Classifying acute heart failure patients may improve quality of care and outcomes
Clinical phenotypes and outcome of patients hospitalized for acute heart failure: the ESC Heart Failure Long-Term RegistryChioncel O, Mebazaa A, Harjola V-P, et al. - Eur J Heart Fail (2017) 19, 1242–1254
Several registries describe the demographic, clinical, and therapeutic characteristics of acute heart failure (AHF) patients. A drawback is that descriptions are mainly restricted to the inpatient phase or the initial weeks post-discharge [1-3]. Moreover, some of these registries included limited numbers of centers or clinical settings, sometimes in only one country.
The ESC-HF-LT Registry is a prospective, multicenter, observational study of patients admitted to 211 cardiology centers from 21 European and Mediterranean countries. In the present analysis of the ESC-HF-LT Registry, all patients admitted for AHF were included, with either de novo, or worsening of pre-existing HF, for whom iv therapy with inotropes, vasodilators, or diuretics was needed. Differences in clinical characteristics, in-hospital treatment and outcomes were identified, in AHF patients stratified according to well-specified clinical profiles, according to the ESC guidelines: decompensated HF (DHF), cardiogenic shock (CS), pulmonary edema (PE), right HF (RHF), hypertensive HF (HT-HF) and ACS-HF.
Another two classifications, including SBP at presentation (<85 mmHg, 85–110 mmHg, 110–140mmHg and >140 mmHg) and a classification based on the presence of clinical signs of congestion and/or hypo-perfusion (no congestion and no hypo-perfusion; congestion without hypo-perfusion; hypo-perfusion without congestion; hypo-perfusion and congestion) were used for reporting in-hospital and 1-year adverse outcomes.
- 13.2% AHF patients enrolled in the registry presented with PE, 2.9% with CS, 61.1% with DHF, 4.8% with HT-HF, 3.5% with RHF, and 14.4% with ACS-HF.
- Considering the SBP classification, 1.9% of AHF patients presented with SBP <85 mmHg, 24.9% with SBP 85–110 mmHg, 42.9% with SBP 110–140 mmHg, and 30.3% with SBP >140 mmHg.
- 14.8% had no congestion and no hypo-perfusion, 69.7% had congestion without hypo-perfusion, 13.6% had congestion and hypo-perfusion, and 0.9% had hypo-perfusion without congestion.
- The highest rate of in-hospital all-cause mortality was noted in CS patients (36.1%) and the lowest in HT-HF patients (1.8%).
- The highest in-hospital mortality was observed in patients with SBP <85mmHg (26.6%) and the lowest in patients with SBP >140mmHg (2.7%).
- The highest mortality was noted in patients with congestion and hypo-perfusion signs (16.5%) and the lowest in patients without congestion and without hypo-perfusion (1.7%).
- For patients hospitalized with CS, of the total number of deaths during hospitalization, 49% occurred in the first 24 hours from presentation, while for patients with PE, 16.3% of deaths occurred in the first 24 hours. For the remaining clinical profiles, the rate of death in the first 24 hours represented less than 10% of the total number of deaths occurring during hospitalization.
- The highest 1-year mortality rate was observed in patients with CS (54.0%), low SBP at admission (34.8%) and in patients with both congestion and hypo-perfusion (29.8%).
- When analysis of Kaplan–Meier curves was performed between 6 and 12 months post-discharge, all 6 clinical profiles have comparable 1-year outcomes.
- At 1-year post-discharge there were no significant differences in outcomes among all clinical profiles and SBP groups.
In the ESC-HF-LT Registry, rates of adverse outcomes in patients admitted for AHF remain very high, both in-hospital and during the follow-up period. Substantial differences were found when patients were stratified by clinical profile, SBP, or congestion/hypo-perfusion phenotypes, although differences in 1-year outcome rates tend to diminish. These findings show that classifying AHF patients on the basis of clinical relevant data may mediate improvements in quality of care and outcomes.
In their editorial article , Ambrosy and Gheorghiade note that although HF is a heterogeneous syndrome, clinical studies have not matched the right drug with the right patient. They conclude: ‘Although the proposed approaches to patient phenotyping in the acute setting (i.e. clinical profiles, SBP and congestion/perfusion status) are informative and complementary, none of these classification systems provides a comprehensive assessment in isolation and additional research is required before their use to guide treatment decisions in routine practice can be recommended. In an era of ‘omics’ and personalized medicine, future research should focus on the role of a multimarker approach and the application of cluster analysis to identify novel and clinically meaningful patient profiles in an effort to develop new therapies and improve the quality of care.’