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Canadian Journal of Cardiology

Prediction of Early Adverse Events in Emergency Department Patients With Acute Heart Failure: A Systematic Review

Published:September 12, 2017DOI:https://doi.org/10.1016/j.cjca.2017.09.004

      Abstract

      Background

      Acute heart failure (AHF) accounts for a substantial proportion of Emergency Department (ED) visits and hospitalizations. Previous studies have shown that emergency physicians' clinical gestalt is not sufficient to stratify patients with AHF into severe and requiring hospitalization vs nonsevere and safe to be discharged. Various prognostic algorithms have been developed to risk-stratify patients with AHF, however there is no consensus as to the best-performing risk assessment tool in the ED.

      Methods

      A systematic review of Medline, PubMed, and Embase up to May 2016 was conducted using established methods. Major cardiology and emergency medicine conference proceedings from 2010 to 2016 were also screened. Two independent reviewers identified studies that evaluated clinical risk scores in adult (ED) patients with AHF, with risk prognostication for mortality or significant morbidity within 7-30 days. Studies included patients who were discharged or admitted.

      Results

      The systematic review search generated 2950 titles that were screened according to title and abstract. Nine articles, describing 6 risk prediction tools met full inclusion criteria, however, prognostic performance and ease of bedside application is limited for most. Because of clinical heterogeneity in the prognostic tools and study outcomes, a meta-analysis was not performed.

      Conclusions

      Several risk scores exist for predicting short-term mortality or morbidity in ED patients with AHF. No single risk tool is clearly superior, however, the Emergency Heart Failure Mortality Risk Grade might aid in prognostication of mortality and the Ottawa Heart Failure Risk Score might provide useful prognostic information in patients suitable for ED discharge.

      Résumé

      Introduction

      L’insuffisance cardiaque aiguë (ICA) constitue une part importante des visites au service des urgences (SU) et des hospitalisations. Les études antérieures ont démontré que l’expérience clinique des médecins d’urgence n’est pas suffisante pour répartir les patients atteints d’une ICA en un groupe de patients atteints gravement et nécessitant une hospitalisation vs en un groupe de patients non atteints gravement et aptes à obtenir un congé de l’hôpital en toute sécurité. Divers algorithmes de pronostics ont été élaborés pour stratifier le risque des patients atteints d’ICA, toutefois, il n’y a aucun consensus sur le meilleur outil d’évaluation du risque au SU.

      Méthodes

      Nous avons mené une revue systématique de Medline, PubMed et Embase jusqu’en mai 2016 à l’aide de méthodes établies. Nous avons également examiné les comptes rendus majeurs des conférences de 2010 à 2016. Deux examinateurs indépendants ont relevé les études qui permettaient d’évaluer les scores de risque clinique chez les patients (SU) adultes atteints d’ICA, qui avaient un pronostic de risque de mortalité ou de morbidité importante entre 7 et 30 jours. Les études portaient sur les patients qui avaient obtenu leur congé d’hôpital ou avaient été admis.

      Résultats

      La recherche de revues systématiques a permis de générer 2950 titres que nous avons examinés en fonction du titre et du résumé. Neuf articles qui décrivaient 6 outils de prédiction du risque répondaient entièrement aux critères d’inclusion. Toutefois, la performance pronostique et la facilité de mise en œuvre au chevet du patient sont limitées pour la plupart. En raison de l’hétérogénéité clinique des outils de pronostics et des résultats des études, nous n’avons pas réalisé de méta-analyses.

      Conclusions

      De nombreux scores de risque existent pour prédire la mortalité à court terme ou la morbidité des patients du SU atteints d’ICA. Aucun outil de risque n’est nettement supérieur. Toutefois, le Emergency Heart Failure Mortality Risk Grade aiderait au pronostic de mortalité et le Ottawa Heart Failure Risk Score fournirait des renseignements utiles sur le pronostic des patients admissibles au congé du SU.
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      References

      1. Heart and Stroke Foundation. 2016 Report on the Health of Canadians: the Burden of Heart Failure. Available at: https://www.heartandstroke.ca/-/media/pdf-files/canada/2017-heart-month/heartandstroke-reportonhealth-2016.ashx?la=en. Accessed December 13, 2017.

        • Gheorghiade M.
        • Zannad F.
        • Sopko G.
        • et al.
        Acute heart failure syndromes.
        Circulation. 2005; 112: 3958-3968
        • Lee D.S.
        • Schull M.J.
        • Alter D.A.
        • et al.
        Early deaths in patients with heart failure discharged from the emergency department: a population-based analysis.
        Circ Heart Fail. 2010; 3: 228-235
        • Ezekowitz J.A.
        • Bakal J.A.
        • Kaul P.
        • Westerhout C.M.
        • Armstrong P.W.
        Acute heart failure in the emergency department: short and long-term outcomes of elderly patients with heart failure.
        Eur J Heart Fail. 2008; 10: 308-314
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of studies that evaluate health care interventions: explanation and elaboration.
        PLoS Med. 2009; 6: e1000100
        • McGowan J.
        • Sampson M.
        • Salzwedel D.M.
        • et al.
        PRESS Peer Review of Electronic Search Strategies: 2015 guideline statement.
        J Clin Epidemiol. 2016; 75: 40-46
        • Collins S.P.
        • Storrow A.B.
        • Levy P.D.
        • et al.
        Early management of patients with acute heart failure: state of the art and future directions–a consensus document from the SAEM/HFSA acute heart failure working group.
        Acad Emerg Med. 2015; 22: 94-112
        • Garcia-Gutierrez S.
        • Quintana J.M.
        • Antón-Ladislao A.
        • et al.
        Creation and validation of the acute heart failure risk score: AHFRS.
        Intern Emerg Med. 2017; 12: 1197-1206
        • Hsiao J.
        • Motta M.
        • Wyer P.
        Validating the acute heart failure index for patients presenting to the emergency department with decompensated heart failure.
        Emerg Med J. 2012; 29: e5
        • Lee D.S.
        • Stitt A.
        • Austin P.C.
        • et al.
        Prediction of heart failure mortality in emergent care: a cohort study.
        Ann Intern Med. 2012; 156 (W-261, W-262): 767-775
        • Greig D.
        • Austin P.C.
        • Zhou L.
        • et al.
        Ischemic electrocardiographic abnormalities and prognosis in decompensated heart failure.
        Circ Heart Fail. 2014; 7: 986-993
      2. Gil V, Miró Ò, Schull MJ, et al. Emergency Heart Failure Mortality Risk Grade score performance for 7-day mortality prediction in patients with heart failure attended at the emergency department: validation in a Spanish cohort [e-pub ahead of print]. Eur J Emerg Med https://doi.org/10.1097/MEJ.0000000000000422. accessed December 13, 2017.

        • Martin-Sanchez F.J.
        • Gil V.
        • Llorens P.
        • et al.
        Barthel Index-Enhanced Feedback for Effective Cardiac Treatment (BI-EFFECT) study: contribution of the Barthel Index to the Heart Failure Risk Scoring System model in elderly adults with acute heart failure in the emergency department.
        J Am Geriatr Soc. 2012; 60: 493-498
        • Stiell I.G.
        • Clement C.M.
        • Brison R.J.
        • et al.
        A risk scoring system to identify emergency department patients with heart failure at high risk for serious adverse events.
        Acad Emerg Med. 2013; 20: 17-26
        • Stiell I.G.
        • Perry J.J.
        • Clement C.M.
        • et al.
        Prospective and explicit clinical validation of the Ottawa Heart Failure Risk Scale, with and without use of quantitative NT-proBNP.
        Acad Emerg Med. 2017; 24: 316-327
        • Auble T.E.
        • Hsieh M.
        • Gardner W.
        • et al.
        A prediction rule to identify low-risk patients with heart failure.
        Acad Emerg Med. 2005; 12: 514-521
        • Lee D.S.
        • Austein P.C.
        • Rouleau J.L.
        • et al.
        Predicting mortality among pateints hospitalized for heart failure: derivation and validation of a clinical model.
        JAMA. 2003; 290: 2581-2587
        • Laupacis A.
        • Sekar N.
        • Stiell I.G.
        Clinical prediction rules: a review and suggested modifications of methodological standards.
        JAMA. 1997; 277: 488-494
        • Stiell I.G.
        • Wells G.A.
        Methodologic standards for the development of clinical decision rules in emergency medicine.
        Ann Emerg Med. 1999; 33: 437-447
        • Morganstern J.
        The Ottawa Heart Failure Risk Scale.
        (Available at:) (Accessed June 21, 2017)
        • Lee D.S.
        • Ezekowitz J.A.
        Risk stratification in acute heart failure.
        Can J Cardiol. 2014; 30: 312-319
        • Hale M.K.
        • Stiell I.G.
        • Clement C.M.
        Emergency department management of heart failure and COPD: a national survey of attitudes and practice.
        CJEM. 2016; 18: 429-436