IMPORTANCE Patients categorized as having heart failure (HF) with left ventricular ejection fraction (LVEF) in the midrange between 40% and 50% (HFmrEF) are known to be at increased risk of future events. Although patients can transition into the midrange through either improvement or deterioration in their LVEF, there is limited information available assessing the association of directional change in LVEF with future events. Understanding the association between change in LVEF and the clinical course of patients with HFmrEF would be of value in guiding management strategies.OBJECTIVE To determine whether risk of clinical events experienced by patients with HFmrEF varies according to whether LVEF improved or deteriorated into the range of 40% to 50% from previous measurements. DESIGN, SETTING, AND PARTICIPANTSIn this retrospective cohort study, patients were identified from the electronic health records at the UC San Diego Health System who had an LVEF measured between 40% and 50% on transthoracic echocardiography (TTE) performed during the calendar year of 2015 and who also had at least 1 prior TTE for comparison. The clinical course of these patients was then followed from the time of the index TTE through December 2018. Data were analyzed from January to March 2019. MAIN OUTCOMES AND MEASURESThe composite of all-cause mortality and all-cause hospitalization, the composite of cardiovascular mortality and HF hospitalization, and each of the individual components. RESULTSOf the 448 patients who were identified with HFmrEF, 278 (62.1%) were male, and the mean (SD) age was 67.4 (9.7) years. Left ventricular ejection fraction improved from less than 40% in 157 patients (35.0%), deteriorated from greater than 50% in 224 patients (50.0%), and remained between 40% and 50% over time in 67 patients (15.0%). Compared with patients whose LVEF improved from less than 40% to midrange levels, patients whose LVEF deteriorated from greater than 50% had higher risk of all-cause mortality and hospitalization (hazard ratio, 1.34; 95% CI, 1.10-1.82; P = .03) and of cardiovascular mortality and HF hospitalization (hazard ratio, 1.71; 95% CI, 1.08-2.50; P = .02), and these differences persisted after multivariable analysis. Outcomes did not differ significantly between patients whose LVEF improved and those in whom it remained stable. CONCLUSION AND RELEVANCEIn a cohort of patients with HFmrEF from a large academic medical center, the clinical course was strongly influenced by the directional change in LVEF from prior study. Patients whose LVEF deteriorated into midrange levels experienced a significantly higher risk of adverse clinical events than patients whose LVEF had improved. These results suggest that directional change in LVEF from prior measurements should be considered when devising management strategies for patients with HFmrEF.
High-sensitivity troponin assay gained FDA approval for use in the USA, and studies demonstrated its diagnostic utility can be extended to patients with renal impairment. Gender-specific cut points may be utilized for high-sensitivity troponin assays. In the realm of the natriuretic peptides, studies demonstrated states of natriuretic peptide deficiency in obesity and in subjects of African-American race. Regardless, BNP and NT-proBNP both retained prognostic utilities across a variety of comorbid conditions. We are rapidly gaining clinical evidence with use of soluble ST2 and procalcitonin levels in management of cardiac disease states. In order to get the most utility from their measurement, one must be aware of non-cardiac pathologies that may affect the levels of biomarkers as although many of these are actually true values, they may not represent the disease we are trying to delineate. A few take-home points are as follows: 1. A biomarker value should never be used without clinical context 2. Serial sampling of biomarkers is often helpful 3. Panels of biomarkers may be valuable.
AimsPatients with heart failure with preserved ejection fraction (HFpEF) are at high risk for hospitalization and mortality and many of these patients experience a deterioration in left ventricular ejection fraction (LVEF) over time. Global longitudinal strain (GLS) is a sensitive marker of myocardial dysfunction that could help predict risk for future events in this population. We assessed whether GLS can predict adverse clinical outcomes and future deterioration in LVEF in patients with HFpEF.Methods and resultsIn this retrospective cohort study, patients with HFpEF were divided into groups according to abnormal GLS (>−15.8%) or normal GLS (<−15.8%).The primary outcomes were: a composite of cardiovascular mortality or heart failure hospitalization and deterioration in LVEF to <40%. Among the 311 patients with HFpEF, 128 patients (41%) had normal GLS and 183 patients (59%) had abnormal GLS. After a median follow‐up of 4.6 years, the composite outcome occurred more commonly in patients with abnormal GLS compared to patients with normal GLS (62% vs. 44%; hazard ratio [HR] 1.74, 95% confidence interval [CI] 1.3–2.4, p < 0.001). Patients with abnormal GLS were also more likely to experience a deterioration in LVEF (19% vs. 10%; HR 2.2, 95% CI 1.2–4.3, p = 0.018). When assessed as a continuous variable, each 1% increase in GLS was associated with 10% increased odds for the composite outcome and 13% increased odds for deterioration in LVEF.ConclusionIn patients with HFpEF, abnormal GLS is common and is a strong predictor for clinical events and future deterioration in LVEF.
Aims Patients hospitalized for heart failure (HF) are at increased risk for events post-discharge. Mineralocorticoid receptor antagonists (MRAs) improve the clinical course of patients with HF with reduced ejection fraction. We assessed MRA use in high-risk patients following an HF hospitalization to determine rate of MRA prescription, likelihood of drug continuation post-discharge, reasons for discontinuation, and association between MRA maintenance and outcomes.Methods and results Patients admitted to our hospital system between 2011 and 2013 were identified retrospectively through automated search of electronic medical records for appropriate ICD 9 and 10 codes. Patients with left ventricular ejection fraction <40%, New York Heart Association class III-IV symptoms, >1 year of follow-up and no contraindication to MRA use were included. Of 271 patients meeting inclusion criteria, 105 (38.7%) were prescribed an MRA on discharge from index admission. Over a median follow-up of 3.12 ± 0.09 years, 70 (66.7%) continued MRA therapy, while 35 (33.3%) discontinued MRA therapy. Hyperkalemia, which occurred in 43 of the 105 patients (40.1%), was the most frequent cause of MRA discontinuation. Patients who maintained MRA therapy had significantly less all-cause, cardiovascular, and HF hospitalizations and significantly better survival compared with those who discontinued drug. Conclusions A minority of HF with reduced ejection fraction patients who were eligible for an MRA received them following HF hospitalization and nearly a third of them discontinued drug. Patients who discontinued an MRA were more likely to be hospitalized or die during follow-up. These findings indicate a need for better strategies to increase MRA prescription and maintain therapy following a hospitalization for HF.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.