Five-year mortality of heart failure with preserved, mildly reduced, and reduced ejection fraction in a 4880 Chinese cohort

Shiqun Chen, Zhidong Huang, Yan Liang, Xiaoli Zhao, Xiemuxikaimaier Aobuliksimu, Bo Wang, Yibo He, Yu Kang, Haozhang Huang, Qiang Li, Younan Yao, Xiaozhao Lu, Xiaoxian Qian, Xujing Xie, Jin Liu, Yong Liu, Shiqun Chen, Zhidong Huang, Yan Liang, Xiaoli Zhao, Xiemuxikaimaier Aobuliksimu, Bo Wang, Yibo He, Yu Kang, Haozhang Huang, Qiang Li, Younan Yao, Xiaozhao Lu, Xiaoxian Qian, Xujing Xie, Jin Liu, Yong Liu

Abstract

Aims: Available evidence is incomplete and inconsistent in the outcomes of heart failure (HF) patients with preserved ejection fraction (HFpEF), mildly reduced ejection fraction (HFmrEF), and reduced ejection fraction (HFrEF). There are also limited data on the proportions and long-term prognosis among the three HF phenotypes in China. We aimed to characterize the 5 year prognosis in three HF phenotypes according to EF in a cohort of hospitalized HF patients undergoing coronary angiography in southern China.

Methods and results: Hospitalized patients with HF were enrolled from the Cardiorenal ImprovemeNt registry (CIN; ClinicalTrials.gov NCT04407936) between January 2007 and December 2014. HF phenotypes were defined as HFpEF (EF ≥ 50%), HFmrEF (EF 41-49%), and HFrEF (EF ≤ 40%). Kaplan-Meier and Cox proportional hazards models were constructed to examine differences in 5 year outcomes in HF patients with different phenotypes. A total of 4880 HF patients [mean age: 61.8 ± 10.3, male: 3156 (64.7%)] were included: 2768 (57%) had HFpEF, 1015 (21%) had HFmrEF, and 1097 (22%) had HFrEF. Patients with HFrEF were older than those with HFpEF (62.5 ± 10.6 vs. 61.3 ± 10.1, P < 0.001) and more likely to be male (78.0% vs. 55.9%, P < 0.001). With 5 year follow-up through the end of December 2019, 1624 (27.6%) patients died. Controlling confounding variables, declined EF category was independently associated with increased 5 year mortality {HFrEF 25.2% vs. HFpEF 13.4%, adjusted hazard ratio [aHR]: 1.85 [95% confidence interval (CI): 1.45 to 2.35]; HFmrEF 18.1% vs. HFpEF 13.4%, aHR: 1.40 [95% CI: 1.08 to 1.81]; HFrEF 25.2% vs. HFmrEF 18.1%, aHR: 1.32 [95% CI: 1.02 to 1.71]}.

Conclusions: In this Chinese cohort, patients with HFrEF account for less than a fourth of HF patients. One-sixth individuals with HF died in 5 years. HFrEF was associated with a nearly two-fold increased risk of 5 year mortality than HFpEF. Further studies are needed to prospectively evaluate the efficacy of improving treatment on outcomes in all three HF phenotypes.

Keywords: EF-ejection fraction; Five-year mortality; HFmrEF-heart failure with mildly reduced ejection fraction; HFpEF-heart failure with preserved ejection fraction; HFrEF-heart failure with reduced ejection fraction.

Conflict of interest statement

None declared.

© 2022 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.

Figures

Figure 1
Figure 1
Study flow diagram. LVEF, left ventricular ejection fraction.
Figure 2
Figure 2
Kaplan–Meier curves for 5 year all‐cause mortality in 4880 heart failure patients. Five‐year mortality in patients hospitalized with heart failure with preserved ejection fraction (HFpEF), mildly reduced ejection fraction (HFmrEF), and reduced ejection fraction (HFrEF).
Figure 3
Figure 3
Geographic proportions of mortality of heart failure (HF) patients according to ejection fraction category. (A) Different proportions of HF with reduced ejection fraction (HFrEF), mildly reduced ejection fraction (HFmrEF), and preserved ejection fraction (HFpEF) in the China cohort and comparison with other cohorts. (B) Five‐year all‐cause mortality of HFrEF, HFmrEF, and HFpEF in China and comparison with other cohorts. Part of the data is extrapolated from the Kaplan–Meier curves of the self‐corresponding research results, and the mortality may be overestimated. However, it does show some of the differences in mortality among the three HF types in these studies.
Figure 4
Figure 4
Forest plots of hazard ratio and Kaplan–Meier curves for 5 year all‐cause mortality in subgroup analysis by gender. Hazard ratio adjusted for demographics (age), complication (acute myocardial infarction, congestive heart failure, anaemia, hypertension, diabetes, chronic kidney disease, stroke, atrial fibrillation, chronic obstructive pulmonary disease, valvular heart disease, and New York Heart Association classification), medical history (pre‐acute myocardial infarction, pre‐percutaneous coronary intervention, and pre‐coronary artery bypass graft), examination (low‐density lipoprotein cholesterol, potassium, and albumin), and discharge medication (angiotensin‐converting enzyme inhibitor or angiotensin receptor blocker, beta‐blockers, spironolactone, and diuretics). CI, confidence interval; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction.
Figure 5
Figure 5
Graphical abstract of the current study. Different proportions of patients with heart failure with reduced ejection fraction (HFrEF), mildly reduced ejection fraction (HFmrEF), or preserved ejection fraction (HFpEF); 5 year mortality of patients with HFrEF, HFmrEF, or HFpEF; forest plots of hazard ratio among HFrEF, HFmrEF, and HFpEF. CI, confidence interval.

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