Impact of Heart Failure Phenotype on Functional Outcomes After Carotid Artery Stenting

Heart failure (HF) is a common comorbidity in patients undergoing carotid artery stenting (CAS), but its impact on outcomes by HF phenotype is unclear. This is the first study to compare short-term CAS outcomes between patients with heart failure with reduced ejection fraction (HFrEF) and those with preserved ejection fraction (HFpEF).

This multicenter, prospective observational study started by screening 889 patients from the CASSH registry. After applying predefined criteria, 105 patients with heart failure undergoing CAS were included (69 HFpEF, 36 HFrEF). Baseline demographics, comorbidities, and procedural details were compared. The primary outcome was a composite of 30-day procedure-related mortality, stroke, or myocardial infarction. Secondary outcomes included disability, measured by the modified Rankin Scale (mRS), at 30 days and at 90 days. Multivariable ordinal regression was used to assess the independent association between HF phenotype and poor functional outcome.

Baseline characteristics were similar between groups. The primary outcome occurred in 5.6% of HFrEF patients versus 1.4% of HFpEF patients (p = 0.561). However, functional outcomes were significantly worse in the HFrEF group, with higher mean mRS scores at 30 days (2.7 vs. 1.6, p = 0.003) and 90 days (2.7 vs. 1.4, p = 0.001). All-cause mortality was 11.1% in HFrEF vs. 1.4% in HFpEF (p = 0.085). After adjustment for age, sex, atrial fibrillation, and preprocedural mRS, HFrEF was independently associated with a higher risk of poor functional outcome at 30 days (β = 0.89, p = 0.018) and 90 days (β = 1.05, p = 0.006).

HFrEF, but not HFpEF, independently predicts poorer functional recovery following CAS. These findings highlight the importance of incorporating heart failure phenotype into risk stratification and clinical guidelines to improve patient selection and peri-procedural management.