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Chen X, Zhang P, Lou J, Zhao R, Zhang S, Xie M, Lv Q. Application of an echocardiographic index to characterize right ventricular-pulmonary arterial coupling in heart failure. ESC Heart Fail 2024; 11:1290-1304. [PMID: 38229524 PMCID: PMC11098638 DOI: 10.1002/ehf2.14663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/29/2023] [Accepted: 12/19/2023] [Indexed: 01/18/2024] Open
Abstract
Heart failure (HF), with its high morbidity and mortality, remains a global public health issue. Right ventricular (RV) dysfunction is a sign of deterioration in the natural history of HF, and a thorough evaluation of the relationship between RV contractility and its afterload through RV-pulmonary arterial (RV-PA) coupling can aid in accurately assessing overall RV function. The ratio of RV end-systolic elastance (Ees) to pulmonary arterial elastance (Ea) invasively measured by right heart catheterization served as the gold standard for evaluating RV-PA coupling. An echocardiographic index termed tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) has been shown to correlate well with Ees/Ea. TAPSE/PASP is recognized as a non-invasive surrogate of RV-PA coupling and has been extensively studied in patients with HF. This review briefly describes the methods of assessing RV-PA coupling, mainly discussing echocardiography, summarizes the clinical utility of TAPSE/PASP in patients with different HF types, and provides an overview of the available literature.
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Affiliation(s)
- Xin Chen
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Peige Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Jie Lou
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Ruohan Zhao
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Siyi Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Mingxing Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
- Shenzhen Huazhong University of Science and Technology Research InstituteShenzhenChina
- Tongji Medical College and Wuhan National Laboratory for OptoelectronicsHuazhong University of Science and TechnologyWuhanChina
| | - Qing Lv
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
- Clinical Research Centre for Medical Imaging in Hubei ProvinceWuhanChina
- Hubei Province Key Laboratory of Molecular ImagingWuhanChina
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Mustafina I, Elkholey K, Fudim M, Stavrakis S. The Impact of Atrial Fibrillation on Clinical Outcomes in Heart Failure with Mid-range and Preserved Ejection Fraction Patients. Heart Rhythm 2024:S1547-5271(24)02633-X. [PMID: 38797306 DOI: 10.1016/j.hrthm.2024.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND The combined effect of left ventricular ejection fraction (LVEF) and atrial fibrillation (AF) on clinical outcomes in heart failure (HF) remains complex. OBJECTIVE In this post-hoc analysis of the TOPCAT trial, we aimed to evaluate the impact of AF on clinical outcomes in patients with HF patients stratified by LVEF range. METHODS A total of 3442 patients were included, stratified into three groups according to LVEF range: 1) HF with mid-range EF (HFmrEF) - LVEF 45-50% (n=823); 2) HF with preserved LVEF (HFpEF) - LVEF 51-60% (n=1682); 3) HF with normal LVEF (HFnEF) - LVEF >60 % (n=937) and subdivided according to the presence of AF at enrollment. Cox regression analysis was used to define independent associations between AF and clinical outcomes. RESULTS AF was prevalent in 38.6% in HFmrEF, 34.6% in HFpEF, and 33.7% in HFnEF (p=0.07). In each subgroup, AF was associated with worse primary outcome and HF hospitalizations, and worse cardiovascular mortality in HFpEF and HFnEF. The hazard ratio (HR) for the primary outcome in those with AF compared to sinus rhythm (SR) was 1.11 (1.01-1.22, p=0.03) in HFmrEF; 1.20 (1.11-1.28, p<0.001) in HFpEF; and 1.16 (1.05-1.28, p=0.004) in HFnEF. When LVEF was treated as a continuous variable, there was a linear negative association between LVEF and the effect of AF vs. SR for the primary endpoint and HF hospitalizations and a linear positive association for cardiovascular mortality. CONCLUSION Compared to SR, AF was independently associated with worse outcomes across all LVEF ranges.
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Affiliation(s)
- Irina Mustafina
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Oklahoma City, OK; Department of Internal Medicine, Bashkir State Medical University, Lenina 3, Ufa, Russia
| | - Khaled Elkholey
- Department of Medicine, Centennial Medical Center, Nashville, TN
| | - Marat Fudim
- Duke University Medical Center Durham, NC; Duke Clinical Research Institute, Durham, NC; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Stavros Stavrakis
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Oklahoma City, OK.
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Kusayev J, Levy Y, Weininger D, Frishman WH, Aronow WS. Semaglutide in Heart Failure With Preserved Ejection Fraction: Exploring Recent Evidence in Therapeutic Potential for the Obese Population. Cardiol Rev 2024:00045415-990000000-00269. [PMID: 38757954 DOI: 10.1097/crd.0000000000000726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is an increasingly prevalent condition, particularly among the aging population in the United States, and is associated with significant challenges due to its complex pathophysiology and limited therapeutic options. Historically, few pharmacological therapies have successfully mitigated HFpEF, making the emergence of effective treatments particularly significant. This review evaluates recent evidence on the therapeutic potential of semaglutide for managing HFpEF, especially in the obese population. Results from the STEP-HFpEF and STEP-HFpEF DM trials demonstrate that semaglutide, a glucagon-like peptide-1 receptor agonist originally developed for type 2 diabetes but now also approved for obesity treatment, significantly improves clinical outcomes such as symptom scores, body weight, exercise capacity, and inflammation markers in the obese population suffering from HFpEF. These improvements are attributed to both the weight loss induced by semaglutide and its direct effects on the congestive pathophysiology of HFpEF. The efficacy of semaglutide offers new hope for addressing a condition that has long lacked effective pharmacological interventions.
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Affiliation(s)
- Josef Kusayev
- From the Department of Medicine, New York Medical College, Valhalla, NY
| | - Yisrael Levy
- From the Department of Medicine, New York Medical College, Valhalla, NY
| | - David Weininger
- Departments of Cardiology and Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | | | - Wilbert S Aronow
- Departments of Cardiology and Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
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4
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Al-Sadawi M, Tao M, Dhaliwal S, Goldschmit M, Tam E, Mann N. Safety and Efficacy of Anti-Hypertensive Medications in Patients with Heart Failure with Preserved Ejection Fraction: A Systematic Review and Meta-analysis. High Blood Press Cardiovasc Prev 2024:10.1007/s40292-024-00646-0. [PMID: 38740725 DOI: 10.1007/s40292-024-00646-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/17/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Hypertension (HTN) is a co-morbidity that is commonly associated with heart failure with preserved ejection fraction (HFpEF). However, it remains unclear whether treatment of hypertension in HFpEF patients is associated with improved cardiovascular outcomes. AIM The purpose of this meta-analysis is to evaluate the association of anti-hypertensive medical therapy with cardiovascular outcomes in patients with HFpEF. METHODS We performed a database search for studies reporting on the association of anti-hypertensive medications with cardiovascular outcomes and safety endpoints in patients with HFpEF. The databases searched include OVID Medline, Web of Science, and Embase. The primary endpoint was all-cause mortality. Secondary endpoints include cardiovascular (CV) mortality, worsening heart failure (HF), CV hospitalization, composite major adverse cardiovascular events (MACE), hyperkalemia, worsening renal function, and hypotension. RESULTS A total of 12 studies with 14062 HFpEF participants (7010 treated with medical therapy versus 7052 treated with placebo) met inclusion criteria. Use of anti-hypertensive medications was not associated with lower all-cause mortality, CV mortality or CV hospitalization compared to treatment with placebo (OR 1.02, 95% CI 0.77-1.35; p = 0.9, OR 0.88, 95% CI 0.73-1.06; p = 0.19, OR 0.99, 95% CI 0.87-1.12; p = 0.83, OR 0.90, 95% CI 0.79-1.03; p = 0.11). Anti-hypertensive medications were not associated with lower risk of subsequent acute myocardial infarction (AMI) (OR 0.53, 95% CI 0.07-3.73; p = 0.5). Use of anti-hypertensive medications was associated with a statistically significant lower risk of MACE (OR 0.90, 95% CI 0.83-0.98; p = 0.02). CONCLUSIONS While treatment with anti-hypertensive medications was not associated with lower risk of all-cause mortality, their use may be associated with reduce risk of adverse cardiovascular outcomes in patients with HFpEF regardless of whether they have HTN. Additional high quality studies are required to clarify this association and determine the effect based on specific classes of medications.
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Affiliation(s)
- Mohammed Al-Sadawi
- University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - Michael Tao
- Stony Brook University Hospital, 101 Nicolls Rd, Stony Brook, NY, 11794, USA
| | - Simrat Dhaliwal
- Stony Brook University Hospital, 101 Nicolls Rd, Stony Brook, NY, 11794, USA
| | - Mark Goldschmit
- Stony Brook University Hospital, 101 Nicolls Rd, Stony Brook, NY, 11794, USA
| | - Edlira Tam
- Stony Brook University Hospital, 101 Nicolls Rd, Stony Brook, NY, 11794, USA
| | - Noel Mann
- Stony Brook University Hospital, 101 Nicolls Rd, Stony Brook, NY, 11794, USA
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Kawai A, Nagatomo Y, Yukino-Iwashita M, Ikegami Y, Takei M, Goda A, Kohno T, Mizuno A, Kitamura M, Nakano S, Sakamoto M, Shiraishi Y, Kohsaka S, Adachi T, Yoshikawa T. Supra-normal and mildly reduced ejection fraction in women -An overlooked vulnerable subpopulation in heart failure. Int J Cardiol 2024; 409:132166. [PMID: 38744340 DOI: 10.1016/j.ijcard.2024.132166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/04/2024] [Accepted: 05/11/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Recently, patients with supra-normal left ventricular ejection fraction (snEF) are reported to have high risk of adverse outcomes, especially in women. We sought to evaluate sex-related differences in the association between LVEF and long-term outcomes in heart failure (HF) patients. METHODS The multicenter WET-HF Registry enrolled all patients hospitalized for acute decompensated HF (ADHF). We analyzed 3943 patients (age 77 years; 40.1% female) registered from 2006 to 2017. According to LVEF the patients were divided into the 3 groups: HF with reduced EF (HFrEF), mildly reduced EF (HFmrEF) and preserved EF. The primary endpoint was defined as the composite of cardiac death and ADHF rehospitalization after discharge. RESULTS In HFmrEF, implementation of guideline-directed medical therapy (GDMT) such as the combination of renin-angiotensin-system inhibitor (RASi) and β-blocker at discharge was significantly lower in women than men even after adjustment for covariates (p = 0.007). There were no such sex-related differences in HFrEF. Female sex was associated with higher incidence of the primary endpoint and ADHF rehospitalization after adjustment for covariates exclusively in HFmrEF. Restricted cubic spline analysis demonstrated a U-shaped relationship between LVEF and the hazard ratio of the primary endpoint showing higher event rate in HFmrEF and HFsnEF in women, but such relationship was not observed in men (p for interaction = 0.037). CONCLUSIONS In women, mrEF and snEF were associated with worse long-term outcomes. Additionally, sex-related differences in the GDMT implementation for HFmrEF highlight the need for further exploration, which might lead to creation of sex-specific guidelines to optimize HF management.
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Affiliation(s)
- Akane Kawai
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan; Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan.
| | | | - Yukinori Ikegami
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
| | - Makoto Takei
- Department of Cardiology, Saiseikai Central Hospital, Tokyo, Japan
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Atsushi Mizuno
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | | | - Shintaro Nakano
- Department of Cardiology, Saitama Medical University, International Medical Center, Hidaka, Japan
| | - Munehisa Sakamoto
- Department of Cardiology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Adachi
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan
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Nair A, Tuan LQ, Jones-Lewis N, Raja DC, Shroff J, Pathak RK. Heart Failure with Mildly Reduced Ejection Fraction-A Phenotype Waiting to Be Explored. J Cardiovasc Dev Dis 2024; 11:148. [PMID: 38786970 PMCID: PMC11121955 DOI: 10.3390/jcdd11050148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 04/30/2024] [Accepted: 05/03/2024] [Indexed: 05/25/2024] Open
Abstract
Heart failure (HF) presents a significant global health challenge recognised by frequent hospitalisation and high mortality rates. The assessment of left ventricular (LV) ejection fraction (EF) plays a crucial role in diagnosing and predicting outcomes in HF, leading to its classification into preserved (HFpEF), reduced (HFrEF), and mildly reduced (HFmrEF) EF. HFmrEF shares features of both HFrEF and HFpEF but also exhibits distinct characteristics. Despite advancements, managing HFmrEF remains challenging due to its diverse presentation. Large-scale studies are needed to identify the predictors of clinical outcomes and treatment responses. Utilising biomarkers for phenotyping holds the potential for discovering new treatment targets. Given the uncertainty surrounding optimal management, individualised approaches are imperative for HFmrEF patients. This chapter examines HFmrEF, discusses the rationale for its re-classification, and elucidates HFmrEF's key attributes. Furthermore, it provides a comprehensive review of current treatment strategies for HFmrEF patients.
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Affiliation(s)
- Anugrah Nair
- Department of Cardiac Electrophysiology, Canberra Heart Rhythm Centre, Canberra, ACT 2605, Australia; (A.N.); (L.Q.T.); (N.J.-L.); (J.S.)
- ANU College of Health and Medicine, Australian National University, Acton Campus, Canberra, ACT 0200, Australia;
| | - Lukah Q. Tuan
- Department of Cardiac Electrophysiology, Canberra Heart Rhythm Centre, Canberra, ACT 2605, Australia; (A.N.); (L.Q.T.); (N.J.-L.); (J.S.)
- ANU College of Health and Medicine, Australian National University, Acton Campus, Canberra, ACT 0200, Australia;
| | - Natasha Jones-Lewis
- Department of Cardiac Electrophysiology, Canberra Heart Rhythm Centre, Canberra, ACT 2605, Australia; (A.N.); (L.Q.T.); (N.J.-L.); (J.S.)
| | - Deep Chandh Raja
- ANU College of Health and Medicine, Australian National University, Acton Campus, Canberra, ACT 0200, Australia;
| | - Jenish Shroff
- Department of Cardiac Electrophysiology, Canberra Heart Rhythm Centre, Canberra, ACT 2605, Australia; (A.N.); (L.Q.T.); (N.J.-L.); (J.S.)
- ANU College of Health and Medicine, Australian National University, Acton Campus, Canberra, ACT 0200, Australia;
| | - Rajeev Kumar Pathak
- Department of Cardiac Electrophysiology, Canberra Heart Rhythm Centre, Canberra, ACT 2605, Australia; (A.N.); (L.Q.T.); (N.J.-L.); (J.S.)
- ANU College of Health and Medicine, Australian National University, Acton Campus, Canberra, ACT 0200, Australia;
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7
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Omar AMS, Murphy S, Felker GM, Piña I, Butler J, Liu Y, Mohebi R, Bhatia K, Ward JH, Williamson KM, Solomon SD, Januzzi JL, Contreras J. Isovolumic Contraction Velocity in Heart Failure With Reduced Ejection Fraction and Effect of Sacubitril/Valsartan: the PROVE-HF Study. J Card Fail 2024; 30:653-665. [PMID: 37816446 DOI: 10.1016/j.cardfail.2023.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 10/12/2023]
Abstract
OBJECTIVES To assess tissue Doppler-derived mitral annular isovolumic contraction velocity (ICV) after starting sacubitril/valsartan (sac/val) for the treatment of heart failure with reduced ejection fraction (HFrEF) and left ventricular [LV] EF < 40%). BACKGROUND ICV may inform load-independent systolic function; combining ICV and LVEF may improve assessment of LV contractility. METHODS Among 651 participants with HFrEF treated with sac/val, echocardiograms were performed at baseline, 6 and 12 months. Pretreatment median ICVs and LVEFs were used for classification to predict LV reverse remodeling, health status using the Kansas City Cardiomyopathy Questionnaire, and biomarker concentrations. RESULTS The mean age was 64.6 ± 12.4 years, and 28% were women, baseline LVEF: 28.9% ± 6.9%. Compared to baseline, median ICV increased post sac/val therapy (4.6 [3.5, 6.1] vs 4.9 [3.6, 6.4]; P = 0.005). ICV added value to separate and combined models of biomarkers and clinical and echocardiographic variables for prediction of post-therapy EF recovery. Classification using baseline ICV/EF yielded relatively equal numbers in 4 groups based on low/high ICV or LVEF. Most deleterious results for remodeling, health status and biomarkers were found in patients with low ICV/low EF, whereas patients with high ICV/high EF had the best profiles; other groups were intermediate. Significant shifts toward better ICV/EF profiles were noted post sac/val treatment compared to baseline, with doubling of high ICV/high EF (241 [60%] vs 123 [31%]) and 78% reduction of low ICV/low EF (28 [7%] vs 125 [32%]). CONCLUSIONS In HFrEF, ICV adds to the profiling of systolic function and represents an independent predictor of reverse cardiac remodeling after treatment with sac/val. ICV changes may be used for assessment of treatment responses.
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Affiliation(s)
| | | | | | - Ileana Piña
- Thomas Jefferson University, Philadelphia, PA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX; University of Mississippi, Jackson, MS
| | - Yuxi Liu
- Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Reza Mohebi
- Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Kirtipal Bhatia
- Department of Cardiovascular Medicine, Mount Sinai Morningside, New York, NY
| | | | | | - Scott D Solomon
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston. Baim Institute for Clinical Research, Boston, MA.
| | - Johanna Contreras
- Department of Cardiovascular Medicine, Mount Sinai Health System, New York, NY
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8
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Szabo B, Benson L, Savarese G, Hage C, Fudim M, Devore A, Pitt B, Lund LH. Previous heart failure hospitalization, spironolactone, and outcomes in heart failure with preserved ejection fraction - a secondary analysis of TOPCAT. Am Heart J 2024; 271:136-147. [PMID: 38412897 DOI: 10.1016/j.ahj.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Hospitalization for heart failure (HHF) is associated with poor postdischarge outcomes but the role of time since most recent HHF and potential treatment interactions are unknown. We aimed to assess history of and time since previous HHF, associations with composite of cardiovascular (CV) death and total HHF, first HHF and interactions with randomization to spironolactone, in heart failure with preserved ejection fraction. METHODS AND RESULTS We assessed these objectives using uni- and multivariable regressions and spline analyses in TOPCAT-Americas. Among 1,765 patients, 66% had a previous HHF. Over a median of 2.9 years, 1,064 composite events of CV death or total HHFs occurred. Previous HHF was associated with more severe HF, and was independently associated with the composite outcome (HR 1.26, 95%CI 1.05-1.52, P = .014), and all secondary outcomes. A shorter time since most recent HHF appeared to be associated with subsequent first HHF, but not the composite of CV death or total HHF. Spironolactone had a significant interaction with previous HHF (interaction-P .046). Patients without a previous HHF had a larger effect of spironolactone on the composite outcome (HR 0.63, 95%CI 0.46-0.87, P = .005) than patients with a previous HHF (HR 0.91, 95%CI 0.78-1.06, P = .224). CONCLUSION In TOPCAT-Americas, previous HHF was associated with CV death and first and total HHF. Duration since most recent HHF seemed to be associated with time to first HHF only. Spironolactone was associated with better outcomes in patients without a previous HHF. This interaction is hypothesis-generating and requires validation in future trials.
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Affiliation(s)
- Barna Szabo
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden
| | - Lina Benson
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden
| | - Gianluigi Savarese
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden; Karolinska University Hospital, Heart, Vascular and Neuro Theme, Stockholm, Sweden
| | - Camilla Hage
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden; Karolinska University Hospital, Heart, Vascular and Neuro Theme, Stockholm, Sweden
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, USA; Duke University Medical Center, Department of Medicine, Durham, USA
| | - Adam Devore
- Duke Clinical Research Institute, Durham, USA; Duke University Medical Center, Department of Medicine, Durham, USA
| | - Bertram Pitt
- University of Michigan School of Medicine, Department of Medicine, Ann Arbor, USA
| | - Lars H Lund
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden; Karolinska University Hospital, Heart, Vascular and Neuro Theme, Stockholm, Sweden.
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9
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Schmitt A, Behnes M, Rusnak J, Akin M, Reinhardt M, Abel N, Forner J, Müller J, Weidner K, Abumayyaleh M, Akin I, Schupp T. Characteristics Associated with Ventricular Tachyarrhythmias and Their Prognostic Impact in Heart Failure with Mildly Reduced Ejection Fraction. J Clin Med 2024; 13:2665. [PMID: 38731194 PMCID: PMC11084292 DOI: 10.3390/jcm13092665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/19/2024] [Accepted: 04/27/2024] [Indexed: 05/13/2024] Open
Abstract
Background: The occurrence of ventricular tachyarrhythmias represents an established risk factor of mortality in heart failure (HF). However, data concerning their prognostic impact in heart failure with mildly reduced ejection fraction (HFmrEF) is limited. Therefore, the present study aims to investigate patient characteristics associated with ventricular tachyarrhythmias and their prognostic impact in patients with HFmrEF. Methods: Consecutive patients hospitalized with HFmrEF (i.e., left ventricular ejection fraction 41-49% and signs and/or symptoms of HF) were retrospectively included at one institution from 2016 to 2022. The prognosis of patients with HFmrEF and different types of ventricular tachyarrhythmias (i.e., non-sustained ventricular tachycardia (nsVT), sustained VT (sVT), and ventricular fibrillation (VF) was investigated for the primary endpoint of long-term all-cause mortality at 30 months. Secondary endpoints included in-hospital all-cause mortality and long-term HF-related rehospitalization at 30 months. Results: From a total of 2184 patients with HFmrEF, 4.4% experienced ventricular tachyarrhythmias (i.e., 2.0% nsVT, 0.7% sVT, and 1.6% VF). The occurrence of nsVT was associated with higher New York Heart Association (NYHA) functional class, whereas the incidence of sVT/VF was associated with acute myocardial infarction and ischemic heart disease. However, nsVT (25.0%; HR = 0.760; 95% CI 0.419-1.380; p = 0.367) and sVT/VF (28.8%; HR = 0.928; 95% CI 0.556-1.549; p = 0.776) were not associated with a higher risk of long-term all-cause mortality compared to patients with HFmrEF without ventricular tachyarrhythmias (31.5%). In-hospital cardiovascular mortality was more frequently observed in patients with HFmrEF and sVT/VF compared to those with HFmrEF but without sustained ventricular tachyarrhythmias (7.7% vs. 1.5%; p = 0.004). Finally, the risk of rehospitalization for worsening HF was not affected by the presence of ventricular tachyarrhythmias. Conclusions: The occurrence of ventricular tachyarrhythmias in patients hospitalized with HFmrEF was low and not associated with long-term prognosis.
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Affiliation(s)
- Alexander Schmitt
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, 69047 Heidelberg, Germany
| | - Muharrem Akin
- Department of Cardiology, St. Josef-Hospital, Ruhr-Universität Bochum, 44791 Bochum, Germany
| | - Marielen Reinhardt
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Noah Abel
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Jan Forner
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Julian Müller
- Department of Cardiology, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, 79106 Freiburg im Breisgau, Germany
| | - Kathrin Weidner
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Mohammad Abumayyaleh
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Tobias Schupp
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
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Sindone AP, Driscoll A, Audehm R, Sverdlov AL, McVeigh J, Alicia Chan WP, Hickey A, Hopper I, Chang T, Maiorana A, Atherton JJ. Optimising Transitional Care Following a Heart Failure Hospitalisation in Australia. Heart Lung Circ 2024:S1443-9506(24)00193-8. [PMID: 38692982 DOI: 10.1016/j.hlc.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 11/18/2023] [Accepted: 11/26/2023] [Indexed: 05/03/2024]
Abstract
Hospitalisations for heart failure (HF) are associated with high rates of readmission and death, the most vulnerable period being within the first few weeks post-hospital discharge. Effective transition of care from hospital to community settings for patients with HF can help reduce readmission and mortality over the vulnerable period, and improve long-term outcomes for patients, their family or carers, and the healthcare system. Planning and communication underpin a seamless transition of care, by ensuring that the changes to patients' management initiated in hospital continue to be implemented following discharge and in the long term. This evidence-based guide, developed by a multidisciplinary group of Australian experts in HF, discusses best practice for achieving appropriate and effective transition of patients hospitalised with HF to community care in the Australian setting. It provides guidance on key factors to address before and after hospital discharge, as well as practical tools that can be used to facilitate a smooth transition of care.
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Affiliation(s)
- Andrew P Sindone
- Heart Failure Unit and Department of Cardiology, Concord Hospital, Sydney, NSW, Australia; The University of Sydney, Sydney, NSW, Australia.
| | - Andrea Driscoll
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; School of Nursing and Midwifery, Centre for Quality and Patient Safety, Faculty of Health, Deakin University, Geelong, Vic, Australia
| | - Ralph Audehm
- Department of General Practice and Primary Health Care, The University of Melbourne, Melbourne, Vic, Australia
| | - Aaron L Sverdlov
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia; Cardiovascular Department, John Hunter Hospital, Newcastle, NSW, Australia; Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - James McVeigh
- Heart Failure Service, The Prince of Wales Hospital, Randwick, NSW, Australia
| | | | | | - Ingrid Hopper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology and General Medicine Unit, Alfred Health, Melbourne, Vic, Australia
| | - Tim Chang
- Fiona Stanley Hospital, Perth, WA, Australia
| | - Andrew Maiorana
- School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia; Allied Health Department and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Perth, WA, Australia
| | - John J Atherton
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia; Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia; Faculty of Science, Health, Education and Engineering, University of Sunshine Coast, Sunshine Coast, Qld, Australia; Faculty of Health, Queensland University of Technology, Brisbane, Qld, Australia
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11
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von Haehling S, Assmus B, Bekfani T, Dworatzek E, Edelmann F, Hashemi D, Hellenkamp K, Kempf T, Raake P, Schütt KA, Wachter R, Schulze PC, Hasenfuss G, Böhm M, Bauersachs J. Heart failure with preserved ejection fraction: diagnosis, risk assessment, and treatment. Clin Res Cardiol 2024:10.1007/s00392-024-02396-4. [PMID: 38602566 DOI: 10.1007/s00392-024-02396-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/02/2024] [Indexed: 04/12/2024]
Abstract
The aetiology of heart failure with preserved ejection fraction (HFpEF) is heterogenous and overlaps with that of several comorbidities like atrial fibrillation, diabetes mellitus, chronic kidney disease, valvular heart disease, iron deficiency, or sarcopenia. The diagnosis of HFpEF involves evaluating cardiac dysfunction through imaging techniques and assessing increased left ventricular filling pressure, which can be measured directly or estimated through various proxies including natriuretic peptides. To better narrow down the differential diagnosis of HFpEF, European and American heart failure guidelines advocate the use of different algorithms including comorbidities that require diagnosis and rigorous treatment during the evaluation process. Therapeutic recommendations differ between guidelines. Whilst sodium glucose transporter 2 inhibitors have a solid evidence base, the recommendations differ with regard to the use of inhibitors of the renin-angiotensin-aldosterone axis. Unless indicated for specific comorbidities, the use of beta-blockers should be discouraged in HFpEF. The aim of this article is to provide an overview of the current state of the art in HFpEF diagnosis, clinical evaluation, and treatment.
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Affiliation(s)
- Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.
| | - Birgit Assmus
- Department of Cardiology and Angiology, Universitätsklinikum Gießen und Marburg, Giessen, Germany
| | - Tarek Bekfani
- Department of Cardiology and Angiology, Universitätsklinikum Magdeburg, Magdeburg, Germany
| | - Elke Dworatzek
- Institute of Gender in Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Frank Edelmann
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Campus Virchow-Klinikum, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Djawid Hashemi
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Campus Virchow-Klinikum, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Program, Berlin, Germany
| | - Kristian Hellenkamp
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
| | - Tibor Kempf
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Philipp Raake
- I. Medical Department, Cardiology, Pneumology, Endocrinology and Intensive Care Medicine, University Hospital Augsburg, University of Augsburg, Augsburg, Germany
| | - Katharina A Schütt
- Department of Internal Medicine I, University Hospital RWTH Aachen, Aachen, Germany
| | - Rolf Wachter
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Paul Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, FSU, Jena, Germany
| | - Gerd Hasenfuss
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Michael Böhm
- Kardiologie, Angiologie und Internistische Intensivmedizin, Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
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12
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Balestrieri G, Limonta R, Ponti E, Merlo A, Sciatti E, D'Isa S, Gori M, Casu G, Giannattasio C, Senni M, D'Elia E. The Therapy and Management of Heart Failure with Preserved Ejection Fraction: New Insights on Treatment. Card Fail Rev 2024; 10:e05. [PMID: 38708376 PMCID: PMC11066852 DOI: 10.15420/cfr.2023.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 10/28/2023] [Indexed: 05/07/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome characterised by the presence of diastolic dysfunction and elevated left ventricular filling pressure, in the setting of a left ventricular ejection fraction of at least 50%. Despite the epidemiological prevalence of HFpEF, a prompt diagnosis is challenging and many uncertainties exist. HFpEF is characterised by different phenotypes driven by various cardiac and non-cardiac comorbidities. This is probably the reason why several HFpEF clinical trials in the past did not reach strong outcomes to recommend a single therapy for this syndrome; however, this paradigm has recently changed, and the unmet clinical need for HFpEF treatment found a proper response as a result of a new class of drug, the sodium-glucose cotransporter 2 inhibitors, which beneficially act through the whole spectrum of left ventricular ejection fraction. The aim of this review was to focus on the therapeutic target of HFpEF, the role of new drugs and the potential role of new devices to manage the syndrome.
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Affiliation(s)
| | - Raul Limonta
- School of Medicine and Surgery, Milano Bicocca UniversityMilan, Italy
| | - Enrico Ponti
- Department of Medical, Surgical and Experimental Sciences, University of SassariSassari, Italy
| | - Anna Merlo
- School of Medicine and Surgery, Milano Bicocca UniversityMilan, Italy
| | - Edoardo Sciatti
- Cardiovascular Department, ASST Papa Giovanni XXIIIBergamo, Italy
| | - Salvatore D'Isa
- Cardiovascular Department, ASST Papa Giovanni XXIIIBergamo, Italy
| | - Mauro Gori
- Cardiovascular Department, ASST Papa Giovanni XXIIIBergamo, Italy
| | - Gavino Casu
- Department of Medical, Surgical and Experimental Sciences, University of SassariSassari, Italy
| | | | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIIIBergamo, Italy
- Department of Medicine and Surgery, University of Milano BicoccaMilan, Italy
| | - Emilia D'Elia
- Cardiovascular Department, ASST Papa Giovanni XXIIIBergamo, Italy
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13
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Zafeiropoulos S, Farmakis IT, Milioglou I, Doundoulakis I, Gorodeski EZ, Konstantinides SV, Cooper L, Zanos S, Stavrakis S, Giamouzis G, Butler J, Giannakoulas G. Pharmacological Treatments in Heart Failure With Mildly Reduced and Preserved Ejection Fraction: Systematic Review and Network Meta-Analysis. JACC. HEART FAILURE 2024; 12:616-627. [PMID: 37656079 DOI: 10.1016/j.jchf.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Medical treatment for heart failure with preserved ejection (HFpEF) and heart failure with mildly reduced ejection fraction (HFmrEF) has weaker evidence compared with reduced ejection fraction, despite recent trials with an angiotensin receptor neprilysin inhibitor (ARNI) and sodium glucose co-transporter 2 inhibitors (SGLT2is). OBJECTIVES The authors aimed to estimate the aggregate therapeutic benefit of drugs for HFmrEF and HFpEF. METHODS The authors performed a systematic review of MEDLINE, CENTRAL, and Web of Science for randomized trials including patients with heart failure (HF) and left ventricular ejection fraction (LVEF) >40%, treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (analyzed together as renin-angiotensin system inhibitors [RASi]), beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), digoxin, ARNI, and SGLT2i. An additive component network meta-analysis was performed. The primary outcome was a composite of cardiovascular (CV) death and first hospitalization for heart failure (HHF); secondary outcomes were CV death, total HHF, and all-cause mortality. RESULTS The authors identified 13 studies with a total of 29,875 patients and a mean LVEF of 56.3% ± 8.7%. ARNI, MRA, and SGLT2i separately, but not RASi, BB, or digoxin, reduced the primary composite outcome compared with placebo. The combination of ARNI, BB, MRA, and SGLT2i was the most effective (HR: 0.47 [95% CI: 0.31-0.70]); this was largely explained by the triple combination of ARNI, MRA, and SGLT2i (HR: 0.56 [95% CI 0.43-0.71]). Results were similar for CV death (HR: 0.63 [95% CI 0.43-0.91] for ARNI, MRA, and SGLT2i) or total HHF (HR: 0.49 [95% CI 0.33-0.71] for ARNI, MRA, and SGLT2i) alone. In a subgroup analysis, only SGLT2i had a consistent benefit among all LVEF subgroups, whereas the triple combination had the greatest benefit in HFmrEF, robust benefit in patients with LVEF 50% to 59%, and a statistically marginal benefit in patients with LVEF ≥60%. CONCLUSIONS In patients with HF and LVEF>40%, the quadruple combination of ARNI, BB, MRA, and SGLT2i provides the largest reduction in the risk of CV death and HHF; driven by the robust effect of the triple combination of ARNI, MRA, and SGLT2i. The benefit was more pronounced in HFmrEF patients.
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Affiliation(s)
- Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, New York, USA; Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Germany; Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece
| | - Ioannis Milioglou
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio, USA
| | - Ioannis Doundoulakis
- Athens Heart Center, Athens Medical Center, Athens, Greece; First Department of Cardiology, National and Kapodistrian University, "Hippokration" Hospital, Athens, Greece
| | - Eiran Z Gorodeski
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio, USA
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupoli, Greece
| | - Lauren Cooper
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA; Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, USA
| | - Stavros Zanos
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - Grigorios Giamouzis
- Department of Cardiology, University of Thessaly, Larissa, Greece; Faculty of Medicine, School of Health Sciences, University of Thessaly, Greece
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA
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14
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Triposkiadis F, Xanthopoulos A, Drakos SG, Boudoulas KD, Briasoulis A, Skoularigis J, Tsioufis K, Boudoulas H, Starling RC. Back to the basics: The need for an etiological classification of chronic heart failure. Curr Probl Cardiol 2024; 49:102460. [PMID: 38346611 DOI: 10.1016/j.cpcardiol.2024.102460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/09/2024] [Indexed: 02/23/2024]
Abstract
The left ventricular (LV) ejection fraction (LVEF), despite its severe limitations, has had an epicentral role in heart failure (HF) classification, management, and risk stratification for decades. The major argument favoring the LVEF based HF classification has been that it defines groups of patients in which treatment is effective. However, this reasoning has recently collapsed, since medical treatment with neurohormonal inhibitors, has proved beneficial in most HF patients regardless of the LVEF. In addition, there has been compelling evidence, that the LVEF provides poor guidance for device treatment of chronic HF (implantation of cardioverter defibrillator, cardiac resynchronization therapy) since sudden cardiac death may occur and cardiac dyssynchronization may be disastrous in all HF patients. The same holds true for LV assist device implantation, in which the LVEF has been used as a surrogate for LV size. In this review article we update the evidence questioning the use of LVEF-based HF classification and argue that guidance of chronic HF treatment should transition to more contemporary concepts. Specifically, we propose an etiologic chronic HF classification predominantly based on epidemiological data, which will be foundational for further higher resolution phenotyping in the emerging era of precision medicine.
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Affiliation(s)
- Filippos Triposkiadis
- School of Medicine, European University Cyprus, Nicosia 2404, Cyprus; Department of Cardiology, University Hospital of Larissa, Larissa 41110, Greece.
| | - Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, Larissa 41110, Greece
| | - Stavros G Drakos
- University of Utah Health and School of Medicine and Salt Lake VA Medical Center, Salt Lake City, UT 84108, USA
| | | | - Alexandros Briasoulis
- Medical School of Athens, National and Kapodistrian University of Athens, Athens 15772, Greece
| | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, Larissa 41110, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, Medical School, Hippokration Hospital, University of Athens, Athens 115 27, Greece
| | | | - Randall C Starling
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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15
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Bozkurt B. Contemporary pharmacological treatment and management of heart failure. Nat Rev Cardiol 2024:10.1038/s41569-024-00997-0. [PMID: 38532020 DOI: 10.1038/s41569-024-00997-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 03/28/2024]
Abstract
The prevention and treatment strategies for heart failure (HF) have evolved in the past two decades. The stages of HF have been redefined, with recognition of the pre-HF state, which encompasses asymptomatic patients who have developed either structural or functional cardiac abnormalities or have elevated plasma levels of natriuretic peptides or cardiac troponin. The first-line treatment of patients with HF with reduced ejection fraction includes foundational therapies with angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, mineralocorticoid receptor antagonists, sodium-glucose cotransporter 2 (SGLT2) inhibitors and diuretics. The first-line treatment of patients with HF with mildly reduced ejection fraction or with HF with preserved ejection fraction includes SGLT2 inhibitors and diuretics. The timely initiation of these disease-modifying therapies and the optimization of treatment are crucial in all patients with HF. Reassessment after initiation of these therapies is recommended to evaluate patient symptoms, health status and left ventricular function, and timely referral to a HF specialist is necessary if a patient has persistent advanced HF symptoms or worsening HF. Lifestyle modification and treatment of comorbidities such as diabetes mellitus, ischaemic heart disease and atrial fibrillation are crucial through each stage of HF. This Review provides an overview of the management strategies for HF according to disease stages that are derived from the recommendations in the latest US and European HF guidelines.
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Affiliation(s)
- Biykem Bozkurt
- Winters Center for Heart Failure Research, Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX, USA.
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16
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Fan L, Gu L, Yao Y, Ma G. High serum fibroblast growth factor 21 levels were related to the prognosis and ventricular remodeling of heart failure patients with mildly reduced and reduced ejection fraction. Perfusion 2024; 39:285-293. [PMID: 36321746 DOI: 10.1177/02676591221137482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Previous studies have shown that fibroblast growth factor 21 (FGF21) is involved in the ventricular remodeling process in heart failure with preserved ejection fraction (HFpEF). We hypothesized that high levels of FGF21 correlated with the ventricular remodeling of heart failure patients with mildly reduced (HFmrEF) and reduced ejection fraction (HFrEF). METHODS A total of 203 participants with HFmrEF or HFrEF were enrolled and followed up from June 2018 to June 2021. 68 subjects without heart failure (HF) underwent physical examinations during the same time were selected as the control group. The primary endpoint was the occurrence of major adverse cardiovascular events (MACEs), which were defined as all-cause or cardiac mortality and rehospitalization for decompensation. Serum FGF21 levels were measured early the next morning after admission using enzyme-linked immunosorbent assay (ELISA). RESULTS The FGF21 levels were significantly higher in patients with HFmrEF or HFrEF than that in the control group (213.57 ± 42.65 pg/mL, 222.93 ± 34.36 pg/mL vs 171.00 ± 12.86 pg/mL, p < .001). The serum levels of FGF21 and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were both higher in the endpoint event group than those of non-endpoint event group regardless of the HFmrEF or HFrEF group (p < .001). Spearman's correlation revealed that FGF21 was positively correlated with left ventricular end-systolic diameter left ventricular end-diastolic diameter left ventricular mass index (p < .01). Moreover, there was a negative correlation between FGF21 and left ventricular ejection fraction in addition to relative wall thickness (p < .001). The area under the receiver operating characteristic (ROC) curve (AUC) of FGF21 was 0.874. The optimal cut-off value of FGF21 determined by ROC curve was 210.11 pg/mL. The Kaplan-Meier analysis demonstrated that the low FGF21 levels group had an increased MACE-free survival rate compared with the high FGF21 levels group. On univariate and multivariate Cox analysis, it was seen that both serum FGF21 and NT-proBNP were independent predictors of a poor prognosis in HF patients. CONCLUSION Baseline levels of FGF21 and NT-proBNP were related to the ventricular remodeling of patients with a mildly reduced or reduced ejection fraction. FGF21 and NT-proBNP both had good prognostic value for MACEs in heart failure patients with a mildly reduced and reduced ejection fraction.
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Affiliation(s)
- Liuzhang Fan
- Department of Cardiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, China
- Department of Cardiology, Yancheng First Hospital, Affiliated Hospital of Nanjing University Medical School, Yancheng, China
| | - Lingyun Gu
- Department of Cardiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, China
| | - Yuyu Yao
- Department of Cardiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, China
| | - Genshan Ma
- Department of Cardiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, China
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17
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Dimond MG, Ibrahim NE, Fiuzat M, McMurray JJV, Lindenfeld J, Ahmad T, Bozkurt B, Bristow MR, Butler J, Carson PE, Felker GM, Jessup M, Murillo J, Kondo T, Solomon SD, Abraham WT, O'Connor CM, Psotka MA. Left Ventricular Ejection Fraction and the Future of Heart Failure Phenotyping. JACC. HEART FAILURE 2024; 12:451-460. [PMID: 38099892 DOI: 10.1016/j.jchf.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/19/2023] [Accepted: 11/04/2023] [Indexed: 02/04/2024]
Abstract
Heart failure (HF) is a complex syndrome traditionally classified by left ventricular ejection fraction (LVEF) cutpoints. Although LVEF is prognostic for risk of events and predictive of response to some HF therapies, LVEF is a continuous variable and cutpoints are arbitrary, often based on historical clinical trial enrichment decisions rather than physiology. Holistic evaluation of the treatment effects for therapies throughout the LVEF range suggests the standard categorization paradigm for HF merits modification. The multidisciplinary Heart Failure Collaboratory reviewed data from large-scale HF clinical trials and found that many HF therapies have demonstrated therapeutic benefit across a large range of LVEF, but specific treatment effects vary across that range. Therefore, HF should practically be classified by association with an LVEF that is reduced or not reduced, while acknowledging uncertainty around the precise LVEF cutpoint, and future research should evaluate new therapies across the continuum of LVEF.
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Affiliation(s)
| | | | - Mona Fiuzat
- Duke University Medical Center, Durham, North Carolina, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - JoAnn Lindenfeld
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Tariq Ahmad
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Michael R Bristow
- University of Colorado Anschutz School of Medicine, Aurora, Colorado, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA
| | | | | | | | | | - Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | | | - Christopher M O'Connor
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA; Duke University Medical Center, Durham, North Carolina, USA
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18
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Meifang W, Ying W, Wen C, Kaizu X, Meiyan S, Liming L. Advance in the pharmacological and comorbidities management of heart failure with preserved ejection fraction: evidence from clinical trials. Heart Fail Rev 2024; 29:305-320. [PMID: 37561223 DOI: 10.1007/s10741-023-10338-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 08/11/2023]
Abstract
The prevalence of heart failure with preserved ejection fraction (HFpEF) accounts for approximately 50% of the total heart failure population, and with the aging of the population and the increasing prevalence of hypertension, obesity, and type 2 diabetes (T2DM), the incidence of HFpEF continues to rise and has become the most common subtype of heart failure. Compared with heart failure with reduced ejection fraction, HFpEF has a more complex pathophysiology and is more often associated with hypertension, T2DM, obesity, atrial fibrillation, renal insufficiency, pulmonary hypertension, obstructive sleep apnea, and other comorbidities. HFpEF has generally been considered a syndrome with high phenotypic heterogeneity, and no effective treatments have been shown to reduce mortality to date. Diuretics and comorbidity management are traditional treatments for HFpEF; however, they are mostly empirical due to a lack of clinical evidence in the setting of HFpEF. With the EMPEROR-Preserved and DELIVER results, sodium-glucose cotransporter 2 inhibitors become the first evidence-based therapies to reduce rehospitalization for heart failure. Subgroup analyses of the PARAGON-HF, TOPCAT, and CHARM-Preserved trials suggest that angiotensin receptor-neprilysin inhibitors, spironolactone, and angiotensin II receptor blockers may be beneficial in patients at the lower end of the ejection fraction spectrum. Other potential pharmacotherapies represented by non-steroidal mineralocorticoid receptor antagonists finerenone and antifibrotic agent pirfenidone also hold promise for the treatment of HFpEF. This article intends to review the clinical evidence on current pharmacotherapies of HFpEF, as well as the comorbidities management of atrial fibrillation, hypertension, T2DM, obesity, pulmonary hypertension, renal insufficiency, obstructive sleep apnea, and iron deficiency, to optimize the clinical management of HFpEF.
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Affiliation(s)
- Wu Meifang
- Department of Cardiology, School of Clinical Medicine, Fujian Medical University, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Wu Ying
- Department of Cardiology, School of Clinical Medicine, Fujian Medical University, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Chen Wen
- Department of Cardiology, School of Clinical Medicine, Fujian Medical University, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Xu Kaizu
- Department of Cardiology, School of Clinical Medicine, Fujian Medical University, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Song Meiyan
- Department of Cardiology, School of Clinical Medicine, Fujian Medical University, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Lin Liming
- Department of Cardiology, School of Clinical Medicine, Fujian Medical University, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China.
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19
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Santas E, Llácer P, Palau P, de la Espriella R, Miñana G, Lorenzo M, Núñez-Marín G, Miró Ò, Chorro FJ, Bayés-Genís A, Sanchis J, Núñez J. Noncardiovascular morbidity and mortality across left ventricular ejection fraction categories following hospitalization for heart failure. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:206-214. [PMID: 37315921 DOI: 10.1016/j.rec.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 05/16/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION AND OBJECTIVES Noncardiovascular events represent a significant proportion of the morbidity and mortality burden in patients with heart failure (HF). However, the risk of these events appears to differ by left ventricular ejection fraction (LVEF) status. In this study, we sought to evaluate the risk of noncardiovascular death and recurrent noncardiovascular readmission by LVEF status following an admission for acute HF. METHODS We retrospectively assessed a cohort of 4595 patients discharged after acute HF in a multicenter registry. We evaluated LVEF as a continuum, stratified in 4 categories (LVEF ≤ 40%, 41%-49%, 50%-59%, and ≥ 60%). Study endpoints were the risks of noncardiovascular mortality and recurrent noncardiovascular admissions during follow-up. RESULTS At a median follow-up of 2.2 [interquartile range, 0.76-4.8] years, we registered 646 noncardiovascular deaths and 4014 noncardiovascular readmissions. After multivariable adjustment including cardiovascular events as a competing event, LVEF status was associated with the risk of noncardiovascular mortality and recurrent noncardiovascular admissions. When compared with patients with LVEF ≤ 40%, those with LVEF 51%-59%, and especially those with LVEF ≥ 60%, were at higher risk of noncardiovascular mortality (HR, 1.31; 95%CI, 1.02-1,68; P=.032; and HR, 1.47; 95%CI, 1.15-1.86; P=.002; respectively), and at higher risk of recurrent noncardiovascular admissions (IRR, 1.17; 95%CI, 1.02-1.35; P=.024; and IRR, 1.26; 95%CI, 1.11-1.45; P=.001; respectively). CONCLUSIONS Following an admission for HF, LVEF status was directly associated with the risk of noncardiovascular morbidity and mortality. Patients with HFpEF were at higher risk of noncardiovascular death and total noncardiovascular readmissions, especially those with LVEF ≥ 60%.
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Affiliation(s)
- Enrique Santas
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Pau Llácer
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Patricia Palau
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Rafael de la Espriella
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Gema Miñana
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Miguel Lorenzo
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Gonzalo Núñez-Marín
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Òscar Miró
- Servicio de Urgencias, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Francisco Javier Chorro
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Antoni Bayés-Genís
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
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20
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Faluk M, Wardhere A, Thakker R, Khan FA. SGLT2 inhibitors in heart failure with preserved ejection fraction. Curr Probl Cardiol 2024; 49:102388. [PMID: 38184133 DOI: 10.1016/j.cpcardiol.2024.102388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 01/04/2024] [Indexed: 01/08/2024]
Abstract
Heart failure (HF) is a clinical syndrome due to either functional or structural impairment of the ventricular pump or filling, representing a major cause of global morbidity and mortality. Heart failure with preserved ejection fraction (HFpEF), characterized by a left ventricular ejection fraction (LVEF) of ≥50%, constitutes over half of the HF population, with a rising prevalence. Until recently, therapeutic options in treating HFpEF and reducing hospitalization and mortality remained limited. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown promising results in this patient population. This review article explores current literature and significant clinical trials investigating the impact of sodium- SGLT2 inhibitors in patients with HFpEF.
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Affiliation(s)
- Mohammed Faluk
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX 77550.
| | - Abdirahman Wardhere
- Department of Internal Medicine, Division of Cardiovascular Medicine, Columbia University Irving Medical Center
| | - Ravi Thakker
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX 77550
| | - Fatima A Khan
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX 77550
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21
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Lucà F, Oliva F, Abrignani MG, Di Fusco SA, Gori M, Giubilato S, Ceravolo R, Temporelli PL, Cornara S, Rao CM, Caretta G, Pozzi A, Binaghi G, Maloberti A, Di Nora C, Di Matteo I, Pilleri A, Gelsomino S, Riccio C, Grimaldi M, Colivicchi F, Gulizia MM. Heart Failure with Preserved Ejection Fraction: How to Deal with This Chameleon. J Clin Med 2024; 13:1375. [PMID: 38592244 PMCID: PMC10933980 DOI: 10.3390/jcm13051375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/11/2024] [Accepted: 02/14/2024] [Indexed: 04/10/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is characterized by a notable heterogeneity in both phenotypic and pathophysiological features, with a growing incidence due to the increase in median age and comorbidities such as obesity, arterial hypertension, and cardiometabolic disease. In recent decades, the development of new pharmacological and non-pharmacological options has significantly impacted outcomes, improving clinical status and reducing mortality. Moreover, a more personalized and accurate therapeutic management has been demonstrated to enhance the quality of life, diminish hospitalizations, and improve overall survival. Therefore, assessing the peculiarities of patients with HFpEF is crucial in order to obtain a better understanding of this disorder. Importantly, comorbidities have been shown to influence symptoms and prognosis, and, consequently, they should be carefully addressed. In this sense, it is mandatory to join forces with a multidisciplinary team in order to achieve high-quality care. However, HFpEF remains largely under-recognized and under-treated in clinical practice, and the diagnostic and therapeutic management of these patients remains challenging. The aim of this paper is to articulate a pragmatic approach for patients with HFpEF focusing on the etiology, diagnosis, and treatment of HFpEF.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, 89129 Reggio Calabria, Italy
| | - Fabrizio Oliva
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (A.M.)
| | | | | | - Mauro Gori
- Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Simona Giubilato
- Cardiology Department, Ospedale Lamezia Terme, 88046 Catanzaro, Italy
| | - Roberto Ceravolo
- Cardiac Rehabilitation Unitof Maugeri, IRCCS, 28010 Gattico-Veruno, Italy
| | | | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy;
| | | | - Giorgio Caretta
- Levante Ligure Sant’Andrea Hospital, ASL 5 Liguria, 19121 La Spezia, Italy
| | - Andrea Pozzi
- Cardiology Division, Valduce Hospital, 22100 Como, Italy
| | - Giulio Binaghi
- Department of Cardiology, Azienda Ospedaliera Brotzu, 09134 Cagliari, Italy
| | - Alessandro Maloberti
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (A.M.)
| | - Concetta Di Nora
- Department of Cardiothoracic Science, Azienda Sanitaria UniversitariaIntegrata di Udine, 33100 Udine, Italy
| | - Irene Di Matteo
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (A.M.)
| | - Anna Pilleri
- Department of Cardiology, Azienda Ospedaliera Brotzu, 09134 Cagliari, Italy
| | - Sandro Gelsomino
- Cardiovascular Research Institute, Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy
| | - Furio Colivicchi
- Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Rome, Italy
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22
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Schmitt A, Schupp T, Reinhardt M, Abel N, Lau F, Forner J, Ayoub M, Mashayekhi K, Weiß C, Akin I, Behnes M. Prognostic impact of acute decompensated heart failure in patients with heart failure with mildly reduced ejection fraction. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:225-241. [PMID: 37950915 DOI: 10.1093/ehjacc/zuad139] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/13/2023]
Abstract
AIMS This study sought to determine the prognostic impact of acute decompensated heart failure (ADHF) in patients with heart failure with mildly reduced ejection fraction (HFmrEF). ADHF is a major complication in patients with heart failure (HF). However, the prognostic impact of ADHF in patients with HFmrEF has not yet been clarified. METHODS AND RESULTS Consecutive patients hospitalized with HFmrEF (i.e. left ventricular ejection fraction 41-49% and signs and/or symptoms of HF) were retrospectively included at one institution from 2016 to 2022. The prognosis of patients with ADHF was compared with those without (i.e. non-ADHF). The primary endpoint was long-term all-cause mortality. Secondary endpoints included in-hospital all-cause mortality and long-term HF-related re-hospitalization. Kaplan-Meier, multivariable Cox proportional regression, and propensity score matched analyses were performed for statistics. Long-term follow-up was set at 30 months. A total of 2184 patients with HFmrEF were included, ADHF was present in 22%. The primary endpoint was higher in ADHF compared to non-ADHF patients with HFmrEF [50% vs. 26%; hazard ratio (HR) = 2.269; 95% confidence interval (CI) 1.939-2.656; P = 0.001]. Accordingly, the secondary endpoint of long-term HF-related re-hospitalization was significantly higher (27% vs. 10%; HR = 3.250; 95% CI 2.565-4.118; P = 0.001). A history of previous ADHF before the index hospitalization was associated with higher rates of long-term HF-related re-hospitalization (42% vs. 23%; HR = 2.073; 95% CI 1.420-3.027; P = 0.001), but not with long-term all-cause mortality (P = 0.264). CONCLUSION ADHF is a common finding in patients with HFmrEF associated with an adverse impact on long-term prognosis.
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Affiliation(s)
- Alexander Schmitt
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
| | - Tobias Schupp
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
| | - Marielen Reinhardt
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
| | - Noah Abel
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
| | - Felix Lau
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
| | - Jan Forner
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
| | - Mohamed Ayoub
- Division of Cardiology and Angiology, Heart Centre University of Bochum, Bad Oeynhausen 32545, Germany
| | - Kambis Mashayekhi
- Department of Internal Medicine and Cardiology, MediClin Heart Centre Lahr, Lahr, Germany
| | - Christel Weiß
- Faculty of Medicine Mannheim, Institute of Biomathematics and Medical Statistics, University Medical Centre, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
| | - Michael Behnes
- First Department of Medicine, Section for Invasive Cardiology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany
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23
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Rivera-Toquica A, Saldarriaga C, Buelvas-Herazo J, Rolong B, Manzur-Jatin F, Mosquera-Jimenez JI, Pacheco-Jimenez OA, Rodriguez-Ceron AH, Rodriguez-Gomez P, Rivera-Toquica F, Trout-Guardiola G G, De Leon-Espitia MA, Castro-Osorio EE, Echeverria LE, Gomez-Mesa JE. Characteristics and Outcomes of Atrial Fibrillation in Chronic Heart Failure Patients: A Comprehensive Analysis of the Colombian Heart Failure Registry. Cardiol Res 2024; 15:37-46. [PMID: 38464710 PMCID: PMC10923258 DOI: 10.14740/cr1589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/02/2023] [Indexed: 03/12/2024] Open
Abstract
Background Heart failure (HF) and atrial fibrillation (AF) represent conditions that commonly coexist. The impact of AF in HF has yet to be well studied in Latin America. This study aimed to characterize the sociodemographic and clinical features, along with patients' outcomes with AF and HF from the Colombian Heart Failure Registry (RECOLFACA). Methods Patients with ambulatory HF and AF were included in RECOLFACA, mainly with persistent or permanent AF. A 6-month follow-up was performed. Primary outcome was all-cause mortality. To assess the impact of AF on mortality, we used a logistic regression model. A P value of < 0.05 was considered significant. All statistical tests were two-tailed. Results Of 2,528 patients with HF in the registry, 2,514 records included information regarding AF diagnosis. Five hundred sixty (22.3%) were in AF (mean age 73 ± 11, 56% men), while 1,954 had no AF (mean age 66 ± 14 years, 58% men). Patients with AF were significantly older and had a different profile of comorbidities and implanted devices compared to non-AF patients. Moreover, AF diagnosis was associated with lower quality of life score (EuroQol-5D), mainly in mobility, personal care, and daily activity. AF was prevalent in patients with preserved ejection fraction (EF), while no significant differences in N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels were observed. Although higher mortality was observed in the AF group compared to individuals without AF (8.9% vs. 6.1%, respectively; P = 0.016), this association lost statistical significance after adjusting by age in a multivariate regression model (odds ratio (OR): 1.35; 95% confidence interval (CI): 0.95 - 1.92). Conclusions AF is more prevalent in HF patients with higher EF, lower quality of life and different clinical profiles. Similar HF severity and non-independent association with mortality were observed in our cohort. These results emphasize the need for an improved understanding of the AF and HF coexistence phenomenon.
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Affiliation(s)
- Alex Rivera-Toquica
- Department of Cardiology, Centro Medico para el Corazon, Pereira, Colombia
- Department of Cardiology, Clinica Los Rosales S.A., Pereira, Colombia
- Department of Cardiology, Universidad Tecnologica de Pereira, Pereira, Colombia
| | | | | | - Balkis Rolong
- Department of Cardiology, Cardiologia Integral, Barranquilla, Colombia
| | | | | | | | | | | | - Fernando Rivera-Toquica
- Department of Internal Medicine, Clinica Los Rosales S.A., Pereira, Colombia
- Department of Internal Medicine, IPS Virrey Solis, Pereira, Colombia
| | | | | | | | | | - Juan Esteban Gomez-Mesa
- Department of Cardiology, Fundacion Valle del Lili, Cali, Colombia
- Department of Health Sciences, Universidad Icesi, Cali, Colombia
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24
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Zheng Y, Zheng H, Guo Z. Comparative efficacy of five traditional Chinese medicine injections for treating heart failure with reduced and mildly reduced ejection fraction: Bayesian network meta-analysis. Heliyon 2024; 10:e23194. [PMID: 38116192 PMCID: PMC10726254 DOI: 10.1016/j.heliyon.2023.e23194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 10/12/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
Background More than half of all heart failure (HF) patients have heart failure with reduced ejection fraction (HFrEF) or mildly reduced ejection fraction (HFmrEF). The combination of traditional Chinese medicine injections (TCMIs) with Western medicine treatment (WMT) has been reported to have better efficacy than using WMT alone. However, the positive effects of TCMIs combined with WMT on HFrEF and HFmrEF require more comprehensive and systematic evidence and warrant further investigation. Methods The NMA searched eight databases, including four English and four Chinese, from database creation to November 10, 2022. We used the Cochrane Risk of Bias tool (ROB 2) to assess the selected studies' quality. OpenBUGS and STATA 17.0 were used for network meta-analysis. Results The 101 RCTs were included in the systematic review. Studies have shown that when combined with any of the five TCMIs, WMT was more efficient than WMT alone. Shenmai injection (SMI) + WMT may be the best treatment for clinical effectiveness rate (CER) improvement and b-type natriuretic peptide (BNP) reduction. Huangqi injection (HQI) + WMT was the best treatment for improving left ventricular ejection fraction (LVEF). Danhong injection (DHI) + WMT may be the best treatment for lowering left ventricular end-diastolic dimension (LVEDD). Xinmailong injection (XMLI) + WMT was likely the best treatment for increasing the 6-min walking test (6MWT). In addition, XMLI had the lowest incidence of adverse reactions (3.38%). Conclusions Shenfu injection (SFI), SMI, DHI, XMLI, and HQI combined with WMT have stronger efficiency in treating HFrEF and HFmrEF. However, as all studies were conducted in China, this review is limited by the inevitable selection bias, and further high-quality multicenter randomized controlled trials (RCTs) are required.
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Affiliation(s)
- Yu Zheng
- First Clinical College of Chinese Medicine, Hunan University of Chinese Medicine, Changsha 410007, China
- College of Chinese Medicine, Hunan University of Chinese Medicine, Changsha 410208, China
| | - Huizhen Zheng
- First Clinical College of Chinese Medicine, Hunan University of Chinese Medicine, Changsha 410007, China
- College of Chinese Medicine, Hunan University of Chinese Medicine, Changsha 410208, China
| | - Zhihua Guo
- College of Chinese Medicine, Hunan University of Chinese Medicine, Changsha 410208, China
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25
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Savarese G, Gatti P, Benson L, Adamo M, Chioncel O, Crespo-Leiro MG, Anker SD, Coats AJS, Filippatos G, Lainscak M, McDonagh T, Mebazaa A, Metra M, Piepoli MF, Rosano GMC, Ruschitzka F, Seferovic P, Volterrani M, Maggioni AP, Lund LH. Left ventricular ejection fraction digit bias and reclassification of heart failure with mildly reduced vs reduced ejection fraction based on the 2021 definition and classification of heart failure. Am Heart J 2024; 267:52-61. [PMID: 37972677 DOI: 10.1016/j.ahj.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/23/2023] [Accepted: 11/04/2023] [Indexed: 11/19/2023]
Abstract
AIMS Aims were to evaluate (1) reclassification of patients from heart failure with mildly reduced (HFmrEF) to reduced (HFrEF) ejection fraction when an EF = 40% was considered as HFrEF, (2) role of EF digit bias, ie, EF reporting favouring 5% increments; (3) outcomes in relation to missing and biased EF reports, in a large multinational HF registry. METHODS AND RESULTS Of 25,154 patients in the European Society of Cardiology (ESC) HF Long-Term registry, 17% had missing EF and of those with available EF, 24% had HFpEF (EF≥50%), 21% HFmrEF (40%-49%) and 55% HFrEF (<40%) according to the 2016 ESC guidelines´ classification. EF was "exactly" 40% in 7%, leading to reclassifying 34% of the HFmrEF population defined as EF = 40% to 49% to HFrEF when applying the 2021 ESC Guidelines classification (14% had HFmrEF as EF = 41% to 49% and 62% had HFrEF as EF≤40%). EF was reported as a value ending with 0 or 5 in ∼37% of the population. Such potential digit bias was associated with more missing values for other characteristics and higher risk of all-cause death and HF hospitalization. Patients with missing EF had higher risk of all-cause and CV mortality, and HF hospitalization compared to those with recorded EF. CONCLUSIONS Many patients had reported EF = 40%. This led to substantial reclassification of EF from old HFmrEF (40%-49%) to new HFrEF (≤40%). There was considerable digit bias in EF reporting and missing EF reporting, which appeared to occur not at random and may reflect less rigorous overall care and worse outcomes.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden.
| | - Paolo Gatti
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Maria G Crespo-Leiro
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Complexo Hospitalario Universitario A Coruna, CHUAC, INIBIC, UDC, CIBERCV, La Coruna, Spain
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | | | - Gerasimos Filippatos
- Heart Failure Unit, Department of Cardiology, University Hospital Attikon, National and Kapodistrian Univeristy of Athens, Athens, Greece
| | - Mitja Lainscak
- Division of Cardiology, Murska Sobota, Murska Sobota and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Alexandre Mebazaa
- UMR 942 Inserm - MASCOT; University of Paris, Paris, France; Department of Anesthesia-Burn-Critical Care, APHP Saint Louis Lariboisière University Hospitals, Paris, France
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Massimo F Piepoli
- Clinical Cardiology, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | | | | | - Petar Seferovic
- University of Belgrade Faculty of Medicine, Belgrade, Serbia
| | | | - Aldo P Maggioni
- ANMCO Research Center, He 1 art Care Foundation, Firenze, Italy
| | - Lars H Lund
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
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26
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Chen X, Kang Y, Dahlström U, Fu M. Impact of adherence to guideline-directed therapy on risk of death in HF patients across an ejection fraction spectrum. ESC Heart Fail 2023; 10:3656-3666. [PMID: 37803813 PMCID: PMC10682881 DOI: 10.1002/ehf2.14358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 02/26/2023] [Accepted: 03/05/2023] [Indexed: 10/08/2023] Open
Abstract
AIMS How different degrees of adherence to guideline-directed medical therapy (GDMT) affect mortality risk in patients with heart failure (HF) in a real-world clinical setting is poorly understood. This study sought to investigate how different levels of adherence to GDMT were associated with the risk of all-cause mortality in patients with HF across a spectrum of left ventricular ejection fractions (LVEFs) in a real-world clinical setting. METHODS AND RESULTS A total of 64 610 HF patients with no missing value of LVEF from the Swedish Heart Failure Registry were included in the study. Patients were divided according to different LVEFs (<30%, 30-39%, 40-49%, and≥50%) and stratified by an adherence score (good, moderate, or poor) according to the triple, double, and single one usage of GDMT: angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists. The outcome is time to all-cause mortality. The mean age of the whole cohort was 73.9 ± 12.1 years, and the proportion of patients in LVEF < 30%, 30-39%, 40-49%, and≥50% groups was 27.6%, 26.9%, 22.1%, and 23.3%, respectively. Patients with LVEF < 30% had the highest mortality rate, almost 20% higher than those with LVEF ≥ 50% {hazard ratio [HR] [95% confidence interval (CI)]: 0.80 [0.71-0.90], P < 0.001}. After treatment of GDMT with good adherence, patients with LVEF < 30% had similar mortality to those with LVEF ≥ 50% [HR (95% CI): 0.97 (0.86-1.10), P = 0.664]. However, the percentage of moderate or poor GDMT was alarmingly high, with good adherence only in 20% of the patients. CONCLUSIONS Good adherence to GDMT works best in patients with LVEF < 50%, whereas moderate adherence to GDMT varies in efficacy depending on the components of the drug combinations.
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Affiliation(s)
- Xiaojing Chen
- Department of CardiologyWest China Hospital, Sichuan UniversityChengduSichuanChina
- Department of Molecular and Clinical Medicine, Institute of MedicineSahlgrenska Academy, University of GothenburgGothenburgSweden
| | - Yu Kang
- Department of CardiologyWest China Hospital, Sichuan UniversityChengduSichuanChina
| | - Ulf Dahlström
- Department of CardiologyLinköping UniversityLinköpingSweden
- Department of Health, Medicine and Caring SciencesLinköping UniversityLinköpingSweden
| | - Michael Fu
- Department of Molecular and Clinical Medicine, Institute of MedicineSahlgrenska Academy, University of GothenburgGothenburgSweden
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Butler J, Abildstrøm SZ, Borlaug BA, Davies MJ, Kitzman DW, Petrie MC, Shah SJ, Verma S, Abhayaratna WP, Chopra V, Ezekowitz JA, Fu M, Ito H, Lelonek M, Núñez J, Perna E, Schou M, Senni M, van der Meer P, von Lewinski D, Wolf D, Altschul RL, Rasmussen S, Kosiborod MN. Semaglutide in Patients With Obesity and Heart Failure Across Mildly Reduced or Preserved Ejection Fraction. J Am Coll Cardiol 2023; 82:2087-2096. [PMID: 37993201 DOI: 10.1016/j.jacc.2023.09.811] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/21/2023] [Accepted: 09/21/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Many therapies for heart failure (HF) have shown differential impact across the spectrum of left ventricular ejection fraction (LVEF). OBJECTIVES In this prespecified analysis, the authors assessed the effects of semaglutide across the baseline LVEF strata in patients with the obesity phenotype of HF with preserved ejection fraction (HFpEF) in the STEP-HFpEF (Semaglutide Treatment Effect in People with obesity and HFpEF) trial. METHODS STEP-HFpEF randomized 529 patients (263 semaglutide; 266 placebo). For this prespecified analysis, patients were categorized into 3 groups based on LVEF: 45% to 49% (n = 85), 50% to 59% (n = 215), and ≥60% (n = 229). RESULTS At 52 weeks, semaglutide improved the dual primary endpoints of Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (estimated treatment difference: EF [ejection fraction] 45%-49%: 5.0 points [95% CI: -2.7 to 12.8 points], EF 50%-59%: 9.8 points [95% CI: 5.0 to 14.6 points], and EF ≥60%: 7.4 points [95% CI: 2.8 to 12.0 points]; P interaction = 0.56) and body weight (EF: 45%-49%: -7.6 [95% CI: -10.7 to -4.4], EF 50%-59%: -10.6 [95% CI: -12.6 to -8.6] and EF ≥60%: -11.9 [95% CI: -13.8 to -9.9]; P interaction = 0.08), to a similar extent across LVEF categories. Likewise, LVEF did not influence the benefit of semaglutide on confirmatory secondary endpoints: 6-minute walk distance (P interaction = 0.19), hierarchal composite endpoint (P interaction = 0.43), and high-sensitivity C-reactive protein (P interaction = 0.26); or exploratory endpoint of N-terminal pro-brain natriuretic peptide (P interaction = 0.96). Semaglutide was well-tolerated across LVEF categories. CONCLUSIONS In patients with HFpEF and obesity, semaglutide 2.4 mg improved symptoms, physical limitations, and exercise function, and reduced inflammation and body weight to a similar extent across LVEF categories. These data support treatment with semaglutide in patients with the obesity phenotype of HFpEF regardless of LVEF. (Research Study to Investigate How Well Semaglutide Works in People Living With Heart Failure and Obesity [STEP-HFpEF]; NCT04788511).
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Affiliation(s)
- Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA; University of Mississippi, Jackson, Mississippi, USA.
| | | | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom; National Institute for Health and Care Research, Leicester Biomedical Research Centre, Leicester, United Kingdom
| | - Dalane W Kitzman
- Department of Cardiovascular Medicine and Section on Geriatrics and Gerontology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Subodh Verma
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Walter P Abhayaratna
- College of Health and Medicine, the Australian National University, Canberra, Australian Capital Territory, Canberra, Australia
| | | | | | - Michael Fu
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hospital-Ostra, Gothenburg, Sweden
| | - Hiroshi Ito
- Department of General Internal Medicine 3, Kawasaki Medical School, Okayama, Japan
| | - Małgorzata Lelonek
- Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland
| | - Julio Núñez
- Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de Valencia, Valencia, Spain; CIBER Cardiovascular, Valencia, Spain
| | - Eduardo Perna
- Instituto de Cardiologia J. F. Cabral, Corrientes, Argentina
| | - Morten Schou
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | | | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Dennis Wolf
- Cardiology and Angiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | | | - Mikhail N Kosiborod
- Department of Cardiovascular Disease, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA.
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Kapelios CJ, Shahim B, Lund LH, Savarese G. Epidemiology, Clinical Characteristics and Cause-specific Outcomes in Heart Failure with Preserved Ejection Fraction. Card Fail Rev 2023; 9:e14. [PMID: 38020671 PMCID: PMC10680134 DOI: 10.15420/cfr.2023.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/15/2023] [Indexed: 12/01/2023] Open
Abstract
Heart failure (HF) is a global pandemic affecting 64 million people worldwide. HF with preserved ejection fraction (HFpEF) has traditionally received less attention than its main counterpart, HF with reduced ejection fraction (HFrEF). The incidence and prevalence of HFpEF show geographic variation and are increasing over time, soon expected to surpass those of HFrEF. Morbidity and mortality rates of HFpEF are considerable, albeit lower than those of HFrEF. This review focuses on the burden of HFpEF, providing contemporary data on epidemiology, clinical characteristics and comorbidities, cause-specific outcomes, costs and pharmacotherapy.
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Affiliation(s)
- Chris J Kapelios
- Department of Cardiovascular Medicine, University of Utah Health Sciences CenterSalt Lake City, UT, US
| | - Bahira Shahim
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University HospitalStockholm, Sweden
| | - Lars H Lund
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University HospitalStockholm, Sweden
| | - Gianluigi Savarese
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University HospitalStockholm, Sweden
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Vasyuk YA, Shupenina EY, Namazova GA, Zavyalova AI. [Can a lipophilic statin improve the treatment of heart failure with preserved ejection fraction in patients with hypertension and obesity?]. KARDIOLOGIIA 2023; 63:47-54. [PMID: 37970855 DOI: 10.18087/cardio.2023.10.n2488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/23/2023] [Indexed: 11/19/2023]
Abstract
AIM To evaluate the effect of pleiotropic (anti-inflammatory and antifibrotic) effects of a lipophilic statin (atorvastatin) in the treatment of heart failure (HF) with preserved left ventricular (LV) ejection fraction (HFpEF)Material and methods. This observational study included 80 patients with HFpEF; 40 of them received atorvastatin 20-80 mg/day in addition to a standard treatment. 40 patient who refused of the statin treatment or had intolerance of the drug received only the standard treatment. The follow-up period was 12 months and included 5 visits. At the visits, the general condition of patients was evaluated; electrocardiography and echocardiography were performed at rest and during dosed physical exercise (PE); anthropometry was analyzed; and office blood pressure (BP), heart rate (HR) and parameters of systolic and diastolic LV function were recorded. RESULTS Among the patients included into the study, women aged 60-70 years prevailed who had pronounced obesity (n=46; 57.5% with class II-II obesity), severe arterial hypertension (AH) (n=65; 81.2% with grade 3 hypertension), dyslipidemia, type 2 diabetes mellitus, and chronic kidney disease. The administration of atorvastatin in addition to standard therapy was associated with regression of HF symptoms and increased PE tolerance; these effects were more pronounced after 6 months of observation. Furthermore, during a 12-month follow-up, significant multidirectional changes in LV global longitudinal strain were noted; in the main group, the LV global longitudinal strain increased indicating an improvement in the LV systolic function while in the control group, it decreased reflecting early, preclinical manifestations of HF progression. A diastolic stress test in combination with a cardiopulmonary stress test was performed in 64 patients with HFpEF at enrollment and at 6 and 12 months of follow-up. When the load reached 50 W in the atorvastatin treatment group after 12 months, a significant increase in tissue Doppler velocity parameters was revealed, specifically in e' septal and e' lateral. This led to a significant decrease in the E / e' ratio while in the control group, no time-related changes in these parameters were noted. Similar changes were also detected at higher levels of PE. CONCLUSION Long-term use of the lipophilic statin (atorvastatin) in addition to a standard therapy was associated with regression of clinical manifestations of HFpEF, provided preservation of the systolic function, and some improvement in the LV diastolic function both at rest and during dosed PE.
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Affiliation(s)
- Yu A Vasyuk
- Evdokimov Moscow State University of Medicine and Dentistry
| | - E Yu Shupenina
- Evdokimov Moscow State University of Medicine and Dentistry
| | - G A Namazova
- Evdokimov Moscow State University of Medicine and Dentistry
| | - A I Zavyalova
- Evdokimov Moscow State University of Medicine and Dentistry
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30
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Charbonnel C, Jagu A, Vannier C, De Cordoue M, Aroulanda MJ, Lozinguez O, Komajda M, Garcon P, Antakly-Hanon Y, Moeuf Y, Lesage JB, Mantes L, Midey C, Izabel M, Boukefoussa W, Manne J, Standish B, Duc P, Iliou MC, Cador R. [Introduction of treatments for heart failure and reduced ejection fraction under 50 % : In-hospital optimization using an algorithmic approach]. Ann Cardiol Angeiol (Paris) 2023; 72:101640. [PMID: 37677914 DOI: 10.1016/j.ancard.2023.101640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 09/09/2023]
Abstract
Recent international guidelines recommend rapid initiation and titration of basic treatments of heart failure but do not explain how to achieve this goal. Despite these recommendations, implementation of treatment in daily practice is poor. This may be partly explained by the profile of the patients (frailty, comorbidities), safety considerations and tolerability issues related to kydney function, low blood pressure or heart rate and hyperkalaemia. In this special article, we intended to help the physician, through an algorithmic approach, to quickly and safely introduce guideline-directed medical therapy in the field of heart failure with ejection fraction under 50%.
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Affiliation(s)
- Clément Charbonnel
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France.
| | - Annabelle Jagu
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Claire Vannier
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Maylis De Cordoue
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | | | - Olivier Lozinguez
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Michel Komajda
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Philippe Garcon
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Yara Antakly-Hanon
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Yoann Moeuf
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | | | - Lucie Mantes
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Charlotte Midey
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Mathilde Izabel
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Wahiba Boukefoussa
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Julien Manne
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Brigitte Standish
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Philippe Duc
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | | | - Romain Cador
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
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31
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Triposkiadis F, Briasoulis A, Sarafidis P, Magouliotis D, Athanasiou T, Paraskevaidis I, Skoularigis J, Xanthopoulos A. The Sympathetic Nervous System in Hypertensive Heart Failure with Preserved LVEF. J Clin Med 2023; 12:6486. [PMID: 37892623 PMCID: PMC10607346 DOI: 10.3390/jcm12206486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023] Open
Abstract
The neurohormonal model of heart failure (HF) pathogenesis states that a reduction in cardiac output caused by cardiac injury results in sympathetic nervous system (SNS) activation, that is adaptive in the short-term and maladaptive in the long-term. This model has proved extremely valid and has been applied in HF with a reduced left ventricular (LV) ejection fraction (LVEF). In contrast, it has been undermined in HF with preserved LVEF (HFpEF), which is due to hypertension (HTN) in the vast majority of the cases. Erroneously, HTN, which is the leading cause of cardiovascular disease and premature death worldwide and is present in more than 90% of HF patients, is tightly linked with SNS overactivity. In this paper we provide a contemporary overview of the contribution of SNS overactivity to the development and progression of hypertensive HF (HHF) as well as the clinical implications resulting from therapeutic interventions modifying SNS activity. Throughout the manuscript the terms HHF with preserved LVEF and HfpEF will be used interchangeably, considering that the findings in most HFpEF studies are driven by HTN.
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Affiliation(s)
| | - Alexandros Briasoulis
- Department of Therapeutics, Heart Failure and Cardio-Oncology Clinic, National and Kapodistrian University of Athens, 115 27 Athens, Greece;
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Dimitrios Magouliotis
- Unit of Quality Improvement, Department of Cardiothoracic Surgery, University of Thessaly, 411 10 Biopolis, Greece;
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, London W2 1NY, UK;
| | | | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, 411 10 Larissa, Greece;
| | - Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 411 10 Larissa, Greece;
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32
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Xanthopoulos A, Papamichail A, Briasoulis A, Loritis K, Bourazana A, Magouliotis DE, Sarafidis P, Stefanidis I, Skoularigis J, Triposkiadis F. Heart Failure in Patients with Chronic Kidney Disease. J Clin Med 2023; 12:6105. [PMID: 37763045 PMCID: PMC10532148 DOI: 10.3390/jcm12186105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023] Open
Abstract
The function of the kidney is tightly linked to the function of the heart. Dysfunction/disease of the kidney may initiate, accentuate, or precipitate of the cardiac dysfunction/disease and vice versa, contributing to a negative spiral. Further, the reciprocal association between the heart and the kidney may occur on top of other entities, usually diabetes, hypertension, and atherosclerosis, simultaneously affecting the two organs. Chronic kidney disease (CKD) can influence cardiac function through altered hemodynamics and salt and water retention, leading to venous congestion and therefore, not surprisingly, to heart failure (HF). Management of HF in CKD is challenging due to several factors, including complex interplays between these two conditions, the effect of kidney dysfunction on the metabolism of HF medications, the effect of HF medications on kidney function, and the high risk for anemia and hyperkalemia. As a result, in most HF trials, patients with severe renal impairment (i.e., eGFR 30 mL/min/1.73 m2 or less) are excluded. The present review discusses the epidemiology, pathophysiology, and current medical management in patients with HF developing in the context of CKD.
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Affiliation(s)
- Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
| | - Adamantia Papamichail
- Amyloidosis Center, Department of Clinical Therapeutics, Faculty of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Alexandros Briasoulis
- Amyloidosis Center, Department of Clinical Therapeutics, Faculty of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Konstantinos Loritis
- Amyloidosis Center, Department of Clinical Therapeutics, Faculty of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, 15772 Athens, Greece
| | - Angeliki Bourazana
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
| | - Dimitrios E. Magouliotis
- Unit of Quality Improvement, Department of Cardiothoracic Surgery, University of Thessaly, 41110 Larissa, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Ioannis Stefanidis
- Department of Nephrology, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece
| | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
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Stolfo D, Lund LH, Sinagra G, Lindberg F, Dahlström U, Rosano G, Savarese G. Heart failure pharmacological treatments and outcomes in heart failure with mildly reduced ejection fraction. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:526-535. [PMID: 37204037 PMCID: PMC10509568 DOI: 10.1093/ehjcvp/pvad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/25/2023] [Accepted: 05/17/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Guideline recommendations for the treatment of heart failure with mildly reduced ejection fraction (HFmrEF) derive from small subgroups in post-hoc analyses of randomized trials. OBJECTIVES We investigated predictors of renin-angiotensin system inhibitors/angiotensin receptor neprilysin inhibitors (RASI/ARNI) and beta-blockers use, and the associations between these medications and mortality/morbidity in a large real-world cohort with HFmrEF. METHODS AND RESULTS Patients with HFmrEF (EF 40-49%) from the Swedish HF Registry were included. The associations between medications and cardiovascular (CV) mortality/HF hospitalization (HFH), and all-cause mortality were assessed through Cox regressions in a 1:1 propensity score-matched cohort. A positive control analysis was performed in patients with EF < 40%, while a negative control outcome analysis had cancer-related hospitalization as endpoint. Of 12 421 patients with HFmrEF, 84% received RASI/ARNI and 88% beta-blockers. Shared-independent predictors of RASI/ARNI and beta-blockers use were younger age, being an outpatient, follow-up in specialty care, and hypertension. In the matched cohorts, use of both RASI/ARNI and beta-blocker use was separately associated with lower risk of CV mortality/HFH [hazard ratio (HR) = 0.90, 95% confidence interval (CI): 0.83-0.98 and HR = 0.82, 95% CI: 0.74-0.90, respectively] and of all-cause mortality (HR = 0.75, 95% CI: 0.69-0.81 and HR = 0.79, 95% CI: 0.72-0.87, respectively). Results were consistent at the positive control analysis, and there were no associations between treatment use and the negative control outcome. CONCLUSIONS RASI/ARNI and beta-blockers were extensively used in this large real-world cohort with HFmrEF. Their use was safe since associated with lower mortality and morbidity. Our findings confirm the real-world evidence from previous post-hoc analyses of trials, and represent a further call for implementing guideline recommendations.
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Affiliation(s)
- Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Heart, Vascular and Neuro Theme Karolinska University Hospital, Norrbacka S3:00, Stockholm 171 76, Sweden
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and Univeristy Hospital of Trieste, Trieste, Italy
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Heart, Vascular and Neuro Theme Karolinska University Hospital, Norrbacka S3:00, Stockholm 171 76, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and Univeristy Hospital of Trieste, Trieste, Italy
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Heart, Vascular and Neuro Theme Karolinska University Hospital, Norrbacka S3:00, Stockholm 171 76, Sweden
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele, Rome, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Heart, Vascular and Neuro Theme Karolinska University Hospital, Norrbacka S3:00, Stockholm 171 76, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
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Chen X, Hocher CF, Shen L, Krämer BK, Hocher B. Reno- and cardioprotective molecular mechanisms of SGLT2 inhibitors beyond glycemic control: from bedside to bench. Am J Physiol Cell Physiol 2023; 325:C661-C681. [PMID: 37519230 DOI: 10.1152/ajpcell.00177.2023] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/01/2023]
Abstract
Large placebo-controlled clinical trials have shown that sodium-glucose cotransporter-2 inhibitors (SGLT2i) delay the deterioration of renal function and reduce cardiovascular events in a glucose-independent manner, thereby ultimately reducing mortality in patients with chronic kidney disease (CKD) and/or heart failure. These existing clinical data stimulated preclinical studies aiming to understand the observed clinical effects. In animal models, it was shown that the beneficial effect of SGLT2i on the tubuloglomerular feedback (TGF) improves glomerular pressure and reduces tubular workload by improving renal hemodynamics, which appears to be dependent on salt intake. High salt intake might blunt the SGLT2i effects on the TGF. Beyond the salt-dependent effects of SGLT2i on renal hemodynamics, SGLT2i inhibited several key aspects of macrophage-mediated renal inflammation and fibrosis, including inhibiting the differentiation of monocytes to macrophages, promoting the polarization of macrophages from a proinflammatory M1 phenotype to an anti-inflammatory M2 phenotype, and suppressing the activation of inflammasomes and major proinflammatory factors. As macrophages are also important cells mediating atherosclerosis and myocardial remodeling after injury, the inhibitory effects of SGLT2i on macrophage differentiation and inflammatory responses may also play a role in stabilizing atherosclerotic plaques and ameliorating myocardial inflammation and fibrosis. Recent studies suggest that SGLT2i may also act directly on the Na+/H+ exchanger and Late-INa in cardiomyocytes thus reducing Na+ and Ca2+ overload-mediated myocardial damage. In addition, the renal-cardioprotective mechanisms of SGLT2i include systemic effects on the sympathetic nervous system, blood volume, salt excretion, and energy metabolism.
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Affiliation(s)
- Xin Chen
- Department of Nephrology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Carl-Friedrich Hocher
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
- Klinik für Innere Medizin, Bundeswehrkrankenhaus Berlin, Berlin, Germany
| | - Linghong Shen
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bernhard K Krämer
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Berthold Hocher
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology/Pneumology), University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- Institute of Reproductive and Stem Cell Engineering, NHC Key Laboratory of Human Stem Cell and Reproductive Engineering, School of Basic Medical Science, Central South University, Changsha, China
- IMD Institut für Medizinische Diagnostik Berlin-Potsdam GbR, Berlin, Germany
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35
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Kerwagen F, Koehler K, Vettorazzi E, Stangl V, Koehler M, Halle M, Koehler F, Störk S. Remote patient management of heart failure across the ejection fraction spectrum: A pre-specified analysis of the TIM-HF2 trial. Eur J Heart Fail 2023; 25:1671-1681. [PMID: 37368507 DOI: 10.1002/ejhf.2948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/27/2023] [Accepted: 06/20/2023] [Indexed: 06/29/2023] Open
Abstract
AIMS The benefit of non-invasive remote patient management (RPM) for patients with heart failure (HF) has been demonstrated. We evaluated the effect of left ventricular ejection fraction (LVEF) on treatment outcomes in the TIM-HF2 (Telemedical Interventional Management in Heart Failure II; NCT01878630) randomized trial. METHODS AND RESULTS TIM-HF2 was a prospective, randomized, multicentre trial investigating the effect of a structured RPM intervention versus usual care in patients who had been hospitalized for HF within 12 months before randomization. The primary endpoint was the percentage of days lost due to all-cause death or unplanned cardiovascular hospitalization. Key secondary endpoints were all-cause and cardiovascular mortality. Outcomes were assessed by LVEF in guideline-defined subgroups of ≤40% (HF with reduced EF [HFrEF]), 41-49% (HF with mildly reduced EF [HFmrEF]), and ≥50% (HF with preserved EF [HFpEF]). Out of 1538 participants, 818 (53%) had HFrEF, 224 (15%) had HFmrEF, and 496 (32%) had HFpEF. Within each LVEF subgroup, the primary endpoint was lower in the treatment group, i.e. the incidence rate ratio [IRR] remained below 1.0. Comparing intervention and control group, the percentage of days lost was 5.4% versus 7.6% for HFrEF (IRR 0.72, 95% confidence interval [CI] 0.54-0.97), 3.3% versus 5.9% for HFmrEF (IRR 0.85, 95% CI 0.48-1.50) and 4.7% versus 5.4% for HFpEF (IRR 0.93, 95% CI 0.64-1.36). No interaction between LVEF and the randomized group became apparent. All-cause and cardiovascular mortality were also reduced by RPM in each subgroup with hazard ratios <1.0 across the LVEF spectrum for both endpoints. CONCLUSION In the clinical set-up deployed in the TIM-HF2 trial, RPM appeared effective irrespective of the LVEF-based HF phenotype.
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Affiliation(s)
- Fabian Kerwagen
- Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
- Department of Medicine I, Cardiology, University Hospital Würzburg, Würzburg, Germany
| | - Kerstin Koehler
- Centre for Cardiovascular Telemedicine, Campus Charité Mitte, German Heart Center Charité, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Eik Vettorazzi
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Verena Stangl
- German Center for Cardiovascular Research (DZHK), Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care, Campus Charité Mitte, German Heart Center Charité, Berlin, Germany
| | - Magdalena Koehler
- Ludwig-Maximilians Universität München, Munich, Germany
- Department of Preventive Sports Medicine and Sports Cardiology, University Hospital 'Klinikum rechts der Isar', School of Medicine, Technical University Munich, Munich, Germany
| | - Martin Halle
- Department of Preventive Sports Medicine and Sports Cardiology, University Hospital 'Klinikum rechts der Isar', School of Medicine, Technical University Munich, Munich, Germany
| | - Friedrich Koehler
- Centre for Cardiovascular Telemedicine, Campus Charité Mitte, German Heart Center Charité, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Stefan Störk
- Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
- Department of Medicine I, Cardiology, University Hospital Würzburg, Würzburg, Germany
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36
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Bak M, Choi JO. Optimization of guideline-directed medical treatment for heart failure patients with reduced ejection fraction. Korean J Intern Med 2023; 38:595-606. [PMID: 37680097 PMCID: PMC10493440 DOI: 10.3904/kjim.2023.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/18/2023] [Accepted: 08/23/2023] [Indexed: 09/09/2023] Open
Abstract
With the increasing number of medications demonstrating mortality benefits in heart failure with reduced ejection fraction (HFrEF), the pharmacological treatment of HFrEF is entering a new phase. To enhance outcomes in heart failure patients through medical treatment, the choice of appropriate medications and simultaneous and rapid uptitration are critical. However, there are several challenges encountered during this medication uptitration, including issues like hypotension, fatigue, worsening renal function, and hyperkalemia. This paper addresses strategies for effectively managing these challenges to successfully reach the maximum tolerated dose in patients. Additionally, it will discuss the management of comorbidities often associated with heart failure, the importance of exercise and rehabilitation, and the significance of proper nutrition intake, in addition to guideline-directed medical therapy.
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Affiliation(s)
- Minjung Bak
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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37
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Kondo T, Dewan P, Anand IS, Desai AS, Packer M, Zile MR, Pfeffer MA, Solomon SD, Abraham WT, Shah SJ, Lam CSP, Jhund PS, McMurray JJV. Clinical Characteristics and Outcomes in Patients With Heart Failure: Are There Thresholds and Inflection Points in Left Ventricular Ejection Fraction and Thresholds Justifying a Clinical Classification? Circulation 2023; 148:732-749. [PMID: 37366061 DOI: 10.1161/circulationaha.122.063642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/30/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Recent guidelines proposed a classification for heart failure (HF) on the basis of left ventricular ejection fraction (LVEF), although it remains unclear whether the divisions chosen were biologically rational. Using patients spanning the full range of LVEF, we examined whether there was evidence of LVEF thresholds in patient characteristics or inflection points in clinical outcomes. METHODS Using patient-level information, we created a merged dataset of 33 699 participants who had been enrolled in 6 randomized controlled HF trials including patients with reduced and preserved ejection fraction. The relationship between the incidence of all-cause death (and specific causes of death) and HF hospitalization, and LVEF, was evaluated using Poisson regression models. RESULTS As LVEF increased, age, the proportion of women, body mass index, systolic blood pressure, and prevalence of atrial fibrillation and diabetes increased, whereas ischemic pathogenesis, estimated glomerular filtration rate, and NT-proBNP (N-terminal pro-B-type natriuretic peptide) decreased. As LVEF increased >50%, age and the proportion of women continued to increase, and ischemic pathogenesis and NT-proBNP decreased, but other characteristics did not change meaningfully. The incidence of most clinical outcomes (except noncardiovascular death) decreased as LVEF increased, with a LVEF inflection point of around 50% for all-cause death and cardiovascular death, around 40% for pump failure death, and around 35% for HF hospitalization. Higher than those thresholds, there was little further decline in the incidence rate. There was no evidence of a J-shaped relationship between LVEF and death; no evidence of worse outcomes in patients with high-normal ("supranormal") LVEF. Similarly, in a subset of patients with echocardiographic data, there were no structural differences in patients with a high-normal LVEF suggestive of amyloidosis, and NT-proBNP levels were consistent with this conclusion. CONCLUSIONS In patients with HF, there was a LVEF threshold of around 40% to 50% where the pattern of patient characteristics changed, and event rates began to increase compared with higher LVEF values. Our findings provide evidence to support current upper LVEF thresholds defining HF with mildly reduced ejection fraction on the basis of prognosis. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifiers: NCT00634309, NCT00634400, NCT00634712, NCT00095238, NCT01035255, NCT00094302, NCT00853658, and NCT01920711.
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Affiliation(s)
- Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (T.K., P.D., P.S.J., J.J.V.M.)
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan (T.K.)
| | - Pooja Dewan
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (T.K., P.D., P.S.J., J.J.V.M.)
| | - Inder S Anand
- VA Medical Center and University of Minnesota, Minneapolis (I.S.A.)
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (A.S.D., M.A.P., S.D.S.)
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Michael R Zile
- Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.)
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (A.S.D., M.A.P., S.D.S.)
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (A.S.D., M.A.P., S.D.S.)
| | - William T Abraham
- The Ohio State University, Division of Cardiovascular Medicine (W.T.A.)
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore (C.S.P.L.)
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (T.K., P.D., P.S.J., J.J.V.M.)
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (T.K., P.D., P.S.J., J.J.V.M.)
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Triposkiadis F, Sarafidis P, Briasoulis A, Magouliotis DE, Athanasiou T, Skoularigis J, Xanthopoulos A. Hypertensive Heart Failure. J Clin Med 2023; 12:5090. [PMID: 37568493 PMCID: PMC10419453 DOI: 10.3390/jcm12155090] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/19/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023] Open
Abstract
Despite overwhelming epidemiological evidence, the contribution of hypertension (HTN) to heart failure (HF) development has been undermined in current clinical practice. This is because approximately half of HF patients have been labeled as suffering from HF with preserved left ventricular (LV) ejection fraction (EF) (HFpEF), with HTN, obesity, and diabetes mellitus (DM) being considered virtually equally responsible for its development. However, this suggestion is obviously inaccurate, since HTN is by far the most frequent and devastating morbidity present in HFpEF. Further, HF development in obesity or DM is rare in the absence of HTN or coronary artery disease (CAD), whereas HTN often causes HF per se. Finally, unlike HTN, for most major comorbidities present in HFpEF, including anemia, chronic kidney disease, pulmonary disease, DM, atrial fibrillation, sleep apnea, and depression, it is unknown whether they precede HF or result from it. The purpose of this paper is to provide a contemporary overview on hypertensive HF, with a special emphasis on its inflammatory nature and association with autonomic nervous system (ANS) imbalance, since both are of pathophysiologic and therapeutic interest.
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Affiliation(s)
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Alexandros Briasoulis
- Department of Therapeutics, Heart Failure and Cardio-Oncology Clinic, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Dimitrios E. Magouliotis
- Unit of Quality Improvement, Department of Cardiothoracic Surgery, University of Thessaly, 41110 Larissa, Greece
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, London W2 1NY, UK
| | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
| | - Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
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39
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MacDonald BJ, Virani SA, Zieroth S, Turgeon R. Heart Failure Management in 2023: A Pharmacotherapy- and Lifestyle-Focused Comparison of Current International Guidelines. CJC Open 2023; 5:629-640. [PMID: 37720183 PMCID: PMC10502425 DOI: 10.1016/j.cjco.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/17/2023] [Indexed: 09/19/2023] Open
Abstract
This review examines the pharmacotherapy and lifestyle recommendations of the most recent iterations of the Canadian Cardiovascular Society (CCS) / Canadian Heart Failure Society (CHFS), the European Society of Cardiology (ESC), and the American Heart Association (AHA) / American College of Cardiology (ACC) / Heart Failure Society of America (HFSA) heart failure (HF) guidelines, which all have been updated in response to therapeutic developments across the spectrum of left ventricular ejection fraction. Identified areas of unanimity across these guidelines include the following: recommending quadruple therapy for patients with HF with reduced ejection fraction (HFrEF; although no guideline proposed an ideal sequence of initiation); intravenous iron administration for patients with HFrEF and iron deficiency; and sodium restriction for patients with HF. Recent evidence regarding the harms of HFrEF medication withdrawal in patients with HF with improved ejection fraction has prompted subsequent guidelines to recommend against withdrawal. Due to the lower quality of evidence, there are disagreements regarding management of HF with preserved ejection fraction and uncertainty regarding management of HF with mildly reduced ejection fraction. Practical guidance is provided to clinicians navigating these challenging areas. In addition to these clinically focused comparisons, we describe opportunities for guideline improvement and harmonization. Specifically, these include opportunities regarding HFrEF sequencing, the need for timely updates, shared decision-making, Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework adoption, and the creation of recommendations where high-quality evidence is lacking. Although these guidelines have broad agreement, key areas of controversy remain that may be addressed by emerging evidence and changes in guideline methodology.
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Affiliation(s)
| | - Sean A. Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Ricky Turgeon
- University of British Columbia, Vancouver, British Columbia, Canada
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40
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Shahim B, Kapelios CJ, Savarese G, Lund LH. Global Public Health Burden of Heart Failure: An Updated Review. Card Fail Rev 2023; 9:e11. [PMID: 37547123 PMCID: PMC10398425 DOI: 10.15420/cfr.2023.05] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/10/2023] [Indexed: 08/08/2023] Open
Abstract
Heart failure (HF) is a rapidly growing public health issue with an estimated prevalence of 64 million people globally. Although the incidence of HF has stabilised worldwide and seems to be declining in developed countries, the prevalence is increasing due to the ageing of the population, improved survival after MI and improved treatment and survival of patients with HF. Yet, HF remains associated with high mortality and morbidity, poor quality of life and functional capacity, and confers a substantial burden to the healthcare system. The prevalence, incidence, mortality and morbidity rates reported show geographical variations, depending on the different aetiologies and clinical characteristics observed among patients with HF. In this review, we provide an overview of the global epidemiology of HF with updated data on prevalence, incidence, mortality and morbidity worldwide.
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Affiliation(s)
- Bahira Shahim
- Division of Cardiology, Department of Medicine, Karolinska InstitutetStockholm, Sweden
- Heart and Vascular Theme, Karolinska University HospitalStockholm, Sweden
| | - Chris J Kapelios
- Department of Cardiovascular Medicine, University of Utah Health Sciences CenterSalt Lake City, UT, US
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska InstitutetStockholm, Sweden
- Heart and Vascular Theme, Karolinska University HospitalStockholm, Sweden
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska InstitutetStockholm, Sweden
- Heart and Vascular Theme, Karolinska University HospitalStockholm, Sweden
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41
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Lopez-Candales A, Asif T, Sawalha K, Norgard NB. Heart Failure with Preserved Left Ventricular Ejection Fraction: A Complex Conundrum Simply Not Limited to Diastolic Dysfunction. Cardiovasc Ther 2023; 2023:1552826. [PMID: 37496726 PMCID: PMC10368509 DOI: 10.1155/2023/1552826] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 05/25/2023] [Accepted: 06/06/2023] [Indexed: 07/28/2023] Open
Abstract
Over the last two decades, the changing paradigm of heart failure with preserved ejection fraction (HFpEF) has transformed our understanding not only of the pathophysiology of this clinical entity but also the diagnostic and therapeutic approaches aimed at treating this complex patient population. No longer HFpEF should be seen as simply left ventricular diastolic dysfunction but as a group of that in addition of having small and thick left ventricles with abnormal diastolic filling patterns as their main pathophysiologic abnormality; they also have whole host of different abnormalities. In fact, this heterogeneous clinical entity embodies numerous mechanisms and is linked to multiorgan dysfunction, with hypertension and obesity playing a major role. Although we have gained an enormous amount of understanding not only on the causes but also the downstream effects of HFpEF, there is still much to be learned before we can fully comprehend this complex clinical entity. It is the main intention of this review to synthesize the most recent attributes, mechanism, diagnostic tools, and most useful therapeutic alternatives to be considered when evaluating patients either complaining of dyspnea on exertion as well as exercise intolerance or those recently admitted with HF symptoms but with normal LVEF in the absence of any other valvular abnormalities.
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Affiliation(s)
- Angel Lopez-Candales
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, USA
| | - Talal Asif
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, USA
| | - Khalid Sawalha
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, USA
| | - Nicholas B. Norgard
- University of Missouri-Kansas City, School of Medicine, Kansas City, Missouri, USA
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42
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Jhund PS. Improving heart failure outcomes with sodium-glucose cotransporter 2 inhibitors in different patient groups. Diabetes Obes Metab 2023; 25 Suppl 3:26-32. [PMID: 37334518 PMCID: PMC10946463 DOI: 10.1111/dom.15171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/18/2023] [Accepted: 05/26/2023] [Indexed: 06/20/2023]
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT-2is) were originally developed for the treatment of hyperglycaemia in type 2 diabetes. Because of regulatory requirements to show the safety of this new class of drugs, a large randomized cardiovascular (CV) outcomes trial was completed but this showed that instead of having a neutral effect on heart failure (HF) outcomes, that these drugs could reduce HF outcomes in this population. Subsequent trials with SGLT-2is have shown that HF hospitalizations are reduced by 30% and CV death or HF hospitalization by 21% in patients with type 2 diabetes. These findings have extended to patients with HF with reduced and mildly reduced or preserved ejection fraction in whom further HF hospitalizations are reduced by 28% and CV death or HF hospitalizations reduced by 23%, and that it is becoming a central therapy for the treatment of HF. Moreover, the benefit in patients with HF is observed regardless of the presence or absence of type 2 diabetes. Similarly, in patients with chronic kidney disease and albuminuria, with and without type 2 diabetes, the benefit of SGLT-2is is clearly seen with a 44% reduction in HF hospitalization and 25% reduction in CV death or HF hospitalization. These trials support the use of SGLT-2is in improving HF outcomes in a broad range of patients, from those with type 2 diabetes, chronic kidney disease and those with pre-existing HF regardless of ejection fraction.
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Affiliation(s)
- Pardeep S. Jhund
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic HealthUniversity of GlasgowGlasgowUK
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43
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Horiuchi Y, Asami M, Ide T, Yahagi K, Komiyama K, Yuzawa H, Tanaka J, Aoki J, Matsushima S, Tohyama T, Enzan N, Tsutsui H, Tanabe K. Prevalence, characteristics and cardiovascular and non-cardiovascular outcomes in patients with heart failure with supra-normal ejection fraction: Insight from the JROADHF study. Eur J Heart Fail 2023; 25:989-998. [PMID: 37191180 DOI: 10.1002/ejhf.2895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/14/2023] [Accepted: 05/08/2023] [Indexed: 05/17/2023] Open
Abstract
AIMS We aimed to investigate the characteristics and prognosis of patients with heart failure (HF) with supra-normal ejection fraction (HFsnEF) compared to HF with normal ejection fraction (HFnEF). METHODS AND RESULTS Among 11 573 patients enrolled in the nationwide registry of hospitalized patients with HF in Japan, 1943 patients (16.8%) were classified as HFsnEF (left ventricular ejection fraction [LVEF] >65%), 3277 (28.3%) as HFnEF (50% ≤ LVEF ≤65%), 2024 (17.5%) as HF with mildly reduced ejection fraction (40% ≤ LVEF <50%) and 4329 (37.4%) as HF with reduced ejection fraction (LVEF <40%). Patients with HFsnEF were older, more likely to be women, had lower natriuretic peptide values, and had smaller left ventricles than those with HFnEF. The primary endpoint, the composite of cardiovascular death or HF readmission, did not differ between HFsnEF (802/1943, 41.3%) and HFnEF (1413/3277, 43.1%) during a median follow-up period of 870 days (hazard ratio [HR] 0.96, 95% confidence interval 0.88-1.05, p = 0.346). The incidence of secondary outcomes, including all-cause, cardiovascular, and non-cardiovascular deaths and HF readmission, did not differ between HFsnEF and HFnEF. In the multivariable Cox regression analysis, HFsnEF compared to HFnEF was associated with a lower adjusted HR for HF readmission but not with the primary and other secondary endpoints. HFsnEF was associated with a higher HR for the composite endpoint and all-cause death in women, and a higher HR for all-cause death in patients with renal dysfunction. CONCLUSIONS Heart failure with supra-normal ejection fraction is a common and distinctive phenotype, and has different characteristics and prognoses from HFnEF.
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Affiliation(s)
- Yu Horiuchi
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Masahiko Asami
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Division of Cardiovascular Medicine Research, Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuyuki Yahagi
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Kota Komiyama
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Hitomi Yuzawa
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Jun Tanaka
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Jiro Aoki
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Shouji Matsushima
- Department of Cardiovascular Medicine, Division of Cardiovascular Medicine Research, Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeshi Tohyama
- Department of Cardiovascular Medicine, Division of Cardiovascular Medicine Research, Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobuyuki Enzan
- Department of Cardiovascular Medicine, Division of Cardiovascular Medicine Research, Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Division of Cardiovascular Medicine Research, Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
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Castiglione V, Gentile F, Ghionzoli N, Chiriacò M, Panichella G, Aimo A, Vergaro G, Giannoni A, Passino C, Emdin M. Pathophysiological Rationale and Clinical Evidence for Neurohormonal Modulation in Heart Failure with Preserved Ejection Fraction. Card Fail Rev 2023; 9:e09. [PMID: 37427009 PMCID: PMC10326668 DOI: 10.15420/cfr.2022.23] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/02/2023] [Indexed: 07/11/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome resulting from the interaction between cardiac diseases, comorbidities and ageing. HFpEF is characterised by the activation of neurohormonal axes, namely of the renin-angiotensin-aldosterone system and the sympathetic nervous system, although to a lesser extent compared with heart failure with reduced ejection fraction. This provides a rationale for neurohormonal modulation as a therapeutic approach for HFpEF. Nonetheless, randomised clinical trials have failed to demonstrate a prognostic benefit from neurohormonal modulation therapies in HFpEF, with the sole exception of patients with left ventricular ejection fraction in the lower range of normality, for whom the American guidelines suggest that such therapies may be considered. In this review, the pathophysiological rationale for neurohormonal modulation in HFpEF is summarised and the clinical evidence on pharmacological and nonpharmacological approaches backing current recommendations discussed.
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Affiliation(s)
- Vincenzo Castiglione
- Interdisciplinary Research Center Health Science, Scuola Superiore Sant’AnnaPisa, Italy
- Cardiology Division, Pisa University HospitalPisa, Italy
| | | | - Nicolò Ghionzoli
- Department of Medical Biotechnologies, Division of Cardiology, University of SienaSiena, Italy
| | - Martina Chiriacò
- Department of Clinical and Experimental Medicine, University of PisaPisa, Italy
| | - Giorgia Panichella
- Interdisciplinary Research Center Health Science, Scuola Superiore Sant’AnnaPisa, Italy
| | - Alberto Aimo
- Interdisciplinary Research Center Health Science, Scuola Superiore Sant’AnnaPisa, Italy
- Fondazione Toscana Gabriele MonasterioPisa, Italy
| | - Giuseppe Vergaro
- Interdisciplinary Research Center Health Science, Scuola Superiore Sant’AnnaPisa, Italy
- Fondazione Toscana Gabriele MonasterioPisa, Italy
| | - Alberto Giannoni
- Interdisciplinary Research Center Health Science, Scuola Superiore Sant’AnnaPisa, Italy
- Fondazione Toscana Gabriele MonasterioPisa, Italy
| | - Claudio Passino
- Interdisciplinary Research Center Health Science, Scuola Superiore Sant’AnnaPisa, Italy
- Fondazione Toscana Gabriele MonasterioPisa, Italy
| | - Michele Emdin
- Interdisciplinary Research Center Health Science, Scuola Superiore Sant’AnnaPisa, Italy
- Fondazione Toscana Gabriele MonasterioPisa, Italy
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45
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Lin MS, Wang PC, Lin MH, Kuo TY, Lin YS, Chen TH, Tsai MH, Yang YH, Lin CL, Chung CM, Chu PH. Acute heart failure with mildly reduced ejection fraction and myocardial infarction: a multi-institutional cohort study. BMC Cardiovasc Disord 2023; 23:272. [PMID: 37221514 DOI: 10.1186/s12872-023-03286-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/09/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Little research has been done on ischemic outcomes related to left ventricular ejection fraction (EF) in acute decompensated heart failure (ADHF). METHODS A retrospective cohort study was conducted between 2001 and 2021 using the Chang Gung Research Database. ADHF Patients discharged from hospitals between January 1, 2005, and December 31, 2019. Cardiovascular (CV) mortality and heart failure (HF) rehospitalization are the primary outcome components, along with all-cause mortality, acute myocardial infarction (AMI) and stroke. RESULTS A total of 12,852 ADHF patients were identified, of whom 2,222 (17.3%) had HFmrEF, the mean (SD) age was 68.5 (14.6) years, and 1,327 (59.7%) were males. In comparison with HFrEF and HFpEF patients, HFmrEF patients had a significant phenotype comorbid with diabetes, dyslipidemia, and ischemic heart disease. Patients with HFmrEF were more likely to experience renal failure, dialysis, and replacement. Both HFmrEF and HFrEF had similar rates of cardioversion and coronary interventions. There was an intermediate clinical outcome between HFpEF and HFrEF, but HFmrEF had the highest rate of AMI (HFpEF, 9.3%; HFmrEF, 13.6%; HFrEF, 9.9%). The AMI rates in HFmrEF were higher than those in HFpEF (AHR, 1.15; 95% Confidence Interval, 0.99 to 1.32) but not in HFrEF (AHR, 0.99; 95% Confidence Interval, 0.87 to 1.13). CONCLUSION Acute decompression in patients with HFmrEF increases the risk of myocardial infarction. The relationship between HFmrEF and ischemic cardiomyopathy, as well as optimal anti-ischemic treatment, requires further research on a large scale.
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Affiliation(s)
- Ming-Shyan Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Po-Chang Wang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
| | - Meng-Hung Lin
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
| | - Ting-Yu Kuo
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
| | - Yu-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
| | - Tien-Hsing Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chiayi Branch, Keelung, Taiwan
| | - Ming-Horng Tsai
- Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan
| | - Yao-Hsu Yang
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Liang Lin
- Department of Nephrology, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
| | - Chang-Min Chung
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chiayi Branch, Chiayi, Taiwan
| | - Pao-Hsien Chu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Linkou Branch, No.5, Fu-Hsing Street, Gueishan District, Taoyuan, 33305, Taiwan.
- Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital Chang Gung University College of Medicine, Taipei, Taiwan.
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Peters AE, Nguyen M, Green JB, Pearson ER, Buse J, Sourij H, Hernandez AF, Sattar N, Holman RR, Mentz RJ, Shah SH. Proteomic Pathways across Ejection Fraction Spectrum in Heart Failure: an EXSCEL Substudy. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.16.23288273. [PMID: 37293003 PMCID: PMC10246051 DOI: 10.1101/2023.05.16.23288273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background Ejection fraction (EF) is a key component of heart failure (HF) classification, including the increasingly codified HF with mildly reduced EF (HFmrEF) category. However, the biologic basis of HFmrEF as an entity distinct from HF with preserved EF (HFpEF) and reduced EF (HFrEF) has not been well characterized. Methods The EXSCEL trial randomized participants with type 2 diabetes (T2DM) to once-weekly exenatide (EQW) vs. placebo. For this study, profiling of ∼5000 proteins using the SomaLogic SomaScan platform was performed in baseline and 12-month serum samples from N=1199 participants with prevalent HF at baseline. Principal component analysis (PCA) and ANOVA (FDR p<0.1) were used to determine differences in proteins between three EF groups, as previously curated in EXSCEL (EF>55% [HFpEF], EF 40-55% [HFmrEF], EF<40% [HFrEF]). Cox proportional hazards was used to assess association between baseline levels of significant proteins, and changes in protein level between baseline and 12-month, with time-to-HF hospitalization. Mixed models were used to assess whether significant proteins changed differentially with exenatide vs. placebo therapy. Results Of N=1199 EXSCEL participants with prevalent HF, 284 (24%), 704 (59%) and 211 (18%) had HFpEF, HFmrEF and HFrEF, respectively. Eight PCA protein factors and 221 individual proteins within these factors differed significantly across the three EF groups. Levels of the majority of proteins (83%) demonstrated concordance between HFmrEF and HFpEF, but higher levels in HFrEF, predominated by the domain of extracellular matrix regulation, e.g. COL28A1 and tenascin C [TNC]; p<0.0001. Concordance between HFmrEF and HFrEF was observed in a minority of proteins (1%) including MMP-9 (p<0.0001). Biologic pathways of epithelial mesenchymal transition, ECM receptor interaction, complement and coagulation cascades, and cytokine receptor interaction demonstrated enrichment among proteins with the dominant pattern, i.e. HFmrEF-HFpEF concordance. Baseline levels of 208 (94%) of the 221 proteins were associated with time-to-incident HF hospitalization including domains of extracellular matrix (COL28A1, TNC), angiogenesis (ANG2, VEGFa, VEGFd), myocyte stretch (NT-proBNP), and renal function (cystatin-C). Change in levels of 10 of the 221 proteins from baseline to 12 months (including increase in TNC) predicted incident HF hospitalization (p<0.05). Levels of 30 of the 221 significant proteins (including TNC, NT-proBNP, ANG2) were reduced differentially by EQW compared with placebo (interaction p<0.0001). Conclusions In this HF substudy of a large clinical trial of people with T2DM, we found that serum levels of most proteins across multiple biologic domains were similar between HFmrEF and HFpEF. HFmrEF may be more biologically similar to HFpEF than HFrEF, and specific related biomarkers may offer unique data on prognosis and pharmacotherapy modification with variability by EF.
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47
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Meijs C, Brugts JJ, Lund LH, Linssen GCM, Rocca HPBL, Dahlström U, Vaartjes I, Koudstaal S, Asselbergs FW, Savarese G, Uijl A. Identifying distinct clinical clusters in heart failure with mildly reduced ejection fraction. Int J Cardiol 2023:S0167-5273(23)00718-0. [PMID: 37201609 DOI: 10.1016/j.ijcard.2023.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/12/2023] [Accepted: 05/14/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Heart failure (HF) is a heterogeneous syndrome, and the specific sub-category HF with mildly reduced ejection fraction (EF) range (HFmrEF; 41-49% EF) is only recently recognized as a distinct entity. Cluster analysis can characterize heterogeneous patient populations and could serve as a stratification tool in clinical trials and for prognostication. The aim of this study was to identify clusters in HFmrEF and compare cluster prognosis. METHODS AND RESULTS Latent class analysis to cluster HFmrEF patients based on their characteristics was performed in the Swedish HF registry (n = 7316). Identified clusters were validated in a Dutch cross-sectional HF registry-based dataset CHECK-HF (n = 1536). In Sweden, mortality and hospitalisation across the clusters were compared using a Cox proportional hazard model, with a Fine-Gray sub-distribution for competing risks and adjustment for age and sex. Six clusters were discovered with the following prevalence and hazard ratio with 95% confidence intervals (HR [95%CI]) vs. cluster 1: 1) low-comorbidity (17%, reference), 2) ischaemic-male (13%, HR 0.9 [95% CI 0.7-1.1]), 3) atrial fibrillation (20%, HR 1.5 [95% CI 1.2-1.9]), 4) device/wide QRS (9%, HR 2.7 [95% CI 2.2-3.4]), 5) metabolic (19%, HR 3.1 [95% CI 2.5-3.7]) and 6) cardio-renal phenotype (22%, HR 2.8 [95% CI 2.2-3.6]). The cluster model was robust between both datasets. CONCLUSION We found robust clusters with potential clinical meaning and differences in mortality and hospitalisation. Our clustering model could be valuable as a clinical differentiation support and prognostic tool in clinical trial design.
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Affiliation(s)
- Claartje Meijs
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Helmholtz Zentrum München GmbH - German Research Center for Environmental Health, Institute of Computational Biology, Neuherberg, Germany
| | - Jasper J Brugts
- Department of Cardiology, Thoraxcenter, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gerard C M Linssen
- Department of Cardiology, Hospital Group Twente, Almelo and Hengelo, the Netherlands
| | | | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linköping, Sweden
| | - Ilonca Vaartjes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Stefan Koudstaal
- Department of Cardiology, Groene Hart Ziekenhuis, Gouda, the Netherlands
| | - Folkert W Asselbergs
- Amsterdam UMC Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, Amsterdam, Netherlands; Health Data Research UK London, Institute for Health Informatics, University College London, United Kingdom; Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, United Kingdom
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Alicia Uijl
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Amsterdam UMC Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, Amsterdam, Netherlands.
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48
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Butler J, Zheng Y, Khan MS, Bonderman D, Lund LH, deFilippi CR, Blaustein RO, Ezekowitz JA, Freitas C, Hernandez AF, O'Connor CM, Voors AA, Westerhout CM, Lam CSP, Armstrong PW. Ejection Fraction, Biomarkers, and Outcomes and Impact of Vericiguat on Outcomes Across EF in VICTORIA. JACC. HEART FAILURE 2023; 11:583-592. [PMID: 37137660 DOI: 10.1016/j.jchf.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 11/29/2022] [Accepted: 12/08/2022] [Indexed: 05/05/2023]
Abstract
BACKGROUND Vericiguat reduced the risk of cardiovascular death (CVD) or hospitalization for heart failure (HF) in patients with worsening HF and reduced left ventricular ejection fraction (LVEF). OBJECTIVES The authors assessed the association of LVEF with biomarker levels, risk of outcome, and whether the effect of vericiguat was homogeneous across LVEF in the VICTORIA (Vericiguat Global Study in Subjects with Heart Failure With Reduced Ejection Fraction) trial. METHODS Patients were grouped by LVEF tertiles (≤24%, 25%-33%, and >33%). Patient characteristics, clinical outcomes, and efficacy and safety of vericiguat were examined by tertile. Prespecified biomarkers including N-terminal pro-B-type natriuretic peptide, cardiac troponin T, growth differentiation factor 15, interleukin 6, high-sensitivity C-reactive protein, and cystatin C were examined. RESULTS The mean LVEF was 29% ± 8% (range: 5%-45%). A pattern of higher N-terminal pro-B-type natriuretic peptide, high-sensitivity C-reactive protein, and interleukin 6 was evident in patients in the lowest LVEF tertile vs the other tertiles. Patients with lower LVEF experienced higher rates of the composite outcome (41.7%, 36.3%, and 33.4% for LVEF ≤24, 25-33, and >33; P < 0.001). There was no significant treatment effect heterogeneity of vericiguat across LVEF groups (adjusted HR from lowest to highest tertiles: 0.79 [95% CI: 0.68-0.94]; 0.95 [95% CI: 0.82-1.11]; 0.94 [95% CI: 0.79-1.11]; P for interaction = 0.222), although the HR was numerically lower in the lowest tertile. There was also no heterogeneity of effect for CVD and HF hospitalization individually (P interaction for CVD = 0.964; HF hospitalization = 0.438). Discontinuation of treatment because of adverse events, symptomatic hypotension, or syncope was consistent across the range of LVEF. CONCLUSIONS Patients with lower LVEF had a distinctive biomarker profile and a higher risk for adverse clinical outcomes vs those with a higher LVEF. There was no significant interaction for the benefit of vericiguat across LVEF tertiles, although the largest signal for benefit in both the primary outcome and HF hospitalizations was noted in tertile 1 (LVEF ≤24%). (Vericiguat Global Study in Subjects with Heart Failure With Reduced Ejection Fraction [VICTORIA]; NCT02861534).
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Affiliation(s)
- Javed Butler
- Baylor University Medical Center, Dallas, Texas, USA; Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Lars H Lund
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center of Groningen, Groningen, the Netherlands
| | | | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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Popovic D, Alogna A, Omar M, Sorimachi H, Omote K, Reddy YNV, Redfield MM, Burkhoff D, Borlaug BA. Ventricular stiffening and chamber contracture in heart failure with higher ejection fraction. Eur J Heart Fail 2023; 25:657-668. [PMID: 36994635 PMCID: PMC10330082 DOI: 10.1002/ejhf.2843] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/02/2023] [Accepted: 03/26/2023] [Indexed: 03/31/2023] Open
Abstract
AIMS Ancillary analyses from clinical trials have suggested reduced efficacy for neurohormonal antagonists among patients with heart failure and preserved ejection fraction (HFpEF) and higher ranges of ejection fraction (EF). METHODS AND RESULTS A total of 621 patients with HFpEF were grouped into those with low-normal left ventricular EF (LVEF) (HFpEF<65% , n = 319, 50% ≤ LVEF <65%) or HFpEF≥65% (n = 302, LVEF ≥65%), and compared with 149 age-matched controls undergoing comprehensive echocardiography and invasive cardiopulmonary exercise testing. A sensitivity analysis was performed in a second non-invasive community-based cohort of patients with HFpEF (n = 244) and healthy controls without cardiovascular disease (n = 617). Patients with HFpEF≥65% had smaller left ventricular (LV) end-diastolic volume than HFpEF<65% , but LV systolic function assessed by preload recruitable stroke work and stroke work/end-diastolic volume was similarly impaired. Patients with HFpEF≥65% displayed an end-diastolic pressure-volume relationship (EDPVR) that was shifted leftward, with increased LV diastolic stiffness constant β, in both invasive and community-based cohorts. Cardiac filling pressures and pulmonary artery pressures at rest and during exercise were similarly abnormal in all EF subgroups. While patients HFpEF≥57% displayed leftward shifted EDPVR, those with HFpEF<57% had a rightward shifted EDPVR more typical of heart failure with reduced EF. CONCLUSION Most pathophysiologic differences in patients with HFpEF and higher EF are related to smaller heart size, increased LV diastolic stiffness, and leftward shift in the EDPVR. These findings may help to explain the absence of efficacy for neurohormonal antagonists in this group and raise a new hypothesis, that interventions to stimulate eccentric LV remodelling and enhance diastolic capacitance may be beneficial for patients with HFpEF and EF in the higher range.
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Affiliation(s)
- Dejana Popovic
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alessio Alogna
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Massar Omar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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50
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Kagami K, Obokata M, Harada T, Saito Y, Naito A, Sorimachi H, Yuasa N, Kato T, Wada N, Adachi T, Ishii H. Effects of Mineralocorticoid Receptor Antagonists in Early-Stage Heart Failure With Preserved Ejection Fraction. CJC Open 2023; 5:380-391. [PMID: 37377513 PMCID: PMC10290949 DOI: 10.1016/j.cjco.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/03/2023] [Indexed: 06/29/2023] Open
Abstract
Background Hospitalization with a first episode of heart failure (HF) is a serious event associated with poor clinical outcomes in HF with preserved ejection fraction (HFpEF). Identification of HFpEF via detection of elevated left ventricular filling pressure at rest or during exercise may allow early intervention. Benefits of treatment with mineralocorticoid receptor antagonists (MRAs) in established HFpEF have been reported, but use of MRAs is not well studied in early HFpEF without prior HF hospitalization. Methods We retrospectively studied 197 patients with HFpEF who did not have prior hospitalization but had been diagnosed by exercise stress echocardiography or catheterization. We examined changes in natriuretic peptide levels and echocardiographic parameters reflecting diastolic function following MRA initiation. Results Of the 197 patients with HFpEF, MRA treatment was initiated for 47 patients. After a median 3-month follow-up, reduction in N-terminal pro-B-type natriuretic peptide levels from baseline to follow-up was greater in patients treated with MRA than in those who were not (median, -200 pg/mL [interquartile range, -544 to -31] vs 67 pg/mL [interquartile range, -95 to 456], P < 0.0001 in 50 patients with paired data). Similar results were observed for the changes in B-type natriuretic peptide levels. Reduction in the left atrial volume index was also greater in the MRA-treated group than in the non-MRA-treated group after a median 7-month follow-up (77 patients with paired echocardiographic data). Patients with lower left ventricular global longitudinal strain experienced a greater reduction in N-terminal pro-B-type natriuretic peptide levels following MRA treatment. In the safety assessment, MRA modestly decreased renal function but did not change potassium levels. Conclusions Our results suggest that MRA treatment has potential benefits for early-stage HFpEF.
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Affiliation(s)
- Kazuki Kagami
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
- Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yuki Saito
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Ayami Naito
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
- Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Naoki Yuasa
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Naoki Wada
- Department of Rehabilitation Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Takeshi Adachi
- Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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