Abstract
The benefit of repeat assessment of left ventricular (LV) systolic and diastolic function in heart failure (HF) remains uncertain. We assessed the prognostic value of repeat echocardiographic assessment of LV filling pressure (LVFP) and its interaction with cardiac index (CI) in ambulatory patients with chronic HF and reduced ejection fraction (HFrEF). We enrolled 357 patients (age 68 ± 11years; 22% female) with chronic HFrEF. Patients underwent a clinical and echocardiographic examination at baseline. LVFP as assessed by the 2016 Guidelines and Doppler-derived CI were estimated. After the second echocardiographic examination, patients were followed for a median time of 30months. The study endpoint included all-cause death and hospitalization for worsening HF. Patients who normalized LVFP or showed persistently normal LVFP at the follow-up examination had a significantly lower mortality rate than those with worsening or persistently raised LVFP (p < 0.0001). After stratification by CI, patients with elevated LVFP and CI < 2.0 l/min/m2 had a further worse outcome than those with elevated LVFP and CI ≥ 2.0 l/min/m2 (p < 0.0001). Multivariate survival analysis confirmed an independent prognostic impact of changes in LVFP, incremental to that of established clinical, laboratory and echocardiographic predictors. Repeat assessment of LVFP and CI significantly improved risk stratification of chronic HFrEF outpatients compared to baseline evaluation.
Highlights
Management of heart failure (HF), improvement of survival and prevention of hospitalizations largely depend on left ventricle (LV) structural and/or functional cardiac abnormalities, resulting in a reduced cardiac output (CO) and/or elevated intracardiac pressures at rest or during stress
Repeated evaluation based on a full diastolic function assessment of LV filling pressure (LVFP) and cardiac index (CI) significantly improved risk stratification of stable HF and reduced ejection fraction (HFrEF) outpatients compared to baseline evaluation
Several echocardiographic studies have shown that markers of elevated LVFP have been associated with an adverse prognosis[2], but their reversal toward normality with treatment favourably impact clinical outcome[3,4,5]
Summary
Management of heart failure (HF), improvement of survival and prevention of hospitalizations largely depend on LV structural and/or functional cardiac abnormalities, resulting in a reduced cardiac output (CO) and/or elevated intracardiac pressures at rest or during stress. Doppler echocardiography can provide reliable and reproducible LV filling pressure measures (LVFP) and forward flow, i.e., stroke volume and CO[1]. Several echocardiographic studies have shown that markers of elevated LVFP have been associated with an adverse prognosis[2], but their reversal toward normality with treatment favourably impact clinical outcome[3,4,5]. The EAEVI Euro-Filling Study has demonstrated that the 2016 ASE/EACVI algorithms are reliable and clinically useful for non-invasively estimating LVFP[6]. The impact of normalization and persistently elevated LVFP at follow-up on prognosis in patients with chronic HF remains unknown. Since diastolic dysfunction (DD) plays an important role in determining CO[7, 8] and because a decreased forward flow is negatively associated with prognosis[9, 10], the present study was designed to ascertain: 1) the prognosis of ambulatory HF patients with persistent or worsening DD as assessed by the 2016 recommendations, 2) whether the recovery of DD during follow-up was associated with improved patients' clinical outcome; 3) the prognostic impact of reduced forward flow in patients with persistent or worsening DD at follow-up
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