Acute Heart Failure Across the Ejection Fraction Spectrum: Phenotypes, Management, and Outcomes From Nationwide KorHF III Registry

Figures

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  Figure 1. Study flow and phenotype classification. This flow diagram summarizes enrollment, exclusions, and the analytic cohort with available LVEF, followed by classification into HFrEF, HFmrEF, and HFpEF. It details the number of patients assessed, included, and assigned to each phenotype for subsequent analyses. LVEF = left ventricular ejection fraction; HFrEF = heart failure with reduced ejection fraction; HFmrEF = heart failure with mildly reduced ejection fraction; HFpEF = heart failure with preserved ejection fraction; KorHF III = Korean Heart Failure III.

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  Figure 2. Phenotype-specific features at presentation. Panel (A) shows the distribution of HF phenotypes in the analytic cohort. Panels (B) and (C) display etiologic and aggravating factors by phenotype, highlighting more dilated/ischemic causes in HFrEF and greater valvular/hypertensive and tachycardia-related patterns in HFpEF, with acute coronary syndrome frequently precipitating decompensation in HFrEF/HFmrEF. HF = heart failure; HFrEF = heart failure with reduced ejection fraction; HFpEF = heart failure with preserved ejection fraction; HFmrEF = heart failure with mildly reduced ejection fraction; DCMP = dilated cardiomyopathy; IHD = ischemic heart disease; ACS = acute coronary syndrome.

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  Figure 3. Use of key HF medications at admission and discharge by phenotype. Stacked bars depict the use of key heart failure medications admission and discharge, showing overall increases driven mainly by HFrEF, modest gains in HFmrEF, and minimal change in HFpEF. SGLT2i uptake remained low compared with RAAS inhibitors, beta-blockers, and MRAs, particularly in HFpEF. HF = heart failure; HFrEF = heart failure with reduced ejection fraction; HFmrEF = heart failure with mildly reduced ejection fraction; HFpEF = heart failure with preserved ejection fraction; SGLT2i = sodium–glucose cotransporter-2 inhibitor; RAAS = renin–angiotensin–aldosterone system; MRA = mineralocorticoid receptor antagonist; ARNI = angiotensin receptor–neprilysin inhibitor; ACEi = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BB = beta-blocker.

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  Figure 4. IPTW-adjusted KM survival curves for the primary composite outcome. KM curves show the cumulative incidence of the primary composite outcome (all-cause mortality or heart transplantation) according to heart failure phenotype after IPTW adjustment. HRs and 95% confidence intervals were derived from weighted Cox proportional-hazards models with HFrEF as the reference group. IPTW = inverse probability of treatment weighting; KM = Kaplan-Meier; HR = hazard ratio; HFrEF = heart failure with reduced ejection fraction; HFmrEF = heart failure with mildly reduced ejection fraction; HFpEF = heart failure with preserved ejection fraction; HF = heart failure.

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  Figure 5. Phenotype-specific multivariable predictors for 12-month post-discharge primary composite outcome. Forest plots display adjusted associations for in-hospital and 12-month post-discharge outcomes, modeled separately by phenotype. Adverse markers (e.g., hyponatremia, CKD, congestion, low BMI in HFpEF) contrast with protective associations for discharge therapies (ACEi/ARB, ARNI, BBs), with effect sizes shown as HRs with 95% CIs. CKD = chronic kidney disease; BMI = body mass index; HFpEF = heart failure with preserved ejection fraction; ACEi = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; ARNI = angiotensin receptor–neprilysin inhibitor; BB = beta-blocker; HR = hazard ratio; CI = confidence interval; HFrEF = heart failure with reduced ejection fraction; ADHF = acute decompensated heart failure; SBP = systolic blood pressure; RV = right ventricular; COPD = chronic obstructive pulmonary disease; ECG = electrocardiogram; CMP = cardiomyopathy; HFmrEF = heart failure with mildly reduced ejection fraction.