The representativeness of VICTORIA and GALACTIC-HF trials in a contemporary cohort of patients with heart failure with reduced ejection fraction
A Oliveira CampinasSalomé CamposR.C.T. CostaAna FríasAndré AlexandreCatarina GomesMário SantosSevero Torres
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Abstract Introduction New therapies for heart failure with reduced ejection fraction (HFrEF) have been recently developed. It is still unclear the proportion of patients of clinical practice that will benefit from them. We aimed to examine the representativeness of the VICTORIA and GALACTIC-HF trials among a contemporary cohort of HFrEF patients followed at an HF outpatient clinic. Methods We performed a retrospective, cross-sectional, single-center study of 100 consecutive HFrEF patients from our HF outpatient clinic (January-June 2020). VICTORIA eligibility criteria were an LVEF <45%; NT-proBNP ≥1000 pg/mL if sinus rhythm (SR) or ≥1600 pg/mL if atrial fibrillation (Afib); and prior hospitalization in the last 6 months or IV diuretic therapy in the last 3 months. GALACTIC-HF eligibility criteria were an LVEF <35%, hospitalization or emergency room visit in the last 12 months; NT-proBNP >400 ng/mL if SR or ≥1200 pg/mL if Afib or atrial flutter. Results The mean age of our patients was 62±12 years and only 24% were female. The etiology of HF was ischemic in 42% of the patients, 86% of patients were in NYHA II class and 5% in NYHA III-IV. The mean LVEF was 34±5% and the median NT-proBNP was 482 pg/mL [172–1120]. Regarding treatment, 92% of patients were on betablockers (BB), 67% on ACEI/ARBs, 25% on ARNI, 81% on MRA and 30% on iSGLT2. The use of implantable cardioverter-defibrillators was 38% and 20% of patients were resynchronized. The proportion of patients meeting VICTORIA and GALACTIC-HF eligibility criteria was 11% and 21%, respectively. But excluding the criteria of recent hospitalization the representativeness of the VICTORIA trial increased to 28% and the GALACTIC-HF to 44%. The patients that met VICTORIA eligibility criteria were older (60±11 y vs 10±12 y; p=0.006), had worse functional class (NYHA III-IV: 18% vs 3%; p=0.03), were less likely to be treated with an MRA (55% vs 85%; p=0.013) and an iSGLT2 (0% vs 34%; p=0.02). Those that met GALACTIC-HF eligibility criteria had a lower LVEF (31±3% vs 35±6%; p=0.01), were less likely to be treated with an iSGLT2 (35% vs 10%; p=0.02) and more likely to be treated with a loop diuretic (86% vs 65%; p=0.06). Conclusions In a contemporary optimally treated HFrEF cohort only a small proportion of patients met the eligibility criteria used in VICTORIA and GALACTIC-HF trials, which identified older patients with more advanced disease. Funding Acknowledgement Type of funding sources: None.Heart failure is a clinical syndrome associated with poor quality of life, substantial healthcare resource utilization, and premature mortality, in large part related to high rates of hospitalizations. The clinical manifestations of heart failure are similar regardless of the ejection fraction. Unlike heart failure with reduced ejection fraction, there are few therapeutic options for treating heart failure with preserved ejection fraction. Molecular therapies that have shown reduced mortality and morbidity in heart failure with reduced ejection have not been proven to be effective for patients with heart failure and preserved ejection fraction. The study of pathophysiological processes involved in the production of heart failure with preserved ejection fraction is the basis for identifying new therapeutic means. In this narrative review, we intend to synthesize the existing therapeutic means, but also those under research (metabolic and microRNA therapy) for the treatment of heart failure with preserved ejection fraction.
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Objective To investigate the hypercoagulation state markers in patients with atrial fibrillation and their clinical significance.Methods Sixty patients with chronic atrial fibrillation were divided into two groups,one group having no heart failure(group one,n=30) and the other having heart failure(group two,n=30).There were two age-matched and sex-matched control groups,the normal sinus rhythm group including 40 patients with cardiovascular disease but in sinus rhythm and normal heart function, the health control group including 33 healthy subjects.The plasma fibrin D-dimer was assayed using enzyme linked immunoassay.Fibrinogen(Fg) was measured.Results Compared with the healthy control group and the normal sinus rhythm group,patients with atrial fibrillation(group one) had significant increase of fibrin D-dimer(474.5) μg/L((220.0)-(843.9) μg/L) and Fg((3.74)±(0.76)) g/L,patients with atrial fibrillation and heart failure(group two) had significant increase of fibrin Ddimer(657.9) μg/L((365.8)-(1448.6) μg/L) and Fg((4.25)±(0.95)) g/L,(P(0.05)).Plasma Fg and D-dimer level were higher in group two than that in group one,(P(0.05)).In atrial fibrillation patients with left atrial diameter≥40 mm,Plasma Fg and(D-dimer) level were higher than those with left atrial diameter40 mm(P(0.05)).Conclusion Patients with atrial fibrillation show evidence of hypercoagulation,which may be correlated with the atrial thrombogenesis.In patients with atrial fibrillation,heart failure and left atrial diameter effect the levels of plasma Ddimer and Fg.
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To study the characteristics and prognostic implications of type 2 diabetes in different heart failure entities from a nationwide perspective.This observational study comprised 30,696 heart failure patients prospectively included in the Swedish Heart Failure Registry (SwedeHF) 2003-2011 from specialist care, with mortality information available until December 2014. Patients were categorized into three heart failure entities by their left ventricular ejection fraction (heart failure with preserved ejection fraction: ⩾50%, heart failure with mid-range ejection fraction: 40%-49% and heart failure with reduced ejection fraction: <40%). All-cause mortality stratified by type 2 diabetes and heart failure entity was studied by Cox regression.Among the patients, 22% had heart failure with preserved ejection fraction, 21% had heart failure with mid-range ejection fraction and 57% had heart failure with reduced ejection fraction. The proportion of type 2 diabetes was similar, ≈25% in each heart failure entity. Patients with type 2 diabetes and heart failure with preserved ejection fraction were older, more often female and burdened with hypertension and renal impairment compared with heart failure with mid-range ejection fraction and heart failure with reduced ejection fraction patients among whom ischaemic heart disease was more common. Type 2 diabetes remained an independent mortality predictor across all heart failure entities after multivariable adjustment, somewhat stronger in heart failure with left ventricular ejection fraction below 50% (hazard ratio, 95% confidence interval; heart failure with preserved ejection fraction: 1.32 [1.22-1.43], heart failure with mid-range ejection fraction: 1.51 [1.39-1.65], heart failure with reduced ejection fraction: 1.46 [1.39-1.54]; p-value for interaction, p = 0.0049).Type 2 diabetes is an independent mortality predictor across all heart failure entities increasing mortality risk by 30%-50%. In type 2 diabetes, the heart failure with mid-range ejection fraction entity resembles heart failure with reduced ejection fraction in clinical characteristics, risk factor pattern and prognosis.
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Patients with congestive heart failure have a high mortality rate and are also hospitalized frequently. We studied the effect of an angiotensin-converting–enzyme inhibitor, enalapril, on mortality and hospitalizaron in patients with chronic heart failure and ejection fractions ≤0.35.
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The aim of this prospective study was to assess the presence of sinus rhythm and atrial transport function after surgical ablation of atrial fibrillation using cryoenergy, and to evaluate predictors of the success of the procedure.Between January 2005 and September 2006, 100 consecutive patients underwent left atrial cryoablation as a concomitant surgical procedure (46 patients with paroxysmal or persistent atrial fibrillation and 54 with permanent atrial fibrillation). Mitral valve surgery was performed in 74%. The mean and the median times of follow-up were 20 +/- 8.5, and 24 months respectively. Atrial mechanical function was assessed by echocardiography.Sinus rhythm was achieved during the postoperative follow-up in 71-81% of patients - significantly more often in the group with paroxysmal and persistent atrial fibrillation (90-98%), than patients with permanent atrial fibrillation prior to surgery (51-65%) (p<0.002). At 12 and 24 months after the surgery, a total of 68.2% and 51.2% of the patients were free from atrial fibrillation; 73.9% and 60.7% of the patients from the paroxysmal and persistent atrial fibrillation group, and 60.3% and 37.7% of patients with permanent atrial fibrillation (p=0.05). Five per cent of patients required postoperative permanent pacemaker implantation. An effective left and right atrial mechanical function was detected in 70-90%, and 96-98% of patients with sinus rhythm respectively. The following circumstances were identified as negative predictors of the presence of sinus rhythm after the ablation procedure: growing diameter of the left atrium, the duration of atrial fibrillation and the severity of mitral and tricuspid regurgitation before surgery (p<0.05). Restoration of the left atrial transport function was negatively predicted by the preoperative diameter of the left atrium, the presence of mitral valve stenosis and the severity of tricuspid regurgitation (p<0.05). A total of 95.4% of patients were free from stroke at one-year follow-up, and 94.1% at 2 years after surgery.Stable sinus rhythm and effective left atrial transport function are the main factors resulting in decreased morbidity after successful ablation of atrial fibrillation. A careful post-operative follow-up of the patients and individualised treatment are necessary.
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Diastolic heart failure
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ABSTRACT: Left ventricular ejection fraction was measured by gated wall motion in 62 patients, 75 years old or older, admitted to a Geriatric Acute Assessment Ward. From this group, 42 patients not taking digitalis or other cardioactive medication were selected for analysis. Thirty of them had clinically identifiable heart disease, whereas 12 did not. Resting left ventricular ejection fractions in the 12 patients without clinically identifiable heart disease averaged 0.60 ± 0.09. None had an ejection fraction below 0.50. In the 30 patients with clinically identifiable heart disease, mean ejection fraction was 0.49 ± 0.15 (range 0.17‐0.84), P < 0.01. In the patients with heart disease, reduction of ejection fraction was correlated with either cardiac enlargement or congestive heart failure. Neither age nor electrocardiographic abnormalities added to the strength of this correlation. Fifty‐eight per cent of patients with congestive heart failure had ejection fractions 3=0.40, suggesting that congestive heart failure in this age group is frequently related to diastolic left ventricular dysfunction unaccompanied by major systolic dysfunction. The prognosis of patients with congestive heart failure and ejection fractions above 0.35 was significantly better than of patients with congestive heart failure and ejection fractions below 0.35. From these data and other data available in the literature, it is proposed that the lower limit for ejection fraction be 0.50 for patients 75 years old or older. Congestive heart failure in patients 75 years old or older appears to be associated with relatively higher ejection fractions or even with ejection fractions within the normal range. In these patients, digitalis may not be indicated, and short term‐prognosis is relatively favorable.
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Background Although the predictive value of galectin-3 for heart failure with preserved ejection fraction has been demonstrated, the diagnostic value remains unclear. The present study was performed to address this issue. Hypothesis Galectin-3 has diagnostic value for heart failure with preserved ejection fraction. Methods This is a diagnostic experiment. We conducted an observational study of 223 patients with combined symptoms of heart failure and diseases that can lead to heart failure with preserved ejection fraction. Patients were grouped into the heart failure group and control group in accordance with the 2016 European Society of Cardiology heart failure guidelines for heart failure with preserved ejection fraction. Baseline information and serum galectin-3 concentration were assessed within 24 h after admission. Results Serum galectin-3 concentration was significantly higher in the heart failure group compared with the control group. Binary logistic regression analysis showed that higher galectin-3 concentration was associated with the occurrence of heart failure with preserved ejection fraction. The area under the curve of galectin-3 was 0.763, indicating that galectin-3 has moderate diagnostic value for heart failure with preserved ejection fraction. Galectin-3 >15.974 ng/mL identified heart failure with preserved ejection fraction with 76.0% sensitivity and 71.9% specificity. Conclusions There was a correlation between galectin-3 and heart failure with preserved ejection fraction, and galectin-3 was an independent predictor of heart failure with preserved ejection fraction. The diagnostic value of galectin-3 for heart failure with preserved ejection fraction was moderate (AUC: 0.763, 95% CI: 0.696–0.821, P < 0.01, and the sensitivity is 76.0% while the specificity is 71.9% at the threshold 15.974 ng/mL) and was higher than that of interventricular septal thickness or E/A ratio.
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Last two decade, heart failure with preserved ejection fraction was deprived from being considered as a part of spectrum of heart failure. May be heart failure with preserved ejection fraction was common but not recognized by cardiology fraternity. Heart failure with reduced ejection fraction and heart failure with preserved ejection fraction each make up about half of the overall heart failure burden. But the paradox is: morbidity and mortality in heart failure with preserved ejection fraction despite being similar to patients with heart failure with reduced ejection fraction, today’s cardiology community has not much to offer in terms of mortality reducing treatment. The term diastolic heart failure has been well replaced by heart failure with preserved ejection fraction because multiple non-diastolic abnormalities in cardiovascular function also contribute to heart failure with preserved ejection fraction and diastolic dysfunction always accompanied heart failure with reduced ejection fraction. Diagnosis of heart failure with preserved ejection fraction is an uphill task since it relies upon careful clinical evaluation, doppler (pulse wave and tissue) echocardiography, and invasive hemodynamic assessment after exclusion of potential noncardiac causes of symptoms suggestive of heart failure. Patients with heart failure with preserved ejection fraction are usually older women with a history of hypertension. Obesity, coronary artery disease, diabetes mellitus, and atrial fibrillation are also highly prevalent in heart failure with preserved ejection fraction. Cornerstone of treatment of this entity revolves around treatment of underlying cause and symptom guided therapy. Nepalese Heart Journal | Volume 10 | No.1 | November 2013| Pages 46-56 DOI: http://dx.doi.org/10.3126/njh.v10i1.9747
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• Chronic heart failure with preserved ejection fraction is as common as chronic heart failure with reduced ejection fraction.• After hospitalization for heart failure with preserved ejection fraction, prognosis and rehospitalization rates are comparable to heart failure with reduced ejection fraction.• Systolic function of the cardiac muscle is impaired in heart failure with preserved ejection fraction.• According to a recent consensus statement of the Heart Failure Association of the European Society of Cardiology, the diagnosis of heart failure with preserved ejection fraction remains challenging, but the use of serum brain natriuretic peptide (BNP) and tissue Doppler imaging (TDI) has increased accuracy.• Treatment of heart failure with preserved ejection fraction should be empiric, and phenotype-oriented as well as symptom-oriented.
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