Serum cholinesterase level provides the additional long-time prognostic information over AHEAD risk score in patients with acute decompensated heart failure with preserved ejection fraction
Authors: Seo M , Kondo T , Watanabe T , Yamada T , Yano M , Hayashi T , Nakagawa A , Nakagawa Y , Tamaki S , Yasamura Y , Sotomi Y , Hikoso S , Nakatani D , Fukunami M , Sakata Y 
Published: November 2023

Abstract

Background and purpose
In patients with heart failure with preserved ejection fraction (HFpEF), comorbidities strongly influence the prognosis. AHEAD (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus) score is a simple risk model based on several comorbidities. Its prognostic role has been reported in patients with HFpEF. Although malnutrition is one of the most important comorbidities, it is not included in AHEAD score. We previously reported the prognostic value of cholinesterase (CHE), which is a simple nutritional biomarker in daily practice, in patients with HFpEF. Here, we aimed to investigate whether serum CHE level provides the additional prognostic information over AHEAD risk score in patients with HFpEF.

Methods
We studied 888 patients admitted for acute decompensated heart failure (ADHF) in our multicenter-prospective HFpEF cohort study (PURSUIT-HFpEF registry). Laboratory data including CHE was obtained at discharge. We evaluated AHEAD risk score (range 0-5, atrial fibrillation, hemoglobin &lt;13mg/dL for men and 12mg/dL for women, age &gt;70years, creatinine &gt;130μmol/L, and diabetes mellitus).The endpoint of this study was set as the composite of worsening heart failure readmission and all-cause mortality.

Results
During a follow up period of 1.6±1.3 years, 428 patients experienced primary composite endpoint. On multivariate Cox analysis, CHE (p&lt;0.001) and AHEAD risk score (p = 0.003) were independently and significantly associated with primary composite endpoint. Kaplan-Meier analysis that patients with higher AHEAD risk score (defined as 4-5 point) and those with intermediate AHEAD score (defined as 2-3 point) had significantly greater risk of primary composite endpoint than those with low AHEAD score (defined as 0-1 point) (67% vs 54% vs 37%, log-rank p&lt;0.001). Kaplan-Meier analysis in the subgroup with low AHEAD risk score revealed that primary composite event was significantly more frequently observed in patients with low CHE (&lt;207 IU/L determined by the median of the whole cohort) (56% vs 28% p = 0.009). Moreover, in the subgroup with intermediate AHEAD risk score, the incidence of primary composite event was also significantly higher in patients with low CHE (56% vs 37% p&lt;0.001). Finally, in the subgroup with high AHEAD risk score, the incidence of primary outcome was also significantly higher in patients with low CHE (69% vs 48% p&lt;0.001). Receiver operating curve analysis showed that the addition of CHE significantly improved the risk prediction of AHEAD score (AUC: 0.641 vs 0.573, p&lt;0.001).

Conclusion
Malnutrition, as evaluated by serum cholinesterase level, provided the additional long-time prognostic information beyond AHEAD risk score in patients with ADHF-HFpEF.