Patients with newly diagnosed heart failure may experience different outcomes depending on ejection fraction phenotype, but prospective comparative data remain limited. A prospective cohort analysis from the Stockholm PREFERS study, published in ESC Heart Failure, evaluated long-term outcomes in patients with new-onset heart failure managed in specialized heart failure clinics, stratified by ejection fraction into heart failure with preserved ejection fraction (HFpEF), mildly reduced ejection fraction (HFmrEF), and reduced ejection fraction (HFrEF).

Between 2015 and 2019, the analysis included 547 patients, comprising 135 with HFpEF (25%), 61 with HFmrEF (11%), and 351 with HFrEF (64%). Mean ages were 76, 71, and 67 years, respectively, and median baseline ejection fraction values were 55%, 45%, and 30% across groups (p<0.001).

The primary outcome was time to cardiovascular (CV) mortality or first heart failure hospitalization (HFH), with secondary outcomes including all-cause mortality, CV mortality, and HFH. Over a median follow-up of 3.8 years (interquartile range 3.0-4.7), HFpEF was associated with a higher risk of the primary outcome compared with HFmrEF and HFrEF combined (unadjusted HR 2.2; 95% CI 1.5-3.1; p<0.001; adjusted HR 1.7; 95% CI 1.1-2.9; p<0.05). Overall event rates were 12.8% for all-cause mortality, 9.1% for CV mortality, and 12.3% for HFH.

At 1 year, NT-proBNP decreased by 42% in HFmrEF (p<0.05) and 55% in HFrEF (p<0.001), accompanied by ejection fraction increases of 2 and 16 percentage points, respectively. In contrast, HFpEF showed a 5 percentage point reduction in ejection fraction with no change in NT-proBNP.

These findings show that HFpEF is associated with less favorable long-term outcomes compared with HFmrEF and HFrEF, highlighting an ongoing need for more effective management strategies in this population.