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Author Spotlight: Unveiling Prognostic Indicators in Heart Failure - The Role of Phase Angle and Bioelectrical Impedance Analysis
Published on: June 30, 2023
Echocardiographically defined haemodynamic categorization predicts prognosis in ambulatory heart failure patients
Frank L Dini1, Erberto Carluccio2, Roberto Bitto3
1Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy.
Insights
Echocardiography can classify heart failure patients into risk groups. This classification helps predict outcomes in patients with heart failure and reduced ejection fraction (HFrEF) treated with sacubitril/valsartan.
Area of Science:
- Cardiology
- Echocardiography
- Heart Failure Research
Background:
- Echocardiography-derived hemodynamic classification, using forward flow and left ventricular filling pressure, can phenotype patients with heart failure and reduced ejection fraction (HFrEF).
- Assessing the prognostic relevance of baseline hemodynamic profiles is crucial for guiding treatment in ambulatory HFrEF patients.
Purpose of the Study:
- To evaluate the prognostic significance of baseline echocardiographically determined hemodynamic profiles in ambulatory HFrEF patients prior to initiating sacubitril/valsartan therapy.
- To determine if hemodynamic profiling can improve risk stratification in HFrEF patients.
Main Methods:
- A multicenter, open-label study classified 727 HFrEF outpatients into four hemodynamic profiles (A, B, C, D) based on cardiac index and E/e' ratio.
- Patients were initiated on sacubitril/valsartan and followed for a median of 12.3 months, with composite endpoints of death or HF hospitalization assessed.
- Multivariable Cox proportional-hazards models were used to analyze outcomes, and net reclassification improvement was calculated.
Main Results:
- Profile-D (low-flow, high-pressure) patients exhibited more comorbidities and poorer renal and LV function.
- The rate of death/HF hospitalization progressively increased from Profile-A to Profile-D (12.0% to 35.2% per 100 patient-years).
- Low forward flow (Profiles B and D) was independently associated with adverse outcomes, and the hemodynamic classification significantly improved risk prediction when added to existing scores.
Conclusions:
- Echocardiographic hemodynamic classification effectively identifies ambulatory HFrEF patients with varying risk profiles.
- Sacubitril/valsartan demonstrated efficacy in improving outcomes across all identified hemodynamic profiles in a real-world setting.
Aim:
Echo-derived haemodynamic classification, based on forward-flow and left ventricular (LV) filling pressure (LVFP) correlates, has been proposed to phenotype patients with heart failure and reduced ejection fraction (HFrEF). To assess the prognostic relevance of baseline echocardiographically defined haemodynamic profile in ambulatory HFrEF patients before starting sacubitril/valsartan.
Methods And Results:
In our multicentre, open-label study, HFrEF outpatients were classified into 4 groups according to the combination of forward flow (cardiac index; CI:< or ≥2.0 L/min/m2 ) and early transmitral Doppler velocity/early diastolic annular velocity ratio (E/e': ≥ or <15): Profile-A: normal-flow, normal-pressure; Profile-B: low-flow, normal-pressure; Profile-C: normal-flow, high-pressure; Profile-D: low-flow, high-pressure. Patients were started on sacubitril/valsartan and followed-up for 12.3 months (median). Rates of the composite of death/HF-hospitalization were assessed by multivariable Cox proportional-hazards models. Twelve sites enrolled 727 patients (64 ± 12 year old; LVEF: 29.8 ± 6.2%). Profile-D had more comorbidities and worse renal and LV function. Target dose of sacubitril/valsartan (97/103 mg BID) was more likely reached in Profile-A (34%) than other profiles (B: 32%, C: 24%, D: 28%, P < 0.001). Event-rate (per 100 patients per year) progressively increased from Profile-A to Profile-D (12.0%, 16.4%, 22.9%, and 35.2%, respectively, P < 0.0001). By covariate-adjusted Cox model, profiles with low forward-flow (B and D) remained associated with poor outcome (P < 0.01). Adding this categorization to MAGGIC-score and natriuretic peptides, provided significant continuous net reclassification improvement (0.329; P < 0.001). Intermediate and high-dose sacubitril/valsartan reduced the event's risk independently of haemodynamic profile.
Conclusions:
Echocardiographically-derived haemodynamic classification identifies ambulatory HFrEF patients with different risk profiles. In real-world HFrEF outpatients, sacubitril/valsartan is effective in improving outcome across different haemodynamic profiles.
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