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Canadian Journal of Cardiology

Cardiovascular Autonomic Disturbances in Heart Failure With Preserved Ejection Fraction

Published:December 10, 2020DOI:https://doi.org/10.1016/j.cjca.2020.12.006

      Abstract

      In heart failure with reduced ejection fraction (HFrEF), diminished tonic and reflex vagal heart rate modulation and exaggerated sympathetic outflow and neural norepinephrine release are evident from disease inception. Each of these disturbances of autonomic regulation has been independently associated with shortened survival, and β-adrenoceptor antagonism and therapeutic autonomic modulation by other means have been demonstrated, in clinical trials, to lessen symptoms and prolong survival. In contrast, data concerning the autonomic status of patients with heart failure with preserved ejection fraction (HFpEF) are comparatively sparse. Little is known concerning the prognostic consequences of autonomic dysregulation in such individuals, and therapies applied with success in HFrEF have in most trials failed to improve symptoms or survival of those with HFpEF. A recent HFpEF Expert Scientific Panel report emphasised that without a deeper understanding of the pathophysiology of HFpEF, establishing effective treatment will be challenging. One aspect of such pathology may be cardiovascular autonomic disequilibrium, often worsened by acute exercise or routine daily activity. This review aims to summarise existing knowledge concerning parasympathetic and sympathetic function of patients with HFpEF, consider potential mechanisms and specific consequences of autonomic disturbances that have been identified, and propose hypotheses for future investigation.

      Résumé

      En cas d’insuffisance cardiaque avec fraction d’éjection réduite (ICFER), une diminution de la modulation vagale réflexe et tonique de la fréquence cardiaque et une augmentation excessive de l’influx sympathique et de la libération de noradrénaline neurale sont manifestes dès l’apparition de la maladie. Toutes ces perturbations de la régulation autonome ont été associées de manière indépendante à une diminution de la survie; au cours des essais cliniques, les antagonistes des récepteurs adrénergiques β (bêtabloquants) et la modulation autonome thérapeutique par d’autres moyens se sont révélés efficaces pour ce qui est d’atténuer les symptômes et de prolonger la survie. On dispose en revanche de peu de données sur l’état de la fonction autonome des patients présentant une insuffisance cardiaque avec fraction d’éjection préservée (ICFEP). Les conséquences d’une dysrégulation de la fonction autonome (dysautonomie) sur le pronostic de tels patients ne sont pas bien connues, et dans la plupart des essais cliniques, les traitements efficaces en cas d’ICFER n’ont pas atténué les symptômes ni prolongé la survie chez les patients atteints d’ICFEP. Dans un rapport publié récemment, un comité scientifique de spécialistes soulignait que sans une meilleure compréhension de la physiopathologie de l’ICFEP, il sera difficile de trouver un traitement efficace. Ce trouble serait notamment caractérisé par un déséquilibre de la fonction cardiovasculaire autonome, souvent accentué par un effort aigu ou l’exécution des activités de la vie quotidienne. Le compte rendu qui suit résume les connaissances actuelles concernant les fonctions parasympathique et sympathique chez les patients atteints d’ICFEP, examine les mécanismes possibles et les conséquences particulières des perturbations de la fonction autonome qui ont été cernés et formule des hypothèses pour de futures études.
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