Electrocardiographic Predictors of Heart Failure With Reduced Versus Preserved Ejection Fraction: The Multi‐Ethnic Study of Atherosclerosis

Background Several markers detected on the routine 12‐lead ECG are associated with future heart failure events. We examined whether these markers are able to separate the risk of heart failure with reduced ejection fraction ( HF r EF ) from heart failure with preserved ejection fraction ( HF p EF ). Methods and Results We analyzed data of 6664 participants (53% female; mean age 62±10 years) from MESA (Multi‐Ethnic Study of Atherosclerosis) who were free of cardiovascular disease at baseline (2000–2002). A competing risks analysis was used to compare the association of several baseline ECG predictors with HF r EF and HF p EF detected during a median follow‐up of 12.1 years. A total of 127 HF r EF and 117 HF p EF events were detected during follow‐up. In a multivariable adjusted model, prolonged QRS duration, delayed intrinsicoid deflection, left‐axis deviation, right‐axis deviation, prolonged QT interval, abnormal QRS ‐T axis, left ventricular hypertrophy, ST /T‐wave abnormalities, and left bundle‐branch block were associated with HF r EF . In contrast, higher resting heart rate, abnormal P‐wave axis, and abnormal QRS ‐T axis were associated with HF p EF . The risk of HF r EF versus HF p EF was significantly differently for delayed intrinsicoid deflection (hazard ratio: 4.90 95% confidence interval ( CI ), 2.77–8.68 versus 0.94 95% CI , 0.29–2.97; comparison P =0.013), prolonged QT interval (hazard ratio: 2.39 95% CI , 1.55–3.68 versus 0.52 95% CI , 0.23–1.19; comparison P <0.001), and ST /T‐wave abnormalities (hazard ratio: 2.47 95% CI , 1.69–3.62 versus 1.13 95% CI , 0.72–1.77; comparison P =0.0093). Conclusions Markers of ventricular repolarization and delayed ventricular activation are able to distinguish between the future risk of HF r EF and HF p EF . These findings suggest a role for ECG markers in the personalized risk assessment of heart failure subtypes.