Characterization of the Progression From Ambulatory to Hospitalized Heart Failure With Preserved Ejection Fraction

Background: Heart failure (HF) with preserved ejection fraction (HFpEF) is a heterogeneous syndrome. Some patients develop elevated filling pressures exclusively during exercise and never require hospitalization, whereas others periodically develop congestion that requires inpatient treatment. The features differentiating these cohorts are unclear. Methods: We performed a secondary analysis of 7 National Institutes of Health-sponsored multicenter trials of HFpEF (EF >= 50%, N = 727). Patients were stratified by history of hospitalization because of HF, comparing patients never hospitalized (HFpEF(NH)) to those with a prior hospitalization (HFpEF(PH)). Currently hospitalized (HFpEF(CH)) patients were included to fill the spectrum. Clinical characteristics, cardiac structure, biomarkers, quality of life, functional capacity, activity levels, and outcomes were compared. Results: As expected, HFpEF(CH) (n = 338) displayed the greatest severity of congestion, as assessed by N terminal pro B-type natriuretic peptide levels, edema and orthopnea. As compared to HFpEF(NH) (n = 109), HFpEF(PH) (n = 280) displayed greater comorbidity burden, with more lung disease, renal dysfunction and anemia, along with lower activity levels (accelerometry), poorer exercise capacity (6-minute walk distance and peak exercise capacity), and more orthopnea. Patients with current or prior hospitalization displayed higher rates of future HF hospitalization, but quality of life was similarly impaired in all patients with HFpEF, regardless of hospitalization history. Conclusions: A greater burden of noncardiac organ dysfunction, sedentariness, functional impairment, and higher event rates distinguish patients with HFpEF and prior HF hospitalization from those never hospitalized. Despite lower event rates, quality of life is severely and similarly limited in patients with no history of hospitalization. These data suggest that the 2 clinical profiles of HFpEF may require different treatment strategies.