Zhang Xinxin, Sun Yuxi, Zhang Yanli, Chen Feifei, Zhang Shuyuan, He Hongyan, Song Shuang, Tse Gary, Liu Ying
Heart Failure and Structural Cardiology Ward, The First Affiliated Hospital of Dalian Medical University, Dalian, China.
Kent and Medway Medical School, Canterbury, United Kingdom.
Front Cardiovasc Med. 2021 Aug 2;8:697221. doi: 10.3389/fcvm.2021.697221. eCollection 2021.
Evidence-based guidelines for heart failure management depend mainly on current left ventricular ejection fraction (LVEF). However, fewer studies have examined the impact of prior LVEF. Patients may enter the heart failure with midrange ejection fraction (HFmrEF) category when heart failure with preserved ejection fraction (HFpEF) deteriorates or heart failure with reduced ejection fraction (HFrEF) improves. In this study, we examined the association between change in LVEF and adverse outcomes. HFmrEF patients with at least two or more echocardiograms 3 months apart at the First Affiliated Hospital of Dalian Medical University between September 1, 2015 and November 30, 2019 were identified. According to the prior LVEF, the subjects were divided into improved group (prior LVEF < 40%), stable group (prior LVEF between 40 and 50%), and deteriorated group (prior LVEF ≥ 50%). The primary outcomes were cardiovascular death, all-cause mortality, hospitalization for worsening heart failure, and composite event of all-cause mortality or all-cause hospitalization. A total of 1,168 HFmrEF patients (67.04% male, mean age 63.60 ± 12.18 years) were included. The percentages of improved, stable, and deteriorated group were 310 (26.54%), 334 (28.60%), and 524 (44.86%), respectively. After a period of follow-up, 208 patients (17.81%) died and 500 patients met the composite endpoint. The rates of all-cause mortality were 35 (11.29%), 55 (16.47%), and 118 (22.52%), and the composite outcome was 102 (32.90%), 145 (43.41%), and 253 (48.28%) for the improved, stable, and deteriorated groups, respectively. Cox regression analysis showed that the deterioration group had higher risk of cardiovascular death (HR: 1.707, 95% CI: 1.064-2.739, = 0.027), all-cause death (HR 1.948, 95% CI 1.335-2.840, = 0.001), and composite outcome (HR 1.379, 95% CI 1.096-1.736, = 0.006) compared to the improvement group. The association still remained significant after fully adjusted for both all-cause mortality (HR = 1.899, 95% CI 1.247-2.893, = 0.003) and composite outcome (HR: 1.324, 95% CI: 1.020-1.718, = 0.035). HFmrEF patients are heterogeneous with three different subsets identified, each with different outcomes. Strategies for managing HFmrEF should include previously measured LVEF to allow stratification based on direction changes in LVEF to better optimize treatment.
心力衰竭管理的循证指南主要取决于当前的左心室射血分数（LVEF）。然而，较少有研究探讨既往LVEF的影响。当射血分数保留的心力衰竭（HFpEF）病情恶化或射血分数降低的心力衰竭（HFrEF）病情改善时，患者可能进入射血分数中等范围的心力衰竭（HFmrEF）类别。在本研究中，我们探讨了LVEF变化与不良结局之间的关联。我们纳入了2015年9月1日至2019年11月30日期间在大连医科大学附属第一医院进行至少两次间隔3个月以上超声心动图检查的HFmrEF患者。根据既往LVEF，将受试者分为改善组（既往LVEF<40%）、稳定组（既往LVEF在40%至50%之间）和恶化组（既往LVEF≥50%）。主要结局为心血管死亡、全因死亡率、因心力衰竭恶化住院以及全因死亡率或全因住院的复合事件。共纳入1168例HFmrEF患者（男性占67.04%，平均年龄63.60±12.18岁）。改善组、稳定组和恶化组的比例分别为310例（26.54%）、334例（28.60%）和524例（44.86%）。经过一段时间的随访，208例患者（17.81%）死亡，500例患者达到复合终点。改善组、稳定组和恶化组的全因死亡率分别为35例（11.29%）、55例（16.47%）和118例（22.52%），复合结局分别为102例（32.90%）、145例（43.41%）和253例（48.28%）。Cox回归分析显示，与改善组相比，恶化组发生心血管死亡（HR：1.707，95%CI：1.064 - 2.739，P = 0.027）、全因死亡（HR 1.948，95%CI 1.335 - 2.840，P = 0.001）和复合结局（HR 1.379，95%CI 1.096 - 1.736，P = 0.006）的风险更高。在对全因死亡率（HR = 1.899，95%CI 1.247 - 2.893，P = 0.003）和复合结局（HR：1.324，95%CI：1.020 - 1.718，P = 0.035）进行充分调整后，这种关联仍然显著。HFmrEF患者存在异质性，可分为三个不同亚组，每个亚组的结局不同。管理HFmrEF的策略应包括既往测量的LVEF，以便根据LVEF的变化方向进行分层，从而更好地优化治疗。
