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    Ottawa Heart Failure Risk Scale (OHFRS)

    Identifies ED patients with heart failure at high risk for serious adverse events.
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    INSTRUCTIONS

    Use in patients presenting to the emergency department with acute dyspnea secondary to new-onset or chronic heart failure (HF), after initial intervention. Do not use prior to ED intervention. Do not use in patients who are hemodynamically unstable (see When to Use for full exclusion criteria).

    When to Use
    Pearls/Pitfalls
    Why Use
    • Patients presenting to the ED with HF exacerbation who have responded to treatment.
    • Do not use if:
      • Resting O₂ sat <85% on room air on normal home O₂ for >20 minutes.
      • Heart rate >120 on arrival.
      • Systolic BP <85 mmHg on arrival.
      • Confusion, disorientation, or dementia.
      • Ischemic chest pain requiring nitrates on arrival.
      • ST segment elevation on EKG.
      • Death expected within weeks from chronic illness.
      • Nursing home or chronic care facility resident.
      • On chronic hemodialysis.
    • The Ottawa Heart Failure Risk Scale (OHFRS) identifies ED patients with HF at high risk for serious adverse events (SAE), including death, MI, need for ICU/intubation.
    • Best suited for ED patients presenting with HF exacerbation who have responded to treatment in the ED.
    • Not intended to be used in determining disposition until after ED intervention (in the study, OHFRS was assessed 2-8 hours after initial ED treatment).
    • Can be used even if NT-proBNP is unavailable without sacrificing accuracy significantly.
    • Derivation study was conducted in Canada, where only 38% of patients presenting to EDs with acute HF are admitted, compared with 80% in the US (citation). Regional practice patterns should be considered in applying this score.
    • Patients presenting with acute HF or exacerbations of chronic HF are at high risk for adverse events. Even with appropriate ED management, many require admission for further evaluation and treatment. This score helps identify both:

      • Patients at low risk for adverse events and thus potentially safe for discharge with close follow-up.
      • Patients who are at higher risk and require admission and close monitoring.
    • More widely validated than the Emergency Heart Failure Mortality Risk Grade (EHMRG), but with stricter inclusion/exclusion criteria (see When to Use).
    History
    No
    0
    Yes
    +1
    No
    0
    Yes
    +2
    Examination
    No
    0
    Yes
    +2
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    Investigations
    No
    0
    Yes
    +2
    No
    0
    Yes
    +1
    No
    0
    Yes
    +2
    No
    0
    Yes
    +2
    No
    0
    Yes
    +1

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    Interpreting medium risk scores can be the most difficult part of the OHFRS. Using scores >1 as an admission threshold increases sensitivity for serious adverse events (SAE) and increases admission rates, but a threshold of scores >2 leads to similar sensitivity to previous practice with a notable reduction in admission rates.

    • Consider patient-specific factors to help determine disposition for patients with scores 1–2, e.g. access to medical care and timely follow-up, comorbidities, living conditions, frequency of HF exacerbations.
    • As with all risk scores, use clinician judgment and shared decision-making model to ensure the patient is informed of the benefits and risks associated with their disposition regardless of whether they are admitted or discharged.  
    • Patients being discharged should receive thorough return precautions, as heart failure patients are at higher risk for severe complications than the general population.

    Management

    • For patients with higher OHFRS (>1 or 2 depending on preference) or a concerning clinical presentation after initial intervention, consider admission for monitoring and further treatment.
    • Patients with OHFRS <2, good response to ED intervention, and encouraging clinical presentation may be safe for discharge with close follow-up.

    Critical Actions

    High or worsening score should trigger consideration of a higher level of care, including early involvement of intensivists, cardiologists, and other specialists.

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    About the Creator
    Dr. Ian Stiell
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