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Heart failure in the U.S. over the past 30 years has been marked by a shift in phenotype, with those showing reduced ejection fraction enjoying a better prognosis than before, researchers said.

Over three decades in the Framingham Heart Study, participants without clinical heart failure became less likely to have left ventricular (LV) systolic dysfunction (2.2% in 2005-2014 versus 3.38% in 1985-1994, P<0.0001) and showed a higher average LV ejection fraction (68% vs 65%, P<0.001).

During the same time, preserved ejection fraction (HFpEF, ≥50%) (HFrEF, <40%) among patients with new-onset heart failure. The proportion of the former rose from 41.0% to 56.2% (P<0.001) and the latter dropped from 44.1% to 31.06% (P=0.002), according to Ramachandran S. Vasan, MD, of Boston University School of Medicine, and colleagues,.

Meanwhile, the proportion of heart failure patients with mid-range LV ejection fraction (HFmrEF) remained stable (14.93% versus 12.77%, P=0.66), they wrote online in JACC: Cardiovascular Imaging.

HFrEF patients were less likely to suffer cardiovascular mortality during 2005-2014 versus 1985-1994 (HR 0.61, 95% CI 0.39-0.97).

"The decline in cardiovascular mortality for HFrEF over the decades suggests the effectiveness of evidence-based management strategies. In comparison, the prognosis of HFmrEF and HFpEF remained unchanged, underscoring the importance of ongoing trials of ," Vasan's group said.

They determined that trends in risk factors -- in particular, the falling prevalence of coronary heart disease in patients with heart failure -- explained 47% of the improvement in ejection fraction among those without heart failure and 75% of HFpEF newfound prominence.

"The consistent reports of increasing HFpEF prevalence among heart failure in-patients from 1987-2001, among a mixed in- and out-population from 2000-2010, and now for community-dwelling out-patients with newly diagnosed heart failure from 1985-2014 all represent the changing face of heart failure," commented James E. Udelson, MD, of Tufts Medical Center in Boston.

In an , he said that these findings underline the importance of finding therapies for this growing group.

"As some have noted, this effort may require more informed pathophysiologic phenotyping to enable better in order to improve outcomes," he continued. "A complimentary or alternative approach would focus therapeutic efforts more prominently on symptoms of everyday life and functional capacity, ensuring safety but not focusing on long-term outcomes."

The authors' Framingham Heart Study dataset included patients with new-onset heart failure (n=894, mean age 75, 52% women) and people without heart failure (n=12,857, mean age 53, 56% women).

For this analysis, Vasan's group defined LV systolic dysfunction as having an ejection fraction less than 50%. That LV systolic dysfunction was tied to a two to four times greater risk of heart failure and death was unchanged over time.

Among its limitations are the possible misclassification of LV ejection fraction and the predominantly white study cohort.

"There are substantial strengths to the analysis, including the decades long consistent capture of data in one of the world's leading long-term epidemiologic studies, and the consistent application of their diagnostic criteria for heart failure, which the Framingham study investigators have validated over time," Udelson maintained.