Triage of Patients With Moderate to Severe Heart Failure: Who Should Be Referred to a Heart Failure Center?

Study Questions:

What are the criteria for referral of patients from the general practitioner to a heart failure (HF) center?


The investigators assessed observed and expected all-cause mortality in 10,062 patients with New York Heart Association (NYHA) III-IV HF and ejection fraction (EF) <40% registered in the Swedish Heart Failure Registry between 2000 and 2013. Next, five prespecified universally available risk factors were assessed as potential triggers for referral, using multivariable Cox regression: systolic blood pressure ≤90 mm Hg; creatinine ≥160 μmol/L; hemoglobin ≤120 g/L; no renin-angiotensin system antagonist; and no beta-blocker.


In NYHA III-IV and age-groups ≤65, 66-80, and >80, there were 2,247, 4,632, and 3,183 patients, with 1-year observed versus expected survivals of 90% versus 99%, 79% versus 97%, and 61% versus 89%, respectively. In age ≤80, the presence of 1, 2, or 3-5 of these risk factors conferred an independent hazard ratio for all-cause mortality of 1.40, 2.30, and 4.07, and a 1-year survival of 79%, 60%, and 39%, respectively (p < 0.001).


The authors concluded that potential heart transplantation (HTx)/left ventricular assist device (LVAD) candidacy is suggested by ≥1 and potential palliative care by multiple universally available risk factors.


This analysis suggests that in a large unselected population, age ≤80 with NYHA III-IV HF and EF <40% mortality was mainly related to HF and/or its comorbidities, and that the presence of any one or more of five prespecified universally available risk factors (systolic blood pressure ≤90 mm Hg; creatinine ≥160 μmol/L; hemoglobin ≤120 g/L; not treated with renin-angiotensin system antagonist; not treated with beta-blocker) conferred a 1-year survival of 79% or worse, and could identify patients who may benefit from referral to an advanced HF center. Presence of one or more risk factors may be used as a trigger for generalists to refer to an advanced HF center for optimization and potential evaluation for HTx, LVAD, palliative care, or other possible interventions.

Keywords: Heart-Assist Devices, Referral and Consultation, Renin-Angiotensin System, Comorbidity, Blood Pressure, Risk Factors, Creatinine, New York, Heart Transplantation, Triage, Heart Diseases, Incidence, Registries, Palliative Care, Hemoglobins, Heart Failure

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