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

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. 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. 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). 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.