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.
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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. 2012;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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