Group In Chronic Heart Failure Research Articles

Performance of existing risk scores around heart transplantation: validation study in a 4-year cohort.

Several risk scores exist to help identify best candidate recipients for heart transplantation (HTx). This study describes the performance of five heart failure risk scores and two post-HTx mortality risk scores in a French single-centre cohort. All patients listed for HTx through a 4-year period were included. Waiting-list risk scores [Heart Failure Survival Score (HFSS), Seattle Heart Failure Model (SHFM), Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC), Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) and Get With The Guidelines-Heart Failure (GWTG-HF)] and post-HTx scores Index for Mortality Prediction After Cardiac Transplantation (IMPACT and CARRS) were computed. Main outcomes were 1-year mortality on waiting list and after HTx. Performance was assessed using receiver operator characteristic (ROC), calibration and goodness-of-fit analyses. The cohort included 414 patients. Waiting-list mortality was 14.0%, and post-HTx mortality was 16.3% at 1-year follow-up. Heart failure risk scores had adequate discrimination regarding waiting-list mortality (ROC AUC for HFSS=0.68, SHFM=0.74, OPTIMIZE-HF=0.72, MAGGIC= 0.70 and GWTG=0.77; all P-values <0.05). On the contrary, post-HTx risk scores did not discriminate post-HTx mortality (AUC for IMPACT=0.58, and CARRS=0.48, both P-values >0.50). Subgroup analysis on patients undergoing HTx after ventricular assistance device (VAD) implantation (i.e. bridge-to-transplantation) (n=36) showed an IMPACT AUC=0.72 (P<0.001). In this single-centre cohort, existing heart failure risk scores were adequate to predict waiting-list mortality. Post-HTx mortality risk scores were not, except in the VAD subgroup.

Incremental value of right heart metrics and exercise performance to well-validated risk scores in dilated cardiomyopathy.

Risk stratification in heart failure (HF) relies on several established clinical risk scores, however, myocardial deformation, right heart metrics, and exercise performance have not usually been considered. This study sought to assess the incremental value of advanced echocardiographic and cardiopulmonary exercise testing (CPX) parameters to validated risk scores in HF. The Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) and Metabolic Exercise Test Data Combined with Cardiac and Kidney Indexes (MECKI) scores were applied to 208 ambulatory patients with dilated cardiomyopathy (DCM) who completed echocardiography in conjunction with CPX as part of the Stanford Exercise Testing registry. Patients were followed for the composite end point of death, heart transplant, left ventricular device implantation, and hospitalization for acute HF. Mean age, left ventricular ejection fraction (LVEF), and left ventricular global longitudinal strain (LVGLS) were 47 ± 13 years, 33 ± 13%, and -10.6 ± 4.4%, respectively, while right ventricular free-wall longitudinal strain was -18.8 ± 5.5%. Partial correlation mapping identified strong correlations between LVEF, LVGLS, and LV systolic strain rate, with a moderate correlation between these metrics and peak VO2. Over a median follow up of 5.3 years, the composite end point occurred in 60 patients. Cox proportional hazards identified MAGGIC score [hazard ratio (HR) (2.04 [1.39-3.01], P < 0.01], peak VO2 HR (0.52 [0.28-0.97], P = 0.04), and right atrial volume indexed (RAVI) HR (1.31 [1.07-1.61], P < 0.01) as independent correlates of outcome. RAVI remained an independent correlate when combined with the MECKI score (2.21 [1.59-3.07]), P < 0.01, RAVI, 1.33 [1.06-1.67], P = 0.01). Our study demonstrates that RAVI is complementary to well-validated HF risk scores and highlights the importance of exercise performance in DCM.

14 St2 levels are elevated in patients with advanced heart failure but are not consistently associated with other markers of adverse prognosis

Introduction Heart transplantation and mechanical circulatory support (MCS) improve survival in selected patients with advanced heart failure and an adverse prognosis. Soluble ST2 is a protein belonging to the interleukin-1 receptor family. ST2 is released in response to cardiomyocyte stess and thought to be a marker of adverse prognosis. We examined the association between ST2 levels and currently accepted markers of adverse prognosis in patients with advanced heart failure. Methods We included 20 consecutive outpatients who were assessed for heart transplantation at Papworth Hospital over ten weeks. All patients underwent echocardiography, six minute walk testing, cardiopulmonary exercise testing and right heart catheterisation, in addition to blood tests including serum ST2 measurement using a commercial assay. Prognosis was estimated using the Seattle Heart Failure Model (SHFM) and the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) scores. A multi-disciplinary team decided whether listing for heart transplantation was indicated. We examined the association between ST2 levels and other markers of adverse prognosis. Results Ten patients were too well to be listed for heart transplantation (group A) and ten patients were sufficiently unwell to be listed for heart transplantation (group B). There was no difference in age, gender or body mass index. Key prognostic variables are presented in table 1. Compared with patients in group A, patients in group B had higher ST2 levels, lower peak VO2, shorter six minute walk distance and higher SHFM predicted one-year mortality. However, there was no difference in LVEF, serum Creatinine, NTproBNP, cardiac index or predicted one-year mortality by MAGGIC score. Previous studies have found that an ST2 level of >35 ng/ml is indicative of adverse prognosis. At this cut-off, there was frequent disagreement between ST2 level and other markers of adverse prognosis. Patients identified as high risk by ST2 level were identified as low risk by peak VO2 (n=5) and six minute walk distance (n=6). In addition, eight patients identified as low risk by ST2 level were identified as high risk by NTproBNP (figure 1). Conclusions ST2 levels are higher in patients who are sufficiently unwell to be listed for heart transplantation, compared with those who are too well to be listed for heart transplantation. However, there is frequent disagreement between ST2 levels and other markers of adverse prognosis such as six minute walk distance, peak VO2 and NTproBNP. Larger studies with assessment of real world outcomes, such as death, urgent heart transplantation or MCS, are required to determine whether ST2 measurement can improve assessment of prognosis in patients with advanced heart failure.

Comparative Analysis of Four Scores to Stratify Patients With Heart Failure and Reduced Ejection Fraction

There are several prognostic risk scores available for patients with heart failure with reduced ejection fraction (HFrEF) that can aid in the decision of listing candidates for heart transplant (HTx). A direct comparison between these scores has not been performed. Therefore, our objective was to evaluate the calibration and discriminative power of 4 contemporary HF scores. A retrospective analysis of 259 patients with HFrEF who underwent cardiopulmonary exercise test was conducted. The Heart Failure Survival Score (HFSS), Seattle Heart Failure Model (SHFM), Meta-analysis Global Group in Chronic Heart Failure (MAGGIC), and Metabolic Exercise Cardiac Kidney Index (MECKI) were compared. During the first year, 7 deaths occurred (6 cardiovascular) and 25 patients were submitted to HTx (8 urgent). Over a 2-year period, 14 deaths occurred (10 cardiovascular) and 34 patients received an HTx (8 urgent). Calibration analysis showed that SHFM and HFSS tended to underestimate event occurrence, whereas MAGGIC and MECKI tended to overestimate risk, especially inthe highest risk subgroups. Interestingly, MECKI score at 1year was well calibrated (expected similar to observed events). Overall, the MECKI score consistently showed betterdiscrimination ability for all studied end points (areas under the curve between 0.8 and0.9). In conclusion, along with HFSS and SHFM, the MECKI score can also be used to aid treatment decisions, such as HTx listing with the advantage of being very well calibrated at 1-year intervals, which might allow us to avoid the pitfalls of under/overestimation ofrisk.

Construction of a mortality score in French heart failure outpatients: Model comparisons

Introduction Cardiologists need to assess the mortality risk of their patients with heart failure (HF). The meta-analysis global group in chronic heart failure (MAGGIC) validated a precise score, but its complexity prevents cardiologists to use it in clinical settings. We aimed to derive a simple mortality score on a small cohort of HF patients of the CHU of Montpellier, using a piecewise constant Poisson model. Our secondary objectives were to compare the estimates and the validity of our model with those of other models. Methods At inclusion, we assessed age, sex, body mass index, ejection fraction, serum creatinin, NT-ProBNP, NYHA status, diabetes, chronic obstructive pulmonary disease, smoking habits, and treatment by beta-blockers. The outcome measure was the time to death. The censoring date was 4.4 years after first inclusion. The assumptions of linearity and of proportional hazards were assessed in Cox models, and potential predictive variables were defined on clinical and statistical arguments. The time intervals of the Poisson Model PM1 were chosen on clinical and statistical arguments. Variables were selected with a backward procedure, targeting the minimal AIC of PM1. We converted the Poisson model predictor to an integer score, and represented discrimination (ROC curve) and calibration (observed and predicted mortality risk) graphs. We built 4 other models, with the same variables as PM1: PM2/with 1 time interval, PM3/with 3 time intervals, defined on statistical arguments, PM4/with age as a time-dependent variable, and a Cox model. In order, to compare the global results and clinical interpretation of these models, we represented graphically the relative risks and hazard ratios of these models, with their confidence intervals. In order to compare the validity of the individual predictions, we performed a cross-validation for each Poisson model. The size of our training samples was 2/3 of the size of our complete sample. We present the mean percent of the validation samples that was correctly classified. Results We included 182 patients, and performed a complete case analysis on 134 patients. Selected variables were age >75 years, Ejection Fraction 5000, NYHA 3–4, no beta-blockers, diabetes, chronic pneumopathy, current smoker. Age did not verify the assumption of proportional hazard, but the interaction with time was not included for usability reasons. The integer risk score was built in attributing 1 point to each risk factor. The c-statistic of this score was of 0.77. Patients with scores ≤2, 2–5, and ≥6, had mortality risks ≤0.2, 0.2–0.8, and ≥0.8, respectively. The relative risks of the 4 Poisson models and the hazard ratios of the Cox model were not graphically different (figure). We performed the cross-validation on 100 training samples of 89 subjects. The mean percent of correctly classified patients in the validation samples was of 63.3, 63.4, 60.1, and 63.0% for PM1, PM2, PM3, and PM4, respectively. Discussion We propose a simple mortality risk score for chronic heart failure patients. Its discriminative ability and its calibration were moderate. The statistical choices seem to be of mild importance, as more complicated or simpler models did not increase or decrease the predictive ability. The research of a user-friendly score could be pursued in larger cohorts, keeping in mind that the clinical aim and the statistical choices should be simplified.

Right atrial volume by cardiovascular magnetic resonance predicts mortality in patients with heart failure with reduced ejection fraction.

BackgroundRight Atrial Volume Index (RAVI) measured by echocardiography is an independent predictor of morbidity in patients with heart failure (HF) with reduced ejection fraction (HFrEF). The aim of this study is to evaluate the predictive value of RAVI assessed by cardiac magnetic resonance (CMR) for all-cause mortality in patients with HFrEF and to assess its additive contribution to the validated Meta-Analysis Global Group in Chronic heart failure (MAGGIC) score.Methods and resultsWe identified 243 patients (mean age 60 ± 15; 33% women) with left ventricular ejection fraction (LVEF) ≤ 35% measured by CMR. Right atrial volume was calculated based on area in two- and four -chamber views using validated equation, followed by indexing to body surface area. MAGGIC score was calculated using online calculator. During mean period of 2.4 years 33 patients (14%) died. The mean RAVI was 53 ± 26 ml/m2; significantly larger in patients with than without an event (78.7±29 ml/m2 vs. 48±22 ml/m2, p<0.001). RAVI (per ml/m2) was an independent predictor of mortality [HR = 1.03 (1.01–1.04), p = 0.001]. RAVI has a greater discriminatory ability than LVEF, left atrial volume index and right ventricular ejection fraction (RVEF) (C-statistic 0.8±0.08 vs 0.55±0.1, 0.62±0.11, 0.68±0.11, respectively, all p<0.02). The addition of RAVI to the MAGGIC score significantly improves risk stratification (integrated discrimination improvement 13%, and category-free net reclassification improvement 73%, both p<0.001).ConclusionRAVI by CMR is an independent predictor of mortality in patients with HFrEF. The addition of RAVI to MAGGIC score improves mortality risk stratification.

PERFORMANCE OF THE MAGGIC HEART FAILURE RISK SCORE IN JAPANESE ACUTE HEART FAILURE PATIENTS: A REPORT FROM THE WEST TOKYO HEART FAILURE REGISTRY

Background: Predictive models for heart failure patients such as the Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) score is used widely to stratify patients’ long-term risk, and can enable clinicians to tailor their approach. In this study, we aimed to validate the performance of

Abstract 11925: Differences in End-of-Life Preferences and Planning by Prognosis in Patients Hospitalized With Acute Decompensated Heart Failure

Introduction: In patients with heart failure, preferences for end-of-life (EOL) care and involvement in advance care planning can vary over their illness trajectory. The aim of this study was to compare EOL preferences by prognosis, assessed using the validated Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) risk score, in patients hospitalized with acute decompensated heart failure (ADHF). Hypothesis: EOL preferences and planning vary by prognosis. Methods: Between January 2014 and January 2016, Southeastern Minnesota residents hospitalized with ADHF at Mayo Clinic hospitals in Rochester, MN were prospectively recruited into an observational cohort study. Information on EOL preferences and advance care planning were assessed by patient questionnaire. MAGGIC risk scores and associated 1-year mortality estimates were calculated using patient characteristics at the time of hospital admission and stratified by quartile. The associations of EOL preferences/ planning and prognosis were examined using two sample t-tests and linear regression. Results: Among 400 patients (mean age 77.7 years, 46% female), predicted 1-year mortality ranged from 3.9-72.5% (median 22.5%). Patients with higher estimated mortality (worse prognosis) more often elected Do Not Resuscitate (DNR) status (p=0.001) and more often had an advanced directive (p&lt;0.001, Table). No other differences in EOL preferences or planning by prognosis were observed. Conclusions: In community patients hospitalized with ADHF, resuscitation preferences and rates of completion of advance care planning documents varied with prognosis, though patient-clinician EOL discussions and awareness and attitudes about EOL options did not.

Abstract 12623: Complementary Role of Exercise Performance and Right Heart Metrics to the Validated MAGGIC score: Insights From a Network Analysis

Background: Risk stratification in heart failure can be completed with established risk scores. However, right heart metrics, deformation imaging and the cardiopulmonary response to exercise have not been routinely incorporated. We investigated the interaction and incremental prognostic value of novel echocardiographic metrics and exercise performance in a consecutive cohort of patients with dilated cardiomyopathy (DCM). Methods: The Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) score was applied to 208 ambulatory patients with DCM (age 47 ± 13 years) who had undergone echocardiography in conjunction with cardiopulmonary exercise testing. Patients were followed for the composite end point of death, heart transplant, left ventricular device implantation and hospitalization for acute heart failure. Partial correlation network analysis was used to assess interaction between variables. Cox proportional hazard models identified independent predictors of outcome. Results: Mean LVEF and LV GLS were 33 ± 13 % and -10.6 ± 4.4 % respectively. Among echocardiographic variables, LVEF and LV GLS and LV strain rate were strongly related (r = -0.89, and -0.86, respectively, p &lt; 0.01). Age, sex, BMI, LV GLS and RV GLS explained 56% of the variance in peak VO 2 . Over a median follow up of 5.3 years, 60 events occurred including 16 deaths. MAGGIC scores were normally distributed (Figure 1, left) and log rank testing showed significant differences in survival. Cox proportional hazards identified MAGGIC score (1.78 [1.27-2.50], p &lt;0.01), peak VO 2 (HR 0.40 [0.24-0.84], p&lt;0.01) and right atrial volume indexed (RAVI) (HR 1.10 [1.02-1.19], p = 0.01) as independently associated with outcome. In combination these variables were incremental in prognostic value compared to MAGGIC score alone ( x 2 = 65 vs 42, p &lt;0.01, Figure 1, right). Conclusion: In patients with DCM exercise performance and RAVI provide incremental prognostic value when combined with the validated MAGGIC score.

Baseline Hemodynamics and Response to Contrast Media During Diagnostic Cardiac Catheterization Predict Adverse Events in Heart Failure Patients.

Contrast media administered during cardiac catheterization can affect hemodynamic variables. However, little is documented about the effects of contrast on hemodynamics in heart failure patients or the prognostic value of baseline and changes in hemodynamics for predicting subsequent adverse events. In this prospective study of 150 heart failure patients, we measured hemodynamics at baseline and after administration of iodixanol or iopamidol contrast. One-year Kaplan-Meier estimates of adverse event-free survival (death, heart failure hospitalization, and rehospitalization) were generated, grouping patients by baseline measures of pulmonary capillary wedge pressure (PCWP) and cardiac index (CI), and by changes in those measures after contrast administration. We used Cox proportional hazards modeling to assess sequentially adding baseline PCWP and change in CI to 5 validated risk models (Seattle Heart Failure Score, ESCAPE [Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness], CHARM [Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity], CORONA [Controlled Rosuvastatin Multinational Trial in Heart Failure], and MAGGIC [Meta-Analysis Global Group in Chronic Heart Failure]). Median contrast volume was 109 mL. Both contrast media caused similarly small but statistically significant changes in most hemodynamic variables. There were 39 adverse events (26.0%). Adverse event rates increased using the composite metric of baseline PCWP and change in CI (P<0.01); elevated baseline PCWP and decreased CI after contrast correlated with the poorest prognosis. Adding both baseline PCWP and change in CI to the 5 risk models universally improved their predictive value (P≤0.02). In heart failure patients, the administration of contrast causes small but significant changes in hemodynamics. Calculating baseline PCWP with change in CI after contrast predicts adverse events and increases the predictive value of existing models. Patients with elevated baseline PCWP and decreased CI after contrast merit greatest concern.

19th Annual SCMR Scientific Sessions.

Background Right Atrial Volume Indexed (RAVI) measured by echocardiogram was identified to be an independent predictor of morbidity in patients with heart failure (HF) with reduced ejection fraction (HFrEF). Meta-Analysis Global Group in Chronic heart failure (MAGGIC) risk score is a robust tool in predicting mortality in HF patients. The aim of this study is to evaluate RAVI by cardiac magnetic resonance (CMR) imaging as an independent predictor of all-cause mortality in patients with HFrEF and to compare it with the validated risk score

Comparing LCZ696 With Enalapril According to Baseline Risk Using the MAGGIC and EMPHASIS-HF Risk Scores: An Analysis of Mortality and Morbidity in PARADIGM-HF

BackgroundAlthough most patients in the PARADIGM-HF (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial had mild symptoms, there is a poor correlation between reported functional limitation and prognosis in heart failure. ObjectivesThe aim of this study was to examine the spectrum of risk in PARADIGM-HF and the effect of LCZ696 across that spectrum. MethodsThis study analyzed rates of the primary composite outcome of cardiovascular death or heart failure hospitalization, its components, and all-cause mortality using the MAGGIC (Meta-Analysis Global Group in Chronic Heart Failure) and EMPHASIS-HF (Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure) risk scores to categorize patients. The authors determined whether risk, on the basis of these scores, modified the treatment effect of LCZ696. ResultsThe complete MAGGIC risk score was available for 8,375 of the 8,399 patients in PARADIGM-HF. The median MAGGIC score was 20 (IQR: 16 to 24). An increase of 1 point was associated with a 6% increased risk for the primary endpoint (p < 0.001) and a 7% increased risk for cardiovascular death (p < 0.001). The benefit of LCZ696 over enalapril for the primary endpoint was similar across the spectrum of risk (p = 0.159). Treating 100 patients for 2 years with LCZ696 instead of enalapril led to 7 fewer patients in the highest quintile of risk experiencing primary outcomes, compared with 3 in the lowest quintile. Analyses using the EMPHASIS-HF risk score gave similar findings. ConclusionsAlthough most PARADIGM-HF patients had mild symptoms, many were at high risk for adverse outcomes and obtained a large absolute benefit from LCZ696, compared with enalapril, over a relatively short treatment period. LCZ696’s benefit was consistent across the spectrum of risk. (PARADIGM-HF trial [Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure]; NCT01035255)

Is heart rate a risk marker in patients with chronic heart failure and concomitant atrial fibrillation? Results from the MAGGIC meta-analysis.

To investigate the relationship between heart rate and survival in patients with heart failure (HF) and coexisting atrial fibrillation (AF). Patients with AF included in the Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) meta-analysis were the main focus of this analysis (3259 patients from 17 studies). The outcome was all-cause mortality at 3 years. Heart rate was analysed as a categorical (tertiles; T1 ≤77 b.p.m., T2 78-98 b.p.m., T3 ≥98 b.p.m.) and continuous variable. Cox proportional hazard models were used to compare the risk of all-cause death between tertiles of baseline heart rate. Patients in the highest tertile were more often female, less likely to have an ischaemic aetiology or diabetes, had a lower ejection fraction but higher blood pressure and New York Heart Association (NYHA) class. Higher heart rate was associated with higher mortality in patients with sinus rhythm (SR) but not in those in AF. In patients with heart failure and reduced ejection fraction (HF-REF) and AF, death rates per 100 patient years were lowest in the highest heart rate tertile (T1 18.9 vs. T3 15.9) but this difference was not statistically significant (P = 0.10). In patients with heart failure and preserved ejection fraction (HF-PEF), death rates per 100 patient years were highest in the highest heart rate tertile (T1 14.6 vs. T3 16.0, P = 0.014). However, after adjustment for other important prognostic variables, higher heart rate was no longer associated with higher mortality in HF-PEF (or HF-REF). In this meta-analysis of patients with HF, heart rate does not have the same prognostic significance in patients in AF as it does in those in SR, irrespective of ejection fraction or treatment with beta-blocker.

Long-term survival after MitraClip® therapy in patients with severe mitral regurgitation and severe congestive heart failure: A comparison among survivals predicted by heart failure models

BackgroundThe aim of the study was to investigate mortality following transcatheter mitral valve repair with the MitraClip System (MC) (Abbott Vascular, Santa Clara, CA, USA) in patients with mitral regurgitation and moderate-to-severe symptomatic heart failure in comparison to mortality predicted by the Seattle Heart Failure Model (SHFM) and the heart failure calculator of the meta-analysis global group in chronic heart failure (MAGGIC). Methods and resultsThis retrospective study included 194 consecutive patients, who received a MC implantation between 2009 and 2013 at our institution. The observed mortality was compared with that predicted by the SHFM and the MAGGIC after 1 year: 24% observed, 18% by SHFM (p=0.185) and 20.9% by MAGGIC (p=0.542). At 2 years: 32% observed vs. 33% by SHFM (p=0.919). The subgroup of patients with end-stage heart failure and N-terminal pro-B-type natriuretic peptide (NTproBNP) >10,000pg/ml (n=41) had significantly worse mortality after 1 year (49%) than predicted by SHFM (24%, p=0.034) and MAGGIC (24.8%, p=0.041). ConclusionIn the overall patient cohort defined by 3+ to 4+ mitral valve regurgitation with New York Heart Association III and IV symptomatic heart failure, mortality following MC is consistent with that predicted by SHFM and MAGGIC for patients that are not at high risk. However, the subset of patients with severe heart failure defined by NTproBNP >10,000pg/ml had worse than predicted mortality and may not benefit from MC therapy, mainly due to a high 30-day mortality.

MitraClip in CRT non-responders with severe mitral regurgitation

BackgroundSevere mitral regurgitation (MR) ≥3+ and left ventricular dyssynchrony in heart failure patients are markers of CRT non response. The MitraClip (MC) implantation is a therapy for MR ≥3+ in patients with high surgical risk of mitral valve reconstruction. Methods and resultsWe investigated 42 patients with CRT and MR ≥3+ who received an MC device at our center. One and two year mortality rates were compared with the predicted mortality by Seattle Heart Failure Model (SHFM) and meta-analysis global group in chronic heart failure (MAGGIC), using the baseline characteristics of patients at the time of MC implantation.The median time interval between CRT and MC implantation was 20.1 (4.5–43.3) months. In 19 patients we observed a functional regurgitation with normal leaflets and in 23 patients a degenerative mechanism for mitral regurgitation. There was no change in mean QRS duration by biventricular pacing or MC implantation. The use of MC led to significant reductions in: median N-terminal pro-brain natriuretic peptide (NT-proBNP) level (pg/ml) from 3923 to 2636 (p=0.02), tricuspid regurgitation pressure gradient (TRPG) from 43 to 35mmHg (p=0.019) and in left ventricular end-diastolic volume (LVEDV) by MC (p=0.008). At the 2year follow-up interval the all-cause mortality was 25%. ConclusionMC implantation leads to an improvement of NT-proBNP level, TRPG and LVEDV in both functional and degenerative MR but does not influence QRS duration. Two year all-cause mortality was 25% and did not differ significantly from that predicted by SHFM and MAGGIC.

Heart failure in younger patients: the Meta-analysis Global Group in Chronic Heart Failure (MAGGIC)

Our understanding of heart failure in younger patients is limited. The Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) database, which consisted of 24 prospective observational studies and 7 randomized trials, was used to investigate the clinical characteristics, treatment, and outcomes of younger patients. Patients were stratified into six age categories: <40 (n = 876), 40-49 (n = 2638), 50-59 (n = 6894), 60-69 (n = 12 071), 70-79 (n = 13 368), and ≥80 years (n = 6079). Of 41 926 patients, 2.1, 8.4, and 24.8% were younger than 40, 50, and 60 years of age, respectively. Comparing young (<40 years) against elderly (≥80 years), younger patients were more likely to be male (71 vs. 48%) and have idiopathic cardiomyopathy (63 vs. 7%). Younger patients reported better New York Heart Association functional class despite more severe left ventricular dysfunction (median ejection fraction: 31 vs. 42%, all P < 0.0001). Comorbidities such as hypertension, myocardial infarction, and atrial fibrillation were much less common in the young. Younger patients received more disease-modifying pharmacological therapy than their older counterparts. Across the younger age groups (<40, 40-49, and 50-59 years), mortality rates were low: 1 year 6.7, 6.6, and 7.5%, respectively; 2 year 11.7, 11.5, 13.0%; and 3 years 16.5, 16.2, 18.2%. Furthermore, 1-, 2-, and 3-year mortality rates increased sharply beyond 60 years and were greatest in the elderly (≥80 years): 28.2, 44.5, and 57.2%, respectively. Younger patients with heart failure have different clinical characteristics including different aetiologies, more severe left ventricular dysfunction, and less severe symptoms. Three-year mortality rates are lower for all age groups under 60 years compared with older patients.

Predicting survival in heart failure: validation of the MAGGIC heart failure risk score in 51 043 patients from the Swedish Heart Failure Registry

The aim of this study was to evaluate the performance of a recently developed risk score for mortality in heart failure by external validation in a national heart failure registry. From 13 routinely available patient characteristics, the Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) constructed a risk score for prediction of mortality in heart failure. We included 51 043 patients from the national Swedish Heart Failure Registry and calculated the MAGGIC risk score for each patient. The outcome measure was 3-year mortality. The predicted probability of death obtained from the calculated risk score was compared with the observed 3-year mortality, and model discrimination and calibration were assessed by formal tests and graphical means. The overall 3-year mortality in the study population was 39.4% and the MAGGIC project heart failure risk score predicted mortality was 36.4% (observed to expected ratio: 1.08). Discrimination was excellent overall (C index = 0.741). The difference between the model-predicted and the observed 3-year mortality in the six risk groups varied between 5% and -12%. Calibration plots demonstrated slight overprediction for the lowest risk patients, and underprediction in high risk patients. The MAGGIC project heart failure risk score demonstrated an excellent ability to categorize patients in separate risk strata. Although the predicted 3-year mortality risk was higher in low risk groups and lower in high risk groups compared with the observed 3-year mortality in the Swedish Heart Failure Registry, the MAGGIC project heart failure risk score performed well in a large nationwide contemporary external validation cohort.

Known and missing left ventricular ejection fraction and survival in patients with heart failure: a MAGGIC meta‐analysis report

Treatment of patients with heart failure (HF) relies on measurement of LVEF. However, the extent to which EF is recorded varies markedly. We sought to characterize the patient group that is missing a measure of EF, and to explore the association between missing EF and outcome. Individual data on 30 445 patients from 28 observational studies in the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) project were used to compare the prevalence of co-morbidities and outcome across three groups of HF patients: those with missing EF (HF-mEF), reduced EF (HF-REF), and preserved EF (HF-PEF). A total of 29% had HF-mEF, 52% HF-REF, and 19% HF-PEF. Compared with patients in whom EF was known, patients with HF-mEF were older, had a greater prevalence of COPD and previous stroke, and were smokers. Patients with HF-mEF were less likely to receive evidence-based treatment than those with HF-REF. Adjusted mortality in HF-mEF was similar to that in HF-REF and greater than that in HF-PEF at 3 years [HF-REF, hazard ratio (HR) 1.03, 95% confidence interval (CI) 0.95-1.12); HF-PEF, HR 0.78, 95% CI 0.71-0.86]. Missing EF is common. The short- and long-term outcome of patients with HF-mEF is poor and they exhibit different co-morbidity profiles and treatment patterns compared with patients with known EF. HF patients with missing EF represent a high risk group.

Defining hyponatraemia: a call for action

Defining hyponatraemia: a call for action

Gender and survival in patients with heart failure: interactions with diabetes and aetiology. Results from the MAGGIC individual patient meta‐analysis†

The aim of this study was to investigate the relationship between gender and survival of patients with heart failure, using data from both randomized trials and observational studies, and the relative contribution of age, left ventricular systolic function, aetiology, and diabetes to differences in prognosis between men and women. Data from 31 studies (41 949 patients; 28 052 men, 13 897 women) from the Meta-Analysis Global Group In Chronic Heart Failure (MAGGIC) individual patient meta-analysis were used. We performed survival analysis to assess the association of gender with mortality, adjusting for predictors of mortality, including age, reduced or preserved ejection fraction (EF), and ischaemic or non-ischaemic aetiology. Women were older [70.5 ( standard deviation 12.1) vs. 65.6 (standard deviation 11.6) years], more likely to have a history of hypertension (49.9% vs. 40.0%), and less likely to have a history of ischaemic heart disease (46.3% vs. 58.7%) and reduced EF (62.6% vs. 81.6%) compared with men. During 3 years follow-up, 3521 (25%) women and 7232 (26%) men died. After adjustment, male gender was an independent predictor of mortality, and the better prognosis associated with female gender was more marked in patients with heart failure of non-ischaemic, compared with ischaemic, aetiology (P-value for interaction = 0.03) and in patients without, compared with those with, diabetes (P-value for interaction <0.0001). This large, individual patient data meta-analysis has demonstrated that survival is better for women with heart failure compared with men, irrespective of EF. This survival benefit is slightly more marked in non-ischaemic heart failure but is attenuated by concomitant diabetes.