Left ventricular ejection fraction is not a determinant of outcome in acute heart failure

Abstract

Abstract Aims Attention to left ventricular performance in acute heart failure (AHF) has historically focussed on deteriorating systolic function in the left ventricle (LV) as assessed by impaired LV ejection fraction (LVEF). Methods 418 consecutive AHF patients presenting over 12 months were prospectively recruited and underwent bed-side echocardiography within 24 hours of recruitment. LV systolic function was assessed by LVEF >50% (HFpEF), 41–49% (HFmrEF) and <40% (HFrEF). Contractile function was assessed by LV MR dp/dt with ROC analysis identifying the cut-off of 570mmHg/s with the maximum Younden Index. Diastolic function was assessed by the ratio of mitral inflow E wave velocity to lateral e' velocity (E/e'), with a cut-off of 10.9 associated with the maximum Younden Index. Results The average age of patients was 78.7±11.7 years and 47.1% of patients were female. Mean BNP was 1331 pg/ml. 55.5% of patients had hypertension, 36.4% had coronary artery disease, 31.1% diabetes and 45.2% chronic kidney disease. Overall 2-year mortality was 38%. A 3-way comparison of 2-year mortality by LVEF (HFpEF vs. HFmrEF vs. HFmrEF) from ESC guideline criteria was not prognostic (38.6% vs. 30.9% vs. 43.9% [p=0.10). An LV MR dp/dt cut-off of 570mmHg was associated with worse outcome (HR 1.55 95% CI (1.05–2.29 [p=0.026]). Cut-offs for diastolic dysfunction identified from this AHF cohort (E/e' >10.9) and from ESC guidelines (E/e' >14) [p=0.09 & p=0.20]) could not identify those at risk of poor outcome. Conclusion In this study of acute heart failure LV ejection fraction is not associated with prognosis. LV systolic function assessed by the MR dp/dt, a measure of global contractile function, identified a cut-off of 570mmHg which could predict 2-year outcome. This suggests decline the ability of LV to generate contractile force predicts outcome in AHF. Diastolic function remains challenging to assess and a crude evaluation using E/e' could not identify those at risk of poor outcome in AHF. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Abbott