Role of ejection fraction in patients at risk for advanced heart failure: insights from the HELP-HF registry.

Abstract

Patients with heart failure (HF) with reduced ejection fraction (EF) (HFrEF), mildly reduced EF (HFmrEF), and preserved EF (HFpEF) may all progress to advanced HF, but the impact of EF in the advanced setting is not well established. Our aim was to assess the prognostic impact of EF in patients with at least one 'I NEED HELP' marker for advanced HF. Patients with HF and at least one high-risk 'I NEED HELP' criterion from four centres were included in this analysis. Outcomes were assessed in patients with HFrEF (EF≤40%), HFmrEF (EF 41-49%), and HFpEF (EF≥50%) and with EF analysed as a continuous variable. The prognostic impact of medical therapy for HF in patients with EF<50% and EF>50% was also evaluated. All-cause death was the primary endpoint, and cardiovascular death was a secondary endpoint. Among 1149 patients enrolled [mean age 75.1±11.5years, 67.3% males, 67.6% hospitalized, median follow-up 260days (inter-quartile range 105-390days)], HFrEF, HFmrEF, and HFpEF were observed in 699 (60.8%), 122 (10.6%), and 328 (28.6%) patients, and 1year mortality was 28.3%, 26.2%, and 20.1, respectively (log-rank P=0.036). As compared with HFrEF patients, HFpEF patients had a lower risk of all-cause death [adjusted hazard ratio (HRadj ) 0.67, 95% confidence interval (CI) 0.48-0.94, P=0.022], whereas no difference was noted for HFmrEF patients. After multivariable adjustment, a lower risk of all-cause death (HRadj for 5% increase 0.94, 95% CI 0.89-0.99, P=0.017) and cardiovascular death (HRadj for 5% increase 0.94, 95% CI 0.88-1.00, P=0.049) was observed at higher EF values. Beta-blockers and renin-angiotensin system inhibitors or sacubitril/valsartan were associated with lower mortality in both EF<50% and EF≥50% groups. Among patients with HF and at least one 'I NEED HELP' marker for advanced HF, left ventricular EF is still of prognostic value.