Diagnosis of heart failure (HF) carries a poor prognosis, often comparable with that of cancer. The annual mortality for mild-to-moderate HF (NYHA class II or III) is 24–28%, and increases to 50% in patients with severe NYHA class IV symptoms. Hospital admission with acute HF is a strong and independent predictor of worse prognosis, and is associated with 2–4% in-hospital and 5–15% 90-day mortality. Between 30% and 50% of patients with acute HF are readmitted within 6 months, although 50% of these readmissions are due to comorbidities, often associated with advanced age, rather than existing HF.
Prognosis of HF in individual patients is challenging as a number of independent variables must be considered, including symptoms, severity, etiology and type of HF. The fact that sudden death can occur at any stage of the disease makes the prognostic process even less predictable. In general, patients with NYHA class IV symptoms, and HF caused by infiltrative heart disease, HIV infection or anthracycline toxicity, with systolic left ventricular (LV) or biventricular dysfunction, have the worse prognosis.
Outcomes are poor when the intensity of HF treatment is low and the patient does not adhere to the medications prescribed. Comorbidities (e.g. renal disease, diabetes mellitus), advanced age, male sex and ethnicity all contribute to worse outcomes.
Markers of poor prognosis
Several clinical and laboratory markers of poor prognosis have been validated (Table 9.1). Other identified factors of reduced survival in patients with HF include attenuated response to diuretics, low peak oxygen consumption (VO2max) or short distance in the 6-Minute Walk Test (6MWT), a large burden of ventricular ectopy and complex ventricular arrhythmia, significant pulmonary hypertension, new-onset atrial fibrillation and specific echocardiographic features (significant LV dyssynchrony, evidence of ongoing remodeling and a marked increase in left atrial volume).
TABLE 9.1 | |
Cardiac function • LVEF < 20% (mortality doubles when LVEF drops from 35% to 17%) |
• Abnormal RV systolic function |
Hospitalization for heart failure • Almost threefold increase in risk of death within 12 months of discharge |
• Highest risk within 1 month of discharge |
Hypotension • Low mean arterial blood pressure (a 10-mmHg decrease is associated with an 11% increase in risk) | |
Low eGFR and serum sodium level • Impaired renal function (e.g. cardiorenal syndrome and hyponatremia) | |
Conduction disease • Marked prolongation of QRS (> 150 ms) on surface ECG with evidence of LBBB morphology | |
Clinical findings • S3 gallop (a third heart sound) • Persistently elevated JVP |
• Elevated resting heart rate • Weight loss |
Neurohormones • Chronically elevated plasma levels of norepinephrine (noradrenaline), epinephrine (adrenaline) and aldosterone |
• High plasma renin activity • Elevated BNP level • Elevated troponin levels |
Autonomic dysfunction • Reduced heart rate variability • Poor baroreflex sensitivity • Increased central and peripheral chemoreflex activation |
• Activation of skeletal muscle ergoreceptors |
Others • Depression • Hypoalbuminemia |
• Hyperuricemia • Hypocholesterolemia |
*Reduced survival or higher mortality. BNP, type B natriuretic peptide; eGFR, estimated glomerular filtration rate; JVP, jugular venous pressure; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; RV, right ventricular. | |
Reversible factors
Initial assessment in patients with HF should include a review of the prognosis but, importantly, a search for reversible factors contributing to disease progression (Table 9.2). If any of these problems are identified, prompt and comprehensive treatment should improve HF symptoms, in many cases arrest disease progression and improve prognosis.
TABLE 9.2 Reversible factors that contribute to disease progression | |
• Non-adherence to treatment • Cardiac arrhythmia • Myocardial ischemia • Arterial hypertension • Cardiac dyssynchrony | • Thyroid disease • Alcohol abuse • Type 2 diabetes mellitus • Obstructive sleep apnea |
Palliative care in end-stage heart failure
Palliative care improves the quality of life of patients and their families facing the problems associated with life-threatening illness. This is accomplished by the prevention and relief of symptoms, including early identification, assessment and treatment of pain and other physical, psychosocial and spiritual problems (Table 9.3).
TABLE 9.3 The principles of palliative care |
• Provides relief from pain and other distressing symptoms • Affirms life and regards dying as a normal process • Intends neither to hasten nor postpone death • Integrates the psychological and spiritual aspects of patient care • Offers a support system to help patients live as actively as possible until death • Offers a support system to help the family cope during the patient’s illness and in their own bereavement • Uses a team approach to address the needs of patients and their families • Enhances quality of life and positively influences the course of illness • Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life and includes those investigations needed to better understand and manage distressing clinical complications |
Adapted from the WHO 2004 definition of palliative care; available at www.who.int/cancer/palliative/en, last accessed 12 May 2017. |
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