Clinical predictors of all‐cause mortality in patients presenting to specialist heart failure clinic with raised NT‐proBNP and no heart failure

Abstract

Aims Clinical outcomes for patients suspected of having heart failure (HF) who do not meet the diagnostic criteria of any type of HF by echocardiography remain unknown. The aim of this study was to investigate the clinical predictors of all-cause mortality in patients with suspected HF, a raised N-terminal pro-b-type natriuretic peptide (NTproBNP) and who do not meet the diagnostic criteria of any type of HF by echocardiography. Methods and results Relevant data were taken from the Sheffield HEArt Failure (SHEAF) registry (222349P4). The inclusion criteria were presence of symptoms raising suspicion of HF, NTproBNP > 400 pg/mL, and preserved left ventricular function. Exclusion criteria were any type of HF by echocardiography. The outcome was defined as all-cause mortality. Cox proportional-hazards regression model was used to investigate the association between the survival time of patients and clinical variables; 1031 patients were identified with NTproBNP > 400 pg/mL but who did not have echocardiographic evidence of HF. All-cause mortality was 21.5% (222 deaths) over the mean follow-up (FU) period of 6 ± 2 years. NTproBNP was similar in patients who were alive or dead (P = 0.96). However, age (HR 1, P < 0.01), chronic kidney disease (CKD, HR 1.2, P < 0.01), chronic pulmonary obstructive disease (COPD, HR 1.6, P < 0.01), dementia (HR 5.9, P < 0.01), male gender (HR 1.4, P < 0.01), first-degree atrioventricular block (HR 2.1, P < 0.01), left axis deviation (HR 1.6, P = 0.04), and diabetes (HR 1.4, P = 0.03) were associated with all-cause mortality. In multivariate regression, age, gender, CKD stage, COPD, and dementia were independently associated with mortality. In patients with NTproBNP > 627 pg/mL, NYHA class predicted death (II, 19.6%; III, 27.4%; IV, 66.7%; P < 0.01). Conclusions Patients with no HF on echocardiography but raised NTproBNP suffer excess mortality particularly in the presence of certain clinical variables. Age, male gender, worsening CKD stage, presence of COPD, and dementia are independently associated with all-cause mortality in these patients. An NTproBNP > 627 pg/mL coupled with NYHA class could identify patients at greatest risk of death.

Cardiovascular medication in patients with raised NT-proBNP, but no heart failure in the SHEAF registry

“…On univariate analysis, beta-blockers showed an association with survival, however that apparent association disappeared with multivariate Cox proportional-hazards regression that adjusted for all variables found in our previous report to be associated with mortality. 8 None of the other cardiovascular therapeutic agents (diuretics, ACEi, MRA or digoxin) were shown to have any association with these patients’ survival.…”

“…However, using multivariate Cox proportional-hazards regression to adjust for all variables associated with mortality, 8 the influence of beta-blockers became non-significant (HR 0.96; 95% CI: 0.85 to 1.1, p=0.49) ( table 3 ).…”

“… 7 The clinical variables independently associated with all-cause mortality in this group of patients were: age, male gender, chronic obstructive pulmonary disease, dementia and worsening chronic kidney disease (CKD) stage. 8 …”

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

“…We have published the clinical predictors of mortality in this group of people. 11 The patients diagnosed with HF had a significantly higher mortality rate of 11.5 (95% CI 11 to 12.2) per 100PY.…”

“…We prospectively entered all patients referred to the HF clinic into the SHEAF registry. 11 We excluded the few patients before 2013 whose entry into the diagnostic algorithm was through a history of MI. We observed that GPs tended to test the NT-proBNP even when there was a history of MI.…”