Clinical Investigation
A Comparison of Patient and Physician-Rated New York Heart Association Class in a Community-Based Heart Failure Clinic

https://doi.org/10.1016/j.cardfail.2008.01.014Get rights and content

Abstract

Objective

The New York Heart Association (NYHA) classification is recommended for grading symptoms of chronic heart failure and is a powerful prognostic marker. Patient-rated NYHA (Pa-NYHA) and physician-rated NYHA (Dr-NYHA) class have never been compared directly, and it is unknown whether they carry similar prognostic significance.

Methods and Results

NYHA class was rated independently by a physician and patient in 1752 patients referred with suspected heart failure. Pa-NYHA and Dr-NYHA varied by 1 class in 37.1% cases and by 2 classes in 12.8% cases. Mean Dr-NYHA and Pa-NYHA were higher in women than men (1.98 vs 1.89, P = .016; 2.17 vs 2.02, P = .002) despite less cardiac disease. Dr-NYHA correlated more with 6-minute walk test distance and severity of left ventricular systolic dysfunction than Pa-NYHA (Spearman's ρ: −0.53 vs −0.44 and 0.32 vs 0.16). Dr-NYHA better predicted mortality when compared with Pa-NYHA (log-rank: χ2 = 105 vs 46, both P < .001).

Conclusion

Patients rate NYHA differently from physicians, and women rate NYHA differently from men. Dr-NYHA relates more strongly to survival and severity of left ventricular systolic dysfunction, suggesting that for physicians the NYHA classification may have become a “heart failure severity score” and not as was intended, purely a measure of a patient's symptoms and functional status.

Section snippets

Study Population

This study is an analysis of consecutive patients referred to a community HF clinic (Kingston-upon-Hull, UK) for the assessment of suspected HF between 2002 and 2004. All participants provided written informed consent, and the study was carried out in accordance with the Helsinki Declaration II and the European Standards for Good Clinical Practice. Ethical approval was granted by the Hull and East Yorkshire Local Research Ethics Committee.

Standard Clinical Assessment

All patients underwent a standard assessment, including

Patient Characteristics

Data were collected on 1752 patients for this analysis. Most patients were men (62%) who were younger than the women (median 70 vs 74 years, P < .001) but had twice the prevalence of LVSD and significantly more MSHD (59.6% vs 45.4%, P < .0001) (Table 1). Despite having less LVSD and MSHD, women had more lower-limb edema (21.7% vs 14.5%, P = .001) and higher mean Dr-NYHA and mean Pa-NYHA than men (1.98 vs 1.89, P = .016; 2.17 vs 2.02, P = .002). In patients with LVSD, a higher proportion of men

Discussion

This analysis shows that the relationship between Dr-NYHA and Pa-NYHA is modest, with only a 44% agreement in patients with MSHD. In addition, where Dr-NYHA and Pa-NYHA are discordant, woman are more likely to rate their NYHA worse than the physician when compared with men. NYHA class, whether assessed by physicians or the patient, was a powerful predictor of mortality. However, when NYHA class is being used to select patients with an adverse prognosis, using the physician-rated value may be

Study Limitations

Dr-NYHA was assessed unblinded to the echocardiogram, and this is a potential source of bias. However, assessment in this way is consistent with normal clinical practice and therefore reflects a true picture of Dr-NHYA class. In fact, we consider this to be a strength of this study, because to determine Dr-NYHA in a manner different to normal clinical practice may itself be considered a source of bias.

Interobserver variability for Dr-NYHA has been shown to be poor with only 54% to 56% agreement

Conclusions

Dr-NYHA and Pa-NYHA class differ substantially, probably because physicians are influenced by factors other than symptoms and functional status such as the perceived severity of the underlying cardiac disease, suggesting that in the physicians' hands the NYHA classification has become an “HF severity score.” This may go some way to explaining why Dr-NYHA has better prognostic power than Pa-NYHA. Equally, patients may be influenced by environmental and psychologic factors that are diluting the

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    Dr Cleland has received grants and speakers' honoraria from Roche Diagnostics related to the clinical use of natriuretic peptides. Dr Goode has received travel and accommodation grants for conference presentation from Roche Diagnostics. Drs Clark and Nabb have no conflicts of interest.

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