Validation of the impact of post discharge change in hemoglobin by renal function on the prognosis of HFpEF patients after acute decompensated heart failure from the PURSUIT-HFpEF registry

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Abstract Background Anemia has been reported as poor prognostic factor on heart failure with preserved ejection fraction (HFpEF). However, it is not clear at what minimum level hemoglobin (Hb) by renal function should be managed to prevent worsening the prognosis of HFpEF. Aim The aim of this study is to evaluate the impact of the change in Hb by renal function from discharge of congestive heart failure to one year after discharge on the prognosis of HFpEF and verify at what minimum level hemoglobin (Hb) should be managed to prevent worsening the prognosis of HFpEF. Method 809 HFpEF cases enrolled from 2016 to 2021 in PURSUIT-HFpEF registry were divided into two groups according to estimated glomerular filtration rate (eGFR) at discharge, group with eGFR < 45 (n = 438) and group with eGFR ≥ 45 (n = 371). Two groups were further divided according to whether Hb was above or below 11 < g/dl at discharge: the group with Hb < 11 g/dl was divided into two groups, one with progression anemia (G1) and preserved anemia (G2) after one year, and the group with Hb ≥ 11 g/dl was divided into three groups, Hb < 11 g/dl (G3), 11 g/dl ≤ Hb < 13 g/dl (G4a), Hb ≥ 13 g/dl (G4b). We examined Hazard ratio (HR) and incidence rate of Major Adverse Cardiovascular Events (MACE), all-cause death and heart failure readmission between each two groups, G1 and G2, G3 and G4a, G4a and G4b, and examined predictor for MACE in each two groups with Hb < 11g/dl and ≥ 11 g/dl at discharge by Cox regression model, in two groups with eGFR <45 and ≥ 45 at discharge. Result All-cause death was significantly lower in G2 than in G1 (HR : 0.33, [95%Confidence Interval (CI), 0.14 - 0.80], p = 0.011) in the group with eGFR ≥ 45. MACE was significantly higher in G3 than in G4a by log-rank test (HR : 1.61, [95%CI, 1.02 - 3.45], p = 0.038) in the group with eGFR < 45, however, MACE, all-cause death and heart failure readmission were significantly higher in G3 than in G4a in the group with eGFR ≥ 45 (MACE ; HR : 1.99, [95%CI, 1.15 - 3.45], p = 0.013, All-cause death ; HR : 2.09, [95%CI, 1.02 - 4.29], p = 0.042, heart failure readmissio ; HR : 2.43, [95%CI, 1.22 - 4.82], p = 0.009). Only all-cause death was significantly lower in G4b than in G4a by log-rank test regardless of renal function (eGFR < 45 ; HR : 0.08, [95%CI, 0.01 - 0.60], p = 0.002, eGFR ≥ 45 ; HR : 0.38, [95%CI, 0.18 - 0.83], p = 0.012). In multivariate Cox regression model, worsening anemia to Hb < 11 g/dl one year later was independent predictor for MACE in patients with eGFR ≥ 45 and Hb ≥ 11 g/dl at discharge (HR : 2.45, [95%CI, 1.22 – 4.91], p = 0.012). Conclusion Hb levels of at least 11 g/dl should be maintained to prevent the prognosis of HFpEF worse after discharge of acute decompensated heart failure regardless of renal function, however it might be necessary to maintain higher hemoglobin level in HFpEF patients with moderate to severe renal dysfunction than those with mild renal dysfunction.study flow by eGFR and outcomekaplan-meier curves of outcomes