What is the clinical evidence from this study?

Study design: Cohort. Population: Recent-onset heart failure with reduced ejection fraction (HFrEF) (n=364). Intervention: Ischaemic aetiology vs. Non-ischaemic aetiology. Primary outcome: Clinical composite outcome of worsening (OR 2.94, 95% CI 1.51-5.74, p=0.002).

November 4, 2022Open Access

Treatment Response in Recent-Onset Heart Failure with Reduced Ejection Fraction: Non-Ischaemic vs. Ischaemic Aetiology

Key Result

In patients with recent-onset HFrEF, ischaemic aetiology was associated with significantly increased odds of clinical worsening (OR 2.94) compared to non-ischaemic aetiology.

Study Design

Type

Cohort (n=364)

Multicenter

Structured PICO

Does guideline-directed medical treatment improve outcomes more in non-ischaemic compared to ischaemic aetiology in patients with recent-onset HFrEF?

Population

364 patients aged 16 to 85 years hospitalized with recent-onset heart failure with reduced ejection fraction (LVEF < 40%), followed for 28 weeks to assess treatment response.

Exposure

Guideline-directed medical treatment (GDMT) in patients with recent-onset HFrEF of non-ischaemic aetiology (non-IHF)

Comparator

Guideline-directed medical treatment (GDMT) in patients with recent-onset HFrEF of ischaemic aetiology (IHF)

Outcome

Hierarchical clinical composite outcome classifying each patient as worsened, improved, or unchanged based on hard outcomes (mortality, heart transplantation, and HF hospitalization) and soft outcomes (± ≥10 unit change in LVEF, ± ≥30% change in N-terminal pro-B-type natriuretic peptide, and ± ≥1 point change in New York Heart Association functional class) during 28 weeks of follow-upcomposite

In patients with recent-onset HFrEF, those with a non-ischaemic aetiology demonstrate a significantly better short-term clinical and echocardiographic response to guideline-directed medical therapy compared to those with an ischaemic aetiology.

Main Result

Odds Ratio: 2.94 (95% CI 1.51–5.74)

Absolute Event Rate: 43.9% vs 19.1%

p-value: p=0.002

Limitations

Retrospective single-centre study
Ejection fraction data obtained from first examination whereas NYHA and NT-proBNP collected near discharge
20% missing data for NYHA class
Patients with HFrEF due to myocardial infarctions included only if re-hospitalized for HF
Short duration of follow-up (28 weeks)

Abstract

AIMS: In heart failure (HF) with reduced left ventricular ejection fraction (HFrEF), the prognosis appears better in non-ischaemic than in ischaemic aetiology. Infrequent diagnostic work-up for ischaemic heart disease (IHD) in HF is reported. In this study, we compared short-term response to initiated guideline-directed medical treatment (GDMT) in recent-onset HFrEF of non-ischaemic (non-IHF) vs. ischaemic (IHF) aetiology and evaluated the frequency of coronary investigation. METHODS AND RESULTS: Patients hospitalized with recent-onset HFrEF left ventricular ejection fraction (LVEF) < 40% between 1 January 2016 and 31 December 2019 were included. Treatment response was determined by use of a hierarchical clinical composite outcome classifying each patient as worsened, improved, or unchanged based on hard outcomes (mortality, heart transplantation, and HF hospitalization) and soft outcomes (± ≥10 unit change in LVEF, ± ≥30% change in N-terminal pro-B-type natriuretic peptide, and ± ≥1 point change in New York Heart Association functional class) during 28 weeks of follow-up. The associations between baseline characteristics and composite changes were analysed with multiple logistic regression. Among the 364 patients analysed, 47 were not investigated for IHD. Comparing non-IHF (n = 203) vs. IHF (n = 114), patients were younger (mean age 61.0 vs. 69.4 years, P < 0.001) with lower mean LVEF (26% vs. 31%, P < 0.001), but with similar male predominance (70.4% vs. 75.4%, P = 0.363). For non-IHF vs. IHF, the composite outcomes were worsened (19.1% vs. 43.9%, P < 0.001) and improved (74.2% vs. 43.9%, P < 0.001). After multivariable adjustments, IHF was associated with increased odds for worsening odds ratio (OR) 2.94; 95% confidence interval (CI) 1.51-5.74; P = 0.002 and decreased odds for improvement (OR 0.35; 95% CI 0.18-0.65; P < 0.001). In cases without previous IHD or new-onset myocardial infarction (n = 261), a decision for coronary investigation was made in 69.0%. CONCLUSIONS: In recent-onset HFrEF, patients with non-IHF responded better to GDMT than patients with IHF. Almost one-third of patients selected for follow-up at HF clinics were never investigated for IHD.

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