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CLINICAL RESEARCH: HEART FAILURE

Utility of the Seattle Heart Failure Model in Patients With Advanced Heart Failure

Andreas P. Kalogeropoulos, MD^_*, Vasiliki V. Georgiopoulou, MD^_*, Grigorios Giamouzis, MD, PhD^_*, Andrew L. Smith, MD^_*, Syed A. Agha, MD^_*, Sana Waheed, MD^_*, Sonjoy Laskar, MD^_*, John Puskas, MD, MSc^_*, Sandra Dunbar, RN, DSN^_*, David Vega, MD^_*, Wayne C. Levy, MD and Javed Butler, MD, MPH, FACC^_*,_*

^_* Emory University, Atlanta, Georgia
University of Washington, Seattle, Washington

Manuscript received April 14, 2008; revised manuscript received September 16, 2008, accepted October 7, 2008.

^_* Reprint requests and correspondence: Dr. Javed Butler, Emory University Hospital, 1365 Clifton Road, Suite AT430, Atlanta, Georgia 30322 (Email: javed.butler{at}emory.edu).

Objectives: The aim of this study was to validate the Seattle Heart Failure Model (SHFM) in patients with advanced heart failure (HF).

Background: The SHFM was developed primarily from clinical trial databases and extrapolated the benefit of interventions from published data.

Methods: We evaluated the discrimination and calibration of SHFM in 445 advanced HF patients (age 52 ± 12 years, 68.5% male, 52.4% white, ejection fraction 18 ± 8%) referred for cardiac transplantation. The primary end point was death (n = 92), urgent transplantation (n = 14), or left ventricular assist device (LVAD) implantation (n = 3); a secondary analysis was performed on mortality alone.

Results: Patients were receiving optimal therapy (angiotensin-II modulation 92.8%, beta-blockers 91.5%, aldosterone antagonists 46.3%), and 71.0% had an implantable device (defibrillator 30.4%, biventricular pacemaker 3.4%, combined 37.3%). During a median follow-up of 21 months, 109 patients (24.5%) had an event. Although discrimination was adequate (c-statistic >0.7), the SHFM overall underestimated absolute risk (observed vs. predicted event rate: 11.0% vs. 9.2%, 21.0% vs. 16.6%, and 27.9% vs. 22.8% at 1, 2, and 3 years, respectively). Risk underprediction was more prominent in patients with an implantable device. The SHFM had different calibration properties in white versus black patients, leading to net underestimation of absolute risk in blacks. Race-specific recalibration improved the accuracy of predictions. When analysis was restricted to mortality, the SHFM exhibited better performance.

Conclusions: In patients with advanced HF, the SHFM offers adequate discrimination, but absolute risk is underestimated, especially in blacks and in patients with devices. This is more prominent when including transplantation and LVAD implantation as an end point.

Key Words: heart failure • prognosis • statistical models

Abbreviations and Acronyms   HF = heart failure   IQR = interquartile range   LVAD = left ventricular assist device   SHFM = Seattle Heart Failure Model   SHFS = Seattle Heart Failure Score

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