Non-Invasive Hemodynamic Whole-Body Bioimpedance Indices for the Early Detection of Cancer Treatment-Related Cardiotoxicity: A Retrospective Observational Study

Cardiology ◽  
2020 ◽  
Vol 145 (6) ◽  
pp. 350-355
Author(s):  
Nili Schamroth Pravda ◽  
Shaul Lev ◽  
Osnat Itzhaki Ben Zadok ◽  
Ran Kornowski ◽  
Zaza Iakobishvili
Keyword(s):  
Heart Failure ◽  
Early Detection ◽  
Predictive Value ◽  
Medical Center ◽  
Left Ventricular ◽  
Whole Body ◽  
Left Ventricular Ejection ◽  
Stroke Index ◽  
Ventricular Ejection Fraction ◽  
Non Invasive

Introduction: Patients undergoing chemotherapy are extremely vulnerable to cardiotoxicity. Early detection of cardiac dysfunction is of vital importance to optimize the management of these patients. Objective: The aim of this study was to test the effectiveness of non-invasive hemodynamic whole-body bioimpedance (WBI) technology as a modality to detect heart failure in patients undergoing chemotherapy treatment. Methods: This retrospective observational trial included 84 patients treated at the cardio-oncology outpatient clinic of the Rabin Medical Center. Clinical assessments were performed including biomarker testing and measurement of hemodynamic and volume status parameters as measured by WBI. Results: We included 84 patients with a median age of 64.8 years, and 40.5% were males. Clinical heart failure was detected in 43% of the whole group. Patients were divided into two groups according to baseline NT-proBNP levels with a cut-off of 900 pg/mL. Left ventricular ejection fraction did not differ between the groups. Those with NT-proBNP >900 pg/mL had lower levels of stroke index, cardiac index, and Granov-Goor index (GGI; 25.9 vs. 34.0, 2.0 vs. 2.3, 8.3 vs. 11.4, respectively, with p < 0.001 for all comparisons). The optimal cut-off value for the GGI to detect NT-proBNP >900 pg/mL was 8.3. The area under the curve of a GGI cut-off <8.3 to detect NT-proBNP >900 pg/mL was 0.81 (positive predictive value 95% and negative predictive value 72%), with a 51% sensitivity and 98% specificity. Conclusion: GGI, a parameter measured by WBI, can reliably correlate to biomarker evidence of heart failure in patients after chemotherapy. Its use as a screening tool for cardiotoxicity in patients with ongoing anticancer therapy is promising.

External validation of an electrocardiography artificial intelligence-generated algorithm to detect left ventricular systolic function in a general cardiac clinic in Uganda

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
C.K Mondo ◽  
Z.I Attia ◽  
E.D Benavente ◽  
P Friedman ◽  
P Noseworthy ◽  
...  
Keyword(s):  
Artificial Intelligence ◽  
Heart Failure ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Left Ventricular Systolic Dysfunction ◽  
External Validation ◽  
Left Ventricular ◽  
Receiver Operating Curve ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction

Abstract Background Left ventricular systolic dysfunction (LVSD) is associated with increased morbidity and mortality. Although there are effective treatments for patients with LVSD to prevent mortality, heart failure and to improve symptoms, many patients remain undetected and untreated. We have recently derived a deep learning algorithm to detect LVSD using the electrocardiogram (ECG) which could have an important screening role, particularly in limited resources settings. We evaluated the accuracy of this algorithm for the first time in Africa in a sample of subjects attending a cardiology clinic. Methods We conducted a retrospective study in a general cardiac clinic in Uganda. Consecutive patients ≥18 years who had a digital ECG and echocardiogram done within two days of each other were included. We excluded patients with pacemakers or missing information regarding left ventricular ejection fraction (LVEF). Routine 10-second, twelve-lead surface rest ECG were performed using an Edan PC ECG Model SE-1515, Hamburg, Germany. The probability of LVSD was estimated with the Mayo Clinic artificial intelligence (AI) ECG algorithm. LVEF was calculated by the MMode (Teichholz method) using a Philips Ultrasound system, HD7XE, Bothel, Washington, USA. LVSD was defined as a LVEF≤35%. We assessed the overall diagnostic performance of the algorithm to identify LVSD in this population with the area under the receiver operating curve (AUC), and estimated sensitivity, specificity and accuracy using a pre-specified cut-off based on the probability for LVSD generated by the algorithm. We conducted secondary analyses using different LVEF cutoff values. Results We included 634 subjects, 32% (200) of whom had hypertension and 12% (77) clinical heart failure. Mean age was 57±18.8 years, 58% were women and the overall prevalence of LVSD was 4%. The AI-ECG had an AUC of 0.866 (see figure below), sensitivity 73.08%, specificity 91.10%, negative predictive value 98.75%, positive predictive value 26.03% and an accuracy of 90.96% using the original threshold. Using the optimal cutoff based on the AUCs, the sensitivity was 80.77% and specificity was 81.05% with a negative predictive value of 98.99%. The ROC for the detection of LVEF of 40% or below was 0.821. Conclusion The Mayo AI-ECG algorithm demonstrated good accuracy, sensitivity and specificity to detect LVSD in patients seen in a clinical setting in Uganda. This tool may facilitate the identification of people at a high risk for LVSD in settings with low resources. ROC Funding Acknowledgement Type of funding source: None

scholarly journals Racial differences of heart failure with midrange ejection fraction (HFmrEF): a large urban centre-based retrospective cohort study in the USA

BMJ Open ◽  
2019 ◽  
Vol 9 (4) ◽  
pp. e026479
Author(s):  
Dan Leslie Li ◽  
Renato Quispe ◽  
Chioma Onyekwelu ◽  
Robert T Faillace ◽  
Cynthia C Taub
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Racial Differences ◽  
Medical Center ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Survival Outcomes ◽  
Racial Groups ◽  
Mineralocorticoid Receptor Antagonist ◽  
Ventricular Ejection Fraction

ObjectivesWe aimed to study the racial differences in clinical presentations, survival outcomes and outcome predictors among patients with heart failure (HF) with midrange ejection fraction (HFmrEF, EF 40%–49%).DesignThis is a retrospective study.SettingAdults with HF diagnosis at Montefiore Medical Center, Bronx, New York between 2008 and 2012, with an inpatient echocardiogram showing left ventricular ejection fraction of 40%–49% were included as HFmrEF population.Participants1,852 HFmrEF patients are included in the study (56% male, mean age 67 years). There were 493 (26.5%) non-Hispanic whites, 541 (29.2%) non-Hispanic black, 489 (26.4%) Hispanics and 329 (17.8%) other racial populations.Outcome measuresCumulative probabilities of all-cause mortality among different racial groups were estimated and multivariable adjusted Cox proportional regressions were performed to assess predictors of mortality.ResultsAmong the HFmrEF patients, white patients were older and were less likely to be on guideline-directed medications. Blacks had a lower prevalence of prior myocardial infarction comparing to other groups. Hispanics had more chronic diseases and yet better survival comparing to whites and blacks after adjustment for age, sex and comorbidities. Distinct sets of survival predictors were revealed in individual racial groups. Baseline use of mineralocorticoid receptor antagonist (MRA) was associated with lower mortality among HFmrEF patients in general (HR 0.61, 95% CI 0.37 to 0.99).ConclusionsThere are significant racial/ethnic differences in clinical phenotypes, survival outcomes and mortality predictors of HFmrEF. Furthermore, the use of MRA predicted a reduced mortality in HFmrEF patients.

scholarly journals Real-world outcomes of long-term prednisone and deflazacort use in patients with Duchenne muscular dystrophy: experience at a single, large care center

2020 ◽  
Vol 9 (3) ◽  
pp. 177-189
Author(s):  
Jessica R Marden ◽  
Jonathan Freimark ◽  
Zhiwen Yao ◽  
James Signorovitch ◽  
Cuixia Tian ◽  
...  
Keyword(s):  
Duchenne Muscular Dystrophy ◽  
Muscular Dystrophy ◽  
Real World ◽  
Medical Center ◽  
Care Center ◽  
Left Ventricular ◽  
Whole Body ◽  
Left Ventricular Ejection ◽  
Mineral Density ◽  
Ventricular Ejection Fraction

Aim: To assess outcomes among patients with Duchenne muscular dystrophy receiving deflazacort or prednisone in real-world practice. Methods: Clinical data for 435 boys with Duchenne muscular dystrophy from Cincinnati Children’s Hospital Medical Center were studied retrospectively using time-to-event and regression analyses. Results: Median ages at loss of ambulation were 15.6 and 13.5 years among deflazacort- and prednisone-initiated patients, respectively. Deflazacort was also associated with a lower risk of scoliosis and better ambulatory function, greater % lean body mass, shorter stature and lower weight, after adjusting for age and steroid duration. No differences were observed in whole body bone mineral density or left ventricular ejection fraction. Conclusion: This single center study adds to the real-world evidence associating deflazacort with improved clinical outcomes.

scholarly journals 709 Non-invasive assessment of myocardial work: an useful tool for predicting LV remodelling after myocardial infarction?

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Rodolfo Caminiti ◽  
Antonio Parlavecchio ◽  
Giampaolo Vetta ◽  
Giuseppe Pelaggi ◽  
Francesca Lofrumento ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Transthoracic Doppler Echocardiography ◽  
Ventricular Ejection Fraction ◽  
Non Invasive ◽  
Global Work

Abstract Aims Left ventricular function recovery (LV-REC) or left ventricular adverse remodelling (LV-REM) after acute myocardial infarction (AMI) play an important role for identifying patients at risk of heart failure. In this study we aim to evaluate the usefulness of non-invasive myocardial work (MW), a new index of global and regional myocardial performance, to predict LV-REC or LV-REM after AMI. Methods and results Fifty patients with AMI (mean age, 63.8 ± 13.4 years), treated by primary percutaneous coronary intervention (PCI), were prospectively enrolled. They underwent a baseline transthoracic Doppler echocardiography (TTE) within 48 h after PCI and a second TTE after a median of 31 days during the follow-up. MW was derived from the strain-pressure loops, integrating in its calculation the non-invasive arterial pressure, according to standard speckle tracking echocardiography recommendations. LV-REC was defined as an absolute improvement of left ventricular ejection fraction (LVEF) ≥ 5% from LVEF at baseline, whereas LV-REM was defined as an increase of ≥ 20% of the LV end diastolic volume (LVEDV) at 1 month follow-up. We overall found a significant improvement from baseline to one-month follow-up for values of LVEF (49.8 ± 9.5% vs. 52.8 ± 9.3%, P = 0.001), global longitudinal strain (GLS) (−13.4 ± 3.9% vs. −18.7 ± 5.4%, P = 0.016), global work index (GWI) (1368.6 ± 435.2 vs. 1788 ± 493 mmHg/%, P = 0.0001), global work efficiency (GWE) (89.96 ± 9.3% vs. 91.3 ± 6.4%, P = 0.001), global constructive work (GCW) (1619.16 ± 497.9 mmHg/% vs. 2008.6 ± 535.3 mmHg/%, P = 0.0001), global wasted work (GWW) (188.8 ± 19.8 mmHg/% vs. 149.2 ± 16.5 mmHg/%). However, LV-REC at 1 month of follow-up was observed only in 36% of the population enrolled, whereas LV-REM was described in 18% of cases. Using ROC curve analysis, we identified a cut off value of 202 mmHg/% for baseline GWW (sensitivity 75%, specificity 62%, AUC 0.6667, CI 95%: 0.51618–0.81715, P = 0.0001) to identify patients with LV-REM at 1 month. With regards to conventional echo parameters, patients with LV-REC showed lower baseline wall motion score index (WMSI) than those without LV-REC (1.73 vs. 1.38, P = 0.007). Conclusions Among standard and advanced TTE parameters, only baseline GWW is able to predict early LV-REM at 1 month after primary PCI. Therefore, it could be used during baseline evaluation of AMI patients for a more accurate stratification of those at higher risk of heart failure. However, further larger scale studies are needed to validate these findings.

Suppression of circulating free fatty acids with acipimox in chronic heart failure patients changes whole body metabolism but does not affect cardiac function

2010 ◽  
Vol 299 (4) ◽  
pp. H1220-H1225 ◽  
Author(s):  
Mads Halbirk ◽  
Helene Nørrelund ◽  
Niels Møller ◽  
Ole Schmitz ◽  
Liv Gøtzsche ◽  
...  
Keyword(s):  
Heart Failure ◽  
Fatty Acids ◽  
Exercise Capacity ◽  
Myocardial Function ◽  
Left Ventricular ◽  
Whole Body ◽  
Left Ventricular Ejection ◽  
Regional Myocardial Function ◽  
Ventricular Ejection Fraction ◽  
Whole Body Metabolism

Circulating free fatty acids (FFAs) may worsen heart failure (HF) due to myocardial lipotoxicity and impaired energy generation. We studied cardiac and whole body effects of 28 days of suppression of circulating FFAs with acipimox in patients with chronic HF. In a randomized double-blind crossover design, 24 HF patients with ischemic heart disease [left ventricular ejection fraction: 26 ± 2%; New York Heart Association classes II ( n = 13) and III ( n = 5)] received 28 days of acipimox treatment (250 mg, 4 times/day) and placebo. Left ventricular ejection fraction, diastolic function, tissue-Doppler regional myocardial function, exercise capacity, noninvasive cardiac index, NH2-terminal pro-brain natriuretic peptide (NT-pro-BNP), and whole body metabolic parameters were measured. Eighteen patients were included for analysis. FFAs were reduced by 27% in the acipimox-treated group [acipimox vs. placebo ( day 28 − day 0): −0.10 ± 0.03 vs. +0.01 ± 0.03 mmol/l, P < 0.01]. Glucose and insulin levels did not change. Acipimox tended to increase glucose and decrease lipid utilization rates at the whole body level and significantly changed the effect of insulin on substrate utilization. The hyperinsulinemic euglycemic clamp M value did not differ. Global and regional myocardial function did not differ. Exercise capacity, cardiac index, systemic vascular resistance, and NT-pro-BNP were not affected by treatment. In conclusion, acipimox caused minor changes in whole body metabolism and decreased the FFA supply, but a long-term reduction in circulating FFAs with acipimox did not change systolic or diastolic cardiac function or exercise capacity in patients with HF.

scholarly journals Haemodynamic Effects of Anaemia in Patients with Acute Decompensated Heart Failure

2020 ◽  
Vol 2020 ◽  
pp. 1-9 ◽  
Author(s):  
Paweł Krzesiński ◽  
Agata Galas ◽  
Grzegorz Gielerak ◽  
Beata Uziębło-Życzkowska
Keyword(s):  
Heart Failure ◽  
Fluid Overload ◽  
Acute Decompensated Heart Failure ◽  
Decompensated Heart Failure ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Stroke Index ◽  
Ventricular Ejection Fraction ◽  
Patients With Heart Failure ◽  
Systolic Performance

Anaemia is a common comorbidity in patients with heart failure (HF) and is associated with more severe symptoms and increased mortality. The aim of this study was to evaluate haemodynamic profiles of HF patients with respect to the presence of reduced left ventricular ejection fraction (LVEF) and anaemia. Methods and Results. Haemodynamic status was evaluated in 97 patients with acute decompensated HF. Impedance cardiography, echocardiography, and N-terminal probrain natriuretic peptide (NT-proBNP) results were analysed. The study group was stratified into four subgroups according to LVEF (<40% vs ≥40%) and the presence of anaemia (haemoglobin <13.0 g/dL in men and <12.0 g/dL in women). Thoracic fluid content was higher (p=0.037) in anaemic subjects, while no significant relation between anaemia and NYHA was observed. Anaemic subjects with LVEF ≥ 40% were distinguished from those with LVEF < 40% by significantly higher stroke index (p=0.002), Heather index (p=0.014), and acceleration index (p=0.047). Patients with reduced LVEF and anaemia presented the highest NT-proBNP (p=0.003). Conclusions. In acute decompensated HF, anaemia is related with fluid overload, relatively higher cardiac systolic performance but no clinical benefit in patients with preserved/midrange LVEF, and increased left ventricular tension, fluid overload, and impaired cardiac systolic performance in patients with reduced LVEF.

scholarly journals Supervised Analysis for Phenotype Identification: The Case of Heart Failure Ejection Fraction Class

2021 ◽  
Vol 8 (6) ◽  
pp. 85
Author(s):  
Cristina Lopez ◽  
Jose Luis Holgado ◽  
Raquel Cortes ◽  
Inma Sauri ◽  
Antonio Fernandez ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Electronic Health Records ◽  
Predictive Value ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Acute Myocardial Infarct ◽  
Health Records ◽  
Ventricular Ejection Fraction ◽  
Electronic Health

Artificial Intelligence is creating a paradigm shift in health care, with phenotyping patients through clustering techniques being one of the areas of interest. Objective: To develop a predictive model to classify heart failure (HF) patients according to their left ventricular ejection fraction (LVEF), by using available data from Electronic Health Records (EHR). Subjects and methods: 2854 subjects over 25 years old with a diagnosis of HF and LVEF, measured by echocardiography, were selected to develop an algorithm to predict patients with reduced EF using supervised analysis. The performance of the developed algorithm was tested in heart failure patients from Primary Care. To select the most influentual variables, the LASSO algorithm setting was used, and to tackle the issue of one class exceeding the other one by a large amount, we used the Synthetic Minority Oversampling Technique (SMOTE). Finally, Random Forest (RF) and XGBoost models were constructed. Results: The full XGBoost model obtained the maximum accuracy, a high negative predictive value, and the highest positive predictive value. Gender, age, unstable angina, atrial fibrillation and acute myocardial infarct are the variables that most influence EF value. Applied in the EHR dataset, with a total of 25,594 patients with an ICD-code of HF and no regular follow-up in cardiology clinics, 6170 (21.1%) were identified as pertaining to the reduced EF group. Conclusion: The obtained algorithm was able to identify a number of HF patients with reduced ejection fraction, who could benefit from a protocol with a strong possibility of success. Furthermore, the methodology can be used for studies using data extracted from the Electronic Health Records.

scholarly journals Routine Measurements of Cardiac Parasympathetic and Sympathetic Nervous Systems Assists in Primary and Secondary Risk Stratification and Management of Cardiovascular Clinic Patients

2019 ◽  
pp. 27-33 ◽  
Author(s):  
Gary L Murray ◽  
Joseph Colombo
Keyword(s):  
Heart Failure ◽  
Predictive Value ◽  
New Technology ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Cardiac Autonomic Neuropathy ◽  
Ventricular Ejection Fraction ◽  
Sympathetic Nervous Systems ◽  
Cardiovascular Patients ◽  
Coronary Syndromes

Objective: To review our studies of the ease and importance of Parasympathetic and Sympathetic (P&S) measures in managing cardiovascular patients. Background: The autonomic nervous system is responsible for the development or progression of Hypertension (HTN), orthostasis, Coronary Disease (CAD), Congestive Heart Failure (CHF) and arrhythmias. Finally, new technology provides us with rapid, accurate P and S measures critically needed to manage these patients much more successfully. Methods: Using the ANX 3.0 autonomic monitor, P&S activity was recorded in 4 studies: 163 heart failure patients in total, mean follow-up (f/u) 12-24.5 months; 109 orthostasis patients, f/u 2.28 years and 483 patients with risk factors or known HTN, CAD or CHF, f/u 4.92 yrs. All were on guideline-driven therapy. Results: 59% of CHF patients had dangerously high Sympathovagal Balance (SB) or Cardiac Autonomic Neuropathy (CAN) and Ranolazine markedly improved 90% of these, improved left ventricular ejection fraction in 70% of patients on average 11.3 units, and reduced Major Adverse Cardiac Event (MACE) [Acute Coronary Syndromes (ACS), death, acute CHF, Ventricular Tachycardia/Ventricular Fibrillation (VT/VF)] 40%. 66% of orthostatic patients corrected with (r) Alpha Lipoic Acid ([r]ALA); non-responders had the lowest S-tone. In the 483 patient study, SB>2.5 best predicted MACE when compared to nuclear stress and echocardiography (sensitivity 0.59 or 7.03 [CI (Confidence Interval) 4.59-10.78], specificity 0.83, positive predictive value 0.64 and negative predictive value 0.80). Conclusion: Parasympathetic and sympathetic measures significantly improve care of cardiovascular patients.

P6456Role of cardiac imaging in the prediction of ventricular arrythmias, heart failure and death in dilated non-ischemic cardiomyopathy with severe left ventricular systolic disfunction

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
A Travieso Gonzalez ◽  
F Islas ◽  
M Ferrandez Escarabajal ◽  
T S Luque-Diaz ◽  
J Palacios-Rubio ◽  
...  
Keyword(s):  
Heart Failure ◽  
Myocardial Fibrosis ◽  
Predictive Value ◽  
Ischemic Cardiomyopathy ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Cardiac Events ◽  
Predictive Tool ◽  
Ventricular Ejection Fraction ◽  
All Cause Mortality

Abstract Background and purpose Dilated non-ischemic cardiomyopathy (DCM) is associated with an increased risk of cardiac events. Implantable Cardioverter Defibrillator (ICD) is recommended in DCM with severe left ventricular ejection fraction impairment, but the evidence of its usefulness is somewhat controversial. We evaluated the predictive value of myocardial fibrosis measured by cardiac magnetic resonance (CMR) and of global longitudinal strain (GLS) in the incidence of adverse cardiac events. Methods From 2009 to 2019, sixty-six patients with DCM were evaluated. CMR with a 1.5 Tesla scanner was performed, and the presence and extent of late gadolinium enhancement (LGE) was blindly assessed. GLS was measured using speckle-tracking 2D echocardiography. We examined the incidence of sustained ventricular arrhythmias (SVA, including appropriate anti-tachycardia pacing and shocks), admissions due to heart failure (HF) and all-cause mortality. Results 62.1% of the patients were male, with a median age of 63.8 years. 50.0% had cardiac resynchronization therapy and 73.9% had ICD as primary prevention therapy. Median LVEF was 25.7%. Median follow-up was 32 months. In that period, 10.6% of patients died, 25.8% had hospital admissions due to HF, and 9.2% had SVA. A burden of LGE over 14% was independently associated with higher risk of SVA (3.0% vs 19.2%, p=0.041). This cut-off value had a sensitivity of 83.3% and a negative predictive value of 97.0%. LGE was not associated with higher risk of HF admissions (27.3% vs 23.1%, p=0.731) or death (9.1% vs 11.5%, p=0.757). On the other hand, GLS was not associated with higher risk of SVA (8.7% vs 4.55% for a cut-off value of −10.6%, p=0.577), HF admissions (26.1% vs 30.4%, p=0.743) or death (8.7% vs 8.7%, p=1.00). Table 1. Main etiologies of DCM Causes N (%) Idiopathic 43 (65.2) Alcoholic 6 (9.1) Chemotherapy 4 (6.1) Non-compaction 4 (6.1) Familiar 3 (4.6) Thoracic radiotherapy 2 (3.0) Chagas disease 2 (3.0) Conclusions The burden of myocardial fibrosis measured by LGE is a high sensitive marker for the development of SVA. However, is not a predictive tool for HF admissions or all-cause mortality. GLS was not associated with the incidence of cardiac events in this population.

scholarly journals Pulmonary Hypertension in Patients With Heart Failure With Mid-Range Ejection Fraction

2021 ◽  
Vol 8 ◽  
Author(s):  
Micha T. Maeder ◽  
Lukas Weber ◽  
Marc Buser ◽  
Roman Brenner ◽  
Lucas Joerg ◽  
...  
Keyword(s):  
Heart Failure ◽  
Pulmonary Hypertension ◽  
Ejection Fraction ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Non Invasive ◽  
Patients With Heart Failure ◽  
Underlying Mechanisms

Pulmonary hypertension (PH) is common in patients with heart failure (HF). The role of PH in patients with HF with reduced (HFrEF) and preserved (HFpEF) left ventricular ejection fraction (LVEF) has been extensively characterized during the last years. In contrast, the pathophysiology of HF with mid-range LVEF (HFmrEF), and in particular the role of PH in this context, are largely unknown. There is a paucity of data in this field, and the prevalence of PH, the underlying mechanisms, and the optimal therapy are not well-defined. Although often studied together there is increasing evidence that despite similarities with both HFrEF and HFpEF, HFmrEF also differs from both entities. The present review provides a summary of the current concepts of the mechanisms and clinical impact of PH in patients with HFmrEF, a proposal for the non-invasive and invasive diagnostic approach required to define the pathophysiology of PH and its management, and a discussion of future directions based on insights from mechanistic studies and randomized trials. We also provide an outlook regarding gaps in evidence, future clinical challenges, and research opportunities.

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