Prognostic effects of longitudinal changes in left ventricular ejection fraction with cardiac resynchronization therapy

Risk and Protective Factors of Poor Clinical Outcomes in Heart Failure with Improved Ejection Fraction Population: A Systematic Review and Meta-Analysis

AIMS

Heart failure with improved ejection fraction (HFimpEF) patients could still develop adverse outcomes despite EF improvement. This study evaluates the risk and protective factors of poor clinical outcomes in HFimpEF patients.

METHODS

Systematic searching was done to include studies that evaluate the risks of developing poor outcomes in HFimpEF patients. HFimpEF is defined as improvement of 5-10% EF within 6-12 months or normalization of EF > 40%. Poor clinical outcome is defined as a composite of all-cause mortality, cardiovascular events, HF rehospitalization, and requirement of LVAD/ transplant. Odds ratios of outcome are pooled with random effects model. A subgroup analysis of multivariate analysis-only studies was also conducted.

RESULTS

32 studies comprising 10,740 HFimpEF patients are included. Poor clinical outcomes followed up for approximately 3 years, are seen in 18.9% of HFimpEF patients. Twelve statistically significant factors that increase the risk of outcome are found. Among them, anemia (OR 7.69, CI 3.48-16.99, I2 0%) and baseline NT pro-BNP (OR 3.25) are the two most important predictors. Other significant risk factors are increasing age, ischemic heart disease, NYHA III/IV, diabetes mellitus, atrial fibrillation, dyslipidemia, cerebrovascular disease, hypertension, use of diuretics, and baseline LVEDD. Alternately, protective factors of poor clinical outcome are regression of left atrial diameter (LAD) (OR 0.33, CI: 0.18-0.61, p 0.0003, I2 0%), use beta-blockers, SGLT- 2 inhibitors, and baseline LVEF level (OR 0.60, 0.78, 0.90, respectively).

CONCLUSION

HFimpEF patients are not fully recovered and patient stratification based on risk and protective factors is recommended.

The Role of Cardiac Resynchronization Therapy in Heart Failure: A Narrative Review

Introduction

Structural and functional cardiac defects leading to inadequate tissue oxygenation is known as Heart failure (HF) which is characterized by extensive morbidity and mortality. Pathophysiology of HF involves systolic and diastolic dysfunction, neurohormonal dysregulation, and imbalance in inflammatory mediators which complicates treatment further. Cardiac resynchronization therapy (CRT) is an approach used for restoring ventricular synchrony and enhancing mechanical efficiency. This study discusses various key points of CRT and its uses in HF and discusses challenges and future implications.

Methods

An extensive review of the literature was conducted with evidence from several databases like Medline, PubMed Central, and Embase. Preference was given to articles published after 2010, but relevant articles even pre-2010 were included. Mendeley was used as a reference manager for formatting.

Results

Functional improvements and an enhanced quality of life across a diverse range of patients have been demonstrated using CRT. This has significantly impacted the mortality rates of patients with HF. This manuscript conducted a comparative analysis various hallmark clinical trials conducted in lieu of CRT, across many years (2002, 2003, 2004, 2005, 2017, 2018, 2020). All trials have noted the supremacy of CRT compared to pharmaceutical treatment or other therapeutic methods. Majority of the trial participants had an LVEF of ≤ 35%, a QRS duration of ≤ 150 ms, and were categorized as NYHA class II-IV before initiation of CRT and, posttreatment, LVEF was improved significantly. The main advantages noted were functional improvements, such as enhanced quality of life and reduced mortality.

Conclusion

There have been multiple efforts undertaken to address the challenges in CRT, which include a reduction in the rates of nonresponding patients and using alternative adjunctive therapies like defibrillators. These have been shown to improve outcomes among HF patients. Although CRT is noted to be very efficient, some challenges like technological limitations, uncertainty regarding optimal pacing, and nonresponding patients, exist. Ongoing research aims to further develop and revolutionize HF care and improve patient outcomes across the world by refining patient selections and CRT efficacy.

Implication of geriatric nutritional risk index on treatment response and long-term prognosis in patients with cardiac resynchronization therapy

PURPOSE

Geriatric Nutritional Risk Index (GNRI) is a simple tool for assessing the nutritional status of the aging population. This study aims to explore the clinical implication of GNRI on treatment response and long-term clinical outcomes in heart failure (HF) patients receiving cardiac resynchronization therapy (CRT).

METHODS

Patients who underwent CRT implantation or upgrade at our hospital were retrospectively included. The association of GNRI and its tertiles with the echocardiographic response, all-cause mortality or heart transplantation, and the first hospitalization due to HF were investigated.

RESULTS

Totally, 647 patients were enrolled, with a median age of 60 [Interquartile Range (IQR): 52-67] years and mean score of GNRI at 107.9 ± 23.7. Super-response rates increased significantly among the GNRI T1, T2, and T3 groups (25.1%, 29.8% vs. 41.1%, P = 0.002). Patients with higher GNRI were more likely to have better LVEF improvement after multiple adjustments (OR = 1.13, 95% CI: 1.04-1.23, P = 0.010). Higher GNRI was independently associated with a lower risk of all-cause mortality or heart implantation (HR = 0.95, 95% CI: 0.93-0.96, P < 0.001) and HF hospitalization (HR = 0.96, 95% CI: 0.95-0.98, P < 0.001). The inclusion of GNRI enhanced the predictability of all-cause mortality based on traditional model, including sex, New York Heart Association functional class, left bundle branch block, QRS reduction, and N-terminal pro-B-type natriuretic peptide level (C statistics improved from 0.785 to 0.813, P = 0.007).

CONCLUSION

Higher GNRI was associated with better treatment response and long-term prognosis in HF patients with CRT. Evaluation of nutritional status among CRT population is necessary for individualized choice of potential responders.

Length of Hospitalization-Related Differences and Associated Long-Term Prognosis of Patients with Cardiac Resynchronization Therapy: A Propensity Score-Matched Cohort

Previous studies indicated that prolonged lengths of hospitalization (LOH) during cardiac resynchronization therapy (CRT) implantation are associated with poorer physical status and higher in-hospital mortality. However, evidence on the impact of LOH on the long-term prognosis of CRT patients is limited. The purpose of this study was to assess LOH-related prognostic differences in CRT patients. In the propensity score-matched cohort, patients with standard LOH (≤7 days, n = 172) were compared with those with prolonged LOH (>7 days, n = 172) for cardiac function and study outcomes during follow-up. The study outcomes were all-cause death and heart failure (HF) hospitalization. In addition, cardiac function and changes in cardiac function at the follow-up period were used for comparison. At a mean follow-up of 3.36 years, patients with prolonged LOH, as compared with those with standard LOH, were associated with a significantly higher risk of all-cause death (hazard ratio [HR] 1.87, 95% confidence interval [CI] 1.18−2.96, p = 0.007), and a higher risk of HF hospitalization (HR 1.68, 95% CI 1.08−2.63, p = 0.023). Moreover, patients with standard LOH had a more significant improvement in cardiac function and a pronounced reduction in QRS duration during follow-up than those with prolonged LOH. LOH-associated differences were found in the long-term prognosis of CRT patients. Patients with prolonged LOH had a worse prognosis than those with standard LOH.

Frequency, predictors, and prognosis of heart failure with improved left ventricular ejection fraction: a single-centre retrospective observational cohort study

Aims

An improved left ventricular ejection fraction (HFiEF) was observed across heart failure (HF) patients with a reduced or mid‐range ejection fraction (HFrEF or HFmrEF, respectively). We postulated that HFiEF patients are clinically distinct from non‐HFiEF patients.

Methods and results

A total of 447 patients hospitalized due to a clinical diagnosis of HF (LVEF <50% at baseline) were enrolled from September 2017 to September 2019. Echocardiogram re‐evaluation was conducted repeatedly over 6 months of follow‐up after discharge. The primary endpoint included the composite of HF hospitalization and all‐cause mortality. Subjects (n = 184) with HFiEF (defined as an absolute LVEF improvement≥10%) were compared with 263 non‐HFiEF (defined by <10% improvement in LVEF) subjects. Multivariable Cox regression was performed and identified younger age, smaller left ventricular end diastolic dimension (LVEDD), beta‐blocker use, AF ablation and cardiac resynchronization therapy (CRT) as independent predictors of HFiEF. According to Kaplan–Meier analysis, HFiEF subjects had lower cardiac composite outcomes (P = 0.002) and all‐cause mortality (P = 0.003) than non‐HFiEF subjects. Multivariate Cox survival analysis revealed that non‐HFiEF (compared with HFiEF) was an independent predictor of both the primary endpoints (HR = 0.679, 95% CI: 0.451–0.907, P = 0.012), which was driven by all‐cause mortality (HR = 0.504, 95% CI: 0.256–0.991, P = 0.047).

Conclusions

These data confirm that compared with non‐HFiEF, HFiEF is a distinct HF phenotype with favourable clinical outcomes.