Performance of the MAGGIC heart failure risk score and its modification with the addition of discharge natriuretic peptides

Overlap of frailty and malnutrition as prognosticators in older patients with heart failure

Background

Physical frailty and malnutrition coexist in older patients with heart failure (HF) and form a vicious cycle exacerbating each other and can cause poor clinical outcomes. We aimed to clarify the association of prevalence of physical frailty and malnutrition and clinical outcomes in hospitalized patients with HF.

Methods

A total of 862 hospitalized patients aged ≥65 years with HF decompensation were included in this FRAGILE-HF post-hoc sub-analysis. Patients were categorized into Neither, Either, or Both groups based on the prevalence of physical frailty and malnutrition. The primary outcome was all-cause mortality within 1 year after discharge. Prognoses among the groups were compared in the entire cohort and in subgroups with preserved ejection fraction (pEF) and reduced/mildly reduced left ventricular ejection fractions (rEF/mrEF).

Results

The Neither, Either, and Both groups comprised 32 %, 40 %, and 28 % respectively. During a 1-year follow-up period, 101 (12 %) patients died. Kaplan-Meier analysis showed significant differences in the primary outcomes among the groups (P < 0.001). The Both group had a higher risk of mortality (HR: 2.47, 95 % CI: 1.38-4.42) than the Neither group, while the Either group showed insignificant risk increase (HR: 1.58, 95 % CI: 0.86-2.90). Similar trends were observed in the pEF and rEF/mrEF subgroups (P = 0.60).

Conclusions

Physical frailty and malnutrition coexist in approximately one-quarter of hospitalized older patients with HF and are associated with an increased risk of mortality. Assessing both conditions is crucial for risk stratification and interventions to mitigate their interplay.

Ultrasound-measured Quadriceps Muscle Thickness and Mortality in Older Patients With Heart Failure

BACKGROUND

Ultrasound might be helpful for muscle mass assessment in patients with heart failure (HF). We aimed to determine the feasibility and prognostic implications of ultrasound-measured quadriceps muscle thickness (QMT) in older patients with HF.

METHODS

This was a post hoc analysis of a multicentre prospective cohort study including patients hospitalized for HF aged 65 years and older. QMT at rest and during isometric contractions using ultrasound was measured with the patient in the supine position before discharge.

RESULTS

The interobserver agreement for measuring QMT was excellent, with intraclass correlation coefficients of 0.979 (95% confidence interval [CI], 0.963-0.988) at rest and 0.997 (95% CI, 0.994-0.998) during isometric contraction. The intraobserver reproducibility was also excellent (intraclass correlation coefficient > 0.92). Of the 595 patients (median age, 81 years; 56% male), median QMT at rest and during contraction were 18.9 mm and 24.9 mm, respectively. The patients were grouped according to sex-specific tertiles of height-adjusted QMT. During the median follow-up of 735 days, 157 deaths occurred, and Kaplan-Meier curve analysis showed that the lowest tertile of the height-adjusted QMT was associated with a higher mortality. Cox proportional hazard analysis revealed that thinner height-adjusted QMT was independently associated with higher mortality, even after adjusting for conventional risk factors (per 1 mm/m increase: hazard ratio, 0.94; 95% CI, 0.89-0.99; P = 0.030 [at rest] and hazard ratio, 0.94; 95% CI, 0.90-0.99; P = 0.015 [during isometric contraction]).

CONCLUSIONS

Ultrasound-measured QMT in older patients with HF is feasible, and thinner height-adjusted QMT at rest and during isometric contraction was independently associated with higher mortality.

Prognostic Value of Borg Scale Following Six-minute Walk Test in Hospitalized Older Patients with Heart Failure

AIMS

The six-minute walk test (6MWT) is a widely accepted tool for evaluating exercise tolerance and physical capacity, and the six-minute walk distance (6MWD) is an established prognostic factor in patients with heart failure (HF). However, the prognostic implications of post-6MWT dyspnoea remain unknown. We aimed to investigate the prognostic value of Borg scores after the 6MWT in patients with HF.

METHODS

Patients hospitalized for HF who underwent the 6MWT before discharge were included. Post-test dyspnoea was assessed using the Borg scale. Patients were stratified into low and high Borg score groups based on the median Borg score. The primary outcome was 2-year mortality.

RESULTS

Among 1,185 patients analysed, the median Borg score was 12. The 6MWD was significantly shorter in the high Borg score group than in the low Borg score group. The 2-year mortality rate was 20.2%. In the Kaplan-Meier analysis, the high Borg score group demonstrated an association with 2-year mortality, which remained significant even after adjustment for conventional risk factors, including the 6MWD. Furthermore, Borg scale provided significant net reclassification improvement to the conventional risk model incorporating 6MWD.

CONCLUSION

In hospitalized patients with HF, post-6MWT Borg scores were associated with 2-year mortality independent of the 6MWD, providing incremental prognostic value to the 6MWD. Even if patients are able to walk long distances for 6 minutes, it is essential to closely observe dyspnoea immediately thereafter.

Titration of Medications After Acute Heart Failure Is Safe, Tolerated, and Effective Regardless of Risk

BACKGROUND

Guideline-directed medical therapy (GDMT) decisions may be less affected by single patient variables such as blood pressure or kidney function and more by overall risk profile. In STRONG-HF (Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure), high-intensity care (HIC) in the form of rapid uptitration of heart failure (HF) GDMT was effective overall, but the safety, tolerability and efficacy of HIC across the spectrum of HF severity is unknown. Evaluating this with a simple risk-based framework offers an alternative and more clinically translatable approach than traditional subgroup analyses.

OBJECTIVES

The authors sought to assess safety, tolerability, and efficacy of HIC according to the simple, powerful, and clinically translatable MAGGIC (Meta-Analysis Global Group in Chronic) HF risk score.

METHODS

In STRONG-HF, 1,078 patients with acute HF were randomized to HIC (uptitration of treatments to 100% of recommended doses within 2 weeks of discharge and 4 scheduled outpatient visits over the 2 months after discharge) vs usual care (UC). The primary endpoint was the composite of all-cause death or first HF rehospitalization at day 180. Baseline HF risk profile was determined by the previously validated MAGGIC risk score. Treatment effect was stratified according to MAGGIC risk score both as a categorical and continuous variable.

RESULTS

Among 1,062 patients (98.5%) with complete data for whom a MAGGIC score could be calculated at baseline, GDMT use at baseline was similar across MAGGIC tertiles. Overall GDMT prescriptions achieved for individual medication classes were higher in the HIC vs UC group and did not differ by MAGGIC risk score tertiles (interaction nonsignificant). The incidence of all-cause death or HF readmission at day 180 was, respectively, 16.3%, 18.9%, and 23.2% for MAGGIC risk score tertiles 1, 2, and 3. The HIC arm was at lower risk of all-cause death or HF readmission at day 180 (HR: 0.66; 95% CI: 0.50-0.86) and this finding was robust across MAGGIC risk score modeled as a categorical (HR: 0.51; 95% CI: 0.62-0.68 in tertiles 1, 2, and 3; interaction nonsignificant) for all comparisons and continuous (interaction nonsignificant) variable. The rate of adverse events was higher in the HIC group, but this observation did not differ based on MAGGIC risk score tertile (interaction nonsignificant).

CONCLUSIONS

HIC led to better use of GDMT and lower HF-related morbidity and mortality compared with UC, regardless of the underlying HF risk profile. (Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP testinG, of Heart Failure Therapies [STRONG-HF]; NCT03412201).

Regional Collaboration for Heart Failure Patients Certified as Needing Support or Care in Long-Term Care Insurance System

BACKGROUND

Heart failure (HF) patients with complex care needs often experience exacerbations during the transitional phase as care providers and settings change. Regional collaboration aims to ensure continuity of care; however, its impact on vulnerable patients certified as needing support or care under the Japanese long-term care insurance (LTCI) system remains unclear.

METHODS AND RESULTS

We implemented a regional collaborative program for HF patients involving 3 pillars of transitional care with general practitioners and nursing care facilities: (1) standardized health monitoring using a patient diary and identification of exacerbation warning signs; (2) standardized information sharing among care providers; and (3) standardized HF management manuals. We evaluated outcomes within 1 year of discharge for patients hospitalized with HF and referred to other facilities for outpatient follow-up in 2017-2018 before program implementation (n=110) and in 2019-2020 after implementation (n=126). Patients with LTCI frequently received non-cardiologist follow up and care services and had a higher risk of all-cause mortality and HF readmission compared with those without LTCI (P<0.05). Program implementation was significantly associated with a greater reduction in HF readmissions among patients with LTCI compared with those without (P<0.05 for interaction), although mortality rates remained unchanged.

CONCLUSIONS

A regional collaborative program significantly reduces HF readmissions in HF patients with LTCI who are at high risk of worsening HF.

Bendopnea prevalence and prognostic value in older patients with heart failure: FRAGILE-HF-SONIC-HF post hoc analysis

AIMS

This study aimed to investigate the prevalence, clinical characteristics, and prognostic value of bendopnea in older patients hospitalized for heart failure.

METHODS AND RESULTS

This post hoc analysis was performed using two prospective, multicentre, observational studies: the FRAGILE-HF (main cohort) and SONIC-HF (validation cohort) cohorts. Patients were categorized based on the presence of bendopnea, which was evaluated before discharge. The primary endpoint was 2-year all-cause mortality after discharge. Among the 1243 patients (median age, 81 years; 57.2% male) in the FRAGILE-HF cohort and 225 (median age, 79 years; 58.2% men) in the SONIC-HF cohort, bendopnea was observed in 31 (2.5%) and 10 (4.4%) patients, respectively. Over a 2-year follow-up period, all-cause death occurred in 20.8 and 21.9% of the patients in the FRAGILE-HF and SONIC-HF cohorts, respectively. Kaplan-Meier survival curves demonstrated significantly higher mortality rates in patients with bendopnea than in those without bendopnea in the FRAGILE-HF (log-rank P = 0.006) and SONIC-HF cohorts (log-rank P = 0.014). Cox proportional hazard analysis identified bendopnea as an independent prognostic factor for all-cause mortality in both the FRAGILE-HF [hazard ratio (HR) 2.11, 95% confidence interval (CI) 1.18-3.78, P = 0.012] and SONIC-HF cohorts (HR 4.20, 95% CI 1.63-10.79, P = 0.003), even after adjusting for conventional risk factors.

CONCLUSION

Bendopnea was observed in a relatively small proportion of older patients hospitalized for heart failure before discharge. However, its presence was significantly associated with an increased risk of all-cause mortality.

Prognostic Impact of Sarcopenia Assessed Using Modified Asian Working Group for Sarcopenia 2019 Criteria in Heart Failure

BACKGROUND

Sarcopenia is a substantial therapeutic target, yet the validity of risk stratification values per the latest Asian Working Group for Sarcopenia in 2019 (AWGS 2019) remains unconfirmed in patients with heart failure. We hypothesized that using the 6-minute walk test (6MWT) to assess physical performance improves risk stratification.

METHODS

The study included 832 hospitalized patients with heart failure who could walk at discharge. Sarcopenia was diagnosed using both the original AWGS 2019 criteria (AWGS 2019 model) and an alternative method in which physical performance components were replaced with the 6MWT (modified model). An < 300 m 6MWT indicated low physical performance in the modified model. The primary outcome was 2-year mortality.

RESULTS

Sarcopenia and severe sarcopenia were identified in 45 and 150 patients with the AWGS 2019 model and in 75 and 108 patients with the modified model, respectively. Over the 2-year follow-up period, 145 (17.4%) deaths occurred. Adjusted Cox proportional hazard analysis showed both sarcopenia and severe sarcopenia were significantly associated with 2-year mortality in the modified model. In the AWGS 2019 model, only severe sarcopenia was significantly related to 2-year mortality. The modified model demonstrated significant net reclassification improvement (NRI) over the AWGS 2019 model (NRI, 0.396; 95% CI, 0.214-0.578; P < 0.001).

CONCLUSIONS

In patients with heart failure who were ambulatory at discharge, sarcopenia assessment with the modified AWGS 2019 model using the 6MWT as a physical performance component improved risk stratification compared with the original AWGS 2019 model. Reconsidering the current criteria to improve risk stratification is necessary to ensure timely, appropriate treatment.

CLINICAL TRIAL REGISTRATION

UMIN000023929.

Lymphocyte-to-C-reactive protein ratio and score in patients with heart failure: Nutritional status, physical function, and prognosis

AIMS

In heart failure (HF), inflammation is linked to malnutrition and impaired physical function. In this study, we aimed to assess how novel nutritional-inflammatory markers and lymphocyte-to-C-reactive protein ratio (LCR) and score (LCS) are associated with the nutritional status, physical function, and prognosis of patients with HF.

METHODS AND RESULTS

This study was a secondary analysis of the FRAGILE-HF study, a prospective observational study conducted across 15 hospitals in Japan. We included 1212 patients (mean age, 80.2 ± 7.8 years; 513 women) hospitalized with HF, who were classified into three groups according to their LCS score: 0 (n = 498), 1 (n = 533), and 2 (n = 181). Baseline data on physical examination, echocardiography, blood test results (including lymphocyte counts and CRP levels), and oral medication usage were collected in a clinically compensated state before discharge. Nutritional status and physical function were evaluated using several indices and tests. The primary outcome of this study was all-cause death within 2 years. Univariate and multivariate linear regression analyses were performed to evaluate the associations among the nutritional status, physical function, and LCR/LCS. Patients with an LCS score of 2 were older and had a lower body mass index than those in the other two groups. Multivariate linear regression analysis revealed that lower LCR and higher LCS were independently associated with worse nutritional status, lower handgrip strength, shorter physical performance battery score, and shorter 6-min walk distance. At 2 years, all-cause death occurred in 254 patients: 86 (17.6%), 113 (21.5%), and 55 (30.9%) with LCS scores of 0, 1, and 2, respectively (P = 0.001). Cox proportional hazards analysis revealed that LCR and LCS were significantly associated with 2-year mortality even after adjusting for the conventional risk model (LCS score, 0 vs. 2: hazard ratio, 1.64; 95% confidence interval [CI]; 1.14-2.35; P = 0.007; log-transformed LCR: hazard ratio, 0.88; 95% CI, 0.81-0.95; P = 0.002). LCR yielded additional prognostic predictability compared with the conventional risk model (continuous net reclassification improvement, 0.153; 95% CI, 0.007-0.299; P = 0.041).

CONCLUSIONS

LCR and LCS emerge as potential predictors of nutritional status, physical function, and prognosis in older patients with HF.

Examining arterial pulsation to identify and risk-stratify heart failure subjects with deep neural network

Hemodynamic parameters derived from pulse wave analysis have been shown to predict long-term outcomes in patients with heart failure (HF). Here we aimed to develop a deep-learning based algorithm that incorporates pressure waveforms for the identification and risk stratification of patients with HF. The first study, with a case-control study design to address data imbalance issue, included 431 subjects with HF exhibiting typical symptoms and 1545 control participants with no history of HF (non-HF). Carotid pressure waveforms were obtained from all the participants using applanation tonometry. The HF score, representing the probability of HF, was derived from a one-dimensional deep neural network (DNN) model trained with characteristics of the normalized carotid pressure waveform. In the second study of HF patients, we constructed a Cox regression model with 83 candidate clinical variables along with the HF score to predict the risk of all-cause mortality along with rehospitalization. To identify subjects using the HF score, the sensitivity, specificity, accuracy, F1 score, and area under receiver operating characteristic curve were 0.867, 0.851, 0.874, 0.878, and 0.93, respectively, from the hold-out cross-validation of the DNN, which was better than other machine learning models, including logistic regression, support vector machine, and random forest. With a median follow-up of 5.8 years, the multivariable Cox model using the HF score and other clinical variables outperformed the other HF risk prediction models with concordance index of 0.71, in which only the HF score and five clinical variables were independent significant predictors (p < 0.05), including age, history of percutaneous coronary intervention, concentration of sodium in the emergency room, N-terminal pro-brain natriuretic peptide, and hemoglobin. Our study demonstrated the diagnostic and prognostic utility of arterial waveforms in subjects with HF using a DNN model. Pulse wave contains valuable information that can benefit the clinical care of patients with HF.

Prognostic Value of Objective Social Isolation and Loneliness in Older Patients With Heart Failure: Subanalysis of FRAGILE-HF and Kitasato Cohort

BACKGROUND

Social factors encompass a broad spectrum of nonmedical factors, including objective (social isolation [SI]) and perceived (loneliness) conditions. Although social factors have attracted considerable research attention, information regarding their impact on patients with heart failure is scarce. We aimed to investigate the prognostic impact of objective SI and loneliness in older patients with heart failure.

METHODS AND RESULTS

This study was conducted using the FRAGILE-HF (Prevalence and Prognostic Value of Physical and Social Frailty in Geriatric Patients Hospitalized for Heart Failure; derivation cohort) and Kitasato cohorts (validation cohort), which included hospitalized patients with heart failure aged ≥65 years. Objective SI and loneliness were defined using the Japanese version of Lubben Social Network Scale-6 and diagnosed when the total score for objective and perceived questions on the Lubben Social Network Scale-6 was below the median in the FRAGILE-HF. The primary outcome was 1-year death. Overall, 1232 and 405 patients in the FRAGILE-HF and Kitasato cohorts, respectively, were analyzed. Objective SI and loneliness were observed in 57.8% and 51.4% of patients in the FRAGILE-HF and 55.4% and 46.2% of those in the Kitasato cohort, respectively. During the 1-year follow-up, 149 and 31 patients died in the FRAGILE-HF and Kitasato cohorts, respectively. Cox proportional hazard analysis revealed that objective SI, but not loneliness, was significantly associated with 1-year death after adjustment for conventional risk factors in the FRAGILE-HF. These findings were consistent with the validation cohort.

CONCLUSIONS

Objective SI assessed using the Lubben Social Network Scale-6 may be a prognostic indicator in older patients with heart failure. Given the lack of established SI assessment methods in this population, further research is required to refine such methods.

Association of a Transitional Heart Failure Management Program With Readmission and End-of-Life Care in Rural Japan

Background: Evidence on transitional care for heart failure (HF) in Japan is limited. Methods and Results: We implemented a transitional HF management program in rural Japan in 2019. This involved collaboration with general practitioners or nursing care facilities and included symptom monitoring by medical/nursing staff using a handbook; standardized discharge care planning and information sharing on self-care and advance care planning using a collaborative sheet; and sharing expertise on HF management via manuals. We compared the outcomes within 1 year of discharge among patients hospitalized with HF in the 2 years before program implementation (2017-2018; historical control, n=198), in the first 2 years after program implementation (2019-2020; Intervention Phase 1, n=205), and in the second 2 years, following program revision and regional dissemination (2021-2022; Intervention Phase 2, n=195). HF readmission rates gradually decreased over Phases 1 and 2 (P<0.05). This association was consistent regardless of physician expertise, follow-up institution, or the use of nursing care services (P>0.1 for interaction). Mortality rates remained unchanged, but significantly more patients received end-of-life care at home in Phase 2 than before (P<0.05). Conclusions: The implementation of a transitional care program was associated with decreased HF readmissions and increased end-of-life care at home for HF patients in rural Japan.

Association and Prognostic Value of Multidomain Frailty Defined by Cumulative Deficit and Phenotype Models in Patients With Heart Failure

BACKGROUND

Frailty is associated with a poor prognosis in older patients with heart failure (HF). However, multidomain frailty assessment tools have not been established in patients with HF, and the association between the frailty phenotype and the deficit-accumulation frailty index in these patients is unclear. We aimed to understand this relationship and evaluate the prognostic value of the deficit-accumulation frailty index in older patients with HF.

METHODS

We retrospectively analyzed FRAGILE-HF cohort, which consisted of prospectively registered hospitalized patients with HF aged ≥ 65 years. The frailty index was calculated using 34 health-related items. The physical, social, and cognitive domains of frailty were evaluated using a phenotypic approach. The primary endpoint was all-cause mortality.

RESULTS

Among 1027 patients with HF (median age, 81 years; male, 58.1%; median frailty index, 0.44), a higher frailty index was associated with a higher prevalence in all domains of cognitive, physical, and social frailty defined by the phenotype model. During the 2-year follow-up period, a higher frailty index was independently associated with all-cause death even after adjustment for Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score plus log B-type natriuretic peptide (per 0.1 increase: hazard ratio, 1.21; 95% confidence interval, 1.07-1.37; P = 0.002). The addition of the frailty index to the baseline model yielded statistically significant incremental prognostic value (net reclassification improvement, 0.165; 95% confidence interval, 0.012-0.318; P = 0.034).

CONCLUSIONS

A higher frailty index was associated with a higher prevalence of all domains of frailty defined by the phenotype model and provided incremental prognostic information with pre-existing risk factors in older patients with HF.

Sarcopenia prognosis using dual-energy X-ray absorptiometry and prediction model in older patients with heart failure

AIMS

This study aimed to determine whether there is a difference in the prognostic value of sarcopenia diagnosed using dual-energy X-ray absorptiometry (DEXA) and that predicted by prediction equations in older patients with heart failure (HF).

METHODS AND RESULTS

We included 269 patients (aged ≥65 years) who were hospitalized for HF. We used two appendicular skeletal muscle mass (ASM) prediction equations: (i) Anthropometric-ASM, including age, sex, height, and weight, and (ii) Predicted-ASM, including sex, weight, calf circumference, and mid-arm circumference. ASM index (ASMI) was calculated by dividing the sum of the ASM in the extremities by the height squared (kg/m2). The cut-off values proposed by the Asian Working Group for Sarcopenia 2019 were used to define low ASMI. The prognostic endpoint was all-cause mortality. The median age of the cohort was 83 years [interquartile range (IQR): 75-87], and 135 patients (50.2%) were men. Sarcopenia diagnosed according to DEXA, Anthropometric measurements, and Predicted-ASM was observed in 134 (49.8%), 171 (63.6%), and 157 (58.4%) patients, respectively. During the median follow-up period of 690 days (IQR: 459-730), 54 patients (19.9%) died. DEXA-sarcopenia [hazard ratio (HR), 2.33; 95% confidence interval (CI), 1.26-4.31; P = 0.007] was associated with all-cause mortality after adjusting for pre-existing risk factors, whereas Predicted-sarcopenia (HR, 1.68; 95% CI, 0.87-3.25; P = 0.123) and Anthropometric-sarcopenia (HR, 1.64; 95% CI, 0.86-3.12; P = 0.132) were not.

CONCLUSIONS

Sarcopenia diagnosed using DEXA was associated with poor prognosis in older patients with HF; however, the prediction equations were not.

Predictive value of the Ishii score for sarcopenia and the prognosis of older patients hospitalized with heart failure

AIMS

Although sarcopenia is common and associated with poor outcomes in patients with heart failure, its simple screening methods remain unclear. We aimed to investigate the predictive value of the Ishii score, which includes age, grip strength, and calf circumference, for sarcopenia and its prognostic predictability in patients with heart failure.

METHODS

This was a subanalysis of the FRAGILE-HF study. Receiver operating characteristic curves were used to evaluate the predictive value for sarcopenia. Patients were stratified into the high and low Ishii score groups based on the cutoff values of the Ishii score determined by the Youden index for sarcopenia, and the 1-year mortality rates were compared.

RESULTS

Of the 1262 study participants, 936 were evaluated with sarcopenia, and 184 (55 women, 129 men) were diagnosed with sarcopenia. The areas under the receiver operating characteristic curves for sarcopenia were 0.73 and 0.87 for women and men, respectively. The optimal cutoff values for predicting sarcopenia were 165 and 141 for women and men, respectively. Using these cutoff values, the sensitivity and specificity for sarcopenia were 70.9% and 68.5% for women and 88.4% and 69.7% for men, respectively. At 1 year, 151 (low Ishii score group, 98; high Ishii score group, 53) deaths were observed. Adjusted Cox proportional hazards analysis showed that the high Ishii score group was significantly associated with 1-year mortality.

CONCLUSION

Among older patients hospitalized for heart failure, the Ishii score is useful for predicting sarcopenia and 1-year mortality. Geriatr Gerontol Int 2024; 24: 147-153.

Development and Validation of a Protein Risk Score for Mortality in Heart Failure : A Community Cohort Study

BACKGROUND

Heart failure (HF) is a complex clinical syndrome with high mortality. Current risk stratification approaches lack precision. High-throughput proteomics could improve risk prediction. Its use in clinical practice to guide the management of patients with HF depends on validation and evidence of clinical benefit.

OBJECTIVE

To develop and validate a protein risk score for mortality in patients with HF.

DESIGN

Community-based cohort.

SETTING

Southeast Minnesota.

PARTICIPANTS

Patients with HF enrolled between 2003 and 2012 and followed through 2021.

MEASUREMENTS

A total of 7289 plasma proteins in 1351 patients with HF were measured using the SomaScan Assay (SomaLogic). A protein risk score was derived using least absolute shrinkage and selection operator regression and temporal validation in patients enrolled between 2003 and 2007 (development cohort) and 2008 and 2012 (validation cohort). Multivariable Cox regression was used to examine the association between the protein risk score and mortality. The performance of the protein risk score to predict 5-year mortality risk was assessed using calibration plots, decision curves, and relative utility analyses and compared with a clinical model, including the Meta-Analysis Global Group in Chronic Heart Failure mortality risk score and N-terminal pro-B-type natriuretic peptide.

RESULTS

The development (n = 855; median age, 78 years; 50% women; 29% with ejection fraction <40%) and validation cohorts (n = 496; median age, 76 years; 45% women; 33% with ejection fraction <40%) were mostly similar. In the development cohort, 38 unique proteins were selected for the protein risk score. Independent of ejection fraction, the protein risk score demonstrated good calibration, reclassified mortality risk particularly at the extremes of the risk distribution, and showed greater clinical utility compared with the clinical model.

LIMITATION

Participants were predominantly of European ancestry, potentially limiting the generalizability of the findings to different patient populations.

CONCLUSION

Validation of the protein risk score demonstrated good calibration and evidence of predicted benefits to stratify the risk for death in HF superior to that of clinical methods. Further studies are needed to prospectively evaluate the score's performance in diverse populations and determine risk thresholds for interventions.

PRIMARY FUNDING SOURCE

Division of Intramural Research at the National Heart, Lung, and Blood Institute of the National Institutes of Health.

Low Energy Intake Diagnosed Using the Harris-Benedict Equation Is Associated with Poor Prognosis in Elderly Heart Failure Patients

INTRODUCTION

Insufficient nutrient intake is a strong independent predictor of mortality in elderly patients with heart failure. However, it is unclear to what extent energy intake affects their prognosis. This study investigated the association between patient outcomes and actual measured energy intake in elderly patients (≥65 years) with heart failure.

METHODS

This study enrolled 139 elderly patients who were hospitalized with worsening heart failure at Shingu Municipal Medical Center, Shingu, Japan, between May 2017 and April 2018. Energy intake was evaluated for three days (from three days prior to the day of discharge until the day of discharge). Based on basal energy expenditure calculated using the Harris-Benedict equation, the patients were classified into a low-energy group (n = 38) and a high-energy group (n = 101). We assessed the prognosis in terms of both all-cause mortality and readmission due to worsening heart failure as a primary outcome.

RESULTS

Compared to the patients in the high-energy group, the patients in the low-energy group were predominantly female, less frequently had smoking habits and ischemic heart diseases, and had a higher left ventricular ejection fraction. The low-energy group had higher mortality than the high-energy group (p = 0.028), although the two groups showed equivalent event rates of the primary outcome (p = 0.569).

CONCLUSION

Calculations based on the Harris-Benedict equation revealed no significant difference in the primary outcome between the two groups, with a secondary outcome that showed worse mortality in the low-energy group. Given this result, energy requirement-based assessments using the Harris-Benedict equation might help in the management of elderly heart failure patients in terms of improved life outcomes.

Development and Validation of R-hf Risk Score in Acute Heart Failure Patients in the Middle East

Objectives

The Rajan's heart failure (R-hf) score was proposed to aid risk stratification in heart failure patients. The aim of this study was to validate R-hf risk score in patients with acute decompensated heart failure.

Methods

R-hf risk score is derived from the product estimated glomerular filtration rate (mL/min), left ventricular ejection fraction (%), and hemoglobin levels (g/dL) divided by N-terminal pro-brain natriuretic peptide (pg/mL). This was a multinational, multicenter, prospective registry of heart failure from seven countries in the Middle East. Univariable and multivariable logistic regression was applied.

Results

A total of 776 patients (mean age = 62.0±14.0 years, 62.4% males; mean left ventricular ejection fraction = 33.0±14.0%) were included. Of these, 459 (59.1%) presented with acute decompensated chronic heart failure. The R-hf risk score group (≤ 5) was marginally associated with a higher risk of all-cause cumulative mortality at three months (adjusted odds ratio (aOR) = 4.28; 95% CI: 0.90-20.30; p =0.067) and significantly at 12 months (aOR = 3.84; 95% CI: 1.23-12.00; p =0.021) when compared to those with the highest R score group (≥ 50).

Conclusions

Lower R-hf risk scores are associated with increased risk of all-cause cumulative mortality at three and 12 months.

Prevalence and prognostic impact of the coexistence of cachexia and sarcopenia in older patients with heart failure

BACKGROUND

No study with an adequate patients' number has examined the relationship/overlap between sarcopenia and cachexia. We examined the prevalence of the overlap and prognostic implications of sarcopenia and cachexia in older patients with heart failure using well-accepted definitions.

METHODS

This was a post-hoc sub-analysis of the FRAGILE-HF study, a prospective, multicenter, observational study conducted at 15 hospitals in Japan. In total, 905 hospitalized older patients were classified into four groups based on the presence or absence of cachexia and/or sarcopenia, which were defined according to the Evans and Asian Working Group for Sarcopenia criteria revised in 2019, respectively. The primary endpoint was 2-year all-cause mortality.

RESULTS

Cachexia and sarcopenia prevalence rates were 32.7% and 22.7%, respectively. Patients were classified into the non-cachexia/non-sarcopenia (55.7%), cachexia/non-sarcopenia (21.7%), non-cachexia/sarcopenia (11.6%), and cachexia/sarcopenia (11.0%) groups. During the 2-year follow-up period after discharge, 158 (17.5%) all-cause deaths (124 cardiovascular deaths [CVD] and 34 non-CVD) were observed. The cachexia/sarcopenia group had the lowest body fat mass and exhibited significantly higher mortality rates (log-rank P < 0.001). Cox proportional hazard analysis revealed that cachexia/sarcopenia was an independent prognostic factor after adjusting for known prognostic factors (versus non-cachexia/non-sarcopenia: hazard ratio, 2.78; 95% confidence interval, 1.80-4.29; P < 0.001). Neither cachexia/non-sarcopenia nor non-cachexia/sarcopenia were significantly associated with all-cause mortality compared with non-cachexia/non-sarcopenia.

CONCLUSIONS

Cachexia and sarcopenia are prevalent among older hospitalized patients with heart failure; nonetheless, the overlap is not as prominent as previously expected. The presence of cachexia and sarcopenia is a risk factor for all-cause mortality.

Lung water estimation on cardiac magnetic resonance imaging for predicting adverse cardiovascular outcomes in patients with heart failure

OBJECTIVES

Pulmonary congestion is a central feature of heart failure (HF) seen in acute decompensated state as well as in chronic stable disease. The present study sought to determine whether simplified cardiac magnetic resonance imaging (CMR)-derived lung water density (LWD) measurement has prognostic relevance in predicting adverse cardiovascular outcomes in patients with HF and left ventricular ejection fraction (LVEF)<50%.

METHODS

Eighty consecutive patients referred for CMR with HF and LVEF<50% along with 22 healthy age- and sex-matched controls were prospectively recruited. LWD was the lung-to-liver signal intensity ratio multiplied by 70% (estimated hepatic water density). The primary endpoint was composite of all-cause mortality or HF-related hospitalization within 6 months from CMR.

RESULTS

The mean LWD was significantly higher in HF patients compared to healthy controls (19.78 ± 6.1 vs 13.6 ± 2.3; p < 0.001). The mean LWD was significantly different among patients with NYHA class I/II and NYHA class III/IV (17.88 ± 4.8 vs 21.77 ± 1.08; p = 0.004). At 6 months, the primary endpoint was reached in 12 (15%) patients. Patients with "wet lungs" (LWD > 18.1%) had higher incidence of adverse cardiovascular outcomes compared to patients with "dry lungs". LWD was an independent predictor of adverse cardiovascular outcomes in multivariable analysis. At the optimal cut-off of LWD > 23.38%, the sensitivity and specificity were 91.67 and 91.18%, respectively, to predict adverse cardiovascular outcomes.

CONCLUSION

LWD on CMR is independently associated with increased risk of mortality and HF-related hospitalization in HF patients with LVEF<50%.

ADVANCES IN KNOWLEDGE

Non-invasive quantitative estimation of LWD on CMR can improve risk stratification and guide management in HF patients.

External Validation of the Japanese Clinical Score for Mortality Prediction in Patients With Acute Heart Failure

BACKGROUND

To predict mortality in patients with acute heart failure (AHF), we created and validated an internal clinical risk score, the KICKOFF score, which takes physical and social aspects, in addition to clinical aspects, into account. In this study, we validated the prediction model externally in a different geographic area.

METHODS AND RESULTS

There were 2 prospective multicenter cohorts (1,117 patients in Osaka Prefecture [KICKOFF registry]; 737 patients in Kochi Prefecture [Kochi YOSACOI study]) that had complete datasets for calculation of the KICKOFF score, which was developed by machine learning incorporating physical and social factors. The outcome measure was all-cause death over a 2-year period. Patients were separated into 3 groups: low risk (scores 0-6), moderate risk (scores 7-11), and high risk (scores 12-19). Kaplan-Meier curves clearly showed the score's propensity to predict all-cause death, which rose independently in higher-risk groups (P<0.001) in both cohorts. After 2 years, the cumulative incidence of all-cause death was similar in the KICKOFF registry and Kochi YOSACOI study for the low-risk (4.4% vs. 5.3%, respectively), moderate-risk (25.3% vs. 22.3%, respectively), and high-risk (68.1% vs. 58.5%, respectively) groups.

CONCLUSIONS

The unique prediction score may be used in different geographic areas in Japan. The score may help doctors estimate the risk of AHF mortality, and provide information for decisions regarding heart failure treatment.

Prognostic implications of six-minute walking distance in patients with heart failure with preserved ejection fraction

BACKGROUND

The incremental prognostic value of the six-minute walking test over conventional risk factors has not been evaluated in an adequate number of patients with heart failure with preserved ejection fraction (HFpEF). Therefore, we aimed to examine its prognostic significance using data from the FRAGILE-HF study.

METHODS AND RESULTS

A total of 513 older patients who were hospitalized for worsening heart failure were examined. Patients were classified according to the tertiles of six-minute walking distance (6MWD): T1 (<166 m), T2 (166-285 m), and T3 (≥285 m). During the 2-year follow-up period after discharge, 90 all-cause deaths occurred. Kaplan-Meier curves showed that the T1 group had significantly higher event rates than the other groups (log-rank p = 0.007). Cox proportional hazard analysis revealed that the T1 group was independently associated with lower survival, even after adjusting for conventional risk factors (T3: hazard ratio 1.79, 95% confidence interval 1.02-3.14, p = 0.042). The addition of the 6MWD to the conventional prognostic model showed a statistically significant incremental prognostic value (net reclassification improvement 0.27, 95% confidence interval 0.04-0.49; p = 0.019).

CONCLUSIONS

The 6MWD is associated with survival in patients with HFpEF and has an incremental prognostic value over conventional well-validated risk factors.

Prognostic implications of post-discharge hemodynamic congestion assessed by peripheral venous pressure among patients discharged from acute heart failure

BACKGROUND

Congestion is a major cause of hospitalization for heart failure (HF). Peripheral venous pressure (PVP) strongly correlates with right atrial pressure. We recently reported that high PVP at discharge portends a poor prognosis in patients hospitalized for HF. In the same population, we aimed to analyze changes in PVP after discharge and to evaluate prognostic implications of post-discharge PVP.

METHODS

PVP was measured at the forearm vein of 163 patients in the 1-month post-discharge follow-up visit. The primary outcome was a composite of cardiovascular death or re-hospitalization for HF after the 1-month follow-up visit up to 1 year after discharge.

RESULTS

Post-discharge PVP correlated with jugular venous pressure, the inferior vena cava diameter, and brain-type natriuretic peptide levels. The cumulative incidence of the primary outcome event was significantly higher in patients with PVP above the median (6 mmHg) than in those with median PVP or lower (39.8% versus 16.9%, Log-rank P = 0.04). Age- and sex-adjusted risk of PVP per 1 mmHg for the primary outcome measure was significant (hazard ratio: 1.12 [95% confidence interval 1.03-1.21]). 35% of patients who had PVP ≤6 mmHg at discharge had PVP >6 mmHg at the 1-month follow-up. PVP significantly decreased from discharge to 1-month follow-up in patients without the primary outcome event (from 6 [4-10] to 6 [4-8] mmHg, P=0.01), but remained high in those with the primary outcome event (from 8 [5-11] to 7 [5-10.5] mmHg, P = 0.9).

CONCLUSIONS

PVP measurements during the early post-discharge period may be useful to identify high risk patients.

TRIAL REGISTRATION NUMBER

UMIN000034279.

Validation of the Meta-Analysis Global Group in Chronic Heart Failure risk score for the prediction of 1-year mortality in a Chinese cohort

BACKGROUND

The Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score was developed in 2013 to predict survival in heart failure (HF) patients. However, it has yet to be validated in a Chinese population. Our study aimed to investigate the ability of the score to predict 1-year mortality in a Chinese population.

METHODS

Consecutive patients with HF were retrospectively selected from the inpatient electronic medical records of the cardiology department in a regional hospital in China. A total integer score was calculated for each enrolled patient based on the value of each risk factor in the MAGGIC scoring system. Each enrolled patient was followed for at least 1 year. The observational endpoint of this study was all-cause mortality. The predictive ability of the MAGGIC score was assessed by comparing observed and predicted mortality within 1 year.

RESULTS

Between January 2018 and December 2020, a total of 635 patients were included in the study: 57 (9.0%) of whom died within 1 year after discharge. The average age of all patients was 74.6 ± 11.2 years, 264 of them (41.6%) were male, and the average left ventricular ejection fraction was 50.7% ± 13.2%. The area under the receiver operating characteristic curve was 0.840 (95% confidence interval: 0.779, 0.901), which indicated a fair discriminatory ability of the score. The Hosmer-Lemeshow test result ( χ2  = 12.902, degree of freedom = 8, P   =  0.115) indicated that the MAGGIC score had good calibration. The decision curve analysis showed that the MAGGIC score yielded a good clinical net benefit and net reduction in interventions.

CONCLUSIONS

This validation of the MAGGIC score showed that it has a good ability to predict 1-year mortality in Chinese patients with HF after discharge. Due to regional and inter-hospital differences, external validation studies need to be further confirmed in other centers.

The MAGGIC risk score in the prediction of death or hospitalization in patients with heart failure: Comparison with natriuretic peptides

BACKGROUND

The MAGGIC risk score has been validated to predict mortality in patients with heart failure (HF).

OBJECTIVES

To assess the score ability to predict hospitalization and death and to compare with natriuretic peptides.

METHODS

Ninety-three consecutive patients (mean age 62±10 years) with chronic HF and left ventricular ejection fraction (EF) <50% were studied. The MAGGIC score was applied at baseline and the patients were followed for 219±86 days. MAGGIC score was compared with NT-proBNP in the prediction of events. The primary end point was the time to the first event, which was defined as cardiovascular death or hospitalization for HF.

RESULTS

There were 23 (24.7%) events (3 deaths and 20 hospitalizations). The median score in patients with and without events was, respectively, 20 [interquartile range 14.2-22] vs. 15.5 [11/21], p=0.16. A ROC curve was performed and a cutoff point of 12 points showed a sensitivity of 87% and specificity of 37% with an area under the curve of 0.59 (95% CI 0.48-0.69) which was lower than that of NT-proBNP (AUC 0.67; 95% CI 0.56-0.76). The mean event-free survival time for patients above and below this cutpoint was 248.8±13 vs. 290±13.7 days (log rank test with p=0.044). Using the COX proportional hazard model, age (p=0.004), NT-proBNP >1000 pg/mL (p=0.014) and the MAGGIC score (p=0.025) were independently associated with the primary outcome.

CONCLUSION

The MAGGIC risk score was an independent predictor of events, including heart failure hospitalization. The addition of biomarkers improved the accuracy of the score.

Sarcopenic obesity is associated with impaired physical function and mortality in older patients with heart failure: insight from FRAGILE-HF

Background

The purpose of this study was to clarify the prevalence, association with frailty and exercise capacity, and prognostic implication of sarcopenic obesity in patients with heart failure.

Methods

The present study included 779 older adults hospitalized with heart failure (median age: 81 years; 57.4% men). Sarcopenia was diagnosed based on the guidelines by the Asian Working Group for Sarcopenia. Obesity was defined as the percentage of body fat mass (FM) obtained by bioelectrical impedance analysis. The FM cut-off points for obesity were 38% for women and 27% for men. The primary endpoint was 1-year all-cause death. We assessed the associations of sarcopenic obesity occurrence with the short physical performance battery (SPPB) score and 6-minute walk distance (6MWD).

Results

The rates of sarcopenia and obesity were 19.3 and 26.2%, respectively. The patients were classified into the following groups: non-sarcopenia/non-obesity (58.5%), non-sarcopenia/obesity (22.2%), sarcopenia/non-obesity (15.3%), and sarcopenia/obesity (4.0%). The sarcopenia/obesity group had a lower SPPB score and shorter 6MWD, which was independent of age and sex (coefficient, − 0.120; t-value, − 3.74; P < 0.001 and coefficient, − 77.42; t-value, − 3.61; P < 0.001; respectively). Ninety-six patients died during the 1-year follow-up period. In a Cox proportional hazard analysis, sarcopenia and obesity together were an independent prognostic factor even after adjusting for a coexisting prognostic factor (non-sarcopenia/non-obesity vs. sarcopenia/obesity: hazard ratio, 2.48; 95% confidence interval, 1.22–5.04; P = 0.012).

Conclusion

Sarcopenic obesity is a risk factor for all-cause death and low physical function in older adults with heart failure.

Trial registration

University Hospital Information Network (UMIN-CTR: UMIN000023929).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03168-3.

Prognostic values of muscle mass assessed by dual-energy X-ray absorptiometry and bioelectrical impedance analysis in older patients with heart failure

AIM

This study aimed to compare bioelectrical impedance analysis (BIA) and dual-energy X-ray absorptiometry (DEXA) in measuring skeletal muscle mass (MM), and its prognostic implications in old patients with heart failure.

METHODS

We prospectively evaluated MM measured by both BIA and DEXA in 226 hospitalized elderly (≥65 years) patients with heart failure. The cut-off values proposed by the Asian Working Group in Sarcopenia were used to define low MM. The prognostic endpoint was all-cause death.

RESULTS

The median age of the cohort was 82 years (interquartile range: 75-87), and 51.8% of patients were men. According to the BIA and DEXA, 177 (78.3%) and 120 (53.1%) patients were diagnosed with low MM, respectively, and the two assessment tools showed poor agreement (Cohen's kappa coefficient: 0.294). During the follow-up, 32 patients (14.2%) died; only low MM defined by DEXA (hazard ratio 2.45, 95% confidence interval 1.05-5.72, P = 0.039), but not BIA (hazard ratio 1.03, 95% confidence interval 0.35-3.06, P = 0.955), was associated with poor prognosis after adjusting for pre-existing risk factors. Moreover, low MM defined by DEXA (net reclassification improvement: 0.58, P < 0.001), but not BIA (net reclassification improvement: -0.005, P = 0.975), provides incremental prognostic predictability when considered with pre-existing risk factors and brain natriuretic peptide level at discharge.

CONCLUSIONS

In elderly hospitalized patients with heart failure, low MM defined by DEXA and BIA show significant discordance. The MM defined by DEXA, but not BIA, provides additional prognostic value to pre-existing prognostic models. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2022; ••: ••-••.

Data standards for heart failure: the European Unified Registries for Heart Care Evaluation and Randomized Trials (EuroHeart)

Standardized data definitions are essential for assessing the quality of care and patient outcomes in observational studies and randomized controlled trials. The European Unified Registries for Heart Care Evaluation and Randomized Trials (EuroHeart) project of the European Society of Cardiology (ESC) aims to create contemporary pan-European data standards for cardiovascular diseases, including heart failure (HF). We followed the EuroHeart methodology for cardiovascular data standard development. A Working Group including experts in HF registries, representatives from the Heart Failure Association of the ESC, and the EuroHeart was formed. Using Embase and Medline (2016-21), we conducted a systematic review of the literature on data standards, registries, and trials to identify variables pertinent to HF. A modified Delphi method was used to reach a consensus on the final set of variables. For each variable, the Working Group developed data definitions and agreed on whether it was mandatory (Level 1) or additional (Level 2). In total, 84 Level 1 and 79 Level 2 variables were selected for nine domains of HF care. These variables were reviewed by an international Reference Group with the Level 1 variables providing the dataset for registration of patients with HF on the EuroHeart IT platform. By means of a structured process and interaction with international stakeholders, harmonized data standards for HF have been developed. In the context of the EuroHeart, this will facilitate quality improvement, international observational research, registry-based randomized trials, and post-marketing surveillance of devices and pharmacotherapies across Europe.

Association of peripheral venous pressure with adverse post-discharge outcomes in patients with acute heart failure: a prospective cohort study

AIMS

Congestion is the major cause of hospitalization for heart failure (HF). Traditional bedside assessment of congestion is limited by insufficient accuracy. Peripheral venous pressure (PVP) has recently been shown to accurately predict central venous congestion. We examined the association between PVP before discharge and post-discharge outcomes in hospitalized patients with acute HF.

METHODS AND RESULTS

Bedside PVP measurement at the forearm vein and traditional clinical examination were performed in 239 patients. The association with the primary composite endpoint of cardiovascular death or HF hospitalization and the incremental prognostic value beyond the established HF risk score was examined. The PVP correlated with peripheral oedema, jugular venous pressure, and inferior vena cava diameter, but not with brain-type natriuretic peptide. The 1-year incidence of the primary outcome measure in the first, second, and third tertiles of PVP was 21.4, 29.9, and 40.7%, respectively (log-rank P = 0.017). The adjusted hazard ratio of PVP per 1 mmHg increase for the 1-year outcome was 1.08 [95% confidence interval (1.03-1.14), P = 0.004]. When added onto the Meta-Analysis Global Group in Chronic HF risk score, PVP significantly increased the area under the receiver-operating characteristic curve for predicting the outcome [from 0.63 (0.56-0.71) to 0.70 (0.62-0.77), P = 0.02), while traditional assessments did not. The addition of PVP also yielded significant net reclassification improvement [0.46 (0.19-0.74), P < 0.001].

CONCLUSION

The PVP at discharge correlated with prognosis. The results warrant further investigation to evaluate the clinical application of PVP measurement in the care of HF.

TRIAL REGISTRATION NUMBER

UMIN000034279.

Prognostic value of postural hypotension in hospitalized patients with heart failure

Although postural hypotension (PH) is reportedly associated with mortality in the general population, the prognostic value for heart failure is unclear. This was a post-hoc analysis of FRAGILE-HF, a prospective multicenter observational study focusing on frailty in elderly patients with heart failure. Overall, 730 patients aged ≥ 65 years who were hospitalized with heart failure were enrolled. PH was defined by evaluating seated PH, and was defined as a fall of ≥ 20 mmHg in systolic and/or ≥ 10 mmHg in diastolic blood pressure within 3 min after transition from a supine to sitting position. The study endpoints were all-cause death and heart failure readmission at 1 year. Predictive variables for the presence of PH were also evaluated. PH was observed in 160 patients (21.9%). Patients with PH were more likely than those without PH to be male with a New York Heart Association classification of III/IV. Logistic regression analysis showed that male sex, severe heart failure symptoms, and lack of administration of angiotensin-converting enzyme inhibitors were independently associated with PH. PH was not associated with 1-year mortality, but was associated with a lower incidence of readmission after discharge after adjustment for other covariates. In conclusion, PH was associated with reduced risk of heart failure readmission but not with 1-year mortality in older patients with heart failure.

Sex differences in the prevalence and prognostic impact of physical frailty and sarcopenia among older patients with heart failure

BACKGROUND AND AIMS

Frailty and sarcopenia are common and confer poor prognosis in elderly patients with heart failure; however, gender differences in its prevalence or prognostic impact remain unclear.

METHODS AND RESULTS

We included 1332 patients aged ≥65 years, who were hospitalized for heart failure. Frailty and sarcopenia were defined using the Fried phenotype model and Asian Working Group for Sarcopenia criteria, respectively. Gender differences in frailty and sarcopenia, and interactions between sex and prognostic impact of frailty/sarcopenia on 1-year mortality were evaluated. Overall, 53.9% men and 61.0% women and 23.7% men and 14.0% women had frailty and sarcopenia, respectively. Although sarcopenia was more prevalent in men, no gender differences existed in frailty after adjusting for age. On Kaplan-Meier analysis, frailty and sarcopenia were significantly associated with 1-year mortality in both sexes. On Cox proportional hazard analysis, frailty was associated with 1-year mortality only in men, after adjusting for confounding factors (hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.19-3.16; P = 0.008 for men; HR, 1.63; 95% CI, 0.84-3.13; P = 0.147 for women); sarcopenia was an independent prognostic factor in both sexes (HR, 1.93; 95% CI, 1.13-3.31; P = 0.017 for men; HR, 3.18; 95% CI, 1.59-5.64; P = 0.001 for women). There were no interactions between sex and prognostic impact of frailty/sarcopenia (P = 0.806 for frailty; P = 0.254 for sarcopenia).

CONCLUSIONS

Frailty and sarcopenia negatively affect older patients with heart failure from both sexes.

CLINICAL TRIALS

This study was registered at the University Hospital Information Network (UMIN-CTR, unique identifier: UMIN000023929) before the first patient was enrolled.

A clinical score to predict mortality in patients after acute heart failure from Japanese registry

Aims

Clinical scores that consider physical and social factors to predict long‐term observations in patients after acute heart failure are limited. This study aimed to develop and validate a prediction model for patients with acute heart failure at the time of discharge.

Methods and results

This study was retrospective analysis of the Kitakawachi Clinical Background and Outcome of Heart Failure Registry database. The registry is a prospective, multicentre cohort of patients with acute heart failure between April 2015 and August 2017. The primary outcome to be predicted was the incidence of all‐cause mortality during the 3 years of follow‐up period. The development cohort derived from April 2015 to July 2016 was used to build the prediction model, and the test cohort from August 2016 to August 2017 was used to evaluate the prediction model. The following potential predictors were selected by the least absolute shrinkage and selection operator method: age, sex, body mass index, activities of daily living at discharge, social background, comorbidities, biomarkers, and echocardiographic findings; a risk scoring system was developed using a logistic model to predict the outcome using a simple integer based on each variable's β coefficient. Out of 1253 patients registered, 1117 were included in the analysis and divided into the development (n = 679) and test (n = 438) cohorts. The outcomes were 246 (36.2%) in the development cohort and 143 (32.6%) in the test cohort. Eleven variables including physical and social factors were set into the logistic regression model, and the risk scoring system was created. The patients were divided into three groups: low risk (score 0–5), moderate risk (score 6–11), and high risk (score ≥12). The observed and predicted mortality rates were described by the Kaplan–Meier curve divided by risk group and independently increased (P < 0.001). In the test cohort, the C statistic of the prediction model was 0.778 (95% confidence interval: 0.732–0.824), and the mean predicted probabilities in the groups were low, 6.9% (95% confidence interval: 3.8–10%); moderate, 30.1% (95% confidence interval: 25.4%–34.8%); and high, 79.2% (95% confidence interval: 72.6%–85.8%). The predicted probability was well calibrated to the observed outcomes in both cohorts.

Conclusions

The Kitakawachi Clinical Background and Outcome of Heart Failure score was helpful in predicting adverse events in patients with acute heart failure over a long‐term period. We should evaluate the physical and social functions of such patients before discharge to prevent adverse outcomes.

Judgement of the multidisciplinary team is an important predictor of mortality after cardiac resynchronization therapy

Aims

Cardiac resynchronization therapy (CRT) in appropriately selected patients with heart failure improves symptoms and survival. It is necessary to correctly identify patients who will benefit most from this therapy. We aimed to assess the predictive power of the multidisciplinary team's clinical judgement in the short‐term death after CRT implantation.

Methods and results

Patients with heart failure and referred for the first CRT implant were prospectively included. Prior to implantation, all patients underwent a systematic assessment with a team composed of social work, nurse, psychologist, nutritionist, and clinical cardiologist. Based on this assessment, patients could be contraindicated to CRT or referred to the procedure as favourable or unfavourable. All patients should complete 12 months of follow‐up; 172 patients were referred for CRT, 21 (12.2%) were contraindicated after the multidisciplinary team evaluation, 71 (47%) referred to CRT as non‐favourable implants, and 80 (53%) as favourable implants. All‐cause mortality occurred in only 2 (2.5%) patients in the favourable group and in 30 (42.3%) in the non‐favourable group, P < 0.001 (log rank). Among the 20 variables used as possible predictors of worse prognosis by the multidisciplinary team, four were independently associated with mortality in the follow‐up after the multivariate analysis: 1 year MAGGIC score between 40% and 49%, relative risk (RR) 5.0, 95% confidence interval (CI) 1.3–18.6, P = 0.016; poor pharmacological adherence, RR 4.9, 95% CI 1.6–15.6, P = 0.007; glomerular filtration rate <35 mL/min/1.73 m², RR 3.0, 95% CI 1.1–8.5, P = 0.041; and right ventricular dysfunction, RR 2.6, 95% CI 1.2–5.7, P = 0.018.

Conclusions

The clinical judgement before the CRT implantation performed by a multidisciplinary team through the analysis of clinical and psychosocial variables is a strong predictor of short‐term mortality.

Measuring lung water adds prognostic value in heart failure patients undergoing cardiac magnetic resonance

To assess whether a simplified cardiac magnetic resonance (CMR)-derived lung water density (LWD) quantification predicted major events in Heart Failure (HF). Single-centre retrospective study of consecutive HF patients with left ventricular ejection fraction (LVEF) < 50% who underwent CMR. All measurements were performed on HASTE sequences in a parasagittal plane at the right midclavicular line. LWD was determined by the lung-to-liver signal ratio multiplied by 0.7. A cohort of 102 controls was used to derive the LWD upper limit of normal (21.2%). The primary endpoint was a composite of time to all-cause death or HF hospitalization. Overall, 290 patients (mean age 64 ± 12 years) were included. LWD measurements took on average 35 ± 4 s, with good inter-observer reproducibility. LWD was increased in 65 (22.4%) patients, who were more symptomatic (NYHA ≥ III 29.2 vs. 1.8%; p = 0.017) and had higher NT-proBNP levels [1973 (IQR: 809-3766) vs. 802 (IQR: 355-2157 pg/mL); p < 0.001]. During a median follow-up of 21 months, 20 patients died and 40 had ≥ 1 HF hospitalization. In multivariate analysis, NYHA (III-IV vs. I-II; HR: 2.40; 95%-CI: 1.30-4.43; p = 0.005), LVEF (HR per 1%: 0.97; 95%-CI: 0.94-0.99; p = 0.031), serum creatinine (HR per 1 mg/dL: 2.51; 95%-CI: 1.36-4.61; p = 0.003) and LWD (HR per 1%: 1.07; 95%-CI: 1.02-1.12; p = 0.007) were independent predictors of the primary endpoint. These findings were mainly driven by an association between LWD and HF hospitalization (p = 0.026). A CMR-derived LWD quantification was independently associated with an increased HF hospitalization risk in HF patients with LVEF < 50%. LWD is a simple, reproducible and straightforward measurement, with prognostic value in HF.

Performance of Prognostic Risk Scores in Elderly Chinese Patients with Heart Failure

Purpose

Elderly heart failure (HF) patients have different clinical characteristics and poorer prognosis compared with younger patients. Prognostic risk scores for HF have not been validated well in elderly patients. We aimed to validate the Seattle Heart Failure Model (SHFM) and the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score in an elderly Chinese HF cohort.

Patients and Methods

This retrospective study enrolled 675 elderly HF patients (age≥70 years) discharged from our hospital between 2012 and 2017. The performance of the two risk scores was evaluated in terms of discrimination, using receiver-operating characteristic analysis, and calibration using a calibration plot and Hosmer–Lemeshow (H-L) test. Absolute risk reclassification was used to compare the two scores.

Results

During the mean follow-up time of 32.6 months, 193 patients (28.6%) died, and 1-year mortality was 10.5%. The predicted median 1-year mortality was 8% for the SHFM and 18% for the MAGGIC score. A Kaplan–Meier survival curve demonstrated that event rates of all-cause mortality significantly increased with increasing SHFM and MAGGIC scores. The discriminatory capacity of the SHFM was greater than that of the MAGGIC score (c-statistics were 0.72 and 0.67, respectively; P = 0.05). The calibration plot for the SHFM was better than that for MAGGIC score for 1-year mortality (SHFM: H-L χ² =8.2, P = 0.41; MAGGIC: H-L χ² =18.8, P =0.02). Compared with the MAGGIC score, the net reclassification index (NRI) of the SHFM was 2.96% (Z=5.88, P< 0.0001).

Conclusion

The SHFM performs better than MAGGIC score, having good discrimination, calibration and risk classification for the prediction of 1-year mortality in elderly Chinese HF patients.

Variability in estimated glomerular filtration rate and patients' outcomes in a real-world heart failure population

Aims

The prognostic significance of renal function variability has not been fully elucidated in heart failure (HF). This multicentre, prospective cohort study aimed to evaluate the usefulness of visit‐to‐visit variability in estimated glomerular filtration rate (eGFR) for predicting patients' outcomes in a real‐world HF population.

Methods

A total of 564 patients who had survived HF hospitalization were randomly assigned with a 2:1 ratio to derivation and validation cohorts, and they were then followed after discharge. Using the data for 6 months after discharge, each patient's visit‐to‐visit eGFR variability (EGV) was estimated. In the derivation cohort, Cox regression analyses were performed to assess the association of EGV with a subsequent composite event (death and HF hospitalization). In the validation cohort, the predictive performance was compared among Cox regression models with EGV, those with B‐type natriuretic peptide (BNP) and those with eGFR.

Results

In the derivation cohort (376 patients), median age, left ventricular ejection fraction (LVEF), BNP and eGFR at discharge were 72 years, 53.3%, 134.8 pg/mL and 58.7 mL/min/1.73 m², respectively. During a median follow‐up of 2.2 years, higher EGV was associated with an increased risk of the composite event (adjusted hazard ratio [per standard deviation increase in log‐transformed EGV], 1.5; 95% confidence interval, 1.1–2.0). A similar finding was observed in a stratified analysis by LVEF. In the validation cohort (188 patients), better model fit, discrimination, reclassification and calibration were observed for EGV than for 6‐month averaged BNP or eGFR for predicting the composite event when added to HF risk prediction models. Adding EGV to models with BNP or eGFR improved model discrimination and reclassification.

Conclusions

EGV predicts HF outcomes regardless of LVEF. Risk prediction models with EGV have good performance in real‐world HF patients. The study findings highlight the clinical importance of observing visit‐to‐visit fluctuations in renal function in this population.

Impact of Social Frailty in Hospitalized Elderly Patients With Heart Failure: A FRAGILE-HF Registry Subanalysis

Background

Frailty is conceptualized as an accumulation of deficits in multiple areas and is strongly associated with the prognosis of heart failure (HF). However, the social domain of frailty is less well investigated. We prospectively evaluated the clinical characteristics and prognostic impact of social frailty (SF) in elderly patients with HF.

Methods and Results

FRAGILE‐HF (prevalence and prognostic value of physical and social frailty in geriatric patients hospitalized for heart failure) is a multicenter, prospective cohort study focusing on patients hospitalized for HF and aged ≥65 years. We defined SF by Makizako’s 5 items, which have been validated as associated with future disability. The primary end point was a composite of all‐cause death and rehospitalization because of HF. The impact of SF on all‐cause mortality alone was also evaluated. Among 1240 enrolled patients, 825 (66.5%) had SF. During the 1‐year observation period after discharge, the rates of the combined end point and all‐cause mortality were significantly higher in patients with SF than in those without SF (Log‐rank test: both P < 0.05). SF remained as significantly associated with both the combined end point (hazard ratio, 1.30; 95% CI, 1.02–1.66; P = 0.038) and all‐cause mortality (hazard ratio, 1.53; 95% CI, 1.01–2.30; P = 0.044), even after adjusting for key clinical risk factors. Furthermore, SF showed significant incremental prognostic value over known risk factors for both the combined end point (net‐reclassification improvement: 0.189, 95% CI, 0.063–0.316, P = 0.003) and all‐cause mortality (net‐reclassification improvement: 0.234, 95% CI, 0.073–0.395, P = 0.004).

Conclusions

Among hospitalized geriatric patients with HF, two thirds have SF. Evaluating SF provides additive prognostic information in elderly patients with HF.

Registration

URL: https://upload.umin.ac.jp/. Unique identifier: UMIN000023929.

Standardized gait speed ratio in elderly patients with heart failure

Aims

Although aging is strongly associated with both heart failure and a decline in gait speed, a definition of slowness incorporating an age‐related decline has yet to be developed. We aimed to define an event‐driven cut‐off for the relative decline in gait speed against age‐adjusted reference values derived from the general population and evaluate its prognostic implications.

Methods and results

Standardized gait speed (SGS) was defined as the median gait speed stratified by age, sex, and height in 3777 elderly (age ≥ 65 years) individuals without a history of cardiovascular diseases (Tokyo Metropolitan Institute of Gerontology‐Longitudinal Interdisciplinary Study on Aging: general population cohort). The mortality event‐driven optimal cut‐off of the SGS ratio (actual gait speed divided by the respective SGS) was defined using FRAGILE‐HF cohort data and externally validated using Kitasato cohort data, comprising 1301 and 1247 hospitalized elderly patients with heart failure, respectively. Using FRAGILE‐HF data, the optimal SGS ratio cut‐off was determined as 0.527. In the Kitasato cohort, SGS ratio < 0.527 was associated with a higher 1 year [hazard ratio (HR): 1.70, 95% confidence interval (CI): 1.07–2.72, P = 0.024] and long‐term (HR: 1.46, 95% CI: 1.05–2.02, P = 0.024) mortality rate, independent of pre‐existing covariates.

Conclusions

Gait speed was significantly declined in patients with heart failure, even after taking age and sex‐related decline into account. A SGS ratio of 0.527 is a validated cut‐off for slowness independently associated with mortality in patients with heart failure age ≥65.

Prognostic value of natriuretic peptides in heart failure: systematic review and meta-analysis

Risk models, informing optimal long-term medical management, seldom use natriuretic peptides (NP) in ascertaining the absolute risk of outcomes for HF patients. Individual studies evaluating the prognostic value of NPs in HF patients have reported varying effects, arriving at best estimates requires a systematic review. We systematically summarized the best evidence regarding the prognostic value of brain natriuretic peptide (BNP) and NT-proBNP in predicting mortality and hospitalizations in ambulatory heart failure (HF) patients. We searched bibliographic databases from 2005 to 2018 and included studies evaluating the association of BNP or NT-proBNP with mortality or hospitalization using multivariable Cox proportional hazard models. We pooled hazard ratios using random-effect models, explored heterogeneity using pre-specified subgroup analyses, and evaluated the certainty of evidence using the Grading of Recommendations and Development Evaluation framework. We identified 67 eligible studies reporting on 76,178 ambulatory HF patients with a median BNP of 407 pg/mL (261-574 pg/mL). Moderate to high-quality evidence showed that a 100-pg/mL increase in BNP was associated with a 14% increased hazard of mortality (HR 1.14, 95% CI 1.06-1.22); a 1-log-unit increase was associated with a 51% increased hazard of mortality (HR 1.51, 95% CI 1.41-1.61) and 48% increased hazard of mortality or hospitalization (HR 1.48, 95% CI 1.29-1.69). With moderate to high certainty, we observed a 14% independent relative increase in mortality, translating to a clinically meaningful increase in absolute risk even for low-risk patients. The observed associations may help in developing more accurate risk models that incorporate NPs and accurately prognosticate HF patients.

Aspartate aminotransferase to alanine aminotransferase ratio is associated with frailty and mortality in older patients with heart failure

Frailty is a common comorbidity associated with adverse events in patients with heart failure, and early recognition is key to improving its management. We hypothesized that the AST to ALT ratio (AAR) could be a marker of frailty in patients with heart failure. Data from the FRAGILE-HF study were analyzed. A total of 1327 patients aged ≥ 65 years hospitalized with heart failure were categorized into three groups based on their AAR at discharge: low AAR (AAR < 1.16, n = 434); middle AAR (1.16 ≤ AAR < 1.70, n = 487); high AAR (AAR ≥ 1.70, n = 406). The primary endpoint was one-year mortality. The association between AAR and physical function was also assessed. High AAR was associated with lower short physical performance battery and shorter 6-min walk distance, and these associations were independent of age and sex. Logistic regression analysis revealed that high AAR was an independent marker of physical frailty after adjustment for age, sex and body mass index. During follow-up, all-cause death occurred in 161 patients. After adjusting for confounding factors, high AAR was associated with all-cause death (low AAR vs. high AAR, hazard ratio: 1.57, 95% confidence interval, 1.02–2.42; P = 0.040). In conclusion, AAR is a marker of frailty and prognostic for all-cause mortality in older patients with heart failure.

Risk Stratification Towards Precision Medicine in Heart Failure - Current Progress and Future Perspectives

Clinical risk stratification is a key strategy used to identify low- and high-risk subjects to optimize the management, ranging from pharmacological treatment to palliative care, of patients with heart failure (HF). Using statistical modeling techniques, many HF risk prediction models that combine predictors to assess the risk of specific endpoints, including death or worsening HF, have been developed. However, most risk prediction models have not been well-integrated into the clinical setting because of their inadequacy and diverse predictive performance. To improve the performance of such models, several factors, including optimal sampling and biomarkers, need to be considered when deriving the models; however, given the large heterogeneity of HF, the currently advocated one-size-fits-all approach is not appropriate for every patient. Recent advances in techniques to analyze biological "omics" information could allow for the development of a personalized medicine platform, and there is growing awareness that an integrated approach based on the concept of system biology may be an excessively naïve view of the multiple contributors and complexity of an individual's HF phenotype. This review article describes the progress in risk stratification strategies and perspectives of emerging precision medicine in the field of HF management.

The impact of frailty according to Clinical Frailty Scale on clinical outcome in patients with heart failure

AIMS

There is currently no gold standard in evaluating frailty in patients with heart failure (HF), and the prognostic value of frailty according to the Canadian Study of Health and Aging Clinical Frailty Scale (CFS) on mortality in patients with HF is still unknown.

METHODS AND RESULTS

Among consecutive 596 patients after their discharge from HF in Kokura Memorial Hospital (Kitakyushu, Japan) during 2015, their frailty at discharge was assessed according to CFS. Patients were classified into three groups: low (N = 232, 38.9%), intermediate (N = 230, 38.6%), and high (N = 134, 22.5%). The primary endpoint was defined as 2 year all-cause death. The mean age was 76.6 ± 10.1 years, and 55.3% were men in entire cohort. There were significant differences in age, living environment, and dementia among low, intermediate, and high CFS groups. Left ventricular ejection fraction (LVEF) and co-morbidities such as severe renal failure and severe anaemia tended to increase with frailty severity, while body mass index (BMI) and albumin level tended to decrease with frailty severity. Two year cumulative incidences of all-cause death for the three groups were 12.8%, 25.4%, and 52.7% (P < 0.001), respectively. This significant difference in the risk for all-cause death among the CFS groups was driven by the risk for cardiac (8.6%, 14.2%, and 31.0%, respectively, P < 0.001) and non-cardiac death (4.6%, 13.0%, and 31.4%, respectively, P < 0.001). The multivariate analysis showed that high frailty was independently associated with all-cause death (intermediate CFS group: adjusted hazard ratio, 1.43, 95% confidence interval, 0.86-2.36, P = 0.16; high CFS group: adjusted hazard ratio, 3.90, 95% confidence interval, 2.32-6.55, P < 0.001), and this result was consistent, irrespective of stratification based on age, sex, BMI, and LVEF without significant interaction.

CONCLUSIONS

The simple CFS tool was successful in predicting the risk for all-cause death in patients with HF, and frailty according to CFS was independently associated with all-cause death irrespective of stratification based on age, sex, BMI, and LVEF without significant interaction. The CFS is a valuable prognostic tool in clinical settings.

Validity and Utility of the Questionnaire-based FRAIL Scale in Older Patients with Heart Failure: Findings from the FRAGILE-HF

OBJECTIVES

We investigated whether the FRAIL scale questionnaire is consistent with the Fried criteria, predicts all-cause mortality, and reflects physical dysfunction in patients with heart failure (HF).

DESIGN

Secondary analysis of FRAGILE-HF, a cohort study that enrolled participants from 2016 to 2018 and followed-up for 1-year of discharge.

SETTING AND PARTICIPANTS

A prospective multicenter cohort study in which 15 hospitals in Japan (8 university hospitals and 7 nonuniversity teaching hospitals) participated. We prospectively enrolled 1332 consecutive hospitalized patients ≥65 years old with HF and analyzed 1028 patients after excluding 304 patients with missing data on the FRAIL scale.

METHODS

The FRAIL scale, the Fried model, and physical function were measured before discharge. The endpoint was all-cause mortality.

RESULTS

According to the FRAIL scale, 459 (44.6%) and 491 (47.8%) were classified as frail and prefrail, respectively. The Kappa coefficient between the FRAIL scale and the Fried criteria were 0.39 [95% confidence interval (CI) 0.34-0.44; P < .001]. The area under the receiver-operating characteristic curves for frailty diagnosed by the Fried criteria of the FRAIL scale was 0.74 (95% CI 0.71-0.76; P < .001). A total of 118 deaths occurred during 1 year of follow-up. After adjusting for the MAGGIC risk score and log-BNP, The FRAIL scale predicted all-cause mortality (hazard ratio 1.17; 95% CI 1.01-1.36; P = .035). The FRAIL scale was also associated with various physical dysfunctions that correlated with poor prognosis.

CONCLUSIONS AND IMPLICATIONS

The FRAIL scale had moderate consistency with the Fried criteria, predicted all-cause mortality, and reflected clinically important physical dysfunctions.

MAGGIC Risk Model Predicts Adverse Events and Left Ventricular Remodeling in Non-Ischemic Dilated Cardiomyopathy

Purpose

We aimed to study the Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) risk model’s prognostic value and relationship with left ventricular remodeling in dilated cardiomyopathy.

Patients and Methods

Dilated cardiomyopathy patients were prospectively recruited and underwent clinical assessments. MAGGIC risk score was calculated. Patients were followed up for adverse events and echocardiography. Primary endpoints were all-cause mortality and first rehospitalization due to heart failure. Secondary endpoint was left ventricular remodeling defined as a decline in left ventricular ejection fraction >10% or an increase in left ventricular end-diastolic diameter >10%. Survival status was examined using Cox regression analysis. The model’s ability to discriminate adverse events and left ventricular remodeling was calculated using a receiver operating characteristics curve.

Results

In total, 114 patients were included (median follow-up time = 31 months). The risk score was independently related to adverse events (2-year all-cause mortality: hazard ratio [HR] = 1.122; 95% confidence interval [CI], 1.043–1.208; 1-year first rehospitalization due to heart failure: HR = 1.094; 95% CI, 1.032–1.158; 2-year first rehospitalization due to heart failure: HR = 1.088; 95% CI, 1.033–1.147, all P < 0.05). One-year change in left ventricular end-diastolic diameter was correlated with the risk score (r = 0.305, P = 0.002). The model demonstrated modest ability in discriminating adverse events and left ventricular remodeling (all areas under the curve were 0.6–0.7).

Conclusion

The MAGGIC risk score was related to adverse events and left ventricular remodeling in dilated cardiomyopathy.

Prevalence and prognostic value of the coexistence of anaemia and frailty in older patients with heart failure

Aims

There have been no investigations of the prevalence and clinical implications of coexistence of anaemia and frailty in older patients hospitalized with heart failure (HF) despite their association with adverse health outcomes. The present study was performed to determine the prevalence and prognostic value of the coexistence of anaemia and frailty in hospitalized older patients with HF.

Methods and results

We performed post hoc analysis of consecutive hospitalized HF patients ≥65 years old enrolled in the FRAGILE‐HF, which was the prospective, multicentre, observational study. Anaemia was defined as haemoglobin < 13 g/dL in men and <12 g/dL in women, and frailty was evaluated according to the Fried phenotype model. The study endpoint was all‐cause mortality. Of the total of 1332 patients, 1217 (median age, 81 years; 57.4% male) were included in the present study. The rates of anaemia and frailty in the study population were 65.7% and 57.0%, respectively. The patients were classified into the non‐anaemia/non‐frail group (16.6%), anaemia/non‐frail group (26.4%), non‐anaemia/frail group (17.7%), and anaemia/frail group (39.3%). A total of 144 patients died during 1 year of follow‐up. In multivariate analyses, only the anaemia/frail group showed a significant association with elevated mortality rate (adjusted hazard ratio, 1.94; 95% confidence interval, 1.02–3.70; P = 0.043), compared with the non‐anaemia/non‐frail group after adjusting for other covariates.

Conclusions

Coexistence of anaemia and frailty are prevalent in hospitalized older patients with HF, and it has a negative impact on mortality.

Differences in the prognoses of patients referred to an advanced heart failure center from hospitals with different bed volumes

Few reports have discussed appropriate strategies for patient referrals to advanced heart failure (HF) centers with available left ventricular assist devices (LVADs). We examined the association between the characteristics and prognoses of referred patients with advanced HF and the bed volume of the referring hospitals. This retrospective analysis evaluated 186 patients with advanced HF referred to our center for consultation about the indication of LVAD between January 1, 2015, and August 31, 2018. We divided the patients into two groups according to the bed volume of their referring hospital (high bed volume hospitals (HBHs): ≥ 500 beds in the hospital; low bed volume hospitals (LBHs): < 500 beds). We compared the primary outcome measure, a composite of LVAD implantation and all-cause death, between the patients referred from HBHs and patients referred from LBHs. The 186 patients with advanced HF referred to our hospital, who were referred from 130 hospitals (87 from LBHs and 99 from HBHs), had a mean age of 43.0 ± 12.6 years and a median left ventricular ejection fraction of 22% [15–33%]. The median follow-up duration of the patients was 583 days (119–965 days), and the primary outcome occurred during follow-up in 42 patients (43%) in the HBH group and 20 patients (23%) in the LBH group. Patients referred from HBHs tended to require catecholamine infusion on transfer more often than those referred from LBLs (36.5% (HBH), 20.2% (LBL), P = 0.021). Kaplan–Meier analysis indicates that the occurrence of the primary outcome was significantly higher in the HBH patients than in the LBH patients (log-rank P = 0.0022). Multivariate Cox proportional hazards analysis revealed that catecholamine support on transfer and long disease duration were statistically significant predictors of the primary outcome. Patients from HBHs had a greater risk of the primary outcome. However, the multivariate analysis did not indicate an association between referral from an HBH and the primary outcome. In contrast, catecholamine support on transfer, long duration of disease, and low blood pressure were independent predictors of the primary outcome. Therefore, these should be considered when determining the timing of a referral to an advanced HF center, irrespective of the bed volume of the referring hospital.