What is the incidence of heart failure with preserved ejection fraction (HFpEF) versus heart failure with reduced ejection fraction (HFrEF) in breast cancer survivors compared to non-cancer controls?

Background Breast cancer survivors face elevated cardiovascular risks, yet the differential burden of heart failure with preserved ejection fraction (HFpEF) versus heart failure with reduced ejection fraction (HFrEF) remains poorly characterized. Understanding these heart failure phenotypes is crucial for optimizing cardio-oncology care and risk stratification in this vulnerable population. Methods This retrospective cohort study analyzed data from the National Inpatient Sample (2016-2022), including 23,387,119 adult female hospitalizations. Women with breast cancer (active diagnosis or history; n=5,000,103 weighted) were compared to controls without breast cancer (n=111,935,438 weighted). Heart failure subtypes were identified using ICD-10 codes, and outcomes were assessed using survey-weighted logistic regression adjusted for age, race, hypertension, diabetes, obesity, coronary artery disease, chronic kidney disease, smoking, hyperlipidemia, chronic obstructive pulmonary disease, anemia, and Charlson Comorbidity Index. Results Breast cancer patients were older (mean age 70.9 vs. 54.9 years, p<0.001) and had higher comorbidity burden (mean Charlson score 3.14 vs. 1.62, p<0.001). HFpEF prevalence was significantly higher in breast cancer patients compared to controls (10.16% vs. 7.23%, p<0.001), with an unadjusted odds ratio (OR) of 1.45 (95% CI: 1.44-1.47). HFrEF prevalence was similarly elevated (4.73% vs. 3.20%, p<0.001; unadjusted OR 1.50, 95% CI: 1.49-1.52). Overall heart failure prevalence reached 14.87% in breast cancer patients versus 10.41% in controls (p<0.001). In-hospital mortality was significantly higher among breast cancer patients (3.13% vs. 2.11%, p<0.001; unadjusted OR 1.50, 95% CI: 1.48-1.52). Among breast cancer patients, those with heart failure demonstrated increased mortality compared to those without heart failure (4.03% vs. 2.97%, p<0.001). Breast cancer patients experienced higher rates of atrial fibrillation (20.83% vs. 12.52%, p<0.001), acute kidney injury (16.64% vs. 12.98%, p<0.001), and sepsis (9.39% vs. 7.89%, p<0.001). Mean length of stay was longer for breast cancer patients (4.82 vs. 4.54 days, p<0.001), with progressive increases observed across heart failure phenotypes: 4.67 days (no HF), 5.71 days (HFpEF), and 5.65 days (HFrEF). Conclusions Breast cancer patients exhibit substantially elevated risks of both HFpEF and HFrEF, with HFpEF demonstrating the highest prevalence. These findings show the critical need for cardiovascular surveillance in breast cancer care, particularly for heart failure prevention and early detection. The disproportionate burden of HFpEF emphasizes the importance of disease-specific management strategies in cardio-oncology practice.