Heart failure with preserved ejection fraction has a better long-term prognosis than heart failure with reduced ejection fraction in old patients in a 5-year follow-up retrospective study

Heart Failure with Preserved Ejection Fraction: The Pathophysiological Mechanisms behind the Clinical Phenotypes and the Therapeutic Approach

Heart failure (HF) with preserved ejection fraction (HFpEF) is an increasingly frequent form and is estimated to be the dominant form of HF. On the other hand, HFpEF is a syndrome with systemic involvement, and it is characterized by multiple cardiac and extracardiac pathophysiological alterations. The increasing prevalence is currently reaching epidemic levels, thereby making HFpEF one of the greatest challenges facing cardiovascular medicine today. Compared to HF with reduced ejection fraction (HFrEF), the medical attitude in the case of HFpEF was a relaxed one towards the disease, despite the fact that it is much more complex, with many problems related to the identification of physiopathogenetic mechanisms and optimal methods of treatment. The current medical challenge is to develop effective therapeutic strategies, because patients suffering from HFpEF have symptoms and quality of life comparable to those with reduced ejection fraction, but the specific medication for HFrEF is ineffective in this situation; for this, we must first understand the pathological mechanisms in detail and correlate them with the clinical presentation. Another important aspect of HFpEF is the diversity of patients that can be identified under the umbrella of this syndrome. Thus, before being able to test and develop effective therapies, we must succeed in grouping patients into several categories, called phenotypes, depending on the pathological pathways and clinical features. This narrative review critiques issues related to the definition, etiology, clinical features, and pathophysiology of HFpEF. We tried to describe in as much detail as possible the clinical and biological phenotypes recognized in the literature in order to better understand the current therapeutic approach and the reason for the limited effectiveness. We have also highlighted possible pathological pathways that can be targeted by the latest research in this field.

Sex differences in the nutritional status and its association with long-term prognosis in patients with heart failure with reduced ejection fraction: a prospective cohort study

AIMS

Many studies show the association between malnutrition and poor prognosis in heart failure (HF) patients. Our research aimed to analyse sex differences in patients with HF with reduced ejection fraction (HFrEF), emphasizing nutritional status and the influence of selected parameters on the prognosis.

METHODS AND RESULTS

We enrolled 276 consecutive patients diagnosed with HFrEF. Nutritional status was assessed using Mini Nutritional Assessment (MNA), geriatric nutritional risk index (GNRI), and body mass index (BMI). The mean follow-up period was 564.4 ± 346.3 days. The analysed group included 81.2% of men. The median age was 58, interquartile range (IQR) 49-64 years. Among all patients, almost 60% were classified as NYHA III or IV. Half of the participants were at risk of malnutrition, and 2.9% were malnourished. During follow-up, 72 (26.1%) patients died. The female sex was not associated with a higher occurrence of malnutrition (P = 0.99) or nutritional risk (P = 0.85), according to MNA. Coherently, GNRI scores did not differ significantly between the sexes (P = 0.29). In contrast, BMI was significantly higher in males (29.4 ± 5.3 vs. 25.9 ± 4.7; P < 0.001). Impaired nutritional status assessed with any method (MNA, GNRI, BMI) was not significantly associated with a worse prognosis. In multivariable analysis, NYHA class, lower estimated glomerular filtration rate, higher B-type natriuretic peptide (BNP), higher N-terminal fragment of proBNP, and higher uric acid were independent of sex and age predictors of all-cause mortality.

CONCLUSION

There were no sex differences in the nutritional status in the HFrEF patients, apart from lower BMI in females. Impaired nutritional status was not associated with mortality in both men and women.

Differential Impact of Systolic and Diastolic Heart Failure on In-Hospital Treatment, Outcomes, and Cost of Patients Admitted for Pneumonia

Background

Patients admitted with pneumonia and heart failure (HF) have increased mortality and cost compared to those without HF, but it is not known whether outcomes differ between systolic and diastolic HF. Management of concomitant pneumonia and HF is complicated because HF treatments can worsen complications of pneumonia.

Methods

This is a retrospective cohort study from the Premier Database among patients admitted with pneumonia between 2010-2015. Patients were categorized based on systolic, diastolic, and combined HF using ICD-9 codes. The primary outcome was in-hospital mortality. Secondary outcomes included use of HF medications, length of stay, cost, intensive care unit (ICU) admission, as well as use of invasive mechanical ventilation (IMV), vasopressors and inotropes. Multivariable logistic regression was used to describe associations of these outcomes with type of HF.

Results

Of 123,211 patients with pneumonia and HF, 41,196 (33.4%) had systolic HF, 69,982 (56.8%) diastolic HF, and 12,033 (9.8%) had combined HF. Compared to patients with diastolic HF, after multivariable adjustment systolic HF was associated with higher in-hospital mortality (OR 1.15; 95% CI:1.11-1.20), ICU admission, and use of IMV and vasoactive agents, but not with increased length of stay or cost. Among patients with systolic HF, 80% received a loop diuretic, 72% a beta blocker, 48% angiotensin converting enzyme inhibitor or angiotensin receptor blocker, and 12.5% a mineralocorticoid receptor antagonist.

Conclusion

Systolic HF is associated with added risk in pneumonia compared to diastolic HF. There may also be an opportunity to optimize medications in systolic HF prior to discharge.

Systematic review and meta-analysis of the association between all-cause mortality and statin therapy in patients with preserved ejection fraction heart failure (HFpEF)

BACKGROUND

Heart failure (HF) is a growing global health burden increasing in prevalence as the average age of the population rises. HF with preserved ejection fraction (HFpEF) is defined as EF that is ≥50% and represents almost half of the population with HF.

METHODS

We conducted a systematic review and meta-analysis exploring an association between HFpEF and statin use on all-cause mortality and cardiovascular rehospitalisation. Searches were conducted in MEDLINE via Ovid, The Cochrane Library for clinical trials in CENTRAL and Embase via Ovid for articles published between 1 January 2000 and 2 July 2021. Risk of bias was assessed using the Newcastle-Ottawa Scale and evidence rated for quality using the GRADE approach.

RESULTS

A total of 19 studies were included in the review. The analysis suggests a risk reduction of 27% for the statin exposed participants compared to the statin non-exposed participants (HR 0.73, 95% CI: 0.68-0.79) with regard to all-cause mortality. There is a low level of heterogeneity (I² = 38%) associated with this result that has been accounted for by using a random effects model, however given the included studies are observational, the quality of the evidence is rated as low. Information on rehospitalisation was insufficient for determining the impact of statin use on rehospitalisations.

CONCLUSION

Our meta-analysis revealed a reduction in all-cause mortality in patients with HFpEF on statin therapy. Considering the outcomes from this meta-analysis there is a need for high level studies to provide quality evidence on the use of statins in patients with HFpEF.

The Interaction Effect of Cardiac and Noncardiac Co-morbidities on Mortality Rates in Patients With Heart Failure

The prevalence of heart failure (HF) and co-morbidities are increasing. The prognostic impact of interaction between co-morbidity and HF remains unknown. The purpose of the present study was to examine if HF interacts with co-morbidity burden to increase mortality. We conducted a cohort study of all adult Danish patients (aged ≥18 years) with a hospital inpatient or outpatient clinic diagnosis of HF (n = 252,726) between 1995 and 2016. We matched each patient with up to 3 members of the general population without a history of HF (n = 744,372). Noncardiac co-morbidities were assessed using the Charlson co-morbidity index and were defined by 4 categories of co-morbidity: 0 (none), 1 (low), 2 to 3 (moderate), and ≥4 (severe). Cardiac co-morbidities were assessed individually. Among patients with HF with severe co-morbidity, 42% of the mortality rate during 30 days of follow-up was explained by the interaction with co-morbidity. The interaction effect was also substantial in patients with moderate (31%) and low co-morbidity burden (16%). During 31 to 365 days of follow-up, interaction effects were 1% for low co-morbidity, 8% for moderate co-morbidity, and 22% for severe co-morbidity. Beyond 1 year of follow-up, no interaction effect was observed. With the exception of cardiomyopathy, cardiac co-morbidities did not interact substantially with HF during the first year of follow-up. During longer follow-up, pulmonary hypertension, cardiomyopathy, and endocarditis showed interaction. In conclusion, noncardiac co-morbidities had biological interaction with HF that increased short-term mortality substantially beyond the individual effects of HF and co-morbidity.

Exploring and Identifying Prognostic Phenotypes of Patients with Heart Failure Guided by Explainable Machine Learning

Identifying patient prognostic phenotypes facilitates precision medicine. This study aimed to explore phenotypes of patients with heart failure (HF) corresponding to prognostic condition (risk of mortality) and identify the phenotype of new patients by machine learning (ML). A unsupervised ML was applied to explore phenotypes of patients in a derivation dataset (n = 562) based on their medical records. Thereafter, supervised ML models were trained on the derivation dataset to classify these identified phenotypes. Then, the trained classifiers were further validated on an independent validation dataset (n = 168). Finally, Shapley additive explanations were used to interpret decision making of phenotype classification. Three patient phenotypes corresponding to stratified mortality risk (high, low, and intermediate) were identified. Kaplan−Meier survival curves among the three phenotypes had significant difference (pairwise comparison p < 0.05). Hazard ratio of all-cause mortality between patients in phenotype 1 (n = 91; high risk) and phenotype 3 (n = 329; intermediate risk) was 2.08 (95%CI 1.29−3.37, p = 0.003), and 0.26 (95%CI 0.11−0.61, p = 0.002) between phenotype 2 (n = 142; low risk) and phenotype 3. For phenotypes classification by random forest, AUCs of phenotypes 1, 2, and 3 were 0.736 ± 0.038, 0.815 ± 0.035, and 0.721 ± 0.03, respectively, slightly better than the decision tree. Then, the classifier effectively identified the phenotypes for new patients in the validation dataset with significant difference on survival curves and hazard ratios. Finally, age and creatinine clearance rate were identified as the top two most important predictors. ML could effectively identify patient prognostic phenotypes, facilitating reasonable management and treatment considering prognostic condition.

Left atrial volume and left ventricular mass indices in heart failure with preserved and reduced ejection fraction

AIMS

Two key echocardiographic parameters that are currently used to diagnose heart failure (HF) with preserved ejection fraction (HFpEF) are left atrial volume index (LAVi) and left ventricular mass index (LVMi). We investigated whether patients' characteristics, biomarkers, and co-morbidities are associated with these parameters and whether the relationships differ between patients with HFpEF or HF with reduced ejection fraction (HFrEF).

METHODS

We consecutively enrolled 831 outpatients with typical signs and symptoms of HF and elevated N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels and categorized patients based upon left ventricular ejection fraction (LVEF): LVEF < 40% (HFrEF), LVEF between 40% and 50% (HF with mid-range ejection fraction), and LVEF ≥ 50% (HFpEF). The study includes consecutively enrolled HF patients from an HF outpatient clinic at a tertiary medical centre in the Netherlands. All patients underwent baseline characterization, laboratory measurements, and echocardiography.

RESULTS

Four hundred sixty-nine patients had HFrEF, 189 HF with mid-range ejection fraction, and 173 HFpEF. The patients with HFrEF were rather male [HFrEF: 323 (69%); HFpEF: 80 (46%); P < 0.001], and the age was comparable (HFrEF 67 ± 13; HFpEF 70 ± 14; P = 0.069). In HFpEF, more patients had hypertension [190 (40.5%); 114 (65.9%); P < 0.001], higher body mass indices (27 ± 8; 30 ± 7; P < 0.001), and atrial fibrillation [194 (41.4); 86 (49.7); P = 0.029]. The correlation analyses showed that in HFrEF patients, LAVi was significantly associated with age (β 0.293; P < 0.001), male gender (β 0.104; P = 0.042), body mass index (β -0160; P = 0.002), diastolic blood pressure (β -0.136; P < 0.001), New York Heart Association (β 0.174; P = 0.001), atrial fibrillation (β 0.381; P < 0.001), galectin 3 (β 0.230; P < 0.001), NT-proBNP (β 0.183; P < 0.001), estimated glomerular filtration rate (β -0.205; P < 0.001), LVEF (β -0.173; P = 0.001), and LVMi (β 0.337; P < 0.001). In HFpEF patients, only age (β 0.326; P < 0.001), atrial fibrillation (β 0.386; P < 0.001), NT-proBNP (β 0.176; P = 0.036), and LVMi (β 0.213; P = 0.013) were associated with LAVi.

CONCLUSIONS

Although LVMi and LAVi are hallmark parameters to diagnose HFpEF, they only correlate with a few characteristics of HF and mainly with atrial fibrillation. In contrast, in HFrEF patients, LAVi relates strongly to several other HF parameters. These findings underscore the complexity in visualizing the pathophysiology of HFpEF and question the relation between cardiac structural remodeling and the impact of co-morbidities.

Five-year mortality and readmission rates in patients with heart failure in India: Results from the Trivandrum heart failure registry

INTRODUCTION

Heart failure (HF) has emerged as an important and increasing disease burden in India. We present the 5-year outcomes of patients hospitalized for HF in India.

METHODS

The Trivandrum Heart Failure Registry (THFR) recruited consecutive patients admitted for acute HF among 16 hospitals in Trivandrum, Kerala in 2013. Guideline-directed medical therapy (GDMT) was defined as the combination of beta-blockers (BB), renin angiotensin system blockers (RAS), and mineralocorticoid receptor antagonists (MRA) in patients with HF with reduced ejection fraction (HFrEF, EF < 40%) at discharge. We used Cox proportional hazards models and Kaplan-Meier survival plots for analysis. The MAGGIC risk score variables were included as exposure variables.

RESULTS

Among 1205 patients [69% male, mean (SD) age = 61.2 (13.7) years], HFrEF constituted 62% of patients and among them, 25% received GDMT. The 5-year mortality rate was 59% (n = 709 deaths), and median survival was 3.1 years. Sudden cardiac death and pump failure caused 46% and 49% of the deaths, respectively. In the multivariate Cox model, components of GDMT associated with lower 5-year mortality risks were discharge prescription of BB, RAS blocker, and MRA. Older age, lower systolic blood pressure, NYHA class III or IV, and higher serum creatinine were also associated with higher 5-year mortality.

CONCLUSIONS

Three out of every 5 patients had died during 5-years of follow-up with a median survival of approximately 3 years. Lack of GDMT in patients with HFrEF and frequent readmissions were associated with higher 5-year mortality. Quality improvement programmes with strategies to improve adherence to GDMT and reduction in readmissions may improve HF outcomes in this region.

Association between atrial fibrillation and heart failure with different ejection fraction categories and its influence on outcomes

Background: The important role of atrial fibrillation (AF) in different types of heart failure (HF) according to ejection fraction (EF) is much less explored. In this study, we compared AF in HF with preserved (HFpEF), mid-range (HFmrEF) and reduced (HFrEF) EF with regard to prevalence, association, and prognostic role.Methods and results: A total of 405 inpatients with HF between February 2014 and June 2016 were prospectively analysed in this study. Patients were divided into three groups: HFrEF group (n = 109, 26.9%), HFmrEF group (n = 94, 23.2%), and HFpEF group (n = 202, 49.8%). There was a higher prevalence of AF in patients in the HFpEF and HFmrEF groups than in patients in the HFrEF. Several baseline variables were found to be independently associated with AF, including age, coronary heart disease, heart rate, left atrial diameter, and left ventricular (LV) end-diastolic diameter, regardless of EF category after multivariable adjustment. In addition, AF was found to be a more powerful predictor of all-cause mortality, HF rehospitalisation, and the composite event of all-cause mortality or rehospitalisation in HFpEF and HFmrEF patients, but not in HFrEF patients.Conclusions: HFmrEF resembled HFpEF rather than HFrEF with regard to both a higher prevalence of AF and a greater risk of all-cause mortality, HF rehospitalisation, and the composite event of all-cause mortality or rehospitalisation.

Heart Failure with Preserved Ejection Fraction-a Concise Review

Purpose of Review

Heart failure with preserved ejection fraction (HFpEF) is a relatively new disease entity used in medical terminology; however, both the number of patients and its clinical significance are growing. HFpEF used to be seen as a mild condition; however, the symptoms and quality of life of the patients are comparable to those with reduced ejection fraction. The disease is much more complex than previously thought. In this article, information surrounding the etiology, diagnosis, prognosis, and possible therapeutic options of HFpEF are reviewed and summarized.

Recent Findings

It has recently been proposed that heart failure (HF) is rather a heterogeneous syndrome with a spectrum of overlapping and distinct characteristics. HFpEF itself can be distilled into different phenotypes based on the underlying biology. The etiological factors of HFpEF are unclear; however, systemic low-grade inflammation and microvascular damage as a consequence of comorbidities associated with endothelial dysfunction, oxidative stress, myocardial remodeling, and fibrosis are considered to play a crucial role in the pathogenesis of a disease. The H₂FPEF score and the HFpEF nomogram are recently validated highly sensitive tools employed for risk assessment of subclinical heart failure.

Summary

Despite numerous studies, there is still no evidence-based pharmacotherapy for HFpEF and the mortality and morbidity associated with HFpEF remain high. A better understanding of the etiological factors, the impact of comorbidities, the phenotypes of the disease, and implementation of machine learning algorithms may play a key role in the development of future therapeutic strategies.

[Combined Approach for Management of the Chronic Heart Failure with Preserved Left Ventricular Ejection Fraction and Permanent Atrial Fibrillation: a Case Report]

The article described a clinical case of a patient with chronic heart failure (CHF) with preserved ejection fraction (CHF-PEF) and permanent normosystolic atrial fibrillation (AF). A 73 year-old man (body mass index, 26.4 kg /m2) with permanent normosystolic AF (duration, 10 years) was hospitalized for augmenting of CHF symptoms. The patient had NYHA II-III functional class CHF and a history of long-standing arterial hypertension. The patient received chronic therapy according to the effective guidelines (angiotensin receptor blockers, diuretics, beta-blockers, and new oral anticoagulants). Transthoracic echocardiography showed a normal ejection fraction (EF) (57 %), a moderate enlargement of the left atrium (48 mm), and moderate left ventricular (LV) hypertrophy. Radiofrequency catheter ablation (RFCA) of left atrial AF was performed. For preparation to the RFCA, the patient was administered propanorm two weeks prior to the procedure. Following external electrical cardioversion (ECV) after RFCA, sinus rhythm did not recover. The patient was prescribed amiodarone, and repeat ECV was performed in a month, which resulted in successful recovery of sinus rhythm. However, due to an increase in serum thyrotropic hormone, amiodaron was replaced with the sotalol therapy (240 mg/day). This resulted in development of symptomatic sinus bradycardia and AF relapse at 3 days after ECV. A dual-chamber cardioverter defibrillator was implanted to the patient; in another three months, repeat AF RFCA was performed with successful recovery of sinus rhythm. During the cardioverter testing for one year, the patient had one more AF episode, which was stopped by external ECV. Also, a 6-hour AF episode occurred at three months after the repeat RFCA. Symptoms of CHF disappeared by the 12th month. The combination therapy administered to the patient with normosystolic permanent AF and preserved EF, which included a pathogenetic therapy for CHF, antiarrhythmic drugs, implantation of a dual-chamber ECV, two sessions of AF RFCA, and repeat external ECVs, provided considerable improvement of CHF symptoms and stable sinus rhythm during a one-year follow-up. The return to sinus rhythm after 10 years of permanent AF necessitated changing the arrhythmia diagnosis to long-standing, persistent AF.

Age-dependent differences in clinical phenotype and prognosis in heart failure with mid-range ejection compared with heart failure with reduced or preserved ejection fraction

BACKGROUND

HFmrEF has been recently proposed as a distinct HF phenotype. How HFmrEF differs from HFrEF and HFpEF according to age remains poorly defined. We aimed to investigate age-dependent differences in heart failure with mid-range (HFmrEF) vs. preserved (HFpEF) and reduced (HFrEF) ejection fraction.

METHODS AND RESULTS

42,987 patients, 23% with HFpEF, 22% with HFmrEF and 55% with HFrEF, enrolled in the Swedish heart failure registry were studied. HFpEF prevalence strongly increased, whereas that of HFrEF strongly decreased with higher age. All cardiac comorbidities and most non-cardiac comorbidities increased with aging, regardless of the HF phenotype. Notably, HFmrEF resembled HFrEF for ischemic heart disease prevalence in all age groups, whereas regarding hypertension it was more similar to HFpEF in age ≥ 80 years, to HFrEF in age < 65 years and intermediate in age 65-80 years. All-cause mortality risk was higher in HFrEF vs. HFmrEF for all age categories, whereas HFmrEF vs. HFpEF reported similar risk in ≥ 80 years old patients and lower risk in < 65 and 65-80 years old patients. Predictors of mortality were more likely cardiac comorbidities in HFrEF but more likely non-cardiac comorbidities in HFpEF and HFmrEF with < 65 years. Differences among HF phenotypes for comorbidities were less pronounced in the other age categories.

CONCLUSION

HFmrEF appeared as an intermediate phenotype between HFpEF and HFrEF, but for some characteristics such as ischemic heart disease more similar to HFrEF. With aging, HFmrEF resembled more HFpEF. Prognosis was similar in HFmrEF vs. HFpEF and better than in HFrEF.

Epidemiology and long-term outcome in outpatients with chronic heart failure in Northwestern Europe

OBJECTIVE

To describe the epidemiology, long-term outcomes and temporal trends in mortality in ambulatory patients with chronic heart failure (HF) with reduced (HFrEF), mid-range (HFmrEF) or preserved ejection fraction (HFpEF) from three European countries.

METHODS

We identified 10 312 patients from the Norwegian HF Registry and the HF registries of the universities of Heidelberg, Germany, and Hull, UK. Patients were classified according to baseline left ventricular ejection fraction (LVEF) and time of enrolment (period 1: 1995-2005 vs period 2: 2006-2015). Predictors of mortality were analysed by use of univariable and multivariable Cox regression analyses.

RESULTS

Among 10 312 patients with stable HF, 7080 (68.7%), 2086 (20.2%) and 1146 (11.1%) were classified as having HFrEF, HFmrEF or HFpEF, respectively. A total of 4617 (44.8%) patients were included in period 1, and 5695 (55.2%) patients were included in period 2. Baseline characteristics significantly differed with respect to type of HF and time of enrolment. During a median follow-up of 66 (33-105) months, 5297 patients (51.4%) died. In multivariable analyses, survival was independent of LVEF category (p>0.05), while mortality was lower in period 2 as compared with period 1 (HR 0.81, 95% CI 0.72 to 0.91, p<0.001). Significant predictors of all-cause mortality regardless of HF category were increasing age, New York Heart Association functional class, N-terminal pro-brain natriuretic peptide and use of loop diuretics.

CONCLUSION

Ambulatory patients with HF stratified by LVEF represent different phenotypes. However, after adjusting for a wide range of covariates, long-term survival is independent of LVEF category. Outcome significantly improved during the last two decades irrespective from type of HF.

Correlation with invasive left ventricular filling pressures and prognostic relevance of the echocardiographic diastolic parameters used in the 2016 ESC heart failure guidelines and in the 2016 ASE/EACVI recommendations: a systematic review in patients with heart failure with preserved ejection fraction

AIMS

Five echocardiographic parameters-left atrial volume index, left ventricular mass index, tricuspid regurgitation velocity, myocardial tissue velocity, and the ratio of early mitral inflow to tissue velocity of the mitral annulus (E/e')-are recommended in both the current European Society of Cardiology heart failure guidelines and the American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations for the evaluation of left ventricular diastolic function. We aimed to perform a systematic review of these echocardiographic parameters at resting conditions for their correlation with left ventricular filling pressures in patients with heart failure with preserved ejection fraction (HFpEF). In addition, the prognostic value of these parameters was assessed.

METHODS AND RESULTS

Nine studies reported the correlation between echocardiography and invasive haemodynamics, and 18 papers reported on the prognostic value of echocardiography in HFpEF. Among the parameters, most data were reported for E/e'. The pooled correlation coefficient r was 0.56 for the relation between E/e' and invasively measured filling pressures. Combined weighted-mean meta-analysis of prognostic studies resulted in a hazard ratio of 1.05 (95% confidence interval 1.03-1.06) per unit increase in E/e' for the combined outcome of all-cause mortality and cardiovascular hospitalization. The other echocardiographic parameters, when taken individually, had similar or lower association with prognosis.

CONCLUSION

Only a small number of studies validated the use of echocardiographic parameters at rest in patients with HFpEF. The best established parameter appears to be E/e', but the existing data only show modest correlations of E/e' with invasive filling pressures and outcomes in HFpEF.