Myocardial strain to identify benefit from beta-blockers in patients with heart failure with reduced ejection fraction

Abstract

Aims: Not all patients with heart failure with reduced ejection fraction (HFrEF) benefit equally from beta-blockers. Previous studies suggest that myocardial strain that reflects myocardial deformation may have a better prognostic value than the left ventricular ejection fraction. We aimed to evaluate the differential effect of beta-blockers according to the global longitudinal strain (GLS) in patients with HFrEF.

Methods and results: Of the 4312 patients in the Strain for Risk Assessment and Therapeutic Strategies in Patients with Acute Heart Failure registry, we included 2126 HFrEF patients whose data on beta-blocker use and GLS were available. Patients were categorized into two groups: one group of patients had GLS ≥ 10%, and the other group had GLS < 10%. The primary outcome was 5 year all-cause mortality according to beta-blocker use. Of the 2126 patients with HFrEF, 526 (24.7%) and 1600 (75.3%) patients had GLS ≥ 10% and <10%, respectively. Overall, 1399 patients (65.8%) received beta-blockers, and 864 (40.6%) patients died during the 5 year follow-up. Beta-blocker use was associated with improved survival in patients with GLS < 10% in both the inverse probability treatment-weighted (hazard ratio 0.70, 95% confidence interval 0.59-0.83, P < 0.001) and Cox regression analyses (hazard ratio 0.69, 95% confidence interval 0.59-0.81; P < 0.001). However, beta-blocker use was not associated with better survival in patients with GLS ≥ 10% in the inverse probability treatment-weighted and Cox regression analyses (both P > 0.05).

Conclusions: Beta-blocker use appears to be associated with improved survival in patients with HFrEF and GLS < 10%, but this is not the case in patients with GLS ≥ 10%. Therefore, GLS may be used to identify patients who have attenuated benefits from beta-blockers in HFrEF.

Clinical trial registration: ClinicalTrials.gov: NCT03513653 (https://clinicaltrials.gov/ct2/show/NCT03513653).

Keywords: Beta-blocker; Heart failure with reduced ejection fraction; Mortality; Myocardial strain; Prognosis.

Figure 1

Study population. Flow chart of this study is presented. GLS, global longitudinal strain; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction; STRATS‐AHF, Strain for Risk Assessment and Therapeutic Strategies in Patients with Acute Heart Failure.

Figure 2

Clinical outcomes according to beta‐blockers (BB) stratified by global longitudinal strain (GLS) in the crude population. Left panel: Kaplan–Meier survival curves for 5 year mortality according to BB use are presented in both the crude population of patients with GLS values of <10% and ≥10%. Right panel: KaplanMeier survival curves using different GLS cut‐off values (7% and 13%) in the sensitivity analyses. HR, hazard ratio.

Figure 3

Association between 5 year all‐cause mortality and beta‐blocker use in subgroups. (A) The effect of beta‐blockers in subgroups stratified by age, sex, heart failure (HF) onset, previous history of hypertension (HTN), diabetes mellitus (DM), ischaemic heart disease (IHD), and atrial fibrillation (AF), heart rate, and global longitudinal strain (GLS) is presented. The squares with horizontal lines indicate the hazard ratios (HRs) and corresponding 95% confidence intervals (CIs). (B) Cox regression analysis demonstrates the relative HRs (solid line) and 95% CIs (shaded area) for patients taking beta‐blockers in comparison with those not taking beta‐blockers. ADHF, acute decompensated heart failure.