Phenotyping Heart Failure According to the Longitudinal Ejection Fraction Change: Myocardial Strain, Predictors, and Outcomes

Jin Joo Park, Alexandre Mebazaa, In-Chang Hwang, Jun-Bean Park, Jae-Hyeong Park, Goo-Yeong Cho, Jin Joo Park, Alexandre Mebazaa, In-Chang Hwang, Jun-Bean Park, Jae-Hyeong Park, Goo-Yeong Cho

Abstract

Background Many patients with heart failure (HF) experience changes in left ventricular ejection fraction (LVEF) during follow-up. We sought to evaluate the predictors and outcomes of different HF phenotypes according to longitudinal changes in EF. Methods and Results A total of 2104 patients with acute HF underwent echocardiography at baseline and follow-up. Global longitudinal strain was measured at index admission. HF phenotypes were defined as persistent HF with reduced EF (persistent HFrEF, LVEF ≤40% at baseline and follow-up), heart failure with improved ejection fraction (LVEF≤40% at baseline and improved to >40% at follow-up), heart failure with declined ejection fraction (LVEF>40% at baseline and declined to ≤40% at follow up), and persistent HF with preserved EF (persistent HFpEF, LVEF>40% at baseline and follow-up). Overall, 1130 patients had HFrEF at baseline; during follow-up, 54.2% and 46.8% had persistent HFrEF and heart failure with improved ejection fraction, respectively. Among 975 patients with HFpEF at baseline, 89.5% and 10.5% had persistent HFpEF and heart failure with declined ejection fraction at follow-up, respectively. The 5-year all-cause mortality rates were 43.1%, 33.1%, 24%, and 17% for heart failure with declined ejection fraction, persistent HFrEF, persistent HFpEF, and heart failure with improved ejection fraction, respectively (global log-rank P<0.001). In multivariable analyses, each 1% increase in global longitudinal strain (greater contractility) was associated with 10% increased odds for heart failure with improved ejection fraction among patients with HFrEF at baseline and 7% reduced odds for heart failure with declined ejection fraction among patients with HFpEF at baseline. Conclusions LVEF changed during follow-up. Each HF phenotype according to longitudinal LVEF changes has a distinct prognosis. Global longitudinal strain can be used to predict the HF phenotype. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03513653.

Keywords: HFdEF; HFiEF; ejection fraction change; heart failure; myocardial strain.

Figures

Figure 1. Study population
Figure 1. Study population
HFrEF, heart failure with reduced ejection fraction; HFiEF, heart failure with improved ejection fraction; HFpEF, heart failure with preserved ejection fraction; and HFdEF, heart failure with declined ejection fraction.
Figure 2. Longitudinal changes in ejection fraction…
Figure 2. Longitudinal changes in ejection fraction according to heart failure phenotypes and baseline ejection fraction.
A, In patients with heart failure with improved ejection fraction (HFiEF), the left ventricular ejection fraction (LVEF) improved to >50% in mildly (LVEF: 30–40%), moderately (LVEF: 20–30%), and severely (LVEF ≤20%) depressed LVEF; whereas the change in LVEF was minimal among patients with persistent heart failure with reduced ejection fraction (HFrEF). B, In patients with heart failure with declined ejection fraction (HFdEF), the LVEF decreased to <35% in all 3 groups (LVEF: 40–50%, 50–60%, or >60%); whereas the change in LVEF was minimal among patients with persistent heart failure with preserved ejection fraction (HFpEF).
Figure 3
Figure 3
Myocardial strain and heart failure phenotypes according to changes in LVEF. A, Patients were stratified according to GLS tertiles. The proportion of persistent HFrEF and that of HFdEF was highest in the lowest GLS tertile. B, Incremental prognostic value of predictors by binary logistic regression model presented as global χ2 value. The addition of GLS offers a significant additional benefit over conventional parameters. BB indicates beta‐blockers; GLS, global longitudinal strain; HFdEF, heart failure with declined ejection fraction; HFiEF, heart failure with improved ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HR, heart rate; IDI, integrated discrimination index; LA, left atrium; LVEDD, left ventricular end diastolic diameter; LVEF, left ventricular ejection fraction; NP, natriuretic peptide; and SBP, systolic blood pressure.
Figure 4
Figure 4
Five‐year ACM and its composite and hospitalization according to HF phenotypes. A, ACM in HFrEF vs HFpEF. B, ACM according to HF phenotypes. HFiEF, heart failure with improved ejection fraction; C, The composite of ACM and hospitalization for HF according to HF phenotypes. ACM indicates all‐cause mortality; HF, heart failure; HFdEF, heart failure with declined ejection fraction; HFiEF, heart failure with improved ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; and HHF, hospitalization for HF.
Figure 5
Figure 5
Longitudinal changes of HF phenotypes and outcomes. Patients with HFpEF and HFrEF have a similar prognosis according to classification at baseline. LVEF is not static but changes during follow‐up. Each HF phenotype according to the longitudinal LVEF change (ie, persistent HFrEF, HFiEF, persistent HFpEF, and HFdEF) has a distinct prognosis. HF indicates heart failure; HFdEF, heart failure with declined ejection fraction; HFiEF, heart failure with improved ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction, and LVEF, left ventricular ejection fraction.

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