Associations between rapid renal function decline and prior cardiovascular events in patients with heart failure and preserved ejection fraction: insights from the PURSUIT-HFpEF registry

Introduction Renal function declines with age, and its impairment is associated with adverse clinical outcomes. While individual renal function trajectories vary, the mechanisms driving this decline beyond baseline characteristics remain unclear. Recurrent cardiovascular events may accelerate renal deterioration. Purpose To investigate the natural decline of renal function and its association with prior cardiovascular events in patients with heart failure and preserved ejection fraction (HFpEF). Methods This study analyzed data from the PURSUIT-HFpEF registry, a prospective multicenter observational registry for HFpEF conducted in the Osaka region of Japan. Of 1,238 patients hospitalized for acute heart failure and left ventricular ejection fraction (LVEF) of ≥50%, we included 862 patients (age, 80 ± 9 years; men, 46%; atrial fibrillation, 37%) whose laboratory data were available at both discharge and 1-year follow-up. The annual percentage change in the estimated glomerular filtration rate (eGFR) was calculated, and risk factors for rapid eGFR decline were examined. Results Over 1 year, eGFR declined significantly from 43.7 ± 18.7 to 40.1 ± 18.4 ml/min/1.73m2 (p<0.001), with a median change of -8.4% (interquartile range: -20.6% to 8.7%). Patients in the lowest quartile of annual eGFR change were classified as having rapid eGFR decline. These patients had higher baseline eGFR and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels and experienced cardiovascular hospitalizations more frequently within 1 year than those without rapid eGFR decline (41.7% vs. 32.0%, p=0.010). Even after adjustment for age, sex, body mass index, LVEF, left atrial diameter, LV filling pressure, hemoglobin, baseline eGFR, NT-proBNP levels, sodium-glucose transporter-2 inhibitor use, and diuretic use, cardiovascular hospitalizations remained an independent predictor of rapid eGFR decline (odds ratio 1.67, 95% confidence interval 1.14-2.46, p=0.009). Conclusions Renal function decline was heterogeneous in patients with HFpEF. Recurrent cardiovascular hospitalizations independently predicted subsequent rapid eGFR decline, suggesting that cardiovascular events accelerate the trajectory of renal dysfunction in this population.