Heart Failure With Mid-range Ejection Fraction

Srivastava, Pratyaksh K.; Hsu, Jeffrey J.; Ziaeian, Boback; Fonarow, Gregg C.

doi:10.1007/s11897-019-00451-0

Cited by 32 publications

(41 citation statements)

References 46 publications

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“…Furthermore, the emergence of HFmrEF presents an interesting development in HF given the results of a meta-analysis demonstrating its shared characteristics with both the HFrEF and HFpEF populations [ 12 ]. At present, HFmrEF remains a poorly understood phenotype due to the lack of randomized controlled trials included in this particular HF category [ 13 ].…”

Section: Introductionmentioning

confidence: 99%

Evaluation of the prescribing practice of guideline-directed medical therapy among ambulatory chronic heart failure patients

Parajuli

Shakib

Eng-Frost

et al. 2021

BMC Cardiovasc Disord

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Background Studies have demonstrated that heart failure (HF) patients who receive direct pharmacist input as part of multidisciplinary care have better clinical outcomes. This study evaluated/compared the difference in prescribing practices of guideline-directed medical therapy (GDMT) for chronic HF patients between two multidisciplinary clinics—with and without the direct involvement of a pharmacist. Methods A retrospective audit of chronic HF patients, presenting to two multidisciplinary outpatient clinics between March 2005 and January 2017, was performed; a Multidisciplinary Ambulatory Consulting Service (MACS) with an integrated pharmacist model of care and a General Cardiology Heart Failure Service (GCHFS) clinic, without the active involvement of a pharmacist. Results MACS clinic patients were significantly older (80 vs. 73 years, p < .001), more likely to be female (p < .001), and had significantly higher systolic (123 vs. 112 mmHg, p < .001) and diastolic (67 vs. 60 mmHg, p < .05) blood pressures compared to the GCHF clinic patients. Moreover, the MACS clinic patients showed more polypharmacy and higher prevalence of multiple comorbidities. Both clinics had similar prescribing rates of GDMT and achieved maximal tolerated doses of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in HFrEF. However, HFpEF patients in the MACS clinic were significantly more likely to be prescribed ACEIs/ARBs (70.5% vs. 56.2%, p = 0.0314) than the GCHFS patients. Patients with both HFrEF and HFpEF (MACS clinic) were significantly less likely to be prescribed β-blockers and mineralocorticoid receptor antagonists. Use of digoxin in chronic atrial fibrillation (AF) in MACS clinic was significantly higher in HFrEF patients (82.5% vs. 58.5%, p = 0.004), but the number of people anticoagulated in presence of AF (27.1% vs. 48.0%, p = 0.002) and prescribed diuretics (84.0% vs. 94.5%, p = 0.022) were significantly lower in HFpEF patients attending the MACS clinic. Age, heart rate, systolic blood pressure (SBP), anemia, chronic renal failure, and other comorbidities were the main significant predictors of utilization of GDMT in a multivariate binary logistic regression. Conclusions Lower prescription rates of some medications in the pharmacist-involved multidisciplinary team were found. Careful consideration of demographic and clinical characteristics, contraindications for use of medications, polypharmacy, and underlying comorbidities is necessary to achieve best practice.

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Section: Introductionmentioning

confidence: 99%

Evaluation of the prescribing practice of guideline-directed medical therapy among ambulatory chronic heart failure patients

Parajuli

Shakib

Eng-Frost

et al. 2021

BMC Cardiovasc Disord

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“…Heart failure (HF) with mid-range ejection fraction (HFmrEF) is a relatively new entity, introduced by the European Society of Cardiology (ESC) in 2016, in an attempt to address the “gray zone” issue for patients with HF and left ventricular ejection fraction (LVEF) between 41% and 49% [ 1 , 2 ]. Currently HF is categorized into HF with reduced (LVEF ≤ 40%) ejection fraction (HFrEF), HFmrEF (LVEF 41% to 49%), and HF with preserved (LVEF ≥ 50%) ejection fraction (HFpEF) [ 2 , 3 , 4 ].…”

Section: Introductionmentioning

confidence: 99%

Treatment of Heart Failure with Mid-Range Ejection Fraction: What Is the Evidence

Koufou

Arfaras-Melainis

Rawal

et al. 2021

JCM

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In this review, we briefly outline our current knowledge on the epidemiology, outcomes, and pathophysiology of heart failure (HF) with mid-range ejection fraction (HFmrEF), and discuss in more depth the evidence on current treatment options for this group of patients. In most studies, the clinical background of patients with HFmrEF is intermediate between that of patients with HF and reduced ejection fraction (HFrEF) and patients with HF and preserved ejection fraction (HFpEF) in terms of demographics and comorbid conditions. However, the current evidence, stemming from observational studies and post hoc analyses of randomized controlled trials, suggests that patients with HFmrEF benefit from medications that target the neurohormonal axes, a pathophysiological behavior that resembles that of HFrEF. Use of β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists, and sacubitril/valsartan is reasonable in patients with HFmrEF, whereas evidence is currently scarce for other therapies. In clinical practice, patients with HFmrEF are treated more like HFrEF patients, potentially because of history of systolic dysfunction that has partially recovered. Assessment of left ventricular systolic function with contemporary noninvasive modalities, e.g., echocardiographic strain imaging, is promising for the selection of patients with HFmrEF who will benefit from neurohormonal antagonists and other HFrEF-targeted therapies.

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“…An E a /E es ratio of 0.7–1.0 indicates maximum stroke work while >1 indicates ineffective coupling. 9 , 10 Brachial arterial blood pressure (BP) is a gross representation of these afterload parameters but is not without its limitations. 9 …”

Section: Introductionmentioning

confidence: 99%

“…Heart failure is a continuous spectrum as reflected by the intermediate phenotypes ‘HF with mid-range EF’ or ‘HF with improving EF’. 10 A scattered plethora of mechanisms have been proposed including neurohormonal over-activation, inflammation and endothelial dysfunction but so far no unifying model exists. 11 We propose a complementary framework of myocardial fatigue, injury, and damage discussed in detail elsewhere that reconciles LVEF classification with the physiological derangements across the HF spectrum ( Figure 1 ).…”

Section: Introductionmentioning

confidence: 99%

Concept of myocardial fatigue in reversible severe left ventricular systolic dysfunction from afterload mismatch: a case series

Tran

Joshi

Banerjee

2021

European Heart Journal - Case Reports

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Background There is already extensive literature on the natural history of hypertensive heart disease (HHD) and aortic stenosis (AS). Once these patients develop severe left ventricular systolic dysfunction (LVSD) despite guideline-directed therapy for heart failure (HF), it is often thought to be end-stage from irreversible adverse remodelling. Our case series challenges this traditional paradigm. A more holistic model that factors in the interactions between the ventricle and vasculature is required. Based on a novel hypothetical concept of myocardial fatigue, we propose that occasionally LVSD is not an inherent myocardial or valvular disease but a consequence of an arterial afterload mismatch. By addressing this, the ventricle may recover and contract efficiently in unison with the arterial system. Case summary We present two cases of severe LVSD in a young lady with long-standing essential hypertension and a gentleman with stable severe AS. Both patients were already established on HF medications. After optimizing their blood pressure control, repeat echocardiography revealed normalization of left ventricular ejection fraction within 3 months, along with a demonstrable improvement in ventricular–arterial coupling and for AS, a reduction in valvular-arterial impedance. Discussion Just as Frank–Starling’s law was discovered by initially drawing analogies to skeletal muscle behaviour, it is biologically plausible that cardiac fatigue can occur in the setting of afterload mismatch. The chance of recovery rests upon early recognition before it transitions to irreversible myocardial damage. Only by testing new emerging theories of HF can we galvanize original research and find new avenues to understanding this complex syndrome.

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Heart Failure With Mid-range Ejection Fraction

Cited by 32 publications

References 46 publications

Evaluation of the prescribing practice of guideline-directed medical therapy among ambulatory chronic heart failure patients

Evaluation of the prescribing practice of guideline-directed medical therapy among ambulatory chronic heart failure patients

Treatment of Heart Failure with Mid-Range Ejection Fraction: What Is the Evidence

Concept of myocardial fatigue in reversible severe left ventricular systolic dysfunction from afterload mismatch: a case series

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