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The trajectory that led to midrange left ventricular ejection fraction (LVEF) was linked to how patients ultimately fared in this gray area of heart failure (HF), one center reported in a retrospective study.

Compared to those who ended up at a midrange 40% to 50% LVEF as an improvement, those who deteriorated to that range were at greater risk of all-cause mortality and all-cause hospitalization over a median 2.24 years after the index transthoracic echocardiography (TTE, HR 1.34, 95% CI 1.10-1.82).

Both mortality and hospitalization individually trended the same direction but without reaching statistical significance, Barry Greenberg, MD, of University of California San Diego, and colleagues reported online in .

Similarly, the deteriorated group was at higher risk of combined cardiovascular mortality and HF hospitalization (HR 1.71, 95% CI 1.08-2.50), a result that was driven by a between-group difference in death from cardiovascular causes.

The elevated risk of those with falling LVEF persisted after multivariable analysis, study authors noted. Outcomes did not differ significantly between patients whose LVEF improved and those in whom it remained stable.

"Overall, these differences underscore the considerable heterogeneity between patients in the HFmrEF [heart failure with midrange ejection fraction] population," the researchers concluded.

Finding increased risk for the deteriorated group in particular "identifies a subgroup of patients for whom clinical trials designed to help improve outcomes are badly needed," they suggested.

People who improved to midrange LVEF were most likely to be receiving guideline-directed medical therapy in the form of an ACE inhibitor, angiotensin receptor blocker, beta-blocker, mineralocorticoid receptor antagonist, and diuretic therapy, compared to the other subgroups. Moreover, they were more often on implantable cardioverter-defibrillator or cardiac resynchronization therapy than the others.

"Whether this supports initiation of guideline-directed medical therapy for all patients with a midrange LVEF warrants further investigation," according to Greenberg's team.

They had performed an EHR review to find their population of interest: the 448 HF patients who had a 40-50% LVEF on TTE in 2015 and at least one prior TTE for comparison in the UC San Diego Health System. Patients included were 62.1% men, with a mean age of 67.4 years. Among them:

• 35.0% had LVEF improve from <40% to 40-50% (over a median of 3.4 years between TTEs)
• 50.0% had LVEF deteriorate from >50% to 40-50% (over 3.9 years)
• 15.0% had LVEF consistently in the 40-50% range (over 3.2 years)

Patients in the deterioration group were older and more likely to be female than patients in the improved group. Fewer of the deterioration group had symptomatic HF or had experienced an HF hospitalization at baseline.

Coronary artery disease (CAD) was diagnosed in about half of the patients. There was no significant difference in CAD prevalence across the deteriorated, improved, or stable LVEF groups.

Greenberg and colleagues cautioned that their study had excluded nearly half of patients with HFmrEF because they did not have a prior LVEF assessment available in the EHR. Their findings may also not apply to other hospitals.

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