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Debate: LVEF significance or lack thereof in HF decision-making
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PHILADELPHIA — The consideration of left ventricular ejection fraction when diagnosing or making treatment decisions for HF was a topic for debate at the Heart Failure Society of America Scientific Meeting.
A proponent for LVEF, Gregg C. Fonarow, MD, FACC, FAHA, FHFSA, director, Ahmanson-UCLA Cardiomyopathy Center; co-director, UCLA Preventive Cardiology Program; co-chief, division of cardiology at UCLA; and Eliot Corday Chair in Cardiovascular Medicine and Science, asserted that it is essential for the diagnosis and treatment decisions for HF and nearly ubiquitous in care of patients in clinical practice and research in HF.
“EF is continually used and is an indispensable component of the enrollment criteria in nearly every randomized clinical trial in heart failure,” Fonarow said during his presentation. “It is proven to be as such substantial clinical research value and the assessment and treatment of HF patients that there is actually an explicit class I recommendation for EF measurement and reassessment in every single national as well as international guideline for HF.”
Expounding on this point, Fonarow highlighted the necessity for LVEF and how it has become a standard of practice in the decision-making process for HF diagnosis and treatment.
“For deciding which patients are candidates for cardiac resynchronization therapy or implantable cardioverter defibrillator, you must assess the ejection fraction on optimal guideline-directed medical therapy,” Fonarow said. “In the U.S., if you put in an implantable cardioverter defibrillator without ejection fraction, the Office of Inspector General will investigate you and potentially hold you credibly liable, because EF is part of Medicare coverage. It is absolutely essential, and I want every single one of you to stay out of jail. We have data now that shows when the ejection fraction improves, their outcome is dramatically better. So is the measure of response to therapy as well as subsequent prognosis too.”
In his counter argument, Filippos Triposkiadis, MD, FESC, FACC, professor of cardiology and director of the department of cardiology at Larissa University Hospital in Greece, presented findings from his study published in the European Heart Journal that suggested LVEF taxonomy for HF may be imprecise.
“In acute myocardial infarction, the reduction in contractility results in a decreased stroke volume in the presence of relatively normal LV end-diastolic volume, resulting in reduced LVEF. However, LVEF is also dependent on loading conditions, which becomes especially important in conditions such as mitral regurgitation, aortic stenosis, etc, that alter ventricular preload or afterload,” Triposkiadis and colleagues wrote. “Furthermore, LVEF may be preserved or even augmented in patients with LV hypertrophy even in the presence of myocardial systolic dysfunction. Although circumferential strain is not always reduced in patients with HFpEF compared with age-matched controls, global longitudinal strain is often reduced. As a result, myocardial strain has been increasingly advocated as a complementary metric to LVEF.”
In addition, Triposkiadis claimed LVEF to be a chimera index due to one-half of EF being determined by stroke volume, which depends on physiological variables, whereas LV end-diastolic volume is dependent on architectural variables. He also discussed the issues with LVEF cutoffs in classifying HF.
“Despite the fact that the LVEF measurements with the currently available imaging modalities are moderately reproducible, LVEF cutoffs continue to be used to classify HF,” Triposkiadis said. “In this regard, HF is classified in HF with reduced LVEF (HFrEF; LVEF < 40%), HF with intermediate LVEF (HFmrEF; LVEF 40%-49%) and HF with preserved LVEF (HFpEF; LVEF 50%). Unfortunately, based on these cutoffs, it is decided who is going to receive specific HF treatment (HFrEF) and who is not (HFmrEF and predominantly HFpEF).”
Triposkiadis concluded that, “By accepting the limitations of LVEF and embracing the spectral nature of HF, the HF field will move from an originally unspecified approach based on statistical analyses of data from large groups of heterogeneous LVEF-clustered populations to a more personalized and mechanistic approach based on smaller studies with homogeneous patient population.”
“The use of ejection fraction is near ubiquitous in characterizing patients in clinical practice and research in HF,” Fonarow concluded during his presentation. “It continues to be absolutely indispensable component in the enrollment criteria. Nearly every single randomized trials, including the ones that were just completed like PARAGON-HF, EF assessment and reassessment is essential to determine eligibility for each of our guideline recommended medical and device therapies for heart failure and is proven to be of such substantial benefit that even in the most current versions in our guidelines remains an indispensable class I recommendation.” – by Scott Buzby
References:
Fonarow G, et al. Great Debates and Current Controversies Across the Atlantic. Presented at: Heart Failure Society of America Scientific Meeting; Sept. 13-16, 2019; Philadelphia.
Triposkiadis F, et al. Eur Heart J. 2019;doi:10.1093/eurheartj/ehz158.
Disclosures: Fonarow and Triposkiadis report no relevant financial disclosures.