Research in context
Systematic review
We did a search of publicly available sources including PubMed, learned body guidelines (including those published by the American Heart Association, American College of Cardiology, and European Society of Cardiology), and the Cochrane Library using the search terms “diastolic heart failure”, “heart failure with preserved ejection fraction”, and “clinical trials” on Dec 22, 2015. We regarded multicentre, randomised controlled trials as clinically important. We identified a series of studies that focused on the role of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and mineralocorticoid receptor antagonists in patients with heart failure with preserved ejection fraction (HFPEF). We also identified a large number of ongoing studies, which is consistent with the substantial unmet clinical need represented by HFPEF.
Added value of this study
The REDUCe Elevated Left Atrial Pressure in Patients with Heart Failure (REDUCE LAP-HF) study was the first large-scale trial designed to systematically investigate the effect of placement of an interatrial shunt device (IASD) to decompress the left atrium in patients with HFPEF. Following placement of the shunt, patients had improved quality of life, did better on the 6-min walk test, and had a reduction in exercise pulmonary capillary wedge pressure.
Implications of all the available evidence
Previous evidence highlights the key role of raised left atrial pressure, especially during exertion, as a key pathophysiological feature in patients with HFPEF. This study reports the effect of a purpose-designed device (IASD) placed in the interatrial septum intended to reduce left atrial pressure. The demonstration of a beneficial effect of the IASD provides further support for the notion that increased left atrial pressure is the fundamental abnormality in patients with HFPEF and that a mechanical approach to reduce left atrial pressure is feasible.