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The Stanford acute heart failure symptom score for patients hospitalized with heart failure
Christopher S Almond1, Sharon Chen1, John C Dykes1
1Department of Pediatrics, Division of Cardiology, Stanford University School of Medicine, Palo Alto, California.
Insights
A new Heart Failure Score (HFS) effectively measures acute heart failure (HF) symptom severity in hospitalized children. This tool shows excellent reliability and predicts outcomes like length of stay and mortality.
Area of Science:
- Pediatric Cardiology
- Clinical Assessment Tools
- Heart Failure Management
Background:
- Existing heart failure scores (HFS) lack inpatient calibration and fail to capture key symptoms like gastrointestinal issues.
- Current tools often prioritize treatment intensity over actual patient symptom burden.
- There is a need for a simple, reliable tool to assess acute heart failure (HF) symptom severity in hospitalized children.
Purpose of the Study:
- To develop and validate a novel inpatient Heart Failure Score (HFS) for pediatric acute decompensated heart failure (ADHF).
- To create a tool that accurately reflects symptom severity based on breathing, feeding, and activity.
- To establish a score usable for clinical decision-making and clinical trials in pediatric HF.
Main Methods:
- Iterative development of an acute HFS over a 3-year pilot phase, focusing on 3 cardinal HF symptoms.
- Assessment of inter-rater reliability (IRR) using the final HFS version across various healthcare providers.
- Analysis of peak HFS against mortality and length of stay (LOS) in pediatric HF patients.
Main Results:
- The final HFS is a 4-point ordinal scale (0-12) with excellent IRR (ICC=0.94).
- Score trajectory correlated with clinical response to therapy across diverse HF types.
- Higher peak HFS quartiles were significantly associated with increased LOS and in-hospital mortality (p < 0.01).
Conclusions:
- The developed acute HFS is a simple, reliable tool for quantifying and monitoring HF symptoms in hospitalized children with ADHF.
- The score demonstrates strong clinical validity, evidenced by excellent IRR and association with key hospital outcomes.
- Further validation in a multicenter cohort is recommended to support widespread adoption.
Background:
Currently, there are no simple tools to evaluate the acute heart failure (HF) symptom severity in children hospitalized with acute decompensated HF (ADHF). We sought to develop an inpatient HF score (HFS) that could be used as a clinical tool and for clinical trials.
Methods:
Pediatric HF clinicians at Stanford reviewed the limitations of existing HFSs, which include lack of calibration to the inpatient setting, omission of gastrointestinal symptoms, need for multiple age-based tools, and scores that prioritize treatment intensity over patient symptoms. To address these, we developed an acute HFS corresponding to the 3 cardinal symptoms of HF: difficulty with breathing, feeding, and activity. The score was iteratively improved over a 3-year pilot phase until no further changes were made. The inter-rater reliability (IRR) across a range of providers was assessed using the final version. Peak HFSs were analyzed against mortality and length of stay (LOS) for all pediatric HF discharges between July and October 2019.
Results:
The final HFS was a 4-point ordinal severity score for each of the 3 symptom domains (total score 0-12). Among clinicians who scored 12 inpatients with ADHF simultaneously, the intraclass correlation (ICC) was 0.94 (respiratory ICC = 0.89, feeding ICC = 0.85, and activity ICC = 0.80). Score trajectory reflected our clinical impression of patient response to HF therapies across a range of HF syndromes including 1- and 2-ventricle heart disease and reduced or preserved ejection fraction. Among the 28 patients hospitalized during a 3-months period (N = 28), quartiles of peak score were associated with LOS (p < 0.01) and in-hospital mortality (p < 0.01): HFS 0 to 3 (median LOS of 5 days and mortality of 0%), HFS 4 to 6 (median LOS of 18 days and mortality of 0%), HFS 5 to 9 (median LOS of 29 days and mortality of 23%), and HFS 10 to 12 (median LOS of 121 days and mortality of 50%).
Conclusion:
This simple acute HFS may be a useful tool to quantify and monitor day-to-day HF symptoms in children hospitalized with ADHF regardless of etiology or age group. The score has excellent IRR across provider levels and is associated with major hospital outcomes supporting its clinical validity. Validation in a multicenter cohort is warranted.
