Physicians' Academy for Cardiovascular Education

Incidence, predictors and associated outcomes of EF change in HF patients

Prevalence and Prognostic Implications of Longitudinal Ejection Fraction Change in Heart Failure

Literature - Savarese G, Vedin O, D’Amario D et al. - JACC Heart Failure 2019; DOI: 10.1016/j.jchf.2018.11.019

Introduction and methods

Heart failure (HF) phenotyping and therapy decisions are profoundly determined by assessment of ejection fraction (EF) [1]. In addition, EF also independently provides prognostic information [2]. Baseline EF assessment therefore is mandatory for purposes of diagnosis, prognostication, and treatment assignment in every HF patient [1,2]. However, EF may change over time [3-5], requiring renewed stratification and prognostic evaluation. Furthermore, worsening EF may indicate HF treatment, whereas benefits and risks of continuation vs. withdrawal of treatment with improving EF remain unknown. This indicates the need for comprehensive assessment of changes in EF in large HF populations. However, most contemporary studies only focus on recovery of EF [6-12], and do not examine the whole spectrum of EF changes across all EF categories, including determinants of change and associated prognosis.

This study (n=4.942) therefore examined the incidence and type of EF change, the predictors of different types of EF change (increase and decrease), and the prognostic implications of different types of EF change in the large contemporary and unselected SwedeHF (Swedisch Heart Failure) study population. HF patients with ≥2 consecutive EF assessment were enrolled between May 2000 and Dec 2012. Data of the SwedeHF were linked to data on mortality from the Population Registry, data on baseline comorbidities and hospitalization for HF (HHF) from the Patient Registry, and socio-economic data from the Statistics Sweden SCB. HF patients were categorized based on EF: HFrEF [EF <40%], HFmrEF [EF 40%-49%], and HFpEF [EF ≥50%]. EF decrease was defined as pooled transitions from HFpEF to HFmrEF, HFpEF to HFrEF, or HFmrEF to HFrEF. EF increase was defined as pooled transitions from HFrEF to HFmrEF, HFrEF to HFpEF, or HFmrEF to HFpEF. Stable EF was defined as no changes among EF groups. Primary outcome was a composite of all-cause mortality and HHF.

Main results

Incidence and EF change patterns

Predictors of EF change

EF change and outcomes

Incidence, predictors and associated outcomes of EF change in HF patients


This nationwide HF cohort showed an increase in EF over time in one-fourth of patients with HFrEF and HFmrEF, and a decrease in EF in more than one-third of those with HFpEF and HFmrEF. A wide range of important clinical, treatment, and organizational factors predicted EF changes. Decrease in EF was linked to higher risk of all-cause mortality and HHF, particularly in those transitioning to HFrEF.


Show references

Download the slide Find this article online at JACC Heart Failure

Share this page with your colleagues and friends: