HFrEF phenotyping in real life

Abstract Background In May 2021 an HFA position paper[1] by Rosano GMC et al. classified patients with heart failure with reduced ejection fraction (HFrEF) into 11 phenotypes based on blood pressure, heart rate, renal function, potassium level and rhythm and assigned them to different prescription attitudes. Aim We aim to investigate the distribution of phenotype frequency in our cohort and their respective outcomes. Methods From 2016 to 2022 we enrolled 900 advanced HFrEF patients with severely reduced ejection fraction (LVEF <35%) in a prospective registry from our tertiary care heart failure unit. Patients were grouped according to the suggested phenotypes. Distribution and outcome for the different groups was analyzed. Results Characteristics of the different phenotypes, the distribution and outcome are shown in Figure 1. 65.8% of patients belong to 5 categories [3, 4, 5, 7b and 9]. Baseline characteristics of these 5 profiles are shown in Table 1. With the exception of Profile 3, which is characterized by a low resting hear rate, these major profiles are all eligible to receive all 4 drugs with class I recommendation at maximal dosages (RASi, BB, MRA, SGLT2i). The 6 remaining categories, all with GDMT limiting features, comprise solely another 3.8% of patients [1.8%, 1.2%, 0.3%, 0.3%, 0.2%, 0%, for the categories 7c, 7a, 1, 2, 6, 8 respectively]. With 30.2% a significant proportion of patients could not be assigned to one profile exclusively mostly because they showed a combination of profile attributes. Thus, of all classifiable HFrEF patients, with 83.4% the majority has no GDMT limiting features and should receive full HFrEF therapy. All-cause mortality did not differ between patient phenotypes [4,5,7b and 9] and the others (p = 0.193), while uncategorizable patients had significantly worse survival (p<0.0001) (Figure 1c). Conclusion The study provides insight into heart failure phenotyping in a real-world setting. Most HFrEF patients are eligible for the 4 class I drugs of HFrEF medication, and only a minority may not be able to receive them. However, nearly one-third of all patients could not be categorized, including those with the poorest survival. Given these findings, the added value of the classification of patients according to this pattern seems limited in routine practice, possibly resulting from the complexity of the clinical picture of HFrEF.Figure 1BL characteristics