Five Risk Factors Can Guide Referrals to a HF Center

To help general practitioners recognize when to refer severe heart failure (HF) patients to an advanced HF treatment center, researchers in Sweden have identified five risk factors — systolic blood pressure ≤90 mm Hg, creatinine ≥ 160 μmol/L, hemoglobin ≤120 g/L, no renin-angiotensin system (RAS) antagonist therapy and no β-blocker therapy — that can be used to guide referrals of patients who have New York Heart Association (NYHA) Class III-IV HF and an ejection fraction less than 40 percent, according to a study published Nov. 6 in the Journal of the American College of Cardiology.

The study used data on 10,062 HF patients registered in the Swedish Heart Failure Registry between 2000 and 2013. It assessed the five pre-specified, universally available risk factors as potential triggers for referral.

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The investigators observed actual all-cause mortality at one year among patients with NYHA Class III-IV HF in three age groups: ≤ 65 years old; 66 to 80 years old; and > 80 years old. The age groups studied were based on HF treatment considerations in Europe, where heart transplantation is considered mainly for patients ≤ 65, left-ventricular assist device (LVAD) therapy is considered for patients in their 70s and up to age 80, and palliation therapy is considered for patients > 80 or in younger patients with contraindications for transplantation or LVAD therapy.

Previous studies have shown that the blood pressure level used in this study is a criterion for cardiogenic shock, the creatinine level represents considerable end-organ impairment, the hemoglobin level is a marker of cardiorenal syndrome and progressive HF, and the absence of RAS antagonist or β-blocker therapy is considered a mortality risk in these patients.

The researchers found that all five of the risk factors were independent predictors of all-cause mortality and that in severe HF patients the presence of one risk factor was associated with 79 percent one-year survival rates, two risk factors were associated with 60 percent one-year survival and three to five risk factors were associated with 39 percent one-year survival.

"We propose that the presence of one or more risk factors should be a trigger for generalists to refer to an advanced HF center for optimization and potentially evaluated for heart transplantation, LVAD, palliative care or other potential interventions," the study's authors concluded.

Keywords: Cardio-Renal Syndrome, Heart-Assist Devices, Referral and Consultation, Renin-Angiotensin System, Blood Pressure, Risk Factors, Creatinine, Heart Transplantation, Shock, Cardiogenic, Registries, Palliative Care, Hemoglobins, Sweden, Survival Rate, Heart Failure

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