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Gentile F, Sciarrone P, Panichella G, Bazan L, Chubuchny V, Buoncristiani F, Gasparini S, Taddei C, Poggianti E, Fabiani I, Aimo A, Petersen C, Passino C, Emdin M, Giannoni A. Echocardiography-Derived Forward Left Ventricular Output Improves Risk Prediction in Systolic Heart Failure. J Am Soc Echocardiogr 2024:S0894-7317(24)00321-3. [PMID: 38942218 DOI: 10.1016/j.echo.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/30/2024] [Accepted: 06/05/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Although it is widely used to classify patients with heart failure (HF), the prognostic role of left ventricular ejection fraction (LVEF) is debated. The aim of this study was to test the hypothesis that echocardiographic measures of forward left ventricular (LV) output, being more representative of cardiac hemodynamics, might improve risk prediction in a large cohort of patients with HF with systolic dysfunction. METHODS Consecutive stable patients with HF with LVEF <50% on guideline-recommended therapies undergoing echocardiography including the evaluation of forward LV output (i.e., LV outflow tract [LVOT] velocity-time integral [VTI], stroke volume index [SVi], and cardiac index) over a 6-year period were selected and followed for the end point of cardiac and all-cause death. RESULTS Among the 1,509 patients analyzed (mean age, 71 ± 12 years; 75% men; mean LVEF, 35 ± 9%), 328 (22%) died during a median follow-up period of 28 months (interquartile range, 14-40 months), 165 (11%) of cardiac causes. On multivariable regression analysis, LVOT VTI (P < .001), SVi (P < .001), and cardiac index (P < .001), but not LVEF (P > .05), predicted cardiac and all-cause death. The optimal prognostic cutoffs for LVOT VTI, SVi, and cardiac index were 15 cm, 38 mL/m2, and 2 L/min/m2, respectively. Adding each of these measures to a multivariable risk model (including clinical, biohumoral, and echocardiographic markers) improved risk prediction (P < .001). Among the different measures of forward LV output, cardiac index was less accurate than LVOT VTI and SVi. CONCLUSIONS The echocardiographic evaluation of forward LV output improves risk prediction in patients with HF across a wide LVEF spectrum over other well-established clinical, biohumoral, and echocardiographic prognostic markers.
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Affiliation(s)
- Francesco Gentile
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Giorgia Panichella
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Lorenzo Bazan
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | - Simone Gasparini
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | | | - Alberto Aimo
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Claudio Passino
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alberto Giannoni
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
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Petmezas G, Papageorgiou VE, Vassilikos V, Pagourelias E, Tsaklidis G, Katsaggelos AK, Maglaveras N. Recent advancements and applications of deep learning in heart failure: Α systematic review. Comput Biol Med 2024; 176:108557. [PMID: 38728995 DOI: 10.1016/j.compbiomed.2024.108557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/12/2024] [Accepted: 05/05/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Heart failure (HF), a global health challenge, requires innovative diagnostic and management approaches. The rapid evolution of deep learning (DL) in healthcare necessitates a comprehensive review to evaluate these developments and their potential to enhance HF evaluation, aligning clinical practices with technological advancements. OBJECTIVE This review aims to systematically explore the contributions of DL technologies in the assessment of HF, focusing on their potential to improve diagnostic accuracy, personalize treatment strategies, and address the impact of comorbidities. METHODS A thorough literature search was conducted across four major electronic databases: PubMed, Scopus, Web of Science and IEEE Xplore, yielding 137 articles that were subsequently categorized into five primary application areas: cardiovascular disease (CVD) classification, HF detection, image analysis, risk assessment, and other clinical analyses. The selection criteria focused on studies utilizing DL algorithms for HF assessment, not limited to HF detection but extending to any attempt in analyzing and interpreting HF-related data. RESULTS The analysis revealed a notable emphasis on CVD classification and HF detection, with DL algorithms showing significant promise in distinguishing between affected individuals and healthy subjects. Furthermore, the review highlights DL's capacity to identify underlying cardiomyopathies and other comorbidities, underscoring its utility in refining diagnostic processes and tailoring treatment plans to individual patient needs. CONCLUSIONS This review establishes DL as a key innovation in HF management, highlighting its role in advancing diagnostic accuracy and personalized care. The insights provided advocate for the integration of DL in clinical settings and suggest directions for future research to enhance patient outcomes in HF care.
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Affiliation(s)
- Georgios Petmezas
- 2nd Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece; Centre for Research and Technology Hellas, Thessaloniki, Greece.
| | | | - Vasileios Vassilikos
- 3rd Department of Cardiology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efstathios Pagourelias
- 3rd Department of Cardiology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Tsaklidis
- Department of Mathematics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aggelos K Katsaggelos
- Department of Electrical and Computer Engineering, Northwestern University, Evanston, IL, USA
| | - Nicos Maglaveras
- 2nd Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Ahmad FS, Hu TL, Adler ED, Petito LC, Wehbe RM, Wilcox JE, Mutharasan RK, Nardone B, Tadel M, Greenberg B, Yagil A, Campagnari C. Performance of risk models to predict mortality risk for patients with heart failure: evaluation in an integrated health system. Clin Res Cardiol 2024:10.1007/s00392-024-02433-2. [PMID: 38565710 DOI: 10.1007/s00392-024-02433-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 03/05/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Referral of patients with heart failure (HF) who are at high mortality risk for specialist evaluation is recommended. Yet, most tools for identifying such patients are difficult to implement in electronic health record (EHR) systems. OBJECTIVE To assess the performance and ease of implementation of Machine learning Assessment of RisK and EaRly mortality in Heart Failure (MARKER-HF), a machine-learning model that uses structured data that is readily available in the EHR, and compare it with two commonly used risk scores: the Seattle Heart Failure Model (SHFM) and Meta-Analysis Global Group in Chronic (MAGGIC) Heart Failure Risk Score. DESIGN Retrospective, cohort study. PARTICIPANTS Data from 6764 adults with HF were abstracted from EHRs at a large integrated health system from 1/1/10 to 12/31/19. MAIN MEASURES One-year survival from time of first cardiology or primary care visit was estimated using MARKER-HF, SHFM, and MAGGIC. Discrimination was measured by the area under the receiver operating curve (AUC). Calibration was assessed graphically. KEY RESULTS Compared to MARKER-HF, both SHFM and MAGGIC required a considerably larger amount of data engineering and imputation to generate risk score estimates. MARKER-HF, SHFM, and MAGGIC exhibited similar discriminations with AUCs of 0.70 (0.69-0.73), 0.71 (0.69-0.72), and 0.71 (95% CI 0.70-0.73), respectively. All three scores showed good calibration across the full risk spectrum. CONCLUSIONS These findings suggest that MARKER-HF, which uses readily available clinical and lab measurements in the EHR and required less imputation and data engineering than SHFM and MAGGIC, is an easier tool to identify high-risk patients in ambulatory clinics who could benefit from referral to a HF specialist.
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Affiliation(s)
- Faraz S Ahmad
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Suite 600, Chicago, IL, 60611, USA.
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL, USA.
- Institute for Augmented Intelligence in Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Ted Ling Hu
- Institute for Augmented Intelligence in Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eric D Adler
- Division of Cardiology, Department of Medicine, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Lucia C Petito
- Division of Biostatistics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ramsey M Wehbe
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL, USA
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jane E Wilcox
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Suite 600, Chicago, IL, 60611, USA
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL, USA
| | - R Kannan Mutharasan
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Suite 600, Chicago, IL, 60611, USA
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL, USA
| | - Beatrice Nardone
- Institute for Augmented Intelligence in Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Matevz Tadel
- Physics Department, UC San Diego, La Jolla, CA, USA
| | - Barry Greenberg
- Division of Cardiology, Department of Medicine, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Avi Yagil
- Physics Department, UC San Diego, La Jolla, CA, USA
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Zheng S, Li L, Jiang C, He L, Lai Y, Li W, Zhao X, Wang X, Li L, Du X, Ma C, Dong J. Association between performance measures and clinical outcomes in patients with heart failure in China: Results from the HERO study. Clin Cardiol 2024; 47:e24233. [PMID: 38375935 PMCID: PMC10877660 DOI: 10.1002/clc.24233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/30/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND There is great heterogeneity in the quality of care among hospitals in China, but studies on the performance measures and prognosis of patients with heart failure (HF) are still deficient. HYPOTHESIS Performance measures have been used as a guideline to clinicans, however, the association between them and outcomes among HF patients in China remains unclear. METHODS We analyzed 4497 patients with HF from the Heart Failure Registry of Patient Outcomes study. Performance measures were determined according to the guidelines, and the patients were divided into four groups based on a composite performance score. Multiple imputation and Cox proportional-hazard regression models were used to assess the association between the performance measures and clinical outcomes. RESULTS Overall, only 12.5% of patients met the top 25% of the performance measures, whereas 33.5% of patients met the bottom 25% of the measures. A total of 992 (22.2%) patients died within 1 year, involving a larger proportion of patients who had met only the bottom 25% of the performance measures than had met the top 25% (27.0% vs. 16.3%, respectively). The patients who met the top 25% of the measures had a lower 1-year mortality rate (adjusted hazard ratio: 0.78, 95% confidence interval: 0.61-0.98). CONCLUSIONS The association between performance measures and mortality appeared to follow a dose-response pattern with a larger degree of compliance with performance measures being associated with a lower mortality rate in patients with HF. Accordingly, the quality of care for patients with HF in China needs to be further improved.
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Affiliation(s)
- Shiyue Zheng
- Department of Cardiology, Beijing AnZhen HospitalCapital Medical UniversityBeijingChina
| | - Li Li
- Department of CardiologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Chao Jiang
- Department of Cardiology, Beijing AnZhen HospitalCapital Medical UniversityBeijingChina
| | - Liu He
- Department of Cardiology, Beijing AnZhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular DiseasesCapital Medical UniversityBeijingChina
| | - Yiwei Lai
- Department of Cardiology, Beijing AnZhen HospitalCapital Medical UniversityBeijingChina
| | - Wenjie Li
- Department of Cardiology, Beijing AnZhen HospitalCapital Medical UniversityBeijingChina
| | - Xiaoyan Zhao
- Department of CardiologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Xiaofang Wang
- Department of CardiologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Ling Li
- Department of CardiologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Xin Du
- Department of Cardiology, Beijing AnZhen HospitalCapital Medical UniversityBeijingChina
| | - Changsheng Ma
- Department of Cardiology, Beijing AnZhen HospitalCapital Medical UniversityBeijingChina
| | - Jianzeng Dong
- Department of Cardiology, Beijing AnZhen HospitalCapital Medical UniversityBeijingChina
- Department of CardiologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
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Seferović P, Polovina M, Milinković I, Krljanac G, Ašanin M. Risk stratification models for predicting mortality in heart failure: a favourite or an outsider? Eur J Prev Cardiol 2024; 31:272-273. [PMID: 35950368 DOI: 10.1093/eurjpc/zwac173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Petar Seferović
- Faculty of Medicine, Belgrade University, 8 Dr Subotića, 11000 Belgrade, Serbia
- Serbian Academy of Sciences and Arts, 35 Kneza Mihaila, 11000 Belgrade, Serbia
| | - Marija Polovina
- Faculty of Medicine, Belgrade University, 8 Dr Subotića, 11000 Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, 8 Koste Todorovića, Belgrade, Serbia
| | - Ivan Milinković
- Faculty of Medicine, Belgrade University, 8 Dr Subotića, 11000 Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, 8 Koste Todorovića, Belgrade, Serbia
| | - Gordana Krljanac
- Faculty of Medicine, Belgrade University, 8 Dr Subotića, 11000 Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, 8 Koste Todorovića, Belgrade, Serbia
| | - Milika Ašanin
- Faculty of Medicine, Belgrade University, 8 Dr Subotića, 11000 Belgrade, Serbia
- Department of Cardiology, University Clinical Centre of Serbia, 8 Koste Todorovića, Belgrade, Serbia
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Paixão da Silva E, Ranielly Dos Santos Avelino R, Zuza Diniz RV, Dantas de Lira NR, Monteiro Lourenço Queiroz SI, Gomes Dantas Lopes MM, Maurício Sena-Evangelista KC. Body composition, lipid profile and clinical parameters are predictors of prognosis in patients with heart failure: Two-year follow-up. Clin Nutr ESPEN 2023; 56:52-58. [PMID: 37344083 DOI: 10.1016/j.clnesp.2023.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 04/16/2023] [Accepted: 04/28/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Heart failure (HF) is a complex syndrome that leads to changes in body composition and eventually results in unfavorable outcomes. AIM This study aimed to evaluate body composition, lipid profiles and clinical parameters of patients with HF, and their associations with both survival and unfavorable clinical outcomes. METHODS This prospective cohort study included 94 adults and older people with HF. Body composition was assessed by bioelectrical impedance analysis (BIA). Anthropometric variables and lipid profile were also evaluated. Electronic medical records were checked to collect information on clinical outcomes (mortality and hospitalization), considering a follow-up period of 24 months. Survival was calculated using the Kaplan-Meier estimate, and the curves compared using Log-Rank. The death risk rate (Hazard Ratio, HR) was calculated using Cox's univariate models. RESULTS Mean age was 55.1 (13.9) years and there was a higher frequency of males. There was a predominance of HF with reduced ejection fraction, and ischemic etiology. Patients with New York Heart Association (NYHA) functional classification I/II had a better overall survival rate at 24 months than those with NYHA III/IV (univariate HR 4.93 (1.76-13.82); p = 0.001). Greater survival rates were found in patients without chronic kidney disease (CKD) (univariate HR 2.93 (1.59-5.39); p = 0.01). In the multivariate analyses, both dyslipidemia (adjusted HR 3.84 (1.22-12.00); p = 0.021) and increased fat mass index (FMI) were associated with overall survival rate (adjusted HR 3.59 (1, 10-11.74); p = 0.034). CONCLUSION The severity of HF symptoms and the presence of chronic kidney disease are associated with higher mortality. Increased fat mass index and dyslipidemia are predictors of favorable outcomes in this population.
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Affiliation(s)
- Eduardo Paixão da Silva
- Multiprofessional Residency in Health - Cardiology, Onofre Lopes University Hospital, Federal University of Rio Grande Do Norte (EPS, RRSA, RVZD, NRDL, MMGDL, KCMSE), Brazil
| | - Regina Ranielly Dos Santos Avelino
- Multiprofessional Residency in Health - Cardiology, Onofre Lopes University Hospital, Federal University of Rio Grande Do Norte (EPS, RRSA, RVZD, NRDL, MMGDL, KCMSE), Brazil
| | - Rosiane Viana Zuza Diniz
- Multiprofessional Residency in Health - Cardiology, Onofre Lopes University Hospital, Federal University of Rio Grande Do Norte (EPS, RRSA, RVZD, NRDL, MMGDL, KCMSE), Brazil; Department of Clinical Medicine, Health Sciences Center, Federal University of Rio Grande Do Norte (RVZD), Brazil
| | - Niethia Regina Dantas de Lira
- Multiprofessional Residency in Health - Cardiology, Onofre Lopes University Hospital, Federal University of Rio Grande Do Norte (EPS, RRSA, RVZD, NRDL, MMGDL, KCMSE), Brazil; Brazilian Hospital Services Company. Onofre Lopes University Hospital, Health Sciences Center, Federal University of Rio Grande Do Norte (NRDL), Brazil
| | | | - Márcia Marília Gomes Dantas Lopes
- Multiprofessional Residency in Health - Cardiology, Onofre Lopes University Hospital, Federal University of Rio Grande Do Norte (EPS, RRSA, RVZD, NRDL, MMGDL, KCMSE), Brazil; Department of Nutrition, Health Sciences Center, Federal University of Rio Grande Do Norte (MMGDL, KCMSE), Brazil
| | - Karine Cavalcanti Maurício Sena-Evangelista
- Multiprofessional Residency in Health - Cardiology, Onofre Lopes University Hospital, Federal University of Rio Grande Do Norte (EPS, RRSA, RVZD, NRDL, MMGDL, KCMSE), Brazil; Department of Nutrition, Health Sciences Center, Federal University of Rio Grande Do Norte (MMGDL, KCMSE), Brazil.
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7
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Docherty KF, Lam CSP, Rakisheva A, Coats AJS, Greenhalgh T, Metra M, Petrie MC, Rosano GMC. Heart failure diagnosis in the general community - Who, how and when? A clinical consensus statement of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2023; 25:1185-1198. [PMID: 37368511 DOI: 10.1002/ejhf.2946] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/17/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023] Open
Abstract
A significant proportion of patients experience delays in the diagnosis of heart failure due to the non-specific signs and symptoms of the syndrome. Diagnostic tools such as measurement of natriuretic peptide concentrations are fundamentally important when screening for heart failure, yet are frequently under-utilized. This clinical consensus statement provides a diagnostic framework for general practitioners and non-cardiology community-based physicians to recognize, investigate and risk-stratify patients presenting in the community with possible heart failure.
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Affiliation(s)
- Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore, Singapore
| | - Amina Rakisheva
- Scientific Research Institute of Cardiology and Internal Medicine, Almaty, Kazakhstan
| | | | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Cardiology. ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Täger T, Rößmann P, Frey N, Estler B, Mäck M, Schlegel P, Beckendorf J, Frankenstein L, Fröhlich H. Long-Term Trajectories of Biomarkers, Functional, and Echocardiographic Parameters in Patients with Chronic Heart Failure from Dilated or Ischaemic Cardiomyopathy. Cardiology 2023; 148:485-496. [PMID: 37517385 DOI: 10.1159/000532070] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION The long-term evolution of clinical, echocardiographic, and laboratory parameters of cardiac function in patients with chronic heart failure (HF) with either reduced (HFrEF) or mildly reduced (HFmrEF) left ventricular ejection fraction (LVEF) is incompletely characterised. METHODS We identified patients with chronic stable HF who presented at least twice to a university HF outpatient clinic between 1995 and 2021. Trajectories of NYHA functional class, LVEF, left ventricular internal end-diastolic diameter (LVIDD), NT-proBNP concentrations, and HF treatment over 10 years of follow-up were analysed using fractional polynomials. Analyses were repeated after stratifying patients according to aetiology (ischaemic vs. dilated) or HF category (HFrEF vs. HFmrEF). RESULTS A total of 2,132 patients were included, of whom 51% had ischaemic and 49% had dilated HF. Eighty six percent and 14% were classified as HFrEF and HFmrEF, respectively. Mean LVEF was 28 ± 10%, and median NT-proBNP and estimated glomerular filtration rate values were 1,170 (385-3,176) pmol/L and 81 (62-100) mL/min/1.73 m2, respectively. Median follow-up was 5.2 (2.6-9.2) years. Overall, NYHA functional class and LVIDD trajectories were U-shaped, whereas LVEF and NT-proBNP concentrations markedly improved during the first year and remained stable thereafter. However, the evolution of HF parameters significantly differed with respect to HF category and aetiology, with greater improvements seen in patients with HFrEF of non-ischaemic origin. Improvements in HF variables were associated with optimization of HF therapy, notably with initiation and up-titration of renin-angiotensin-system blockers. CONCLUSION This study provides insights into the natural history of HF in a large cohort of well-treated chronic HF outpatients with respect to subgroups of HF and different aetiologists.
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Affiliation(s)
- Tobias Täger
- Department for Cardiology, Angiology and Pulmology, University Hospital Heidelberg, Heidelberg, Germany
| | - Paulina Rößmann
- Department for Cardiology, Angiology and Pulmology, University Hospital Heidelberg, Heidelberg, Germany
| | - Norbert Frey
- Department for Cardiology, Angiology and Pulmology, University Hospital Heidelberg, Heidelberg, Germany
| | - Bent Estler
- Department for Cardiology, Angiology and Pulmology, University Hospital Heidelberg, Heidelberg, Germany
| | - Mirjam Mäck
- Department for Cardiology, Angiology and Pulmology, University Hospital Heidelberg, Heidelberg, Germany
| | - Philipp Schlegel
- Department for Cardiology, Angiology and Pulmology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jan Beckendorf
- Department for Cardiology, Angiology and Pulmology, University Hospital Heidelberg, Heidelberg, Germany
| | - Lutz Frankenstein
- Department for Cardiology, Angiology and Pulmology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hanna Fröhlich
- Department for Cardiology, Angiology and Pulmology, University Hospital Heidelberg, Heidelberg, Germany
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Wilcox JE, Al-Khatib SM. Personalizing Risk Assessment for Sudden Cardiac Death in Heart Failure: A Dream or a Reality? JACC. HEART FAILURE 2023; 11:55-57. [PMID: 36599550 DOI: 10.1016/j.jchf.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/25/2022] [Indexed: 01/03/2023]
Affiliation(s)
- Jane E Wilcox
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Sana M Al-Khatib
- Duke Clinical Research Institute and Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Katapadi A, Umland M, Khandheria BK. Update on the Practical Role of Echocardiography in Selection, Implantation, and Management of Patients Requiring Left Ventricular Assist Device Therapy. Curr Cardiol Rep 2022; 24:1587-1597. [PMID: 35984555 DOI: 10.1007/s11886-022-01771-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Echocardiography is a valuable tool for management of patients with a left ventricular assist device (LVAD). We present an updated review on the practical applications of the role of echocardiography for pre- and postoperative evaluation of patients selected. RECENT FINDINGS The LVAD is a temporary or permanent option for patients with advanced heart failure who are unresponsive to other therapy. Use of the device has its own risks, and implantation remains a complex procedure. Transthoracic and transesophageal echocardiography are useful tools for patient evaluation and monitoring both peri- and postoperatively, as we previously presented. Assessment of left and right ventricular function, complications such as thrombus formation or intracardiac shunting, and valvular disease are all important in this assessment. This also aids in predicting postoperative complications. Placement of the device is confirmed intraoperatively, and subsequent ramp studies are used to determine optimal device settings. Right ventricular (RV) failure is the most common postoperative complication and preoperative evaluation of its function is crucial. Studies suggest that tricuspid annular plane systolic excursion, RV fractional area change, and RV global longitudinal strain are strong predictors of RV failure; LV ejection fraction, size, and end-diastolic diameter are also important markers. Aortic regurgitation and mitral stenosis must always be corrected prior to LVAD placement. However, direct visualization before and after implantation, especially to rule out potential contraindications such as thrombi, cannot be overemphasized. Ramp studies remain an integral part of device optimization and may result in greater myocardial recovery than previously realized.
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Affiliation(s)
- Aashish Katapadi
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, WI, 53215, USA
| | - Matt Umland
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, WI, 53215, USA
| | - Bijoy K Khandheria
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Advocate Aurora Health, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, WI, 53215, USA.
- School of Medicine and Public Health, University of Wisconsin, Milwaukee, WI, 53215, USA.
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11
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Sammut‐Powell C, Taylor JK, Motwani M, Leonard CM, Martin GP, Ahmed FZ. Remotely Monitored Cardiac Implantable Electronic Device Data Predict All-Cause and Cardiovascular Unplanned Hospitalization. J Am Heart Assoc 2022; 11:e024526. [PMID: 35943063 PMCID: PMC9496305 DOI: 10.1161/jaha.121.024526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Unplanned hospitalizations are common in patients with cardiovascular disease. The "Triage Heart Failure Risk Status" (Triage-HFRS) algorithm in patients with cardiac implantable electronic devices uses data from up to 9 device-derived physiological parameters to stratify patients as low/medium/high risk of 30-day heart failure (HF) hospitalization, but its use to predict all-cause hospitalization has not been explored. We examined the association between Triage-HFRS and risk of all-cause, cardiovascular, or HF hospitalization. Methods and Results A prospective observational study of 435 adults (including patients with and without HF) with a Medtronic Triage-HFRS-enabled cardiac implantable electronic device (cardiac resynchronization therapy device, implantable cardioverter-defibrillator, or pacemaker). Cox proportional hazards models explored association between Triage-HFRS and time to hospitalization; a frailty term at the patient level accounted for repeated measures. A total of 274 of 435 patients (63.0%) transmitted ≥1 high HFRS transmission before or during the study period. The remaining 161 patients never transmitted a high HFRS. A total of 153 (32.9%) patients had ≥1 unplanned hospitalization during the study period, totaling 356 nonelective hospitalizations. A high HFRS conferred a 37.3% sensitivity and an 86.2% specificity for 30-day all-cause hospitalization; and for HF hospitalizations, these numbers were 62.5% and 85.6%, respectively. Compared with a low Triage-HFRS, a high HFRS conferred a 4.2 relative risk of 30-day all-cause hospitalization (8.5% versus 2.0%), a 5.0 relative risk of 30-day cardiovascular hospitalization (3.6% versus 0.7%), and a 7.7 relative risk of 30-day HF hospitalization (2.0% versus 0.3%). Conclusions In patients with cardiac implantable electronic devices, remotely monitored Triage-HFRS data discriminated between patients at high and low risk of all-cause hospitalization (cardiovascular or noncardiovascular) in real time.
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Affiliation(s)
- Camilla Sammut‐Powell
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and HealthUniversity of Manchester, Manchester Academic Health Science CentreManchesterUnited Kingdom
| | - Joanne K. Taylor
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and HealthUniversity of Manchester, Manchester Academic Health Science CentreManchesterUnited Kingdom
| | - Manish Motwani
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterUnited Kingdom,Department of CardiologyManchester University Hospitals National Health Service Foundation TrustManchesterUnited Kingdom
| | | | - Glen P. Martin
- Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and HealthUniversity of Manchester, Manchester Academic Health Science CentreManchesterUnited Kingdom
| | - Fozia Zahir Ahmed
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterUnited Kingdom,Department of CardiologyManchester University Hospitals National Health Service Foundation TrustManchesterUnited Kingdom
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12
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van Diepen S, Katz JN. A Call to Move from Point-in-Time towards Comprehensive Dynamic Risk Prediction in Critically Ill Patients with Heart Failure. J Card Fail 2022; 28:1100-1103. [PMID: 35561895 DOI: 10.1016/j.cardfail.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada.
| | - Jason N Katz
- Divison of Cardiology, Duke University School of Medicine, Durham, NC, USA
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13
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Ahmad FS, Luo Y, Wehbe RM, Thomas JD, Shah SJ. Advances in Machine Learning Approaches to Heart Failure with Preserved Ejection Fraction. Heart Fail Clin 2022; 18:287-300. [PMID: 35341541 PMCID: PMC8983114 DOI: 10.1016/j.hfc.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) represents a prototypical cardiovascular condition in which machine learning may improve targeted therapies and mechanistic understanding of pathogenesis. Machine learning, which involves algorithms that learn from data, has the potential to guide precision medicine approaches for complex clinical syndromes such as HFpEF. It is therefore important to understand the potential utility and common pitfalls of machine learning so that it can be applied and interpreted appropriately. Although machine learning holds considerable promise for HFpEF, it is subject to several potential pitfalls, which are important factors to consider when interpreting machine learning studies.
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Affiliation(s)
- Faraz S. Ahmad
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL
| | - Yuan Luo
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL
| | - Ramsey M. Wehbe
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL
| | - James D. Thomas
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL
| | - Sanjiv J. Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Bluhm Cardiovascular Institute Center for Artificial Intelligence, Northwestern Medicine, Chicago, IL
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14
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Wehbe RM, Thomas JD. Validating Deep Learning to Distinguish Takotsubo Syndrome From Acute Myocardial Infarction-Beware of Shortcuts, Human Supervision Required. JAMA Cardiol 2022; 7:477-479. [PMID: 35353132 DOI: 10.1001/jamacardio.2022.0193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Ramsey M Wehbe
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - James D Thomas
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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15
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Wang Q, Song Y, Wu Q, Dong Q, Yang S. Liver stiffness for predicting adverse cardiac events in chinese patients with heart failure: a two-year prospective study. BMC Cardiovasc Disord 2022; 22:51. [PMID: 35164689 PMCID: PMC8842900 DOI: 10.1186/s12872-022-02497-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 02/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate whether liver stiffness (LS) can predict adverse cardiac events in Chinese patients with heart failure (HF). METHODS A total of 53 hospitalized patients with HF were enrolled, and LS and tricuspid annual plane systolic excursion (TAPSE) were determined with Fibroscan® and echocardiography before discharge. They were divided into two groups: high LS group (LS > 6.9 Kpa, n = 23) and low LS group (LS ≤ 6.9 Kpa, n = 30). Patients were followed up for 24 months at an interval of 3 months. The endpoint of follow-up was death or rehospitalization for HF. RESULTS All patients were followed up for 24 months or until the endpoint. Patients in the high LS group had lower platelet count (P = 0.014), lower creatine clear rate (P = 0.014), higher level of B-type natriuretic peptide at discharge (P = 0.012), and lower TAPSE (P < 0.001) than those in the low LS group. During 24 months of follow-up, 3 (5.7%) deaths and 21 (39.6%) hospitalizations for HF were observed. Patients in the high LS group had a higher rate of death/rehospitalization than those in the low LS group (Hazard ratio 4.81; 95% confidence interval 1.69-13.7, P = 0.003) after adjustment for age, sex, platelet count, creatine clear rate, and B-type natriuretic peptide level. Moreover, TAPSE ≤ 16 could predict adverse cardiac events with an HR of 6.63 (95% confidence interval 1.69-13.7, P = 0.004) after adjustment for age, sex, platelet count, creatine clear rate, and B-type natriuretic peptide level. CONCLUSION LS and TAPSE could be used to predict worse outcomes in patients with HF.
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Affiliation(s)
- Qian Wang
- Department of Cardiovascular Diseases, Beijing Ditan Hospital of Capital Medical University, Beijing, 100015, China
| | - Yuqing Song
- Department of Cardiovascular Diseases, Beijing Ditan Hospital of Capital Medical University, Beijing, 100015, China
| | - Qiming Wu
- Department of Cardiovascular Diseases, Beijing Ditan Hospital of Capital Medical University, Beijing, 100015, China
| | - Qian Dong
- Department of Cardiovascular Diseases, Beijing Ditan Hospital of Capital Medical University, Beijing, 100015, China
| | - Song Yang
- Center of Hepatology, Beijing Ditan Hospital of Capital Medical University, Beijing, 100015, China. .,Center of Hepatology, Beijing Ditan Teaching Hospital, Peking University Health Science Center, Beijing, 100015, China. .,Department of Hepatology, The Fourth People's Hospital of Qinghai Province, Xining, 81000, China.
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16
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Wehbe RM. Unleashing the Power of Machine Learning to Predict Myocardial Recovery After Left Ventricular Assist Device: A Call for the Inclusion of Unstructured Data Sources in Heart Failure Registries. Circ Heart Fail 2021; 15:e009278. [PMID: 34949097 DOI: 10.1161/circheartfailure.121.009278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ramsey M Wehbe
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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17
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Subudhi S, Verma A, Patel AB, Hardin CC, Khandekar MJ, Lee H, McEvoy D, Stylianopoulos T, Munn LL, Dutta S, Jain RK. Comparing machine learning algorithms for predicting ICU admission and mortality in COVID-19. NPJ Digit Med 2021; 4:87. [PMID: 34021235 PMCID: PMC8140139 DOI: 10.1038/s41746-021-00456-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/16/2021] [Indexed: 02/06/2023] Open
Abstract
As predicting the trajectory of COVID-19 is challenging, machine learning models could assist physicians in identifying high-risk individuals. This study compares the performance of 18 machine learning algorithms for predicting ICU admission and mortality among COVID-19 patients. Using COVID-19 patient data from the Mass General Brigham (MGB) Healthcare database, we developed and internally validated models using patients presenting to the Emergency Department (ED) between March-April 2020 (n = 3597) and further validated them using temporally distinct individuals who presented to the ED between May-August 2020 (n = 1711). We show that ensemble-based models perform better than other model types at predicting both 5-day ICU admission and 28-day mortality from COVID-19. CRP, LDH, and O2 saturation were important for ICU admission models whereas eGFR <60 ml/min/1.73 m2, and neutrophil and lymphocyte percentages were the most important variables for predicting mortality. Implementing such models could help in clinical decision-making for future infectious disease outbreaks including COVID-19.
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Affiliation(s)
- Sonu Subudhi
- Department of Medicine/Gastroenterology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ashish Verma
- Department of Medicine/Renal Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ankit B Patel
- Department of Medicine/Renal Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - C Corey Hardin
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Melin J Khandekar
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Hang Lee
- Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Dustin McEvoy
- Mass General Brigham Digital Health eCare, Somerville, MA, USA
| | - Triantafyllos Stylianopoulos
- Cancer Biophysics Laboratory, Department of Mechanical and Manufacturing Engineering, University of Cyprus, Nicosia, Cyprus
| | - Lance L Munn
- Edwin L. Steele Laboratories, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Sayon Dutta
- Mass General Brigham Digital Health eCare, Somerville, MA, USA.
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| | - Rakesh K Jain
- Edwin L. Steele Laboratories, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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18
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Radhachandran A, Garikipati A, Zelin NS, Pellegrini E, Ghandian S, Calvert J, Hoffman J, Mao Q, Das R. Prediction of short-term mortality in acute heart failure patients using minimal electronic health record data. BioData Min 2021; 14:23. [PMID: 33789700 PMCID: PMC8010502 DOI: 10.1186/s13040-021-00255-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/21/2021] [Indexed: 12/15/2022] Open
Abstract
Background Acute heart failure (AHF) is associated with significant morbidity and mortality. Effective patient risk stratification is essential to guiding hospitalization decisions and the clinical management of AHF. Clinical decision support systems can be used to improve predictions of mortality made in emergency care settings for the purpose of AHF risk stratification. In this study, several models for the prediction of seven-day mortality among AHF patients were developed by applying machine learning techniques to retrospective patient data from 236,275 total emergency department (ED) encounters, 1881 of which were considered positive for AHF and were used for model training and testing. The models used varying subsets of age, sex, vital signs, and laboratory values. Model performance was compared to the Emergency Heart Failure Mortality Risk Grade (EHMRG) model, a commonly used system for prediction of seven-day mortality in the ED with similar (or, in some cases, more extensive) inputs. Model performance was assessed in terms of area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity. Results When trained and tested on a large academic dataset, the best-performing model and EHMRG demonstrated test set AUROCs of 0.84 and 0.78, respectively, for prediction of seven-day mortality. Given only measurements of respiratory rate, temperature, mean arterial pressure, and FiO2, one model produced a test set AUROC of 0.83. Neither a logistic regression comparator nor a simple decision tree outperformed EHMRG. Conclusions A model using only the measurements of four clinical variables outperforms EHMRG in the prediction of seven-day mortality in AHF. With these inputs, the model could not be replaced by logistic regression or reduced to a simple decision tree without significant performance loss. In ED settings, this minimal-input risk stratification tool may assist clinicians in making critical decisions about patient disposition by providing early and accurate insights into individual patient’s risk profiles. Supplementary Information The online version contains supplementary material available at 10.1186/s13040-021-00255-w.
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Affiliation(s)
| | - Anurag Garikipati
- Dascena, Inc, 12333 Sowden Rd Ste B PMB 65148, Houston, TX, 77080-2059, USA
| | - Nicole S Zelin
- Dascena, Inc, 12333 Sowden Rd Ste B PMB 65148, Houston, TX, 77080-2059, USA
| | - Emily Pellegrini
- Dascena, Inc, 12333 Sowden Rd Ste B PMB 65148, Houston, TX, 77080-2059, USA.
| | - Sina Ghandian
- Dascena, Inc, 12333 Sowden Rd Ste B PMB 65148, Houston, TX, 77080-2059, USA
| | - Jacob Calvert
- Dascena, Inc, 12333 Sowden Rd Ste B PMB 65148, Houston, TX, 77080-2059, USA
| | - Jana Hoffman
- Dascena, Inc, 12333 Sowden Rd Ste B PMB 65148, Houston, TX, 77080-2059, USA
| | - Qingqing Mao
- Dascena, Inc, 12333 Sowden Rd Ste B PMB 65148, Houston, TX, 77080-2059, USA
| | - Ritankar Das
- Dascena, Inc, 12333 Sowden Rd Ste B PMB 65148, Houston, TX, 77080-2059, USA
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