Clinical study
A multivariate model for predicting mortality in patients with heart failure and systolic dysfunction

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Abstract

Background

Heart failure is a leading cause of morbidity and mortality, but there are no reliable models based on readily available clinical variables to predict outcomes in patients taking angiotensin-converting enzyme (ACE) inhibitors.

Methods

A multivariate statistical model to predict mortality was developed in a random sample (n = 4277 patients [67%]) of the 6422 patients enrolled in the Digitalis Investigation Group trial who had a depressed ejection fraction (≤45%), were in sinus rhythm, and were taking ACE inhibitors. The model was then validated in the remaining 2145 patients.

Results

Total mortality in the derivation sample was 11.2% (n = 480) at 12 months and 29.9% (n = 1277) at 36 months. Lower ejection fraction, worse renal function, cardiomegaly, worse functional class, signs or symptoms of heart failure, lower blood pressure, and lower body mass index were associated with reduced 12-month survival. This model provided good predictions of mortality in the verification sample. The same variables, along with age and the baseline use of nitrates, were also predictive of 36-month mortality.

Conclusion

Routine clinical variables can be used to predict short- and long-term mortality in patients with heart failure and systolic dysfunction who are treated with ACE inhibitors.

Section snippets

Study sample

The trial recruited 7788 patients from February 1991 through August 1993 in over 300 North American centers. The design and principal outcomes of this trial, which compared digoxin with placebo in patients with heart failure and normal sinus rhythm, have been published 7, 8. The diagnosis of heart failure was based on current or past symptoms and signs, or radiological evidence of pulmonary congestion. Patients were excluded from the trial if they had a serum creatinine level >3.0 mg/dL, age

Results

Patients in the derivation and validation samples had similar characteristics (Table 1). The mean (± SD) age in the derivation sample was 63.3 ± 11.0 years. Over half were known to have heart failure for at least 12 months. Virtually all had signs and symptoms of heart failure at randomization, and only a minority was in NYHA functional class I. The mean ejection fraction was 28% ± 9%, and the mean creatinine level was 1.3 ± 0.4 mg/dL.

Discussion

More than 50 demographic, clinical, biochemical, hemodynamic, electrophysiologic, and echocardiographic factors have been correlated with outcomes in heart failure patients; neurohormonal markers have perhaps the strongest association (10). However, most patients are diagnosed, treated, and followed in general medical practices and do not always have access to these markers. Therefore, we concentrated on predictors that are readily available, and demonstrated that they can be used to predict

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1

Dr. Brophy is a funded researcher from Le Fonds de la Recherche en Santé du Québec. Dr. Yusuf holds a Senior Scientist Award of the Canadian Institutes of Health Research and is an Endowed Chair of the Heart and Stroke Foundation of Ontario.

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