Guideline-directed medical therapy is similarly effective in heart failure with mildly reduced ejection fraction

Abstract

Aims Current guidelines recommend that disease-modifying pharmacological therapies may be considered for patients who have heart failure with mildly reduced ejection fraction (HFmrEF). We aimed to describe the characteristics, outcomes, provision of pharmacological therapies and dose-related associations with mortality risk in HFmrEF. Methods and results We explored data from two prospective observational studies, which permitted the examination of the effects of pharmacological therapies across a broad spectrum of left ventricular ejection fraction (LVEF). The combined dataset consisted of 2388 unique patients, with a mean age of 73.7 ± 13.2 years of whom 1525 (63.9%) were male. LVEF ranged from 5 to 71% (mean 37.2 ± 12.8%) and 1504 (63.0%) were categorised as having reduced ejection fraction (HFrEF), 421 (17.6%) as HFmrEF and 463 (19.4%) as preserved ejection fraction (HFpEF). Patients with HFmrEF more closely resembled HFrEF than HFpEF. Adjusted all-cause mortality risk was lower in HFmrEF (hazard ratio [HR] 0.86 (95% confidence interval [CI] 0.74–0.99); p = 0.040) and in HFpEF (HR 0.61 (95% CI 0.52–0.71); p < 0.001) compared to HFrEF. Adjusted all-cause mortality risk was lower in patients with HFrEF and HFmrEF who received the highest doses of beta-blockers or renin-angiotensin inhibitors. These associations were not evident in HFpEF. Once adjusted for relevant confounders, each mg equivalent of bisoprolol (HR 0.95 [95% CI 0.91–1.00]; p = 0.047) and ramipril (HR 0.95 [95%CI 0.90–1.00]; p = 0.044) was associated with incremental reductions in mortality risk in patients with HFmrEF. Conclusions Pharmacological therapies were associated with lower mortality risk in HFmrEF, supporting guideline recommendations which extend the indications of these agents to all patients with LVEF < 50%. Graphic abstract HFmrEF more closely resembles HFrEF in terms of clinical characteristics and outcomes. Pharmacological therapies are associated with lower mortality risk in HFmrEF and HFrEF, but not in HFpEF.

The Relationship between Angiotensin–Neprilysin Treatment, Echocardiographic Parameters, and NT-proBNP Levels in HFpEF Patients with Acute Decompensated Heart Failure

“…While LVEF improved significantly in both treatment groups, these improvements were more pronounced for individuals that were subject to ARNI treatment as compared to ACEI treatment. Several prior studies have reported similar LVEF improvement in patients diagnosed with HFrEF [17][18][19][20]. The PARAGON-HF study determined that sacubitrilvalsartan treatment was associated with more pronounced absolute and relative benefit as compared to valsartan in HFpEF patients when this therapeutic regimen was initiated during the high-risk window following hospitalization, in line with the present study [21].…”

Impact of sex and diabetes in patients with heart failure with mildly reduced ejection fraction

“…The clinical characteristics and outcomes in HFmrEF population were found in a large part to be intermediate between heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). 1 These findings were consistent with a previous analysis from European Society of Cardiology (ESC) heart failure longterm registry 2 as well as a prospective international multiethnic cohort study. 3 However, whether HFmrEF is a distinct entity from HFrEF and HFpEF remains a heated debate.…”

Cardiac contractility index identifies systolic dysfunction in preserved ejection fraction heart failure

“…The prospective evaluation of the diagnostic efficacy of the 2010 United Kingdom National Institute for Clinical Excellence guidelines on Chronic Heart Failure (NICE-CHF) is an observational cohort study including people newly referred to secondary care for suspected heart failure. 9 Consecutive unselected patients from a primary care catchment of over 750,000 people between May 2012 and May 2013, who had signs and/or symptoms of chronic heart failure as well as elevated natriuretic peptides (N-terminal pro B-type natriuretic peptide [NT-proBNP] ≥125pg/L), were included.…”