• Òscar Miró, Xavier Rossello, Víctor Gil, Francisco Javier Martín-Sánchez, Pere Llorens, Pablo Herrero-Puente, Javier Jacob, Héctor Bueno, Stuart J Pocock, and ICA-SEMES Research Group.
• From Hospital Clínic, University of Barcelona, Barcelona, Spain; London School of Hygiene and Tropical Medicine, London, United Kingdom; National Centre for Cardiovascular Research, Hospital Clínico San Carlos, Hospital Universitario 12 de Octubre, and Universidad Complutense, Madrid, Spain; Hospital General de Alicante, Alicante, Spain; Hospital Universitario Central de Asturias, Oviedo, Spain; and Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain.
• Ann. Intern. Med. 2017 Nov 21; 167 (10): 698-705.

BackgroundPhysicians in the emergency department (ED) need additional tools to stratify patients with acute heart failure (AHF) according to risk.ObjectiveTo predict mortality using data that are readily available at ED admission.DesignProspective cohort study.Setting34 Spanish EDs.ParticipantsThe derivation cohort included 4867 consecutive ED patients admitted during 2009 to 2011. The validation cohort comprised 3229 patients admitted in 2014.Measurements88 candidate risk factors and 30-day mortality.ResultsThirteen independent risk factors were identified in the derivation cohort and were combined into an overall score, the MEESSI-AHF (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF) score. This score predicted 30-day mortality with excellent discrimination (c-statistic, 0.836) and calibration (Hosmer-Lemeshow P = 0.99) and provided a steep gradient in 30-day mortality across risk groups (<2% for patients in the 2 lowest risk quintiles and 45% in the highest risk decile). These characteristics were confirmed in the validation cohort (c-statistic, 0.828). Multiple sensitivity analyses did not find important amounts of confounding or bias.LimitationsThe study was confined to a single country. Participating EDs were not selected randomly. Many patients had missing data. Measurement of some risk factors was subjective.ConclusionThis tool has excellent discrimination and calibration and was validated in a different cohort from the one that was used to develop it. Physicians can consider using this tool to inform clinical decisions as further studies are done to determine whether the tool enhances physician decision making and improves patient outcomes.Primary Funding SourceInstituto de Salud Carlos III, Spanish Ministry of Health; Fundació La Marató de TV3; and Catalonia Govern.

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