PL01: Creation of a risk scoring system for emergency department patients with acute heart failure

Introduction: Acute heart failure (AHF) is a common emergency department (ED) presentation and may be associated with poor outcomes. Conversely, many patients rapidly improve with ED treatment and may not need hospital admission. Because there is little evidence to guide disposition decisions by ED and admitting physicians, we sought to create a risk score for predicting short-term serious outcomes (SSO) in patients with AHF. Methods: We conducted prospective cohort studies at 9 tertiary care hospital EDs from 2007 to 2019, and enrolled adult patients who required treatment for AHF. Each patient was assessed for standardized real-time clinical and laboratory variables, as well as for SSO (defined as death within 30 days or intubation, non-invasive ventilation (NIV), myocardial infarction, coronary bypass surgery, or new hemodialysis after admission). The fully pre-specified, logistic regression model with 13 predictors (age, pCO2, and SaO2 were modeled using spline functions with 3 knots and heart rate and creatinine with 5 knots) was fitted to the 10 multiple imputation datasets. Harrell's fast stepdown procedure reduced the number of variables. We calculated the potential impact on sensitivity (95% CI) for SSO and hospital admissions and estimated a sample size of 170 SSOs. Results: The 2,246 patients had mean age 77.4 years, male sex 54.5%, EMS arrival 41.1%, IV NTG 3.1%, ED NIV 5.2%, admission on initial visit 48.6%. Overall there were 174 (7.8%) SSOs including 70 deaths (3.1%). The final risk scale is comprised of five variables (points) and had c-statistic of 0.76 (95% CI: 0.73-0.80): 1.Valvular heart disease (1) 2.ED non-invasive ventilation (2) 3.Creatinine 150-300 (1) ≥300 (2) 4.Troponin 2x-4x URL (1) ≥5x URL (2) 5.Walk test failed (2) The probability of SSO ranged from 2.0% for a total score of 0 to 90.2% for a score of 10, showing good calibration. The model was stable over 1,000 bootstrap samples. Choosing a risk model total point admission threshold of >2 would yield a sensitivity of 80.5% (95% CI 73.9-86.1) for SSO with no change in admissions from current practice (48.6% vs 48.7%). Conclusion: Using a large prospectively collected dataset, we created a concise and sensitive risk scale to assist with admission decisions for patients with AHF in the ED. Implementation of this risk scoring scale should lead to safer and more efficient disposition decisions, with more high-risk patients being admitted and more low-risk patients being discharged.

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LO02: Development of the HEARTRISK6 Scale for emergency department patients with acute heart failure

CJEM ◽

10.1017/cem.2019.45 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S7

Author(s):

I. Stiell ◽

A. McRae ◽

B. Rowe ◽

J. Dreyer ◽

L. Mielniczuk ◽

...

Keyword(s):

Heart Failure ◽

Emergency Department ◽

Acute Heart Failure ◽

Tertiary Care ◽

Care Hospital ◽

Invasive Ventilation ◽

Non Invasive ◽

Non Invasive Ventilation ◽

Risk Patients ◽

Risk Scale

Introduction: We previously derived (N = 559) and validated (N = 1,100) the 10-item Ottawa Heart Failure Risk Scale (OHFRS), to assist with disposition decisions for patients with acute heart failure (AHF) in the emergency department (ED). In the current study we sought to use a larger dataset to develop a more concise and more accurate risk scale. Methods: We analyzed data from the prior two studies and from a new cohort. For all 3 groups we conducted prospective cohort studies that enrolled patients who required treatment for AHF at 8 tertiary care hospital EDs. Patients were followed for 30 days. The primary outcome was short-term serious outcome (SSO), defined as death within 30 days, intubation or non-invasive ventilation (NIV) after admission, myocardial infarction, or relapse resulting in hospital admission within 14 days. The fully pre-specified logistic regression model with 13 predictors (where age, pCO2, and SaO2 were modeled using spline functions) was fitted to 10 multiple imputation datasets. Harrell's fast stepdown procedure reduced the number of variables. We calculated the potential impact on sensitivity (95% CI) for SSO and hospital admissions, and estimated a sample size of 2,000 patients. Results: The 1,986 patients had mean age 77.3 years, male 54.1%, EMS arrival 41.2%, IV NTG 3.3%, ED NIV 5.4%, admission on initial visit 49.5%. Overall there were 236 (11.9%) SSOs including 61 deaths (3.1%), meaning that current admission practice sensitivity for SSO was only 59.7%. The final HEARTRISK6 scale is comprised of 6 variables (points) (C-statistic 0.68): Valvular heart disease (2) Antiarrhythmic medication (2) ED non-invasive ventilation (3) Creatinine 80–150 (1); ≥150 (3) Troponin ≥3x URL (2) Walk test failed (1). The probability of SSO ranged from 4.8% for a total score of 0 to 62.4% for a score of 10, showing good calibration. Choosing a HEARTRISK6 total point admission threshold of ≥3 would yield sensitivity of 70.8% (95%CI 64.5-76.5) for SSO with a slight decrease in admissions to 47.9%. Choosing a threshold of ≥2 would yield a sensitivity of 84.3% (95%CI 79.0-88.7) but require 66.6% admissions. Conclusion: Using a large prospectively collected dataset, we created a more concise and more sensitive risk scale to assist with admission decisions for patients with AHF in the ED. Implementation of the HEARTRISK6 scale should lead to safer and more efficient disposition decisions, with more high-risk patients being admitted and more low-risk patients being discharged.

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Effects on short term outcome of non-invasive ventilation use in the emergency department to treat patients with acute heart failure: A propensity score-based analysis of the EAHFE Registry

European Journal of Internal Medicine ◽

10.1016/j.ejim.2018.03.008 ◽

2018 ◽

Vol 53 ◽

pp. 45-51 ◽

Cited By ~ 4

Author(s):

Òscar Miró ◽

Gemma Martínez ◽

Josep Masip ◽

Víctor Gil ◽

Francisco Javier Martín-Sánchez ◽

...

Keyword(s):

Heart Failure ◽

Emergency Department ◽

Propensity Score ◽

Acute Heart Failure ◽

Invasive Ventilation ◽

Short Term ◽

Term Outcome ◽

Non Invasive ◽

Short Term Outcome ◽

Non Invasive Ventilation

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Safety and Efficacy of Aerobic Exercise Training Associated to Non-Invasive Ventilation in Patients with Acute Heart Failure

Arquivos Brasileiros de Cardiologia ◽

10.5935/abc.20180039 ◽

2018 ◽

Cited By ~ 1

Author(s):

Mayron F. Oliveira ◽

Rita C. Santos ◽

Suellen A. Artz ◽

Vanessa M. F. Mendez ◽

Denise M. L. Lobo ◽

...

Keyword(s):

Heart Failure ◽

Exercise Training ◽

Aerobic Exercise ◽

Acute Heart Failure ◽

Aerobic Exercise Training ◽

Invasive Ventilation ◽

Safety And Efficacy ◽

Non Invasive ◽

Non Invasive Ventilation

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Indications and practical approach to non-invasive ventilation in acute heart failure

European Heart Journal ◽

10.1093/eurheartj/ehx580 ◽

2017 ◽

Vol 39 (1) ◽

pp. 17-25 ◽

Cited By ~ 33

Author(s):

Josep Masip ◽

W Frank Peacock ◽

Susanna Price ◽

Louise Cullen ◽

F Javier Martin-Sanchez ◽

...

Keyword(s):

Heart Failure ◽

Acute Heart Failure ◽

Practical Approach ◽

Invasive Ventilation ◽

Non Invasive ◽

Non Invasive Ventilation

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Non-invasive ventilation in acute heart failure

Indian Heart Journal ◽

10.1016/j.ihj.2020.11.067 ◽

2020 ◽

Vol 72 ◽

pp. S23-S24

Author(s):

Sarda Mukund Shyam ◽

Darshan Mehra ◽

R.R. Chaudhary

Keyword(s):

Heart Failure ◽

Acute Heart Failure ◽

Invasive Ventilation ◽

Non Invasive ◽

Non Invasive Ventilation

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Is hypocapnia a risk factor for non-invasive ventilation failure in acute heart failure?

European Heart Journal ◽

10.1093/ehjci/ehaa946.1183 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

L Carrillo-Aleman ◽

A Montenegto Moure ◽

L Lopez Gomez ◽

P.S Bayoumi Delis ◽

A.A Agamez Luengas ◽

...

Keyword(s):

Risk Factors ◽

Heart Failure ◽

Risk Factor ◽

Respiratory Failure ◽

Respiratory Rate ◽

Acute Heart Failure ◽

Invasive Ventilation ◽

Coronary Syndrome ◽

Non Invasive ◽

Non Invasive Ventilation

Abstract Introduction Non-invasive ventilation (NIV) has become a standard treatment for acute respiratory failure. Multiple factors associated with failure of this ventilatory technique have been described. Some authors postulate that the presence of hypocapnia at the onset of NIV increases the mortality of patients with acute heart failure (AHF). Purpose To analyse whether the presence of hypocapnia is a risk factor for failure of NIV in the patient with AHF. Methods Observational, retrospective study on a prospective database. All patients with AHF admitted to Intensitive Care Unit (ICU) between January 1997 and December 2017 for respiratory failure and requiring NIV are included. The inclusion criteria were the presence of dyspnea, respiratory rate ≥30 and PaO2/FiO2 <250 mmHg. The exclusion criteria were the presence of cardiogenic shock and AHF due to involvement of the right ventricle. Hypocapnia is defined as the presence of PaCO2 <35 mmHg) in basal gasometry prior to NIV, normocapnia as PaCO2 between 35 and 45 mmHg and PaCO2 hypercapnia greater than 45 mmHg. NIV failure is defined as the need for endotracheal intubation or death in ICU. Quantitative variables are expressed as means ± standard deviation, and qualitative variables as percentages. Comparison between variables has been made using the Ji2 linear trend test and single factor ANOVA. Multivariate analysis was performed using logistic regression with the calculation of odds ratios (OR) and their 95% confidence intervals (CI-95%). Results A total of 1009 patients with AHF, 158 (15.7%) normocapnic, 361 (35.8%) hypocapnic and 490 (48.5%) hypercapnic were analyzed. The age in the 3 groups was 73.3±10.4, 73.3±11.2 and 75.6±8.9 years (p=0.001), respectively. In the normocapnic group the respiratory rate was 36±4, PaCO2 40±3 and PaO2/FiO2 125±31. In the hypocapnic group 37±3, 28±3 and 134±30; and in the hypercapnic group 37±6, 65±16 and 126±36, respectively. NIV failure was observed in 15 (9.5%) of normocapnic patients, 56 (15.5%) of hypocapnic patients and 54 (11%) of hypercapnic patients (p=0.070). Independent risk factors for NIV failure were SAPS II (OR=1.07, CI-95%=1.04–1.09), order of non-intubation (OR=2.88, CI-95%=1.45–1.81), baseline SOFA (OR=1.76, CI-95%=1.48–2.08), HACOR index at 1 hour NIV (OR=1,62, CI-95%=1.45–1.08), the presence of acute coronary syndrome (OR=2.18, CI-95%=1.18–4.01), the presence of NIV-related complication (OR=6.42, CI-95%=3.47–11.89) and hypocapnia at the onset of NIV (OR=3.842, CI-95%=2.02–7.27). Conclusions Hypocapnia at the beginning of NIV in the patient with AHF is a frequent finding. Among the risk factors for poor prognosis, the presence of hypocapnia is a strong predictor of NIV failure. Funding Acknowledgement Type of funding source: None

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320 Non invasive ventilation with continuous positive airway pressure and exercise tolerance in outpatients with chronic heart failure

European Journal of Heart Failure Supplements ◽

10.1016/s1567-4215(04)90230-5 ◽

2004 ◽

Vol 3 (1) ◽

pp. 79

Author(s):

S CHERMONT

Keyword(s):

Heart Failure ◽

Continuous Positive Airway Pressure ◽

Chronic Heart Failure ◽

Exercise Tolerance ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Invasive Ventilation ◽

Non Invasive ◽

Non Invasive Ventilation

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Non-Invasive Ventilation in Patients with Heart Failure: A Systematic Review and Meta-Analysis

Arquivos Brasileiros de Cardiologia ◽

10.5935/abc.20170001 ◽

2017 ◽

Author(s):

Hugo Souza Bittencourt ◽

Helena França Correia dos Reis ◽

Melissa Santos Lima ◽

Mansueto Gomes Neto

Keyword(s):

Heart Failure ◽

Systematic Review ◽

Meta Analysis ◽

Invasive Ventilation ◽

Non Invasive ◽

Non Invasive Ventilation ◽

Patients With Heart Failure

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Abstract 15821: Safety and Efficacy of Non-invasive Ventilation During Exercise Training in Patients With Acute Heart Failure. A Randomized Prospective Controlled Study

Circulation ◽

10.1161/circ.132.suppl_3.15821 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Mayron F Oliveira ◽

Rita L Santos ◽

Vanessa M Mendez ◽

Priscila A Sperandio ◽

Iracema I Umeda ◽

...

Keyword(s):

Heart Failure ◽

Exercise Training ◽

Adverse Events ◽

Hospital Stay ◽

Length Of Hospital Stay ◽

Invasive Ventilation ◽

Serious Adverse Events ◽

Safety And Efficacy ◽

Non Invasive ◽

Non Invasive Ventilation

Background: Exercise training (ET) is well established to improve functional capacity and quality of life in patients (pts) with chronic heart failure. However, the ET benefits in acute heart failure (AHF) are unknown. Purpose: We aimed to study the safety and efficacy of ET alone or combined with non-invasive ventilation (NIV) compared to standard medical treatment in hospitalized pts with AHF. Methods: Twenty-nine pts with AHF (68% ischemic), 56±7 years, left ventricle ejection fraction of 25±5%, NTproBNP of 2456±730, 6-minute walk test distance (6MWD = 225±39meters) were randomized into 3 groups: ET + NIV with sub therapeutic positive airway pressure (PAP) (ET,n=9), ET + NIV set to 14 of inspiratory and 8 cmH2O of expiratory PAP, respectively (EV,n=11) and standard treatment (CO,n=9). The ET and EV groups performed a daily session of unloaded exercise on cycle ergometer for 20 min or tolerance limit, for 8 consecutives days. In EV and ET, oxygen pulse saturation (SpO2), heart rate (HR), respiratory rate (RR), blood pressure (BP), blood lactate were measured at baseline (D1), during exercise, and at day 10 (D10). Serious adverse events (death or worsening heart failure) were also assessed on D10. Results: Length of hospital stay was shorter in EV group (17±10 days) compared to ET (23±8 days) and CO (39±15 days) (p<0,05). There were more serious adverse events in CO (66,6%) compared to both EV and ET (15%). Dobutamine use at D10 was less frequent in EV (18,2%) and ET (22,2%) groups than in CO (33,3%) (p<0.05). There was a marked improvement in Δ6MWD between D1 and D10 in EV (Δ127±72 meters), though increase in Δ6MWD was also seen in ET (Δ72±26 meters) and CO (Δ41±19meters), p<0,05. The EV group also showed higher endurance and lower peak HR at end-exercise than ET at D10 (128±10 vs. 92±8 min and 73±12 vs. 104±25 bpm, respectively; p<0,05). There was a similar reduction in NTproBNP levels but no differences were found in BP, SpO2, RR and blood lactate. Conclusion: Aerobic exercise in AHF was safe, reduced length of hospital stay and need for inotropics at D10. NIV + ET increased exercise endurance with lower cardiovascular stress.

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