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Emergency Heart Failure Mortality Risk Grade score performance for 7-day mortality prediction in patients with heart failure attended at the emergency department

validation in a Spanish cohort

Gil, Víctora,b,*; Miró, Òscara,b,*; Schull, Michael J.i,j; Llorens, Peref; Herrero-Puente, Pablog; Jacob, Javierd; Ríos, Joséc,e; Lee, Douglas S.k,l; Martín-Sánchez, Francisco J.h on behalf of the ICA-SEMES Research Group

European Journal of Emergency Medicine: June 2018 - Volume 25 - Issue 3 - p 169–177
doi: 10.1097/MEJ.0000000000000422

Objective The Emergency Heart Failure Mortality Risk Grade (EHMRG) scale, derived in 86 Canadian emergency departments (EDs), stratifies patients with acute-decompensated heart failure (ADHF) according to their 7-day mortality risk. We evaluated its external validity in a Spanish cohort.

Patients and methods We applied the EHMRG scale to ADHF patients consecutively included in the Epidemiology of Acute Heart Failure in Emergency departments (EAHFE) registry (29 Spanish EDs) and measured its performance. Patients were distributed into quintiles according to the original and their self-defined score cutoffs. The 7-day mortality rates were compared internally among different categories and with categories of Canadian cohorts.

Results The EAHFE group [n: 1553 patients; 80 (10) years; 55.6% women] had a 5.5% 7-day mortality rate and the EHMRG scale c-statistic was 0.741 (95% confidence interval: 0.688–0.793) compared with 0.807 (0.761–0.842) and 0.804 (0.763–0.840) obtained in the Canadian derivation and validation cohorts. The mortality rate of the EAHFE group mortality increased progressively as the quintile categories increased using intervals defined by either the Canadian or the Spanish EHMRG score cutoffs, although with more regular increments with the EAHFE-defined intervals; using the latter, patients at quintiles 2, 3, 4, 5a and 5b had (compared with quintile 1) odds ratios of 1.77, 3.36, 4.44, 9.39 and 16.19, respectively.

Conclusion The EHMRG scale stratified risk in an ADHF cohort that included both palliative and nonpalliative patients in Spanish EDs, showing an extrapolation to a higher mortality risk cohort than the original derivation sample. Stratification improved when the score was recalibrated in the Spanish cohort.

aEmergency Department, Hospital Clínic

b‘Emergencies: Processes and Pathologies’ Research Group

cBiostatistics and Data Management Core Facility, IDIBAPS, Hospital Clinic

dEmergency Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat

eBiostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona

fEmergency Department, Home Hospitalization and Short Stay Unit, Hospital General de Alicante, Alicante

gEmergency Department, Hospital Universitario Central de Asturias, Oviedo

hEmergency Department, Hospital Clínico San Carlos, Madrid, Spain

iEmergency Department, Sunnybrook Health Sciences Centre

jDepartment of Medicine, Institute for Clinical Evaluative Sciences

kInstitute for Clinical Evaluative Sciences

lPeter Munk Cardiac Centre and the Joint Department of Medical Imaging of the University Health Network-Toronto General Hospital, University of Toronto, Toronto, Canada

* Víctor Gil and Òscar Miró equally contributed to the writing of this paper.

Correspondence to Víctor Gil, MD, Emergency Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Catalonia, Spain Tel: +34 93 227 98 33; fax: +34 93 227 56 93; e-mail:

Received February 3, 2016

Accepted August 11, 2016

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