Predicting the transition to and progression of heart failure with preserved ejection fraction: a weighted risk score using bio-humoural, cardiopulmonary, and echocardiographic stress testing

Abstract

Aims Risk stratification of heart failure (HF) patients with preserved ejection fraction (HFpEF) can promote a more personalized treatment. We tested the prognostic value of a multi-parametric evaluation, including biomarkers, cardiopulmonary exercise testing-exercise stress echocardiography (CPET-ESE), and lung ultrasound, in HFpEF patients and subjects at risk of developing HF (HF Stages A and B). Background Risk stratification of heart failure (HF) patients with preserved ejection fraction (HFpEF) can promote a more personalized treatment. Design We tested the prognostic value of a multi-parametric evaluation, including biomarkers, cardiopulmonary exercise testing-exercise stress echocardiography (CPET-ESE), and lung ultrasound, in HFpEF patients and subjects at risk of developing HF (HF Stages A and B). Methods and results We performed a resting clinical/bio-humoural evaluation and a symptom-limited CPET-ESE in 274 patients (45 Stage A, 68 Stage B, and 161 Stage C-HFpEF) and 30 age- and sex-matched healthy controls. During a median follow-up of 18.5 months, we reported 71 HF hospitalizations and 10 cardiovascular deaths. Cox proportional-hazards regression identified five independent predictors and each was assigned a number of points proportional to its regression coefficient: stress-rest ΔB-lines >10 (3 points), peak oxygen consumption <16 mL/kg/min (2 points), minute ventilation/carbon dioxide production slope ≥36 (2 points), peak systolic pulmonary artery pressure ≥50 mmHg (1 point) and resting N-terminal pro-brain natriuretic peptide (NT-proBNP) >900 pg/mL (1 point). The event-free survival probability for low risk (<3 points), intermediate risk (3–6 points), and high risk (>6 points) were 93%, 52%, and 20%, respectively. The area under the curve (AUC) for the scoring system to predict events was 0.92 (95% CI 0.88–0.96), with an accuracy significantly higher than the individual components of the score (all P < 0.01 vs. individual AUCs). Conclusion A weighted risk score including NT-proBNP, markers of cardiopulmonary dysfunction and indices of exercise-induced pulmonary congestion identifies HFpEF patients at increased risk for adverse events and Stage A and B subjects more likely to progress towards more advanced HF stages.

A Practical Risk Score for Prediction of Early Readmission after a First Episode of Acute Heart Failure with Preserved Ejection Fraction

“…However, the monitoring will continue for another 18 months. A potential limit of the present study is the lack of evaluation of pulmonary congestion using lung ultrasound (LUS) that was shown to be of prognostic value in recent studies [29,30].…”

Diagnostic and Prognostic Value of Lung Ultrasound B-Lines in Acute Heart Failure With Concomitant Pneumonia

“…PC is one of the main features of patients with HF and the main pathophysiological reason of AHF hospitalizations and readmissions (31)(32)(33). The sensibility and specificity of LUS B-lines in detecting PC support the use of B-lines as "point-of-care" ultrasound approach in different relevant settings, from emergency departments to outpatients clinics, for the differential diagnosis of dyspnea of unclear origin, to rule in or rule out AHF (11)(12)(13)(14)(15)(16)(17)(18)(19). According to our results, there is no difference in AL B-lines score at admission between AHF and AHF/PNM group.…”

“…On the other hand, being an indirect effect of the increase in extravascular lung water (EVLW), LUS B-lines provide the clinician with an accurate, non-invasive and low-cost technique for pulmonary congestion (PC) evaluation in AHF patients. Substantial evidence supports this echographic approach as a useful diagnostic tool and valid prognosticator in emergency departments and outpatient clinics (11)(12)(13)(14)(15)(16)(17)(18)(19). In patients admitted for AHF, LUS B-lines evaluation at discharge can detect subclinical residual PC, which proved to predict adverse outcome (e.g., hospitalization for worsening HF) for up to 6 months (12)(13)(14).…”

Combined use of stress echocardiography and cardiopulmonary exercise testing to assess exercise intolerance in patients treated for acute myocardial infarction

“…It has mainly been used in studies of patients with heart failure [ 14 , 15 , 17 , 19 , 20 ]. Recently, it has also been applied to patients at risk of developing heart failure [ 21 , 22 ].…”