Objective: This study aims to investigate the prevalence and prognostic impact of coronary chronic total occlusions (CTO) in patients hospitalized due to heart failure with mildly reduced ejection fraction (HFmrEF). 

Background: There is limited data regarding the prevalence and prognostic impact of CTO in patients with HFmrEF.

Methods: A large retrospective registry was used including all consecutive hospitalized patients with HFmrEF (i.e., left ventricular ejection fraction (LVEF) 41 – 49%) undergoing coronary angiography (CA) from 2016 to 2022 according to current European guidelines. The prognostic impact of patients suffering from CTO was compared to patients without (non-CTO). The primary endpoint was the first cardiovascular re-hospitalization at 36 months. Secondary endpoints comprised heart failure related re-hospitalization and in-hospital mortality. Kaplan-Meier, uni- and multivariable Cox regression analyses were applied for statistics.

Results: From a total of 803 HFmrEF patients, the rate of CA was 39%. The prevalence of CTO was 11% (right coronary artery (RCA) 53%, left anterior descending (LAD) 19%, left circumflex (LCX) 8% and multiple vessel CTO 19%). The rate of CTO-PCI was 36%. HFmrEF patients with at least one CTO were associated with an increased risk of cardiovascular re-hospitalization compared to non-CTO patients (36% vs. 22%; p=0.034; HR=1.883; 95% CI 1.037 – 3.420; p=0.038), which was still significant after multivariable adjustment (HR=2.066; 95% CI 1.053 – 4.054; p=0.035). In contrast, CTO patients were not associated with higher rates of heart failure related re-hospitalization (14% vs 7%; p=0.130; HR=2.091; 95% CI 0.788-5.545; p=0.138) and in-hospital mortality (3% vs 1% ; p=0.509).
Conclusions: HFmrEF patients revealed a lower rate of CA with an according lower rate of CTO of 11% still associated with a higher risk of cardiovascular re-hospitalization.