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This is a Observational study (also classified as: Pre-Registered Trial).

August 22, 2025Open Access

Coronary Chronic Total Occlusions Affect Long‐Term Prognosis in Heart Failure With Mildly Reduced Ejection Fraction

MBMichael BehnesInterventional Cardiology MSMoritz SchmidbergerHeidelberg University KMKambis MashayekhiInterventional / Structural Cardiology

Key Points

Patients with coronary chronic total occlusions showed a 33% rate of long-term all-cause mortality, indicating a severe outcome.
In a consecutive cohort of 1,545 patients, 17% had at least 1 coronary chronic total occlusion, with significant implications for treatment decisions.
Analysis based on invasive coronary angiography revealed a higher risk of major adverse cardiac events in patients with chronic total occlusions compared to those without.
Successful percutaneous coronary intervention was linked to improved survival rates for heart failure patients with chronic total occlusions.

Abstract

Background This study investigates the prevalence and prognostic impact of coronary chronic total occlusions (CTO) in patients with heart failure with mildly reduced ejection fraction (HFmrEF). Although coronary artery disease represents the leading cause of HFmrEF, data about CTO in this population are rare. Methods All consecutive patients with HFmrEF (ie, left ventricular ejection fraction 41%–49% with signs and/or symptoms of heart failure) undergoing invasive coronary angiography from 2016 to 2022 were included retrospectively. Patients with at least 1 CTO were compared with patients with no CTO, further risk stratification was performed according to the extend of coronary artery disease. The primary end point was long‐term all‐cause mortality at 30 months (ie, median follow‐up). Secondary end points comprised the risks of major adverse cardiac and cerebrovascular events, as well as heart failure‐related and cardiac rehospitalization at 30 months. Furthermore, the association of percutaneous coronary intervention with long‐term outcomes was investigated. Results Seventy‐one percent of patients with HFmrEF (1545/2184, primary cohort) underwent invasive coronary angiography. In patients undergoing invasive coronary angiography during index hospitalization, the rate of coronary artery disease was 81% (836/1037, final cohort), and at least 1 CTO was present in 17% (n=141). The presence of a CTO was associated with the highest rate of the primary end point (33%) compared with non‐CTO (19%), single‐vessel (12%) and multivessel coronary artery disease (21%) in HFmrEF ( P =0.001). Accordingly, HFmrEF patients with CTO had the highest rates of long‐term major adverse cardiac and cerebrovascular events compared with patients without CTO (60% versus 32%, P =0.001). Successful CTO‐percutaneous coronary intervention was associated with improved long‐term survival (21% versus 38%; hazard ratio, 0.49 95% CI, 0.24–0.99; P =0.046). Conclusions Coronary CTO are common in patients with HFmrEF and significantly impair long‐term prognosis. Registration URL: https://www.clinicaltrials.gov ; unique identifier: NCT0560339.

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