Predictors and prognostic implications of left ventricular ejection fraction trajectory improvement in the spectrum of heart failure with reduced and mildly reduced ejection fraction

Abstract

Background: The latest guidelines emphasize the significance of evaluating the left ventricular ejection fraction (LVEF) trajectory in patients with heart failure (HF). Because patients with HF with reduced ejection fraction (HFrEF) and HF with mildly reduced ejection fraction (HFmrEF) have reduction in systolic function, they might be in a trajectory of LVEF improvement after medical and device-based therapies. While previous studies have primarily focused on LVEF improvement in HFrEF, there is limited research on LVEF trajectory improvement across the spectrum of HFrEF and HFmrEF. This study aimed to assess the determinants and prognostic implications of LVEF trajectory improvement in HFrEF and HFmrEF patients.

Methods: The cohort was classified into the improved group (HFrEF-to-HF with improved ejection fraction (HFimpEF) and HFmrEF-to-HF with preserved ejection fraction (HFpEF)) and the unimproved group (lack of improved group criteria). The primary endpoints were the composite of all-cause mortality or HF hospitalization, all-cause mortality, and HF hospitalization. Predictors of LVEF trajectory improvement were also evaluated.

Results: A total 1303 patients were included in the study (improved/unimproved group: n = 497/806). Cox regression analysis showed that the improved group experienced lower risks of prespecified end points than the unimproved group. Multivariate logistic regression analysis showed that atrial flutter, use of spironolactone, and treatment with catheter ablation were associated with LVEF trajectory improvement, while myocardial infarction, prior percutaneous catheter intervention or coronary artery bypass graft, E/e', and left ventricular end-diastolic diameter were identified as negative predictors of LVEF trajectory improvement. In the improved subgroup, the prognosis for the HFrEF-to-HFimpEF and HFmrEF-to-HFpEF was comparable.

Conclusions: LVEF trajectory improvement patients had improved clinical outcomes and it was associated with important clinical, baseline cardiac structure and function, and treatment factors. Outcomes were similar in both HFrEF-to-HFimpEF and HFmrEF-to-HFpEF subgroups. These results suggest that emphasis should be placed on LVEF trajectory improvement to improve the outcomes of this population.

Keywords: Heart failure with mildly reduced ejection fraction; Heart failure with reduced ejection fraction; Improvement; Left ventricular ejection fraction; Trajectory.