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Heart failure and cardiomyopathies
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Drug treatment effects on outcomes in heart failure with preserved ejection fraction: a systematic review and meta-analysis
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  • Published on: 12 February 2018
    Targeting beta blocker therapy to individual heart failure with preserved ejection fraction phenotypes
    • Sean L Zheng, Core Medical Trainee Royal Brompton Hospital, London

    The letter by Dr Al-Mohammad is welcomed by the study authors and highlights some of the important challenges with using single value cut-offs for diagnosis and in determining treatment options. This is particularly true for heart failure with preserved left ventricular ejection fraction (LVEF) (HFpEF) (and more recently mid-range ejection fraction [HFmrEF], 40-49%) where decisions on starting prognostic medications can be made based on subjective echocardiographic measurements, albeit with evidence of diastolic dysfunction (tissue Doppler, flow Doppler, and volumes). Clearly, additional patient-specific factors should be taken into account, including aetiology, co-morbidities, and underlying rhythm, which are nicely highlighted in the editorial piece accompanying our study[1 2].
    The Study Effects of Nebivolol Intervention on Outcomes and Rehospitalisation in Seniors With Heart Failure (SENIORS) trial investigated the effects of the beta-blocker nebivolol in the treatment of heart failure in patients aged 70 and over[3]. Patients were required to have a clinical diagnosis of heart failure with either hospitalisation for heart failure in the previous 12 months, or a documented LVEF ≤35%. Baseline LVEF was measured by transthoracic echocardiography in 94% of cases. While van Veldhuisen et al. used an LVEF cut-off of 35% to compare “reduced” with “preserved” ejection fraction, they also examined and reported on the effect of Nebivolol in 643 patients with an LVEF ≥40%....

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    Conflict of Interest:
    None declared.
  • Published on: 12 February 2018
    Do Beta Blockers really reduce the mortality in patients with HFPEF?

    I do welcome the systemic review and meta-analysis on drug treatment effects on outcomes in heart failure with preserved ejection fraction, by Dr Zheng and co-workers.(1) I do note the authors' definition of HFPEF as having a left ventricular ejection fraction of >40% as per the suggestions of the American Guidelines.(2) They acknowledge the difficulties posed by those with LVEF 40-49% where the evidence base is largely lacking with the exception of the more recent sub-study of CHARM data in those with LVEF in the above mid-range.(3)
    I have however an issue with their inclusion of the SENIORS study data.(4) Although the mean LVEF of those labelled as HF with preserved LVEF was 49%, the patients included as those with preserved left ventricular ejection fraction, were those with LVEF>35%. This calls into question as to whether the positive effect on mortality of beta-blockers in this trial was caused by the impact of including patients with LVEF 35-40% within this group. I am sure that the authors would agree that the positive impact of the beta-blockers on the mortality of patients with LVEF 35-40%, is un-controversial.(4) While another publication from the SENIORS study group found no statistically significant difference between those deemed HFREF and those deemed HFPEF. We do know that the comparison here may be flawed for the above mentioned issue.
    I would therefore, encourage the authors to reconsider their firm conclusion about the effectivenes...

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    Conflict of Interest:
    None declared.