Key result
LVEF <40% linked to ~20.5-fold higher all-cause mortality vs LVEF 40–50% in end-stage HCM.
Why the study?
The traditional definition of end-stage HCM using an LVEF cut-off below 50% may oversimplify the continuum of systolic dysfunction and fail to accurately capture its prognostic significance for long-term all-cause mortality.
Does an LVEF cut-off point of <40% improve the prediction of long-term all-cause mortality compared to an LVEF of 40–50% in patients with end-stage hypertrophic cardiomyopathy?
Cohort (n=691)
Yes
Does an LVEF cut-off point of <40% improve the prediction of long-term all-cause mortality compared to an LVEF of 40–50% in patients with end-stage hypertrophic cardiomyopathy?
In end-stage hypertrophic cardiomyopathy with systolic dysfunction, an LVEF cut-off of 40% identifies a subgroup at substantially higher risk of long-term all-cause mortality compared to the traditional 50% threshold.
LVEF <40% may identify higher-risk end-stage HCM patients for intensified monitoring; hypothesis-generating and requires prospective validation before changing practice.
Introduction In hypertrophic cardiomyopathy (HCM), end-stage stage is traditionally defined by a left ventricular ejection fraction (LVEF) below 50%. This cut-off point is widely used and supported by observational data linking it to increased mortality. However, this binary definition may oversimplify the continuum of systolic dysfunction and fail to accurately capture its prognostic significance. We aim to determine the optimal LVEF cut-off point for predicting long-term all-cause mortality in a large cohort of end-stage HCM patients. Methods All patients referred for cardiovascular magnetic resonance (CMR) assessment of HCM at three French university hospitals between 2008 and 2024 were retrospectively screened. All patients with HCM and LVEF <50% were included. The primary endpoint was all-cause mortality using the National Registry of Death. A conditional inference tree (C-Tree) and Youden index method were applied to identify the optimal cut-off point of LVEF for predicting all-cause mortality. A propensity score matching approach was applied to optimize covariate balance between groups, ensuring standardized mean differences <0.1. Cox proportional hazards models were used both before and after propensity score matching, as well as after adjustment for traditional prognostic factors. A restricted cubic spline model assessed the continuous relationship between LVEF and all-cause mortality, adjusted for covariates used in the Cox model. Results Among 2,873 eligible patients with HCM, we included 691 patients (mean age 53 ± 7 years, 54% male) with a LVEF <50% for the study. The optimal cut-off point of LVEF for predicting all-cause mortality was 40% with both methods. Among those, 492 patients had a LVEF of 40–50%, and 199 a LVEF <40%. The patients with LVEF < 40% had more advanced structural and functional abnormalities: larger LV end-diastolic volumes (LVEDV indexed 99 ±11 vs 83 ±7 mL/m², p<0.001), higher prevalence of right ventricular dysfunction (28% vs 5%, p<0.001), and greater presence (66% vs 26%) and extent (2.4 ± 1.9 vs 0.6 ± 1.2 segments; p<0.001) of late gadolinium enhancement (LGE). After propensity score matching, two groups of 191 patients were obtained, with comparable baseline characteristics. After a median follow-up of 9 years (IQR 6–11), 226 patients died (32%). After adjustment for traditional prognostic factors, a LVEF value <40% was strongly associated with increased mortality before and after propensity score matching (HR: 23.6 [95% CI: 14.6–38.1]; p<0.001 and HR: 20.5 [95% CI: 12.4-33.9], p<0.001 respectively) (Figure 1). Annualized mortality rate was strongly higher with LVEF<40% (15.1 versus 0.7, p<0.001). Conclusion In this large multicenter cohort of end-stage HCM patients, a LVEF cut-off point of 40% delineated a subgroup with substantially increased mortality, which remained significant after adjustment for traditional prognostic factors and was confirmed following propensity score matching.Figure 1Figure 2
No takes yet. Share an insight, caveat, or question.
Hudelo et al. (2026) conducted a cohort in End-stage hypertrophic cardiomyopathy with systolic dysfunction (n=691). LVEF <40% vs. LVEF 40-50% was evaluated on All-cause mortality (HR 20.5, 95% CI 12.4-33.9, p=<0.001). An LVEF <40% in end-stage HCM strongly increased all-cause mortality vs LVEF 40-50% after propensity matching (HR 20.5; 95% CI 12.4-33.9; p<0.001; annualized rate 15.1% vs 0.7%).
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: