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Comorbidity Burden for HFpEF, HFrEF on the Rise Among Women and Men


Evidence may support a greater comorbidity burden among patients with heart failure with preserved ejection fraction (HFpEF) or reduced ejection fraction (HFrEF), although this finding was shown to be worse among women with HFpEF.

Evidence may support a greater comorbidity burden among patients with heart failure with preserved ejection fraction (HFpEF; ejection fraction >50%) or reduced ejection fraction (HFrEF; ejection fraction <50%), although this finding was shown to be worse among women with HFpEF, according to study results appearing in a recent issue of the journal Circulation.

"The medical complexity of patients hospitalized with HFpEF and HFrEF appears to be increasing over time," Melissa Caughey, PhD, an epidemiologist and instructor in the UNC/NC State Joint Department of Biomedical Engineering, and senior author of the study, said in a statement announcing the findings. “This finding is consistent with the hypothesis that the epidemiology of heart failure is evolving—shifting from an ischemic etiology to more of a multi-morbidity heart failure over time.”

Caughey and her fellow authors used data from the Atherosclerosis Risk in Communities (ARIC) study on 5460 patients with 24,937 weighted hospitalizations who had discharge dates between January 1, 2005, and December 31, 2014, in order to fill a knowledge gap they saw in better comprehending trends in acute decompensated heart failure to guide future management of the disease.

Most patients (53%) were female, white (68%), and had HFrEF (53%). All were at least 55 years old, with a mean age of 75 years. Information on the following 15 comorbidities were extracted from medical records: coronary artery disease, peripheral artery disease, hypertension, pulmonary hypertension, atrial fibrillation, stroke/transient ischemic attack, valvular heart disease, body mass index, diabetes, serum creatinine, chronic obstructive pulmonary disease (COPD), sleep apnea, depression, anemia, and thyroid disease.

Results show that HFpEF presented with more comorbidities than HFrEF, for both the women (5.53 vs 4.94; P < .0001) and the men (5.20 vs 4.82; P < .0001) in the study. In addition, between the 2005-2009 and 2010-2013 periods, the authors found temporal increases (P < .0001 for all) in the overall comorbidity burden of both sex for both heart failure types, but this was deemed more significant for the women:

  • HFpEF:
    • Women: 5.17 to 5.87
    • Men: 4.94 to 5.45
  • HFrEF:
    • Women: 4.78 to 5.14
    • Men: 4.62 to 5.06

Findings also show that for every additional comorbidity, there was a 19% increase to the 1-year adjusted mortality risk for HFpEF (HR, 1.19; 95% CI, 1.14-1.25) and a 10% increase for patients with HFrEF (HR, 1.10; 95% CI, 1.05-1.14; P for interaction by heart failure type = .02).

The associated mortality risk per additional comorbidity was also deemed significant for 2005-2009 vs 2010-2013, respectively for HFpEF (1.07; 95% CI, 0.99-1.16 vs 1.26; 95% CI, 0.99-1.16; P for interaction by half-decade = .002). and HFrEF (1.06; 95% CI, 0.99-1.12 vs 1.15; 95% CI, 1.09-1.22; P for interaction by half-decade = .02).

For coronary artery disease especially, both women and men hospitalized with HFpEF between 2005 and 2014 had fewer instances of the conditions compared with those with HFrEF. However, there remained more instances of COPD/bronchitis, sleep apnea, and anemia.

For hospitalizations, women with HFrEF compared with those who had HFpEF had longer stays, 9 vs 8 days (P = .03), while this measure was similar for both patient groups among the men, at 9 days each (P = .6).

“Taken together, our study findings provide insights into the distinct temporal trends and prognostic implications of overall and individual comorbidities in patients with acute decompensated HFpEF and HFrEF,” the authors concluded. “Future studies are needed to better understand the biological mechanisms that may drive the observed sex differences in mortality risk associated with HFpEF versus HFrEF.”


Pandey A, Vaduganathan M, Arora S, et al.Temporal trends in prevalence and prognostic implications of comorbidities among patients with acute decompensated heart failure: the ARIC Study Community Surveillance. Circulation. 2020;142(3):230-243. doi:10.1161/CIRCULATIONAHA.120.047019

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