Tool helps estimate heart failure patients' risk for low quality of life
Researchers have designed a simple tool to help recognize heart failure patients who, at the time of hospital discharge, are at high risk for death or a persistently unfavorable quality of life.
Researchers have designed a simple tool to help recognize heart failure patients who, at the time of hospital discharge, are at high risk for death or a persistently unfavorable quality of life.
Current prognostic models for heart failure patients focus only on death or readmissions, but quality-of-life (QoL) prognosis can help with shared decision-making between physicians and patients, noted the authors of the study, published online June 21 by Circulation: Cardiovascular Quality and Outcomes. Researchers analyzed data from 1,458 heart failure patients in the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial. Baseline data, including formal health status measures, were taken for these patients within 48 hours of hospital admission as well as one week and 24 weeks after hospital discharge. Health status was measured via the Kansas City Cardiomyopathy Questionnaire (KCCQ), a 23-item self-administered questionnaire for heart failure patients with scores ranging from 0 to 100. The primary end point of the analysis was a composite of all-cause death or unfavorable QoL (defined by KCCQ <45 at weeks one and 24 after discharge).
There were 478 deaths (32.8%) and another 192 patients (13.2%) who had persistently unfavorable QoL throughout follow-up. After adjustment for 23 covariates, independent predictors of the composite end point were:
- low baseline KCCQ score (per 10-U increase in baseline QoL: risk ratio [RR], 0.82; 95% CI, 0.78 to 0.87),
- high B-type natriuretic peptide (500 to 999 pg/mL: RR, 1.27 [95% CI, 1.05 to 1.53]; ≥1,000 pg/mL: RR, 1.41 [95% CI, 1.14 to 1.73], both compared with ≤500 pg/mL),
- hyponatremia (sodium 135 mEq/L: RR, 1.30 [95% CI, 1.04 to 1.62] compared with sodium 135 to 145 mEq/L),
- increased heart rate at discharge (per 10 bpm increase: RR, 1.08 [95% CI, 1.01 to 1.15]),
- decreased systolic blood pressure at discharge (per 10 mm Hg increase: RR, 0.92 [95% CI, 0.88 to 0.97]),
- absence of beta-blocker therapy at discharge (beta-blocker prescribed: RR, 0.80 [95% CI, 0.64 to 0.99]),
- history of diabetes (HR, 1.18 [95% CI, 1.01 to 1.39]), and
- history of arrhythmia (RR, 1.32 [95% CI, 1.08 to 1.60]).
A simplified predischarge heart failure score for later death or unfavorable QoL had moderate discrimination (c-statistic 0.72), the authors noted. Study limitations include that the findings come from a retrospective, post hoc analysis of patients enrolled in a clinical trial that excluded those with end-stage heart failure and an expected survival of less than six months, thus eliminating patients at the highest risk for adverse outcomes, the authors noted. The cohort was also limited to heart failure patients with reduced left ventricular ejection fraction, and those who were younger, mostly white and more likely to be male than community heart failure populations—though it also included patients with high comorbidity, the authors noted.
Still, the results should help physicians adhere to clinical practice guidelines that recommend discussing risk with heart failure inpatients. Providing a prognosis of QoL and death, rather than readmissions and death, gives information “that most directly relates to patients' concerns and experiences,” the authors noted. This information can help patients and physicians make appropriate, personalized treatment decisions going forward, they said.