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Treatment of Heart Failure With Normal Ejection Fraction: An Inconvenient Truth!

https://doi.org/10.1016/j.jacc.2009.06.067Get rights and content
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Despite use of similar drugs, outcomes of recent heart failure (HF) trials were frequently neutral in heart failure with normal left ventricular ejection fraction (HFNEF) and positive in heart failure with reduced left ventricular ejection fraction (HFREF). The neutral outcomes of HFNEF trials were often attributed to deficient HFNEF patient recruitment with inclusion of many HFREF or noncardiac patients. Patient recruitment criteria of 21 HFNEF trials were therefore reviewed in reference to diagnostic guidelines for HFNEF. In the 4 published sets of guidelines, a definite diagnosis of HFNEF required the simultaneous and obligatory presence of signs and/or symptoms of HF and evidence of normal systolic left ventricular (LV) function and of diastolic LV dysfunction. In 3 of 4 sets of guidelines, normal systolic LV function comprised both a left ventricular ejection fraction (LVEF) >50% and an absence of LV dilation. Among the 21 HFNEF trials, LVEF cutoff values ranged from 35% to 50%, with only 8 trials adhering to an LVEF >50%. Furthermore, only 1 trial specified a normal LV end-diastolic dimension as an enrollment criterion and only 7 trials required evidence of diastolic LV dysfunction. Nonadherence to diagnostic guidelines induced excessive enrollment into HFNEF trials of HF patients with eccentric LV remodeling and ischemic heart disease compared with HF patients with concentric LV remodeling and arterial hypertension. Nonadherence to guidelines also led to underpowered HFNEF trials with a low incidence of outcome events such as death or HF hospitalizations. Future HFNEF trials should therefore adhere to diagnostic guidelines for HFNEF.

Key Words

heart failure
diastole
hemodynamics
ejection fraction

Abbreviations and Acronyms

ACEI
angiotensin-converting enzyme inhibitor
AGE
advanced glycation end product
ARB
angiotensin II receptor blocker
cGMP
guanosine 3′,5′-cyclic monophosphate
HF
heart failure
HFNEF
heart failure with normal left ventricular ejection fraction
HFREF
heart failure with reduced left ventricular ejection fraction
LA
left atrial
LBBB
left bundle branch block
LV
left ventricle/ventricular
LVEDP
left ventricular end-diastolic pressure
LVEDVI
left ventricular end-diastolic volume index
LVEF
left ventricular ejection fraction
MMP
matrix metalloproteinase
NP
natriuretic peptide
PCWP
pulmonary capillary wedge pressure
PDE5
phosphodiesterase-5
PFR
peak filling rate
PKG
protein kinase G
TDI
tissue Doppler imaging
TIMP
tissue inhibitors of matrix metalloproteinase

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Supported by grant 2006B035from the Dutch Heart Foundation.