The TRIAGE-ProADM Score for an Early Risk Stratification of Medical Patients in the Emergency Department - Development Based on a Multi-National, Prospective, Observational Study

Kutz, Alexander; Hausfater, Pierre; Amin, Devendra; Amin, Adina; Canavaggio, Pauline; Sauvin, Gabrielle; Bernard, Maguy; Conca, Antoinette; Haubitz, Sebastian; Struja, Tristan; Huber, Andreas; Müeller, Beat; Schuetz, Philipp

doi:10.1371/journal.pone.0168076

Cited by 21 publications

(16 citation statements)

References 38 publications

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“…In addition, since prognostic accuracy was retained across broad clinical phenotypes (children and adults, with bacterial and viral sepsis, with community-acquired and HAIs, from multiple institutions around the world) the models appear to have successfully incorporated the broad clinical heterogeneity of sepsis. The derived discriminatory power of the gene models (AUCs near 0.85) is at least similar to the AUC of proadrenomedullin (0.83) in a recent large prospective trial (TRIAGE study) 8 . Furthermore, the impact of the addition of the severity score to clinical practice could be substantial.…”

Section: Discussionsupporting

confidence: 60%

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A community approach to mortality prediction in sepsis via gene expression analysis

et al. 2018

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Improved risk stratification and prognosis prediction in sepsis is a critical unmet need. Clinical severity scores and available assays such as blood lactate reflect global illness severity with suboptimal performance, and do not specifically reveal the underlying dysregulation of sepsis. Here, we present prognostic models for 30-day mortality generated independently by three scientific groups by using 12 discovery cohorts containing transcriptomic data collected from primarily community-onset sepsis patients. Predictive performance is validated in five cohorts of community-onset sepsis patients in which the models show summary AUROCs ranging from 0.765–0.89. Similar performance is observed in four cohorts of hospital-acquired sepsis. Combining the new gene-expression-based prognostic models with prior clinical severity scores leads to significant improvement in prediction of 30-day mortality as measured via AUROC and net reclassification improvement index These models provide an opportunity to develop molecular bedside tests that may improve risk stratification and mortality prediction in patients with sepsis.

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Section: Discussionsupporting

confidence: 60%

“…Some peptide markers of sepsis severity have been validated (e.g. proadrenomedullin 8 among others 9 ), but these are not yet cleared for clinical use.…”

Section: Introductionmentioning

confidence: 99%

A community approach to mortality prediction in sepsis via gene expression analysis

et al. 2018

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“…Several studies have demonstrated that the prognostic abilities of various biomarkers in acutely admitted patients in improving risk assessment in EDs [ 4 – 9 ]. These biomarkers include lactate [ 10 ], copeptin [ 8 , 9 ], pro-adrenomedullin [ 5 , 6 , 11 ], albumin [ 12 , 13 ], C-reactive protein (CRP) [ 14 , 15 ], and soluble urokinase plasminogen activator receptor (suPAR) [ 16 – 20 ]. However, none of these studies have addressed whether risk assessment that is strengthened by prognostic biomarkers improves patient outcome.…”

Section: Introductionmentioning

confidence: 99%

Use of the prognostic biomarker suPAR in the emergency department improves risk stratification but has no effect on mortality: a cluster-randomized clinical trial (TRIAGE III)

Schultz

Rasmussen

Andersen

et al. 2018

Scand J Trauma Resusc Emerg Med

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BackgroundRisk stratification of patients in the emergency department can be strengthened using prognostic biomarkers, but the impact on patient prognosis is unknown. The aim of the TRIAGE III trial was to investigate whether the introduction of the prognostic and nonspecific biomarker: soluble urokinase plasminogen activator receptor (suPAR) for risk stratification in the emergency department reduces mortality in acutely admitted patients.MethodsThe TRIAGE III trial was a cluster-randomized interventional trial conducted at emergency departments in the Capitol Region of Denmark. Eligible hospitals were required to have an emergency department with an intake of acute medical and surgical patients and no previous access to suPAR measurement. Three emergency departments were randomized; one withdrew shortly after the trial began. The inclusion period was from January through June of 2016 consisting of twelve cluster-periods of 3-weeks alternating between intervention and control and a subsequent follow-up of ten months. Patients were allocated to the intervention if they arrived in interventional periods, where suPAR measurement was routinely analysed at arrival. In the control periods suPAR measurement was not performed. The main outcome was all-cause mortality 10 months after arrival of the last patient in the inclusion period. Secondary outcomes included 30-day mortality.ResultsThe trial enrolled a consecutive cohort of 16,801 acutely admitted patients; all were included in the analyses. The intervention group consisted of 6 cluster periods with 8900 patients and the control group consisted of 6 cluster periods with 7901 patients. After a median follow-up of 362 days, death occurred in 1241 patients (13.9%) in the intervention group and in 1126 patients (14.3%) in the control group.The weighted Cox model found a hazard ratio of 0.97 (95% confidence interval, 0.89 to 1.07; p = 0.57). Analysis of all subgroups and of 30-day all-cause mortality showed similar results.ConclusionsThe TRIAGE III trial found no effect of introducing the nonspecific and prognostic biomarker suPAR in emergency departments on short- or long-term all-cause mortality among acutely admitted patients. Further research is required to evaluate how prognostic biomarkers can be implemented in routine clinical practice.Trial registrationclinicaltrials.gov, NCT02643459. Registered 31 December 2015.Electronic supplementary materialThe online version of this article (10.1186/s13049-018-0539-5) contains supplementary material, which is available to authorized users.

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“…28 Proper triage relies on adequate risk stratification and can be improved by incorporation of prognostic markers. 29 A number of previous investigations examined the prognostic value of the QRS-T angle in various populations, including patients with arterial hypertension, diabetes, CKD, myocarditis, implanted cardiac devices, chronic heart failure, and suspected and confirmed myocardial ischaemia, as well as in the general population. [4][5][6][7][8][9][10][11][12][13][14] Across the spectrum, greater QRS-T angles were associated with increased risk of adverse events, rehospitalizations, and mortality.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic and prognostic values of the QRS‐T angle in patients with suspected acute decompensated heart failure

et al. 2020

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Aims The aim of this study was to investigate the diagnostic and prognostic utility of the QRS-T angle, an electrocardiogram (ECG) marker quantifying depolarization-repolarization heterogeneity, in patients with suspected acute decompensated heart failure (ADHF). Methods and results We prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of ADHF. The QRS-T angle was automatically derived from a standard 12-lead ECG recorded at presentation. The primary diagnostic endpoint was a final adjudicated diagnosis of ADHF. The primary prognostic endpoint was all-cause mortality during 2 years of follow-up. Among the 1915 patients enrolled, those with higher QRS-T angles were older, were more commonly male, and had a higher rate of co-morbidities such as arterial hypertension, coronary artery disease, or chronic kidney disease. ADHF was the final adjudicated diagnosis in 1140 (60%) patients. The QRS-T angle in patients with ADHF was significantly larger than in patients with non-cardiac causes of dyspnoea {median 110°[inter-quartile range (IQR) 46-156°] vs. median 33°[IQR 15-57°], P < 0.001}. The diagnostic accuracy of the QRS-T angle as quantified by the area under the receiver operating characteristic curve (AUC) was 0.75 [95% confidence interval (CI) 0.73-0.77, P < 0.001], which was inferior to N-terminal pro-B-type natriuretic peptide (AUC 0.93, 95% CI 0.92-0.94, P < 0.001), but similar to that of high-sensitivity troponin T (AUC 0.78, 95% CI 0.76-0.80, P = 0.09). The AUC of the QRS-T angle for discrimination between ADHF and non-cardiac dyspnoea remained similarly high in subgroups of patients known to be diagnostically challenging, including patients older than 75 years [0.71 (95% CI 0.67-0.74)], renal failure [0.79 (95% CI 0.71-0.87)], and atrial fibrillation at presentation [0.68 (95% CI 0.60-0.76)]. Mortality rates according to QRS-T angle tertiles were 4%, 6%, and 10% after 30 days (P < 0.001) and 24%, 31%, and 43% after 2 years (P < 0.001). After adjustment for clinical, laboratory, and ECG parameters, the QRS-T angle remained an independent predictor for 2 year mortality with a 4% increase in mortality for every 20°increase in QRS-T angle (P = 0.02). Conclusions The QRS-T angle is a readily available and inexpensive marker that can assist in the discrimination between ADHF and non-cardiac causes of acute dyspnoea and may aid in the risk stratification of these patients.

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The TRIAGE-ProADM Score for an Early Risk Stratification of Medical Patients in the Emergency Department - Development Based on a Multi-National, Prospective, Observational Study

Cited by 21 publications

References 38 publications

A community approach to mortality prediction in sepsis via gene expression analysis

A community approach to mortality prediction in sepsis via gene expression analysis

Use of the prognostic biomarker suPAR in the emergency department improves risk stratification but has no effect on mortality: a cluster-randomized clinical trial (TRIAGE III)

Diagnostic and prognostic values of the QRS‐T angle in patients with suspected acute decompensated heart failure

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