Determinants of the Survival Benefit Associated with Statins in Patients with Acute Heart Failure

Figures

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  Figure 1. Study population. Flow chart of this study is presented. EF, ejection fraction; GLS, global longitudinal strain; LV, left ventricle; RV, right ventricle; STRATS‐AHF, Strain for Risk Assessment and Therapeutic Strategies in Patients with Acute Heart Failure.

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  Figure 2. Hazard ratios for mortality in statin users vs. non‐users according to type and aetiology of heart failure. Multivariable‐adjusted survival curves demonstrating the difference in all‐cause mortality between statin users and non‐users at 5 year follow‐up. Note a smaller mortality reduction with statin therapy in the HFrEF group (A) compared with that in the HFpEF group (B). Mortality reduction with statin therapy was also smaller in non‐ischaemic HF group (D) than ischaemic HF group (C). Adjusted comparisons were based on multivariate Cox regression models. HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction.

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  Figure 3. Relative magnitude of survival benefit with statin therapy by left ventricular systolic function. Cox regression analysis showing the multivariable‐adjusted relative hazard ratios (solid line) and 95% confidence intervals (shaded area). Note that the magnitude of mortality reduction with statin therapy substantially increased as LV‐EF increased in the overall study patients (A). This association was more pronounced in patients with ischaemic HF (B) than those with non‐ischaemic HF (C). Similar associations were found for LV‐GLS (D–F). HF, heart failure; LV‐EF, left ventricular‐ejection fraction; LV‐GLS, left ventricular‐global longitudinal strain.

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  Figure 4. Relative magnitude of survival benefit with statin therapy by right ventricular systolic function. Cox regression analysis showing the multivariable‐adjusted relative hazard ratios (solid line) and 95% confidence intervals (shaded area). Note that the magnitude of mortality reduction with statin therapy substantially decreased as RV‐FAC increased in the overall study patients (A). The magnitude of association between RV‐FAC and survival benefit was similar in both ischaemic (B) and non‐ischaemic HF groups (C). The magnitude of mortality reduction with statin therapy decreased as RV‐GLS increased in the overall study patients, with a less steep slope (D) than in the case of RV‐FAC. The magnitude of this association was more evident in ischaemic HF group (E) than non‐ischaemic HF group (F). HF, heart failure; RV‐FAC, right ventricular‐fractional area change; RV‐GLS, right ventricular‐global longitudinal strain.

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  Figure 5. Forest plot depicting multivariable‐adjusted subgroup analyses. Forest plots of adjusted hazard ratios for the relationship between relevant subgroups and all‐cause mortality according to statin therapy in patients with ischaemic HF (A) and those with non‐ischaemic HF (B). Interaction P values are shown. The hazard ratio within each stratum was adjusted for the independent variables shown in Table 2 . CI, confidence interval; DM, diabetes mellitus, HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HL, hyperlipidaemia; HR, hazard ratio; HTN, hypertension; LV‐EF, left ventricular‐ejection fraction; LV‐GLS, left ventricular‐global longitudinal strain. Take home figure: Postulated associations between aetiology of heart failure, myocardial contractility, and effect of statin therapy. Ischaemic aetiology for HF and LV and RV myocardial contractility may be associated with the magnitude of survival benefits with statin therapy in patients with acute HF. HF, heart failure; LV, left ventricular; RV, right ventricular.