In-hospital and 1 year incremental prognostic value of drug abuse detection in acute heart failure

Abstract

Aims: The study aims to assess the in-hospital and 1 year incremental prognostic value of recent drug abuse use, detected by a systematic urinary screening, in a consecutive cohort of patients hospitalized for acute heart failure (AHF).

Methods: All patients admitted for AHF with a drug abuse screening using a urinary assay were included in this prospective multicentric study (39 French centres). The outcomes were (i) in-hospital major adverse cardiovascular events (MACEs) defined as all-cause death, resuscitated cardiac arrest or cardiogenic shock; and (ii) 1 year MACEs defined as cardiovascular death or hospitalization for AHF. Incremental prognostic value was assessed using the C-index, the global χ² and likelihood-ratio (LR) test, the net reclassification improvement (NRI) and integrated discrimination improvement (IDI).

Results: In total, 458 patients with AHF were included (mean age 68 ± 14 years, 67% male, 79% of new heart failure onset). In-hospital and 1 year MACEs occurred, respectively, in 65 (14.2%) and 129 (28.2%) patients. Drug abuse detection was independently associated with in-hospital MACEs [model 1-known comorbidities: odds ratio (OR) = 4.46, 95% confidence interval (CI) (1.88-10.3), P < 0.001; model 2-clinical severity: OR = 3.64, 95% CI (1.56-8.26), P = 0.002], even after propensity-matched population analysis [OR = 3.34, 95% CI (1.32-8.70), P = 0.011], with a significant incremental prognostic value over and above traditional risk factors (C-statistic improvement 0.04 with LR test P < 0.001 for both models). Patients with drug abuse detection had worse 1 year survival: HR = 1.82, 95% CI (1.13-2.92), P = 0.012. Drug abuse detection was independently associated with 1 year MACEs after adjustment with traditional prognosticators [OR = 2.54, 95% CI (1.28-4.98), P = 0.008] and propensity-matched population analysis [OR = 2.77, 95% CI (1.98-5.21), P = 0.001], with an incremental prognostic value as well (C-statistic improvement 0.02, LR test P < 0.001, positive NRI and IDI).

Conclusions: Drug abuse use was independently associated with a higher occurrence of both in-hospital and 1 year MACEs with an incremental prognostic value. These results suggest a potential interest of a systematic illicit drug screening in these patients.

Trial registration: ClinicalTrials.gov Identifier: NCT05063097.

Keywords: acute heart failure; death; drug abuse; outcomes; prognostic value.

Figure 1

Flow chart of the study. ICCU, intensive cardiac care unit; MACE, major cardiac adverse event.

Figure 2

Among patients with drug abuse detected prevalence of drug abuse detection according to (A) gender, (B) age, (C) type of HF and (D) HF duration. HF: heart failure; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF: heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction.

Figure 3

Forrest plot of adjusted odds ratio for the occurrence of (A) in‐hospital MACEs and (B) 1 year MACEs according to drug abuse detection. Forest plots with adjusted OR and 95% CI for the occurrence of in‐hospital MACEs (panel A), and 1 year MACEs (panel B). Four methods were used to assess the independent association between drug abuse detection and MACEs. CI, confidence interval; OR, odds ratio.

Figure 4

Incremental prognostic value of drug abuse detection for (A) in‐hospital and (B) 1 year MACEs. (Panel A) Model 1 (known comorbidities) included age, male, body mass index, active cancer, worsening heart failure, ischaemic cardiomyopathy, haemoglobin, glomerular filtration rate and left ventricular ejection fraction. Model 2 (clinical severity) included age, male, heart rate, systolic blood pressure, Killip score ≥ 2, O₂ saturation, NT‐proBNP level and left ventricular ejection fraction. (Panel B) Final model for multivariable logistic regression included: drug abuse detection, age, male, BMI, active cancer, worsening HF, non‐ischaemic cardiomyopathy, heart rate, systolic blood pressure, Killip score ≥ 2, O₂ saturation, haemoglobin, GFR, NT‐proBNP level and LVEF.

Figure 5

Survival curves comparison for 1 year MACEs between patients with versus without drug abuse detection. HR, hazard ratio.