Regional differences and coronary microvascular dysfunction in heart failure with preserved ejection fraction

Mikael Erhardsson*, Ulrika Ljung Faxén, Ashwin Venkateshvaran, Sara Svedlund, Antti Saraste, Maria Lagerström Fermer, Li Ming Gan, Sanjiv J. Shah, Jasper Tromp, Carolyn SP Lam, Lars H. Lund, Camilla Hage

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Aims: In heart failure with preserved ejection fraction (HFpEF), regional heterogeneity of clinical phenotypes is increasingly recognized, with coronary microvascular dysfunction (CMD) potentially being a common shared feature. We sought to determine the regional differences in clinical characteristics and prevalence of CMD in HFpEF. Methods and results: We analysed clinical characteristics and CMD in 202 patients with stable HFpEF (left ventricular ejection fraction ≥40%) in Finland, Singapore, Sweden, and United States in the multicentre PROMIS-HFpEF study. Patients with unrevascularized macrovascular coronary artery disease were excluded. CMD was assessed using Doppler echocardiography and defined as coronary flow reserve (adenosine-induced vs. resting flow) < 2.5. Patients from Singapore had the lowest body mass index yet highest prevalence of hypertension, dyslipidaemia, and diabetes; patients from Finland and Sweden were oldest, with the most atrial fibrillation, chronic kidney disease, and high smoking rates; and those from United States were youngest and most obese. The prevalence of CMD was 88% in Finland, 80% in Singapore, 77% in Sweden, and 59% in the United States; however, non-significant after adjustment for age, sex, N-terminal pro-brain natriuretic peptide, smoking, left atrial reservoir strain, and atrial fibrillation. Associations between CMD and clinical characteristics did not differ based on region (interaction analysis). Conclusions: Despite regional differences in clinical characteristics, CMD was present in the majority of patients with HFpEF across different regions of the world with the lowest prevalence in the United States. This difference was explained by differences in patient characteristics. CMD could be a common therapeutic target across regions.

Original languageEnglish (US)
Pages (from-to)3729-3734
Number of pages6
JournalESC Heart Failure
Issue number6
StatePublished - Dec 2023


  • Coronary flow reserve
  • Coronary microvascular dysfunction
  • HFpEF
  • Region

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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