Heart Failure With Mid-range Ejection Fraction Research Articles

Evaluation of Perfusion and Function in Cardiac Radionuclide Imaging in Cases of Heart Failure with Mid-Range Ejection Fraction

Objective: Heart failure with mid-range ejection fraction (HFmrEF) poses a significant clinical challenge due to its diverse etiology and variable prognosis. Patients with HFmrEF exhibit an intermediate level of left ventricular dysfunction, making their management and prognosis less well-defined compared to those with heart failure with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF). Coronary artery disease (CAD) is a common underlying cause of HFmrEF and can further exacerbate myocardial dysfunction under stress conditions. In this study, we aimed to evaluate the change in left ventricular ejection fraction with stress in the presence of coronary artery disease in cases of heart failure with mid-range ejection fraction. Material and Methods: In this retrospective study, we included 507 patients diagnosed with coronary artery disease and an left ventricular ejection fraction (LVEF) of 41-49% measured by echocardiography. All patients underwent a treadmill exercise test using the Bruce protocol, with progressively increasing speed and incline. Myocardial perfusion was assessed using stress gated myocardial perfusion scintigraphy (MPS), and fixed and reversible defects were identified in cases of coronary artery disease. Cardiac scintigraphic images were acquired from the right anterior oblique to the left posterior oblique. We calculated post-stress LVEF and the percentage decrease in LVEF to evaluate cardiac function. Results: Resting LVEF was measured as 46 (43-50), while post-stress LVEF was 35 (25-47) in all patients. Myocardial perfusion was evaluated using stress gated MPS in all patients, with 200 (39.5%) patients showing both fixed and reversible perfusion defects. The rate of decrease in LVEF due to stress was significantly higher in patients with reversible perfusion defects (15.90 (6-30.43) vs. 28.26 (24-43.18), p: 0.0005). Post-stress LVEF was lower in patients with reversible perfusion defects (40 (31-47) vs. 33 (25-38), p: 0.0005). Conclusion: In cases of impaired left ventricular perfusion, quantitative calculations of LVEF may vary, and their reliability may decrease as the ejection fraction decreases under stress conditions. Clinicians should consider this variability in the follow-up of patients with heart failure and mid-range ejection fraction.

Association of pulse pressure and aortic root diameter in elderly Chinese patients with chronic heart failure.

High pulse pressure (PP) and aortic root diameter (AoD) are hallmarks of arterial stiffness or vascular aging and they are considered as risk factors for age-related cardiovascular disease, including heart failure (HF). However, the relationship between PP and AoD in patients with heart failure (HF) is uncertain. This study aimed to evaluate the relationship between PP and AoD in the middle-aged and the elderly with HF. A total of 1,027 Chinese middle-aged and elderly patients with HF, including HF with reduced ejection fraction (HFrEF), HF with mid-range EF (HFmrEF), and HF with preserved EF (HFpEF) were included in this study. Pearson correlation analysis was used to evaluate the relationship between PP and AoD in the three types of HF. Multiple linear regression analysis was performed to assess the factors that affected AoD. Multivariate logistic regression was performed to determine the association between the PP level quartiles and AoD. The results were validated in an independent dataset included a total of 378 consecutive patients with HFrEF hospitalized at the Pingtan Branch of Fujian Medical University Union Hospital (Fujian, China). There was a positive correlation between PP and AoD in the middle-aged and the elderly with HFrEF. Multiple linear regression analysis revealed that PP, age, and body mass index (BMI) were independently correlated with AoD in HFrEF patients. In multivariate logistic regression analysis, an increased risk of aortic root dilation was observed in the highest quartile of the PP level compared with the lowest quartile. Age significantly interacted with PP (p = 0.047). A significant association between PP levels and AoD was only observed in patients ≥ 65 years old, but not in patients < 65 years old. In the validation dataset, PP was independently related to AoD in patients with HFrEF (β = 0.205, p = 0.001). PP level was independently and positively associated with AoD, especially in the elderly with HFrEF, but not in patients with HFmrEF and HFpEF. Arterial stiffening or vascular aging may play a certain role in the elderly HFrEF patients.

Both HFpEF and HFmrEF should be included in calculating CHA2DS2-VASc score: A Taiwanese longitudinal cohort

BackgroundCongestive heart failure (CHF) as a risk of stroke in patients with atrial fibrillation (AF) mainly referred to patients with left ventricular systolic dysfunction. Whether this should include patients with preserved ejection fraction is debatable. ObjectiveThe study aimed to investigate the variation in stroke risk of AF patients with heart failure with preserved ejection fraction (HFpEF), heart failure with mid-range ejection fraction (HFmrEF), and heart failure with reduced ejection fraction (HFrEF) for enhancing risk assessment and subsequent management strategies. MethodsIn a longitudinal study using the National Taiwan University Hospital integrated Medical Database, 8358 patients with AF were observed for 10 years (mean follow-up, 3.76 years). The study evaluated the risk of ischemic stroke in patients with differing ejection fractions and CHA2DS2-VASc score, further using Cox models adjusted for risk factors of AF-related stroke. ResultsPatients with HFpEF and HFmrEF had a higher mean CHA2DS2-VASc score compared with patients with HFrEF (4.30 ± 1.729 vs 4.15 ± 1.736 vs 3.73 ± 1.712; P < .001) and higher risk of stroke during follow-up (hazard ratio [HR], 1.40 [1.161–1.688; P < .001] for HFmrEF; HR, 1.184 [1.075–1.303; P = .001] after multivariate adjustment). In patients with lower CHA2DS2-VASc score (0–4), presence of any type of CHF increased ischemic stroke risk (HFrEF HR, 1.568 [1.189–2.068; P = .001]; HFmrEF HR, 1.890 [1.372–2.603; P < .001]; HFpEF HR, 1.800 [1.526–2.123; P < .001]). ConclusionAfter multivariate adjustment, HFpEF and HFmrEF showed a similar risk of stroke in AF patients. Therefore, it is important to extend the criteria for C in the CHA2DS2-VASc score to include patients with HFpEF. In patients with fewer concomitant stroke risk factors, the presence of any subtype of CHF increases risk for ischemic stroke.

Guideline-directed medical therapy in heart failure patients with reduced ejection fraction in Palestine: Retrospective clinical audit study

ObjectivesTo assess the characteristics of patients with heart failure with reduced ejection fraction (HFrEF) and heart failure with mid-range ejection fraction (HFmrEF), as well as the current application of guideline-directed medical therapy (GDMT) in Palestine. MethodsThis retrospective cohort study involved a population of heart failure (HF) patients who visited cardiology clinics at An-Najah National University Hospital and the National Hospital, Palestine. The primary outcome measures of interest were the proportions of patients prescribed guideline-based cardiovascular medications (GBCMs), such as angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs), β-blockers, and mineralocorticoid receptor antagonists (MRAs), and the corresponding optimized doses at ≥ 50 % of targets and the reasons underlying the non-prescription of GDMT. ResultsA total of 70.5%, 56.6%, and 88.6% of patients were on ACEIs/ARBs, MRAs, and β-blockers, respectively. Of all patients, 38.7% were on the triple GDMT regimen. ConclusionLess than half the patients received the triple combination treatment. Age, diabetes mellitus, chronic renal disease, and admission to the hospital for HF all had significant independent relationships with the reduced utilization and inadequate dosage of GDMT.

Precision Cardiology: Phenotype-targeted Therapies for HFmrEF and HFpEF.

Heart failure with mid-range ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF) represent over half of heart failure cases but lack proven effective therapies beyond sodium-glucose cotransporter 2 inhibitor and diuretics. HFmrEF and HFpEF are heterogeneous conditions requiring precision phenotyping to enable tailored therapies. This review covers concepts on precision medicine approaches for HFmrEF and HFpEF. Areas discussed include HFmrEF mechanisms, anti-inflammatory and antifibrotic treatments for obesity-related HFpEF, If inhibition for HFpEF with atrial fibrillation, and mineralocorticoid receptor antagonism for chronic kidney disease-HFpEF. Incorporating precision phenotyping and matched interventions in HFmrEF and HFpEF trials will further advance therapy compared to blanket approaches.

Diagnostic and prognostic value of an ejection fraction corrected for myocardial remodelling

Abstract Introduction Despite clinical guideline recommendations to use left ventricular ejection fraction (EF) as a marker of left ventricular function in heart failure (HF), it is prone to measurement error, is load dependent and is skewed during geometric cardiac remodelling. EF also cannot distinguish between patients with HF with preserved EF (HFpEF) and those with a normal heart. By evaluating EF at the ventricular mid-wall layer (the corrected EF (EFc)) instead of the endocardial surface, the geometric dependency shortcomings of EF can be overcome. Purpose We evaluated whether EFc can provide additional diagnostic and prognostic information compared with traditional EF. Methods We conducted a retrospective cohort study using a dataset of all consecutive patients who were admitted to hospital following the request of a troponin across three centres between 2010 and 2017. Patients who underwent an echocardiogram either within 3 months before or 5 months after their hospital admission were included. Patients were classified according to whether their index hospital admission was due to HF, and further classified according to EF ((i) EF&amp;lt;40, HF with reduced EF (HFrEF); (ii) 40≤EF&amp;lt;50, HF with mid-range EF (HFmrEF); (iii) EF≥50, HFpEF). All-cause mortality was assessed as a competing risk to HF admission. Cox-proportional regression models were constructed to compare the EFc to EF in evaluating risk of HF admission. Results The study population consisted of 2752 individuals (56.5% male, age 69.3±16.4 years). Comparing patients with HFpEF to those with an index admission without HF, there was no difference in EF between the groups (62.3% versus 64.2%, p = 0.79), however a significant difference was observed when comparing EFc (56.6% versus 61.8%, p = 0.0007) (Figure 1). Both low EF (&amp;lt;50%) and low EFc (&amp;lt;50%) were associated with a high HF readmission risk, which were comparable. However, in the cohort with a normal EF (EF≥50%), predictive models using EFc were significantly more accurate in predicting HF readmissions within 3 years, where the leave one out cross validation ROC analysis showed a 18.6% reduction in errors when EFc replaces EF in the risk prediction models. Table 1 shows the specific IDI and NRI scores to quantify the improvements to predictions when EF or EFc are added to the baseline model (age, gender and creatinine), for assessing readmissions within 3 years in the EF≥50% cohort. The higher IDI and NRI scores for EFc compared to EF shows that adding EFc to "baseline" improves predictions more than adding EF to "baseline". The results also show that using EFc instead of EF will lead to 12.2% more patients in the event group (HF readmission) being correctly identified as higher risk, and 16.6% more patients in the non-event group (no HF readmission) being correctly identified as lower risk. Conclusions In comparison to EF, the EFc improves the prediction of hospital admissions due to HF for patients where the EF≥50%.Figure 1Table 1

The impact of COVID-19 on BNP, NT-proBNP and ANP in heart failure.

Extensive research has been conducted on biomarkers associated with coronavirus disease 2019 (COVID-19) in both healthy individuals and those with various conditions, particularly heart diseases. However, there is a limited investigation into the relationship between widely used cardiac biomarkers known as natriuretic peptides, including Brain natriuretic peptide (BNP), N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP), and Atrial natriuretic peptide (ANP), and COVID-19 infection specifically in patients with heart failure. These natriuretic peptides assess the hemodynamic stress on the heart wall and have the potential to serve as biomarkers for evaluating the severity of COVID-19 infection in heart failure patients. Therefore, this study aimed to assess the plasma concentration of BNP, NT-proBNP, and ANP in a medium-sized cross-sectional case-control study involving 360 heart failure patients, both infected and uninfected with COVID-19. The heart failure patients were categorized into subgroups based on their Ejection Fraction (EF) percentage, namely heart failure with reduced EF (HFrEF), heart failure with mid-range EF (HFmrEF), and heart failure with preserved EF (HFpEF). Our findings demonstrate a significant increase in plasma levels of BNP and NT-proBNP in all heart failure patients, as well as in each subgroup (HFrEF, HFmrEF, and HFpEF) when infected with COVID-19, compared to uninfected heart failure patients. These established cardiac biomarkers have the potential to be utilized as future indicators for assessing the severity of COVID-19 infection in heart failure patients, thereby enhancing heart failure management and reducing irreversible cardiac damage.

Safety and Efficacy of Traditional Heart Failure Therapies in Patients With Cardiac Amyloidosis and Heart Failure

Randomized controlled trials have demonstrated mortality benefits for several medication classes in patients with heart failure (HF), especially with reduced ejection fraction (EF). However, the benefit of these traditional HF therapies in patients with HF from cardiac amyloidosis is unclear. our study aimed to evaluate the safety and efficacy of traditional HF therapies in patients with cardiac amyloidosis and HF with reduced EF or HF with mid-range EF (HFmrEF). We conducted a single-center retrospective study. Patients were included if they were diagnosed with cardiac amyloidosis and HF with reduced EF or HF with mid-range EF between January 2012 and 2022. The primary outcomes of interest were medication use patterns (for β blockers [BB], angiotensin-converting enzyme inhibitors [ACEI], angiotensin receptor blockers [ARBs], angiotensin receptor neprilysin inhibitors [ARNI], and mineralocorticoid receptor antagonists [MRAs]); potential medication side effects (symptomatic bradycardia, fatigue, hypotension, lightheadedness, and syncope); hospitalization; and death. The associations of BB, ACEI/ARB/ARNI, and MRA use with clinical outcomes were evaluated using Kaplan-Meier and Cox proportional hazards regression. A total of 82 patients met study criteria. At time of cardiac amyloidosis diagnosis, 63.4% were on a BB, 51.2% were on an ACEI/ARB/ARNI, and 43.9% were on an MRA. At last follow-up, 51.2% were on a BB, 35.4% were on an ACEI/ARB/ARNI, and 43.9% were on an MRA. There were no statistically significant differences in rates of potential medication side effects in patients on the medication class compared with those who were not. There was no association with hospitalization or mortality for baseline or follow-up BB, ACEI/ARB/ARNI, or MRA use. In conclusion, BBs, ACEI/ARB/ARNIs, and MRAs may be safely used in this population. However, their use does not appear to improve mortality or hospitalization.

The Improvement of Left Atrial Function after Twelve Weeks of Supervised Concurrent Training in Patients with Heart Failure with Mid-Range Ejection Fraction: A Pilot Study.

Left atrial dysfunction is associated with exercise intolerance and poor prognosis in heart failure (HF). The effects of exercise training on atrial function in patients with HF with mid-range ejection fraction (HFmrEF) are unknown. The purpose of the present study was to assess the effects of a supervised concurrent training (SCT) program, lasting 12 weeks, on left atrial function of patients with HFmrEF. The study included 70 stable patients, who were randomly assigned into two groups: SCT with (three sessions/week) or a control (CON) group directed to follow contemporary exercise preventive guidelines at home. Before starting the training program and at 12 weeks, all patients performed an ergometric test, a 6 min walk test, and echocardiography. Between-group comparisons were made by analysis of variance (ANOVA). At 12 weeks, the duration of the ergometric test and distance walked at 6 min walk test presented a significant greater increase in SCT compared to the control (between-group p 0.0001 and p 0.004 respectively). Peak atrial longitudinal strain and conduit strain presented an increase of 29% and 34%, respectively, in the SCT, and were unchanged in CON (between-group p 0.008 and p 0.001, respectively). Peak atrial contraction strain increased by 21% in SCT, with no changes in CON (between-group p 0.002). Left ventricular global longitudinal strain increased significantly in SCT compared to control (between-groups p 0.03). In conclusions, SCT improved left atrial and left ventricular function in HFmrEF. Further studies are needed in order to verify whether these favourable effects of SCT on LA function are sustained and whether they will translate into clinical benefits for patients with HFmrEF.

Association between mitral annulus calcification and subtypes of heart failure rehospitalization.

Mitral annulus calcification (MAC) has been associated with cardiovascular diseases, including heart failure (HF); however, the associations between MAC and both the category and etiology of HF have not been fully elucidated. The aim of this study was to investigate the relationship between MAC and three types of HF rehospitalization: HF with preserved ejection fraction (HFpEF), HF with mid-range EF (HFmrEF), and HF with reduced EF (HFrEF). We enrolled consecutive patients undergoing echocardiography, who were admitted to our hospital for clinically indicated congestive HF between April 2014 and March 2018. Cox proportionalhazards models were used after adjusting for age, gender, and hypertension. Of 353 patients, 40 (11.3%) had MAC. With a median follow-up of 2.8 years, 100 (28%) patients were rehospitalized for congestive HF (HFpEF 40%, HFmrEF 16%, HFrEF 44%, respectively). According to the Kaplan-Meier method, the estimated incidence of HFpEF rehospitalization in the MAC group was significantly greater than that in the non-MAC group (p < 0.001) whereas the incidences of HFmrEF and HFrEF rehospitalization were comparable between the groups (p = 0.101 and p = 0.291, respectively). In a multivariate analysis, MAC remained significantly associated with HFpEF rehospitalization (hazard ratio: 3.379; 95% confidence interval: 1.651-6.597). At initial HF hospitalization, E/e' was significantly higher in the MAC group (both septum and lateral, p < 0.05), suggesting a possible relationship between MAC and left ventricular diastolic function. Mitral annulus calcification was associated with increased HFpEF rehospitalization and might be a cause of left ventricular diastolic dysfunction.

Association Between Anemia Status and the Risk of Different Types of Heart Failure: A RCSCD-TCM Study in China.

We investigated the association between anemia status and the risk of heart failure (HF) in patients with coronary heart disease (CHD) based on a multi-center, large-sample and retrospective cross-sectional study including 89,207 patients. Heart failure was categorized as HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), and HF with mid-range ejection fraction (HFmrEF). In multi-adjusted models, compared with patients without anemia, mild anemia (odds ratio [OR] 1.71; 95% confidence interval [CI] 1.53-1.91; P < .001), moderate anemia (OR 3.68; 95% CI, 3.25-4.17; P < .001), and severe anemia (OR 8.02; 95% CI, 6.50-9.88; P < .001) were associated with the risk of HF among CHD patients. Men aged <65years were more likely to develop HF. In subgroup analyses, the multi-adjusted ORs and 95% CI of HFpEF, HFrEF, and HFmrEF related to anemia were 3.24 (95% CI 1.43-7.33), 2.22 (95% CI 1.28-3.84), and 2.55 (95% CI 2.24-2.89), respectively. These findings suggest that anemia might be associated with increased risk of different types of HF, especially HFpEF.

Sodium-Glucose Cotransporter 2 Inhibitors Among Heart Failure With Mildly Reduced and Preserved Ejection Fraction.

Results from large placebo-controlled randomized trials in patients with heart failure with mid-range ejection fraction (HFmrEF) and HF with preserved EF (HFpEF) have become available recently. This article discusses results of these clinical trials. Peer-reviewed articles were identified from MEDLINE (1966 to December 31, 2022) using search terms dapagliflozin, empagliflozin, SGLT-2Is, HFmrEF, and HFpEF. Eight completed, pertinent clinical trials were included. EMPEROR-Preserved, and DELIVER demonstrated that empagliflozin and dapagliflozin reduce CV death and heart failure hospitalization (HHF) in patients with HFmrEF and HFpEF, with/without diabetes when added to a standard heart failure (HF) regimen. The benefit is primarily due to reduction in HHF. Additional data from post hoc analyses of trials of dapagliflozin, ertugliflozin, and sotagliflozin suggest that these benefits may be a class effect. Benefits appear greatest in patients with left ventricular ejection fraction 41% up to about 65%. While many pharmacologic treatments have been proven to reduce mortality and improve cardiovascular (CV) outcomes in people with HFmrEF and HF with reduced EF (HFrEF), there are few therapy which improve CV outcome in people with HFpEF. SGLT-2I become one of the first class of pharmacologic agent that can be used to reduce HHF and CV mortality. Studies showed that empagliflozin and dapagliflozin reduce the combined risk of CV death or HHF in patients with HFmrEF and HFpEF when added to a standard HF regimen. Given that benefit has now been demonstrated across the spectrum of HF, SGLT-2Is should be considered one of the standard HF pharmacotherapy.

Reduced functional capacity is associated with the proportion of impaired myocardial deformation assessed in heart failure patients by CMR.

Heart failure (HF) does not only reduce the life expectancy in patients, but their life is also often limited by HF symptoms leading to a reduced quality of life (QoL) and a diminished exercise capacity. Novel parameters in cardiac imaging, including both global and regional myocardial strain imaging, promise to contribute to better patient characterization and ultimately to better patient management. However, many of these methods are not part of clinical routine yet, their associations with clinical parameters have been poorly studied. An imaging parameters that also indicate the clinical symptom burden of HF patients would make cardiac imaging more robust toward incomplete clinical information and support the clinical decision process. This prospective study conducted at two centers in Germany between 2017 and 2018 enrolled stable outpatient subjects with HF [n = 56, including HF with reduced ejection fraction (HFrEF), HF with mid-range ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF)] and a control cohort (n = 19). Parameters assessed included measures for external myocardial function, for example, cardiac index and myocardial deformation measurements by cardiovascular magnetic resonance imaging, left ventricular global longitudinal strain (GLS), the global circumferential strain (GCS), and the regional distribution of segment deformation within the LV myocardium, as well as basic phenotypical characteristics including the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the 6-minute walk test (6MWT). If less than 80% of the LV segments are preserved in their deformation capacity the functional capacity by 6MWT (6 minutes walking distance: MyoHealth ≥ 80%: 579.8 ± 177.6 m; MyoHealth 60-<80%: 401.3 ± 121.7 m; MyoHealth 40-<60%: 456.4 ± 68.9 m; MyoHealth < 40%: 397.6 ± 125.9 m, overall p-value: 0.03) as well as the symptom burden are significantly impaired (NYHA class: MyoHealth ≥ 80%: 0.6 ± 1.1 m; MyoHealth 60-<80%: 1.7 ± 1.2 m; MyoHealth 40-<60%: 1.8 ± 0.7 m; MyoHealth < 40%: 2.4 ± 0.5 m; overall p-value < 0.01). Differences were also observed in the perceived exertion assessed by on the Borg scale (MyoHealth ≥ 80%: 8.2 ± 2.3 m; MyoHealth 60-<80%: 10.4 ± 3.2 m; MyoHealth 40-<60%: 9.8 ± 2.1 m; MyoHealth < 40%: 11.0 ± 2.9 m; overall p-value: 0.20) as well as quality of life measures (MLHFQ; MyoHealth ≥ 80%: 7.5 ± 12.4 m; MyoHealth 60-<80%: 23.4 ± 23.4 m; MyoHealth 40-<60%: 20.5 ± 21.2 m; MyoHealth < 40%: 27.4 ± 24.4 m; overall p-value: 0.15)-while these differences were not significant. The share of LV segments with preserved myocardial contraction promises to discriminate between symptomatic and asymptomatic subjects based on the imaging findings, even when the LV ejection fraction is preserved. This finding is promising to make imaging studies more robust toward incomplete clinical information.

Diagnostic and prognostic value of the electrocardiogram in stable outpatients with type 2 diabetes

Aims . The European Society of Cardiology guidelines on diabetes and cardiovascular disease (CVD) recommend an electrocardiogram (ECG) in patients with diabetes and hypertension or with suspected CVD. We investigated whether ECG abnormalities can be used as a diagnostic and prognostic marker of heart failure (HF) in patients with type-2 diabetes (T2D) in secondary care diabetes-clinics. Methods . We included 722 patients with T2D in sinus rhythm. HF with preserved ejection fraction (HFpEF) was defined according to the European Society of Cardiology guidelines. Heart failure with mid-range ejection fraction (HFmrEF) was patients with dyspnoea and an LVEF 41–49%. Heart failure with reduced ejection fraction (HFrEF) or asymptomatic left ventricular systolic dysfunction (ALVSD) was defined as a LVEF ≤40%. Results . Overall, 24% patients had ECG abnormalities. A total of 15% had HF whereof 48% had ECG abnormalities. A normal ECG had a 99.3% negative predictive value (NPV) of ruling out HFrEF/ALVSD. In a sub-group with 0-1 simple clinical risk markers, the ECG ruled out both HFrEF/ALVSD, HFmrEF, and HFpEF with an NPV of 96.6%. The hazard-ratio (HR) of incident CVD or death in patients with HF and a normal ECG compared with patients without HF was 1.85 [95%CI 1.01–3.39], p = .05, while an abnormal ECG increased the HR to 3.84 [2.33–6.33], p < .001. Conclusion . HFrEF/ALVSD and HFmrEF were rare and HFpEF was frequent in this T2D population. A normal ECG ruled out HFrEF/ALVSD and in a sub-population with 0–1 simple clinical risk markers also both HFrEF/ALVSD, HFmrEF, and HFpEF. Key messages What is already known about this subject? In early studies of unselected patients from primary care with suspected chronic heart failure, the presence of a normal ECG was found be useful to rule out heart failure with reduced ejection fraction. What does this study add? This study confirms that a standard electrocardiogram when normal in 722 stable outpatients with type 2 diabetes can be used to rule out HFrEF/ALVSD. Further, it adds knowledge about the risk of incident cardiovascular disease or death as a pathologic electrocardiogram increases the hazard ratio. How might this implicate clinical practice? With this study clinicians in secondary diabetes care clinics can use an electrocardiogram to select patients to undergo echocardiography when suspecting heart failure with reduced ejection fraction, as a normal electrocardiogram will rule out this diagnosis with a negative predictive value of >99%.

Cardiovascular magnetic resonance phenotyping of heart failure with mildly reduced ejection fraction.

The 2016 European Society of Cardiology Heart Failure Guidelines defined a new category: heart failure with mid-range ejection fraction (HFmrEF) of 40-49%. This new category was highlighted as having limited evidence and research was advocated into underlying characteristics, pathophysiology, and diagnosis. We used multi-parametric cardiovascular magnetic resonance (CMR) to define the cardiac phenotype of presumed non-ischaemic HFmrEF. Patients (N = 300, 62.7 ± 13 years, 63% males) with a clinical diagnosis of heart failure with no angina symptoms, history of myocardial infarction, or coronary intervention were prospectively recruited. Patients underwent clinical assessment and CMR including T1 mapping, extracellular volume (ECV) mapping, late gadolinium enhancement, and measurement of myocardial blood flow at rest and maximal hyperaemia. Of 273 patients in the final analysis, 93 (34%) patients were categorized as HFmrEF, 46 (17%) as heart failure with preserved ejection fraction (HFpEF), and 134 (49%) as heart failure with reduced ejection fraction (HFrEF). Nineteen (20%) patients with HFmrEF had evidence of occult ischaemic heart disease. Diffuse fibrosis and hyperaemic myocardial blood flow were similar in HFmrEF and HFpEF, but HFmrEF showed significantly lower native T1 (1311 ± 32 vs. 1340 ± 45 ms, P < 0.001), ECV (24.6 ± 3.2 vs. 26.3 ± 3.1%, P < 0.001), and higher myocardial perfusion reserve (2.75 ± 0.84 vs. 2.28 ± 0.84, P < 0.001) compared with HFrEF. Patients with HFmrEF share most phenotypic characteristics with HFpEF, including the degree of microvascular impairment and fibrosis, but have a high prevalence of occult ischaemic heart disease similar to HFrEF. Further work is needed to confirm how the phenotype of HFmrEF responds to medical therapy.

Long-Term prognosis of radiofrequency catheter ablation for atrial fibrillation with different subtypes of heart failure in the era of ablation index guidance.

BackgroundThe long-term outcomes of ablation index (AI)-guided radiofrequency catheter ablation (RFCA) on atrial fibrillation (AF) and different subtypes of heart failure (HF) remain unknown. The aim of the study was to evaluate the long-term prognosis of AI-guided RFCA procedures in patients with AF and concomitant HF.MethodsWe retrospectively included consecutive patients with AF and HF who underwent the initial RFCA procedure with AI guidance from March 2018 to June 2021 in our institution. The patients were categorized into two groups: HF with preserved ejection fraction (HFpEF) group and HF with mid-range ejection fraction (HFmrEF) +HF with reduced ejection fraction (HFrEF) group.ResultsA total of 101 patients were included. HFpEF and HFmrEF + HFrEF groups consisted of 71 (70.3%) and 30 patients (29.7%), respectively. During a median follow-up of 32.0 (18.2, 37.6) months, no significant difference was detected in AF recurrence between groups (21.1 vs. 33.3%) after multiple procedures, whereas the incidence of the composite endpoint of all-cause death, thromboembolic events, and HF hospitalization was significantly lower in HFpEF group (9.9 vs. 25.0%, Log-rank p = 0.018). In multivariable analysis, a history of hypertension [hazard ratio (HR) 4.667, 95% confidence interval (CI) 1.433–15.203, p = 0.011], left ventricular ejection fraction (LVEF) < 50% (HR 5.390, 95% CI 1.911–15.203, p = 0.001) and recurrent AF after multiple procedures (HR 7.542, 95% CI 2.355–24.148, p = 0.001) were independently associated with the incidence of the composite endpoint.ConclusionLong-term success could be achieved in 75% of patients with AF and concomitant HF after AI-guided RFCA procedures, irrespective of different HF subtypes. Preserved LVEF was associated with a reduction in the composite endpoint compared with impaired LVEF. Patients with recurrent AF tend to have a poorer prognosis.

Prevalence, treatment, and 1-year outcomes of heart failure with mid-range ejection fraction

Background: The prevalence of patients with heart failure with mid-range ejection fraction (HFmrEF) remains unchanged regardless of healthcare strategies. HFmrEF has mixed characteristics of heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). The treatment of HFmrEF was recommended to be similar to the treatment of HFpEF in the 2016 guidelines of the European Society of Cardiology (ESC) but was changed to those of HFrEF in the 2021 version. Objective: To describe the clinical characteristics of inpatients with HFmrEF with a focus on treatment practices. Methods: A prospective study was conducted on patients diagnosed with HFmrEF who were admitted to the cardiology department of Nhan Dan Gia Dinh hospital from July 2019 to July 2020. Rehospitalization and mortality were followed up by telephone after 1 year. Results: Of a total of 529 heart failure cases admitted to the hospital during the study period, there were 73 patients (13.8%) with HFmrEF. The mean age was 68 years and males comprised 53%. The average hospitalization stay length was 6.7 days. The most common precipitating factors of heart failure were non-adherence (42.5%) and infection (39.7%) followed by hypertensive crisis (8.2%), anemia (6.8%), acute myocardial infarction (5.5%), arrhythmia (4.1%), and hyperthyroidism (2.7%). Ischemic heart disease was the leading cause (61.6%) of HFmrEF, followed by hypertension (12.3%). The rates of HFmrEF patients treated with beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, and aldosterone receptor antagonists were 76.1%, 76.71%, 37.73%, and 47.95%, respectively. There were no statistically significant differences in the guideline-directed medical therapy (GDMT) medications administered between HFmrEF due to ischemic and non-ischemic causes. After 1-year follow-up, the combined outcome of rehospitalization and mortality in HFmrEF was 24.7%. Conclusion: The treatment of HFmrEF was similar to that of HFrEF between 2019 and 2020 at Nhan Dan Gia Dinh hospital and was in accordance with the 2021 ESC guidelines.

[Correlation between heart rate index, SBPpeak-to-SBPrest ratio and peak oxygen consumption in patients with chronic heart failure].

Objective: To investigate the correlation between heart rate index (HRI), systolic blood pressure(SBP) peak-to-SBPrest ratio (SBPR) and peak oxygen consumption (peakVO2) in patients with chronic heart failure (CHF), and discuss the possibility of using HRI and SBPR collected during exercise to assess the exercise tolerance of CHF patients in the absence of gas analysis. Methods: In this cross-sectional study, a total of 547 patients with CHF who underwent cardiopulmonary exercise test(CPET) in Tongji Hospital Heart Rehabilitation Center Affiliated to Tongji University from March 2007 to December 2018 were collected retrospectively, focusing on their clinical data including age, gender, type of heart failure,BMI as well as data collected during their CPETs, such as peakVO2, HRI and SBPR. Spearman univariate correlation analysis was used for statistical analysis, to unveil the correlations between peakVO2 and those parameters, and multiple linear regression analysis was also conducted. Results: A total of 547 CHF patients conducting CPET were included in this research, of which 447 were male, at age of 63(56, 69). Univariate analysis indicates that HRI, SBPR and peakVO2 showed significant positive correlation (r=0.323, 0.263, respectively, all P<0.001); Age and peak VO2 showed significant negative correlation(r=-0.207, P<0.001); Male patients showed peakVO2 higher than female(r=-0.229, P<0.001); PeakVO2 of heart failure with reduced ejection fraction(HFrEF) was lower than heart failure with mid-range ejection fraction(HFmrEF)and heart failure with preserved ejection fraction(HFpEF) (r=0.181, P<0.001). Body mass index (BMI) had no significant correlation with peakVO2 (P>0.05). Multivariate linear regression analysis showed that the HRI, SBPR were positively correlated with peakVO2(t=7.68, 5.08, respectively, all P<0.05), while age and BMI showed negative correlation with peakVO2(t=-5.43, -0.31, respectively, all P<0.05). PeakVO2 of male was higher than female(t=-6.03, P<0.05), and peakVO2 of HFrEF was lower than those of HFmrEF and HFpEF(t=3.17, 4.48, respectively, all P<0.05). A linear equation (F=33.52, adjusted R2=0.29) could be constructed: peakVO2=10.65(male) or 8.53(female)+4.26HRI+3.31SBPR-0.07age-0.13BMI+0(HFrEF) or 1.05 (HFmrEF) or 1.62(HFpEF). Conclusion: HRI and SBPR are positively correlated with peakVO2. In the absence of gas analysis, it is possible to apply HRI and SBPR during exercise to predict exercise tolerance in patients with CHF.

Surgical treatment of patients with aortic valve disease complicated with moderate functional mitral regurgitation and heart failure with midrange ejection fraction: a cohort study.

Background Controversies exist on the treatment of moderate functional mitral regurgitation (FMR) in patients with severe aortic valve disease undergoing the aortic valve replacement (AVR). While a substantial proportion of these patients can be complicated with heart failure with midrange ejection fraction (HFmrEF), established studies show that the latter might compromise the patient outcome. This study was aimed to evaluate the prognostic value of concomitant mitral valve surgery during AVR in patients with severe aortic valve disease followed by moderate FMR and HFmrEF.MethodsA total of 78 consecutive patients were retrospectively recruited. Patients were divided into control (isolated AVR) and treatment (AVR + mitral valve surgery) groups. Follow-up outcomes were compared by Kaplan-Meier method, followed by multiple adjustment with inverse probability treatment weighting (IPTW) analysis. The primary outcome was the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE).ResultsThirty-six patients received isolated AVR, while 42 received AVR with mitral valve repair or replacement. The median follow-up time was 28.7 months. Unadjusted analysis showed that there was no significant difference in the rate of MACCE between the two groups [hazard ratio (HR): 1.14, 95% confidence interval (CI): 0.48–2.69, Plogrank=0.770], which was sustained in IPTW analysis (HR: 1.64, 95% CI: 0.59–4.55, Plogrank=0.342). In addition, while concomitant mitral valve surgery improved follow-up FMR more completely (P=0.026) in the IPTW analysis, the ejection fraction was comparable between the two groups (P=0.276). Furthermore, IPTW analysis also showed that mitral valve surgery was associated with the increased risk of postoperative acute kidney injury (P=0.007).ConclusionsIn patients with aortic valve disease followed by moderate FMR and HFmrEF, mitral valve surgery concomitant to AVR may not bring extra benefit in the MACCE-free survival and the improvement of HFmrEF. However, while concomitant mitral valve surgery has priority on the complete improvement of FMR, it might increase the risk of postoperative acute kidney injury.

Myocardial fibrosis markers changes in patients with heart failure with mid-range ejection fraction of ischemic genesis under therapy

Background and Aims : The aim of the study was to evaluate the therapy effectiveness by β-blockers bisoprolol or nebivolol in combination with eplerenone on myocardial fibrosis markers in patients with heart failure with mid-range ejection fraction (HFmrEF) and metabolic disorders.