title: Identification of Emergency Department Patients With Acute Heart Failure at Low Risk for 30-Day Adverse Events: The STRATIFY Decision Tool.
abstract: OBJECTIVE
  No prospectively derived or validated decision tools identify emergency department (ED) patients with acute heart failure (AHF) at low risk for 30-day adverse events who are thus potential candidates for safe ED discharge. This study sought to accomplish that goal.
  
  
  BACKGROUND
  The nearly 1 million annual ED visits for AHF are associated with high proportions of admissions and consume significant resources.
  
  
  METHODS
  We prospectively enrolled 1,033 patients diagnosed with AHF in the ED from 4 hospitals between July 20, 2007, and February 4, 2011. We used an ordinal outcome hierarchy, defined as the incidence of the most severe adverse event within 30 days of ED evaluation (acute coronary syndrome, coronary revascularization, emergent dialysis, intubation, mechanical cardiac support, cardiopulmonary resuscitation, and death).
  
  
  RESULTS
  Of 1,033 patients enrolled, 126 (12%) experienced at least one 30-day adverse event. The decision tool had a C statistic of 0.68 (95% confidence interval: 0.63 to 0.74). Elevated troponin (p < 0.001) and renal function (p = 0.01) were significant predictors of adverse events in our multivariable model, whereas B-type natriuretic peptide (p = 0.09), tachypnea (p = 0.09), and patients undergoing dialysis (p = 0.07) trended toward significance. At risk thresholds of 1%, 3%, and 5%, we found 0%, 1.4%, and 13.0% patients were at low risk, with negative predictive values of 100%, 96%, and 93%, respectively.
  
  
  CONCLUSIONS
  The STRATIFY decision tool identifies ED patients with AHF who are at low risk for 30-day adverse events and may be candidates for safe ED discharge. After external testing, and perhaps when used as part of a shared decision-making strategy, it may significantly affect disposition strategies. (Improving Heart Failure Risk Stratification in the ED [STRATIFY]; NCT00508638).
authors.affiliation: Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee. Electronic address: sean.collins@vanderbilt.edu.
authors.forename: Sean P
authors.initials: SP
authors.lastname: Collins
authors.affiliation: Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Cathy A
authors.initials: CA
authors.lastname: Jenkins
authors.affiliation: Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Frank E
authors.initials: FE
authors.lastname: Harrell
authors.affiliation: Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Dandan
authors.initials: D
authors.lastname: Liu
authors.affiliation: Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Karen F
authors.initials: KF
authors.lastname: Miller
authors.affiliation: Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Lindsell
authors.affiliation: Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Allen J
authors.initials: AJ
authors.lastname: Naftilan
authors.affiliation: Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: John A
authors.initials: JA
authors.lastname: McPherson
authors.affiliation: Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California.
authors.forename: David J
authors.initials: DJ
authors.lastname: Maron
authors.affiliation: Department of Medicine, Division of Cardiovascular Medicine, Maine Medical Center, Portland, Maine.
authors.forename: Douglas B
authors.initials: DB
authors.lastname: Sawyer
authors.affiliation: Department of Medicine and Vascular Biology Center, Georgia Regents University, Augusta, Georgia.
authors.forename: Neal L
authors.initials: NL
authors.lastname: Weintraub
authors.affiliation: Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Fermann
authors.affiliation: Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Susan K
authors.initials: SK
authors.lastname: Roll
authors.affiliation: Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Matthew
authors.initials: M
authors.lastname: Sperling
authors.affiliation: Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Alan B
authors.initials: AB
authors.lastname: Storrow
mesh_terms: D000208:Acute Disease; D000368:Aged; D015331:Cohort Studies; D016001:Confidence Intervals; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010343:Patient Admission / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D018570:Risk Assessment; D013997:Time Factors; D014481:United States
keywords: acute heart failure; decision tool; emergency department; prospective study