Abstract
Our aims were to create and validate a clinical decision rule to assess severity in acute heart failure. We conducted a prospective cohort study of patients with symptoms of acute heart failure who attended the emergency departments (EDs) of three hospitals between April 2011 and April 2013. The following data were collected on arrival to or during the stay in the ED: baseline severity of symptoms; presence of decompensated comorbidities; number of hospital admissions/visits to EDs for acute heart failure during the previous 24 months; triggers of the exacerbation; clinical signs and symptoms; results of ancillary tests requested in the ED; treatments prescribed; and response to the initial treatment in the ED. The main outcome was poor course during the acute phase, in-hospital for admitted patients and during the first week following the ED visit for discharged patients, this being a composite endpoint that included death, admission to an intensive care unit, need for invasive mechanical ventilation, cardiac arrest and use of non-invasive mechanical ventilation. Multivariate logistic regression models were developed. Predictors of poor course in acute heart failure were oedema on chest radiography, visits to the ED and/or admissions in the previous two years, and levels of glycemia and blood urea nitrogen (areas under the curve of 0.83 in the derivation sample, and 0.82 in the validation sample). Four clinical predictors available in the ED can be used to create a simple score to predict poor course in acute heart failure.
Clinical Trials.gov ID: NCT02437058.
Similar content being viewed by others
References
Rodriguez-Artalejo F, Guallar-Castillon P, Banegas B Jr, del Rey CJ (2000) Geographic variation in hospitalizations and mortality related to congestive heart failure in Spain, 1980–1993. Rev Esp Cardiol 53(6):776–782
Auble TE, Hsieh M, Gardner W, Cooper GF, Stone RA, McCausland JB et al (2005) A prediction rule to identify low-risk patients with heart failure. Acad Emerg Med 12(6):514–521
Grafstein E, Bullard MJ, Warren D, Unger B; CTAS National Working Group (2008) Revision of the Canadian Emergency Department Information System (CEDIS) presenting complaint list version 1.1. CJEM 10(2):151–173
Chin MH, Goldman L (1997) Correlates of early hospital readmission or death in patients with congestive heart failure. Am J Cardiol 79(12):1640–1644
Fonarow GC, Adams KF Jr, Abraham WT, Yancy CW, Boscardin WJ, ADHERE Scientific Advisory Committee, Study Group, and Investigators (2005) Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis. JAMA 293(5):572–580
Lee DS, Austin PC, Rouleau JL, Liu PP, Naimark D, Tu JV (2003) Predicting mortality among patients hospitalized for heart failure: derivation and validation of a clinical model. JAMA 290(19):2581–2587
Lee DS, Stitt A, Austin PC, Stukel TA, Schull MJ, Chong A et al (2012) Prediction of heart failure mortality in emergent care: a cohort study. Ann Intern Med 156(11):767–775, w-261, w-262
Stiell IG, Clement CM, Brison RJ, Rowe BH, Borgundvaag B, Aaron SD et al (2013) A risk scoring system to identify emergency department patients with heart failure at high risk for serious adverse events. Acad Emerg Med 20(1):17–26
McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al (2012) ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 14(8):803–869 (Erratum in: Eur J Heart Fail. 2013; 15(3):361–362)
Pang PS, Komajda M, Gheorghiade M (2010) The current and future management of acute heart failure syndromes. Eur Heart J 31(7):784–793
Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383
Steyerberg EW (2009) Chapter 11: selection of main effects. In: Steyerberg EW (ed) Clinical prediction models. A practical aprroach to development, validation and updating, 1st edn. Springer, New York, pp 191–212
Barrio I, Arostegui I, Rodríguez-Álvarez MX, Quintana JM (2015) A new approach to categorising continuous variables in prediction models: Proposal and validation. Stat Methods Med Res [Epub ahead of print]
Jacob RJ (2014) Las 20 mejores comunicaciones al XXVI Congreso Nacional de la SEMES. Emergencias. 26:323–340
Caldentey G, Khairy P, Roy D, Leduc H, Talajic M, Racine N et al (2014) Prognostic value of the physical examination in patients with heart failure and atrial fibrillation: insights from the AF-CHF Trial (Atrial Fibrillation and Chronic Heart Failure). JACC: Heart Fail 2(1):15–23
Negi S, Sawano M, Kohsaka S, Inohara T, Shiraishi Y, Kohno T et al (2014) Prognostic implication of physical signs of congestion in acute heart failure patients and its association with steady-state biomarker levels. PLoS One 9(5):e96325
Eschalier R, Chenaf C, Al Mulliez, Yalioua A, Clerfond G, Authier N et al (2015) Impact of clinical characteristics and management on the prognosis of unselected heart failure patients. Cardiovasc Drugs Ther 29(1):89–98
Helfand BK, Maselli NJ, Lessard DM, Yarzebski J, Gore JM, McManus DD et al (2015) Elevated serum glucose levels and survival after acute heart failure: a population-based perspective. Diabetes Vasc Dis Res 12(2):119–125
Sud M, Wang X, Austin PC, Lipscombe LL, Newton GE, Tu JV et al (2015) Presentation blood glucose and death, hospitalization, and future diabetes risk in patients with acute heart failure syndromes. Eur Heart J 36(15):924–931
O’Connor CM, Mentz RJ, Cotter G, Metra M, Cleland JG, Davison BA et al (2012) The PROTECT in-hospital risk model: 7-day outcome in patients hospitalized with acute heart failure and renal dysfunction. Eur J Heart Fail 14(6):605–612
Chen CY, Yoshida A, Asakura M, Hasegawa T, Takahama H, Amaki M et al (2012) Serum blood urea nitrogen and plasma brain natriuretic peptide and low diastolic blood pressure predict cardiovascular morbidity and mortality following discharge in acute decompensated heart failure patients. Circ J 76(10):2372–2379
van Riet EES, Hoes AW, Limburg A, Landman MAJ, van der Hoeven H, Rutten FH (2014) Prevalence of unrecognized heart failure in older persons with shortness of breath on exertion. Eur J Heart Fail 16(7):772–777
Senni M, Gavazzi A, Oliva F, Mortara A, Urso R, Pozzoli M et al (2014) In-hospital and 1-year outcomes of acute heart failure patients according to presentation (de novo vs. worsening) and ejection fraction. Results from IN-HF Outcome Registry. Int J Cardiol 173(2):163–169
Setoguchi S, Stevenson LW, Schneeweiss S (2007) Repeated hospitalizations predict mortality in the community population with heart failure. Am Heart J 154(2):260–266
Wang H, Robinson R, Johnson C, Zenarosa N, Jayswal R, Keithley J et al (2014) Using the LACE index to predict hospital readmissions in congestive heart failure patients. BMC Cardiovasc Disord 14(1):97
Sidhu RS, Youngson E, McAlister FA (2014) Physician continuity improves outcomes for heart failure patients treated and released from the emergency department. JACC: Heart Fail 2(4):368–376
Feltner C, Jones CD, Cené CW, Zheng ZJ, Sueta CA, Coker-Schwimmer EJL et al (2014) Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis transitional care for persons with heart failure. Ann Intern Med 160(11):774–784
Jacob J, Martin-Sanchez FJ, Herrero P, Miro O, Llorens P (2013) Prognostic value of troponin in patients with acute heart failure attended in Spanish Emergency Departments: TROPICA study (TROPonin in acute heart failure). Med Clin (Barc) 140(4):145–151
Martin Sanchez FJ, Covarrubias M, Teran C, Llorens P, Herrero P, Jacob J et al (2013) Prognostic role of NT-proBNP in emergency department in the elderly with acute heart failure. Rev Esp Geriatr Gerontol 48(4):155–160
Ho EC, Schull MJ, Lee DS (2012) The challenge of heart failure discharge from the emergency department. Curr Heart Fail Rep 9(3):252–259
Stiell IG, Wells GA (1999) Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med 33(4):437–447
Collins GS, Reitsma JB, Altman DG, Moons KG (2015) Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement. BJOG 122(3):434–443
Chin MH, Goldman L (1996) Correlates of major complications or death in patients admitted to the hospital with congestive heart failure. Arch Intern Med. 156(16):1814–1820
Peterson PN, Rumsfeld JS, Liang L, Albert NM, Hernandez AF, Peterson ED, Fonarow GC, Masoudi FA, American Heart Association Get With the Guidelines-Heart Failure Program (2010) A validated risk score for in-hospital mortality in patients with heart failure from the American Heart Association get with the guidelines program. Circ Cardiovasc Qual Outcomes. 3(1):25–32
Acknowledgments
The authors are grateful for the support of the participating hospitals, as well as the emergency physicians, other clinicians and staff members of the various clinical, research, quality, and medical units of these hospitals; the patients who participated in the study; and the editorial assistance provided by J. Fenn. The AHFRS-Group included the following co-investigators: Susana García-Gutiérrez, MD, PhD; José M. Quintana, MD, MPH, PhD; Iratxe Lafuente, MSc; Ane Antón-Ladislao, MSc, Urko Aguirre, MSc; Hospital Galdakao-Usansolo Research Unit (REDISSEC-Health Services Research in Chronic diseases Network]; Maria Soledad Gallardo Rebollal, MD; Iñaki Areitio, MD; Esther Pulido Herrero, MD; Adriana Laura Fretin MD, Amaia Fernández, MD, Mikel Sanchez Fernández MD; (Hospital Galdakao-Usansolo Emergency Department], Miren Morillas, MD, PhD; Jose Juan Onaindia, MD; Jose Fernández-Ruiz, MD; (Hospital Galdakao-Usansolo Cardiology Department]; Nekane Murga, Hospital Basurto Cardiology Department]; Irene Rilo MD, Juan Ramón Beramendi, MD; (Hospital Donostia Cardiology Department]; Elena Zubillaga, MD, PhD; Elena Zubillaga, MD, PhD; (Hospital Donostia Internal Medicine Department]; Ricardo Palenzuela, MD, Oihana Urbina, MD, Pablo Busca MD; (Hospital Donostia Emergency Department].
Author information
Authors and Affiliations
Consortia
Corresponding author
Ethics declarations
Conflict of interest
Authors declare no conflict of interest.
Statement of human and animal rights
Institutional Review Board evaluated and approved this study.
Informed consent
Patients were only included once they or their caregivers had provided written informed consent.
Funding
This work was supported by Euskal Irrati Telebista Maratoia 2010-Basque Foundation for Health Innovation and Research -BIOEF [BIO10/EC/009] and Department of Health of Basque Government [2011111045].
Rights and permissions
About this article
Cite this article
Garcia-Gutierrez, S., Quintana, J.M., Antón-Ladislao, A. et al. Creation and validation of the acute heart failure risk score: AHFRS. Intern Emerg Med 12, 1197–1206 (2017). https://doi.org/10.1007/s11739-016-1541-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11739-016-1541-4