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Three-year outcomes better among patients with HF with recovered EF than other kinds of HF
Compared with adult outpatients with other types of HF, reduced rates of mortality and hospitalization are experienced by patients with HF with recovered ejection fraction, researchers reported in JAMA Cardiology.
Andreas P. Kalogeropoulos, MD, MPH, PhD, of the division of cardiology, department of medicine, Emory University School of Medicine, and colleagues reviewed the medical records of 2,166 patients with HF (median age, 65 years; 41% women; 49% white) who received outpatient care in the Emory Healthcare system from January to April 2012. Patients were classified as having HF with reduced EF (HFrEF), HF with preserved EF (HFpEF) or HF with recovered EF (HFrecEF), defined as current left ventricular EF greater than 40% but a previously documented LVEF of 40% or less.
Primary endpoints included mortality; a composite of death or first hospitalization for any cause; a composite of death or first hospitalization for CV causes; and a composite of death or first HF-related hospitalization. Median follow-up was 3 years.
New HF phenotype
The researchers classified 350 patients with HFpEF as having HFrecEF (16.2%; 95% CI, 14.6-17.8). Compared with those with HFpEF, patients with HFrecEF were more likely to be younger and male (P < .001 for both); less likely to have CAD (P = .004), diabetes (P < .001) and chronic kidney disease (P = .02); more likely to have lower systolic BP (P < .001); and more likely to have an implantable cardioverter defibrillator or cardiac resynchronization therapy (P < .001 for both). They also were more likely, according to the researchers, to receive an ACE inhibitor or angiotensin receptor blocker regimen (P < .001), but not loop diuretics (P < .001), aspirin (P = .001) or digoxin (P < .001).
During the study period, mortality occurred in 13.3% of the total cohort. During the first year of follow-up, no differences in mortality were observed between the three groups of patients with HF. However, in the second and third year, patients with HFrecEF had lower mortality rates compared with those with HFpEF (HR = 0.56; P = .02) and HFrEF (HR = 0.55; P = .01). At 3 years, age- and sex-adjusted mortality rates were 16.3% in those with HFrEF, 13.2% in those with HFpEF and 4.8% in those with HFrecEF (P for HFrecEF < .01 vs. HFrEF and HFpEF).
Compared with patients with HFpEF, those with HFrEF had less all-cause hospitalization (adjusted rate ratio = 0.71; 95% CI, 0.55-0.91), less CV hospitalization (adjusted rate ratio = 0.5; 95% CI, 0.35-0.71) and HF-related hospitalization (adjusted rate ratio = 0.48; 95% CI, 0.3-0.76), according to the researchers.
Compared with patients with HFrEF, those with HFrecEF were at lower risk for death or all-cause hospitalization (HR = 0.63; 95% CI, 0.52-0.75), death or CV hospitalization (HR = 0.34; 95% CI, 0.26-0.44) or death or HF hospitalization (HR = 0.29; 95% CI, 0.21-0.39), the researchers wrote.
Kalogeropoulos and colleagues wrote that the retrospective design of the study did not allow them “to provide insights into potential predictors of LVEF recovery, including clinical and genetic characteristics. That would require a different, longitudinal study design because our present cross-sectional approach of HF group assignment does not allow us to causally link characteristics to LVEF recovery.”
Data not conclusive
In an accompanying editorial, Jane E. Wilcox, MD, MSc, and Clyde W. Yancy, MD, MSc, both from the division of cardiology, department of medicine at Northwestern University Feinberg School of Medicine, wrote that one of the most important limitations of the study was the absence of a concurrent comparator group or inception cohort. This “could very well represent a survival bias alone, which leads us to interpret the data with interest but not yet with conviction,” they wrote.
Clyde W. Yancy
Wilcox and Yancy, deputy editor of JAMA Cardiology, wrote, however, that the existence of this new category cannot be denied.
“It is our opinion that myocardial recovery exists, as evidenced by clinical trials, observational data and recent integration into current guidelines. Now is the time to recognize recovery as a clinical reality for patients with HFrEF and to begin a deliberate pursuit of the underlying mechanisms and future clinical considerations,” they wrote. – by Tracey Romero
Disclosure: The researchers and editorial writers report no relevant financial disclosures.