Risk stratification according to diastolic function indices in heart failure patients with mildly reduced or reduced ejection fraction

Aims: The aim of the study is to evaluate the risk of all-cause mortality or heart failure hospitalizations in ambulatory patients with heart failure with reduced and mildly reduced ejection fraction (HFrEF or HFmrEF) according to diastolic function indices. Diastolic dysfunction in HF is both common and associated with poor prognosis. However, specific cut-off values of diastolic function parameters for prognostication of hard outcomes in HF have not been conclusively established. Methods and results: Analysis of full echocardiographic examination of consecutive ambulatory HFrEF and HFmrEF patients seen at a single tertiary hospital between 2010 and 2021 was retrospectively done. Data on all-cause mortality or heart failure hospitalizations were obtained from the electronic medical records and national mortality registry. Patients with > moderate left heart valvular dysfunction were excluded from the study. The final cohort included 4717 patients (75% males, median age 70 years interquartile range 61.3-78.4). After adjusting for clinical or echocardiographic variables, increased rates of mortality or HF hospitalizations were found when E/e′>10, left atrial volume index (LAVI) > 40mL/m2, E/A ratio < 0.6, deceleration time (DT) < 180ms, peak E-wave velocity > 0.78m/s, and sPAP > 26mmHg. However, no significant difference in outcomes between near-normal and normal values of E/e′ (< 8 compared with 8-10) or LAVI (≤34mL/m2 compared with LAVI 34-40mL/m2) was found. Conclusion: In patients with HFmrEF and HFrEF, slightly abnormal diastolic indices were found to be associated with worse outcomes. Summary: We have demonstrated that in patients with heart failure with reduced and mildly reduced ejection fraction (HFrEF or HFmrEF), near-normal diastolic indices are associated with worse outcomes with the following cut-off values: max E-wave velocity > 0.78m/s, E/e′ ratio > 10, a LAVi > 40mL/m2, DT > 180, E/A between 0.6 and 1.4, and a sPAP > 26mmHg. Further research is needed to establish these suggested cut-off values.