Association of GWTG-HF Risk Score with Major Adverse Cardiovascular Events in Acute Heart Failure Patients: A Retrospective Study in a Tertiary Hospital in Indonesia

INTRODUCTION

Heart failure (HF) is a clinical syndrome characterized by typical symptoms such as dyspnea, ankle swelling, and fatigue, often accompanied by signs such as elevated jugular venous pressure, pulmonary crackles, and peripheral edema. It results from structural or functional cardiac abnormalities, leading to increased intracardiac pressure and/or inadequate cardiac output at rest or during exercise. Most cases arise from myocardial dysfunction in the systolic, diastolic, or both phases, with contributions from valvular abnormalities, pericardial/endocardial disorders, and rhythm/conduction disturbances [1].

In developed countries, the age-adjusted HF incidence has declined due to improved cardiovascular disease management; however, the overall prevalence has increased with population aging. Globally, HF affects more than 64 million individuals. In Europe, the incidence is approximately 3–5 per 1000 person-years, with a prevalence of 1–2% in adults, increasing from <1% in those <55 years to >10% in those >70 years. Approximately 50% of patients have heart failure with reduced ejection fraction (HFrEF), while the remainder have heart failure with preserved ejection fraction (HFpEF) or mildly reduced ejection fraction (HFmrEF). Long-term ESC of Cardiology registry data indicate proportions of 60% HFrEF, 24% HFmrEF, and 16% HfpEF [1].

HF remains a complex syndrome with persistently high morbidity and mortality, which is projected to increase with global aging and impose substantial healthcare burdens. Effective risk stratification is essential for optimizing management, including outpatient follow-up, pharmacotherapy titration, and device therapies. Individual clinical parameters, such as age, blood pressure, heart rate, renal function, B-type natriuretic peptide levels, inflammatory biomarkers, echocardiographic findings, respiratory capacity, anemia, and sleep-disordered breathing, serve as prognostic indicators to distinguish high- from low-risk patients [2]. In the REPORT-HF registry, crude 1-year mortality varied across Asia, being highest in Indonesia (34.1%) and lowest in Korea (10.9%), with Indonesian patients (n=337 discharged alive) having a median age of 56 years and 38.6% being female [3]. In Indonesia, age-adjusted cardiovascular mortality rose from 2000 to 2019, contributing significantly to the overall burden [4]. Local data from a Medan hospital (2019) reported 417 HF admissions, predominantly in males (72.7%), with hypertension as the leading risk factor (64%) and major cardiovascular events in 184 patients [5].

Major adverse cardiovascular events (MACE) typically comprise a composite of all-cause death, myocardial infarction, coronary revascularization, stroke, and heart failure hospitalization, contributing to substantial morbidity, mortality, reduced quality of life, and increased healthcare costs [6-8]. MACE has profound socioeconomic implications, with cardiovascular diseases causing over 17 million deaths annually [9,10]. In Indonesia, coronary heart disease is the leading cause of death, with a rising prevalence of risk factors such as obesity and diabetes [11]. Several risk prediction models have been developed, including the Seattle Heart Failure Model, GWTG-HF, ADHERE, MAGGIC-HF, and GISSI-HF models [12]. Comprehensive scores that incorporate multiple parameters better predict outcomes. For instance, the AHEAD score targets the long-term risk of acute HF [2].

In 2010, Peterson et al. developed and validated the GWTG-HF risk score to predict in-hospital mortality in acute HF using seven admission variables: age, systolic blood pressure, blood urea nitrogen, heart rate, serum sodium, history of chronic obstructive pulmonary disease, and non-Black race. Derived from 39,783 patients across 198 U.S. hospitals, it reported 2.86% in-hospital mortality and similar poor prognosis in HFrEF and HFpEF [13]. Subsequent studies have confirmed its discriminatory ability for in-hospital and 1-year mortality [14]. In Japanese cohorts, higher GWTG-HF scores were correlated with elevated natriuretic peptide levels and increased all-cause mortality (23.9%) and cardiovascular events (28%) [15]. Validation in Japan showed good discrimination, which was enhanced by the addition of BNP [16]. In Asian American patients, comparable outcomes supported generalizability [17]. Indian studies have demonstrated competitive performance versus APACHE II, with a significant NT-proBNP correlation [18]. External validations consistently affirmed reliability, although local adaptation may be needed due to demographic variations [19].

The GWTG-HF score offers practical advantages by utilizing routinely collected admission variables for easy calculation and high-risk identification to inform decisions [20]. Its applicability for mortality and MACE prediction in acute HF warrants further evaluation, particularly in under-represented populations. At Adam Malik General Hospital, Medan, no routine risk scoring assesses mortality or MACE in patients with HF, prompting an investigation into the association between the GWTG-HF score and in-hospital MACE in acute HF. Despite the available scores, routine clinical use remains limited because of their complexity and individual-level accuracy. HF prognosis involves multifaceted factors, with acute exacerbations signaling worse outcomes and high readmission rates (10–30% within 90 days to 1 year) [12].

METHOD

This retrospective observational cohort study investigated the association between the Get With The Guidelines-Heart Failure (GWTG-HF) risk score and in-hospital major adverse cardiovascular events (MACE) in patients with acute heart failure (AHF). This study was conducted at Adam Malik General Hospital, a tertiary referral center in Medan, Indonesia. Data will be retrieved from the medical records of consecutive patients admitted with AHF between January 2024 and March 2025.

The target population comprised adult patients diagnosed with AHF. Eligible participants were aged ≥18 years, admitted through the emergency department or directly to wards, and had a diagnosis supported by history, physical examination, and ancillary investigations. Patients were required to have complete medical records sufficient for the GWTG-HF score calculation. The exclusion criteria included end-stage renal disease requiring hemodialysis, implanted pacemaker, pregnancy, palliative care status, and congenital heart disease. The minimum sample size was calculated to detect a clinically meaningful difference in MACE incidence between the high- and low-risk GWTG-HF categories, yielding approximately 77 patients per group, for a total of 231 patients. However, all consecutive eligible patients during the study period were included to enhance the precision. Data collection involved the review of electronic and paper medical records. Baseline characteristics, admission vital signs, laboratory results, comorbidities, and in-hospital outcomes were also recorded. The GWTG-HF risk score was computed using the seven established variables and categorized into low-, moderate-, and high-risk groups. The primary outcome was in-hospital MACE, a composite endpoint that included all-cause mortality, acute myocardial infarction, stroke, cardiogenic shock, and malignant ventricular arrhythmia.

Table 1. Study Variables

Variable Type	Variable	Measurement Scale
Independent	GWTG-HF Risk Score	Ordinal
Dependent	Major Adverse Cardiovascular Events	Nominal

Table 2 Research Budget

No.	Activity	Cost (IDR)
1	Research permit processing	1,500,000
2	Stationery and photocopying	2,000,000
3	Data collection and processing	2,000,000
4	Contingency	500,000

Total 6,000,000

The operational definitions for key variables, including the components of the GWTG-HF score (age, systolic blood pressure, heart rate, blood urea nitrogen, serum sodium, COPD history, and race) and MACE, followed established guidelines and prior validations. Categorical data were expressed as frequencies and percentages, while continuous data were presented as mean ± standard deviation or median (range) based on normality assessed using the Kolmogorov-Smirnov test. Associations were examined using chi-square or Fisher's exact tests for categorical variables and independent t-tests or Mann-Whitney U tests for continuous variables. Significant bivariate predictors were included in the multivariate logistic regression models. Statistical analyses were performed using SPSS version 22, with p < 0.05 denoting significance. Ethical approval was obtained from the Health Research Ethics Committee of the Faculty of Medicine, Universitas Sumatera Utara, and research permission was obtained from the Research and Development Unit of Adam Malik General Hospital. The study adhered to the principles of confidentiality and was granted a waiver of informed consent owing to its retrospective design.

RESULTS

This retrospective cohort study included 319 patients with acute heart failure (AHF) admitted to Adam Malik General Hospital, Medan, Indonesia, between January 2024 and March 2025. Initially, 382 potential cases were identified from hospital records; 63 were excluded due to incomplete data or meeting exclusion criteria, yielding the final analytical sample.

Table 4.1. Baseline Categorical Characteristics by GWTG-HF Risk Category

Parameter	Low (n=124)	Moderate (n=86)	High (n=109)
Male sex	85 (68.5%)	50 (58.1%)	78 (71.6%)
Acute decompensated HF	82 (66.1%)	61 (70.9%)	69 (63.3%)
Acute pulmonary edema	39 (31.5%)	22 (25.6%)	30 (27.5%)
Cardiogenic shock	0 (0.0%)	0 (0.0%)	6 (5.5%)
Infection etiology	50 (40.3%)	36 (41.9%)	45 (41.3%)
Coronary heart disease	76 (61.3%)	51 (59.3%)	72 (66.1%)
Smoking	64 (51.6%)	39 (45.3%)	59 (54.1%)
Hypertension	72 (58.1%)	44 (51.2%)	49 (45.0%)
HFrEF	53 (42.7%)	46 (53.5%)	67 (61.5%)
Furosemide use	115 (92.7%)	84 (97.7%)	108 (99.1%)

The baseline characteristics are summarized in Tables 4.1 and 4.2. The cohort had a median age of 55 years (range, 18–85 years), with males predominating (213 patients; 66.8%). The most common clinical presentation was acute decompensated heart failure (212 patients, 66.5%), followed by acute pulmonary edema. Infection was the leading etiology (131 patients, 41.1%), and coronary heart disease was the most frequent comorbidity (199 patients, 62.4%). HFrEF was present in 166 patients (52.0%). Loop diuretics (furosemide) were prescribed in almost all patients (307 patients, 96.2%).

Table 4.2. Baseline Continuous Characteristics by GWTG-HF Risk Category (Median (range) unless stated otherwise)

Parameter	Low (n=124)	Moderate (n=86)	High (n=109)
Age (years)	51.5 (18–75)	58 (23–82)	61 (21–85)
Length of stay (days)	5 (2–23)	5 (1–47)	6 (1–30)
Systolic BP (mmHg)	140 (100–235)	121 (90–195)	105 (70–153)
Heart rate (bpm)	87.5 (30–146)	99.5 (44–185)	109 (34–212)
Sodium (mEq/L)	143 (122–151)	141 (128–150)	142 (114–152)
BUN (mg/dL)	14.5 (3.7–57.5)	19.2 (6.5–60.7)	28 (7.5–100)

Patients were stratified by the GWTG-HF risk score into low (n=124; 38.9%), moderate (n=86; 27.0%), and high (n=109; 34.2%) categories (Table 4.3). Higher risk categories were associated with older age, lower systolic blood pressure, higher heart rate, elevated blood urea nitrogen levels, and a greater prevalence of chronic obstructive pulmonary disease. In-hospital major adverse cardiovascular events (MACE) occurred in 95 patients (29.8%), predominantly all-cause mortality (60 patients; 18.8%), followed by cardiogenic shock and malignant arrhythmias. MACE incidence increased markedly across risk strata: 8.1% in low-risk, 29.1% in moderate-risk, and 55.0% in high-risk groups (p<0.001)

Table 4.3. In-Hospital MACE by GWTG-HF Risk Category

Event	Low (n=124)	Moderate (n=86)	High (n=109)	p-value
Any MACE	10 (8.1%)	25 (29.1%)	60 (55.0%)	<0.001
All-cause mortality	5 (4.0%)	15 (17.4%)	40 (36.7%)
Cardiogenic shock	2 (1.6%)	13 (15.1%)	36 (33.0%)

Multivariate logistic regression identified age (OR 1.052; 95% CI 1.027–1.078; p=0.001), systolic blood pressure (OR 0.974; 95% CI 0.964–0.985; p=0.001), heart rate (OR 1.015; 95% CI 1.004–1.026; p=0.006), BUN (OR 1.033; 95% CI 1.013–1.054; p=0.001), and sodium (OR 0.990; 95% CI 0.946–1.036; p=0.011) as independent predictors of MACE Receiver operating characteristic analysis demonstrated good discriminatory performance of the GWTG-HF score for in-hospital MACE (AUC 0.759; 95% CI not reported; p<0.001), with sensitivity 63.2% and specificity 78.1%

DISCUSSION

This retrospective cohort study of 319 patients with acute heart failure (AHF) at a tertiary hospital in Indonesia confirmed a strong association between the Get With The Guidelines-Heart Failure (GWTG-HF) risk score and in-hospital major adverse cardiovascular events (MACE). The observed MACE rate of 29.8%, which increased to 55.0% in high-risk patients, underscores the score's utility in identifying individuals requiring intensified management.

The demographic profile—predominantly male (66.8%) with a median age of 55 years—is consistent with global HF epidemiology, where male preponderance reflects higher exposure to ischemic triggers and differing hormonal influences on cardiac remodeling [21-37]. Acute decompensated heart failure dominated presentations, but high-risk strata showed enrichment for cardiogenic shock and right ventricular failure, aligning with evidence that advanced hemodynamic compromise portends poor short-term outcomes [38,39]. Acute coronary syndrome, the leading etiology in high-risk patients (48.6%), reinforces its role in precipitating rapid deterioration, extensive myocardial necrosis, and arrhythmogenic substrates [38]. The comorbidity burden escalated with the risk category, with coronary heart disease, chronic kidney disease, and chronic obstructive pulmonary disease being more prevalent in the high-risk groups. [38] These findings corroborate those of multinational registries demonstrating the multiplicative prognostic impact of cardiorenal and cardiopulmonary interactions [39]. HFrEF predominance in high-risk patients (61.5%) versus HFpEF in low-risk strata reflects greater structural myocardial damage and neurohormonal activation in reduced ejection fraction phenotypes [37].

Guideline-directed therapy revealed near-universal loop diuretic use, modest ARNI uptake in severe cases, and strikingly low SGLT2 inhibitor prescription, highlighting persistent implementation gaps in resource-constrained settings despite robust evidence for mortality reduction across the ejection fraction spectra [40,41]. Laboratory derangements, such as elevated BUN, lower systolic blood pressure, tachycardia, and relative hyponatremia in high-risk patients, mirror established markers of cardiorenal syndrome, inadequate perfusion, and neurohormonal dysregulation [42-51]. Multivariate analysis identified age, systolic blood pressure, heart rate, BUN, and sodium as independent MACE predictors, recapitulating the core GWTG-HF components and validating their pathophysiological relevance [52-61]. The score's discriminatory performance (AUC 0.759) compares favorably with external validations in diverse populations, confirming moderate-to-good accuracy using readily available admission variables [62]. This supports the routine GWTG-HF calculation for early risk stratification, potentially guiding resource allocation, monitoring intensity, and timely escalation of advanced therapies.

The strengths of this study include the comprehensive characterization of a Southeast Asian cohort and the addressing of underrepresented regions in the HF prognostication literature. The limitations of this study include its single-center retrospective design, potential selection bias from the exclusion criteria, and inability to assess race effects due to ethnic homogeneity. Prospective multicenter validation, ideally incorporating contemporary biomarkers or machine-learning enhancements, would strengthen the generalizability of our findings. In conclusion, the GWTG-HF risk score reliably predicts in-hospital MACE in Indonesian patients with AHF, offering a simple, pragmatic tool to optimize clinical decision-making and improve outcomes in real-world practice.

CONCLUSION

This study of 319 acute heart failure patients at Adam Malik General Hospital demonstrated a predominantly male cohort (54.5%) with a mean age of 55 years, chiefly presenting with acute decompensated heart failure (65.8%) and coronary heart disease comorbidity (62.4%). The GWTG-HF risk score showed good predictive accuracy for in-hospital MACE (AUC 0.759; p<0.001; sensitivity 63.2%; specificity 78.1%), with age, systolic blood pressure, heart rate, sodium, and BUN as significant independent predictors of in-hospital MACE. MACE occurred in 29.8% of patients (mortality 18.8%), and increased significantly with higher risk categories. These findings validate the GWTG-HF score as an effective risk stratification tool in this population and recommend its routine use at admission. Multicenter studies with larger sample sizes are required to improve the generalizability of the results.

DECLARATIONS

Ethics approval and consent to participate were obtained. Permission for this study was obtained from the Ethics Committee of the Universitas Sumatera Utara and Haji Adam Malik General Hospital.

CONSENT FOR PUBLICATION

The Authors agree to the publication in the Journal of Society Medicine.

FUNDING

None

COMPETING INTERESTS

The authors declare that there is no conflict of interest in this report.

AUTHORS’ CONTRIBUTIONS

All authors significantly contribute to the work reported execution, acquisition of data, analysis, and interpretation, or in all these areas. Contribute to drafting, revising, or critically reviewing the article. Approved the final version to be published, agreed on the journal to be submitted, and agreed to be accountable for all aspects of the work.

ACKNOWLEDGMENTS

None