IJCS | Volume 33, Nº1, January / February 2019

DOI: https://doi.org/10.36660/ijcs.20190230 The ejection fraction returns to Hyde Park Session’s Speakers’ Corner About two decades ago, the Heart Failure Society of America created the Hyde Park Session at its annual meeting. 1 The analogy with the free and innovative proposals that took place in the historic London park were transposed to that scientific event. One of the first proposals made there was the extinction of the left ventricular ejection fraction (LVEF) as if it was an absolutist tyrant determining the life of his/her subjects. The proposition took no breath. The overwhelming majority of heart failure (HF) trials used LVEF as an inclusion criterion. The cutoff points varied. Magical numbers had little pathophysiological or clinical foundation. LVEF was measured by noninvasive methods, especially echocardiography, with high intra- and inter-examiner variability, dependent on preload and afterload changes. 2 Later, in 2001, a clinical entity was recognized, where acute pulmonary edema of cardiogenic cause occurred despite LVEF at levels above 50%. 3 The following years saw incredulous initial acceptance until the epidemiological and clinical characterization of what we today call “heart failure with preserved ejection fraction (HFpEF).” From rare, it became frequent, especially in primary care. Considered benign, the prognosis became almost as reserved as heart failure with reduced ejection fraction (HFrEF). There were different proposals for diagnosis, prognostic scores, but such evolution in the knowledge of HFpEF resulted in a frustrating succession of negative therapeutic trials. In 2013, ACCF/AHA 4 re-stratified LVEF levels and created “borderline heart failure,” which was in fact settled by the 2016 European guideline 5 under the “mid-range” nomenclature. Something was created that was not known in depth. The race for the demographic, clinical and prognostic characterization of the new entity began. What is heart failure with mid-range ejection fraction (HFmrEF)? Which direction of travel? HFrEF in reverse remodeling under optimal treatment? HFpEF following natural history with progressive necrosis, fibrosis and dilation vis-à-vis lack of treatment?An early manifestation of the disease? Would these different phenotypes grouped together by LVEF strata have the same clinical behavior? Tsuji et al., 6 showed that the clinical characteristics of HFmrEF are intermediate between HFpEF and HFrEF and that HFmrEF has a dynamic transition to HFpEF or HFrEF, especially within a year, then suggesting that HFmrEF would represent a transition phenotype or an overlap zone between HFpEF and HFrEF instead of an independent heart failure entity. Currently, it is known that there are many HF phenotypes besides the simplification of LVEF strata. There are few studies addressing the HFpEF and HFmrEF strata, either due to the relative novelty of HFrEF or the need for inclusion in clinical trials of lower LVEF patients, where the expectation of mortality and major events would increase the statistical power of the study. 2 Currently, there is a tendency for higher valuation of studies that include higher LVEF. The paper published by Cavalcanti et al., 7 in the International Journal of Cardiovascular Sciences draws a picture of 493 patients admitted for decompensatedHF in the northeast region of Brazil over a 10-year period. Then, it compares the three strata defined by the ESC: reduced, mid-range and preserved. If we break free from the dictatorship of the p-value, we can see from the results 43 EDITORIAL International Journal of Cardiovascular Sciences. 2020;33(1):43-44 Mailing Address: Wolney de Andrade Martins Rua Marques do Paraná, 303, 6º andar. Postal Code: 24030-215, Centro, Niterói, RJ - Brazil. E-mail: wolney_martins@hotmail.com The Ejection Fraction Returns to Hyde Park Session's Speakers' Corner Wolney de Andrade Martins 1, 2 a nd Antonio José Lagoeiro Jorge 1 Universidade Federal Fluminense (UFF), 1 Niterói, RJ - Brazil Complexo Hospitalar de Niterói (CHN), 2 Niterói, RJ - Brazil Heart Failure/physiopathology; Stroke Volume/ physiology; Ventricular Dysfunction; Prognosis. Keywords