Diastolic Determinants of Excess Mortality in Heart Failure With Reduced Ejection Fraction

Giovanni Benfari, Wayne L. Miller, Clémence Antoine, Andrea Rossi, G. Lin, J. K. Oh, Veronique L. Roger, Prabin Thapa, Maurice Enriquez-Sarano

Research output: Contribution to journalArticlepeer-review

19 Scopus citations


Objectives: The objective of this study was to determine short- and long-term excess mortality associated with diastolic echocardiographic measures (primarily E/e′ ratio) in patients with HF with reduced ejection fraction. Background: In patients with heart failure (HF), Doppler echocardiography diastolic alterations are frequently but not convincingly linked to survival. Consequently, they are not included in risk-score algorithms or substantially mentioned in HF guidelines. Methods: Consecutive patients with HF Stage B to C, diagnosed between 2003 and 2011, with ejection fraction <50%, Doppler diastolic characterization, complete clinical evaluation, and estimated pulmonary pressure, were analyzed. Outcome measure was mortality under medical management. Results: The 12,421 eligible patients were 69 ± 14 years of age, 32% were women, 72% had Stage C HF, with ejection fraction 36 ± 10% and E/e′ ratio of 17 ± 9. During median follow-up 4.0 (1.1 to 7.0) years, 1-year and 5-year mortality were 17 ± 0.4% and 42 ± 0.5%. E/e′ ratio >20 was linked to elevated 1-year mortality (adjusted odds ratio: 1.45 [95% confidence interval (CI): 1.16 to 1.83]; p = 0.001). Long-term E/e′ ratios >20 and >14 to 20 were associated with reduced survival (adjusted hazard ratio: 1.21 [95% CI: 1.07 to 1.37]; p = 0.003, and adjusted hazard ratio: 1.15 [95% CI: 1.02 to 1.29]; p = 0.02), independent of all HF characteristics and in all patients’ subsets, including HF Stage B and Stage C. Guideline-based diastolic-grade algorithm also independently predicted mortality (p < 0.0001) but was definable less frequently (70%). Conclusions: In reduced ejection fraction HF, diastolic Doppler alterations entail considerable mortality independent of all presentation characteristics. Elevated E/e′ ratio, associated with worse HF at diagnosis, is also, independent of presentation, linked to substantial short-term reduced survival and long-term sustained excess mortality and should be incorporated into HF risk assessment.

Original languageEnglish (US)
Pages (from-to)808-817
Number of pages10
JournalJACC: Heart Failure
Issue number9
StatePublished - Sep 2019


  • diastolic function
  • heart failure
  • left ventricular dysfunction

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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