Amino Acid-Derived Metabolic Signature Across Stages of Systolic Dysfunction: Derivation and Internal Evaluation of...

Heart failure with reduced ejection fraction (HFrEF) is increasingly recognized as a systemic metabolic disorder. The aim of this study was to characterize amino acid-related metabolic differences between heart failure with moderately reduced ejection fraction (HFmrEF) (LVEF 40-49%) and HFrEF (LVEF < 40%) and to derive a biologically interpretable composite metabolomic index capable of discriminating between these two stages of systolic dysfunction. We conducted a cross-sectional metabolomic analysis of 42 patients stratified by left ventricular ejection fraction (LVEF < 40% vs. 40-49%). The reference group comprised patients with mildly reduced ejection fraction (LVEF 40-49%), without inclusion of individuals with preserved or normal cardiac function. Targeted amino acid profiling was performed using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Metabolites were standardized and analyzed individually and in combination. A composite index (Heart Failure Amino Acid-Derived Systolic Index: HASI-40), integrating markers of proteolysis and metabolic resilience, was derived to distinguish patients with HFrEF from those with HFmrEF. Discrimination was assessed using receiver operator curve (ROC) analysis with internal validation and multivariable adjustment. Patients with LVEF < 40% exhibited a coordinated metabolic phenotype characterized by reduced methionine, sarcosine, serine, and taurine. While individual metabolites did not retain significance after multiple-testing correction, the composite HASI-40 index remained strongly associated with HFrEF (OR 5.56, 95% CI: 1.70-18.14; p = 0.004), although the wide confidence interval indicates limited precision due to sample size. The index demonstrated good discrimination with an area under the curve (AUC) of 0.862, which improved when combined with age (AUC 0.932). The index represents a standardized composite measure and does not define a diagnostic cutoff for individual patients. These findings suggest that HFmrEF and HFrEF exhibit partially distinct metabolic phenotypes despite overlapping clinical characteristics. These findings suggest that HASI-40 captures metabolic differences between patients with HFmrEF (LVEF 40-49%) and those with HFrEF (LVEF < 40%), reflecting progression toward more advanced systolic dysfunction. However, due to the absence of a control group with preserved ejection fraction, small sample size, and lack of external validation, the index should be considered exploratory and hypothesis-generating rather than clinically applicable.