1076
SCRUTINIO D et al.
ORIGINAL ARTICLE
Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp
Heart Failure
Predicting Short-Term Mortality in Advanced Decompensated Heart Failure – Role of the Updated Acute Decompensated Heart Failure/N-Terminal Pro-B-Type Natriuretic Peptide Risk Score – Domenico Scrutinio, MD; Enrico Ammirati, MD; Andrea Passantino, MD; Pietro Guida, PhD; Luciana D’Angelo, MD; Fabrizio Oliva, MD; Marco Matteo Ciccone, MD; Massimo Iacoviello, MD; Ilaria Dentamaro, MD; Daniela Santoro, MD; Rocco Lagioia, MD; Simona Sarzi Braga, MD; Daniela Guzzetti, MD; Maria Frigerio, MD
Background: The first few months after admission are the most vulnerable period in patients with acute decompensated heart failure (ADHF). Methods and Results: We assessed the association of the updated ADHF/N-terminal pro-B-type natriuretic peptide (NT-proBNP) risk score with 90-day and in-hospital mortality in 701 patients admitted with advanced ADHF, defined as severe symptoms of worsening HF, severely depressed left ventricular ejection fraction, and the need for i.v. diuretic and/or inotropic drugs. A total of 15.7% of the patients died within 90 days of admission and 5.2% underwent ventricular assist device (VAD) implantation or urgent heart transplantation (UHT). The C-statistic of the ADHF/NTproBNP risk score for 90-day mortality was 0.810 (95% CI: 0.769–0.852). Predicted and observed mortality rates were in close agreement. When the composite outcome of death/VAD/UHT at 90 days was considered, the C-statistic decreased to 0.741. During hospitalization, 7.6% of the patients died. The C-statistic for in-hospital mortality was 0.815 (95% CI: 0.761–0.868) and Hosmer-Lemeshow χ2=3.71 (P=0.716). The updated ADHF/NT-proBNP risk score outperformed the Acute Decompensated Heart Failure National Registry, the Organized Program to Initiate Lifesaving Treatment in Patients Hospitalized for Heart Failure, and the American Heart Association Get with the Guidelines Program predictive models. Conclusions: Updated ADHF/NT-proBNP risk score is a valuable tool for predicting short-term mortality in severe ADHF, outperforming existing inpatient predictive models. (Circ J 2015; 79: 1076 – 1083) Key Words: ADHERE logistic model; ADHF/NT-proBNP risk score; Advanced decompensated heart failure; GWTG-HF risk score; OPTIMIZE-HF risk score
H
eart failure (HF) is a lethal disease and a leading cause of hospitalization in developed countries. Worsening chronic HF is the most common clinical presentation at admission, accounting for 70% of all admissions, and is associated with increased mortality compared with de novo HF.1,2 Approximately 12–15% of the patients hospitalized for acute HF die within 12 weeks, and 30% within 12 months of admission,1,3–7 with severe left ventricular (LV)
systolic dysfunction substantially worsening prognosis.1,8 In addition, 24–30% of the patients are readmitted within 60–90 days after discharge.3,4 Accurate estimation of absolute risk, combined with expert clinical judgment and supplementary evaluations, is essential to developing a tailored management plan including discharge planning, continuity and transition of care, outpatient followup, use of advanced treatment, and end-of-life issues.6,9,10 Risk
Received November 9, 2014; revised manuscript received January 7, 2015; accepted January 22, 2015; released online March 3, 2015 Time for primary review: 36 days Division of Cardiology and Cardiac Rehabilitation, “S. Maugeri” Foundation, IRCCS, Institute of Cassano Murge, Bari (D. Scrutinio, A.P., P.G., D. Santoro, R.L.); Cardiothoracic and Vascular Department, Niguarda Ca’ Granda Hospital, Milan (E.A., L.D’A., F.O., M.F.); San Raffaele Hospital and Vita-Salute University, Milan (E.A.); Cardiovascular Diseases Section, Department of Emergency and Organ Transplantation (DETO), University of Bari, Bari (M.M.C., M.I., I.D.); and Division of Cardiology and Cardiac Rehabilitation, “S. Maugeri” Foundation, IRCCS, Institute of Tradate, Varese (S.S.B., D.G.), Italy Mailing address: Domenico Scrutinio, MD, Fondazione “S. Maugeri”, IRCCS, Istituto di Cassano Murge, 70020 Cassano Murge (Bari), Italy. E-mail: [email protected] ISSN-1346-9843 doi: 10.1253/circj.CJ-14-1219 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: [email protected] Circulation Journal Vol.79, May 2015
Prediction of Early Mortality in ADHF
1077
Table 1. Variables Incorporated in the Predictive Models Risk markers
C-statistic
Follow-up
Mortality rate
Updated ADHF/ NT-proBNP24
Predictive model
Age / Prior admission for HF / COPD / SBP / eGFR / Sodium / Hb / NT-proBNP / LVEF / TR
0.748 (entire cohort) / 0.784 (patients aged ≤70 years)
12 months
32.4% (VAD/UHT: 15.5%)
ADHERE logistic model14
Age / SBP / BUN / Heart rate
0.759 (logistic model)
In-hospital
4.2% derivation cohort / 4.0% validation cohort
OPTIMIZE-HF12
Age / HF as primary cause of admission / Heart rate / SBP / Sodium / SCr / LVEF
SCRUTINIO D et al.
ORIGINAL ARTICLE
Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp
Heart Failure
Predicting Short-Term Mortality in Advanced Decompensated Heart Failure – Role of the Updated Acute Decompensated Heart Failure/N-Terminal Pro-B-Type Natriuretic Peptide Risk Score – Domenico Scrutinio, MD; Enrico Ammirati, MD; Andrea Passantino, MD; Pietro Guida, PhD; Luciana D’Angelo, MD; Fabrizio Oliva, MD; Marco Matteo Ciccone, MD; Massimo Iacoviello, MD; Ilaria Dentamaro, MD; Daniela Santoro, MD; Rocco Lagioia, MD; Simona Sarzi Braga, MD; Daniela Guzzetti, MD; Maria Frigerio, MD
Background: The first few months after admission are the most vulnerable period in patients with acute decompensated heart failure (ADHF). Methods and Results: We assessed the association of the updated ADHF/N-terminal pro-B-type natriuretic peptide (NT-proBNP) risk score with 90-day and in-hospital mortality in 701 patients admitted with advanced ADHF, defined as severe symptoms of worsening HF, severely depressed left ventricular ejection fraction, and the need for i.v. diuretic and/or inotropic drugs. A total of 15.7% of the patients died within 90 days of admission and 5.2% underwent ventricular assist device (VAD) implantation or urgent heart transplantation (UHT). The C-statistic of the ADHF/NTproBNP risk score for 90-day mortality was 0.810 (95% CI: 0.769–0.852). Predicted and observed mortality rates were in close agreement. When the composite outcome of death/VAD/UHT at 90 days was considered, the C-statistic decreased to 0.741. During hospitalization, 7.6% of the patients died. The C-statistic for in-hospital mortality was 0.815 (95% CI: 0.761–0.868) and Hosmer-Lemeshow χ2=3.71 (P=0.716). The updated ADHF/NT-proBNP risk score outperformed the Acute Decompensated Heart Failure National Registry, the Organized Program to Initiate Lifesaving Treatment in Patients Hospitalized for Heart Failure, and the American Heart Association Get with the Guidelines Program predictive models. Conclusions: Updated ADHF/NT-proBNP risk score is a valuable tool for predicting short-term mortality in severe ADHF, outperforming existing inpatient predictive models. (Circ J 2015; 79: 1076 – 1083) Key Words: ADHERE logistic model; ADHF/NT-proBNP risk score; Advanced decompensated heart failure; GWTG-HF risk score; OPTIMIZE-HF risk score
H
eart failure (HF) is a lethal disease and a leading cause of hospitalization in developed countries. Worsening chronic HF is the most common clinical presentation at admission, accounting for 70% of all admissions, and is associated with increased mortality compared with de novo HF.1,2 Approximately 12–15% of the patients hospitalized for acute HF die within 12 weeks, and 30% within 12 months of admission,1,3–7 with severe left ventricular (LV)
systolic dysfunction substantially worsening prognosis.1,8 In addition, 24–30% of the patients are readmitted within 60–90 days after discharge.3,4 Accurate estimation of absolute risk, combined with expert clinical judgment and supplementary evaluations, is essential to developing a tailored management plan including discharge planning, continuity and transition of care, outpatient followup, use of advanced treatment, and end-of-life issues.6,9,10 Risk
Received November 9, 2014; revised manuscript received January 7, 2015; accepted January 22, 2015; released online March 3, 2015 Time for primary review: 36 days Division of Cardiology and Cardiac Rehabilitation, “S. Maugeri” Foundation, IRCCS, Institute of Cassano Murge, Bari (D. Scrutinio, A.P., P.G., D. Santoro, R.L.); Cardiothoracic and Vascular Department, Niguarda Ca’ Granda Hospital, Milan (E.A., L.D’A., F.O., M.F.); San Raffaele Hospital and Vita-Salute University, Milan (E.A.); Cardiovascular Diseases Section, Department of Emergency and Organ Transplantation (DETO), University of Bari, Bari (M.M.C., M.I., I.D.); and Division of Cardiology and Cardiac Rehabilitation, “S. Maugeri” Foundation, IRCCS, Institute of Tradate, Varese (S.S.B., D.G.), Italy Mailing address: Domenico Scrutinio, MD, Fondazione “S. Maugeri”, IRCCS, Istituto di Cassano Murge, 70020 Cassano Murge (Bari), Italy. E-mail: [email protected] ISSN-1346-9843 doi: 10.1253/circj.CJ-14-1219 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: [email protected] Circulation Journal Vol.79, May 2015
Prediction of Early Mortality in ADHF
1077
Table 1. Variables Incorporated in the Predictive Models Risk markers
C-statistic
Follow-up
Mortality rate
Updated ADHF/ NT-proBNP24
Predictive model
Age / Prior admission for HF / COPD / SBP / eGFR / Sodium / Hb / NT-proBNP / LVEF / TR
0.748 (entire cohort) / 0.784 (patients aged ≤70 years)
12 months
32.4% (VAD/UHT: 15.5%)
ADHERE logistic model14
Age / SBP / BUN / Heart rate
0.759 (logistic model)
In-hospital
4.2% derivation cohort / 4.0% validation cohort
OPTIMIZE-HF12
Age / HF as primary cause of admission / Heart rate / SBP / Sodium / SCr / LVEF
