Comparing New York Heart Association Class and Patient-Reported Outcomes Among Patients Hospitalized for Heart Failure

Abstract

Background: Alignment between clinician-reported New York Heart Association (NYHA) class compared and patient-reported outcomes among patients hospitalized for heart failure is unclear. Methods: ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) was a global randomized trial comparing nesiritide versus placebo among patients hospitalized for heart failure, irrespective of ejection fraction. Among patients with complete baseline data for NYHA class and the patient-reported EuroQOL-5 dimensions ([EQ-5D], both utility index and visual analog scale), levels of each scale were mapped across 4 prespecified categories "best"to "worst."Minor and moderate-severe discordance were defined as NYHA class and EQ-5D differing by 1 level and ≥2 levels, respectively. Multivariable models assessed factors independently associated with moderate-severe discordance, and associations between discordance and clinical outcomes. Results: Among 5741 patients, concordance, minor discordance, and moderate-severe discordance between NYHA class and EQ-5D utility index occurred in 22%, 40%, and 38% of patients, respectively. For NYHA class and EQ-5D visual analog scale, this categorization occurred in 29%, 48%, and 23%. Discordance was more often due to disproportionately higher EQ-5D score (78% of discordance cases with utility index, and 70% with visual analog scale). NYHA class IV, higher EQ-5D scores, race, and geographic region were among patient factors independently associated with moderate-severe discordance. Magnitude of discordance was not associated with clinical outcomes; however, EQ-5D utility index disproportionately worse than NYHA class was associated with increased 180-day mortality (adjusted hazard ratio 1.27 [95% CI, 1.01-1.60]; P=0.04). Conclusions: In a global trial cohort of patients hospitalized for heart failure, the majority of patients exhibited discordance between clinician-reported NYHA class and patient-reported health status. Multiple patient factors were independently associated with moderate-severe discordance, and patients who perceived their health status as worse than the clinician's perception had higher mortality.