Prognostic value of a disease-specific health-related quality score in acute heart failure

Background

Despite the striking therapeutic progress made in the treatment of heart failure (HF), rehospitalization rate and mortality remain a major and often unpredictable problem. Previous studies have shown the prognostic value of Kansas City Cardiomyopathy Questionnaire (KCCQ), a score assessing disease-specific health-related quality of life in stable chronic HF patients. Recently, a large study including 4898 patients with acute HF (AHF) enrolled in China reported the incremental predictive ability of KCCQ for a composite outcome of death and rehospitalization. However, these findings were not yet confirmed. In order to address this unmet need, the aim of this study was to examine the prognostic value of KCCQ in another AHF cohort.

Purpose

To validate the prognostic value of the KCCQ in AHF.

Methods

Goal-directed AfterLoad Reduction in Acute Congestive Cardiac Decompensation Study (GALACTIC) was a prospective, multicenter (n=10), randomized, interventional controlled trial enrolling adult patients presenting with AHF. KCCQ was assessed shortly after admission. We focused on the prognostic value of the short version KCCQ-12, explored the association with the composite of all-cause mortality and AHF rehospitalization within 30- and 180-day follow-up and compared it to the original score. Patients were grouped into quartiles according their KCCQ: high-risk (0–<25), moderate- to high-risk (25–<50), low- to moderate-risk (50–<75) and low-risk group (75–100). Cumulative incidence of assessed endpoints was displayed in Kaplan-Meier curves. Covariate adjustments were made using Cox regression. Prognostic accuracy over N-terminal pro-B-type natriuretic peptide (NT-proBNP) was evaluated by time-dependent area under the curve.

Results

Among 781 patients, 419 (median age 78, 35% female, 32% new onset of HF) had a complete set of variables to calculate KCCQ. Follow-up was available in all patients up to 180 days. 29 (7%) and 122 (29%) patients died or were rehospitalized for AHF within 30- and 180-days, respectively. Median KCCQ-12 was 37.5 with 25% of patients attaining the high- and 8% the low-risk group. After adjustment, each 10-point decrease in the KCCQ was associated with a 10% increase in 180-day risk regardless of new onset or acute decompensated chronic HF, age, sex, comorbidities, systolic blood pressure, creatinine, NT-proBNP and sodium levels. The prognostic ability for a 30-day risk was not significant. Using the same adjustments, a 10-point decrease in the original KCCQ was significant for a 20% and a 11% increase in risk for the short- and long-term composite outcome. The prognostic accuracy of KCCQ was comparable to NT-proBNP.

Conclusions

Health status, measured by the KCCQ-12 among patients with AHF, is significantly associated with a long-term composite outcome of all-cause mortality and AHF rehospitalization. The original KCCQ overall score is an independent predictor for both, the 30- and 180-day composite outcome.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union, the Swiss National Science Foundation

Prognostic value of self-reported subjective exercise capacity in patients with acute dyspnea

Background

Quantitative assessment of self-reported exercise capacity as provided by the Duke Activity Status Index (DASI) is a validated measure of exercise capacity in stable ambulatory patients.

Objectives

This study aimedto test whether the quantification of self-reported exercise capacityusing the DASI may aid physicians in the risk stratification of patients presenting with acute dyspnea to the emergency department (ED).

Methods

Basics in Acute Shortness of Breath EvaLuation (BASEL V) was a prospective cohort study recruiting dyspneic patients at the ED. The prognostic value and accuracy of theDASI assessed shortly after presentation were quantified using Cox regression analyses and the Area under the curve (AUC).

Results

Among 1019 patients eligible for this analysis 529 (51.9%) had an adjudicated final diagnosis of acute heart failure, 75 (7.4%) and 297 (29.1%) patients died within 90 and 720 days after presentation. Unadjusted hazard ratios (HR) and multivariable adjusted hazard ratios (aHR) for 90-day and 720-day mortality increased continuously from the fourth (best self-reported exercise capacity) to the first DASI-quartile (worst self-reported exercise capacity). For 720-day mortality in the first quartile theHR was 9.1 (95%-CI 5.5–14.9) (aHR 6.1 [95%-CI 3.7–10.1]), in the second quartile 6.4 (95%-CI 3.9–10.6) (aHR 4.4 [95%-CI 2.6–7.3]), while in the third quartile the HR was 3.2 (95%-CI 1.9–5.5) (aHR 2.4 [95%-CI 1.4–4.0]). The prognostic accuracy of the DASI was moderate-to-high and higher than that of B-type natriuretic peptide (BNP) and NT-proBNP (N-terminal pro-BNP) concentrations, e.g. for 720-day mortality prediction AUC 0.70 versus 0.64, p=0.020; 0.72 versus 0.68, p=0.074.

Conclusions

Quantification of self-reported subjective exercise capacityusing the DASI provides moderate-to-high prognostic accuracy in patients presenting with acute dyspnea to the ED and may aid physicians in further risk stratification.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union, the Swiss National Science Foundation. Duke Activity Status Index

Prognostic value of health-related quality of life in patients with acute dyspnea

Background

Previous studies have shown the prognostic value of health-related quality of life (HRQL) in stable and ambulatory chronic heart failure patients. However, it is unknown whether HRQL can predict all-cause mortality in patients presenting to the emergency department (ED) after acute onset of symptoms. In order to address this unmet need, the aim of this study was to assess the prognostic value of HRQL in patients with acute dyspnea caused by acute heart failure (AHF) and other dyspnea aetiologies for 360-day mortality.

Purpose

To assess prognostic value of HRQL using the generic EQ-5D and visual analogue scale (EQ VAS) in patients with acute dyspnea.

Methods

Basics in Acute Shortness of Breath EvaLuation (BASEL V) is a prospective, multicenter, diagnostic study enrolling adult patients presenting with acute dyspnea to the ED. For this analysis, only patients with a complete set of variables necessary for calculation of EQ-5D (range 0–10; with higher score indicating worse HRQL) and EQ VAS (range 0–100; with 100 being the best imaginable health state) at baseline were included. The endpoint was the prognostic value of EQ-5D and EQ VAS at 360 days of follow-up regarding all-cause death. Prognostic accuracy was calculated using c-statistics. In a cox regression analysis EQ-5D was treated as both, a continuous and categorical variable. Adjustments were made for clinically relevant covariates (age, sex, orthopnoea, edema, level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) at presentation, history of coronary artery disease and chronic obstructive pulmonary disease, diuretics, β-blockers and ACE-inhibitors at discharge).

Results

Among 2605 patients enrolled, 1141 (43,8%) had a complete set of variables allowing the calculation of EQ-5D and EQ VAS. Of these patients 594 (52.1%) had an adjudicated final diagnosis of AHF. 211 (18.5%) patients died within 360 days of follow-up. Median EQ-5D was 3 (interquartile range (IQR) 1.5–5) and median EQ VAS was 50 (IQR 40–70). The prognostic accuracy for 360-day mortality was 0.65 (95% confidence interval ((CI) 0.61–0.69) and 0.58 (95% CI 0.54–0.62) for EQ-5D and EQ VAS, respectively (p=0.002). After combining EQ-5D and EQ VAS in a logistic regression model c-statistics regarding all-cause mortality within 360 days did not improve. The prognostic accuracy of EQ-5D was comparable to that of NT-proBNP (c-statistics 0.69, p=0.385). In an adjusted cox regression analysis the hazard ratio for patients with EQ-5D >4 was 2.2 (95% CI 1.7–2.9; p<0.001).

Conclusions

In patients presenting with acute dyspnea HRQL is a strong prognostic instrument. Independently of the aetiology of the dyspnea the prognostic value of the generic EQ-5D for 360-day mortality is comparable to NT-proBNP. Patients with an EQ-5D >4 are at significantly higher risk for mortality within 360 days.

Figure 1. Prognostic value of HRQL

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, Swiss Heart Foundation

Quantifying inflammation using interleukin-6 for improved phenotyping and risk stratification in acute heart failure

Background

Acute heart failure (AHF) is the most common cause of hospital admission and continues to have unacceptable high rates of mortality and morbidity. In contrast to acute myocardial infarction, the pathophysiology of AHF is incompletely understood and risk-prediction is poorly defined.

Aim

We aimed to quantify systemic inflammation to assess its possible role in the pathophysiology and risk stratification of patients with AHF.

Methods

Using a novel Interleukin-6 immunoassay with unprecedented sensitivity (limit of detection 0.01ng/l) we quantified systemic inflammation in unselected patients presenting with acute dyspnea to the emergency department in a multicenter study. Plasma concentrations of NT-proBNP (open label) and Interleukin-6 (blinded) were measured at presentation and at discharge. The final diagnosis of AHF and the AHF phenotype were adjudicated by two independent cardiologists. 1-year mortality was the prognostic endpoint.

Results

Among 2042 patients, 1026 (50.2%) had an adjudicated diagnosis of AHF. Interleukin-6 concentrations were significantly higher in AHF patients compared to patients with other causes of dyspnoea (11.2 [6.1–26.5] ng/l vs 9.0 [3.2–32.3] ng/l, p<0.0005). Among patients with AHF Interleukin-6 concentrations were elevated (>4.45ng/l) in 83.7% of them. Among the different AHF phenotypes, Interleukin-6 concentrations were highest in patients with cardiogenic shock (25.7 [14.0–164.2] ng/l) and lowest in patients with hypertensive HF (9.3 [4.8–21.6] ng/l, p=0.001). Inflammation as quantified by Interleukin-6 was a strong predictor of 1-year mortality both in AHF as well as in other causes of acute dyspnea (Figure). During in-hospital treatment Interleukin-6 concentrations significantly decreased in AHF patients. However, changes in the extend of systemic inflammation (delta Interleukin-6) were poorly correlated with changes in hemodynamic stress as quantified by NT-proBNP (delta NT-proBNP, Φc=0.11, p=0.004).

Conclusions

An unexpectedly high percentage of patients with AHF have subclinical systemic inflammation that can be quantified by Interleukin-6, which seems to contribute to the AHF phenotype and to the risk of death.

Kaplan Meier curves for mortality

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swiss National Science Foundation, Swiss Heart Foundation, European Union, Stiftung für kardiovaskuläre Forschung Basel, University of Basel, University Hospital Basel

P2617Activity of the adrenomedullin system to personalize post-discharge treatment in acute heart failure

Objectives

Activity of the adrenomedullin system was quantified by using bioactive-adrenomedullin (bio-ADM), the biologically active moiety, and midregional proadrenomedullin (MR-proADM), a prohormone fragment, to 1) identify acute heart failure (AHF) phenotypes with disproportional benefit or harm from specific treatments at hospital discharge, 2) predict mortality, and 3) compare the prognostic utility of both biomarkers.

Methods

This prospective multicentre study using central adjudication of AHF measured bio-ADM in all patients and MR-proADM in a predefined subgroup in a blinded fashion on admission. Both biomarkers were measured at discharge as well. Interaction with specific treatments at hospital discharge and the biomarkers' prognostic utility during 365 days' follow-up were assessed.

Results

Among 1,886 patients with adjudicated AHF, 514 patients (27.3%) died during the 365 days' follow-up. Patients with bio-ADM plasma concentrations above the median were at a much higher risk of death (HR 1.87, 95% CI 1.57–2.24; p<0.001). After adjusting for age, creatinine plasma concentrations, and medical treatment at discharge, those patients derived disproportional benefit if treated with diuretics and/or angiotensin-converting-enzyme inhibitors/angiotensin receptor blocker (interaction p-values <0.05). These findings were confirmed only for the diuretics treatment when quantifying the adrenomedullin system using MR-proADM plasma concentrations (n=764). For predicting mortality, both biomarkers performed well and MR-proADM had a higher predictive accuracy as compared to bio-ADM (p<0.001).

Table 1. Interaction p-values in multivariate models using a cox proportional hazard analysis for predicting all-cause mortality at 365 days including age, bio-ADM or MR-proADM, creatinine at discharge, and medication at discharge Diuretics ACE inhibitors or ARB Beta blockers Aldosterone antagonists lg bio-ADM*, ng/l <0.001 0.011 0.760 0.175 lg bio-ADM†, ng/l <0.001 0.020 0.807 0.396 lg MR-proADM*, nmol/l 0.031 0.095 0.169 0.441 lg MR-proADM†, nmol/l 0.001 0.126 0.741 0.272 *At admission; †at discharge. ACE: Angiotensin-converting-enzyme; ARBs: Angiotensin receptor blocker; bio-ADM: bioactive adrenomedullin; MR-proADM: midregional proadrenomedullin.

Figure 1

Conclusion

Quantifying the activity of the adrenomedullin system helps to personalize post-discharge treatment and risk-prediction in AHF.

Acknowledgement/Funding

Swiss National Science Foundation, Swiss Heart Foundation, University of Base, Sphingotec

P1653Admission high-sensitivity troponin T and NT-proBNP for outcome prediction in acute heart failure

Background

High-sensitivity troponin T (hs-TnT) reflects the severity of ongoing myocardial damage and holds independent prognostic significance in chronic heart failure (HF). In acute HF (AHF), its additive prognostic value over natriuretic peptides is unclear.

Methods

Individual data of 1571 AHF patients with admission hs-TnT were collected from 3 cohorts.

Results

Patients were aged 78±10 years, and 51% were men. Median hs-TnT and N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP) concentrations were 43 ng/L (interquartile interval 26–69) and 5660 (2693–12466), respectively. Patients experiencing in-hospital death (n=187, 13%) had significantly higher hs-TnT and NT-proBNP on admission (both p<0.001). The risk of in-hospital death increased by 45% per each doubling of hs-TnT (HR 1.45, 95% confidence interval - CI 1.31–1.59, p<0.001), and by 32% per each doubling of NT-proBNP (HR 1.32, 95% CI 1.17–1.50, p<0.001). Patients with hs-TnT ≥43 ng/L and NT-proBNP ≥5660 ng/L had a 2.7-fold higher risk of in-hospital death (relative risk - RR 2.7, 95% CI 1.7–4.5). Among the 1262 patients discharged, 1024 deaths occurred over a median 11-month follow-up (4–22). In a model including NT-proBNP, hs-TnT ≥43 ng/L was a strong, independent predictor of all-cause death at 6, 12 and 24 months, and the composite of cardiovascular death or HF hospitalization at 6 and 24 months. hs-TnT ≥43 ng/L also improved risk reclassification.

Conclusions

The risk of in-hospital death is almost 3 folds higher with admission hs-TnT ≥43 ng/L and NT-proBNP ≥5660 ng/L, and hs-TnT ≥43 ng/L holds strong independent prognostic significance for post-discharge outcome.

P1656Incremental value of interleukin-6 and C-reactive protein to the MEESSI acute heart failure risk score

Background

The MEESSI-acute heart failure (AHF) risk score has high accuracy in the prediction of 30-day mortality in patients presenting with AHF and may be considered the current gold standard for this indication.

Purpose

As the original MEESSI model does not include measurements of inflammatory biomarkers, the impact of interleukin-6 or C-reactive protein (CRP) on the model's goodness of fit is unknown.

Methods

In a prospective multicenter diagnostic study the presence of AHF was centrally adjudicated by two independent cardiologists among patients presenting with acute dyspnea to the ED. The MEESSI-AHF risk score was calculated using a recalibrated model containing 12 independent risk factors. The incremental value of interleukin-6 and CRP was examined by the use of logistic regression analysis and enter method variable selection with an entry criterion of p<0.05. Goodness of fit tests were performed to measure the updated model's discrimination and calibration.

Results

In 1247 patients with adjudicated AHF, the MEESSI-AHF risk score was calculated. Of these, 1113 patients (89.3%) had available measurements of interleukin-6 and CRP. In the logistic regression analysis both biomarkers had a highly significant impact on the MEESSI model (p<0.001, respectively). Compared to the original MEESSI-Model (c-statistic, 0.79 (95% CI, 0.75–0.83)) the addition of interleukin-6 (c-statistic, 0.81 (95% CI, 0.77–0.85)) or CRP (c-statistic, 0.83 (95% CI, 0.79–0.86)) significantly improved the model's discrimination (p=0.022 and p=0.011, respectively). When assessing the cumulative mortality, the gradient in 30-day mortality over six predefined risk groups was increased by addition of interleukin-6 or CRP. 30-day mortality rates in the lowest and highest risk groups of the original model were 0.4% and 32.5% compared to 0% and 34.9% in the model updated with interleukin-6 and 0.6% and 37.6% in the model updated with CRP. All compared models showed good overall calibration (Hosmer-Lemeshow p=0.302 (original model), p=0.136 (model updated by interleukin-6) and p=0.902 (model updated by CRP)).

Discrimination original_updated

Conclusion

There is significant incremental value of interleukin-6 and CRP to the MEESSI score as indicated by the improved goodness of fit compared to the original model.

Acknowledgement/Funding

European Union, the Swiss National Science Foundation, the Swiss Heart Foundation, the Cardiovascular Research Foundation Basel,

Evaluation of a physical activity promotion program in primary care

BACKGROUND

Physical inactivity increases the risk of many chronic disorders. It is not clear which strategies are the most appropriate to enable people to adopt a more active lifestyle. Randomized controlled trials have found that brief advice from GPs supported by written material had a significant positive effect on patient's physical activity. The pilot project 'Move for Health and the Environment' translated this evidence into a program suitable for the real-life situation of busy practices. The aim of this study was to evaluate the change in physical activity level of the participating patients 1 year after the intervention.

METHODS

Patients aged 16-65 years completed a screening questionnaire before consultation with their physician. Insufficiently active patients were offered an information leaflet and a voucher for a physical activity counselling session. One year later, all inactive patients and a random selection of the active were re-contacted and invited to answer identical questions.

RESULTS

A total of 1239 (73.9%) returned the follow-up questionnaire. In all, 37.3% of the formerly inactive patients met the threshold of sufficient activity at follow-up, whereas 20.3% of the previously active no longer did. Formerly inactive patients reported an increase of 58.8 minutes/week of moderate and 34.6 minutes/week of vigorous activity and spending more time walking and cycling. Formerly active patients reported less time spent in moderate activities.

CONCLUSIONS

Systematic counselling in primary care encouraged insufficiently active patients to adopt a more active lifestyle. Yet it became evident that active patients also need counselling to maintain their activity levels.