Incremental Prognostic Value of Conventional Echocardiography in Patients with Acutely Decompensated Heart Failure

Abstract Background: Acutely decompensated heart failure (ADHF) presents high morbidity and mortality in spite of therapeutic advance. Identifying factors of worst prognosis is important to improve assistance during the hospital phase and follow-up after discharge. The use of echocardiography for diagnosis and therapeutic guidance has been of great utility in clinical practice. However, it is not clear if it could also be useful for risk determination and classification in patients with ADHF and if it is capable of adding prognostic value to a clinical score (OPTIMIZE-HF). Objective: To identify the echocardiographic variables with independent prognostic value and to test their incremental value to a clinical score. Methods: Prospective cohort of patients consecutively admitted between January 2013 and January 2015, with diagnosis of acutely decompensated heart failure, followed up to 60 days after discharge. Inclusion criteria were raised plasma level of NT-proBNP (> 450 pg/ml for patients under 50 years of age or NT-proBNP > 900 pg/ml for patients over 50 years of age) and at least one of the signs and symptoms: dyspnea at rest, low cardiac output or signs of right-sided HF. The primary outcome was the composite of death and readmission for decompensated heart failure within 60 days. Results: Study participants included 110 individuals with average age of 68 ± 16 years, 55% male. The most frequent causes of decompensation (51%) were transgression of the diet and irregular use of medication. Reduced ejection fraction (<40%) was present in 47% of cases, and the NT-proBNP median was 3947 (IIQ = 2370 to 7000). In multivariate analysis, out of the 16 echocardiographic variables studied, only pulmonary artery systolic pressure remained as an independent predictor, but it did not significantly increment the C-statistic of the OPTMIZE-HF score. Conclusion: The addition of echocardiographic variables to the OPTIMIZE-HF score, with the exception of left ventricular ejection fraction, did not improve its prognostic accuracy concerning cardiovascular events (death or readmission) within 60 days

摘要 背景：尽管治疗技术已有进展，急性失代偿性心力衰竭（Acutely decompensated heart failure, ADHF）仍具有较高的发病率与死亡率。明确不良预后相关因素，对于改善患者住院期间诊疗及出院后随访质量具有重要意义。超声心动图在临床实践中已被广泛用于疾病诊断与治疗指导，但目前尚不明确其是否可用于急性失代偿性心力衰竭患者的风险评估与分层，亦无法确认其是否能为临床评分模型（OPTIMIZE-HF）增加预后预测价值。
目的：筛选具有独立预后价值的超声心动图变量，并验证其对临床评分模型的增量预测价值。
方法：纳入2013年1月至2015年1月期间连续收治的急性失代偿性心力衰竭患者，开展前瞻性队列研究，随访至出院后60天。纳入标准为：血浆NT-proBNP水平升高（50岁以下患者＞450 pg/ml，50岁及以上患者＞900 pg/ml），且至少存在以下一项体征或症状：静息性呼吸困难、低心输出量或右侧心力衰竭体征。主要结局指标为出院后60天内发生死亡或因失代偿性心力衰竭再住院的复合终点。
结果：本研究共纳入110例患者，平均年龄为68±16岁，男性占比55%。最常见的失代偿诱因（占比51%）为饮食违规与药物不规律服用。47%的患者存在射血分数降低（＜40%），血浆NT-proBNP中位数为3947（四分位间距2370~7000）。多变量分析显示，在研究的16项超声心动图变量中，仅肺动脉收缩压保留为独立预测因子，但该变量并未显著提升OPTIMIZE-HF评分的C统计量。
结论：除左心室射血分数外，向OPTIMIZE-HF评分中加入超声心动图变量，并未改善其对60天内心血管事件（死亡或再住院）的预后预测准确性。