Aims An improved left ventricular ejection fraction (HFiEF) was observed across heart failure (HF) patients with a reduced or mid-range ejection fraction (HFrEF or HFmrEF, respectively). We postulated that HFiEF patients are clinically distinct from non-HFiEF patients. Methods and results A total of 447 patients hospitalized due to a clinical diagnosis of HF (LVEF <50% at baseline) were enrolled from September 2017 to September 2019. Echocardiogram re-evaluation was conducted repeatedly over 6 months of follow-up after discharge. The primary endpoint included the composite of HF hospitalization and all-cause mortality. Subjects (n = 184) with HFiEF (defined as an absolute LVEF improvement≥10%) were compared with 263 non-HFiEF (defined by <10% improvement in LVEF) subjects. Multivariable Cox regression was performed and identified younger age, smaller left ventricular end diastolic dimension (LVEDD), beta-blocker use, AF ablation and cardiac resynchronization therapy (CRT) as independent predictors of HFiEF. According to Kaplan-Meier analysis, HFiEF subjects had lower cardiac composite outcomes (P = 0.002) and all-cause mortality (P = 0.003) than non-HFiEF subjects. Multivariate Cox survival analysis revealed that non-HFiEF (compared with HFiEF) was an independent predictor of both the primary endpoints (HR = 0.679, 95% CI: 0.451-0.907, P = 0.012), which was driven by all-cause mortality (HR = 0.504, 95% CI: 0.256-0.991, P = 0.047). Conclusions These data confirm that compared with non-HFiEF, HFiEF is a distinct HF phenotype with favourable clinical outcomes.

Background: We aimed to investigate the association of lesion-specific epicardial adipose tissue (EAT) volume and density with the presence of myocardial ischemia. Methods: We enrolled 45 patients (55 lesions) with known or suspected coronary artery disease who underwent coronary computed tomography angiography (CTA) followed by invasive fractional flow reserve (FFR) assessment within 30 days. EAT volume (index) and density in patient-, vessel-and lesion-level were measured on CTA images. Lesion-specific ischemia was defined as a lesion with stenosis diameter > 90% or FFR ≤0.80. Multivariate analysis determined the independent association of EAT parameters with lesion-specific ischemia. Results: Mean age of the patients was 60 years, and 75% were male. Overall, 55.6% of patients had ischemic lesions and a mean FFR baseline value of 0.82 ± 0.10. Total EAT volume index was significantly higher in patients with functionally or anatomically significant stenosis. Specifically, peri-lesion EAT volume index, not the density, was positively correlated with lesion-specific ischemia independent of luminal stenosis and plaque characteristics (hazard ratio 1.56, 95% confidence interval 1.04-2.33, P = 0.032; per 0.1 ml/m 2 increase). Moreover, peri-lesion EAT volume was negatively correlated with lesion FFR values, whereas total EAT volume was positively correlated with fat accumulation and glucose metabolism. In addition, there was no association of EAT volume or density with myocardial ischemia in vessel-level analysis. Conclusions: Lesion-specific EAT volume index, but not density, seems positively and independently associated with myocardial ischemia, while its incremental diagnostic value of lesion-specific ischemia should be further investigated.

This study aimed to investigate the favorable revascularization threshold for fractional flow reserve (FFR) in daily practice. Between March 2013 and March 2017 in a high-volume center in China, 903 patients with 1210 lesions underwent coronary intervention with adjunctive FFR and were consecutively enrolled. The mean FFR was 0.80 ± 0.11, revascularization was deferred for 68% of lesions, and the median follow-up period was 21 months. For lesions with an FFR > 0.80, deferral of revascularization appeared safe. In contrast, for lesions with an FFR ≤ 0.80, deferral of revascularization was associated with a greater risk of target lesion failure (TLF) than revascularization (hazard ratio [HR] 4.63, 95% confidence interval [CI] 2.02-10.06, P < .001). For lesions with an FFR value in the gray-zone (0.76-0.80), medical treatment alone was less effective than revascularization ( P = .020). For deferred lesions, FFR was an independent predictor for the future risk of TLF, when data were categorized (HR [FFR ≤ 0.75 vs FFR ≥ 0.86] 3.35, 95% CI 1.13-9.97, P = .030; HR [FFR 0.76-0.80 vs FFR ≥ 0.86] 4.01, 95% CI 1.73-9.31, P = .001) or continuous (HR 0.004, 95% CI 0.00-0.13, P = .002). Thus, an FFR value of 0.80 appears to be the optimal threshold for decision-making regarding revascularization and risk stratification.

We searched PubMed, EMBASE, Cochrane Library, and Web of Science for studies using fractional flow reserve (FFR) to determine whether revascularization should be performed or deferred for patients with coronary stenosis and grey zone FFR. Meta-analysis was performed using the generic inverse variance method, and hazard ratios (HR) were synthesized with a random-effects model. Of 2766 records, 7 nonrandomized studies including 2683 patients were selected. The pooled results demonstrated, during a median follow-up of 32 months, that revascularization significantly reduced the risk of major adverse cardiac events (MACE; 7 studies: HR [95% confidence interval, CI]: 0.65 [0.45-0.93], P = .02) and target vessel revascularization (TVR; 4 studies: HR [95% CI]: 0.52 [0.36-0.76], P < .01). Whereas revascularization was not significantly superior in terms of all-cause death (3 studies: HR [95% CI]: 0.56 [0.26-1.22], P = .14), cardiac death (2 studies: HR [95% CI]: 0.57 [0.16-2.01], P = .38), myocardial infarction (MI; 4 studies: HR [95% CI]: 1.03 [0.26-4.03]), and all-cause death or MI (3 studies: HR [95% CI]: 0.66 [0.20-2.19], P = .50). Therefore, revascularization appeared to be superior to deferral for patients with grey zone FFR in MACE and TVR, while hard end points did not show such significance. This work was registered in PROSPERO (CRD42019118432).