Prognostic Significance of the PROFUND Index on One Year Mortality in Acute Heart Failure: Results from the RICA Registry.

Background: Heart failure (HF) is a syndrome with high prevalence, mainly affecting elderly patients, where the presence of associated comorbidities is of great importance. Methods: An observational study from a prospective registry was conducted. Patients identified from the National Registry of Heart Failure (RICA), which belongs to the Working Group on Heart Failure and Atrial Fibrillation of the Spanish Society of Internal Medicine (SEMI), were included. The latter is a prospective, multicenter registry that has been active since 2008. It includes individual consecutive patients over 50 years of age with a diagnosis of HF at hospital discharge (acute decompensated or new-onset HF). Results: In total, 5424 patients were identified from the registry. Forty-seven percent were men and mean left ventricular ejection fraction (LVEF) was 51.4%; 1132 had a score of 0 to 2 according to the PROFUND index, 3087 had a score of 3 to 6, and 952 patients had a score of 7 to 10 points. In the sample, 252 patients had a score above 11 points. At the end of the year of follow-up, 61% of the patients died. This mortality increased proportionally as the PROFUND index increased, specifically 75% for patients with PROFUND greater than 11. The Kaplan-Meier survival curve shows that survival at one year progressively decreases as the PROFUND index value increases. Thus, subjects with scores greater than seven (intermediate-high and high-risk) presented the worst survival with a log rank of 0.96 and a p < 0.05. In the regression analysis, we found a higher risk of death from any cause at one year in the group with the highest risk according to the PROFUND index (score greater than 11 points (HR 1.838 (1.410−2.396)). Conclusions: The PROFUND index is a good index for predicting mortality in patients admitted for acute HF, especially in those subjects at intermediate to high risk with scores above seven. Future studies should seek to determine whether the PROFUND index score is simply a prognostic marker or whether it can also be used to make therapeutic decisions for those subjects with very high short-term mortality.

Prognostic Value of the PROFUND Index for 30-Day Mortality in Acute Heart Failure.

Background and Objectives: The prevalence and incidence of heart failure (HF) have been increasing in recent years as the population ages. These patients show a distinct profile of comorbidity, which makes their care more complex. In recent years, the PROFUND index, a specific tool for estimating the mortality rate at one year in pluripathology patients, has been developed. The aim of this study was to evaluate the prognostic value of the PROFUND index and of in-hospital and 30-day mortality after discharge of patients admitted for acute heart failure (AHF). Materials and Methods: A prospective multicenter longitudinal study was performed that included patients admitted with AHF and ≥2 comorbid conditions. Clinical, analytical, and prognostic variables were collected. The PROFUND index was collected in all patients and rates of in-hospital and 30-day mortality after discharge were analyzed. A bivariate analysis was performed with quantitative variables between patients who died and those who survived at the 30-day follow-up. A logistic regression analysis was performed with the variables that obtained statistical significance in the bivariate analysis between deceased and surviving subjects. Results: A total of 128 patients were included. Mean age was 80.5 +/- 9.98 years, and women represented 51.6%. The mean PROFUND index was 5.26 +/- 4.5. The mortality rate was 8.6% in-hospital and 20.3% at 30 days. Preserved left ventricular ejection fraction was found in 60.9%. In the sample studied, there were patients with a PROFUND score < 7 predominated (89 patients (70%) versus 39 patients (31%) with a PROFUND score ≥ 7). Thirteen patients (15%) with a PROFUND score < 7 died versus the 13 (33%) with a PROFUND score ≥ 7, p = 0.03. Twelve patients (15%) with a PROFUND score < 7 required readmission versus 12 patients (35%) with a PROFUND score ≥ 7, p = 0.02. The ROC curve of the PROFUND index for in-hospital mortality and 30-day follow-up in patients with AHF showed AUC 0.63, CI: 95% (0.508-0.764), p <0.033. Conclusions: The PROFUND index is a clinical tool that may be useful for predicting short-term mortality in elderly patients with AHF. Further studies with larger simple sizes are required to validate these results.

La pluripatologia en una Unidad de Insuficiencia Cardíaca: la perspectiva de un internista / Pluripathology in a Heart Failure Unit - a internist’ perspective

Objetivo: Determinar la frecuencia de pluripatología en una Unidad de Insuficiencia Cardíaca, definir las características de los pacientes pluripatológicos y su pronóstico vital según dos modelos: el índice PROFUND y el Seattle Heart Failure Model. Material y métodos: Se han analizado de forma consecutiva los pacientes observados en la consulta de insuficiencia cardíaca de un hospital de tercer nivel durante dos meses. Se han registrado comorbilidades, categorías de pluripatología y los índices de Charlson, Barthel, Seattle Heart Failure Model y PROFUND. Resultados: Se incluyeron 246 pacientes, de los que 118 (48%) fueron pluripatológicos, con índice de Charlson 7,9±3,8 y PROFUND 3,5±7,1.La categoría de pluripatología más prevalente fue la A, seguida de la B yC. Los pluripatológicos fueron mayores (77 vs. 73 años, p=0,001), más frágiles, con mayor limitación funcional (Barthel: 84,7 vs. 96,1, p<0,001),mayor prevalencia de factores de riesgo cardiovascular y enfermedades crónicas e ingresaron más (14,4 vs. 4,7, p=0,015). La etiología más frecuente fue la cardiopatía isquémica. Los pacientes pluripatológicos tenían clase funcional más avanzada NHYA III-IV (4,2 vs. 0,8, p<0,001), NT-proBNP más elevados (2985 pg/ml vs. 1780 pg/ml, p=0,013) y precisaron mayor dosis de diuréticos (60 vs 40, p<0,001). Se verificó una concordancia en la estimativa de mortalidad entre el PROFUND y el Seattle Heart Failure Model. Conclusiones: Este estudio demuestra la elevada frecuencia de pacientes pluripatológicos en una unidad de insuficiencia cardíaca, reflejando una mayor sobrecarga asistencial y necesidad de cuidados más complejos. Se trata de una población con gran fragilidad, dependencia funcional y comorbilidad, que obliga a plantear un abordaje multidisciplinar. (AU)

Objectives: to determine the frequency of pluripathology in a Heart Failure Unit, defining the characteristics of pluripathological patients and their vital prognosis according to two models: PROFUND score and Seattle Heart Failure Model. Methods: consecutive patients from a Heart Failure Unit of a third level hospital were analized during two months. Comorbidities, pluripathology categories and Charlson, Barthel, Seattle Heart Failure Model and PROFUND scores were registered. Results: 246 patients were included, of which 118 (48%) were pluripathological, with Charlson score 7.9 ± 3.8 and PROFUND 3.5 ± 7.1.The most prevalent category of pluripathology was A, followed by B and C. The pluripathological patients were older (77 vs. 73 years, p = 0.001),more fragile, with greater functional limitation (Barthel: 84.7 vs. 96, 1,p <0.001), higher prevalence of cardiovascular risk factors and chronic diseases and admitted more (14.4 vs. 4.7, p = 0.015). The most frequent etiology was ischemic heart disease. The pluripathological patients hadmore advanced functional class NHYA III-IV (4.2 vs. 0.8, p <0.001), higherNT-proBNP (2985 pg/ml vs. 1780 pg/ml, p = 0.013) and required higherdose of diuretics (60 vs 40, p <0.001). A concordance in the mortality estimate between the PROFUND and the Seattle Heart Failure Model wasverified. Conclusion: Our study demonstrates the high frequency of pluripathological patients in a heart failure unit, population with great fragility, due to functional dependence and the association of comorbidities, that requires a multidisciplinary approach. (AU)

Índice PROFUND y valoración global subjetiva. Valor pronóstico en pacientes pluripatológicos internados / PROFUND index and global subjective assessment. Prognostic value in hospitalized pluripathological patients

Resumen El índice PROFUND es una de las puntuaciones pronósticas sugeridas en pacientes pluripatológicos (PP). A pesar del valor pronóstico de la desnutrición y su prevalencia en esta población, el mismo no incluye una variable que estime el estado nutricional. La valoración global subjetiva (VGS) es una herramienta ampliamente validada para tal fin. Se evaluó mediante un estudio prospectivo y observacional, la capacidad pronóstica de mortalidad a 12 meses del índice PROFUND y VGS en PP internados en clínica médica. Ingresaron al estudio 111 pacientes. Edad 75.8 (± 9.3) años. Índice PROFUND 7.6 (± 4.7) puntos. El 60.1% presentaba desnutrición moderada-severa por VGS. Fallecieron 66 dentro del año. En el modelo de Cox, la VGS y el índice PROFUND se asocian con mortalidad a los 12 meses (p < 0.0001 y p 0.0026 respectivamente). En los desnutridos severos, el riesgo es aproximadamente 6 veces mayor en comparación a los normonutridos (HR: 6.514, IC95% 2.826-15.016) y para un mismo nivel de VGS, el riesgo es un 10% mayor por cada punto que aumenta el índice PROFUND (HR: 1.106, IC95% 1.036-1.181). El AUC para predecir mortalidad a 12 meses del índice PROFUND y VGS fue: 0.747 (IC95%: 0.656-0.838); 0.733 (IC95%: 0.651-0.816) y al combinar las dos variables: 0.788 (IC95%: 0.703-0.872, p 0.048). Como conclusión el índice PROFUND y la VGS se asocian con mortalidad y tienen un valor pronóstico similar. La combinación de ambas herramientas permitiría establecer mejor el pronóstico y el manejo en esta compleja población

Abstract The PROFUND index is one of the suggested prognostic scores in pluripathological patients (PP). Despite the prognostic value of malnutrition and its prevalence in this population, it does not include a variable that estimates nutritional status. Subjective global assessment (SGA) is a widely validated tool for this purpose. The prognostic capacity of 12-month mortality of PROFUND index and SGA in PP admitted to a medical clinic was evaluated by a prospective and observational study. 111 patients entered the study. Age 75.8 (± 9.3) years. PROFUND index 7.6 (± 4.7) points. 60.1% had moderate-severe malnutrition due to VGS. 66 died within the year. In the Cox model, SGA and PROFUND index are associated with mortality at 12 months (p <0.0001 and p 0.0026 respectively). In severe malnutrition, the risk is approximately 6 times higher compared to normonutrition (HR: 6.514, 95% CI 2.826-15.016) and for the same level of SGA, the risk is 10% higher for each point that the PROFUND index increases (HR: 1.106, 95% CI 1.036-1.181). The AUC for predicting 12-month mortality from PROFUND index and SGA was: 0.747 (95% CI: 0.656-0.838); 0.733 (95% CI: 0.651-0.816) and when combining the two variables: 0.788 (95% CI: 0.703-0.872, p 0.048). In conclusion, PROFUND index and SGA are associated with mortality and have a similar prognostic value. The combination of both tools would allow better prognosis and management in this complex population.

[PROFUND index and global subjective assessment. Prognostic value in hospitalized pluripathological patients]. / índice PROFUND y valoración global subjetiva. Valor pronóstico en pacientes pluripatológicos internados.

The PROFUND index is one of the suggested prognostic scores in pluripathological patients (PP). Despite the prognostic value of malnutrition and its prevalence in this population, it does not include a variable that estimates nutritional status. Subjective global assessment (SGA) is a widely validated tool for this purpose. The prognostic capacity of 12-month mortality of PROFUND index and SGA in PP admitted to a medical clinic was evaluated by a prospective and observational study. 111 patients entered the study. Age 75.8 (± 9.3) years. PROFUND index 7.6 (± 4.7) points. 60.1% had moderate-severe malnutrition due to VGS. 66 died within the year. In the Cox model, SGA and PROFUND index are associated with mortality at 12 months (p < 0.0001 and p 0.0026 respectively). In severe malnutrition, the risk is approximately 6 times higher compared to normonutrition (HR: 6.514, 95% CI 2.826-15.016) and for the same level of SGA, the risk is 10% higher for each point that the PROFUND index increases (HR: 1.106, 95% CI 1.036-1.181). The AUC for predicting 12-month mortality from PROFUND index and SGA was: 0.747 (95% CI: 0.656-0.838); 0.733 (95% CI: 0.651-0.816) and when combining the two variables: 0.788 (95% CI: 0.703-0.872, p 0.048). In conclusion, PROFUND index and SGA are associated with mortality and have a similar prognostic value. The combination of both tools would allow better prognosis and management in this complex population.

El índice PROFUND es una de las puntuaciones pronósticas sugeridas en pacientes pluripatológicos (PP). A pesar del valor pronóstico de la desnutrición y su prevalencia en esta población, el mismo no incluye una variable que estime el estado nutricional. La valoración global subjetiva (VGS) es una herramienta ampliamente validada para tal fin. Se evaluó mediante un estudio prospectivo y observacional, la capacidad pronóstica de mortalidad a 12 meses del índice PROFUND y VGS en PP internados en clínica médica. Ingresaron al estudio 111 pacientes. Edad 75.8 (± 9.3) años. índice PROFUND 7.6 (± 4.7) puntos. El 60.1% presentaba desnutrición moderada-severa por VGS. Fallecieron 66 dentro del año. En el modelo de Cox, la VGS y el índice PROFUND se asocian con mortalidad a los 12 meses (p < 0.0001 y p 0.0026 respectivamente). En los desnutridos severos, el riesgo es aproximadamente 6 veces mayor en comparación a los normonutridos (HR: 6.514, IC95% 2.826-15.016) y para un mismo nivel de VGS, el riesgo es un 10% mayor por cada punto que aumenta el índice PROFUND (HR: 1.106, IC95% 1.036-1.181). El AUC para predecir mortalidad a 12 meses del índice PROFUND y VGS fue: 0.747 (IC95%: 0.656-0.838); 0.733 (IC95%: 0.651-0.816) y al combinar las dos variables: 0.788 (IC95%: 0.703-0.872, p 0.048). Como conclusión el índice PROFUND y la VGS se asocian con mortalidad y tienen un valor pronóstico similar. La combinación de ambas herramientas permitiría establecer mejor el pronóstico y el manejo en esta compleja población.

Death risk stratification in elderly patients with covid-19. A comparative cohort study in nursing homes outbreaks.

Elderly people are more severely affected by COVID-19. Nevertheless scarce information about specific prognostic scores for this population is available. The main objective was to compare the accuracy of recently developed COVID-19 prognostic scores to that of CURB-65, Charlson and PROFUND indices in a cohort of 272 elderly patients from four nursing homes, affected by COVID-19. Accuracy was measured by calibration (calibration curves and Hosmer-Lemeshov (H-L) test), and discriminative power (area under the receiver operation curve (AUC-ROC). Negative and positive predictive values (NPV and PPV) were also obtained. Overall mortality rate was 22.4 %. Only ACP and Shi et al. out of 10 specific COVID-19 indices could be assessed. All indices but CURB-65 showed a good calibration by H-L test, whilst PROFUND, ACP and CURB-65 showed best results in calibration curves. Only CURB-65 (AUC-ROC = 0.81 [0.75-0.87])) and PROFUND (AUC-ROC = 0.67 [0.6-0.75])) showed good discrimination power. The highest NPV was obtained by CURB-65 (95 % [90-98%]), PROFUND (93 % [77-98%]), and their combination (100 % [82-100%]); whereas CURB-65 (74 % [51-88%]), and its combination with PROFUND (80 % [50-94%]) showed highest PPV. PROFUND and CURB-65 indices showed the highest accuracy in predicting death-risk of elderly patients affected by COVID-19, whereas Charlson and recent developed COVID-19 specific tools lacked it, or were not available to assess. A comprehensive clinical stratification on two-level basis (basal death risk due to chronic conditions by PROFUND index, plus current death risk due to COVID-19 by CURB-65), could be an appropriate approach.

Prevalence of comorbidities and the prognostic value of the PROFUND index in a hospital cardiology unit. / Prevalencia de pluripatología y valor pronóstico del índice PROFUND en una unidad de hospitalización de Cardiología.

INTRODUCTION: The aim of this study was to understand the prevalence of comorbidities and the usefulness of the PROFUND index for the prognostic stratification of patients with comorbidities in a hospital cardiology unit. PATIENTS AND METHODS: We consecutively analysed all patients hospitalized in 2012 in the department of cardiology. We recorded the comorbidities, length of stay, hospital mortality, Charlson indices and PROFUND indices. In the patients with comorbidities, we also recorded the readmissions and mortality during a 1-year follow-up. RESULTS: The study included 1,033 patients (mean age, 67±13.1 years; 35% women), 381 (36.9%) of whom had comorbidities, with a mean Charlson index of 6.4±1.7 and a mean PROFUND index of 2.5±2.5. Compared with the other patients, the patients with comorbidities were older (72 vs. 64 years, p<.001), had a higher mortality rate (2.9% vs. 1.1%, p=.046) and longer hospital stays (8±5.5 vs. 6±5.7 days, p<.001) and were more often admitted for heart failure (42.3% vs. 15.8%, p<.001). The PROFUND index was independently associated with overall mortality (hazard ratio [HR], 1.13; 95% CI: 1.01-1.27; p=.034) and with the presence of major adverse events during the 12-month follow-up (HR, 1.09; 95% CI: 1.01-1.18; p=.026). CONCLUSIONS: A high percentage of patients hospitalized in the department of cardiology had comorbidities. These patients had a higher prevalence of cardiovascular risk factors, longer stays and greater hospital mortality. The PROFUND index independently predicted mortality and adverse events during the follow-up.

Validation of PROFUND prognostic index over a four-year follow-up period.

BACKGROUND/OBJECTIVES: The PROFUND index stratifies accurately the 12-month mortality risk of polypathological patients (PPs), but its fitness over a longer follow-up period remains unknown. We aimed to explore the calibration and discrimination power of PROFUND index over 4-years, in order to assess its follow-up interval generalizability. DESIGN: Multicenter prospective cohort-study. SETTING: 33 Spanish hospitals. PARTICIPANTS: PPs included after hospital discharge, outpatient clinics, or home hospitalization. MEASUREMENTS: Mortality over a 4-year follow-up period. METHODS: PROFUND index calibration was assessed by risk-quartiles predicted/observed mortality (Hosmer-Lemeshow goodness-of-fit test), and its discrimination power by ROC curves. RESULTS: A total of 768 patients were included (630 [82%] of them completed the 4-year follow-up). Global mortality rate was 63.5%. When assessing individual patient scores, mortality was 52% in the lowest risk group (0-2 points in PROFUND score); 73.5% in the low-intermediate risk group (3-6 points), 85% in the intermediate-high group (7-10 points); and 92% in the highest risk group (≥11 points). Accuracy testing of the PROFUND index showed good calibration (P=.8 in the Hosmer-Lemeshow goodness-of-fit test), and also a good discrimination power (AUC=0.71 [0.67-0.77] in ROC curve). CONCLUSIONS: The PROFUND index maintained its accuracy in predicting mortality of polypathological patients over a 4-year follow-up period. This index may be of potential usefulness in deciding the most appropriate health-care interventions in populations with multimorbidity.