Functional class and comorbidity drive health status in ambulatory older adults with heart failure
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Aims
Heart failure (HF) management in older adults is complicated by cardiac decline, comorbidities and frailty. Current practice categorises patients by left ventricular ejection fraction (LVEF) into heart failure with reduced ejection fraction (HFrEF), mildly reduced ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF). However, LVEF frequently shows weak relationships with patient symptoms and functional limitations. We examined associations among patient-reported health status as measured by the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12), New York Heart Association (NYHA) functional classes and comorbidity burdens across HF phenotypes.
Methods
This cross-sectional study included 150 older patients (median age: 75 years) with chronic HF recruited from a tertiary centre in Vietnam between August 2024 and March 2025. The patients were categorised by LVEF as HFrEF (n = 54), HFmrEF (n = 23) or HFpEF (n = 73). We assessed KCCQ-12 scores; NYHA class; frailty, using the Clinical Frailty Scale; and comorbidity burden, using the Charlson Comorbidity Index (CCI). Multivariable linear regression identified independent predictors of KCCQ-12 scores, adjusting for age, sex, NYHA class, CCI, heart rate, N-terminal pro-B-type natriuretic peptide (NT-proBNP), smoking status, sodium-glucose cotransporter-2 inhibitor (SGLT2i) use and HF phenotype.
Results
HF disease burdens were similar across phenotypes, with no significant differences in median KCCQ-12 scores (HFrEF: 70.3; HFmrEF: 72.4; HFpEF: 66.1; p = 0.494), NYHA class distribution (p = 0.138) or frailty rates (p = 0.243). Multivariable analysis revealed that higher comorbidity burdens (CCI: β coefficient -2.36, 95% confidence interval [CI] -3.03 to -1.69; p < 0.001) and worse NYHA class (Class III vs. I: β -25.74, 95% CI -29.33 to -22.16; p < 0.001) strongly predicted lower KCCQ-12 scores, whilst LVEF-based phenotypes did not (HFmrEF vs. HFrEF: β −1.35, p = 0.465; HFpEF vs. HFrEF: β 0.86, p = 0.550). SGLT2i use was independently associated with 3.89-point higher KCCQ-12 scores (95% CI 1.30 to 6.48; p = 0.003). The model explained 85% of the variance in health status (R 2 = 0.851).
Conclusions
In older adults with HF, patient-reported disease burdens were similar across LVEF-based phenotypes and more strongly associated with functional limitations and comorbidities. These findings support patient-centred approaches prioritising comprehensive assessments of functional capacity and comorbidity burdens over LVEF-based classification in geriatric HF management.
