Clinical characteristics and prognosis of decompensated acute heart failure according to the precipitating factor

Background

Heart failure (HF) is a global public health priority with a natural history defined by chronic progression punctuated by acute decompensation episodes. Although most hospitalisations have an identifiable precipitating factor, evidence regarding the specific prognostic effect of these triggers on outcomes such as mortality.

Purpose

The present study aimed to evaluate the clinical, laboratory, and echocardiographic characteristics of patients hospitalized for decompensated acute HF based on the primary precipitating factor, and to assess their prognostic impact.

Methods

This retrospective observational study included 818 patients hospitalized for HF. Patients were stratified into seven groups according to the precipitating factor: lack of therapeutic adherence (Group 1), infections (Group 2), arrhythmias (Group 3), poorly controlled hypertension or hypertensive crisis (Group 4), anaemia (Group 5), idiopathic (Group 6), and other motives (Group 7). Patients were followed for up to 1 year, with censoring at death or end of follow-up. The primary endpoint was 1-year all-cause mortality. Survival was assessed using Kaplan–Meier analysis and compared with the log-rank test. The association between precipitating factors and clinical outcome was evaluated using Cox proportional hazards regression models

Results

The median age was 87 (IQR 83–90) years, and 65.3% were women. Marked clinical heterogeneity was observed among precipitating factors. Group 4 (hypertensive crisis) exhibited the highest systolic blood pressure and older age. Group 2 (infection) showed a higher prevalence of COPD and markedly elevated C-reactive protein levels. Group 5 (anaemia) had the lowest haemoglobin and poorer renal function. Mortality differed significantly, peaking in the infectious phenotype and being lowest in hypertensive crisis.

(Figure 1)

During a median follow-up of 383.5 days (IQR 133–661), 322 patients (38.9%) died. Kaplan–Meier curves demonstrated significantly worse survival in Group 2, while hypertensive crisis and idiopathic decompensation showed more favourable profiles (log-rank p=0.001). (Figure 1) In multivariable Cox regression, the precipitating factor remained independently associated with mortality. Using Group 2 as the reference, hypertensive crisis showed an 83% lower risk of death (HR 0.17; 95% CI 0.04–0.69; p=0.013), and idiopathic decompensation a 47% lower risk (HR 0.53; p=0.007).

(Figure 2)

Conclusion

Precipitating factors for heart failure identify distinct clinical phenotypes and carry meaningful prognostic implications. Infectious triggers are linked to significantly poorer outcomes, whereas hypertensive crises present a more favourable prognosis. These findings highlight the need for personalised management and precise risk stratification based on the underlying cause of decompensation.Figure 1For image description, please refer to the figure legend and surrounding text.Figure 2For image description, please refer to the figure legend and surrounding text.