Effect of sacubitril valsartan on heart failure with mid-range or preserved ejection fraction in patients on maintenance hemodialysis: real-world experience in a single-center, prospective study

BACKGROUND

This study aimed to evaluate the effect of sacubitril valsartan (SV) on heart failure (HF) hospitalization and cardiovascular mortality in patients on hemodialysis with HF with preserved ejection fraction (EF; HFpEF).

METHODS

This single-center, prospective study enrolled 155 stable hemodialysis patients with EF > 40% who were followed up for 12 months. Fifty-nine patients were treated with SV; the others were matched for EF (57.89 ± 9.35 vs. 58.00 ± 11.82, P = 0.9) at a ratio of 1:1 and included as controls. The target dosage of SV was 200 mg/day.

RESULTS

Twenty-three (23/155; 14.84%) had HF with mid-range EF (HFmrEF), while 132 (85.16%) had HFpEF. After SV treatment, the peak early diastolic transmitral flow velocity/peak early diastolic mitral annular tissue velocity(E/e') improved from 17.19 ± 8.74 to 12.80 ± 5.52 (P = 0.006), the left ventricular (LV) end-diastolic diameter decreased from 53.14 ± 7.67 mm to 51.56 ± 7.44 mm (P = 0.03), and the LV mass index decreased from 165.7 ± 44.6 g/m2 to 154.8 ± 24.0 g/m2 (P = 0.02). LVEF (P = 0.08) and LV global longitudinal strain (P = 0.7) did not change significantly. The composite outcome of first and recurrent HF hospitalization or cardiovascular death showed no difference between group. However, the Acute Dialysis Quality Initiative Workgroup (ADQI) HF class improved in 39 and 15 patients and worsened in 1 and 11 patients in the SV and control groups, respectively (P < 0.001). Age, diabetes mellitus, and pulmonary arterial pressure were independent risk factors for HF hospitalization and cardiovascular mortality in patients with HFpEF.

CONCLUSIONS

SV improved LV hypertrophy, diastolic function, and the ADQI class for HF; however, it failed to reduce the composite endpoints of HF hospitalization and cardiovascular disease-related mortality over 12 months of follow-up in patients on maintenance hemodialysis with EF of > 40%.

A comprehensive characterization of acute heart failure with preserved versus mildly reduced versus reduced ejection fraction - insights from the ESC-HFA EORP Heart Failure Long-Term Registry

AIMS

To perform a comprehensive characterization of acute heart failure (AHF) with preserved (HFpEF), versus mildly reduced (HFmrEF) versus reduced ejection fraction (HFrEF).

METHODS AND RESULTS

Of 5951 participants in the ESC HF Long-Term Registry hospitalized for AHF (acute coronary syndromes excluded), 29% had HFpEF, 18% HFmrEF, and 53% HFrEF. Hospitalization reasons were most commonly atrial fibrillation (more in HFmrEF and HFpEF), followed by ischaemia (HFmrEF), infection (HFmrEF and HFpEF), worsening renal function (HFrEF), and uncontrolled hypertension (HFmrEF and HFpEF). Hospitalization characteristics included lower blood pressure, more oedema and higher natriuretic peptides with lower ejection fraction, similar pulmonary congestion, more mitral regurgitation in HFrEF and HFmrEF and more tricuspid regurgitation in HFrEF. In-hospital mortality was 3.4% in HFrEF, 2.1% in HFmrEF and 2.2% in HFpEF. Intravenous diuretic (∼80%) and nitrate (∼15%) use was similar but inotrope use greater in HFrEF (16%, vs. HFmrEF 7.4% vs. HFpEF 5.3%). Weight loss and estimated glomerular filtration rate improvement were greater in HFrEF, whereas reduction in natriuretic peptides was similar. Over 1 year post-discharge, events per 100 patient-years (95% confidence interval) in HFrEF versus HFmrEF versus HFpEF were: all-cause death 22 (20-24) versus 17 (14-20) versus 17 (15-20); cardiovascular (CV) death 12 (10-13) versus 8.6 (6.6-11) versus 8.4 (6.9-10); non-CV death 2.4 (1.8-3.1) versus 3.3 (2.1-4.8) versus 4.5 (3.5-5.9); all-cause hospitalization 48 (45-51) versus 35 (31-40) versus 42 (39-46); HF hospitalization 29 (27-32) versus 19 (16-22) versus 17 (15-20); and non-CV hospitalization 7.7 (6.6-8.9) versus 9.6 (7.5-12) versus 15 (13-17).

CONCLUSION

In AHF, HFrEF is more severe and has greater in-hospital mortality. Post-discharge, HFrEF has greater CV risk, HFpEF greater non-CV risk, and HFmrEF lower overall risk.

Eligibility of patients with heart failure with preserved ejection fraction for sacubitril/valsartan according to the PARAGON-HF trial

Aims

In the heart failure (HF) with preserved ejection fraction (HFpEF) PARAGON‐HF trial, sacubitril/valsartan vs. valsartan improved mortality/morbidity in patients with left ventricular ejection fraction (LVEF) below median (57%). We assessed eligibility for sacubitril/valsartan based on four scenarios.

Methods and results

Eligibility was assessed in the Karolinska‐Rennes study (acute HFpEF, LVEF ≥ 45%, and N‐terminal pro‐B‐type natriuretic peptide ≥300 pg/mL subsequently assessed as outpatients including echocardiography) in (i) a trial scenario (all trial criteria); (ii) a pragmatic scenario (selected trial criteria); (iii) LVEF below lower limit of normal range (<54% in women and <52% in men); and (iv) LVEF below mean of normal range (<64% in women and <62% in men). Among 425 patients [age 78 (72–83) years, 57% women, 28% LVEF ≤ 57% (median in PARAGON‐HF), the trial scenario, identified 34% as eligible. Left atrial enlargement and/or left ventricular hypertrophy were present in 99%. Inclusion criteria not met were diuretic treatment and New York Heart Association class. Important exclusion criteria were estimated glomerular filtration rate <30 mL/min/1.73 m², haemoglobin <10 g/day, and cancer. In the pragmatic scenario, 63% were eligible. In LVEF below lower limit of normal range, 5.4% were eligible, and in LVEF below mean of normal range, 41% were eligible. In patients with LVEF ≤ 57%, eligibility was 42%, 69%, 21%, and 91% according to the trial scenario, pragmatic scenario, LVEF below lower limit of normal range, and LVEF below mean of normal range, respectively.

Conclusions

In real‐world HFpEF (LVEF ≥ 45%) with N‐terminal pro‐B‐type natriuretic peptide and cardiac structure/function assessed, eligibility for sacubitril/valsartan was according to PARAGON‐HF complete criteria 34%, pragmatic criteria 63%, LVEF below lower limit of normal range 5.4%, and LVEF below mean of normal range 41%. Cardiac structural impairment was almost ubiquitous. Ineligibility was more due to exclusion criteria than failing to meet inclusion criteria.

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.

Exercise hemodynamics in heart failure patients with preserved and mid-range ejection fraction: key role of the right heart

OBJECTIVE

We sought to explore whether classification of patients with heart failure and mid-range (HFmrEF) or preserved ejection fraction (HFpEF) according to their left ventricular ejection fraction (LVEF) identifies differences in their exercise hemodynamic profile, and whether classification according to an index of right ventricular (RV) function improves differentiation.

BACKGROUND

Patients with HFmrEF and HFpEF have hemodynamic compromise on exertion. The classification according to LVEF implies a key role of the left ventricle. However, RV involvement in exercise limitation is increasingly recognized. The tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure (TAPSE/PASP) ratio is an index of RV and pulmonary vascular function. Whether exercise hemodynamics differ more between HFmrEF and HFpEF than between TAPSE/PASP tertiles is unknown.

METHODS

We analyzed 166 patients with HFpEF (LVEF ≥ 50%) or HFmrEF (LVEF 40-49%) who underwent basic diagnostics (laboratory testing, echocardiography at rest, and cardiopulmonary exercise testing [CPET]) and exercise with right heart catheterization. Hemodynamics were compared according to echocardiographic left ventricular or RV function.

RESULTS

Exercise hemodynamics (e.g. pulmonary arterial wedge pressure/cardiac output [CO] slope, CO increase during exercise, and maximum total pulmonary resistance) showed no difference between HFpEF and HFmrEF, but significantly differed across TAPSE/PASP tertiles and were associated with CPET results. N-terminal pro-brain natriuretic peptide concentration also differed significantly across TAPSE/PASP tertiles but not between HFpEF and HFmrEF.

CONCLUSION

In patients with HFpEF or HFmrEF, TAPSE/PASP emerged as a more appropriate stratification parameter than LVEF to predict clinically relevant impairment of exercise hemodynamics. Stratification of exercise hemodynamics in patients with HFpEF or HFmrEF according to LVEF or TAPSE/PASP, showing significant distinctions only with the RV-based strategy. All data are shown as median [upper limit of interquartile range] and were calculated using the independent-samples Mann-Whitney U test or Kruskal-Wallis test. PVR pulmonary vascular resistance; max maximum level during exercise.

Heart failure with mid-range ejection fraction and the effect of β-blockers after acute myocardial infarction

There is currently an ongoing debate about the 'grey area' of heart failure with mid-range ejection fraction (HFmrEF). We evaluated characteristics, prognosis, and the effect of β-blockers on clinical outcomes in patients with HFmrEF after acute myocardial infarction (AMI). We included a total of 10,785 patients and divided them into three groups: EF 40-49% (HFmrEF; n = 2717; reference); EF < 40% (reduced EF [HFrEF]; n = 1194); and EF ≥ 50% (preserved EF [HFpEF]; n = 6874). The primary outcome was 2-year all-cause mortality. HFmrEF was intermediate between HFrEF and HFpEF for baseline characteristics. The risk of all-cause mortality was lower for HFmrEF patients compared to HFrEF patients (adjusted hazard ratio [HR] 0.710; 95% confidence interval [CI] 0.544-0.927; P = 0.012). However, HFmrEF patients tended to be at higher risk for 2-year all-cause mortality than HFpEF patients (adjusted HR 1.235; 95% CI 0.989-1.511; P = 0.090). β-blockers were associated with reductions in all-cause mortality for the entire cohort (adjusted HR 0.760; 95% CI 0.592-0.975; P = 0.031). β-blockers were effective in patients with HFrEF (adjusted HR 0.667; 95% CI 0.471-0.944; P = 0.022), tended to be effective in patients with HFmrEF (adjusted HR 0.665; 95% CI 0.426-1.038; P = 0.072), but not effective in patients with HFpEF (adjusted HR 0.852; 95% CI 0.548-1.326; P = 0.478; interaction P = 0.026). In conclusion, clinical profiles and prognosis of patients with post-AMI HFmrEF are largely intermediate between HFrEF and HFpEF. β-blockers reduced or tended to reduce 2-year all-cause mortality in patients with HFrEF or HFmrEF, respectively, but not those with HFpEF after AMI.

Impact of diastolic dysfunction on outcome in heart failure patients with mid-range or reduced ejection fraction

Aims

The role of diastolic dysfunction (DD) in prognostic evaluation in heart failure (HF) patients with impaired systolic function remains unclear. We investigated the impact of echocardiography‐defined DD on survival in HF patients with mid‐range (HFmrEF, EF 41–49%) and reduced ejection fraction (HFrEF, EF < 40%).

Methods and results

A total of 2018 consecutive hospitalized HF patients were retrospectively included and divided in two groups based on baseline EF: HFmrEF group (n = 951, aged 69 ± 13 years, 74.2% male) and HFrEF group (n = 1067, aged 68 ± 13 years, 76.3% male). Clinical data were collected and analysed. All patients completed ≥1 year clinical follow‐up. The primary endpoint was defined as all‐cause death (including heart transplantation) and cardiovascular (CV)‐related death. All‐cause mortality (30.8% vs. 24.9%, P = 0.003) and CV mortality (19.1% vs. 13.5%, P = 0.001) were significantly higher in the HFrEF group than the HFmrEF group during follow‐up [median 24 (13–36) months]. All‐cause mortality increased in proportion to DD severity (mild, moderate, and severe) in either HFmrEF (17.1%, 25.4%, and 37.0%, P < 0.001) or HFrEF (18.9%, 30.3%, and 39.2%, P < 0.001) patients. The risk of all‐cause mortality [hazard ratio (HR) = 1.347, P = 0.015] and CV mortality (HR = 1.508, P = 0.007) was significantly higher in HFrEF patients with severe DD compared with non‐severe DD after adjustment for identified clinical and echocardiographic covariates. For HFmrEF patients, severe DD was independently associated with increased all‐cause mortality (HR = 1.358, P = 0.046) but not with CV mortality (HR = 1.155, P = 0.469).

Conclusions

Echocardiography‐defined severe DD is independently associated with increased all‐cause mortality in patients with HFmrEF and HFrEF.

Use of angiotensin receptor blocker is associated with improved 1 year mortality in heart failure with mid-range ejection fraction

AIMS

Current evidence about the effect of angiotensin receptor blocker (ARB) on the outcome of heart failure with mid-range ejection fraction (HFmrEF) is lacking. We aim to assess the association between use of ARB and 1 year all-cause mortality after hospitalization for HFmrEF.

METHODS AND RESULTS

We analysed the data of patients with ejection fraction of 40-49% in China Patient-centred Evaluative Assessment of Cardiac Events Prospective Heart Failure Study; 4907 patients hospitalized for heart failure from 52 Chinese hospitals were enrolled from August 2016 to May 2018. Use of ARB was determined by prescriptions at discharge. Patients who died during hospitalization or were using angiotensin-converting enzyme inhibitors at discharge were excluded. The association between the use of ARB and outcome was assessed using stabilized inverse probability of treatment weighting-adjusted Kaplan-Meier and Cox regression analyses. A total of 701 patients with HFmrEF were included for analysis. The mean age was 66.4 ± 12.8 years, and 267 (38.1%) were female. Of them, 244 were treated (34.8%) with ARB. During the 1 year follow-up period, patients treated with ARB had lower all-cause mortality compared with untreated patients (11.5% vs. 21.9%, P = 0.0005). Inverse probability of treatment weighting-adjusted Cox regression analysis showed that use of ARB was associated with significantly reduced all-cause mortality (adjusted hazard ratio 0.44, 95% confidence interval 0.28-0.69, P = 0.0004).

CONCLUSIONS

Among patients hospitalized for HFmrEF, the use of ARB was associated with lower 1 year mortality after discharge.

β-blocker and 1-year outcomes among patients hospitalized for heart failure with mid-range ejection fraction

Aims

The beneficial effect of β-blocker on heart failure with reduced ejection fraction is well established. However, its effect on the 1-year outcome of heart failure with mid-range ejection fraction (HFmrEF) remains unclear.

Methods and results

We analysed the data of the patients with left ventricular ejection fraction (LVEF) between 40% and 49% in China Patient-centred Evaluative Assessment of Cardiac Events Prospective Heart Failure Study (China PEACE 5p-HF Study), in which patients hospitalized for heart failure from 52 Chinese hospitals were recruited from 2016 to 2018. Two primary outcomes were all-cause death and all-cause hospitalization. The associations between β-blocker use at discharge and outcomes were assessed by inverse probability of treatment weighting (IPTW)-weighted Cox regression analyses. To assess consistency, IPTW adjusting medications analyses, multivariable analyses and dose-effect analyses were performed. A total of 1035 HFmrEF patients were included in the analysis. The mean age was 65.5 ± 12.7 years and 377 (36.4%) were female. The median (interquartile range) of LVEF was 44% (42–47%). Six hundred and sixty-one (63.8%) were treated with β-blocker. Patients using β-blocker were younger with better cardiac function, and more likely to use renin–angiotensin system inhibitor and mineralocorticoid receptor antagonist. During the 1-year follow-up, death occurred in 84 (12.7%) treated and 85 (22.7%) untreated patients (P < 0.0001); all-cause hospitalization occurred in 298 (45.1%) treated and 188 (50.3%) untreated patients (P = 0.04). After IPTW-weighted adjustment, β-blocker use was significantly associated with lower risk of all-cause death [hazard ratio (HR): 0.70; 95% confidence interval (CI): 0.51–0.96, P = 0.03], but not with lower all-cause hospitalization (HR, 0.92, 95% CI, 0.76–1.10, P = 0.36). Consistency analyses showed consistent favourable effect of β-blocker on all-cause death, but not on all-cause hospitalization.

Conclusions

Among patients with HFmrEF, β-blocker use was associated with lower risk of all-cause death, but not with lower risk of all-cause hospitalization.

The predictive value of global longitudinal strain in patients with heart failure mid-range ejection fraction

BACKGROUND

Heart failure (HF) with mid-range ejection fraction (HFmrEF) is defined as HF with a left ventricular (LV) ejection fraction (LVEF) of 41-49%. However, the change in LV function and the subsequent prognosis in these patients remain unclear. We aimed to investigate whether LV global longitudinal strain (LV GLS) could differentiate the changes in LVEF and predict the clinical outcomes in patients with HFmrEF.

METHODS

According to the changes in LVEF on follow-up echocardiography, 273 outpatients with HFmrEF were divided into 3 groups: HFwEF (HF with worse EF: <40%), HFsEF (HF with similar EF: 40-49%), and HFrecEF (HF with recovered EF: >50%). Further, the LV GLS at diagnosis was evaluated.

RESULTS

The average follow-up duration was 31 months. Among patients with HFmrEF, the more impaired the LV GLS at baseline, the higher probability of HFwEF development. In comparison with patients with HFwEF and HFsEF, those with HFrecEF had a lower risk of hospitalization for HF. At a cut-off value of -11%, LV GLS differentiated the subsequent risk of cardiovascular death in patients with HFmrEF. In Cox regression, patients with LV GLS >-11% had a high risk of cardiovascular death.

CONCLUSION

In patients with HFmrEF, LV GLS is associated with LVEF changes and subsequent cardiovascular death. Patients with HFrecEF had a lower risk of hospitalization for HF.

The Effect of Sacubitril-Valsartan in Heart Failure Patients With Mid-Range and Preserved Ejection Fraction: A Meta-Analysis

BACKGROUND

The effect of sacubitril-valsartan in heart failure patients with mid-range (HFmEF) and preserved (HFpEF) ejection fractions remains unclear. This study aimed to investigate the clinical benefits of sacubitril-valsartan in HFmEF and HFpEF patients.

METHODS

PubMed, EMBASE, Cochrane Library, and China National Knowledge Infrastructure were searched from inception to 29 February 2020 to identify pertinent articles. Studies meeting the inclusion criteria were included and analysed.

RESULTS

Six (6) studies, with a total of 5,503 patients, were included. Compared with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, sacubitril-valsartan significantly reduced the rate of HF hospitalisation (risk ratios, 0.84; 95% CI, 0.77-0.91; p<0.001) and improved the New York Heart Association class (risk ratios, 1.25; 95% CI, 1.10-1.43; p=0.001) in HFmEF and HFpEF patients. Both the cardiovascular mortality and all-cause mortality were not significantly decreased by sacubitril-valsartan. In addition, there were no significant between-group differences in the N-terminal pro-B-type natriuretic peptide and left ventricular ejection fraction changes. Regarding safety, sacubitril-valsartan was likely to increase the risk of hypotension, but the incidence of serum creatinine elevation was significantly lower in the sacubitril-valsartan group than in the angiotensin-converting enzyme inhibitors and angiotensin receptor blockers group.

CONCLUSIONS

This meta-analysis suggests that sacubitril-valsartan may be an effective and safe strategy with which to improve the clinical symptoms and reduce HF hospitalisation in HFmEF and HFpEF patients.

Ventricular tachyarrhythmia detection by implantable loop recording in patients with heart failure and preserved ejection fraction: the VIP-HF study

AIMS

The primary aim of the VIP-HF study was to examine the incidence of sustained ventricular tachyarrhythmias (VTs) in heart failure (HF) with mid-range (HFmrEF) or preserved ejection fraction (HFpEF). Secondary aims were to examine the incidence of non-sustained VTs, bradyarrhythmias, HF hospitalizations and mortality.

METHODS AND RESULTS

This was an investigator-initiated, prospective, multicentre, observational study of patients with HF and left ventricular ejection fraction (LVEF) >40%. Patients underwent extensive phenotyping, after which an implantable loop recorder was implanted. We enrolled 113 of the planned 250 patients [mean age 73 ± 8 years, 51% women, New York Heart Association class II/III 54%/46%, median N-terminal pro B-type natriuretic peptide 1367 (710-2452) pg/mL and mean LVEF 54 ± 6%; 75% had LVEF >50%]. Eighteen percent had non-sustained VTs and 37% had atrial fibrillation on Holter monitoring. During a median follow-up of 657 (219-748) days, the primary endpoint of sustained VT was observed in one patient. The incidence of the primary endpoint was 0.6 (95% confidence interval 0.2-3.5) per 100 person-years. The incidence of the secondary endpoint of non-sustained VT was 11.5 (7.1-18.7) per 100 person-years. Five patients developed bradyarrhythmias [3.2 (1.4-7.5) per 100 person-years], three were implanted with a pacemaker. In total, 23 patients (20%) were hospitalized for HF [16.3 (10.9-24.4) per 100 person-years]. Fourteen patients (12%) died [8.7 (5.2-14.7) per 100 person-years]; 10 due to cardiovascular causes, and four sudden deaths, one with implantable loop recorder-confirmed bradyarrhythmias as terminal event, three others undetermined.

CONCLUSION

Despite the lower than expected number of included patients, the incidence of sustained VTs in HFmrEF/HFpEF was low. Clinically relevant bradyarrhythmias were more often observed than expected.

Angiotensin receptor neprilysin inhibition versus individualized RAAS blockade: design and rationale of the PARALLAX trial

Aims

Although the effect of the angiotensin receptor blocker neprilysin inhibitor (ARNI) sacubitril/valsartan on heart failure (HF) hospitalizations and cardiovascular death has been evaluated, its effects on functional capacity in patients with HF and ejection fraction (EF) >40% has yet to be determined. In addition, no prior studies have compared sacubitril/valsartan with angiotensin‐converting enzyme inhibitor therapy. We sought to compare the effect of ARNI to background‐medication‐based individualized comparators (BMICs) on N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP), functional capacity [6 min walk distance (6MWD)], symptoms, and quality of life [Kansas City Cardiomyopathy Questionnaire (KCCQ)] in patients with HF and EF >40% in a randomized clinical trial.

Methods

PARALLAX is a prospective, randomized, controlled, double‐blind multicentre clinical trial in patients with chronic symptomatic HF with EF >40%, New York Heart Association (NYHA) class II–IV symptoms, elevated natriuretic peptides, and evidence of structural heart disease. Eligible patients are randomized to sacubitril/valsartan vs. BMIC for cardiovascular and related co‐morbidities. BMIC includes (i) enalapril, (ii) valsartan, and (iii) placebo depending on the type of medical therapy prior to enrolment. The primary endpoints are the change in plasma NT‐proBNP concentration from baseline to 12 weeks and the change from baseline in 6MWD distance at 24 weeks. The secondary endpoints assess quality of life and symptom burden.

Conclusions

PARALLAX will determine if sacubitril/valsartan compared with standard medical therapy for co‐morbidities improves NT‐proBNP levels, exercise capacity, quality of life, and symptom burden in HF patients with EF >40%.

Heart failure with mid-range ejection fraction: pro and cons of the new classification of Heart Failure by European Society of Cardiology guidelines

Currently, the assessment of left ventricular ejection fraction (LVEF) is the cornerstone of the classification of patients with heart failure (HF). The mid-range LVEF (HFmrEF) category was identified in an attempt to uncover specific characteristics of these patients. So far, the analysis of trials, registries, and observational studies have demonstrated that patients with mid-range LVEF belong to a patient cohort with generally intermediate clinical profile as compared with other groups but with a remarkable variety of intrinsic phenotypes. This is due to the limitations of LVEF as the sole criterion to categorize patients with HF and characterize their prognosis, above all when it is >40%. To better define the HFmrEF phenotype, it is reasonable to consider other parameters, such as LVEF changes over time, HF aetiology, co-morbidities, and other imaging parameters. A multiparametric evaluation may contextualize a patient with HFmrEF in a more defined phenotype with a specific prognosis.

Rehospitalization burden and morbidity risk in patients with heart failure with mid-range ejection fraction

Aims

Heart failure with mid‐range ejection fraction (HFmrEF) has been proposed as a distinct HF phenotype, but whether patients on this category fare worse, similarly, or better than those with HF with reduced EF (HFrEF) or preserved EF (HFpEF) in terms of rehospitalization risks over time remains unclear.

Methods and results

We prospectively included 2961 consecutive patients admitted for acute HF (AHF) in our institution. Of them, 158 patients died during the index admission, leaving the sample size to be 2803 patients. Patients were categorized according to their EF: HFrEF if EF ≤ 40% (n = 908, 32.4%); HFmrEF if EF = 41–49% (n = 449, 16.0%); and HFpEF if EF ≥ 50% (n = 1446, 51.6%). Covariate‐adjusted incidence rate ratios (IRRs) were used to evaluate the association between EF status and recurrent all‐cause and HF‐related admissions. At a median follow‐up of 2.6 years (inter‐quartile range: 1.0–5.3), 1663 (59.3%) patients died, and 6035 all‐cause readmissions were registered in 2026 patients (72.3%), 2163 of them HF related. Rates of all‐cause readmission per 100 patients‐years of follow‐up were 150.1, 176.9, and 163.6 in HFrEF, HFmrEF, and HFpEF, respectively (P = 0.097). After multivariable adjustment, when compared with that of patients with HFrEF and HFpEF, HFmrEF status was not significantly associated with a different risk of all‐cause readmissions (IRR = 0.99; 95% confidence interval [CI], 0.77–1.27; P = 0.926; and IRR = 0.93; 95% CI, 0.74–1.18; P = 0.621, respectively) or HF‐related readmissions (IRR = 1.06; 95% CI, 0.77–1.46; P = 0.725; and IRR = 1.11; 95% CI, 0.82–1.50; P = 0.511, respectively).

Conclusions

Following an admission for AHF, patients with HFmrEF had a similar rehospitalization burden and a similar risk of recurrent all‐cause and HF‐related admissions than had patients with HFrEF or HFpEF. Regarding morbidity risk, HFmrEF seems not to be a distinct HF phenotype.

Spironolactone use is associated with improved outcomes in heart failure with mid-range ejection fraction

Aims

Spironolactone has been shown to improve outcomes in patients with heart failure (HF) with reduced ejection fraction (EF). We investigated whether the discharge use of spironolactone could be associated with better long‐term outcomes among patients with HF with mid‐range EF (HFmrEF).

Methods and results

We analysed HFmrEF (left ventricular EF 40–49%) patients enrolled in the Japanese Cardiac Registry of Heart Failure in Cardiology, which prospectively studied the clinical characteristics, treatments, and long‐term outcomes of patients hospitalized due to HF. Patients were divided into two groups according to the use of spironolactone at discharge. The primary outcome was a composite of all‐cause death or HF rehospitalization. A total of 457 patients had HFmrEF. The mean age was 69.3 years and 286 (62.6%) were male. Among them, spironolactone was prescribed at discharge in 158 patients (34.6%). Chronic kidney disease (7.6% vs. 16.8%, P = 0.007) was less prevalent and loop diuretics (89.2% vs. 70.2%, P < 0.001) were more often prescribed in patients with spironolactone. During a mean follow‐up of 2.2 years, patients with spironolactone had a lower incidence rate of the primary outcome than those without it (171.5 vs. 278.8 primary outcome per 1000 patient‐years, incidence rate ratio 0.61, 95% confidence interval 0.44–0.86; P = 0.004). After multivariable adjustment, spironolactone use at discharge was associated with a significant reduction in the composite of all‐cause death or HF rehospitalization (adjusted hazard ratio 0.63, 95% confidence interval 0.44–0.90, P = 0.010).

Conclusions

Among patients with HF hospitalized for HFmrEF, spironolactone use at discharge was associated with better long‐term outcomes.

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.

Exercise oscillatory ventilation and prognosis in heart failure patients with reduced and mid-range ejection fraction

AIMS

Exercise oscillatory ventilation (EOV) is a pivotal cardiopulmonary exercise test parameter for the prognostic evaluation of patients with chronic heart failure (HF). It has been described in patients with HF with reduced ejection fraction (<40%, HFrEF) and with HF with preserved ejection fraction (>50%, HFpEF), but no data are available for patients with HF with mid-range ejection fraction (40-49%, HFmrEF). The aim of the study was to evaluate the prognostic role of EOV in HFmrEF patients.

METHODS AND RESULTS

We analysed 1239 patients with HFmrEF and 4482 patients with HFrEF, enrolled in the MECKI score database, with a 2-year follow-up. The study endpoint was the composite of cardiovascular death, urgent heart transplant, and ventricular assist device implantation. We identified EOV in 968 cases (16% and 17% of cases in HFmrEF and HFrEF, respectively). HFrEF EOV+ patients were significantly older, and their parameters suggested a more severe HF than HFrEF EOV- patients. A similar behaviour was found in HFmrEF EOV+ vs. EOV- patients. Kaplan-Meier analysis, irrespective of ejection fraction, showed that EOV is associated with a worse survival, and that patients with HFrEF and HFmrEF EOV+ had a significantly worse outcome than the EOV- of the same ejection fraction groups. EOV-associated survival differences in HFmrEF patients started after 18 months of follow-up.

CONCLUSION

Exercise oscillatory ventilation has a similar prevalence and ominous prognostic value in both HFmrEF and HFrEF patients, indicating a group of patients in need of a more intensive follow-up and a more aggressive therapy. In HFmrEF, the survival curves between EOV+ and EOV- patients diverged only after 18 months.

Differences in blood pressure riser pattern in patients with acute heart failure with reduced mid-range and preserved ejection fraction

Aims

Heart failure (HF) is classified into three types according to left ventricular ejection fraction (EF). The effect of blood pressure (BP) on the pathogenesis of each type is assumed to be different. However, the association between the prognosis of each type of HF and abnormal BP variations assessed by ambulatory BP monitoring (ABPM), such as nocturnal hypertension and the riser pattern, remains unclear.

Methods and results

We studied 325 consecutive patients with decompensated HF who were acutely admitted to our hospital and underwent ABPM at discharge. During a mean follow‐up of 30.0 months, 52 cardiovascular and 112 all‐cause deaths occurred. The Cox proportional hazards model showed that the mean values of 24 h, awake, and sleep‐time systolic BP (SBP), and abnormal 24 h ABPM patterns, such as nocturnal hypertension and non‐dipper pattern, were not associated with either all‐cause or cardiovascular mortality in patients with HF with reduced EF (HFrEF), HF with mid‐range EF (HFmrEF), or HF with preserved EF (HFpEF), except for sleep‐time SBP in HFrEF. However, the riser pattern was a significant and independent predictor of all‐cause and cardiovascular deaths in patients with HFpEF (hazard ratio, 2.01; 95% confidence interval, 1.12–3.62; 0.0200; and hazard ratio, 2.48; 95% confidence interval, 1.08–5.90; 0.0332, respectively). Sleep‐time pulse rate was similarly decreased in both the riser and non‐riser groups.

Conclusions

The riser pattern of SBP was associated with an increased risk of adverse outcomes among patients with HFpEF but not HFrEF or HFmrEF.

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

BACKGROUND

To determine and compare the demographic characteristics, clinical profile and management of patients with heart failure with mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF) in a Turkish cohort.

METHODS

The APOLLON trial (A comPrehensive, ObservationaL registry of heart faiLure with mid-range and preserved ejection fractiON) is an observational and multicenter study conducted in Turkey. Consecutive patients admitted to the cardiology clinics who were at least 18 years of age and had HFmrEF or HFpEF were included (NCT03026114).

RESULTS

The study population included 1065 (mean age of 67.1 ± 10.6 years, 54% women) patients from 12 sites in Turkey. Among participants, 246 (23.1%) had HFmrEF and 819 (76.9%) had HFpEF. Compared to patients with HFpEF, those with HFmrEF were more likely to be male (57.7 vs 42.2%; p < 0.001), had higher N-terminal pro-B-type natriuretic peptide levels (853 vs 528 pg/ml, p < 0.001), were more likely to have ECG abnormalities (72.4 vs 53.5%, p < 0.001) and hospitalization history for heart failure (28 vs 18.6%; p = 0.002). HFmrEF patients were more likely to use β-blockers (69.9 vs 55.2%, p < 0.001), aldosterone receptor antagonists (24 vs 14.7%, p = 0.001), statins (37 vs 23%, p < .001), and loop diuretics (39.8 vs 30.5%, p = 0.006) compared to patients with HFpEF.

CONCLUSIONS

The results of APOLLON study support that the basic characteristics and etiology of HFmrEF are significantly different from HFpEF. This registry also showed that the patients with HFmrEF and HFpEF were younger but undertreated in Turkey compared to patients in western countries.

The prognosis of mid-range ejection fraction heart failure: a systematic review and meta-analysis

AIMS

Mid-range ejection fraction is a new entity of heart failure (HF) with undetermined prognosis till now. In our systematic review and meta-analysis, we assess the mortality and hospitalization rates in mid-range ejection fraction HF (HFmrEF) and compare them with those of reduced ejection fraction heart failure (HFrEF) and preserved ejection fraction HF (HFpEF).

METHODS AND RESULTS

We conducted our search in March 2018 in the following databases for relevant articles: PubMed, CENTRAL, Google Scholar, Web of Science, Scopus, NYAM, SIEGLE, GHL, VHL, and POPLINE. Our primary endpoint was assessing all-cause mortality and all-cause hospital re-admission rates in HFmrEF in comparison with HFrEF and HFpEF. Secondary endpoints were the possible causes of death and hospital re-admission. Twenty-five articles were included in our meta-analysis with a total of 606 762 adult cardiac patients. Our meta-analysis showed that HFmrEF had a lower rate of all-cause death than had HFrEF [relative risk (RR), 0.9; 95% confidence interval (CI), 0.85-0.94]. HFpEF showed a higher rate of cardiac mortality than did HFmrEF (RR, 1.09; 95% CI, 1.02-1.16). Also, HFrEF had a higher rate of non-cardiac mortality than had HFmrEF (RR, 1.31; 95% CI, 1.22-1.41).

CONCLUSIONS

We detected a significant difference between HFrEF and HFmrEF regarding all-cause death, and non-cardiac death, while HFpEF differed significantly from HFmrEF regarding cardiac death.

Epicardial fat in heart failure patients with mid-range and preserved ejection fraction

Aims

Adipose tissue and inflammation may play a role in the pathophysiology of patients with heart failure (HF) with mildly reduced or preserved ejection fraction. We therefore investigated epicardial fat in patients with HF with preserved (HFpEF) and mid‐range ejection fraction (HFmrEF), and related this to co‐morbidities, plasma biomarkers and cardiac structure.

Methods and results

A total of 64 HF patients with left ventricular ejection fraction >40% and 20 controls underwent routine cardiac magnetic resonance examination. Epicardial fat volume was quantified on short‐axis cine stacks covering the entire epicardium and was related to clinical correlates, biomarkers associated with inflammation and myocardial injury, and cardiac function and contractility on cardiac magnetic resonance. HF patients and controls were of comparable age, sex and body mass index. Total epicardial fat volume was significantly higher in HF patients compared to controls (107 mL/m² vs. 77 mL/m², P <0.0001). HF patients with atrial fibrillation and/or type 2 diabetes mellitus had more epicardial fat than HF patients without these co‐morbidities (116 vs. 100 mL/m², P =0.03, and 120 vs. 97 mL/m², P =0.001, respectively). Creatine kinase‐MB, troponin T and glycated haemoglobin in patients with HF were positively correlated with epicardial fat volume (R =0.37, P =0.006; R =0.35, P =0.01; and R =0.42, P =0.002, respectively).

Conclusion

Heart failure patients had more epicardial fat compared to controls, despite similar body mass index. Epicardial fat volume was associated with the presence of atrial fibrillation and type 2 diabetes mellitus and with biomarkers related to myocardial injury. The clinical implications of these findings are unclear, but warrant further investigation.

Fate of Acute Heart Failure Patients With Mid-Range Ejection Fraction

BACKGROUND

The outcomes of heart failure (HF) with mid-range ejection fraction (HFmrEF) have been rarely studied, and follow-up data on left ventricular ejection fraction (LVEF) are scarse.Methods and Results:Patients were selected from a prospective multicenter registry of patients hospitalized for acute HF and then classified in the improved group if they exhibited %LVEF change ≥5 with follow-up LVEF ≥50%. Follow-up LVEF reported at least 90 days after discharge was used for classification. Of the 3,085 patients with acute HF, 454 were classified in the HFmrEF, and 276 had follow-up data. Of these 276 patients, 34.1% were classified in the improved group. Multivariate analysis revealed that hypertension, higher heart rate, lower serum sodium level, and maintenance therapy with β-blocker were associated with improved LVEF. The survival rate was significantly higher in the improved group than in the other groups. Young age and maintenance therapy with renin-angiotensin system blockers or aldosterone antagonists were significantly associated with better survival in HFmrEF.

CONCLUSIONS

One-third of HFmrEF patients showed improved LVEF; moreover, the survival rate in the improved group was higher than the other groups. Renin-angiotensin system blockers and aldosterone antagonists could improve the survival of HFmrEF patients.

A flattening oxygen consumption trajectory phenotypes disease severity and poor prognosis in patients with heart failure with reduced, mid-range, and preserved ejection fraction

BACKGROUND

In heart failure (HF), a flattening oxygen consumption (VO₂ ) trajectory during cardiopulmonary exercise test (CPET) reflects an acutely compromised cardiac output. We hypothesized that a flattening VO₂ trajectory is helpful in phenotyping disease severity and prognosis in HF with either reduced (HFrEF), mid-range (HFmrEF), or preserved (HFpEF) ejection fraction.

METHODS AND RESULTS

Overall, 319 HF patients (198 HFrEF, 80 HFmrEF, and 41 HFpEF) underwent CPET. A flattening VO₂ trajectory was tracked and defined as an inflection of VO₂ linearity as a function of work rate with a second slope downward inflection >35% extent of the first one. Peak VO₂ , the minute ventilation/carbon dioxide production (VE/VCO₂ ) slope, and the presence of exercise oscillatory ventilation (EOV) were also determined. Pulmonary artery systolic pressure (PASP) and tricuspid annular plane systolic excursion (TAPSE) were measured by echocardiography. A flattening VO₂ occurred in 92 patients (28.8%). PASP and TAPSE at rest were significantly higher and lower (P < 0.001), respectively. The primary outcome was the combination of all-cause death, heart transplantation and left ventricular assist device implantation. The secondary outcome was the primary outcome plus hospitalization for cardiac reasons. In the multivariate model including peak VO₂ , VE/VCO₂ slope, EOV and VO₂ trajectory, a flattening VO₂ trajectory and EOV were retained in the regression for primary (X² = 35.78, and 36.36, respectively; P < 0.001) and secondary (X² = 12.45 and 47.91, respectively; P < 0.001) outcomes.

CONCLUSIONS

Results point to a flattening VO₂ trajectory as a likely new and strong predictor of events in HF with any ejection fraction. Given the relation of right-sided cardiac dysfunction to pulmonary hypertension, this oxygen pattern might suggest a real-time decrease in pulmonary blood flow to the left heart.

Recovered heart failure with reduced ejection fraction and outcomes: a prospective study

AIMS

Significant recovery of left ventricular ejection fraction (LVEF) occurs in a proportion of patients with heart failure (HF) and reduced ejection fraction (HFrEF). We analysed outcomes, including mortality [all-cause, cardiovascular (CV), HF-related, and sudden death], and HF-related hospitalizations in this HF-recovered group. The primary endpoint was a composite of CV death or HF hospitalization.

METHODS AND RESULTS

LVEF was assessed at baseline and at 1 year in 1057 consecutive HF patients. Patients were classified into three groups: (i) HF-recovered: LVEF <45% at baseline and ≥45% at 1 year (n = 233); (ii) HF with preserved EF (HFpEF): LVEF ≥45% throughout follow-up (n = 117); and (iii) HFrEF: LVEF <45% throughout follow-up (n = 707). Mean follow-up was 5.6 ± 3.1 years. HF-recovered patients differed from HFrEF and HFpEF groups in demographic and clinical characteristics. The mean LVEF increase was 21.1 ± 10 points in HF-recovered patients. Using the HF-recovered group as a reference, the risks for the primary composite endpoint (n = 376), with non-CV death as competing risk, for HFpEF and HFrEF groups were: hazard ratio (HR) 2.33 [95% confidence interval (CI) 1.60-3.39], P < 0.001 and HR 1.99 (95% CI 1.50-2.65), P < 0.001, respectively. All-cause (n = 429), CV (n = 245), HF-related (n = 127), and sudden death (n = 60) were significantly lower in HF-recovered subjects relative to HFrEF (all P < 0.01). HF-recovered patients also experienced less recurrent HF hospitalizations (P < 0.001).

CONCLUSION

One in four treated patients with HFrEF showed recovery of systolic function. HF-recovered patients had significantly improved mortality and morbidity relative to HFpEF and HFrEF subjects. Further research is needed to identify optimal medications and device indications for HF-recovered patients.

Heart failure with mid-range ejection fraction: a distinct clinical entity? Insights from the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF)

AIMS

While the conditions of heart failure (HF) with reduced (HFrEF, LVEF < 40%) and preserved (HFpEF, LVEF ≥ 50%) left ventricular ejection fraction (LVEF) are well characterized, it is unknown whether patients with HF and mid-range LVEF (HFmrEF, LVEF 40-49%) have to be regarded as a separate clinical entity. The aim of this study was to characterize these three populations and to compare outcome and response to therapy.

METHODS AND RESULTS

The analysis was based on the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF) comprising a population with established HF including the whole spectrum of LVEF. Of the 622 patients, 108 (17%) were classified as having HFmrEF. This group was in general found to be 'intermediate' regarding clinical characteristics with a comparable and high burden of comorbidities and equally impaired quality of life but was more likely to have coronary artery disease as compared with the HFpEF group. During a median follow-up of 794 days, mortality was 39.7% without significant differences between groups. N-terminal pro-B-type natriuretic peptide (NT-proBNP)-guided as compared with standard therapy resulted in improved survival free of HF hospitalizations in HFrEF and HFmrEF, but not in HFpEF.

CONCLUSION

Although the 'intermediate' clinical profile of HFmrEF between HFrEF and HFpEF would support the conclusion that HFmrEF is a distinct clinical entity, we hypothesize that HFmrEF has to be categorized as HFrEF because of the high prevalence of coronary artery disease and the similar benefit of NT-proBNP-guided therapy in HFrEF and HFmrEF, in contrast to HFpEF.