Subclinical systolic impairment may indicate future HF risk in older patients
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Subclinical impairments in left ventricular systolic function were associated with risk for future incident HF among older adults, according to research published in JAMA Cardiology.
“Contemporary echocardiographic data from this large, biracial, longitudinal cohort study of older adults suggest that lower values of LV ejection fraction, longitudinal strain and circumferential strain are associated with incident HF independent of clinical risk factors and with incident HF with reduced EF in particular,” Anne Marie Reimer Jensen, BS, research fellow in the division of cardiovascular medicine at Brigham and Women’s Hospital, and colleagues wrote.
For the time-to-event analysis of 4,960 ARIC participants (mean age, 75 years; 59% women; 19% Black) without HF at baseline, the researchers evaluated the associations of subclinical systolic impairments and incident HF and HFrEF in late life. The main outcomes included incident adjusted HF and HFpEF and HFrEF. Median follow-up was 5.5 years.
Measure of systolic impairment included LVEF, longitudinal strain and circumferential strain as measured by 2D and strain echocardiography.
In the overall cohort, LVEF was less than 50% in 1.5% of the population.
For every standard deviation (SD) decrease in LVEF, the risk for incident HF increased by 41% among older patients (HR for each SD increase = 1.41; 95% CI, 1.29-1.55). The risk for incident HF among patients with LVEF less than 60% was more than twofold compared with individuals with no systolic impairment (HR = 2.59; 95% CI, 1.99-3.37).
Researchers observed similar results for continuous longitudinal strain (HR = 1.37; 95% CI, 1.22-1.53), dichotomized longitudinal strain (HR = 1.93; 95% CI, 1.46-2.55), continuous circumferential strain (HR = 1.39; 95% CI, 1.22-1.57) and dichotomized circumferential strain (HR = 2.3; 95% CI, 1.64-3.22).
According to the study, impaired LVEF, longitudinal strain and circumferential strain were all independently associated with future HFrEF (P for all < .001); however, no systolic impairments were significantly associated with future HFpEF.
“These results suggest potential utility of LV strain in identifying persons at heightened risk of heart failure, and question the current cutpoints used to define abnormal LVEF in late life,” Amil M. Shah, MD, MPH, associate professor of medicine at Harvard Medical School and associate physician in the division of cardiovascular medicine at Brigham and Women’s Hospital, told Healio. “Ultimately, a more comprehensive evaluation of systolic function may help identify older adults at particularly high risk to develop heart failure, towards whom preventative efforts could be directed.”
Although risk for incident HF or death associated with impaired LVEF was greater using guideline-based limits compared with limits set in the ARIC study (HR for guideline limits = 2.99; 95% CI, 2.19-4.09; vs HR for ARIC limits = 1.88; 95% CI, 1.58-2.25), only 2.1% were classified as impaired based on guideline thresholds for systolic impairment compared with 13.9% based on a limit of LVEF less than 60%.
Moreover, the population-attributable risk for incident HF associated with LVEF less than 60% was 11% compared with 5% using guideline-based limits.
“One major question is why these relatively subtle impairments in systolic function are so robustly associated with risk of developing HF,” Shah told Healio. “In our analysis, these subtle impairments in systolic function by LVEF or strain were most strongly associated with risk of developing HFrEF, as opposed to HFpEF. This suggests that these modest impairments in LV systolic function may reflect ‘early’ contractile dysfunction and herald worsening dysfunction and frank reductions in LVEF. However, future studies with prospective longitudinal imaging will be necessary to address this.”
For more information:
Amil M. Shah, MD, MPH, can be reached at ashah11@rics.bwh.harvard.edu.
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