Sadek Mahmoud Hazem Ahmed, Aboul-Saud Mona Ibrahim, El Missiri Ahmed Mohamed, Abdellatif Yasser Alaaeldin Mahmoud
Department of Cardiology, Military Medical Academy, Cairo, Egypt.
Department of Cardiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
J Cardiovasc Echogr. 2025 Jan-Mar;35(1):23-31. doi: 10.4103/jcecho.jcecho_58_24. Epub 2025 Apr 30.
Cardiac remodeling in response to hemodynamic and neurohormonal factors is the primary driver of heart failure progression. Angiotensin receptor-neprilysin inhibitor (ARNI) has superior beneficial effects on mortality and quality of life compared to angiotensin-converting enzyme inhibitor (ACEI). Speckle-tracking echocardiography can detect early subtle changes in cardiac structure in numerous cardiac diseases. The study was conducted to evaluate the possible impact of ARNI therapy compared to ACEI on cardiac remodeling using echocardiographic parameters, including global longitudinal strain (GLS) in heart failure with reduced left ventricular ejection fraction (HFrEF) patients.
This prospective observational study included eighty recently diagnosed HFrEF patients with left ventricular ejection fraction (LVEF) ≤35%, prescribed the four pillars of guideline-directed medical therapy, and uptitrated to the maximally tolerated doses. The study included two groups: the ARNI group included forty patients prescribed ARNI, and the ACEI group included forty patients prescribed ACEI. All patients underwent two- and three-dimensional (2D and 3D) echocardiography to assess baseline parameters, including indexed left ventricular (LV) volumes and 2D and 3D GLS, at baseline and after a 6-month follow-up period.
Both groups had no significant differences regarding demographic data and echocardiographic findings at baseline. After a 6-month follow-up period, there was a significant reduction in LV-indexed volumes in the ARNI group ( < 0.001) and indexed left atrial volumes ( = 0.013) compared to the ACEI group. There was a significant improvement in the ARNI group regarding LVEF ( = 0.011), 2D GLS ( < 0.001), and 3D GLS compared to the ACEI group, but no significant change in the LV mass index. Multivariate regression analysis showed that the use of ARNI, absence of diabetes mellitus, and a higher baseline GLS (above-9.1%) are independent predictors for the occurrence of reverse remodeling (defined as an increase in LVEF ≥5%).
The inclusion of ARNI in the pharmacotherapy of HFrEF patients is an independent predictor of LV reverse remodeling, as observed in a significant improvement in both 2D and 3D volumetric echocardiographic parameters, improved LVEF and longitudinal LV systolic function, represented in 2D and 3D GLS. Baseline 3D GLS and not LVEF or 2D GLS can help predict the occurrence of reverse remodeling in HFrEF patients.
心脏对血流动力学和神经激素因素的重塑是心力衰竭进展的主要驱动因素。与血管紧张素转换酶抑制剂（ACEI）相比，血管紧张素受体脑啡肽酶抑制剂（ARNI）对死亡率和生活质量具有更显著的有益影响。斑点追踪超声心动图可以检测多种心脏疾病中心脏结构的早期细微变化。本研究旨在使用超声心动图参数，包括左心室射血分数降低（HFrEF）患者的整体纵向应变（GLS），评估与ACEI相比，ARNI治疗对心脏重塑的可能影响。
这项前瞻性观察性研究纳入了80例最近诊断为HFrEF且左心室射血分数（LVEF）≤35%的患者，这些患者接受了指南指导的药物治疗的四大支柱，并滴定至最大耐受剂量。该研究包括两组：ARNI组包括40例服用ARNI的患者，ACEI组包括40例服用ACEI的患者。所有患者在基线和6个月随访期后均接受二维和三维（2D和3D）超声心动图检查，以评估基线参数，包括左心室（LV）指数容积以及2D和3D GLS。
两组在基线时的人口统计学数据和超声心动图检查结果方面无显著差异。在6个月的随访期后，与ACEI组相比，ARNI组的LV指数容积显著降低（<0.001），左心房指数容积显著降低（=0.013）。与ACEI组相比，ARNI组在LVEF（=0.011）、2D GLS（<0.001）和3D GLS方面有显著改善，但LV质量指数无显著变化。多因素回归分析表明，使用ARNI、无糖尿病以及较高的基线GLS（高于9.1%）是逆向重塑（定义为LVEF增加≥5%）发生的独立预测因素。
在HFrEF患者的药物治疗中加入ARNI是LV逆向重塑的独立预测因素，这在二维和三维容积超声心动图参数显著改善、LVEF改善以及LV纵向收缩功能改善（以二维和三维GLS表示）中得到体现。基线三维GLS而非LVEF或二维GLS有助于预测HFrEF患者逆向重塑的发生。
