Mortality Risk Prediction Dynamics After Heart Failure Treatment Optimization: Repeat Risk Assessment Using Online Risk Calculators

Abstract

ObjectivesHeart failure (HF) management has significantly improved over the past two decades, leading to better survival. This study aimed to assess changes in predicted mortality risk after 12 months of management in a multidisciplinary HF clinic.Materials and MethodsOut of 1,032 consecutive HF outpatients admitted from March-2012 to November-2018, 357 completed the 12-months follow-up and had N-terminal pro-B-type natriuretic peptide (NTproBNP), high sensitivity troponin T (hs-TnT), and interleukin-1 receptor-like-1 (known as ST2) measurements available both at baseline and follow-up. Three contemporary risk scores were used: MAGGIC-HF, Seattle HF Model (SHFM), and the Barcelona Bio-HF (BCN Bio-HF) calculator, which incorporates the three above mentioned biomarkers. The predicted risk of all-cause death at 1 and 3 years was calculated at baseline and re-evaluated after 12 months.ResultsA significant decline in predicted 1-and 3-year mortality risk was observed at 12 months: MAGGIC ~16%, SHFM ~22% and BCN Bio-HF ~15%. In the HF with reduced ejection fraction (HFrEF) subgroup guideline-directed medical therapy led to a complete normalization of left ventricular ejection fraction (≥50%) in almost a third of the patients and to a partial normalization (41–49%) in 30% of them. Repeated risk assessment after 12 months with SHFM and BCN Bio-HF provided adequate discrimination for all-cause 3-year mortality (C-Index: MAGGIC-HF 0.762, SHFM 0.781 and BCN Bio-HF 0.791).ConclusionMortality risk declines in patients with HF managed for 12 months in a multidisciplinary HF clinic. Repeating the mortality risk assessment after optimizing the HF treatment is recommended, particularly in the HFrEF subgroup.

Global Public Health Burden of Heart Failure: An Updated Review

“…It has been reported that after the initial months following diagnosis of HF, outcomes might improve due to implementation of guideline-directed medical therapy. [ 73 ] Therefore, repeat assessment of the risk of death from HF should be considered for optimal patient care.…”

Is My Patient Fit for Surgery? Navigating Between the Rock of Heart Failure and the Hard Place of Semiurgent Surgery

“…However, it should be used as a starting point, with the initial risk estimate being modified based on factors known to impact HF mortality (eg, B-type natriuretic peptide, ability to tolerate optimal therapy, recent hospitalizations or emergency department visits for HF). 6 This approach leverages a key strength in the HF field, which is the availability of several robust risk scores shown to enhance the prediction of survival among ambulatory patients with HF. 6 For example, our hypothetical overweight 55-year-old man undergoing laryngectomy after surviving cardiogenic shock would be considered relatively low risk by the Danish risk score.…”

“…6 This approach leverages a key strength in the HF field, which is the availability of several robust risk scores shown to enhance the prediction of survival among ambulatory patients with HF. 6 For example, our hypothetical overweight 55-year-old man undergoing laryngectomy after surviving cardiogenic shock would be considered relatively low risk by the Danish risk score. However, when the additional negative prognostic factor of recent cardiogenic shock is considered, we can estimate his risk of 1-year mortality (irrespective of whether he goes for surgery) to be >40%.…”

Current Role of SLGT2 Inhibitors in the Management of the Whole Spectrum of Heart Failure: Focus on Dapagliflozin

“…Despite traditional treatments with renin-angiotensin system inhibitors and beta blockers, death rates of patients with HF have remained unacceptably high (i.e., 40% after a median follow-up of 2.5 years) [5]. Fortunately, these numbers are improving, particularly in those countries with a higher implementation of guideline-directed medical therapy [6,7]. Along this same line, a meta-analysis of three studies, EMPHASIS-HF trial (Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure), PARADIGM-HF trial (Prospective Comparison of ARNI [Angiotensin Receptor-Neprilysin Inhibitor] with ACEI [Angiotensin-Converting-Enzyme Inhibitor] to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial) and DAPA-HF trial (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) showed that compared with the combination of an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blockers (ARB) and a beta blocker, the combination of an angiotensin receptor-neprilysin inhibitor (ARNI), a beta blocker, eplerenone (a mineralocorticoid receptor antagonist) and dapagliflozin (a sodium-glucose cotransporter 2 inhibitor [SGLT2i]) was associated with a significant 50% risk reduction of cardiovascular death and a significant 47% risk reduction of all-cause mortality [8].…”