Total cholesterol levels and mortality risk in nonischemic systolic heart failure

Background Prior studies have demonstrated that low serum total cholesterol (TC) is associated with increased mortality in heart failure (HF); however, this association has not been consistently observed in HF of nonischemic etiology. Methods We analyzed a cohort of 614 patients with nonischemic systolic HF (left ventricular ejection fraction [LVEF] <40%). Fasting lipid panels were drawn at time of referral. Patients were stratified into quartiles of TC (Q1 <133, Q2 134-168, Q3 169-209, and Q4 >210 mg/dL). Results The cohort was 68% male, mean age was 48 ± 13 years, and LVEF was 23% ± 7%. Patients with lower serum TC had worse hemodynamic profiles, lower LVEF, and higher New York Heart Association class. Low TC was associated with increased risk of 1-year death and urgent transplant (UT) (49%, 29%, 18%, 14% for Q1-Q4 respectively, P < .0001) as well as all-cause mortality (P < .0001). On multivariate analysis, adjusting for multiple HF prognostic factors, low TC proved to be an independent predictor of worse outcomes, with hazard ratios for death and UT of 3.4, 1.8, and 1.6 for Q1 to Q3, respectively, compared with Q4. Based on receiver operating characteristic curve analysis, the best cutoff for prediction of death and UT for TC was 161 mg/dL. Conclusions Low TC is strongly associated with increased mortality in patients with nonischemic, systolic HF. Further research is necessary to determine the nature of this relationship, optimal lipid levels, and the therapeutic role, if any, of statins in patients with established HF.