Characteristics and clinical outcomes of patients with acute heart failure with a supranormal left ventricular ejection fraction

The use of left ventricular ejection fraction in the diagnosis and management of heart failure. A clinical consensus statement of the Heart Failure Association (HFA) of the ESC, the Heart Failure Society of America (HFSA), and the Japanese Heart Failure Society (JHFS)

This clinical consensus statement revisits the role of left ventricular ejection fraction (LVEF) as a measurement of cardiac function, a prognostic marker and a major criterion to classify patients with heart failure, and gives new advice for clinical practice. Heart failure is traditionally classified on the basis of LVEF thresholds and this has major implications for treatment recommendations. However, the reproducibility of LVEF measurement is poor and its prognostic and diagnostic value lessens when it is above 45%, with no relationship with the severity of either cardiac dysfunction or outcomes at higher values. These limitations dictate the need for a more comprehensive approach to classify and assess heart failure focusing more on the trajectory of LVEF rather than to its absolute value. Furthermore, the assessment of LVEF is not required for the initiation of treatments like sodium-glucose cotransporter 2 inhibitors, mineralocorticoid receptor antagonists and diuretics in patients with suspected de novo heart failure and elevated N-terminal pro-B-type natriuretic peptide levels. Future research utilizing advanced imaging techniques and biomarkers which can better characterize myocardial structure, metabolism and performance may facilitate the identification of alternative therapeutic targets and better ways to monitor heart failure therapies across the entire spectrum of LVEF.

Influence of ejection fraction on outcomes with sacubitril/valsartan in patients with worsening heart failure with EF>40%: The PARAGLIDE-HF Trial

BACKGROUND

n the PARAGLIDE-HF trial, treatment with sacubitril/valsartan (Sac/Val) was associated with greater reduction in NT-proBNP than valsartan (Val) alone in patients stabilized after an episode of worsening heart failure (HF) with left ventricular ejection fraction (LVEF) >40%. Treatment effects were most apparent in the subgroup with LVEF below normal (≤60%). This pre-specified analysis sought to compare the detailed treatment effects and adverse event profiles of Sac/Val vs. Val in patients with LVEF ≤60% vs. >60%.

METHODS

Baseline demographics and clinical characteristics were compared between patients with baseline LVEF ≤60% vs. >60%. Rates of recurrent composite events (adjudicated CV death, HF hospitalizations, and urgent HF visits) were compared between groups using a semi-parametric proportional rates model. These recurrent composite events were also analyzed across the continuous LVEF spectrum using restricted cubic splines. Incidence of adverse events were analyzed using a logistic regression model with LVEF ≤60% vs. >60%, treatment arm, and in-hospital/out-of-hospital randomization as covariates. The interaction of LVEF category and treatment arm was assessed for all models RESULTS: : Compared to those with LVEF >60%, patients with LVEF ≤60% were younger with lower NYHA class, but similar NT-proBNP values at baseline and similar co-morbidity burden. Among patients with LVEF ≤60%, those treated with Sac/Val experienced fewer recurrent composite events compared to those treated with Val (rate ratio 0.60 [95% CI: 0.37-0.99], p=0.046); predominantly driven by HF hospitalizations. Patients with LVEF >60% treated with Sac/Val vs. Val demonstrated similar rates of recurrent composite events (RR 1.46 [0.77-2.79], p=0.24) (interaction p-value = 0.032). This was consistent with the continuous analysis in which patients treated with Sac/Val were significantly less likely to have events compared with patients with Val at LVEF values below 58%. Patients with LVEF >60% treated with Sac/Val experienced more symptomatic hypotension (OR 3.55 [95% CI: 1.35-9.37], p=0.01) compared to those treated with Val, whereas rates of symptomatic hypotension were comparable across treatment groups in patients with LVEF ≤60% (OR 1.36 [0.79-2.32], p=0.27, interaction p-value 0.09).

CONCLUSIONS

Compared to treatment with Val in patients with worsening HF and LVEF>40%, treatment with Sac/Val is associated with greater clinical benefit in those with LVEF ≤60% than in those with LVEF >60%.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier, NCT03988634.

Clinical and plasma proteomic characterization of heart failure with supranormal left ventricular ejection fraction: An emerging entity of heart failure

AIMS

The clinical guidelines categorize heart failure (HF) based on left ventricular ejection fraction (LVEF). However, the current LVEF cutoffs, 40% and 50%, may not fully address the underlying characteristics and cardiovascular risk of HF, particularly for HF with higher LVEF. This study aimed to characterize HF with supranormal ejection fraction (HFsnEF) using different LVEF cutoffs (35%, 55%, and 70% for men, and 40%, 60%, and 75% for women).

METHODS AND RESULTS

This study divided 442 patients from the CHART-Omics study into four groups: HF with reduced ejection fraction (HFrEF) (n = 55, 65.5 years), HF with mildly reduced ejection fraction (HFmrEF) (n = 125, 69.3 years), HF with normal ejection fraction (HFnEF) (n = 215, 69.0 years) and HFsnEF (n = 47, 67.1 years). When clinical backgrounds were adjusted and HFnEF served as the reference, HFsnEF carried an increased hazard ratio (HR) for the composite of cardiovascular death and HF hospitalization of 2.71 (95% confidence interval [CI] 1.10-6.66, p = 0.030), while HFrEF had a HR of 3.14 (95% CI 1.36-7.23, p = 0.007). HFsnEF was characterized by an increase in relative left ventricular wall thickness and a decrease in left ventricular dimensions, whereas increased left ventricular mass and dimensions characterized HFrEF. Quantitative analysis of 4670 plasma proteins showed essential differences between HFsnEF and HFrEF, for example, 'protein synthesis' versus 'cell morphology', 'cellular assembly and organization' and 'nucleic acid metabolism' for underlying pathophysiology, and 'energy production' versus 'connective tissue disorders' and 'cell-to-cell signalling and interaction' for prognostication.

CONCLUSIONS

Heart failure with supranormal ejection fraction, an unnoticed but emerging entity in HF, carries a similarly increased cardiovascular risk as HFrEF but has unique structural and plasma proteomic characteristics.

Outcomes and Left Ventricular Ejection Fraction in Cardiac Magnetic Resonance: Challenging the "Higher Is Better"

BACKGROUND

Contradictory evidence exists regarding the correlation between supranormal left ventricular ejection fraction (LVEF) and adverse outcomes. This study aimed to elucidate the prognostic value of supranormal LVEF.

METHODS

This retrospective cohort study analyzed patients referred for cardiac magnetic resonance imaging to assess myocardial ischemia or viability. Subjects were stratified into eig8ht LVEF groups: <20%, 20% to 30%, 30% to 40%, 40% to 50%, 50% to 60%, 60% to 70%, 70% to 80%, and ≥80%. Primary outcomes included cardiovascular death, heart failure, myocardial infarction, and stroke. The extracellular volume fraction was measured.

RESULTS

The study cohort comprised 3279 patients (mean age 68.0±12.7 years; 64.0% female). The group with 60% to 70% LVEF had the lowest risk and was used as the reference group. The median follow-up was 41.4 months (interquartile range, 33.9-49.7 months). The group with LVEF <20% exhibited the highest composite outcome risk (unadjusted hazard ratio [HR], 6.77 [95% CI, 3.81-12.03]; P<0.001; adjusted HR, 2.68 [95% CI, 1.28-5.62]; P<0.001). The groups with LVEF 70% to 80% and ≥80% showed increased risk (adjusted HR, 1.96 [95% CI, 1.23-3.08]; P=0.004; 2.16 [95% CI, 1.33-3.52]; P=0.002, respectively). A greater extracellular volume fraction was associated with an LVEF of 70% to 80% and ≥80% (adjusted odds ratios, 1.34 [95% CI, 1.03-1.74]; P=0.027; and 1.74 [95% CI, 1.30-2.34]; P<0.001, respectively).

CONCLUSIONS

LVEF >70% demonstrated increased event rates compared with an LVEF of 60% to 70%. The supranormal LVEF warrants further investigation into its pathogenesis and management.

The use of Left Ventricular Ejection Fraction in the Diagnosis and Management of Heart Failure. A Clinical Consensus Statement of the Heart Failure Association (HFA) of the ESC, the Heart Failure Society of America (HFSA), and the Japanese Heart Failure Society (JHFS)

This clinical consensus statement revisits the role of left ventricular ejection fraction (LVEF) as a measurement of cardiac function, a prognostic marker and a major criterion to classify patients with heart failure, and gives new advice for clinical practice. Heart failure is traditionally classified on the basis of LVEF thresholds and this has major implications for treatment recommendations. However, the reproducibility of LVEF measurement is poor and its prognostic and diagnostic value lessens when it is above 45%, with no relationship with the severity of either cardiac dysfunction or outcomes at higher values. These limitations dictate the need for a more comprehensive approach to classify and assess heart failure focusing more on the trajectory of LVEF rather than to its absolute value. Furthermore, the assessment of LVEF is not required for the initiation of treatments like sodium-glucose cotransporter 2 inhibitors, mineralocorticoid receptor antagonists and diuretics in patients with suspected de novo heart failure and elevated N-terminal pro-B-type natriuretic peptide levels. Future research utilizing advanced imaging techniques and biomarkers which can better characterize myocardial structure, metabolism and performance may facilitate the identification of alternative therapeutic targets and better ways to monitor heart failure therapies across the entire spectrum of LVEF.

Characterizing Heart Failure Across the Spectrum of the Preserved Ejection Fraction: Does Heart Failure With Supranormal Ejection Fraction Exist? Data From the Swedish Heart Failure Registry

BACKGROUND

Sparce data suggest higher mortality in heart failure (HF) with left ventricular ejection fraction (EF) >65% to 70%. We characterized EF distribution, characteristics, and outcomes in patients with HF and EF ≥50%.

METHODS AND RESULTS

There were 5576 patients enrolled in the Swedish HF registry between 2017 and 2021 and included in the study; 21% had EF ≥60%, 5% EF ≥65%, and 1.5% EF ≥70%. Patient characteristics independently associated with EF ≥60% were assessed by multivariable logistic regression and were identified as being a diagnosis of hypertrophic cardiomyopathy, worse New York Heart Association class, hypertension, and valvular disease, whereas use of medications and devices also recommended for HF with reduced EF, male sex, history of ischemic heart disease, peripheral artery disease, and chronic obstructive pulmonary disease were associated with an EF of 50% to 59%. Outcomes (all-cause, cardiovascular, and noncardiovascular death; all-cause and HF hospitalizations) were assessed by univariable and multivariable Cox regressions with EF modeled as a spline. The risk of all-cause and noncardiovascular mortality and first all-cause hospitalization was higher with EF values >55% in crude but not adjusted analyses.

CONCLUSIONS

Among patients with HF with preserved EF, 21% had EF ≥60%. A higher EF was characterized by more severe symptoms, hypertrophic cardiomyopathy, hypertension, female sex, and valvular disease. Crude higher but not adjusted risk of all-cause and noncardiovascular mortality and of all-cause hospitalization was observed with EF values >55%, suggesting that prognostically impactful conditions were more prevalent in the upper bound of the EF spectrum.

Clinical determinants and long-term survival in heart failure with supra-normal ejection fraction. Insights from LECRA-HF registry

PURPOSE

Heart failure with supra-normal ejection fraction (HFsnEF), defined as HF with left ventricular ejection fraction (LVEF) ​> ​65 ​%, constitutes a novel HF category. However, its clinical characteristics and long-term outcomes remain insufficiently elucidated. We sought to characterize Polish HFsnEF patients and provide their long-term mortality.

MATERIAL AND METHODS

Of 1186 patients enrolled in the single-center Lesser Poland Cracovian Heart Failure (LECRA-HF) registry between years 2009 and 2019, 261 (22 ​%) were classified as HF with LVEF ≥50 ​%. Of them, 40 (15.3 ​%) were classified as HFsnEF, and the remaining 221 (84.7 ​%) as HF with preserved EF (HFpEF). Baseline characteristics, prior cardiovascular treatment, laboratory and echocardiographic measurements have been collected during index hospitalization. The long-term follow-up of all-cause mortality was obtained from the National Death Registry.

RESULTS

HFsnEF patients were less frequently hypertensive (75 vs 88.2 ​%, P ​= ​0.026) and they were less often treated with mineralocorticoid receptor antagonists (25 vs 46.2 ​%, P ​= ​0.013) and loop diuretics (60 vs 76 ​%, P ​= ​0.017). The Kaplan-Meier analysis showed that all-cause mortality is higher in HFsnEF than in HFpEF (65 vs 55.2 ​%, P ​= ​0.044). The independent predictors of long-term mortality were age and HFsnEF diagnosis (hazard ratio [HR] 1.037, 95 ​% confidence interval [CI] 1.018-1.056; HR 1.665, 95 ​% CI 1.063-2.608, respectively).

CONCLUSIONS

Our findings indicate that every 7th Polish patient admitted with HFpEF could be classified as HFsnEF. Baseline characteristics of HFsnEF patients are not significantly different from HFpEF. Simultaneously, in the longest follow-up to date, HFsnEF diagnosis is associated with lower long-term survival.

Heart failure with supranormal ejection fraction: clinical characteristics and outcomes compared to mildly reduced and preserved ejection fraction

BACKGROUND

Little is known about the recently emerging entity, heart failure with supranormal ejection fraction (HFsnEF).

OBJECTIVE

To describe the clinical characteristics and outcome of HFsnEF, compared to HF with mildly reduced EF (HFmrEF) and HF with preserved EF (HFpEF) patients.

DESIGN

A single center retrospective analysis.

PATIENTS

Hospitalized and ambulatory heart failure (HF) patients who underwent echocardiography with left ventricular ejection fraction (LVEF) > 40%.

MAIN MEASURES

Clinical and echocardiographic parameters, hospitalization rates and mortality.

KEY RESULTS

A total of 6,202 patients (mean age 81.4 ± 14.1 years, 52% females) were analyzed: 750 in the HFmrEF group (LVEF 41-49%), 4360 in the HFpEF group (LVEF 50-64%), and 1092 in the HFsnEF group (LVEF ≥ 65%). Patients were followed for a median of 32 (11-65) months. HFsnEF patients were older, predominantly female, exhibited higher hypertension prevalence, more severe LV hypertrophy, smaller LV dimensions, and higher filling pressures compared to the other groups (p < 0.001 for all). These features were consistent in both hospitalized and ambulatory patients. In a univariable model, HFsnEF patients had higher mortality rates compared to HFmrEF and HFpEF patients (HR 1.258, 95% CI 1.117-1.418; p < 0.001 and HR 1.112, 95% CI 1.023-1.208; p = 0.012, respectively). However, in a multivariable model, adjusted for age, sex, comorbidities, and echocardiographic parameters, there was no significant difference in the mortality rates between all groups. The total hospitalization rate was similar between the HFpEF and HFsnEF groups, and lower in the HFmrEF group (p = 0.022). However, the HFsnEF group had the lowest rate of HF-related hospitalizations (p = 0.002).

CONCLUSION

HFsnEF represents a group of patients with a distinct clinical and echocardiographic profile accompanied by worse outcomes, likely mediated by older age and a higher comorbidity burden, compared to HFmrEF and HFpEF. Therefore, the supranormal EF may serve as a marker rather than an independent prognostic factor.

2024 update in heart failure

In the last years, major progress has occurred in heart failure (HF) management. The 2023 ESC focused update of the 2021 HF guidelines introduced new key recommendations based on the results of the last years of science. First, two drugs, sodium-glucose co-transporter-2 (SGLT2) inhibitors and finerenone, a novel nonsteroidal, selective mineralocorticoid receptor antagonist (MRA), are recommended for the prevention of HF in patients with diabetic chronic kidney disease (CKD). Second, SGLT2 inhibitors are now recommended for the treatment of HF across the entire left ventricular ejection fraction spectrum. The benefits of quadruple therapy in patients with HF with reduced ejection fraction (HFrEF) are well established. Its rapid and early up-titration along with a close follow-up with frequent clinical and laboratory re-assessment after an episode of acute HF (the so-called 'high-intensity care' strategy) was associated with better outcomes in the STRONG-HF trial. Patients experiencing an episode of worsening HF might require a fifth drug, vericiguat. In the STEP-HFpEF-DM and STEP-HFpEF trials, semaglutide 2.4 mg once weekly administered for 1 year decreased body weight and significantly improved quality of life and the 6 min walk distance in obese patients with HF with preserved ejection fraction (HFpEF) with or without a history of diabetes. Further data on safety and efficacy, including also hard endpoints, are needed to support the addition of acetazolamide or hydrochlorothiazide to a standard diuretic regimen in patients hospitalized due to acute HF. In the meantime, PUSH-AHF supported the use of natriuresis-guided diuretic therapy. Further options and most recent evidence for the treatment of HF, including specific drugs for cardiomyopathies (i.e., mavacamten in hypertrophic cardiomyopathy and tafamidis in transthyretin cardiac amyloidosis), device therapies, cardiac contractility modulation and percutaneous treatment of valvulopathies, with the recent finding from the TRILUMINATE Pivotal trial, are also reviewed in this article.

Relaxin Inhibits Angiotensin II-Induced Cardiac Fibrosis by Activating NO/cGMP Signaling Pathway

BACKGROUND

Cardiac fibrosis, a key contributor to heart failure, is driven by the activation of cardiac fibroblasts (CFs), often induced by angiotensin II (Ang II). Relaxin, a peptide hormone, has been reported to counteract fibrotic processes. This study aims to investigate the antifibrotic effects of relaxin on Ang II-induced CF activation, with a focus on the involvement of the nitric oxide/cyclic guanosine monophosphate (NO/cGMP) signaling pathway.

METHODS

Primary CFs were isolated and treated with Ang II to induce fibrotic activation. Relaxin was used to assess its antifibrotic effects. Inhibitors of the NO/cGMP pathway, NG-nitro-L-arginine methyl ester (L-NAME) (a nitric oxide synthase inhibitor) and 1H-(1 ,2,4) -Oxadiazolo-(4, 3-a) quinoxalin-1-one (ODQ) (a guanylyl cyclase inhibitor), were co-administered to examine their effects on relaxin-mediated inhibition. Proliferation and migration were assessed using 5-Ethynyl-2'-de oxyur idine incorporation and Transwell assays. Western blot analysis was conducted to measure the expression of alpha-smooth muscle actin (α-SMA), collagen I, and collagen III, key markers of fibroblast activation. Nitric oxide, cGMP, total nitric oxide synthase (TNOS), and inducible nitric oxide synthase (iNOS) levels were measured in the culture media.

RESULTS

Ang II significantly increased CF proliferation, migration, and the expression of fibrosis markers α-SMA, collagen I, and collagen III. Relaxin treatment markedly reduced these effects. Inhibition of the NO/cGMP pathway by L-NAME or ODQ partially reversed relaxin's suppressive effects on CF proliferation and migration. Relaxin restored Ang II-induced reductions in NO, cGMP, and TNOS levels, while iNOS levels remained largely unchanged, except for a reduction in the L-NAME group.

CONCLUSION

Relaxin attenuates Ang II-induced cardiac fibroblast activation and fibrosis primarily through the NO/cGMP signaling pathway.

Clinical phenotypes of heart failure patients with supranormal ejection fraction

AIMS

Heart failure (HF) with supranormal ejection fraction (HFsnEF) represents a distinct clinical entity characterized by limited treatment options and an unfavourable prognosis. Revealing its phenotypic diversity is crucial for understanding disease mechanism and optimizing patient management. We aim to identify phenotypic subgroups in HFsnEF using unsupervised clustering analysis.

METHODS

Consecutive hospitalized patients with a diagnosis of HF and a left ventricular ejection fraction ≥65% at baseline echocardiographic evaluations were included for analysis. We conducted unsupervised hierarchical clustering analysis on principal components (HCPC) to identify HFsnEF phenogroups using mixed data variables including demographics, HF duration, vital signs, anthropometrics, smoking/drinking status, HF aetiology, comorbid diseases, laboratory tests and echocardiographic parameters. We then employed decision tree modelling to identify parameters capable of distinguishing distinct clusters. Clinical outcomes, including all-cause death, cardiovascular (CV) death and CV readmission for different clusters, were examined.

RESULTS

Three mutually exclusive clusters were identified from the cohort of 221 HFsnEF patients. Cluster 1 (52.5%) predominantly consisted of patients with valvular heart disease, who had larger cardiac chambers and a higher prevalence of atrial fibrillation/atrial flutter. Cluster 2 (26.2%) primarily comprised older ischaemic patients with a higher prevalence of metabolic comorbidities. Cluster 3 (21.3%) were mainly hypertrophic cardiomyopathy patients. Two clinical variables were identified that could be used to group all HFsnEF patients into one of the clusters; they were HF aetiology and comorbid diabetes. During the median follow-up of 53.4 months, 46 (20.8%) all-cause deaths occurred, among them 39 of CV causes. Seventy (31.7%) patients experienced CV readmissions. Three clusters showed distinct differences in mortality outcomes, with Cluster 1 exhibiting the highest risk of all-cause mortality [Cluster 1 vs. Cluster 2: adjusted hazard ratio (aHR) = 3.32, P = 0.022; Cluster 1 vs. Cluster 3: aHR = 3.81, P = 0.036; Cluster 2 vs. Cluster 3: aHR = 1.15, P = 0.865] and CV mortality (Cluster 1 vs. Cluster 2: aHR = 3.73, P = 0.022; Cluster 1 vs. Cluster 3: aHR = 4.27, P = 0.020; Cluster 2 vs. Cluster 3: aHR = 1.15, P = 0.870). CV readmission risk was comparable among the three clusters (Cluster 1 vs. Cluster 2: aHR = 0.82, P = 0.590; Cluster 1 vs. Cluster 3: aHR = 1.04, P = 0.900; Cluster 2 vs. Cluster 3: aHR = 1.28, P = 0.580).

CONCLUSIONS

In a heterogeneous HFsnEF cohort, three clusters were identified by unsupervised HCPC with distinct clinical characteristics and outcomes.

Supranormal Left Ventricular Ejection Fraction, Concentric Remodeling, and Long-Term Survival

Background

Supranormal left ventricular ejection fraction (LVEF) confers a paradoxically higher mortality risk; however, whether intrinsic structural changes of left ventricle (LV) play an important role remain unclear.

Objectives

The authors sought to investigate the prognostic implication of supranormal LVEF and its interaction with LV concentric remodeling.

Methods

Consecutive participants undergoing echocardiography in a tertiary medical center with LVEF >60% were included. LV concentric remodeling was defined as LV relative wall thickness >0.42. The primary outcome was all-cause mortality. The association between LVEF and all-cause mortality was assessed using Cox models and restricted cubic splines. Subgroup analysis was performed to evaluate the association between LVEF and risk of death stratified by LV concentric remodeling.

Results

In total, 67,108 participants (age 60.5 ± 17.2 years, men 44.6% [n = 29,924]) were included. 7,029 deaths of 67,108 (10.5%) occurred over a median of 50.3 months (Q1, Q3: 20.9, 91.3 months). In multivariable Cox models, subjects with LVEF above 70% had a significantly higher risk (vs 60%-65%) for all-cause mortality (adjusted HR: 1.15; 95% CI: 1.05-1.26; P = 0.003) after adjusting for potential confounders. A significant interaction was observed between LVEF and LV concentric remodeling (P for interaction <0.001), particularly in women, such that a higher mortality risk of supranormal LVEF could be observed mainly among those with LV concentric remodeling.

Conclusions

Supranormal LVEF >70% is associated with a greater risk for all-cause mortality. The higher mortality risk could be predominantly observed among individuals presented with LV concentric remodeling, particularly in women.

Lower heart rate in patients with acute heart failure: the role of left ventricular ejection fraction

BACKGROUND

The clinical impact of heart rate (HR) in heart failure with preserved ejection fraction (HFpEF) is a matter of debate. Among those with HFpEF, chronotropic incompetence (CI) has emerged as a pathophysiological mechanism linked to the severity of the disease. In this study, we sought to evaluate whether admission heart rate in acute heart failure differs along left ventricular ejection fraction (LVEF).

METHODS

We included retrospectively 3,712 consecutive patients admitted for acute heart failure (AHF) in the Cardiology department of a third level center. HR values were assessed at presentation. LVEF was assessed by transthoracic echocardiogram during the index admission and stratified into four categories: reduced ejection fraction (≤ 40%), mildly reduced ejection fraction (41-49%), preserved ejection fraction (50-64%) and supranormal ejection fraction (≥ 65%). The association between HR and LVEF was assessed by multivariate linear and multinomial regression analyses.

RESULTS

The mean age of the sample was 73,9 ± 11.3 years, 1,734 (47,4%) were women, and 1,214 (33,2%), 570 (15,6%), 1,229 (33,6%) and 648 (17,7%) patients showed LVEF ≤ 40%, 41-49%, 50-64%, and ≥65% respectively. The median HR at admission was 95 (IQR 78-120) beats per minute and 1,653 were on atrial fibrillation (45.2%). There was an inverse relationship between HR at admission and LVEF. Lower HR was significantly associated with a higher LVEF in the whole sample (p < 0,001). This inverse relationship was found in sinus rhythm but not in patients with atrial fibrillation.

CONCLUSION

HR at admission for AHF is a predictor of LVEF but only in patients with sinus rhythm.

A Comprehensive Nomogram Integrating Phonocardiogram and Echocardiogram Features for the Diagnosis of Heart Failure With Preserved Ejection Fraction

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is associated with high hospitalization and mortality rates, representing a significant healthcare burden. This study aims to utilize various information including echocardiogram and phonocardiogram to construct and validate a nomogram, assisting in clinical decision-making.

METHODS

This study analyzed 204 patients (68 HFpEF and 136 non-HFpEF) from the First Affiliated Hospital of Chongqing Medical University. A total of 49 features were integrated and used, including phonocardiogram, echocardiogram features, and clinical parameters. The least absolute shrinkage and selection operator (LASSO) regression was used to select the optimal matching factors, and a stepwise logistic regression was employed to determine independent risk factors and develop a nomogram. Model performance was evaluated by the area under receiver operating characteristic (ROC) curve (AUC), calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC).

RESULTS

The nomogram was constructed using five significant indicators, including NT-proBNP (OR = 4.689, p = 0.015), E/e' (OR = 1.219, p = 0.032), LAVI (OR = 1.088, p < 0.01), D/S (OR = 0.014, p < 0.01), and QM1 (OR = 1.058, p < 0.01), and showed a better AUC of 0.945 (95% CI = 0.908-0.982) in the training set and 0.933 (95% CI = 0.873-0.992) in the testing set compared to conventional nomogram without phonocardiogram features. The calibration curve and Hosmer-Lemeshow test demonstrated no statistical significance in the training and testing sets (p = 0.814 and p = 0.736), indicating the nomogram was well-calibrated. The DCA and CIC results confirmed favorable clinical usefulness.

CONCLUSION

The nomogram, integrating phonocardiogram and echocardiogram features, enhances HFpEF diagnostic efficiency, offering a valuable tool for clinical decision-making.

Predictors of hypercontractile heart phenotype in patients with chronic coronary syndromes or heart failure

Hypercontractile phenotype (HP) of the left ventricle (LV) is an actionable therapeutic target in patients with chronic coronary syndromes (CCS) or heart failure (HF), but its clinical recognition remains difficult. To assess the clinical variables associated with the HP. In a prospective, observational, multicenter study, we recruited 5122 patients (age 65 ± 11 years, 2974 males, 58%) with CCS and/or HF with preserved ejection fraction (EF). Systolic blood pressure (SBP) was measured. We assessed wall motion score index (WMSI), LV end-diastolic volume (EDV), end-systolic volume (ESV), EF, force (SBP/ESV), stroke volume (SV), arterial elastance (SBP/SV), and ventricular-arterial coupling (VAC, as SV/ESV). Univariable and multivariable logistic regression analysis assessed independent factors associated with the highest force sextile. For all the studied patients, force was 4.51 ± 2.11 mmHg/ml, with the highest sextile (Group 6) > 6.36 mmHg/ml. By multivariable logistic regression model, the highest sextile of force was associated with age > 65 years (OR 1.62, 95% CI 1.36-1.93, p < 0.001), hypertension (OR 1.76, 95% CI 1.40-2.21, p < 0.001), female sex (OR 4.52, 95% CI 3.77-5.42, p < 0.001), absence of beta-blocker therapy (OR 1.41, 95% CI 1.16-1.68), rest SBP ≥ 160 mmHg (OR 2.81, 95% CI 2.21-3.56, p < 0.001), high heart rate (OR 2.08, 95% CI 1.61-2.67, p < 0.001), and absence of prior myocardial infarction (OR 1.34, 95% CI 1.07-1.68, p = 0.012). Patients in the highest sextile of force showed lower values of WMSI, SV, EDV, and ESV, and higher values of arterial elastance and VAC. HP of the LV with high force was clinically associated with advanced age, female sex, high resting SBP, and the absence of β-blocker therapy. By transthoracic echocardiography, HP was associated with a small heart with reduced EDV, reduced SV despite high EF, and higher arterial elastance.

Association of Supranormal Left Ventricular Function With Major Adverse Cardiovascular Events: A Systematic Review of Literature

This systematic review aims to assess the prognostic implications of supranormal left ventricular ejection fraction (snLVEF) in cardiovascular disease, particularly heart failure (HF), and explore its association with major adverse cardiovascular events (MACE). A comprehensive search of electronic databases was conducted to identify relevant studies examining the relationship between snLVEF and cardiovascular outcomes. Studies utilizing various imaging modalities, including echocardiography, cardiac positron emission tomography, computed tomography, and cardiac magnetic resonance imaging, were included. Data extraction and quality assessment were performed according to predefined criteria. The review identified several studies investigating the association between snLVEF and cardiovascular outcomes. Findings revealed an increased risk of MACE, including HF hospitalization and stroke, in patients with snLVEF, particularly in women. Coronary microvascular dysfunction and autonomic dysregulation were proposed mechanisms underlying these associations. However, conflicting results were observed when focusing exclusively on snLVEF, with some studies reporting similar outcomes between snLVEF and other HF subgroups. snLVEF (>65%) appears to be associated with an elevated risk of MACE, particularly in women, suggesting a U-shaped mortality curve. However, the prognostic implications may vary among HF patients, necessitating further research to elucidate the specific contributions of HF phenotypes and comorbidities. These findings underscore the importance of tailored risk assessment and management strategies for patients with snLVEF, particularly in the context of HF.

Prevalence and Prognostic Implications of Changes in Tricuspid Regurgitation Severity in Acute Heart Failure

BACKGROUND

Tricuspid regurgitation (TR), prevalent in acute heart failure (AHF), has a poor prognosis; however, the dynamics of TR severity during hospitalization and its prognostic implications remain unclear. We investigated TR dynamism during hospitalization and its prognostic impact in AHF.

METHODS AND RESULTS

This is a post hoc analysis of a prospective multicenter study of patients with AHF who underwent echocardiographic TR severity evaluation at admission and before discharge. The primary end point was a combined of 1-year all-cause mortality and HF rehospitalization after discharge. Among 1079 participants, TR severity changed dynamically, with 60.3% of those with moderate TR and 29.6% of those with severe TR at admission being diagnosed as no or mild TR at discharge. In 3 groups stratified by changes in TR severity, the persistent TR groups had a higher incidence of the primary end point than the resolution and absence groups. In adjusted analyses, the persistent group (hazard ratio, 1.37; 95% confidence interval, 1.04-1.80), but not the resolution group (hazard ratio, 1.07; 95% confidence interval, 0.79-1.44), had a higher primary end point incidence than the absence group.

CONCLUSIONS

TR severity at admission in patients with AHF can change dynamically and is associated with subsequent prognosis. Significant TR that remains even after decongestive therapy might be a target for further treatment in hospitalized patients with AHF.

Differential sex-related effect of left ventricular ejection fraction trajectory on the risk of mortality and heart failure readmission following hospitalization for acute heart failure: A longitudinal study

AIMS

There is limited information on the sex-specific longitudinal changes of left ventricular ejection fraction (LVEF) after an acute heart failure (AHF) hospitalization. We aimed to investigate whether LVEF trajectories over time and their impact on mortality and AHF readmission rates differ between men and women.

METHODS AND RESULTS

We conducted a retrospective sex-specific analysis of longitudinal LVEF measurements (n = 9581) in 3383 patients with an index hospitalization for AHF in a single tertiary-level hospital. Statistical techniques suited for longitudinal data analysis were used. The mean age of the sample was 73.8 ± 11.2 years, and 47.9% were women. The mean LVEF was 49.4 ± 15.3%. At a median follow-up of 2.58 years (interquartile range 0.77-5.62), we registered 2197 deaths (64.9%) and 2597 AHF readmissions in 1302 (38.5%) patients. The longitudinal analysis showed that women had consistently higher LVEF values throughout the follow-up with both trajectories characterized by an early peak-approximately at 1 year-followed by decreasing values in men but a plateau in women. Multivariate between-sex comparisons across LVEF categories revealed that women had lower rates of AHF readmissions when LVEF ≤40%. On the contrary, women displayed an excess risk of AHF readmissions when LVEF >60%. A trend in the same direction was found for cardiovascular and all-cause mortality.

CONCLUSION

Sex was a significant factor in determining the follow-up trajectory of LVEF and predicting differences in outcomes after an AHF admission. The findings suggest that women have a higher risk of AHF readmissions at higher LVEF values, while men have a higher risk at lower LVEF values. For all-cause and cardiovascular mortality, the same direction of the association was inferred but they were not significant.

Age-stratified profiles and outcomes of patients with heart failure with preserved ejection fraction

AIMS

This study aimed to elucidate age-stratified clinical profiles and outcomes in patients with heart failure (HF) with preserved left ventricular ejection fraction (LVEF) (HFpEF).

METHODS AND RESULTS

The Chronic Heart Failure Registry and Analysis in the Tohoku District-2 (CHART-2) Study included 2824 consecutive HFpEF patients with LVEF ≥ 50% (mean age 69.0 ± 12.3 years; 67.7% male) with a median follow-up of 9.8 years. We stratified them into five age groups: ≤54 (N = 349, 12.4%), 55-64 (N = 529, 18.7%), 65-74 (N = 891, 31.6%), 75-84 (N = 853, 30.2%), and ≥85 years (N = 202, 7.2%), and we categorized these age groups into younger (≤64 years) and older (≥65 years) groups. We compared the clinical profiles and outcomes of HFpEF patients across age groups. Younger HFpEF groups exhibited a male predominance, elevated body mass index (BMI), and poorly controlled diabetes (haemoglobin A1c > 7.0%). Older HFpEF groups were more likely to be female with multiple comorbidities, including coronary artery disease, hypertension, renal impairment, and atrial fibrillation. The positive association between elevated BMI and HFpEF was more pronounced with lower classes of age from ≥85 to ≤54 years, especially in males. With higher classes of age from ≤54 to ≥85 years, mortality rates increased, and HF death became proportionally more prevalent (Ptrend < 0.001), whereas sudden cardiac death (SCD) exhibited the opposite trend (Ptrend = 0.002). Poorly controlled diabetes emerged as the only predictor of SCD in the younger groups (adjusted hazard ratio 4.26; 95% confidence interval 1.45-12.5; P = 0.008). Multiple comorbidities were significantly associated with an increased risk of HF-related mortality in the older groups.

CONCLUSIONS

Younger HFpEF patients (≤64 years) exhibit a male predominance, elevated BMI, and poorly controlled diabetes, highlighting the importance of glycaemic control in reducing SCD risk. Older HFpEF patients (≥65 years) are more likely to be female, with multiple comorbidities linked to an increased risk of HF-related mortality. These findings underscore the need for physicians to recognize age-related, distinct HFpEF phenotypes for personalized patient management.

Inhibition of vascular calcification by Compound Danshen Dripping Pill through multiple mechanisms

BACKGROUND

Vascular calcification refers to the abnormal accumulation of calcium in the walls of blood vessels and is a risk factor often overlooked in cardiovascular disease. However, there is currently no specific drug for treating vascular calcification. Compound Danshen Dripping Pill (CDDP) is widely used to treat cardiovascular diseases, but its effect on vascular calcification has not been reported.

PURPOSE

We investigated the effects of CDDP on vascular calcification in ApoE-/- mice and in vitro and elucidated its mechanism of action.

STUDY DESIGN

Firstly, we found that CDDP has the potential to improve calcification based on network pharmacology analysis. Then, we performed the following experiments: in vivo, ApoE-/- mice were fed a high-fat diet randomly supplemented with CDDP for 16 weeks. Atherosclerosis and vascular calcification were determined. In vitro, human aortic smooth muscle cells (HASMCs), human umbilical vein endothelial cells (HUVECs), and human aortic endothelial cells (HAECs) were used to determine the mechanisms for CDDP-inhibited vascular calcification.

RESULTS

In this study, we observed that CDDP reduced intimal calcification in atherosclerotic lesions of ApoE-deficient mice fed a high-fat diet, as well as the calcification in cultured SMCs and ECs. Mechanistically, CDDP inhibited the Wnt/β-catenin pathway by up-regulating the expression of DKK1 and LRP6, which are upstream inhibitors of Wnt, leading to a reduction in the expression of osteoblastic transition markers (ALP, OPN, BMP2, and RUNX2). Furthermore, CDDP enhanced the secretion of DKK1, which plays a role in mediating EC-SMC crosstalk in calcification. Additionally, VC contributes to vascular aging by inhibiting Sirt1 and increasing senescence parameters (SA-β-gal, p21, and p16). However, CDDP reversed these changes by activating Sirt1. CDDP also reduced the levels of pro-inflammatory cytokines and the senescence-associated secretory phenotype in vivo and in vitro.

CONCLUSIONS

Our study suggests that CDDP reduces vascular calcification by regulating the DKK1/LRP6/β-catenin signaling pathway in ECs/SMCs and interactions with the crosstalk of ECs and SMCs. It also reduces the senescence of ECs/SMCs, contributing to the Sirt1 activation, indicating CDDP's novel role in ameliorating vascular calcification.

404-error "Disease not found": Unleashing the translational potential of -omics approaches beyond traditional disease classification in heart failure research

The emergence of personalized medicine, facilitated by the progress in -omics technologies, has initiated a new era in medical diagnostics and treatment. This review examines the potential of -omics approaches in heart failure, a condition that has not yet fully capitalized on personalized strategies compared to other medical fields like cancer therapy. Here, we argue that integrating multi-omics technology with systems medicine approaches could fundamentally transform heart failure management, moving away from the traditional paradigm of 'one size fits all'. Our review examines how omics can enhance understanding of heart failure's molecular foundations and contribute to a more comprehensive disease classification. We draw attention to the current state of medical practice that only relies on clinical evidence and a number of standard laboratory tests. At the same time, we propose a shift towards a universal approach that uses quantitative data from multi-omics to unravel complex molecular interactions. The discussion centres around the potential of the transition as a means to enhance individual risk assessment and emphasizes management within clinical settings. While the use of omics in cardiovascular research is not recent, many past studies have focused only on a single omics approach. In order to achieve a better understanding of disease mechanisms, we explore more holistic approaches using genomics, transcriptomics, epigenomics, and proteomics. This review concludes with a call to action to adopt multi-omics in clinical trials and practice to pave the way for more personalized disease management and more effective heart failure interventions.

Noncardiovascular morbidity and mortality across left ventricular ejection fraction categories following hospitalization for heart failure

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%.

Risk of supranormal left ventricular ejection fraction in patients with aortic stenosis

BACKGROUND

Cardiovascular events are increasing in patients with supranormal left ventricular ejection fraction (snLVEF). However, the effect of snLVEF in patients with aortic stenosis (AS) remains unclear, especially in patients with moderate AS.

HYPOTHESIS

This study aimed to evaluate the prognosis of mortality and heart failure (HF) in patients with LVEF ≥ 50% and moderate or severe AS.

METHODS

This retrospective study targeted patients with moderate or severe AS and LVEF > 50%. LVEF of 50%-65% was classified as normal LVEF (nLVEF, nEF group) and >65% as snLVEF (snEF group). AS severity was stratified based on the aortic valve area into moderate (1.0-1.5 cm²) and severe (<1.0 cm²). Primary outcomes included all-cause mortality and HF hospitalization.

RESULTS

A total of 226 participants were included in this study. There were 67 and 65 participants with moderate AS in snEF (m-snEF) and nEF groups (m-nEF), respectively, and 41 and 53 participants with severe AS in the snEF (s-snEF) and nEF groups (s-nEF), respectively. During the observation period (median: 554 days), the primary composite outcome occurred in 108 individuals. Cox hazard analysis revealed no significant differences among the four groups in primary composite outcomes. With respect to HF hospitalization, the adjusted hazard ratios (95% confidence intervals) with m-snEF as the reference were as follows: m-nEF, 0.41 (0.19-0.89); s-nEF, 1.43 (0.76-2.67); and s-snEF, 1.83 (1.00-3.35).

CONCLUSIONS

The risk of HF hospitalization for m-snLVEF was higher than m-nLVEF and not significantly different from s-nLVEF.

Clinical Implication of Supra-Normal Left Ventricular Ejection Fraction in Patients Undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

Individuals with heart failure displaying supra-normal left ventricular ejection fraction (snLVEF) may exhibit less favorable clinical outcomes in contrast to their counterparts with normal left ventricular ejection fraction (nLVEF). The distinctive characteristics and mid-term prognosis of individuals with severe aortic stenosis and snLVEF following transcatheter aortic valve replacement (TAVR) remain enigmatic.

METHODS

Among 7393 patients diagnosed with severe aortic stenosis who underwent TAVR between 2013 and 2019 and were enlisted in the optimized transcatheter valvular intervention (OCEAN-TAVI) multicenter registry (UMIN000020423), we selected patients with left ventricular ejection fraction (LVEF) ≥ 50%. snLVEF was defined as LVEF exceeding 65%. We compared the baseline characteristics and assessed three-year post-TAVR mortality and heart failure readmission rates between the snLVEF (LVEF > 65%) and nLVEF cohorts (LVER 50-65%).

RESULTS

Our study cohort comprised 5989 patients (mean age 84.4 ± 5.1 years and 1783 males). Among these, 2819 patients were categorized within the snLVEF cohort, while the remaining 3170 were allocated to the nLVEF group. Individuals within the snLVEF cohort were more likely to be female and displayed lower levels of natriuretic peptides, as well as smaller left ventricular dimensions in comparison to their nLVEF counterparts (p < 0.05 for all). The presence of snLVEF emerged as an independent predictor of the three-year composite endpoint relative to nLVEF, with an adjusted hazard ratio of 1.16 (95% confidence interval 1.02-1.31, p = 0.023) after accounting for several potential confounding factors.

CONCLUSIONS

snLVEF was relatively common among candidates for TAVR with preserved ejection fraction. Patients harboring snLVEF appear to manifest a distinctive clinical profile and encounter less favorable clinical outcomes following TAVR in contrast to those characterized by nLVEF.

Supra-Normal Left Ventricular Function

Heart failure (HF) is often categorized by left ventricular (LV) ejection fraction (LVEF). A new category of HF characterized by supra-normal LVEF (>65%), named HF with supra-normal ejection fraction (HFsnEF), has been recently proposed. Some studies reported that patients with supra-normal LVEF might have an increased risk of long-term major adverse cardiovascular events and U-shaped mortality patterns. Currently, the prognosis of HFsnEF is not well established but seems to be associated with an increased risk of long-term major adverse cardiovascular events. It has been reported that HFsnEF is more prevalent in women and is associated with higher prevalence of nonischemic HF, higher blood urea nitrogen plasma levels, lower levels of natriuretic peptides, and to be less likely treated with β blockers. The pathophysiology of HFsnEF would be associated with microvascular dysfunction because of microvascular inflammation or reduced coronary flow reserve, and low stroke volume index with smaller cardiac chamber dimensions and concentric LV geometry. In this study, we systematically reviewed published data on patients with s supra-normal LV function and reported its definition, proposed pathophysiology, phenotypes, diagnostic strategy, and prognosis.

Prevalence, characteristics and cardiovascular and non-cardiovascular outcomes in patients with heart failure with supra-normal ejection fraction: Insight from the JROADHF study

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.