Influence of patient sex on clinical decision-making in acute heart failure: a risk-adjusted analysis using the...

We aimed to assess whether the MEESSI-AHF score for 30-day mortality stratification in acute heart failure (AHF) patients presenting to the emergency department (ED) is equally accurate in men and women. As a secondary objective, we explored whether sex influences decision-making in aspects that largely depend on severity as estimated by MEESSI-AHF. We analyzed patients diagnosed with AHF in 56 Spanish ED that were consecutively included in the EAHFE registry during eight different time points between 2007 and 2022 for whom sex and MEESSI-AHF score were available. Patients were classified into the four MEESSI-AHF risk groups (low, intermediate, high, and very high) and by sex (men/women) as stated in the administrative records. We compared 30-day mortality in men and women (to independently assess the reliability of MEESSI-AHF in men and women, as MEESSI-AHF was derived to estimate the risk of death at 30 days); ED physicians' decisions regarding hospitalization and extended (> 24 h) ED observation in patients discharged home after ED care; and for hospital physicians' decisions regarding prolonged hospitalization (> 7 days) in hospitalized patients. We supposed that ED and hospital physicians' decisions should not differ between men and women in the same MEESSI-AHF risk category. These associations were tested using logistic regression and interaction analyses. The same analyses were repeated treating the MEESSI-AHF score as a continuous variable, modeled with restricted cubic splines. We included 13,042 patients (median age 83 years; 56% women). MEESSI-AHF accurately stratified 30-day mortality overall (2.9%, 9.6%, 18.2%, and 39.7% across risk groups; with a c-statistic of 0.78; p < 0.001), with no differences according to patient's sex (c-statistics of 0.77 for men and 0.78 for women, p > 0.05). We did not find sex interaction for the relationship between MEESSI-AHF score and 30-day mortality in categorical or continuous analyses (all p > 0.05). Hospital admission decisions (76%) and extended ED observation among discharged patients (9%), both made by ED physicians, as well as prolonged hospitalization (47%) determined by hospital physicians, increased with higher MEESSI-AHF risk (all p < 0.05). No sex interaction was observed in either categorical or continuous analyses (all p > 0.05).The MEESSI-AHF scale, as originally derived, provides equally reliable estimations of risk in men and women. Clinical decisions taken by ED and hospital physicians in patients with AHF did not differ in men and women with the same risk.