Assessment of a multimarker strategy for prediction of mortality in older heart failure patients: a cohort study
- 1Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, University of Gothenburg, Gothenburg, Sweden
- 2Department of Medicine, Centre for Applied Biostatistics, University of Gothenburg, Gothenburg, Sweden
- 3Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Correspondence to Dr Michael L X Fu;
- Received 25 October 2012
- Accepted 8 February 2013
- Published 9 March 2013
Objective Primarily to develop a multimarker score for prediction of 3-year mortality in older patients with decompensated heart failure (HF).
Design Prospective cohort study.
Setting Secondary care. Single centre.
Patients and biomarkers 131 patients, aged ≥65 years, with decompensated HF were included. Assessment of biomarkers was performed at discharge.
Primary outcome measure 3-year mortality.
Results Mean age was 73±11 years; mean left ventricular ejection fraction , 43±14%; 53% were male. The 3-year mortality was 53.4%. The following N-terminal brain natriuretic peptide (NTproBNP) levels could optimally stratify mortality: <2000 ng/l (n=39), 30.8% mortality; 2000–8000 ng/l (n=58), 51.7% mortality; and >8000 ng/l (n=34), 82.4% mortality. However, in the 2000–8000 ng/l range, NTproBNP levels had low-prognostic capacity, based on the area under the receiver operating characteristic curve (AUC=0.53; 95% CI 0.40 to 0.67). In this group, multivariate analysis identified age, cystatin C (CysC), and troponin T (TnT) levels as independent risk factors. A risk score based on these three risk factors separated a high-risk and low-risk groups within the NTproBNP range of 2000–8000 ng/l. The score exhibited a significantly higher AUC (0.75; 95% CI 0.62 to 0.86) than NTproBNP alone (p=0.03) in this NTproBNP group and had similar prognostic capacity as NTproBNP in patients below or above this NTproBNP range (p=0.57). Net reclassification improvement and integrated discriminatory improvement in the group with NTproBNP levels between 2000 and 8000 ng/l was 54% and 23%, respectively, and in the whole cohort 22% and 11%, respectively.
Conclusions Our results suggested that, to assess risk in HF, older patients required significantly higher levels of NTproBNP than younger patients. Furthermore, a risk score that included TnT and CysC at discharge, and age could improve risk stratification for mortality in older patients with HF in particular when NTproBNP was moderately elevated.
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