1st Cardiology Department, National and Kapodistrian University of Athens, University Medical School, Hippokration Hospital, Vasilissis Sofias 114, 11528, Athens, Greece.
Heart Fail Rev. 2017 Nov;22(6):641-655. doi: 10.1007/s10741-017-9624-5.
Heart failure (HF) consists the fastest growing clinical cardiac disease. HF patients are categorized on the basis of underlying left ventricular ejection fraction (LVEF) into HF with preserved EF (HFpEF), reduced LVEF (HFrEF), and mid-range LVEF (HFmrEF). While LVEF is the most commonly used surrogate marker of left ventricular (LV) systolic function, the implementation of two-dimensional echocardiography in estimating this parameter imposes certain caveats on current HF classification. Most importantly, LVEF could fluctuate in repeated measurements or even recover after treatment, thus blunting the borders between proposed categories of HF and enabling upward classification of patients. Under this prism, we sought to summarize possible procedures to improve systolic function in patients with HFrEF either naturally or by the means of pharmacologic and non-pharmacologic treatment and devices. Therefore, we reviewed established pharmacotherapy, including beta-blockers, inhibitors of renin-angiotensin-aldosterone axis, statins, and digoxin as well as novel treatments like sacubitril-valsartan, ranolazine, and ivabradine. In addition, we assessed evidence in favor of cardiac resynchronization therapy and exercise training programs. Finally, innovative therapeutic strategies, including stem cells, xanthine oxidase inhibitors, antibiotic regimens, and omega-3 polyunsaturated fatty acids, were also taken into consideration. We concluded that LVEF is subject to changes in HF after intervention and besides the aforementioned HFrEF, HFpEF, and HFmrEF categories, a new entity of HF patients with recovered LVEF should be acknowledged. An improved global and refined LV function assessment by sophisticated imaging modalities and circulating biomarkers is expected to render HF classification more accurate and indicate patients with viable-yet dysfunctional-myocardium and favorable characteristics as the ideal candidates for LVEF recovery by individualized HF therapy.
心力衰竭（HF）是增长最快的临床心脏疾病。HF 患者根据潜在的左心室射血分数（LVEF）分为射血分数保留的心力衰竭（HFpEF）、射血分数降低的心力衰竭（HFrEF）和中间范围的射血分数心力衰竭（HFmrEF）。虽然 LVEF 是左心室（LV）收缩功能最常用的替代标志物，但二维超声心动图在估计此参数时的应用对当前的 HF 分类提出了一定的限制。最重要的是，LVEF 在重复测量中可能会波动，甚至在治疗后恢复，从而削弱了 HF 分类中提出的类别之间的界限，并使患者向上分类。在此背景下，我们试图总结改善 HFrEF 患者收缩功能的可能方法，无论是通过自然方法还是通过药物和非药物治疗以及设备。因此，我们回顾了已确立的药物治疗，包括β受体阻滞剂、肾素-血管紧张素-醛固酮轴抑制剂、他汀类药物和地高辛，以及新型治疗方法，如沙库巴曲缬沙坦、雷诺嗪和伊伐布雷定。此外，我们评估了有利于心脏再同步治疗和运动训练计划的证据。最后，还考虑了一些创新的治疗策略，包括干细胞、黄嘌呤氧化酶抑制剂、抗生素方案和ω-3 多不饱和脂肪酸。我们得出结论，LVEF 在 HF 干预后会发生变化，除了上述 HFrEF、HFpEF 和 HFmrEF 类别外，还应承认 LVEF 恢复的 HF 患者的新实体。通过复杂的成像方式和循环生物标志物进行的 LVEF 改善的全球和更精细的 LV 功能评估有望使 HF 分类更加准确，并指示具有可行但功能障碍性心肌和有利特征的患者作为个体化 HF 治疗恢复 LVEF 的理想候选者。
