![]() The study population consisted of 1732 patients with chronic HF (International Classification of Diseases, Ninth Revision codes: 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, and 428.1/2/3/4/9) admitted to six specialized inpatient CR units of a nationwide Research Institute in the field of Rehabilitation Medicine in Italy between January 2013 and December 2016, who had available data for NT-proBNP and 6MWT at admission to CR. This was a multicenter observational retrospective study. To test this hypothesis, we studied patients with chronic HF admitted to inpatient CR. The aim of the study was to determine the incremental prognostic value of functional limitation on the top of well-established prognostic factors, including N-terminal pro-brain natriuretic peptide (NT-proBNP), and to build a point-based risk score to predict 1-year mortality. We hypothesized that a measure of functional impairment, as assessed by six-minute walking test (6MWT), would improve the accuracy of a prognostic model incorporating a NP in HF. ![]() Risk assessment and stratification are key features of a CR program 10, 16. Data from large observational studies have shown an association between participation in CR and reduced risk of mortality 13, 14, 15. Meta-analyses of randomized clinical trials have shown that participation in CR is associated with reduced hospitalizations 12. ![]() The key outcomes of CR have evolved over time to include effects on morbidity and mortality 10, 11. However, the Authors acknowledged the lack of a measure of functional capacity was a limitation 8.Ĭardiac rehabilitation (CR) has been regarded as an evidence-based pillar of HF management 9. The recently published Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure trial (PARADIGM-HF) predictive model for patients with chronic HF with reduced EF included as many as 27 predictors 8. Nonetheless, the conjoint contribution of NPs and functional limitation to risk prediction has not been examined in any study aimed at developing a prognostic model for HF. The degree of functional limitation has also been demonstrated to be a powerful, though underappreciated, predictor of mortality 6, 7. Among these variables, NP are recognized as the most powerful predictors of short and long-term adverse outcomes in HF 5 as such, they are recommended by current guidelines for risk assessment 5. Age, sex, diabetes, New York Heart Association (NYHA) class, left ventricular ejection fraction (EF), systolic blood pressure (SBP), resting heart rate, natriuretic peptides (NP), creatinine, blood urea nitrogen, and sodium are the predictors most often incorporated in prognostic models 4. Many predictors of mortality have been identified in HF and used to develop prognostic models 4. Risk assessment is an integral part of the complex process of clinical decision-making in HF and, ideally, a crucial step to match the type and intensity of care with patient risk 3. Heart failure (HF) is an increasingly prevalent clinical syndrome burdened by high mortality and morbidity rates and characterized by impaired functional capacity and quality of life 1, 2. Our data suggest that a simple, 6MWT-derived measure of SFI is a strong predictor of death and provide incremental prognostic information over well-established risk markers in HF, including NP, and the MAGGIC score. Adding SFI to the baseline risk model or the MAGGIC score yielded a significant improvement in discrimination and risk classification. After adjusting for the baseline multivariable risk model-including age, sex, systolic blood pressure, anemia, renal dysfunction, sodium level, and NT-proBNP-or for the MAGGIC score, SFI had an odds ratio of 2.58 (95% CI 1.72–3.88 p < 0.001) and 3.12 (95% CI 2.16–4.52 p < 0.001), respectively. The primary outcome was 1-year all-cause mortality. ![]() We studied the prognostic value of severe functional impairment (SFI), defined as the inability to perform a 6MWT or a distance walked during a 6MWT < 300 m, in 1696 patients with HF admitted to cardiac rehabilitation. We hypothesized that a measure of functional limitation, as assessed by 6-min walking test (6MWT), would improve the accuracy of a prognostic model incorporating a NP. Natriuretic peptides (NP) are recognized as the most powerful predictors of adverse outcomes in heart failure (HF).
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