Kearney et al identified risk factors that can be used to identify patients with mild or moderate chronic heart failure who are likely to have progressive disease. This can help identify those patients who may require more aggressive management. The authors are from multiple university hospitals in England, Scotland and the United States.

Patient selection:

(1) NYHA functional classes I (2%), II (59%), III (39%)

(2) age 18 to 85 years with mean age 62.7 (+/- 9.7)

(3) ejection fraction < 45%, cardiothoracic ratio > 0.55 or pulmonary edema on chest X-ray

(4) Most patients were treated with ACE inhibitors and loop diuretics.


Risk factors:

(1) low standard deviation of all normal-to-normal RR intervals (SDNN), measured as described in Nolan (1998) and Task Force (1996), below median of 112 ms

(2) low serum sodium (below median of 140 mmol/L)

(3) increased serum creatinine (above median of 111 µmol/L)


Risk Factor Hazard Ratio 95% CI p value
SDDN 10% decrease 1.06 1.01 – 1.12 0.012
sodium 2 mmol/L decrease 1.22 1.08 – 1.38 < 0.001
creatinine 10 µmol/L increase 1.14 1.09 – 1.19 0.001


The presence of one or more of these risk factors in a patient with heart failure indicates a patient at increased risk of progressive disease.



(1) I could not find a risk score showing a change in risk as the number of risk factors increased. Since the risk factors are independent I assume that the risk is additive.

(2) The number of NYHA class I is small while number of class III is significant.

(3) Transportability of score might require some slight modification of cut-off values. Sodium and creatinine tend to show good agreement between methods, although this would need to be checked.

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