In‐hospital worsening heart failure: a clinically relevant endpoint?

Abstract

Outcome measures used for the clinical evaluation of patients with acute heart failure differ between studies and may neither adequately address the characteristic presenting symptoms and signs nor reflect the pathophysiological processes involved. In‐hospital worsening of heart failure (WHF) is associated with poor outcomes and thus a potential endpoint conveying clinically meaningful prognostic information.Current definitions of WHF are based on the combination of worsening symptoms and signs and the intensification of treatment during admission. Definitions vary across studies and do not fully account for baseline therapy or circumstances in which there is failure to respond to treatment. Further, there are limited data to inform healthcare professionals as to which patients are most at risk of developing in‐hospital WHF.In this opinion piece, we review the definitions for WHF used in recent and ongoing clinical trials and propose a novel definition, which captures failure to respond to treatment as well as clinical worsening (deterioration of symptoms and signs) of the patient's condition. Such a definition, applied consistently across studies, would help clarify the characteristics of patients likely to develop in‐hospital WHF, allow comparative assessments of the effectiveness of interventions, and help guide appropriate patient management in order to improve outcomes.

Impact of SGLT2 Inhibitors on Heart Failure: From Pathophysiology to Clinical Effects

“…HF hospitalization for acute episodes of decompensation represents a major human and economic burden [ 15 ], and it is affected by both gender [ 16 ] and frailty [ 17 ].…”

Therapeutic Advances in the Management of Acute Decompensated Heart Failure

“…In hospital worsening HF (IH-WHF) is an appealing concept and was proposed as mediator of 180-day mortality in RELAX I trial. However, the definitions used so far have largely varied, limiting the appropriate understanding and clinical applicability (71). Current definitions of worsening HF are based on worsening HF symptoms and signs, intensification to and/or failure to respond to HF therapy during hospitalization (71).…”

“…However, the definitions used so far have largely varied, limiting the appropriate understanding and clinical applicability (71). Current definitions of worsening HF are based on worsening HF symptoms and signs, intensification to and/or failure to respond to HF therapy during hospitalization (71). The hypothesis that IH-WHF, as in-hospital outcome, would mediate long term outcomes has been investigated in RELAX II but with disappointing results, highlighting the disconnection between short and long term outcomes and the disconnection between the mechanism of action of the drug and targeted pathophysiology.…”

Development and Validation of a Prediction Model for Irreversible Worsened Cardiac Function in Patients With Acute Decompensated Heart Failure

“…Some patients are discharged from the hospital after treatment, while in others deterioration of heart failure occurs during hospitalization, and remaining patients show irreversible worsening of heart function. Patients who experienced inhospital worsening heart failure had high 30-day mortality (29.7%) (3). Therefore, it is necessary to predict the clinical course of heart failure as early as possible, to enable the selection of evidence-based management strategies to improve the treatment and nursing of patients with heart failure.…”