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
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.
- Acute heart failure syndromes.Circulation. 2005; 112: 3958-3968
- Early deaths in patients with heart failure discharged from the emergency department: a population-based analysis.Circ Heart Fail. 2010; 3: 228-235
- 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
- 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
- PRESS Peer Review of Electronic Search Strategies: 2015 guideline statement.J Clin Epidemiol. 2016; 75: 40-46
- 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
- Creation and validation of the acute heart failure risk score: AHFRS.Intern Emerg Med. 2017; 12: 1197-1206
- Validating the acute heart failure index for patients presenting to the emergency department with decompensated heart failure.Emerg Med J. 2012; 29: e5
- Prediction of heart failure mortality in emergent care: a cohort study.Ann Intern Med. 2012; 156 (W-261, W-262): 767-775
- Ischemic electrocardiographic abnormalities and prognosis in decompensated heart failure.Circ Heart Fail. 2014; 7: 986-993
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.
- 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
- 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
- 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
- A prediction rule to identify low-risk patients with heart failure.Acad Emerg Med. 2005; 12: 514-521
- Predicting mortality among pateints hospitalized for heart failure: derivation and validation of a clinical model.JAMA. 2003; 290: 2581-2587
- Clinical prediction rules: a review and suggested modifications of methodological standards.JAMA. 1997; 277: 488-494
- Methodologic standards for the development of clinical decision rules in emergency medicine.Ann Emerg Med. 1999; 33: 437-447
- The Ottawa Heart Failure Risk Scale.(Available at:) (Accessed June 21, 2017)
- Risk stratification in acute heart failure.Can J Cardiol. 2014; 30: 312-319
- Emergency department management of heart failure and COPD: a national survey of attitudes and practice.CJEM. 2016; 18: 429-436
Article info
Publication history
Published online: September 12, 2017
Accepted:
September 5,
2017
Received:
July 5,
2017
Footnotes
See page 178 for disclosure information.
Identification
Copyright
© 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
