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1FSBO National Medical research center of cardiology of the Ministry of healthcare of the Russian Federation. fake@neicon.ru.
Insights
Patients with mid-range ejection fraction (EF) heart failure (HF) respond well to beta-blockers and RAAS inhibitors, unlike those with preserved EF. A new HF classification should include clinical phenotype for better treatment guidance.
Area of Science:
- Cardiology
- Heart Failure Research
Background:
- Heart failure (HF) classification traditionally categorizes patients based on left ventricular ejection fraction (LVEF) into reduced (<40%), mid-range (40-49%), and preserved (≥50%) groups.
- Patients with mid-range LVEF exhibit heterogeneous clinical and demographic characteristics, often occupying an intermediate position between reduced and preserved LVEF groups.
Purpose of the Study:
- To evaluate the clinical expediency of a separate classification subgroup for heart failure patients with mid-range ejection fraction (40-49%).
- To analyze the treatment response and etiological differences within the mid-range LVEF subgroup compared to reduced and preserved LVEF groups.
- To advocate for a revised HF classification incorporating clinical phenotype alongside LVEF.
Main Methods:
- Analysis of studies published between 2017-2018 focusing on patients with mid-range LVEF.
- Comparison of clinical and demographic parameters, treatment responses (beta-blockers, RAAS inhibitors), and etiological factors (ischemic vs. non-ischemic phenotypes) across different LVEF groups.
Main Results:
- Patients with mid-range LVEF demonstrate a positive response to beta-blocker and RAAS inhibitor therapy, similar to patients with reduced LVEF.
- This therapeutic response differs significantly from patients with preserved LVEF, who typically do not benefit from these treatments.
- Etiology plays a key role, with ischemic heart disease prevalent in reduced and mid-range LVEF, while non-cardiac causes are more common in preserved LVEF.
Conclusions:
- The mid-range LVEF subgroup is clinically distinct and warrants separate consideration.
- The positive response to specific therapies in mid-range LVEF suggests a pathogenesis more aligned with reduced LVEF, primarily linked to ischemic heart disease.
- A comprehensive HF classification should integrate clinical phenotype (e.g., ischemic vs. non-ischemic) with LVEF, especially for the heterogeneous mid-range group, to guide therapeutic strategies.
Abstract:
The article discusses the clinical expedience of isolating into a separate classification subgroup of patients with heart failure and a mid‑range ejection fraction (EF) of 40-49 %. Analysis of studies 2017-2018 focusing on the issue of patients with mid‑range LV EF showed that this subgroup is highly heterogenous and by some clinical and demographic parameters takes an intermediate position between heart failure (HF) patients with reduced (<40 %) and preserved (>50 %) LV EF. However, patients with mid‑range LV EF positively respond to beta‑blocker and RAAS inhibitor therapy, and their response is close to that of patients with reduced LV EF. This is a principal difference between patients with mid‑range and preserved LV EF who generally do not display any beneficial effect of such therapy. One of the major causes for such difference is a dissimilarity of HF etiology and, hence, pathogenesis in patients with reduced and mid‑range LV EF: primarily IHD (so‑called "ischemic" phenotype) in patients with reduced and mid‑range LV EF and non‑cardiac causes ("non‑ischemic" phenotype) in patients with preserved LV EF. Since the nonischemic phenotype is also rather common among patients with mid‑range LV EF a new HF classification should definitely indicate, in addition to LV EF, the clinical phenotype of disease, which is particularly important for patients with mid‑range LV EF of 40-49 %. Further studies should focus on variants of HF clinical phenotypes.