More than blood: echocardiographic evidence of HFpEF in polycythemia vera

Background The latest ESC guidelines emphasise the significance of identifying and managing comorbidities in heart failure with preserved ejection fraction (HFpEF), alongside SGLT2 inhibitors and congestion management. While the association between cancer and heart failure (HF) is well recognised, most cardio-oncology studies concentrate on systolic dysfunction and HFrEF, leaving HFpEF underexplored. Haematologic malignancies, particularly Philadelphia-negative myeloproliferative neoplasms, such as polycythemia vera (PV), are increasingly diagnosed due to advancements in genetics. These conditions present a high cardiovascular risk due to chronic inflammation, pulmonary hypertension, and JAK2 mutations, which elevate thrombotic risk. Purpose This study aims to assess the impact of Philadelphia-negative myeloproliferative neoplasms on HFpEF development and progression, with a focus on the presence of echocardiographic criteria for HFpEF in patients with PV, while emphasising the role of comorbidity management. Methods The study involved 60 patients from January to April 2025: 30 with PV and 30 controls without hematologic or solid neoplasms. All patients underwent transthoracic echocardiography to assess both systolic and diastolic functions. Key parameters evaluated included left ventricular mass index, left atrial volume index, E/e’ ratio and pulmonary artery systolic pressure. Ejection fraction was measured using the Simpson biplane method. HFpEF was diagnosed in accordance with ESC guidelines. The same examiner conducted all echocardiograms to ensure consistency. Results The two groups of patients included in the study did not differ significantly in terms of age (p=0.548), gender (p=0.446), or comorbidities commonly found in patients with HFpEF (p=0.456). Patients in the PV group met the diagnostic criteria for HFpEF significantly more frequently, with HF symptoms (p<0.001) and echocardiographic criteria for volume overload being more prevalent (E/e’ p<0.001; LVMI p=0.032; PASP p=0.046; LAVI p=0.018). Furthermore, the average values of these parameters were also significantly higher in the group of patients with PV (E/e’ 6.79 vs. 10.25 - p<0.001; LVMI 82.52 g/m2 vs. 100.25 g/m2 - p=0.04; PASP 10.92 mmHg vs. 23.14 mmHg - p<0.001; LAVI 33.74 ml/m2 vs. 37.15 ml/m2 - p=0.038). Interestingly, the values of these parameters did not differ significantly based on the treatment of PV, suggesting that the development of HFpEF in these patients may be due to factors related to the hematologic neoplastic process itself, rather than the administered treatment. Conclusion Patients with PV exhibited a higher prevalence of meeting the diagnostic criteria for HFpEF, accompanied by significantly elevated echocardiographic indicators of diastolic dysfunction and volume overload. These findings were independent of PV treatment, indicating a direct connection between PV and the development of HFpEF.