Clinical phenotypes and mid-term outcomes according to precipitating factors of acute heart failure

Background

Acute heart failure (AHF) is frequently triggered by identifiable precipitating factors; however, their relationship with underlying disease severity and subsequent outcomes remains incompletely understood. Clarifying trigger-specific clinical phenotypes may improve risk stratification and inform post-discharge management.

Methods

We analyzed a single-center registry of consecutive patients hospitalized with AHF. Precipitating factors were classified as behavioral (e.g., medication non-adherence or lifestyle-related), non-behavioral (e.g., infection, arrhythmia, uncontrolled hypertension, or ischemia), or other/unknown. More than one precipitating factor could be present in the same patient; however, if at least one behavioral precipitating factor was identified, the patient was classified in the behavioral group. Baseline clinical, laboratory, and echocardiographic characteristics were compared across groups. A hierarchical composite endpoint of all-cause mortality, need for renal replacement therapy, or AHF rehospitalization at 6 months was assessed.

Results

Among 407 patients (median age 80 years), precipitating factors were behavioral in 132 (32.4%), non-behavioral in 202 (49.6%), and other/unknown in 73 (18.0%). Most patients had a single precipitating factor, although nearly one-third presented with multiple concurrent triggers.

Patients with behavioral/non-behavioral precipitants were younger, more frequently had de novo heart failure, and presented with higher systolic blood pressure and more preserved renal function. In contrast, patients with other or unknown precipitants exhibited a more advanced cardiorenal phenotype, characterized by lower admission and baseline eGFR, higher urea and NT-proBNP levels, lower hemoglobin, higher RDW, lower systolic blood pressure, and more pronounced echocardiographic markers of congestion, including higher ePASP, elevated E/e′ ratio and larger left atrial volume index. Multivalvular heart disease and right-sided heart failure were also more prevalent in this group.

During 6-month follow-up, the hierarchical composite endpoint occurred progressively more frequently across precipitating factor categories, with the highest event rate observed in patients with other or unknown precipitants (28.8%, 38.1%, and 49.3% for behavioral, non-behavioral, and other/unknown groups, respectively; p=0.013).

Conclusions

Precipitating factors of AHF identify distinct clinical phenotypes with graded cardiorenal, hemodynamic, and congestive burden and are associated with differential mid-term outcomes. The absence of an identifiable precipitating factor is associated with more advanced cardiorenal disease and may reflect progressive heart failure rather than an acute reversible trigger. Recognition of trigger-specific risk profiles may support targeted preventive strategies and individualized post-discharge management following AHF hospitalization.Baseline characteristicsFor image description, please refer to the figure legend and surrounding text.Labs and echocardiographic parametersFor image description, please refer to the figure legend and surrounding text.