1Immanuel Klinikum Bernau Herzzentrum Brandenburg / Kardiologie Bernau bei Berlin, Deutschland; 2Universitätsklinikum Brandenburg an der Havel Kardiologie Brandenburg an der Havel, Deutschland; 3Universitätsklinik der Salzburger Landeskliniken Klinik für Innere Med. II, Kardiologie u. intern. Intensivmedizin Salzburg, Österreich; 4Institut für Laboratoriumsmedizin, Klinische Chemie und Molekulare Diagnostik Leipzig, Deutschland; 5Universitätsklinikum Brandenburg an der Havel Institut für Biochemie Brandenburg an der Havel, Deutschland; 6Medizinische Hochschule Hannover Zentrum Innere Medizin, Abteilung Nephrologie Hannover, Deutschland
Background: Acute decompensated heart failure (ADHF) is one of the leading causes for hospital admissions and is associated with an increased risk of death. Risk scores such as ELANE-HF or ADHF/NT-proBNP Score use established kidney function markers to determine risk for mortality of patients hospitalized for ADHF. The aim of the study was to evaluate the predictive value of such risk scores in patients with ADHF with and without the addition of novel and established cardio-renal biomarkers.
Methods: In this single-center, exploratory prospective cohort study, we analyzed data from 50 adults with ADHF. The predictive value of the ELANE-HF, ADHF/NT-proBNP and A2B scores for mortality with and without novel and conventional cardio-renal biomarkers including uNGAL, Cystatin C-based eGFR or troponin T on the predictive value (AUC-ROC) was analyzed.
Results: Full biomarker and clinical data was available in 44 of 50 patients. Median age was 78.0 (69.3-83.8) years, 50% (22/44) were female. Twelve patients (27.3%) died within 90 days. At admission, non-survivors had higher values of NT-proBNP (7345pg/mL vs. 4297pg/mL, p=0.037), serum urea (14.7mmol/L vs. 9.1mmol/L p<0.001) and Troponin T (56.2pg/mL vs 32.9pg/mL p=0.005) and lower concentrations of hemoglobin (6.8mmol/L vs 8.0mmol/L p=0.008) and cystatin-C based eGFR (23.5mL/min vs 34.0mL/min p=0.012) compared to survivors. Urinary NGAL did not differ between non-survivors (7.6ng/mL) and survivors (2.4ng/mL) and had a predictive value for mortality of AUC 0.701 (95%CI 0.511-0.851), p=0.113. All three risk scores were higher in non-survivors (Table 1) and showed fair to good AUC (<0.80) for 90-day mortality (ELANE-HF: 0.792; ADHF-NTproBNP score: 0.749; A2B score: 0.734), (Table 2). Adding Troponin or Cystatin C-based eGFR or uNGAL showed AUC-ROC >0.80 for all models. The combination of Troponin T, Cystatin C-based eGFR and uNGAL added to risk scores improved AUC to >0.91 (Figure 1a-c).
Conclusion: Our findings imply that risk models for mortality in patients with ADHF may be further improved adding cardio-renal biomarkers.
Table 1 Risk scores
|
|
Overall (n=44) |
Non-Survivors (n=12) |
Survivors (n=32) |
p-value |
|
Risk Score | ||||
|
ELANE-HF, points |
4.0 (3.0-7.0) |
6.5 (5.0-8.0) |
4.0 (3.0-5.0) |
0.002 |
|
ADHF/NT-proBNP, points |
39.7 (22.7-57.4) |
55.1 (39.7-69.3) |
30.7 (19.6-46.3) |
0.010 |
|
A2B, points |
4.0 (3.0-5.0) |
5.0 (4.0-5.0) |
4.0 (3.0-4.0) |
0.017 |
Table 2 ROC Analysis for mortality
|
Variable |
AUC-ROC |
95% CI (lower limit) |
95% CI (upper limit) |
SE |
p-value |
|
*ELANE-HF, points |
0.792 |
0.639 |
0.901 |
0.082 |
0.003 |
|
*ADHF/NT-proBNP, points |
0.749 |
0.559 |
0.938 |
0.097 |
0.012 |
|
*A2B, points |
0.734 |
0.541 |
0.927 |
0.099 |
0.017 |
|
|
|
|
|
|
|
|
Routine Biomarkers not yet included in established mortality risk scores* | |||||
|
Troponin T |
0.774 |
0.626 |
0.921 |
0.075 |
0.006 |
|
Cystatin C-based eGFR |
0.770 |
0.597 |
0.895 |
0.084 |
0.001 |
|
|
|
|
|
|
|
|
Novel cardio-renal Biomarker not included in established mortality risk scores* | |||||
|
NGAL in Urine |
0.701 |
0.511 |
0.851 |
0.037 |
0.113 |
Figure 1 Receiver operating characteristic (ROC) curves of a) ELAN-HF Score B) ADHF/NT-proBNP score and c) A2B Score with and without a combination of biomarkers (Troponin T, cystatin C-based eGFR and NGAL in urine) for predicting mortality.
aa) ELANE-HF score
b) ADHF/NT-proBNP score
c) A2B score