Trajectories in <scp>New York</scp> Heart Association functional class in heart failure across the ejection fraction spectrum: data from the <scp>Swedish</scp> Heart Failure Registry

Lindberg, Felix; Lund, Lars H.; Benson, Lina; Dahlström, Ulf; Karlström, Patric; Linde, Cecilia; Rosano, Giuseppe; Savarese, Gianluigi

doi:10.1002/ejhf.2644

Cited by 17 publications

(28 citation statements)

References 32 publications

(62 reference statements)

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“…Outcome was better among those with an improvement in NYHA class. However, NYHA class itself, assessed at baseline and follow‐up, predicted morbidity and mortality on top of its changes, suggesting that the one‐time NYHA class assessment is to be preferred compared to the trajectory 7 …”

Section: Prognosismentioning

confidence: 99%

“…However, NYHA class itself, assessed at baseline and follow-up, predicted morbidity and mortality on top of its changes, suggesting that the one-time NYHA class assessment is to be preferred compared to the trajectory. 7 Bendopnea is a symptom of advanced HF, although its prognostic role remains uncertain. A study including 440 patients with advanced HF aimed to assess the prognostic role of bendopnea and of oxygen saturation when bending forward (bending oxygen saturation [SpO 2 ] index [BOSI]).…”

Section: Prognosis Symptomsmentioning

confidence: 99%

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November 2022 at a glance: focus on epidemiology, prognosis and comorbidities

Tomasoni

Adamo

Metra

2022

European J of Heart Fail

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The association between cardiometabolic health (CMH) and the risk of heart failure (HF) was assessed in a cohort of 5080 patients with type 2 diabetes (T2D) and without prevalent HF from the Look AHEAD trial. The CMH score included 2 points each for target levels of waist circumference, glomerular filtration rate (GFR), urine albumin-to-creatinine ratio, and 1 point each for blood pressure and glycated haemoglobin at target. Higher baseline CMH score and an improvement in CMH parameters were associated with a lower risk of incident HF. 1 Heart failure with preserved ejection fraction (HFpEF) accounts for more than half of HF hospitalizations. 2 Data regarding 41 708 patients hospitalized for HFpEF were collected between 2017 and 2021 across several centres in China. Patients were often burdened by multiple comorbidities, namely hypertension, atrial fibrillation and coronary artery disease (CAD). At 1-year follow-up, rehospitalization due to HF occurred in 13.6% of patients, while cardiovascular death in 3.1%. 3 The relationship between quality of care as assessed using the European Society of Cardiology (ESC) quality indicators (QIs) and outcome was investigated among 43 704 patients with HF from the Swedish HF registry. 4,5 Out of the 16 QIs, 13 could be measured and 5 were inversely associated with all-cause mortality during follow-up. Quality of care varied across the 80 centres included in the study. 5 BLITZ-HF was a nationwide initiative across 106 Italian centres evaluating the effectiveness of educational intervention to implement guideline-directed medical therapy (GDMT) in HF patients. Overall, 7218 HF patients, with both acute and chronic HF, were enrolled and a web-based pop-up system reminding GDMT recommendations was tested. At baseline, level of adherence to HF guidelines was already elevated. The use of the pop-up system led to a further improvement of six out of nine indicators. 6 Atrial diseaseAtrial function and dynamics play a key role in the development, progression and prognosis of HF. 16,17 Left atrial adverse remodelling (LAAR), defined as an increase in left atrial dimensions on

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Section: Prognosismentioning

confidence: 99%

Section: Prognosis Symptomsmentioning

confidence: 99%

November 2022 at a glance: focus on epidemiology, prognosis and comorbidities

Tomasoni

Adamo

Metra

2022

European J of Heart Fail

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“…With these considerations in mind, it seems logical to conclude that assessing the trajectory of serially assessed clinical metrics over time might provide greater insight into a patient's overall location in their HF journey. In this issue of the Journal, Lindberg et al 3 test this hypothesis by assessing the predictive value of change in New York Heart Association functional class (NYHA FC) assessments over time as a clinical metric. While hypothesis testing in this case proved negative, we believe the concept is nevertheless valid.…”

Section: This Article Refers To 'Trajectories In New Yorkmentioning

confidence: 99%

“…In this setting, the frequency of testing required to reliably describe a change in clinical status may be challenging to quantify. 6 In their analysis, Lindberg et al 3 sought to identify the predictive value of NYHA FC trajectory based on a single observed change. Given the above considerations, the probability of separating signal from noise in this experiment was therefore very low from the outset.…”

Section: This Article Refers To 'Trajectories In New Yorkmentioning

confidence: 99%

“…10 More important than these limitations, however, is the fact that NYHA FC relies on a physician to determine clinical status instead of a patient. In fact, the problems we have identified with the analysis from Lindberg et al 3 would have been effectively addressed had a patient-completed clinical status assessment been employed. Permitting patients to assess their own current clinical status theoretically overcomes the limitations inherent to intermittent testing in a dynamic disease process.…”

Section: This Article Refers To 'Trajectories In New Yorkmentioning

confidence: 99%

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Don't tell your patients where they are, let them tell you

Cedars

Joseph

2022

European J of Heart Fail

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What Role for New York Heart Association Class in Heart Failure Clinical Trials?

2023

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peptides (NPs) and the Kansas City Cardiomyopathy Questionnaire (KCCQ). Moreover, patients with NYHA class I and higher NPs experienced a higher event rate than those with NYHA classes II or III and lower NPs. Thus, as also highlighted by the authors, the current practice of considering patients with NYHA class I as a stable, homogeneous group at low risk of outcomes and crudely excluding them from HF trials might constitute a missed opportunity, affect generalizability, and decrease the feasibility of the enrollment. Beyond the suitability of using NYHA classification as treatment eligibility criteria, we believe that the current study has further implications for trial design.Changes in NYHA class are frequently used as a surrogate end point in HF trials. A meaningful surrogate trial end point ought to either gauge the risk of hard clinical outcomes or detect meaningful changes in clinical status. In this analysis, changes in NYHA class did not significantly predict subsequent harder events when adjusted for the NYHA value at follow-up. 1 Similar findings have been recently reported in 2 independent studies from the CHAMP-HF and Swedish HF Registries. 2,3 This would not necessarily compromise the value of NYHA class changes as trial end points if they were able to detect patients' well-being or objective measures of functional capacity. However, the NYHA classification appears a poor discriminant of patient-reported health status 1,2,4 and functional capacity as assessed by 6-minute walk test 4 when viewed crosssectionally and hardly correlates with changes in KCCQ scores when viewed longitudinally. 2 In contrast, the KCCQ was more sensitive in detecting changes in health status over time and its trajectories were associated with prognosis. 2 The NYHA classification has remained largely unchanged since its introduction a century ago. Meanwhile, the HF clinicians and trialists of today now have access to biomarkers that might better predict clinical events, the validated and more sensitive KCCQ to assess patient-reported symptoms, and simpleto-use objective measures of functional capacity. While the NYHA classification remains a useful tool to assess patients' clinical status in everyday practice, we are left questioning: does it still belong in our trials?

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Trajectories in New York Heart Association functional class in heart failure across the ejection fraction spectrum: data from the Swedish Heart Failure Registry

Abstract: To investigate incidence, predictors and prognostic implications of longitudinal New York Heart Association (NYHA) class changes (i.e. improving or worsening vs. stable NYHA class) in heart failure (HF) across the ejection fraction (EF) spectrum.

Cited by 17 publications

References 32 publications

November 2022 at a glance: focus on epidemiology, prognosis and comorbidities

November 2022 at a glance: focus on epidemiology, prognosis and comorbidities

Don't tell your patients where they are, let them tell you

What Role for New York Heart Association Class in Heart Failure Clinical Trials?

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