Unfavourable outcomes in patients with heart failure with higher preserved left ventricular ejection fraction

Abstract

Aims Newly introduced drugs for heart failure (HF) have been reported to improve the prognosis of HF with preserved ejection fraction (HFpEF) in the lower range of left ventricular ejection fraction (LVEF). We hypothesized that a higher LVEF is related to an unfavourable prognosis in patients with HFpEF. Methods and results We tested this hypothesis by analysing the data from a prospective multicentre cohort study in 255 patients admitted to the hospital due to decompensated HF (LVEF > 40% at discharge). The primary endpoint of this study was a composite outcome of all-cause death and readmission due to HF, and the secondary endpoint was readmission due to HF. LVEF and the mitral E/e′ ratio were measured using echocardiography. In multicovariate parametric survival time analysis, LVEF [hazard ratio (HR) = 1.046 per 1% increase, P = 0.001], concurrent atrial fibrillation (AF) (HR = 3.203, P < 0.001), and E/e′ (HR = 1.083 per 1.0 increase, P < 0.001) were significantly correlated with the primary endpoint. In addition to these covariates, angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) use was significantly correlated with the secondary endpoint (HR = 0.451, P = 0.008). Diagnostic performance plot analysis demonstrated that the discrimination threshold value for LVEF that could identify patients prone to reaching the primary endpoint was ≥57.2%. The prevalence of AF or E/e′ ratio did not differ significantly between patients with LVEF ≥ 58% and with 40% < LVEF < 58%. Conclusion A higher LVEF is independently related to poor prognosis in patients with HFpEF, in addition to concurrent AF and an elevated E/e′ ratio. ACEI/ARB use, in contrast, was associated with improved prognosis, especially with regard to readmission due to HF. Clinical Trial Registration https://www.umin.ac.jp/ctr/index.htm Unique identifier UMIN000017725

Time to Reconsider Ejection Fraction in Heart Failure

“…Recently, we have reported that a higher EF of ≥58% is independently related to a poor prognosis in patients with HFpEF. 2 Many studies support our findings, showing a U-shaped relationship between EF and mortality, with the nadir at an EF of 60% to 65%. 3 Surprisingly, patients with an EF of ≥70% (supernormal EF) had a similar adjusted mortality rate as patients with an EF of 35% to 40%.…”

Retinal Vascular Changes in Heart Failure with Preserved Ejection Fraction Using Optical Coherence Tomography Angiography

“…Microvascular endothelial dysfunction in the heart of patients with HFpEF can cause a cascade of events, resulting in concentric LV remodeling, diastolic dysfunction, and higher end-systolic volume and pressure [1], reflected by non-invasive echocardiography markers such as decreased e' and elevated E/e' [19]. The degree of impairment in these echocardiography markers is associated with a worse prognosis [20,21]. These impairments can be improved, thereby partially restoring exercise capacity [22].…”

Canagliflozin Ameliorates Ventricular Remodeling through Apelin/Angiotensin-Converting Enzyme 2 Signaling in Heart Failure with Preserved Ejection Fraction Rats

“…Animal models and clinical trials have shown that inhibition of the RAAS can improve cardiac diastolic function and downregulate these harmful processes [27], but the clinical benefits of neurohormone antagonists in HFpEF patients are uncertain. In HFpEF patients, the use of ACE inhibitors/Ang II type 1 receptor blockers is related to the improvement of prognosis, especially in terms of readmission due to HF [28]. In this study, we used DSS rats to induce an HFpEF model, intervened with CANA and IRB administration, and studied the mechanism of action of CANA.…”