Cardiology Letters 2023, 32(3):185-1

Is left ventricular ejection fraction still a limiting factor in the treatment of heart failure?

Lesný P, Luknár M, Gonçalvesová E

Kardiologická klinika Lekárská fakulta Univerzita Komenského a Národný ústav srdcových a cievnych chorôb, a. s., Bratislava, Slovenská republika

Left ventricular ejection fraction (LVEF) is a key parameter in the decision about drug treatment of chronic heart failure (HF). In the case of adequate echocardiography image quality, it is recommended to prefer quantitative measurement of LVEF to visual estimation. Four drugs with a documented mortality benefit in patients with HF with reduced LVEF are as follows: a renin-angiotensin-aldosterone blocker (angiotensin receptor-neprilysin inhibitor should be preferred), a beta-blocker, a mineralocorticoid receptor antagonist, and a sodium-glucose cotransporter-2 inhibitor (SGLT2i). The first three drugs show a reduction in benefit with increasing LVEF and the benefit disappears at normal LVEF. Studies with empagliflozin and dapagliflozin showed a mortality and morbidity profit in patients with an LVEF over 40%. A prespecified meta-analysis of EMPEROR-Preserved and DELIVER trials (patients with LVEF > 40%) was performed to clear the uncertainty around the consistency of clinical benefits across the preserved and normal LVEF, impact on cardiovascular mortality, and their effect in different subgroups of patients. Three other trials (DAPA-HF, EMPEROR-Reduced, and SOLOIST-WHF) were added post hoc into the comprehensive five-trial meta-analysis. The prespecified meta-analysis showed a significant 20% reduction of cardiovascular mortality or first hospitalization for HF in patients with LVEF ≥ 60%. A comprehensive meta-analysis of five studies showed that dapagliflozin and empagliflozin reduce cardiovascular mortality and morbidity in patients with HF across the whole spectrum of LVEF. However, heart imaging, most often echocardiography, remains vital in patients with a suspicion of HF. It brings key information necessary for further diagnostic and therapeutic management.

Keywords: heart failure; ejection fraction; SGLT2 inhibitors; meta-analysis

Published: March 1, 2023  Show citation