title: Risk stratification of ambulatory patients with advanced heart failure undergoing evaluation for heart transplantation.
abstract: BACKGROUND
  Risk stratification of ambulatory heart failure (HF) patients has relied on peak VO(2)<14 ml/kg/min. We investigated whether additional clinical variables might further specify risk of death, ventricular assist device (VAD) implantation (INTERMACS <4) or heart transplantation (HTx, Status 1A or 1B) within 1 year after HTx evaluation. We hypothesized that right ventricular stroke work index (RVSWI), pulmonary capillary wedge pressure (PCWP) and the model for end-stage liver disease-albumin score (MELD-A) would be additive prognostic predictors.
  
  
  METHODS
  We retrospectively collected data on 151 ambulatory patients undergoing HTx evaluation. Primary outcomes were defined as HTx, LVAD or death within 1 year after evaluation.
  
  
  RESULTS
  Average age in our cohort was 55 ± 11.1 years, 79.1% were male and 39% had an ischemic etiology (LVEF 21 ± 10.5% and peak VO(2) 12.6 ± 3.5 ml/kg/min). Fifty outcomes (33.1%) were observed (27 HTxs, 15 VADs and 8 deaths). Univariate logistic regression showed a significant association of RVSWI (OR 0.47, p = 0.036), PCWP (OR 2.65, p = 0.007) and MELD-A (OR 2.73, p = 0.006) with 1-year events. Stepwise regression showed an independent correlation of RVSWI<5gm-m(2)/beat (OR 6.70, p < 0.01), PCWP>20 mm Hg (OR 5.48, p < 0.01), MELD-A>14 (OR 3.72, p< 0.01) and peak VO(2)<14 ml/kg/min (OR 3.36, p = 0.024) with 1-year events. A scoring system was developed: MELD-A>14 and peak VO(2)<14-1 point each; and PCWP>20 and RVSWI<5-2 points each. A cut-off at≥4 demonstrated a 54% sensitivity and 88% specificity for 1-year events.
  
  
  CONCLUSIONS
  Ambulatory HF patients have significant 1-year event rates. Risk stratification based on exercise performance, left-sided congestion, right ventricular dysfunction and liver congestion allows prediction of 1-year prognosis. Our findings support early and timely referral for VAD and/or transplant.
authors: Department of Medicine, Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Medical Center, New York, NY 10032, USA.
authors: Tomoko S
authors: TS
authors: Kato
authors: Gerin R
authors: GR
authors: Stevens
authors: Jeffrey
authors: J
authors: Jiang
authors: P Christian
authors: PC
authors: Schulze
authors: Natalie
authors: N
authors: Gukasyan
authors: Matthew
authors: M
authors: Lippel
authors: Alison
authors: A
authors: Levin
authors: Shunichi
authors: S
authors: Homma
authors: Donna
authors: D
authors: Mancini
authors: Maryjane
authors: M
authors: Farr
mesh_terms: D000553:Ambulatory Care; D018450:Disease Progression; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D016027:Heart Transplantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index