Heart Failure With Mid-range or Recovered Ejection Fraction: Differential Determinants of Transition

Heart failure with improved ejection fraction: patient characteristics, clinical outcomes and predictors for improvement

Background

Heart failure with improved ejection fraction (HFimpEF) is a recently recognized entity presenting a diagnostic and therapeutic challenge. Our aim was to characterize the profile of HFimpEF patients and evaluate predictors for EF lack of improvement among heart failure with reduced ejection fraction (HFrEF) patients.

Methods

We included ambulatory HFrEF patients (EF≤40%) between January 1, 2015, and September 1, 2022, with two consecutive echocardiography exams at least 6 months apart. HFimpEF was defined as improved EF from ≤40%->40% and by ≥10%.

Results

A total of 567 HFrEF patients (72% male, 54.3 ± 14.4 years old) were analyzed. Patients without EF improvement were more likely to be male, had more comorbidities, ischemic cardiomyopathy (ICMP), markers of adverse cardiac remodeling (lower EF and higher left and right ventricular diameters) and presence of late gadolinium enhancement (LGE) in MRI (P < 0.05 for all). In a multivariate analysis, male sex, ICMP, lower EF, larger ventricular size and LGE remained independent predictors for lack of EF improvement. A prediction model for lack of EF improvement including LVEF, LV diameter, diastolic blood pressure and ischemic etiology exhibited an area under the ROC curve of 0.77 (95% CI 0.73-0.81; P < 0.001). HFimpEF patients had better prognosis with lower hospitalizations and mortality rates. Guideline directed medical therapy (GDMT) were associated with improved outcomes in both groups regardless of EF improvement.

Conclusions

Lack of improvement in EF among HFrEF patients may be predicted by HF etiology and imaging parameters of adverse cardiac remodeling, and is associated with worse prognosis. GDMT were associated with improved outcomes in both HFimpEF and HFrEF patients.

The Interplay of Comorbidities in Chronic Heart Failure: Challenges and Solutions

BACKGROUND

Chronic heart failure (HF) is frequently associated with various comorbidities. These comorbid conditions, such as anemia, diabetes mellitus, renal insufficiency, and sleep apnea, can significantly impact the prognosis of patients with HF.

OBJECTIVE

This review aims to synthesize current evidence on the prevalence, impact, and management of comorbidities in patients with chronic HF.

METHODS

A comprehensive review was conducted, with a rigorous selection process. Out of an initial pool of 59,030 articles identified across various research modalities, 134 articles were chosen for inclusion. The selection spanned various research methods, from randomized controlled trials to observational studies.

RESULTS

Comorbidities are highly prevalent in patients with HF and contribute to increased hospitalization rates and mortality. Despite advances in therapies for HF with reduced ejection fraction, options for treating HF with preserved ejection fraction remain sparse. Existing treatment protocols often lack standardization, reflecting a limited understanding of the intricate relationships between HF and associated comorbidities.

CONCLUSION

There is a pressing need for a multidisciplinary, tailored approach to manage HF and its intricate comorbidities. This review underscores the importance of ongoing research efforts to devise targeted treatment strategies for HF patients with various comorbid conditions.

Heart failure with improved ejection fraction: Beyond diagnosis to trajectory analysis

Left ventricular (LV) systolic dysfunction represents a highly treatable cause of heart failure (HF). A substantial proportion of patients with HF with reduced ejection fraction (EF;HFrEF) demonstrate improvement in LV systolic function (termed HF with improved EF [HFimpEF]), either spontaneously or when treated with guideline-directed medical therapy (GDMT). Although it is a relatively new HF classification, HFimpEF has emerged in recent years as an important and distinct clinical entity. Improvement in LVEF leads to decreased rates of mortality and adverse HF-related outcomes compared to patients with sustained LV systolic dysfunction (HFrEF). While numerous clinical and imaging factors have been associated with HFimpEF, identification of which patients do and do not improve requires further investigation. In addition, patients improve at different rates, and what determines the trajectory of HFimpEF patients after improvement is incompletely characterized. A proportion of patients maintain improvement in LV systolic function, while others experience a recrudescence of systolic dysfunction, especially with GDMT discontinuation. In this review we discuss the contemporary guideline-recommended classification definition of HFimpEF, the epidemiology of improvement in LV systolic function, and the clinical course of this unique patient population. We also offer evidence-based recommendations for the clinical management of HFimpEF and provide a roadmap for future directions in understanding and improving outcomes in the care of patients with HFimpEF.

Angiotensin-Converting Enzyme Inhibitor Therapy Effects in Patients With Heart Failure With Preserved and Mid-Range Ejection Fraction

Background

There is hypothesis that endothelial function enhancement is strongly associated with better outcome and functional class improvement in heart failure with preserved ejection fraction (HFpEF) and heart failure with mid-range ejection fraction (HFmrEF) patients. Perindopril is the only angiotensin-converting enzyme inhibitor (ACEI) drug with proven positive effect on the endothelium in coronary artery disease (CAD) patients. In patients with HFpEF and HFmrEF, its impact is still unknown. The aim of this study was to assess perindopril’s influence on endothelial dysfunction markers in these groups of patients.

Methods

We included 60 patients with HFpEF and HFmrEF. At the baseline, endothelial dysfunction biomarkers were measured by IFA and echocardiographic parameters (left atrial volume index (LAVI), ejection fraction (EF), left ventricular mass index (LVMI), left ventricular end-diastolic diameter (LVEDD), and left ventricular end-diastolic volume (LVEDV)) were studied. In patients with no history of previous ACEI or angiotensin II receptor blockers (ARBs) therapy, perindopril was prescribed for 12 months. If patient was treated with ARB or ACEI drug other than perindopril before the study, after 48-h withdrawal period, previous drug was replaced by perindopril.

Results

After 12-month therapy with perindopril, E-selectin decreased from 57.25 to 46.05 ng/mL and from 56.55 to 47.6 ng/mL in HFpEF and HFmrEF patients, respectively (P < 0.05). Significant reductions from 0.99 to 0.76 pg/mL (P < 0.05) and from 1.08 to 0.97 pg/mL (P < 0.05) in endothelin-1 level were shown in patients with HFpEF and HFmrEF.

Conclusion

The 12-month therapy with perindopril leads to LAVI reduction in HFmrEF patients and potential endothelial dysfunction markers decrease in HFpEF and HFmrEF patients.

Heart failure with recovered ejection fraction and the utility of defibrillator therapy: a review

Heart failure with recovered ejection fraction (HFrecEF) involves those who have previously had reduced cardiac function that has subsequently improved. However, there is not a single definition of this phenomenon and recovery of cardiac function in terms of left ventricular ejection fraction (LVEF) itself does not necessarily correlate with remission from the detrimental physiology of heart failure (HF) and its consequences. There is also the question of the utility of defibrillators in these patients, and whether they should be replaced at the time of battery depletion. To address this, several studies have shown specific predictors of ensuing LVEF recovery, including patient demographics, co‐morbidities, and medication use, as well as predictors of ventricular arrhythmias (VA) following LVEF recovery. Recent studies have also shown novel imaging parameters that may aid in predicting which patients would have a higher risk of these arrhythmias. Additional data describe a small, yet appreciable risk of VA, in addition to appropriate shocks as well. In this review, we describe predictors of LVEF recovery, carefully analyse and characterize the continued risk for VA and appropriate shocks following LVEF recovery, and explore additional novel modalities that may aid in decision‐making.

Beta-blockers are associated with reverse remodeling in patients with dilated cardiomyopathy and mid-range ejection fraction

Background

Beta-blockers have been shown to induce left ventricular reverse remodeling (LVRR) in heart failure with reduced ejection fraction. This study aimed to determine whether beta-blockers could induce LVRR in patients with heart failure with mid-range ejection fraction (HFmrEF).

Methods

We analyzed the national database from clinical personal records of dilated cardiomyopathy (DCM) maintained by Japanese Ministry of Health, Labour and Welfare, between 2003 and 2014. Patients with left ventricular ejection fraction (LVEF) of ≥40% and < 50% were included. Patients who did not have echocardiography at 2 years of follow-up were excluded. Eligible patients were divided into two groups according to the use of beta-blockers. Patient characteristics of two groups were adjusted by propensity score matching. The primary outcome was LVRR at 2 years of follow-up, defined as an improvement in LVEF ≥10%.

Results

Out of 3064 patients, propensity score matching yielded 602 pairs. The mean age was 59.3 years and 896 patients (74.4%) were male. The primary outcome was observed more frequently in beta-blocker group (24.3% vs. 17.8%; Odds ratio [OR], 1.48; 95% confidence interval [CI], 1.12-1.96; P = 0.006). Subgroup analysis demonstrated that patients with heart rate ≥ 75 bpm (≥ 75 bpm; OR, 2.61; 95% CI, 1.66-4.11: < 75 bpm; OR, 1.03; 95% CI, 0.72-1.48; P for interaction = 0.002) and atrial fibrillation (AF) (AF; OR, 2.30; 95% CI, 1.37-3.86: No AF; OR 1.23; 95% CI, 0.88-1.72; P for interaction = 0.046) were benefited by beta-blockers.

Conclusions

Beta-blockers could induce LVRR in patients with DCM and HFmrEF.

Association Between the Angiotensin II/Angiotensin (1-7) Imbalance and Left Ventricular Hypertrophy in Patients with Heart Failure

Introduction: Angiotensin II (AngII) and angiotensin-(1-7) [Ang-(1-7)] are key components of the renin angiotensin system (RAS). They exhibit counter-regulatory effects in the systemic circulation, as well as in tissues important for cardiovascular regulation.

Aim: To investigate the association between the AngII/Ang-(1-7) balance and left ventricular hypertrophy (LVH) in patients with heart failure and mid-range ejection fraction (HFmrEF).

Material and methods: 56 patients with HFmrEF were included, with a mean age of 65.62 ± 9.69 years and 22 age- and sex-matched healthy subjects, their mean age - 56.4 ± 5.53 years. The patients were divided in two subgroups: subjects with left ventricular hypertrophy (n = 32); (HFmrEF+LVH) and subjects without left ventricular hypertrophy (n = 24); (HFmrEFLVH). AngII and Ang-(1-7) levels were measured with an ELISA kit.

Results: Patients with HFmrEF+LVH showed significantly higher levels of AngII: 8.53 pg/mL (1.47 ÷ 13.0) than HFmrEF-LVH – 1.33 pg/mL (0.47 ÷ 6.93) and healthy controls – 1.53 pg/mL (0.27 ÷ 5.21); (KW = 3.48; p = 0.04). There was no significant difference between Ang-(1-7) levels in all patients compared to controls (p > 0.05). AngII/Ang-(1-7) ratio was significantly higher in all patients than controls: 3.81 (2.03 ÷ 6.66) vs. 1.5 (0.93 ÷ 2.06) (KW = 18.68; p < 0.001). Patients with HFmrEF+LVH showed statistically higher AngII/Ang-(1-7) ratio compared with controls (4.7 vs. 1.5). Moreover, subjects with LVH showed the highest AngII/Ang-(1-7) ratio among all particpants in the study. The AngII/Ang-(1-7) ratio correlated with LVH (r = -0.39; p = 0.03), DBP (r = 0.25; p = 0.04), HDL (r = 0.33; p = 0.01), SBP (r = 0.34; p = 0.01).

Conclusion: Our study showed an association between AngII/Ang-(1-7) ratio, blood pressure and LVH. The imbalance between Ang-II and Ang-(1-7) could contribute to the mechanisms determining LVH in HFmrEF. Further studies are warranted to clarify whether evaluation of serum Ang-II/Ang-(1-7) ratio could predict LVH development in patients with HFmrEF.

Tricuspid Regurgitation in Left Ventricular Systolic Dysfunction: Marker or Target?

Far from being historically considered a primary healthcare problem, tricuspid regurgitation (TR) has recently gained much attention from the scientific community. In fact, in the last years, robust evidence has emerged regarding the epidemiological impact of TR, whose prevalence seems to be similar to that of other valvulopathies, such as aortic stenosis, with an estimated up to 4% of people >75 years affected by at least moderate TR in the United States, and up to 23% among patients suffering from heart failure with reduced ejection fraction. This recurrent coexistence of left ventricular systolic dysfunction (LVSD) and TR is not surprising, considered the multiple etiologies of tricuspid valve disease. TR can complicate heart failure mostly as a functional disease, because of pulmonary hypertension (PH), subsequent to elevated left ventricular end-diastolic pressure, leading to right ventricular dilatation, and valve tethering. Moreover, the so-called "functional isolated" TR can occur, in the absence of PH, as a result of right atrial dilatation associated with atrial fibrillation, a common finding in patients with LVSD. Finally, TR can result as a iatrogenic consequence of transvalvular lead insertion, another frequent scenario in this cohort of patients. Nonetheless, despite the significant coincidence of these two conditions, their mutual relation, and the independent prognostic role of TR is still a matter of debate. Whether significant TR is just a marker for advanced left-heart disease, or a crucial potential therapeutical target, remains unclear. Aim of the authors in this review is to present an update concerning the epidemiological features and the clinical burden of TR in the context of LVSD, its prognostic value, and the potential benefit for early tricuspid intervention in patients affected by contemporary TR and LVSD.