J Cardiovasc Imaging.  2019 Oct;27(4):257-265. 10.4250/jcvi.2019.27.e36.

Improvement of Left Ventricular Ejection Fraction and Pulmonary Hypertension Are Significant Prognostic Factors in Heart Failure with Reduced Ejection Fraction Patients

• Kwon HJ
• Park JH
• Park JJ
• Lee JH
• Seong IW

• KMID: 2468352
• DOI: http://doi.org/10.4250/jcvi.2019.27.e36

Abstract

BACKGROUND
We evaluated long-term prognosis according to improvement of pulmonary hypertension (PH) and left ventricular ejection fraction (LVEF) in patients with heart failure with reduced ejection fraction (HFrEF) and PH.
METHODS
We included all consecutive patients with HFrEF and PH who had a baseline and follow-up echocardiographic examinations from September 2011 to March 2017. PH was defined as maximal velocity of tricuspid regurgitation (TR Vmax) over 3.0 m/s, and LVEF improvement was defined as LVEF change ≥ 15% from the baseline echocardiography. Primary outcome was 5-year major adverse cardio-cerebrovascular events (MACCE).
RESULTS
We analyzed 271 patients. Mean LVEF was 28±8% and TR Vmax was 3.4±0.4 m/s. On follow-up, 183 (68%) showed improvement of LVEF, and 165 (61%) demonstrated improvement of PH. We classified patients into 4 groups according to improvement of PH and LVEF; group 1 (both improvement, 134 patients), group 2 (PH improvement only, 31 patients), group 3 (LVEF improvement only, 49 patients) and group 4 (no improvement, 57 patients). Group 4 had older age, higher incidence of myocardial infarction and aggravation of pre-existing HF. During the follow-up (31±20 months), 27% died and 40.8% experienced MACCE. Group 4 had the worst survival (HR=4.332, 95% CI=2.396-7.833, p<0.001), and group 3 had increased MACCE rate (HR=2.030, 95% CI=1.060-3.888, p=0.033) compared with group 1. Group 2 had similar long-term clinical events (HR=1.085, 95% CI=0.458-2.571, p=0.853) to group 1.
CONCLUSIONS
In patients with HFrEF and PH, persistence of PH and no LVEF improvement was associated with the worst long-term outcome.

Keyword

Pulmonary hypertension; Heart failure with reduced ejection fraction; Follow-up echocardiography; Improvement outcomes

MeSH Terms

Echocardiography
Follow-Up Studies
Heart Failure*
Heart*
Humans
Hydrogen-Ion Concentration
Hypertension, Pulmonary*
Incidence
Myocardial Infarction
Prognosis
Stroke Volume*
Tricuspid Valve Insufficiency

Figure

• 

  Figure 1 Scheme of study population. ΔLVEF: change of left ventricular ejection fraction, HFrEF: heart failure with reduced ejection fraction, PH: pulmonary hypertension, TR Vmax: maximal velocity of tricuspid regurgitation.

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  Figure 2 MACCE free survival according to the group by Kaplan-Meier survival analysis. Group 4 has the lowest 5- year MACCE-free survival rate (19.0 ± 9.2%) than other groups (A, p < 0.001 by Log-rank test). The group with improved PH (B, 62.7 ± 5.4% vs 38.2 ± 6.7%, p < 0.001 by Log-rank test) and improvement of left ventricular ejection fraction (C, 60.5 ± 4.8% vs 36.6 ± 7.9%, p < 0.001 by Log-rank test) have better 5-year MACCE-free survival rate than the other group. ΔLVEF: change of left ventricular ejection fraction, MACCE: major adverse cardio-cerebrovascular event, PH: pulmonary hypertension.

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