title: Ischemic electrocardiographic abnormalities and prognosis in decompensated heart failure.
abstract: BACKGROUND
  Identification of coronary ischemia may enable targeted diagnostic and therapeutic strategies for acute heart failure. We determined the risk of 30-day mortality associated with ischemic ECG abnormalities in patients with acute heart failure.
  
  
  RESULTS
  Among 8772 patients (53.4% women, median 78 years [Q1, Q3: 68,84]) presenting with acute heart failure to 86 hospital emergency departments in Ontario, Canada, Q-waves, T-wave inversion, or ST-depression were present in 51.8% of subjects. However, presence of ST-depression was the only finding associated with 30-day mortality with adjusted odds ratio 1.24 (95% confidence interval [CI], 1.02-1.50). Using continuous net reclassification improvement, addition of ST-depression to the Emergency Heart failure Mortality Risk Grade model reclassified 16.9% of patients overall, and 29.3% of those with a history of ischemic heart disease (both P<0.001). By adding ST-depression to the model, the Emergency Heart failure Mortality Risk Grade was extended to predict 30-day death with high discrimination (c-statistic 0.801), with 0.57% mortality rate in the lowest risk decile. Adjusted odds ratios for 30-day mortality were 2.81 (95% CI, 1.48-5.31; P=0.002) in quintile 2, 7.41 (95% CI, 4.13-13.30; P<0.001) in quintile 3, and 14.47 (95% CI, 8.20-25.54; P<0.001) in quintile 4 compared with the lowest risk quintile. When the highest risk quintile was subdivided into 2 equally sized risk strata (deciles 9 and 10), the adjusted odds ratios for 30-day mortality were 27.20 (95% CI, 15.33-48.27; P<0.001) in decile 9 and 58.96 (95% CI, 33.54-103.65; P<0.001) in highest risk decile 10.
  
  
  CONCLUSIONS
  Presence of ST-depression on the ECG reclassified risk of 30-day mortality in patients with acute heart failure, identifying both high- and low-risk subsets.
authors.affiliation: From the Division of Cardiology, Peter Munk Cardiac Centre (D.G., H.J.R., D.S.L.) and Joint Department of Medical Imaging (D.S.L.), University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada (D.G., P.C.A., J.V.T., H.J.R., D.S.L.); Division of Cardiovascular Diseases, School of Medicine, P. Universidad Católica de Chile, Santiago, Chile (D.G.); Institute for Clinical Evaluative Sciences, Toronto, Canada (P.C.A., L.Z., J.V.T., D.S.L.); Institute of Health Policy, Management, and Evaluation, Toronto, Canada (P.C.A., J.V.T., D.S.L.); Division of Cardiology, Sunnybrook Schulich Heart Centre, Toronto, Canada (J.V.T.); and Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.S.P.).
authors.forename: Douglas
authors.initials: D
authors.lastname: Greig
authors.affiliation: From the Division of Cardiology, Peter Munk Cardiac Centre (D.G., H.J.R., D.S.L.) and Joint Department of Medical Imaging (D.S.L.), University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada (D.G., P.C.A., J.V.T., H.J.R., D.S.L.); Division of Cardiovascular Diseases, School of Medicine, P. Universidad Católica de Chile, Santiago, Chile (D.G.); Institute for Clinical Evaluative Sciences, Toronto, Canada (P.C.A., L.Z., J.V.T., D.S.L.); Institute of Health Policy, Management, and Evaluation, Toronto, Canada (P.C.A., J.V.T., D.S.L.); Division of Cardiology, Sunnybrook Schulich Heart Centre, Toronto, Canada (J.V.T.); and Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.S.P.).
authors.forename: Peter C
authors.initials: PC
authors.lastname: Austin
authors.affiliation: From the Division of Cardiology, Peter Munk Cardiac Centre (D.G., H.J.R., D.S.L.) and Joint Department of Medical Imaging (D.S.L.), University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada (D.G., P.C.A., J.V.T., H.J.R., D.S.L.); Division of Cardiovascular Diseases, School of Medicine, P. Universidad Católica de Chile, Santiago, Chile (D.G.); Institute for Clinical Evaluative Sciences, Toronto, Canada (P.C.A., L.Z., J.V.T., D.S.L.); Institute of Health Policy, Management, and Evaluation, Toronto, Canada (P.C.A., J.V.T., D.S.L.); Division of Cardiology, Sunnybrook Schulich Heart Centre, Toronto, Canada (J.V.T.); and Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.S.P.).
authors.forename: Limei
authors.initials: L
authors.lastname: Zhou
authors.affiliation: From the Division of Cardiology, Peter Munk Cardiac Centre (D.G., H.J.R., D.S.L.) and Joint Department of Medical Imaging (D.S.L.), University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada (D.G., P.C.A., J.V.T., H.J.R., D.S.L.); Division of Cardiovascular Diseases, School of Medicine, P. Universidad Católica de Chile, Santiago, Chile (D.G.); Institute for Clinical Evaluative Sciences, Toronto, Canada (P.C.A., L.Z., J.V.T., D.S.L.); Institute of Health Policy, Management, and Evaluation, Toronto, Canada (P.C.A., J.V.T., D.S.L.); Division of Cardiology, Sunnybrook Schulich Heart Centre, Toronto, Canada (J.V.T.); and Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.S.P.).
authors.forename: Jack V
authors.initials: JV
authors.lastname: Tu
authors.affiliation: From the Division of Cardiology, Peter Munk Cardiac Centre (D.G., H.J.R., D.S.L.) and Joint Department of Medical Imaging (D.S.L.), University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada (D.G., P.C.A., J.V.T., H.J.R., D.S.L.); Division of Cardiovascular Diseases, School of Medicine, P. Universidad Católica de Chile, Santiago, Chile (D.G.); Institute for Clinical Evaluative Sciences, Toronto, Canada (P.C.A., L.Z., J.V.T., D.S.L.); Institute of Health Policy, Management, and Evaluation, Toronto, Canada (P.C.A., J.V.T., D.S.L.); Division of Cardiology, Sunnybrook Schulich Heart Centre, Toronto, Canada (J.V.T.); and Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.S.P.).
authors.forename: Peter S
authors.initials: PS
authors.lastname: Pang
authors.affiliation: From the Division of Cardiology, Peter Munk Cardiac Centre (D.G., H.J.R., D.S.L.) and Joint Department of Medical Imaging (D.S.L.), University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada (D.G., P.C.A., J.V.T., H.J.R., D.S.L.); Division of Cardiovascular Diseases, School of Medicine, P. Universidad Católica de Chile, Santiago, Chile (D.G.); Institute for Clinical Evaluative Sciences, Toronto, Canada (P.C.A., L.Z., J.V.T., D.S.L.); Institute of Health Policy, Management, and Evaluation, Toronto, Canada (P.C.A., J.V.T., D.S.L.); Division of Cardiology, Sunnybrook Schulich Heart Centre, Toronto, Canada (J.V.T.); and Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.S.P.).
authors.forename: Heather J
authors.initials: HJ
authors.lastname: Ross
authors.affiliation: From the Division of Cardiology, Peter Munk Cardiac Centre (D.G., H.J.R., D.S.L.) and Joint Department of Medical Imaging (D.S.L.), University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada (D.G., P.C.A., J.V.T., H.J.R., D.S.L.); Division of Cardiovascular Diseases, School of Medicine, P. Universidad Católica de Chile, Santiago, Chile (D.G.); Institute for Clinical Evaluative Sciences, Toronto, Canada (P.C.A., L.Z., J.V.T., D.S.L.); Institute of Health Policy, Management, and Evaluation, Toronto, Canada (P.C.A., J.V.T., D.S.L.); Division of Cardiology, Sunnybrook Schulich Heart Centre, Toronto, Canada (J.V.T.); and Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.S.P.). dlee@ices.on.ca.
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Lee
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D004562:Electrocardiography; D005260:Female; D006333:Heart Failure / Q000453:epidemiology / Q000401:mortality*; D006801:Humans; D016015:Logistic Models; D008297:Male; D017202:Myocardial Ischemia / Q000175:diagnosis / Q000453:epidemiology*; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment
keywords: electrocardiography; heart failure; mortality; prognosis