Serial measures of self-reported symptoms and health-related quality of life (HRQoL) are predictive of heart failure (HF) outcomes among different groups of patients, while also providing the potential for a patient-centered, cost-effective, and straightforward approach to risk stratification, according to new original research published in JACC: Asia as part of a special two-part focused series exploring racial disparities in cardiovascular disease. Other studies included in the series offer insights into additional disparities as they relate to TAVR, bleeding risk, diabetes, ICD implantation and more.

In the HF-related study, researchers led by Claire A. Lawson, PhD, and ASIAN-HF Investigators, et al., used data from the ASIAN-HF Registry to evaluate the relationship between changing symptoms, signs, HRQoL and outcomes by sex, ethnicity and socioeconomic status. Specifically, the team assessed associations between the six-month change in a “global” symptoms and signs score (GSSS), Kansas City Cardiomyopathy Questionnaire overall score (KCCQ-OS), and visual analogue scale (VAS) and one-year mortality or hospitalization due to HF in 6,549 patients.

“In this study of ethnically and socioeconomically diverse groups of HF patients enrolled prospectively from 10 countries, we report two new and key findings of clinical importance,” say Lawson and colleagues. “First, we found that, whereas baseline symptoms, signs, and overall self-reported HRQoL differed among population groups, they remained independent predictors of outcomes across groups. Importantly, in addition to the baseline symptoms, signs or health status, subsequent change in clinical status was a significant predictor of poor outcomes, independent of diverse clinical characteristics and across different patient groups. Second, by using a range of serial clinical status measures, we found that the HRQoL measures, including the simple single-item VAS, had a superior model fit to the global signs and symptoms score.”

What does this mean for practice? The study investigators say their findings “show that routine monitoring of patient-reported health allows for patient-centered risk stratification and may facilitate timely adjustments to management.” They suggest that health care providers consider routine recording of patient-reported information to support shared decision-making and care.

“These results shed light on an essential aspect of disease management: the patient’s perspective,” write Antonio Cannata, MD, and Gianluigi Savarese, MD, PhD, in a related editorial comment. “Although doctors and patients aim to improve prognosis, the doctor’s perspective seldom goes beyond the assessment and management of signs and symptoms. Often, functional limitations, mental health, and a significant discrepancy between expected and perceived functional capacities significantly affect the patient’s QoL and require proper assessment.”

Also in the issue:

• A State of the Art Review from Arwa Younis, MD, and Bruce L. Wilkoff, MD, FACC, explores the pros and cons of early ICD implantation for primary prevention in patients living in Asia, especially in countries with limited resources and high-risk of non-sudden cardiac death (SCD). Younis and Wilkoff highlight the challenges of ICD treatment for primary prevention in a region where there is low risk of SCD, compared with the U.S. and Europe, while also noting the “enormous gap” in ICD use among eligible patients (∼12% in Asia vs. ∼45% in the U.S./Europe). “The disparity between Asia and Western countries, together with significant variation among the Asian population and the previously mentioned challenges, requires an individualized approach and specific regional recommendation, especially in countries with limited resources where ICDs are being extremely underutilized,” they write.

• Another original research study from Jinho Lee, MD, Min-Ju Kim, Msc, and Mijin Kim, MD, et al., used data from the TICAKOREA trial to validate the clinical applicability of the Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria in East-Asian patients receiving different potencies of antiplatelet therapy (ticagrelor or clopidogrel) for acute coronary syndromes (ACS). Key findings showed approximately 15% of patients met the ARC-HBR definition. Additionally, the rate of the primary bleeding endpoint of BARC 3 or 5 bleeding at one year was significantly higher in HBR patients than in non-HBR patients. Significantly higher rates of the ischemic endpoints of major adverse cardiovascular events, all-cause mortality, spontaneous myocardial infarction, repeat revascularization and stent thrombosis were also observed in HBR patients. The researchers add that “the prognostic value of the ARC-HBR definition on the relative effect of ticagrelor or clopidogrel on bleeding and ischemic events was unexpectedly not discriminative.”
  
  Looking ahead, while the ARC-HBR criteria were predictive of bleeding and ischemic events, Lee, et al., say “additional studies are needed to understand the interplay between bleeding and thrombotic risks associated with different antithrombotic strategies.” In a related editorial comment, Shinya Suzuki, MD, writes: “Even if patients with ACS can be stratified into HBR and non-HBR, several points should be considered to further reduce the risk of bleeding. From the clinical perspective, whether or not the non-HBR truly reflects a low bleeding risk is important.”
  
  

• The race-specific impact of the STS conventional surgical risk score on one-year mortality following TAVR was the focus of original research from Hoyun Kim, MD, and Do-Yoo Kang, MD. The study, which used data from a multinational multicenter registry, found the relative proportion of the STS risk category was substantially different between Asian and non-Asian groups. “Importantly, there was a differential prognostic effect of STS score on one-year mortality between Asian and non-Asian patients,” they write.
  
  Kim and Kang suggest that further research is needed to develop new race-based risk prediction and stratification tools for selecting appropriate candidates for TAVR and for predicting outcomes. In a related editorial comment, Yosuke Kobari, MD, PhD, and Kentaro Hayashida, MD, PhD, FACC, echo the need for additional studies, possibly including “randomized controlled trials, whose baseline characteristics are equal are warranted to make a robust conclusion regarding this racial difference.” However, they note that Kim and Kang “should be congratulated for clarifying the racial differences in the characteristics, procedural outcomes, and prognosis of TAVR patients in real-world data for the first time.”

• In another original research study, researchers led by Nilay S. Shah, MD, MPH, and Sadiya S. Khan, MD, MSc, FACC, found disparities in diabetes-related cardiovascular and all-cause mortality across Asian American subgroups, particularly Filipino and Asian Indian groups. As a whole, Asian Americans experience a disproportionate burden of diabetes-related mortality compared with other patient populations. However, according to Shah, Khan and colleagues, these new findings underscore the need to go a step further and understand “the clinical, social, and structural causes of differences in diabetes-related mortality among Asian American subgroups, including differences in quality of care, social factors such as the influence of cultural norms on health behaviors, and potential role of discrimination and structural racism experienced by Asian American individuals in the United States.”
  
  In a related editorial comment from Sandra Echeverria, PhD, MPH, and Md Towfiqul Alam, MPH, they write that this study has “paved the way for future studies to build on this evidence and consider how diabetes risk patterns change over time for Asian Americans. The study is also one of the first to show substantial variability in diabetes-related mortality among subgroups of Asian Americans.” They go on to add that the findings “call our attention to the importance of broader social, cultural, and clinical contexts for interpreting results and considering prevention efforts.”

Part two of the issue, published June 20, includes a state-of-the-art review looking at the 10 year findings of the SYNTAX trial, and studies looking at topics ranging from calcium-channel blockers vs. beta-blockers after acute myocardial infraction, examine the impact of serum GDF-15 on clinical outcomes in patients with ischemic heart disease, and more. Find all the studies included in part two of the special issue in JACC: Asia here.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure

Keywords: Socioeconomic Factors, Heart Failure, Transcatheter Aortic Valve Replacement, Cardiovascular Diseases, Quality of Life, ACC International

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