Clinical InvestigationA Comparison of Patient and Physician-Rated New York Heart Association Class in a Community-Based Heart Failure Clinic
Section snippets
Study Population
This study is an analysis of consecutive patients referred to a community HF clinic (Kingston-upon-Hull, UK) for the assessment of suspected HF between 2002 and 2004. All participants provided written informed consent, and the study was carried out in accordance with the Helsinki Declaration II and the European Standards for Good Clinical Practice. Ethical approval was granted by the Hull and East Yorkshire Local Research Ethics Committee.
Standard Clinical Assessment
All patients underwent a standard assessment, including
Patient Characteristics
Data were collected on 1752 patients for this analysis. Most patients were men (62%) who were younger than the women (median 70 vs 74 years, P < .001) but had twice the prevalence of LVSD and significantly more MSHD (59.6% vs 45.4%, P < .0001) (Table 1). Despite having less LVSD and MSHD, women had more lower-limb edema (21.7% vs 14.5%, P = .001) and higher mean Dr-NYHA and mean Pa-NYHA than men (1.98 vs 1.89, P = .016; 2.17 vs 2.02, P = .002). In patients with LVSD, a higher proportion of men
Discussion
This analysis shows that the relationship between Dr-NYHA and Pa-NYHA is modest, with only a 44% agreement in patients with MSHD. In addition, where Dr-NYHA and Pa-NYHA are discordant, woman are more likely to rate their NYHA worse than the physician when compared with men. NYHA class, whether assessed by physicians or the patient, was a powerful predictor of mortality. However, when NYHA class is being used to select patients with an adverse prognosis, using the physician-rated value may be
Study Limitations
Dr-NYHA was assessed unblinded to the echocardiogram, and this is a potential source of bias. However, assessment in this way is consistent with normal clinical practice and therefore reflects a true picture of Dr-NHYA class. In fact, we consider this to be a strength of this study, because to determine Dr-NYHA in a manner different to normal clinical practice may itself be considered a source of bias.
Interobserver variability for Dr-NYHA has been shown to be poor with only 54% to 56% agreement
Conclusions
Dr-NYHA and Pa-NYHA class differ substantially, probably because physicians are influenced by factors other than symptoms and functional status such as the perceived severity of the underlying cardiac disease, suggesting that in the physicians' hands the NYHA classification has become an “HF severity score.” This may go some way to explaining why Dr-NYHA has better prognostic power than Pa-NYHA. Equally, patients may be influenced by environmental and psychologic factors that are diluting the
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2022, Heart and LungCitation Excerpt :Our findings have been supported by other researchers that when assigning NYHA-FC, there was a large amount of inconsistency among physicians and advanced practice nurses with decision-making around the NYHA-FC assessment.25 In addition, some suggest the NYHA-FC has become a score of severity and not as it was intended, as a measure of a patient's symptoms and functional status.28 It has been suggested by researchers that differences in approaches used to assess patients and education of the providers may contribute to some of the observed disparities in decision-making.24,29
Dr Cleland has received grants and speakers' honoraria from Roche Diagnostics related to the clinical use of natriuretic peptides. Dr Goode has received travel and accommodation grants for conference presentation from Roche Diagnostics. Drs Clark and Nabb have no conflicts of interest.