Mid-range Ejection Fraction Research Articles

Predictors of relapse after improved ejection fraction in patients with heart failure

Abstract Background Patients with systolic dysfunction with improvement in left ventricular ejection fraction (LVEF) present a more favorable clinical profile when compared to those that maintain dysfunction. However, little is known about the characteristics of patients who “relapse” after LVEF improvement. Purpose Evaluate prevalence, clinical characteristics and outcomes of patients in whom ejection fraction declined after previous improvement. Methods We retrospectively studied patients followed at a heart failure (HF) clinic with LVEF improvement after an initial diagnosis of HF with reduced ejection fraction (EF), which was defined as having an LVEF >40% on follow-up. We then evaluated the presence of LVEF “relapse” in these patients – a decline in LVEF to <50% or <40%, in cases where it recovered to preserved EF or to mid-range EF, respectively. We analysed patient demographics, clinical parameters and outcomes and used logistic regression to assess the predictors of LVEF “relapse”. Results 98 patients were studied, 70 (71%) male, median age 69 (58–76) years. Fifty-four (55%) patients had recovered EF (>50%) and in 44 (45%) it had improved to mid-range values. In 36 (37%) occurred LVEF “relapse”: in 10 (10%) patients to an EF 40–50% and in 88 (90%) to an EF<40%. Ischemic cardiomyopathy and non-ischemic dilated cardiomyopathy were the main HF aetiologies (38% and 35%, respectively). During a median follow-up of 7 years, 39 (40%) patients had at least one HF hospitalization. Global mortality was 30%, with no significant statistical difference between the two groups. In univariate analysis, HF duration, type 2 diabetes mellitus (T2DM), left main or left anterior descending coronary (LAD) disease, valvular heart disease (VHD) and chronic kidney disease (CKD) predicted LVEF “relapse”. In multivariate analysis, T2DM, left main or LAD disease and VHD were the only predictors of LVEF “relapse” (Table). Conclusion In this group of patients, LVEF “relapse” after it had initially improved was frequent and was predicted by the presence of T2DM, left main or LAD disease and VHD. Despite improved systolic function, these patients remain at high risk, thus the need to maintain treatment. Funding Acknowledgement Type of funding source: None

Heart failure and left ventricular dysfunction in older patients with chronic kidney disease: the China Hypertension Survey (2012-2015).

BackgroundHeart failure (HF) is a leading cause of hospitalization and mortality for older chronic kidney disease (CKD) patients. However, the epidemiological data is scarce. We aimed to determine the prevalence of left ventricular (LV) dysfunction and HF, and to explore the risk factors for HF among those patients.MethodsThis is a cross-sectional analysis of the China Hypertension Survey conducted between October 2012 and December 2015. A total of 5, 808 participants aged ≥ 65 years were included in the analysis. Self-reported history of HF and any other cardiovascular diseases was acquired. 2-D and Doppler echocardiography were used to assess LV dysfunction. CKD was defined as either estimated glomerular filtration rate (eGFR) < 60 mL/min per 1.73 m2 or urinary albumin to creatinine ratio (ACR) ≥ 30 mg/g.ResultsAmong CKD patients aged ≥ 65 years, the weighted prevalence of HF, heart failure with preserved ejection fraction (HFpEF), heart failure with mid-range ejection fraction (HFmrEF), and heart failure with reduced ejection fraction (HFrEF) was 4.8%, 2.5%, 0.8%, and 1.7%, respectively. The weighted prevalence of HF was 5.0% in patients with eGFR < 60 mL/min per 1.73 m2, and was 5.9% in patients with ACR ≥ 30 mg/g. The prevalence of LV systolic dysfunction was 3.1%, and while it was 8.9% for moderate/severe diastolic dysfunction. Multivariate analysis showed that smoking was significantly associated with the risk of HF. Furthermore, age, smoking, and residents in rural areas were significantly associated with a risk of LV diastolic dysfunction.ConclusionsThe prevalence of HF and LV dysfunction was high in older patients with CKD, suggesting that particular strategies will be required.

Association Between β-Blocker Use and Mortality/Morbidity in Patients With Heart Failure With Reduced, Midrange, and Preserved Ejection Fraction and Advanced Chronic Kidney Disease.

It is unknown if β-blockers reduce mortality/morbidity in patients with heart failure (HF) and advanced chronic kidney disease (CKD), a population underrepresented in HF trials. Observational cohort of HF patients with advanced CKD (estimated glomerular filtration rate <30 mL/min per 1.73 m2) from the Swedish Heart Failure Registry between 2001 and 2016. We first explored associations between β-blocker use, 5-year death, and the composite of cardiovascular death/HF hospitalization among 3775 patients with HF with reduced ejection fraction (HFrEF) and advanced CKD. We compared observed hazards with those from a control cohort of 15 346 patients with HFrEF and moderate CKD (estimated glomerular filtration rate <60-30 mL/min per 1.73 m2), for whom β-blocker trials demonstrate benefit. Second, we explored outcomes associated to β-blocker among advanced CKD participants with preserved (HFpEF; N=2009) and midrange ejection fraction (HFmrEF; N=1514). During a median follow-up of 1.3 years, 2012 patients had a subsequent HF hospitalization, and 2849 died in the HFrEF cohort, of which 2016 died due to cardiovascular causes. Among patients with HFrEF, β-blocker use was associated with lower risk of death (adjusted hazard ratio 0.85 [95% CI, 0.75-0.96]) and cardiovascular mortality/HF hospitalization (0.87 [0.77-0.98]) compared with nonuse. The magnitude of the associations was similar to that observed for HFrEF patients with moderate CKD. Conversely, no significant association was observed for β-blocker users in advanced CKD with HFpEF (death: 0.88 [0.77-1.02], cardiovascular mortality/HF hospitalization: 1.05 [0.90-1.23]) or HFmrEF (death: 0.95 [0.79-1.14], cardiovascular mortality/HF hospitalization: 1.09 [0.90-1.31]). In HFrEF patients with advanced CKD, the use of β-blockers was associated with lower morbidity and mortality. Although inconclusive due to limited power, these benefits were not observed in similar patients with HFpEF or HFmrEF.

Heart Failure With Mid-range or Recovered Ejection Fraction: Differential Determinants of Transition.

The recent definition of an intermediate clinical phenotype of heart failure (HF) based on an ejection fraction (EF) of between 40% and 49%, namely HF with mid-range EF (HFmrEF), has fuelled investigations into the clinical profile and prognosis of this patient group. HFmrEF shares common clinical features with other HF phenotypes, such as a high prevalence of ischaemic aetiology, as in HF with reduced EF (HFrEF), or hypertension and diabetes, as in HF with preserved EF (HFpEF), and benefits from the cornerstone drugs indicated for HFrEF. Among the HF phenotypes, HFmrEF is characterised by the highest rate of transition to either recovery or worsening of the severe systolic dysfunction profile that is the target of disease-modifying therapies, with opposite prognostic implications. This article focuses on the epidemiology, clinical characteristics and therapeutic approaches for HFmrEF, and discusses the major determinants of transition to HFpEF or HFrEF.

Does heart failure with mid-range ejection fraction resemble heart failure with preserved ejection fraction?

Does heart failure with mid-range ejection fraction resemble heart failure with preserved ejection fraction?

Prediction of chronic heart failure and chronic obstructive pulmonary disease in a general population: the Tromsø study.

AimsHeart failure (HF) and chronic obstructive pulmonary disease (COPD) are main causes of dyspnoea, and echocardiography and spirometry are essential investigations for these diagnoses. Our aim was to determine the prevalence of HF and COPD in a general population, also how the diseases may be identified, and to what extent their clinical characteristics differ.Methods and resultsIn the seventh survey of Tromsø study (2015–16), subjects aged 40 years or more were examined with echocardiography, spirometry, lung sound recordings, questionnaires, including the modified Medical Research Council (mMRC) questionnaire on dyspnoea, and N‐terminal pro‐brain natriuretic peptide analysis. A diagnosis of HF (HF with reduced ejection fraction, HF with mid‐range ejection fraction, or HF with preserved ejection fraction) or COPD was established according to current guidelines. Predictors of HF and COPD were evaluated by logistic regression and receiver operating characteristic curve analysis. A total of 7110 participants could be evaluated for COPD, 1624 for HF, and 1538 for both diseases. Age‐standardized prevalence of HF was 6.8% for women and 6.1% for men; the respective figures for COPD were 5.2% and 5.1%. Among the 1538 evaluated for both diseases, 139 subjects fulfilled the HF criteria, but only 17.1% reported to have the disease. Of those fulfilling the COPD criteria, 31.6% reported to have the disease. Shortness of breath at exertion was a frequent finding in HF; 59% of those with mMRC ≥2 had HF, while such shortness of breath was found in 24% among those with COPD. Reporting mMRC ≥2 had an odds ratio for HF of 19.5 (95% confidence interval 11.3–33.7), whereas the odds ratio for COPD was 6.3 (95% confidence interval 3.5–11.6). Current smoking was the strongest predictor of COPD but did not predict HF. Basal inspiratory crackles were significant predictors of HF in multivariable analysis. Among the subtypes of HF, an age <70 years was most frequently found in HF with reduced ejection fraction, in 51.7%. Clinical scores based on the predictive value in multivariable analysis of history, symptoms, and signs predicted HF and COPD with areas under the curve of 0.833 and 0.829, respectively.ConclusionsStudy participants with HF and COPD were in most cases not aware of their condition. In general practice, when an elderly patient present with shortness of breath, both diseases should be considered. Previous cardiovascular disease points at HF, while a history of smoking points at COPD. The threshold should be low for ordering echocardiography or spirometry for verifying the suspected cause of dyspnoea.

Non-severe aortic regurgitation increases short-term mortality in acute heart failure with preserved ejection fraction.

AimsMild or moderate aortic regurgitation (AR) has only little effect on cardiovascular outcome in people with normal left ventricular ejection fraction (EF); therefore, it is not perceived as a major clinical problem. This study investigates whether mild or moderate AR is associated with increased short‐term mortality in patients hospitalized for treatment of acute heart failure (AHF) and whether mild or moderate AR impacts differently on short‐term mortality in AHF patients with reduced EF (AHFrEF), mid‐range EF (AHFmrEF), or preserved EF (AHFpEF).Methods and resultsThis mono‐centric study included 505 consecutive adult patients hospitalized for de novo or worsening chronic HF not related to acute ischaemia or severe valvular pathology in the echocardiogram at index hospitalization. Cox regression analysis studied the impact of AR on all‐cause mortality (ACM) over the 150 days' study period. Mild or moderate AR was associated with increased ACM (HR 1.75 [95% CI: 1.1–2.7]; P = 0.009). The prevalence of mild or moderate AR in the study population was 42% and not significantly different between AHFpEF (n = 227), AHFmrEF (n = 86), and AHFrEF (n = 192) study participants (37.9% vs. 50.0% vs. 42.7%; P = 0.144). In AHFpEF patients, the age‐adjusted hazard for ACM was increased in patients with AR compared with patients without AR (HR 2.17 [95% CI: 1.1–4.2]; P = 0.002). The age‐adjusted hazard for ACM was increased by a trend in AHFmrEF with AR (HR 7.11, [95% CI: 0.9–57.8]; P = 0.067) and not different between the AHFrEF groups (HR 0.95 [95% CI: 0.5–1.8]; P = 0.875).ConclusionsMild or moderate AR increased ACM only in AHFpEF patients, highlighting a distinct clinical relevance.

Heart failure from ATTRwt amyloid cardiomyopathy is associated with poor prognosis.

AimsAmyloid cardiomyopathy is an underappreciated cause of morbidity and mortality. Recent evidence suggests that ATTR wild‐type cardiomyopathy (ATTRwt‐CM) is probably much more common than widely appreciated. So far, no data are available on comparison of mortality from ATTRwt‐CM and other heart failure aetiologies.Methods and resultsThis was a retrospective, observational, cohort study of 2251 patients and their data collected prospectively from May 2000 to June 2018. Long‐term mortality was the main outcome measure. Underlying cardiomyopathies were classified as amyloid CM (6.1%) [ATTRwt 3.0%; light‐chain amyloidosis (AL) 3.1%], dilated CM (dCMP) (46.4%), ischaemic heart disease (IHD) (24.4%), hypertensive heart disease (HHD) (14.6%), hypertrophic CM (HCM) (5.1%), and valvular heart disease (VHD) (3.4%). Median duration of follow‐up was 7.1 years (interquartile range 3.4–11.3). Five‐year overall survival in the whole cohort was 80.1%. In multivariate analysis, individuals with amyloid CM were 3.74 times [95% confidence interval (CI) 2.72–5.14; P < 0.001] more likely to die of any reason than were individuals with dCMP. Mortality was higher in AL‐CM compared with ATTRwt‐CM [hazard ratio (HR) 2.88; 95% CI 1.48–5.58; P = 0.002]. Mortality rates in patients with ATTRwt‐CM were higher than in patients with dCMP (HR 1.96; 95% CI 1.24–3.22; P = 0.007), HCM (HR 2.94; 95% CI 1.28–6.67; P = 0.011), HHD (HR 2.08; 95% CI 1.27–3.45; P = 0.004), VHD (HR 2.38; 95% CI 1.30–4.35; P = 0.005), or left ventricular ejection fraction ≥ 40% (HR 1.99; 95% CI 1.12–3.52; P = 0.018).ConclusionsOur study demonstrates that amyloid CM is independently associated with poor survival among patients with various causes of heart failure. ATTRwt‐CM had a better long‐term prognosis than did AL‐CM, but was associated with higher mortality than were dCMP, HCM, HHD, VHD, and heart failure with preserved or mid‐range ejection fraction.

Biomarker Guided Therapy For Heart Failure With Mid-Range EF

Background Heart failure (HF) with mid-range ejection fraction (HFmrEF, EF 40-49%) accounts for ∼15% of HF patients and these are a heterogeneous group with a phenotypic character that reflects aspects of both preserved and reduced EF HF. There are no proven treatments for this group but identifying subsets of patients that will respond to conventional therapies such as beta blockers (BB) would be desirable. We hypothesized that HFmrEF patients with elevated Nt-proBNP or ST2 would have more favorable response to BB therapy. Methods A prospective registry was conducted that enrolled 1760 HF patients who met Framingham HF criterion and who received care through our health system and insurance product. Participants donated blood for biomarker measurements at enrollment and their medication exposure was quantified over time using pharmacy claims data. The current study utilized all participants who had EF 40-49% and baseline biomarker measurement (n=338). The primary endpoint was all-cause mortality. Biomarker categories were dichotomized at Nt-BNP >1000ng/L and ST2 ≥35ng/mL. We quantified the HR for BB exposure overall and divided by biomarker level using Cox models adjusted for MAGGIC score and BB propensity score. Results Vital status and Nt-BNP measurements were available for all 338 patients, while 279 had ST2 measured, and 201 had both markers (Table 1). For Nt-BNP, 200 (58%) had elevated levels while 143 (42%) had low values. BB use in patients with elevated Nt-BNP levels had a hazard ratio (HR) of 0.43 (p=0.1) compared to HR 0.97 (p=0.97) in the low Nt-BNP group. For ST2, 195 patients (70%) had levels 0.99) while in patients with either ST2 or Nt-BNP elevated the BB HR was 0.06 (p=0.03). Conclusions In this observational study of HFmrEF patients, those with low ST2 and Nt-BNP have low risk of death and little benefit of BB therapy whereas among the approximately two-thirds of patients with either marker elevated a substantial BB benefit association was seen

Modes of death in heart failure according to age, sex and left ventricular ejection fraction.

Modes of death in patients with heart failure (HF) have been well characterized in randomized studies, but data from real-life are scarce, especially in the elderly, women and in HF with mid-range or preserved left ventricular ejection fraction (LVEF). Our purpose was to examine modes of death in HF patients according to age, sex and LVEF. We analysed the mode of death of HF patients from two prospective multicentre contemporary Spanish registries conducted by cardiologists (REDINSCOR, n = 2150) and by internists (RICA, n = 1396). Mode of death was pre-specified. Out of 3546 patients, 485 (13.7%) died during the 9-month follow-up. Cardiovascular (CV) causes were the most frequent, regardless of the age, sex and LVEF. More than half of patients died due to worsening HF in both groups of patients, followed by other non-CV causes in those attended by internists, and sudden cardiac death in those cared by cardiologists. Stroke was more common among elderly patients, women and HF with preserved LVEF. Non-CV causes, particularly infectious diseases, accounted for a remarkable proportion of deaths, especially in the elderly and in HF patients with preserved LVEF. Functional class, age and anaemia had a strong influence on both CV and non-CV death. CV death due to refractory HF was the most prevalent among our population, irrespective of age, sex or LVEF. However, a significant proportion of HF patients died from non-CV causes, particularly elderly with mid-range and preserved LVEF. These patients could benefit significantly from a multidisciplinary follow-up.

Arrhythmic risk stratification in heart failure mid-range ejection fraction patients with a non-invasive guiding to programmed ventricular stimulation two-step approach.

BackgroundAlthough some post myocardial infarction (post‐MI) and dilated cardiomyopathy (DCM) patients with mid‐range ejection fraction heart failure (HFmrEF/40%‐49%) face an increased risk for arrhythmic sudden cardiac death (SCD), current guidelines do not recommend an implantable cardiac defibrilator (ICD). We risk stratified hospitalized HFmrEF patients for SCD with a combined non‐invasive risk factors (NIRFs) guiding to programmed ventricular stimulation (PVS) two‐step approach.MethodsForty‐eight patients (male = 83%, age = 64 ± 14 years, LVEF = 45 ± 5%, CAD = 69%, DCM = 31%) underwent a NIRFs screening first‐step with electrocardiogram (ECG), SAECG, Echocardiography and 24‐hour ambulatory ECG (AECG). Thirty‐two patients with presence of one of three NIRFs (SAECG ≥ 2 positive criteria for late potentials, ventricular premature beats ≥ 240/24 hours, and non‐sustained ventricular tachycardia [VT] episode ≥ 1/24 hours) were further investigated with PVS. Patients were classified as either low risk (Group 1, n = 16, NIRFs−), moderate risk (Group 2, n = 18, NIRFs+/PVS−), and high risk (Group 3, n = 14, NIRFs+/PVS+). All in Group 3 received an ICD.ResultsAfter 41 ± 18 months, 9 of 48 patients, experienced the major arrhythmic event (MAE) endpoint (clinical VT/fibrillation = 3, appropriate ICD activation = 6). The endpoint occurred more frequently in Group 3 (7/14, 50%) than in Groups 1 and 2 (2/34, 5.8%). Logistic regression model adjusted for PVS, age, and LVEF revealed that PVS was an independent MAE predictor (OR: 21.152, 95% CI: 2.618‐170.887, P = .004). Kaplan‐Meier curves diverged significantly (log rank, P < .001) while PVS negative predictive value was 94%.ConclusionsIn hospitalized HFmrEF post‐MI and DCM patients, a NIRFs guiding to PVS two‐step approach efficiently detected the subgroup at increased risk for MAE.

Trends in cause-specific readmissions in heart failure with preserved vs. reduced and mid-range ejection fraction.

AimsThe aim of this study was to investigate whether the readmission of heart failure (HF) patients has decreased over time and how it differs among HF with preserved ejection fraction (EF) (HFpEF) vs. reduced EF (HFrEF) and mid‐range EF (HFmrEF).Methods and resultsWe evaluated HF patients index hospitalized from January 2004 to December 2011 in the Swedish Heart Failure Registry with 1 year follow‐up. Outcome measures were the first occurring all‐cause, cardiovascular (CV), and HF readmissions. A total of 20 877 HF patients (11 064 HFrEF, 4215 HFmrEF, and 5562 HFpEF) were included in the study. All‐cause readmission was the highest in patients with HFpEF, whereas CV and HF readmissions were the highest in HFrEF. From 2004 to 2011, HF readmission rates within 6 months (from 22.3% to 17.3%, P = 0.003) and 1 year (from 27.7% to 23.4%, P = 0.019) in HFpEF declined, and the risk for 1 year HF readmission in HFpEF was reduced by 7% after adjusting for age and sex (P = 0.022). Likewise, risk factors for HF readmission in HFpEF changed. However, no significant changes were observed in all‐cause or CV readmission rates in HFpEF, and no significant changes in cause‐specific readmissions were observed in HFrEF. Time to the first readmission did not change significantly from 2004 to 2011, regardless of EF subgroup (all P‐values > 0.05).ConclusionsDeclining temporal trend in HF readmission rates was found in HFpEF, but all‐cause readmission still remained the highest in HFpEF vs. HFrEF and HFmrEF. More efforts are needed to reduce the non‐HF‐related readmission in patients with HFpEF.

Prognostic value of heart failure echocardiography index in HF patients with preserved, mid-ranged and reduced ejection fraction

BackgroundTo investigate the clinical value of heart failure echocardiography index (HFEI) in evaluating the cardiac function and predicting the prognosis of patients with different types of heart failure (HF).MethodsFour hundred eighty-nine consecutively admitted HF patients were divided into three groups: HF with reduced ejection (HFrEF), HF with mid-range ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF). The baseline characteristics and ultrasound indexes were compared between the three groups. The correlation between HFEI and one-year risk of adverse events was compared by multivariate logistic regression. The clinical value of HFEI and plasma level of NT-proBNP in assessing the prognosis of patients with chronic heart failure (CHF) was analyzed by the receiver operating characteristic (ROC) curve.ResultsHFEI in HFrEF was significantly higher than that in HFmrEF and HFpEF. Multivariate regression analysis indicated that HFEI and plasma level of NT-proBNP were independent risk factors for predicting the short-time prognosis of HF patients. The ROC curve indicated that the HFEI cutoff level of 3.5 and the plasma NT-proBNP level of 3000 pg/ml predicted a poor prognosis of CHF patients with a sensitivity of 64% and a specificity of 75% vs. 68 and 65%.ConclusionHFEI can comprehensively evaluate the overall cardiac function of patients with various types of HF, and may prove to be an important index of assessing the prognosis of HF patients.

The prognostic role of mid-range ejection fraction in ST-segment elevation myocardial infarction

ObjectiveThere is a paucity of studies investigating the impact of mid-range ejection fraction (mrEF) on clinical outcomes, including ventricular arrhythmias, in ST-segment-elevation myocardial infarction (STEMI). We sought to investigate the prognostic role of mrEF post STEMI and whether recommended medical therapy may modify future risk. Methods533 consecutive patients from a single large-volume centre who underwent primary percutaneous coronary intervention were included. Reduced EF (<40%), mrEF (40–49%) and preserved EF (≥50%) were defined according to the European Society of Cardiology guidelines. Clinical outcomes were prospectively collected, and the primary endpoint was defined as the composite of death, re-admission with heart failure, sustained ventricular arrhythmia requiring hospitalisation or implantable cardioverter defibrillator over three years follow-up. ResultsThere was a stepwise increase in the primary endpoint according to EF group (8%, 17%, 30%, P < .001), which was derived from each individual component. Compared to preserved EF, patients with mrEF had significantly higher risk [HR 4.08 (95%CI 2.38 to 6.99), P < .001]. The use of suboptimal medical therapy was associated with increased future risk, particularly in mrEF [HR 2.62, (95%CI 1.18 to 5.83), P = .018]. The proportion of mrEF patients who experience the primary endpoint was significantly different according the status of kidney function and recommended medical therapy (8%, 20%, 33%, 50%, P < .001). ConclusionsPatients presenting with mrEF following STEMI had increased risk of death, heart failure hospitalisation and ventricular arrhythmias compared to preserved EF. Suboptimal medical therapy in mrEF was associated with increased adverse events, particularly in patients with renal dysfunction.

Recurrent hospitalizations are associated with increased mortality across the ejection fraction range in heart failure.

AimsThe proportion of patients hospitalized for heart failure (HF) with preserved left ventricular ejection fraction (LVEF) is rising, but no approved treatment exists, in part owing to incomplete characterization of this particular HF phenotype. In order to better define the characteristics of HF phenotypes in Finland, a large cohort with 12 years' follow‐up time was analysed.Methods and resultsPatients diagnosed between 2005 and 2017 at the Hospital District of Southwest Finland were stratified according to LVEF measure and N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) levels. For this retrospective registry study, previously diagnosed HF patients were defined as follows: patients with reduced ejection fraction (HFrEF; LVEF ≤ 40%; n = 4042), mid‐range ejection fraction (HFmrEF; LVEF > 40–50% and NT‐proBNP ≥ 125 pg/mL; n = 1468), and preserved ejection fraction (HFpEF; LVEF > 50% and NT‐proBNP ≥ 125 pg/mL; n = 3122) and followed up for 15 022, 4962, and 10 097 patient‐years, respectively. Cardiovascular (CV) hospitalization and mortality, influence of pre‐selected covariates on hospitalization and mortality, and the proportion of HFpEF and HFmrEF patients with a drop in LVEF to HFrEF phenotype were analysed. All data were extracted from the electronic patient register. HFrEF patients were rehospitalized slightly earlier than HFpEF/HFmrEF patients, but the second, third, and fourth rehospitalization rates did not differ between the subgroups. Female gender and better kidney function were associated with reduced rehospitalizations in HFmrEF and HFrEF, with a non‐significant trend in HFpEF. Each additional hospitalization was associated with a two‐fold increased risk of death and 2.2‐ to 2.3‐fold increased risk of CV death. All‐cause mortality was higher in patients with HFpEF. Although CV mortality was less frequent in HFpEF patients, it was associated with increased NT‐proBNP concentrations at index in all patient groups. During the 10 years following the index date, 26% of HFmrEF patients and 10% of HFpEF patients progressed to an HFrEF phenotype.ConclusionsThese findings suggest that disease progression, in terms of increased frequency of hospitalizations, and the relationship between increased number of hospitalizations and mortality are similar by LVEF phenotypes. These data highlight the importance of effective treatments that can reduce hospitalizations and suggest a role for monitoring NT‐proBNP levels in the management of HFpEF patients in particular.

TAPSE/PASP use in heart failure: Implementing the evidence for simplicity.

Commentary to: "Assessment of right ventricular-arterial coupling by echocardiography in patients with heart failure with reduced to mid-range ejection fraction: impact on survival" by Rosa et al.

Clinical course and risk prediction of permanent atrial fibrillation development in patients with chronic heart failure and mid-range ejection fraction of the left ventricle.

The purpose of the study was to establish clinical features of permanent atrial fibrillation (AF) in patients with heart failure mid-range ejection fraction (HFmrEF) and to develop a mathematical model for predicting arrhythmia development. The study included 42 patients with IHD, arterial hypertension (AH), permanent AF and HFmrEF (1 group), mean age – 68.0±1.2 years (21 men and 21 women) and 36 patients with CAD / АH and HFmrEF without AF, mean age- 67.5±0.7 years (22 men and 14 women). The results of the study show, that patients with permanent AF and HFmrEF are characterized by the higher diastolic arterial pressure, higher values of the LDLP, iESV LV, index of end-systolic volume of LV septal thickness and lower EF of the LV in comparison with patients without AF. Patients with permanent AF and HFmrEF also have increased plasma levels of hsCRP, IL-1β, IL-6 and IL-10 in comparison with patients without AF. A mathematical model with scoring system of hsCRP, IL-1β, LV mass index, HDLP, LDLP was developed to assess the risk of AF development in patients with HFmrEF with accuracy of 85.9%, sensitivity of 85.7% and specificity of 86.1%.

Clinical Representativeness of the PARADIGM-HF Study in an Outpatient Cohort of Patients with Heart Failure, Including Chagas Disease, Treated According to Guideline-directed Medical Therapy: Prospective Study, in a Single Center in Brazil

Background: In the PARADIGM-HF trial there was a 20% reduction in hospitalization and cardiovascular mortality in patients with heart failure (HF) and treated according to guideline-directed medical therapy. Eligibility for the use of sacubitril/valsartan in the real world has varied between 12% and 76%. There are no studies on the national scene on this eligibility.&#x0D; Aims: To investigate the clinical eligibility of the PARADIGM-HF trial in patients with HF in the outpatient clinic of a university institution, which also includes Chagas disease, and to compare the profile of the two populations.&#x0D; Study Design: This is a single center, prospective, observational study.&#x0D; Place and Duration of Study: Department of Internal Medicine, Faculty of Medicine, Hospital das Clínicas, Federal University of Minas Gerais, Brazil, duration 6 consecutive months.&#x0D; Methods and Results: We included 136 consecutive outpatients with HF, 53 women, and mean age of 54.2 years, underwent clinical and laboratory evaluation. The main etiologies of HF were ischemic, Chagas disease and idiopathic. The means of baseline variables were 117.2 mmHg for systolic blood pressure, 78.4 bpm for heart rate, 1.8 for dyspnea functional class, 0.39 for ejection fraction (EF) and 74.2 mL/min for creatinine clearance. The exclusion criteria considered in the PARADIGM-HF trial and present in this study were systolic blood pressure less than 95 mmHg in 15.4% and creatinine clearance less than 30 mL/min in 5.1% of patients. 22.1% had mid-range EF and 55.9% had reduced EF. Comparing this cohort of patients with the population of the PARADIGM-HF trial, age, systolic blood pressure, proportion of male patients, ischemic etiology, hypertension, patients with atrial fibrillation, use of angiotensin-converting enzyme inhibitor, furosemide and beta-blocker were lower in this study (p ≤ 0.01, chi-square and Student's t tests). The proportion of diabetic patients, use of angiotensin receptor blocker, aldosterone antagonist and digoxin were similar between groups as well as proportion of patients with cardiac resynchronization therapy.&#x0D; Conclusions: Up to 44% of patients in this study did not meet the main randomized trial criteria. Chagas disease was one of the main etiologies. Furthermore, systolic blood pressure, proportion of hypertensive patients was lower, which may have influenced the underutilization of some medications.

Гендерные особенности метаболических нарушений у пожилых больных с сердечной недостаточностью с промежуточной фракцией выброса

Гендерные особенности метаболических нарушений у пожилых больных с сердечной недостаточностью с промежуточной фракцией выброса

Response to beta-blockers and natriuretic peptide level in acute heart failure: analysis of data from the Korean acute heart failure registry.

To investigate the effect of beta-blockers according to NP levels and HF phenotypes because natriuretic peptide (NP) level can be used to risk-stratify HF patients regardless of left ventricular ejection fraction (LVEF). Of 5,625 patients in the Korean acute heart failure registry, we included patients with LVEF and NP levels. HF phenotypes were defined as HF with reduced ejection fraction (HFrEF) (EF ≤ 40%), HF with midrange ejection fraction (HFmrEF) (40% < EF < 50%), and HF with preserved EF (HFpEF) (EF ≥ 50%). Patients were further stratified by NP tertiles. Primary outcome was 5-year all-cause mortality according to beta-blocker use at discharge. Both B-type NP (BNP) (r = -0.279, P < 0.001) and N-terminal pro-BNP (r = -0.186, P < 0.001) levels correlated inversely with LVEF. During a median follow-up duration of 961days, 1560 (35.3%) patients died. In HFrEF, patients taking beta-blockers showed better survival regardless of NP levels. Regarding HFmrEF, there was no mortality difference between those taking and not taking beta-blockers. In HFpEF, beta-blocker use demonstrated lower mortality in those in the 3rd NP tertile (log-rank P = 0.041) but not in those in the 1st and 2nd NP tertiles (log-rank P > 0.05). After adjusting covariates, the use of beta-blockers was associated with a 38%-reduced mortality (hazard ratio: 0.62; 95% confidence interval: 0.39-0.98; P = 0.040) in HFpEF patients in the 3rd NP tertile but not in those in 1st and 2nd tertiles. We confirm that the use of beta-blockers is beneficial in patients with HFrEF. Furthermore, we extend the benefits of beta-blockers to patients with HFpEF and high NP levels. ClinicalTrial.gov identifier: NCT01389843 URL: https://clinicaltrials.gov/ct2/show/NCT01389843.