Physicians' Academy for Cardiovascular Education

Risk stratification tool improves outcomes in acute HF

Trial of an Intervention to Improve Acute Heart Failure Outcomes

Literature - Lee DS, Straus SE, Farkouh ME, et al. - N Engl J Med. 2023 Jan 5;388(1):22-32. doi: 10.1056/NEJMoa2211680

Introduction and methods


For patients with acute HF (AHF), the first point of medical contact is often the emergency department (ED). There, physicians have traditionally relied on their clinical judgment to decide whether to discharge these patients or admit them to the hospital [1]. However, an obstacle for the selection of the patients is the inability to accurately predict the occurrence of adverse events based on risk estimation by physicians alone [2].

Aim of the study

The authors assessed the effect of a strategy to support clinical decision-making for the discharge or admission of patients who presented to the ED with AHF on clinical outcomes compared with usual care.


The COACH (Comparison of Outcomes and Access to Care for Heart Failure) trial was a multicenter, cross-sectional, stepped-wedge, cluster-randomized trial conducted in Ontario, Canada. The authors randomly assigned 10 hospitals to staggered start dates for one-way crossover from the control phase (usual care) to the intervention phase. During the trial, 5452 patients were enrolled (2972 during control phase and 2480 during intervention phase). Median follow-up time was 280 days (IQR: 82–520) for the control phase and 144 days (IQR: 64–286) for the intervention phase.

The intervention consisted of the use of a validated point-of-care algorithm to stratify AHF patients according to the risk of death, in addition to clinical judgment. For patients who had a low risk of both death within 7 days and death within 30 days, the recommendation was early discharge (≤3 days) and standardized transitional care in the Rapid Ambulatory Program for Investigation and Diagnosis of Heart Failure clinic, while hospital admission was recommended for high-risk patients. For intermediate-risk patients, clinicians were advised to use their clinical judgment, but the general guidance was to admit patients who had an intermediate-to-high risk and to consider early discharge for patients who had a low-to-intermediate risk. For the control phase, risk scores could be calculated after completion of the trial.


The first coprimary endpoint was a composite outcome of all-cause mortality or hospitalization for CV causes within 30 days after presentation to the ED. The second coprimary endpoint was the composite outcome within 20 months after presentation. Secondary endpoints were hospitalization for CV causes, hospitalization for HF, all-cause mortality, and a composite outcome of first nonelective ED visit, all-cause mortality, or hospitalization for CV causes.

Serious adverse events included death or hospitalization for either CV causes or any cause that occurred in low- or intermediate-risk patients after early discharge and before the first outpatient visit.

Main results


The use of a hospital-based strategy with a point-of-care tool for risk stratification to support clinical decision-making for the discharge or admission of AHF patients who presented to the ED, combined with rapid follow-up in an outpatient clinic, resulted in a lower risk of all-cause mortality or hospitalization for CV causes within 30 days (–12%) and within 20 months (–5%) than usual care, with no apparent safety concerns.


Show references

Find this article online at N Engl J Med.

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