ADHERE CART versus GWTG-HF for 30-day mortality and intensive care outcomes in emergency department patients with heart failure: A retrospective cohort study (MIMIC-IV-ED)

Early risk stratification may support emergency department (ED) decision-making for patients hospitalized with heart failure (HF), yet commonly used tools may perform differently across clinically relevant outcomes. We conducted a retrospective observational cohort study using MIMIC-IV (v3.1) linked to MIMIC-IV-ED (2011-2019). Adult ED encounters with HF International Classification of Diseases-9/10 codes from the ED diagnosis table that were linkable to an inpatient admission were included. The primary analytic cohort was restricted to complete-case encounters with sufficient data to compute both Acute Decompensated Heart Failure National Registry (ADHERE) CART and Get With The Guidelines-Heart Failure (GWTG-HF). The primary outcome was 30-day all-cause mortality; secondary outcomes were intensive care unit (ICU) admission within 24 hours after ED disposition, any ICU admission, acute kidney injury (AKI; Kidney Disease Improving Global Outcomes creatinine criteria), and hospital/ICU length of stay. Associations were evaluated using univariable logistic regression. Discrimination was assessed by area under the receiver operating characteristic curve (bootstrap 95% confidence intervals [CI]s) and compared using DeLong test. Calibration was assessed with patient-level 10-fold cross-validated calibration intercept/slope and calibration curves. Among 5508 eligible encounters, 4812 had complete data for both scores and constituted the analytic cohort. Thirty-day mortality occurred in 317/4812 (6.6%). ICU admission within 24 hours after ED disposition occurred in 822/4812 (17.1%), any ICU admission in 1098/4812 (22.8%), and AKI in 1373/4810 (28.5%). GWTG-HF was associated with higher 30-day mortality (odds ratio 2.3 per 10 points, 95% CI 2.1-2.6); ADHERE CART also showed higher odds across strata (group 4 vs 1 odds ratio 5.2, 95% CI 3.1-8.8). Mortality discrimination was higher for GWTG-HF than ADHERE (area under the receiver operating characteristic curve 0.75 vs 0.64; difference 0.10; P < .001), with near-ideal calibration for both. In ED patients hospitalized with HF, GWTG-HF more reliably stratified 30-day mortality risk than ADHERE CART, while both scores showed limited utility for ICU utilization and AKI, supporting outcome-specific and dynamic risk assessment.