Association between De Ritis ratio and long-term outcomes in elderly patients with acute decompensated heart failure
Main Article Content
Abstract
A combined prospective and retrospective cohort study was conducted on 249 patients aged ≥ 65 years old with acute decompensated heart failure (ADHF) (median age 78 years old, 46.2% male) to evaluate the association between the De Ritis ratio and 1-year mortality. Multivariate Cox regression analysis was performed to identify independent associations. The 1-year mortality rate was 27.3%. The median De Ritis ratio was significantly higher in the mortality group compared to the survivors (1.49 vs. 1.29; p < 0.001). ROC analysis showed that the De Ritis ratio predicted 1-year mortality with an AUC of 0.66, sensitivity of 83.9%, specificity of 52%, and an optimal cutoff value of 1.31. Multivariate Cox regression identified the following independent predictors of 1-year mortality: age (HR = 1.04; 95% CI: 1.01 - 1.07; p = 0.022), type 2 diabetes (HR. 4.73; 95% CI: 2.38 - 9.40; p < 0.001), history of stroke (HR = 2.96; 95% CI: 1.69 - 5.17; p < 0.001), log-transformed NT-proBNP (HR = 10.80; 95% CI: 3.82 - 30.48; p < 0.001), left ventricular ejection fraction (LVEF) ≤ 40% (HR = 2.52; 95% CI: 1.32 - 4.84; p = 0.005), and De Ritis ratio ≥ 1.31 (HR = 2.51; 95% CI: 1.22 - 5.18; p = 0.013). An elevated De Ritis ratio is an independent predictor of 1-year mortality in elderly ADHF patients, alongside age, type 2 diabetes, history of stroke, NT-proBNP, and reduced LVEF.
Article Details
Keywords
Acute decompensated heart failure, De Ritis ratio, elderly, mortality, prognosis
References
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19. Nikolaou M, Parissis J, Yilmaz MB, et al. Liver function abnormalities, clinical profile, and outcome in acute decompensated heart failure. Eur Heart J. 2013;34(10):742-749. doi:10.1093/eurheartj/ehs332
20. Maeda D, Sakane K, Kanzaki Y, et al. Relation of aspartate aminotransferase to alanine aminotransferase ratio to nutritional status and prognosis in patients with acute heart failure. Am J Cardiol. 2021;139:64-70. doi:10.1016/j.amjcard.2020.10.036
21. Zoppini G, Cacciatori V, Negri C, et al. The aspartate aminotransferase-to-alanine aminotransferase ratio predicts all-cause and cardiovascular mortality in patients with type 2 diabetes. Med (United States). 2016;95(43). doi:10.1097/MD.0000000000004821
22. Sette LHBC, Lopes EP de A. The reduction of serum aminotransferase levels is proportional to the decline of the glomerular filtration rate in patients with chronic kidney disease. Clinics. 2015;70(5):346-349. doi:10.6061/clinics/2015(05)07
23. Huang JW, Yen CJ, Pai MF, et al. Association between serum aspartate transaminase and homocysteine levels in hemodialysis patients. Am J Kidney Dis. 2002;40(6):1195-1201. doi:10.1053/ajkd.2002.36948b
24. Ndrepepa G. De Ritis ratio and cardiovascular disease: evidence and underlying mechanisms. J Lab Precis Med. 2023;8:6. doi:10.21037/JLPM-22-68
25. Ferrannini G, Rosenthal N, Hansen MK, et al. Liver function markers predict cardiovascular and renal outcomes in the CANVAS Program. Cardiovasc Diabetol. 2022;21(1):127. doi:10.1186/s12933-022-01558-w
26. Liu X, Liu P. Elevated AST/ALT ratio is associated with all-cause mortality in patients with stable coronary artery disease: a secondary analysis based on a retrospective cohort study. Sci Rep. 2022;12(1):9231. doi:10.1038/s41598-022-13355-2
27. Liu HH, Cao YX, Jin JL, et al. Liver fibrosis scoring systems as novel tools for predicting cardiovascular outcomes in patients following elective percutaneous coronary intervention. J Am Heart Assoc. 2021;10(3):e018869. doi:10.1161/JAHA.120.018869
28. Ndrepepa G, Holdenrieder S, Kastrati A. De Ritis ratio and long-term major cardiovascular adverse events in patients undergoing elective percutaneous coronary intervention. Eur J Clin Invest. 2023;53(5):e13942.
29. Chioncel O, Lainscak M, Seferovic PM, et al. Epidemiology and one-year outcomes in patients with chronic heart failure and preserved, mid-range and reduced ejection fraction: an analysis of the ESC Heart Failure Long-Term Registry. Eur J Heart Fail. 2017;19(12):1574–1585.
30. Marques I, Mendonça D, Teixeira L. One-year rehospitalisation and mortality after acute heart failure hospitalisation: a competing risk analysis. Open Hear. 2023;10(1):e002167. doi:10.1136/openhrt-2022-002167
31. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895-e1032. doi:10.1161/CIR.0000000000001063
32. Scrutinio D, Ammirati E, Guida P, et al. The ADHF/NT-proBNP risk score to predict 1-year mortality in hospitalized patients with advanced decompensated heart failure. J Hear Lung Transplant. 2014;33(4):404-411. doi:10.1016/j.healun.2013.12.005
33. Doehner W, Böhm M, Boriani G, et al. Interaction of heart failure and stroke: A clinical consensus statement of the ESC Council on Stroke, the Heart Failure Association (HFA) and the ESC Working Group on Thrombosis. Eur J Heart Fail. 2023;25(12):2107-2129. doi:10.1002/ejhf.3071
34. Lorlowhakarn K, Arayakarnkul S, Trongtorsak A, et al. Outcomes and predictors of one-year mortality in patients hospitalized with Acute Heart Failure. IJC Hear Vasc. 2022;43:101159. doi:10.1016/j.ijcha.2022.101159
2. Díez-Villanueva P, Alfonso F. Heart failure in the elderly. J Geriatr Cardiol. 2016;13(2):115-117. doi:10.11909/j.issn.1671-5411.2016.02.009
3. Shrivastava A, Haase T, Zeller T, et al. Biomarkers for Heart Failure Prognosis: Proteins, Genetic Scores and Non-coding RNAs. Front Cardiovasc Med. 2020;7:601364. doi:10.3389/fcvm.2020.601364
4. Djakpo DK, Wang ZQ, Shrestha M. The significance of transaminase ratio (AST/ALT) in acute myocardial infarction. Arch Med Sci – Atheroscler Dis. 2020;5(1):279-283. doi:10.5114/amsad.2020.103028
5. Xanthopoulos A, Starling RC, Kitai T, et al. Heart Failure and Liver Disease: Cardiohepatic Interactions. JACC Hear Fail. 2019;7(2):87-97. doi:10.1016/j.jchf.2018.10.007
6. Maeda D, Kagiyama N, Jujo K, et al. Aspartate aminotransferase to alanine aminotransferase ratio is associated with frailty and mortality in older patients with heart failure. Sci Rep. 2021;11(1):11957. doi:10.1038/s41598-021-91368-z
7. Schupp T, Rusnak J, Weidner K, et al. Prognostic Value of the AST/ALT Ratio versus Bilirubin in Patients with Cardiogenic Shock. J Clin Med. 2023;12(16):5275. doi:10.3390/jcm12165275
8. Naschitz JE, Slobodin G, Lewis RJ, et al. Heart diseases affecting the liver and liver diseases affecting the heart. Am Heart J. 2000;140(1):111-120. doi:10.1067/mhj.2000.107177
9. Ewid M, Sherif H, Allihimy AS, et al. AST/ALT ratio predicts the functional severity of chronic heart failure with reduced left ventricular ejection fraction. BMC Res Notes. 2020;13:178. doi:10.1186/s13104-020-05031-3
10. Đặng Vạn Phước, Nguyễn Lân Việt, Huỳnh Văn Minh, và cs. 2022 Khuyến cáo của Hội Tim mạch Việt Nam về Chẩn đoán và Điều trị Suy tim cấp và Suy tim mạn.; 2022.
11. AlFaleh H, Elasfar AA, Ullah A, et al. Acute heart failure with and without acute coronary syndrome: Clinical correlates and prognostic impact (From the HEARTS registry). BMC Cardiovasc Disord. 2016;16:98. doi:10.1186/s12872-016-0267-6
12. Jasiewicz M, Siedlaczek M, Kasprzak M, et al. Elevated serum transaminases in patients with acute coronary syndromes: Do we need a revision of exclusion criteria for clinical trials? Cardiol J. 2023;30(5):747-752. doi:10.5603/CJ.a2021.0081
13. World Health Organization. Guideline on Haemoglobin Cutoffs to Define Anaemia in Individuals and Populations. (World Health Organization, ed.). Geneva; 2024. https://www.who.int/publications/i/item/9789240088542.
14. Fonarow GC. Overview of acutely decompensated congestive heart failure (ADHF): A report from the ADHERE Registry. Heart Fail Rev. 2005;9(3):179-185. doi:10.1007/s10741-005-6127-6
15. Verdu-Rotellar JM, Vaillant-Roussel H, Abellana R, et al. Precipitating factors of heart failure decompensation, short-term morbidity and mortality in patients attended in primary care. Scand J Prim Health Care. 2020;38(4):473-480. doi:10.1080/02813432.2020.1844387
16. Bendary A, Hassanein M, Bendary M, et al. The predictive value of precipitating factors on clinical outcomes in hospitalized patients with decompensated heart failure: insights from the Egyptian cohort in the European Society of Cardiology Heart Failure long-term registry. Egypt Hear J. 2023;75(1):16. doi:10.1186/s43044-023-00342-9
17. Cardoso JN, Del Carlo CH, de Oliveira Junior MT, et al. Infection in patients with decompensated heart failure: In-hospital mortality and outcome. Arq Bras Cardiol. 2018;110(4):364-370. doi:10.5935/abc.20180037
18. Cao Y, Guo S, Dong Y, et al. Comparison of liver fibrosis scores for predicting mortality and morbidity in heart failure with preserved ejection fraction. ESC Hear Fail. 2023;10(3):1771-1780. doi:10.1002/ehf2.14336
19. Nikolaou M, Parissis J, Yilmaz MB, et al. Liver function abnormalities, clinical profile, and outcome in acute decompensated heart failure. Eur Heart J. 2013;34(10):742-749. doi:10.1093/eurheartj/ehs332
20. Maeda D, Sakane K, Kanzaki Y, et al. Relation of aspartate aminotransferase to alanine aminotransferase ratio to nutritional status and prognosis in patients with acute heart failure. Am J Cardiol. 2021;139:64-70. doi:10.1016/j.amjcard.2020.10.036
21. Zoppini G, Cacciatori V, Negri C, et al. The aspartate aminotransferase-to-alanine aminotransferase ratio predicts all-cause and cardiovascular mortality in patients with type 2 diabetes. Med (United States). 2016;95(43). doi:10.1097/MD.0000000000004821
22. Sette LHBC, Lopes EP de A. The reduction of serum aminotransferase levels is proportional to the decline of the glomerular filtration rate in patients with chronic kidney disease. Clinics. 2015;70(5):346-349. doi:10.6061/clinics/2015(05)07
23. Huang JW, Yen CJ, Pai MF, et al. Association between serum aspartate transaminase and homocysteine levels in hemodialysis patients. Am J Kidney Dis. 2002;40(6):1195-1201. doi:10.1053/ajkd.2002.36948b
24. Ndrepepa G. De Ritis ratio and cardiovascular disease: evidence and underlying mechanisms. J Lab Precis Med. 2023;8:6. doi:10.21037/JLPM-22-68
25. Ferrannini G, Rosenthal N, Hansen MK, et al. Liver function markers predict cardiovascular and renal outcomes in the CANVAS Program. Cardiovasc Diabetol. 2022;21(1):127. doi:10.1186/s12933-022-01558-w
26. Liu X, Liu P. Elevated AST/ALT ratio is associated with all-cause mortality in patients with stable coronary artery disease: a secondary analysis based on a retrospective cohort study. Sci Rep. 2022;12(1):9231. doi:10.1038/s41598-022-13355-2
27. Liu HH, Cao YX, Jin JL, et al. Liver fibrosis scoring systems as novel tools for predicting cardiovascular outcomes in patients following elective percutaneous coronary intervention. J Am Heart Assoc. 2021;10(3):e018869. doi:10.1161/JAHA.120.018869
28. Ndrepepa G, Holdenrieder S, Kastrati A. De Ritis ratio and long-term major cardiovascular adverse events in patients undergoing elective percutaneous coronary intervention. Eur J Clin Invest. 2023;53(5):e13942.
29. Chioncel O, Lainscak M, Seferovic PM, et al. Epidemiology and one-year outcomes in patients with chronic heart failure and preserved, mid-range and reduced ejection fraction: an analysis of the ESC Heart Failure Long-Term Registry. Eur J Heart Fail. 2017;19(12):1574–1585.
30. Marques I, Mendonça D, Teixeira L. One-year rehospitalisation and mortality after acute heart failure hospitalisation: a competing risk analysis. Open Hear. 2023;10(1):e002167. doi:10.1136/openhrt-2022-002167
31. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895-e1032. doi:10.1161/CIR.0000000000001063
32. Scrutinio D, Ammirati E, Guida P, et al. The ADHF/NT-proBNP risk score to predict 1-year mortality in hospitalized patients with advanced decompensated heart failure. J Hear Lung Transplant. 2014;33(4):404-411. doi:10.1016/j.healun.2013.12.005
33. Doehner W, Böhm M, Boriani G, et al. Interaction of heart failure and stroke: A clinical consensus statement of the ESC Council on Stroke, the Heart Failure Association (HFA) and the ESC Working Group on Thrombosis. Eur J Heart Fail. 2023;25(12):2107-2129. doi:10.1002/ejhf.3071
34. Lorlowhakarn K, Arayakarnkul S, Trongtorsak A, et al. Outcomes and predictors of one-year mortality in patients hospitalized with Acute Heart Failure. IJC Hear Vasc. 2022;43:101159. doi:10.1016/j.ijcha.2022.101159