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Multivariate model accurately predicted mortality risk in HF patients in the ED
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A model incorporating routinely collected variables accurately predicted 7-day mortality risk in HF patients presenting to the ED. This tool, researchers said, may improve clinical decision-making for these patients.
Currently, clinicians rely solely on clinical judgment to assess patients with HF in the ED. To develop and evaluate a model for HF mortality based on prognostic quantification, researchers examined 12,591 patients who presented to the ED with HF. They separated patients into two cohorts: a derivation cohort designed to extrapolate a model to predict HF risk (n=7,433; mean age, 75.4 years) and a validation cohort to test the accuracy and viability of the model (n=5,158; mean age, 75.7 years). The outcome was 7-day mortality.
Results indicated that mortality risk increased with the following in the derivation cohort:
- Higher triage heart rate (adjusted OR=1.15; 95% CI, 1.03-1.3 per 10 beats per minute).
- Creatinine concentration (OR=1.35; 95% CI, 1.14-1.6 per 1 mg/dL).
- Lower triage systolic BP (OR=1.52; 95% CI, 1.31-1.77 per 20 mm Hg).
- Initial oxygen saturation (OR=1.16; 95% CI, 1.01-1.33 per 5%).
- Non-normal serum troponin levels (OR=2.75; 95% CI, 1.86-4.07).
In the multivariate model, named the Emergency Heart Failure Mortality Risk Grade (EHMRG), the areas under the receiver-operating characteristic curves were 0.805 for the derivation cohort (bootstrap-corrected, 0.811), suggesting high discrimination, and 0.826 for the validation cohort.
Researchers also found that a 20-point increase in EHMRG score increased odds for 7-day mortality by 41% in the derivation cohort and by 39% in the validation cohort (both P<.001). Further, risk for 7-day mortality increased 2.9-fold with each 1-standard deviation increase in both cohorts (both P<.001).
When stratified into quintiles of mortality risk according to the multivariate model, mortality rates were 0.3%, 0.3%, 0.7% and 1.9% for quintiles 1 through 4, respectively. Mortality rates for the two highest risk groups, which were contained in quartile 5, was 3.5% in decile 9 and 8.2% in decile 10.
“The EHMRG is a simple clinical risk model that can predict, with high accuracy, acute mortality among patients with HF who present to the ED,” the researchers concluded. “The importance of this risk model for prognostication is underscored by the inclusion of patients who present to the ED regardless of disposition and its utility in guiding acute care decisions. The care and outcomes of patients with acute HF may be substantially improved if clinical judgment is supported by prognostic quantification in emergent care.”
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