Distinguishing heart failure with reduced ejection fraction from heart failure with preserved ejection fraction: A phenomics approach

AIM

Pathophysiological differences between patients with heart failure with preserved (HFpEF) and reduced (HFrEF) ejection fraction (EF) remain unclear. Therefore we used a phenomics approach, integrating selected proteomics data with patient characteristics and cardiac structural and functional parameters, to get insight into differential pathophysiological mechanisms and identify potential treatment targets.

METHODS AND RESULTS

We report data from a representative subcohort of the prospective Singapore Heart Failure Outcomes and Phenotypes (SHOP), including patients with HFrEF (EF <40%, n = 217), HFpEF (EF ≥50%, n = 213), and age- and sex-matched controls without HF (n = 216). We measured 92 biomarkers using a proximity extension assay and assessed cardiac structure and function in all participants using echocardiography. We used multi-block projection to latent structure analysis to integrate clinical, echocardiographic, and biomarker variables. Candidate biomarker targets were cross-referenced with small-molecule and drug databases. The total cohort had a median age of 65 years (interquartile range 60-71), and 50% were women. Protein profiles strongly discriminated patients with HFrEF (area under the curve [AUC] = 0.89) and HFpEF (AUC = 0.94) from controls. Phenomics analyses identified unique druggable inflammatory markers in HFpEF from the tumour necrosis factor receptor superfamily (TNFRSF), which were positively associated with hypertension, diabetes, and increased posterior and relative wall thickness. In HFrEF, interleukin (IL)-8 and IL-6 were possible targets related to lower EF and worsening renal function.

CONCLUSION

We identified pathophysiological mechanisms related to increased cardiac wall thickness parameters and potentially druggable inflammatory markers from the TNFRSF in HFpEF.

Titration of medications and outcomes in multi-ethnic heart failure cohorts (with reduced ejection fraction) from Singapore and New Zealand

AIMS

We investigated titration patterns of angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs) and beta-blockers, quality of life (QoL) over 6 months, and associated 1 year outcome [all-cause mortality/heart failure (HF) hospitalization] in a real-world population with HF with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

Participants with HFrEF (left ventricular ejection fraction <40%) from a prospective multi-centre study were examined for use and dose [relative to guideline-recommended maintenance dose (GRD)] of ACEis/ARBs and beta-blockers at baseline and 6 months. 'Stay low' was defined as <50% GRD at both time points, 'stay high' as ≥50% GRD, and 'up-titrate' and 'down-titrate' as dose trajectories. Among 1110 patients (mean age 63 ± 13 years, 16% women, 26% New York Heart Association Class III/IV), 714 (64%) were multi-ethnic Asians from Singapore and 396 were from New Zealand (mainly European ethnicity). Baseline use of either ACEis/ARBs or beta-blockers was high (87%). Loop diuretic was prescribed in >80% of patients, mineralocorticoid receptor antagonist in about half of patients, and statins in >90% of patients. At baseline, only 11% and 9% received 100% GRD for each drug class, respectively, with about half (47%) achieving ≥50% GRD for ACEis/ARBs or beta-blockers. At 6 months, a large majority remained in the 'stay low' category, one third remained in 'stay high', whereas 10-16% up-titrated and 4-6% down-titrated. Patients with lower (vs. higher) N-terminal pro-beta-type natriuretic peptide levels were more likely to be up-titrated or be in 'stay high' for ACEis/ARBs and beta-blockers (P = 0.002). Ischaemic aetiology, prior HF hospitalization, and enrolment in Singapore (vs. New Zealand) were independently associated with higher odds of 'staying low' (all P < 0.005) for prescribed doses of ACEis/ARBs and beta-blockers. Adjusted for inverse probability weighting, ≥100% GRD for ACEis/ARBs [hazard ratio (HR) = 0.42; 95% confidence interval (CI) 0.24-0.73] and ≥50% GRD for beta-blockers (HR = 0.58; 95% CI 0.37-0.90) (vs. Nil) were associated with lower hazards for 1 year composite outcome. Country of enrolment did not modify the associations of dose categories with 1 year composite outcome. Higher medication doses were associated with greater improvements in QoL.

CONCLUSIONS

Although HF medication use at baseline was high, most patients did not have these medications up-titrated over 6 months. Multiple clinical factors were associated with changes in medication dosages. Further research is urgently needed to investigate the causes of lack of up-titration of HF therapy (and its frequency), which could inform strategies for timely up-titration of HF therapy based on clinical and biochemical parameters.

The effect of the COVID-19 pandemic on heart failure unplanned admission: a single center study

Background

Acute heart failure (AHF) is a leading cause of admissions among adults. The COVID-19 pandemic has placed a high burden on healthcare systems globally. Many countries announced lockdowns which restricted residents' movement. There is a reported reduction in AHF admissions during the pandemic in several countries, potentially leading to adverse outcomes such as increased morbidity and mortality. To date, little is known on whether similar trends are observed in Southeast Asian (SEA) countries.

Purpose

We aim to evaluate whether AHF admissions have been affected by the pandemic and the lockdown restrictions in a multi-ethnic, urban SEA country. We hypothesized that the pandemic and lockdown restrictions (called a “circuit breaker (CB)”) will influence heart failure (HF) admission rates.

Methods

We conducted a retrospective analysis of patients who were admitted with a principal diagnosis of HF to a tertiary hospital in a SEA country. The study period was from the first confirmed case of COVID-19 (January 23, 2020) to July 31, 2020 (n=378). This was further divided into 3 sub-periods for inter-year and intra-year subgroup analysis. Pre-CB: January 23, 2020 to April 6, 2020, CB: April 7, 2020 to June 1, 2020, and Post-CB reopening (Phase 1 & 2): June 2, 2020 to July 31, 2020. The control period was the same timeframe in the preceding year (January 23, 2019 to July 31, 2019) (n=398) and was similarly divided into 3 subgroups. The primary outcome was the overall HF admission rate. Where appropriate, Poisson regression or Negative Binomial regression was utilised to compare the incidence rate ratios of the HF admissions between the periods. Mann-Whitney test or student's t-test was used to compare the length of stay (LOS) and Charlson Comorbidity Index (CCI) scores.

Results

Details on the study cohort can be found in Table 1. The study period's overall mean admission rate was 2.08 per day, which was not significantly different from the control (2.00 per day). Subgroup analysis showed that the CB admission rates were significantly lower compared to (i) the control (1.39 per day vs. 2.02 per day) and (ii) pre-CB period in the same year (1.39 per day vs. 2.44 per day) (Fig. 1). Phase 1 & 2 admission rates were significantly higher compared to the control (2.28 per day vs. 1.68 per day), and CB admission rates (2.28 per day vs. 1.39 per day). There were no inter-year or intra-year differences for LOS. There was a significant inter-year difference in CCI scores during the CB period (CB: 2.88 vs. control: 1.97).

Conclusions

Our study showed significant decreases in AHF admissions during the CB period, and a significant increase in AHF admissions from CB to Post-CB reopening. These suggest that the lockdown restrictions had an influence on patients' health seeking behaviour. We also recognise the need to raise public awareness to encourage HF patients to seek timely treatment, prevent complications and adverse events.

Funding Acknowledgement

Type of funding sources: None.

Prognostic Factors After Index Hospitalization for Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) has a high clinical burden and constitutes approximately 20% to 30% of patients with heart failure in Asia. Impaired global longitudinal strain (GLS), defined as an absolute value of <15.8%, has been shown to be a predictor of heart failure hospitalization, cardiovascular death, and aborted cardiac arrest in HFpEF. We sought to validate this finding in our Asian cohort and identify other prognostic factors in HFpEF. In this cohort study, we included all patients with an index hospitalization for heart failure and left ventricular ejection fraction of >45%, from January 1, 2012, to December 31, 2012. All patients had follow-up for at least 3 years. In our study, the absolute value of mean GLS was impaired at 13.50 ± 4.00%, whereas mean left ventricular ejection fraction was 52.00 ± 7.67%. In multivariate Cox regression, impaired GLS of absolute value <15.8% (hazard ratio 4.72, 95% CI 1.25 to 17.81, p = 0.022), every unit increase in age-adjusted Charlson Comorbidity Index (hazard ratio 1.46, 95% CI 1.03 to 2.05, p = 0.031) and low body mass index <18.5 kg/m² (hazard ratio 4.30, 95% CI 1.25 to 14.78, p = 0.020) were associated with a shorter time to mortality over the 3-year period. Our study validates absolute GLS value of <15.8% to be a prognostic marker for patients with HFpEF.