Steinhart Model for Acute Heart Failure (AHF) in Undifferentiated Dyspnea

Why did you develop the Steinhart Model for Acute Heart Failure in Undifferentiated Dyspnea? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

Undifferentiated dyspnea presentations to the ED can be a challenge to sort out. The differential typically includes acute heart failure (AHF), COPD, afib, pneumonia, and PE. Often, empiric treatment for all possible causes is started as lengthy investigations continue. These treatments are not without serious potential side effects. Natriuretic peptide biomarkers are used in a binary way to help rule in/out AHF but have limited specificity. So we undertook research studies that ultimately led to the creation of this diagnostic prediction model that risk stratifies for AHF, guiding the clinician right at patient presentation.

What pearls, pitfalls and/or tips do you have for users of the Steinhart Model? Do you know of cases when it has been applied, interpreted, or used inappropriately?

After initial bedside assessment and chest x-ray interpretation, the patient has to have intermediate pretest probability for AHF (20-80%) which we define as investigating and/or treating for causes other than just AHF. Severe renal failure patients are excluded. The Model uses NT-proBNP; BNP results cannot be applied.

What recommendations do you have for doctors once they have applied the Steinhart Model? Are there any adjustments or updates you would make to the score based on new data or practice changes?

In analyzing over 1,100 cases we found in 95% of them where the Model result was <20% posttest probability for AHF, the actual final diagnosis was not AHF; likewise, if >80%, the actual final diagnosis was AHF. We feel the clinician can confidently use them as definitive treatment thresholds.

How do you use the Steinhart Model in your own clinical practice? Can you give an example of a scenario in which you use it?

I find it especially helpful in those dyspnea cases that present with a history of mixed cardiac and pulmonary disease.

Any other research in the pipeline that you’re particularly excited about?

We are in the early stages of designing an RCT that compares the model and lung ultrasound separately and together for ruling in/out AHF in this selective ED patient population.

Brian D. Steinhart, MD, FRCPC, dABEM, is an emergency physician at St. Michael’s Hospital in Ontario, Canada. He is also an associate professor in the department of medicine at the University of Toronto. Dr. Steinhart’s primary research is focused on acute coronary syndromes and cardiac biomarkers.