Prognostic significance of unintentional weight loss in heart failure with preserved ejection fraction

Abstract

Aims: While intentional weight loss achieved through cardiometabolic medications has been associated with robust salutary effects in heart failure (HF) with preserved ejection fraction (HFpEF), the clinical significance of unintentional weight loss in this setting remains unclear.

Methods and results: This retrospective cohort study included 434 overweight or obese patients with invasively proven HFpEF (67 ± 11 years, 236 female), without weight-reducing therapies or known malignancy, who underwent invasive hemodynamic cardiopulmonary testing and long-term clinical follow-up. The annualized weight change from index to final evaluation for the tertiles was: -21.1 to -1.8 kg/year (tertile 1); -1.8 to 0 kg/year (tertile 2); and 0 to +17.0 kg/year (tertile 3). Patients in tertile 1 had subtle abnormalities in ventilatory control at baseline, but there were no other significant differences between groups across a vast array of haemodynamic and metabolic parameters, both at rest and during exercise. Baseline weight was directly correlated with right and left heart filling pressures (r = 0.23-0.34, p < 0.001), but annualized weight change showed no correlation with any baseline haemodynamic measurements (all p > 0.05). Over a median follow-up of 4.7 years (interquartile range 2.3-6.5), patients in tertile 1 had higher risk of all-cause death (hazard ratio [HR] 3.36, 95% confidence interval [CI] 1.77-6.39, p < 0.001), all-cause death or HF hospitalization (HR 2.49, 95% CI 1.53-4.04, p < 0.001) and cardiac death or HF hospitalization (HR 2.28, 95% CI 1.28-4.07, p = 0.005) compared with those in tertile 2 or 3. These findings were consistent after multivariable adjustment.

Conclusions: Unintentional weight loss is associated with worse prognosis in patients with HFpEF and overweight or obesity, even as haemodynamics, exercise capacity, and gas exchange are not different from patients with stable or increasing weight. These data underline important and fundamental differences between therapeutic and unintended weight loss in HFpEF.

Keywords: Heart failure with preserved ejection fraction; Prognosis; Weight loss.

Figure 1.

Associations of baseline weight and annualized weight change with cardiac filling pressures. Associations of baseline weight and annualized weight change with resting or peak right atrial pressure (RAP) and pulmonary artery wedge pressure (PAWP) were assessed using Pearson’s correlation analysis.

Figure 2.

Survival stratified by annualized weight change. (A) represents survival for all-cause death, (B) for all-cause death or heart failure (HF) hospitalization, and (C) for cardiac death or HF hospitalization. HR, hazard ratio; CI, confidence interval.

Figure 3.

Survival stratified by tertile 1 and tertile 2 + 3 of the annualized weight change is shown for (A) all-cause death, (B) all-cause death or heart failure (HF) hospitalization, and (C) cardiac death or HF hospitalization. The second row presents survival for subjects matched by propensity score analysis based on baseline age, sex, body mass index, diabetes, and coronary artery disease, with (D) all-cause death, (E) all-cause death or HF hospitalization, and (F) cardiac death or HF hospitalization. The median matching distance was 0.001 (IQR 0.0004–0.002). Comparisons of the survival were performed using the log-rank test and univariable Cox regression analysis.

Figure 4.

Continuous relationship between annualized weight change and events, represented by a spline curve with four knots based on percentiles. (A) shows the hazard ratio for all-cause death, (B) for all-cause death or heart failure (HF) hospitalization, and (C) for cardiac death or HF hospitalization.