Cardiology Division, Massachusetts General Hospital, 32 Fruit Street, Yawkey 5984, Boston, MA, 02114, USA.
Baim Institute for Clinical Research, Boston, MA, USA.
ESC Heart Fail. 2019 Aug;6(4):784-792. doi: 10.1002/ehf2.12455. Epub 2019 Jul 3.
Guidelines for management of patients with heart failure with mid-range ejection fraction [HFmrEF; left ventricular EF (LVEF) 41-49%] do not exist. Disagreement exists whether HFmrEF should be considered a distinct group. The aim of this study is to examine characteristics of patients with HFmrEF with HF with reduced EF (HFrEF; LVEF ≤ 40%) or preserved EF (HFpEF; LVEF ≥ 50%).
We examined data collected in the American College of Cardiology's National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) Registry® for first HF patient visits between 1 May 2008 and 30 June 2016. Analysis was performed using ANOVA F-tests (or Kruskal-Wallis tests for non-normally distributed variables) for continuous parameters and χ tests for nominal covariates at the first diagnosed HF visit. Given the NCDR PINNACLE Registry® is a US-based registry, we opted to define HFmrEF as per the US guidelines, which define HFmrEF as LVEF 41-49% in contrast to European guidelines, which define HFmrEF as LVEF 40-49%. Among 1 103 386 patients with available data, 36.1% (N = 398 228) had HFrEF, 7.5% (N = 82 292) had HFmrEF, and 56.5% (N = 622 866) had HFpEF. Compared with patients with HFrEF or HFpEF, patients with HFmrEF had more prevalent coronary and peripheral artery disease and more history of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery (all P < 0.001). Patients with HFmrEF were also more likely to have atrial fibrillation/flutter, diabetes, and chronic kidney disease and to have a history of tobacco use (both P < 0.001). Among those with EF assessment prior to this analysis, only 4.8% (N = 1032) previously had HFrEF that improved to HFmrEF; 32.9% (N = 7072) had HFpEF previously and progressed to HFmrEF. Those patients who transitioned from HFpEF to HFmrEF had considerably more complex profiles and were less aggressively managed compared with those who remained with HFmrEF (all P < 0.001).
In this large descriptive analysis, patients with HFmrEF had an atherothrombotic phenotype distinct from other forms of HF. Interventions aimed at treating coronary ischaemia and addressing prevalent risk factors may play a particularly important role in the management of patients with HFmrEF.
对于射血分数中间值的心衰（HFmrEF；左心室射血分数 [LVEF] 为 41%-49%）患者，目前尚无管理指南。HFmrEF 是否应被视为一个独立的组别，这一点尚存争议。本研究旨在研究射血分数中间值心衰（HFmrEF）患者的特征，这些患者同时患有射血分数降低的心衰（HFrEF；LVEF≤40%）或射血分数保留的心衰（HFpEF；LVEF≥50%）。
我们分析了 2008 年 5 月 1 日至 2016 年 6 月 30 日期间，美国心脏病学会国家心血管数据注册（NCDR）实践创新与临床卓越（PINNACLE）注册中心®中首次心衰患者就诊的数据。采用方差分析 F 检验（或非正态分布变量的 Kruskal-Wallis 检验）对连续参数进行分析，采用 χ 检验对首次诊断心衰就诊时的名义协变量进行分析。鉴于 NCDR PINNACLE 注册中心®是一个基于美国的数据注册中心，我们选择按照美国指南定义 HFmrEF，即 LVEF 为 41%-49%，与欧洲指南不同，欧洲指南将 HFmrEF 定义为 LVEF 为 40%-49%。在 1103386 名有可用数据的患者中，36.1%（N=398228）患有 HFrEF，7.5%（N=82292）患有 HFmrEF，56.5%（N=622866）患有 HFpEF。与 HFrEF 或 HFpEF 患者相比，HFmrEF 患者更常见冠状动脉疾病和外周动脉疾病，且更常患有心肌梗死、经皮冠状动脉介入治疗或冠状动脉旁路移植术（均 P<0.001）。HFmrEF 患者也更可能患有心房颤动/扑动、糖尿病和慢性肾病，且有吸烟史（均 P<0.001）。在接受 EF 评估的患者中，仅有 4.8%（N=1032）此前患有 HFrEF，后改善为 HFmrEF；32.9%（N=7072）此前患有 HFpEF，后进展为 HFmrEF。与 HFpEF 转为 HFmrEF 的患者相比，HFmrEF 保持不变的患者的情况要复杂得多，且治疗方案也较为保守（均 P<0.001）。
在这项大型描述性分析中，HFmrEF 患者的动脉粥样硬化血栓表型与其他形式的心衰不同。针对缺血性冠状动脉疾病和已有的风险因素的干预措施，可能在 HFmrEF 患者的管理中发挥特别重要的作用。
