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Epidemiology, pathophysiology and clinical outcomes for heart failure patients with a mid-range ejection fraction.

ABSTRACT: AIMS:Heart failure (HF) patients with a mid-range ejection fraction (HFmrEF) are not well characterized. Accordingly, we examined the epidemiology, pathophysiology and clinical outcomes of HF patients with a left ventricular ejection fraction (LVEF) of 40-50%. METHODS AND RESULTS:We identified 168 patients with an LVEF between 40-50% at enrollment into a HF registry, and determined whether LVEF was improved, worsened, or the same compared to a prior LVEF. Three subgroups of HFmrEF patients were identified: HFmrEF improved (prior LVEF <40%); HFmrEF deteriorated (prior LVEF >50%); HFmrEF unchanged (prior LVEF 40-50%). The majority of patients (73%) were HFmrEF improved, 17% were HFmrEF deteriorated, and 10% were HFmrEF unchanged. The demographics of the HFmrEF cohort were heterogeneous, with more coronary artery disease in the HFmrEF improved group and more hypertension and diastolic dysfunction in the HFmrEF deteriorated group. HFmrEF improved patients had significantly (P<0.001) better clinical outcomes relative to matched patients with HF and reduced ejection fraction, and significantly (P<0.01) improved clinical outcomes relative to HFmrEF deteriorated patients, whereas clinical outcomes of the HFmrEF deteriorated subgroup of patients were not significantly different from matched HF patients with preserved ejection fraction. CONCLUSIONS:Patients with a mid-range LVEF are heterogeneous. Obtaining historical information with regard to prior LVEF allows one to identify a distinct pathophysiological substrate and clinical course for HFmrEF patients. Viewed together, these results suggest that in the modern era of HF therapeutics, the use of LVEF to categorize the pathophysiology of HF may be misleading, and argue for establishing a new taxonomy for classifying HF patients.

SUBMITTER: Rastogi A

PROVIDER: S-EPMC5730502 | biostudies-literature | 2017 Dec

REPOSITORIES: biostudies-literature

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Epidemiology, pathophysiology and clinical outcomes for heart failure patients with a mid-range ejection fraction.

Rastogi Ashish A Novak Eric E Platts Anne E AE Mann Douglas L DL

European journal of heart failure 20170614 12

<h4>Aims</h4>Heart failure (HF) patients with a mid-range ejection fraction (HFmrEF) are not well characterized. Accordingly, we examined the epidemiology, pathophysiology and clinical outcomes of HF patients with a left ventricular ejection fraction (LVEF) of 40-50%.<h4>Methods and results</h4>We identified 168 patients with an LVEF between 40-50% at enrollment into a HF registry, and determined whether LVEF was improved, worsened, or the same compared to a prior LVEF. Three subgroups of HFmrEF ...[more]

PMID: 29024350

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Project description:OBJECTIVES:The aim of this study was to analyse baseline characteristics and outcome of patients with heart failure and mid-range left ventricular ejection fraction (HFmrEF, left ventricular ejection fraction (LVEF) 40%-49%) and the effect of 1-year change in LVEF in this group. SETTING:Multicentre prospective observational study of ambulatory patients with HF followed up at four university hospitals with dedicated HF units. PARTICIPANTS:Fourteen per cent (n=504) of the 3580 patients included had HFmrEF. INTERVENTIONS:Baseline characteristics, 1-year LVEF and outcomes were collected. All-cause death, HF hospitalisation and the composite end-point were the primary outcomes. RESULTS:Median follow-up was 3.66 (1.69-6.04) years. All-cause death, HF hospitalisation and the composite end-point were 47%, 35% and 59%, respectively. Outcomes were worse in HF with preserved ejection fraction (HFpEF) (LVEF>50%), without differences between HF with reduced ejection fraction (HFrEF) (LVEF<40%) and HFmrEF (all-cause mortality 52.6% vs 45.8% and 43.8%, respectively, P=0.001). After multivariable Cox regression analyses, no differences in all-cause death and the composite end-point were seen between the three groups. HF hospitalisation and cardiovascular death were not statistically different between patients with HFmrEF and HFrEF. At 1-year follow-up, 62% of patients with HFmrEF had LVEF measured: 24% had LVEF<40%, 43% maintained LVEF 40%-49%?and 33% had LVEF>50%. While change in LVEF as continuous variable was not associated with better outcomes, those patients who evolved from HFmrEF to HFpEF did have a better outcome. Those who remained in the HFmrEF and HFrEF groups had higher all-cause mortality after adjustment for age, sex and baseline LVEF (HR 1.96 (95% CI 1.08 to 3.54, P=0.027)?and HR 2.01 (95% CI 1.04 to 3.86, P=0.037), respectively). CONCLUSIONS:Patients with HFmrEF have a clinical profile in-between HFpEF and HFrEF, without differences in all-cause mortality and the composite end-point between the three groups. At 1?year, patients with HFmrEF exhibited the greatest variability in LVEF and this change was associated with survival.

Project description:Background: Although central apneas (CA) and obstructive apneas (OA) are highly prevalent in heart failure (HF), a comparison of apnea prevalence, predictors and clinical correlates in the whole HF spectrum, including HF with reduced ejection fraction (HFrEF), mid-range EF (HFmrEF) and preserved EF (HFpEF) has never been carried out so far. Materials and methods: 700 HF patients were prospectively enrolled and then divided according to left ventricular EF (408 HFrEF, 117 HFmrEF, 175 HFpEF). All patients underwent a thorough evaluation including: 2D echocardiography; 24-h Holter-ECG monitoring; cardiopulmonary exercise testing; neuro-hormonal assessment and 24-h cardiorespiratory monitoring. Results: In the whole population, prevalence of normal breathing (NB), CA and OA at daytime was 40, 51, and 9%, respectively, while at nighttime 15, 55, and 30%, respectively. When stratified according to left ventricular EF, CA prevalence decreased (daytime: 57 vs. 43 vs. 42%, p = 0.001; nighttime: 66 vs. 48 vs. 34%, p < 0.0001) from HFrEF to HFmrEF and HFpEF, while OA prevalence increased (daytime: 5 vs. 8 vs. 18%, p < 0.0001; nighttime 20 vs. 29 vs. 53%, p < 0.0001). In HFrEF, male gender and body mass index (BMI) were independent predictors of both CA and OA at nighttime, while age, New York Heart Association functional class and diastolic dysfunction of daytime CA. In HFmrEF and HFpEF male gender and systolic pulmonary artery pressure were independent predictors of CA at daytime, while hypertension predicted nighttime OA in HFpEF patients; no predictor of nighttime CA was identified. When compared to patients with NB, those with CA had higher neuro-hormonal activation in all HF subgroups. Moreover, in the HFrEF subgroup, patients with CA were older, more comorbid and with greater hemodynamic impairment while, in the HFmrEF and HFpEF subgroups, they had higher left atrial volumes and more severe diastolic dysfunction, respectively. When compared to patients with NB, those with OA were older and more comorbid independently from background EF. Conclusions: Across the whole spectrum of HF, CA prevalence increases and OA decreases as left ventricular systolic dysfunction progresses. Different predictors and specific clinical characteristics might help to identify patients at risk of developing CA or OA in different HF phenotypes.

Project description:AimsGuidelines for management of patients with heart failure with mid-range ejection fraction [HFmrEF; left ventricular EF (LVEF) 41-49%] do not exist. Disagreement exists whether HFmrEF should be considered a distinct group. The aim of this study is to examine characteristics of patients with HFmrEF with HF with reduced EF (HFrEF; LVEF ≤ 40%) or preserved EF (HFpEF; LVEF ≥ 50%).Methods and resultsWe examined data collected in the American College of Cardiology's National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) Registry® for first HF patient visits between 1 May 2008 and 30 June 2016. Analysis was performed using ANOVA F-tests (or Kruskal-Wallis tests for non-normally distributed variables) for continuous parameters and χ2 tests for nominal covariates at the first diagnosed HF visit. Given the NCDR PINNACLE Registry® is a US-based registry, we opted to define HFmrEF as per the US guidelines, which define HFmrEF as LVEF 41-49% in contrast to European guidelines, which define HFmrEF as LVEF 40-49%. Among 1 103 386 patients with available data, 36.1% (N = 398 228) had HFrEF, 7.5% (N = 82 292) had HFmrEF, and 56.5% (N = 622 866) had HFpEF. Compared with patients with HFrEF or HFpEF, patients with HFmrEF had more prevalent coronary and peripheral artery disease and more history of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery (all P < 0.001). Patients with HFmrEF were also more likely to have atrial fibrillation/flutter, diabetes, and chronic kidney disease and to have a history of tobacco use (both P < 0.001). Among those with EF assessment prior to this analysis, only 4.8% (N = 1032) previously had HFrEF that improved to HFmrEF; 32.9% (N = 7072) had HFpEF previously and progressed to HFmrEF. Those patients who transitioned from HFpEF to HFmrEF had considerably more complex profiles and were less aggressively managed compared with those who remained with HFmrEF (all P < 0.001).ConclusionsIn this large descriptive analysis, patients with HFmrEF had an atherothrombotic phenotype distinct from other forms of HF. Interventions aimed at treating coronary ischaemia and addressing prevalent risk factors may play a particularly important role in the management of patients with HFmrEF.

Dataset Information

Epidemiology, pathophysiology and clinical outcomes for heart failure patients with a mid-range ejection fraction.

Publications

Epidemiology, pathophysiology and clinical outcomes for heart failure patients with a mid-range ejection fraction.

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