Prognostic value of pupil area for all-cause mortality in patients with heart failure

Pupil reflex as a marker of activity and prognosis in heart failure: a longitudinal and prospective study

AIMS

Compensatory mechanisms in heart failure (HF) are triggered to maintain adequate cardiac output. Among them, hyperactivation of the sympathetic nervous system (SNS) is one of the main ones and carries a worse prognosis. The pupillary reflex depends on the SNS, and we can evaluate it through pupillometry. The aim of the study was to compare the differences in pupillary reflex between patients with acute HF and controls and to analyse whether these differences in pupillary reflex may offer a new and easy prognostic factor in such patients.

METHODS AND RESULTS

We prospectively and consecutively included 107 patients admitted with decompensated HF. Quantitative pupillometry was performed with the NeuroOptics pupillometry during the first 24 h after admission and prior to discharge. The results were compared with those of a group of 100 healthy volunteers who also underwent pupillometry. The maximum baseline pupil size (MBPS) and the minimum pupil diameter (MPD) were measured. Patients with decompensated HF have a higher MBPS (3.64 ± 0.81) and higher MPD (2.60 ± 0.58) than HF patients at discharge and in the control group (P-value = 0.01 and 0.01, respectively). Also, HF patients presented an improvement in pupillometric values at discharge [MBPS (3.47 ± 0.79) and MPD (2.51 ± 0.58)] and showed no differences compared with the control group [MBPS (3.34 ± 0.82) and MPD (2.40 ± 0.53)] (P-value = 0.19 and 0.14, respectively). In addition, MBPS provides a good independent predictor of in-hospital and 1 month mortality in patients admitted with HF. Six patients (5.61%) died during hospital admission, and 11 patients (10.2%) died in the first month after discharge. Also, four patients (3.74%) were readmitted within 1 month of discharge. The receiver operating characteristic (ROC) curve for predicting in-hospital mortality through MBPS was 0.823. No patient with an MBPS < 3.7 mm died. The ROC curve for predicting combined mortality or readmission within the first month for MBPS was 0.698.

CONCLUSIONS

Pupillometry may be a new, non-invasive, and simple tool to determine the status of SNS, help in the prognostic stratification of acute HF patients, and improve therapeutic management.

Why Do We Not Assess Sympathetic Nervous System Activity in Heart Failure Management: Might GRK2 Serve as a New Biomarker?

Heart failure (HF) represents the end-stage condition of several structural and functional cardiovascular diseases, characterized by reduced myocardial pump function and increased pressure load. The dysregulation of neurohormonal systems, especially the hyperactivity of the cardiac adrenergic nervous system (ANS), constitutes a hallmark of HF and exerts a pivotal role in its progression. Indeed, it negatively affects patients’ prognosis, being associated with high morbidity and mortality rates, with a tremendous burden on global healthcare systems. To date, all the techniques proposed to assess the cardiac sympathetic nervous system are burdened by intrinsic limits that hinder their implementation in clinical practice. Several biomarkers related to ANS activity, which may potentially support the clinical management of such a complex syndrome, are slow to be implemented in the routine practice for several limitations due to their assessment and clinical impact. Lymphocyte G-protein-coupled Receptor Kinase 2 (GRK2) levels reflect myocardial β-adrenergic receptor function in HF and have been shown to add independent prognostic information related to ANS overdrive. In the present manuscript, we provide an overview of the techniques currently available to evaluate cardiac ANS in HF and future perspectives in this field of relevant scientific and clinical interest.

Prognostic value of pupil area for all-cause mortality in patients with heart failure

Aims

The area of the pupil can be used as an indicator of autonomic function. However, the relation between pupil area and prognosis in heart failure (HF) patients remains unclear. This study was performed to examine whether pupil area can be used as a prognostic indicator in patients with HF.

Methods and results

This retrospective review was performed in 870 consecutive patients (mean age: 67.0 ± 14.1 years, 37.0% women) hospitalized for acute HF. Pupil area was measured with a pupilometer at least 7 days after hospitalization for HF. The primary endpoint was all‐cause mortality, and the secondary endpoint was readmission due to HF. A total of 131 patients died, and 328 patients were readmitted because of HF over a median follow‐up of 1.9 (interquartile range: 1.0–3.7 years) years. After adjustment for several pre‐existing prognostic factors, including Seattle Heart Failure Score (SHFS), pupil area was shown to be independently associated with all‐cause mortality (hazard ratio: 0.72; 95% confidence interval: 0.59–0.88; P = 0.001) and readmission due to HF (hazard ratio: 0.82; 95% confidence interval: 0.73–0.93; P = 0.003). Addition of pupil area to SHFS significantly increased the area under the receiver‐operating characteristic curve for all‐cause mortality (0.69 vs. 0.72, respectively; P = 0.034).

Conclusions

Pupil area is an independent predictor of all‐cause mortality and readmission due to HF and adds prognostic information to SHFS in patients with HF. The results presented here suggest that pupil area may be useful as a prognostic marker in patients with HF.