A heart failure phenotype stratified model for predicting 1-year mortality in patients admitted with acute heart failure: results from an individual participant data meta-analysis of four prospective European cohorts

Abstract

Background Prognostic models developed in general cohorts with a mixture of heart failure (HF) phenotypes, though more widely applicable, are also likely to yield larger prediction errors in settings where the HF phenotypes have substantially different baseline mortality rates or different predictor-outcome associations. This study sought to use individual participant data meta-analysis to develop an HF phenotype stratified model for predicting 1-year mortality in patients admitted with acute HF. Methods Four prospective European cohorts were used to develop an HF phenotype stratified model. Cox model with two rounds of backward elimination was used to derive the prognostic index. Weibull model was used to obtain the baseline hazard functions. The internal-external cross-validation (IECV) approach was used to evaluate the generalizability of the developed model in terms of discrimination and calibration. Results 3577 acute HF patients were included, of which 2368 were classified as having HF with reduced ejection fraction (EF) (HFrEF; EF < 40%), 588 as having HF with midrange EF (HFmrEF; EF 40–49%), and 621 as having HF with preserved EF (HFpEF; EF ≥ 50%). A total of 11 readily available variables built up the prognostic index. For four of these predictor variables, namely systolic blood pressure, serum creatinine, myocardial infarction, and diabetes, the effect differed across the three HF phenotypes. With a weighted IECV-adjusted AUC of 0.79 (0.74–0.83) for HFrEF, 0.74 (0.70–0.79) for HFmrEF, and 0.74 (0.71–0.77) for HFpEF, the model showed excellent discrimination. Moreover, there was a good agreement between the average observed and predicted 1-year mortality risks, especially after recalibration of the baseline mortality risks. Conclusions Our HF phenotype stratified model showed excellent generalizability across four European cohorts and may provide a useful tool in HF phenotype-specific clinical decision-making.

A comprehensive characterization of acute heart failure with preserved versus mildly reduced versus reduced ejection fraction – insights from the ESC‐HFA EORP Heart Failure Long‐Term Registry

“…In‐hospital mortality was higher in HFrEF (3.4%), with no difference between HFpEF (2.2%) and HFmrEF (2.1%). This is consistent with most previous registries, although single studies have suggested similar in‐hospital or short‐term mortality in all three EF categories 15–23 . Overall, in‐hospital mortality in our mostly European cohort was low and comparable to previous large, American AHF registries (OPTIMIZE‐HF, ADHERE, GWTG‐HF) 15–17 .…”

“…The proportions of different EF categories were HFrEF 53%, HFmrEF 18%, and HFpEF 29%, consistent with previous AHF studies, with HFrEF proportions ranging from 36% to 66%, HFpEF from 17% to 43%, and HFmrEF from 13% to 25% 15–22 . In AHF diagnosed in emergency departments, HFpEF may be more common (64% in one study 23 ).…”

“…Acute HF characteristics were similar to those available in previous AHF and chronic HF studies 5,15–24 . HFmrEF was intermediate between HFpEF and HFrEF with respect to age, sex, and non‐cardiac comorbidities.…”

“…On the one hand, HFpEF has lower HF hospitalization risk and would be expected to be less common in AHF, but on the other hand, ambulatory HF clinics may be referral‐based and thus encounter less HFpEF 5,6,24 . HFmrEF is typically the smallest group, 6,15–17,19–24 which may be due to HFmrEF patients being in transition 25 . HFmrEF is also a narrower range (40%–49% in the 2016 ESC guidelines 1 and this study, but 41%–49% in a recent global consensus statement, 4 which, given a common 5% digit preference in EF reporting, would likely mean an even lower proportion with HFmrEF).…”

Discriminative Utility of Apelin-to-NT-Pro-Brain Natriuretic Peptide Ratio for Heart Failure with Preserved Ejection Fraction among Type 2 Diabetes Mellitus Patients

“…Heart failure (HF) with preserved ejection fraction (HFpEF) is a highly prevalent and intractable phenotype of HF which commonly occurs in patients with hypertension, metabolic diseases including type 2 diabetes mellitus (T2DM), abdominal obesity, metabolic syndrome and female gender [1,2]. Despite all-cause mortality risk and economic burden being found to be higher in HF with reduced (HFrEF) and mildly reduced (HFmrEF) ejection fraction than in HFpEF, cardiovascular (CV) death and HF-related complications, such as primary urgent hospital admission and early re-hospitalization, in patients with HFrEF/HFmrEF have exhibited a strict resemblance with those who had HFpEF [3,4].…”