Can coronary artery disease cause heart failure with preserved ejection fraction?

Yes, coronary artery disease (CAD) can absolutely cause HFpEF and is one of its most important comorbidities requiring aggressive management.

CAD is explicitly recognized as a key comorbidity in HFpEF that requires risk stratification and management 1. The 2023 ACC Expert Consensus specifically lists CAD among the critical comorbidities to address in HFpEF management, alongside hypertension, diabetes, obesity, atrial fibrillation, and chronic kidney disease 1.

The Relationship Between CAD and HFpEF

Prevalence and Clinical Significance

The connection between CAD and HFpEF is substantial:

• CAD is present in 51-68% of HFpEF patients who undergo coronary angiography 2, 3
• Approximately half of these patients have no prior history of CAD, making it an often unrecognized contributor 3
• Among HFpEF patients without obstructive epicardial CAD, 81% still have coronary microvascular dysfunction (CMD) 3
• Overall, 91% of hospitalized HFpEF patients have evidence of epicardial CAD, CMD, or both 3

Mechanisms of CAD-Related HFpEF

CAD contributes to HFpEF through multiple pathways:

1. Epicardial coronary obstruction causing regional ischemia and myocardial fibrosis
2. Coronary microvascular dysfunction (present in 66-85% of HFpEF patients) leading to impaired myocardial perfusion 3, 4
3. Endothelial dysfunction affecting both epicardial and microvascular beds 3
4. Progressive myocardial fibrosis - 42% of HFpEF patients show diffuse myocardial fibrosis on cardiac MRI 3

Prognostic Impact

CAD significantly worsens outcomes in HFpEF:

• HFpEF patients with CAD have 71% increased mortality compared to those without CAD (HR 1.71,95% CI 1.03-2.98) 2
• CAD is associated with greater deterioration in ejection fraction over time 2
• Patients with both HFpEF and CAD are at particularly high risk of sudden cardiac death (adjusted HR 2.22) 5

Clinical Approach

Diagnostic Considerations

When evaluating HFpEF, CAD should be considered as:

1. A contributing comorbidity rather than a "mimic" - the 2023 ACC guidelines distinguish HFpEF mimics (like infiltrative cardiomyopathies, valvular disease, pericardial disease) from comorbidities like CAD 1
2. Often clinically silent - angina symptoms and heart failure symptoms are similar in HFpEF patients with and without CAD 2
3. Requiring comprehensive assessment including evaluation for both obstructive CAD and microvascular dysfunction 3

Management Strategy

Complete revascularization appears beneficial in HFpEF with obstructive CAD:

• Complete revascularization is associated with 44% reduction in mortality (HR 0.56,95% CI 0.33-0.93) compared to incomplete/no revascularization 2
• Complete revascularization reduces unplanned repeat revascularization (4.7% vs 10.9%) and cardiovascular death (0.1% vs 0.9%) 6
• Revascularization may preserve cardiac function and prevent deterioration in ejection fraction 2

Key Clinical Pitfalls

1. Don't assume absence of angina excludes significant CAD - symptoms overlap considerably between HFpEF and ischemia 2
2. Don't overlook microvascular dysfunction - even without obstructive CAD, CMD is present in the vast majority and contributes to both systolic and diastolic dysfunction 3, 4
3. Don't undertreate revascularization - incomplete revascularization is associated with worse outcomes; aim for complete revascularization when feasible 2, 6

Bottom Line

CAD is not just a cause of HFpEF but one of its most prevalent and prognostically important comorbidities. The 2023 ACC guidelines appropriately position CAD management as a cornerstone of HFpEF treatment 1. Given the paucity of effective HFpEF therapies, identifying and completely revascularizing CAD represents one of the few interventions with demonstrated mortality benefit in this population 2, 6.