Diastolic Determinants of Excess Mortality in Heart Failure With Reduced Ejection Fraction

Giovanni Benfari, Wayne Miller, Clémence Antoine, Andrea Rossi, Grace D Lin, Jae Kuen Oh, Veronique Lee Roger, Prabin Thapa, Maurice E Sarano

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Objectives: The objective of this study was to determine short- and long-term excess mortality associated with diastolic echocardiographic measures (primarily E/e′ ratio) in patients with HF with reduced ejection fraction. Background: In patients with heart failure (HF), Doppler echocardiography diastolic alterations are frequently but not convincingly linked to survival. Consequently, they are not included in risk-score algorithms or substantially mentioned in HF guidelines. Methods: Consecutive patients with HF Stage B to C, diagnosed between 2003 and 2011, with ejection fraction <50%, Doppler diastolic characterization, complete clinical evaluation, and estimated pulmonary pressure, were analyzed. Outcome measure was mortality under medical management. Results: The 12,421 eligible patients were 69 ± 14 years of age, 32% were women, 72% had Stage C HF, with ejection fraction 36 ± 10% and E/e′ ratio of 17 ± 9. During median follow-up 4.0 (1.1 to 7.0) years, 1-year and 5-year mortality were 17 ± 0.4% and 42 ± 0.5%. E/e′ ratio >20 was linked to elevated 1-year mortality (adjusted odds ratio: 1.45 [95% confidence interval (CI): 1.16 to 1.83]; p = 0.001). Long-term E/e′ ratios >20 and >14 to 20 were associated with reduced survival (adjusted hazard ratio: 1.21 [95% CI: 1.07 to 1.37]; p = 0.003, and adjusted hazard ratio: 1.15 [95% CI: 1.02 to 1.29]; p = 0.02), independent of all HF characteristics and in all patients’ subsets, including HF Stage B and Stage C. Guideline-based diastolic-grade algorithm also independently predicted mortality (p < 0.0001) but was definable less frequently (70%). Conclusions: In reduced ejection fraction HF, diastolic Doppler alterations entail considerable mortality independent of all presentation characteristics. Elevated E/e′ ratio, associated with worse HF at diagnosis, is also, independent of presentation, linked to substantial short-term reduced survival and long-term sustained excess mortality and should be incorporated into HF risk assessment.

Original languageEnglish (US)
Pages (from-to)808-817
Number of pages10
JournalJACC: Heart Failure
Volume7
Issue number9
DOIs
StatePublished - Sep 1 2019

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Heart Failure
Mortality
Confidence Intervals
Survival
Diastolic Heart Failure
Guidelines
Doppler Echocardiography
Odds Ratio

Keywords

  • diastolic function
  • heart failure
  • left ventricular dysfunction

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Diastolic Determinants of Excess Mortality in Heart Failure With Reduced Ejection Fraction. / Benfari, Giovanni; Miller, Wayne; Antoine, Clémence; Rossi, Andrea; Lin, Grace D; Oh, Jae Kuen; Roger, Veronique Lee; Thapa, Prabin; Sarano, Maurice E.

In: JACC: Heart Failure, Vol. 7, No. 9, 01.09.2019, p. 808-817.

Research output: Contribution to journalArticle

Benfari, Giovanni ; Miller, Wayne ; Antoine, Clémence ; Rossi, Andrea ; Lin, Grace D ; Oh, Jae Kuen ; Roger, Veronique Lee ; Thapa, Prabin ; Sarano, Maurice E. / Diastolic Determinants of Excess Mortality in Heart Failure With Reduced Ejection Fraction. In: JACC: Heart Failure. 2019 ; Vol. 7, No. 9. pp. 808-817.
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abstract = "Objectives: The objective of this study was to determine short- and long-term excess mortality associated with diastolic echocardiographic measures (primarily E/e′ ratio) in patients with HF with reduced ejection fraction. Background: In patients with heart failure (HF), Doppler echocardiography diastolic alterations are frequently but not convincingly linked to survival. Consequently, they are not included in risk-score algorithms or substantially mentioned in HF guidelines. Methods: Consecutive patients with HF Stage B to C, diagnosed between 2003 and 2011, with ejection fraction <50{\%}, Doppler diastolic characterization, complete clinical evaluation, and estimated pulmonary pressure, were analyzed. Outcome measure was mortality under medical management. Results: The 12,421 eligible patients were 69 ± 14 years of age, 32{\%} were women, 72{\%} had Stage C HF, with ejection fraction 36 ± 10{\%} and E/e′ ratio of 17 ± 9. During median follow-up 4.0 (1.1 to 7.0) years, 1-year and 5-year mortality were 17 ± 0.4{\%} and 42 ± 0.5{\%}. E/e′ ratio >20 was linked to elevated 1-year mortality (adjusted odds ratio: 1.45 [95{\%} confidence interval (CI): 1.16 to 1.83]; p = 0.001). Long-term E/e′ ratios >20 and >14 to 20 were associated with reduced survival (adjusted hazard ratio: 1.21 [95{\%} CI: 1.07 to 1.37]; p = 0.003, and adjusted hazard ratio: 1.15 [95{\%} CI: 1.02 to 1.29]; p = 0.02), independent of all HF characteristics and in all patients’ subsets, including HF Stage B and Stage C. Guideline-based diastolic-grade algorithm also independently predicted mortality (p < 0.0001) but was definable less frequently (70{\%}). Conclusions: In reduced ejection fraction HF, diastolic Doppler alterations entail considerable mortality independent of all presentation characteristics. Elevated E/e′ ratio, associated with worse HF at diagnosis, is also, independent of presentation, linked to substantial short-term reduced survival and long-term sustained excess mortality and should be incorporated into HF risk assessment.",
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AU - Benfari, Giovanni

AU - Miller, Wayne

AU - Antoine, Clémence

AU - Rossi, Andrea

AU - Lin, Grace D

AU - Oh, Jae Kuen

AU - Roger, Veronique Lee

AU - Thapa, Prabin

AU - Sarano, Maurice E

PY - 2019/9/1

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N2 - Objectives: The objective of this study was to determine short- and long-term excess mortality associated with diastolic echocardiographic measures (primarily E/e′ ratio) in patients with HF with reduced ejection fraction. Background: In patients with heart failure (HF), Doppler echocardiography diastolic alterations are frequently but not convincingly linked to survival. Consequently, they are not included in risk-score algorithms or substantially mentioned in HF guidelines. Methods: Consecutive patients with HF Stage B to C, diagnosed between 2003 and 2011, with ejection fraction <50%, Doppler diastolic characterization, complete clinical evaluation, and estimated pulmonary pressure, were analyzed. Outcome measure was mortality under medical management. Results: The 12,421 eligible patients were 69 ± 14 years of age, 32% were women, 72% had Stage C HF, with ejection fraction 36 ± 10% and E/e′ ratio of 17 ± 9. During median follow-up 4.0 (1.1 to 7.0) years, 1-year and 5-year mortality were 17 ± 0.4% and 42 ± 0.5%. E/e′ ratio >20 was linked to elevated 1-year mortality (adjusted odds ratio: 1.45 [95% confidence interval (CI): 1.16 to 1.83]; p = 0.001). Long-term E/e′ ratios >20 and >14 to 20 were associated with reduced survival (adjusted hazard ratio: 1.21 [95% CI: 1.07 to 1.37]; p = 0.003, and adjusted hazard ratio: 1.15 [95% CI: 1.02 to 1.29]; p = 0.02), independent of all HF characteristics and in all patients’ subsets, including HF Stage B and Stage C. Guideline-based diastolic-grade algorithm also independently predicted mortality (p < 0.0001) but was definable less frequently (70%). Conclusions: In reduced ejection fraction HF, diastolic Doppler alterations entail considerable mortality independent of all presentation characteristics. Elevated E/e′ ratio, associated with worse HF at diagnosis, is also, independent of presentation, linked to substantial short-term reduced survival and long-term sustained excess mortality and should be incorporated into HF risk assessment.

AB - Objectives: The objective of this study was to determine short- and long-term excess mortality associated with diastolic echocardiographic measures (primarily E/e′ ratio) in patients with HF with reduced ejection fraction. Background: In patients with heart failure (HF), Doppler echocardiography diastolic alterations are frequently but not convincingly linked to survival. Consequently, they are not included in risk-score algorithms or substantially mentioned in HF guidelines. Methods: Consecutive patients with HF Stage B to C, diagnosed between 2003 and 2011, with ejection fraction <50%, Doppler diastolic characterization, complete clinical evaluation, and estimated pulmonary pressure, were analyzed. Outcome measure was mortality under medical management. Results: The 12,421 eligible patients were 69 ± 14 years of age, 32% were women, 72% had Stage C HF, with ejection fraction 36 ± 10% and E/e′ ratio of 17 ± 9. During median follow-up 4.0 (1.1 to 7.0) years, 1-year and 5-year mortality were 17 ± 0.4% and 42 ± 0.5%. E/e′ ratio >20 was linked to elevated 1-year mortality (adjusted odds ratio: 1.45 [95% confidence interval (CI): 1.16 to 1.83]; p = 0.001). Long-term E/e′ ratios >20 and >14 to 20 were associated with reduced survival (adjusted hazard ratio: 1.21 [95% CI: 1.07 to 1.37]; p = 0.003, and adjusted hazard ratio: 1.15 [95% CI: 1.02 to 1.29]; p = 0.02), independent of all HF characteristics and in all patients’ subsets, including HF Stage B and Stage C. Guideline-based diastolic-grade algorithm also independently predicted mortality (p < 0.0001) but was definable less frequently (70%). Conclusions: In reduced ejection fraction HF, diastolic Doppler alterations entail considerable mortality independent of all presentation characteristics. Elevated E/e′ ratio, associated with worse HF at diagnosis, is also, independent of presentation, linked to substantial short-term reduced survival and long-term sustained excess mortality and should be incorporated into HF risk assessment.

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