title: Clinical implications of chronic heart failure phenotypes defined by cluster analysis.
abstract: BACKGROUND
  Classification of chronic heart failure (HF) is on the basis of criteria that may not adequately capture disease heterogeneity. Improved phenotyping may help inform research and therapeutic strategies.
  
  
  OBJECTIVE
  This study used cluster analysis to explore clinical phenotypes in chronic HF patients.
  
  
  METHODS
  A cluster analysis was performed on 45 baseline clinical variables from 1,619 participants in the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) study, which evaluated exercise training versus usual care in chronic systolic HF. An association between identified clusters and clinical outcomes was assessed using Cox proportional hazards modeling. Differential associations between clinical outcomes and exercise testing were examined using interaction testing.
  
  
  RESULTS
  Four clusters were identified (ranging from 248 to 773 patients in each), in which patients varied considerably among measures of age, sex, race, symptoms, comorbidities, HF etiology, socioeconomic status, quality of life, cardiopulmonary exercise testing parameters, and biomarker levels. Differential associations were observed for hospitalization and mortality risks between and within clusters. Compared with cluster 1, risk of all-cause mortality and/or all-cause hospitalization ranged from 0.65 (95% confidence interval [95% CI]: 0.54 to 0.78) for cluster 4 to 1.02 (95% CI: 0.87 to 1.19) for cluster 3. However, for all-cause mortality, cluster 3 had a disproportionately lower risk of 0.61 (95% CI: 0.44 to 0.86). Evidence suggested differential effects of exercise treatment on changes in peak oxygen consumption and clinical outcomes between clusters (p for interaction <0.04).
  
  
  CONCLUSIONS
  Cluster analysis of clinical variables identified 4 distinct phenotypes of chronic HF. Our findings underscore the high degree of disease heterogeneity that exists within chronic HF patients and the need for improved phenotyping of the syndrome. (Exercise Training Program to Improve Clinical Outcomes in Individuals With Congestive Heart Failure; NCT00047437).
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Tariq
authors.initials: T
authors.lastname: Ahmad
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Pencina
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Phillip J
authors.initials: PJ
authors.lastname: Schulte
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Emily
authors.initials: E
authors.lastname: O'Brien
authors.affiliation: Thomas Jefferson University, Philadelphia, Pennsylvania.
authors.forename: David J
authors.initials: DJ
authors.lastname: Whellan
authors.affiliation: Montefiore Medical Center, Bronx, New York.
authors.forename: Ileana L
authors.initials: IL
authors.lastname: Piña
authors.affiliation: Wake Forest School of Medicine, Winston-Salem, North Carolina.
authors.forename: Dalane W
authors.initials: DW
authors.lastname: Kitzman
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Kerry L
authors.initials: KL
authors.lastname: Lee
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Christopher M
authors.initials: CM
authors.lastname: O'Connor
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina. Electronic address: michael.felker@duke.edu.
authors.forename: G Michael
authors.initials: GM
authors.lastname: Felker
mesh_terms: D000328:Adult; D000368:Aged; D015415:Biomarkers; D002908:Chronic Disease; D016000:Cluster Analysis; D005080:Exercise Test; D005260:Female; D054143:Heart Failure, Systolic / Q000175:diagnosis* / Q000401:mortality / Q000473:pathology*; D006760:Hospitalization; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010101:Oxygen Consumption; D010641:Phenotype; D016016:Proportional Hazards Models; D011788:Quality of Life; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers
keywords: mortality; prognosis; rehospitalization; socioeconomic