Predictors of short term mortality in heart failure — Insights from the Euro Heart Failure survey

https://doi.org/10.1016/j.ijcard.2008.08.004Get rights and content

Abstract

Objective

To identify factors associated with short term mortality in hospitalised patients with heart failure.

Background

Hospitalisation is frequent in patients with heart failure and is associated with a high mortality.

Methods

The Euro Heart Failure survey collected data from patients with suspected heart failure. We searched this data for predictors of short term mortality.

Results

Of 10,701 patients, 1404 (13%) died within 12 weeks of admission. On univariate analysis, increasing age, hyponatraemia, renal impairment, hyperkalaemia, anaemia, severe mitral regurgitation, severe LV systolic dysfunction(LVSD), increasing QRS and female sex carried adverse prognosis. ACEI, beta-blockers, nitrates, anti-thrombotic and lipid lowering drugs were associated with a better prognosis. On multivariable analysis the following provided independent prognostic information: increasing age (OR per SD = 1.5, 95% CI 1.4–1.6), severe LVSD (1.8, 1.5–2.1), serum creatinine (1.2, 1.2–1.3), sodium (0.9, 0.8–0.9), Hb (0.9, 0.8–0.9) and treatment with ACEI (0.5, 0.5–0.6), beta-blockers (0.7, 0.6–0.8), statins (0.6, 0.5–0.7), calcium channel blockers (0.7, 0.6–0.8), warfarin (0.5, 0.4–0.6), heparin (1.7, 1.4–1.9), anti-platelet drugs (0.6, 0.5–0.6) and need for inotropes (5.5, 4.6–6.6). A simple risk score (range 0–11) identified cohorts with a 12 week mortality ranging from 2% to 44%.

Conclusions

Simple and readily available clinical variables and a risk score based on medical history and routine tests that all patients admitted with heart failure have, can identify patients with good, intermediate and high short term mortality.

Introduction

Heart failure affects 1–2% of the population and is a major cause of death and disability [1]. The lifetime risk of developing heart failure is one in five in industrialised countries [2]. 30–40% of patients die within a year of diagnosis and 60–70% die within 5 years, despite treatment [3]. It causes about 5% of medical admissions and complicates a further 10–15% [4]. More than half of these cases are due to left ventricular systolic dysfunction, usually due to ischaemic heart disease or dilated cardiomyopathy. Patients with heart failure due to left ventricular systolic dysfunction have a worse prognosis than those with preserved systolic function [5]. Worsening heart failure is associated with increase in mortality during hospital admission and in the post-discharge period [6].

Data from large heart failure registries has demonstrated that simple clinical variables can predict mortality in patients hospitalised with heart failure [7]. Some are modifiable, potential causes of deterioration and death and therefore possible targets for therapy. Others may just be markers of risk but nonetheless identify patients in need of intensive management or, palliative care. Standard treatment for heart failure includes ACE inhibitors, angiotensin receptor blockers, beta-blockers, aldosterone antagonists and, in selected patients, cardiac resynchronisation therapy and implantable defibrillators [8]. They have improved the prognosis of heart failure but are often not implemented correctly [9]. New treatments are being developed that target specific problems such as renal dysfunction (adenosine A1 receptor antagonists) and anaemia (erythropoietin).

The Euro Heart Failure survey investigated whether appropriate tests were being performed and therapeutic interventions done according to ESC guidelines in patients hospitalised with a diagnosis of or suspected heart failure [10], [11], [12]. We used this survey data to identify factors that independently predicted short term mortality.

Section snippets

Study population

In the Euro Heart Failure survey, vital data were collected from 10,701 patients enrolled with suspected heart failure in 115 hospitals across Europe during 2000–2001. The detailed design of this study has been published [10]. In short, consecutive hospital discharges and deaths were screened for 6 weeks and patients enrolled if they fulfilled at least one of the following: (1) a clinical diagnosis of heart failure during admission; (2) a diagnosis of heart failure recorded at any time in last

Results

Vital status was available for 10,701 patients at 12 weeks after admission. 1404 (13%) had died during this period. Most patients fulfilled three or more enrolment criteria, 84% of patients had a diagnostic label of heart failure and only 10% were enrolled solely because they received loop diuretics, as previously reported [11]. Of 1603 patients who werenotenrolled with a diagnostic label of heart failure, 145 (8.3%) died, compared to 1259 (14.1%) of 7694 patients with a reported diagnosis of

Discussion

This analysis shows that simple clinical information acquired during hospitalisation in an international clinical survey can be used to risk-stratify patients with suspected heart failure. The scoring system was able to identify patients with a 12 week mortality risk as low as 2% and as high as 44%. This information may help with planning of care. Patients at higher risk may benefit from more intense monitoring and therapy during and after hospitalisation. Alternatively, patients with poor

Conclusions

Simple and readily available clinical variables and a risk score using this information may be useful to identify patients at high risk of dying during or soon after hospital discharge. Randomised controlled trials are required to distinguish those risk markers that are also targets for therapy.

Acknowledgement

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [33].

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