Abstract
Aims
The National Early Warning Score (NEWS) is a scoring system that predicts increased mortality and morbidity in critical diseases. The National Early Warning Score + Lactate (NEWS + L) score was created by adding lactate values to this scoring system. In our study, we aimed to determine the value of the NEWS + L score in predicting clinical deterioration in patients presenting with acute decompensated heart failure (chronic heart failure).
Methods and results
In this observational, cross‐sectional study, patients with decompensated heart failure who were admitted to the emergency department between 1 October 2020 and 31 December 2020 were included. Patients were divided into two groups: those with and without poor prognostic outcomes. The main outcomes were in‐hospital mortality, discharge after treatment in the emergency department, admission to the ward, and admission to the intensive care unit. We analysed a total of 141 applications from 130 patients. The mean age was 72.6 ± 11.8 years, and 50.8% were female. Poor prognostic outcomes were observed in 92 (65%) patients. There was no difference between the patients with and without poor prognostic outcomes in terms of mean age, gender, and comorbidities, except for atrial fibrillation. There was a statistically significant difference between the patients without and with poor prognosis outcomes in terms of NEWS {3 [interquartile range (IQR): 0–5] and 6 [IQR: 3–8]} and NEWS + L scores [4.7 (IQR: 2.3–7.2) and 8.0 (IQR: 5.2–10.4)] (P < 0.001). The area under the curve values for predicting poor prognosis were calculated as 0.719 for NEWS, 0.734 for NEWS + L, and 0.601 for lactate values. The rate of poor prognostic outcomes was higher (79%) in patients with moderate and high NEWS scores. Patients with Q1 NEWS + L scores had a lower rate of poor prognostic outcomes, while patients with Q2, Q3, and Q4 scores of NEWS + L had a higher rate of poor prognostic outcomes.
Conclusions
The NEWS score and the addition of the lactate value to this score, the NEWS + L score, were higher in patients with poor prognostic outcomes who presented with decompensated heart failure in our emergency department. NEWS + L slightly outperformed the NEWS score in predicting prognosis. The NEWS + L score shows promise as a prognostic indicator for patients with decompensated heart failure presenting to the emergency department.
Keywords: Decompensated heart failure, National Early Warning Score + Lactate score, NEWS + L score, Emergency department, Lactate, NEWS
Introduction
Decompensated chronic heart failure (CHF) is an important acute critical condition presented to the emergency department. In developed countries, heart failure (HF) is seen in approximately 1–2% of the adult patient group. 1 The prevalence of HF is increasing all over the world due to the rising average age and the treatment approaches developed. 2 The prognostic value of the scorings such as the New York Heart Association (NYHA) Classification of Heart Failure, The Seattle Heart Failure Model, and The Meta‐Analysis Global Group in Chronic Heart Failure risk score used in HF patients is limited and their calculations are complex/impractical.
The National Early Warning Score (NEWS) is a scoring system used in critical diseases to predict mortality and morbidity. NEWS employs a straightforward scoring system in which a score is attributed to physiological measurements such as respiratory rate, peripheral oxygen saturation, need for supplemental oxygen, body temperature, systolic blood pressure, heart rate, and neurological status. Several studies have validated the utility of NEWS as a track‐and‐trigger system for predicting unplanned intensive care admissions or death. 3 , 4 The National Early Warning Score + Lactate (NEWS + L) is a newer scoring system created by adding lactate to the NEWS scoring system. Studies on this scoring system have been conducted in different populations, such as the critical geriatric patient population, the general patient population, upper gastrointestinal bleeding, community‐acquired pneumonia, and intensive care unit patients. 5 , 6 , 7 , 8 , 9 In the current literature, we have not found a study on either of these scoring systems to predict poor outcomes in patients with decompensated HF.
In our study, we aimed to determine the value of the NEWS + L score in predicting the complicated clinical course in patients presenting with acute decompensated HF in the emergency department.
Methods
Our study is an observational, cross‐sectional study. All consecutive patients with decompensated HF who were admitted to The Tertiary Emergency Department of Dokuz Eylül University Hospital between 1 October 2020 and 31 December 2020 were included in the study. For patients with multiple visits with HF, all the visits were included in the study. Our study was started after the approval of The Dokuz Eylul University Non‐Interventional Clinical Research Ethics Committee (28 September 2020, protocol number 5752‐GOA, decision number 2020/23‐18).
Inclusion criteria included patients over 18 years old who were diagnosed with decompensated HF in the emergency department by an emergency medicine physician.
Exclusion criteria included (i) patients with HF and other co‐existing diagnoses such as pneumonia, sepsis, and pulmonary embolism; (ii) patients with HF but whose reason for admission is unrelated to HF; and (iii) patients whose arterial or venous blood lactate level was not measured on admission.
Demographic data of patients (age and gender) and comorbid diseases (such as diabetes mellitus, hypertension (HT), coronary artery disease, and chronic kidney failure), blood lactate values in venous or arterial blood gas, brain natriuretic peptide (BNP) and troponin values, left ventricular ejection fraction (LVEF), NYHA classification, treatments applied in the emergency department (diuretic, nitrate, oxygen support with nasal cannula/mask, non‐invasive mechanical ventilation, invasive mechanical ventilation, inotropic support, vasopressor support, and cardiopulmonary resuscitation), and outcomes (discharge, hospitalization, admission to intensive care unit, and death) were recorded via the hospital information management system. NEWS and NEWS + L scores (Table 1 ) were calculated from these data. Patients were classified as low‐risk (0–4 points), medium‐risk (5–6 points), and high‐risk (≥7 points) groups according to their admission NEWS scores, and according to their NEWS + L scores, they were divided into four groups: Q1 (≤3), Q2 (3.1–5.2), Q3 (5.3–8), and Q4 (≥8.1).
Table 1.
National Early Warning Score + Lactate score used in the study
| 3 | 2 | 1 | 0 | 1 | 2 | 3 | Score | |
|---|---|---|---|---|---|---|---|---|
| Physiological parameter | ||||||||
| Respiration rate (per minute) | ≤8 | 9–11 | 12–20 | 21–24 | ||||
| SpO2 scale 1 (%) | ≤91 | 92–93 | 94–95 | ≥96 | ||||
| SpO2 scale 2 a (%) | ≤83 | 84–85 | 86–87 |
88–92 On air ≥93 |
93–94 oxygen | 95–96 oxygen | ≥97 oxygen | |
| Air or oxygen? | Oxygen | Air | ||||||
| Systolic blood pressure (mmHg) | ≤90 | 91–100 | 101–110 | 111–219 | ≥220 | |||
| Pulse (per minute) | ≤40 | 41–50 | 51–90 | 91–110 | 111–130 | ≥131 | ||
| Consciousness | Alert | CVPU | ||||||
| Temperature (°C) | ≤35.0 | 35.1–36.0 | 36.1–38.0 | 38.1–39.0 | ≥39.1 | |||
| Laboratory component + | ||||||||
| Lactate level (mmol/L) | ||||||||
| NEWS + L score | ||||||||
CVPU, confusion, voice, pain, unresponsive; NEWS‐L, National Early Warning Score + Lactate.
For use in patients with hypercapnic respiratory failure (usually due to chronic obstructive pulmonary disease) who have clinically recommended oxygen saturation of 88–92%.
In our study, mortality was defined as the primary endpoint, while the occurrence of any adverse prognostic event was designated as the secondary endpoint. At least one of the following features was considered as a poor prognostic outcome:
deterioration of the patient's consciousness due to haemodynamic instability or respiratory failure;
the patient's need for at least one of the invasive mechanic ventilation (IMV), non‐invasive mechanic ventilation (NIMV), inotrope, or vasopressor treatments;
high‐sensitivity troponin I values above normal on admission (upper limit for female, 18.3 ng/L; upper limit for male, 42.9 ng/L);
the patient's admission to the intensive care unit;
the need for cardiopulmonary resuscitation; or
in‐hospital death.
Statistical analysis
Data were evaluated in SPSS 22.0 (IBM Corporation, Armonk, NY, USA) programme. The normal distribution of variables was evaluated with the Kolmogorov–Smirnov test, and the homogeneity of variance was evaluated with the Levene test. Data determined by measurement were given as mean and standard deviation for those with normal distribution and as median and range or median and interquartile range (IQR) for those not normally distributed. The t‐test or Mann–Whitney U test was used in the statistical analysis of these data. Categorical data were shown as ratio percentage, and in the statistical analysis, the χ 2 test or Fisher's exact test was used. Variables were analysed at a 95% confidence interval, and P < 0.05 was considered as significant. Receiver operating characteristic (ROC) analysis was used for area under the curve (AUC) calculations. The medcalc.org website was used to calculate specificity, sensitivity, positive and negative likelihood ratios, and positive and negative predictive values. In the calculations, low‐risk patients for NEWS were considered as negative and intermediate–high‐risk patients were considered as positive test results, and analyses were performed. For NEWS + L, patients with Q1 scores were considered negative and patients with Q2, Q3, and Q4 scores were accepted as positive test results, and analyses were performed. The logistic regression analysis was conducted for patients' prognostic outcomes. In addition, predictor variables with P < 0.20 value were also evaluated using multivariate regression analysis.
Results
During the study period, 249 patients were admitted to the emergency department with a clinical diagnosis of decompensated HF. One hundred seven patients were excluded from the study because of other co‐existing diseases, nine patients because the reason for admission was unrelated to HF, and three patients because the lactate level in blood gas was not studied. Eleven patients had recurrent admissions. Ultimately, a total of 141 applications from 130 patients were included in the study.
The mean age of the patients was 72.6 ± 11.8 (31–96), and 64 (49.2%) patients were male. Patients of the baseline characteristics such as demographic data, comorbid diseases, NYHA classification lactate, BNP and troponin values, treatments, and outcomes were shown in Table 2 . Poor prognostic outcomes were present in 92 (65%) patients; 77 patients had elevated troponin levels, 43 needed NIMV support, 5 needed IMV support, 5 needed intravenous (i.v.) vasopressors, 4 needed i.v. inotropes, 4 needed cardiopulmonary resuscitation, and 3 had in‐hospital mortality.
Table 2.
Baseline characteristics of the patients
| Patients without poor prognostic outcome (n = 49) | Patients with poor prognostic outcome (n = 92) | Total (n = 141) | P | ||
|---|---|---|---|---|---|
| Age (mean ± SD) | 72.1 ± 13.7 | 73.4 ± 10.7 | 72.6 ± 11.8 | 0.595 a | |
| Gender, n (%) | Female | 27 (55) | 47 (51) | 74 (53) | 0.649 b |
| Male | 22 (50) | 45 (49) | 67 (48) | ||
| Comorbidities, n (%) | HT | 38 (78) | 77 (84) | 115 (82) | 0.370 b |
| CAD | 22 (45) | 39 (42) | 61 (43) | 0.775 b | |
| CABG | 7 (14) | 10 (11) | 17 (12) | 0.553 b | |
| DM | 24 (49) | 46 (50) | 70 (50) | 0.908 b | |
| COPD | 6 (12) | 18 (20) | 24 (17) | 0.271 b | |
| AF | 17 (35) | 17 (19) | 34 (24) | 0.032 b | |
| CVE | 4 (8) | 5 (5) | 9 (6) | 0.719 b | |
| CRF | 4 (8) | 12 (13) | 16 (11) | 0.578 b | |
| Others | 7 (14) | 7 (8) | 14 (10) | 0.207 b | |
| NYHA score, n (%) | NYHA 2 | 20 (41) | 12 (13) | 32 (23) | <0.001 b |
| NYHA 3 | 18 (37) | 29 (32) | 47 (33) | ||
| NYHA 4 | 11 (22) | 51 (55) | 62 (44) | ||
| Lactate, median (IQR) | 2 (1.4–2.4) | 2.3 (1.4–3) | 2.1 (1.4–2.7) | 0.048 c | |
| Troponin I, median (IQR) | 15.4 (9.9–24.3) | 40.1 (17.7–147.4) | 23.6 (14.1–60.4) | <0.001 c | |
| BNP (pg/mL), median (IQR) | 942 (420–1672) | 1197 (699–2259) | 1142 (556–2142) | 0.023 c | |
| LVEF (%), median (IQR) | 50 (30–60) | 35 (25–55) | 40 (25–55) | 0.034 c | |
| Pretibial oedema, n (%) | 33 (67) | 62 (67) | 95 (67) | 0.996 b | |
| Hospitalization in the last year, n (%) | 14 (29) | 24 (26) | 38 (27) | 0.752 b | |
| The treatment given, n (%) | i.v. diuretics | 46 (94) | 87 (95) | 133 (94) | 1.0 b |
| i.v. nitrates | 41 (84) | 76 (83) | 117 (83) | 0.873 b | |
| O2 support | 14 (29) | 55 (60) | 69 (49) | <0.001 b | |
| NIMV support | 0 (0) | 43 (47) | 43 (31) | ||
| IMV support | 0 (0) | 5 (5) | 5 (4) | ||
| Inotropes | 0 (0) | 4 (4) | 4 (3) | ||
| Vasopressors | 0 (0) | 5 (5) | 5 (4) | ||
| CPR | 0 (0) | 4 (4) | 4 (3) | ||
| Outcome | Discharge | 29 (59) | 10 (11) | 39 (28) | 0.001 |
| Admitted to ward | 20 (41) | 17 (19) | 37 (26) | ||
| Admitted to intensive care unit | 0 (0) | 62 (67) | 62 (44) | ||
| Death | 0 (0) | 3 (3) | 3 (2) | ||
AF, atrial fibrillation; BNP, brain natriuretic peptide; CABG, coronary artery bypass graft; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; CPR, cardiopulmonary resuscitation; CRF, chronic renal failure; CVE, cerebrovascular event; DM, diabetes mellitus; HT, hypertension; i.v., intravenous; IMV, invasive mechanic ventilation; IQR, interquartile range; LVEF, left ventricular ejection fraction; NIMV, non‐invasive mechanic ventilation; NYHA, New York Heart Association. Statistically significant values are bolded.
Independent groups t‐test.
χ 2 test.
Mann–Whitney U test.
Patients with the poor prognosis outcome had higher NYHA scores and lower LVEF (P < 0.001 and P = 0.034, respectively). However, there was no difference between the groups in comorbidities other than atrial fibrillation (AF), which was more common in the patients without poor prognostic outcome (P = 0.0321). The rate of administration of diuretic and nitrate treatments was similar in patients with and without poor prognostic outcome. Oxygen therapy was used more frequently in patients with poor prognostic outcome.
Of the patients, 28% (n = 39) were discharged after treatment in the emergency department, 26% (n = 37) were admitted to the ward, and 44% (n = 62) were admitted to the intensive care unit. Three patients died in the emergency department follow‐up. The NEWS scores of the three patients who died were 5.6 and 9, and the NEWS + L scores were 7.9, 8.8, and 30. There was a statistically significant difference between the two groups in terms of primary outcomes (P < 0.001; Table 2 ).
The median of NEWS + L and NEWS was higher in the patients with poor prognostic outcome than those without poor prognostic outcome (P < 0.001). The rate of poor prognosis outcome was higher (79%) in patients with moderate and high NEWS scores. In the NEWS + L scoring, patients with Q1 scores had a lower rate of having poor prognostic outcome, while patients with Q2, Q3, and Q4 scores had a higher rate of having poor prognostic outcome (Table 3 ).
Table 3.
National Early Warning Score and National Early Warning Score + Lactate groups according to with or without poor prognostic outcome
| Patients without poor prognostic outcome (n = 49) | Patients with poor prognostic outcome (n = 92) | Total (n = 141) | P | ||
|---|---|---|---|---|---|
| NEWS, median (IQR) | 3 (0–5) | 6 (3–8) | 5 (1.5–7) | <0.001 | |
| NEWS + L, median (IQR) | 4.7 (2.3–7.2) | 8.0 (5.2–10.4) | 6.7 (3.6–9.2) | <0.001 | |
| NEWS, n (%) | Low | 34 (69) | 34 (37) | 68 (48) | <0.001 |
| Medium | 10 (20) | 25 (27) | 35 (25) | ||
| High | 5 (10) | 33 (36) | 38 (27) | ||
| NEWS + L, n (%) | Q1 (≤3) | 17 (35) | 12 (13) | 29 (21) | <0.001 |
| Q2 (3.1–5.2) | 9 (18) | 11 (12) | 20 (14) | ||
| Q3 (5.3–8) | 17 (35) | 25 (27) | 42 (30) | ||
| Q4 (≥8.1) | 6 (12) | 44 (48) | 50 (36) | ||
IQR, interquartile range; NEWS, National Early Warning Score; NEWS‐L, National Early Warning Score + Lactate. Statistically significant values are bolded.
The AUC values for predicting poor prognosis were calculated as 0.719 for NEWS, 0.734 for NEWS + L, and 0.601 for lactate values (Figure 1 ).
Figure 1.
Receiver operating characteristic (ROC) curves for National Early Warning Score (NEWS), National Early Warning Score + Lactate (NEWS + L), and lactate.
The sensitivity was 63% and the specificity was 69.4% when a score of 4 points was used as the cut‐off value in distinguishing patients with low NEWS scores from those with moderate and high NEWS scores. For NEWS + L, the sensitivity was 86.96% and the specificity was 34.69% when a score of 3 points of cut‐off value was used to differentiate patients with Q1 scores from patients with Q2, Q3, and Q4 scores (Table 4 ).
Table 4.
The test analyses for National Early Warning Score and National Early Warning Score + Lactate scores
| Statistic | NEWS | NEWS + L | ||
|---|---|---|---|---|
| Value | 95% CI | Value | 95% CI | |
| Sensitivity | 63.04% | 52.34–72.88% | 86.96% | 78.32–93.07% |
| Specificity | 69.39% | 54.58–81.75% | 34.69% | 21.67–49.64% |
| Positive likelihood ratio | 2.06 | 1.31–3.23 | 1.33 | 1.07–1.66 |
| Negative likelihood ratio | 0.53 | 0.38–0.74 | 0.38 | 0.20–0.72 |
| Positive predictive value | 79.45% | 71.15–85.84% | 71.43% | 66.76–75.68% |
| Negative predictive value | 50.00% | 41.94–58.06% | 58.62% | 42.45–73.12% |
| Accuracy | 65.25% | 56.78–73.06% | 68.79% | 60.45–76.33% |
CI, confidence interval; NEWS, National Early Warning Score; NEWS‐L, National Early Warning Score + Lactate.
A logistic regression analysis was performed for the poor prognostic outcome, and odds ratios were calculated for NEWS as 4.470 and NEWS + L as 4.276 (Table 5 ). Parameters HT, AF, and NEWS with P < 0.20 were also included in the multivariate regression analysis. The odds ratios were found as follows: for HT, 2.685 (P = 0.040, 95% CI 1.045–6.894); for AF, 0.395 (P = 0.036, 95% CI 0.166–0.942); and for NEWS, 5.282 (P < 0.001, 95% CI 2.372–11.763). In the case of NEWS + L in the multivariate regression analysis, the odds ratios were as follows: for HT, 2.530 (P = 0.008, 95% CI 1.383–9.008); for AF, 0.510 (P = 0.123, 95% CI 0.217–1.200); and for NEWS + L, 5.634 (P < 0.001, 95% CI 2.257–14.065).
Table 5.
Logistic regression analysis for poor prognostic outcome
| P value | Odds ratio | 95% CI | |
|---|---|---|---|
| Age | 0.173 | 1.021 | 0.991–1.051 |
| Male | 0.920 | 1.036 | 0.517–2.075 |
| HT | 0.075 | 2.194 | 0.925–5.206 |
| CAD | 0.943 | 1.026 | 0.509–2.065 |
| CABG | 0.960 | 0.973 | 0.337–2.813 |
| DM | 0.908 | 1.042 | 0.521–2.084 |
| COPD | 0.873 | 1.079 | 0.426–2.734 |
| AF | 0.086 | 0.502 | 0.228–1.104 |
| CVE | 0.531 | 0.647 | 0.165–2.527 |
| CRF | 0.388 | 1.687 | 0.514–5.542 |
| NEWS | <0.001 | 4.470 | 2.107–9.482 |
| NEWS + L | <0.001 | 4.276 | 1.815–10.071 |
AF, atrial fibrillation; CABG, coronary artery bypass graft; CAD, coronary artery disease; CI, confidence interval; COPD, chronic obstructive pulmonary disease; CRF, chronic renal failure; CVE, cerebrovascular event; DM, diabetes mellitus; HT, hypertension; NEWS + L, National Early Warning Score + Lactate; NEWS, National Early Warning Score.
Discussion
In our study, in which we investigated the prognostic value of the NEWS + L score in patients with decompensated CHF, NEWS + L values were found to be higher in the patients with poor prognostic outcome. When the NEWS and NEWS + L scores were evaluated categorically, both scoring systems were found useful in distinguishing patients with poor prognoses. In both scoring, as the score value increased, the rate of patients with poor prognosis also increased. For NEWS + L, only patients with Q1 scores had a higher rate of the patients without poor prognostic outcome, while all the other scores had an increasingly poorer prognosis. While the rate of patients with and without poor prognostic outcome was equal in the low group for the NEWS score, the rate of poor prognosis increased when the NEWS score increased. In addition, when the NEWS + L scoring system was used as a screening test, its sensitivity was higher than NEWS (86.96% and 63.04%, respectively), and it was better in identifying the patients with poor prognostic outcome. On the other hand, its specificity was found to be worse than the NEWS score.
When two scores are compared with each other, the NEWS + L score was slightly more successful than the NEWS score in predicting prognosis. Previously, the NEWS + L score was studied by Dundar et al. in the critically geriatric patient population admitted to the emergency department, and when the ROC curves were examined in terms of predicting in‐hospital mortality, the AUC was found to be 0.686 for NEWS and 0.714 for NEWS + L. 8 In our study, when the ROC curves were examined for the prognostic value of NEWS and NEWS + L scoring, the AUC was calculated as 0.719 for NEWS and 0.734 for NEWS + L. This supports that NEWS + L values are more successful in predicting poor outcomes in the emergency department. Lactate values, which were shown as an independent factor in demonstrating the clinical worsening of patients in different studies, were also observed to be higher in the poor prognosis group in our study. 10 , 11
Compared with other commonly used risk scores, the NEWS and NEWS + L scores appear to be more suitable in emergency settings due to limitations and impracticalities found in alternatives such as the NYHA Classification of Heart Failure, which only includes symptoms and functional status of the patient. On the other hand, The Seattle Heart Failure Model and The Meta‐Analysis Global Group in Chronic Heart Failure risk score use >10 different variables, including LVEF measurement.
In our study, we found that the rate of poor prognostic outcome increased by 5.634 times in patients with high NEWS + L scores. Additionally, the rate of poor prognostic outcome was found to increase by 5.282 times in patients with high NEWS scores compared with those without. These findings suggest that the use of NEWS and NEWS + L scores may be applicable in predicting poor prognostic outcomes in patients with HF in the emergency department.
Furthermore, although the incidence of AF was lower in the group with poor prognostic outcome compared with those without in our study, multivariate regression analysis did not reveal a significant impact of AF on poor prognostic outcomes. On the other hand, the presence of HT comorbidity was found to increase the risk of poor prognostic outcomes by approximately 2.5 times, as determined by multivariate regression analysis.
In another study by Jo et al., it was stated that the NEWS + L score could be used to predict inpatient mortality in a study of community‐acquired pneumonia patients. The patients included in this study were divided into groups according to their NEWS + L scores: ≤3 (Q1), 3.1–5.2 (Q2), 5.3–8 (Q3), and ≥8.1 (Q4). 5 In our study, these threshold values were used in grouping the patients. However, the value of the NEWS + L score in predicting mortality could not be analysed, as the number of patients who died in our study was very low.
In a study by Kim et al., findings that the NEWS + L score can be used to identify low‐risk patients in patients with upper gastrointestinal bleeding were shown. 7 In our study, patients with Q1 scores were 35% in the patients without poor prognostic outcome and 13% in the patients with poor prognostic outcome. However, patients with Q3 scores were also found to be 35% in the patients without poor prognostic outcome, and it was not possible to make a similar assumption in this regard.
In a study conducted by Gray et al., in which the treatment given to patients with CHF was examined in the literature, the use of diuretics was found to be 89%, and nitrate use was 90.4%. 12 In our study, the use of diuretics was found to be 94% and nitrate use was 83%, and the rates are found to be similar.
In a meta‐analysis of NIMV application in patients with CHF, it was shown that in‐hospital mortality, need for intubation, and length of stay in the intensive care unit decreased. 13 In our study, NIMV treatment was applied to 31% of the total admissions and 47% of the patients in the poor prognosis group. The very low rate of patients who underwent invasive mechanical ventilation (4%) and died (2%) may be related to the effective use of NIMV. The fact that our hospital is a university hospital that provides treatments by international standards and that there are more NIMV devices compared with many emergency services, and the clinical experience in using the device may also have affected these results. In our study, it was not possible to evaluate NIMV because while the poor prognosis group was determined for applications, all patients who needed NIMV were included in this group. However, when considering the need for oxygen support with nasal cannula/mask, it was found that the number of patients receiving oxygen support was higher in the poor prognosis group with higher NEWS + L scores.
Considering the discharge rates for patients with CHF, it was found that the discharge rate of HF patients from the emergency room was 16% in a study conducted in the United States, 24% in a study conducted in Spain, and 36% in a study conducted in Canada. 14 , 15 , 16 Similarly, in our study, 28% of the patients were treated in the emergency department and discharged.
Limitations
Our study is a single‐centre study and the number of patients included is less than anticipated due to the COVID‐19 pandemic at the time of the study. As only three patients died in our study, no analysis could be made in terms of mortality. Mortality analysis could be performed in a larger population.
The baseline treatments of the patients were not assessed. The therapies and treatment adherence employed for conditions such as diabetes, CHF, or AF could have potentially impacted the outcomes of emergency department interventions. In our study, only the NEWS + L scores at the time of admission were evaluated. In terms of the usability of NEWS or NEWS + L scores in treatment responses, studies using repetitive measurements can be conducted.
Conclusions
According to the results of our study, NEWS and NEWS + L scores were found to be useful in distinguishing patients with poor prognosis in patients who presented to the emergency department with a clinical diagnosis of decompensated HF. In both scoring, as the score value increased, the rate of patients with poor prognosis also increased. The NEWS + L score was found to be slightly more successful in predicting prognosis than the NEWS score, with higher sensitivity but lower specificity.
The NEWS + L score shows promise as a prognostic indicator for patients with decompensated HF presenting to the emergency department.
Conflict of interest
The authors have no conflict of interest to declare.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.
Guzelce, M. C. , Colak, N. , Ucar, G. , and Orhan, E. (2023) Prognostic value of the NEWS + Lactate score in patients with decompensated heart failure in the emergency department. ESC Heart Failure, 10: 3604–3611. 10.1002/ehf2.14537.
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