Myocardial Histopathology-Based Heart Failure Phenotyping

Myocardial hypertrophy and interstitial fibrosis are the structural hallmarks evaluated on histopathology in heart failure (HF). Direct study of myocardial tissue has re-emerged as a strategy to dissect the biology of HF with preserved ejection fraction (HFpEF), but whether these features, assessed together, define distinct subgroups within HF phenotypes remains unknown.

We assessed whether phenogroups defined by fibrosis and hypertrophy (histogroups) display distinct clinical profiles and outcomes in HFpEF versus HF with reduced ejection fraction (HFrEF).

We identified patients with HF who underwent right ventricular endomyocardial biopsy (EMB) from 1999 to 2023, after excluding transplant, infiltrative, inflammatory, and hypertrophic cardiomyopathy cases. Patients with HFpEF (LVEF ≥50%; n=124) and HFrEF (LVEF <50%; n=170) were studied. A single cardiac pathologist, blinded to clinical data, graded fibrosis semiquantitatively and measured cardiomyocyte diameter to assess hypertrophy. Prespecified histogroups integrated the severity of fibrosis and hypertrophy. Associations with clinical characteristics and 10-year all-cause mortality were assessed separately in HFpEF and HFrEF.

In HFpEF, more advanced histogroups showed a higher proportion of men, diabetes, higher NT-proBNP, lower LVEF, and greater left ventricular mass index (P<0.05 for all), whereas most other clinical and hemodynamic characteristics were similar. The severe histogroup was associated with higher mortality overall and after adjustment for age and sex (severe vs mild: HR, 2.3 [95% CI, 1.05-4.9]; P=0.037), whereas histogroup was not associated with mortality in HFrEF. The prognostic association differed significantly by HF phenotype (adjusted interaction P=0.034).

Integrated assessment of fibrosis and hypertrophy identifies clinically and prognostically distinct histogroups in HFpEF, but not in HFrEF. These findings should be interpreted within the context of a tertiary-referral cohort undergoing diagnostic EMB.