Risk stratification in acute heart failure New insights into the management of acute failure

Differently from myocardial infarction that has comparable incidence and short term mortality, risk stratification models for patient with acutely decompensated heart failure are not available for current clinical practice. The identification of clinical variables able to predict short-term prognosis may be very helpful in guiding medical decision making including the need of a more intensive management in an intensive or a coronary care unit.

The EuroHeart Survey on Heart Failure collected data on 3,579 patients admitted acutely for heart failure by 133 centres in 30 countries. We excluded from this analysis the patients with cardiogenic shock, whose short-term mortality is so high that specific models for risk stratification are less useful since an intensive management is needed in all patients.

The database of the remaining 3,441 patients included in the EuroHeart Survey on Heart Failure showed that in-hospital all-cause mortality of patients with acute decompensation of an already known heart failure condition was 5.3% (116/2202 patients), while total in-hospital mortality of patients with de novo acute heart failure was 5.4% (67/1239 patients).

Even if overall mortality was 5.3%, the mortality risk greatly varied from less than 1% to more than 50% according to the presence or absence of clinical variables that significantly influence in-hospital death. In both situations (worsening or de novo heart failure), the strongest independent predictors of short-term all-cause mortality were the following ones: advanced age, low systolic blood pressure, renal dysfunction, signs of peripheral hypo-perfusion and an acute coronary syndrome as precipitating factor for heart failure. With the exception of age, all these clinical conditions can be appropriately and timely managed to reduce in-hospital mortality.

These simple clinical variables, easy to detect in any clinical setting, can be very helpful in the identification of patients at high risk of early death after hospital admission for acute heart failure, allowing a tailored use of intensive therapeutic strategies including the setting (intensive vs usual) in which the patients may be more appropriately managed.