Author + information
- Received April 12, 2019
- Accepted April 29, 2019
- Published online August 26, 2019.
- Giovanni Benfari, MDa,b,∗,
- Wayne L. Miller, MD, PhDa,∗,
- Clémence Antoine, MDa,
- Andrea Rossi, MDb,
- Grace Lin, MDa,
- Jae K. Oh, MDa,
- Veronique L. Roger, MD, MPha,
- Prabin Thapa, MSca and
- Maurice Enriquez-Sarano, MDa,∗ ()
- aDepartment of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
- bDepartment of Medicine, Section of Cardiology, University of Verona, Verona, Italy
- ↵∗Address for correspondence:
Dr. Maurice Enriquez-Sarano, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905.
Objectives The objective of this study was to determine short- and long-term excess mortality associated with diastolic echocardiographic measures (primarily E/e′ ratio) in patients with HF with reduced ejection fraction.
Background In patients with heart failure (HF), Doppler echocardiography diastolic alterations are frequently but not convincingly linked to survival. Consequently, they are not included in risk-score algorithms or substantially mentioned in HF guidelines.
Methods Consecutive patients with HF Stage B to C, diagnosed between 2003 and 2011, with ejection fraction <50%, Doppler diastolic characterization, complete clinical evaluation, and estimated pulmonary pressure, were analyzed. Outcome measure was mortality under medical management.
Results The 12,421 eligible patients were 69 ± 14 years of age, 32% were women, 72% had Stage C HF, with ejection fraction 36 ± 10% and E/e′ ratio of 17 ± 9. During median follow-up 4.0 (1.1 to 7.0) years, 1-year and 5-year mortality were 17 ± 0.4% and 42 ± 0.5%. E/e′ ratio >20 was linked to elevated 1-year mortality (adjusted odds ratio: 1.45 [95% confidence interval (CI): 1.16 to 1.83]; p = 0.001). Long-term E/e′ ratios >20 and >14 to 20 were associated with reduced survival (adjusted hazard ratio: 1.21 [95% CI: 1.07 to 1.37]; p = 0.003, and adjusted hazard ratio: 1.15 [95% CI: 1.02 to 1.29]; p = 0.02), independent of all HF characteristics and in all patients’ subsets, including HF Stage B and Stage C. Guideline-based diastolic-grade algorithm also independently predicted mortality (p < 0.0001) but was definable less frequently (70%).
Conclusions In reduced ejection fraction HF, diastolic Doppler alterations entail considerable mortality independent of all presentation characteristics. Elevated E/e′ ratio, associated with worse HF at diagnosis, is also, independent of presentation, linked to substantial short-term reduced survival and long-term sustained excess mortality and should be incorporated into HF risk assessment.
↵∗ Drs. Benfari and Milley contributed equally to this work.
Mayo Foundation provided the funding for the data retrieval and analysis and for all ancillary support. Dr. M. Enriquez-Sarano has received grants from Edwards, outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 12, 2019.
- Accepted April 29, 2019.
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