IJCS | Volume 33, Nº1, January / February 2019

52 groups. Similarly, urea has been strongly associated to in-hospital death risk in traditional scores, such as BIOSTAT 32 and ADHERE. 10 The persistence of urea in all these models indicates its prognostic strength. Thus it should be the object of more attention by those who monitor patients with HF, due to the higher death risk among HFmrEF individuals (6 times more), for instance. It is possible to suggest that the presence of valve disease as a factor of worse prognosis in HF patients with LVEF greater than 40% indicates that it could be the etiology of heart failure. At the same time, it involves clinical characteristics and challenges, especially among the elderly population, due to the small number of randomized clinical trials. Consequently, treatment is also less well established. It is necessary to highlight the efficacy of medication, since recent international publications, as observed by this study, originally in Brazil, have demonstrated significant benefits of beta-blockers both in HFrEF 32 and HFmrEF, 34 thus suggesting benefits in all HF patientswith an ejection fraction less than or equal to 49%. This fact has not been registered in randomized clinical trials which have included exclusively patients with systolic HF. 17,35 A recent meta-analysis involving 11 randomized studies and over 14,000 patients on the use of beta-blockers has confirmed their benefits in patients with EF < 50% and sinus rhythm. 36 As for ACEI/ARB, it is important to point out that the results only remained among HFmrEF patients, with a 5 times increased mortality among those who did not receive the medication. In the OPTIMIZE- HF registry, although the use of ACEI/ARB has been associated with less mortality and hospital readmission within 30- and 90-days in HFrEF patients, such benefit has not been observed among the HFmrEF and HFpEF groups. 28 In a subanalysis of CHARM, the benefit of candesartan was also seen in patients with HFmrEF. 37 Furthermore, in spite of the results of the TOPCAT trial, studies have found benefits of spironolactone in patients with EF between 45-49%, 38 which was not observed in this study's population. Therefore, HFmrEF signals a transition behavior or a “gray area” in which a better characterization of this groupmay soon bring prognostic and therapeutic benefits. Limitations The study is based on patients with a clinical picture of decompensated heart failure, and their physical and laboratory variables were collected at admission on a database. Thus informationwas collected retrospectively. Other potentially relevant variables, such as natriuretic peptide levels, were not selected in the multivariate model because data was not available in all patients. Conclusion The demographic/clinical profiles of HFmrEF are intermediate, between those of HFpEF and HFrEF. Kidney disease was the only risk factor for death in HFrEF and HFpEF, whereas valve disease and increased urea levels were associated with HFmrEF. The use of ACEI/ARB and beta-blockers, already established as mortality reducing drugs in HFrEF, has been independently related to better evolution in this HF group. The benefits of the beta-blockers in HFmrEF have also been reported, which indicates this conduct in the intermediate scenario, since there have been no recommendations based on guidelines. Author contributions Conception and design of the research: Cavalcanti GP, Sarteschi C, Gomes GES, Medeiros CA, Pimentel JHM, Lafayette AR, Almeida MC, Oliveira PSR, Martins SM. Acquisition of data: Cavalcanti GP, Sarteschi C, Gomes GES, Medeiros CA, Pimentel JHM, Lafayette AR, Almeida MC, Oliveira PSR, Martins SM. Analysis and interpretation of the data: Cavalcanti GP, Sarteschi C, Gomes GES, Medeiros CA, Pimentel JHM, Lafayette AR, Almeida MC, Oliveira PSR, Martins SM. Statistical analysis: Cavalcanti GP, Sarteschi C, Gomes GES, Medeiros CA, Pimentel JHM, LafayetteAR, AlmeidaMC, Oliveira PSR, Martins SM. Writing of the manuscript: Cavalcanti GP, Sarteschi C, Gomes GES, Medeiros CA, Pimentel JHM, Lafayette AR, Almeida MC, Oliveira PSR, Martins SM. Critical revision of the manuscript for intellectual content: Cavalcanti GP, Sarteschi C, Gomes GES, Medeiros CA, Pimentel JHM, LafayetteAR, Almeida MC, Oliveira PSR, Martins SM. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Cavalcanti et al. Decompensated heart failure with intermediate ejection fraction Int J Cardiovasc Sci. 2020;33(1):45-54 Original Article