Clinical Prognostic Characteristics And Meta-analysis Of Heart Failure Patients With Middle-range Ejection Fraction

ObjectiveThe purpose of this study was to investigate the difference and relationship among patients with the new-classified middle-range ejection fraction(HFmr EF)heart failure,reduced ejection fraction(HFr EF)and preserved ejection fraction(HFp EF).To explore clinical features and prognosis of HFmr EF patients and provide reference for treatment.Method1.Retrospective study:Retrieve the electronic medical record system of Tianjin Chest Hospital for medical records of 710 adult patients diagnosed with heart failure who were hospitalized in the Department of Cardiology from June 2014 to October2016.Information of demographic data,vital signs,main causes of heart failure,and concomitant diseases,images and tests,and treatment were finely recorded.Patients were divided into three groups including HFp EF,HFmr EF and HFr EF according to their left ventricular ejection fraction.We compared the baseline information of the three groups to explore the differences,and summarized the characteristics of different types of heart failure.Discharged patients were followed up for 3 years by telephone for their survival and readmission status in detail.The follow-up ended in October 31,2019.Retrospectively analyze patient’s epidemiological and clinical data.Statistical analyses were performed using SPSS(version24.0).Continuity variables in accordance with the normal distribution were expressed as mean±standard deviation(x±s)and the comparison were performed using analysis of variance;while non-normally distributed continuity variables were used as median and quartile[M(P25,P75)],comparison between groups were performed by Wilcoxon test.Counting data was expressed as a percentage and compared byχ2 test.Kaplan-Meier method and Log-rank test were used to draw survival curves and analyze the prognosis of the three groups of heart failure patients.A Cox proportional hazards model was used for multi-factor analysis.All P-values were two-sided,with statistical significance set at 0.05.2.Meta-analysis:Pub Med,Embase and Web of Science were searched for studies concerning outcomes of HF patients from the inception up to 23 April 2019 without language restriction.The search terms were((((((((Heart Failure[Me SH Terms])OR((((((("Heart Diseases")OR"Cardio-Renal Syndrome")OR"heart failure")OR"Dyspnea,Paroxysmal")OR"Edema,Cardiac")OR"Heart Failure,Diastolic")OR"Heart Failure,Systolic")))AND(((((HFmr EF)OR"40-49")OR"mid-range ejection")OR"borderline ejection fraction")OR"HFb EF")OR"intermediate ejection fraction"))AND(((("all-cause mortality")OR"heart failure rehospitalization")OR"cardiovascular death")OR mortality)))))).Reviewed the articles strictly according to the inclusion and exclusion criteria.Baseline data and hazard ratios(HR)of patients in each study were mainly extracted.Quality of articles were evaluated by Newcastle-Ottawa scale(NOS).We applied"reference group conversion method"to balance problem of different reference groups when calculating HR in each article.Heterogeneity was tested using I~2test and Q test.All meta-analysis used a random effects model.Sensitivity analysis was used to observe whether the combined results were stable and to discover potential heterogeneity studies.Funnel graph,Begg and Egger tests were applied to verify whether there was a release bias.Result1.HFmr EF patients had the highest proportion of smoking and PCI history,the proportion of IHD was similar to HFr EF patients and significantly higher than HFp EF.Total mortality rate was 24.93%and the loss of follow-up rate was 15.63%in all patients,while 25.32%and 10.30%in HFmr EF patients.The 3-year mortality rate of HFmr EF patients was closer to HFr EF patients and significantly higher than that of HFp EF.Cox regression model suggested that e GFR and gender were independent factors affecting the prognosis of patients,low e GFR and men were relative risk factors.HR of death in HFp EF:HFr EF(reference)was 0.791(0.520,1.020(P=0.271),while in HFmr EF:HFr EF(reference)was 0.799(0.560,1.140)(P=0.216).2.There were totally 19 studies included in this mete-analysis with 164678 patients enrolled.The follow-up time of LAM was 3.6±2.5 years.HRs of LAM,SAM,LCD,LHR indicated that the risks of patients with HFmr EF were higher than HFp EF patients but lower than HFr EF patients,as for LAM,HFmr EF:HFp EF(reference)HR:1.07,95%CI:1.00-1.05,(I~2=63%,P=0.0005);HFmr EF:HFr EF(reference)HR:0.80,95%CI:0.73-0.88,(I~2=70%,P<0.0001).ConclusionHFmrEF is a new classification whose many clinical features in the middle of the three types of heart failure,but it also has the distinctive features of the least number of NYHA class III and above,the high use of digoxin,and the highest proportion of PCI.As for prognosis,HFmr EF patients have the lowest incidence of endpoints and the hazard risk of endpoints is higher than the HFpEF patients which called"separation"phenomenon”.