Triage after hospitalization with advanced heart failure: the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) risk model and discharge score.
OBJECTIVE
Identifying high-risk heart failure (HF) patients at hospital discharge may allow more effective triage to management strategies.


BACKGROUND
Heart failure severity at presentation predicts outcomes, but the prognostic importance of clinical status changes due to interventions is less well described.


METHODS
Predictive models using variables obtained during hospitalization were created using data from the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) trial and internally validated by the bootstrapping method. Model coefficients were converted to an additive risk score. Additionally, data from FIRST (Flolan International Randomized Survival Trial) was used to externally validate this model.


RESULTS
Patients discharged with complete data (n = 423) had 6-month mortality and death and rehospitalization rates of 18.7% and 64%, respectively. Discharge risk factors for mortality included BNP, per doubling (hazard ratio [HR]: 1.42, 95% confidence interval [CI]: 1.15 to 1.75), cardiopulmonary resuscitation or mechanical ventilation during hospitalization (HR: 2.54, 95% CI: 1.12 to 5.78), blood urea nitrogen, per 20-U increase (HR: 1.22, 95% CI: 0.96 to 1.55), serum sodium, per unit increase (HR: 0.93, 95% CI: 0.87 to 0.99), age >70 years (HR: 1.05, 95% CI: 0.51 to 2.17), daily loop diuretic, furosemide equivalents >240 mg (HR: 1.49, 95% CI: 0.68 to 3.26), lack of beta-blocker (HR: 1.28, 95% CI: 0.68 to 2.41), and 6-min walk, per 100-foot increase (HR: 0.955, 95% CI: 0.99 to 1.00; c-index 0.76). A simplified discharge score discriminated mortality risk from 5% (score = 0) to 94% (score = 8). Bootstrap validation demonstrated good internal validation of the model (c-index 0.78, 95% CI: 0.68 to 0.83).


CONCLUSIONS
The ESCAPE study discharge risk model and score refine risk assessment after in-hospital therapy for advanced decompensated systolic HF, allowing clinicians to focus surveillance and triage for early life-saving interventions in this high-risk population. (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness [ESCAPE]; NCT00000619).
O'Connor
Christopher M
CM
Duke Clinical Research Institute, Duke University Medical Center, 2400 North Pratt Street, Box 3356, Durham, North Carolina 27705, USA. oconn002@mc.duke.edu
Hasselblad
Vic
V
Mehta
Rajendra H
RH
Tasissa
Gudaye
G
Califf
Robert M
RM
Fiuzat
Mona
M
Rogers
Joseph G
JG
Leier
Carl V
CV
Stevenson
Lynne W
LW
D000368:Aged; D002170:Canada / Q000453:epidemiology; D002407:Catheterization, Swan-Ganz / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D017052:Hospital Mortality / Q000639:trends; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017146:Models, Organizational; D010351:Patient Discharge / Q000706:statistics & numerical data*; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D014218:Triage / Q000458:organization & administration*; D014481:United States / Q000453:epidemiology