Beyond Research, KCCQ Scores Can Help Predict Events Post-TAVI/TMVR

Patient-reported health status metrics before and after both TAVI and transcatheter mitral valve repair (TMVR) are associated with postprocedural risk of death and heart failure (HF) hospitalization, according to a new analysis.

The authors believe the data support the use of the Kansas City Cardiomyopathy Questionnaire (KCCQ) as a prognostic tool.

“In clinic, oftentimes we struggle trying to understand what the patient's physical abilities are, despite how good we are with history taking,” lead author Vittal Hejjaji, MD (St Luke’s Mid America Heart Institute, Kansas City, MO), told TCTMD. “This gives you the opportunity to understand the symptom burden from the patient, . . . and it's easily interpretable by physicians. So far, we say we understand KCCQ [and] what it does, but then how do we exactly use it? We hope that this paper will lay that out as a foundation.”

Hejjaji explained that until recently, the KCCQ score has mostly been used by physicians as a requirement for research. As such, many providers don’t understand its clinical utility, he said. “We're trying to say, ‘Hey, here is this tool. We know so much about it, but in our daily clinical practice, this is how we use it.’”

KCCQ and Risk

For the study, published online February 18, 2021, in Circulation: Cardiovascular Quality and Outcomes, Hejjaji and colleagues included Society of Thoracic Surgeons/American College of Cardiology TVT Registry data for 73,699 patients who underwent transfemoral TAVI or TMVR at 575 sites between 2011 and 2018. All patients had KCCQ overall summary score data at baseline and 30 days postprocedure.

KCCQ scores were somewhat higher for TAVI than for TMVR patients at both baseline and 30 days, but both cohorts saw “very large health status improvements” following their procedures, according to the authors.

Overall, those with higher KCCQ scores were less likely to die or be hospitalized for heart failure at 1 year following the 30-day assessment. Models looking at baseline and 30-day scores both independently and together showed this association, but among the various combinations, the strongest relationships were seen for 30-day KCCQ score in the combined model. Here, each 5-point increase was tied to lower risks of death (HR 0.89; 95% CI 0.89-0.90) and hospitalization for heart failure (HR 0.91; 95% CI 0.90-0.91).

Additionally, change in KCCQ from baseline to 30 days appeared to influence 1-year outcomes, with improvements of up to 25 points associated to an 8% drop in risk of death (HR 0.92; 95% CI 0.92-0.93). A final model combining the 30-day KCCQ score and accounting for the change from baseline score was associated with the greatest survival benefit (HR 0.86; 95% CI 0.86-0.87).

Finally, these associations were maintained when adjusted for patient factors as well as when studied separately in TAVI and TMVR, “suggesting that health status provided similar prognostic information in both procedures,” the authors write.

“Although KCCQ has been used extensively in research and, to some degree, as a metric of favorable outcome after transcatheter valve procedures, our findings suggest health status data could also be a powerful tool for improving both patient selection and clinical management,” they suggest. “The goals of treatment of severe valve disease are to improve patients’ health status, reduce HF hospitalizations, and prolong survival. Keeping these goals in mind and integrating current data with previous studies, we can envision a system where health status is used at multiple time points to establish a patient-centered approach to manage care around the time of TAVR/TMVR.”

Despite the mandate for KCCQ data by the TVT Registry, up to one in four patients considered for inclusion in this study lacked such details, Hejjaji said. “That's a huge, huge percentage.”

Hejjaji said his team is studying how to ease implementation, in order to encourage clinicians to use the KCCQ score more to their benefit and not simply because of a mandate. “Once it's collected, we hope that providers use [the score] on a daily basis both for patient selection before the procedure—saying who benefits the most from this procedure—and also use it after the procedure is done, 30 days after, to say who is going to have a better clinical outcome at the end of 1 year,” he said.