Douglas Greig1, Peter C Austin1, Limei Zhou1, Jack V Tu1, Peter S Pang1, Heather J Ross1, Douglas S Lee2. 1. From the Division of Cardiology, Peter Munk Cardiac Centre (D.G., H.J.R., D.S.L.) and Joint Department of Medical Imaging (D.S.L.), University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada (D.G., P.C.A., J.V.T., H.J.R., D.S.L.); Division of Cardiovascular Diseases, School of Medicine, P. Universidad Católica de Chile, Santiago, Chile (D.G.); Institute for Clinical Evaluative Sciences, Toronto, Canada (P.C.A., L.Z., J.V.T., D.S.L.); Institute of Health Policy, Management, and Evaluation, Toronto, Canada (P.C.A., J.V.T., D.S.L.); Division of Cardiology, Sunnybrook Schulich Heart Centre, Toronto, Canada (J.V.T.); and Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.S.P.). 2. From the Division of Cardiology, Peter Munk Cardiac Centre (D.G., H.J.R., D.S.L.) and Joint Department of Medical Imaging (D.S.L.), University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada (D.G., P.C.A., J.V.T., H.J.R., D.S.L.); Division of Cardiovascular Diseases, School of Medicine, P. Universidad Católica de Chile, Santiago, Chile (D.G.); Institute for Clinical Evaluative Sciences, Toronto, Canada (P.C.A., L.Z., J.V.T., D.S.L.); Institute of Health Policy, Management, and Evaluation, Toronto, Canada (P.C.A., J.V.T., D.S.L.); Division of Cardiology, Sunnybrook Schulich Heart Centre, Toronto, Canada (J.V.T.); and Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (P.S.P.). dlee@ices.on.ca.
Abstract
BACKGROUND: Identification of coronary ischemia may enable targeted diagnostic and therapeutic strategies for acute heart failure. We determined the risk of 30-day mortality associated with ischemic ECG abnormalities in patients with acute heart failure. METHODS AND RESULTS: Among 8772 patients (53.4% women, median 78 years [Q1, Q3: 68,84]) presenting with acute heart failure to 86 hospital emergency departments in Ontario, Canada, Q-waves, T-wave inversion, or ST-depression were present in 51.8% of subjects. However, presence of ST-depression was the only finding associated with 30-day mortality with adjusted odds ratio 1.24 (95% confidence interval [CI], 1.02-1.50). Using continuous net reclassification improvement, addition of ST-depression to the Emergency Heart failure Mortality Risk Grade model reclassified 16.9% of patients overall, and 29.3% of those with a history of ischemic heart disease (both P<0.001). By adding ST-depression to the model, the Emergency Heart failure Mortality Risk Grade was extended to predict 30-day death with high discrimination (c-statistic 0.801), with 0.57% mortality rate in the lowest risk decile. Adjusted odds ratios for 30-day mortality were 2.81 (95% CI, 1.48-5.31; P=0.002) in quintile 2, 7.41 (95% CI, 4.13-13.30; P<0.001) in quintile 3, and 14.47 (95% CI, 8.20-25.54; P<0.001) in quintile 4 compared with the lowest risk quintile. When the highest risk quintile was subdivided into 2 equally sized risk strata (deciles 9 and 10), the adjusted odds ratios for 30-day mortality were 27.20 (95% CI, 15.33-48.27; P<0.001) in decile 9 and 58.96 (95% CI, 33.54-103.65; P<0.001) in highest risk decile 10. CONCLUSIONS: Presence of ST-depression on the ECG reclassified risk of 30-day mortality in patients with acute heart failure, identifying both high- and low-risk subsets.
BACKGROUND: Identification of coronary ischemia may enable targeted diagnostic and therapeutic strategies for acute heart failure. We determined the risk of 30-day mortality associated with ischemic ECG abnormalities in patients with acute heart failure. METHODS AND RESULTS: Among 8772 patients (53.4% women, median 78 years [Q1, Q3: 68,84]) presenting with acute heart failure to 86 hospital emergency departments in Ontario, Canada, Q-waves, T-wave inversion, or ST-depression were present in 51.8% of subjects. However, presence of ST-depression was the only finding associated with 30-day mortality with adjusted odds ratio 1.24 (95% confidence interval [CI], 1.02-1.50). Using continuous net reclassification improvement, addition of ST-depression to the Emergency Heart failure Mortality Risk Grade model reclassified 16.9% of patients overall, and 29.3% of those with a history of ischemic heart disease (both P<0.001). By adding ST-depression to the model, the Emergency Heart failure Mortality Risk Grade was extended to predict 30-day death with high discrimination (c-statistic 0.801), with 0.57% mortality rate in the lowest risk decile. Adjusted odds ratios for 30-day mortality were 2.81 (95% CI, 1.48-5.31; P=0.002) in quintile 2, 7.41 (95% CI, 4.13-13.30; P<0.001) in quintile 3, and 14.47 (95% CI, 8.20-25.54; P<0.001) in quintile 4 compared with the lowest risk quintile. When the highest risk quintile was subdivided into 2 equally sized risk strata (deciles 9 and 10), the adjusted odds ratios for 30-day mortality were 27.20 (95% CI, 15.33-48.27; P<0.001) in decile 9 and 58.96 (95% CI, 33.54-103.65; P<0.001) in highest risk decile 10. CONCLUSIONS: Presence of ST-depression on the ECG reclassified risk of 30-day mortality in patients with acute heart failure, identifying both high- and low-risk subsets.
Authors: Òscar Miró; Xavier Rossello; Elke Platz; Josep Masip; Danielle M Gualandro; W Frank Peacock; Susanna Price; Louise Cullen; Salvatore DiSomma; Mucio Tavares de Oliveira; John Jv McMurray; Francisco J Martín-Sánchez; Alan S Maisel; Christiaan Vrints; Martin R Cowie; Héctor Bueno; Alexandre Mebazaa; Christian Mueller Journal: Eur Heart J Acute Cardiovasc Care Date: 2020-08
Authors: Livia Goldraich; Peter C Austin; Limei Zhou; Jack V Tu; Michael J Schull; Susanna Mak; Heather J Ross; David A Morrow; Douglas S Lee Journal: J Am Heart Assoc Date: 2016-07-22 Impact factor: 5.501