Longitudinal improvements in perceptual voice quality in acute heart failure: results of the AHF-Voice Strobo substudy
M Bauser, F Kraus, V Cejka, F Sahiti, C Morbach, R Pryss, K Rak, S Frantz, J Hoxha, S Stoerk, F KerwagenAbstract
Background
According to the European Laryngological Society (ELS), auditory-perceptual assessment represents a central component of functional voice diagnostics and forms the basis for standardized rating scales such as the RBH scale. While perceptual voice alterations have been described in various clinical conditions, systematic longitudinal data in patients with acute heart failure (AHF) are lacking.
Methods
The AHF-Voice Strobo substudy is part of the prospective, monocentric AHF-Voice cohort and aimed to provide a comprehensive longitudinal voice assessment, including auditory-perceptual evaluation, videolaryngostroboscopy, acoustic features, and patient-reported outcome measures. Assessments were performed at admission, discharge, and at 6 week and 6 month follow-up visits. Audio recordings were independently evaluated by a blinded phoniatric expert using the RBH scale (roughness, breathiness, hoarseness; 0–3 scale). Spearman correlations were used to assess associations between RBH scores and clinical parameters. Longitudinal changes were analyzed using cumulative link mixed models (CLLM), with time effects evaluated via likelihood ratio tests. In addition to primary time-effect models, explanatory CLMMs were constructed for roughness (R) and hoarseness (H) to evaluate the influence of clinical variables (NYHA functional class, NT-proBNP, body weight, and overhydration) as well as ELS-recommended stroboscopic parameters.
Results
Between Apr 2023 and Nov 2025, 50 patients hospitalized for AHF were included in the stroboscopy substudy (mean age 73±11 years; 22% women; 26% de novo heart failure). Median NT-proBNP at admission was 6573 [quartiles 2472–14535] pg/mL, 84% were NYHA class III/IV, and mean LVEF was 44±17%. Longitudinal analyses using cumulative link mixed models demonstrated significant improvements in roughness (χ²(3) =11.8, p=0.008) and hoarseness (χ²(3) =13.2, p=0.004) over time, whereas breathiness showed no significant change (χ²(3)=6.1, p=0.106). Post-hoc comparisons showed roughness scores at 6 months were lower than at discharge (p=0.010), and hoarseness scores at 6 months were lower than at baseline, discharge, and 6 weeks (all p<0.05). These temporal effects remained significant after adjustment for systemic disease severity, clinical status, body weight, and ELS stroboscopic parameters. Among all evaluated variables, only regularity was independently associated with both roughness and hoarseness severity, see Table.
Conclusion
In patients with AHF, perceptual voice quality—particularly roughness and hoarseness—improves over time, largely independent of systemic disease severity and structural stroboscopic findings. Vibratory regularity emerged as the most relevant determinant of perceptual voice impairment. These findings support the use of auditory-perceptual voice assessment, but further studies are needed to clarify its role in patient management.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.