Author + information
- Received December 7, 2015
- Revision received February 24, 2016
- Accepted March 3, 2016
- Published online June 1, 2016.
- Connie W. Tsao, MD, MPHa,b,∗ (, )
- Asya Lyass, PhDb,c,
- Martin G. Larson, ScDb,c,
- Susan Cheng, MD, MPHb,d,
- Carolyn S.P. Lam, MBBSe,
- Jayashri R. Aragam, MDd,f,
- Emelia J. Benjamin, MD, ScMb,g and
- Ramachandran S. Vasan, MDb,f,g
- aDepartment of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
- bBoston University’s and National Heart, Lung, and Blood Institute’s Framingham Heart Study, Framingham, Massachusetts
- cDepartment of Mathematics and Statistics, Boston University, Boston, Massachusetts
- dDepartment of Medicine, Division of Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts
- eDepartment of Medicine, Division of Cardiology, National University Health Centre, Singapore
- fDepartment of Medicine, Division of Cardiology, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- gDepartment of Medicine, Sections of Cardiology and Preventive Medicine, Boston University School of Medicine, Boston, Massachusetts
- ↵∗Reprint requests and correspondence:
Dr. Connie W. Tsao, Cardiovascular Division, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, Massachusetts 02215.
Objectives This study sought to examine the association of a borderline left ventricular ejection fraction (LVEF) of 50% to 55% with cardiovascular morbidity and mortality in a community-based cohort.
Background Guidelines stipulate a LVEF >55% as normal, but the optimal threshold, if any, remains uncertain. The prognosis of a “borderline” LVEF, 50% to 55%, is unknown.
Methods This study evaluated Framingham Heart Study participants who underwent echocardiography between 1979 and 2008 (n = 10,270 person-observations, mean age 60 years, 57% women). Using pooled data with up to 12 years of follow-up and multivariable Cox regression, we evaluated the associations of borderline LVEF and continuous LVEF with the risk of developing a composite outcome (heart failure [HF] or death; primary outcome) and incident HF (secondary outcome).
Results During follow-up (median 7.9 years), HF developed in 355 participants, and 1,070 died. Among participants with an LVEF of 50% to 55% (prevalence 3.5%), rates of the composite outcome and HF were 0.24 and 0.13 per 10 years of follow-up, respectively, versus 0.16 and 0.05 in participants having a normal LVEF. In multivariable-adjusted analyses, LVEF of 50% to 55% was associated with increased risk of the composite outcome (hazard ratio [HR]: 1.37; 95% confidence interval [CI]: 1.05 to 1.80) and HF (HR: 2.15; 95% CI: 1.41 to 3.28). There was a linear inverse relationship of continuous LVEF with the composite outcome (HR per 5 LVEF% decrement: 1.12; 95% CI: 1.07 to 1.16) and HF (HR per 5 LVEF% decrement: 1.23; 95% CI: 1.15 to 1.32).
Conclusions Persons with an LVEF of 50% to 55% in the community have greater risk for morbidity and mortality relative to persons with an LVEF >55%. Additional studies are warranted to elucidate the optimal management of these individuals.
This work was supported by the National Heart, Lung, and Blood Institute (contract NO1-HC-25195); by grants from the American Heart Association (13SDG14250015 [Dr. Tsao], NIH K23HL118529 [Dr. Tsao], K99HL107642 [Dr. Cheng], R01HL093328 [Dr. Vasan], 6R01-NS17950 [Dr. Vasan], and R01HL080124 [Dr. Vasan]); by a Harvard Medical School fellowship (Dr. Tsao); and by the Ellison Foundation (Dr. Cheng). Dr. Lam has been supported by a Clinician Scientist Award from the National Medical Research Council of Singapore; has received research support from Boston Scientific, Medtronic, and Vifor Pharma; and has been a consultant for Bayer, Novartis, Takeda, Merck, AstraZeneca, Janssen Research and Development, and Menarini. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 7, 2015.
- Revision received February 24, 2016.
- Accepted March 3, 2016.
- American College of Cardiology Foundation