Douglas S. Lee, MD, PhD; Audra Stitt, MSc; Peter C. Austin, PhD; Therese A. Stukel, PhD; Michael J. Schull, MD, MSc; Alice Chong, BSc; Gary E. Newton, MD; Jacques S. Lee, MD, MSc; Jack V. Tu, MD, PhD
Disclaimer: The opinions, results, and conclusions are those of the authors and no endorsement by the Ministry of Health and Long-Term Care or the Institute for Clinical Evaluative Sciences is intended or should be inferred.
Acknowledgment: The authors thank Dr. David Henry for reviewing and providing comments on an earlier draft of the manuscript.
Grant Support: The Institute for Clinical Evaluative Sciences is supported in part by a grant from the Ontario Ministry of Health and Long-Term Care. This research was supported by an operating grant from the Canadian Institutes of Health Research (CIHR MOP 114937), a Canadian Institutes of Health Research clinician-scientist award (Dr. D.S. Lee), a Career Investigator Award from the Heart and Stroke Foundation of Ontario (Dr. Austin, Dr. Tu), a Canadian Institutes of Health Research Applied Chair in Health Services and Policy Research (Dr. Schull), and a Canada Research Chair in Health Services Research (Dr. Tu).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-2177.
Reproducible Research Statement:Study protocol: Available from Dr. D.S. Lee (e-mail, firstname.lastname@example.org). Data set and statistical code: Not available.
Requests for Single Reprints: Douglas S. Lee, MD, PhD, Institute for Clinical Evaluative Sciences and University Health Network, University of Toronto, Room G-106, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; e-mail, email@example.com.
Current Author Addresses: Drs. D.S. Lee, Austin, Stukel, Schull, and Tu; Ms. Stitt; and Ms. Chong: Institute for Clinical Evaluative Sciences, Room G-106, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.
Dr. Newton: University Health Network and Mt. Sinai Hospital, 600 University Avenue, Suite 1543, Toronto, Ontario M5G 1X5, Canada.
Dr. J.S. Lee: Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.
Author Contributions: Conception and design: D.S. Lee, M.J. Schull, J.S. Lee, J.V. Tu.
Analysis and interpretation of the data: D.S. Lee, P.C. Austin, M.J. Schull, A. Chong, J.S. Lee, J.V. Tu.
Drafting of the article: D.S. Lee, A. Stitt, M.J. Schull, J.S. Lee.
Critical revision of the article for important intellectual content: D.S. Lee, P.C. Austin, M.J. Schull, G.E. Newton, J.S. Lee, J.V. Tu.
Final approval of the article: D.S. Lee, A. Stitt, P.C. Austin, M.J. Schull, G.E. Newton, J.S. Lee, J.V. Tu.
Provision of study materials or patients: D.S. Lee, J.S. Lee.
Statistical expertise: D.S. Lee, P.C. Austin, T.A. Stukel.
Obtaining of funding: D.S. Lee, J.V. Tu.
Administrative, technical, or logistic support: D.S. Lee, A. Stitt, J.S. Lee, J.V. Tu.
Collection and assembly of data: D.S. Lee, A. Stitt, J.S. Lee, J.V. Tu.
Heart failure contributes to millions of emergency department (ED) visits, but hospitalization-versus-discharge decisions are often not accompanied by prognostic risk quantification.
To derive and validate a model for acute heart failure mortality applicable in the ED.
Clinical data abstraction with development of a broadly applicable multivariate risk index for 7-day death using initial vital signs, clinical and presentation features, and readily available laboratory tests.
Multicenter study of 86 hospitals in Ontario, Canada.
Population-based random sample of 12 591 patients presenting to the ED from 2004 to 2007.
Death within 7 days of presentation.
In the derivation cohort (n = 7433; mean age, 75.4 years [SD, 11.4]; 51.5% men), mortality risk increased with higher triage heart rate (adjusted odds ratio [OR], 1.15 [95% CI, 1.03 to 1.30] per 10 beats/min) and creatinine concentration (OR, 1.35 [CI, 1.14 to 1.60] per 1 mg/dL [88.4 µmol/L]), and lower triage systolic blood pressure (OR, 1.52 [CI, 1.31 to 1.77] per 20 mm Hg) and initial oxygen saturation (OR, 1.16 [CI, 1.01 to 1.33] per 5%). Nonnormal serum troponin levels (OR, 2.75 [CI, 1.86 to 4.07]) were associated with increased mortality risk. Areas under the receiver-operating characteristic curves of the multivariate model were 0.805 for the derivation data set (bootstrap-corrected, 0.811) and 0.826 for validation data set (n = 5158; mean age, 75.7 years [SD, 11.4]; 51.6% men). In the derivation cohort, a multivariate index score stratified 7-day mortality with rates of 0.3%, 0.3%, 0.7%, and 1.9% in quintiles 1 to 4, respectively. Mortality rates in the 2 highest risk groups were 3.5% and 8.2% in deciles 9 and 10, respectively.
Left ventricular ejection fraction was not included in the model.
A multivariate index comprising routinely collected variables stratified mortality risk with high discrimination in a broad group of patients with acute heart failure presenting to the ED.
Canadian Institutes of Health Research.
Lee DS, Stitt A, Austin PC, Stukel TA, Schull MJ, Chong A, et al. Prediction of Heart Failure Mortality in Emergent Care: A Cohort Study. Ann Intern Med. ;156:767–775. doi: 10.7326/0003-4819-156-11-201206050-00003
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Published: Ann Intern Med. 2012;156(11):767-775.
Cardiology, Emergency Medicine, Heart Failure, Hospital Medicine.
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