Epidemiology, pathophysiology and clinical outcomes for heart failure patients with a mid‐range ejection fraction

Abstract

Aims Heart failure (HF) patients with a mid-range LVEF (HFmrEF) are not well characterized. Accordingly, we examined the epidemiology, pathophysiology and clinical outcomes of HF patients with an LV EF of 40–50%. Methods and Results We identified patients with an LVEF between 40–50% at enrollment into a HF registry, and determined whether LVEF was improved, worsened, or the same compared to a prior LVEF. Three subgroups of HFmrEF patients were identified: HFmrEF improved (prior LVEF < 40%); HFmrEF deteriorated (prior LVEF > 50%); HFmrEF unchanged (prior LVEF 40–50%). The majority of patients (73%) were HFmrEF improved, 17% were HFmrEF deteriorated and 10% were HFmrEF unhanged. The demographics of the HFmrEF cohort were heterogeneous, with more CAD in the HFmrEF improved group and a more hypertension and diastolic dysfunction in the HFmrEF deteriorated group. HFmrEF improved patients had significantly (p < 0.001) better clinical outcomes relative to matched patients with HFrEF, and significantly (P < 0.01) improved clinical outcomes relative to HFmrEF deteriorated patients, whereas clinical outcomes of the HFmrEF deteriorated subgroup of patients were not significantly different from matched HFpEF patients. Conclusions Patients with a mid-range EF are heterogeneous. Obtaining historical information with regard to prior LVEF allows one to identify a distinct pathophysiological substrate and clinical course for HFmrEF patients. Viewed together, these results suggest that in the modern era of HF therapeutics, the use of LVEF to categorize the pathophysiology of HF may be misleading, and argue for establishing a new taxonomy for classifying HF patients.

Spironolactone use is associated with improved outcomes in heart failure with mid‐range ejection fraction

“…In the present study, patients with HFmrEF accounted for 19.1% of the total cohort in JCARE‐CARD, which was consistent with previous studies . We have previously reported characteristics of HFrEF and HFpEF .…”

“…The 2016 European Society of Cardiology HF guidelines defined HFmrEF in patients with EF of 40–49% . Recent observational studies extensively described characteristics of patients with HFmrEF in comparison with HFpEF and HFrEF; however, it remains unknown whether patients with HFmrEF represent a transitional phenotype between HFpEF and HFrEF or a distinct pathophysiological entity. Furthermore, effective treatment strategies for these patients have not been established.…”

Effect of digoxin in patients with heart failure and mid‐range (borderline) left ventricular ejection fraction

“…Lack of these treatments also makes it less likely that the HFmrEF patients in DIG included many patients with ‘recovered LVEF’, i.e. the HFmrEF patients in DIG were likely a more homogeneous group than in more current cohorts …”

The year in cardiology 2017: heart failure

“…1 However, EF is not an ideal marker to classify HF, and EF may change with treatment and time. 47 A recent study suggested that 17-34% of patients with HFrEF or HFmrEF improve to a higher category, and that this, as expected, was more common in the absence of ischaemic heart disease. 48 Other modalities may refine characterization of HF, such as global longitudinal strain, 49,50 but their impact in clinical routine remains to be seen.…”