Fast Fact and Concept #143: Prognostication in Heart Failure

Authors: Gary M. Reisfield, MD and George R. Wilson, MD

This Fast Fact reviews prognostication data in Heart Failure (HF). Although the Framingham Heart Study (1990-1999) showed a 5-year mortality rate of 50% for newly identified cases, providing accurate prognostic data for 6-12 month mortality is nearly impossible. Reasons cited include: 1) an unpredictable disease trajectory with high incidence (25-50%) of sudden death; 2) disparities in the application of evidence-based treatment guidelines; 3) inter-observer differences in New York Heart Association (NYHA) classification; and 4) heterogeneous study populations in the HF literature. The NYHA classification remains the major gauge of disease severity. Based on data from SUPPORT, Framingham, IMPROVEMENT, and other studies, 1-year mortality estimates are as follows:

• Class II (mild symptoms) …………….. 5-10%
• Class III (moderate symptoms) ……... 10-15%
• Class IV (severe symptoms) ……..….. 30-40%

The following indicators have been independently associated with a limited prognosis in HF:

• Recent cardiac hospitalization (triples 1-year mortality)
• Elevated BUN (defined by upper limit of normal) and/or creatinine ≥1.4 mg/dl (120 μmol/l)
• Systolic blood pressure <100 mm Hg and/or pulse >100 bpm (each doubles 1-year mortality)
• Decreased left ventricular ejection fraction (linearly correlated with survival at LVEF ≤ 45%.)
• Ventricular dysrhythmias, treatment resistant
• Anemia (each 1/ g/dl reduction in Hb is associated with a 16% increase in mortality)
• Hyponatremia (Na + ≤135-137 mEq/l).
• Cachexia
• Reduced functional capacity
• Co-morbidities: diabetes, depression, COPD, cirrhosis, cerebrovascular disease, cancer, and HIV-associated cardiomyopathy.

Medicare Hospice Benefit

The National Hospice and Palliative Care Organization’s 1996 guidelines for Heart Disease admission criteria include: 1. Symptoms of recurrent HF at rest NYHA class IV AND 2. Optimal treatment with ACE inhibitors, diuretics, and vasodilators (note: optimal treatment now includes β-blockers, aldosterone and device therapies). The NHPCO guide indicates that an ejection fraction < 20% is “helpful supplemental objective evidence”, but not required. The NHPCO guidelines also assert that each of the following further decreases survival: treatment resistant ventricular or supraventricular arrhythmias, history of cardiac arrest in any setting, history of unexplained syncope, cardiogenic brain embolism, and concomitant HIV disease.

1. Since publication of the NHPCO’s guidelines, several models have been developed for predicting short- and/or long-term mortality among HF patients. Two recent models purport to predict mortality among patients hospitalized with acutely decompensated HF. Fonarow (2005), using a model based on admission BUN (≥ 43 mg/dl), creatinine (≥ 2.75 mg/dl), SBP (< 115 mmHg), identified in-hospital mortality rates ranging from about 2% (0/3 risk factors) to 20% (3/3 risk factors). Lee (2003), using a model based on admission physiologic variables and co-morbidities (almost all from above list of indicators) identified 30-day mortality and 1-year mortality rates ranging from <1% and <10%, respectively (for the lowest risk patients) to >50% and >75%, respectively (for the highest risk patients). While both models are applicable to bedside use, neither have been applied prospectively or in independent patient samples, nor do they address HF treatments as predictive variables.
2. Bottom Line: Meticulous application of medication and device therapies can and will continue to change HF prognostic data. HF follows an unpredictable disease trajectory, one which is highly modifiable by application of evidence-based therapies, yet still associated with a high incidence of sudden death. The 1996 NHPCO criteria are not predictors of 6-month mortality. Several models have recently been developed to aid in determining short- and long-term mortality in hospitalized, decompensated HF patients. These models await prospective testing and will need to address the dynamic of optimizing medical therapy. Future models should address prognostication in unselected ambulatory HF patients. Finally, models will need periodic updating to control for continually evolving standards of HF care. At present, accurate prognostication remains problematic.

References

1. Anand I, McMurray JJV, Whitmore J. Anemia and its relationship to clinical outcome in heart failure. Circulation 2004;110:149-154.
2. Anker SD, Ponikowski P, Varney S, et al. Wasting as an independent risk factor for mortality in chronic heart failure. Lancet 1997;349:1050-1053.
3. Curtis JP, Sokol SI, Wang Y, et al. The association of left ventricular ejection fraction, mortality, and cause of death in stable outpatients with heart failure. J Am Coll Cardiol 2003;42(4):736-742).
4. Fonarow GC, Adams KF, Abraham WT, et al. Risk stratification for in-hospital mortality in acutely decompensated heart failure. JAMA 2005;293(5):572-580.
5. Horwich TB, Fonarow GC, Hamilton MA, et al. Anemia is associated with worse symptoms, greater impairment in functional capacity and a significant increase in mortality in patients with advanced heart failure. J Am Coll Cardiol 2002;39(11):1780-1786.
6. Kearney MT, Fox KAA, Lee AJ. Predicting death due to progressive heart failure in patients with mild-to-moderate chronic heart failure. J Am Coll Cardiol 2002;40(10):1801-1808.
7. Lee DS, Austin PC, Rouleau JL, et al. Predicting mortality among patients hospitalized for heart failure. JAMA 2003;290(19):2581-2587.
8. Levenson JW, McCarthy EP, Lynn J, et al. The last six months of life for patients with congestive heart failure. J Am Geriatr Soc 2000;48(Suppl 5):S101-S109.
9. Levy D, Kenchaiah S, Larson MG, et al. Long-term trends in the incidence of and survival with heart failure. NEJM 2002;347(18):1397-1402.
10. Muntwyler J, Abetel G, Gruner C, et al. One-year mortality among unselected outpatients with heart failure. Eur Heart J 2002;23:1861-1866.
11. Stuart B, et al. Medical Guidelines for determining prognosis in selected non-cancer diseases. 2 nd Edition. National Hospice Organization. 1996
12. Zannad F, Briancon S, Julliere Y. Incidence, clinical and etiologic features, and outcomes of advanced chronic heart failure: the EPICAL study. J Am Coll Cardiol 1999;33(3):734-742.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Reisfield GM and Wilson GR. Fast Facts and Concepts #143; Prognostication in Heart Failure. September, 2005; Revised October 2006.

End-of-Life / Palliative Education Resource Center www.eperc.mcw.edu.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Purpose: Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge and Patient Care

Keyword(s): prognosis; cardiac diseases and heart failure

Specific Disease and Organ System Category(s): Cardiac diseases & heart failure