Characterisation of the patients with suspected heart failure: experience from the SHEAF registry

Abstract

Objectives: To characterise and risk-stratify patients presenting to a heart failure (HF) clinic according to the National Institute for health and Care Excellence (NICE) algorithm.

Methods: This is an observational study of prospectively collected data in the Sheffield HEArt Failure registry of consecutive patients with suspected HF between April 2012 and January 2020. Outcome was defined as all-cause mortality.

Results: 6144 patients were enrolled: 71% had HF and 29% had no HF. Patients with N-terminal pro-brain-type natriuretic peptide (NT-proBNP) >2000 pg/mL were more likely to have HF than those with NT-proBNP of 400-2000 pg/mL (92% vs 64%, respectively). Frequency of HF phenotypes include: HF with preserved ejection fraction (HFpEF) (33%), HF with reduced ejection fraction (HFrEF) (29%), HF due to valvular heart disease (4%), HF due to pulmonary hypertension (5%) and HF due to right ventricular systolic dysfunction (1%). There were 1485 (24%) deaths over a maximum follow-up of 6 years. The death rate was higher in HF versus no HF (11.49 vs 7.29 per 100 patient-years follow-up, p<0.0001). Patients with HF and an NT-proBNP >2000 pg/mL had lower survival than those with NT-proBNP 400-2000 pg/mL (3.8 years vs 5 years, p<0.0001). Propensity matched survival curves were comparable between HFpEF and HFrEF (p=0.88).

Conclusion: Our findings support the use by NICE's HF diagnostic algorithm of tiered triage of patients with suspected HF based on their NT-proBNP levels. The two pathways yielded distinctive groups of patients with varied diagnoses and prognosis. HFpEF is the most frequent diagnosis, with its challenges of poor prognosis and paucity of therapeutic options.

Keywords: diastolic; epidemiology; heart failure; systolic.

Figure 1

Final diagnosis in heart failure clinics for the whole population. (A) Histogram of the number of patients in each category of diagnosis. From a total of 6144 patients seen in the HF clinic, 29% of patients did not have HF. (B) In patients with NT-proBNP > 2000pg/ml, HFrEF was the main presenting diagnosis (50%) which was followed by HFpEF (31%).HF, heart failure; HFpEF, HF with preserved ejection fraction; HF-PH, HF with pulmonary hypertension; HFrEF, HF with reduced ejection fraction; HF-RVSD, HF with right ventricular systolic dysfunction; HF-VHD, HF with valvular heart disease; NT-proBNP, N-terminal pro-brain-type natriuretic peptide.

Figure 2

Stacked histogram demonstrating the percentage of patients with a specific HF diagnosis in each category of NYHA and CKD stage. (A) Patients with HFpEF were predominantly in NYHA functional class I/II, versus patients with HFrEF, who were predominantly in NYHA functional class IV. (B) HF patients with a diagnosis of HFpEF were more likely to have worse CKD stage than any other type of HF diagnosis. CKD, chronic kidney disease; HFpEF, heart failure with preserved ejection fraction; HF-PH, heart failure with pulmonary hypertension; HFrEF, heart failure with reduced ejection fraction; NYHA, New York Heart Association; RVSD, right ventricular systolic dysfunction; VHD, valvular heart disease

Figure 3

Incidence of all-cause mortality in each sub-phenotype of heart failure per 100 patient-years. Statistical significant changes to other groups are highlighted with letters representing the specific group. The lines represent the 95% confidence interval. HF, heart failure; HFpEF, HF with preserved ejection fraction; HF-PH, HF with pulmonary hypertension; HFrEF, HF with reduced ejection fraction; HF-RVSD, HF with right ventricular systolic dysfunction; HF-VHD, HF with valvular heart disease.

Figure 4

Kaplan-Meier survival curves. (A and B) Survival comparison of patients with versus without HF and with HFpEF versus HFrEF, over a follow-up period of up to 6 years. (C and D) Propensity matched survival comparison of patients with versus without HF and with HFpEF versus HFrEF, over a follow-up period of up to 6 years. HF, heart failure; HFpEF, HF with preserved ejection fraction; HFrEF, HF with reduced ejection fraction.

Figure 5

Kaplan-Meier survival curves. (A and B) Survival comparison of patients with NTproBNP 400-1999pg/ml versus ≥NTproBNP 400-1999pg/ml, and in different NYHA functional status, over a follow-up period of up to 6 years. (C and D) Propensity matched survival comparison of patients with NTproBNP 400-1999pg/ml versus ≥NTproBNP 400-1999pg/ml, and in different NYHA functional status, over a follow-up period of up to 6 years. NT-proBNP, N-terminal pro-brain-type natriuretic peptide; NYHA, New York Heart Association.

Figure 6

Kaplan-Meier curves comparing HFpEF and HFrEF survival. These curves have been adjusted for covariates using the Cox’s proportional-hazards regression. CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; MI; myocardial infarction; NT-proBNP, N-terminal pro-brain-type natriuretic peptide; VHD, valvular heart disease.