What does HFMedChoice do?
HFMedChoice is an interactive decision support tool to assess individualized prognosis and potential impact of medication for patients living with heart failure with reduced ejection fraction (HFrEF). It is not intended for use in patients with heart failure with preserved ejection fraction (HFpEF). HFMedChoice is divided into 3 steps designed to emulate the process of patient assessment, consultation, and documentation at the point of care.
In Step 1, the clinician selects from validated HF risk calculators to estimate a patient’s current risk of death or HF hospitalization. The evidence behind these risk calculators is summarized and referenced on this page. You can choose between 2 different calculators for use in Step 1:
- MAGGIC: This calculates the risk of death at 1 year or 3 years.
- BCN Bio-HF (Lupón 2014, Lupón 2015, Lupón 2018): This calculates the risk of death or heart failure hospitalization at 1 to 5 years.
Step 2 involves selecting among the available medication options to manage HFrEF. Each of these options has been evaluated in at least one high-quality randomized controlled trial; this evidence is summarized below.
Step 3 illustrates the estimated risk and change in death or HF hospitalizations, potential side-effects and other considerations from adding the options selected in Step 2. Risk is presented as an absolute risk (%) with and without the therapy selected in Step 2, illustrated with face pictograms, along with the individualized number needed to treat (NNT).
How do I use HFMedChoice?
Step 1
- Select the risk calculator that you wish to use (MAGGIC or BCN Bio-HF)
- Enter patient data
Step 2
- Select from the available drug therapy options. Any drugs the patient is already taking as selected in Step 1 will be highlighted in green and not selectable again in Step 2. Medications that the patient is already taking will be accounted for in the current risk estimate.
- The relative benefit is shown at the top of Step 2. If you select multiple options, the cumulative relative benefit will be shown based on the assumption that the benefits of HF medications are additive.
Step 3
- Select from the available outcomes and timepoints to present.
- View the patient’s current risk based on input in Step 1 and risk with adding therapies selected in Step 2, as well as possible side-effects and other considerations from the therapies selected in Step 2.
How were the risk calculators chosen?
Several risk calculators ("risk scores" or "risk prediction tools") have been developed to predict outcomes among people living with heart failure, each with their own strengths and limitations. To identify the best risk scores to use in our decision aid, we performed a comprehensive search, including a review of HF guidelines (Ezekowitz 2017, O'Meara 2020, Yancy 2013, Yancy 2017, Ponikowski 2016), and tertiary references (Dynamed, UpToDate), consultation with HF experts, supplemented with a search of PubMed (inception to July 2019) and use of Web of Science’s "cited reference search" for systematic reviews and validation studies. We considered any risk score for inclusion if they met the following criteria:
- Evaluated outcomes of all-cause mortality/survival, all-cause hospitalizations, and/or HF hospitalizations at a timepoint of ≥1 year;
- Incorporated variables that are readily measured and available in clinical practice;
- Included ambulatory patients with HFrEF;
- Had been externally validated in ≥1 study; and
- Demonstrated good predictive power, as indicated by at least "fair" model discrimination (e.g. c-statistic ≥0.70) with good calibration in external validation.
Based on these criteria, we chose to include the MAGGIC (Meta-Analysis Global Group in Chronic Heart Failure) risk score for estimation of survival. The MAGGIC score includes 13 routinely-available variables to predict survival at 1 and 3 years of follow-up, and has been externally validated with reasonably good predictive power (validation study 1, 2, 3, 4). Furthermore, the MAGGIC risk score has been shown to predict survival with accuracy as good as or better than several other risk scores, including the well-known Seattle Heart Failure Model (comparison study 1, 2, 3). Key limitations of the MAGGIC score are that it has not been evaluated to predict morbidity outcomes such as HF hospitalizations, and only predicts outcomes to 3 years.
In order to estimate HF hospitalizations, determine longer-term outcomes, and consider the prognostic impact of additional risk factors such as biomarkers, we chose to also include the BCN Bio-HF (Barcelona Bio-Heart Failure) risk calculator. The BCN Bio-HF calculator includes several routinely-collected variables, many of which are also included in the MAGGIC risk score, and also provides the option of including certain biomarkers, when available, for an improvement in accuracy. The BCN Bio-HF has been externally validated with good accuracy for the composite outcome of HF hospitalization and mortality, as well as both individual outcomes, at 1 to 5 years (validation studies 1, 2). The main limitation of the BCN Bio-HF calculator is that it has primarily been validated in white males with HF of ischemic etiology; however, further external validation studies are ongoing.
How were therapies for Step 2 chosen and where do the estimates of benefits and side-effects come from?
We selected pharmacological interventions to display in this tool by performing a comprehensive review of guidelines and reviews on HFrEF, as well as consultation with heart failure experts. The estimates of benefits and side-effects come from randomized controlled trials (RCTs) and meta-analyses of RCTs. With HFMedChoice, a patient’s individualized benefit is estimated using their current risk and the relative risk reduction for that outcome derived from RCTs. For side-effects, adverse events that were statistically significantly higher with therapy in RCTs are reported as absolute risk increases.
| Relative Risk Reduction | Key Trials & References | ||
|---|---|---|---|
| Death | Heart Failure Hospitalization | ||
| ACEI | NYHA 1-3: 20% NYHA 4: 40% |
36% | SOLVD, CONSENSUS, Lancet meta-analysis, Meta-analysis of angioedema risk |
| ARB | 17% | 33% | CHARM-ALTERNATIVE, Ann Intern Med meta-analysis |
| ARNI | vs. ACEI: 16% vs. placebo: 28% |
vs. ACEI: 21% vs. placebo: 49% |
PARADIGM-HF, Analysis of PARADIGM-HF vs. putative placebo |
| High-dose ACEI/ARB vs low-dose ACEI/ARB | 0% | 13% | ATLAS, HEAAL, PLoS meta-analysis |
| Beta-blocker | 35% | 36% | CIBIS-II, COPERNICUS, MERIT-HF, US Carvedilol HF trial, Ann Intern Med meta-analysis, Meta-analysis of side-effects |
| MRA | NYHA 2: 24% NYHA 3-4: 30% |
NYHA 2: 42% NYHA 3-4: 35% |
EMPHASIS-HF, RALES, Analysis of EMPHASIS-HF & RALES based on baseline BP |
| SGLT2 inhibitor | 13% | 31% | DAPA-HF, EMPEROR-Reduced, Lancet pooled analysis of DAPA-HF & EMPEROR-Reduced |
| Ivabradine | 0% | 26% | SHIFT |
| Vericiguat | 0% | 10% | VICTORIA |
| Digoxin | 0% | 28% | DIG, Cochrane review |
| Hydralazine-nitrate | 39% | 32% | A-HeFT Note: enrolment for this trial was restricted to patients who self-identified as black (defined as of African descent) and were already receiving an ACEI/ARB plus a beta-blocker) |
| Fish oil | 9% | - | GISSI-HF |
Why are some medications listed in both Step 1 and Step 2?
Medications that are included in Step 1 are used directly by the risk calculators to estimate current risk. On the other hand, the effect of medications listed in Step 2 is based on applying the relative risk reduction derived from randomized controlled trials to the current risk. As a result, for example, the effect of being on a beta-blocker at baseline can be different from the estimated effect of adding a beta-blocker "during the visit".
How were costs estimated? (last updated 28 Feb 2020)
Cost estimates are based on Canadian dollars (CAD), updated annually or more frequently as needed, and estimated using the following websites:
- https://acfp.ca/wp-content/uploads/2019/02/ACFPPricingDoc2019.pdf
- http://www.medi-mouse.com/drugfind.php
- https://www.studybuffalo.com/tools/drug-price-calculator/
Acknowledgments
This tool was developed by the HFMedChoice Development Panel:
Clinical Pharmacy and Research Specialist, Fraser Health, BC
Associate Professor, University of British Columbia, Vancouver, BC
Medical Director, HeartLife Foundation
We would like to thank Drs. Antoni Bayés-Genís and Josep Lupón for sharing the BCN Bio-HF code for use in HFMedChoice. The original online BCN Bio-HF risk calculator can be found at http://ww2.bcnbiohfcalculator.org.