Abstract
Background
Although 2-dimensional echocardiography (2DE) is widely used to measure left ventricular ejection fraction (LVEF), the prognostic value of 2DE-derived LVEF has not been clearly demonstrated in a broad range of patients, including those acutely hospitalized as well as ambulatory patients. In particular, the prognostic value of echocardiographic LVEF has not been demonstrated for cardiovascular and heart failure hospitalizations.
Purpose
To determine if greater degrees of LV dysfunction are associated with progressively increasing risks of death or cardiovascular hospitalizations among patients undergoing echocardiography in hospital or outpatient settings.
Methods
We examined quantitative LVEFs from patient-level echocardiographic reports at 3 large hospital laboratories, which were linked to the Canadian Institute for Health Information hospitalization database and to death registries in Ontario, Canada. LVEF was categorized as <25%, 25–35%, 36–45%, or 46–55% (reference). Analyses were performed using cause-specific hazard competing risk models and stratified by: a) outpatient vs. inpatient echocardiogram, and b) if inpatient study, whether the reason for hospitalization was cardiac or noncardiac in nature.
Results
In the echocardiographic cohort of 27,323 patients (median age 68 [IQR: 58–77], 14,828 women [31.7%]), greater reductions in LVEF were associated with higher rates of all-cause mortality, with adjusted hazard ratios (95% CI) of 1.67 (1.57, 1.77) for LVEF <25%, 1.30 (1.24, 1.36) for LVEF 25–35%, and 1.17 (1.11, 1.23) for LVEF 36–45%, compared to LVEF 46–55% (all p<0.001). The cumulative incidence of cardiovascular death was higher as LVEF progressively worsened (Figure). The rate of heart failure hospitalizations was also increased with hazard ratios of 1.71 (1.59, 1.85) for LVEF <25%, 1.39 (1.31, 1.48) for LVEF 25–35%, and 1.21 (1.13, 1.29) for LVEF 36–45%, compared to LVEF 46–55% (all p<0.001). Cardiovascular hospitalizations were also increased with hazard ratios of 1.35 (1.27, 1.42), 1.21 (1.16, 1.27), and 1.13 (1.07, 1.18) for LVEFs <25%, 25–35%, and 36–45%, respectively (all p<0.001). The risk of mortality and hospitalizations increased comparably with greater reductions in LVEF during both inpatient cardiac or noncardiac admissions (p<0.001).
Cumulative incidence of CV death
Conclusions
Quantitative LVEF assessed by 2DE is potent prognostically and was able to stratify the risk of both death and hospitalization outcomes in a wide range of clinical settings. Patients with reduced LVEF measured on inpatient or outpatient echocardiograms, and even in the context of non-cardiac admission, should be considered an at-risk group in whom quality of care metrics could be evaluated in future studies.
Acknowledgement/Funding
Canadian Institutes of Health Research, Heart and Stroke Foundation, and the Ted Rogers Centre for Heart Research
HFA-PEFF scores: prognostic value in heart failure with preserved left ventricular ejection fraction
