Burden, treatment use, and outcome of secondary mitral regurgitation across the spectrum of heart failure: observational cohort study

Abstract

Objectives To define prevalence, long term outcome, and treatment standards of secondary mitral regurgitation (sMR) across the heart failure spectrum. Design Large scale cohort study. Setting Observational cohort study with data from the Viennese community healthcare provider network between 2010 and 2020, Austria. Participants 13 223 patients with sMR across all heart failure subtypes. Main outcome measures Association between sMR and mortality in patients assigned by guideline diagnostic criteria to one of three heart failure subtypes: reduced, mid-range, and preserved ejection fraction, was assessed. Results Severe sMR was diagnosed in 1317 patients (10%), correlated with increasing age (P<0.001), occurred across the entire spectrum of heart failure, and was most common in 656 (25%) of 2619 patients with reduced ejection fraction. Mortality of patients with severe sMR was higher than expected for people of the same age and sex in the same community (hazard ratio 7.53; 95% confidence interval 6.83 to 8.30, P<0.001). In comparison with patients with heart failure and no/mild sMR, mortality increased stepwise with a hazard ratio of 1.29 (95% confidence interval 1.20 to 1.38, P<0.001) for moderate and 1.82 (1.64 to 2.02, P<0.001) for severe sMR. The association between severe sMR and excess mortality was consistent after multivariate adjustment and across all heart failure subgroups (mid-range ejection fraction: hazard ratio 2.53 (95% confidence interval 2.00 to 3.19, P<0.001), reduced ejection fraction: 1.70 (1.43 to 2.03, P<0.001), and preserved ejection fraction: 1.52 (1.25 to 1.85, P<0.001)). Despite available state-of-the-art healthcare, high volume heart failure, and valve disease programmes, severe sMR was rarely treated by surgical valve repair (7%) or replacement (5%); low risk transcatheter repair (4%) was similarly seldom used. Conclusion Secondary mitral regurgitation is common overall, increasing with age and associated with excess mortality. The association with adverse outcome is significant across the entire heart failure spectrum but most pronounced in those with mid-range and reduced ejection fractions. Despite these poor outcomes, surgical valve repair or replacement are rarely performed; similarly, low risk transcatheter repair, specifically in the heart failure subsets with the highest expected benefit from treatment, is seldom used. The current data suggest an increasing demand for treatment, particularly in view of an expected increase in heart failure in an ageing population.

Global Research on Neuropathic Pain Rehabilitation over the Last 20 Years

“…The efficacy of different interventions in the treatment of neuropathic pain could be evaluated by analyzing data on pain, function, dose, and adverse effects in randomized controlled trials. Knowledge of outcomes can help patients choose the appropriate rehabilitation treatment [ 54 , 55 ].…”

Functional mitral regurgitation: a proportionate or disproportionate focus of attention?

“…In this context, resolving the FMR conundrum requires new data, to define the risk associated with FMR presence, that clinical trials cannot resolve, and to determine its independent association with outcome in very large cohorts comprehensively characterized. Three such large cohorts 5,24,25 were reported this year, including that by Pagnesi et al . in the current issue of the Journal.…”

“…The studies published this year on large cohorts of patients with heart failure with FMR prospectively defined, 5,24,25 which were based on quantitative FMR assessment in heart failure with reduced ejection fraction, 5 on all comer heart failure patients, 24 and on multicentre heart failure registry, 25 provide several new insights that clarify the uncertainties due to previous small studies: FMR is a strong, independent and incremental marker of risk in patients with any form of heart failure, symptomatic or not, progressive or not, with reduced ejection fraction or not, of ischaemic or non‐ischaemic cause. FMR severity is best defined by the ERO but any integrative form of FMR assessment is associated with outcome so that FMR assessment is a mandatory requirement of heart failure imaging. FMR is profoundly different from organic MR, not only in mechanisms but in its scale of severity and should be graded differently. We have proposed a scale based on ERO increments of 10 mm 2 noted in Table 1 .…”

Mitral regurgitation tips the scales in acute or worsening heart failure

“…Mitral regurgitation (MR) in patients with heart failure impairs quality of life, increases rates of hospital admission, and has a poor prognosis 1–4 . The prevalence of MR is substantial and expected to gain ground with population ageing indicating increasing demands on public health care systems in the future 1,2 .…”

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This article refers to 'Impact of mitral regurgitation in patients with worsening heart failure: insights from BIOSTAT-CHF' by M. Pagnesi et al, published in this issue on pages 1750-1758.Mitral regurgitation (MR) in patients with heart failure impairs quality of life, increases rates of hospital admission, and has a poor prognosis. [1][2][3][4] The prevalence of MR is substantial and expected to gain ground with population ageing indicating increasing demands on public health care systems in the future. 1,2 Much of these aspects have been studied in patient cohorts recruited and followed in specialized heart failure clinics after optimized guideline-directed heart failure treatment.

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