title: Triage of patients with moderate to severe heart failure: who should be referred to a heart failure center?
abstract: OBJECTIVE
  The purpose of this study was to evaluate simple criteria for referral of patients from the general practitioner to a heart failure (HF) center.
  
  
  BACKGROUND
  In advanced HF, the criteria for heart transplantation, left ventricular assist device, and palliative care are well known among HF specialists, but criteria for referral to an advanced HF center have not been developed for generalists.
  
  
  METHODS
  We assessed observed and expected all-cause mortality in 10,062 patients with New York Heart Association (NYHA) functional class III to IV HF and ejection fraction <40% registered in the Swedish Heart Failure Registry between 2000 and 2013. Next, 5 pre-specified 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.
  
  
  RESULTS
  In NYHA functional class III to IV and age groups ≤65 years, 66 to 80 years, and >80 years, 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 the age ≤80 years group, the presence of 1, 2, or 3 to 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).
  
  
  CONCLUSIONS
  In patients ≤80 years of age with NYHA functional class III to IV HF and ejection fraction <40%, mortality is predominantly related to HF or its comorbidities. Potential heart transplantation/left ventricular assist device candidacy is suggested by ≥1 risk factor and potential palliative care by multiple universally available risk factors. These patients may benefit from referral to an advanced HF center.
authors.affiliation: Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Tonje
authors.initials: T
authors.lastname: Thorvaldsen
authors.affiliation: Department of Clinical Science and Education, Karolinska Institutet, SöS, Stockholm, Sweden.
authors.forename: Lina
authors.initials: L
authors.lastname: Benson
authors.affiliation: Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Marcus
authors.initials: M
authors.lastname: Ståhlberg
authors.affiliation: Division of Cardiovascular Medicine, Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University, and Department of Cardiology UHL, County Council of Östergötland, Linköping, Sweden.
authors.forename: Ulf
authors.initials: U
authors.lastname: Dahlström
authors.affiliation: Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Magnus
authors.initials: M
authors.lastname: Edner
authors.affiliation: Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden. Electronic address: lars.lund@alumni.duke.edu.
authors.forename: Lars H
authors.initials: LH
authors.lastname: Lund
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006333:Heart Failure / Q000175:diagnosis* / Q000453:epidemiology* / Q000628:therapy; D016027:Heart Transplantation / Q000639:trends; D006760:Hospitalization / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation / Q000639:trends; D012042:Registries; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume / Q000502:physiology; D013548:Sweden / Q000453:epidemiology; D014218:Triage / Q000379:methods*
keywords: heart failure; heart transplantation; left ventricular assist device; palliative care; referral