Risk stratification in patients presenting with acute heart failure.
Risk stratification in patients presenting with acute heart failure.
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急性心力衰竭患者的危险分层。
DOI：
10.1093/ehjacc/zuab005
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发表时间：
2021
期刊：
影响因子：
--
通讯作者：
Jhund,PardeepS
中科院分区：
文献类型：
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作者：
Platz,Elke;Jhund,PardeepS
急性心力衰竭(AHF)是一个主要的公共卫生问题，AHF的住院与显著的发病率、死亡率和费用有关。由于大多数AHF患者是通过急诊科(ED)入院的，因此了解他们在急诊科最初评估和护理后的发展轨迹对于提供安全的临床护理和优化资源利用(包括急诊科和住院床位)非常重要。1如果我们要实现更好的临床护理和利用我们有限的资源，我们应该研究两个主要方面。第一个方面是了解哪些AHF患者风险较低，有可能安全出院。这可能是在教育部进行了初步评估和适当的测试之后，或者是在专门的观察单位进行了1-3天的观察期之后。第二是了解哪些AHF患者是住院不良事件的高危人群，以便将患者分流到最合适的住院环境。先前的几项研究已经开发出预测不良的短期ED或住院事件、出院后7至30天的死亡率或严重不良事件(例如，所有原因死亡、机械心脏支持、插管、紧急透析或冠状动脉干预的组合)的预后评分。这些现有的模型最近在系统的回顾和荟萃分析中进行了总结。2从前瞻性收集的关注30天死亡率的队列中得出的模型包括11-13个变量，在派生队列中得到的c-统计量范围从0.77到0.84，在后续的验证研究中也有类似的结果。2这些数据表明，根据对疑似AHF的ED患者通常收集的参数，如生命体征、基本实验室检查和心电图结果，可以确定30天死亡率为低风险的AHF患者的亚组(表1)。目前预测30天严重不良事件的模型预测准确性较低，但仍可能有助于识别可以安全地作为门诊患者管理的极低风险个人，可能会在急诊室观察一段时间后。在首次急诊后预测住院死亡率或反复急诊/心衰住院的特定模型的文献很少，这些主题值得进一步研究。Rossello等人。现在，通过检查2014至2016年间收集的41名西班牙急诊室的登记数据，进一步了解我们在这一领域的知识。根据Framingham标准的定义，成人患有AHF。排除并发ST段抬高心肌梗死的患者。他们使用了MEESSI-AHF风险评分，该评分之前已经得出并验证用于预测30天的全因死亡率。使用同样的13个变量，本研究现在评估了其他结果，包括住院死亡、7天死亡率、30天反复急诊或因心力衰竭住院。在7755例AHF患者中，7.4%的患者在指数住院期间死亡，4.7%的患者在7d内死亡，10.1%的患者在首次急诊后的30d内死亡。出院后，30天死亡率为4.9%，24%为急诊科，16%为急性心衰再入院。该模型在预测急诊室就诊和出院后的7天和30天死亡率方面表现良好。然而，MEESSI-AHF风险评分在预测出院后30天急诊室就诊或再次住院治疗AHF方面表现不佳(c-统计0.54-0.62)。我们应该如何解读这项研究的发现？目前的研究支持这样一种观点，即风险分层模型可以根据…的数据帮助识别30天死亡率的低风险患者
Acute heart failure (AHF) is a major public health problem and hospitalizations for AHF are associated with significant morbidity, mortality, and cost. Since most patients with AHF are admitted through the emergency department (ED) understanding their trajectory following the initial assessment and care in the ED is important for providing safe clinical care and optimizing resource utilization (including ED and inpatient beds). 1 There are two main aspects that we should examine if we are to realize better clinical care and use of our scarce resources. The first area is to understand which AHF patients are at low risk and could potentially be safely discharged from the ED. This could be either after an initial evaluation and appropriate tests in the ED or following an observation period of 1–3 days in a dedicated observation unit. The second is to understand which patients with AHF are at high risk for adverse inpatient events in order to facilitate triage to the most appropriate inpatient setting. Several prior studies have developed prognostic scores predicting adverse short-term ED or inpatient events, 7-to 30-day postdischarge mortality or serious adverse events (eg a composite of allcause death, mechanical cardiac support, intubation, emergent dialysis, or coronary intervention) following an ED visit for AHF. These existing models have recently been summarized in a systematic review and meta-analysis. 2 Models derived from prospectively collected cohorts focusing on 30-day mortality include 11–13 variables and resulting c-statistics range from 0.77 to 0.84 in the derivation cohorts, with similar results in subsequent validation studies. 2 These data suggest that subsets of patients with AHF at low risk for 30-day mortality can be identified based on parameters commonly collected on ED patients with suspected AHF, such as vital signs, basic laboratory tests, and ECG findings (Table 1). Current models predicting 30-day serious adverse events have lower prognostic accuracy but may still facilitate the identification of very low-risk individuals who could safely be managed as outpatients, perhaps after an observation period in the ED. Literature on specific models predicting either inpatient mortality or recurrent ED visits/HF hospitalizations after an initial ED visit are sparse and these topics warrant further investigation. Rossello et al. now further our knowledge in this area by examining registry data, from 41 Spanish EDs collected between 2014 and 2016, of adults presenting with AHF as defined by Framingham criteria.[Rossello et al]. Patients were excluded if they had a concurrent ST-segment elevation myocardial infarction. They used the MEESSI-AHF risk score which has been previously derived and validated for predicting 30-day all-cause mortality. Using the same 13 variables, the current study now evaluated additional outcomes, including inhospital death, 7-day mortality, 30-day recurrent ED visits, or hospitalizations for HF. Among 7755 patients with AHF, 7.4% died during the index hospitalization, 4.7% within 7days, and 10.1% within 30 days based on the initial ED visit. Following hospital discharge, 30-day mortality was 4.9%, 24% represented to the ED, and 16% were readmitted for AHF. The model performed well for predicting 7-day and 30-day mortality both from the ED visit and following hospital discharge. However, the MEESSI-AHF risk score performed poorly predicting 30-day ED visits or readmissions for AHF following hospital discharge (c-statistic 0.54–0.62). How should we interpret the findings from this study? The current study supports the notion that risk stratification models can help identify patients at low risk for 30-day mortality based on data …