Routinely reported ejection fraction and mortality in clinical practice: where does the nadir of risk lie?

Wehner, G. J. et al. (2020) Routinely reported ejection fraction and mortality in clinical practice: where does the nadir of risk lie? European Heart Journal, 41(12), pp. 1249-1257. (doi: 10.1093/eurheartj/ehz550) (PMID:31386109)

Abstract

Aims: We investigated the relationship between clinically assessed left ventricular ejection fraction (LVEF) and survival in a large, heterogeneous clinical cohort. Methods and results: Physician-reported LVEF on 403 977 echocardiograms from 203 135 patients were linked to all-cause mortality using electronic health records (1998–2018) from US regional healthcare system. Cox proportional hazards regression was used for analyses while adjusting for many patient characteristics including age, sex, and relevant comorbidities. A dataset including 45 531 echocardiograms and 35 976 patients from New Zealand was used to provide independent validation of analyses. During follow-up of the US cohort, 46 258 (23%) patients who had undergone 108 578 (27%) echocardiograms died. Overall, adjusted hazard ratios (HR) for mortality showed a u-shaped relationship for LVEF with a nadir of risk at an LVEF of 60–65%, a HR of 1.71 [95% confidence interval (CI) 1.64–1.77] when ≥70% and a HR of 1.73 (95% CI 1.66–1.80) at LVEF of 35–40%. Similar relationships with a nadir at 60–65% were observed in the validation dataset as well as for each age group and both sexes. The results were similar after further adjustments for conditions associated with an elevated LVEF, including mitral regurgitation, increased wall thickness, and anaemia and when restricted to patients reported to have heart failure at the time of the echocardiogram. Conclusion: Deviation of LVEF from 60% to 65% is associated with poorer survival regardless of age, sex, or other relevant comorbidities such as heart failure. These results may herald the recognition of a new phenotype characterized by supra-normal LVEF.

• Item Type: Articles
• Additional Information: This work was supported by a National Institutes of Health Early Independence Award [DP5 OD012132]. This project was also funded, in part, under a grant with the Pennsylvania Department of Health (#SAP 4100070267)
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: Cleland, Professor John
• Authors: Wehner, G. J., Jing, L., Haggerty, C. M., Suever, J. D., Leader, J. B., Hartzel, D. N., Kirchner, H. L., Manus, J. N.A., James, N., Ayar, Z., Gladding, P., Good, C. W., Cleland, J. G.F., and Fornwalt, B. K.
• College/School: College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > Robertson Centre
• Journal Name: European Heart Journal
• Publisher: Oxford University Press
• ISSN: 0195-668X
• ISSN (Online): 1522-9645
• Published Online: 06 August 2019
• Copyright Holders: Copyright © The Author(s) 2019
• First Published: First published in European Heart Journal 41(12):1249-1257
• Publisher Policy: Reproduced in accordance with the publisher copyright policy