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Left ventricular ejection fraction as therapeutic target: is it the ideal marker?
V Katsi1, G Georgiopoulos2, A Laina1
11st Cardiology Department, National and Kapodistrian University of Athens, University Medical School, Hippokration Hospital, Vasilissis Sofias 114, 11528, Athens, Greece.
Insights
Heart failure (HF) patient classification using left ventricular ejection fraction (LVEF) is evolving. Studies suggest LVEF can recover with treatment, necessitating a new category for HF patients with recovered LVEF.
Area of Science:
- Cardiology
- Internal Medicine
Background:
- Heart failure (HF) is a growing clinical concern, with current classification based on left ventricular ejection fraction (LVEF).
- Two-dimensional echocardiography, used for LVEF estimation, has limitations, including measurement variability and potential for LVEF recovery post-treatment.
- This variability challenges existing HF categories (HFpEF, HFrEF, HFmrEF) and patient stratification.
Purpose of the Study:
- To review and summarize interventions aimed at improving systolic function in patients with reduced LVEF (HFrEF).
- To explore both established and novel pharmacologic, non-pharmacologic, and device-based treatment strategies for HF.
- To propose an updated HF classification acknowledging LVEF recovery.
Main Methods:
- Comprehensive literature review of pharmacologic treatments (e.g., beta-blockers, RAAS inhibitors, sacubitril-valsartan, ranolazine, ivabradine).
- Assessment of non-pharmacologic interventions including cardiac resynchronization therapy and exercise training.
- Consideration of innovative therapies such as stem cells, xanthine oxidase inhibitors, antibiotics, and omega-3 fatty acids.
Main Results:
- Established and novel pharmacotherapies demonstrate potential for improving LVEF in HFrEF patients.
- Cardiac resynchronization therapy and exercise programs show efficacy in enhancing systolic function.
- Emerging strategies like stem cells and specific nutraceuticals warrant further investigation for LVEF recovery.
Conclusions:
- Left ventricular ejection fraction (LVEF) is dynamic and can improve with various interventions in heart failure (HF).
- A new category for HF patients with recovered LVEF should be considered alongside existing classifications.
- Advanced imaging and biomarkers are crucial for accurate HF assessment and identifying candidates for LVEF-guided therapy.
Abstract:
Heart failure (HF) consists the fastest growing clinical cardiac disease. HF patients are categorized on the basis of underlying left ventricular ejection fraction (LVEF) into HF with preserved EF (HFpEF), reduced LVEF (HFrEF), and mid-range LVEF (HFmrEF). While LVEF is the most commonly used surrogate marker of left ventricular (LV) systolic function, the implementation of two-dimensional echocardiography in estimating this parameter imposes certain caveats on current HF classification. Most importantly, LVEF could fluctuate in repeated measurements or even recover after treatment, thus blunting the borders between proposed categories of HF and enabling upward classification of patients. Under this prism, we sought to summarize possible procedures to improve systolic function in patients with HFrEF either naturally or by the means of pharmacologic and non-pharmacologic treatment and devices. Therefore, we reviewed established pharmacotherapy, including beta-blockers, inhibitors of renin-angiotensin-aldosterone axis, statins, and digoxin as well as novel treatments like sacubitril-valsartan, ranolazine, and ivabradine. In addition, we assessed evidence in favor of cardiac resynchronization therapy and exercise training programs. Finally, innovative therapeutic strategies, including stem cells, xanthine oxidase inhibitors, antibiotic regimens, and omega-3 polyunsaturated fatty acids, were also taken into consideration. We concluded that LVEF is subject to changes in HF after intervention and besides the aforementioned HFrEF, HFpEF, and HFmrEF categories, a new entity of HF patients with recovered LVEF should be acknowledged. An improved global and refined LV function assessment by sophisticated imaging modalities and circulating biomarkers is expected to render HF classification more accurate and indicate patients with viable-yet dysfunctional-myocardium and favorable characteristics as the ideal candidates for LVEF recovery by individualized HF therapy.
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