Deterioration of left ventricular ejection fraction to mid-range ejection fraction associated with increased mortality and cardiovascular events

1. Heart failure patients whose EF deteriorated from ≥50% to between 40% and 50% were at an increased risk of mortality and cardiovascular events

Evidence Level Rating: 2 (Good)

Clinicians use left ventricular ejection fraction (LVEF) to guide treatment of heart failure (HF). Patients with HF are commonly divided into two separate and clinically distinct cohorts, those with an EF <40% having “heart failure with reduced ejection fraction” (HFrEF) and those with an EF ≥50% having “heart failure with persevered ejection fraction” (HFpEF). This categorization, however, fails to account for patients with an EF between 40% and 50%, sometimes classified as having “heart failure with mid-range ejection fraction” (HFmrEF). The aim of this study was to determine future risk of cardiovascular events based on a prior transition into the HFmrEF group, either by reduction or increase in EF from a previous measurement. Primary outcomes included all-cause mortality, cardiovascular mortality, and all-cause hospitalization, among others. Using health records from the UC San Diego Health System, 448 patients with HFmrEF were identified and followed over an additional two years to track outcomes. 157 patients (M [SD] age = 63.8 [8.1] years, 63.7% male, 54.7% white) improved, 67 patients (M [SD] age = 66.6 [9.8] years, 75.0% male, 64.0% white) remained stable, and 224 patients (M [SD] age = 70.9 [9.5] years, 56.3% male, 62.5% white) deteriorated with regards to their EF prior to inclusion. A 1.34-fold increase in the risk of combined all-cause mortality and hospitalization was seen in the deteriorated group (p = 0.03). The deteriorated group was also at a significantly increased risk of cardiovascular death or hospitalization for HF (HR 1.71, 95% CI 1.08 to 2.50, p = 0.02). Both findings were consistent after adjusting for age, sex, and comorbidity. In contrast, there was no significant difference in risk for any of the primary outcomes between patients in the improved and stable groups even after adjustment. Overall, this study suggests that the directional change of EF in HFmrEF patients has implications for future clinical course and could be used to guide and tailor therapy.

Click to read the study in JAMA Cardiology

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