Desiree Wussler, MD; Nikola Kozhuharov, MD; Zaid Sabti, MD; Joan Walter, MD; Ivo Strebel, MS; Letizia Scholl, MD; Oscar Miró, PhD; Xavier Rossello, MD, PhD; Francisco Javier Martín-Sánchez, MD, PhD; Stuart J. Pocock, PhD; Albina Nowak, MD; Patrick Badertscher, MD; Raphael Twerenbold, MD; Karin Wildi, MD; Christian Puelacher, MD; Jeanne du Fay de Lavallaz, MD; Samyut Shrestha, MD; Olivia Strauch; Dayana Flores, MD; Thomas Nestelberger, MD; Jasper Boeddinghaus, MD; Carmela Schumacher, MSc; Assen Goudev, PhD; Otmar Pfister, MD; Tobias Breidthardt, MD; Christian Mueller, MD
Note: Drs. Wussler, Sabti, and Mueller had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Acknowledgment: The authors thank the patients who participated in the study, the staff of the participating emergency departments, the research coordinators, and the laboratory technicians (particularly Michael Freese, Caroline Kulangara, Claudia Stelzig, Kathrin Meissner, Esther Garrido, Irina Klimmeck, Beate Hartmann, Ina Ferel, and Natascha Herr) for their valuable efforts.
Grant Support: This study was supported by research grants from the European Union, the Swiss National Science Foundation, the Swiss Heart Foundation, the Cardiovascular Research Foundation Basel, the University of Basel, University Hospital Basel, Critical Diagnostics, Abbott, Alere, BRAHMS, Roche, and Singulex.
Disclosures: Dr. Miró reports grants from Instituto de Salud Carlos III (supported with funds from the Spanish Ministry of Health) and Fundació La Marató de TV3 during the conduct of the study. Dr. Martín-Sánchez reports grants from the Spanish Ministry of Health and FEDER outside the submitted work. Dr. Twerenbold reports grants from the Swiss National Science Foundation, the Swiss Heart Foundation, the Cardiovascular Research Foundation, University Hospital Basel, and the University of Basel and personal fees from Roche, Abbott, Siemens, Singulex, and Thermo Scientific BRAHMS outside the submitted work. Dr. Wildi reports grants from Freiwillige Akademische Gesellschaft Basel and Gottfried und Julia Bangerter-Rhyner Stiftung outside the submitted work. Dr. Puelacher reports grants from Roche Diagnostics outside the submitted work. Dr. Nestelberger reports personal fees from Beckman Coulter outside the submitted work. Dr. Boeddinghaus reports personal fees from Siemens and Roche outside the submitted work. Dr. Goudev reports personal fees from Pfizer, Novartis, AstraZeneca, and Amgen outside the submitted work. Dr. Pfister reports personal fees from Vifor Pharma, Novartis Pharma, and MSD outside the submitted work. Dr. Mueller reports grants from the Swiss National Science Foundation, the Swiss Heart Foundation, the University of Basel, University Hospital Basel, Abbott, Alere, BRAHMS, Pronota, Roche, Sphingotec, and Singulex during the conduct of the study and personal fees from Abbott, Alere, Amgen, AstraZeneca, BioMérieux, Boehringer Ingelheim, Bristol-Myers Squibb, BRAHMS, Cardiorentis, Novartis, Roche, Sanofi, Siemens, and Singulex outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-1967.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Proctor & Gamble, Pfizer, and Johnson & Johnson.
Data Sharing Statement: The authors have indicated that they will not be sharing data.
Corresponding Author: Christian Mueller, MD, Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland; e-mail, christian.mueller@usb.ch.
Current Author Addresses: Drs. Wussler, Kozhuharov, Walter, Badertscher, Twerenbold, Puelacher, du Fay de Lavallaz, Shrestha, Flores, Nestelberger, Boeddinghaus, Pfister, and Mueller: Department of Cardiology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
Drs. Sabti, Scholl, and Breidthardt; Mr. Strebel; Ms. Strauch; and Ms. Schumacher: Cardiovascular Research Institute Basel, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland.
Dr. Miró: Emergency Department, Hospital Clínic, University of Barcelona, Villarroel 170, Barcelona 08290, Spain.
Dr. Rossello: Centro Nacional de Investigaciones Cardiovasculares Carlos III, Calle de Melchor Fernández Almagro, 3, Madrid 28029, Spain.
Dr. Martín-Sánchez: Emergency Department, Hospital Clínico San Carlos, Universidad Complutense, Profesor Martin Lagos s/n, Madrid 28020, Spain.
Dr. Pocock: Department of Medical Statistics, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
Dr. Nowak: Department of Endocrinology, Department of Psychiatry, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland.
Dr. Wildi: Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Queensland 4032, Australia.
Dr. Goudev: Department of Cardiology, Queen Ioanna University Hospital Sofia, Medical University of Sofia, Byalo More 8 Str, Sofia 1527, Bulgaria.
Author Contributions: Conception and design: D. Wussler, J. Walter, A. Nowak, P. Badertscher, A. Goudev, C. Mueller.
Analysis and interpretation of the data: D. Wussler, N. Kozhuharov, J. Walter, O. Miró, A. Nowak, P. Badertscher, T. Nestelberger, A. Goudev, C. Mueller.
Drafting of the article: D. Wussler, J. Walter, A. Nowak, P. Badertscher, D. Flores, C. Mueller.
Critical revision of the article for important intellectual content: N. Kozhuharov, Z. Sabti, J. Walter, O. Miró, X. Rossello, F.J. Martín-Sánchez, S.J. Pocock, A. Nowak, R. Twerenbold, K. Wildi, C. Puelacher, J. du Fay de Lavallaz, S. Shrestha, D. Flores, J. Boeddinghaus, C. Schumacher, A. Goudev, O. Pfister, T. Breidthardt, C. Mueller.
Final approval of the article: D. Wussler, N. Kozhuharov, Z. Sabti, J. Walter, I. Strebel, L. Scholl, O. Miró, X. Rossello, F.J. Martín-Sánchez, S.J. Pocock, A. Nowak, P. Badertscher, R. Twerenbold, K. Wildi, C. Puelacher, J. du Fay de Lavallaz, S. Shrestha, O. Strauch, D. Flores, T. Nestelberger, J. Boeddinghaus, C. Schumacher, A. Goudev, O. Pfister, T. Breidthardt, C. Mueller.
Provision of study materials or patients: L. Scholl, X. Rossello, P. Badertscher, J. Boeddinghaus, A. Goudev, T. Breidthardt, C. Mueller.
Statistical expertise: J. Walter, I. Strebel, S.J. Pocock, A. Nowak, P. Badertscher, J. du Fay de Lavallaz, A. Goudev, C. Mueller.
Obtaining of funding: P. Badertscher, R. Twerenbold, C. Mueller.
Administrative, technical, or logistic support: I. Strebel, O. Miró, P. Badertscher, R. Twerenbold, K. Wildi, D. Flores, C. Schumacher, A. Goudev, C. Mueller.
Collection and assembly of data: D. Wussler, N. Kozhuharov, Z. Sabti, J. Walter, L. Scholl, P. Badertscher, R. Twerenbold, K. Wildi, C. Puelacher, S. Shrestha, O. Strauch, D. Flores, J. Boeddinghaus, T. Breidthardt, C. Mueller.
The MEESSI-AHF (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF) score was developed to predict 30-day mortality in patients presenting with acute heart failure (AHF) to emergency departments (EDs) in Spain. Whether it performs well in other countries is unknown.
To externally validate the MEESSI-AHF score in another country.
Prospective cohort study. (ClinicalTrials.gov: NCT01831115).
Multicenter recruitment of dyspneic patients presenting to the ED.
The external validation cohort included 1572 patients with AHF.
Calculation of the MEESSI-AHF score using an established model containing 12 independent risk factors.
Among 1572 patients with adjudicated AHF, 1247 had complete data that allowed calculation of the MEESSI-AHF score. Of these, 102 (8.2%) died within 30 days. The score predicted 30-day mortality with excellent discrimination (c-statistic, 0.80). Assessment of cumulative mortality showed a steep gradient in 30-day mortality over 6 predefined risk groups (0 patients in the lowest-risk group vs. 35 [28.5%] in the highest-risk group). Risk was overestimated in the high-risk groups, resulting in a Hosmer–Lemeshow P value of 0.022. However, after adjustment of the intercept, the model showed good concordance between predicted risks and observed outcomes (P = 0.23). Findings were confirmed in sensitivity analyses that used multiple imputation for missing values in the overall cohort of 1572 patients.
External validation was done using a reduced model. Findings are specific to patients with AHF who present to the ED and are clinically stable enough to provide informed consent. Performance in patients with terminal kidney failure who are receiving long-term dialysis cannot be commented on.
External validation of the MEESSI-AHF risk score showed excellent discrimination. Recalibration may be needed when the score is introduced to new populations.
The European Union, the Swiss National Science Foundation, the Swiss Heart Foundation, the Cardiovascular Research Foundation Basel, the University of Basel, and University Hospital Basel.
Wussler D, Kozhuharov N, Sabti Z, Walter J, Strebel I, Scholl L, et al. External Validation of the MEESSI Acute Heart Failure Risk Score: A Cohort Study. Ann Intern Med. [Epub ahead of print 29 January 2019]170:248–256. doi: 10.7326/M18-1967
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© 2019
Published: Ann Intern Med. 2019;170(4):248-256.
DOI: 10.7326/M18-1967
Published at www.annals.org on 29 January 2019
Cardiology, Heart Failure, Hospital Medicine.
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