The predictive efficacy of multidimensional prognostic index in the elderly with heart failure and reduced ejection fraction in a real world sample: the Post-Acute Long-Term Care setting

Abstract

The multidimensional prognostic index (MPI) is an accurate predictor of mortality validated in hospitalized older patients. Aim of this study was to evaluate the reliability of the MPI in predicting shortand long-term mortality in patients with heart failure (HF), particularly in those with reduced left ventricular ejection fraction (HFrEF). The study population included all patients older than 65 years admitted in a Post-Acute Long-Care Unit from 2013 to 2018. Patients were divided into two groups: patients with HF (N=143) and patients without HF as controls (N=1254). Furthermore, patients affected by HF were subdivided according to echocardiographic left ventricular ejection fraction (LVEF), i.e. reduced, mid-range and preserved LVEF (respectively HFrEF, HFmrEF, HFpEF). All patients underwent a comprehensive geriatric assessment (CGA) to calculate the MPI based on information on functional, cognitive, nutritional and mobility status, comorbidity, poli-pharmacy and co-habitation. Mortality rates in the HF group was 46% in patients MPI-1 or MPI-2 groups versus 59% in patients included in the MPI3 group. In particular, of 32 HF patients with HFrEF 67.7% were in the MPI-3 class compared to 43% of 14 patients with HFmrEF group and to 41% of 63 patients with HFpEF. These findings suggest that MPI is a reliable predictor of mortality in HF patients and that it was particularly useful in the subgroup of patients with HFrEF. Introduction Heart failure (HF) is a clinical syndrome characterized by typical symptoms that may be accompanied by signs caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress.1 HF has a prevalence of 1-2% in developed countries with around 20 million cases worldwide. It affects about 10% of patients over 70 years, representing one of the main cause of hospitalization in this age group.2 Although the available treatments have allowed an improvement in mortality, HF continues to have a poor prognosis with a high mortality both in hospitalized patients and in the outpatient care setting.3 Studies have shown that patients discharged from the hospital with a diagnosis of HF have a high risk of mortality (11.3% at 30 days and 33.1% at 1 year)4,5 and rehospitalization (about 40% in the 6-month follow-up period after their index hospitalization).6 The Cardiovascular Health Study, a U.S. longitudinal cohort of communitydwelling older adults, reported 1-year, 5year, and 10-year mortality rates of 19%, 56%, and 83% following the onset of HF, respectively.7 Administrative data from the Canadian Chronic Disease Surveillance System confirm that once HF develops, mortality increases exponentially with age.8 This study focused on HF patients admitted to a Post-Acute Long-Term Care (LPA) Unit. The majority of patients were older subjects. Given their complexity, the great number of comorbidities and the high rate of frailty, all patients included in the study underwent a standardized comprehensive geriatric assessment (GCA) with the calculation of the Multidimensional Prognostic Index (MPI). The MPI is based on CGA information on the following eight domains: Basic Activities of Daily Living (B-ADL), Instrumental Activities of Daily Living (I-ADL), Short Portable Mental Status Questionnaire (SPMSQ), Mini Nutritional Assessment (MNA), ExtonSmith scale to evaluate the risk of bedsores, Cumulative Illness Rating Scale (CIRS) to evaluate comorbidity, the number of medications taken and the co-habitation status (alone, in institution, with family).9 We choose to use MPI because it has been demonstrated to be a strong and independent predictor of mortality in hospitalized older subjects.10 Moreover, studies proved its accuracy and reliability in older patients with cardiovascular disease,11 aortic stenosis who underwent a transcatheter valve implantation (TAVI),12,13 atrial fibrillation14,15 as well as in older patients hospitalized for HF.16 The aim of the present study was to assess whether the MPI could be a reliable predictor of mortality in older subjects with HF, particularly in those HF patients with reduced LVEF. Materials and Methods