Mild systolic dysfunction in heart failure (left ventricular ejection fraction >35%): Baseline characteristics, prognosis and response to therapy in the vasodilator in heart failure trials (V-HeFT)

Objectives. This analysis sought to evaluate the clinical characteristics and outcome in heart failure with mild systolic dysfunction. Background. Although heart failure with mild systolic dysfunction occurs commonly, this is an understudied are because clinical trials have usually excluded patients with ejection fraction >35%. Methods. The 422 patients with left ventricular ejection fraction less-than-or-equals, slant35% were compared with 172 with left ventricular ejection fraction > 35% in the Vasodilator in Heart Failure Trial (V-HeFT I), whereas in V-HeFT-II 554 patients with left ventricular ejection fraction less-than-or-equals, slant 35% were compared with 218 patients with left ventricular ejection fraction > 35% for mortality and clinical care. For left ventricular ejection fraction >35%, treatment with hydralazine/isosorbide dinitrate was compared with prazosin and placebo therapy in V-HeFT I, and hydralazine/isosorbide dinitrate was compared with enalapril in V-HeFT II for mortality, clinical course and change in physiologic variables: ejection fraction, plasm norepinephrine levels, ventricular tachycardi and echocardiographic variables. Results. In both studies, patients with left ventricular ejection fraction > 35% differed principally in hypertensive history, higher functional capacity and radiographic and echocardiographic cardiac dimension from patients with left ventricular ejection fraction less-than-or-equals, slant35%, and plasm norepinephrine levels differed in V-HeFT II (p < 0.01). Patients with left ventricular ejection fraction >35% had lower cumulative mortality than those with left ventricular ejection fraction less-than-or-equals, slant35% (p < 0.0001) and less frequent hospital admissions for heart failure (p < 0.014, V-HeFT I; p < 0.005, V-HeFT II). Although cumulative mortality and morbidity did not differ between treatment groups in V-HeFT I, enalapril decreased overall mortality versus hydralazine/isosorbide dinitrate (p < 0.035) in V-HeFT II. For physiologic variables in V-HeFT II, enalapril decreased ventricular tachycardi at follow-up (p < 0.05). Conclusion. In V-HeFT, heart failure with mild systolic dysfunction was associated with different characteristics and more favorable prognosis than heart failure with more severe systolic dysfunction. Enalapril decreased overall mortality and sudden death compared with hydralazine/isosorbide dinitrate. Prospective trials are needed to address therapy for heart failure with mild systolic dysfunction.