Identifying patients hospitalized with heart failure at risk for unfavorable future quality of life

Abstract

Background: Communicating prognosis to enable shared decision-making is strongly endorsed by heart failure (HF) guidelines. Patients are concerned with both their quantity and quality of life (QoL). To facilitate the recognition of patients at high risk for unfavorable future QoL or death, we created a simple prognostic tool to estimate this combined outcome.

Methods and results: We identified factors associated with 6-month mortality or persistently unfavorable QoL, defined by Kansas City Cardiomyopathy Questionnaire (KCCQ) scores <45 at 1 and 24 weeks after hospital discharge, among 1458 patients from the Efficacy of Vasopressin Antagonism in HF Outcome Study with Tolvaptan (EVEREST). Within 24 weeks of discharge, 478 (32.8%) patients had died and 192 (13.2%) patients had serial KCCQ scores <45. After adjusting for 23 predischarge covariates, independent predictors of the combined end point included low admission KCCQ score, high B-type natriuretic peptide, hyponatremia, tachycardia, hypotension, absence of β-blocker therapy, and history of diabetes mellitus and arrhythmia. A simplified predischarge HF score for subsequent death or unfavorable QoL had moderate discrimination (c-statistic 0.72). Predischarge clinical covariates were substantially different in predicting the QoL end point as compared with traditional death or rehospitalization end points.

Conclusions: At the time of hospital discharge, readily available clinical characteristics are associated with HF patients at high risk for persistently unfavorable QoL or death over the next 6 months. Such information can target patients for whom aggressive treatment options (eg, devices or transplantation) and/or end-of-life discussions should be strongly considered before hospital discharge.

Trial registration: ClinicalTrials.gov NCT00071331.

Figure 1

Distribution of patients with KCCQ <45 versus >=45 at 1 week post discharge and 24 weeks post discharge.

Figure 2

The refractory heart failure score: a reduced model with a simplified clinical risk score predicting unfavorable future health status, defined as death or KCCQ persistently < 45 in the 24 weeks following heart failure hospitalization, determined using clinical information at the time of hospital discharge

Figure 3

Distribution of refractory heart failure risk scores and their probabilities

Figure 4

Separate adjusted multivariable risk models for the association of in-hospital clinical covariates with selected 24-week outcomes.

Figure 5

Relative prognostic contribution of various in-hospital clinical covariates with selected 24-week outcomes as assessed by F-testing.