Two phenotypes, one outcome: short-term prognosis of preserved versus non-preserved ejection fraction in acute heart failure

Introduction

Heart failure with preserved ejection fraction (HFpEF) represents an increasing proportion of patients hospitalized with acute heart failure (AHF). Despite well-recognized differences in clinical profile and pathophysiology, the short-term prognosis of HFpEF compared with non-preserved ejection fraction (EF) during acute decompensation remains uncertain. Clarifying these differences may help refine risk stratification and management strategies in the acute setting.

Purpose

To assess whether patients with HFpEF differ in clinical presentation and short-term outcomes from those with non-preserved EF during acute heart failure hospitalization, and to explore independent predictors of early adverse outcomes.

Methods

We conducted a retrospective observational study including 121 consecutive patients admitted with AHF to a medical ward. Patients were classified according to left ventricular ejection fraction as non-preserved EF (<50%) or preserved EF (≥50%). The primary analysis compared baseline characteristics and short-term outcomes between EF phenotypes. A secondary analysis aimed to identify independent predictors of a composite adverse outcome, defined as in-hospital death, prolonged hospitalization (>30 days), or 30-day heart failure (HF) readmission. Variables with clinical or statistical relevance entered into a multivariable logistic regression model.

Results

Among the 121 patients included, 75 had non-preserved EF and 46 had preserved EF. Patients with preserved EF were older (median 86 [79—89] vs 79 [71—86] years; p=0.002) and more frequently female (67% vs 35%; p<0.001). The prevalence of hypertension, dyslipidemia, diabetes, atrial fibrillation, and chronic kidney disease was similar between EF phenotypes. NT-proBNP levels were lower in patients with preserved EF (4596 [1885—12245] vs 8850 [4855—17624] pg/mL; p=0.012), while laboratory parameters and in-hospital treatments were otherwise comparable.

In-hospital mortality (6.5% vs 8.0%; p=0.764), prolonged hospitalization (21.7% vs 25.3%; p=0.653), and 30-day HF readmission (13.0% vs 9.3%; p=0.522) did not differ between EF phenotypes. The composite adverse outcome occurred in 32.6% of patients with preserved EF and 34.7% of those with non-preserved EF (p=0.816). In the multivariable analysis, no individual variable emerged as an independent predictor of the composite adverse outcome.

Conclusion

Despite distinct demographic and biochemical profiles, patients with preserved and non-preserved EF exhibited comparable short-term outcomes. These findings support the concept of acute heart failure as a common final pathway of decompensation across EF phenotypes, with early prognosis driven more by the acute severity of illness than by baseline ventricular function.Baseline characteristics and outcomesFor image description, please refer to the figure legend and surrounding text.