Routinely reported ejection fraction and mortality in clinical practice: where does the nadir of risk lie?

Author:

Wehner Gregory J1ORCID,Jing Linyuan23,Haggerty Christopher M23ORCID,Suever Jonathan D23ORCID,Leader Joseph B3,Hartzel Dustin N3ORCID,Kirchner H Lester3,Manus Joseph N A3,James Nick4ORCID,Ayar Zina5,Gladding Patrick4,Good Christopher W6,Cleland John G F7ORCID,Fornwalt Brandon K2368

Affiliation:

1. Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA

2. Department of Imaging Science and Innovation, Geisinger, Danville, PA, USA

3. Biomedical and Translational Informatics Institute, Geisinger, Danville, PA, USA

4. Department of Cardiology, Waitemata District Health Board, Auckland, New Zealand

5. Clinical Informatics Service, Waitemata District Health Board, Auckland, New Zealand

6. Heart Institute, Geisinger, Danville, PA, USA

7. Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow and National Heart & Lung Institute, Imperial College London, London, UK

8. Department of Radiology, Geisinger, 100 North Academy Avenue, Danville 17822-4400, PA, USA

Abstract

Abstract Aims We investigated the relationship between clinically assessed left ventricular ejection fraction (LVEF) and survival in a large, heterogeneous clinical cohort. Methods and results Physician-reported LVEF on 403 977 echocardiograms from 203 135 patients were linked to all-cause mortality using electronic health records (1998–2018) from US regional healthcare system. Cox proportional hazards regression was used for analyses while adjusting for many patient characteristics including age, sex, and relevant comorbidities. A dataset including 45 531 echocardiograms and 35 976 patients from New Zealand was used to provide independent validation of analyses. During follow-up of the US cohort, 46 258 (23%) patients who had undergone 108 578 (27%) echocardiograms died. Overall, adjusted hazard ratios (HR) for mortality showed a u-shaped relationship for LVEF with a nadir of risk at an LVEF of 60–65%, a HR of 1.71 [95% confidence interval (CI) 1.64–1.77] when ≥70% and a HR of 1.73 (95% CI 1.66–1.80) at LVEF of 35–40%. Similar relationships with a nadir at 60–65% were observed in the validation dataset as well as for each age group and both sexes. The results were similar after further adjustments for conditions associated with an elevated LVEF, including mitral regurgitation, increased wall thickness, and anaemia and when restricted to patients reported to have heart failure at the time of the echocardiogram. Conclusion Deviation of LVEF from 60% to 65% is associated with poorer survival regardless of age, sex, or other relevant comorbidities such as heart failure. These results may herald the recognition of a new phenotype characterized by supra-normal LVEF.

Funder

National Institutes of Health Early Independence Award

National Institutes of Health

Pennsylvania Department of Health

Publisher

Oxford University Press (OUP)

Subject

Cardiology and Cardiovascular Medicine

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