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:
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).
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:
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.
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|
|Digoxin||0%||28%||DIG, Cochrane review|
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)
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".
Cost estimates are based on Canadian dollars (CAD), updated annually or more frequently as needed, and estimated using the following websites:
This tool was developed by the HFMedChoice Development Panel:
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.
HFMedChoice is a decision support tool intended for use by healthcare professionals. It is not meant to be a substitute for professional advice.
© 2020 Ricky Turgeon