Phenotyping Heart Failure According to the Longitudinal Ejection Fraction Change: Myocardial Strain, Predictors, and Outcomes

BACKGROUND: Many patients with heart failure (HF) experience changes in left ventricular ejection fraction (LVEF) during follow‐up. We sought to evaluate the predictors and outcomes of different HF phenotypes according to longitudinal changes in EF. METHODS AND RESULTS: A total of 2104 patients with acute HF underwent echocardiography at baseline and follow‐up. Global longitudinal strain was measured at index admission. HF phenotypes were defined as persistent HF with reduced EF (persistent HFrEF, LVEF ≤40% at baseline and follow‐up), heart failure with improved ejection fraction (LVEF≤40% at baseline and improved to >40% at follow‐up), heart failure with declined ejection fraction (LVEF>40% at baseline and declined to ≤40% at follow up), and persistent HF with preserved EF (persistent HFpEF, LVEF>40% at baseline and follow‐up). Overall, 1130 patients had HFrEF at baseline; during follow‐up, 54.2% and 46.8% had persistent HFrEF and heart failure with improved ejection fraction, respectively. Among 975 patients with HFpEF at baseline, 89.5% and 10.5% had persistent HFpEF and heart failure with declined ejection fraction at follow‐up, respectively. The 5‐year all‐cause mortality rates were 43.1%, 33.1%, 24%, and 17% for heart failure with declined ejection fraction, persistent HFrEF, persistent HFpEF, and heart failure with improved ejection fraction, respectively (global log‐rank P<0.001). In multivariable analyses, each 1% increase in global longitudinal strain (greater contractility) was associated with 10% increased odds for heart failure with improved ejection fraction among patients with HFrEF at baseline and 7% reduced odds for heart failure with declined ejection fraction among patients with HFpEF at baseline. CONCLUSIONS: LVEF changed during follow‐up. Each HF phenotype according to longitudinal LVEF changes has a distinct prognosis. Global longitudinal strain can be used to predict the HF phenotype. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03513653.