Perils and Pitfalls With Associations in Heart Failure, Particularly in HF-pEF

Q: What is the clinical evidence from this study?

Study design: Editorial. Population: Heart Failure (HF-pEF and HF-rEF) with Diabetes Mellitus and Chronic Kidney Disease. Intervention: Diabetes mellitus and chronic kidney disease vs. Absence of diabetes mellitus or chronic kidney disease. Primary outcome: Clinical outcomes and quality of life in heart failure.

Peter E. Carson

doi:10.1016/j.jacasi.2023.05.007

July 4, 2023JACC AsiaOpen Access

Perils and Pitfalls With Associations in Heart Failure, Particularly in HF-pEF

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Key result

Chronic kidney disease consistently worsens clinical outcomes in both HF-rEF and HF-pEF, whereas the lack of isolated diabetes impact in HF-pEF in the Asian-HF registry is likely due to chance.

Graphical abstract published by JACC Asia — Graphical abstract · Published by JACC Asia · CC BY-NC-ND

Key Points

To evaluate the methodological challenges and biological plausibility of observed associations between diabetes mellitus, chronic kidney disease, and outcomes across heart failure phenotypes.
Expert commentary appraising an observational cohort study by Lawson et al. that analyzed the Asian-HF registry (n=5,239, including 1,332 with HF-pEF).
Evaluated the isolated and combined prognostic contributions of diabetes mellitus and chronic kidney disease in HF-rEF versus HF-pEF, contextualized against international registries and clinical trials.
In the Asian-HF registry analysis, chronic kidney disease was consistently associated with worse clinical outcomes and quality of life across phenotypes, whereas diabetes mellitus affected prognosis in HF-rEF but did not demonstrate an unfavorable effect in HF-pEF.
The observed lack of association between diabetes alone and HF-pEF outcomes is attributed to sample size constraints and confounding in registry data rather than a true absence of biological risk, conflicting with established metabolic mechanisms and trial data.
Data from larger registries, such as MAGGIC (20,574 patients with HF, 4,792 with HF-pEF) and PRESERVE (14,579 with HF-pEF), emphasize that risk detection in HF-pEF requires large cohorts due to lower event rates.

Structured PICO

P

Population

Patients with heart failure with reduced ejection fraction (HF-rEF) and preserved ejection fraction (HF-pEF) with comorbid diabetes mellitus (DM) and/or chronic kidney disease (CKD), specifically discussing the Asian-HF registry (n=5,239 total; n=1,332 with HF-pEF).

Limitations

Relatively small sample size in the discussed Asian-HF registry (n = 5,239, with 1,332 HF-pEF)
Lack of biological plausibility for the absence of diabetes mellitus risk in HF-pEF
Residual confounding inherent to observational registry analyses of complex comorbidities
The discussed Asian-HF registry is relatively small (n = 5,239, with only 1,332 HF-pEF patients) with a limited number of events.
Lack of biologic plausibility for the finding that diabetes mellitus alone does not unfavorably affect HF-pEF.
Inability of advanced statistical techniques to completely remove confounding in registry analyses of complex risk factors and comorbidities.

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Implication

This editorial highlights the challenges and potential confounding in interpreting observational registry associations between diabetes, chronic kidney disease, and outcomes in HF-pEF, emphasizing the clinical utility of SGLT2 inhibitors and caution with renin-angiotensin system inhibitors regarding renal function.

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Cite This Study

Peter E. Carson (2023) conducted an editorial in Heart Failure (HF-pEF and HF-rEF) with Diabetes Mellitus and Chronic Kidney Disease. Diabetes mellitus and chronic kidney disease vs. Absence of diabetes mellitus or chronic kidney disease was evaluated on Clinical outcomes and quality of life in heart failure. Chronic kidney disease consistently worsens clinical outcomes in both HF-rEF and HF-pEF, whereas the lack of isolated diabetes impact in HF-pEF in the Asian-HF registry is likely due to chance.

synapsesocial.com/papers/6a709b44e5469ee92be14f3b https://doi.org/10.1016/j.jacasi.2023.05.007

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Perils and Pitfalls With Associations in Heart Failure, Particularly in HF-pEF

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Perils and Pitfalls With Associations in Heart Failure, Particularly in HF-pEF

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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