Heart failure is a global public health issue because of its high prevalence, mortality, morbidity and cost of care.1 Remarkable progress in the therapy and management of patients with chronic heart failure, most prominently angiotensin converting enzyme inhibitors (ACE inhibitors), β-adrenoreceptor antagonists, and aldosterone antagonists, as well as advancements in medical device therapy have bettered that prognosis such that even in heart failure patients who are classified as NYHA class IV, the annual mortality rate can be as low as 9.7%.2
Nevertheless, many patients do not respond to medical therapy and remain symptomatically very limited, with reported survival rates of 50% and 10% at 5 and 10 years, respectively.3 It is important to note that the use of symptoms alone to assign severity puts heart failure patients at risk of considerable misclassification and as a result, mismanagement of disease. For clinical purposes, it is appropriate to identify parameters associated with an adverse prognosis in order to tailor treatment regimens for individual patients.
There are many variables that provide prognostic information. In fact, there are currently over 300 prognostic markers of an adverse outcome described in patients with heart failure.2 Numerous studies have been conducted looking at clinical, hemodynamic, and neurohormonal variables to assist with risk categorization. The more significant variables are described below:
Prognosis according to demographics
- Age – The Framingham Heart Study demonstrated that mortality from congestive heart failure increased with advancing age in both men and women.4
- Sex – The Framingham study also showed that between 1948 and 1988 survival was better in women than in men. Median survival following the onset of congestive heart failure was 1.66 years in men and 3.17 years in women. The one-, two-, five- and ten-year survival rates were 57%, 46%, 25%, and 11% in men. The corresponding survival rates in women were significantly better at 64%, 56%, 38%, and 21%.4 During the period from 1990 thru 1999, the five-year survival improved to 46% in men and 60% in women.5
- Race – A prospective cohort study of patients with decompensated heart failure on hospital admission demonstrated that African Americans had a similar risk of morality but greater decline in functional status when compared to white patients in the six months following hospitalization.6
Prognosis according to etiology
Chronic heart failure of ischemic etiology (also called coronary artery disease, results from a deficiency of blood supply to the heart muscle, caused by constriction or obstruction of the coronary arteries) carries a greater risk of morbidity and mortality than that of a nonischemic etiology (hypertensive heart disease, myocarditis, alcoholic cardiomyopathy and cardiac dysfunction due to rapid atrial fibrillation).7
Prognosis according to coexisting disease
- Chronic kidney disease is present in about one-third of patients with heart failure.8 The interrelatedness of the heart and the kidney is made clear in the cardiorenal syndrome. The cardiorenal syndrome has been described as a “complex pathophysiological disorder of the heart and kidneys in which acute or chronic dysfunction in one organ may induce acute or chronic dysfunction in the other organ.”9 The degree and impact of renal insufficiency is of critical importance to the prognosis of patients with heart failure. Even moderate degrees of renal dysfunction are independently associated with an increased risk for all-cause mortality, cardiovascular death, and hospitalization in patients with heart failure.10 The presence of renal dysfunction in itself is recognized as one of the most common and most troubling heart failure associated comorbidities.
- Diabetes mellitus
- Alcohol Abuse
Prognosis according to clinical variables
1. NYHA class
2. Quality of life
1. Cardiac signs
2. Body weight
Prognosis according to drug therapy
- HMG CoA reductase inhibitors (statins)
Prognosis according to biochemistry and hematology
- Liver function tests
- C-reactive protein
- Erythrocyte sedimentation rate
Prognosis according to ECG
- Atrial fibrillation
- Ventricular tachycardia
Prognosis according to hemodynamics
- Left ventricular ejection fraction
- Right ventricular ejection fraction
- Peak Vo2
- Six-minute walk test
Prognosis according to neurohormones
- Natriuretic peptides
- Atrial natriuretic peptides
- B-type natriuretic peptide
- Tumor necrosis factor
Prognosis according to nutritional status
1. Heidenreich PAM, Albert NMP, Allen LAM et al. Forecasting the Impact of Heart Failure in the United States: A Policy Statement From the American Heart Association. [Miscellaneous Article]. Circulation: Heart Failure 2013;6:606-619.
2. Gardner RS. Prognostication. In: McDonagh T, Gardner RS, Clark AL, Dargie HJ, eds. Oxford Textbook of Heart Failure. Oxford: Oxford University Press; 2011:265-277.
3. Roger VL. The heart failure epidemic. International Journal of Environmental Research and Public Health 2010;7:1807-1830.
4. Ho KK, Anderson KM, Kannel WB, Grossman W, Levy D. Survival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation 1993;88:107-115.
5. Levy D, Kenchaiah S, Larson MG et al. Long-Term Trends in the Incidence of and Survival with Heart Failure. New England Journal of Medicine 2002;347:1397-1402.
6. Vaccarino V, Gahbauer E, Kasl SV et al. Differences between African Americans and whites in the outcome of heart failure: Evidence for a greater functional decline in African Americans. American Heart Journal 2002;143:1058-1067.
7. Simon T, Mary-Krause M, Funck-Brentano C, Jaillon P, on Behalf of the CIBIS II Investigators. Sex Differences in the Prognosis of Congestive Heart Failure: Results From the Cardiac Insufficiency Bisoprolol Study (CIBIS II). Circulation 2001;103:375-380.
8. Mentz RJ, Felker M. Noncardiac comorbidities and acute heart failure patients. Heart Failure Clinics 2013;9:359-367.
9. Cruz DN, House AA, Schmidt-Ott KM et al. Pathophysiology of cardiorenal syndrome type 2 in stable chronic heart failure: workgroup statements from the Eleventh Consensus Conference of the Acute Dialysis Quality Initiative (ADQI). Contrib Nephrol 2013;182:117-136.
10. Hillege HL, Nitsch D, Pfeffer MA et al. Renal Function as a Predictor of Outcome in a Broad Spectrum of Patients With Heart Failure. Circulation 2006;113:671-678.