Diastolic function assessment with left atrial strain in long-term survivors of childhood acute lymphoblastic leukemia.

INTRODUCTION AND OBJECTIVES: Survivors of childhood cancer might be at increased risk of diastolic dysfunction at follow-up due to exposure to cardiotoxic treatment. Although assessment of diastolic function is challenging in this relatively young population, left atrial strain might provide a novel insight in this evaluation. Our aim was to examine diastolic function in a cohort of long-term survivors of childhood acute lymphoblastic leukemia by using left atrial strain and conventional echocardiographic parameters. METHODS: Long-term survivors who were diagnosed at a single center between 1985 and 2015 and a control group of healthy siblings were recruited. Conventional diastolic function parameters and atrial strain were compared, and the latter was measured during the 3 atrial phases: reservoir (PALS), conduit (LACS) and contraction (PACS). Inverse probability of treatment weighting was used to account for differences between the groups. RESULTS: We analyzed 90 survivors (age, 24.6±9.7 years, time since diagnosis 18 [11-26] years) and 58 controls. PALS and LACS were significantly reduced compared with the control group: 46.4±11.2 vs 52.1±11.7; P=.003 and 32.5±8.8 vs 38.2±9.3; P=.003, respectively. Conventional diastolic parameters and PACS were similar between the groups. The reductions in PALS and LACS were associated with exposure to cardiotoxic treatment in age- and sex-adjusted analysis (≥ moderate risk, low risk, controls): 45.4±10.5, 49.5±12.9, 52.1±11.7; Padj=.003, and 31.7±9.0, 35.2±7.5, 38.2±9.3; Padj=.001, respectively. CONCLUSIONS: Long-term childhood leukemia survivors showed a subtle impairment of diastolic function that was detected with atrial strain but not with conventional measurements. This impairment was more pronounced in those with higher exposure to cardiotoxic treatment.

Association between diastolic dysfunction and fluid balance in critically ill patients during weaning from mechanical ventilation / Asociación entre la disfunción diastólica y el balance de hídrico en pacientes críticos durante el destete de la ventilación mecánica

Objective: To assess the role of diastolic dysfunction and fluid balance in weaning failure. Design: Prospective, observational, single center. Setting: Intensive care unit of a university hospital. Patients: Adult patients on mechanical ventilation for more than 48 h who underwent a spontaneous breathing trial (SBT). Interventions: Echocardiography was performed immediately before and at the end of SBT. Patients were classified into two groups according to weaning outcome. Main variable of interest: Weaning failure. Results: Among 89 patients included, weaning failure occurred in 33 patients (37%). Isolated diastolic dysfunction at the end of the SBT was more frequent in the failure group (39.3% vs. 17.8%, p = 0.025). Average daily fluid balance from ICU admission until first SBT was less negative in patients who failed than in those who succeed in the weaning (−648 mL [−884 to -138] vs. −893 mL [−1284 to −501], p = 0.007). Average daily fluid balance from the first SBT until the ICU discharge was more negative in the weaning failure than in the success group (−973 mL [−1493 to −201] vs. −425 mL [−1065 to 12], p = 0.034). Cox regression analysis showed that diastolic dysfunction was not an independent factor related to weaning failure but needed the association of positive fluid balance and age. Conclusions: Weaning failure due to diastolic dysfunction is highly related to fluid balance, and the deleterious effect of fluid balance on diastolic function is associated with age The timing of fluid removal could play a key role in this scenario. (AU)

Objetivo: Evaluar el papel de la disfunción diastólica (DD) y el balance hídrico en el fracaso del destete de la ventilación mecánica. Diseño: Prospectivo, observacional.Ámbito: Unidad de cuidados intensivos hospital universitario. Pacientes: Pacientes adultos con ventilación mecánica más de 48 h sometidos a una prueba de respiración espontánea (SBT).Intervenciones: Ecocardiografía antes y al final del SBT. Los pacientes se clasificaron en dos grupos según el resultado del destete. Variable de interés principal: Fracaso del destete. Resultados: Se incluyeron 89 pacientes, el fracaso del destete ocurrió en 33 (37%). La DD al final de la SBT fue más frecuente en el grupo de fracaso (39,3% vs 17,8%, p = 0,025). El balance hídrico diario desde el ingreso en UCI hasta la SBT fue menos negativo en los pacientes que fracasaron que en los que tuvieron éxito del destete (−648 mL [-884 a -138] vs −893 mL [-1284 a -501], p = 0,007). El balance hídrico diario desde el primer SBT hasta el alta de UCI fue más negativo en el grupo de fracaso que en el de éxito (−973 ml [−1493 a −201] vs. −425 ml [−1065 a 12], p = 0,034). La regresión de Cox mostró que la DD no era un factor independiente relacionado con el fracaso, necesitando la asociación del balance hídrico y la edad. Conclusiones: El fracaso del destete debido a DD se relaciona con el balance hídrico, incrementando su efecto nocivo con la edad. El momento de inicio del balance hídrico negativo puede jugar un papel clave en el fracaso. (AU)

Diastolic dysfunction is an independent predictor for cardiovascular events after an acute kidney injury.

BACKGROUND AND AIM: Acute kidney injury (AKI) conditions several short- and long-term complications. The aim of the present study was to analyse the impact of cardiac function and structure in the cardiovascular prognosis after an in-hospital AKI episode. MATERIAL AND METHODS: This is an observational retrospective cohorts study including all in-hospital AKI episodes in 2013 and 2014 in our centre. At baseline, epidemiological values, comorbidities and echocardiography parameters were collected. During a follow-up of 49 ±â€¯28 months, cardiovascular events (CVE) were collected, and associated factors were analysed. RESULTS: 1255 patients were included (55% male, age 75 ±â€¯13 years). Of the 676 (54%) that had a previous echocardiogram, 46% had left ventricular hypertrophy, 38% pulmonary hypertension, 38% diastolic dysfunction and 22% systolic dysfunction. During the follow-up, 484 (39%) developed a CVE. Associated factors to VCE were male sex, age, diabetes mellitus, hypertension, dyslipidemia, coronary heart disease, heart failure, atrial fibrillation, neoplasia and chronic kidney disease (also, glomerular filtration rate at baseline and after the AKI episode). Survival curves demonstrated that all the echocardiographic parameters were associated to CVE. An adjusted Cox regression model showed that age (HR 1.017), diabetes (HR 1.576) and diastolic dysfunction (HR 1.358) were independent predictors for CVE. CONCLUSION: Diastolic dysfunction is an independent predictor for long-term cardiovascular events after an in-hospital acute kidney injury episode.

Association between diastolic dysfunction and fluid balance in critically ill patients during weaning from mechanical ventilation.

OBJECTIVE: To assess the role of diastolic dysfunction and fluid balance in weaning failure. DESIGN: Prospective, observational, single center. SETTING: Intensive care unit of a university hospital. PATIENTS: Adult patients on mechanical ventilation for more than 48 h who underwent a spontaneous breathing trial (SBT). INTERVENTIONS: Echocardiography was performed immediately before and at the end of SBT. Patients were classified into two groups according to weaning outcome. MAIN VARIABLE OF INTEREST: Weaning failure. RESULTS: Among 89 patients included, weaning failure occurred in 33 patients (37%). Isolated diastolic dysfunction at the end of the SBT was more frequent in the failure group (39.3% vs. 17.8%, p = 0.025). Average daily fluid balance from ICU admission until first SBT was less negative in patients who failed than in those who succeed in the weaning (-648 mL [-884 to -138] vs. -893 mL [-1284 to -501], p = 0.007). Average daily fluid balance from the first SBT until the ICU discharge was more negative in the weaning failure than in the success group (-973 mL [-1493 to -201] vs. -425 mL [-1065 to 12], p = 0.034). Cox regression analysis showed that diastolic dysfunction was not an independent factor related to weaning failure but needed the association of positive fluid balance and age. CONCLUSIONS: Weaning failure due to diastolic dysfunction is highly related to fluid balance, and the deleterious effect of fluid balance on diastolic function is associated with age The timing of fluid removal could play a key role in this scenario.

La disfunción diastólica es un predictor independiente de eventos cardiovasculares tras un fracaso renal agudo / Diastolic dysfunction is an independent predictor for cardiovascular events after an acute kidney injury

Antecedente y objetivo: El desarrollo de un fracaso renal agudo (FRA) condiciona complicaciones a corto, medio y largo plazo. El objetivo de nuestro estudio fue analizar el impacto de las alteraciones cardiacas en el pronóstico cardiovascular de pacientes que presentan un episodio de FRA. Materiales y métodos: Realizamos un estudio observacional de cohortes retrospectivo incluyendo a todos los pacientes con FRA en 2013 y 2014. Basalmente recogimos variables epidemiológicas, comorbilidades y parámetros ecocardiográficos. Seguimos a los pacientes tras el ingreso durante una media de 49 ± 28 meses, recogiendo la incidencia de eventos cardiovasculares (ECV) y los factores asociados a los mismos. Resultados: Se incluyeron 1.255 pacientes (55% varones, edad 75 ± 13 años). De los 676 (54%) pacientes que disponían de un ecocardiograma previo, el 46% tenían hipertrofia de ventrículo izquierdo, el 38% hipertensión pulmonar, el 38% disfunción diastólica y el 22% disfunción sistólica. Tras la hospitalización por FRA, 484 (39%) tuvieron un ECV. Los factores asociados a presentar un ECV fueron el sexo (varón), la edad, diabetes mellitus, hipertensión arterial, dislipidemia, cardiopatía isquémica, insuficiencia cardiaca, fibrilación auricular, neoplasia previa y enfermedad renal crónica (y el filtrado glomerular estimado basal y tras el FRA). El análisis de supervivencia demostró que todos los parámetros ecocardiográficos se asociaban a ECV. Un modelo de regresión de Cox ajustado demostró que la edad (HR 1,017), la diabetes mellitus (HR 1,576) y la disfunción diastólica (HR 1,358) eran predictores independientes de ECV. Conclusiones: La disfunción diastólica es un predictor independiente de ECV a largo plazo tras un episodio hospitalario de FRA. (AU)

Background and aim: Acute kidney injury (AKI) conditions several short- and long-term complications. The aim of the present study was to analyse the impact of cardiac function and structure in the cardiovascular prognosis after an in-hospital AKI episode. Materials and methods: This is an observational retrospective cohorts study including all in-hospital AKI episoes in 2013 and 2014 in our centre. At baseline, epidemiological values, comorbidities and echocardiography parameters were collected. During a follow-up of 49 ± 28 months, cardiovascular events (CVEs) were collected, and associated factors were analysed. Results: 1255 patients were included (55% male, age 75 ± 13 years). Of the 676 (54%) that had a previous echocardiogram, 46% had left ventricular hypertrophy, 38% pulmonary hypertension, 38% diastolic dysfunction and 22% systolic dysfunction. During the follow-up, 484 (39%) developed a CVE. Associated factors to CVE were male sex, age, diabetes mellitus, hypertension, dyslipidemia, coronary heart disease, heart failure, atrial fibrillation, neoplasia and chronic kidney disease (also, glomerular filtration rate at baseline and after the AKI episode). Survival curves demonstrated that all the echocardiographic parameters were associated to CVE. An adjusted Cox regression model showed that age (HR 1.017), diabetes (HR 1.576) and diastolic dysfunction (HR 1.358) were independent predictors for CVE. Conclusion: Diastolic dysfunction is an independent predictor for long-term CVEs after an in-hospital AKI episode. (AU)

Dilemas de la insuficiencia cardíaca con fracción de eyección preservada / Dilemmas of heart failure with preserved ejection fraction / Dilemas da insuficiência cardíaca com fração de ejeção preservada

La insuficiencia cardíaca con fracción de eyección preservada (ICFEp) y reducida presentan marcadas diferencias. Mientras que la última tiene un algoritmo diagnóstico y terapéutico desde hace años, con guías y fármacos que mejoran su pronóstico, la ICFEp no solo presenta dificultades para llegar al diagnóstico, sino que tampoco hay fármacos que hayan demostrado disminuir la mortalidad. En esta revisión se hace un abordaje amplio de la ICFEp, comenzando por definirla y distinguirla de la disfunción diastólica. Se describe el gold standard para su diagnóstico invasivo y se analizan los scores no invasivos recientemente desarrollados que estiman la probabilidad de tener la enfermedad. A través del análisis de las comorbilidades frecuentemente asociadas, se describen los mecanismos fisiopatológicos implicados. Asimismo, se detallan los fenotipos propuestos para agrupar pacientes y diseñar ensayos clínicos con fármacos que prueben disminuir la mortalidad. Por último, se reseñan las medidas terapéuticas no farmacológicas y farmacológicas recomendadas.

Heart failure with preserved and reduced ejection fraction have significant differences. While the latter has had a diagnostic and therapeutic algorithm for years, with guidelines and drugs that improve its prognosis, heart failure with preserved ejection fraction (HFpEF) not only presents difficulties in reaching a diagnosis, but also there are no drugs that have been proven to be effective in reducing mortality. In this review, a broad approach to HFpEF is made, beginning by defining it and distinguishing it from diastolic dysfunction. The gold standard for its invasive diagnosis is described and recently developed non-invasive scores that estimate the probability of having the disease are analyzed. Through the analysis of the frequently associated comorbidities, the pathophysiological mechanisms involved are described. Likewise, the phenotypes proposed to group patients and design clinical trials with drugs that try to reduce mortality are detailed. Finally, the recommended non-pharmacological and pharmacological therapeutic measures are outlined.

A insuficiência cardíaca com fração de ejeção preservada (ICFEp) e reduzida apresentam diferenças marcantes. Enquanto esta última conta com um algoritmo diagnóstico e terapêutico há anos, com diretrizes e medicamentos que melhoram seu prognóstico, a ICFEp não só apresenta dificuldades no diagnóstico, mas nenhum há medicamentos que tenham demonstrado reduzir a mortalidade. Nesta revisão, é feita uma abordagem ampla da ICFEp, começando por defini-la e distinguindo-a da disfunção diastólica. O padrão ouro para seu diagnóstico invasivo é descrito e são analisados os escores não invasivos recentemente desenvolvidos que estimam a probabilidade de ter a doença. Através da análise de comorbidades frequentemente associadas, são descritos os mecanismos fisiopatológicos envolvidos. Da mesma forma, são detalhados os fenótipos propostos para agrupar pacientes e desenhar ensaios clínicos com medicamentos que podem ser mostradas para reduzir a mortalidade. Por fim, são delineadas as medidas terapêuticas não farmacológicas e farmacológicas recomendadas.

Deformación miocárdica de la aurícula izquierda en pacientes con lupus eritematoso sistémico / Left Atrial Strain in Patients With Systemic Lupus Erythematosus

Antecedentes: En los pacientes con lupus eritematoso sistémico (LES) la disfunción diastólica del ventrículo izquierdo (DDVI) puede ser la única manifestación de involucro cardiaco anticipando una disfunción sistólica. Se ha visto que la deformación miocárdica de la aurícula izquierda (AI), mediante el strain longitudinal global de la AI (SLGAI), puede llegar a ser de utilidad en valorar la función diastólica. Objetivo: Evaluar la función de la AI mediante la deformación miocárdica en pacientes con LES. Comparar el strain de la AI en pacientes con LES activos, inactivos y controles. Métodos: Se incluyeron 50 pacientes con LES y se compararon con controles sanos pareados por edad y sexo. Se midió por ecocardiograma transtorácico la deformación miocárdica mediante el SLGAI, el strain de las 3 fases del ciclo de la AI y la tasa de strain. La diferencia entre los grupos se analizó de forma univariante. Resultados: El SLGAI en pacientes con LES fue menor que en los controles sanos (41,6% vs. 50,5%; p=0,02), así como también fue menor en las 3 fases del ciclo de la AI. No hubo diferencias en la tasa de strain en ambos grupos (LES 2,5s−1 vs. controles sanos 2,75s−1; p=0,1). También se encontró que el SLGAI fue menor en pacientes activos en comparación con controles e inactivos. Conclusiones: Los pacientes con LES tienen menor deformación miocárdica de la AI, lo que se expresa como una menor función diastólica correlacionando con daño miocárdico subclínico precoz.(AU)

Background: In patients with systemic lupus erythematosus (SLE), left ventricle diastolic dysfunction (LVDD) may be the only manifestation of cardiac involvement in anticipation of systolic dysfunction. It has been seen that myocardial deformation of the left atrium (LA), through the LA global longitudinal strain (LAGLS), may be useful in assessing diastolic function. Objective: To evaluate LA function through myocardial deformation in patients with LES, and compare the LA strain in patients with active, inactive and controls. Methods: Fifty patients with SLE were included and compared with 50 healthy controls paired by age and gender. Myocardial deformation was measured by transthoracic echocardiogram, to investigate the LAGLS, the strain of the three phases of the LA cycle and the strain rate. The differences between groups were compared in univariate analysis. Results: LAGLS in SLE patients was less than in the controls (41.6% vs. 50.5%; p=.02), and in the 3 phases of the LA cycle. There were no differences in the LA strain rate in both groups (SLE 2.5s−1 vs. controls 2.75s−1; p=.1). It was also found that the LAGLS was lesser in active patients than controls and inactive. Conclusions: SLE patients have lower myocardial deformation of the LA, which is expressed as a lower diastolic function correlating with early subclinical myocardial damage.(AU)

Left Atrial Strain in Patients With Systemic Lupus Erythematosus. / Deformación miocárdica de la aurícula izquierda en pacientes con lupus eritematoso sistémico.

BACKGROUND: In patients with systemic lupus erythematosus (SLE), left ventricle diastolic dysfunction (LVDD) may be the only manifestation of cardiac involvement in anticipation of systolic dysfunction. It has been seen that myocardial deformation of the left atrium (LA), through the LA global longitudinal strain (LAGLS), may be useful in assessing diastolic function. OBJECTIVE: To evaluate LA function through myocardial deformation in patients with LES, and compare the LA strain in patients with active, inactive and controls. METHODS: Fifty patients with SLE were included and compared with 50 healthy controls paired by age and gender. Myocardial deformation was measured by transthoracic echocardiogram, to investigate the LAGLS, the strain of the three phases of the LA cycle and the strain rate. The differences between groups were compared in univariate analysis. RESULTS: LAGLS in SLE patients was less than in the controls (41.6% vs. 50.5%; p=.02), and in the 3 phases of the LA cycle. There were no differences in the LA strain rate in both groups (SLE 2.5s-1 vs. controls 2.75s-1; p=.1). It was also found that the LAGLS was lesser in active patients than controls and inactive. CONCLUSIONS: SLE patients have lower myocardial deformation of the LA, which is expressed as a lower diastolic function correlating with early subclinical myocardial damage.

Falla cardiaca con fracción de eyección preservada: generalidades y aproximación en el perioperatorio / Heart failure with preserved ejection fraction: overview and perioperative management / Falência cardíaca com fração de ejeção preservada: generalidades e abordagens no perioperatório

Resumen: La falla cardiaca con fracción de eyección preservada es frecuente y de difícil abordaje perioperatorio en población adulta. Es un síndrome clínico complejo con alteraciones estructurales y funcionales cardiacas con fracción de eyección del ventrículo izquierdo preservada (FEVI) ≥ 50 %. Los biomarcadores, la ecocardiografía, el cateterismo cardiaco y otros métodos no invasivos confirman el diagnóstico. Actualmente no existe manejo específico efectivo comparado al de la falla con FEVI reducida. Objetivo: Elaborar una revisión de la literatura sobre la falla cardiaca con fracción de eyección preservada y sus implicaciones anestésicas. Métodos: Se realizó una revisión no sistemática de la literatura en las siguientes bases de datos: Pubmed/Medline, LILACS, ScienceDirect. Resultados: La falla cardiaca con fracción de eyección preservada es una entidad común con una prevalencia entre 36,9 % y más del 50 % del total de pacientes. La fisiopatología incluye alteraciones diastólicas del ciclo cardiaco incluyendo las fases de relajación y de compliance ventricular. Desde el punto de vista anestésico se debe mantener el ritmo sinusal en arritmias, controlar la respuesta cronotrópica, evitar congestión pulmonar, manejar específicamente las etiologías-comorbilidades, conservar presiones de llenado ventricular y lograr estabilidad hemodinámica. Conclusión: Los pacientes con este síndrome representan un reto anestésico. El manejo incluye tratamiento específico de las etiologías, comorbilidades y fenotipos. A diferencia de la falla cardiaca con fracción de eyección reducida, no existen terapias que disminuyan la mortalidad, por lo que se requieren nuevos fármacos y estudios clínicos que mejoren las perspectivas anestésicas y el abordaje terapéutico.

Abstract: Heart failure with preserved ejection fraction (HFPEF) is frequent and challenging to manage in the adult population during the perioperative period. It is a complex clinical syndrome with structural and functional cardiac abnormalities with left ventricular preserved ejection fraction (LVPEF) ≥ 50%. Biomarkers, echocardiography, cardiac catheterization, and other noninvasive methods confirm the diagnosis. Currently, there is no specific effective management compared to failure with reduced LVPEF. Aim: To prepare a literature review of HFpEF and its anesthetic implications. Methods: A non-systematic literature review was carried out in the following databases: Pubmed/Medline, LILACS, ScienceDirect. Results: HFpEF is a common entity with a prevalence between 36.9 % and more than 50 % of all patients. The pathophysiology includes diastolic alterations of the cardiac cycle, including relaxation and ventricular compliance phases. From the anesthetic point of view, sinus rhythm should be maintained in arrhythmias, chronotropic response controlled, pulmonary congestion avoided, etiologies/comorbidities specifically managed, ventricular filling pressures preserved, and hemodynamic stability achieved. Conclusion: Patients with HFPEF represent an anesthetic challenge. Management includes specific treatment of etiologies, comorbidities, and phenotypes. Unlike heart failure with reduced ejection fraction, there are no therapies that reduce mortality, so new drugs and clinical studies are required to improve anesthetic prospects and therapeutic management.

Resumo: Introdução: A falência cardíaca de ejecção preservada é frequente e de difícil abordagem perio-peratória na população adulta. É uma síndrome clínica complexa com alterações estruturais e funcionais cardíacas de ejeção do ventrículo esquerdo preservada (FEVI) ≥ 50 %. Os biomarcadores, a ecocardiografia, o cateterismo cardíaco e outros métodos não invasivos confirmam o diagnóstico. Atualmente, não há manejo específico efetivo comparado à da falência com FEVI reduzida. Objetivo: Elaborar uma revisão da literatura sobre falência cardíaca com fração de ejeção preservada e suas implicações anestésicas. Métodos: Foi realizada uma revisão não sistemática da literatura nas bases de dados: PubMed/Medline, LILACS, ScienceDirect. Resultados: A falência cardíaca com fração de ejeção preservada é uma entidade comum com uma prevalência entre 36,9 % e mais de 50 % do total de pacientes. A fisiopatologia inclui alterações diastólicas do ciclo cardíaco incluindo as fases de relaxamento e de complacência ventricular. Do ponto de vista anestésico, deve-se manter o ritmo sinusal em arritmias, controlar a resposta cro-notrópica, evitar congestão pulmonar, lidar em específico com as etiologias-comorbidades, conservar pressões de fibrilação ventricular e atingir estabilidade hemodinâmica. Conclusão: Os pacientes com essa síndrome representam um desafio anestésico. O manejo inclui tratamento específico das etiologias, comorbidades e fenótipos. À diferença da falência cardíaca com fração de ejeção reduzida, não existem terapias que diminuam a mortalidade; portanto, são exigidos novos fármacos e estudos clínicos que melhorem as perspectivas anestésicas e a abordagem terapêutica.

Disfunción diastólica y relación con arritmias: un vínculo más allá de la fibrilación auricular / Diastolic dysfunction and its relationship with arrhythmias: more than just linked to atrial fibrillation

Resumen Introducción: La falla cardíaca es un problema de salud pública, cuya prevalencia aumenta con la edad. Hasta el 50% de los casos tiene fracción de eyección preservada. Pocos estudios evalúan arritmias en este tipo de población. Se conoce una asociación con fibrilación auricular, pero se ignora qué otro tipo de arritmias pueden estar presentes. Objetivo: Describir arritmias por medio de monitorización Holter de 24 horas en pacientes con disfunción diastólica. Materiales y métodos: Se realizó un estudio observacional, descriptivo y retrospectivo, en el que se evaluaron y compararon los parámetros de la monitorización Holter de 24 horas en pacientes con disfunción diastólica, provenientes de un solo centro y residentes en Medellín, durante el año 2017. Resultados: 67 pacientes tenían disfunción diastólica; la mayoría correspondió a mujeres (65.7%). El promedio de edad fue 71 años, el índice de masa corporal fue de 26,8 y las comorbilidades más frecuentes fueron hipertensión arterial (68,7%), fibrilación auricular (19,4%) y enfermedad coronaria (19,4%). El promedio de fracción de eyección fue de 58%; el 67,2% tenía disfunción diastólica tipo I y el promedio del volumen de la aurícula izquierda fue de 33 ml/m2. Las arritmias más frecuentes fueron taquicardia atrial no sostenida (40,3%), fibrilación auricular (10,4%), taquicardia ventricular monomórfica (7,5%) y taquicardia por reentrada intranodal (1.5%). Se presentó bloqueo AV de primer grado (22,4%) y bloqueo sinoatrial (1,5%). El promedio de variabilidad de la frecuencia cardíaca fue 126.23. Conclusiones: En pacientes con disfunción diastólica tipo I y II se documentaron varios tipos de arritmias más allá de la fibrilación auricular. No hubo alteraciones en la variabilidad de la frecuencia cardíaca y tampoco en el tiempo de QTc. Dada la existencia de trasfondo fisiopatológico común, se debe evaluar en estudios futuros la relación entre arritmias y disfunción diastólica, además de su potencial tratamiento y modificación de su curso clínico.

Abstract Introduction: Heart failure is a public health problem, with a prevalence that increases with age. Up to 50% of cases have a preserve ejection fraction. Few studies have evaluated arrhythmias in this population type. It is known that there is an association with atrial fibrillation, but other types of arrhythmias that could be present are ignored. Objective: To describe arrhythmias using 24 hour Holter monitoring in patients with diastolic dysfunction. Materials and methods: An observational, descriptive, and retrospective study was performed in which the parameters from 24 hour Holter monitoring were evaluated and compared in patients with diastolic dysfunction from a single centre and resident in Medellin, during the year 2017. Results: A total of 67 patients had diastolic dysfunction, in which the majority (65.7%) were women. The mean age was 71 years, with a mean body mass index of 26.8. The most frequent comorbidities were arterial hypertension (68.7%), atrial fibrillation (19.4%), and coronary disease (19.4%). The mean ejection fraction was 58%; 67.2% had a type I diastolic dysfunction, and the mean atrial volume was 33 ml/m2. The most common arrhythmias were discontinuous atrial flutter (40.3%), atrial fibrillation (10.4%), monomorphic ventricular tachycardia (7.5%) and nodal re-entrant tachycardia (1.5%). First degree AV block (22.4%) and sinoatrial block (1.5%) were observed. The mean heart rate variability was 126.23. Conclusions: Several types of arrhythmias other than atrial fibrillation were documented in patients with type I and type II diastolic dysfunction. There were no changes in the heart rate variability or in the QTc time. Given the existence of a common pathophysiological background, further studies are needed in order to evaluate the relationship between arrhythmias and diastolic dysfunction, as well as any potential treatment and modification of its clinical course.

Physiopathological and diagnostic aspects of cirrhotic cardiomyopathy.

Cirrhotic cardiomyopathy is characterized by the presence of structural and functional cardiac alterations in patients suffering from hepatic cirrhosis, without previously known cardiac causes that may explain it. Clinically, it is characterized by the presence of variable grades of diastolic and systolic dysfunction (SD), alterations in the electric conductance (elongation of corrected QT interval) and inadequate chronotropic response. This pathology has been related to substandard response in the management of patients with portal hypertension and poor outcome after transplant. Even when the first description of this pathology dates back from 1953, it remains a poorly studied and frequently underdiagnosed entity. Echocardiography prevails as a practical diagnostic tool for this pathology since simple measurements as the E/A index can show diastolic dysfunction. SD discloses as a diminished ejection fraction of the left ventricle and the latent forms are detected by echocardiography studies with pharmacological stress. In recent years, new techniques such as the longitudinal strain have been studied and they seem promising for the detection of early alterations.

La miocardiopatía cirrótica se caracteriza por la presencia de alteraciones cardiacas estructurales y funcionales en pacientes con cirrosis hepática, sin que existan otras causas de enfermedad cardiaca. Clínicamente se caracteriza por la presencia de grados variables de disfunción diastólica y sistólica, alteraciones de la conducción eléctrica (prolongación del intervalo QT) y respuesta cronotrópica inapropiada. Esta patología se ha relacionado con desenlaces clínicos adversos, mala respuesta en el manejo de la hipertensión portal y resultados desfavorables posterior a trasplante hepático ortotópico. A pesar de que las primeras descripciones datan de 1953, es una entidad poco estudiada y frecuentemente subdiagnosticada. El ecocardiograma es una herramienta de diagnóstico importante en esta entidad. Mediciones simples como el índice E/A pueden traducir disfunción diastólica. La disfunción sistólica se manifiesta con disminución de la fracción de eyección del ventrículo izquierdo y las formas latentes se detectan mediante estudios de ecocardiografía con estrés farmacológico; en los últimos años se han estudiado otras técnicas como el strain longitudinal, que parecen prometedoras en la detección de alteraciones tempranas.

Physiopathological and diagnostic aspects of cirrhotic cardiomyopathy / Aspectos fisiopatológicos y diagnósticos de la miocardiopatía cirrótica

Abstract Cirrhotic cardiomyopathy is characterized by the presence of structural and functional cardiac alterations in patients suffering from hepatic cirrhosis, without previously known cardiac causes that may explain it. Clinically, it is characterized by the presence of variable grades of diastolic and systolic dysfunction (SD), alterations in the electric conductance (elongation of corrected QT interval) and inadequate chronotropic response. This pathology has been related to substandard response in the management of patients with portal hypertension and poor outcome after transplant. Even when the first description of this pathology dates back from 1953, it remains a poorly studied and frequently underdiagnosed entity. Echocardiography prevails as a practical diagnostic tool for this pathology since simple measurements as the E/A index can show diastolic dysfunction. SD discloses as a diminished ejection fraction of the left ventricle and the latent forms are detected by echocardiography studies with pharmacological stress. In recent years, new techniques such as the longitudinal strain have been studied and they seem promising for the detection of early alterations.

Resumen La miocardiopatía cirrótica se caracteriza por la presencia de alteraciones cardiacas estructurales y funcionales en pacientes con cirrosis hepática, sin que existan otras causas de enfermedad cardiaca. Clínicamente se caracteriza por la presencia de grados variables de disfunción diastólica y sistólica, alteraciones de la conducción eléctrica (prolongación del intervalo QT) y respuesta cronotrópica inapropiada. Esta patología se ha relacionado con desenlaces clínicos adversos, mala respuesta en el manejo de la hipertensión portal y resultados desfavorables posterior a trasplante hepático ortotópico. A pesar de que las primeras descripciones datan de 1953, es una entidad poco estudiada y frecuentemente subdiagnosticada. El ecocardiograma es una herramienta de diagnóstico importante en esta entidad. Mediciones simples como el índice E/A pueden traducir disfunción diastólica. La disfunción sistólica se manifiesta con disminución de la fracción de eyección del ventrículo izquierdo y las formas latentes se detectan mediante estudios de ecocardiografía con estrés farmacológico; en los últimos años se han estudiado otras técnicas como el strain longitudinal, que parecen prometedoras en la detección de alteraciones tempranas.

Physiopathological and diagnostic aspects of cirrhotic cardiomyopathy.

Cirrhotic cardiomyopathy is characterized by the presence of structural and functional cardiac alterations in patients suffering from hepatic cirrhosis, without previously known cardiac causes that may explain it. Clinically, it is characterized by the presence of variable grades of diastolic and systolic dysfunction, alterations in the electric conductance (elongation of corrected QT interval) and inadequate chronotropic response. This pathology has been related to substandard response in the management of patients with portal hypertension and poor outcome after transplant. Even when the first description of this pathology dates back from 1953, it remains a poorly studied and frequently underdiagnosed entity. Echocardiography prevails as a practical diagnostic tool for this pathology since simple measurements as the E/A index can show diastolic dysfunction. Systolic dysfunction discloses as a diminished ejection fraction of the left ventricle and the latent forms are detected by echocardiography studies with pharmacological stress. In recent years new techniques such as the longitudinal strain have been studied and they seem promising for the detection of early alterations.

La miocardiopatía cirrótica se caracteriza por la presencia de alteraciones cardiacas estructurales y funcionales en pacientes con cirrosis hepática, sin que existan otras causas de enfermedad cardiaca. Clínicamente se caracteriza por la presencia de grados variables de disfunción diastólica y sistólica, alteraciones de la conducción eléctrica (prolongación del intervalo QT) y respuesta cronotrópica inapropiada. Esta patología se ha relacionado con desenlaces clínicos adversos, mala respuesta en el manejo de la hipertensión portal y resultados desfavorables posterior a trasplante hepático ortotópico. A pesar de que las primeras descripciones datan de 1953, es una entidad poco estudiada y frecuentemente subdiagnosticada. El ecocardiograma es una herramienta de diagnóstico importante en esta entidad. Mediciones simples como el índice E/A pueden traducir disfunción diastólica. La disfunción sistólica se manifiesta con disminución de la fracción de eyección del ventrículo izquierdo y las formas latentes se detectan mediante estudios de ecocardiografía con estrés farmacológico; en los últimos años se han estudiado otras técnicas como el strain longitudinal, que parecen prometedoras en la detección de alteraciones tempranas.

Interrelación entre enfisema y disfunción diastólica ventricular izquierda: nuestra experiencia en el Hospital Privado Centro Médico de Córdoba / Interrelation between emphysema and diastolic dysfunction left ventricular: our experience in the Hospital Private Medical Center of Córdoba

Introducción: Las consecuencias hemodinámicas de la hiperinflación y el enfisema se producen por compresión cardíaca debido a elevadas presiones intratorácicas, lo que produciría disfunción diastólica ventricular izquierda subclínica. Nuestro objetivo es correlacionar el porcentaje de enfisema con parámetros de función pulmonar y con el tamaño de las cámaras cardíacas, función sistólica ventricular global y función diastólica ventricular izquierda, en la enfermedad pulmonar obstructiva crónica. Materiales y Métodos: participaron pacientes con enfermedad pulmonar obstructiva crónica moderada y severa asistidos en un Servicio de Neumonología del Hospital Privado Centro Médico de Córdoba, desde el 01 de enero al 31 de octubre de 2014. Se cuantificó el volumen y porcentaje de enfisema por tomografía computada de alta resolución, se realizaron espirometría, prueba de marcha de seis minutos, determinación de volúmenes pulmonares y ecocardiograma Doppler color. Resultados: Se encontró correlación negativa y significativa del porcentaje de enfisema con el porcentaje del valor teórico del VEF1 postbroncodilatador (p = 0.005) y el cociente VEF1/CVF postbroncodilatador (p = 0.004) y; además, entre el cociente VEF1/CVF postbroncodilatador y el volumen del enfisema en cm3 (p = 0.000). De un subgrupo de 20 pacientes. Siete pacientes (35%) presentaron diagnóstico de disfunción diastólica ventricular izquierda de grado I. Se encontraron correlaciones negativas pero no significativas entre el porcentaje de enfisema con función sistólica ventricular global y el tamaño de las cámaras cardíacas. Conclusiones: Se destaca la utilidad del ecocardiograma para reducir el sub diagnóstico de disfunción diastólica ventricular izquierda. Se destaca la importancia que tendrían la hiperinflación y el enfisema en el deterioro del patrón de llenado diastólico ventricular izquierdo y en la reducción del tamaño de las cámaras cardíacas con disminución en la tolerancia al ejercicio.

Effects of carvedilol therapy in patients with heart failure with preserved ejection fraction - Results from the Croatian heart failure (CRO-HF) registry.

BACKGROUND AND OBJECTIVE: According to recent guidelines, the best approach for treatment of heart failure patients with preserved ejection function is still not defined. The aim of this study was to investigate how carvedilol therapy influences the survival rate, ejection fraction and NYHA class in these patients. PATIENTS AND METHODS: We conducted study on heart failure patients with preserved systolic function from the Croatian heart failure registry who were hospitalized in the period between 2005 and 2010. We enrolled patients with carvedilol listed as treatment on their discharge letters and patients who had been using carvedilol for at least 4 years, while for the control group we selected patients with no beta-blockers on their discharge letters (113 vs 204 respectively). The primary outcome was the overall survival rate and the secondary outcome was the change in ejection fraction of the left ventricle and NYHA class during the study. RESULTS: Patients in the carvedilol group had a higher overall survival rate compared to patients in the control group (chi-square=14.1, P<0.001). Patients in the carvedilol group in two measurements had a significantly higher ejection fraction compared to the control group (F=148.04, P<0.001). Also, patients in the carvedilol group showed improvement in NYHA class (chi-square=29.768, P<0.001). CONCLUSION: Long term carvedilol therapy appears to be associated with a higher overall survival rate, improvement in ejection fraction and NYHA class in heart failure patients with preserved ejection fraction.

Anemia and hypoalbuminemia as risk factors for left ventricular diastolic dysfunction in children with chronic kidney disease on peritoneal dialysis. / Anemia e hipoalbuminemia como factores de riesgo de disfunción diastólica del ventrículo izquierdo en niños con insuficiencia renal crónica tratados con diálisis peritoneal.

INTRODUCTION: Left ventricular diastolic dysfunction (LVDD) is an independent predictor of mortality in Chronic Kidney Disease (CKD). The increase in the E/e' ratio is an indicator of LVDD. The association between cardiovascular risk factors (CVRFs) and E/e' in children with automated peritoneal dialysis (APD) has not been widely studied. OBJECTIVE: To measure the association between CVRFs and E/e' in children with CKD on APD. METHODS: Cross-sectional, prolective, observational, analytical study of children aged 6-16 years on APD. We recorded age, gender, time since onset, time on dialysis, and measured weight, height, blood pressure, hemoglobin, albumin, calcium, phosphorus, parathyroid hormone, and C-reactive protein. E/e' ratio was measured and considered to have increased when it was higher than 15. RESULTS: Twenty-nine children were studied, (19 females). Age was 14.0±2.5 years, and 16.9±11.2 months with substitutive therapy. One patient had reduced left ventricular ejection fraction, and 21 (72.4%) had increased E/e'. E/e' correlated significantly with hemoglobin (r=-0.53, P=.003). Hemoglobin and albumin were significantly lower (9.72±1.9 vs. 12.2±1.8; P=.004 and 3.6±0.5 vs. 4.0±0.3; P=.035) and the proportion of patients with anemia and hypoalbuminemia was significantly higher (85.7% vs. 37.5%; P=.019 and 61.9% vs. 12.5%; P=.035) in patients with increased E/e'. Hemoglobin was the only independent predictor of E/e' (ß=-0.66; P=.020) and patients with anemia were 10 times more likely to have increased E/e' (95% CI 1.5-65.6, P=.016). CONCLUSIONS: 75% of the children had increased E/e'. Anemia and hypoalbuminemia were significantly related with an increased E/e'.

Determinants of left ventricular diastolic dysfunction in hypertensive patients.

INTRODUCTION: The progression of hypertensive heart disease leads to the left ventricular diastolic dysfunction (LVDD), which is associated with increased cardiovascular morbidity and mortality. The purpose of this analysis is to explore the determinants for LVDD in patients with hypertension. METHODS: This is a secondary analysis of data of Impedance Cardiography in the Evaluation of Left Ventricular Diastolic Dysfunction in Patients with Arterial Hypertension (IMPEDDANS) Study. Mann-Whitney and Chi-square tests were used for univariable analysis. Multiple logistic regression was used to model for LVDD occurrence and discriminative capacity of the model assessed by the value of the area under the curve given by the receiver-operating characteristic curve. RESULTS: Older age (65 vs. 58 years, p<0.001), longer duration of hypertension (160 vs. 48 months, p<0.001), uncontrolled hypertension (59.8 vs. 15.9%, p<0.001), tobacco smoking (17.8 vs. 3.8%, p=0.016), higher systolic blood pressure (133 vs. 124mmHg, p=0.001) and slower heart rate (62 vs. 66bpm, p=0.023) were associated with LVDD. Multivariate model identified uncontrolled hypertension (AdjOR 36.90; 95% CI 7.94-171.58; p<0.001), smoking (AdjOR 6.66; 95% CI 1.63-27.26; p=0.008), eccentric hypertrophy (AdjOR 3.59; 95% CI 0.89-14.39; p=0.072), duration of hypertension (AdjOR 1.03; 95% CI 1.02-1.05; p<0.001) and concentric remodeling (AdjOR 0.19; 95% CI 0.04-0.93; p=0.041) as the more determinant for occurrence of LVDD. The discriminative capacity of the model was AUC=0.95 (95% CI 0.91-0.98). CONCLUSION: The occurrence of LVDD in hypertensive patients was strongly associated to long-lasting, uncontrolled hypertension, tobacco smoking, concentric remodeling and eccentric hypertrophy.

Estratificación de disfunción diastólica y patrones de llenado del ventrículo izquierdo en pacientes llevados a ecocardiografía en un centro de tercer nivel según las Guías de la Sociedad Americana de Ecocardiografía y la Asociación Europea de Imágenes Cardíacas 2016 / Echocardiographic diastolic disfunction and left ventricle filling patterns in patients studied in a terciary level center according to American Society of echocardiography/ European association of cardiovascular imaging 2016 Guidelines

OBJECTIVE: Characterize the degree of diastolic dysfunction and left ventricular filling patterns according to the 2016 ASE Guidelines applied in a population of patients taken to echocardiography in a reference center in the city of Medellín between February and June 2017. METHODOLOGY: A cross-sectional study was performed in patients undergoing echocardiography. Patients with atrial fibrillation, pacemaker implantation, AV block, mitral ring calcification, any degree of mitral stenosis, mitral insufficiency were excluded. An initial descriptive explora tory analysis was carried out by frequencies and percentages for the categorical variables and measures of central tendency (mean or median according to the normal distribution of the data) for the quantitative variables. Subsequently, it is compared with the different degrees of diastolic dysfunction with respect to age by t-Student test and with respect to categorical variables by 2. RESULTS: A total of 610 patients were recruited, of which 75 were withdrawn from the sample by the exclusion criteria, 530 patients were included of which 198 (37%) were classified as grade I diastolic dysfunction, 63 (11.7%) grade II, 29 (5.4%) grade III, 38 (7.1%) undetermined and 207 (39%) without diastolic dysfunction. The age of the patients stratified in any degree of diastolic dysfunction was significantly higher in comparison with patients without diastolic dysfunction (p < 0.001). Hypertension was the most important associated comorbidity in patients with diastolic dysfunction grade I (in 54%), grade II (in 50%), while coronary disease was the most frequent concomitant in the presence of diastolic dysfunction grade III (in 48%). The E/e' ratio greater than 14 was present in 35% of cases with grade II diastolic dysfunction and in 72% of cases with grade III diastolic dysfunction. CONCLUSION: Diastolic dysfunction is a very frequent finding (323/530, 61%). Hypertension was the most common comorbidity associated in grades I, II of diastolic dysfunction, while coronary disease with grade III. The increase in the E/e' > 14 ratio as an indicator of increased population pressure was present in 35% of patients with grade II diastolic dysfunction and in 72% of patients with grade III dysfunction. Diastolic function was classified as undetermined in 7.1% of the total patient population. The ASE/EACVI Guidelines allowed the classification in different degrees of diastolic dysfunction in the majority of patients evaluated (94%). Other methods of diagnostic evaluation are necessary to adequately classify the group of patients with indeterminate diastolic function.

OBJETIVO: Caracterizar el grado de disfunción diastólica y patrones de llenado del ventrículo izquierdo según las Guías ASE/EACVI 2016 aplicadas en una población de pacientes llevados a ecocardiografía en un centro de referencia de la ciudad de Medellín entre febrero y junio de 2017. METODOLOGÍA: Se realizó un estudio de corte transversal en pacientes llevados a ecocardiografía. Fueron excluidos pacientes con fibrilación auricular, implante de marcapasos, bloqueo AV, calcificación del anillo mitral, cualquier grado de estenosis mitral, insuficiencia mitral severa y válvula mitral protésica. Se realizó un análisis exploratorio inicial de tipo descriptivo mediante frecuencias y porcentajes para variables categóricas y medidas de tendencia central (media o mediana según la distribución normal de los datos) para variables cuantitativas. Posteriormente, se compararon los diferentes grados de disfunción diastólica respecto a la edad mediante prueba t-Student y respecto a variables categóricas mediante 2. RESULTADOS: Se reclutaron un total de 610 pacientes, de los cuales 75 fueron retirados de la muestra por cumplir criterios de exclusión, se incluyeron 535 pacientes de los cuales 198 (37%) se estratificaron como disfunción diastólica grado I, 63 (11,7%) grado II, 29 (5,4%) grado III, 38 (7,1%) indeterminado y 207 (38,6%) sin disfunción diastólica. La edad de los pacientes estratificados en cualquier grado de disfunción diastólica fue significativamente mayor en comparación con los pacientes sin disfunción diastólica (p < 0,001). La hipertensión arterial fue la comorbilidad asociada más importante en los pacientes con disfunción diastólica grado I (en 54%), grado II (en 50%), mientras que la enfermedad coronaria fue la más frecuente comorbilidad encontrada en la presencia de disfunción diastólica grado III (en 48%). La relación E/e' mayor a 14 estuvo presente en el 35% de los casos con disfunción diastólica grado II y en el 72% de los casos con disfunción diastólica grado III. CONCLUSIÓN: La disfunción diastólica es un hallazgo muy frecuente (323/530, 61%). La hipertensión arterial fue la comorbilidad más frecuentemente asociada en los grados I, II de disfunción diastólica, mientras que la enfermedad coronaria con el grado III. El aumento de la relación E/e´ >14 como parámetro indicativo de aumento de la presión de llenado estuvo presente en el 35% de los pacientes con disfunción diastólica grado II y en el 72% de los pacientes con disfunción grado III. La función diastólica se clasificó como indeterminada en el 7,1% de la población total de pacientes. Las Guías ASE/EACVI permitieron la clasificación en diferentes grados de disfunción diastólica en la mayoría de los pacientes evaluados (94%). Otros métodos de evaluación diagnóstica serán necesarios para clasificar adecuadamente al grupo de pacientes con función diastólica indeterminada.

Estudio retrospectivo sobre las diferencias entre insuficiencia cardíaca sistólica y diastólica en un registro de 1.000 pacientes del hospital Puerta de Hierro-Majadahonda-Madrid. Comparación con el Registro Nacional español de Insuficiencia Cardíaca (RICA) / Retrospective study on the differences between systolic and diastolic heart failure in a registry of 1,000 patients from the Puerta de Hierro-Majadahonda Hospital, Madrid. Comparison with the Spanish National Heart Failure Registry

Resumen Objetivo: Comparar las diferencias entre insuficiencia sistólica y diastólica en pacientes ingresados en el Hospital Puerta de Hierro Majadahonda, con diagnóstico al alta de ``primer episodio de insuficiencia cardiaca''. Los resultados se cotejan con el registro nacional español de insuficiencia cardiaca (RICA). Material y método: Estudio retrospectivo que incluye a 1.000 pacientes ingresados desde octubre 2008 hasta mayo 2010. El seguimiento se realizó hasta mayo 2015. Resultados: El 70,6% procedían de Medicina Interna, con predominio del sexo femenino (62%) y una mediana de 87 años de edad. La mortalidad global fue de 69,8%, mayor en pacientes con insuficiencia cardiaca-diastólica. OR 1,03 (IC 95% 0,73-1,45). El 59% de los pacientes reingresaron al menos una vez; en su mayoría eran varones (61%) e hipertensos (89,3%). Conclusiones: Los pacientes con insuficiencia cardiaca-diastólica ingresan preferentemente en Medicina Interna (76,2%); la mayoría son mujeres hipertensas y de edad más avanzada que en el grupo de insuficiencia cardiaca-sistólica. Los resultados fueron similares a los del registro RICA, salvo mayor mortalidad y reingresos, probablemente por la edad más avanzada de los pacientes y el mayor tiempo de seguimiento.

Abstract Objective: To compare the differences between systolic and diastolic dysfunction in patients admitted to the Hospital Puerta de Hierro Majadahonda, Madrid, with a diagnosis on discharge of ``first episode of heart failure''. The results were compared with the Spanish National Heart Failure Registry (RICA). Material and method: A retrospective study that included 1,000 patients admitted from October 2008 to May 2010. The follow-up was carried out up to May 2015. Results The majority of patients were admitted to Internal Medicine, with a majority of females (62%), and with a median age of 87 years. The overall mortality was 69.8%, and was higher in patients with diastolic heart failure (OR: 1.03, 95% CI; 0.73 - 1.45). More than half of the patients (59%) were admitted at least once, with the majority being males (61%) and with hypertension (89.3%). Conclusions: Patients with diastolic heart failure were mainly admitted to Internal Medicine (76.2%). The majority were women with hypertension, and of a more advanced age than the systolic heart failure group. The results were similar to the RICA, except for the higher mortality and admissions, probably due to the more advanced age of the patients, and the longer follow-up time.

Is heart failure with midrange ejection fraction similar to preserved ejection fraction? For. / La insuficiencia cardiaca con fracción de eyección en rango intermedio ¿es similar a la de fracción de eyección preservada? A favor.

Basing heart failure (HF) classification on the echocardiographic values of left ventricular ejection fraction (LVEF) has been useful in defining two sub-types of HF: HF with reduced LVEF and HF with preserved LVEF. A new category has recently been defined: HF with midrange LVEF (40-49%). When current information is taken into account, this new category is more similar to HF with preserved LVEF than reduced LVEF.