The role of the Heart Failure Survival Score and psychosocial stress in predicting event-free survival in patients referred for heart transplantation.

We read with interest the article “Selecting patients for heart transplantation: Comparison of the Heart Failure Survival Score (HFSS) and the Seattle Heart Failure Model (SHFM)” by Goda et al. Their study showed that the HFSS and the SHFM are similarly predictive of event-free survival in heart transplant (HTx) candidates enrolled at a single center in the USA. We also found that a HFSS denoting high medical risk predicts time until death, urgent transplantation, and implantation of ventricular assist devices (VAD) in patients newly listed for an HTx with Eurotransplant; in that same study, we have also shown that low HFSS risk predicts de-listing due to clinical improvement. The article by Goda et al prompted us to examine the HFSS as a predictor of event-free survival in our multisite study of 318 German-speaking patients. Following the analytic approach employed by Goda et al, we combined death, VAD implantation, and urgent HTx into one outcome, and stratified the HFSS into low ( 8.10), medium (7.20–8.09), and high ( 7.19) risk. Overall, our findings (Figure 1) are similar to those reported by Goda et al, showing a significant decrease of event-free survival with increasing medical risk (1-year event-free survival for the low-, medium-, and high-risk groups of 70%, 57%, and 37%, respectively, vs 89%, 72%, and 60% in the Goda et al sample). The overall lower event-free survival rates in our sample may be due to (a) differences in HFSS, indicating a worse health status in our sample than in Goda et al’s sample (mean HFSS: 7.84 0.92, 8.04 0.89, respectively; p 0.001), and (b) the fact that urgent HTx, the most frequently observed outcome in our patients, occurred soon after listing. Moreover, in our prior work, we also showed that psychosocial stress (depression and social isolation) predicted outcomes, such as VAD implantation and urgent HTx, independent of the HFSS. Therefore, we now evaluate low psychosocial stress (neither depressed nor socially integrated), medium (either depressed or socially isolated), and high psychosocial stress (depressed and socially isolated) as predictors of event-free survival. Incidentally, the three psy-