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Gepubliceerd in: Netherlands Heart Journal 9/2022

Open Access 12-08-2022 | Commentary

Thoughts on the usefulness of a new scoring system for heart failure

Auteur: P. Meregalli

Gepubliceerd in: Netherlands Heart Journal | Uitgave 9/2022

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Heart failure (HF) is a highly prevalent and severe cardiac syndrome with a high impact on the patient’s quality and quantity of life. Due to population ageing and the introduction of enhanced cardiovascular techniques, resulting in improved survival following acute cardiac events, the incidence of HF is increasing over time. These developments have a major influence on the organisation and the cost of outpatient care.
In an ideal situation, specialised care should be available whenever a HF patient deteriorates, while stable patients on optimal medical treatment could be safely discharged from the outpatient clinic [1]. There is debate as to the best time for referral to the general practitioner (GP) and which criteria should be used for objective selection. A validated protocol is lacking.
In their present study, Gingele et al. aimed to assess the feasibility of a new scoring system, called the Maastricht Instability Score—Heart Failure (MIS-HF) questionnaire, as a tool for identifying which subgroup of HF patients are stable enough to be safely referred to the GP [2]. They sought to investigate whether the prognosis of the patients receiving first-line treatment remained comparable to that of those seen at the HF units.
This analysis was done in a retrospective manner and with obvious limitations, as pointed out by the authors themselves. The MIS-HF tool consists of a comprehensive questionnaire comprising 33 items, which include not only clinical data on the severity of HF, but also levels of the biomarker N‑type pro-brain natriuretic peptide and other serum parameters as well as electrocardiographic data.
The decision as to how many points were given per item was arbitrary, but the authors state that they wished to remain on the conservative side. They advise that patients with a low score (total of 0–1 or 2) should be referred for primary care, while patients with a higher score should remain under specialised care.
Undoubtedly, patients with a total score of 0 can be considered stable. The same can very likely be said for scores of 1 or 2. It is questionable whether New York Heart Association (NYHA) class III patients can be regarded as stable. According to the MIS-HF score, as proposed by Gingele et al., NYHA class III is assigned ‘only’ 1 point, whereas the risk of (re)hospitalisation in these patients is real. Another issue with the NYHA classification remains its limited objectivity and the significant overlap between classes II and III. As such, the NYHA classification is not sufficient.
Otherwise, the study is well written and provides many aspects for further investigation. First of all, the authors demonstrate that the clinical implementation of such a questionnaire is safe and achievable in daily practice. There was no significant difference in the composite endpoint between patients with a low MIS-HF score treated in primary versus secondary care.
This is encouraging for further research in the same direction. Nevertheless, almost 6% of the patients with a low MIS-HF score died and 7% needed hospitalisation within 1 year of follow-up. It is of crucial importance that the patients can easily re-access secondary care if they develop symptoms and signs of deterioration. We are not informed about how often the patients in both groups were actually seen for regular or urgent visits, but the median time to first outpatient clinic visit was 168 days, which is fairly long.
Before implementing such a scoring system hospitals should, therefore, be able to re-admit deteriorating patients at any time. In my opinion, sharing the same electronic patient dossier is an essential step toward multidisciplinary care. Implementation of real-time access to patients’ data for all involved care givers is mandatory. With this premise, it could be possible to firstly alternate regular visits to the specialist and the GP practice for at least 1 year before taking the definitive decision for referral to the GP. In this manner, patient compliance will possibly increase, due to the fact that they can adapt to this new situation. The psychological and social conditions definitely play a role in the way follow-up is organised. A positive feature is that both social support and mental status are included in the questionnaire.
Unfortunately, no detailed information is given about medical treatment. We can assume that all patients were on optimal medical treatment at the time of enrolment (2015–2018). This aspect should be taken into consideration because new HF medication (sacubitril/valsartan, sodium-glucose cotransporter 2 inhibitors) is increasingly implemented in daily practice [3, 4]. The initiation and the uptitration of specialised HF medication is usually performed in secondary care, which may delay referral to the GP [5].
Finally, it is shown that the MIS-HF questionnaire is an objective and useful tool for the referral process from secondary to primary care, but one may wonder whether it is also suitable for referral in the other direction. The use of laboratory and ECG data makes it quite complex. One might consider a two-step protocol for the GP: a first step aimed at identifying the presence of HF-related symptoms and a second step for further assessment of serum, electrocardiographic and echocardiographic parameters. During this second phase, collaboration with the cardiologist and/or the HF nurse should be encouraged.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​.
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Literatuur
1.
go back to reference Luttik ML, Jaarsma T, van Geel PP, et al. Long-term follow-up in optimally treated and stable heart failure patients: primary care vs. heart failure clinic. Results of the COACH-2 study. Eur J Heart Fail. 2014;16:1241–8. CrossRef Luttik ML, Jaarsma T, van Geel PP, et al. Long-term follow-up in optimally treated and stable heart failure patients: primary care vs. heart failure clinic. Results of the COACH-2 study. Eur J Heart Fail. 2014;16:1241–8. CrossRef
3.
go back to reference Zannad F, Ferreira JP, Pocock SJ, et al. SGLT2 inhibitors in patients with heart failure with reduced ejection fraction: a meta-analysis of the EMPEROR-Reduced and DAPA-HF trials. Lancet. 2020;396:819–29. CrossRef Zannad F, Ferreira JP, Pocock SJ, et al. SGLT2 inhibitors in patients with heart failure with reduced ejection fraction: a meta-analysis of the EMPEROR-Reduced and DAPA-HF trials. Lancet. 2020;396:819–29. CrossRef
4.
go back to reference McMurray JJ, Packer M, Desai AS, et al. Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014;371:993–1004. CrossRef McMurray JJ, Packer M, Desai AS, et al. Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014;371:993–1004. CrossRef
5.
go back to reference McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42:3599–726. CrossRef McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42:3599–726. CrossRef
Metagegevens
Titel
Thoughts on the usefulness of a new scoring system for heart failure
Auteur
P. Meregalli
Publicatiedatum
12-08-2022
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
Netherlands Heart Journal / Uitgave 9/2022
Print ISSN: 1568-5888
Elektronisch ISSN: 1876-6250
DOI
https://doi.org/10.1007/s12471-022-01715-6

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