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Risk factors for adverse outcomes by left ventricular ejection fraction in a contemporary heart failure population
Larry A Allen1, David J Magid, Jerry H Gurwitz
1Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA. larry.allen@ucdenver.edu
Insights
Risk assessment for heart failure (HF) is similar across all left ventricular ejection fraction (LVEF) categories. Prognostic factors for death and hospitalization do not significantly differ by LVEF level in HF patients.
Area of Science:
- Cardiology
- Clinical Research
- Public Health
Background:
- Heart failure (HF) management and risk stratification often differ based on left ventricular ejection fraction (LVEF).
- Existing risk models typically do not differentiate predictors across varying LVEF levels.
- The comparative importance of common predictors for clinical outcomes in HF stratified by LVEF remains unclear.
Purpose of the Study:
- To investigate the performance of common predictor variables for clinical outcomes across different LVEF categories in a large heart failure population.
- To determine if risk stratification models for heart failure need to be LVEF-specific.
Main Methods:
- Retrospective cohort study of 30,094 ambulatory adult patients with HF from four integrated healthcare systems (2005-2008).
- LVEF categorized as preserved (≥50%), borderline (41-49%), and reduced (≤40%).
- Cox regression models used to identify independent predictors of all-cause mortality and HF-related/all-cause hospitalizations, analyzed by LVEF category.
Main Results:
- Nearly all tested covariates demonstrated similar performance across LVEF strata for predicting death from any cause.
- Predictor variable performance was also consistent across LVEF categories for HF-related and all-cause hospitalizations.
- In a large, diverse contemporary HF population, risk assessment showed striking similarity across all LVEF categories.
Conclusions:
- Risk assessment in heart failure patients appears consistent regardless of left ventricular ejection fraction.
- Individual prognostic factor performance is not significantly related to the level of left ventricular systolic function.
- These findings suggest that current risk stratification approaches may be broadly applicable across the spectrum of HF, despite LVEF-specific therapies.
Background:
Although heart failure (HF) is a syndrome with important differences in response to therapy by left ventricular ejection fraction (LVEF), existing risk stratification models typically group all HF patients together. The relative importance of common predictor variables for important clinical outcomes across strata of LVEF is relatively unknown.
Methods And Results:
We identified all members with HF between 2005 and 2008 from 4 integrated healthcare systems in the Cardiovascular Research Network. LVEF was categorized as preserved (LVEF ≥ 50% or normal), borderline (41%-49% or mildly reduced), and reduced (≤ 40% or moderately to severely reduced). We used Cox regression models to identify independent predictors of death and hospitalization by LVEF category. Among 30094 ambulatory adults with HF, mean age was 74 years and 46% were women. LVEF was preserved in 49.5%, borderline in 16.2%, and reduced in 34.3% of patients. During a median follow-up of 1.8 years (interquartile range, 0.8-3.1), 8060 (26.8%) patients died, 8108 (26.9%) were hospitalized for HF, and 20272 (67.4%) were hospitalized for any reason. In multivariable models, nearly all tested covariates performed similarly across LVEF strata for the outcome of death from any cause, as well as for HF-related and all-cause hospitalizations.
Conclusions:
We found that in a large, diverse contemporary HF population, risk assessment was strikingly similar across all LVEF categories. These data suggest that, although many HF therapies are uniquely applied to patients with reduced LVEF, individual prognostic factor performance does not seem to be significantly related to level of left ventricular systolic function.
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01:17Pathophysiology of Heart Failure
01:29Heart Failure II: Pathophysiology
01:30Heart Failure V: Medical Management
01:26Heart Failure III: Clinical Manifestations
01:30Heart Failure IV: Classification and Diagnostic Evaluation