INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) Profiling Identifies Ambulatory Patients at High Risk on Medical Therapy After Hospitalizations for Heart Failure

Abstract

Background— INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profiles provide important prognostic information for patients with advanced heart failure (HF) receiving mechanical support. The value of INTERMACS profiling has not been shown for patients followed on medical therapy for advanced HF at centers that also offer mechanical circulatory support. Methods and Results— This prospective, observational study enrolled 166 patients with chronic New York Heart Association class III–IV HF, ejection fraction ≤30%, and ≥1 HF hospitalization in the previous year, excluding patients listed for transplant or receiving chronic intravenous inotropic therapy. Subjects were followed for at least 12 months or until death, mechanical support, or transplant. Baseline features, quality of life, and outcomes were compared according to INTERMACS profile. Mean age was 57 years, ejection fraction 18%, and 57% had HF >5 years, whereas 23% of subjects were INTERMACS profile 4, 32% profile 5, and 45% profile 6/7. At 1 year, only 47% of this ambulatory advanced HF cohort remained alive on medical therapy. Patients in INTERMACS profile 4 were more likely to die or require mechanical support, with only 52% of these patients alive without support after the first 6 months. Profile 6/7 patients had 1-year survival of 84%, similar to outcomes for contemporary destination left ventricular assist device recipients. Quality of life using the indexed EuroQol score was poor across profiles 4 to 7, although severe limitation was less common than for ambulatory patients enrolled in INTERMACS before ventricular assist device implantation. Conclusions— Ambulatory patients with systolic HF, a heavy symptom burden, and at least 1 recent HF hospitalization are at high risk for death or left ventricular assist device rescue. INTERMACS profiles help identify ambulatory patients with advanced HF who may benefit from current mechanical support devices under existing indications.

Discordant Perceptions of Prognosis and Treatment Options Between Physicians and Patients With Advanced Heart Failure

“…Of note, this MedaMACS Registry study is a larger and distinct study that followed the initial screening pilot MedaMACS feasibility study that enrolled patients in a smaller group of centers between October 2010 and April 2011. 4,5 …”

Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology

“…Although INTERMACS profiles alone are insufficient to evaluate an individual patient for MCS, based on available data selected INTERMACS 1–2 patients and all INTERMACS 3 patients should be considered for MCS. Furthermore, carefully selected INTERMACS 4–7 patients who are willing to accept a risk of adverse events in exchange for potentially longer survival and better functional status can be considered for MCS . In addition to INTERMACS profiles 1–2, risk factors for early mortality after MCS system implantation include renal dysfunction, elevated bilirubin, advanced age, female gender, presence of right heart failure and need for concomitant cardiac surgery …”

“…Furthermore, carefully selected INTER-MACS 4-7 patients who are willing to accept a risk of adverse events in exchange for potentially longer survival and better functional status can be considered for MCS. 104,151,224 In addition to INTERMACS profiles 1-2, risk factors for early mortality after MCS system implantation include renal dysfunction, elevated bilirubin, advanced age, female gender, presence of right heart failure and need for concomitant cardiac surgery. 225 -227 Patient selection for MCS overlaps with indications for heart transplantation.…”

Hemodynamic assessment in heart failure

“…31 Stage D HF patients can be risk stratified by INTERMACS classes, which may assist in clinical decision-making regarding advanced therapies. 38 Home infusions of inotropes can be a helpful bridge to definitive therapy or a palliative measure in patients not suitable for transplant or durable MCS. Short-term optimization with "tailored therapy" including intravenous inotropes, vasodilators, and diuretics has been shown to have sustainable effects and lasting prognostic impact.…”

“…This is essentially what classifies a patient with stage D HF, and at this stage patients typically display right heart failure, cardiorenal syndrome, and intolerance to neurohormonal antagonists and vasodilator therapies . Stage D HF patients can be risk stratified by INTERMACS classes, which may assist in clinical decision‐making regarding advanced therapies . Home infusions of inotropes can be a helpful bridge to definitive therapy or a palliative measure in patients not suitable for transplant or durable MCS.…”