P610Frailty, co-morbidities and survival in heart failure patients with mid-range ejection fraction

Abstract

Background: Heart failure (HF) is a chronic condition highly prevalent among older people. Due to this fact, fragility and co-morbidities are often present among HF patients. The 2016 Heart Failure (HF) ESC Guidelines boost to investigate the ?new? subgroup of patients with HF and left ventricular ejection fraction (EF) mildly reduced (HFmrEF). Purpose: Our aim was to assess the effect of co-morbidities and fragility on longterm prognosis in ambulatory HFmrEF patients, and to compare it with those observed in HF with reduced (HFrEF) and preserved (HFpEF) EF. Methods: A score of co-morbidities was created, ranging from 0 to 7, which include diabetes, hypertension, COPD, renal failure, anaemia, peripheral arteriopathy and atrial fibrillation. Fragility was defined as having at least one abnormal evaluation among 4 standardized geriatric scales. Predefined criteria for such scales were: Barthel Index <90; OARS scale <10 in women and <6 in men; Pfeiffer Test >3 (±1, depending on educational grade); and ≥1 positive response for depression on the abbreviated GDS. Median follow-up was 4.9 years [P25- 75: 2.5-8.4] for living patients. All-cause death, HF-related hospitalization and the composite end-point of both were assessed. Results: 185 patients with HFmrEF were evaluated (127 men and 58 women, mean age 67.7±11.7 years, median HF duration 12 months [Q1-Q3 2-44], ischemic aetiology 58%, 119 (64.3%) and 59 (31.9%) in NYHA class II and III respectively), and compared with 1058 patients with HFrEF and 162 with HFpEF. The number of co-morbidities in HFmrEFpatients (2.41±1.5) was similar to that in HFrEF 2.30±1.4 (p=0.60) and lower (p<0.001) than that in HFpEF patients (3.02±1.5). In contrast fragility tended to be more prevalent in HFmrEF (48.6%) than in HFrEF (41.9%), p=0.09, and similarly prevalent than in HFpEF (54.3%), patients, p=0.29. During follow-up 104 deaths, 35 HF-related first hospitalizations and 112 composite end-points were documented. Co-morbidities and fragility were significantly associated with the 3 end-points: HR 1.56 [1.36-1.78], p<0.001 and HR 2.70 [1.81-4.02], p<0.001 for all-cause death respectively; HR 2.02 [1.60-2.57], p<0.001 and HR 2.21 [1.12-4.37], p=0.02 for HF-related hospitalization respectively; and HR 1.61 [1.42-1.83], p<0.001 and HR 2.53 [1.73-3.71], p<0.001 for the composite end-point respectively. These figures were higher in all the end-points (from 4% to 100%) than that observed in HFrEF and HFpEF patients. In separate multivariable analyses containing also age, sex, NYHA functional class and ischemic aetiology the number co-morbidities remained independently associated with all-cause death (p<0.001), HF-related hospitalization (p<0.001) and the composite end-point (p<0.001); and fragility with all-cause death (p=0.002) and the composite end-point (p=0.01). Conclusion: Co-morbidities and fragility are determinant of outcome in ambulatory patients with HFmrHF, even more than in HFrEF and HFpEF patients.