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Prediction of Heart Failure Mortality in Emergent Care: A Cohort Study

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; and Jack V. Tu, MD, PhD
[+] Article, Author, and Disclosure Information

From the Institute for Clinical Evaluative Sciences, University of Toronto, University Health Network, Dalla Lana School of Public Health, and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

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, dlee@ices.on.ca). 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, dlee@ices.on.ca.

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.

Ann Intern Med. 2012;156(11):767-775. doi:10.7326/0003-4819-156-11-201206050-00003
Text Size: A A A

Background: Heart failure contributes to millions of emergency department (ED) visits, but hospitalization-versus-discharge decisions are often not accompanied by prognostic risk quantification.

Objective: To derive and validate a model for acute heart failure mortality applicable in the ED.

Design: 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.

Setting: Multicenter study of 86 hospitals in Ontario, Canada.

Patients: Population-based random sample of 12 591 patients presenting to the ED from 2004 to 2007.

Measurements: Death within 7 days of presentation.

Results: 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.

Limitation: Left ventricular ejection fraction was not included in the model.

Conclusion: 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.

Primary Funding Source: Canadian Institutes of Health Research.


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Figure 1.

Study flow diagram.

ED = emergency department; HF = heart failure.

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Appendix Figure 1.

Cubic spline curves showing adjusted log odds of 7-day mortality for continuous covariates.

To convert the creatinine units from mg/dL to µmol/L, multiply value by 88.4. BP = blood pressure.

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Appendix Figure 2.

Distribution of EHMRG score in derivation and validation data sets.

EHMRG = Emergency Heart Failure Mortality Risk Grade.

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Figure 2.

Absolute 7-day mortality rates and 95% CIs, by EHMRG score.

Error bars are 95% CIs. EHMRG = Emergency Heart Failure Mortality Risk Grade.

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Figure 3.

Predictiveness of the EMHRG showing ordered distribution of 7-day mortality risk.

Vertical bars indicate 25th (*) and 75th (†) risk percentiles. EHMRG = Emergency Heart Failure Mortality Risk Grade.

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Role of Subjective and Objective Predictors to Heart Failure Mortality in Emergent Care
Posted on June 30, 2012
Gen-Min Lin, Lamin E.S. Jaiteh, Chih-Lu Han
Hualien Armed Forces General Hospital
Conflict of Interest: None Declared

To the Editor:We read with great interest the work by Lee et al which reported that using the Emergency Heart Failure Mortality Risk Grade (EHMRG) produced a discrepancy between the 7-day mortality rate of patients who were hospitalized and discharged from the emergency department (ED) (risk ratio was 2-fold) (1). The authors declared that other unmeasured factors in association with mortality probably remained. Actually, the decision for patients’ admission at ED is determined by two ends: one is the medical evaluation of doctors and the other is the willing of patients, which is related to the family support and economic status. With regard to the patients’ part, we believe the EHMRG made by Lee et al may bring about better outcomes in differentiate 7-day mortality rate between those who hospitalized and discharged in Canada in comparison with that in the United States because of its nationwide medical insurance coverage (2). Accordingly, patients who were against advice discharge at ED should be taken into account in mortality estimation from the EHMRG as well. In the other respect for the doctors’ evaluation, the admission depends on not only the objective parameters but also the subjective descriptions from patients (what the etiology is, how the severity is and when the symptom of heart failure starts?). As we know, the concept of heart failure occurs when cardiac output inadequately meets the peripheral demand. The objective parameters of EHMRG are reasonably composed of some cardiac precipitating factors such as age, ambulance transportation, potassium level, vascular thromboembolic events (troponin), cardiac power output (heart rate and systolic blood pressure), (3) and existed organ failure (metolazone use at home for heart failure; creatinine level for renal failure, oxygen saturation for pulmonary failure and cancer). However, the work load and time of precipitating factor to deteriorate heart failure symptoms have different impact on the following prognosis. For instance, patient A and B may present the same creatinine level of 2.0 mg/dl at ED but the baseline creatinine level for A is 1.0 mg and for B is 2.0 mg/dl. Obviously, patient A has acute renal failure and may have a higher risk for death than B if other factors are in control (4). Besides, sepsis is a vital cause for acute heart failure but it is not counted in the EHMRG (5). Therefore, a selection bias made by physicians should be present between hospitalized and discharged patients because of the subjective findings.


1. Lee DS, Stitt A, Austin PC, Stukel TA, Schull MJ, Chong A, Newton GE, Lee JS, Tu JV. Prediction of heart failure mortality in emergent care: a cohort study. Ann Intern Med. 2012; 156:767-775.

2. Fonarow GC, Adams KF Jr, Abraham WT, Yancy CW, Boscardin WJ; ADHERE Scientific Advisory Committee, Study Group, and Investigators. Risk stratification for in-hospital mortality in acutely decompensated heart failure:classification and regression tree analysis. JAMA. 2005;293: 572-580.

3. Mendoza DD, Cooper HA, Panza JA. Cardiac power output predicts mortality across a broad spectrum of patients with acute cardiac disease. Am Heart J. 2007 Mar;153:366-370

4. Barrantes F, Tian J, Vazquez R, Amoateng-Adjepong Y, Manthous CA. Acute kidney injury criteria predict outcomes of critically ill patients. Crit Care Med. 2008; 36:1397-1403.

5. Rudiger A, Gasser S, Fischler M, Hornemann T, von Eckardstein A, Maggiorini M. Comparable increase of B-type natriuretic peptide and amino-terminal pro-B-type natriuretic peptide levels in patients with severe sepsis, septic shock, and acute heart failure. Crit Care Med. 2006; 34:2140-2144.

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