From Hospital Clínic, University of Barcelona, Barcelona, Spain; London School of Hygiene and Tropical Medicine, London, United Kingdom; National Centre for Cardiovascular Research, Hospital Clínico San Carlos, Hospital Universitario 12 de Octubre, and Universidad Complutense, Madrid, Spain; Hospital General de Alicante, Alicante, Spain; Hospital Universitario Central de Asturias, Oviedo, Spain; and Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain.
Ann Intern Med. 2017 Nov 21;167(10):698-705. doi: 10.7326/M16-2726. Epub 2017 Oct 3.
Physicians in the emergency department (ED) need additional tools to stratify patients with acute heart failure (AHF) according to risk.
To predict mortality using data that are readily available at ED admission.
Prospective cohort study.
34 Spanish EDs.
The derivation cohort included 4867 consecutive ED patients admitted during 2009 to 2011. The validation cohort comprised 3229 patients admitted in 2014.
88 candidate risk factors and 30-day mortality.
Thirteen independent risk factors were identified in the derivation cohort and were combined into an overall score, the MEESSI-AHF (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF) score. This score predicted 30-day mortality with excellent discrimination (c-statistic, 0.836) and calibration (Hosmer-Lemeshow P = 0.99) and provided a steep gradient in 30-day mortality across risk groups (<2% for patients in the 2 lowest risk quintiles and 45% in the highest risk decile). These characteristics were confirmed in the validation cohort (c-statistic, 0.828). Multiple sensitivity analyses did not find important amounts of confounding or bias.
The study was confined to a single country. Participating EDs were not selected randomly. Many patients had missing data. Measurement of some risk factors was subjective.
This tool has excellent discrimination and calibration and was validated in a different cohort from the one that was used to develop it. Physicians can consider using this tool to inform clinical decisions as further studies are done to determine whether the tool enhances physician decision making and improves patient outcomes.
Instituto de Salud Carlos III, Spanish Ministry of Health; Fundació La Marató de TV3; and Catalonia Govern.
急诊科医生需要额外的工具来根据风险对急性心力衰竭（AHF）患者进行分层。
使用急诊科入院时可用的数据预测死亡率。
前瞻性队列研究。
34 家西班牙急诊科。
推导队列纳入了 2009 年至 2011 年期间连续入院的 4867 名急诊科患者。验证队列包括 2014 年入院的 3229 名患者。
88 个候选风险因素和 30 天死亡率。
在推导队列中确定了 13 个独立的风险因素，并将其组合成一个整体评分，即 MEESSI-AHF（基于西班牙急诊科评分的心力衰竭患者的多估计风险）评分。该评分对 30 天死亡率具有出色的区分度（c 统计量为 0.836）和校准度（Hosmer-Lemeshow P=0.99），并且在风险组中呈现出 30 天死亡率的陡峭梯度（风险最低的两个五分位数的患者为<2%，最高风险十分位数的患者为 45%）。这些特征在验证队列中得到了证实（c 统计量为 0.828）。多项敏感性分析并未发现重要的混杂或偏差。
该研究仅限于一个国家。参与的急诊科不是随机选择的。许多患者存在缺失数据。一些风险因素的测量是主观的。
该工具具有出色的区分度和校准度，并在与开发该工具不同的队列中得到验证。随着进一步研究的开展，以确定该工具是否增强了医生的决策能力并改善了患者的结局，医生可以考虑使用该工具来指导临床决策。
西班牙卫生部卡洛斯三世研究所；TV3 基金会的拉马托德；以及加泰罗尼亚政府。
