Analysis Of Clinical Characteristics And Outcomes Of Patients With Heart Failure With Reduced And Midrange Ejection Fraction

BackgroundHeart failure,referred to as heart failure(HF),is a complex clinical syndrome of systolic and/or diastolic dysfunction caused by various causes,and is the end stage of various heart diseases.Due to the high morbidity and high mortality of heart failure,it brings a heavy economic and medical burden to the society.It is one of the most difficult problems in the cardiovascular field.According to the left ventricular ejection fraction(LVEF),the heart failure was divided into heart failure with reduced(HFrEF)and preserved ejection fraction(HFpEF).In 2016,the European Society of Cardiology(ESC)first proposed the new concept of the heart failure with midrange ejection fraction(HFmrEF).But there are few studies on the comparison of the clinical characteristics and outcomes between HFrEF and HFmrEF.Therefore,this study used echocardiography combined with general data of patients with heart failure to explore the clinical characteristics and outcomes of different ejection fractions of heart failure.Objectives1.To compare the clinical characteristics between heart failure with reduced and midrange ejection fraction.2.To analyze the differences in short-term clinical outcomes between heart failure with reduced and midrange ejection fraction.Methods1.Study populationsThe subjects were divided into heart failure group and control group.A total of 173 heart failure patients from September 2016 to January 2019 in Qilu Hospital of Shandong University were enrolled in the heart failure group,which was divided into two subgroups according to the LVEF,the HFrEF subgroup(LVEF<40%)and the HFmrEF(40%≤LVEF<50%)subgroup.The control group selected 36 patients with age,gender matched with observation group,and no history of hypertension,diabetes,coronary heart disease and other major diseases2.Materials and methods2.1 General dataDetailed data of all subjects,including age,gender,height,weight,systolic blood pressure(SBP),diastolic blood pressure(DBP),pulse pressure(PP),heart rate(HR),NT-proBNP,comorbidities(including history of hypertension,coronary heart disease and diabetes),and body surface area(BSA)and body mass index(BMI)were calculated according to the formula.2.2 Echocardiographic image collectionAll subjects underwent echocardiography,connected with synchronized limb lead electrocardiogram,and acquired two-dimensional and doppler echocardiographic images.Each image was collected for 3 cardiac cycles and stored in DICOM format.2.3.Image Measurement and Analysis2.3.1 Two-dimensional echocardiographic parametersMeasure left ventricular end diastolic diameter(LVEDD),left ventricular posterior wall(LVPW),interventricular septum(IVS),left atrial diameter(LAD),left ventricular end systolic volume(LVESV),left ventricular end diastolic volume(LVEDV),left atrial volume(LAV).Left ventricular mass(LVM),left ventricular mass index(LVMI),left atrial volume index(LAVi),left ventricular ejection fraction(LVEF),stroke volume(SV),cardiac output(CO)and heart Index(CI)were calculated according to the formula.2.3.2 Doppler echocardiographic parametersMeasure early diastolic mitral valve anterior blood flow velocity E peak(E)and late diastolic blood flow velocity A peak(A),calculate E/A.Measure early diastolic mitral annulus interval motion velocity(e’-s)and the side wall motion speed(e’-1),the average values e’ and E/e’ are calculated.2.3.3 Two-dimensional speckle tracking parametersUsing two-dimensional speckle tracking technology,the apical two-chamber heart,three-chamber heart,and four-chamber heart image were selected and entered into aCMQ mode.The software automatically calculated the left ventricular global longitudinal strain(GLS).2.4 Follow-upThe outpatient review,re-admission medical records,and monthly telephone follow-up were conducted.The endpoint was defined as all-cause death and cardiovascular disease death and re-admission for the first time due to heart failure.The termination time for follow-up was February 2019.Record the occurrence of patient endpoint events and survival time.ResultsThere were 157 patients completed the follow-up,101 HFrEF patients,56 HFmrEF patients.The patients were followed up for 1-29 months,the median follow-up time was 9 months,and the follow-up rate was 90.8%.1.Differences in clinical features1.1 Clinical dataThere was no significant difference in age,height,weight,BSA,BMI,HR,SBP and DBP between heart failure and control group(P>0.05).Compared with the control group,the pulse pressure increased in the HF group,the difference was statistically significant(P<0.05).The HR of the HFrEF group was higher than the other two groups,the NT-proBNP was higher than the HFmrEF group.The systolic blood pressure and pulse pressure of the HFmrEF group were higher than the other two groups.The differences were statistically significant(P<0.05).NYHA class Ⅲ-Ⅳ were less frequent in HFmrEF than HFrEF groups.The use ratios of ACEI/ARB and aldosterone receptor antagonists were lower in HFmrEF patients,the difference was statistically significant(P<0.05).There was no significant difference in the proportion of the three comorbidities including hypertension,coronary heart disease and diabetes between HFrEF and HFmrEF groups.1.2 Comparative analysis of echocardiographic indicators1.2.1 Two-dimensional echocardiography indicatorsCompared with the control group,the LVPW,LVEDD,LVEDV,LVESV,LVM,LVMI,LAD,LAV and LAVI increased in HF group,and these indicators in the HFrEF group was larger than the HFmrEF group,the difference was statistically significant(P<0.05).There was no significant difference in SV、CO、CI between HFrEF and HFmrEF groups(P>0.05).1.2.2 Doppler echocardiography indicatorsCompared with the control group,e’ of the HF group decreased with statistical significant(P<0.05),and e’ was lower in HFrEF group than HFmrEF group(P<0.05).Compared with the control group,E/e’ of the HF group increased with statistical significant(P<0.05),and E/e’ was higher in HFrEF group than HFmrEF group(P<0.05).1.2.3 Two-dimensional speckle tracking indicatorsCompared with the control group,the GLS was significantly decreased in the HF group,and the GLS was lower in HFrEF group than HFmrEF group.The difference was statistically significant(P<0.05).2.Clinical outcomes(1)There was no significant difference in cumulative mortality and rehospitalization rates between the HFrEF and HFmrEF groups at a median follow-up of 9 months(log-rank P=0.146).The cumulative mortality rate was higher in HFrEF group than HFmrEF group,the difference was statistically significant(log-rank P=0.033);(2)Compared with patients in the non-event group of the HFmrEF group,the patients in the event group had lower diastolic blood pressure and higher pulse pressure,higher NT-proBNP,higher proportion of diabetes,larger LVMI,and lower LVEF and GLS.The differences were statistically significant(P<0.05).Pulse pressure and GLS were independent predictors of HFmrEF patients clinical outcomes.(3)Compared with patients in the non-event group of the HFrEF group,the patients in the event group were elder,and with a poor NYHA class,higher NT-proBNP,lower ACEI/ARB using rate,thinner IVS,larger LVEDD,LVEDV,LVESV,LAD,LAVi,and E/A,lower LVEFand GLS,which were statistically significant(P<0.05).NT-proBNP and GLS were independent predictors of HFrEF patients clinical outcomes.Conclusions1.HFmrEF and HFrEF have different clinical characteristics.2.There are differences in clinical outcome predictors between HFmrEF and HFrEF.NT-proBNP and GLS are independent predictors of short-term clinical outcomes of HFrEF.Pulse pressure and GLS are independent predictors of short-term clinical outcomes of HFmrEF.GLS is of great value in predicting the clinical outcomes of two types of heart failure.