Elsevier

Journal of Cardiac Failure

Volume 10, Issue 6, December 2004, Pages 460-466
Journal of Cardiac Failure

Clinical Investigation
Risk stratification after hospitalization for decompensated heart failure

https://doi.org/10.1016/j.cardfail.2004.02.011Get rights and content

Abstract

Background

Decompensated heart failure (HF) is among the most common indications for hospitalization in the United States, but little is known about features on admission that predict adverse events. We used data from the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) study to develop a model that would predict outcomes in patients with decompensated HF.

Methods and results

OPTIME-CHF randomized 949 patients hospitalized with decompensated HF for 48 to 72 hours of infusion of either milrinone or placebo. We used multivariable modeling to evaluate variables on admission that would be predictive of 60-day mortality or the composite of death or rehospitalization at 60 days. Variables at presentation that predicted death at 60 days were increased age, lower systolic blood pressure, New York Heart Association class IV symptoms, elevated blood urea nitrogen (BUN), and decreased sodium. Predictors of the composite of death or rehospitalization within 60 days were the number of HF hospitalizations in the preceding 12 months, elevated BUN, lower systolic blood pressure, decreased hemoglobin, and a history of percutaneous coronary intervention (PCI). The discriminatory power of the model was substantial for the mortality model (c-index .77) but less for the composite endpoint (c-index .69).

Conclusions

Risk stratification of patients with decompensated HF may be accomplished using easily assessed clinical variables. Further research into the validity of this model in independent samples will potentially aid in the development of risk stratification strategies.

Section snippets

Methods

The study design and primary results of the OPTIME-CHF study have been published elsewhere.20., 21. Briefly, the OPTIME study randomized 949 patients with systolic dysfunction and exacerbations of heart failure to receive 48 to 72 hours of intravenous milrinone therapy (0.5 μg·kg·min without a loading dose) or placebo. Patients were randomized as soon as possible on presentation to the emergency department or hospital (no longer than a 48-hour delay between presentation and randomization).

Results

Baseline characteristics for the patients enrolled in OPTIME-CHF stratified by 60-day outcomes are shown in Table 1. Patients were generally admitted with evidence of volume overload, with the majority of patients demonstrating elevated jugular venous pressure (68%). Baseline hemodynamics tended to be in the normal range, with a median systolic blood pressure of 120 (105–134) mm Hg and median heart rate of 84 (72–96) beats/min. The risk of adverse events at 60 days was substantial, with 60-day

Discussion

Despite advancements in the treatment of heart failure, the morbidity and mortality associated with this clinical syndrome remain high. Although decompensated heart failure is common and associated with substantial morbidity and mortality, features that accurately predict adverse events have not been well defined. Using data from the OPTIME-CHF trial, we developed a predictive model to help assess the risk of 60-day mortality or death + rehospitalization at 60 days in patients hospitalized with

Conclusions

To our knowledge, this is the most powerful predictive model for adverse events in patients hospitalized with decompensated heart failure. By using easily determined clinical characteristics on admission, patients can be identified as high or low risk of death or rehospitalization at 60 days, potentially allowing adjustment of both the intensity and duration of hospital care and follow-up. The model for mortality was able to provide a high degree of discriminatory power using 5 baseline

References (29)

  • C.A. Polanczyk et al.

    Ten-year trends in hospital care for congestive heart failure: improved outcomes and increased use of resources

    Arch Intern Med

    (2000)
  • K.D. Aaronson et al.

    Development and prospective validation of a clinical index to predict survival in ambulatory patients referred for cardiac transplant evaluation

    Circulation

    (1997)
  • K.L. Ho et al.

    Survival after the onset of congestive heart failure in Framingham Heart Study subjects

    Circulation

    (1993)
  • G.M. Felker et al.

    Underlying cause and long-term survival in patients with initially unexplained cardiomyopathy

    N Engl J Med

    (2000)
  • Cited by (273)

    View all citing articles on Scopus

    The OPTIME-CHF trial was sponsored by Sanofi-Synthelabo, Inc, but this study was funded independently by the Duke Clinical Research Institute.

    View full text