Integrated scales for basic therapy of chronic heart failure assessing: Impact at clinical outcomes in patients with acute decompensation
Abstract. Hospitalization with heart failure (HF) is a “window of opportunity” for therapy optimization. The prognostic value of modern basic therapy in real clinical practice for patients with acute decompensation of chronic HF (ADCHF) has not been sufficiently studied, and the methods for its integral assessment require validation.Nazarov I.S., Khutsishvili N.I., Kazakhmedov E.R., Galochkin S.A.
The aim: to evaluate the prognostic role of basic therapy for HF in patients who have experienced an episode of decompensation and to identify the optimal scale for its integral assessment.
Material and methods. A prospective single-center observational study from 01.11.2020 to 01.07.2023 included patients with ADCHF, regardless of the left ventricular ejection fraction (LVEF). Basic therapy for HF at discharge from the hospital was assessed using integral scales (Simple GDMT, OPS, QUAD, KCMO, and GDMT optimization score) and average dosage of quadruple therapy drugs. The period of observation was 1 year. The primary endpoint was all-cause death within 1 year, secondary endpoints were hospitalization with HF and combined outcome (all-cause death and/or hospitalization with HF) within 1 year, as well as outcomes during 180 days of observation.
Results. The study included 658 participants (57.6% male individuals), median age was 72 years, median LVEF was 44%, 46% of participants had HF with reduced LVEF. Overall mortality during the study was 24.3%, hospitalization with HF was 32.5%, and the combined outcome – 49.2%. Simple GDMT scale became the optimal tool for integrated estimation of basic HF therapy for predicting outcomes. After multivariate analysis, a score of 5–9 points on this scale was independently associated with a reduced risk of all-cause mortality (odds ratio 0.54; 95% confidence interval: 0.36–0.80; p = 0.002), and a score of 6–9 points was associated with a reduced risk of the combined outcome (odds ratio 0.74; 95% confidence interval: 0.57–0.96; p = 0.022). During subgroup analysis, no interaction of treatment effect with HF phenotype based on LVEF, level of N-terminal propeptide of natriuretic hormone (B-type), NYHA functional class of HF, or clinical and subclinical congestion at discharge from the hospital was found.
Conclusion. Using of more intensive basic therapy at discharge in patients with ADCHF is associated with improving of prognosis, and integrated assessment of therapy can help identify patients having high risk of adverse outcomes.
Keywords
heart failure
decompensated heart failure
optimal drug therapy for heart failure
References
1. Savarese G, Becher PM, Lund LH, Seferovic P, Rosano GMC, Coats AJS. Global burden of heart failure: A comprehensive and updated review of epidemiology. Cardiovasc Res. 2023;118(17):3272–87.
PMID: 35150240. https://doi.org/10.1093/cvr/cvac013
2. Поляков Д.С., Фомин И.В., Беленков Ю.Н., Мареев В.Ю., Агеев Ф.Т., Артемьева Е.Г. с соавт. Хроническая сердечная недостаточность в Российской Федерации: что изменилось за 20 лет наблюдения? Результаты исследования ЭПОХА-ХСН. Кардиология. 2021;61(4):4–14. (Polyakov DS, Fomin IV, Belenkov YuN, Mareev VYu, Ageev FT, Artemyeva EG et al. Chronic heart failure in the Russian Federation: What has changed over 20 years of follow-up? Results of the EPOCH-CHF study. Kardiologiia = Cardiology. 2021;61(4):4–14 (In Russ)).
EDN: WSZNFS. https://doi.org/10.18087/cardio.2021.4.n1628
3. Шляхто Е.В., Беленков Ю.Н., Бойцов С.А., Виллевальде С.В., Галявич А.С., Глезер М.Г. с соавт. Результаты промежуточного анализа проспективного наблюдательного многоцентрового регистрового исследования пациентов с хронической сердечной недостаточностью в Российской Федерации «ПРИОРИТЕТ-ХСН»: исходные характеристики и лечение первых включенных пациентов. Российский кардиологический журнал 2023;28(10):93–103. (Shlyakhto EV, Belenkov YuN, Boytsov SA, Villevalde SV, Galyavich AS, Glezer MG et al. Interim analysis of a prospective observational multicenter registry study of patients with chronic heart failure in the Russian Federation “PRIORITET-CHF”: Initial characteristics and treatment of the first included patients. Rossiyskiy kardiologicheskiy zhurnal = Russian Journal of Cardiology. 2023;28(10):93–103 (In Russ.)).
EDN: AMDHTV. https://doi.org/10.15829/1560-4071-2023-5593
4. Malgie J, Wilde MI, Brunner-La Rocca HP, Emans ME, De Boer GA, Siegers CEP et al. Newly diagnosed heart failure with reduced ejection fraction: Timing, sequencing, and titration of guideline-recommended medical therapy. Eur Heart J. 2025;46(25):2394–405.
PMID: 40272103. PMCID: PMC12208773. https://doi.org/10.1093/eurheartj/ehaf244
5. Shahid I, Khan MS, Butler J, Fonarow GC, Greene SJ. Initiation and sequencing of guideline-directed medical therapy for heart failure across the ejection fraction spectrum. Heart Fail Rev. 2025;30(3):515–23.
PMID: 39815071. https://doi.org/10.1007/s10741-025-10481-7
6. Виллевальде С.В., Соловьева А.Е. Декомпенсация сердечной недостаточности с низкой фракцией выброса: преодоление барьеров для улучшения прогноза в «уязвимый» период после выписки. Кардиология. 2021;61(12):82–93. (Villevalde SV, Soloveva AE. Decompensated heart failure with reduced ejection fraction: Overcoming barriers to improve prognosis in the “vulnerable” period after discharge. Kardiologiia = Cardiology. 2021;61(12):82–93 (In Russ.)).
EDN: MUTYWE. https://doi.org/10.18087/cardio.2021.12.n1860
7. Bhatt AS, Varshney AS, Nekoui M, Moscone A, Cunningham JW, Jering KS et al. Virtual optimization of guideline-directed medical therapy in hospitalized patients with heart failure with reduced ejection fraction: The IMPLEMENT-HF pilot study. Eur J Heart Fail. 2021;23(7):1191–201.
PMID: 33768599. https://doi.org/10.1002/ejhf.2163
8. Bhagat AA, Greene SJ, Vaduganathan M, Fonarow GC, Butler J. Initiation, continuation, switching, and withdrawal of heart failure medical therapies during hospitalization. JACC Heart failure. 2019;7(1):1–12.
PMID: 30414818. PMCID: PMC8053043. https://doi.org/10.1016/j.jchf.2018.06.011
9. Mebazaa A, Davison B, Chioncel O, Cohen-Solal A, Diaz R, Filippatos G et al. Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): A multinational, open-label, randomised, trial. Lancet. 2022;400(10367):1938–52.
PMID: 36356631. https://doi.org/10.1016/s0140-6736(22)02076-1
10. Pagnesi M, Metra M, Cohen-Solal A, Edwards C, Adamo M, Tomasoni D et al. Uptitrating treatment after heart failure hospitalization across the spectrum of left ventricular ejection fraction. J Am Coll Cardiol. 2023;81(22):2131–44.
PMID: 37257948. https://doi.org/10.1016/j.jacc.2023.03.426
11. Gąsecka A, Siniarski A. Addressing ‘residual congestion’ to improve prognosis after acute heart failure decompensation. Card Fail Rev. 2025;11:e06.
PMID: 40171551. PMCID: PMC11959577. https://doi.org/10.15420/cfr.2024.24
12. Biegus J, Cotter G, Metra M, Ponikowski P. Decongestion in acute heart failure: Is it time to change diuretic-centred paradigm? Eur J Heart Fail. 2024;26(10):2094–106.
PMID: 39169731. https://doi.org/10.1002/ejhf.3423
13. Сelutkiene J, Mebazaa A, Biegus J, Ponikowski P, Davison B, Cotter G. Counteracting the mechanisms of heart failure is the most effective way to decongest patients while improving outcomes. Card Fail Rev. 2025;11:e02.
PMID: 40018521. PMCID: PMC11865671. https://doi.org/10.15420/cfr.2024.19
14. Biegus J, Mebazaa A, Davison B, Cotter G, Edwards C, Celutkiene J et al. Effects of rapid uptitration of neurohormonal blockade on effective, sustainable decongestion and outcomes in STRONG-HF. J Am Coll Cardiol. 2024;84(4):323–36.
PMID: 39019527. https://doi.org/10.1016/j.jacc.2024.04.055
15. Badwan OZ, Braghieri L, Skoza W, Agrawal A, Menon V, Tang WHW. When should we consider SGLT-2 inhibitors in patients with acute decompensated heart failure? Cleve Clin J Med. 2024;91(1):47–51.
PMID: 38167393. https://doi.org/10.3949/ccjm.91a.23034
16 Berg DD, Samsky MD, Velazquez EJ, Duffy CI, Gurmu Y, Braunwald E et al. Efficacy and safety of sacubitril/valsartan in high-risk patients in the PIONEER-HF Trial. Circ Heart Fail. 2021;14(2):e007034.
PMID: 33530704. PMCID: PMC7908815. https://doi.org/10.1161/circheartfailure.120.007034
17. Pocock SJ, Ariti CA, McMurray JJ, Maggioni A, Kober L, Squire IB et al. Predicting survival in heart failure: A risk score based on 39 372 patients from 30 studies. Eur Heart J. 2013;34(19):1404–13.
PMID: 23095984. https://doi.org/10.1093/eurheartj/ehs337
18. Levy WC, Mozaffarian D, Linker DT, Sutradhar SC, Anker SD, Cropp AB et al. The Seattle Heart Failure Model: Prediction of survival in heart failure. Circulation. 2006;113(11):1424–33.
PMID: 16534009. https://doi.org/10.1161/circulationaha.105.584102
19. Komajda M, Cowie MR, Tavazzi L, Ponikowski P, Anker SD, Filippatos GS. Physicians’ guideline adherence is associated with better prognosis in outpatients with heart failure with reduced ejection fraction: the QUALIFY international registry. Eur J Heart Fail. 2017;19(11):1414–23.
PMID: 28463464. https://doi.org/10.1002/ejhf.887
20. Butt JH, Dewan P, DeFilippis EM, Biering-Sørensen T, Docherty KF, Jhund PS et al. Effects of dapagliflozin according to the Heart Failure Collaboratory Medical Therapy Score: Insights from DAPA-HF. JACC Heart Fail. 2022;10(8):543–55.
PMID: 35902157. https://doi.org/10.1016/j.jchf.2022.03.009
21. Abraham WT, Psotka MA, Fiuzat M, Filippatos G, Lindenfeld J, Mehran R et al. Standardized definitions for evaluation of heart failure therapies: Scientific Expert Panel from the Heart Failure Collaboratory and Academic Research Consortium. JACC Heart Fail. 2020;8(12):961–72.
PMID: 33199251. https://doi.org/10.1016/j.jchf.2020.10.002
22. Verma A, Fonarow GC, Hsu JJ, Jackevicius CA, Vaghaiwalla Mody F, Nguyen A et al. DASH-HF study: A pragmatic quality improvement randomized implementation trial for patients with heart failure with reduced ejection fraction. Circ Heart Fail. 2023;16(9):e010278.
PMID: 37494051. PMCID: PMC10524378. https://doi.org/10.1161/circheartfailure.122.010278
23. Matsukawa R, Okahara A, Tokutome M, Itonaga J, Koga E, Hara A et al. A scoring evaluation for the practical introduction of guideline-directed medical therapy in heart failure patients. ESC Heart Fail. 2023;10(6):3352–63.
PMID: 37671603. PMCID: PMC10682854. https://doi.org/10.1002/ehf2.14524
24. Matsukawa R, Kabu K, Koga E, Hara A, Kisanuki H, Sada M et al. Optimizing guideline-directed medical therapy during hospitalization improves prognosis in patients with worsening heart failure requiring readmissions. Circ J. 2024;88(9):1416–24.
PMID: 39034132. https://doi.org/10.1253/circj.CJ-24-0265
25. Steverson A, Calma J, Hsiao S, Sallam K, Varshney AS, Golbus JR et al. Validating the association between composite metrics of guideline-directed medical therapy and clinical outcomes for patients with heart failure with reduced ejection fraction. J Card Fail. 2025;31(3):588–91.
PMID: 39357668. https://doi.org/10.1016/j.cardfail.2024.08.054
26. Ahmad FS, Ahmad T, Allen LA. When the whole is the sum of its parts: Validation of the Heart Failure Collaboratory Medication Composite score in Denmark. Circ Heart Fail. 2023;16(2):e010309.
PMID: 36695188. PMCID: PMC9974734. https://doi.org/10.1161/circheartfailure.122.010309
27. Терещенко С.Н., Галявич А.С., Ускач Т.М., Агеев Ф.Т., Арутюнов Г.П., Беграмбекова Ю.Л. с соавт. Хроническая сердечная недостаточность. Клинические рекомендации 2020. Российский кардиологический журнал. 2020;25(11):311–374. (Tereshchenko SN, Galyavich AS, Uskach TM, Ageev FT, Arutyunov GP, Begrambekova YuL et al. 2020 Clinical practice guidelines for chronic heart failure. Rossiyskiy kardiologicheskiy zhurnal = Russian Journal of Cardiology. 2020;25(11):311–374 (In Russ.)).
EDN: LJGGQV. https://doi.org/10.15829/1560-4071-2020-4083
28. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38(4):577–91.
PMID: 22392031. https://doi.org/10.1007/s00134-012-2513-4
29. Beaubien-Souligny W, Rola P, Haycock K, Bouchard J, Lamarche Y, Spiegel R et al. Quantifying systemic congestion with Point-Of-Care ultrasound: Development of the venous excess ultrasound grading system. Ultrasound J. 2020;12(1):16.
PMID: 32270297. PMCID: PMC7142196. https://doi.org/10.1186/s13089-020-00163-w
30. Castera L, Forns X, Alberti A. Non-invasive evaluation of liver fibrosis using transient elastography. J Hepatol. 2008;48(5):835–47.
PMID: 18334275. https://doi.org/10.1016/j.jhep.2008.02.008
31. Savage HO, Dimarco AD, Li B, Langley S, Hardy-Wallace A, Barbagallo R et al. Sequencing of medical therapy in heart failure with a reduced ejection fraction. Heart. 2023;109(7):511–18.
PMID: 36368882. https://doi.org/10.1136/heartjnl-2022-321497
32. Khan MS, Chan PS, Sherrod CF, Ikemura N, Sauer AJ, Jones PG et al. Generalizable approach to quantifying guideline-directed medical therapy. Circ Heart Fail. 2024;17(5):e011164.
PMID: 38742418. PMCID: PMC11108743. https://doi.org/10.1161/circheartfailure.123.011164
33. Echeverria LE, Rojas LZ, Serrano-Garcia AY, Botero D, Garcia-Rueda KA, Torres-Bustamante A et al. Early prescription of quadruple therapy in acute decompensated heart failure with reduced ejection fraction: A propensity score-matched analysis. ESC Heart Fail. 2025;12(4):2814–26.
PMID: 40232857. PMCID: PMC12287833. https://doi.org/10.1002/ehf2.15286
34. Fiuzat M, Hamo CE, Butler J, Abraham WT, DeFilippis EM, Fonarow GC et al. Optimal background pharmacological therapy for heart failure patients in clinical trials: JACC review topic of the week. J Am Coll Cardiol. 2022;79(5):504–10.
PMID: 35115106. PMCID: PMC9180686. https://doi.org/10.1016/j.jacc.2021.11.033
35. D’Amario D, Rodolico D, Rosano GMC, Dahlstrom U, Crea F, Lund LH et al. Association between dosing and combination use of medications and outcomes in heart failure with reduced ejection fraction: Data from the Swedish Heart Failure Registry. Eur J Heart Fail. 2022;24(5):871–84.
PMID: 35257446. PMCID: PMC9315143. https://doi.org/10.1002/ejhf.2477
About the Authors
Ivan S. Nazarov, MD, junior researcher at the Institute of clinical medicine, RUDN University. Address: 117198, Moscow, 6 Mikloukho-Maklaya St.E-mail: nazarovradomla@mail.ru
ORCID: https://orcid.org/0000-0002-0950-7487. Scopus ID: 57686928900. SPIN: 5954-7828
Nutsiko I. Khutsishvili, MD, postgraduate student of the Department of internal medicine with the course of cardiology and functional diagnostics named after academician V.S. Moiseyev, RUDN University. Address: 117198, Moscow, 6 Mikloukho-Maklaya St.
E-mail: nutsiko.khutsishvili@gmail.com
ORCID: https://orcid.org/0009-0009-2669-8092. Scopus ID: 58558552800. SPIN: 3322-4387
Eldar R. Kazakhmedov, MD, PhD (Medicine), associate professor of the Department of internal medicine with the course of cardiology and functional diagnostics named after academician V.S. Moiseyev, RUDN University. Address: 117198, Moscow, 6 Mikloukho-Maklaya St.
E-mail: dr_kazakhmedov@mail.ru
ORCID: https://orcid.org/0000-0002-6274-8933. SPIN: 7879-8334
Svyatoslav A. Galochkin, MD, PhD (Medicine), associate professor of the Department of internal medicine with a course of cardiology and functional diagnostics named after academician V.S. Moiseyev, RUDN University. Address: 117198, Moscow, 6 Mikloukho-Maklaya St.
E-mail: galochkin_sa@pfur.ru
ORCID: https://orcid.org/0000-0001-7370-8606. Scopus ID: 57205649664. SPIN: 9396-6834
Similar Articles
