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. 2021 Aug 2:8:697221.
doi: 10.3389/fcvm.2021.697221. eCollection 2021.

Heart Failure With Midrange Ejection Fraction: Prior Left Ventricular Ejection Fraction and Prognosis

Xinxin Zhang  1 , Yuxi Sun  1 , Yanli Zhang  1 , Feifei Chen  1 , Shuyuan Zhang  1 , Hongyan He  1 , Shuang Song  1 , Gary Tse  1   2 , Ying Liu  1
Affiliations

Heart Failure With Midrange Ejection Fraction: Prior Left Ventricular Ejection Fraction and Prognosis

Xinxin Zhang et al. Front Cardiovasc Med. .

Abstract

Aims: 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. Methods: 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. Results: 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, P = 0.027), all-cause death (HR 1.948, 95% CI 1.335-2.840, P = 0.001), and composite outcome (HR 1.379, 95% CI 1.096-1.736, P = 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, P = 0.003) and composite outcome (HR: 1.324, 95% CI: 1.020-1.718, P = 0.035). Conclusion: 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.

Keywords: heart failure; left ventricular ejection fraction; mid-range ejection fraction; prior; prognosis.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Flow diagram of patient flow.
Figure 2
Figure 2
Kaplan-Meier curves for mortality for the subsets of heart failure with midrange ejection fraction.
Figure 3
Figure 3
Kaplan-Meier curves for composite outcome of mortality or hospitalization for the subsets of heart failure with midrange ejection fraction.
Figure 4
Figure 4
Forest plot of clinical outcomes in HFmrEF subgroups.
See this image and copyright information in PMC

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