{"id":"674a0dc56f40","type":"article","url":"https://hartvaat.nl/2026/03/03/expertopinie-hierarchische-eindpunten-op-basis-van-verslechterend-hartfalen-voor/","title":"Expertopinie: hiërarchische eindpunten op basis van verslechterend hartfalen, voorbij de ziekenhuisopname","title_en":"Worsening heart failure-based hierarchical endpoints beyond HF hospitalization: expert opinion paper","category":"hartfalen","category_label":"Hartfalen","professions":["cardioloog"],"tags":["acuut-hartfalen"],"journal":"ESC heart failure","doi":"10.1093/eschf/xvag107","source_url":"https://doi.org/10.1093/eschf/xvag107","authors":["Agustín Fernández-Cisnal","Gema Miñana","Rafael de la Espriella","Enrique Santas","Joan Carles Trullas","Jan Biegus","Harriette Van Spall","Julio Núñez"],"significance":5,"published":"2026-03-03","source_date":"2026-03-03","image":"","kennis":["https://hartvaat.nl/kennis/hartfalen/wat-is-hartfalen/","https://hartvaat.nl/kennis/hartfalen/esc-richtlijn-hartfalen-2021/"],"congress":"","summary_en":"The classic composite of cardiovascular death or first heart-failure hospitalisation aligns increasingly poorly with modern HF care: better survival and ambulatory pathways mean much worsening HF is treated outside hospital and patients may have recurrent episodes. Time-to-first-hospitalisation alone therefore misses clinically relevant morbidity. In this expert opinion, the authors propose a standardised, adjudicated definition of worsening-HF events extended to ambulatory settings, and recommend hierarchical endpoints that prioritise all-cause death, measure morbidity via all (first and recurrent) events, and incorporate validated patient-reported outcomes. This better reflects total disease burden and improves statistical power and interpretability across evolving care models.","created":"2026-07-03T10:32:19Z","updated":"2026-07-03T18:39:22Z","licence":"Citeer vrij, met bronvermelding en een link naar hartvaat.nl (de url van het record). Samenvattingen zijn redactioneel werk van HartVaat; de oorspronkelijke publicaties blijven van hun uitgevers (doi). Geen medisch advies.","body_markdown":"Het klassieke samengestelde eindpunt van cardiovasculaire sterfte of eerste hartfalenopname sluit steeds slechter aan op de moderne hartfalenzorg: door betere overleving en ambulante behandelpaden wordt veel verslechterend hartfalen buiten het ziekenhuis behandeld en kunnen patiënten herhaalde episodes doormaken. Alleen kijken naar de tijd tot de eerste opname mist daardoor klinisch relevante morbiditeit. In deze expertopinie stellen de auteurs een gestandaardiseerde, geadjudiceerde definitie van verslechterend-hartfalen-events voor, uitgebreid naar ambulante settings, en bevelen zij hiërarchische eindpunten aan die de totale sterfte vooropstellen, de morbiditeit meten via alle (eerste én herhaalde) events en gevalideerde patiëntgerapporteerde uitkomsten meenemen. Zo weerspiegelen trials de werkelijke ziektelast beter en winnen ze aan statistische kracht en interpreteerbaarheid.","abstract_original":"The traditional, hospitalization-centric composite endpoint of cardiovascular (CV) death or time-to-first heart failure (HF) hospitalization is increasingly misaligned with contemporary HF care and, as evidence-based therapies lower event rates over time, requires larger trials with longer follow-up. Improved survival, modern ambulatory pathways mean that a larger share of worsening HF is treated outside the hospital and that patients may experience recurrent worsening HF episodes. Relying on time-to-first hospitalization alone can therefore miss clinically relevant morbidity; recurrent-event approaches can offer additional power mainly when risk heterogeneity is high and treatment discontinuation after a first event is infrequent. To address this gap, we propose a standardized, adjudicated definition of worsening HF events informed by published consensus definitions, expanded to capture ambulatory events across care settings. Building on this definition, we recommend hierarchical primary endpoints that prioritize all-cause death with CV death evaluated as a secondary mortality outcome when prespecified and adjudicated, while robustly measuring morbidity through total adjudicated worsening HF events (first and recurrent), with validated patient-reported outcomes as additional hierarchical levels. We outline operational considerations for event capture and adjudication, including prioritized composite analytic approaches, and highlight safeguards to mitigate ascertainment bias and dilution by more subjectively defined events. Adoption of worsening HF -based hierarchical endpoints can better reflect the total disease burden, improve statistical power, and enhance interpretability across evolving care models."}