Author + information
- Received March 2, 2015
- Revision received May 19, 2015
- Accepted May 25, 2015
- Published online October 1, 2015.
- Sean P. Collins, MD, MSc∗,†∗ (, )
- Cathy A. Jenkins, MS‡,
- Frank E. Harrell Jr., PhD‡,
- Dandan Liu, PhD‡,
- Karen F. Miller, RN, MPA∗,
- Christopher J. Lindsell, PhD§,
- Allen J. Naftilan, MD‖,
- John A. McPherson, MD‖,
- David J. Maron, MD¶,
- Douglas B. Sawyer, MD, PhD#,
- Neal L. Weintraub, MD∗∗,
- Gregory J. Fermann, MD§,
- Susan K. Roll, RN, BSN§,
- Matthew Sperling, BA§ and
- Alan B. Storrow, MD∗
- ∗Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- †Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee
- ‡Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
- §Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
- ‖Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- ¶Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
- #Department of Medicine, Division of Cardiovascular Medicine, Maine Medical Center, Portland, Maine
- ∗∗Department of Medicine and Vascular Biology Center, Georgia Regents University, Augusta, Georgia
- ↵∗Reprint requests and correspondence:
Dr. Sean Collins, Department of Emergency Medicine, Vanderbilt University Medical Center, 703 Oxford House, Nashville, Tennessee 37232-4700.
Objectives No prospectively derived or validated decision tools identify emergency department (ED) patients with acute heart failure (AHF) at low risk for 30-day adverse events who are thus potential candidates for safe ED discharge. This study sought to accomplish that goal.
Background The nearly 1 million annual ED visits for AHF are associated with high proportions of admissions and consume significant resources.
Methods We prospectively enrolled 1,033 patients diagnosed with AHF in the ED from 4 hospitals between July 20, 2007, and February 4, 2011. We used an ordinal outcome hierarchy, defined as the incidence of the most severe adverse event within 30 days of ED evaluation (acute coronary syndrome, coronary revascularization, emergent dialysis, intubation, mechanical cardiac support, cardiopulmonary resuscitation, and death).
Results Of 1,033 patients enrolled, 126 (12%) experienced at least one 30-day adverse event. The decision tool had a C statistic of 0.68 (95% confidence interval: 0.63 to 0.74). Elevated troponin (p < 0.001) and renal function (p = 0.01) were significant predictors of adverse events in our multivariable model, whereas B-type natriuretic peptide (p = 0.09), tachypnea (p = 0.09), and patients undergoing dialysis (p = 0.07) trended toward significance. At risk thresholds of 1%, 3%, and 5%, we found 0%, 1.4%, and 13.0% patients were at low risk, with negative predictive values of 100%, 96%, and 93%, respectively.
Conclusions The STRATIFY decision tool identifies ED patients with AHF who are at low risk for 30-day adverse events and may be candidates for safe ED discharge. After external testing, and perhaps when used as part of a shared decision-making strategy, it may significantly affect disposition strategies. (Improving Heart Failure Risk Stratification in the ED [STRATIFY]; NCT00508638)
Dr. Storrow and this study were funded by National Institutes of Health (NIH) grant R01 HL088459 with supplement 3R01 HL088459-03S1. Dr. Storrow was additionally funded by K12 HL109019, UL1TR000445 from the National Center for Advancing Translational Sciences and the Centers for Medicare and Medicaid Services. This material is the result of work supported with resources and the use of facilities at the Veterans Administration, Tennessee Valley Healthcare System, Nashville, Tennessee. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government. Dr. Collins was funded by K23 HL085387, and Dr. Weintraub was funded by HL076684 and HL112640 from the NIH. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Dr. Collins has received research support from NIH/National Heart, Lung, and Blood Institute, Radiometer, Medtronic, Cardiorentis, Novartis, The Medicines Company, and Abbott Point of Care; and consultant support from Novartis, The Medicines Company, Trevena, BRAHMS, Bayer, Radiometer, Otsuka, Cardiorentis, Cardioxyl, Abbott Point of Care, and Intersection Medical. Dr. Fermann has received research support from Novartis, Cardiorentis, Trevena, Intersection Medical, Radiometer, Siemens, Insys Therapeutics, The Mayday Foundation, and Pfizer; serves as a consultant for Intersection Medical, Janssen, and Insys Therapeutics; and is on the speakers bureau for Janssen. Dr. Storrow has received grant support from Abbott Diagnostics, Roche Diagnostics, Beckman-Coulter, and Novartis Pharmaceuticals; and consultant support from Roche Diagnostics, Beckman-Coulter, Novartis Pharmaceuticals, and Trevena. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 2, 2015.
- Revision received May 19, 2015.
- Accepted May 25, 2015.
- American College of Cardiology Foundation