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Don't tell your patients where they are, let them tell you

Chronic heart failure (HF) is a dynamic not a static disease state. Individuals with ‘stable’ HF may experience episodic exacerbations, requiring increases in diuretic intensity or acute inpatient hospitalization for transient deteriorations.1 One of the great challenges confronting HF specialists is to differentiate those individuals approaching end-stage disease and in need of advanced HF therapies from those who are either undertreated or are simply experiencing normal dynamic disease stability. Among others, we have previously proposed the concept of patient hysteresis: that a patient’s prognosis may be predicted by and dependent on past history, as a way to resolve an individual HF patient’s position on the pathway toward disease progression.2 While intellectually appealing as a concept, identification of a reliable metric to measure this concept has been elusive. As a result the majority of clinicians and clinical trials have relied on combinations of clinical variables cobbled together into risk scores including ventricular function, plasma biomarkers and exercise capacity among others, to define an individual patient’s position on the spectrum of disease progression. Each of these metrics however provides only a snapshot in time. Each is dependent on multiple unmeasurable lifestyle variables such as diet, physical activity or psychological state at a given moment in a dynamic longitudinal process. With these considerations in mind, it seems logical to conclude that assessing the trajectory of serially assessed clinical metrics over time might provide greater insight into a patient’s overall location in their HF journey. In this issue of the Journal, Lindberg et al.3 test this hypothesis by assessing the predictive value of change in New York Heart Association functional class (NYHA FC) assessments over time as a clinical metric. While hypothesis testing in this case proved negative, we believe the concept is nevertheless valid. In fact, we believe