Optimizing endothelial function: a pathway to improved cardiac performance in heart failure

Endothelial dysfunction is a key factor in the pathophysiology of heart failure (HF), and improving endothelial function may enhance cardiac performance. This study aims to investigate the correlation between optimized endothelial function and improvement in cardiac function assessed by echocardiographic and hemodynamic parameters.

We conducted a prospective monocentric study at the cardiology department of our university hospital involving 120 patients over 18 years old, presenting with chronic heart failure and reduced left ventricular ejection fraction (LVEF). All patients received optimized treatment defined by optimal or maximally tolerated doses of the four pillars of HFrEF treatment including beta-blockers, angiotensin-converting enzyme inhibitors or Sacubitril-Valsartan, aldosterone antagonists, and SGLT2 inhibitors. Endothelial function was assessed using flow-mediated dilation (FMD) at baseline and after 3 months of treatment. Echocardiographic parameters, including LVEF, subaortic velocity-time integral, global longitudinal strain, and hemodynamic parameters including cardiac output and systemic vascular resistance (SVR), were measured using impedance cardiography (ICG).

After 3 months of optimized treatment, we observed a significant improvement in endothelial function (assessed by endothelial quality index (EQI) which improved from 1.27 ± 0.62 at inclusion to 1.44 ± 0.67 during the control phase (after optimizing treatment) , with a p-value < 0.001), was correlated with an increase in left ventricular ejection fraction (correlation coefficient = 0.339, p < 0.001). Additionally, a moderate positive correlation was noted with changes in subaortic velocity-time integral (correlation coefficient = 0.261, p = 0.01), suggesting better flow dynamics. The change in longitudinal strain showed a weak negative correlation (correlation coefficient = -0.046, p = 0.042). A moderate positive correlation was observed with the systemic vascular resistance index (R = 0.269, p = 0.030), suggesting that better endothelial function is associated with improved vascular compliance. Additionally, a weak but significant negative correlation was found with cardiac output (R = -0.226, p = 0.007), reflecting subtle interactions between vascular and cardiac performance. These findings suggest that enhanced endothelial function contributes to better cardiac performance and hemodynamic status in heart failure patients.

The optimization of endothelial function is significantly correlated with improvements in LVEF and cardiac output, as well as reductions in systemic vascular resistance. These results underscore the importance of targeting endothelial health in the management of heart failure, highlighting its potential as a therapeutic strategy to improve patient outcomes.