Discriminating clinical features of heart failure with preserved vs. reduced ejection fraction in the community

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.

Figure 1

Discriminating clinical features of heart failure with reduced ejection fraction vs. heart failure with preserved ejection fraction in the derivation and validation samples. Odds ratios indicate the odds of HFPEF associated with the condition present in dichotomous variables, and per 1 mEq/L increase in serum potassium and per 25 b.p.m. increase in the heart rate for continuous variables (indicated by asterisk).

Figure 2

The actual and predicted risk of heart failure with preserved ejection fraction vs. heart failure with reduced ejection fraction by the decile of the Framingham Heart Study risk function. (A) Framingham Heart Study participants, (B) Enhanced Feedback For Effective Cardiac Treatment participants, and (C) Enhanced Feedback For Effective Cardiac Treatment participants after recalibration.