Risk stratification of ambulatory patients with advanced heart failure undergoing evaluation for heart transplantation

https://doi.org/10.1016/j.healun.2012.11.026Get rights and content

Background

Risk stratification of ambulatory heart failure (HF) patients has relied on peak VO2<14 ml/kg/min. We investigated whether additional clinical variables might further specify risk of death, ventricular assist device (VAD) implantation (INTERMACS <4) or heart transplantation (HTx, Status 1A or 1B) within 1 year after HTx evaluation. We hypothesized that right ventricular stroke work index (RVSWI), pulmonary capillary wedge pressure (PCWP) and the model for end-stage liver disease—albumin score (MELD-A) would be additive prognostic predictors.

Methods

We retrospectively collected data on 151 ambulatory patients undergoing HTx evaluation. Primary outcomes were defined as HTx, LVAD or death within 1 year after evaluation.

Results

Average age in our cohort was 55 ± 11.1 years, 79.1% were male and 39% had an ischemic etiology (LVEF 21 ± 10.5% and peak VO2 12.6 ± 3.5 ml/kg/min). Fifty outcomes (33.1%) were observed (27 HTxs, 15 VADs and 8 deaths). Univariate logistic regression showed a significant association of RVSWI (OR 0.47, p = 0.036), PCWP (OR 2.65, p = 0.007) and MELD-A (OR 2.73, p = 0.006) with 1-year events. Stepwise regression showed an independent correlation of RVSWI<5 gm-m2/beat (OR 6.70, p < 0.01), PCWP>20 mm Hg (OR 5.48, p < 0.01), MELD-A>14 (OR 3.72, p< 0.01) and peak VO2<14 ml/kg/min (OR 3.36, p = 0.024) with 1-year events. A scoring system was developed: MELD-A>14 and peak VO2<14—1 point each; and PCWP>20 and RVSWI<5—2 points each. A cut-off at≥4 demonstrated a 54% sensitivity and 88% specificity for 1-year events.

Conclusions

Ambulatory HF patients have significant 1-year event rates. Risk stratification based on exercise performance, left-sided congestion, right ventricular dysfunction and liver congestion allows prediction of 1-year prognosis. Our findings support early and timely referral for VAD and/or transplant.

Section snippets

Study design

We retrospectively analyzed 151 Stage C/D, New York Heart Association (NYHA) Class III ambulatory HF patients who presented to our institution for HTx evaluation between February 2007 and May 2010. Patients were included if they were able to perform an exercise test and had undergone transthoracic echocardiogram, right heart catheterization and laboratory testing within a time-frame of 30 days. In addition, all patients were on maximal medical therapy and resynchronization therapy and/or a

Baseline characteristics and patients outcome within 1 year after evaluation

The clinical characteristics of the patients studied are summarized in Table 1. The mean age of the patients was 55 years, 79% were male and 39% patients had ischemic heart disease. We were able to obtain detailed information about medications from 90% of patients and from 100% with regard to device therapy. Among these, 93% patients were on β-blocker therapy and 57% patients received cardiac resynchronization therapy. Mean peak VO2 at the time of HTx evaluation was 12.5 ml/kg/min, and the mean

Disclosure statement

The authors have no conflicts of interest to disclose.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

The first and second authors (T.S.K. and G.R.S.) contributed equally to this work. M.F. was supported by the National Center for Advancing Translational Sciences (UL1 RR024156), formerly the National Center for Research Resources, of the National Institutes of Health (UL1 TR000040).

References (32)

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