Differences between HF with poor vs preserved LV function
Differences between HF with poor vs preserved LV function
Washington, DC - Patients hospitalized with heart failure and preserved LV systolic function fare better during hospitalization than those with a low LVEF, but that advantage may go away a few months after discharge, suggest data from a large registry.
The report is published in the August 21, 2007 issue of the Journal of the American College of Cardiology.
The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) analysis also found that among HF patients with preserved LV systolic function, compared with those with LV systolic dysfunction, treatment with ACE inhibitors, angiotensin receptor blockers (ARBs), or beta blockers didn't improve postdischarge outcomes over the short term. For up to three months after the preserved-LVEF group left the hospital, there was "not even a remote suggestion of any benefit seen with these agents," lead author Dr Gregg C Fonarow (University of California, Los Angeles Medical Center) told heartwire.
To distinguish the two groups, you really need to see the echocardiogram and the measurement of LVEF.
"That doesn't preclude that these medications could have a longer-term benefit—maybe the manifestations of [their] clinical benefit are just much earlier in LV-systolic-dysfunction patients than in preserved-systolic-function heart failure," he said. "It may reflect that there is a greater difference in the pathophysiology between these two patient populations than was previously appreciated and that the ability of a ventricle that is more grossly dilated and has an impairment in systolic function may be more amenable to these therapies than the ventricle that is not dilated and has preserved systolic function but also impairments in relaxation and compliance."
The findings, according to Fonarow, "highlight how much more there is to learn about the pathophysiology and important mechanisms of preserved-systolic-function heart failure as we begin to think about which new and additional therapies we need to test in this population."
In the registry of patients hospitalized with new-onset or worsening preexisting HF, preserved LV systolic function was defined as an LVEF >40%. Importantly, Fonarow noted, secondary analyses disclosed little difference in clinical presentation, treatment, or outcomes between those with poor or preserved systolic function, whether the latter was defined as an LVEF >40% or, the cut point used in some reports, >50%.
That makes 40% the "reasonable" threshold for distinguishing the two groups, Fonarow said, and supports the oft-cited "about half" as the proportion of patients with acute HF who have preserved LV function: in this analysis, 51.2% of the patients had an LVEF >40% (or, alternatively for the definition of preserved LV function, had "a qualitatively normal/mildly impaired ejection fraction" when the LVEF numbers weren't available).
In-hospital and postdischarge outcomes by systolic function in OPTIMIZE-HF
*Preserved systolic function defined as LVEF >40%
Some HF specialists contend, with the paucity of randomized-trial data supporting specific drug therapies for preserved-systolic-function HF, that "maybe all heart failure is the same," and so the same treatments and performance measures should apply regardless of systolic function, according to Fonarow. In fact, he said, "there are important differences between the two populations."
On the other hand, the preserved-systolic-function patients aren't likely to be identified based on clinical presentation alone, Fonarow observed. In OPTIMIZE-HF, although preserved-systolic-function patients were older and more likely to be women and have hypertension, the two groups had similar prevalences of, for example, acute congestion, chest pain, and resting and exertional dyspnea. "To distinguish the two groups, you really need to see the echocardiogram and the measurement of LVEF."
Effect of drug therapy on mortality and/or rehospitalization at 60-90 days in OPTIMIZE-HF (risk- and propensity-adjusted model)
a. Preserved systolic function defined as LVEF >40%
b. p=0.002
c. p=0.025
ARB=angiotensin receptor blocker
Washington, DC - Patients hospitalized with heart failure and preserved LV systolic function fare better during hospitalization than those with a low LVEF, but that advantage may go away a few months after discharge, suggest data from a large registry.
The report is published in the August 21, 2007 issue of the Journal of the American College of Cardiology.
The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) analysis also found that among HF patients with preserved LV systolic function, compared with those with LV systolic dysfunction, treatment with ACE inhibitors, angiotensin receptor blockers (ARBs), or beta blockers didn't improve postdischarge outcomes over the short term. For up to three months after the preserved-LVEF group left the hospital, there was "not even a remote suggestion of any benefit seen with these agents," lead author Dr Gregg C Fonarow (University of California, Los Angeles Medical Center) told heartwire.
To distinguish the two groups, you really need to see the echocardiogram and the measurement of LVEF.
"That doesn't preclude that these medications could have a longer-term benefit—maybe the manifestations of [their] clinical benefit are just much earlier in LV-systolic-dysfunction patients than in preserved-systolic-function heart failure," he said. "It may reflect that there is a greater difference in the pathophysiology between these two patient populations than was previously appreciated and that the ability of a ventricle that is more grossly dilated and has an impairment in systolic function may be more amenable to these therapies than the ventricle that is not dilated and has preserved systolic function but also impairments in relaxation and compliance."
The findings, according to Fonarow, "highlight how much more there is to learn about the pathophysiology and important mechanisms of preserved-systolic-function heart failure as we begin to think about which new and additional therapies we need to test in this population."
In the registry of patients hospitalized with new-onset or worsening preexisting HF, preserved LV systolic function was defined as an LVEF >40%. Importantly, Fonarow noted, secondary analyses disclosed little difference in clinical presentation, treatment, or outcomes between those with poor or preserved systolic function, whether the latter was defined as an LVEF >40% or, the cut point used in some reports, >50%.
That makes 40% the "reasonable" threshold for distinguishing the two groups, Fonarow said, and supports the oft-cited "about half" as the proportion of patients with acute HF who have preserved LV function: in this analysis, 51.2% of the patients had an LVEF >40% (or, alternatively for the definition of preserved LV function, had "a qualitatively normal/mildly impaired ejection fraction" when the LVEF numbers weren't available).
In-hospital and postdischarge outcomes by systolic function in OPTIMIZE-HF
| Treatment | LV systolic dysfunction | Preserved systolic function* | p |
| All patients | n=20 118 | n=21 149 | |
| In-hospital mortality (%) | 3.9 | 2.9 | <0.0001 |
| Follow-up cohort | n=2604 | n=2294 | |
| Postdischarge mortality at 60-90 days (%) | 9.8 | 9.5 | 0.459 |
| Postdischarge mortality and/or rehospitalization at 60-90 days (%) | 36.1 | 35.3 | 0.577 |
*Preserved systolic function defined as LVEF >40%
Some HF specialists contend, with the paucity of randomized-trial data supporting specific drug therapies for preserved-systolic-function HF, that "maybe all heart failure is the same," and so the same treatments and performance measures should apply regardless of systolic function, according to Fonarow. In fact, he said, "there are important differences between the two populations."
On the other hand, the preserved-systolic-function patients aren't likely to be identified based on clinical presentation alone, Fonarow observed. In OPTIMIZE-HF, although preserved-systolic-function patients were older and more likely to be women and have hypertension, the two groups had similar prevalences of, for example, acute congestion, chest pain, and resting and exertional dyspnea. "To distinguish the two groups, you really need to see the echocardiogram and the measurement of LVEF."
Effect of drug therapy on mortality and/or rehospitalization at 60-90 days in OPTIMIZE-HF (risk- and propensity-adjusted model)
| Treatment | Preserved systolic function, HR (95% CI) | LV systolic dysfunction, HR (95% CI) |
| ACE inhibitor or ARB, yes vs no | 0.909 (0.692-1.196) | 0.515 (0.339-0.781) |
| Beta blocker, yes vs no | 0.923(0.723 -1.179) | 0.727(0.550-0.960) |
a. Preserved systolic function defined as LVEF >40%
b. p=0.002
c. p=0.025
ARB=angiotensin receptor blocker
| OPTIMIZE-HF and the current analysis were funded by GlaxoSmithKline (GSK). Fonarow reports having received research grants from Amgen, Biosite, Boston Scientific/Guidant, Bristol-Myers Squibb, GSK, Medtronic, Merck, Pfizer, Sanofi-Aventis, and Scios; being on the speakers' bureau of or having received honoraria from AstraZeneca, Biosite, Boston Scientific/Guidant, Bristol-Myers Squibb, GSK, Medtronic, Merck, NitroMed, Pfizer, Sanofi-Aventis, Schering-Plough, Scios, St Jude Medical, and Wyeth; and being a consultant for Biosite, Boston Scientific/Guidant, GSK, Medtronic, Merck, NitroMed, Pfizer, Bristol-Myers Squibb, Sanofi-Aventis, Schering-Plough, Scios, and Wyeth. Disclosures for the other coauthors are provided in the report. |
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