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Heart failure with midrange ejection fraction: prior left ventricular ejection fraction and prognosis

Zhang, Xinxin, Sun, Yuxi, Zhang, Yanli, Chen, Feifei, Zhang, Shuyuan, He, Hongyan, Song, Shuang, Tse, Gary, Liu, Ying (2021) Heart failure with midrange ejection fraction: prior left ventricular ejection fraction and prognosis. Frontiers in Cardiovascular Medicine, 8 . Article Number 697221. E-ISSN 2297-055X. (doi:10.3389/fcvm.2021.697221) (KAR id:98438)


Aims: Evidence-based guidelines for heart failure management depend mainly on current left ventricular ejection fraction (LVEF). However, fewer studies have examined the impact of prior LVEF. Patients may enter the heart failure with midrange ejection fraction (HFmrEF) category when heart failure with preserved ejection fraction (HFpEF) deteriorates or heart failure with reduced ejection fraction (HFrEF) improves. In this study, we examined the association between change in LVEF and adverse outcomes.

Methods: HFmrEF patients with at least two or more echocardiograms 3 months apart at the First Affiliated Hospital of Dalian Medical University between September 1, 2015 and November 30, 2019 were identified. According to the prior LVEF, the subjects were divided into improved group (prior LVEF < 40%), stable group (prior LVEF between 40 and 50%), and deteriorated group (prior LVEF ≥ 50%). The primary outcomes were cardiovascular death, all-cause mortality, hospitalization for worsening heart failure, and composite event of all-cause mortality or all-cause hospitalization.

Results: A total of 1,168 HFmrEF patients (67.04% male, mean age 63.60 ± 12.18 years) were included. The percentages of improved, stable, and deteriorated group were 310 (26.54%), 334 (28.60%), and 524 (44.86%), respectively. After a period of follow-up, 208 patients (17.81%) died and 500 patients met the composite endpoint. The rates of all-cause mortality were 35 (11.29%), 55 (16.47%), and 118 (22.52%), and the composite outcome was 102 (32.90%), 145 (43.41%), and 253 (48.28%) for the improved, stable, and deteriorated groups, respectively. Cox regression analysis showed that the deterioration group had higher risk of cardiovascular death (HR: 1.707, 95% CI: 1.064–2.739, P = 0.027), all-cause death (HR 1.948, 95% CI 1.335–2.840, P = 0.001), and composite outcome (HR 1.379, 95% CI 1.096–1.736, P = 0.006) compared to the improvement group. The association still remained significant after fully adjusted for both all-cause mortality (HR = 1.899, 95% CI 1.247–2.893, P = 0.003) and composite outcome (HR: 1.324, 95% CI: 1.020–1.718, P = 0.035).

Conclusion: HFmrEF patients are heterogeneous with three different subsets identified, each with different outcomes. Strategies for managing HFmrEF should include previously measured LVEF to allow stratification based on direction changes in LVEF to better optimize treatment.

Item Type: Article
DOI/Identification number: 10.3389/fcvm.2021.697221
Uncontrolled keywords: heart failure; mid-range ejection fraction; prior, left ventricular ejection fraction, prognosis
Subjects: R Medicine
Divisions: Divisions > Division of Natural Sciences > Kent and Medway Medical School
Funders: National Natural Science Foundation of China (
Depositing User: Gary Tse
Date Deposited: 28 Nov 2022 10:47 UTC
Last Modified: 04 Mar 2024 16:09 UTC
Resource URI: (The current URI for this page, for reference purposes)

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