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Vancheri F, Longo G, Henein MY. Left ventricular ejection fraction: clinical, pathophysiological, and technical limitations. Front Cardiovasc Med 2024; 11:1340708. [PMID: 38385136 PMCID: PMC10879419 DOI: 10.3389/fcvm.2024.1340708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/12/2024] [Indexed: 02/23/2024] Open
Abstract
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.
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Affiliation(s)
- Federico Vancheri
- Department of Internal Medicine, S.Elia Hospital, Caltanissetta, Italy
| | - Giovanni Longo
- Cardiovascular and Interventional Department, S.Elia Hospital, Caltanissetta, Italy
| | - Michael Y. Henein
- Institute of Public Health and Clinical Medicine, Umea University, Umea, Sweden
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2
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Mulvagh SL, Colella TJ, Gulati M, Crosier R, Allana S, Randhawa VK, Bruneau J, Pacheco C, Jaffer S, Cotie L, Mensour E, Clavel MA, Hill B, Kirkham AA, Foulds H, Liblik K, Van Damme A, Grace SL, Bouchard K, Tulloch H, Robert H, Pike A, Benham JL, Tegg N, Parast N, Adreak N, Boivin-Proulx LA, Parry M, Gomes Z, Sarfi H, Iwegim C, Van Spall HG, Nerenberg KA, Wright SP, Limbachia JA, Mullen KA, Norris CM. The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 9: Summary of Current Status, Challenges, Opportunities, and Recommendations. CJC Open 2024; 6:258-278. [PMID: 38487064 PMCID: PMC10935707 DOI: 10.1016/j.cjco.2023.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/03/2023] [Indexed: 03/17/2024] Open
Abstract
This final chapter of the Canadian Women's Heart Health Alliance "ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women" presents ATLAS highlights from the perspective of current status, challenges, and opportunities in cardiovascular care for women. We conclude with 12 specific recommendations for actionable next steps to further the existing progress that has been made in addressing these knowledge gaps by tackling the remaining outstanding disparities in women's cardiovascular care, with the goal to improve outcomes for women in Canada.
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Affiliation(s)
- Sharon L. Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tracey J.F. Colella
- KITE-UHN-Toronto Rehabilitation, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Martha Gulati
- Barbra Streisand Women’s Heart Center, Cedars Sinai Heart Institute, Los Angeles, California, USA
| | - Rebecca Crosier
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | - Jill Bruneau
- Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Christine Pacheco
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Shahin Jaffer
- Department of Medicine, Division of Community Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa Cotie
- KITE-UHN-Toronto Rehabilitation, Toronto, Ontario, Canada
| | - Emma Mensour
- University of Western Ontario, London, Ontario, Canada
| | | | - Braeden Hill
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Amy A. Kirkham
- KITE-UHN-Toronto Rehabilitation, Toronto, Ontario, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Heather Foulds
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kiera Liblik
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Andrea Van Damme
- University of Alberta Faculty of Graduate & Postdoctoral Studies, Edmonton, Alberta, Canada
| | - Sherry L. Grace
- York University and University Health Network, Toronto, Ontario, Canada
| | - Karen Bouchard
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Heather Tulloch
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Helen Robert
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - April Pike
- Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Jamie L. Benham
- Departments of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nicole Tegg
- Faculties of Nursing, Medicine, and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Nazli Parast
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Najah Adreak
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Zoya Gomes
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Hope Sarfi
- Canadian Women’s Heart Health Alliance, Ottawa, Ontario, Canada
| | - Chinelo Iwegim
- Fraser Health Authority, Surrey, British Columbia, Canada
| | - Harriette G.C. Van Spall
- Departments of Medicine and Health Research Methods, Evidence, and Impact, Research Institute of St Joe’s, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Kara A. Nerenberg
- Departments of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | | | | - Colleen M. Norris
- Faculties of Nursing, Medicine, and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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Requena-Ibanez JA, Santos-Gallego CG, Zafar MU, Badimon JJ. SGLT2-Inhibitors on HFpEF Patients. Role of Ejection Fraction. Cardiovasc Drugs Ther 2023; 37:989-996. [PMID: 35920946 DOI: 10.1007/s10557-022-07371-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2022] [Indexed: 11/03/2022]
Abstract
Results from DELIVER trial and publication of EMPEROR-Preserved with sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with heart failure (HF) with ejection fraction (EF) > 40% represent a significant step forward in the treatment of HF with preserved EF (HFpEF). However, detailed analysis and attenuation of effect at higher EF levels have sparked some doubts about whether empagliflozin is effective across the entire spectrum of EF. HFpEF is no longer considered as one disease entity, but has been reconceptualized as a heterogenous group of phenotypes with derangements in multiple organ systems, driven by comorbidities. This heterogeneity suggests that it should not be considered as a single group in terms of treatment goals or clinical approach. Future research at the higher range of EF should ideally tailor investigations for unequivocally preserved EF (> 50%), consider the dynamic nature of EF over time, and use low-variability imaging techniques such as CMR. Furthermore, classifications based on pathophysiology and HF phenotypes beyond the EF construct will shape the design of future trials and help narrow down groups of patients who may respond to personalized treatment.
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Affiliation(s)
- Juan Antonio Requena-Ibanez
- Atherothrombosis Research Unit, Icahn School of Medicine at Mount Sinai, Mount Sinai Heart, New York, NY, 10029, USA
| | - Carlos G Santos-Gallego
- Atherothrombosis Research Unit, Icahn School of Medicine at Mount Sinai, Mount Sinai Heart, New York, NY, 10029, USA
| | - M Urooj Zafar
- Atherothrombosis Research Unit, Icahn School of Medicine at Mount Sinai, Mount Sinai Heart, New York, NY, 10029, USA
| | - Juan J Badimon
- Atherothrombosis Research Unit, Icahn School of Medicine at Mount Sinai, Mount Sinai Heart, New York, NY, 10029, USA.
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4
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Vaz-Salvador P, Adão R, Vasconcelos I, Leite-Moreira AF, Brás-Silva C. Heart Failure with Preserved Ejection Fraction: a Pharmacotherapeutic Update. Cardiovasc Drugs Ther 2023; 37:815-832. [PMID: 35098432 PMCID: PMC8801287 DOI: 10.1007/s10557-021-07306-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 02/06/2023]
Abstract
While guidelines for management of heart failure with reduced ejection fraction (HFrEF) are consensual and have led to improved survival, treatment options for heart failure with preserved ejection fraction (HFpEF) remain limited and aim primarily for symptom relief and improvement of quality of life. Due to the shortage of therapeutic options, several drugs have been investigated in multiple clinical trials. The majority of these trials have reported disappointing results and have suggested that HFpEF might not be as simply described by ejection fraction as previously though. In fact, HFpEF is a complex clinical syndrome with various comorbidities and overlapping distinct phenotypes that could benefit from personalized therapeutic approaches. This review summarizes the results from the most recent phase III clinical trials for HFpEF and the most promising drugs arising from phase II trials as well as the various challenges that are currently holding back the development of new pharmacotherapeutic options for these patients.
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Affiliation(s)
- Pedro Vaz-Salvador
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Rui Adão
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Inês Vasconcelos
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Adelino F. Leite-Moreira
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Carmen Brás-Silva
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
- Faculty of Nutrition and Food Sciences, University of Porto, Rua Do Campo Alegre, 823 4150-180 Porto, Portugal
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Litwin SE, East CA. Assessing clinical and biomarker characteristics to optimize the benefits of sacubitril/valsartan in heart failure. Front Cardiovasc Med 2022; 9:1058998. [PMID: 36620638 PMCID: PMC9815716 DOI: 10.3389/fcvm.2022.1058998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
Of the various medical therapies for heart failure (HF), sacubitril/valsartan is a first-in-class angiotensin receptor-neprilysin inhibitor that combines sacubitril, a pro-drug that is further metabolized to the neprilysin inhibitor sacubitrilat, and the angiotensin II type 1 receptor blocker valsartan. Inhibition of neprilysin and blockade of the angiotensin II type 1 receptor with sacubitril/valsartan increases vasoactive peptide levels, increasing vasodilation, natriuresis, and diuresis. Left ventricular ejection fraction (LVEF) is widely used to classify HF, to assist with clinical decision-making, for patient selection in HF clinical trials, and to optimize the benefits of sacubitril/valsartan in HF. However, as HF is a complex syndrome that occurs on a continuum of overlapping and changing phenotypes, patient classification based solely on LVEF becomes problematic. LVEF measurement can be imprecise, have low reproducibility, and often changes over time. LVEF may not accurately reflect inherent disease heterogeneity and complexity, and the addition of alternate criteria to LVEF may improve phenotyping of HF and help guide treatment choices. Sacubitril/valsartan may work, in part, by mechanisms that are not directly related to the LVEF. For example, this drug may exert antifibrotic and neurohumoral modulatory effects through inhibition or activation of several signaling pathways. In this review, we discuss markers of cardiac remodeling, fibrosis, systemic inflammation; activation of neurohormonal pathways, including the natriuretic system and the sympathetic nervous system; the presence of comorbidities; patient characteristics; hemodynamics; and HF signs and symptoms that may all be used to (1) better understand the mechanisms of action of sacubitril/valsartan and (2) help to identify subsets of patients who might benefit from treatment, regardless of LVEF.
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Affiliation(s)
- Sheldon E. Litwin
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, United States,Ralph H. Johnson Veterans Affairs Health Network, Charleston, SC, United States,*Correspondence: Sheldon E. Litwin,
| | - Cara A. East
- Baylor Soltero Cardiovascular Research Center, Baylor Scott and White Research Institute, Dallas, TX, United States
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Kalyuzhin VV, Teplyakov AT, Bespalova ID, Kalyuzhina EV, Terentyeva NN, Grakova EV, Kopeva KV, Usov VY, Garganeeva NP, Pavlenko OA, Gorelova YV, Teteneva AV. Promising directions in the treatment of chronic heart failure: improving old or developing new ones? BULLETIN OF SIBERIAN MEDICINE 2022. [DOI: 10.20538/1682-0363-2022-3-181-197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Unprecedented advances of recent decades in clinical pharmacology, cardiac surgery, arrhythmology, and cardiac pacing have significantly improved the prognosis in patients with chronic heart failure (CHF). However, unfortunately, heart failure continues to be associated with high mortality. The solution to this problem consists in simultaneous comprehensive use in clinical practice of all relevant capabilities of continuously improving methods of heart failure treatment proven to be effective in randomized controlled trials (especially when confirmed by the results of studies in real clinical practice), on the one hand, and in development and implementation of innovative approaches to CHF treatment, on the other hand. This is especially relevant for CHF patients with mildly reduced and preserved left ventricular ejection fraction, as poor evidence base for the possibility of improving the prognosis in such patients cannot justify inaction and leaving them without hope of a clinical improvement in their condition. The lecture consistently covers the general principles of CHF treatment and a set of measures aimed at inotropic stimulation and unloading (neurohormonal, volumetric, hemodynamic, and immune) of the heart and outlines some promising areas of disease-modifying therapy.
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Affiliation(s)
| | - A. T. Teplyakov
- Cardiology Research Institute, Tomsk National Research Medical Center (NRMC), Russian Academy of Sciences
| | | | | | | | - E. V. Grakova
- Cardiology Research Institute, Tomsk National Research Medical Center (NRMC), Russian Academy of Sciences
| | - K. V. Kopeva
- Cardiology Research Institute, Tomsk National Research Medical Center (NRMC), Russian Academy of Sciences
| | - V. Yu. Usov
- Cardiology Research Institute, Tomsk National Research Medical Center (NRMC), Russian Academy of Sciences
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Al Sudani H, Lo KB, Essa H, Wattoo A, Gulab A, Akhtar H, Angelim L, Helfman B, Peterson E, Brousas S, Whybrow-Huppatz I, Yazdanyar A, Soman S, Sankaranarayanan R, Rangaswami J. Differences in ejection fraction as inclusion criterion in randomized controlled trials among patients with heart failure with reduced ejection fraction: a systematic review. Expert Rev Cardiovasc Ther 2022; 20:481-484. [PMID: 35654018 DOI: 10.1080/14779072.2022.2085687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Heart failure (HF) with reduced ejection fraction (HFrEF) has been defined by varying ejection fraction (EF) criteria in clinical trials, leading to differences in quantifying treatment effects. AREAS COVERED The definitions of HFrEF in randomized controlled trials from 2010 until 2020 were collected. The EF ranges were clustered into very low (<30%), low (30-39%) and mildly reduced (40-49%) stratified by intervention. Time series regression analysis was performed.A total of 3052 articles were screened and 706 were included. Interventions included were pharmacologic (37%), device therapy (10%) and 53% a combination of programs, procedural, and laboratory testing. By EF cutoffs, 41% of the studies utilized <40% while 26% used <35%. About 31% did not have a clearly defined EF. Between 2010-2020, studies with HFrEF ranges 30-39% have significantly decreased (p value<0.001 for trend) but those which included very low EF (<30%) and mildly reduced EF (40-49%) have remained the same. Expert opinion:EF definitions across clinical trials in HFrEF varied widely. Defining the specific target HF population phenotype when designing trials or in patient treatment is important as various beneficial effects of different heart failure treatment modalities can be modified or even attenuated across the spectrum of EF.
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Affiliation(s)
- Hussein Al Sudani
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Kevin Bryan Lo
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Hani Essa
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool Heart & Chest Hospital, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | - Ammaar Wattoo
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Asma Gulab
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Hamza Akhtar
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Lucas Angelim
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Beth Helfman
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Eric Peterson
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Sophia Brousas
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | | | - Sandeep Soman
- Department of Nephrology, Henry Ford Hospital, Detroit, MI 48202 USA
| | - Rajiv Sankaranarayanan
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool Heart & Chest Hospital, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | - Janani Rangaswami
- George Washington University School of Medicine, Washington, DC, USA
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Latado AL. Prognosis of Heart Failure with Mid-Range Ejection Fraction: A Story or a Version? Arq Bras Cardiol 2022; 118:701-702. [PMID: 35508047 PMCID: PMC9007011 DOI: 10.36660/abc.20220170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Adriana Lopes Latado
- Universidade Federal da BahiaFaculdade de Medicina da BahiaSalvadorBABrasilUniversidade Federal da Bahia – Faculdade de Medicina da Bahia, Salvador, BA – Brasil
- Universidade Federal da BahiaHospital Universitário Professor Edgard SantosSalvadorBABrasilUniversidade Federal da Bahia – Hospital Universitário Professor Edgard Santos, Salvador, BA – Brasil
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The influence of sex and body mass index on the association between soluble neprilysin and risk of heart failure hospitalizations. Sci Rep 2021; 11:5940. [PMID: 33723360 PMCID: PMC7960699 DOI: 10.1038/s41598-021-85490-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 03/02/2021] [Indexed: 12/11/2022] Open
Abstract
A higher neprilysin activity has been suggested in women. In this retrospective analysis, we evaluated the association of sex and body mass index (BMI) with soluble neprilysin (sNEP) and recurrent admissions among 1021 consecutive HF outpatients. The primary and secondary endpoints were the number of HF hospitalizations and all-cause mortality, respectively. The association between sNEP with either endpoint was evaluated across sex and BMI categories (≥ 25 kg/m2 vs. < 25 kg/m2). Bivariate count regression (Poisson) was used, and risk estimates were expressed as incidence rates ratio (IRR). During a median follow-up of 6.65 years (percentile 25%-percentile 75%:2.83–10.25), 702 (68.76%) patients died, and 406 (40%) had at least 1 HF hospitalization. Median values of sNEP and BMI were 0.64 ng/mL (0.39–1.22), and 26.9 kg/m2 (24.3–30.4), respectively. Left ventricle ejection fraction was < 40% in 78.9% of patients, and 28% were women. In multivariable analysis, sNEP (main effect) was positively associated with HF hospitalizations (p = 0.001) but not with mortality (p = 0.241). The predictive value of sNEP for HF hospitalizations varied non-linearly across sex and BMI categories (p-value for interaction = 0.003), with significant and positive effect only on women with BMI ≥ 25 kg/m2 (p = 0.039). For instance, compared to men, women with sNEP of 1.22 ng/mL (percentile 75%) showed a significantly increased risk (IRRs: 1.26; 95% CI: 1.05–1.53). The interaction analysis for mortality did not support a differential prognostic effect for sNEP (p = 0.072). In conclusion, higher sNEP levels in overweight women better predicted an increased risk of HF hospitalization.
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Bozkurt B, Coats AJS, Tsutsui H, Abdelhamid CM, Adamopoulos S, Albert N, Anker SD, Atherton J, Böhm M, Butler J, Drazner MH, Michael Felker G, Filippatos G, Fiuzat M, Fonarow GC, Gomez-Mesa JE, Heidenreich P, Imamura T, Jankowska EA, Januzzi J, Khazanie P, Kinugawa K, Lam CSP, Matsue Y, Metra M, Ohtani T, Francesco Piepoli M, Ponikowski P, Rosano GMC, Sakata Y, Seferović P, Starling RC, Teerlink JR, Vardeny O, Yamamoto K, Yancy C, Zhang J, Zieroth S. Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure: Endorsed by the Canadian Heart Failure Society, Heart Failure Association of India, Cardiac Society of Australia and New Zealand, and Chinese Heart Failure Association. Eur J Heart Fail 2021; 23:352-380. [PMID: 33605000 DOI: 10.1002/ejhf.2115] [Citation(s) in RCA: 542] [Impact Index Per Article: 180.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 12/12/2022] Open
Abstract
In this document, we propose a universal definition of heart failure (HF) as a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion. We also propose revised stages of HF as: At risk for HF (Stage A), Pre-HF (Stage B), Symptomatic HF (Stage C) and Advanced HF (Stage D). Finally, we propose a new and revised classification of HF according to left ventricular ejection fraction (LVEF). This includes HF with reduced ejection fraction (HFrEF): symptomatic HF with LVEF ≤40%; HF with mildly reduced ejection fraction (HFmrEF): symptomatic HF with LVEF 41-49%; HF with preserved ejection fraction (HFpEF): symptomatic HF with LVEF ≥50%; and HF with improved ejection fraction (HFimpEF): symptomatic HF with a baseline LVEF ≤40%, a ≥10 point increase from baseline LVEF, and a second measurement of LVEF > 40%.
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11
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Bozkurt B, Coats AJ, Tsutsui H, Abdelhamid M, Adamopoulos S, Albert N, Anker SD, Atherton J, Böhm M, Butler J, Drazner MH, Felker GM, Filippatos G, Fonarow GC, Fiuzat M, Gomez-Mesa JE, Heidenreich P, Imamura T, Januzzi J, Jankowska EA, Khazanie P, Kinugawa K, Lam CSP, Matsue Y, Metra M, Ohtani T, Francesco Piepoli M, Ponikowski P, Rosano GMC, Sakata Y, SeferoviĆ P, Starling RC, Teerlink JR, Vardeny O, Yamamoto K, Yancy C, Zhang J, Zieroth S. Universal Definition and Classification of Heart Failure: A Report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure. J Card Fail 2021; 27:S1071-9164(21)00050-6. [PMID: 33663906 DOI: 10.1016/j.cardfail.2021.01.022] [Citation(s) in RCA: 317] [Impact Index Per Article: 105.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 02/07/2023]
Abstract
In this document, we propose a universal definition of heart failure (HF) as the following: HF is a clinical syndrome with symptoms and or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and or objective evidence of pulmonary or systemic congestion. We propose revised stages of HF as follows. At-risk for HF (Stage A), for patients at risk for HF but without current or prior symptoms or signs of HF and without structural or biomarkers evidence of heart disease. Pre-HF (stage B), for patients without current or prior symptoms or signs of HF, but evidence of structural heart disease or abnormal cardiac function, or elevated natriuretic peptide levels. HF (Stage C), for patients with current or prior symptoms and/or signs of HF caused by a structural and/or functional cardiac abnormality. Advanced HF (Stage D), for patients with severe symptoms and/or signs of HF at rest, recurrent hospitalizations despite guideline-directed management and therapy (GDMT), refractory or intolerant to GDMT, requiring advanced therapies such as consideration for transplant, mechanical circulatory support, or palliative care. Finally, we propose a new and revised classification of HF according to left ventricular ejection fraction (LVEF). The classification includes HF with reduced EF (HFrEF): HF with an LVEF of ≤40%; HF with mildly reduced EF (HFmrEF): HF with an LVEF of 41% to 49%; HF with preserved EF (HFpEF): HF with an LVEF of ≥50%; and HF with improved EF (HFimpEF): HF with a baseline LVEF of ≤40%, a ≥10-point increase from baseline LVEF, and a second measurement of LVEF of >40%.
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12
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Margonato D, Mazzetti S, De Maria R, Gorini M, Iacoviello M, Maggioni AP, Mortara A. Heart Failure With Mid-range or Recovered Ejection Fraction: Differential Determinants of Transition. Card Fail Rev 2020; 6:e28. [PMID: 33133642 PMCID: PMC7592465 DOI: 10.15420/cfr.2020.13] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/13/2020] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Davide Margonato
- Department of Clinical Cardiology, Policlinico di Monza Monza, Italy.,Department of Cardiology, University of Pavia Pavia, Italy
| | - Simone Mazzetti
- Department of Clinical Cardiology, Policlinico di Monza Monza, Italy
| | - Renata De Maria
- National Research Council, Institute of Clinical Physiology, ASST Great Metropolitan Hospital Niguarda Milan, Italy
| | | | - Massimo Iacoviello
- Department of Medical and Surgical Sciences, University of Foggia Foggia, Italy
| | | | - Andrea Mortara
- Department of Clinical Cardiology, Policlinico di Monza Monza, Italy
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Ferrari R, Fucili A, Rapezzi C. Understanding the results of the PARAGON-HF trial. Eur J Heart Fail 2020; 22:1531-1535. [PMID: 32212295 DOI: 10.1002/ejhf.1797] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/18/2020] [Accepted: 02/29/2020] [Indexed: 12/16/2022] Open
Affiliation(s)
- Roberto Ferrari
- Centro Cardiologico Universitario di Ferrara, University of Ferrara, Ferrara, Italy
- GVM Care & Research, Maria Cecilia Hospital, Cotignola (RA), Italy
| | - Alessandro Fucili
- Centro Cardiologico Universitario di Ferrara, University of Ferrara, Ferrara, Italy
| | - Claudio Rapezzi
- Centro Cardiologico Universitario di Ferrara, University of Ferrara, Ferrara, Italy
- GVM Care & Research, Maria Cecilia Hospital, Cotignola (RA), Italy
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