# Understanding of Prognosis and Estimation of Mortality in Ambulatory Patients With Heart Failure

## TL;DR

Many heart failure patients overestimate their survival, and this overestimation is linked to higher mortality.

## Contribution

This study identifies a link between patient overestimation of survival and increased mortality in high-risk heart failure patients.

## Key findings

- 33% of patients overestimated their life expectancy by more than 50% compared to model estimates.
- Discordant optimism was associated with higher 2-year mortality, independent of heart transplant or VAD likelihood.
- Patient estimates of survival often differ from model-based predictions, impacting clinical decision-making.

## Abstract

This cohort study explores how well ambulatory patients with high-risk chronic heart failure estimate their survival compared with a validated risk model and whether overestimation is associated with 2-year mortality.

How well do ambulatory patients with high-risk heart failure (HF) with reduced ejection fraction estimate their own survival compared with a validated, guideline-endorsed risk score, and is overestimation associated with mortality?

In this cohort study of 296 patients with chronic HF, 33% overestimated their life expectancy by more than 50% compared with model estimates, and such overestimation was associated with higher mortality in the subsequent 2 years.

The findings suggest improving patient understanding of prognosis may enhance shared decision-making for patients with high-risk ambulatory HF.

Accurate patient understanding of prognosis is essential for informed decision-making to pursue therapies for advanced heart failure (HF).

To evaluate (1) patient characteristics associated with overestimating survival with HF and (2) whether overestimation is associated with mortality.

This prospective cohort study was an exploratory secondary analysis of data from the multicenter US Registry Evaluation of Vital Information for Ventricular Assist Devices (VADs) in Ambulatory Life (REVIVAL) study. Participants were high-risk ambulatory patients with HF with reduced ejection fraction enrolled from July 2015 to June 2016. Data were analyzed from December 1, 2024, to December 16, 2025.

Patient characteristics (eg, age) and estimation index (EI), defined as the ratio of patient-estimated life expectancy to Seattle Heart Failure Model (SHFM)–estimated mean survival (EI <0.5, discordantly pessimistic; 0.5 to <1.5, concordant; and ≥1.5, discordantly optimistic).

Primary outcomes were EI and 2-year all-cause mortality. Factors associated with EI were estimated using ordered logistic regression. Association between EI and mortality was assessed using a cause-specific Cox proportional hazards regression model with VAD and heart transplant as censoring events.

A total of 296 high-risk, ambulatory patients with chronic HF were included; 223 (75.3%) were male, and mean (SD) age was 60.1 (11.5) years. The median SHFM-estimated survival was 8.2 years (IQR, 5.1-12.1 years), and median patient-estimated life expectancy was 7.0 years (IQR, 5.0-10.0 years). In all, 98 patients (33.1%) were discordantly optimistic. Increasing EI was associated with increased mortality in the univariable model, which was attenuated with multivariable adjustment (adjusted hazard ratio [AHR] for concordant optimism, 1.21 [95% CI, 0.49-2.99] and for discordant optimism, 2.23 [95% CI, 0.94-5.33] vs discordant pessimism). Compared with discordantly pessimistic or concordantly optimistic estimates (EI <1.5), discordant optimism was associated with increased hazard of 2-year mortality (AHR, 1.98; 95% CI, 1.04-3.77) but a similar hazard for a VAD or heart transplant compared with discordant pessimism (HR, 1.24; 95% CI, 0.64-2.41) in a post hoc analysis.

In this cohort study, discordant optimism regarding life expectancy compared with model estimates was common and associated with mortality that was not due to a lower probability of receiving a heart transplant or VAD. The findings suggest clinicians should objectively evaluate HF risk when considering advanced therapies, rather than relying primarily on patient-reported symptoms.