Heart failure in numbers
The importance of predictors of heart failure course
Characteristics of clinically useful prognostic factors
Demographic data | Older age, male sex, low socio-economic status |
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Medical history | Ischemic etiology, longer HF duration, previous HF hospitalization, adequate and inadequate high-energy ICD interventions, non-compliance with evidence-based HF therapies (β-blockers, RAAS inhibitors) |
Clinical status | Advanced NYHA class, high resting heart rate, low SBP, clinical signs of volume overload (e.g., pulmonary congestion, peripheral edema, jugular vein dilatation, hepatomegaly) and of peripheral hypoperfusion, Cheyne-Stoke ventilation, lower BMI, frailty |
Cardiac imaging, including echocardiography | LV systolic dysfunction (low LVEF, reduced GLS), LV dilatation, LV hypertrophy, severe LV diastolic dysfunction, pseudonormal/restrictive LV filling pattern, left atrial dilatation, pulmonary hypertension, right ventricle dilatation and dysfunction, dyssynchrony, severe valvular disease, large territory of non-viable myocardium or of inducible ischemia in imaging stress testing, late gadolinium enhancement in CMR |
Electrocardiogram | Wide QRS complex, ventricular arrhythmia, atrial fibrillation |
Exercise testing | Short 6-min walk test distance, reduced VO2peak and high VE/VCO2slope in cardiopulmonary exercise test |
Genetic testing | Lamin A/C—LMNA mutations (especially non-missense mutations), phospholamban (PLN) mutation |
Non-cardiac comorbidities | Previous stroke/TIA, peripheral artery disease, diabetes, anemia, iron deficiency, COPD, sleep apnea (both central and obstructive), kidney/liver dysfunction, depression |
Assessment prior to admission | |
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▪ Older age ▪ Number of previous HF hospitalizations ▪ Comorbidities, especially diabetes, COPD, liver disease, cancer, dementia ▪ Frailty ▪ Known low LVEF in HFrEF ▪ RV dysfunction | |
Assessment at admission | Reassessment at discharge |
NYHA Class IV symptoms | Effective decongestion |
Nonadherence to medications or salt/fluid restriction | Adherence |
Elevated natriuretic peptide (NP) levels on admission | % reduction (> 30–60%) in NP levels Discharge NP levels |
Elevated serum creatinine or low clearance on admission | Small increases in creatinine accompanying successful decongestion |
High BUN on admission | High BUN at discharge |
Low spot urine sodium after first IV diuretic dose | Low total urinary sodium excretion Total urine output during hospitalization |
Diuretic resistance with high outpatient doses | Diuretic resistance in-hospital High loop diuretic doses at discharge |
Degree of congestion at admission | Residual congestion after treatment ▪ High measured filling pressures ▪ Orthopnea ▪ Edema ▪ Composite congestion scores ▪ Lack of hemoconcentration |
Hemodynamic profile of “cold and wet” at admission | Discharge with either “cold” or “wet” profile |
Low systolic blood pressure | Low systolic blood pressure at discharge |
Troponin elevation | Troponin elevation at any time during hospitalization |
Hyponatremia | Lower sodium at discharge |
▪ No RAS therapy ▪ No beta blocker therapy | Discontinuation of ACEI/ARB in hospital for hypotension or kidney dysfunction Discharge without RAS inhibition or discharge without beta-blocker |
Unexpected in-hospital events conferring additional risks | |
▪ Resuscitation or intubation ▪ Intravenous inotropic therapy even if brief |
Conversation with the patient—still important
Physical examination
Echocardiographic imaging
New parameters with prognostic value in HFrEF
New parameters with prognostic value in HFpEF
Exercise testing in HF
Six-min walk test
Cardiopulmonary exercise testing
Class | Severity of HF | VO2 peak (ml/kg/min) | VO2-AT (ml/kg/min) |
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A | Mild/none | > 20 | > 14 |
B | Mild/moderate | 16–20 | 11–14 |
C | Moderate/severe | 10–16 | 8–11 |
D | Severe | 6–10 | 5–8 |
E | Very severe | < 6 | < 4 |
Laboratory biomarkers
Pathophysiological pathway | Biomarkers |
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Myocyte stress | BNP; NTpro-BNP; NTpro-ANP; MR-proADM; sST2 |
Myocyte injury | TnT; TnI; CK-MB mass; MLCK-I; hFABP; PTX3; HSPs |
Inflammation | hsCRP; TNF-α; sTNFR; cytokines (e.g. IL-1, IL-6, IL-18); AdipoQ, sST2; PTX3; OPG; PCT |
Oxidative stress | oxLDL; MPO; urinary biopyrrins; IsoPs; MDA |
Neurohormones | NE; renin; AngII; aldosterone; AVP/copeptin; EDNs; Cg; ADM; MR-proADM |
Extracellular matrix remodeling | MMPs; TIMPs; P1NP; P3NP; Gal-3; sST2; GDF-15 |
Cardio-renal syndrome | Serum creatinine; ACR; CysC; NGAL; BTP |
Others | Hbg; serum albumin; RDW, VCAM |
Cut-off levels (pg/ml) | ||||||
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NT-proBNP | BNP | |||||
Age < 50 | Age 50–75 | Age > 75 | Age < 50 | Age 50–75 | Age > 75 | |
Acute setting, patient with acute dyspnea | ||||||
HF unlikely | < 300 | < 100 | ||||
“Gray zone” | 300–450 | 300–900 | 300–1800 | 100–400 | ||
HF likely | > 450 | > 900 | > 1800 | > 400 | ||
Non-acute setting, patient with mild symptoms | ||||||
HF unlikely | < 125 | < 35 | ||||
“Gray zone” | 125–600 | 35–150 | ||||
HF likely | > 600 | > 150 |