ESC Heart Fail. 2026 Jun 6:xvag151. doi: 10.1093/eschf/xvag151. Online ahead of print.
ABSTRACT
BACKGROUND: Transthoracic echocardiography (TTE) identifies a hypercontractile phenotype (HP) in chronic coronary syndromes (CCS), characterized by elevated resting left ventricular (LV) elastance (Force = systolic blood pressure/end-systolic volume).
OBJECTIVES: To evaluate the prognostic significance and functional correlates of HP.
METHODS: In a prospective multicenter study, 10,677 CCS patients underwent resting TTE to assess LV ejection fraction (EF), stroke volume (SV), and force by quantitative volumetric echocardiography. All patients were followed for the endpoint of all-cause mortality. In a subset of 5,834 patients, stress echocardiography (exercise or dobutamine) was performed for LV contractile reserve (LVCR) and heart rate reserve (HRR).
RESULTS: Patients were stratified into Force quintiles (Q1-Q5). HP patients exhibited lower SV at rest (Q5=34.8±12.3 vs. Q1-Q4=57.4 ± 19.1 mL; p<0.01) and higher EF at rest (Q5=64.8±6.9% vs. Q1-Q4= 58.1±8.7%, p<0.01). During a median follow-up of 24 months (interquartile range=12- 40 months), 509 deaths occurred. The exposure-adjusted death rate was lowest in Q3 (3.53-4.51 mmHg/mL; 1.03 per 100 person/years) and higher in Q1 (≤2.62 mmHg/mL, 2.88), Q2 (2.63-3.52 mmHg/mL, 1.86), Q4 (4.52-6.11 mmHg/mL,1.56), and Q5 (HP, >6.11 mmHg/mL; 1.88; p<0.0001 vs. Q1 and Q3). Multivariable analysis identified HP (Q5; HR 1.531 vs Q3, 95% CI 1.116-2.099; p=0.006) and EF (HR 0.963, 95% CI 0.953-0.972; p<0.0001) as independent predictors of death. During exercise or dobutamine stress, HP showed reduced LVCR (ΔEF: Q5 = 4.3± 9.4% vs. Q1-Q4 = 7.0±9.3%; p<0.001) and blunted HRR (Q5 = 1.77± 0.33 vs. Q1-Q4 = 1.85±0.39; p<0.01). All patients with force-based LV contractile reserve >4.1 (present in 185, 3.2% of the population) survived.
CONCLUSIONS: CCS patients with HP assessed by resting TTE demonstrate higher mortality and multilayered functional impairment, including reduced LV contractile and chronotropic reserves. HP improved the prediction of mortality by EF. A "stronger" heart is, in fact, functionally and prognostically weaker.
PMID:42249823 | DOI:10.1093/eschf/xvag151