Prospective Validation and Implementation Pilot Study of an Emergency Department Heart Failure Risk Stratification...

The STRIDE-HF (Systematic Tool for Risk Identification and Decision-making in Emergency Heart Failure) emergency department (ED) risk tool was previously found to accurately predict the risk of a 30-day serious adverse event (SAE), including 30-day mortality, cardiopulmonary resuscitation, intra-aortic balloon pump insertion, intubation, new dialysis, myocardial infarction, or coronary revascularization.

The aim of this study was to prospectively validate STRIDE-HF across 21 community EDs among patients in the ED with acute heart failure (AHF) from January 1, 2023, to December 31, 2023, and to assess the safety of the real-time use of risk estimates in a 2-ED pilot study.

Model area under the receiver operator curve (AUROC) and area under the precision recall curve (AUPRC), sensitivity, specificity, and positive and negative predictive values and likelihood ratios at key clinical thresholds are reported. In the clinical pilot, the rates of 30-day SAEs among patients who were at lower risk by STRIDE-HF and were discharged after ED or observation care were reported.

There were 13,274 patients in the ED in the prospective validation; the median age was 76 years, 50.8% were female, and 44.5% were non-White; and 11.4%, 24.8%, 31.9%, and 31.9% of patients were at very low, low, moderate, and high risk, respectively. The 30-day SAE rates among very-low-risk and low-risk patients were 3.4% and 6.7%, respectively, and the 30-day mortality rates were <1% and <2%, respectively. STRIDE-HF was highly sensitive among low-risk patients (97.6%; 95% CI: 96.8%-98.2%); AUROC was 0.75 (95% CI: 0.74-0.76), and AUPRC was 0.43 (95% CI: 0.39-0.44). There were 845 patients in the pilot study; among patients classified by STRIDE-HF criteria as being at very low risk who were discharged, none experienced a 30-day SAE.

STRIDE-HF maintained high predictive accuracy for 30-day SAE in prospective validation in this large, diverse, multicenter cohort; the use of risk estimates in real time safely identified low-risk patients appropriate for discharge.