Congestion Phenotypes in Elderly Patients with Acute Heart Failure: Distinct Patterns in Preserved vs. Reduced Ejection Fraction

Background Congestion is the main driver of worsening acute heart failure (AHF), yet whether congestion phenotypes differ by left ventricular ejection fraction (LVEF) in the elderly remains uncertain. This study aimed to characterize clinical, echocardiographic, and biomarker congestion profiles by LVEF phenotype (HFpEF ≥ 50% vs. HFrEF < 50%) in older patients hospitalized with AHF and to examine their associations with prognosis. Methods We conducted a retrospective cohort study of 830 consecutive patients admitted with AHF. Congestion was assessed clinically, by echocardiography, and through biomarkers (BNP, CA125) and point-of-care ultrasound. Outcomes included HF rehospitalization and all-cause mortality over a median follow-up of 310 days (IQR 62–543). Cox models adjusted for multiple variables. Results Median age was 87 years, 65.6% were women, and 81.7% had HFpEF. Traditional congestion signs and NYHA class were similar across phenotypes. HFrEF showed greater structural and functional remodeling, while diastolic indices and ultrasound congestion markers were comparable. BNP and CA125 concentrations were significantly higher in HFrEF. Overall, 301 patients (36.3%) were rehospitalized and 418 (50.4%) died. LVEF phenotype was not associated with rehospitalization or mortality. As a continuous variable, LVEF showed a modest positive association with rehospitalization (HR 1.013 per 1%; p = 0.019), but was unrelated to mortality. Conclusions In very elderly patients hospitalized with AHF, HFpEF predominated and exhibited distinct biomarker and echocardiographic patterns despite similar clinical congestion. Prognosis was not determined by EF category but was mainly driven by age and congestion and myocardial stress biomarkers (CA125, BNP), with higher LVEF independently predicting rehospitalization.