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Development of an Echocardiographic Risk-Stratification Index to Predict Heart Failure in Patients With Stable Coronary Artery Disease

The Heart and Soul Study

Steven M. Stevens, MD^_*,_*, Ramin Farzaneh-Far, MD^_*, Beeya Na, MPH, Mary A. Whooley, MD^_*,, Nelson B. Schiller, MD, FACC^_*

^_* Department of Medicine, Division of Cardiology, University of California, San Francisco, California
Veterans Affairs Medical Center, San Francisco, California

^_* Reprint requests and correspondence: Dr. Steven M. Stevens, 10139 Woodly Avenue #112, North Hills, California 91343 (Email: drstevenstevens{at}gmail.com).

Objectives: We sought to determine which transthoracic echocardiographic (TTE) measurements most strongly predict heart failure (HF) and to develop an index for risk stratification in outpatients with coronary artery disease (CAD).

Background: Many TTE measurements have been shown to be predictive of HF, and they might be useful if aggregated into a risk-prediction index.

Methods: We performed TTE in 1,024 outpatients with stable CAD enrolled in the Heart and Soul study and followed them for 4.4 years. With Cox proportional hazard models, we evaluated the association of 15 TTE measurements with subsequent HF hospital stay. Those measurements that independently predicted HF were combined into an index. Variables were defined as normal or abnormal on the basis of dichotomous cutoffs determined from the American Society of Echocardiography. Abnormal variables in each measurement were assigned points on the basis of strength of association with HF.

Results: Of the 15 variables, 5 measurements were independent predictors of HF: left ventricular mass index (LVMI), left atrial volume index (LAVI), mitral regurgitation (MR), left ventricular outflow tract velocity-time integral (VTI_LVOT), and diastolic dysfunction (DD). In multivariate analysis, each of the 5 measurements independently predicted HF: LVMI >90 g/m² (hazard ratio [HR]: 4.1; 95% confidence interval [CI]: 2.3 to 7.2, p < 0.0001); pseudo-normal or restrictive DD (HR: 2.9; 95% CI: 1.8 to 4.5, p < 0.0001); VTI_LVOT <22 mm (HR: 2.2; 95% CI: 1.4 to 3.5, p = 0.0004); mild, moderate, or severe MR (HR: 1.8; 95% CI: 1.2 to 2.8, p = 0.009); and LAVI >29 ml/m² (HR: 1.6; 95% CI: 1.0 to 2.5, p < 0.06). Combining these measurements, the Heart Failure Index ranged from 0 to 8, representing risk as follows: 3 points for LVMI, 2 points for DD, and 1 point for VTI_LVOT, MR, and LAVI. Among participants with 0 to 2 points: 4% had HF hospital stays (reference); 3 to 4 points: 10% (HR: 2.4; 95% CI: 1.3 to 4.4, p = 0.003); 5 to 6 points: 24% (HR: 6.2; 95% CI: 3.6 to 10.6, p < 0.0001); 7 to 8 points: 48% (HR: 13.7; 95% CI: 7.2 to 25.9, p < 0.0001).

Conclusions: We identified 5 TTE measurements that independently predict HF in patients with stable CAD and combined them as an index that might be useful for risk stratification and serial observations.

Key Words: coronary artery disease • echocardiography • heart failure • prognostic index • risk stratification

Abbreviations and Acronyms   CAD = coronary artery disease   CI = confidence interval   DD = diastolic dysfunction   E/A = ratio of peak mitral early diastolic to atrial contraction velocity   EF = ejection fraction   HF = heart failure   HR = hazard ratio   LAVI = left atrial volume index   LV = left ventricle/ventricular   LVMI = left ventricular mass index   LVOT = left ventricular outflow tract   MR = mitral regurgitation   NT-proBNP = N-terminal part of the pro-B-type natriuretic peptide   TTE = transthoracic echocardiography   VTILVOT = left ventricular outflow tract velocity–time integral   VTIRVOT = right ventricular outflow tract velocity–time integral

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