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Combining diastolic dysfunction and natriuretic peptides to risk stratify patients with heart failure with reduced
Mauro Gori1, Brian Claggett2, Michele Senni3
1Cardiovascular Department, Papa Giovanni XXIII Hospital, Piazza OMS, 1 - 24127, Bergamo, Italy; Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
Insights
Diastolic dysfunction (DD) in heart failure with reduced ejection fraction (HFrEF) patients, specifically pseudonormal/restrictive filling, independently predicts adverse events. Integrating DD improves risk stratification beyond natriuretic peptides.
Area of Science:
- Cardiology
- Echocardiography
- Heart Failure Research
Background:
- Diastolic dysfunction (DD) is a potential factor for risk stratification in heart failure with reduced ejection fraction (HFrEF).
- Current heart failure (HF) guidelines and risk scores do not incorporate DD.
- The prognostic value of DD in HFrEF patients, independent of natriuretic peptides (NP), requires further investigation.
Purpose of the Study:
- To determine the independent prognostic value of DD for nonfatal HF or death in HFrEF patients.
- To assess if DD improves risk prediction when added to natriuretic peptides (NP) and conventional risk markers.
Main Methods:
- Analysis of 1155 baseline echocardiograms from the MADIT-CRT study (LVEF ≤ 30%, QRS ≥ 130 ms, NYHA class I/II).
- Classification of DD based on the 2016 ASE/EACVI criteria.
- Statistical analysis including adjusted p-values and C-statistic to evaluate risk prediction.
Main Results:
- Patients with pseudonormal/restrictive filling (alone or with elevated NP) showed a significantly higher risk of HF/death compared to those with normal NP.
- Elevated NP alone did not significantly increase the risk of events.
- Adding DD to conventional markers and NP improved the prediction of events (C-statistic 0.733 vs. 0.708, p=0.024).
Conclusions:
- Pseudonormal/restrictive DD in HFrEF patients with mild symptoms is associated with a high risk of adverse events, especially when combined with elevated NP.
- DD provides incremental risk prediction for death/HF beyond established markers.
- Integration of DD into HF guidelines and risk scores is suggested for improved patient management.
Background:
Diastolic dysfunction (DD) might help to risk stratify patients with heart failure (HF) with reduced ejection fraction (HFrEF). Nonetheless, HF guidelines/risk scores don't consider DD. We aimed to show the independent prognostic value of DD for nonfatal HF/death in patients with HFrEF on top of natriuretic peptides (NP).
Methods:
We analyzed 1155 baseline echocardiograms of the MADIT-CRT study (LVEF≤30%, QRS ≥ 130 ms, NYHA class I/II), classifying DD according to 2016 ASE/EACVI classification.
Results:
Patients were 64 ± 11 years-old, 24% females, LVEF was 24 ± 5%, 58% had abnormal BNP (≥100 pg/ml). While 45% had impaired relaxation, 33% had pseudonormal filling, 12% restrictive pattern, 6% indeterminate diastolic function, 4% were not classifiable due to missing data. During a follow-up of 2.1 ± 1.0 years, there were 233 HF/death. Compared to patients without pseudonormal/restrictive filling and with normal NP (23%), patients with pseudonormal/restrictive filling, alone (15%) or combined to elevated NP (30%), were at higher risk of events (respectively padj = 0.025 and padj < 0.001), as opposed to those with abnormal NP alone (22%; padj = 0.55). Adding DD to conventional markers of risk and NP improved prediction (C-statistic 0.733 versus 0.708, p = 0.024). DD was the first parameter to be considered to risk stratify MADIT-CRT population, according to Classification-And-Regression-Tree analysis.
Conclusions:
Among HFrEF patients with mild symptoms, pseudonormal/restrictive filling, either alone or combined with elevated NP, was associated with high risk of events, as opposed to isolated elevation of NP. DD provided incremental risk prediction for death/HF beyond commonly used markers. These data might suggest to integrate DD into HF guidelines/risk scores.
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