Prognostic value of reverse remodelling criteria in heart failure with reduced or mid-range ejection fraction

Abstract

Aims: Reverse remodelling (RR) is the recovery from left ventricular (LV) dilatation and dysfunction. Many arbitrary criteria for RR have been proposed. We searched the criteria with the strongest prognostic yield for the hard endpoint of cardiovascular death.

Methods and results: We performed a systematic literature search of diagnostic criteria for RR. We evaluated their prognostic significance in a cohort of 927 patients with LV ejection fraction (LVEF) < 50% undergoing two echocardiograms within 12 ± 2 months. These patients were followed for a median of 2.8 years (interquartile interval 1.3-4.9) after the second echocardiogram, recording 123 cardiovascular deaths. Two prognostic models were defined. Model 1 included age, LVEF, N-terminal pro-B-type natriuretic peptide, ischaemic aetiology, cardiac resynchronization therapy, estimated glomerular filtration rate, New York Heart Association, and LV end-systolic volume (LVESV) index, and Model 2 the validated Cardiac and Comorbid Conditions Heart Failure score. We identified 25 criteria for RR, the most used being LVESV reduction ≥15% (12 studies out of 42). In the whole cohort, two criteria proved particularly effective in risk reclassification over Model 1 and Model 2. These criteria were (i) LVEF increase >10 U and (ii) LVEF increase ≥1 category [severe (LVEF ≤ 30%), moderate (LVEF 31-40%), mild LV dysfunction (LVEF 41-55%), and normal LV function (LVEF ≥ 56%)]. The same two criteria yielded independent prognostic significance and improved risk reclassification even in patients with more severe systolic dysfunction, namely, those with LVEF < 40% or LVEF ≤ 35%. Furthermore, LVEF increase >10 U and LVEF increase ≥1 category displayed a greater prognostic value than LVESV reduction ≥15%, both in the whole cohort and in the subgroups with LVEF < 40% or LVEF ≤ 35%. For example, LVEF increase >10 U independently predicted cardiovascular death over Model 1 and LVESV reduction ≥15% (hazard ratio 0.40, 95% confidence interval 0.18-0.90, P = 0.026), while LVESV reduction ≥15% did not independently predict cardiovascular death (P = 0.112).

Conclusions: Left ventricular ejection fraction increase >10 U and LVEF increase ≥1 category are stronger predictors of cardiovascular death than the most commonly used criterion for RR, namely, LVESV reduction ≥15%.

Keywords: Criteria; Heart failure; Prognosis; Reverse remodelling.

Figure 1

Flowchart of study selection. AR, adverse remodelling; HF, heart failure; HFmrEF, HF with mid‐range ejection fraction; HFrEF, HF with reduced ejection fraction; RR, reverse remodelling.

Figure 2

Prevalence of reverse remodelling in the whole cohort using diagnostic criteria from the literature. FS, fractional shortening; LVEDD(i), left ventricular end‐diastolic diameter (index); LVEF, left ventricular ejection fraction; LVESD(i), left ventricular end‐systolic diameter (index); LVESV, left ventricular end‐systolic volume; LVM, left ventricular mass.