Patients with HFpEF and HFmrEF have different clinical characteristics in Turkey: A multicenter observational study

Characteristics of the phenotypes in prevalent and incident cases of heart failure in primary care: IBERICAN study

BACKGROUND

The management in primary care (PC) of the patients with Heart Failure (HF) is different from the management hospital, in a special way compared to cardiology departments.

OBJECTIVE

To define the characteristics in both phenotypes of HF in prevalent and incident cases of HF in patients recruited in a large PC sample.

METHODS

We proposed a and longitudinal analyses, in patients of the IBERICAN cohort, that recruited 8,066 patients in the Spanish primary care system, with 15,488 patients-years of follow-up. Of them, 252 patients (3.1%) had diagnoses of HF. HF was classified according to the 2014 guidelines in two groups: HF with a reduced eject fraction or HFrEF (LVEF < 50%) and HF with preserved eject fraction or HFpEF (LVEF ≥ 50%). Recommended treatment was defined as the patient receiving drug treatment with Renin-Angiotensin-System (RAS) blockers with beta-blockers and, optionally, spironolactone. The incidence of new cases of HF was calculated in the 7,814 patients without HF in the inclusion visit. Finally, we analysed which variables associated the onset new cases and get the hazard ratio (HR) with the confidence interval at 95% ([95%CI]). Clinical trials register: NCT02261441 (02/05/2017).

RESULTS

The HFpEF was the most frequent phenotype in prevalent cases (61.1%) and incident cases (73.9%). Patients with HFrEF had a higher prevalence of coronary heart disease (p = 0.008) and PAD (p = 0.028), and no statistically significant differences was observed in the therapeutic groups used between both groups. The incidence of HF was 12.8 cases/1000 inhabitants/year, 35.6% of them was diagnosed in PC. The renin-angiotensin system blockers were more used in PC (60%) and beta-blockers (100%) and spironolactone (60%) in hospital. The female sex showed a protective effect for incident cases (0.51 [0.28-0.92]); and AF (HR [95%CI]: 2.90 [1.51-5.54]), coronary heart disease (HR [95%CI]: 2.18 [1.19-4.00]) and hypertension (HR [95%CI]: 1.91 [1.00-3.64]) increased the risk of developing HF.

CONCLUSIONS

HF phenotype more frequent and incident in PC was the HFpEF, but only one third of them are diagnosed in PC level. The female sex showed a protective effect and atrial fibrillation, ischaemic heart disease and hypertension increased the risk of develop HF.

Characteristics of symptoms and symptom change across different heart failure subtypes: a sex-stratified analysis

AIMS

To examine sex-stratified differences in the association of left ventricular ejection fraction-based heart failure (HF) subtypes and the characteristics and correlates of self-reported changes in HF symptoms.

METHODS AND RESULTS

We report a secondary data analysis from 528 hospitalized individuals diagnosed with HF characterised by a reduced, mildly reduced, or preserved ejection fraction [HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction (HFmrEF), or HF with preserved ejection fraction (HFpEF)] who completed 12-month follow-up within a multicentre disease management trial. There were 302 men (71.1 ± 11.9 years, 58% with HFrEF) and 226 women (77.1 ± 10.6 years, 49% with HFpEF). The characteristics of self-reported symptoms measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) at baseline and 12-month were analysed. At baseline, shortness of breath and fatigue predominated; with key differences according to HF subtypes in bilateral ankle oedema (both sexes), walking problems (women) and depressive symptoms (men). At 12-month follow-up, most KCCQ scores had not significantly changed. However, 25% of individuals reported worse symptom. In women, those with HFpEF had worse symptoms than those with HFmrEF/HFrEF (P = 0.025). On an adjusted basis, women [odds ratios (OR): 1.78, 95% confidence interval (CI): 1.00-3.16 vs. men], those with coronary artery disease (OR: 2.01, 95% CI: 1.21-3.31) and baseline acute pulmonary oedema (OR: 1.67, 95% CI: 1.02-2.75) were most likely to report worsening symptoms. Among men, worsening symptoms correlated with a history of hypertension (OR: 2.16, 95% CI: 1.07-4.35) and a non-English-speaking background (OR: 2.30, 95% CI: 1.02-5.20).

CONCLUSION

We found significant heterogeneity (with potential clinical implications) in the symptomatic characteristics and subsequent symptom trajectory according to the sex and HF subtype of those hospitalized with the syndrome.

TRIAL REGISTRATION

ANZCTR12613000921785.

Regional expert opinion: Management of heart failure with preserved ejection fraction in the Middle East, North Africa and Turkey

Although epidemiological data on heart failure (HF) with preserved ejection fraction (HFpEF) are scarce in the Middle East, North Africa and Turkey (MENAT) region, Lancet Global Burden of Disease estimated the prevalence of HF in the MENAT region in 2019 to be 0.78%, versus 0.71% globally. There is also a high incidence of HFpEF risk factors and co-morbidities in the region, including coronary artery disease, diabetes, obesity, hypertension, anaemia and chronic kidney disease. For instance, 14.5-16.2% of adults in the region reportedly have diabetes, versus 7.0% in Europe. Together with increasing life expectancy, this may contribute towards a higher burden of HFpEF in the region than currently reported. This paper aims to describe the epidemiology and burden of HFpEF in the MENAT region, including unique risk factors and co-morbidities. It highlights challenges with diagnosing HFpEF, such as the prioritization of HF with reduced ejection fraction (HFrEF), the specific profile of HFpEF patients in the region and barriers to effective management associated with the healthcare system. Guidance is given on the diagnosis, prevention and management of HFpEF, including the emerging role of sodium-glucose co-transporter-2 inhibitors. Given the high burden of HFpEF coupled with the fact that its prevalence is likely to be underestimated, healthcare professionals need to be alert to its signs and symptoms and to manage patients accordingly. Historically, HFpEF treatments have focused on managing co-morbidities and symptoms, but new agents are now available with proven effects on outcomes in patients with HFpEF.

Assessment of Aortic Characteristic Impedance and Arterial Compliance from Non-invasive Carotid Pressure Waveform in The Framingham Heart Study

The primary goal of this study was to test the hypothesis that a hybrid intrinsic frequency-machine learning (IF-ML) approach can accurately evaluate total arterial compliance (TAC) and aortic characteristic impedance (Zao) from a single noninvasive carotid pressure waveform in both women and men with heart failure (HF). TAC and Zao are cardiovascular biomarkers with established clinical significance. TAC is lower and Zao is higher in women than in men, so women are more susceptible to the consequent deleterious effects of them. Although the principles of TAC and Zao are pertinent to a multitude of cardiovascular diseases, including HF, their routine clinical use is limited because of the requirement for simultaneous measurements of flow and pressure waveforms. For this study, the data were obtained from the Framingham Heart Study (n = 6,201, 53% women). The reference values of Zao and TAC were computed from carotid pressure and aortic flow waveforms. IF parameters of carotid pressure waveform were used in ML models. IF models were developed on n = 5,168 of randomly selected data and blindly tested the remaining data (n = 1,033). The final models were evaluated in patients with HF. Correlations between IF-ML and reference values in all HF and HF with preserved ejection fraction for TAC were 0.88 and 0.90, and for Zao were 0.82 and 0.80, respectively. The classification accuracy in all HF and HF with preserved ejection fraction for TAC were 0.9 and 0.93, and for Zao were 0.81 and 0.89, respectively. In conclusion, the IF-ML method provides an accurate estimation of TAC and Zao in all subjects with HF and in the general population.

Pathological mechanism of heart failure with preserved ejection fraction in rats based on iTRAQ technology

Objective

Heart failure with preserved ejection fraction (HFpEF) is a public health problem worldwide. Treatments for the patients with HFpEF are not satisfactory because there is no unified understanding of the pathological mechanism of HFpEF. This study aims at investigating the potential pathological mechanism for the effective diagnosis and treatment of HFpEF.

Methods

Ten adult male Dahl salt sensitive rats (180-200 g) were divided into control and model groups. The rats in model group were fed with high salt diet (8% NaCl) to induce HFpEF for this comparative study. Behavioral changes, biochemical parameters, and histopathological changes of the rats were detected. iTRAQ technology combined with bioinformatics analysis was employed to study the differentially expressed proteins (DEPs) and their enrichment in signaling pathways.

Results

Echocardiography detection showed decreased LVEF, indicating impaired cardiac function (P < 0.01), increased LVPWd, indicating ventricular wall hypertrophy (P < 0.05), prolonged duration of IVRT and decreased E/A ratio, indicating diastolic dysfunction (P < 0.05) of the rats in model group. 563 DEPs were identified in the rats of both groups, with 243 up-regulated and 320 down-regulated. The expression of PPAR signaling pathway in the rats of model group was down-regulated, with PPARα most significantly decreased (91.2%) (P < 0.01), PPARγ obviously decreased (63.60%) (P < 0.05), and PPARβ/δ decreased (45.33%) (P < 0.05). The DEPs enriched in PPAR signaling pathway were mainly related to such biological processes as fatty acid beta-oxidation, such cellular components as peroxisome, and such molecular functions as lipid binding.

Conclusions

NaCl high salt diet is one of the factors to increase the incidence of HFpEF in rats. PPARα, PPARγ and PPAR β/δ might be the targets of HFpEF. The findings may provide a theoretical basis for the treatment of HFpEF in clinical practice.

Similarities and Differences Between HFmrEF and HFpEF

The new guidelines classify heart failure (HF) into three subgroups based on the ejection fraction (EF): HF with reduced EF (HFrEF), HF with mid-range EF (HFmrEF), and HF with preserved EF (HFpEF). The new guidelines regarding the declaration of HFmrEF as a unique phenotype have achieved the goal of stimulating research on the basic characteristics, pathophysiology, and treatment of HF patients with a left ventricular EF of 40-49%. Patients with HFmrEF have more often been described as an intermediate population between HFrEF and HFpEF patients; however, with regard to etiology and clinical indicators, they are more similar to the HFrEF population. Concerning clinical prognosis, they are closer to HFpEF because both populations have a good prognosis and quality of life. Meanwhile, growing evidence indicates that HFmrEF and HFpEF show heterogeneity in presentation and pathophysiology, and the emergence of this heterogeneity often plays a crucial role in the prognosis and treatment of the disease. To date, the exact mechanisms and effective treatment strategies of HFmrEF and HFpEF are still poorly understood, but some of the current evidence, from observational studies and post-hoc analyses of randomized controlled trials, have shown that patients with HFmrEF may benefit more from HFrEF treatment strategies, such as beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists, and sacubitril/valsartan. This review summarizes available data from current clinical practice and mechanistic studies in terms of epidemiology, etiology, clinical indicators, mechanisms, and treatments to discuss the potential association between HFmrEF and HFpEF patients.

Clinical, Echocardiographic, and Therapeutic Characteristics of Heart Failure in Patients with Preserved, Mid-Range, and Reduced Ejection Fraction: Future Directions

Background

Heart failure (HF) is recognized as a worldwide epidemic. Definitions and risk stratification are usually based upon measurements of left ventricular ejection fraction (LVEF) but such classifications reflect an underlying spectrum of different pathologic, phenotypic, and therapeutic patterns.

Methods

This was a retrospective cohort study of HF patients in Saudi Arabia. Patients were divided into three categories based on LVEF: those with preserved ejection fraction (EF) (EF≥50%, HFpEF); those with mid-range EF (EF 40–49%, HFmrEF); and those with reduced EF (EF <40%, HFrEF). Their demographics, co-morbid conditions, echocardiographic findings, pharmacological treatments and all-cause mortality (ACS) after a follow-up period of 24 months were compared.

Results

A total of 293 HF patients were identified (mean age: 63 years). In total, 65% were males, 79% were Saudi nationals, and 70% had type 2 diabetes mellitus (DM). Classification based on EF was established in 288 patients: HFpEF (105 patients, 36.5%), HFmrEF (49, 17.0%), and HFrEF (134, 46.5%). The 3 groups differed in sex distribution: 51% females in the HFpEF group and 78% males in the HFrEF group (P<0.001). Body mass index (BMI) was highest in the HFpEF group and lowest in the HFrEF group (31.5 vs 26.6; P<0.001). Although systolic blood pressure (SBP in mmHg) was highest in patients with HFpEF, left ventricular mass index (LVMI in g/cm²) was highest in patients with HFrEF 121.00 (94.50, 151.50), and eccentric hypertrophy was the dominant LV geometrical characteristic (54.6%). HFrEF patients had the highest use of ACE inhibitors (60.5%), loop diuretics (79.9%), and aldosterone receptor antagonists (56.7%) (P values; 0.009, 0.007, and <0.001, respectively). A total of 42 deaths occurred during follow-up: HFpEF (17 events), HFmrEF (3 events) and HFrEF (22 events) (Logrank test P=0.189).

Conclusion

This Saudi HF population shows similarities to other populations: EF category distribution, sex distribution, therapeutic trends, and survival outcomes. However, findings related to the underlying risk factors, namely type 2 DM and obesity, have identified HFpEF as an emerging threat in this (relatively) young population.

Systolic aortic regurgitation predicts all-cause mortality and hospitalization in outpatients with heart failure and preserved ejection fraction

OBJECTIVE:

Systolic aortic regurgitation (SAR) is considered to be a specific sign of heart failure (HF). However, the prevalence and importance of SAR in patients with HF and preserved ejection fraction (HFpEF) are unknown. Therefore, we sought to examine the prevalence of SAR in HFpEF outpatients and its association with all-cause mortality and/or cardiovascular hospitalizations during a 1-year follow-up.

METHODS:

We enrolled 301 consecutive outpatients with HFpEF (mean age of 67.3±9.6 years, 53.5% women) and prospectively followed up for one year. Demographic, clinical, echocardiographic, and laboratory data were obtained at study entry. The composite endpoint of this study was all-cause mortality or HF-related hospitalizations in one year.

RESULTS:

SAR was noted in 30 (9.9%) of the patients, and 38 patients (12.6%) reached the primary endpoint. The primary composite endpoint in one year was higher for the patients with SAR (26.3%) compared to the patients without SAR (7.6%, p<0.001). After adjusting for important covariates, SAR remained independently associated with primary outcome (OR 2.315; 95% CI 1.188–5.477; p=0.008).

CONCLUSION:

To our knowledge, this is the first study to demonstrate that the presence of SAR is associated with adverse events in patients with HFpEF.

Trajectories of Waist-to-Hip Ratio and Adverse Outcomes in Heart Failure with Mid-Range Ejection Fraction

BACKGROUND

Waist-to-hip ratio (WHR) is a strong predictor of mortality in patients with heart failure (HF). However, common WHR trajectories are not well established in HF with mid-range ejection fraction (HFmrEF) persons, and their relationship to clinical outcomes remains uncertain.

METHOD

We prospectively enrolled 1,396 participants with HFmrEF (left ventricular ejection fraction 40-49%) from April 2013 through April 2017. The waist and hip circumferences of the subjects were measured at regular intervals, and the WHR was calculated as waist circumference divided by hip circumference. Latent mixture modeling was performed to identify WHR trajectories. We then used Cox proportional-hazard models to examine the association between WHR trajectory patterns and incident HF, incident cardiovascular disease (CVD), and all-cause mortality.

RESULTS

We identified four distinct WHR trajectory patterns: lean-moderate increase (9.2%), medium-stable/increase (32.7%), heavy-stable/increase (48.0%), and heavy-moderate decrease (10.1%). After multivariable adjustment, the heavy-stable/increase and heavy-moderate decrease patterns were associated with an increased all-cause mortality risk (heavy-stable/increase: adjusted hazard ratio [HR] 3.18, 95% confidence interval [CI] 2.75-4.62; heavy-moderate decrease: adjusted HR 2.32, 95% CI 1.71-3.04), incident CVD risk (heavy-stable/increase: adjusted HR 4.03, 95% CI 2.39-4.91; heavy-moderate decrease: adjusted HR 3.05, 95% CI 2.34-4.09), and incident HF risk (heavy-stable/increase: adjusted HR 2.72, 95% CI 2.05-3.28; heavy-moderate decrease: adjusted HR 2.39, 95% CI 1.80-3.03) with reference to the lean-moderate increase pattern.

CONCLUSION

Among patients with HFmrEF, the trajectories of WHR gain are associated with poor outcomes. These findings highlight the importance of abdominal fat accumulation management during the progression of HFmrEF.

Gender disparities in heart failure with mid-range and preserved ejection fraction: Results from APOLLON study

Objective:

This study aimed to examine gender-based differences in epidemiology, clinical characteristics, and management of consecutive patients with heart failure with mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF).

Methods:

The APOLLON trial (A comPrehensive, ObservationaL registry of heart faiLure with mid-range and preserved ejection fractiON) is a multicenter, cross-sectional, and observational study. Consecutive patients with HFmrEF or HFpEF who were admitted to the cardiology clinics were included (NCT03026114). Herein, we performed a post-hoc analysis of data from the APOLLON trial.

Results:

The study population included 1065 (mean age of 67.1±10.6 years, 54% women) patients from 11 sites in Turkey. Compared with men, women were older (68 years vs. 67 years, p<0.001), had higher body mass index (29 kg/m² vs. 27 kg/m², p<0.001), and had higher heart rate (80 bpm vs. 77.5 bpm, p<0.001). Women were more likely to have HFpEF (82% vs. 70.9%, p<0.001), and they differ from men having a higher prevalence of hypertension (78.7% vs. 73.2%, p=0.035) and atrial fibrillation (40.7% vs. 29.9%, p<0.001) but lower prevalence of coronary artery disease (29.5% vs. 54.9%, p<0.001). Women had higher N-terminal pro-B-type natriuretic peptide (691 pg/mL vs. 541 pg/mL, p=0.004), lower hemoglobin (12.7 g/dL vs. 13.8 g/dL, p<0.001), and serum ferritin (51 ng/mL vs. 64 ng/mL, p=0.001) levels, and they had worse diastolic function (E/e’=10 vs. 9, p<0.001). The main cause of heart failure (HF) in women was atrial fibrillation, while it was ischemic heart disease in men.

Conclusion:

Clinical characteristics, laboratory findings, and etiological factors are significantly different in female and male patients with HFmrEF and HFpEF. This study offers a broad perspective for increased awareness about this patient profile in Turkey.

Geographical Variations in Patients with Heart Failure and Preserved Ejection Fraction: A Sub-Group Analysis of the APOLLON Registry

Background:

Clinical characteristics of patients with heart failure may vary geographically. However, limited data are available regarding the geographical differences of patients with heart failure and preserved ejection fraction.

Aims:

The present subgroup analysis aims to investigate the geographical differences in clinical characteristics, management, and primary etiology of patients with heart failure and preserved ejection fraction in Turkey.

Study Design:

A cross-sectional study.

Methods:

A comPrehensive, ObservationaL registry of heart faiLure with mid-range and preserved ejection fractiON (APOLLON) is a multicenter and observational study conducted in seven regions of Turkey (NCT03026114). The present study is a post-hoc analysis of the APOLLON registry. In this substudy, we compared the clinical characteristics of 819 consecutive patients with heart failure and preserved ejection fraction (mean age, 67 years; 57.8% women) admitted to cardiology outpatient units in different geographical regions.

Results:

Based on the geographical distribution of the entire Turkish population, the highest number of patients enrolled were from Marmara (271 patients, 33.1%). All demographical characteristics, clinical and laboratory findings, comorbidities, primary etiology, and medications prescribed were significantly different between the regions. Furthermore, inter-regional gender differences were identified. Comparatively, the Aegean and Mediterranean regions had older patients with heart failure and preserved ejection fraction (p<0.001), and the Black Sea, Southeast, and East Anatolia regions had predominantly male patients (51.2, 54.5, and 56.9%, respectively; p=0.002). Notably, the Mediterranean and Southeast Anatolia had more symptomatic patients, and history of hospitalization for heart failure was more prevalent in Southeast Anatolia (33.3%, p<0.001). Prevalence of atrial fibrillation was higher in the Mediterranean and Southeast Anatolia regions (51 and 48.5%, p<0.001), and patients with heart failure and preserved ejection fraction had a higher prevalence of hypertension in the Mediterranean, Southeast Anatolia, and Black Sea regions (p=0.002). Angiotensin-converting enzyme inhibitors were more frequently prescribed in East Anatolia (52.3%, p=0.001), and the prevalence of patients with heart failure and preserved ejection fraction using loop diuretics (48.8%, p=0.003) was higher in the Black Sea region.

Conclusion:

This study was the first to show geographical differences in clinical characteristics of patients with heart failure and preserved ejection fraction in Turkey. Determination of the clinical characteristics of the heart failure and preserved ejection fraction population based on the geographical region may enables physicians to adopt a region-specific clinical approach toward heart failure and preserved ejection fraction.

Clinical features of heart failure with mid-range and preserved ejection fraction in octogenarians: Results of a multicentre, observational study

OBJECTIVES

To compare real-world characteristics and management of individuals aged 80 and older with heart failure (HF) and mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF) derived from a large cohort of survey and to compare them with those younger than 80 from the same survey.

METHODS

This is an observational, multicentre and cross-sectional study conducted in Turkey (NCT03026114). Consecutive 1065 (mean age of 67.1 ± 10.6 years) patients admitted to the cardiology outpatient units with HFmrEF and HFpEF were included.

RESULTS

Participants aged 80 and older (n = 123, 11.5%) were more likely to be female (66.7% vs 52.5%, P = 0.003), had a higher prevalence of atrial fibrillation (49.6% vs 34%, P = 0.001), and anaemia (46.3% vs 33.4%, P = 0.005) than those who were younger than 80. N-terminal pro B-type natriuretic peptide levels were higher in those aged 80 and older than in those younger than 80 (1037 vs 550 pg/ml, P < 0.001). The prescription rates of HF medications (including in ACE-Is/ARBs, β-blockers, MRAs, digoxin, ivabradine and diuretics) were similar (P > 0.05) in both groups. Octogenarians did not significantly differ from younger patients in the prevalence of HFmrEF (24.4% vs 22.9%) and HFpEF (75.6% vs 77.1%). Coronary artery disease was associated with HFmrEF (P < 0.05), whereas atrial fibrillation was associated with HFpEF (P < 0.05) in octogenarians.

CONCLUSIONS

This study revealed that nearly 12% of the individuals with HFmrEF and HFpEF in this real-world sample were aged 80 and older. Participants aged 80 and older are more likely to be female and have more comorbidities than those who were younger than 80. However, HF medication profiles were similar in both groups. This study also showed that associated factors with HFmrEF and HFpEF were differ in octogenarians.