Heart Failure Survival Score Research Articles

Optimizing Triage of Ambulatory Patients With Advanced Heart Failure: 2-Year Outcomes From REVIVAL

BackgroundLeft ventricular assist device (LVAD) use remains uncommon in advanced heart failure (HF) patients not dependent on inotropes. ObjectivesBefore considering a randomized trial comparing a strategy of earlier use of LVAD to continued medical therapy, a better understanding is needed of the clinical trajectory of ambulatory patients with advanced systolic HF on optimal guideline-directed medical therapy (GDMT). MethodsREVIVAL enrolled 400 patients with advanced ambulatory systolic HF, ≥1 HF mortality risk marker (≥2 HF hospitalizations past year; or HF hospitalization and high natriuretic peptide; or no HF hospitalizations but low peak oxygen consumption, 6-minute walk, serum sodium, HF survival score or Seattle HF model predicted survival), and no LVAD contraindication at 21 LVAD centers from July 2015 to June 2016. Patients were followed for 2 years or until a primary outcome (death, durable ventricular assist device, or urgent transplant). Clinical outcomes and health-related quality of life were evaluated. ResultsMean baseline left ventricular ejection fraction was 21%, median 6-minute walk was 341 m, and 92% were Interagency Registry for Mechanically Assisted Circulatory Support profiles 5 to 7. Adherence to GDMT and electrical device therapies was robust. Composite primary outcome occurred in 22% and 37% at 1 and 2 years, with death alone in 8% and 16%, respectively. Patients surviving for 2 years maintained GDMT intensity and had no decline in health-related quality of life. ConclusionsStructured, serial follow-up at programs with expertise in caring for advanced ambulatory systolic HF patients facilitates triage for advanced therapies. Better strategies are still needed to avoid deaths in a small but significant group of patients who die without advanced therapies. REVIVAL patients not selected for VAD or transplant have robust survival and patient-reported outcomes, which challenges advocacy for earlier VAD implantation. (Registry Evaluation of Vital Information for VADs in Ambulatory Life [REVIVAL]; NCT01369407)

The Barcelona Bio-Heart Failure risk calculator may predict 1-year mortality in patients with advanced heart failure.

Accurate risk assessment in patients with heart failure (HF) is crucial. Developing new models that combine biochemical and clinical variables with novel biomarkers is the best approach to improving the management and prognostic evaluation in this population. We aimed to assess and compare the predictive utility of a new prognostic scale, the Barcelona Bio‑Heart Failure (BCN Bio‑HF) risk calculator, as well as traditional risk scores, the Heart Failure Survival Score (HFSS) and the Seattle Heart Failure Model (SHFM), in patients with end‑stage HF. We also searched for other risk factors associated with worse prognosis in the analyzed population. This was a prospective analysis of 279 patients with end‑stage HF listed for heart transplant between 2018 and 2021. The BCN Bio‑HF, HFSS, and SHFM scores were calculated in all patients, and the accuracy of these 3 models for predicting 1‑year mortality was assessed using receiver operating characteristic (ROC) analysis. Median (interquartile range) age of the patients was 56 (50-60) years, and 87.1% of the study population were men. During 1‑year follow‑up, a total of 95 patients (34.1%) died. The areas under the ROC curves for predicting 1‑year mortality were 0.95 (95% CI, 0.92-0.97) for BCN Bio‑HF, 0.81 (95% CI, 0.76-0.86) for HFSS, and 0.7 (95% CI, 0.63-0.76) for SHFM. We found that the BCN Bio‑HF (hazard ratio [HR], 1.015; 95% CI, 1.012-1.019; P <0.001) and HFSS scores (HR, 2.801; 95% CI, 1.848-4.237; P <0.001), along with the circulating bilirubin concentration (HR, 1.015; 95% CI, 1.002-1.028; P = 0.02), were associated with 1‑year mortality in the analyzed population. The BCN Bio‑HF risk score had significantly better prognostic performance than HFSS or SHFM. Lower BCN and HFSS scores and a higher bilirubin concentration were independently associated with a higher risk of 1‑year death in patients with end‑stage HF.

Exercise Oscillatory Ventilation Improves Heart Failure Prognostic Scores.

Several heart failure (HF) prognostic risk scores are available to guide the ideal time for listing candidates for a heart transplant (HTx). The detection of exercise oscillatory ventilation (EOV) during cardiopulmonary exercise testing (CPET) is associated with advanced HF and a worse prognosis, and yet it is not accounted for in these risk scores. Therefore, this study aimed to assess whether EOV further adds prognostic value to HF scores. A single-centre retrospective cohort study was undertaken of consecutive HF patients with reduced ejection fraction (HFrEF) who underwent CPET from 1996 to 2018. 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 calculated. The added value of EOV on top of those scores was assessed using a Cox proportional hazard model. The added discriminative power was also assessed by receiver operating characteristic curve comparison. A total of 390 HF patients with a median age of 58 (IQR 50-65) years were investigated, of whom 78% were male and 54% had ischaemic heart disease. The median peak oxygen consumption was 15.7 mL/kg/min (IQR 12.8-20.1). Exercise oscillatory ventilation was detected in 153 (39.2%) patients. Over a median follow-up of 2 years, 61 patients died (49 due to a cardiovascular reason) and 54 had a HTx. Exercise oscillatory ventilation independently predicted the composite outcome of all-cause death and HTx. Furthermore, the presence of this ventilatory pattern significantly improved the prognostic performance of both HFSS and MAGGIC scores. Exercise oscillatory ventilation was often found in a cohort of HF patients with reduced LVEF who underwent CPET. It was found that EOV added further prognostic value to contemporary HF scores, suggesting that this easily obtained parameter should be included in future modified HF scores.

Optimizing exercise testing-based risk stratification to predict poor prognosis after acute heart failure.

The timely selection of severe heart failure (HF) patients for cardiac transplantation and advanced HF therapy is challenging. Peak oxygen consumption (VO2 ) values obtained by the cardiopulmonary exercise testing are used to determine the transplant recipient list. This study reassessed the prognostic predictability of peak VO2 and compared it with the Heart Failure Survival Score (HFSS) in the modern optimized guideline-directed medical therapy (GDMT) era. We retrospectively selected 377 acute HF patients discharged from the hospital. The primary outcome was a composite of all-cause mortality, or urgent cardiac transplantation. We divided these patients into the more GDMT (two or more types of GDMT) and less GDMT groups (fewer than two types of GDMT) and compared the performance of their peak VO2 and HFSS in predicting primary outcomes. The median follow-up period was 3.3years. The primary outcome occurred in 57 participants. Peak VO2 outperformed HFSS when predicting 1year (0.81 vs. 0.61; P=0.017) and 2year (0.78 vs. 0.58; P<0.001) major outcomes. The cutoff peak VO2 for predicting a 20% risk of a major outcome within 2years was 10.2 (11.8-7.0) for the total cohort. Multivariate Cox regression analyses showed that peak VO2 , sodium, previous implantable cardioverter defibrillator (ICD) implantation, and estimated glomerular filtration rate were significant predictors of major outcomes. Optimizing the cutoff value of peak VO2 is required in the current GDMT era for advanced HF therapy. Other clinical factors such as ICD use, hyponatraemia, and chronic kidney disease could also be used to predict poor prognosis. The improvement of resource allocation and patient outcomes could be achieved by careful selection of appropriate patients for advanced HF therapies, such as cardiac transplantation.

A new cardiopulmonary exercise testing score for predicting heart failure events

Abstract Background Cardiopulmonary exercise test (CPET) provides several variables (V) that are strong predictors of events in patients (pts) with heart failure (HF). Purpose Our aim was to develop and evaluate the predictive power (PP) of a CPET-based score, comparing to that of the Heart Failure Survival Score – HFSS. Methods Retrospective evaluation of adult pts with HF submitted to CPET in a tertiary center. Pts were followed up for at least 1 year for the primary endpoint of cardiac death and urgent heart transplantation/ ventricular assist device implantation (MTV). The PP of several CPET V's was assessed using ROC curve analysis, which was used to define optimal threshold values for each V. A multiple regression analysis was performed to identify independent prognostic predictors and to determine the regression coefficient (β) for the Vs included in the model, each expressed dichotomously using the threshold value. According to β, a weight was assigned to each V and summed to calculate the composite score. ROC curves were compared using the Hanley and McNeil test. Results CPET was performed in 487 HF pts, with a mean age of 56±13 years, 79% were male. 46% of pts were of ischemic etiology, with a mean LVEF of 30±8%, a mean HFSS of 8.6±1.1 and a mean BNP value of 509±668pg/ml. The mortality rate during a mean follow-up of 21 months, was 19% (93pts) with 23 pts (5%) undergoing HT. The primary endpoint was reached by 55 (11%) pts. The variables with higher predictive power were OUES (AUC 0.796), ventilatory power (AUC 0.790), the partial pressure of end-tidal CO2 at the anaerobic threshold (PETCO2L – AUC of 0.787), the pVO2 (AUC 0.767) and heart rhythm (HR) during the test (AUC – 0.640). LVEF also presented a high predictive power with AUC of 0.755. The multivariate analysis revealed that pVO2, PETCO2L, AF, and LVEF were independent prognostic predictors. According to the β of these Vs, the equation was calculated as follows: (pVO2 × 2.194) + (PETCO2L × 1.545) + (LVEF × 1.134) + (HR × 1.055; 0 if AF, 1 if sinus rhythm). The score presented a high PP with an AUC of 0.866. A cut-off of 120 had an 83.6% sensitivity and a 75% specificity for MTV, and pts with a score value of &amp;lt;120 had a markedly lower rate of MTV (log-rank p&amp;lt;0.001). When compared to HFSS, our score presented a higher PP (0.866 vs 0.774, p=0.011). Conclusion A multivariable score based on readily available CPET Vs provides a simple, integrated and powerful method to predict HF events. Funding Acknowledgement Type of funding sources: None.

The Utility of Pentraxin and Modified Prognostic Scales in Predicting Outcomes of Patients with End-Stage Heart Failure.

Risk stratification is an important element of management in patients with heart failure (HF). We aimed to determine factors associated with predicting outcomes in end-stage HF patients listed for heart transplantation (HT), with particular emphasis placed on pentraxin-3 (PXT-3). In addition, we investigated whether the combination of PTX-3 with the Heart Failure Survival Score (HFSS), the Seattle Heart Failure Model (SHFM), or the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) improved the prognostic strength of these scales in the study population. We conducted a prospective analysis of 343 outpatients with end-stage HF who accepted the HT waiting list between 2015 and 2018. HFSS, SHFM, and MAGGIC scores were calculated for all patients. PTX3 was measured by sandwich enzyme-linked immunosorbent assay with a commercially available kit. The endpoints were death, left ventricular assist device implantation, and HT during the one-year follow-up. The median age was 56 (50–60) years, and 86.6% were male. During the follow-up period, 173 patients reached the endpoint. Independent risk factors associated with outcomes were ischemic etiology of HF [HR 1.731 (1.227–2.441), p = 0.0018], mean arterial pressure (MAP) [1.026 (1.010–1.042), p = 0.0011], body mass index (BMI) [1.055 (1.014–1.098), p = 0.0083], sodium [1.056 [(1.007–1.109), p = 0.0244] PTX-3 [1.187 (1.126–1.251, p < 0.0001) and N-terminal pro-brain natriuretic peptide (NT-proBNP) [HR 1.004 (1.000–1.008), p = 0.0259]. The HFSS-PTX-3, SHFM-PTX-3 and MAGGIC-PTX-3 scores had significantly higher predictive power [AUC = 0.951, AUC = 0.973; AUC = 0.956, respectively] than original scores [AUC for HFSS = 0.8481, AUC for SHFM = 0.7976, AUC for MAGGIC = 0.7491]. Higher PTX-3 and NT-proBNP concentrations, lower sodium concentrations, lower MAP and BMI levels, and ischemic etiology of HF are associated with worse outcomes in patients with end-stage HF. The modified SHFM-PTX-3, HFSS-PTX-3, and MAGGIC-PTX-3 scores provide effective methods of assessing the outcomes in the analyzed group.

The role of cardiopulmonary exercise testing in a contemporary heart failure population

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiopulmonary exercise testing (CPET) is used for risk stratification in patients with chronic heart failure (CHF). However, there is a lack of information regarding CPET prognostic power in patients under new HF therapies such as sacubitril/valsartan, Mitraclip, IV iron or SGLT2 inhibitors. The aim of this study was to evaluate the prognostic value of CPET parameters in a contemporary subset of patients with optimal medical and device therapy for CHF. Methods Retrospective evaluation of patients with CHF submitted to CPET in a tertiary center. Patients were followed up for 24 months for the composite endpoint of cardiac death, urgent heart transplantation or left ventricular assist device. CPET parameters, including peak oxygen consumption (pVO2) and VE/VCO2 slope, were analysed and their predictive power was measured. HF events were stratified according to cut-off values defined by the International Society for Heart and Lung Transplantation (ISHLT) guidelines: pVO2 of ≤12 mL/Kg/min and VE/VCO2 slope of &amp;gt;35. Results CPET was performed in 204 patients, from 2014 to 2018. Mean age was 59 ± 13 years, 83% male, with a mean left ventricular ejection fraction of 33 ± 8%, and a mean Heart Failure Survival Score of 8.6 ± 1.3. The discriminative power of CPET parameters is displayed in the Table. In patients with pVO2 ≤12 mL/Kg/min, the composite endpoint occurred in 18% of patients. A pVO2 value of ≤12 mL/Kg/min had a positive predictive power of 18% while pVO2 &amp;gt;12 had a negative predictive power of 93%. Regarding VE/VCO2 slope &amp;gt;35, the composite endpoint occurred in 13% of patients. A VE/VCO2 slope value of &amp;gt;35 had a positive predictive power of 13% while VE/VCO2 slope &amp;lt;35 had a negative predictive power or 94%. Conclusion Using ISHLT guideline cut-off values for advanced HF therapies patient selection, there was a reduced number of HF events (&amp;lt;20%) at 24 months in patients under optimal CHF therapy. While pVO2 and VE/VCO2 slope are still valuable parameters in risk stratification, redefining cut-off values may be necessary in a modern HF population. Discriminative power of CPET parameters Parameters HR; 95% CI AUC p-value Peak VO2 0.824 (0.728-0.934) 0.781 0.001 Percent of predicted pVO2 0.942 (0.907-0.978) 0.774 0.002 VE/VCO2 slope 1.068 (1.031-1.106) 0.756 0.008 Cardiorespiratory optimal point 1.118 (1.053-1.188) 0.746 0.004 PETCO2 maximum exercise 0.854 (0.768-0.950) 0.775 0.003 Ventilatory Power 0.358 (0.176-0.728) 0.796 0.002 HR Hazard ratio, AUC: Area under the curve, PETCO2: end-tidal CO2 pressure

Factors related to the discontinuation and mortality rates of a cardiac rehabilitation programme in patients with Chagas disease: a 6-year experience in a Brazilian tertiary centre.

To describe the clinical and sociodemographic characteristics of participants as well as discontinuation and mortality rates in a cardiac rehabilitation programme (CRP) tailored to Chagas disease (CD). Participants underwent functional capacity, anthropometry and cardiac function evaluations before beginning a CRP. Univariate and multivariate Cox proportional hazards models were performed to investigate the associations between clinical and sociodemographic characteristics at baseline with discontinuation rates and deaths. Forty-two patients were enrolled in the CRP (61.9% men, mean age of 58.1±11.8years). During a median follow-up period of 10.8months, 74% discontinued and 14% died while enrolled in CRP. 34% of the patients who discontinued CRP died during follow-up. White race (HR=0.09; 95% CI 0.01-1.00), right ventricular systolic dysfunction (HR=10.54; 95% CI 1.24-89.50) and oxygen pulse (HR=0.69; 95% CI 0.48-0.99) were independently associated with death while enrolled in CRP. Married status (HR=0.44; 95% CI 0.21-0.95) was independently associated with discontinuation rates from CRP. VO2 peak (HR=0.85; 95% CI 0.74-0.98) and CRP discontinuation due to CD-related reasons (HR=8.33; 95% CI 1.91-36.27) were the variables independently associated with death after discontinuation of CRP. In this population, sociodemographic aspects and severity of CD were important determinants of CRP discontinuation and mortality.

Prognostic value of the cardiorespiratory optimal point during submaximal exercise testing

Abstract Background Peak oxygen consumption (pVO2) is a key parameter in assessing the prognosis of heart failure with reduced ejection fraction (HFrEF) patients (pts). However, it is a less reliable parameter when the cardiopulmonary exercise test (CPET) is not maximal. It is crucial to identify the submaximal exercise variables with the best prognostic power (PP), in order to improve the management of pts that cannot attain a maximal CPET. Purpose The aim of this study was to evaluate and compare the PP of several exercise parameters in submaximal CPET for risk stratification in pts with HFrEF. Methods Prospective evaluation of adult pts with HFrEF submitted to CPET in a tertiary center. A submaximal CPET was defined by a respiratory exchange ratio (RER) ≤1.10. Pts were followed up for at least 1 year for the primary endpoint of cardiac death and urgent heart transplantation/ ventricular assist device implantation. Several CPET parameters were analyzed as potential predictors of the combined endpoint and their PP (area under the curve - AUC) was compared to that of pVO2, using the Hanley and McNeil test. Results CPET was performed in 487 HF pts, of which 317 (66%) performed a submaximal CPET. Pts averaged 57±12 years of age, 77% were male, 45.7% had ischemic cardiomyopathy, with a mean LVEF of 30.4±7.6%, a mean heart failure survival score of 8.6±1.1. The mean pVO2 was 17.1±5.5 ml/kg/min and the mean RER 1.01±0.08. During a mean follow-up (FU) time of 11±1 months, 18 pts (6%) met the primary endpoint. Cardiorespiratory optimal point (OP - VE/VO2) had the highest AUC value (0.915, p=0.001), followed by the partial pressure of end-tidal CO2 at the anaerobic threshold - PETCO2L (0.814, p&amp;lt;0.001). pVO2 presented an AUC of 0.730 (p=0.001). OP≥31 and PETCO2L ≤37mmHg had a sensitivity of 100 and 76.9% and a specificity of 71.1 and 67%, respectively, for the primary outcome. OP presented a significantly higher PP than pVO2 (p=0.048), whether PETCO2L didn't achieve any statistical significance (p=0.164). Pts with anOP≥31 presented a significantly lower survival free of HT during FU (log rank p=0.002). Conclusion OP had the highest PP for HF events of all parameters analyzed for a submaximal CPET. This parameter can help stratify the HF pts physiologically unable to reach a peak level of exercise. Funding Acknowledgement Type of funding source: None

Factors associated with elevated pulmonary vascular resistance in ambulatory patients with end-stage heart failure accepted for heart transplant.

Pulmonary hypertension (PH) is a common complication of heart failure (HF) that results in worse prognosis and heart complications following heart transplantation. To better define and understand left‑sided PH, it is necessary to integrate the clinical context, noninvasive assessment, and invasive hemodynamic variables. The aim of the study was to search for noninvasive factors related to the presence of PH with elevated pulmonary vascular resistance (PVR) in patients with advanced HF. The study is a retrospective analysis of 282 patients with end‑stage HF accepted for transplantation in the cardiology department between 2016 and 2018. A panel of laboratory tests, echocardiography, ergospirometry, and right heart catheterization were performed in all included patients. The Model for End‑Stage Liver Disease Excluding INR (MELD‑XI) and the Heart Failure Survival Score (HFSS) were calculated according to the appropriate formulas. The median age was 57 (51-60) years and 87.6% of patients were men. Pulmonary hypertension with elevated PVR was found in 30.1% of patients. The multivariable logistic regression analysis confirmed that lower HFSS (OR, 0.59; 95% CI, 0.383-0.908; P = 0.016), and higher MELD‑XI scores (OR, 1.13; 95% CI, 1.024-1.24; P = 0.014), as well as higher alkaline phosphatase levels (OR, 1.02; 95% CI, 1.007-1.024; P <0.001) were independent factors associated with increased PVR. To the best of our knowledge, this is the first study to demonstrate that high MELD‑XI and low HFFS scores, as well as high alkaline phosphatase serum concentrations were independently associated with increased PVR in patients with advanced HF referred for transplantation.

Apelin Improves Prognostic Value of HFSS (Heart Failure Survival Score) and MAGGIC (Meta-Analysis Global Group in Chronic Heart Failure) Scales in Ambulatory Patients with End-Stage Heart Failure.

This prospective study aimed to determine the effect of adding apelin to the MAGGIC (Meta-Analysis Global Group In Chronic Heart Failure) and HFSS (Heart Failure Survival Score) scales for predicting one-year mortality in 240 ambulatory patients accepted for heart transplantation (HT) between 2015–2017. The study also investigated whether the combination of N-terminal pro-brain natriuretic peptide (NT-proBNP) with MAGGIC or HFSS improves the ability of these scales to effectively separate one-year survivors from non-survivors on the HT waiting list. The median age of the patients was 58.0 (51.50.0–64.0) years and 212 (88.3%) of them were male. Within a one year follow-up, 75 (31.2%) patients died. The area under the curves (AUC) for baseline parameters was as follows—0.7350 for HFSS, 0.7230 for MAGGIC, 0.7992 for apelin and 0.7028 for NT-proBNP. The HFSS-apelin score generated excellent power to predict the one-year survival, with the AUC of 0.8633 and a high sensitivity and specificity (80% and 78%, respectively). The predictive accuracy of MAGGIC-apelin score was also excellent (AUC: 0.8523, sensitivity of 75%, specificity of 79%). The addition of NT-proBNP to the HFSS model slightly improved the predictive power of this scale (AUCHFFSS-NT-proBNP: 0.7665, sensitivity 83%, specificity 60%), while it did not affect the prognostic strength of MAGGIC (AUCMAGGIC-NT-proBNP: 0.738, sensitivity 71%, specificity 69%). In conclusion, the addition of apelin to the HFSS and MAGGIC models significantly improved their ability to predict the one-year survival in patients with advanced HF. The MAGGIC-apelin and HFSS-apelin scores provide simple and powerful methods for risk stratification in end-stage HF patients. NT-proBNP slightly improved the prognostic power of HFSS, while it did not affect the predictive power of MAGGIC.

P5423Exercise oscillatory ventilation improves the performance of prognosis scores currently used for heart failure

Abstract Background and aim Several prognostic risk scores are available for heart failure with reduced ejection fraction (HFrEF), and are used, together with other criteria, to help decide the ideal timing for listing candidates for a heart transplant. The detection of an oscillatory ventilatory pattern (OVP) during cardiopulmonary exercise testing (CPET) has been associated with more advanced HF and a worse prognosis, but was not considered in the development of all the current risk scores. We evaluated whether OVP adds significant prognostic information to four contemporary HF scores. Methods Single-centre retrospective cohort study of consecutive HFrEF patients undergoing CPET for functional and prognostic assessment from October 1996 till May 2018. 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 obtained in each patient. Cox model was fit with time to death or urgent transplant (whichever came first within 2 years) as the dependent variable and OVP and respective HF score as the independent variables. We further assessed the added discriminative power by performing ROC curve comparisons. Results We studied 387 patients, median age 58 (IQR 49; 65) years, and 77% were male. The most common HFrEF aetiology was ischemic heart disease (54%). Median peak oxygen consumption was 15,7 mL/kg/min (IQR 12,8; 20,0). OVP was present in 150 (39%) patients. Over the 2-year follow-up period, 48 patients died, and 52 underwent heart transplantation (of which 25 were urgent). HFSS showed the weakest (c-statistic 0,625; 95% [CI] 0,54–0,71) and MECKI score the strongest (c-statistic 0,819; 95% [CI] 0,76–0,88) discriminatory ability. Contrasting with NTproBNP value, the presence of OVP predicted the study endpoint independently of the HF prognosis score used (see table). Adding the occurrence of OVP to the HFSS and the MAGGIC scores significantly improved their prognostic performance (see Table). Conclusion An OVP is a common finding in HFrEF patients undergoing CPET, and adds prognostic information to contemporary HF prognosis scores. Systematic evaluation of this easily available criterion may assist the decision on the appropriate timing for heart transplantation listing.

Association between quality of life and prognosis of candidate patients for heart transplantation: a cross-sectional study.

ABSTRACTObjective:to verify the association between the prognostic scores and the quality of life of candidates for heart transplantation. Method:a descriptive cross-sectional study with a convenience sample of 32 outpatients applying to heart transplantation. The prognosis was rated by the Heart Failure Survival Score (HFSS) and the Seattle Heart Failure Model (SHFM); and the quality of life by the Minnesota Living With Heart Failure Questionnaire (MLHFQ) and the Kansas City Cardiomyopathy Questionnaire (KCCQ). The Pearson correlation test was applied. Results:the correlations found between general quality of life scores and prognostic scores were (HFSS/MLHFQ r = 0.21), (SHFM/MLHFQ r = 0.09), (HFSS/KCCQ r = -0.02), (SHFM/KCCQ r = -0.20). Conclusion:the weak correlation between the prognostic and quality of life scores suggests a lack of association between the measures, i.e., worse prognosis does not mean worse quality of life and the same statement is true in the opposite direction.

Prognostic value of selected risk scales in patients with end-stage heart failure

Due to the increasing number of patients placed on waiting lists for orthotopic heart transplantation (OHT), the selection of patients with the highest risk of death has become paramount. This study aimed to evaluate the predictive value of the Model for End-stage Liver Disease eXcluding INR (MELD-XI) and Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) scales in ambulatory patients awaiting OHT and compare them to the Heart Failure Survival Score (HFSS). The study was a retrospective review of 370 adult ambulatory patients with end-stage heart failure, who were added to the OHT waiting list at our institution between 2012 and 2016. The median age of the patients was 54.0 (46.0-60.0) years, and 324 (87.6%) of them were male. The overall one-year mortality was 27.6%. The areas under the curve (AUCs) for the MAGGIC and HFSS scales were comparable: 0.771 (95% confidence interval [CI] 0.720-0.823); sensitivity 77%, specificity 68% vs. 0.781 (95% CI 0.732-0.829); sensitivity 90%, specificity 58%, respectively. The AUC for the MELD-XI scale was higher than that for the HFSS scale: 0.812 (95% CI 0.769-0.856); sensitivity 91%, specificity 63% vs. 0.781 (95% CI 0.732-0.829) sensitivity 90%, specificity 58%, respectively. Our study demonstrated that elevated MELD-XI and MAGGIC scores and lowered HFSS scores were associated with an increased risk of death during one-year follow-up. The prognostic utility of the MELD-XI scoring system was better than that of the HFSS scale, while the MAGGIC scale was comparable to the HFSS.

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.

Prognostic scales in advanced heart failure.

Heart transplantation (HT) is the treatment of choice for patients with advanced heart failure (HF) who remain symptomatic despite optimal medical therapy. Due to the shortage of organs for transplantation and constantly increasing number of patients placed on waiting lists, accurate risk stratification is a crucial element of management in this population. Prognostic scales allow one to evaluate the patient prognosis, estimate the potential benefits of therapy and identify those patients most likely to benefit from advanced methods of treatment. In this review, we describe prognostic scales in advanced HF, concentrating on commonly used tools – the Heart Failure Survival Score (HFSS) and Seattle Heart Failure Model (SHFM) – as well as on the new promising scales for evaluating waiting list mortality and post-transplant outcomes.

Current indications for transplantation: stratification of severe heart failure and shared decision-making.

Heart failure (HF) is a complex clinical syndrome that results from structural or functional cardiovascular disorders causing a mismatch between demand and supply of oxygenated blood and consecutive failure of the body's organs. For those patients with stage D HF, advanced therapies, such as mechanical circulatory support (MCS) or heart transplantation (HTx), are potentially life-saving options. The role of risk stratification of patients with stage D HF in a value-based healthcare framework is to predict which subset might benefit from advanced HF (AdHF) therapies, to improve outcomes related to the individual patient including mortality, morbidity and patient experience as well as to optimize health care delivery system outcomes such as cost-effectiveness. Risk stratification and subsequent outcome prediction as well as therapeutic recommendation-making need to be based on the comparative survival benefit rationale. A robust model needs to (I) have the power to discriminate (i.e., to correctly risk stratify patients); (II) calibrate (i.e., to show agreement between the predicted and observed risk); (III) to be applicable to the general population; and (IV) provide good external validation. The Seattle Heart Failure Model (SHFM) and the Heart Failure Survival Score (HFSS) are two of the most widely utilized scores. However, outcomes for patients with HF are highly variable which make clinical predictions challenging. Despite our clinical expertise and current prediction tools, the best short- and long-term survival for the individual patient, particularly the sickest patient, is not easy to identify because among the most severely ill, elderly and frail patients, most preoperative prediction tools have the tendency to be imprecise in estimating risk. They should be used as a guide in a clinical encounter grounded in a culture of shared decision-making, with the expert healthcare professional team as consultants and the patient as an empowered decision-maker in a trustful safe therapeutic relationship.

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.

The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update

Mandeep R. Mehra, MD (Chair), Charles E. Canter, MD, Margaret M. Hannan, MD, Marc J. Semigran, MD, Patricia A. Uber, PharmD, David A. Baran, MD, Lara Danziger-Isakov, MD, MPH, James K. Kirklin, MD, Richard Kirk, MD, Sudhir S. Kushwaha, MD, Lars H. Lund, MD, PhD, Luciano Potena, MD, PhD, Heather J. Ross, MD, David O. Taylor, MD, Erik A.M. Verschuuren, MD, PhD, Andreas Zuckermann, MD and on behalf of the International Society for Heart Lung Transplantation (ISHLT) Infectious Diseases, Pediatric and Heart Failure and Transplantation Councils

Prognostic significance of reactive pulmonary hypertension in patients with chronic heart failure listed for elective heart transplantation.

Pulmonary hypertension (PH) is recognised in about 60% of patients referred for heart transplantation (HTx), and it influences the patient's prognosis. To assess the prognostic value of reactive PH in patients listed for elective HTx. A total of 522 patients were enlisted from the Polish National Registry (POLKARD), listed for HTx, in whom complete haemodynamic data were reported. The endpoint was all-cause death before HTx. Heart transplantation, elective or urgent, was considered as an end of the follow-up (mean follow-up 1.47 ± 1.26 years). Patients were divided into three subgroups: no PH, passive PH, reactive PH taking into account mean pulmonary artery pressure (PAP) of 25 mm Hg, pulmonary capillary wedge pressure (PCWP) 15 mm Hg, and pulmonary vascular resistance (PVR) 3.0 Wood units. Haemodynamic, clinical, echocardiographic, and biochemical assessments (including NT-proBNP, hs-CRP) were performed. The Heart Failure Survival Score (HFSS) was calculated. Estimated death rate was comparable between patients with no PH, passive PH, and reactive PH, despite the fact that the patients with reactive PH had the worst pulmonary haemodynamic scores (mean PAP 38.4 ± 7.8, PCWP 27 ± 7.4 mm Hg and PVR 4.8 ± 1.7 Wood units). In patients with reactive PH, in multifactor Cox analysis only the serum Na level influenced survival. According to the Kaplan-Meier method, patients with reactive PH, with mean PAP ≥ 41.4 mm Hg had the worst prognosis, estimated survival was: one year - 83%, two years - 65%. Reactive PH is common among patients with chronic HF listed to HTx (28%). It has no further influence on short-term prognosis as compared with patients with no PH and passive PH. Serum Na concentration and mean PAP ≥ 41.4 mm Hg influence the prognosis of patients with reactive PH.