Evaluation of the Incremental Prognostic Utility of Increasingly Complex Testing in Chronic Heart Failure. (July 2015)

• Record Type: Journal Article
• Authors: Ahmad, Tariq; O'Brien, Emily C.; Schulte, Phillip J.; Stevens, Susanna R.; Fiuzat, Mona; Kitzman, Dalane W.; Adams, Kirkwood F.; Kraus, William E.; Piña, Ileana L.; Donahue, Mark P.; Zannad, Faiez; Whellan, David J.; O'Connor, Christopher M.; Felker, G. Michael
• Is Part Of: Circulation. Volume 8:Number 4(2015)
• Publication Date: 2015-07
• Subjects: Heart failure -- Periodicals; 616.129005
• DOI: 10.1161/CIRCHEARTFAILURE.114.001996
• Languages: English
• ISSNs: 1941-3289

Abstract

<abstract> <title> <x xml:space="preserve">Abstract</x> </title> <sec> <title>Background—</title> <p>Current heart failure (HF) risk prediction models do not consider how individual patient assessments occur in incremental steps; furthermore, each additional diagnostic evaluation may add cost, complexity, and potential morbidity.</p> </sec> <sec> <title>Methods and Results—</title> <p>Using a cohort of well-treated ambulatory HF patients with reduced ejection fraction who had complete clinical, laboratory, health-related quality of life, imaging, and exercise testing data, we estimated incremental prognostic information provided by 5 assessment categories, performing an additional analysis on those with available N-terminal pro–B-type natriuretic peptide (NT-proBNP) levels. We compared the incremental value of each additional assessment (quality of life screen, laboratory testing, echocardiography, and exercise testing) to baseline clinical assessment for predicting clinical outcomes (all-cause mortality, all-cause mortality/hospitalization, and cardiovascular death/HF hospitalizations), gauging incremental improvements in prognostic ability with more information using area under the curve and reclassification improvement (net reclassification index), with and without NT-proBNP availability. Of 2331 participants, 1631 patients had complete clinical data; of these, 1023 had baseline NT-proBNP. For prediction of all-cause mortality, models with incremental assessments sans NT-proBNP showed improvements in <italic>C</italic>-indices (0.72 [clinical model alone]−0.77 [complete model]). Compared with baseline clinical assessment alone, net reclassification index improved from 0.035 (w/laboratory data) to 0.085 (complete model). These improvements were significantly attenuated for models in the subset with measured NT-proBNP data (<italic>c</italic>-indices: 0.80 [w/laboratory data]−0.81 [full model]); net reclassification index improvements were similarly marginal (0.091→0.096); prediction of other clinical outcomes had similar findings.</p> </sec> <sec> <title>Conclusions—</title> <p>In chronic HF patients with reduced ejection fraction, the marginal benefit of complex prognostic evaluations should be weighed against potential patient discomfort and cost escalation.</p> </sec> <sec> <title>Clinical Trial Registration—</title> <p>URL: <ext-link ext-link-type="uri" xlink:href="http://www.clinicaltrials.gov" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">http://www.clinicaltrials.gov</ext-link>. Unique identifier: NCT00047437.</p> </sec> </abstract>