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Clinical characteristics and long-term clinical outcomes of Japanese heart failure patients with preserved versus reduced left ventricular ejection fraction: A prospective cohort of Shinken Database 2004–2011
Corresponding author at: The Department of Cardiovascular Medicine, The Cardiovascular Institute, 3-2-19, Nishiazabu, Minato-ku, Tokyo 106-0031, Japan. Tel.: +81 3 3408 2151; fax: +81 3 3408 2159.
Clinical data on the mortality and morbidity of unselected Japanese patients with heart failure (HF) are limited. In this study, we aimed to determine the clinical characteristics, long-term outcomes, and prognostic factors of Japanese HF patients with preserved or reduced left ventricular ejection fraction (LVEF).
Methods and results
We used a single hospital-based cohort from the Shinken Database 2004–2011 that comprised all new patients (n = 17,517) visiting the Cardiovascular Institute Hospital. A total of 1,525 patients diagnosed with symptomatic HF at the initial visit were included in the analysis. Of these, 1121 patients (74%) exhibited a preserved LVEF (>50%) and 404 patients (26%) had a reduced LVEF (≤50%). HF patients with preserved LVEF (HFpEF) were older and more often female than patients with reduced LVEF (HFrEF). Kaplan–Meier curves and log-rank test results showed that HFpEF patients had a better prognosis than HFrEF patients. However, there were no significant differences in clinical outcomes between HFpEF and HFrEF patients when the analysis was limited to inpatients. Cox regression analysis showed that HFpEF patients had a significantly lower risk of all-cause death (p = 0.027; hazard ratio, 0.547, 95% confidence interval, 0.321–0.933). Multivariate analyses performed separately showed that the independent predictors of all-cause death in HFrEF were advanced age, lower body mass index, diabetes mellitus, and the absence of statin treatment, whereas those for HFpEF were advanced age, absence of dyslipidemia, anemia, and left ventricular hypertrophy.
Conclusions
This prospective cohort study identified the clinical characteristics, long-term outcomes, and prognostic factors of Japanese HF patients with reduced and preserved ejection fractions in a real-world clinical setting.
]. In addition to the increased prevalence of HF, HF with a preserved ejection fraction (HFpEF) is increasingly being recognized as a public health problem. The prevalence of HFpEF is similar to that of HF with reduced ejection fraction (HFrEF). HFpEF is associated with poor clinical outcomes, which are believed to be slightly better than those of HFrEF.
The epidemiology of HF in Japan is different from that in Western countries with respect to ethnic background and etiology. However, there are few Japanese hospital-based reports about preserved left ventricular ejection fraction (LVEF) [
JCARE-CARD Investigators Characteristics and outcomes of hospitalized patients with heart failure and reduced vs preserved ejection fraction. Report from the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD).
], and the prevalence and prognosis of HF with preserved LVEF are not well known. Tsuchihashi-Makaya et al. examined patients from the Japanese Cardiac Registry of Heart Failure in Cardiology who were hospitalized for HF and demonstrated that patients with HFpEF had similar mortality rates and equally high rates of rehospitalization as those with HFrEF [
JCARE-CARD Investigators Characteristics and outcomes of hospitalized patients with heart failure and reduced vs preserved ejection fraction. Report from the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD).
]. However, the patients enrolled in these studies had severe HF that required hospitalization. To our knowledge, the differences in clinical characteristics, outcomes, and prognostic factors between patients with HFpEF and those with HFrEF in an unselected Japanese HF population that includes both inpatients and outpatients with mild symptoms have not been examined. Therefore, we examined a hospital-based cohort from the Shinken Database using data obtained between 2004 and 2011. The registry was initiated in 2004, and patients have since been continually registered to the database annually. In the present study, we aimed to clarify the differences in clinical characteristics, outcomes, and prognostic factors between patients with HFpEF and those with HFrEF in an unselected cohort of Japanese HF patients by using the Shinken Database.
Methods
Study patients
The Shinken Database includes all patients (inpatients and outpatients) who were examined at the Cardiovascular Institute in Tokyo, Japan (“Shinken” is a Japanese abbreviation for the name of the hospital), and excludes patients who are foreign travelers and those with active cancer. This hospital-based database was established to investigate the prevalence and prognosis of cardiovascular diseases in the urban areas of Japan [
Role of cardiopulmonary dysfunction and left atrial remodeling in development of acute decompensated heart failure in chronic heart failure with preserved left ventricular ejection fraction.
]. The registry began in June 2004, and patients have been continually registered to the database annually. The present study analyzed data from this database collected between June 2004 and March 2012 (Shinken Database 2004–2011) and included 17,517 new visiting patients. In the present study, HF patients were defined as those with symptomatic HF [New York Heart Association (NYHA) classes II–IV] coexistent with structural heart diseases, which were diagnosed using cardiovascular diagnostic tests such as echocardiography, nuclear scanning, and angiography. We defined HFpEF patients as those with symptomatic HF and preserved LVEF (i.e. LVEF > 50%), and HFrEF patients as those with symptomatic HF and reduced LVEF (i.e. LVEF ≤ 50%), as previously described [
]. We excluded patients with valvular heart disease. Valvular heart disease was defined as long-standing mitral or aortic valve involvement as documented by physical examination and echocardiography, angiography, or history of surgical repair. We defined inpatients as patients who were admitted to or transferred to our hospital because of HF (not for examination) at their first hospital visit, whereas outpatients are patients who have symptomatic HF and visited the outpatient clinic of our hospital without hospital admission at their first hospital visit.
Ethics
The ethical committee of the Cardiovascular Institute approved this study, and all the patients provided written informed consent.
Data collection
For each patient, after undergoing electrocardiography and chest radiography, cardiovascular status was evaluated by echocardiography, an exercise test, 24-h Holter recordings, and blood laboratory data as prescribed by the attending physician within 3 months after the first visit. As initial clinical parameters, collected data included gender, age, body mass index (BMI), drug information, and coexisting conditions, including hypertension, atrial fibrillation, diabetes mellitus, and dyslipidemia. In most patients, additional echocardiographic parameters included left ventricular diameter of the diastole (LVDd), left ventricular diameter of the systole (LVDs), interventricular septum thickness (IVST), posterior wall thickness (PWT), and LVEF using M-mode echocardiography. Left ventricular (LV) hypertrophy was defined by echocardiography (IVST or PWT ≥ 13 mm). Anemia was defined as a hemoglobin level of <11 g/dL. An estimated glomerular filtration rate (eGFR) was calculated using the eGFR equation for the Japanese population: eGFR = 194 × (serum creatinine)−1.094 × (age)−0.287 × (0.739, if the patient is female) [
]. Idiopathic dilated cardiomyopathy was diagnosed by the presence of global LV dilatation with impaired systolic function occurring in the absence of known cardiac causes. Hypertrophic cardiomyopathy was diagnosed by echocardiography when hypertrophy (IWST or PWT > 12 mm) without hypertension was present. We confirmed the deaths of study patients by the medical records of our hospital or by the information obtained during follow-up. We defined cardiovascular death as death resulting from acute myocardial infarction, sudden cardiac death, death due to heart failure, death due to stroke, or death due to other cardiovascular causes. HF admission was defined as exacerbation of chronic HF requiring hospitalization and was determined by the outpatient clinic physician according to the presenting symptoms, physical examination results, laboratory data, and chest radiography findings.
Patient follow-up
The health status and incidence of cardiovascular events and mortality of patients are maintained in the database by linking to the medical records of the hospital and through study documents that were sent once per year to those who stopped hospital visits or who were referred to other hospitals.
We excluded the follow-up data obtained after April 1, 2012, from data analysis. Therefore, the end of the follow-up period was defined as one of the following: (1) the date of death, if the date was before March 31, 2012; (2) the final hospital visit or the final response to our study documents involving prognosis with confirmation of being alive before March 31, 2012; (3) March 31, 2012, when the date of death, the final hospital visit, or the final response to our study documents involving prognosis were later than April 1, 2012.
Statistical analysis
Categorical and consecutive data regarding patient background are presented as numbers (%) and means ± standard deviation, respectively. The chi-square test was used for comparisons between groups, and the unpaired t-test was used for comparison of consecutive variables. Long-term, event-free survival was estimated using Kaplan–Meier curves and the log-rank test to assess the significance of differences between the 2 groups. Cox regression analysis was used to identify the effects of HFpEF on long-term clinical outcomes. Univariate Cox regression analysis was used to identify the co-factors with significant effects on all-cause mortality. Step-wise multivariate Cox regression analysis was performed to determine the independent prognostic factors for all-cause death. For subanalysis, patients with HF were segregated into outpatients and inpatients. Clinical outcomes were compared between patients with HFpEF and HFrEF in the outpatient and inpatient groups, respectively. A probability value of <0.05 was considered to indicate a statistically significant difference. Statistical analyses were performed using SPSS (SPSS Inc., Chicago, IL, USA), version 19.0 software.
Results
Patient characteristics
Of the 17,517 patients who had visited our hospital, 1,525 patients were diagnosed with symptomatic HF without valvular heart disease. These patients were followed for an average period of 1135 ± 764 days. Patients were divided into HFpEF (LVEF > 50%; 1,121 patients, 74%) and HFrEF (LVEF ≤ 50%; 404 patients, 26%). There were 1,330 outpatients (HFpEF: 1,048 patients, 79%; HFrEF: 282 patients, 21%), and 195 inpatients (HFpEF: 73 patients, 37%; HFrEF: 122 patients, 63%). Compared with patients with HFrEF, patients with HFpEF were older, more often female, less likely to have diabetes mellitus, hyperuricemia, CKD, anemia, a prior history of myocardial infarction, dilated cardiomyopathy, or atrial fibrillation, and had a higher rate of dyslipidemia. Ultrasound cardiography results showed that IVST, PWT, LVDd, and LVDs were greater in HFrEF patients than in HFpEF patients. LVEF and left ventricular fractional shortening were greater in HFpEF patients than in HFrEF patients. The mean B-type natriuretic peptide (BNP) level was significantly lower in patients with preserved LVEF than in those with reduced LVEF. The use of beta-blockers, renin–angiotensin-system inhibitors (RAS-Is), diuretics, and digitalis was more common among HFrEF patients, whereas use of calcium channel blockers, statins, and nitrates was more common in HFpEF patients. The HFpEF group had a higher prevalence of NYHA II, but a lower prevalence of NYHA III and IV heart failure than the HFrEF group (Table 1).
Table 1Characteristics of patients.
HFrEF (n = 404)
HFpEF (n = 1,121)
p-Value
Age (years)
63.0 ± 13.8
65.6 ± 11.7
<.001
Male sex
81.2
76.2
.039
BMI (kg/m2)
24.6 ± 4.8
24.3 ± 3.6
.209
Hypertension
59.9
64.5
.100
Dyslipidemia
51.7
66.8
<.001
Diabetes mellitus
39.9
32.4
.007
Hyperuricemia
19.6
11.4
<.001
Cigarette
28.6
24.2
.144
CKD
46.5
27.6
<.001
Anemia
14.3
9.7
.013
Prior MI
26.2
9.6
<.001
DCM
24.5
0.4
<.001
HCM
2.0
3.9
.065
AF
19.3
9.0
<.001
BNP (pg/mL)
671.0 ± 772.7
232.6 ± 460.5
<.001
UCG
IVST (mm)
9.4 ± 2.2
10.0 ± 2.2
<.001
PWT (mm)
8.7 ± 1.8
9.1 ± 1.5
<.001
LVDd (mm)
57.3 ± 8.6
46.0 ± 4.6
<.001
LVDs (mm)
48.0 ± 9.9
28.9 ± 4.7
<.001
LVFS (%)
16.7 ± 6.2
37.4 ± 5.8
<.001
LVEF (%)
34.0 ± 11.7
67.0 ± 7.5
<.001
LVH
8.6
9.7
.542
NYHA class
II
55.4
78.6
<.001
III
23.8
15.7
<.001
IV
20.8
5.7
<.001
Medications
Beta-blockers
55.0
37.7
<.001
Calcium channel blockers
19.1
30.5
<.001
ACE-Is
27.7
13.4
<.001
ARBs
49.8
34.9
<.001
RAS-Is
71.0
44.8
<.001
Statins
43.6
54.9
<.001
Diuretics
63.6
19.1
<.001
Digitalis
15.6
3.4
<.001
Nitrate
39.6
60.8
<.001
HFrEF, heart failure with reduced left ventricular ejection fraction; HFpEF, heart failure with preserved left ventricular ejection fraction; BMI; body mass index; CKD, chronic kidney disease; IHC, ischemic heart disease; prior MI, prior history of myocardial infarction; DCM, idiopathic dilated cardiomyopathy; HCM, hypertrophic cardiomyopathy; AF, atrial fibrillation; BNP, brain natriuretic peptide; UCG, ultrasound cardiography; IVST, interventricular septum thickness; PWT, posterior wall thickness; LVDd, left ventricular end-diastolic dimension; LVDs, left ventricular end-systolic dimension; LVFS, left ventricular fractional shortening; LVEF, left ventricular ejection fraction; LVH, left ventricular hypertrophy; NYHA, New York Heart Association; ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; RAS-I, renin–angiotensin system inhibitor. Data are expressed as mean ± standard deviation, or percentage.
All-cause death occurred in 4.5% of patients in the HFpEF group, and 11.4% of patients in the HFrEF group. Cardiovascular death (HF death) occurred in 1.7% (0.8%) of the patients in the HFpEF group, and 5.2% (2.0%) of the patients in the HFrEF group. Admission for HF occurred in 4.1% of the patients with HFpEF and 15.8% of the patients with HFrEF (Table 2). Kaplan–Meier curves and log-rank test results showed that frequency of all-cause death, cardiovascular death, HF death, and HF admission, were significantly higher in HFrEF patients than in HFpEF patients (Fig. 1).
Table 2Clinical outcomes.
HFrEF (n = 404)
HFpEF (n = 1,121)
p-Value
All-cause death
11.4
4.5
<.001
Heart failure death
2.0
0.8
.053
Cardiovascular death
5.2
1.7
<.001
Heart failure admission
15.8
4.1
<.001
HFrEF, heart failure with reduced left ventricular ejection fraction; HFpEF, heart failure with preserved left ventricular ejection fraction. Data are expressed as percentage.
Cox regression analysis showed that HFpEF was associated with a lower incidence of all-cause death [p < 0.001; hazard ratio (HR) 0.369, 95% confidence interval (95% CI) 0.247–0.549], cardiovascular death (p < 0.001; HR 0.307, 95% CI 0.165–0.571), and HF admission (p < 0.001; HR 0.222, 95% CI 0.152–0.324). The Cox regression model was used in the analysis to adjust for the following covariates: age, sex, dyslipidemia, diabetes mellitus, hyperuricemia, CKD, anemia, prior history of myocardial infarction, dilated cardiomyopathy, atrial fibrillation, BNP level, LVEF, NYHA III/IV, beta blockers, calcium channel blockers, RAS-Is, statins, diuretics, digitalis, and nitrate. It showed that patients with HFpEF had a comparable risk for cardiovascular death (p = 0.436; HR 0.730, 95% CI 0.331–1.611), HF death (p = 0.452, HR 0.626, 95% CI 0.184–2.126), and HF admission (p = 0.360, HR 1.456, 95% CI 0.652–3.237), but had a significantly lower risk for all-cause death (p = 0.027, HR 0.547, 95% CI 0.321–0.933) (Table 3).
Table 3Hazard ratios of clinical outcomes of patients with HFpEF.
p-Value
Hazard ratio
95% CI
All-cause death
Unadjusted HR
<.001
.369
.247–.549
Adjusted HR
.027
.547
.321–.933
Cardiovascular death
Unadjusted HR
<0.001
.307
.165–.571
Adjusted HR
.436
.730
.331–1.611
HF death
Unadjusted HR
.054
.392
.151–1.016
Adjusted HR
.452
.626
.184–2.126
HF admission
Unadjusted HR
<.001
.222
.152–.324
Adjusted HR
.360
1.456
.652–3.237
HFpEF, heart failure with preserved left ventricular ejection fraction; HR, hazard ratio; CI, confidence interval; HF, heart failure.
Univariate Cox regression analysis showed that age, BMI, dyslipidemia, diabetes mellitus, cigarette smoking, CKD, anemia, statins, and BNP level were associated with all-cause death in HF with HFrEF (Table 4). Multivariate Cox regression analysis, including the significant predictors identified in the univariate model, showed that older age, lower BMI, diabetes mellitus, and the absence of statin treatment were independent predictors of all-cause death in HFrEF (Table 4). Univariate Cox regression analysis showed that age, BMI, dyslipidemia, hyperuricemia, CKD, anemia, AF, statins, diuretics, NYHA III/IV, BNP level, and LV hypertrophy were associated with all-cause death in HFpEF (Table 5). Multivariate Cox regression analysis, including the significant predictors, identified in the univariate model showed that advanced age, absence of dyslipidemia, anemia, and LV hypertrophy were independent predictors of all-cause death in HFpEF (Table 5).
Table 4Predictors for death in HFrEF.
p-Value
Hazard ratio
95% CI
Univariate
Age
<.001
1.065
1.039–1.092
Male
.790
1.116
.499–2.495
BMI
.001
.863
.791–.942
Hypertension
.537
.833
.466–1.489
Dyslipidemia
.018
.480
.262–.881
Diabetes mellitus
.006
2.275
1.265–4.092
Hyperuricemia
.094
.416
.149–1.162
Cigarette
.006
.133
.032–.552
CKD
<.001
4.436
2.250–8.743
Anemia
<.001
4.271
2.345–7.782
Prior MI
.148
1.565
.853–2.872
DCM
.475
.767
.370–1.589
HCM
.236
2.357
.571–9.728
AF
.571
.792
.354–1.772
Beta-blockers
.299
.736
.413–1.313
Calcium channel blockers
.507
1.258
.639–2.478
RAS-Is
.151
.641
.349–1.177
Statins
.002
.337
.167–.679
Diuretics
.700
.890
.492–1.610
Nitrate
.483
1.231
.689–2.200
NYHA III/IV
.143
1.541
.564–2.748
BNP
<.001
1.001
1.000–1.001
LVH
.211
1.733
.732–4.101
LVEF
.298
.987
.964–1.011
Multivariate
Age
.011
1.052
1.012–1.095
BMI
.024
.852
.741–.980
DM
.006
3.504
1.431–8.578
Statin
.019
.323
.125–.831
BMI, body mass index; CKD, chronic kidney disease; IHD, ischemic heart disease; prior MI, prior history of myocardial infarction; DCM, idiopathic dilated cardiomyopathy; HCM, hypertrophic cardiomyopathy; AF, atrial fibrillation; RAS-I, renin–angiotensin system inhibitor; NYHA, New York Heart Association; BNP, brain natriuretic peptide; LVH, left ventricular hypertrophy; LVEF, left ventricular ejection fraction; DM, diabetes mellitus. CI, confidence interval.
Kaplan–Meier curves and the log-rank test results revealed that the frequencies of all-cause death, cardiovascular death, HF death, and HF admission were significantly higher in HFrEF than in HFpEF outpatients (Fig. 2), whereas these were all comparable among inpatients (Fig. 3).
Figure 2Kaplan–Meier curves for all-cause death-free survival rate (A), cardiovascular death-free survival rate (B), heart failure death-free survival rate (C), and heart failure admission-free survival rate (D). HFpEF, heart failure patients with preserved left ventricular ejection fraction; HFrEF, heart failure patients with reduced left ventricular ejection fraction.
The present study analyzed data from an observational cohort of HF patients to determine the mortality and morbidity of unselected Japanese HF patients in a real-world clinical setting. The major findings of the present study were as follows:
(1)
HFpEF was present in approximately 74% of all of the HF inpatients (37%) and outpatients (79%) visiting a cardiovascular hospital in Japan.
(2)
Patients with HFpEF showed a better prognosis than those with HFrEF. However, our sub-analysis showed that among inpatients, the clinical outcomes of HFpEF and HFrEF patients were comparable.
(3)
In HFrEF, older age, lower BMI, diabetes mellitus, and the absence of statin treatment were independent predictors of all-cause death, whereas older age, absence of dyslipidemia, anemia, and LV hypertrophy were independent predictors of all-cause death in HFpEF.
The prevalence of HFpEF, which has increased with time in Western countries [
], varies according to age, race, and the cutoff value for LVEF. Nevertheless, there is widespread agreement that HFpEF is noted in more than one-third of all patients admitted with HF [
Clinical presentation, hospital length of stay, and readmission rate in patients with heart failure with preserved and decreased left ventricular systolic function.
A national survey of heart failure in French hospitals. The Myocardiopathy and Heart Failure Working Group of the French Society of Cardiology, the National College of General Hospital Cardiologists and the French Geriatrics Society.
JCARE-CARD Investigators Characteristics and outcomes of hospitalized patients with heart failure and reduced vs preserved ejection fraction. Report from the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD).
]. In our study, the prevalence of HFpEF was 72%, which was significantly higher than that of previous reports in both Western countries and Japan. This could be attributed to the HF outpatients that were included in our cohort. In fact, 40% of the inpatients with HF had preserved LVEF, which was in agreement with the findings of previous studies. The high prevalence of HFpEF suggests that this type of HF merits further attention.
Patients with HFpEF are older, more often female, and more frequently have hypertension compared to patients with HFrEF [
Clinical presentation, hospital length of stay, and readmission rate in patients with heart failure with preserved and decreased left ventricular systolic function.
A national survey of heart failure in French hospitals. The Myocardiopathy and Heart Failure Working Group of the French Society of Cardiology, the National College of General Hospital Cardiologists and the French Geriatrics Society.
JCARE-CARD Investigators Characteristics and outcomes of hospitalized patients with heart failure and reduced vs preserved ejection fraction. Report from the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD).
]. The differences in patients’ backgrounds in our study were almost identical to those of previous reports, and patients with HFpEF were older and more often female.
Whether the long-term clinical outcomes of HFpEF and HFrEF patients differ is not clear. Smith et al. and Solomon et al. reported that patients with HFpEF had a significantly better prognosis than those with HFrEF [
Candesartan in Heart Failure Reduction in Mortality (CHARM) Investigators Influence of ejection fraction on cardiovascular outcomes in a broad spectrum of heart failure patients.
JCARE-CARD Investigators Characteristics and outcomes of hospitalized patients with heart failure and reduced vs preserved ejection fraction. Report from the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD).
]. In the present study, patients with HFpEF had a significantly better prognosis than those with HFrEF. Interestingly, no significant differences in clinical outcomes between HFpEF and HFrEF patients were detected when the analysis was limited to inpatients. This was in agreement with the results of previous studies [
JCARE-CARD Investigators Characteristics and outcomes of hospitalized patients with heart failure and reduced vs preserved ejection fraction. Report from the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD).
] that included hospitalized HF patients and showed that the prognoses of HFpEF and HFrEF were comparable. On the other hand, Solomon et al. reported that LVEF was a powerful predictor of cardiovascular outcome in a broad spectrum of patients with HF, including outpatients and inpatients [
Candesartan in Heart Failure Reduction in Mortality (CHARM) Investigators Influence of ejection fraction on cardiovascular outcomes in a broad spectrum of heart failure patients.
]. The findings of this study suggested that although patients with HFpEF generally had favorable outcomes, the prognosis of HFpEF does not differ from that of HFrEF in patients with decompensated HF requiring hospital admission.
Previous studies identified the prognostic factors for HF, including older age, the severity of HF [
Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group.
Hemoglobin level, chronic kidney disease, and the risks of death and hospitalization in adults with chronic heart failure: the Anemia in Chronic Heart Failure: Outcomes and Resource Utilization (ANCHOR) Study.
]. However, whether these predictors could be applied to both preserved and reduced LVEF remained unclear. In the present study, multivariate analyses demonstrated that the independent predictors of all-cause death in HFrEF were older age, lower BMI, diabetes mellitus, and the absence of statin treatment, whereas, older age, the absence of dyslipidemia, anemia, and LV hypertrophy were independent predictors of all-cause death in HFpEF. Hence, older age was a common risk factor of reduced and preserved LVEF. On the other hand, the effect of other factors differed between the reduced and preserved LVEF groups. Therefore, our results underscore that different factors should be paid more attention to, according to reduced or preserved LVEF.
Study limitations
The present study had several limitations. First, this study was a single center-based study. Because our hospital is a single-department cardiovascular facility, the results of this study cannot be generalized to all medical centers. Second, the definition of HFrEF and HFpEF in the present study was based on LVEF, and it therefore remains unknown whether the study population had objective evidence of diastolic dysfunction, as defined by guidelines for the diagnosis of HFpEF [
]. Third, the proportion of patients treated with drugs known to be effective for the treatment of HF was lower in the present study than in other studies.
Conclusion
The present study analyzed an observational cohort of Japanese patients with HF to determine the real-world clinical characteristics and long-term mortality and morbidity of HF with respect to HFpEF and HFrEF status. Long-term clinical outcomes were better in patients with HFpEF than in those with HFrEF. Interestingly, no significant differences in clinical outcomes between HFpEF and HFrEF patients were detected when the analysis was limited to inpatients. Multivariate analysis showed that older age, lower BMI, diabetes mellitus, and the absence of statin treatment were the independent predictors of all-cause death in HFrEF patients, whereas older age, absence of dyslipidemia, anemia, and LV hypertrophy were the independent predictors of all-cause death in HFpEF patients—suggesting that various factors should be considered for preserved or reduced LVEF.
Acknowledgments
We thank Shiro Ueda and Nobuko Ueda of Medical Edge Co. Ltd., for assembling the database by Clinical Study Supporting System (CliSSS), and Ineko Hayakawa, Hiroaki Arai, and Hiroshi Aoki for data management and system administration.
References
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Chronic heart failure in Japan: implications of the CHART studies.
Characteristics and outcomes of hospitalized patients with heart failure and reduced vs preserved ejection fraction. Report from the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD).
Role of cardiopulmonary dysfunction and left atrial remodeling in development of acute decompensated heart failure in chronic heart failure with preserved left ventricular ejection fraction.
Clinical presentation, hospital length of stay, and readmission rate in patients with heart failure with preserved and decreased left ventricular systolic function.
A national survey of heart failure in French hospitals. The Myocardiopathy and Heart Failure Working Group of the French Society of Cardiology, the National College of General Hospital Cardiologists and the French Geriatrics Society.
Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group.
Hemoglobin level, chronic kidney disease, and the risks of death and hospitalization in adults with chronic heart failure: the Anemia in Chronic Heart Failure: Outcomes and Resource Utilization (ANCHOR) Study.
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