Hot Off the Press: Prospective and Explicit Clinical Validation of the Ottawa Heart Failure Risk Scale, With and Without Use of Quantitative <scp>NT</scp>‐pro<scp>BNP</scp>

BACKGROUNDC ongestive heart failure admissions are common and expensive, and high percentages of patients are readmitted within 3 to 6 months.1-5 Canadian admission rates for heart failure are much lower than in America.6 There is a lack of evidence to guide physicians in disposition decisions-who can go home and who requires admissions?Many risk stratification scales discuss the risk of mortality, but do not include broader adverse events that may occur.7-16 The Ottawa Heart Failure Risk Score (OHFRS) was derived to predict significant adverse events (SAEs) at 14 days.17 The current study aims to validate the tool in a real-time clinical setting. ARTICLE SUMMARYThis prospective cohort study included patients ≥ 50 years old with dyspnea of <7 days' duration, due to acute heart failure.18 Patients too ill to be discharged were excluded.Treating physicians assessed the OHFRS approximately 2 to 8 hours after ED presentation.The primary outcome measured was SAE within 14 days, with SAEs including death from any cause within 30 days, admission to a monitored unit, any positive pressure ventilation, myocardial infarction, major cardiac procedure, new dialysis, or subsequent hospital admission if the patient was initially discharged from the ED.At an admission threshold of ≥1, the OHFRS would increase sensitivity from 71.8% to 91.8% for SAEs, but also increase admission rates.A threshold of ≥2 had a similar sensitivity, but decreased admissions (57.2% vs. 48.3%.)Addition of NT-proBNP levels did not substantially change the results. QUALITY ASSESSMENTThis was a multicenter, prospective, ED-based study, with explicitly specified predictor variables and outcomes.Some limitations were identified.First of all, clinicians were not blinded to the OHFRS score, and in fact the treating clinician calculated the score.Although they were instructed not to use the score when making decisions, this could result in incorporation bias.Patients were not enrolled consecutively, and patients presenting at night could be higher risk than those during the day.At lower scores (<1), the OHFRS increases sensitivity for SAEs, and as a result, admissions increase.However, it is unclear whether admitting patients would prevent any of the SAEs from occurring.The use of a composite outcome can

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