093/eurheartj/ehab368. Erratum in: Eur Heart J. 2021 Dec 21; 42(48):4901. doi: 10.1093/eurheartj/ehab670.
  24. Majmundar M, Doshi R, Zala H, Shah P, Adalja D, Shariff M, et al. Prognostic role of anemia in heart failure with preserved ejection fraction: A systematic review and meta-analysis. Indian Heart J. 2021 Jul-Aug; 73(4):521-523. doi:10.1016/j.ihj.2021.06.011.
  25. Krishnasamy R, Isbel NM, Hawley CM, Pascoe EM, Burrage M, Leano R, et al. Left Ventricular Global Longitudinal Strain (GLS) Is a Superior Predictor of All-Cause and Cardiovascular Mortality When Compared to Ejection Fraction in Advanced Chronic Kidney Disease. PLoS One. 2015 May 15; 10(5):e0127044. doi:10.1371/journal.pone.0127044.
  26. Ikonomidis I, Andreou I, Parissis J, Iliodromitis E. Prognostic significance of global longitudinal strain in chronic kidney disease: the evidence is building. Eur J Heart Fail. 2018 Mar; 20(3):569-571. doi: 10.1002/ejhf.1114. Epub 2017 Dec 18.
  27. Panoulas VF, Sulemane S, Konstantinou K, Bratsas A, Elliott SJ, Dawson D, et al. Early detection of subclinical left ventricular myocardial dysfunction in patients with chronic kidney disease. Eur Heart J Cardiovasc Imaging. 2015 May; 16(5):539-48. doi: 10.1093/ehjci/jeu229.
  28. Keren G, Sonnenblick EH, LeJemtel TH. Mitral anulus motion. Relation to pulmonary venous and transmitral flows in normal subjects and in patients with dilated cardiomyopathy. Circulation. 1988 Sep; 78(3):621-9. doi: 10.1161/01.cir.78.3.621.
  29. DeVore AD, McNulty S, Alenezi F, Ersboll M, Vader JM, Oh JK, et al. Impaired left ventricular global longitudinal strain in patients with heart failure with preserved ejection fraction: insights from the RELAX trial. Eur J Heart Fail. 2017 Jul; 19(7):893-900. doi: 10.1002/ejhf.754.
  30. Mentz RJ, Brunton SA, Rangaswami J. Sodium-glucose cotransporter-2 inhibition for heart failure with preserved ejection fraction and chronic kidney disease with or without type 2 diabetes mellitus: a narrative review. Cardiovasc Diabetol. 2023 Nov 16; 22(1):316. doi: 10.1186/s12933-023-02023-y.
Iranian Heart Journal
Volume 26, Issue 4
Autumn 2025
Pages 34-45