Prognostic stratification in heart failure: what's the point?

max) in 100 men with heart failure and impaired systolic function. Patients were divided into groups based on transmitral flow patterns and E wave deceleration time, with a third group consisting of patients with fused E and A waves due to tachycardia (fusion group). Whilst E wave deceleration time (Dt) correlated strongly with maximal exercise capacity (r=0·65), per cent predicted VO2 max remained the strongest predictor of death or transplantation. Doppler parameters of left ventricular filling did exceed the prognostic power of ejection fraction and left ventricular dimensions; however, further stratification of the three patient groups using the response of transmitral flow patterns to load manipulation and the isovolumetric relaxation time may have improved the predictive power of left ventricular filling parameters. It is unfortunate that neurohormone levels were not included in this study as they have been shown to be extremely good prognostic indicators over and above conventional parameters in patients with heart failure and left ventricular systolic dysfunction. Brain natriuretic peptide (BNP) and atrial natriuretic peptide (ANP) are released as a response to increased atrial and ventricular wall stretch, are related to left ventricular filling pressures and are markers of the severity of heart failure. Patients with restrictive transmitral velocity patterns have higher ANP and BNP levels than patients with non-restrictive patterns, and the close relationship of neurohormone levels with diastolic Doppler indices of left ventricular filling suggests that transmitral velocity profiles may simply be a marker of the degree of neurohormone activation in patients with heart failure. Knowledge of neurohormone levels, transmitral flow velocities, percent predicted VO2 max and various other parameters is useful to allow prediction of survival in patients with heart failure, although this is of little value unless patient management is improved as a consequence. Treatment for chronic heart failure is increasingly complex, management of individual patients is often difficult and polypharmacy a potential problem. Current practice uses clinical evaluation, physician preference and patient adherence rather than objective clinical measures to guide drug selection, and dosage and risk-profiling currently has little role in individual treatment plans. There is, however, recent evidence to suggest that heart failure treatment can be better tailored to individual patients and that such strategies improve patient outcomes. Troughton et al. See page 1864 for the article to which this Editorial refers