Risk stratification with echocardiographic biomarkers in heart failure with preserved ejection fraction: the media echo score

Abstract

Aims Echocardiographic predictors of outcomes in heart failure with preserved ejection fraction (HFpEF) have not been systematically or independently validated. We aimed at identifying echocardiographic predictors of cardiovascular events in a large cohort of patients with HFpEF and to validate these in an independent large cohort. Methods and resultsWe assessed the association between echocardiographic parameters and cardiovascular outcomes in 515 patients with heart failure with preserved left ventricular (LV) ejection fraction (>50%) in the MEtabolic Road to DIAstolic Heart Failure (MEDIA) multicentre study. We validated out findings in 286 patients from the Karolinska-Rennes Prospective Study of HFpEF (KaRen). After multiple adjustments including N-terminal pro-brain natriuretic peptide (NT-proBNP), the significant predictors of death or cardiovascular hospitalization were pulmonary arterial systolic pressure > 40 mmHg, respiratory variation in inferior vena cava diameter > 0.5, E/e' > 9, and lateral mitral annular s' < 7 cm/s. The combination of these four variables differentiated patients with <10% vs. >35% 1 year risk. Adding these four echocardiographic variables on top of clinical variables and NT-proBNP yielded significant net reclassification improvement (33.8%, P < 0.0001) and increase in C-index (5.3%, a change from 72.2% to 77.5%, P = 0.015) of similar magnitude as the addition of NT-proBNP on top of clinical variables alone. In the KaRen cohort, these four variables yielded a similar improvement in net reclassification improvement (22.3%, P = 0.014) and C-index (4.0%, P = 0.029). Conclusions Use of four simple echocardiographic parameters (within the MEDIA echo score), indicative of pulmonary hypertension, elevated central venous pressure, LV diastolic dysfunction, and LV long-axis systolic dysfunction, independently predicted prognosis and improved risk stratification additionally to clinical variables and NT-proBNP in HFpEF. This finding was validated in an independent cohort.

Predictors and Mortality for Worsening Left Ventricular Ejection Fraction in Patients With HFpEF

“…In addition, left ventricular longitudinal strain (LS) has emerged as a more accurate index to evaluate systolic function and predict prognosis ( 22 ). Both the exercise-induced B-lines assessing pulmonary congestion and the MEtabolic Road to DIAstolic Heart Failure (MEDIA) echocardiographic score were shown to independently predict prognosis and improve risk stratification in patients with HFpEF ( 23 , 24 ). However, the latter were rarely measured in our cohort because of extra costs and infrequent application of these assessments in clinical practice.…”

Diagnostic recommendations and phenotyping for heart failure with preserved ejection fraction: knowing more and understanding less?

“…Although the HFA-PEFF and H 2 FPEF algorithms were both developed for primary diagnosis, at least five studies have now compared their utility instead to estimate prognosis. 16,[18][19][20][21] In an elegant and very thorough retrospective cohort study, Verbrugge et al 18 included 443 consecutive patients with EF ≥50% who had been hospitalised and treated with intravenous diuretics for acute HF. Patients with an identifiable specific aetiology such as ischaemia or valve disease were excluded.…”

“…The overall prognostic power of each score was good, but only 27 subjects (4%) were designated to be at high risk by both scores while 28% had discordant findings. 20 In the MEDIA study, Huttin et al 21 evaluated both scores in 515 subjects with HFpEF according to the 2007 ESC consensus This table attempts to indicate input features that were identified by machine learning to discriminate between clusters, and also variables that were then found to vary significantly between the identified clusters. Features have been included if P < 0.05, even if the absolute variations were small.…”

“…Although the HFA‐PEFF and H 2 FPEF algorithms were both developed for primary diagnosis, at least five studies have now compared their utility instead to estimate prognosis 16,18–21 . In an elegant and very thorough retrospective cohort study, Verbrugge et al 18 .…”

Corrigendum

“…In the paper by Huttin et al ., 1 the authors reported that there was a typo in Figure 3 . Indeed, titles of panels B and C were the same.…”