B-type natriuretic peptide (BNP), peak oxygen consumption (VO(2)), blood urea nitrogen (BUN), systolic blood pressure (SBP), and pulmonary capillary wedge pressure are all established predictors of mortality or urgent transplantation in patients with advanced heart failure (HF). However, their comparative predictive ability in estimating prognosis has not been well studied. We analyzed 1,215 patients with advanced systolic HF referred to a university center from 1999 to 2009. BUN, BNP, VO(2), SBP, and pulmonary capillary wedge pressure were measured as a part of the initial evaluation. The patients were divided into groups according to the best cutoffs for predicting both 1- and 2-year mortality from the analysis of the receiver operating characteristic curves (BNP > or =579 pg/ml, peak VO(2) <14 ml/kg/min, BUN > or =53 mg/dl, SBP <118 mm Hg, and pulmonary capillary wedge pressure > or =21 mm Hg). During a 2-year follow-up, 234 patients (19%) died, and 208 (17%) required urgent transplantation. BNP (odds ratio 4.3, 95% confidence interval 3.3 to 5.5) and peak VO(2) (odds ratio 4.5, 95% confidence interval 2.6 to 7.8) were the strongest predictors for death or urgent transplantation. On multivariate analyses, BNP and peak VO(2) were the strongest predictors for both death or urgent transplantation and all-cause mortality. The c-statistic was 0.756 for BNP, 0.701 for VO(2), 0.659 for BUN, 0.638 for SBP, and 0.650 for pulmonary capillary wedge pressure. In conclusion, of the 5 established predictors of outcomes in advanced HF, BNP was the most robust discriminator of risk and thus could be useful, along with other more traditional prognostic variables, in patient counseling regarding prognosis and determining the timing for heart transplantation.
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