Log in to MyACC
Predictors of LVEF Improvement in Heart Failure
Study Questions:
What are the predictors of recovery of left ventricular ejection fraction (LVEF)?
Methods:
The authors conducted a retrospective cohort study of heart failure (HF) patients over age 18 years (at least one hospitalization or one emergency department visit with a diagnosis of HF, and who underwent ≥2 echocardiograms separated by ≥6 months). They classified patients into three groups based on their baseline echocardiograms: 1) HF with reduced EF (HFrEF) if initial LVEF was ≤40%, 2) HF with mid-range EF (HFmEF) if initial LVEF was 41–49%, and 3) HF with preserved EF (HFpEF) if initial LVEF was ≥50%. They examined all-cause mortality, all-cause hospitalizations, all-cause emergency room (ER) visits, HF-specific hospitalizations, or ER visits (i.e., those with HF listed as the most responsible diagnosis), LV assist device (LVAD) implantation, or cardiac transplant after their second echocardiogram. They compared long-term outcomes between patients with HFrecEF (defined by LVEF absolute improvement ≥10%) and persistent HFrEF (defined by <10% improvement in EF) using the Kaplan–Meier curves and Cox proportional hazards models.
Results:
Of 10,641 patients (who had a physician-assigned diagnosis of HF, and who had their LVEF objectively measured on both echocardiograms), 3,124 had HFrEF at baseline. While mean EF declined from 30.2% on initial echocardiogram to 28.6% on the second echocardiogram in those patients with persistent HFrEF, it improved from 26.1% to 46.4% in the 1,174 patients (37.6%) with HFrecEF (90% were taking angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, 92% beta-blockers, and 45% mineralocorticoid receptor antagonists). On multivariate analysis, female gender (adjusted odds ratio [aOR], 1.66; 95% confidence interval [CI] 1.40–1.96), younger age (aOR per decade, 1.16; 95% CI, 1.09–1.23), atrial fibrillation (aOR, 2.00; 95% CI, 1.68–2.38), cancer (aOR, 1.52; 95% CI, 1.03–2.26), hypertension (aOR, 1.38; 95% CI, 1.18–1.62), lower baseline EF (aOR per 1% decrease, 1.07; 95% CI, 1.06–1.08), and using hydralazine (aOR, 1.69; 95% CI, 1.19–2.40) were associated with EF improvements ≥10%. HFrecEF patients demonstrated lower rates per 1,000 patient-years of mortality (106 vs. 164, adjusted hazard ratio, aHR 0.70; 95% CI, 0.62–0.79), all-cause hospitalizations (300 vs. 428, aHR, 0.87; 95% CI, 0.79–0.95), all-cause emergency room (ER) visits (569 vs. 799, aHR, 0.88; 95% CI, 0.81–0.95), and cardiac transplantation or LVAD implantation (2 vs. 10, aHR, 0.21; 95% CI, 0.10–0.45) compared to patients with persistent HFrEF. Females with HFrEF exhibited lower mortality risk (aHR, 0.94; 95% CI, 0.88–0.99) than males after adjusting.
Conclusions:
The study authors concluded that HFrecEF patients tended to be younger, female, and were more likely to have hypertension, atrial fibrillation, or cancer. HFrecEF patients have a substantially better prognosis compared to those with persistent HFrEF, even after multivariable adjustment, and female patients exhibit lower mortality risk than men within each subgroup (HFrecEF and persistent HFrEF) even after multivariable adjustment.
Perspective:
This is an important study because it adds to the literature that LV function is most likely to occur in younger women and in those with underlying nonischemic cardiomyopathy. It also suggests that LV function is better salvaged in those with atrial fibrillation (probably due to underlying fast ventricular rate), cancer patients (who may be receiving excessive amounts of fluid), and in those with underlying high blood pressure. This study raises the question whether there are biomarkers to predict recovery of LV function or to flag those who may have persistent HFrEF. This study also suggests that the role of hydralazine in improving LV function merits further investigation.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support, Interventions and Imaging, Echocardiography/Ultrasound, Hypertension
Keywords: Adrenergic beta-Antagonists, Angiotensin-Converting Enzyme Inhibitors, Angiotensin Receptor Antagonists, Atrial Fibrillation, Cardiomyopathies, Echocardiography, Emergency Service, Hospital, Heart-Assist Devices, Heart Failure, Heart Transplantation, Hydralazine, Hypertension, Mineralocorticoid Receptor Antagonists, Neoplasms, Prognosis, Stroke Volume, Ventricular Function, Left
< Back to Listings
