Supra-Normal Ejection Fraction at Hospital Admission Stratifies Mortality Risk in HFpEF Patients Aged ≥ 70 Years

Background: During the last few years, significant pathophysiological differences between heart failure (HF) patients with “normal” ejection fraction (EF) (50% to 64%) and those with supra-normal EF (≥65%) have been highlighted. However, these distinct EF phenotypes have been poorly investigated in elderly patients aged ≥70 y. Accordingly, the present study aimed at assessing the clinical and echocardiographic characteristics of a retrospective cohort of elderly HFpEF patients (aged ≥ 70 y), categorized on the basis of “normal” EF (50 to 64%) or “supra-normal” EF (≥65%). Methods: All patients aged ≥ 70 y that were discharged from our Institution with a first diagnosis of HF with preserved EF (HFpEF) between January 2020 and March 2021 entered the study. All pa- tients underwent clinical evaluation, blood tests, and transthoracic echocardiography. The primary endpoint was “all-cause mortality”, while the secondary one was the compos- ite “all-cause mortality or rehospitalization for all causes” over a mid-term follow-up. Results: A total of 200 HFpEF patients (86.4 ± 6.6 y, 70% females) were retrospectively evaluated. The “normal” EF group (n = 99) and the “supra-normal” EF one (n = 101) were separately analyzed. Compared to patients with “normal” EF, those with “supra-normal” EF were older, with greater comorbidity burden, and moderate-to-severe frailty status. The mean follow-up duration was 3.6 ± 0.3 y. During follow-up, 79 patients died, and 73 were rehospitalized. In the multivariate Cox regression analysis, age (HR 1.09, 95% CI 1.03–1.16, p = 0.002), EF (HR 1.08, 95% CI 1.03–1.14, p = 0.004), tricuspid annular plane systolic excursion (TAPSE)/systolic pulmonary artery pressure (sPAP) ratio (HR 0.14, 95% CI 0.03–0.61, p = 0.009), and infectious disease occurring during the baseline stay (HR 7.23, 95% CI 2.41–21.6, p < 0.001) were independently associated with the primary endpoint in the whole study population. EF (HR 1.04, 95% CI 1.01–1.07, p = 0.02) also predicted the secondary endpoint. EF ≥65% was the best cut-off to predict both endpoints. Conclusions: “Supra-normal” EF (≥65%) at hospital admission is independently associated with all-cause mortality and rehospitalization for all causes in elderly HFpEF patients over a mid-term follow-up.