Echocardiographically defined haemodynamic categorization predicts prognosis in ambulatory heart failure patients treated with sacubitril/valsartan

Abstract

Aim Echo-derived haemodynamic classification, based on forward-flow and left ventricular (LV) filling pressure (LVFP) correlates, has been proposed to phenotype patients with heart failure and reduced ejection fraction (HFrEF). To assess the prognostic relevance of baseline echocardiographically defined haemodynamic profile in ambulatory HFrEF patients before starting sacubitril/valsartan. Methods and resultsIn our multicentre, open-label study, HFrEF outpatients were classified into 4 groups according to the combination of forward flow (cardiac index; CI:< or ≥2.0 L/min/m 2 ) and early transmitral Doppler velocity/early diastolic annular velocity ratio (E/e′: ≥ or <15): Profile-A: normal-flow, normal-pressure; Profile-B: low-flow, normal-pressure; Profile-C: normal-flow, high-pressure; Profile-D: low-flow, high-pressure. Patients were started on sacubitril/valsartan and followed-up for 12.3 months (median). Rates of the composite of death/HF-hospitalization were assessed by multivariable Cox proportional-hazards models. Twelve sites enrolled 727 patients (64 ± 12 year old; LVEF: 29.8 ± 6.2%). Profile-D had more comorbidities and worse renal and LV function. Target dose of sacubitril/valsartan (97/103 mg BID) was more likely reached in Profile-A (34%) than other profiles (B: 32%, C: 24%, D: 28%, P < 0.001). Event-rate (per 100 patients per year) progressively increased from Profile-A to Profile-D (12.0%, 16.4%, 22.9%, and 35.2%, respectively, P < 0.0001). By covariateadjusted Cox model, profiles with low forward-flow (B and D) remained associated with poor outcome (P < 0.01). Adding this categorization to MAGGIC-score and natriuretic peptides, provided significant continuous net reclassification improvement (0.329; P < 0.001). Intermediate and high-dose sacubitril/valsartan reduced the event's risk independently of haemodynamic profile. Conclusions Echocardiographically-derived haemodynamic classification identifies ambulatory HFrEF patients with different risk profiles. In real-world HFrEF outpatients, sacubitril/valsartan is effective in improving outcome across different haemodynamic profiles.

Effect of Sacubitril-Valsartan on Restoration and Maintenance of Sinus Rhythm in Patients With Persistent Atrial Fibrillation

“…Therefore, based on the pharmacological mechanisms of sacubitril-valsartan, it can be presumed that sacubitril-valsartan could also prevent or modify atrial remodeling through similar or even stronger effects as ACEI/ARB monotherapy. More recently, Carluccio et al assessed changes in echocardiographically derived hemodynamic profiles induced by sacubitril-valsartan in a large consecutive series of patients with HF ( 36 , 37 ). They found that an important role of sacubitril-valsartan on improvement cardiovascular hemodynamics including cardiac output and left ventricular filling pressure ( 36 , 37 ), which might provide new insights into the underlying mechanism of effects of sacubitril-valsartan on restoration and maintenance of sinus rhythm for persistent AF.…”

Prognostic significance of resting cardiac power to left ventricular mass and E/e’ ratio in heart failure with preserved ejection fraction

“…Despite its modest correlations with outcomes in HFpEF ( 33 ), E/e’ ratio displays prominent specificity for identifying patients with increased LV filling pressure ( 34 ). A recent study conducted by Dini et al ( 35 ), which involved 727 outpatients with HFrEF, demonstrated that a functional hemodynamic stratification approach based on a cardiac index (using 2.0 L/min/m 2 as the threshold for low output) and E/e’ ratio (using a value ≥ 15 as a marker of increased LV filling pressure) is useful in predicting survival. A similar pathophysiological stratification approach based on an assessment of cardiac hemodynamics (ventricular forward flow and filling pressure) has also been proposed in patients with cardiogenic shock ( 36 ).…”

The Benefits of Sacubitril-Valsartan in Low Ejection Fraction Heart Failure

“…HFrEF patients with varied risk profiles are identified using echocardiographic hemodynamic classification. Sacubitril/valsartan improves outcome across hemodynamic profiles in real-world HFrEF outpatients (52). Treatment with low doses of ARNI might successfully improve cardiac function in hemodialysis (HD) patients with heart failure and hypotension.…”