Acute Decompensated Heart Failure National Registry (ADHERE) Algorithm

Why did you develop the ADHERE Algorithm? Was there a clinical experience that inspired you to create this tool for clinicians?

There are close to 1 million hospitalizations for heart failure each year in the United States. Despite the public health burden of hospitalization for heart failure, models for the risk stratification of patients during admission for acute decompensated heart failure previously had not well established. Clinical risk prediction tools may be helpful in guiding medical decision making.

What pearls, pitfalls and/or tips do you have for users of ADHERE? Are there cases when it has been applied, interpreted, or used inappropriately?

The ADHERE registry reflects patients cared for by thousands of clinicians at hundreds of hospitals across the country and thus has an excellent chance to adjust for this variation and create a risk prediction model that is robust for most situations. However, this model may not apply to patients who are cared for in settings that deviate substantially from those in ADHERE. In addition, each patient’s actual risk may be influenced by many factors not measured or considered in this model. Therefore, this model enhances, not replaces, physician assessment. This use of this, or other, risk models have been recommended in the ACC/AHA 2013 Heart Failure Guidelines (Class IIA).

What recommendations do you have for healthcare providers once they have applied the ADHERE algorithm? What are the next steps?

Patients estimated to be at a lower risk may be managed with less intensive monitoring and therapies available on a telemetry unit or hospital ward, whereas a patient estimated to be at a higher risk may require more intensive management. The finding that indices of renal status are 2 of the 3 most important variables in providing the best mortality risk discrimination underscores the importance of renal function in hospitalized heart failure patients.

How would you compare ADHERE with other assessments for mortality in heart failure?

The ADHERE Risk Model was designed to assess in-hospital mortality risk and be highly adaptable to bedside use based on variables readily available upon presentation. Other risk models have addressed 7 day or 30 day mortality risk or utilized more detailed point scores or formulas.

Any other comments on ADHERE?

The mortality for patients hospitalized with heart failure provides a compelling indication to apply tools, such as the risk tool derived and validated in ADHERE, to improve the evaluation and, potentially, management and outcomes of these patients.

Gregg C. Fonarow, MD, is a professor of medicine and the director of the Ahmanson-UCLA Cardiomyopathy Center. He also serves as the co-director UCLA Preventative Cardiology Program and co-chief of the UCLA Division of Cardiology. Dr. Fonarow has published over 800 research studies and clinical trials in heart failure management, preventative cardiology and outcomes research.