Overestimating Survival in High-Risk Heart Failure Linked to Higher 2-Year Mortality

In a cohort of high-risk ambulatory patients with heart failure (HF) and reduced ejection fraction, researchers found that 33% overestimated their life expectancy by more than 50% compared with validated model estimates.¹ This overestimation was associated with a nearly 2-fold increase in 2-year mortality, emphasizing the importance of accurate patient understanding for informed treatment decisions.

This prospective cohort study is published in JAMA Network Open.

“In this cohort study, discordant optimism regarding life expectancy compared with model estimates was common and associated with mortality that was not due to a lower probability of receiving a heart transplant or VAD [ventricular assist devices],” wrote the researchers of the study. “The findings suggest clinicians should objectively evaluate HF risk when considering advanced therapies, rather than relying primarily on patient-reported symptoms.”

This study analyzed data from the REVIVAL (NCT01369407) study, which included high-risk patients with HF and reduced ejection fraction who were living at home between 2015 and 2016. REVIVAL is a prospective, observational, multicenter study of ambulatory patients with advanced chronic systolic HF.² REVIVAL enrolled patients at 21 ventricular assist device centers using routine clinical information and high‑risk criteria to identify a cohort with about a 25% annual risk of death, urgent transplant, or durable mechanical circulatory support. The registry provides foundational data to inform risk assessment and future interventions in this patient population.

The researchers compared how long patients thought they would live with predictions from a validated risk model, creating an estimation index to see who over- or underestimated their survival.¹ They looked at patient characteristics linked to overestimation and examined whether overestimating life expectancy was associated with higher risk of death over the next 2 years.

The study included 296 high-risk, ambulatory patients with chronic HF, of whom 223 (75.3%) were male, with a mean (SD) age of 60.1 (11.5) years. The median (IQR) survival predicted by the Seattle Heart Failure Model was 8.2 (5.1, 12.1) years, while patients’ median estimated life expectancy was 7.0 (5.0, 10.0) years.

Overall, 98 patients (33.1%) were overly optimistic about their survival. Overestimation was linked to higher mortality: in adjusted analyses, patients with discordant optimism had nearly double the risk of dying within 2 years (adjusted hazard ratio 1.98; 95% CI, 1.04-3.77) compared with those with realistic or pessimistic estimates. The increased risk was not explained by differences in receiving a ventricular assist device or heart transplant.

However, the researchers noted some limitations. First, it relied on the Seattle Heart Failure Model to estimate survival, which can itself overestimate life expectancy, meaning patients’ optimism may have been even greater than reported. Participants were also enrolled at specialized heart failure centers and willing to share their estimates, which may not reflect all patients. Finally, the statistical approach could overestimate the effect of some factors, potentially affecting the observed associations.

Despite these limitations, the researchers believe the findings of this study highlight the importance of clear, objective discussions about prognosis, which can help patients make informed decisions about their care and guide clinicians in considering advanced therapies.

“Overoptimistic patient estimates of life expectancy compared with model estimates were associated with an increased risk of mortality over 2 years of follow-up compared with patients with more pessimistic life expectancy estimates,” wrote the researchers. “These findings suggest that clinicians should holistically and objectively evaluate HF risk when considering advanced therapies, rather than relying solely on patient-reported symptoms.”

References

1. Cascino TM, Herron G, Richards B, et al. Understanding of prognosis and estimation of mortality in ambulatory patients with heart failure. JAMA Netw Open. 2026;9(3):e260328. doi:10.1001/jamanetworkopen. 2026.0328

2. Aaronson KD, Stewart GC, Pagani FD, et al. Registry Evaluation of Vital Information for VADs in Ambulatory Life (REVIVAL): rationale, design, baseline characteristics, and inclusion criteria performance. J Heart Lung Transplant. 2020;39(1):7-15. doi:10.1016/j.healun.2019.09.008