ADJUDICATED VERSUS ADMINISTRATIVE HEART FAILURE WITH PRESERVED EJECTION FRACTION
Andreas Kalogeropoulos, M.D., Ph.D., Emory University, Atlanta, GA, USA
Heart failure (HF) with preserved ejection fraction (HFpEF) is associated with readmission and mortality rates similar to HF with reduced ejection fraction (HFrEF). No disease-modifying therapy for HFpEF exists to date, partially because of the multifactorial pathophysiology of HFpEF and the heterogeneity of patients. Studies from administrative databases report that HFpEF represents 40%-60% of HF cases. However, limited prospective data suggest a lower proportion, and enrollment in recent HFpEF trials has been slower than anticipated, suggesting that (1) the proportion of HF patients fulfilling all clinical criteria for HFpEF may be considerably lower and (2) administrative data may not have been as specific to exclude patients with recovered ejection fraction (HFrecEF) or specific cardiomyopathies. Therefore, more detailed data are needed on HFpEF epidemiology in order to properly design clinical trials. In a study of 1752 outpatients who received care associated with designated ICD-9 codes between 01/01/2012 and 03/31/2012 in Emory Healthcare (Atlanta, GA), we confirmed the diagnosis of HF in 1652 patients (94.3%). After individual adjudication, we classified 19.4% as HFpEF, 16.2% as HFrecEF; and 60.0% as HFrEF, while 4.3% had HF due to special causes. In comparison, the proportion of HFpEF cases based of ICD-9 codes and last EF without adjudication would have been 39.0%. HFpEF patients were older, more likely to be female, and had a higher burden of comorbidities compared to HFrecEF. After 2 years, age- and gender- adjusted mortality was 10.2% in HFrEF, 8.6% in HFpEF, and 4.4% in HFrecEF patients (stratified log-rank P=0.005). We concluded that (1) the proportion of clinically verified HFpEF is considerably lower compared to administrative estimates; (2) many patients with preserved EF actually represent HFrecEF, which has a more favorable prognosis; and (3) a large number of HFpEF patients would not be eligible for clinical trials due to serious concomitant conditions.