Clinical Research
Heart Failure
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

https://doi.org/10.1016/j.jacc.2009.08.083Get rights and content
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Objectives

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)

Key Words

heart failure
risk stratification
discharge risk model

Abbreviations and Acronyms

ACE
angiotensin-converting enzyme
BNP
B-type natriuretic peptide
BUN
blood urea nitrogen
HF
heart failure
LV
left ventricular
NYHA
New York Heart Association
PAC
pulmonary artery catheter

Cited by (0)

Sources of funding for this study are the National Heart, Lung, and Blood Institute(N01-HV-98177) and Duke Clinical Research Institute, Durham, North Carolina. Dr. O'Connor is a consultant for Amgen, AstraZeneca, Forest, Bristol-Myers Squibb, GlaxoSmithKline, Merck, Medtronic, and Novartis. Dr. Califf has received research funding for a clinical trial by SCIOS, a subsidiary of Johnson and Johnson. Dr. Fiuzat is a shareholder of ARCA Biopharma, Inc.