Identifying heart failure patients at high risk for near-term cardiovascular events with serial health status assessments

Background - Identification of heart failure outpatients at increased risk for clinical deterioration remains a critical challenge, with few tools currently available to assist clinicians. We tested whether serial health status assessments with the Kansas City Cardiomyopathy Questionnaire ( KCCQ) can identify patients at increased risk for mortality and hospitalization. Methods and Results-We evaluated 1358 patients with heart failure after an acute myocardial infarction in the Eplerenone's Neurohormonal Efficacy and Survival Study, a multicenter randomized trial that included serial KCCQ assessments. Cox proportional-hazards models were used to examine whether changes in KCCQ scores during successive outpatient visits were independently associated with all-cause mortality and cardiovascular mortality or hospitalization. Change in KCCQ (Delta KCCQ) was linearly associated with all-cause mortality ( hazard ratio [HR], for each 5-point decrease in Delta KCCQ, 1.11; 95% CI, 1.04 to 1.19) and the combined outcome of cardiovascular mortality or hospitalization ( HR for each 5-point decrease in Delta KCCQ, 1.12; 95% CI 1.07 to 1.18). In Kaplan-Meier survival analysis, all-cause mortality among patients with Delta KCCQ of <=-10, >-10 to < 10, and > 10 points was 26%, 16%, and 13%, respectively ( P = 0.008). After multivariable adjustment, the linear relationship between Delta KCCQ and both all-cause mortality and combined cardiovascular death and hospitalization persisted ( HR, 1.09; 95% CI, 1.00 to 1.18; and HR, 1.11; 95% CI, 1.05 to 1.17 for each 5-point decrease in Delta KCCQ, respectively). Conclusions-In heart failure outpatients, serial health status assessments with the KCCQ can identify high-risk patients and may prove useful in directing the frequency of follow-up and the intensity of treatment.