Abstract
BackgroundHeart failure (HF) is associated with a high rate of readmissions within 30 days post-discharge and in the following year, especially in frail elderly patients. Biomarker data are scarce in this high-risk population. This study assessed the value of early post-discharge circulating levels of ST2, NT-proBNP, CA125, and hs-TnI for predicting 30-day and 1-year outcomes in comorbid frail elderly patients with HF with mainly preserved ejection fraction (HFpEF).MethodsBlood samples were obtained at the first visit shortly after discharge (4.9 ± 2 days). The primary endpoint was the composite of all-cause mortality or HF-related rehospitalization at 30 days and at 1 year. All-cause mortality alone at one year was also a major endpoint. HF-related rehospitalizations alone were secondary end-points.ResultsFrom February 2014 to November 2016, 522 consecutive patients attending the STOP-HF Clinic were included (57.1% women, age 82 ± 8.7 years, mean Barthel index 70 ± 25, mean Charlson comorbidity index 5.6 ± 2.2). The composite endpoint occurred in 8.6% patients at 30 days and in 38.5% at 1 year. In multivariable analysis, ST2 [hazard ratio (HR) 1.53; 95% CI 1.19–1.97; p = 0.001] was the only predictive biomarker at 30 days; at 1 year, both ST2 (HR 1.34; 95% CI 1.15–1.56; p < 0.001) and NT-proBNP (HR 1.19; 95% CI 1.02–1.40; p = 0.03) remained significant. The addition of ST2 and NT-proBNP into a clinical predictive model increased the AUC from 0.70 to 0.75 at 30 days (p = 0.02) and from 0.71 to 0.74 at 1 year (p < 0.05). For all-cause death at 1 year, ST2 (HR 1.50; 95% CI 1.26–1.80; p < 0.001), and CA125 (HR 1.41; 95% CI 1.21–1.63; p < 0.001) remained independent predictors in multivariable analysis. The addition of ST2 and CA125 into a clinical predictive model increased the AUC from 0.74 to 0.78 (p = 0.03). For HF-related hospitalizations, ST2 was the only predictive biomarker in multivariable analyses, both at 30 days and at 1 year.ConclusionsIn a comorbid frail elderly population with HFpEF, ST2 outperformed NT-proBNP for predicting the risk of all-cause mortality or HF-related rehospitalization. ST2, a surrogate marker of inflammation and fibrosis, may be a better predictive marker in high-risk HFpEF.
Highlights
Heart failure (HF) is associated with a high rate of readmissions within 30 days post-discharge and in the following year, especially in frail elderly patients
HF patients differ from younger patients in terms of etiology, comorbidities [12], and phenotype, and elderly patients have a higher prevalence of heart failure with preserved ejection fraction (HFpEF) [13, 14]
We analyzed the following biomarkers: N-terminal pro-brain natriuretic peptide (NT-proBNP; a marker of myocardial stretch and neurohormonal activation), interleukin-1 receptorlike 1 (ST2; a marker of inflammation and stretch and extracellular matrix remodeling), high-sensitivity troponin I, and cancer antigen 125 (CA125; a marker of systemic congestion in HF). Study population This prospective single-center investigation was performed as part of the STructured multidisciplinary outpatient clinic for Old and frail Post-discharge patients hospitalized for HF (STOP-HF-Clinic) study, which aimed to reduce readmission rates and facilitate the transition to primary care [21]
Summary
Heart failure (HF) is associated with a high rate of readmissions within 30 days post-discharge and in the following year, especially in frail elderly patients. HF patients differ from younger patients in terms of etiology, comorbidities [12], and phenotype, and elderly patients have a higher prevalence of heart failure with preserved ejection fraction (HFpEF) [13, 14]. This clinical difference impacts short- and mid-term outcomes, and readmissions can be due to exacerbations of the underlying disease [15] as well as to other medical problems [16]. Predictive biomarker data in such special populations are scarce and the role of biomarkers in elderly subjects with HF is challenged by the presence of comorbidities [20]
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