Elsevier

Journal of Cardiac Failure

Volume 27, Issue 12, December 2021, Pages 1393-1403
Journal of Cardiac Failure

Dynamics of Left Ventricular Myocardial Work in Patients Hospitalized for Acute Heart Failure

https://doi.org/10.1016/j.cardfail.2021.07.004Get rights and content

Abstract

Background

The left ventricular ejection fraction (LVEF) is the most commonly used measure describing pumping efficiency, but it is heavily dependent on loading conditions and therefore not well-suited to study pathophysiologic changes. The novel concept of echocardiography-derived myocardial work (MyW) overcomes this disadvantage as it is based on LV pressure–strain loops. We tracked the in-hospital changes of indices of MyW in patients admitted for acute heart failure (AHF) in relation to their recompensation status and explored the prognostic utility of MyW indices

Methods and Results

We studied 126 patients admitted for AHF (mean 73 ± 12 years, 37% female, 40% with a reduced LVEF [<40%]), providing pairs of echocardiograms obtained both on hospital admission and prior to discharge. The following MyW indices were derived: global constructive and wasted work (GCW, GWW), global work index (GWI), and global work efficiency. In patients with HF with reduced ejection fraction with decreasing N-terminal prohormone B-natriuretic peptide levels during hospitalization, the GCW and GWI improved significantly, whereas the GWW remained unchanged. In patients with HF with preserved ejection fraction, the GCW and GWI were unchanged; however, in patients with no decrease or eventual increase in N-terminal prohormone B-natriuretic peptide, we observed an increase in GWW. In all patients with AHF, higher values of GWW were associated with a higher risk of death or rehospitalization within 6 months after discharge (per 10-point increment hazard ratio 1.035, 95% confidence interval 1.005–1.065).

Conclusions

Our results suggest differential myocardial responses to decompensation and recompensation, depending on the HF phenotype in patients presenting with AHF. The GWW predicted the 6-month prognosis in these patients, regardless of LVEF. Future studies in larger cohorts need to confirm our results and identify determinants of short-term and longer term changes in MyW.

Section snippets

Methods

For the current secondary analysis, we considered all patients admitted for AHF between August 2014 and December 2017 to the University Hospital Würzburg, who consented to participate in the AHF Registry and had pairs of echocardiograms obtained on hospital admission and prior to discharge. The AHF Registry is a monocentric prospective follow-up study that comprehensively identifies and phenotypes consecutive patients admitted for AHF at the emergency department with the aim to capture the

Results

A total of 185 patients had 2 echocardiograms performed during their in-hospital stay. Of them, 59 were excluded due to suboptimal image quality or due to required views missing or recorded with too different heart rate. We included 126 patients in the present analysis: mean age 73 ± 12 years, 46 women (37%). Of those, 21 (17%) had de novo HF, and 75 (60%) patients were in New York Heart Association functional class IV on admission (Table 1). Echocardiography was performed within a median of 43

Discussion

In the present study, we quantified the myocardial response to decongestive treatment during hospitalization for AHF using noninvasively derived indices of MyW. We report 4 major findings. First, in the whole cohort, GCW, GWI, and GWE correlated with parameters of HF severity, LVEF, and NT-proBNP, whereas GWW did not show such an association. Second, GCW, GWI, and GWE improved with an in-hospital decrease of NT-proBNP levels in patients with HFrEF, but not in patients with HFpEF. Third, the GWW

Limitations

We acknowledge the relatively small sample size resulting from the necessity to restrict analyses to patients providing pairs of echocardiograms with sufficient image quality. Hence, our findings should be considered hypothesis generating and await confirmation in future studies. Further, due to logistic reasons in an emergency setting, the median time from admission to the first comprehensively documented echocardiogram was more than 24 hours. Future studies in larger cohorts are needed to

Conclusions

To the best of our knowledge, this study is the first to evaluate indices of MyW in patients with AHF across the total spectrum of LVEF, both in the acute setting and after recompensation. In patients with HFrEF, decreasing NT-proBNP as a surrogate of successful recompensation was associated with an improvement in GCW and GWI and consecutively in GWE. In contrast, in patients with HFpEF, there was no significant change in GCW and GWI, but unsuccessful recompensation was associated with an

Declaration of Competing Interest

Floran Sahiti receives financial support from IZKF Würzburg (MD/PhD program scholarship). Caroline Morbach reports a research cooperation with the University of Würzburg and Tomtec Imaging Systems funded by a research grant from the Bavarian Ministry of Economic Affairs, Regional Development and Energy, Germany, speakers honorarium from Amgen and Tomtec, a travel grant from Orion Pharma and Alnylam, and participation in Advisory and Patient Eligibility Boards sponsored by AKCEA, Alnylam,

Acknowledgments

The athors greatly appreciate the time of all participants with acute heart failure and their willingness to provide data to the study. We thank the entire study team, study nurses, technicians, data managers, and students for their efforts on the acute heart failure study.

Funding

Supported by an unrestricted grant from Boehringer Ingelheim and the German Ministry of Research and Education within the Comprehensive Heart Failure Center, Würzburg (BMBF 01EO1004 and 01EO1504).

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