Ottawa Heart Failure Risk Scale (OHFRS)

OHFRS
History of stroke or TIA
SpO₂ <90% on initial assessment
Heart rate ≥110 on 3-min walk test
CO₂ ≥35 mmHg (venous)
Troponin I or T positive
NT-proBNP ≥5000 pg/mL
New ischemic ECG changes
Acute HF on chest X-ray
Arrived by ambulance/EMS
SBP <140 mmHg on ED presentation
OHFRS Score:0
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Identifies ED patients with heart failure at high risk for serious adverse events.

Why Use

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).

When to 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.

Formula

Addition of the selected points: No Yes History Stroke or TIA 0 +1 Intubation for respiratory distress 0 +2 Examination HR ≥110 on ED arrival 0 +2 SaO 2 <90% on arrival 0 +1 Heart rate ≥110 during 3-minutes walk test (or too ill to perform walk test) 0 +1 Investigations New ischemic changes on EKG 0 +2 Urea ≥12 mmol/L 0 +1 Serum CO 2 ≥35 mmol/L (mEq/L) 0 +2 Troponin I or T elevated to MI level 0 +2 NT-proBNP ≥5,000 ng/L (pg/mL) 0 +1

Pearls / Pitfalls

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.

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.

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.

More Information

Interpretation: Total Score Risk of Serious Adverse Event (SAE)* Category 0 2.8% Low 1 5.1% Medium 2 9.2% Medium 3 15.9% High 4 26.1% High 5 39.8% Very high 6 55.3% Very high 7 69.8% Very high 8 81.2% Very high 9 89.0% Very high >9 >89.0% Very high *Serious adverse events were defined as: 30-day all cause mortality, or Any of the following within 14 days of the index ED visit, regardless of whether initially admitted: Admission to critical care or acute monitoring unit (excluding ambulatory telemetry units). Endotracheal intubation or need for noninvasive ventilation after hospital admission (unless on noninvasive ventilation at home). MI, as defined by international consensus standards. Either one of the following criteria satisfies the diagnosis for an acute, evolving, or recent MI: Typical rise and gradual fall of troponin with at least one of the following: Ischemic symptoms. Pathologic Q waves on EKG. EKG changes indicative of ischemia. Coronary artery intervention (e.g., coronary angioplasty). Pathologic findings of an acute MI. Major procedure, defined as CABG, PCI, other cardiac surgery, or new hemodialysis. Relapse and hospital admission for patients discharged on the initial ED visit, defined as a return to the ED for any related medical problem within 14 days followed by admission to hospital (relapse to the ED without associated admission was not considered a SAE).

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