Mortality risk stratification in acute decompensated heart failure: ICARUS score for four-pillar era

Karen García-Rueda, Heart Failure and Transplant Clinic, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
Luis E. Echeverria, Heart Failure and Transplant Clinic, Fundación Cardiovascular de Colombia, Floridablanca, Colombia;; Faculty of Medical and Health Sciences, Universidad de Santander, Bucaramanga, Colombia
Lyda Z. Rojas, Research Center, Hospital Internacional de Colombia, Fundación Cardiovascular de Colombia, Fundación Universitaria FCV, Colombia
Sergio A. Gómez-Ochoa, Research Center, Hospital Internacional de Colombia, Fundación Cardiovascular de Colombia, Fundación Universitaria FCV, Colombia; Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Heidelberg, Germany
Angela Torres-Bustamante, Heart Failure and Transplant Clinic, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
Angie Y. Serrano-García, Heart Failure and Transplant Clinic, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
Laura V. Arciniegas-Landinez, Medical School, Universidad Industrial de Santander, Bucaramanga, Colombia
Jaime Rodríguez, Heart Failure and Transplant Clinic, Fundación Cardiovascular de Colombia, Floridablanca, Colombia

Background: Acute decompensated heart failure (ADHF) remains a leading cause of hospitalization and short-term death despite quadruple guideline-directed therapy. Early, pragmatic risk stratification at admission is essential. Objective: To identify independent predictors of in-hospital mortality in ADHF within the four-pillar era and to derive a simple bedside score (ICARUS). Methods: A retrospective cohort study was conducted of hospitalized adults, consecutively selected, with acute decompensated heart failure (de novo or chronic). Pre-specified candidate predictors were categorized with clinically informed cutoff and entered into multivariable logistic regression (backward selection). Model fit and discrimination were assessed using the Hosmer-Lemeshow test and the area under the receiver operating characteristic curve (area under the curve [AUC]), respectively. Coefficients were scaled to create a points-based score. Results: Among 1588 patients (median age 68 years; 69.3% male; median left ventricular ejection fraction [LVEF] 30%), in-hospital mortality was 4.28% (68/1,588; 95% confidence interval [CI] 3.34-5.39). Independent risk factors were diabetes (odds ratio [OR] 1.81), the New York Heart Association III-IV (OR: 1.97), the Minnesota Living with Heart Failure Questionnaire ≥ 41 (OR: 2.09), atrial fibrillation (OR: 2.29), hyperkalemia K+ > 5.5 mmol/L (OR: 2.63), and systolic blood pressure ≤ 110 mmHg (OR: 3.14). Protective factors were β-blocker use at admission (OR: 0.38), implantable device (OR: 0.22), and in-hospital sodium-glucose cotransporter 2 inhibitor therapy (OR: 0.27). The model showed good model fit (Hosmer-Lemeshow p = 0.997) and strong discriminative ability (AUC 0.81). The ICARUS points system performed similarly (AUC: 0.792; 95% CI 0.738-0.845), with stepwise increases in mortality across strata. Conclusion: Nine readily obtainable variables accurately stratified in-hospital mortality risk in ADHF. The ICARUS score is a pragmatic bedside tool, integrating clinical status and modern therapy, with a good goodness-of-fit and discrimination.

Keywords: Heart decompensation. Heart failure. Hospitalization. Latin America. Mortality.