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Observational Study
. 2020 Dec;22(12):2258-2268.
doi: 10.1002/ejhf.1945. Epub 2020 Aug 9.

Prognostic impacts of dynamic cardiac structural changes in heart failure patients with preserved left ventricular ejection fraction

Shinsuke Yamanaka  1 , Yasuhiko Sakata  1   2 , Kotaro Nochioka  1   2 , Masanobu Miura  1 , Shintaro Kasahara  1 , Masayuki Sato  1 , Hajime Aoyanagi  1 , Takahide Fujihashi  1 , Hideka Hayashi  1 , Takashi Shiroto  1 , Koichiro Sugimura  1 , Jun Takahashi  1 , Satoshi Miyata  1   3 , Hiroaki Shimokawa  1   2   3 ; CHART-2 Investigators
Affiliations
Observational Study

Prognostic impacts of dynamic cardiac structural changes in heart failure patients with preserved left ventricular ejection fraction

Shinsuke Yamanaka et al. Eur J Heart Fail. 2020 Dec.

Abstract

Aims: We aimed to examine temporal changes in left ventricular (LV) structures and their prognostic impacts in patients with heart failure (HF) and preserved ejection fraction (HFpEF).

Methods and results: In the Chronic Heart Failure Analysis and Registry in the Tohoku District-2 (CHART-2) study (n = 10 219), we divided 2698 consecutive HFpEF patients (68.9 ± 12.2 years, 32.1% female) into three groups by LV hypertrophy (LVH) and enlargement (LVE) at baseline: (-)LVH/(-)LVE (n = 989), (+)LVH/(-)LVE (n = 1448), and (+)LVH/(+)LVE (n = 261). We examined temporal changes in LV structures and their prognostic impacts during a median 8.7-year follow-up. From (-)LVH/(-)LVE, (+)LVH/(-)LVE to (+)LVH/(+)LVE at baseline, the incidence of the primary outcome, a composite of cardiovascular death or HF admission, significantly increased. Among 1808 patients who underwent echocardiography at both baseline and 1 year, we noted substantial group transitions from baseline to 1 year; the transition rates from (-)LVH/(-)LVE to (+)LVH/(-)LVE, from (+)LVH/(-)LVE to (-)LVH/(-)LVE, from (+)LVH/(-)LVE to (+)LVH/(+)LVE, and from (+)LVH/(+)LVE to (+)LVH/(-)LVE were 27% (182/671), 22% (213/967), 6% (59/967), and 26% (44/170), respectively. In the univariable Cox proportional hazard model, patients who transitioned from (+)LVH/(-)LVE to (+)LVH/(+)LVE or remained in (+)LVH/(+)LVE had the worst subsequent prognosis [hazard ratio (HR) 4.65, 95% confidence interval (CI) 3.09-6.99, P < 0.001; HR 4.01, 95% CI 2.85-5.65, P < 0.001, respectively], as compared with those who remained in (-)LVH/(-)LVE. These results were unchanged after adjustment for the covariates including baseline LV ejection fraction (LVEF) and 1-year LVEF change.

Conclusion: In HFpEF patients, LV structures dynamically change over time with significant prognostic impacts, where patients who develop LVE with LVH have the worst prognosis.

Keywords: Cardiac structures; Heart failure with preserved ejection fraction; Prognosis.

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Figures

Figure 1
Figure 1
Study flowchart. HFpEF, heart failure with preserved ejection fraction; LVDdI, left ventricular diastolic dimension index; LVE, left ventricular enlargement; LVEF, left ventricular ejection fraction; LVH, left ventricular hypertrophy; LVMI, left ventricular mass index; VHD, valvular heart disease.
Figure 2
Figure 2
Prognostic impacts of baseline left ventricular structures in patients with heart failure and preserved ejection fraction. In the multivariable Cox hazard model, the following covariates were adjusted: age, sex, ischaemic heart disease, hypertension, diabetes mellitus, atrial fibrillation, baseline left ventricular ejection fraction, and medications. aHR, adjusted hazard ratio; CI, confidence interval; LVE, left ventricular enlargement; LVH, left ventricular hypertrophy.
Figure 3
Figure 3
Dynamic changes in left ventricular structures in patients with heart failure and preserved ejection fraction. The stacked bars show the proportions of patients in each left ventricular structural group at every follow‐up year. The number of patients at every follow‐up year is shown above the bars. The means and standard deviations of baseline values and changes from baseline in left ventricular ejection fraction (LVEF), left ventricular mass index (LVMI), and left ventricular diastolic dimension index (LVDdI) are shown under the bars. LVE, left ventricular enlargement; LVH, left ventricular hypertrophy.
Figure 4
Figure 4
Prognostic impacts of temporal changes in left ventricular (LV) structures in patients with heart failure and preserved ejection fraction (HFpEF). The upper panel shows dynamic LV structural changes in HFpEF patients; temporal LV structural changes occur bidirectionally in terms of the progression/regression of LV hypertrophy (LVH) and enlargement (LVE). The middle panel shows the incidence rates per 1000 person‐years for the primary outcome after 1‐year changes in LV structures. The lower panel shows the subsequent risk for the primary outcome after 1‐year changes in LV structures in the univariable Cox proportional hazard model. CI, confidence interval; HR, hazard ratio.
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