The importance of re-evaluating the risk score in heart failure patients: An analysis from the Metabolic Exercise Cardiac Kidney Indexes (MECKI) score database
Introduction
Heart failure (HF) is currently one of the most relevant challenges in public health, occurring in 1–2% of developed countries adult population [1]. Despite significant treatment and management advances [1], HF patients still have high mortality [2] and rehospitalization rates [3], thus a precise and individually tailored prognosis estimation is of main relevance to establish the appropriate treatment and patients' follow-up strategies. However, risk stratification in HF still remains a challenge mainly due to HF complex pathophysiology, presence of comorbidities, limited access to expensive and novel pharmacological and device therapies, and to sophisticated examinations such as cardiac magnetic resonance and genetic assessment.
Cardiopulmonary exercise test (CPET) is a well-recognized, easy to perform, cheap and accurate tool for risk stratification in HF. Among several CPET variables, peak VO2, [4,5] VE/VCO2 slope [[6], [7], [8],10], and their combination [9,10] have been identified as strong and independent HF prognosis predictors.
Albeit several prognostic markers of death and/or HF hospitalization have been identified, it is currently recognized that the best strategy to predict HF prognosis or re-hospitalization is by multiparametric evaluation [1]. For this purpose, several multivariable prognostic risk scores have been developed. [[11], [12], [13], [14], [15], [16]]
Among the numerous HF prognostic score, the Metabolic Exercise Cardiac Kidney Indexes (MECKI) score [17] is the only one integrating CPET prognostic parameters of both cardiovascular and ventilatory response to effort with established clinical, laboratory and echocardiographic risk factors. MECKI score has been built and validated in a robust database derived from leading HF clinics in Italy. At present, MECKI score is indicated by ESC guidelines among useful HF prognostic scores [1] and, actually, a few reports showed its superiority compared to other scores such as Seattle HF model, HFSS, MAGICC, [18,19] at least in an HF population in whom CPET can be performed.
The MECKI score is built considering the combination of the following parameters: peak oxygen uptake (VO2) % of predicted value, VE/VCO2 slope, left ventricular ejection fraction (LVEF by cardiac ultrasounds Simpson method), hemoglobin (Hb), blood sodium value (Na+), and glomerular filtration rate as estimated by MDRD formula [17].
The major limitation of all the observational prognostic studies in HF, including MECKI, is that they have been exclusively based on parameters evaluated once, i.e. at the beginning of the follow-up, both for incident and prevalent patients. The information of the role of a second evaluation during follow-up assessment is generally lacking with the exception of HFSS [20]. HF is a dynamic condition where the clinical outcome can change dramatically over the course of the syndrome, related to cardiac and not cardiac factors. So repeated evaluations are of main relevance, allowing to update the risk profile and to monitor HF evolution, thereby improving the therapeutic strategy.
The purpose of this study was to investigate whether a second MECKI score evaluation and the analysis of MECKI score changes present an added prognostic value for HF morbidity and mortality prediction.
Section snippets
The MECKI group registry
The MECKI group registry includes at present 7700 consecutive systolic HF patients, recruited and prospectively followed in 24 Italian HF centers since 1993, with mean follow-up >3 years [21].
Currently a similar registry with >1000 patients is ongoing in other European countries and China [22].
MECKI score database inclusion/exclusion criteria have been previously reported in detail [17]. In brief, inclusion criteria are: previous or present HF symptoms (NYHA classes I-III, stage C of ACC/AHA
Study population
Six hundred and sixty patients were enrolled: the main clinical, laboratory, echocardiographic, ergospirometric and treatment characteristics at the time of MECKI I and MECKI II are shown in Table 1. Average time between MECKI I and MECKI II determination was 2.02 ± 1.18 years, while median value was 2.03 years (1.34–3). Most of patients were male (81%) and had an ischemic etiology of HF (47%); the mean age at MECKI I was 60.7 ± 12.2 years. Enrolled patients largely received the most up-to-date
Discussion
The results of our study first confirm the usefulness of the MECKI score for the prognostic evaluation of patients with HFrEF, showing that also the second MECKI score determination has, per se, a strong prognostic power. But most importantly we showed that the time-dependent MECKI score changes bear a very important prognostic information. Specifically, when MECKI score indicates a prognostic improvement, i.e. its value falls, all parameters improved but Hb, while when MECKI score indicates a
Conclusions
The results of our study confirm the value of the MECKI score in the prognostic assessment of patients with HFrEF and highlights the rationale and the usefulness of a re-evaluation of the score during the follow-up, which allow to identify those subjects at increased risk of morbidity and mortality. This could help physicians to improve tailored patients' follow-up strategies, risk stratification, and resources allocation.
Declaration of Competing Interest
B. Pezzuto was partially funded by Fondazione Umberto Veronesi for this project.
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This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.