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How Good Are Cardiologists at Predicting Major Adverse Events in Fontan Patients?
Robert W Elder1, Anne Marie Valente2,3, Brooke Davey4
1Department of Pediatrics and Internal Medicine (Cardiology), Yale University School of Medicine, New Haven, Connecticut, USA.
Insights
Cardiologists have limited accuracy in predicting major adverse events (MAE) in Fontan patients. While some factors overlap, prediction of MAE in Fontan patients needs improvement.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Congenital Heart Disease
Background:
- The ability of cardiologists to predict major adverse events (MAE) in Fontan patients is not well understood.
- Fontan-associated complications necessitate accurate risk stratification for optimal patient management.
Purpose of the Study:
- To evaluate the accuracy of cardiologists in identifying Fontan patients at low risk for MAE within one year.
- To compare the characteristics of predicted low-risk patients with those who actually experienced MAE.
Main Methods:
- A prospective, multicenter study involving patients aged 10 years or older with lateral tunnel or extracardiac Fontan.
- Cardiologists answered a "surprise" question regarding the likelihood of MAE within 12 months.
- Agreement was assessed using the simple kappa coefficient; multivariable models identified factors associated with MAE.
Main Results:
- Of 146 patients, 68% were predicted to be "good Fontan" (no MAE).
- 17% of patients experienced MAE within 12 months.
- Cardiologist prediction accuracy (kappa=0.17) indicated performance slightly better than chance; diuretic/beta-blocker use and systolic dysfunction were associated with predicted MAE.
Conclusions:
- Cardiologists demonstrate marginal ability in predicting 1-year MAE risk in Fontan patients.
- Diuretic/beta-blocker use emerged as a common factor in both predicted and observed MAE, suggesting a potential target for risk assessment.
Background:
It is unknown how well cardiologists predict which Fontan patients are at risk for major adverse events (MAEs).
Objectives:
The purpose of this study was to examine the accuracy of cardiologists' ability to identify the "good Fontan" patient, free from MAE within the following year, and compare that predicted risk cohort to patients who experienced MAE.
Methods:
This prospective, multicenter study included patients ≥10 years with lateral tunnel or extracardiac Fontan. The cardiologist was asked the yes/no "surprise" question: would you be surprised if your patient has a MAE in the next year? After 12 months, the cardiologist was surveyed to assess MAE. Agreement between cardiologist predictions of MAE and observed MAE was determined using the simple kappa coefficient. Multivariable generalized linear mixed effects models were performed to identify factors associated with MAE.
Results:
Overall, 146 patients were enrolled, and 99/146 (68%) patients w`ere predicted to be a "good Fontan." After 12 months, 17 (12%) experienced a MAE. The simple kappa coefficient of cardiologists' prediction was 0.17 (95% CI: 0.02-0.32), suggesting prediction of MAE was 17% better than random chance. In the multivariable cardiologist-predicted MAE (N = 47) model, diuretic/beta-blocker use (P ≤ 0.001) and systolic dysfunction (P = 0.005) were associated with MAE. In the observed multivariable MAE (N = 17) model, prior unplanned cardiac admission (P = 0.006), diuretic/beta-blocker use (P = 0.028), and ≥moderate atrioventricular valve regurgitation (P = 0.049) were associated with MAE.
Conclusions:
Cardiologists are marginally able to predict which Fontan patients are at risk for MAE over a year. There was overlap between factors associated with a cardiologist's prediction of risk and observed MAE, namely the use of diuretic/beta-blocker.
