Raslan Ismail R, Brown Paul, Westerhout Cynthia M, Ezekowitz Justin A, Hernandez Adrian F, Starling Randall C, O'Connor Christopher, McAlister Finlay A, Rowe Brian H, Armstrong Paul W, van Diepen Sean
Canadian VIGOUR Center, Edmonton, Alberta, Canada.
Canadian VIGOUR Center, Edmonton, Alberta, Canada; Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.
Am Heart J. 2017 Jun;188:127-135. doi: 10.1016/j.ahj.2017.03.014. Epub 2017 Mar 25.
Most patients with acute heart failure (AHF) admitted to critical care units (CCUs) are low acuity and do not require CCU-specific therapies, suggesting that they could be managed in a lower-cost ward environment. This study identified the predictors of clinical events and the need for CCU-specific therapies in patients with AHF.
Model derivation was performed using data from patients in the ASCEND-HF trial cohort (n=7,141), and the Acute Heart Failure Emergency Management community-based registry (n=666) was used to externally validate the model and to test the incremental prognostic utility of 4 variables (heart failure etiology, troponin, B-type natriuretic peptide [BNP], ejection fraction) using net reclassification index and integrated discrimination improvement. The primary outcome was an in-hospital composite of the requirement for CCU-specific therapies or clinical events.
The primary composite outcome occurred in 545 (11.4%) derivation cohort participants (n=4,767) and 7 variables were predictors of the primary composite outcome: body mass index, chronic respiratory disease, respiratory rate, resting dyspnea, hemoglobin, sodium, and blood urea nitrogen (c index=0.633, Hosmer-Lemeshow P=.823). In the validation cohort (n=666), 87 (13.1%) events occurred (c index=0.629, Hosmer-Lemeshow P=.386) and adding ischemic heart failure, troponin, and B-type natriuretic peptide improved model performance (net reclassification index 0.79, 95% CI 0.046-0.512; integrated discrimination improvement 0.014, 95% CI 0.005-0.0238). The final 10-variable clinical prediction model demonstrated modest discrimination (c index=0.702) and good calibration (Hosmer-Lemeshow P=.547).
We derived, validated, and improved upon a clinical prediction model in an international trial and a community-based cohort of AHF. The model has modest discrimination; however, these findings deserve further exploration because they may provide a more accurate means of triaging level of care for patients with AHF who need admission.
入住重症监护病房（CCU）的大多数急性心力衰竭（AHF）患者病情较轻，不需要CCU特有的治疗，这表明他们可以在成本较低的病房环境中得到管理。本研究确定了AHF患者临床事件的预测因素以及对CCU特有的治疗的需求。
使用急性失代偿性心力衰竭住院治疗（ASCEND-HF）试验队列（n = 7141）患者的数据进行模型推导，并使用急性心力衰竭急诊管理社区登记处（n = 666）的数据对模型进行外部验证，并使用净重新分类指数和综合判别改善来测试4个变量（心力衰竭病因、肌钙蛋白、B型利钠肽[BNP]、射血分数）的增量预后效用。主要结局是CCU特有的治疗需求或临床事件的院内综合指标。
在推导队列参与者（n = 4767）中有545例（11.4%）发生了主要综合结局，7个变量是主要综合结局的预测因素：体重指数、慢性呼吸系统疾病、呼吸频率、静息呼吸困难、血红蛋白、钠和血尿素氮（c指数 = 0.633，Hosmer-Lemeshow检验P = 0.823）。在验证队列（n = 666）中，发生了87例（13.1%）事件（c指数 = 0.629，Hosmer-Lemeshow检验P = 0.386），加入缺血性心力衰竭、肌钙蛋白和B型利钠肽可改善模型性能（净重新分类指数0.79，95%CI 0.046 - 0.512；综合判别改善0.014，95%CI 0.005 - 0.0238）。最终的10变量临床预测模型显示出适度的判别能力（c指数 = 0.702）和良好的校准（Hosmer-Lemeshow检验P = 0.547）。
我们在一项国际试验和一个基于社区的AHF队列中推导、验证并改进了一个临床预测模型。该模型具有适度的判别能力；然而，这些发现值得进一步探索，因为它们可能为需要入院的AHF患者提供一种更准确的护理级别分诊方法。
