Discriminating Clinical Features of HF in the Community
Aims Heart failure (HF) is a major public health burden worldwide. Of patients presenting with HF, 30–55% have a preserved ejection fraction (HFPEF) rather than a reduced ejection fraction (HFREF). Our objective was to examine discriminating clinical features in new-onset HFPEF vs. HFREF.
Methods and results Of 712 participants in the Framingham Heart Study (FHS) hospitalized for new-onset HF between 1981 and 2008 (median age 81 years, 53% female), 46% had HFPEF (EF >45%) and 54% had HFREF (EF ≤45%). In multivariable logistic regression, coronary heart disease (CHD), higher heart rate, higher potassium, left bundle branch block, and ischaemic electrocardiographic changes increased the odds of HFREF; female sex and atrial fibrillation increased the odds of HFPEF. In aggregate, these clinical features predicted HF subtype with good discrimination (c-statistic 0.78). Predictors were examined in the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study. Of 4436 HF patients (median age 75 years, 47% female), 32% had HFPEF and 68% had HFREF. Distinguishing clinical features were consistent between FHS and EFFECT, with comparable discrimination in EFFECT (c-statistic 0.75). In exploratory analyses examining the traits of the intermediate EF group (EF 35–55%), CHD predisposed to a decrease in EF, whereas other clinical traits showed an overlapping spectrum between HFPEF and HFREF.
Conclusion Multiple clinical characteristics at the time of initial HF presentation differed in participants with HFPEF vs. HFREF. While CHD was clearly associated with a lower EF, overlapping characteristics were observed in the middle of the left ventricular EF range spectrum.
Heart failure (HF) is a major public health problem worldwide, and the lifetime risk of developing HF is one in five for men and women at 40 years of age. Of patients presenting with acute decompensated HF, 30–55% are estimated to have HF with preserved ejection fraction (HFPEF) rather than reduced ejection fraction (HFREF). The extent to which HFPEF and HFREF are overlapping vs. distinct phenotypes remains unclear. Patients with HF in the community often experience cardiovascular death; however, non-cardiovascular comorbidities may also contribute greatly to mortality, particularly in patients with HFPEF. While the clinical course and survival after HF-onset have been described for HFPEF and HFREF, differences in factors present at or before the onset of HF symptoms have not been systematically compared between HF subtypes. Understanding the relations of different clinical factors to the type of HF may lend important pathophysiological insights. Few studies have examined characteristics other than left ventricular ejection fraction (LVEF) that might distinguish HFPEF from HFREF in the clinical setting. We sought to examine the differences in the clinical characteristics between newly diagnosed HFPEF and HFREF in a large community-based study, and to further validate our findings in a large hospital-based cohort of patients with HF.
Abstract and Introduction
Abstract
Aims Heart failure (HF) is a major public health burden worldwide. Of patients presenting with HF, 30–55% have a preserved ejection fraction (HFPEF) rather than a reduced ejection fraction (HFREF). Our objective was to examine discriminating clinical features in new-onset HFPEF vs. HFREF.
Methods and results Of 712 participants in the Framingham Heart Study (FHS) hospitalized for new-onset HF between 1981 and 2008 (median age 81 years, 53% female), 46% had HFPEF (EF >45%) and 54% had HFREF (EF ≤45%). In multivariable logistic regression, coronary heart disease (CHD), higher heart rate, higher potassium, left bundle branch block, and ischaemic electrocardiographic changes increased the odds of HFREF; female sex and atrial fibrillation increased the odds of HFPEF. In aggregate, these clinical features predicted HF subtype with good discrimination (c-statistic 0.78). Predictors were examined in the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study. Of 4436 HF patients (median age 75 years, 47% female), 32% had HFPEF and 68% had HFREF. Distinguishing clinical features were consistent between FHS and EFFECT, with comparable discrimination in EFFECT (c-statistic 0.75). In exploratory analyses examining the traits of the intermediate EF group (EF 35–55%), CHD predisposed to a decrease in EF, whereas other clinical traits showed an overlapping spectrum between HFPEF and HFREF.
Conclusion Multiple clinical characteristics at the time of initial HF presentation differed in participants with HFPEF vs. HFREF. While CHD was clearly associated with a lower EF, overlapping characteristics were observed in the middle of the left ventricular EF range spectrum.
Introduction
Heart failure (HF) is a major public health problem worldwide, and the lifetime risk of developing HF is one in five for men and women at 40 years of age. Of patients presenting with acute decompensated HF, 30–55% are estimated to have HF with preserved ejection fraction (HFPEF) rather than reduced ejection fraction (HFREF). The extent to which HFPEF and HFREF are overlapping vs. distinct phenotypes remains unclear. Patients with HF in the community often experience cardiovascular death; however, non-cardiovascular comorbidities may also contribute greatly to mortality, particularly in patients with HFPEF. While the clinical course and survival after HF-onset have been described for HFPEF and HFREF, differences in factors present at or before the onset of HF symptoms have not been systematically compared between HF subtypes. Understanding the relations of different clinical factors to the type of HF may lend important pathophysiological insights. Few studies have examined characteristics other than left ventricular ejection fraction (LVEF) that might distinguish HFPEF from HFREF in the clinical setting. We sought to examine the differences in the clinical characteristics between newly diagnosed HFPEF and HFREF in a large community-based study, and to further validate our findings in a large hospital-based cohort of patients with HF.
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