Parsimonious echocardiography-based model for predicting long-term all-cause mortality in heart failure with...

The Heart Failure Association Pre-test Assessment, Echocardiography and Natriuretic Peptide, Functional testing, Final aetiology (HFA-PEFF) score and the Heavy, Hypertensive, Atrial Fibrillation, Pulmonary Hypertension, Elder, Filling Pressure (H₂FPEF) score facilitate heart failure with preserved ejection fraction (HFpEF) diagnosis but may not adequately stratify mortality risk. We developed and internally validated a parsimonious echocardiography-based model for long-term all-cause mortality in HFpEF and compared its prognostic discrimination with HFA-PEFF and H₂FPEF.

In a real-world HFpEF echocardiography database linked to territory-wide electronic health records, 792 adults with HFpEF (left ventricular ejection fraction ≥50%) diagnosed between 2010 and 2016 were randomly split in a prespecified 70:30 ratio into training (n=554) and validation (n=238) cohorts. The primary endpoint was all-cause mortality. A parsimonious model was derived using least absolute shrinkage and selection operator (LASSO)-penalised Cox regression and refitted as a multivariable Cox model.

The final nomogram included age, left ventricular posterior wall thickness at end-systole, mitral E velocity, E/e' ratio and pulmonary artery systolic pressure. During median follow-up of 5.17 years (IQR 2.26-9.14) in the training cohort and 5.75 years (IQR 2.17-9.25) in the validation cohort, 393/554 (70.9%) and 165/238 (69.3%) deaths occurred, respectively. In the validation cohort, the nomogram showed better discrimination than HFA-PEFF and H₂FPEF, with 1/3/5-year area under the curves of 0.658/0.706/0.713 versus 0.507/0.561/0.642 and 0.516/0.533/0.607, respectively. Calibration was acceptable at 1 and 3 years but weaker at 5 years, and risk-score tertiles separated survival in both cohorts (log-rank p<0.001).

A five-variable echocardiography-based nomogram showed better discrimination for long-term mortality prediction than the repurposed diagnostic scores evaluated in this cohort. External validation is needed before clinical implementation.