Outpatient Management of Stable Heart Failure with Reduced Ejection Fraction
Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler in Heart Failure, 2022
The epidemic of heart failure is a major public health issue. Heart failure accounts for substantial morbidity and mortality in the world. In the United States, approximately 5 million people suffer from and 400,000 people are newly diagnosed with heart failure each year. The overall prevalence of heart failure is thought to be increasing due to aging of the population, improved management of other cardiovascular problems such as myocardial infarction, valvular heart disease, and arrhythmias. Fortunately, there are many therapies available to patients with heart failure with reduced ejection fraction, regardless of symptomatology. Careful consideration should be taken at every encounter to evaluate not only volume status but also optimize guideline directed medical therapy as well as device therapy. In this chapter we outline the indications, mechanism of action, dosing, and evidence behind the benefit of the currently available therapy for the management of outpatient heart failure with reduced ejection fraction.
Heart Failure with Recovered Ejection Fraction (HFrecEF) and Heart Failure with Midrange Ejection Fraction (HFmrEF)
Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler in Heart Failure, 2022
Heart failure (HF) research and guidelines have primarily focused on two major groups defined by left ventricular ejection fraction (LVEF)—HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF). This chapter discusses two groups of patients with HF that have not been clearly addressed in the existing evidence base. HF with recovered ejection fraction (HFrecEF) refers to the subset of HF patients with low LVEF that subsequently improved to normal or near-normal LVEF. Heart failure with midrange EF (HFmrEF) refers to the subset of patients with HF and an LVEF in the border zone between HFpEF and HFrEF, currently defined as LVEF between 40% and 49%. This chapter reviews the characteristics, clinical course, and treatments of HFrecEF and HFmrEF. The topics discussed include the reliability of LVEF measurements, predictors of LVEF recovery, transitions in LVEF across categories including HFmrEF, and the heterogeneity of phenotypes within HFrecEF and within HFmrEF.
Pathophysiology of Heart Failure with Reduced Ejection Fraction
Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler in Heart Failure, 2022
Heart failure with reduced ejection fraction (HFrEF) is a complex collection of disease entities, all resulting in impairment of myocardial contraction such that cardiac output can no longer meet peripheral tissue demands. The list of etiologies is extensive but can all be conceptualized as occurring after one or more index event(s) either directly damaging the myocardium or preventing cardiomyocytes from contracting normally. In order to maintain cardiac output, cascades of neurohormonal, structural (remodeling), and energetic changes are simultaneously triggered, perpetuating the vicious cycle that characterizes the progression of HFrEF. These mechanisms form the basis of our current understanding of heart failure pathophysiology and serve as targets for established and novel therapies.
Baroreflex activation therapy: a new treatment option for heart failure with reduced ejection fraction
Published in Expert Review of Cardiovascular Therapy, 2014
Marcel Halbach, Tilman Hickethier, Navid Madershahian, Jochen Müller-Ehmsen
Sympathovagal imbalance plays a major role in the progression of heart failure with reduced ejection fraction. Baroreflex activation therapy (BAT) by electrical stimulation of baroreceptors located at the carotid sinus can reduce sympathetic and increase parasympathetic tone. This review provides an overview on the concept of BAT in heart failure with reduced ejection fraction and available preclinical and clinical data. Animal studies of BAT in heart failure with reduced ejection fraction have demonstrated a decline in plasma norepinephrine, an improved left ventricular ejection fraction, a reduced susceptibility to induced ventricular arrhythmias and a survival benefit. First clinical data from uncontrolled studies suggest a relevant improvement in muscle sympathetic nerve activity, ejection fraction, 6-min walk distance, New York Heart Association (NYHA) class and hospitalization rate. BAT appears to be safe in this severely ill patient population.
Dobutamine stress echocardiography in the evaluation of cardiac haemodynamics after repair of tetralogy of Fallot in children: negative effects of pulmonary regurgitation
Published in Acta Cardiologica, 2006
Objective — The aims were to evaluate right and left ventricular systolic function and pulmonary regurgitation (PR) at rest and during dobutamine stress echocardiography (DSE) and to assess relationships between PR and cardiac haemodynamics in late postoperative tetralogy of Fallot patients. Methods and results — Eighteen children (postoperative period 10.9 ± 2.9 years) had heart rates, PR volumes and velocities, right ventricle (RV) volumes, ejection fraction, cardiac output and index measured at rest and during DSE. Left ventricular ejection fraction did not significantly increase and the RV volumes did not change significantly during DSE (p > 0.05). RV ejection fraction was significantly lower than that of the left ventricle at rest (p < 0.001), and patients failed to increase RV ejection fraction during DSE (p > 0.05). PR measurements increased significantly during DSE (p < 0.05). PR velocity correlated positively with RV end-diastolic volume both at rest and during DSE (p < 0.01). PR volume was inversely correlated with ejection fraction, cardiac output and index at rest and during DSE (p < 0.05). Conclusion — Latent dysfunction and impaired functional response to stress of both ventricles are detected by DSE. Although many postoperative patients are asymptomatic; assessment of postoperative haemodynamics by exercise or DSE will probably result in early detection of latent ventricular dysfunction.
Comparison between Videodensitometric and Angiocardiographic Determination of Left Ventricular Ejection Fraction in Patients with Cardiac Disease
Published in Upsala Journal of Medical Sciences, 1978
Angiocardiograms have been widely used to calculate volumes of cardiac chambers. By determining the left ventricular volume in end-diastole and end-systole the ejection fraction can be calculated. The ejection fraction is considered a clinically useful index of left ventricular function and is widely used in the preoperative evaluation of patients with cardiac disease.