MAGGIC Score Research Articles

Effect of Vericiguat in Victoria According to Guideline-directed Medical Therapy

Background In VICTORIA, vericiguat was more effective than placebo in addition to standard of care in reducing the composite outcome of CV death (CVD) or HF hospitalization (HFH). We describe baseline guideline-directed medical therapy (GDMT) and examine if the primary outcome was associated with differences in adherence to GDMT including dosing. Methods We used baseline data for 5 GDMT: ACEi, ARBs, ARNI, beta-blockers (BB), and MRAs. We defined adherence as: (1) basic adherence (yes/no); (2) indication-corrected adherence (basic adherence after accounting for indications, contraindications and tolerance); and (3) dose-corrected adherence (indication-corrected adherence + ≥50% of dose target). Associations of study treatment and the primary outcome by GDMT adherence was assessed with Cox proportional hazard regression and adjustment for the MAGGIC score. Results 5040 patients had relevant data available. Basic adherence was 87.4% for RAS inhibition (73.4% for ACEi or ARB, 14.5% for ARNI), 95.6% using indication-corrected and 40.9% for dose-corrected adherence. For BBs, 93.1% met basic and 96.2% indication-corrected adherence, 45.1% met dose-corrected adherence. For MRA, 70.3% met basic and 90% indication-corrected adherence, 82.6% dose-corrected adherence. For triple therapy (ACEi, ARB or ARNI + beta-blocker + MRA), basic adherence was 59.7%, and 86% using indication-corrected adherence and 80.3% with dose-corrected adherence. Using basic or dose corrected adherence, the treatment effect of vericiguat was consistent across GDMT with no treatment heterogeneity, with or without adjustment for variables (Fig). However, vericiguat appeared to be associated with a greater reduction in the primary outcome in those meeting ≥50% dose target for BB (HR 0.72, 95% CI 0.61-0.84) than those who did not (HR 1.01, 95% CI 0.88-1.15; p-interaction 0.001). Conclusions Patients in VICTORIA were well treated with GDMT and the efficacy of vericiguat was consistent across background GDMT therapy with very high indication-corrected adherence accounting for patient-level indications, contraindications, and tolerance.

Suppression tumorigenicity 2 (ST2) turbidimetric immunoassay compared to enzyme-linked immunosorbent assay in predicting survival in heart failure patients with reduced ejection fraction

BackgroundSuppressor of tumorigenicity 2 (ST2) is a powerful marker of prognosis and treatment response in heart failure (HF), however, it is an enzyme-linked immunosorbent assay (ELISA) which may be cumbersome and costly. A turbidimetric immunoassay (TIA) that can run on common chemistry analyzers could overcome this. We studied a novel TIA for ST2, comparing it to commercial ST2 (ELISA). MethodsPatients age ≥ 18 years meeting Framingham definition for HF were enrolled in a prospective registry (Oct 2007 – March 2015) at Henry Ford Hospital and donated blood samples. Participants with reduced ejection fraction (<50%) and available plasma samples were included and valid ST2 measurements were obtained on the same sample using both TIA and ELISA (N = 721). The primary endpoint was all cause death. Correlation between the methods was quantified. The association with survival was tested using unadjusted and adjusted (for MAGGIC score and NTproBNP) Cox models and comparing the Area Under the Curve (AUC). ResultsThe inter-assay Spearman correlation coefficient was 0.77. Nonparametric regression showed no significant proportional difference (slope = 0.97) and a very small systematic difference (3.2 ng/mL). In univariate analyses, both TIA and ELISA ST2 were significant associates of survival with similar effect sizes (HR 4.46 and 3.50, respectively, both p < 0.001). In models adjusted for MAGGIC score, both ST2 remained significant in Cox models and incrementally improved AUC vs. MAGGIC alone (MAGGIC AUC = 0.757; TIA + MAGGIC AUC = 0.786, p = 0.025; ELISA + MAGGIC AUC = 0.793, p = 0.033). In models with both MAGGIC and NTproBNP included, both ST2 still remained significant but did not improve AUC. ConclusionsA novel TIA method for ST2 quantification correlates highly with ELISA and offers similarly powerful risk-stratification.

Cognitive impairment measured by Mini-Cog provides additive prognostic information in elderly patients with heart failure

BackgroundThere has been no study elucidating whether cognitive impairment (CI) can provide additive prognostic information besides that provided by preexisting prognostic factors in elderly patients with heart failure. This study examined whether CI can provide additive prognostic information in elderly patients with heart failure. MethodsThis multicenter retrospective study included 352 patients with heart failure aged ≥75 years. We administered the Mini-Mental State Examination (MMSE) and Mini-Cog test to assess CI. The Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score was used as a model to incorporate the preexisting prognostic factors. All-cause mortality was considered the prognostic outcome. ResultsThe median age was 85 years old, 47.7% were male. According to MMSE and Mini-Cog, 167 (47.4%) and 159 (45.2%) patients had CI, respectively. The agreement between MMSE and Mini-Cog was fairly low (Cohen’s kappa coefficient 0.37). During the follow-up period of median 346 days, 53 patients (15.1%) died. In multivariate Cox regression analysis, CI defined by MMSE and Mini-cog were individually associated with worse prognosis in older heart failure patients even after adjustment for MAGGIC risk model and log B-type natriuretic peptide levels [CI defined by MMSE, HR: 2.05 (95%CI: 1.16−3.61); and CI defined by Mini-Cog, HR:2.57 (95%CI: 1.46–4.53)]. The area under the curve of receiver operator characteristics curve was numerically greater for Mini-Cog than for MMSE (0.59 vs. 0.52, p = 0.109). Moreover, significant net reclassification improvement was observed when CI defined by Mini-Cog, but not on CI defined by MMSE, was added to the MAGGIC score, and when Mini-Cog, instead of MMSE, was used as a CI assessment tool (0.41, p = 0.004). ConclusionsAmong elderly hospitalized patients with heart failure, CI should be considered as a critical factor for prognosis prediction. Mini-Cog is a potentially preferable tool to assess CI in terms of providing prognostically relevant information compared to MMSE.

P1418Heart failure and atrial fibrillation: clinical, prognostic and echocardiographic outcome

Abstract Background Catheter ablation (CA) for atrial fibrillation (AF) in heart failure (HF) patients is associated with a lower rate of cardiac events compared to medical therapy. Purpose This study deals with the clinical, echocardiographic and prognostic outcomes in these patients. Methods From a single center 47 patients with AF, HF and left ventricular ejection fraction (LVEF) &amp;lt;50%, underwent CA. The primary endpoints were NYHA functional class, LVEF and MAGGIC (Meta-Analysis Global Group in Chronic Heart Failure) Risk score before the procedure and after 12 months. Results The median age of patients was 59 years; 49% had paroxysmal AF. At 12-month a significant improvement of NYHA class (median before II [interquartile range (IQR) II-III] vs median after I [IQR I-II]) and of LVEF (median before 44% [IQR 37-47] vs median after 55% [IQR49-57]) was observed (p-value 0.000). The MAGGIC 1-year and 3-year probability of death was estimated before (mean score 13 [IQR 11-17]) and at 12-month (mean score 11 [IQR 8-13]) showing a significant decrease in the probability of death (p-value 0.000). At 12-month patients with reduced LVEF before the ablation had more HF hospitalizations than HF mid-range patients (p-value 0.035). Coronary artery disease (CAD) (HR 5, p-value 0.035) and MAGGIC score (HR 1.2, p-value 0.030) were predictors of HF hospitalization. Conclusion CA for AF in HF patients was associated with a significant improvement of NYHA functional class and LVEF and a higher life expectation. CAD history, LVEF &amp;lt;40% and MAGGIC score before ablation were predictors of HF hospitalization at 12-month follow-up.

Catheter ablation of atrial fibrillation in heart failure: clinical, prognostic, and echocardiographic outcome.

Catheter ablation (CA) for atrial fibrillation (AF) in heart failure (HF) patients is associated with a lower rate of cardiac events compared with medical therapy. This study deals with the clinical, echocardiographic, and prognostic outcomes in these patients. Prognostic scores, as MAGGIC (Meta-analysis Global Group in Chronic Heart Failure) score, may help to predict the outcomes. From a single center, 47 patients with AF, HF, and left ventricular ejection fraction (LVEF) < 50% underwent CA. The primary endpoints were NYHA functional class, LVEF, and MAGGIC score. The median age of patients was 59years; 49% had paroxysmal AF. At 12months, a significant improvement of NYHA class (median before II [interquartile range (IQR) II-III] vs median after I [IQR I-II]) and of LVEF (median before 44% [IQR 37-47] vs median after 55% [IQR49-57]) was observed (p value < 0.001). The MAGGIC 1-year and 3-year probability of death was estimated before (mean score 13 [IQR 11-17]) and at 12-month (mean score 11 [IQR 8-13]), showing a significant decrease in the probability of death (p value <0.001). At 12-month, a lower LVEF was associated with more HF hospitalizations (p value 0.035). Coronary artery disease (CAD) (HR 5, p value 0.035) and MAGGIC score (HR 1.2, p value 0.030) were predictors of HF hospitalization. CA for AF in HF patients was associated with a significant improvement of NYHA functional class and LVEF and a higher life expectation. CAD history, LVEF < 40%, and MAGGIC score before ablation were predictors of HF hospitalization.

MAGGIC-Predicted Mortality of >20% at One Year is Associated with Poor Prognosis in Ambulatory Patients with Advanced Heart Failure

The MAGGIC score might help select patients who would gain prognostic benefit from heart transplantation or mechanical circulatory support (MCS). We examined the association between MAGGIC predicted prognosis and actual outcomes, in order to assess predictive performance of the score and determine a threshold for identifying patients at risk. We included 702 consecutive outpatients who were assessed for heart transplantation over ten years. The MAGGIC score was calculated for each patient according to the scoring matrix and patients were stratified into quartiles. The co-primary endpoints were death, urgent heart transplantation or need for MCS. Follow up was censored at routine heart transplantation. Kaplan-Meier curves were constructed and calibration testing was performed. 320 (45.6%) patients reached a primary endpoint during a median follow-up of 547 days. MAGGIC-predicted mortality was associated with event-free survival (figure, log rank P<0.0001). The MAGGIC score was well-calibrated at one year but over-estimated event-free survival at three years. 92 (13.1%) of patients had a MAGGIC-predicted one year mortality of >20% and these patients had the worst outcomes. At this threshold, the MAGGIC score had high specificity (93.5%) but low sensitivity (20.9%), giving a positive likelihood ratio of 3.22 for death, urgent heart transplantation or the need for MCS. MAGGIC-predicted mortality is associated with real world outcomes in ambulatory patients with advanced heart failure. Clinicians should not be reassured by low MAGGIC-predicted mortality because sensitivity is poor and event-free survival at three years is lower than predicted. However, high MAGGIC-predicted mortality (>20% at one year) is a specific marker of very poor outcomes and may be used to select patients who might derive prognostic benefit from surgical treatment of advanced heart failure, such as implantation of a left ventricular assist device.

Cardiovascular risk associated with serum potassium in the context of mineralocorticoid receptor antagonist use in patients with heart failure and left ventricular dysfunction.

To assess the prognostic value of mineralocorticoid receptor antagonist (MRA) initiation and change in serum potassium (K+ ) during follow-up in patients post-acute myocardial infarction with left ventricular dysfunction or chronic heart failure (HF) and reduced ejection fraction (HFrEF). Risk scores for predicting cardiovascular death (primary outcome), hospitalization for HF and all-cause death were developed. K+ and other relevant time-updated clinical and biological variables were added to conventional prognostic factors when constructing these new models. EPHESUS (n = 6632) was the derivation cohort, while EMPHASIS-HF (chronic HF, n = 2737) was used as external validation cohort. The final cardiovascular death risk score included medical history, clinical and biological parameters (e.g. K+ , below or above the normal range of 4-5 mmol/L, estimated glomerular filtration rate, and anaemia), as well as aspects of treatment (any diuretic usage, MRA use or discontinuation, and beta-blocker use). The risk score performed well in both the derivation and validation cohorts and outperformed the MAGGIC score. A web-based calculator was created to allow easy determination of the risk score (http://cic-p-nancy.fr/CardiovascularriskscoreCalculator/). Adding time-updated variables, including K+ and MRA treatment, improved risk prediction of cardiovascular death (on top of the MAGGIC score) in patients with HF eligible for renin-angiotensin system inhibitors and MRA therapy. This new risk score including MRA usage and K+ may be of value in helping physicians to better use MRAs, avoid unnecessary and potentially detrimental permanent discontinuations, and therefore improving cardiovascular outcomes in patients with chronic HFrEF or HF after acute myocardial infarction with left ventricular dysfunction.

153 Multiparametric assessment of diastolic function in heart failure

Abstract Background The assessment of diastolic function is still challenging in the setting of heart failure (HF). We tested the hypothesis that applying a machine learning algorithm would detect heterogeneity in diastolic function and improve risk stratification in HF population. Methods This study included consecutive 279 patients with clinically stable HF referred for echocardiographic assessment, for whom diastolic function variables were measured according to the current guidelines. Cluster analysis, an unsupervised machine learning algorithm, was undertaken on these variables to form homogeneous groups of patients with similar profiles of the variables. Sequential Cox models paralleling the clinical sequence of HF assessment were used to elucidate the benefit of cluster-based classification over guidelines-based classification. The primary endpoint was a hospitalization for worsening HF. Results Cluster analysis identified 3 clusters with distinct properties of diastolic function that shared similarities with guidelines-based classification. The clusters were associated with brain natriuretic peptide level (p &amp;lt; 0.001, figure A). During follow-up period of 2.6 ± 2.0 years, 62 patients (22%) experienced the primary endpoint. Cluster-based classification exhibited a significant prognostic value (c2 = 20.3, p &amp;lt; 0.001, figure B), independent from and incremental to an established clinical risk score for HF (MAGGIC score) and left ventricular end-diastolic volume (hazard ratio = 1.677, p = 0.017, model c2: from 47.5 to 54.1, p = 0.015, figure D). Although guideline-based classification showed a significant prognostic value (c2 = 13.1, p = 0.001, figure C), it did not significantly improve overall prognostication from the baseline (model c2: from 47.5 to 49.9, p = 0.199, figure D). Conclusion Machine learning techniques help grading diastolic function and stratifying the risk for decompensation in HF. Abstract 153 Figure.

P198 Long-term outcomes after mitraclip implantation

Abstract Background Mitraclip implantation (MI) is a well-established option for patients (P) with severe mitral regurgitation (MR) noneligible to surgery. Its impact on long term prognosis is being addressed by several recent studies. Purpose To identify predictors of morbidity and mortality in P undergoing MI and evaluate if the COAPT, Everest and MITRAFR exclusion criteria (EC) had any impact on the outcome of our population. Methods prospective study of P who underwent MI between 2013 and 2018 in one medical center. EC: COAPT: LVEF &amp;lt; 20%, LV end-diastolic diameter &amp;gt; 70mm or pulmonary artery systolic pressure &amp;gt; 70mmHg; Everest: LVEF &amp;lt; 25% or LV end-systolic diameter (LVESD)&amp;gt;55mm; MITRA-FR: LVEF &amp;lt; 15% or &amp;gt;40% or primary MR. An univariate analysis was performed followed by a multivariate Cox analysis to evaluate overall mortality (M), overall mortality/ heart failure hospitalization (MH) and mortality in the first year post-MI(M1). Survival analysis using Kaplan-Meier plots. p &amp;lt; 0.05 were considered significant. Results 40P, 60% male, mean age 66 ± 12 years (Y) and mean follow-up time of 18 ± 15 months. 67.5% presented with MR grade IV and 75% had functional MR. Successful implantation in 97.5%, with 55% presenting mild MR post-procedure. Overall mortality was 30% (12P), mostly due to cardiovascular causes, with 9P dying in the first year (30%). There was no difference between pts with functional and primary MR: M- 33%vs20% (p = 0.6); MH– 53.3%vs30% (p = 0.5). P who met the COAPT exclusion criteria (N-22) presented an inferior 1Ysurvival (64.5%vs86.7%, p = 0.046). The overall outcome was comparable between P who matched and didn"t match Everest and MITRA-FR exclusion criteria. Basal BNP value (p = 0.037), mean preprocedural MAGGIC score (p = 0.040) and EROA (p = 0.039) were associated to M1. Multivariate Cox analysis revealed that basal BNP was an independent predictor of M (p = 0.017), whereas a higher distance in the pre-procedural 6 minute walk test (p = 0.008) and the "reduction in the MR severity and PASP" (p = 0.008) presented a protective effect. LVESD &amp;gt; 55mm was an independent predictor of MH (p = 0.017), but MR of grade 2 or less after procedure was protective (p = 0.006). Conclusion There was no M difference between P with functional and primary MR. P with COAPT exclusion criteria had worse 1Ysurvival. A higher distance in 6MWT and a reduction in MR severity and PASP were protective. An LVESD &amp;gt; 55 mm had a worse prognosis. Careful P selection may be crucial to improve MI"s results Abstract P198 Figure. Kaplan-Meier Plots

Risk Prediction in Transition: MAGGIC Score Performance at Discharge and Incremental Utility of Natriuretic Peptides

Risk stratification for hospitalized patients with heart failure (HF) remains a critical need. The Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score is a robust model derived from patients with ambulatory HF. Its validity at the time of discharge and the incremental value of natriuretic peptides (NPs) in this setting is unclear. This was a single-center study examining a total of 4138 patients with HF from 2 groups; hospital discharge patients from administrative data (n = 2503, 60.5%) and a prospective registry of patients with ambulatory HF (n = 1635, 39.5%). The ambulatory registry patients underwent N-terminal pro-B-type NP (BNP) measurement at enrollment, and in the hospitalize discharge cohort clinical BNP levels were abstracted. The primary endpoint was all-cause mortality within 1 year. MAGGIC score performance was compared between cohorts utilizing Cox regression and calibration plots. The incremental value of NPs was assessed using calculated area under the curve and net reclassification improvement (NRI). The hospitalized and ambulatory cohorts differed with respect to primary outcome (777 and 100 deaths, respectively), sex (52.1% vs 41.7% female) and race (35% vs 49.5% African American). The MAGGIC score showed poor discrimination of mortality risk in the hospital discharge (C statistic: 0.668, hazard ratio [HR]: 1.1 per point, 95% confidence interval [CI]: 0.652, 0.684) but fair discrimination in the ambulatory cohorts (C statistic: 0.784, HR: 1.16 per point, 95% CI: 0.74, 0.83), respectively, a difference that was statistically significant (P = .001 for C statistic, 0.002 for HR). Calibration assessment indicated that the slope and intercept (of MAGGIC-predicted to observed mortality) did not statistically differ from ideal in either cohort and did not differ between the cohorts (all P > .1). NP levels did not significantly improve prediction in the hospitalized cohort (P = .127) but did in the ambulatory cohort (C statistic: 0.784 [95% CI: 0.74, 0.83] vs 0.82 [95% CI: 0.78, 0.85]; P = .018) with a favorable NRI of 0.354 (95% CI: 0.202-0.469; P = .002). The MAGGIC score showed poor discrimination when used in patients with HF at hospital discharge, which was inferior to its performance in patients with ambulatory HF. Discrimination within the hospital discharge group was not improved by including hospital NP levels.

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.

428In-hospital coronary angiography is associated with increased evidence based medications and better survival in patients hospitalized with acute heart failure - results from REALITY-AHF

Abstract Background Coronary artery disease is a major cause of heart failure (HF). Urgent coronary angiography (CAG) is recommended for patients with acute HF (AHF) complicated with acute coronary syndrome (ACS); however, clinical usefulness of in-hospital CAG in AHF patients without ACS remains unknown. Purpose To investigate the association between in-hospital CAG and all-cause mortality at 1-year after hospital discharge and effects of medications at discharge on this association. Methods From the REALITY-AHF study, 1344 patients hospitalized with AHF were enrolled in this study and followed up for 1-year after hospital discharge. Results In-hospital CAG was undergone in 511 patients (38%). CAG group had a significantly lower 1-year mortality compared with non-CAG group (unadjusted hazard ratio [HR]; 0.30, 95%-confidence interval [CI] 0.21–0.43, P&lt;0.001, after adjustment for MAGGIC score; HR 0.45, 95%-CI 0.29–0.70, P&lt;0.001, in propensity-score matched 296 pairs; HR 0.60, 95%-CI 0.37–0.98, P=0.04). At discharge, aspirin, statins and beta blockers were prescribed more in CAG group compared with non-CAG group (aspirin 46% versus 30%, P&lt;0.001, statins 51% versus 35%, P&lt;0.001, and beta blockers 76% versus 65%, P=0.007). The prescription of aspirin or statins at discharge was associated with a better 1-year survival in patients with multivessel disease (P&lt;0.001), but not in patients without significant stenosis or single vessel disease (P=0.95) (Figure). CAG results, medications and mortality Conclusions In patients hospitalized with AHF, in-hospital CAG was associated with increased evidence based medications at discharge and a better long-term survival. Aspirin and statins at discharge might improve outcomes in AHF patients with multivessel disease. Acknowledgement/Funding This study was funded by The Cardiovascular Research Fund, Tokyo, Japan.

P1639Prognostic utility of H2FPEF score in heart failure with preserved ejection fraction

Abstract H2FPEF (obesity, atrial fibrillation, age &gt;60 yrs, ≥2 antihypertensives, E/e' &gt;9, and pulmonary artery systolic pressure by echo &gt;35 mmHg) is a newly-developed score used for establishing the likelihood of heart failure with preserved ejection fraction (HFpEF). Given the clinical significance of its components, it is tempting to speculate that this algorithm might be useful for cardiovascular (CV) risk prediction. Aim To investigate the prognostic value of H2FPEF score in a well-characterized HFpEF population. Methods and results A group of 205 patients (64±8yrs) with symptomatic HFpEF, underwent clinical and echocardiographic evaluation. At a mean follow-up of 26.2 months, 64 patients (31%) experienced the composite of CV hospitalization or death, and 51 (25%) HF hospitalization. Cox regression analysis revealed that H2FPEF was significantly associated with both study endpoints (HR: 1.30; 95% CI: 1.10 to 1.54; p=0.002 for CV hospitalization or death, and 1.45; 95% CI: 1.21 to 1.75; p&lt;0.001 for HF hospitalization). The prognostic value of H2FPEF was non-inferior to a traditional prognosticator in HF - MAGGIC (Meta-analysis Global Group in Chronic Heart Failure) risk score (area under ROC curve 0.62 for H2FPEF and 0.65 for MAGGIC, p=0.58, for the composite end-point, and 0.66 for both predictors, p=0.96, for HF hospitalization). Using an externally-derived cutpoint for H2FPEF of 5 (considered as the upper limit of the range corresponding to an intermediate probability of HFpEF), we demonstrated that the subset with the score equal to or above this threshold was characterized by a higher risk of both study end-points (Figure). Figure 1. Kaplan-Meier estimates of survival free of the study outcomes according to H2FPEF score. Conclusions H2FPEF score, originally dedicated to discrimination of HFpEF, is a potent prognosticator in this condition, with the ability to identify increased clinical risk comparable to MAGGIC score.

Impacto de la FRAgilidad y otros síndromes Geriátricos en el manejo clínico y pronóstico del paciente anciano ambulatorio con Insuficiencia Cardiaca (FRAGIC). Estudio prospectivo y multicéntrico

Background and objectivesHeart failure (HF) is a chronic disease that is often associated with ageing. There are predictive models based on variables that associate it with a poor prognosis, although those do not include common conditions in the elderly, such as frailty or comorbidity. The aim of this study is to determine the clinical and epidemiological characteristics of a cohort of elderly outpatients with HF followed-up by cardiologists. This will include a study of the prevalence of frailty and other geriatric syndromes, as well as their impact on the prognosis, and to evaluate whether these may improve predictive ability of such predictive models. Material and methodsObservational, prospective, and multicentre study that will include 400 patients ≥75years old with chronic HF followed-up in Spanish tertiary hospitals by cardiology specialists in HF. Patients will undergo a comprehensive geriatric assessment, and prediction of events will be performed based on MAGGIC (Meta-Analysis Global Group in Chronic Heart Failure) and Barcelona-Bio HF calculator scores. The primary endpoint is cardiovascular and overall mortality at 1 and 3years follow-up. ResultsThis study will assess both the characteristics and prognosis of elderly patients with HF followed-up by cardiologists in Spain and the applicability in the elderly population of scores used in the general population with chronic HF. ConclusionThis is the first prospective study that will systematically assess frailty and other geriatric syndromes in the elderly outpatient with HF in Spain and followed-up by cardiologists, thus contributing to improve knowledge about both its prevalence and impact on our patients.

Performance of Prognostic Risk Scores in Heart Failure Patients: Do Sex Differences Exist?

BackgroundSex differences in the performance of prognostic risk scores in heart failure (HF) patients have not previously been investigated. We examined the performance of 2 commonly used scores in predicting mortality and a composite end point consisting of ventricular assist device, heart transplantation, or mortality in women vs men with HF. MethodsThis was a retrospective study of 1,136 (25% women) consecutive ambulatory adult HF patients with reduced left ventricular ejection fraction (≤ 40%) followed at a single institution from 2000 to 2012. Discrimination, calibration, and absolute risk reclassification of the Seattle Heart Failure Model (SHFM) and the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score to predict 1- and 3-year outcomes were compared between women and men. ResultsAt 1- and 3-year follow-ups, 116 (22% women) and 231 (21% women) patients died, respectively. Survival was equal between sexes (P = 0.41). The SHFM and the MAGGIC score showed similar discriminatory capacity in women (c-statistics 0.84, 95% CI 0.77-0.92, and 0.74, 95% CI 0.64-0.83) and men (c-statistics 0.74, 95% CI 0.69-0.79, and 0.70, 95% CI 0.64-0.75). There was no difference in the predicted and observed 1-year mortality by the scores in both sexes. Compared with the SHFM, the MAGGIC score better reclassified 10% (95% CI 7%-14%) of women and 18% (95% CI 15%-20%) of men. At 3-year follow-up, similar results were seen for discrimination, whereas both scores overestimated mortality with more marked overestimation in women. The results were reproducible for the composite end point, with improved calibration at 3-year follow-up in both scores. ConclusionsOur findings support the use of the MAGGIC score in both women and men owing to better risk classification.

Artificial intelligence algorithm for predicting mortality of patients with acute heart failure.

AimsThis study aimed to develop and validate deep-learning-based artificial intelligence algorithm for predicting mortality of AHF (DAHF).Methods and results12,654 dataset from 2165 patients with AHF in two hospitals were used as train data for DAHF development, and 4759 dataset from 4759 patients with AHF in 10 hospitals enrolled to the Korean AHF registry were used as performance test data. The endpoints were in-hospital, 12-month, and 36-month mortality. We compared the DAHF performance with the Get with the Guidelines–Heart Failure (GWTG-HF) score, Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score, and other machine-learning models by using the test data. Area under the receiver operating characteristic curve of the DAHF were 0.880 (95% confidence interval, 0.876–0.884) for predicting in-hospital mortality; these results significantly outperformed those of the GWTG-HF (0.728 [0.720–0.737]) and other machine-learning models. For predicting 12- and 36-month endpoints, DAHF (0.782 and 0.813) significantly outperformed MAGGIC score (0.718 and 0.729). During the 36-month follow-up, the high-risk group, defined by the DAHF, had a significantly higher mortality rate than the low-risk group(p<0.001).ConclusionDAHF predicted the in-hospital and long-term mortality of patients with AHF more accurately than the existing risk scores and other machine-learning models.

Performance of the Meta-Analysis Global Group in Chronic Heart Failure Score in Black Patients Compared With Whites

Risk stratification is critical in heart failure (HF) and the Meta-Analysis Global Group in Chronic HF (MAGGIC) score is a validated tool derived from ~40,000 patients. However, few of these patients self-identified as black, raising uncertainty regarding performance in blacks with HF. This study analyzed a racially diverse group of 4046 patients (1646 black and 2400 white) from a single center from 2007 to 2015. Baseline characteristics were collected to tabulate MAGGIC score and test its discrimination and calibration within race groups. The primary end point was all-cause mortality. Death was detected using system records and the social security death master file. Discrimination was tested using Cox models of MAGGIC score stratified by race, and combined analysis including MAGGIC, race, and MAGGIC×race. Calibration was assessed using linear regression models and plots of observed versus predicted data. Overall, 901 (21%) patients died during 1-year follow-up. MAGGIC score discrimination was similar in both race groups in terms of C statistic (0.707±0.027 versus 0.725±0.014, for black versus white; P=0.556) and the hazard ratio (HR) per MAGGIC point was 1.12 in black patients (95% CI, 1.10-1.14) and 1.13 in white patients (95% CI, 1.12-1.14). Race was a significant correlate of survival, with better survival in black patients compared with white (HR, 0.66; 95% CI, 0.56-0.78), but the interaction of MAGGIC×race was not significant (β=-0.013; P=0.16), and adding race to the model did not improve discrimination (C statistic for MAGGIC versus MAGGIC+race, 0.721 versus 0.722; P=0.79). In calibration testing, the slope was not significantly different from 1 in either group, but the groups differed from each other, and it was closer to unity among black patients (0.94 versus 1.4; P=0.004). These data support the use of the MAGGIC score to risk stratify black patients with HF.

The MAGGIC risk score predicts mortality in patients undergoing transcatheter aortic valve replacement: sub-analysis of the OCEAN-TAVI registry

This study is aimed to evaluate the performance of MAGGIC risk score for predicting mortality by external validation using multicenter transcatheter aortic valve replacement (TAVR) registry. We assessed 1383 patients who underwent TAVR from October 2013 to April 2016. Patients were divided into 2 groups according to the median of MAGGIC score and we compared the incidence of all-cause death between high and low MAGGIC score. To assess whether the MAGGIC risk score add prognostic value on STS risk score, we also compared the incidence of all-cause death between the 2 groups according to low, intermediate, and high STS score. The median of MAGGIC score was 29 (interquartile range: 13-46). Within 2years, 147 cases of all-cause death were observed. The high MAGGIC (30-46) risk score was significantly associated with an increased risk of all-cause death as compared to low MAGGIC (11-29) risk score and this relationship was also observed in patients with high STS risk score. However, this relationship was not observed in patients with low and intermediate STS score. Multivariate analysis showed that the MAGGIC risk score was an independent predictor of all-cause death (hazard ratio, 1.07; 95% confidence interval, 1.03-1.11). Our results demonstrated that the MAGGIC score predicts all-cause death in TAVR population and provides better risk stratification, particularly in patients with high STS risk.

Usefulness of Different Mortality Risk Scores in Patients with Heart Failure. A Retrospective and Observational Study

Background: The Cardiac and Comorbid Conditions - Heart Failure (3C-HF) and the Meta-Analysis Global Group in ChronicHeart Failure (MAGGIC) are two score models developed to predict mortality in patients with heart failure (HF). The performanceof these scores has been little studied in our setting.Objective: The aim of this study was to assess the performance of the 3C-HF and the MAGGIC scores to predict one-yearmortality in a population of patients with HF.Methods: Ambulatory HF patients discharged after hospitalization due to acute HF in two centers were included in the study.The 3C-HF and MAGGIC scores were calculated and one-year mortality was the study endpoint. The discrimination abilityof the scores was analyzed from the calculated area under the ROC curve and their calibration quality was assessed applyingthe Hosmer-Lemeshow test. Both areas under the ROC curve were compared using the Hanley-Mc Neil test.Results: A total of 704 patients with mean age of 73±11 years and 39.6% women were included in the study. One-year mortalitywas 12.4% (n=87). Both scores were independent predictors of mortality, with HR of 1.03 (95% CI 1.008-1.06; p=0.02)and 1.08 (95% CI 1.02-1.13; p=0.004) for the 3C-HF and MAGGIC scores, respectively. The area under the ROC curve for the3C-HF score was 0.70 (95% CI 0.64-0.75) and for the MAGGIC score 0.67 (95% CI 0.61-0.73), without significant differencesbetween them (p=0.41). Both scores presented adequate calibration (p=0.06 and p=0.32, respectively).Conclusion: The 3C-HF and MAGGIC scores were predictors of one-year mortality, with a moderate ability to discriminateevents and adequate calibration. The discrimination ability between both scores was not significant.

Reduction in mortality from implantable cardioverter-defibrillators in non-ischaemic cardiomyopathy patients is dependent on the presence of left ventricular scar.

In patients with non-ischaemic cardiomyopathy (NICM), the mortality benefit of a primary prevention implantable cardioverter-defibrillator (ICD) has been challenged. Left ventricular (LV) scar identified by cardiac magnetic resonance (CMR) imaging is associated with a high risk of malignant arrhythmia in NICM. We aimed to determine the impact of LV scar on the mortality benefit from a primary prevention ICD in NICM. We recruited 452 consecutive heart failure patients [New York Heart Association (NYHA) Class II/III] with NICM and LV ejection fraction ≤35% from a state-wide CMR service. All patients fulfilled European Society of Cardiology guidelines for primary prevention ICD implantation; however, the decision to implant was at the treating physician's discretion. Baseline clinical and CMR data were recorded prospectively and heart failure mortality risk (MAGGIC score) was calculated. The primary study outcome measurement was all-cause mortality based on presence or absence of ICD, stratified by LV scar. Median follow-up was 37.9 months and there was no difference in MAGGIC score between those who did and did not receive a primary prevention ICD (19.30 ± 5.46 vs. 18.90 ± 5.67, P = 0.50). In patients without LV scar, ICD implantation was not associated with improved mortality [hazard ratio (HR) = 1.22, 95% confidence interval (CI): 0.53-2.78, P = 0.64]. In patients with LV scar, ICD implantation was independently associated with reduced mortality (HR = 0.45, 95% CI: 0.26-0.77, P = 0.003). In patients with NICM, primary prevention ICD implantation is only associated with reduced mortality in patients with LV scar. This may enable more effective selection of NICM patients for ICD implantation compared with current guidelines.