It is no surprise that patients diagnosed with heart failure (HF) wish to see a heightened quality of life after hospital discharge; however, a study published in the July issue of Circulation: Cardiovascular Quality and Outcomes, showed that nearly half of the patients discharged from hospitalization for acute decompensated HF did not survive to experience a favorable quality of life during 24-week follow-up.
“In the care of patients with heart failure (HF), estimating and communicating prognosis is endorsed by clinical guidelines and is considered to be an important component of high-quality healthcare,” Larry A. Allen, MD, of the University of Colorado Denver in Aurora, Colo., and colleagues wrote. “Without explicit education regarding future expectations regarding quantity and quality of life (QoL), patients and families are inadequately equipped to make important decisions about the optimal direction of their treatment.”
To better identify patients with HF who are at a high risk for an unfavorable QoL, Allen and colleagues developed a prognostic tool to estimate a patient’s risk of future unfavorable QoL or death. They identified factors commonly linked to six-month mortality or unfavorable QoL that were defined by the Kansas City Cardiomyopathy Questionnaire (KCCQ) scores less than 45 at one and 24 weeks after hospital discharge among 1,458 patients within the EVEREST (Efficacy of Vasopressin Antagonism in HF Outcomes Study with Tolvaptan) study.
The primary endpoint of the study was a QoL of less than 45 or all-cause mortality.
The patients included in the study had a mean age of 66.5 years; 75 percent were men, 85 percent were white and all had a left ventricular ejection fraction that was 27.2 percent. The average duration of HF diagnosis prior to the study was 5.9 years; 82 percent had a previous HF hospitalization.
The researchers reported KCCQ scores among survivors to be 31.6 at study enrollment, 52.9 one week after discharge and 58.3 at 24 weeks. The results showed gains in health status, however, the gains were made early with only small increments of improvement between week one and week 24. During the study, 478 patients died and 192 patients had unfavorable QoL throughout follow-up. Nearly half of patients from the EVEREST cohort did not sustain a favorable QoL throughout 24 weeks of discharge.
Allen et al also adjusted for 23 covariates during the trial that were independent predictors of the combined endpoint. The 23 factors included high blood pressure, hyponatremia, increased heart rate, and absence of beta-blocker therapy at discharge, among others.
“These findings fundamentally extend the large body of existing literature regarding prognostication in HF by explicitly including patient-centered measures of QoL over time as part of the predicted clinical outcome,” Allen and colleagues wrote. “Given the growing importance of using objective evidence to engage patients in guiding their subsequent care so that decisions can be based on patients’ individual goals and values, we believe that these findings, once validated, may be used at the time of hospital discharge to improve the quality of HF care.”
The authors noted that nearly half of the patients with symptomatic HF healthcare would be influenced by expectations and preferences for quality of future survival. “Fundamentally, these data show that to provide expectations for future quality of life, risk models should include a baseline measure of health status,” the authors wrote.
While the risk score can help improve outcomes for HF patients, future studies will be necessary to determine whether the risk score will be an effective tool in clinical practice.