After a 12-month follow-up of patients in the CHAMP-HF registry, Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OS) was shown to be more prognostically accurate compared with New York Heart Association functional class.
For patients with heart failure with reduced ejection fraction (HFrEF), patient-reported outcomes (PROs) data via the Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OS; the study’s PRO measure) may be more accurate at predicting disease outcomes vs New York Heart Association (NYHA) functional class (the study’s clinician-reported outcomes), reported JAMA Cardiology.
This cohort study also showed that this discordance in results between the evaluation methods was more apparent for women, patients with lower income, and persons with comorbid chronic obstructive pulmonary disease (COPD).
“The COPD finding would be expected if clinicians attempted to exclude shortness of breath due to COPD from heart failure while patients did not,” noted an accompanying editorial. “However, the sex and income differences suggest there may be differences in medical history taking for these patient groups that deserve further study.”
With scarce real-world data on how NYHA functional class compares with KCCQ-OS—with the authors noting that NYHA class can be limited by clinician variation in gathering information and that PROs have evolved substantially—the authors gathered a patient cohort of 2872 US outpatients with HFrEF enrolled in the CHAMP-HF registry between December 2015 and October 2017. They then compared 12-month changes in KCCQ-OS and NYHA functional class. The median (interquartile range [IQR]) patient age was 68 (IQR, 59-75) years, 75.1% were White, and the median ejection fraction was 30.0% (IQR, 23.0%-35.0%).
“The CHAMP-HF registry represents a novel opportunity to compare the role and clinical value of NYHA class and PROs in contemporary US clinical practice,” the authors noted.
Overall, at baseline, most patients (59.5%) had NYHA class II disease; just 1.6% had class IV disease. In addition, on a 0-100 scale (KCCQ-OS, 0-24, worst health status; 75-100, best health status), 39.4% scored between 75 and 100; 33.7%, 50 to 74; 21.3%, 25 to 49; and 5.6%, 0 to 24.
Close to 35.0% of patients overall had a change in NYHA class, with there being a worsening in 14.0% and an improvement in 20.9%. The majority (65.1%), however, had no change.
KCCQ-OS also changed in 75.1% by at least 5 points, with 48.3% bettering their score and 26.8% seeing their score drop. The most common KCCQ-OS change was a 10-point improvement in 36.5%.
Discordance between KCCQ-OS and NYHA class was mild at baseline, for most: there was a 1-level difference in 52.0% and a 2- to 3-level difference in 10.2% (moderate to severe discordance). Close to 38.0% had concordance. In addition, for any discordance noted, 68.4% of the patients had a worse NYHA class vs the 31.6% who had a worse KCCQ-OS. The patients with a worse NYHA class were typically older, too, while those with a worse KCCQ-OS tended to have a higher body mass index, COPD, coronary artery disease, and be of Hispanic ethnicity.
Of particular note, no change in NYHA class was seen despite KCCQ-OS worsening or improving by 10 points. And following unadjusted and adjusted analyses, NYHA class improvement did not positively correlate with improvements in all-cause death, HF hospitalization, or a composite measure of death and hospitalization. In contrast, a 5-points-or-more KCCQ-OS improvement was associated with a 41.0% decrease in all-cause mortality (HR, 0.59; 95% CI, 0.44-0.80; P < .001) and a 27.0% drop in all-cause death or HF hospitalization (HR, 0.73; 95% CI, 0.59-0.89; P = .002).
The authors attributed the differences seen to NYHA classes being disproportionately worse than KCCQ-OS and note that their findings “suggest relative advantages of measuring health status via serial KCCQ assessments, as compared with NYHA class, in the longitudinal care of patients with HFrEF.” Meanwhile, the accompany editorial notes the potential of PRO data to improve patient outcomes, especially because of their inclusion in the new American College of Cardiology and the American Heart Association quality measures.
“Findings of this cohort study suggest that, in contemporary US clinical practice, compared with NYHA class, KCCQ-OS is more sensitive to clinically meaningful changes in health status over time,” the authors concluded. “Changes in KCCQ-OS may have more prognostic value than changes in NYHA class.”
Greene SJ, Butler J, Spertus JA, et al. Comparison of New York Heart Association class and patient-reported outcomes for heart failure with reduced ejection fraction. JAMA Cardiol. Published online March 24, 2021. doi:10.1001/jamacardio.2021.0372