Is heart failure with mid-range or mildly reduced ejection fraction only a transitional stage? Real-world experience

    Authors

    Keywords

    heart failure, sodium glucose cotransporter 2 inhibitors, empagliflozin, dapagliflozin

    DOI

    https://doi.org/10.15836/ccar2023.295

    Full Text

    **Background**: Heart failure (HF) societies classify LVEFs of 41–49% as mildly reduced ejection fraction (HFmrEF) (1, 2). HFmrEF is an intermediate HF type between HF with preserved EF (HFpEF) and HF with reduced EF (HFrEF), as it shares characteristics from both ends of the spectrum. HFmrEF is controversial due to LVEF changes and inter-rater variability (3, 4). Studies on HFmrEF are inconsistent and it is not clear whether HFmrEF is a transition or an independent clinical entity. No prospective studies have assessed the effect of therapy in patients with HFmrEF. Current evidence in patients with HFmrEF is based on post-hoc analyses of studies (3). **Patients and Methods**: This was a prospective observational study conducted at University Hospital Dubrava, Zagreb. We recruited patients presenting with HF symptoms from May 2021 to August 2023. We collected data on gender, age, drugs and adherence, comorbidities, NT-proBNP and HbA1c levels and EF. Categorical variables are presented as frequencies and percentages and continuous variables are presented as medians and interquartile ranges. P value 50% in 21 and decreased to <40% in 4 participants. EF has not changed in 26 participants. Level of NT-proBNP was 1.834pg/mL (95% CI 66-32,127) during initial visit and 651pg/mL (95% CI 44-12,555) at 12 months (p<0.001). HbA1c levels decreased from 6.3% (95% CI 5.3- 10.9) at the initial visit to 5,85% (95% CI 4.9-8.3) at 12 months (p<0.001). **Conclusion**: HFmrEF remains a mystery. Optimal medical treatment might improve EF or prevent it from deteriorating further in some patients, but long-term real-world data is needed.

    Literature

    1. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 September 21;42(36):3599–726. https://doi.org/10.1093/eurheartj/ehab368
    2. Bozkurt B, Coats AJS, Tsutsui H, Abdelhamid CM, Adamopoulos S, Albert N, et al. Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure: Endorsed by the Canadian Heart Failure Society, Heart Failure Association of India, Cardiac Society of Australia and New Zealand, and Chinese Heart Failure Association. Eur J Heart Fail. 2021 March;23(3):352–80. https://doi.org/10.1002/ejhf.2115
    3. Savarese G, Stolfo D, Sinagra G, Lund LH. Heart failure with mid-range or mildly reduced ejection fraction. Nat Rev Cardiol. 2022 February;19(2):100–16. https://doi.org/10.1038/s41569-021-00605-5
    4. Rastogi A, Novak E, Platts AE, Mann DL. Epidemiology, pathophysiology and clinical outcomes for heart failure patients with a mid-range ejection fraction. Eur J Heart Fail. 2017 December;19(12):1597–605. https://doi.org/10.1002/ejhf.879
    Cardiologia Croatica
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    Is heart failure with mid-range or mildly reduced ejection fraction only a transitional stage? Real-world experience

    Extended Abstract
    Issue11-12
    Published
    Pages295
    PDF via DOIhttps://doi.org/10.15836/ccar2023.295
    heart failure
    sodium glucose cotransporter 2 inhibitors
    empagliflozin
    dapagliflozin

    Authors

    Marin Viđak*ORCIDUniversity Hospital Dubrava, Zagreb, Croatia
    Jasmina ĆatićORCIDUniversity Hospital Dubrava, Zagreb, Croatia
    Jelena KursarORCIDUniversity Hospital Dubrava, Zagreb, Croatia
    Petar LišnjićORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Tomislav ŠipićORCIDUniversity Hospital Dubrava, Zagreb, Croatia
    Šime ManolaORCIDUniversity Hospital Dubrava, Zagreb, Croatia
    Ivana JurinORCIDUniversity Hospital Dubrava, Zagreb, Croatia

    *Correspondence email: marin.vidjak@gmail.com

    Full Text

    Background: Heart failure (HF) societies classify LVEFs of 41–49% as mildly reduced ejection fraction (HFmrEF) (1, 2). HFmrEF is an intermediate HF type between HF with preserved EF (HFpEF) and HF with reduced EF (HFrEF), as it shares characteristics from both ends of the spectrum. HFmrEF is controversial due to LVEF changes and inter-rater variability (3, 4). Studies on HFmrEF are inconsistent and it is not clear whether HFmrEF is a transition or an independent clinical entity. No prospective studies have assessed the effect of therapy in patients with HFmrEF. Current evidence in patients with HFmrEF is based on post-hoc analyses of studies (3).

    Patients and Methods: This was a prospective observational study conducted at University Hospital Dubrava, Zagreb. We recruited patients presenting with HF symptoms from May 2021 to August 2023. We collected data on gender, age, drugs and adherence, comorbidities, NT-proBNP and HbA1c levels and EF. Categorical variables are presented as frequencies and percentages and continuous variables are presented as medians and interquartile ranges. P value < 0.05 was considered as significant. Statistical analysis was performed using JASP software.

    Results: We collected data from 850 participants. HFmrEF was diagnosed in 129 patients (15.1%). 76 (58.9%) participants had coronary artery disease and 59 participants (46%) had atrial fibrillation. Dapagliflozin was initiated in 60 (47%) and empagliflozin in 68 (53%) participants. Only 8 participants had optimal medical therapy prior to SGLT-2 initiation. Adherence was evaluated in 87 participants, and it was high in 48, moderate in 21 and low in 18 participants. EF at 12 months was assessed in 51 participants. Median EF was 44.6% (95% CI 44.2%-45%) at initiation and 49% at 12 months (95% CI 47%-51%) (p=0.0001). EF has improved to >50% in 21 and decreased to <40% in 4 participants. EF has not changed in 26 participants. Level of NT-proBNP was 1.834pg/mL (95% CI 66-32,127) during initial visit and 651pg/mL (95% CI 44-12,555) at 12 months (p<0.001). HbA1c levels decreased from 6.3% (95% CI 5.3- 10.9) at the initial visit to 5,85% (95% CI 4.9-8.3) at 12 months (p<0.001).

    Conclusion: HFmrEF remains a mystery. Optimal medical treatment might improve EF or prevent it from deteriorating further in some patients, but long-term real-world data is needed.

    Literature

    1. 1.
      McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 September 21;42(36):3599–726.DOI
    2. 2.
      Bozkurt B, Coats AJS, Tsutsui H, Abdelhamid CM, Adamopoulos S, Albert N, et al. Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure: Endorsed by the Canadian Heart Failure Society, Heart Failure Association of India, Cardiac Society of Australia and New Zealand, and Chinese Heart Failure Association. Eur J Heart Fail. 2021 March;23(3):352–80.DOI
    3. 3.
      Savarese G, Stolfo D, Sinagra G, Lund LH. Heart failure with mid-range or mildly reduced ejection fraction. Nat Rev Cardiol. 2022 February;19(2):100–16.DOI
    4. 4.
      Rastogi A, Novak E, Platts AE, Mann DL. Epidemiology, pathophysiology and clinical outcomes for heart failure patients with a mid-range ejection fraction. Eur J Heart Fail. 2017 December;19(12):1597–605.DOI