Clinical characteristics and prognostic differences among acute heart failure phenotypes in the emergency department: a real-world study.

BACKGROUND: The 2021 European Society of Cardiology (ESC) guidelines classify acute heart failure (AHF) into four phenotypes: acute decompensated heart failure (ADHF), acute pulmonary oedema (APO), isolated right ventricular failure (IRVF), and cardiogenic shock (CS). However, differences in clinical characteristics and long-term outcomes among these phenotypes in the emergency department (ED) remain unclear. This study aimed to evaluate their characteristics and prognostic implications in the ED setting. METHODS: In this prospective-retrospective observational real-world study, adults presenting with AHF in the ED were consecutively enrolled and categorized according to ESC-defined phenotypes. The study endpoints were 1-year all-cause and cardiovascular mortality. Associations between phenotypes and mortality were assessed using Cox regression models with progressive adjustment. RESULTS: A total of 2,960 patients were included. Clinical characteristics and treatment patterns differed substantially across phenotypes. The 1-year all-cause mortality rates were 10.3% in ADHF, 11.0% in APO, 24.5% in IRVF, and 58.7% in CS (P < 0.001). In multivariable Cox analyses adjusting for clinical variables and treatments, IRVF remained independently associated with increased risks of all-cause mortality (HR 1.92, 95% CI 1.02-3.63; P = 0.044) and cardiovascular mortality (HR 2.22, 95% CI 1.10-4.48; P = 0.027). CS was also independently associated with higher risks of all-cause mortality (HR 2.22, 95% CI 1.34-3.67; P = 0.002) and cardiovascular mortality (HR 2.71, 95% CI 1.57-4.66; P < 0.001). CONCLUSIONS: In this ED-based AHF cohort, IRVF and CS were independently associated with worse 1-year outcomes, supporting phenotype-based risk stratification in the ED.