Triage of Patients With Moderate to Severe Heart Failure

• Objectives The purpose of this study was to evaluate simple criteria for referral of patients from the general practitioner to a heart failure (HF) center. Background In advanced HF, the criteria for heart transplantation, left ventricular assist device, and palliative care are well known among HF specialists, but criteria for referral to an advanced HF center have not been developed for generalists. Methods We assessed observed and expected all-cause mortality in 10,062 patients with New York Heart Association (NYHA) functional class III to IV HF and ejection fraction less than 40% registered in the Swedish Heart Failure Registry between 2000 and 2013. Next, 5 pre-specified universally available risk factors were assessed as potential triggers for referral, using multivariable Cox regression: systolic blood pressure less than= 90 mm Hg; creatinine greater than= 160 mmol/l; hemoglobin less than= 120 g/l; no renin-angiotensin system antagonist; and no beta-blocker. Results In NYHA functional class III to IV and age groups less than= 65 years, 66 to 80 years, and greater than 80 years, there were 2,247, 4,632, and 3,183 patients, with 1-year observed versus expected survivals of 90% versus 99%, 79% versus 97%, and 61% versus 89%, respectively. In the age less than= 80 years group, the presence of 1, 2, or 3 to 5 of these risk factors conferred an independent hazard ratio for all-cause mortality of 1.40, 2.30, and 4.07, and a 1-year survival of 79%, 60%, and 39%, respectively (p less than 0.001). Conclusions In patients less than= 80 years of age with NYHA functional class III to IV HF and ejection fraction less than 40%, mortality is predominantly related to HF or its comorbidities. Potential heart transplantation/left ventricular assist device candidacy is suggested by greater than= 1 risk factor and potential palliative care by multiple universally available risk factors. These patients may benefit from referral to an advanced HF center.

Nyckelord

heart failure; heart transplantation; left ventricular assist device; palliative care; referral

MEDICINE

MEDICIN

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