A Survival Prediction for Acute Heart Failure Patients via Web-Based Dynamic Nomogram with Internal Validation: A Prospective Cohort Study

Abstract

Ting Yin,1 Shi Shi,1 Xu Zhu,1 Iokfai Cheang,1 Xinyi Lu,1 Rongrong Gao,1 Haifeng Zhang,1,2 Wenming Yao,1 Yanli Zhou,1 Xinli Li1 1Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, People’s Republic of China; 2Department of Cardiology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, 215002, People’s Republic of ChinaCorrespondence: Xinli Li; Yanli Zhou, Tel [phone], Email [email protected]; [email protected]: The current study aimed to develop a convenient and accurate prognostic dynamic nomogram model for the risk of all-cause death in acute heart failure (AHF) patients that incorporates clinical characteristics including N-terminal pro-brain natriuretic peptide (NT-pro BNP) and growth stimulation expresses gene 2 protein (ST2).Patients and Methods: We prospectively studied 537 consecutive AHF patients and derived a clinical prediction model. The least absolute shrinkage and selection operator regression model combined with clinical characteristics were used for dimensional reduction and feature selection. Multivariate Cox proportional hazard analysis and “Dynnom” package were used to build the dynamic nomogram for prediction of 1-,2-,and 5-year overall survival for AHF. With bootstrap validation, the time-dependent concordance index (C-index) and calibration curves were used to assess predictive discrimination and accuracy. The contributions of NT-pro BNP and ST2 to the nomogram were evaluated using integrated discrimination improvement (IDI) and net reclassification improvement (NRI), while decision curve analysis (DCA) was used to assess clinical value.Results: Patients were randomly divided into derivation (74.9%, n=402) and validation (25.1%, n=135) cohorts. Optimal independent prognostic factors for 1-,2-, and 5-year all-cause mortality were BS-ACMR (B: NT-pro BNP; S: ST2; A: age; C: complete right bundle branch block; M: mean arterial pressure; and R: red cell distribution width > 14.5%); these were incorporated into the dynamic nomogram (https://bs-acmr-nom.shinyapps.io/dynnomapp/) with bootstrap validation. The C-indexes in the derivation (0.793) and validation (0.782) cohorts were consistent with comparable performance parameters. The calibration curve showed good agreement between the nomogram-predicted and actual survival. Adding NT-pro BNP and ST2 provided a significant net benefit and improved performance over other less adequate schemes in terms of DCA of survival probability compared to those neglecting either of these two factors.Conclusion: The study constructed a dynamic BS-ACMR nomogram, which is a convenient, practical and effective clinical decision-making tool for providing accurate prognosis in AHF patients.Keywords: acute heart failure, all-cause mortality, dynamic nomogram, prediction model, internal validation

Keywords

• acute heart failure
• all-cause mortality
• dynamic nomogram
• prediction model
• internal validation