The association of “INEEDHELP” and prognosis of patients with heart failure with reduced ejection fraction (HFrEF)

Abstract

Background: The prognosis among patients with heart failure with reduced ejection fraction (HFrEF) remains a significant concern. The "INEEDHELP" mnemonic was developed as a practical screening tool to identify patients with advanced heart failure who require timely referral and guidance for specific management. We sought to investigate the prevalence and prognostic significance of INEEDHELP criteria in a Thai cohort. Methods: A retrospective cohort study was conducted on HFrEF patients at the outpatient department in a tertiary care center in Thailand (2015–2024). Each of the nine INEEDHELP criteria met by a patient was assigned a value of 1, resulting in a cumulative score ranging from 0 to 9. The primary outcome was a composite of all-cause mortality, first HF rehospitalization, LVAD implantation, and heart transplantation. Survival analysis over a 1-year follow-up was performed using the Kaplan-Meier method with administrative censoring at 365 days. Multivariable Cox proportional hazards regression was used to identify independent factors. Results: A total of 567 patients (mean age 61 years, 28.7% female, mean LVEF 27.0±8.2%) were included. The most prevalent criteria observed were persistent NYHA class III/IV symptoms or elevated natriuretic peptide levels (68.4%) and end-organ dysfunction (54.7%). Multivariable analysis identified prognostic medication intolerance (P) (HR 2.789; 95% CI: 1.700–4.577; p<0.001) and persistent edema or escalating diuretic requirements (E) (HR 2.649; 95% CI: 1.819–3.859; p<0.001) as being most strongly associated with risk. Persistent NYHA III/IV or elevated natriuretic peptides (N) (HR 1.860; 95% CI: 1.250–2.770; p = 0.002) also demonstrated a significant association with outcome. Conversely, the history of inotropic use (I) was associated with a reduced risk (HR: 0.587; 95% CI: 0.358–0.962; P = 0.034), which likely reflects successful stabilization in high-risk patients who survived the acute admission phase. A stepwise correlation was observed between the cumulative number of criteria and mortality risk (p = 0.010). Conclusion: Each of the "INEEDHELP" criteria has significant prognostic utility in patients with HFrEF. A higher cumulative factor is associated with a stepwise deterioration in disease prognosis. Clinical congestion, diuretic resistance, and medication intolerance are powerful independent predictors of adverse clinical outcomes