Physician Prediction of Outcomes in Ambulatory Patients with Advanced Heart Failure

Ambulatory patients on oral heart failure (HF) therapy are increasingly considered for advanced therapies but thresholds for considering patients are not established. We compared baseline characteristics and outcomes of patients with advanced HF based upon whether clinical assessment by HF cardiologists at transplant/VAD centers predicted need for advanced therapies within the next year. Ambulatory patients on oral medications for chronic HF with reduced EF were enrolled in the Medamacs registry after one or more HF hospitalization and at least one other high risk criteria. Patients were divided based on their HF cardiologist’s prediction of whether or not they would be likely to warrant urgent Stage D intervention (home inotropes, hospice, ventricular assist device, or urgent transplant) within 1 year. Of the 160 enrolled patients, 110 (69%) were deemed likely to warrant Stage D intervention within a year, 47 (29%) were deemed unlikely or uncertain, and 3 (2%) were excluded due to missing answers. The two groups did not differ consistently in demographics, physical exam findings, or cardiac tests. Despite this, the mortality was twice as high in patients deemed likely to warrant Stage D intervention as compared to those who were not thought to require an intervention (Table 1). Among ambulatory patients with advanced heart failure at VAD/transplant centers, physician prediction of the need for Stage D interventions is associated with an increased risk of death despite similar traditional risk factors. This suggests that there are other signals which influence experienced physicians in assessing risk. Better appreciation of clinical assessment strategy could improve triage of ambulatory patients to advanced heart failure therapies.