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Echocardiographic functional determinants of survival in heart failure with abnormal ejection fraction
Quirino Ciampi1, Lauro Cortigiani2, Nicola Gaibazzi3
1Cardiology Department, Fatebenefratelli Hospital of Benevento, Benevento, Italy.
Insights
Coronary flow velocity (CFV) and coronary flow velocity reserve (CFVR) predict survival in heart failure (HF) patients with reduced ejection fraction (EF). Higher CFV and lower CFVR indicate worse prognosis, independent of other factors.
Area of Science:
- Cardiology
- Cardiovascular Physiology
- Medical Diagnostics
Background:
- Heart failure (HF) with reduced left ventricular ejection fraction (EF) has a heterogeneous prognosis.
- Established predictors of prognosis in HF include wall motion and EF.
- Coronary physiology assessment using coronary flow velocity (CFV) and coronary flow velocity reserve (CFVR) may offer complementary prognostic information.
Purpose of the Study:
- To investigate the prognostic value of coronary flow velocity (CFV) and coronary flow velocity reserve (CFVR) in patients with heart failure (HF) and reduced ejection fraction (EF).
- To determine if CFV and CFVR add independent prognostic information beyond established predictors like EF and inducible ischemia.
Main Methods:
- Prospective, multicenter study of 1,408 HF patients with EF <50%.
- Baseline CFV measured by pulsed-wave Doppler; CFVR assessed using various stress methods (exercise, dobutamine, vasodilator).
- Inducible ischemia and LV contractile reserve (LVCR) assessed using wall motion score index (WMSI).
- All-cause death as the primary endpoint, with median follow-up of 990 days.
Main Results:
- Independent predictors of death included EF, CFV, CFVR, stress-induced ischemia, and LVCR.
- Higher resting CFV (HR: 2.407) and lower CFVR (HR: 3.908) were significantly associated with increased mortality.
- A composite scoring system integrating these parameters showed lowest mortality (1.2%) for the best score and highest (31.9%) for the worst score.
Conclusions:
- High resting CFV is associated with worse survival in both ischemic and non-ischemic HF with reduced EF.
- CFV provides prognostic information that is independent and additive to EF, CFVR, LVCR, and inducible ischemia.
- Coronary flow velocity and reserve are valuable tools for risk stratification in HF patients with reduced EF.
Background And Aims:
Patients with heart failure (HF) with reduced left ventricular (LV) ejection fraction (EF) have a heterogeneous prognosis, and assessment of coronary physiology with coronary flow velocity (CFV) and coronary flow velocity reserve (CFVR) may complement established predictors based on wall motion and EF.
Methods And Results:
In a prospective multicenter study design, we enrolled 1,408 HF patients (age 66 ± 12 years, 1,035 men), with EF <50%, 743 (53%) with coronary artery disease, and 665 (47%) with normal coronary arteries. Recruitment (years 2004-2022) involved 8 accredited laboratories, with inter-observer variability <10% for CFV measurement. Baseline CFV (abnormal value >31 cm/s) was obtained by pulsed-wave Doppler in mid-distal LAD. CFVR (abnormal value ≤2.0) was assessed with exercise (n = 99), dobutamine (n = 100), and vasodilator stress (dipyridamole in 1,149, adenosine in 60). Inducible myocardial ischemia was identified with wall motion score index (WMSI) stress > rest (cut-off Δ ≥ 0.12). LV contractile reserve (CR) was identified with WMSI stress < rest (cutoff Δ ≥ 0.25). Test response ranged from score 0 (EF > 30%, CFV ≥ 32 cm/s, CFVR > 2.0, LVCR present, ischemia absent) to score 5 (all steps abnormal). All-cause death was the only endpoint. Results. During a median follow-up of 990 days, 253 patients died. Independent predictors of death were EF (HR: 0.956, 95% CI: 0.943-0.968, p < 0.0001), CFV (HR: 2.407, 95% CI: 1.871-3.096, p < 0.001), CFVR (HR: 3.908, 95% CI: 2.903-5.260, p < 0.001), stress-induced ischemia (HR: 2.223, 95% CI: 1.642-3.009, p < 0.001), and LVCR (HR: 0.524, 95% CI: 0.324-.647, p = 0.008). The annual mortality rate was lowest (1.2%) in patients with a score of 0 (n = 61) and highest (31.9%) in patients with a score of 5 (n = 15, p < 0.001).
Conclusion:
High resting CFV is associated with worse survival in ischemic and nonischemic HF with reduced EF. The value is independent and additive to resting EF, CFVR, LVCR, and inducible ischemia.
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