Heart Failure With Recovered Ejection Fraction

Left ventricular ejection fraction: clinical, pathophysiological, and technical limitations

Risk stratification of cardiovascular death and treatment strategies in patients with heart failure (HF), the optimal timing for valve replacement, and the selection of patients for implantable cardioverter defibrillators are based on an echocardiographic calculation of left ventricular ejection fraction (LVEF) in most guidelines. As a marker of systolic function, LVEF has important limitations being affected by loading conditions and cavity geometry, as well as image quality, thus impacting inter- and intra-observer measurement variability. LVEF is a product of shortening of the three components of myocardial fibres: longitudinal, circumferential, and oblique. It is therefore a marker of global ejection performance based on cavity volume changes, rather than directly reflecting myocardial contractile function, hence may be normal even when myofibril's systolic function is impaired. Sub-endocardial longitudinal fibers are the most sensitive layers to ischemia, so when dysfunctional, the circumferential fibers may compensate for it and maintain the overall LVEF. Likewise, in patients with HF, LVEF is used to stratify subgroups, an approach that has prognostic implications but without a direct relationship. HF is a dynamic disease that may worsen or improve over time according to the underlying pathology. Such dynamicity impacts LVEF and its use to guide treatment. The same applies to changes in LVEF following interventional procedures. In this review, we analyze the clinical, pathophysiological, and technical limitations of LVEF across a wide range of cardiovascular pathologies.

Your Heart Function Has Normalized-What Next After TRED-HF?

PURPOSE OF REVIEW

With the widespread implementation of contemporary disease-modifying heart failure therapy, the rates of normalization of ejection fraction are continuously increasing. The TRED-HF trial confirmed that heart failure remission rather than complete recovery is typical in patients with dilated cardiomyopathy who respond to therapy. The present review outlines key points related to the management and knowledge gaps of this growing patient group, focusing on patients with non-ischaemic dilated cardiomyopathy.

RECENT FINDINGS

There is substantial heterogeneity among patients with normalized ejection fraction. The specific etiology is likely to affect the outcome, although a multiple-hit phenotype is frequent and may not be identified without comprehensive characterization. A monogenic or polygenic genetic susceptibility is common. Ongoing pathophysiological processes may be unraveled with advanced cardiac imaging, biomarkers, multi-omics, and machine learning technologies. There are limited studies that have investigated the withdrawal of specific heart failure therapies in these patients. Diuretics may be safely withdrawn if there is no evidence of congestion, while continued therapy with at least some disease-modifying therapy is likely to be required to reduce myocardial workload and sustain remission for the vast majority. Understanding the underlying disease mechanisms of patients with normalized ejection fraction is crucial in identifying markers of myocardial relapse and guiding individualized therapy in the future. Ongoing clinical trials should inform personalized approaches to therapy.

Early emergency department discharge for intermediate heart score patients presenting for chest pain

Study Objective

The use of the HEART score to risk stratify patients for short-term major adverse cardiac events in the emergency department (ED) setting is well established. Although discharge to home for low-risk HEART score patients is widely accepted as safe practice, there are limited outcomes data on moderate-risk HEART score patients discharged to home. We investigated the safety of discharging moderate-risk HEART score patients to home from the ED with established early cardiology follow-up.

Methods

We performed a retrospective cohort analysis of patients presenting to the ED with chest pain from April 2020 through December 2020. Patients were evaluated in the ED and underwent serial conventional troponin testing and electrocardiogram (ECG). Clinicians calculated a HEART score and employed shared decision-making with moderate-risk patients (score 4-6), offering hospital admission versus discharge home with a formalized process for rapid cardiology follow-up (within 2 business days). We assessed the frequency of acute myocardial infarction or death at 30 days and before cardiology follow-up.

Results

During our study period, 2939 patient encounters were screened for chest pain. Of these, 333 of 547 eligible moderate-risk HEART score patients were referred for rapid follow-up. The median time to follow-up appointment was 2.9 business days (interquartile range 1.3, 6.5), and 264 (79%) of patients kept their follow-up appointment. One patient (0.3%) suffered death within 30 days, before cardiology follow-up. There were no myocardial infarctions.

Conclusions

These results suggest that moderate-risk HEART score patients may be considered for discharge from the ED with rapid cardiology follow-up. Formalizing processes to facilitate these early evaluations may represent a viable alternative to hospital admission, without diminishing patient outcomes.

Comprehensive Cardiovascular Magnetic Resonance-Derived Myocardial Strain Analysis Provides Independent Prognostic Value in Acute Myocarditis

Background Late gadolinium enhancement and left ventricular (LV) ejection fraction on cardiovascular magnetic resonance (CMR) are prognostic markers, but their predictive value for incident heart failure or life-threatening arrhythmias in acute myocarditis patients is limited. CMR-derived feature tracking provides a more sensitive analysis of myocardial function and may improve risk stratification in myocarditis. In this study, the prognostic value of LV, right ventricular, and left atrial strain in acute myocarditis patients is evaluated. Methods and Results In this multicenter retrospective study, patients with CMR-proven acute myocarditis were included. The primary end point was occurrence of major adverse cardiovascular events: all-cause mortality, heart transplantation, heart failure hospitalizations, and life threatening arrhythmias. LV global longitudinal strain, global circumferential strain and global radial strain, right ventricular-global longitudinal strain and left atrial strain were measured. Unadjusted and adjusted cox proportional hazard regression analysis were performed. In total, 162 CMR-proven myocarditis patients were included (41 ± 17 years, 75% men). Mean LV ejection fraction was 51 ± 12%, and 144 (89%) patients had presence of late gadolinium enhancement. Major adverse cardiovascular events occurred in 29 (18%) patients during a follow-up of 5.5 (2.2-8.3) years. All LV strain parameters were independent predictors of outcome beyond clinical features, LV ejection fraction and late gadolinium enhancement (LV-global longitudinal strain: hazard ratio [HR] 1.07, P=0.02; LV-global circumferential strain: HR 1.15, P=0.02; LV-global radial strain: HR 0.98, P=0.03), but right ventricular or left atrial strain did not predict outcome. Conclusions CMR-derived LV strain analysis provides independent prognostic value on top of clinical parameters, LV ejection fraction and late gadolinium enhancement in acute myocarditis patients, while left atrial and right ventricular strain seem to be of less importance.

Global Longitudinal Strain is Incremental to Left Ventricular Ejection Fraction for the Prediction of Outcome in Optimally Treated Dilated Cardiomyopathy Patients

Background

Speckle tracking echocardiographic global longitudinal strain (GLS) predicts outcome in patients with new onset heart failure. Still, its incremental value on top of left ventricular ejection fraction (LVEF) in patients with nonischemic, nonvalvular dilated cardiomyopathy (DCM) after optimal heart failure treatment remains unknown.

Methods and Results

Patients with DCM were included at the outpatient clinics of 2 centers in the Netherlands and Italy. The prognostic value of 2‐dimensional speckle tracking echocardiographic global longitudinal strain was evaluated when being on optimal heart failure medication for at least 6 months. Outcome was defined as the combination of sudden or cardiac death, life‐threatening arrhythmias, and heart failure hospitalization. A total of 323 patients with DCM (66% men, age 55±14 years) were included. The mean LVEF was 42%±11% and mean GLS after optimal heart failure treatment was −15%±4%. Twenty percent (64/323) of all patients reached the primary outcome after optimal heart failure treatment (median follow‐up of 6[4–9] years). New York Heart Association class ≥3, LVEF, and GLS remained associated with the outcome in the multivariable‐adjusted model (New York Heart Association class: hazard ratio [HR], 3.43; 95% CI, 1.49–7.90, P =0.004; LVEF: HR, 2.13; 95% CI, 1.11–4.10, P =0.024; GLS: HR, 2.24; 95% CI, 1.18–4.29, P =0.015), whereas left ventricular end‐diastolic diameter index, left atrial volume index, and delta GLS were not. The addition of GLS to New York Heart Association class and LVEF improved the goodness of fit (log likelihood ratio test P <0.001) and discrimination (Harrell’s C 0.703).

Conclusions

Within this bicenter study, GLS emerged as an independent and incremental predictor of adverse outcome, which exceeded LVEF in patients with optimally treated DCM. This presses the need to routinely include GLS in the echocardiographic follow‐up of DCM.

Prognostic Value of Global Longitudinal Strain in Patients With Heart Failure With Improved Ejection Fraction

OBJECTIVES

The authors sought to determine whether global longitudinal strain (GLS) is independently associated with the natural history of patients with heart failure (HF) with improved ejection fraction (HFimpEF).

BACKGROUND

Left ventricular (LV) ejection fraction (EF) often improves in patients with reduced EF. The clinical course of patients with HFimpEF, however, is quite variable. GLS, a sensitive indicator of LV systolic function, could help predict risk of future events in this population.

METHODS

Retrospective analysis of HF patients with LVEF >40% on index echocardiogram who had LVEF <40% on initial study and improvement of ≥10%. GLS was assessed by 2-dimensional speckle-tracking software on index echocardiography. Primary outcome was time to first occurrence of cardiovascular mortality or HF hospitalization/emergency treatment.

RESULTS

Of the 289 patients with HFimpEF, median absolute values of GLS (aGLS) and LVEF from index echocardiography were 12.7% (IQR: 10.8%-14.7%) and 52% (IQR: 46%-58%), respectively. Over 53 months following index echocardiography, the primary endpoint occurred less frequently in patients with aGLS above the median than below it (21% vs 34%; P = 0.014); HR of 0.51; 95% CI: 0.33-0.81; P = 0.004. When assessed as a continuous variable, each 1% increase in aGLS on index echocardiogram was associated with a lower likelihood of the composite endpoint; HR of 0.86; 95% CI: 0.79-0.93; P < 0.001, an association that persisted after multivariable adjustment; HR 0.90; 95% CI: 0.82-0.97; P = 0.01. Lower aGLS was associated with increased likelihood of deterioration in LVEF.

CONCLUSIONS

In patients with HFimpEF, GLS is a strong predictor for future HF events and deterioration in cardiac function.

Heart failure with recovered ejection fraction and the utility of defibrillator therapy: a review

Heart failure with recovered ejection fraction (HFrecEF) involves those who have previously had reduced cardiac function that has subsequently improved. However, there is not a single definition of this phenomenon and recovery of cardiac function in terms of left ventricular ejection fraction (LVEF) itself does not necessarily correlate with remission from the detrimental physiology of heart failure (HF) and its consequences. There is also the question of the utility of defibrillators in these patients, and whether they should be replaced at the time of battery depletion. To address this, several studies have shown specific predictors of ensuing LVEF recovery, including patient demographics, co‐morbidities, and medication use, as well as predictors of ventricular arrhythmias (VA) following LVEF recovery. Recent studies have also shown novel imaging parameters that may aid in predicting which patients would have a higher risk of these arrhythmias. Additional data describe a small, yet appreciable risk of VA, in addition to appropriate shocks as well. In this review, we describe predictors of LVEF recovery, carefully analyse and characterize the continued risk for VA and appropriate shocks following LVEF recovery, and explore additional novel modalities that may aid in decision‐making.

Heart failure with recovered ejection fraction (HFrecEF): A new entity with improved cardiac outcome

BACKGROUND

Aim of the study was a better characterization of heart failure (HF) with recovered ejection fraction (HFrecEF) and undulating EF (HFuEF) with regard to re-hospitalization due to congestive HF (CHF), adequate electric therapies (AETs) and mortality compared to HF with reduced EF (HFrEF), mid-range EF (HFmrEF) and preserved EF (pEF).

METHODS

Retrospective study of 342 participants with an implantable cardioverter defibrillator (ICD) for primary or secondary prevention. Type of HF was classified according to left ventricular EF with 4.7 ± 3.1 investigations for each patient.

RESULTS

Re-hospitalization due to CHF was similar in HFrecEF (7 (9.5%)), HFmrEF (2(9.0%)) and pEF (8(12.9%); p = n.s.) and significantly higher in HFrEF (62(38.0%)) and HFuEF (6(28.6%); p < .001 compared to HFrecEF and HFrEF). AETs were significantly lower in HFrecEF (13(17.6%)) compared to HFrEF (57(35.0%)), HFmrEF (7(31.8%)), pEF (18(29.0%)) and HFuEF (6(28.6%); each p < .01 compared to HFrecEF). Mortality was similar in HFrecEF (6(8.1%)) compared to HFuEF (0(0%)), pEF (4(6.5%)) and HFmrEF (2(9.0%), p = n.s.) and significantly lower compared to HFrEF (52(31.9%), p < .001). HFrEF was the strongest predictor for mortality besides age and chronic renal insufficiency according to Cox Regression (each p < .05) opposite to arterial hypertension, diabetes, type of cardiomyopathy and secondary prevention ICD indication (each p = n.s.).

CONCLUSIONS

HFrecEF indicates as a new entity of HF with similar prognosis as pEF and HFmrEF with regard to re-hospitalization due to CHF and mortality and even better prognosis with regard to AETs. HFuEF showed similar rates of re-hospitalization due to CHF and AETs compared to HFrEF, but lower rates of mortality.

Outcomes of Spironolactone Withdrawal in Dilated Cardiomyopathy With Improved Ejection Fraction

Background: The feasibility of spironolactone withdrawal in dilated cardiomyopathy patients with improved ejection fraction remains unknown. This study sought to determine whether spironolactone can be withdrawn safely in this circumstance. Methods: Consecutive patients with idiopathic dilated cardiomyopathy and prescribed spironolactone at discharge were included in this prospective, observational cohort using the Risk Evaluation and Management in Heart Failure Trial (NCT02998788) database. Those patients who experienced an absolute left ventricular ejection fraction (LVEF) improvement ≥10% and a second measurement of LVEF >40% would choose whether to continue spironolactone therapy and be included in final analysis. The primary endpoint was dilated cardiomyopathy relapse within 12 months, defined as a more than 10% reduction in LVEF, a 15% or greater increase in LVESVi, a 2-fold rise in NT-proBNP, or clinical signs of heart failure. Results: Seventy patients achieved an ejection fraction improvement and were included in the final analysis, of whom 30 chose to continue spironolactone and 40 decided to withdraw. In primary endpoint analysis, 23 (58%) patients from the withdrawal group and 4 (13%) patients from the continuation group relapsed (relative risk for relapse: 4.31; 95% CI: 1.67-11.11; p < 0.001). Patients from the withdrawal group experienced more symptom aggravation than the continuation group. No secondary safety endpoint was recorded. Improvements in cardiac structure parameters were no longer observed after spironolactone withdrawal, while improvements persisted in continuation group. Conclusions: Most dilated cardiomyopathy patients with improved ejection fraction will relapse after spironolactone withdrawal. These results should be weighed before spironolactone withdrawal was attempted.

Prognostic significance of longitudinal strain in dilated cardiomyopathy with recovered ejection fraction

OBJECTIVE

Patients with non-ischaemic dilated cardiomyopathy (NICM) may experience a normalisation in left ventricular ejection fraction (LVEF). Although this correlates with improved prognosis, it does not correspond to a normalisation in the risk of death during follow-up. Currently, there are no tools to risk stratify this population. We tested the hypothesis that absolute global longitudinal strain (aGLS) is associated with mortality in patients with NICM and recovered ejection fraction (LVEF).

METHODS

We designed a retrospective, international, longitudinal cohort study enrolling patients with NICM with LVEF <40% improved to the normal range (>50%). We studied the relationship between aGLS measured at the time of the first recording of a normalised LVEF and all-cause mortality during follow-up. We considered aGLS >18% as normal and aGLS ≥16% as of potential prognostic value.

RESULTS

206 patients met inclusion criteria. Median age was 53.5 years (IQR 44.3-62.8) and 56.6% were males. LVEF at diagnosis was 32.0% (IQR 24.0-38.8). LVEF at the time of recovery was 55.0% (IQR 51.7-60.0). aGLS at the time of LVEF recovery was 13.6%±3.9%. 166 (80%) and 141 (68%) patients had aGLS ≤18% and <16%, respectively. During a follow-up of 5.5±2.8 years, 35 patients (17%) died. aGLS at the time of first recording of a recovered LVEF correlated with mortality during follow-up (HR 0.90, 95% CI 0.91 to 0.99, p=0.048 in adjusted Cox model). No deaths were observed in patients with normal aGLS (>18%). In unadjusted Kaplan-Meier survival analysis, aGLS <16% was associated with higher mortality during follow-up (31 deaths (22%) in patients with GLS <16% vs 4 deaths (6.2%) in patients with GLS ≥16%, HR 3.2, 95% CI 1.1 to 9, p=0.03).

CONCLUSIONS

In patients with NICM and normalised LVEF, an impaired aGLS at the time of LVEF recovery is frequent and associated with worse outcomes.

Integration of imaging and circulating biomarkers in heart failure: a consensus document by the Biomarkers and Imaging Study Groups of the Heart Failure Association of the European Society of Cardiology

Circulating biomarkers and imaging techniques provide independent and complementary information to guide management of heart failure (HF). This consensus document by the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) presents current evidence-based indications relevant to integration of imaging techniques and biomarkers in HF. The document first focuses on application of circulating biomarkers together with imaging findings, in the broad domains of screening, diagnosis, risk stratification, guidance of treatment and monitoring, and then discusses specific challenging settings. In each section we crystallize clinically relevant recommendations and identify directions for future research. The target readership of this document includes cardiologists, internal medicine specialists and other clinicians dealing with HF patients.

A global longitudinal strain cut-off value to predict adverse outcomes in individuals with a normal ejection fraction

Aims

Global longitudinal strain (GLS) has become an alternative to left ventricular ejection fraction (LVEF) to determine systolic function of the heart. The absence of cut‐off values is one of the limitations preventing full clinical implementation. The aim of this study is to determine a cut‐off value of GLS for an increased risk of adverse events in individuals with a normal LVEF.

Methods and results

Echocardiographic images of 502 subjects (52% female, mean age 48 ± 15) with an LVEF ≥ 55% were analysed using speckle tracking‐based GLS. The primary endpoint was cardiovascular death or cardiac hospitalization. The analysis of Cox models with splines was performed to visualize the effect of GLS on outcome. A cut‐off value was suggested by determining the optimal specificity and sensitivity. The median GLS was −22.2% (inter‐quartile range −20.0 to −24.9%). In total, 35 subjects (7%) had a cardiac hospitalization and/or died because of cardiovascular disease during a follow‐up of 40 (5–80) months. There was a linear correlation between the risk for adverse events and GLS value. Subjects with a normal LVEF and a GLS between −22.9% and −20.9% had a mildly increased risk (hazard ratio 1.01–2.0) for cardiac hospitalization or cardiovascular mortality, and the risk was doubled for subjects with a GLS of −20.9% and higher. The optimal specificity and sensitivity were determined at a GLS value of −20.0% (hazard ratio 2.49; 95% confidence interval: 1.71–3.61).

Conclusions

There is a strong correlation between cardiac adverse events and GLS values in subjects with a normal LVEF. In our single‐centre study, −20.0% was determined as a cut‐off value to identify subjects at risk. A next step should be to integrate GLS values in a multi‐parametric model.

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

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

Characteristics, Outcomes, and Treatment of Heart Failure With Improved Ejection Fraction

Background

Many patients with heart failure (HF) with reduced ejection fraction (HFrEF) experience improvement or recovery of left ventricular ejection fraction (LVEF). Data on clinical characteristics, outcomes, and medical therapy in patients with HF with improved ejection fraction (HFiEF) are scarce.

Methods and Results

Of 5625 consecutive patients hospitalized for acute HF in the KorAHF (Registry [Prospective Cohort] for Heart Failure in Korea) study, 5103 patients had baseline echocardiography and 2302 patients had follow‐up echocardiography at 12 months. HF phenotypes were defined as persistent HFrEF (LVEF ≤40% at baseline and at 1‐year follow‐up), HFiEF (LVEF ≤40% at baseline and improved up to 40% at 1‐year follow‐up), HF with midrange ejection fraction (LVEF between 40% and <50%), and HF with preserved ejection fraction (LVEF ≥50%). The primary outcome was 4‐year all‐cause mortality from the time of HFiEF diagnosis. Among 1509 HFrEF patients who had echocardiography 1 year after index hospitalization, 720 (31.3%) were diagnosed as having HFiEF. Younger age, female sex, de novo HF, hypertension, atrial fibrillation, and β‐blocker use were positive predictors and diabetes mellitus and ischemic heart disease were negative predictors of HFiEF. During 4‐year follow‐up, patients with HFiEF showed lower mortality than those with persistent HFrEF in univariate, multivariate, and propensity‐score–matched analyses. β‐Blockers, but not renin–angiotensin system inhibitors or mineralocorticoid receptor antagonists, were associated with a reduced all‐cause mortality risk (hazard ratio: 0.59; 95% CI, 0.40–0.87; P=0.007). Benefits for outcome seemed similar among patients receiving low‐ or high‐dose β‐blockers (log‐rank, P=0.304).

Conclusions

HFiEF is a distinct HF phenotype with better clinical outcomes than other phenotypes. The use of β‐blockers may be beneficial for these patients.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01389843.

Arrhythmic risk stratification in non-ischaemic dilated cardiomyopathy beyond ejection fraction

Sudden cardiac death and arrhythmia-related events in patients with non-ischaemic dilated cardiomyopathy (NICM) have been significantly reduced over the last couple of decades as a result of evidence-based pharmacological and non-pharmacological therapeutic strategies. Nevertheless, the arrhythmic stratification in patients with NICM remains extremely challenging, and the simple indication based on left ventricular ejection fraction appears to be insufficient. Therefore, clinicians need to go beyond the current criteria for implantable cardioverter-defibrillator implantation in the direction of a multiparametric evaluation of arrhythmic risk. Several parameters for arrhythmic risk stratification, ranging from electrocardiographic, echocardiographic, imaging-derived and genetic markers, are crucial for proper arrhythmic risk stratification and a multiparametric evaluation of risk in patients with NICM. In particular, integration of cardiac magnetic resonance parameters (mostly late gadolinium enhancement) and specific genetic information (ie, presence of LMNA, PLN, FLNC mutations) appears fundamental for proper implementation of the current arrhythmic risk stratification. Finally, a novel approach focused on both arrhythmic risk and prediction of left ventricular reverse remodelling during follow-up might be useful for effective multiparametric and dynamic arrhythmic risk stratification in NICM. In the future, a complete and integrated evaluation might be mandatory to implement arrhythmic risk prediction in patients with NICM and to discriminate the competing risk between heart failure-related events and life-threatening arrhythmias.