CLINICAL RESEARCH: HEART FAILURE
The association of left ventricular ejection fraction, mortality, and cause of death in stable outpatients with heart failure
Jeptha P. Curtis, MD*,
Seth I. Sokol, MD*,
Yongfei Wang, MS*,
Saif S. Rathore, MPH*,
Dennis T. Ko, MD*,
Farid Jadbabaie, MD*,
Edward L. Portnay, MD*,
Stephen J. Marshalko, MD, PhD*,
Martha J. Radford, MD, FACC* and
Harlan M. Krumholz, MD, SM, FACC*  ,*
* Section of Cardiovascular Medicine, Department of Internal Medicine and Section of Health Policy and Administration, Yale University School of Medicine, New Haven, Connecticut, USA
Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, USA
Yale-New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA
Yale-New Haven Health Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA
Manuscript received February 24, 2003;
revised manuscript received March 28, 2003,
accepted April 8, 2003.
* Reprint requests and correspondence: Dr. Harlan M. Krumholz, Yale University School of Medicine, 333 Cedar Street, PO Box 208025, New Haven, Connecticut 06520-8025, USA.
harlan.krumholz{at}yale.edu
OBJECTIVES: The aim of this study was to assess the prognostic importance of left ventricular ejection fraction (LVEF) in stable outpatients with heart failure (HF).
BACKGROUND: Although LVEF is an accepted prognostic indicator of prognosis in HF patients, the relationship of LVEF and mortality across the full spectrum of LVEF is incompletely understood.
METHODS: We examined the association of LVEF and outcomes among 7,788 stable HF patients enrolled in the Digitalis Investigation Group trial.
RESULTS: During mean follow-up of 37 months, mortality was substantial in all LVEF groups (range, LVEF  15%, 51.7%, LVEF > 55%, 23.5%). Among patients with LVEF 45%, mortality decreased in a near linear fashion across successively higher LVEF groups (LVEF < 15%, 51.7%; LVEF 36% to 45%, 25.6%; p < 0.0001). This association was present after multivariable adjustment, although the magnitude of this associated risk was reduced (LVEF 15%: hazard ratio [HR] 1.77, 95% confidence interval [CI] 1.48 to 2.11; LVEF 16% to 25%: HR 1.44, 95% CI 1.28 to 1.61; LVEF 26% to 35%: HR 1.10, 95% CI 0.98 to 1.28; LVEF 36% to 45%: referent). In contrast, mortality rates were comparable among patients with LVEF > 45% both before (LVEF 46% to 55%: 23.3%; LVEF > 55%: 23.5%; p = 0.25), and after multivariable adjustment (LVEF 46% to 55%: HR 0.92, 95% CI 0.77 to 1.10; LVEF > 55%: HR 0.88, 95% CI 0.71 to 1.09; LVEF 36% to 45%: referent). Patients with lower LVEF were at increased absolute risk of death due to arrhythmia and worsening HF, but these were leading causes of death in all LVEF groups.
CONCLUSIONS: Among HF patients in sinus rhythm, higher LVEFs were associated with a linear decrease in mortality up to an LVEF of 45%. However, increases above 45% were not associated with further reductions in mortality.
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Abbreviations and Acronyms
| | BMI | = body mass index | | DIG | = Digitalis Investigation Group | | ERNA | = equilibrium radionuclide angiography | | HF | = heart failure | | LVEF | = left ventricular ejection fraction | | MI | = myocardial infarction |
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