Influence of patient sex on clinical decision-making in acute heart failure: A risk-adjusted analysis using the MEESSI-AHF score

Influence of patient sex on clinical decision-making in acute heart failure: A risk-adjusted analysis using the MEESSI-AHF score | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Influence of patient sex on clinical decision-making in acute heart failure: A risk-adjusted analysis using the MEESSI-AHF score Oscar Miro, natalia miota hernández, Pere Llorens, Víctor Gil, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8480632/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Mar, 2026 Read the published version in Internal and Emergency Medicine → Version 1 posted 4 You are reading this latest preprint version Abstract Background: Risk scores for acute heart failure (AHF) are typically developed without sex-specific models. The MEESSI-AHF score estimates 30-day mortality in patients presenting with AHF to the emergency department (ED). Whether its prognostic accuracy and its influence on clinical decisions are comparable between men and women remains unknown. Methods: We analyzed patients from the EAHFE registry with known sex and complete data to calculate the MEESSI-AHF score. Patients were classified into four risk groups (low, intermediate, high, very high). Sex-based differences were evaluated for 30-day mortality and for ED physicians’ decisions regarding hospitalization and extended (>24 h) ED observation, as well as for hospital physicians’ decisions regarding prolonged hospitalization (>7 days). Logistic regression interaction analyses were performed using both categorical and continuous models (restricted cubic splines). Results: We included 13,042 patients (median age 83 years; 56% women). MEESSI-AHF accurately stratified 30-day mortality overall (2.9%, 9.6%, 18.2%, and 39.7% across risk groups; with a c-statistic of 0.78; p0.05), with no significant sex interactions in categorical or continuous analyses (all p>0.05). Hospitalization (76%), extended observation in the ED in discharged patients (9%) and prolonged hospitalization (47%) also increased with higher MEESSI-AHF risk, with no evidence of sex interaction in categorical or continuous analyses (all p>0.05). Conclusions: The MEESSI-AHF score estimates risk with similar accuracy in men and women. Clinical decisions regarding hospitalization and discharge (from ED and after hospitalization) appear to be made equally in patients of both sexes with comparable MEESSI-AHF-estimated risk. Sex Factors Risk Assessment Mortality Heart Failure Emergency Service Hospital Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Acute heart failure (AHF) is one of the leading causes of hospital emergency department (ED) visits worldwide, associated with high morbidity and mortality and representing a major public health challenge [ 1 , 2 ]. Approximately 90% of AHF patients are first managed in the ED [ 3 ]. Data from the EAHFE registry (Epidemiology of Acute Heart Failure in Emergency Departments) show that AHF entails substantial healthcare resource use, with hospitalization rates above 75%, in-hospital mortality near 8%, and one-year mortality around 30% [ 1 ]. Moreover, it is associated with frequent revisits and readmissions, making it a syndrome with persistent clinical impact beyond the initial acute episode [ 4 ]. Taken together, these observations emphasize the need for reliable tools to ensure accurate risk stratification and to guide clinical decision-making in the challenging context of emergency care. European Society of Cardiology guidelines for heart failure recommend initial risk stratification of AHF patients upon ED arrival to inform diagnostic and therapeutic decisions and optimize resource allocation [ 2 ], as accurate early risk assessment is key to reducing adverse outcomes and avoiding unnecessary admissions. In line with these recommendations, early ED management with proper risk estimation is crucial. To this end, the MEESSI-AHF score (Multiple Estimation of risk based on the Emergency Department Spanish Score in patients with AHF) was developed and validated for ED use. It estimates 30-day mortality in AHF patients based on 13 readily available clinical variables, with excellent discrimination (c-statistic > 0.8) and good calibration across independent cohorts and care settings [ 5 – 8 ]. The MEESSI-AHF score classifies patients into four risk groups (low, intermediate, high, very high), supporting decisions on hospital admission or safe discharge from the ED. In recent years, numerous studies have highlighted the importance of incorporating sex and gender perspectives in emergency medicine practice and cardiovascular research, including AHF. Women with AHF show a distinct clinical profile compared with men: older age, higher prevalence of hypertension and elevated blood pressure at presentation, greater frequency of preserved left ventricular ejection fraction (LVEF), more symptoms, and worse functional class [ 9 – 12 ]. Despite these differences, women paradoxically tend to exhibit a favorable long-term prognosis, with similar or slightly better survival and equal or lower readmission rates [ 13 – 15 ]. However, despite growing evidence of sex-related differences in AHF presentation and outcomes, it remains unclear whether risk stratification tools used in EDs perform equally well in both sexes, or whether clinical decisions derived from their use are based solely on estimated risk without sex-related influence. Understanding this is essential, since sex can affect pathophysiology, treatment response, and prognosis, and unrecognized differences could limit the clinical applicability of risk scores. The aim of this study was to examine whether the MEESSI-AHF score has similar prognostic accuracy in men and women for predicting 30-day mortality (the outcome for which MEESSI-AHF was designed), and whether sex differences exist in decision-making in the ED (to decide hospitalization or extended observation in the ED before discharging patient home without hospitalization) and during the hospitalization (length of stay in hospitalized patients) for men and women with the same MEESSI-AHF score. This analysis seeks to provide evidence on the score’s validity in both sexes and to demonstrate equitable, risk-based care in the ED irrespective of patient sex. METHODS Study design and population We conducted a multicenter, retrospective, observational, non-interventional study based on the prospective EAHFE registry, which includes unselected patients diagnosed with AHF and treated in Spanish EDs. The registry prospectively enrolls cases from 52 emergency departments across Spain over intermittent inclusion periods between 2007 and 2022. The only criterion for exclusion to be included in the EAHFE registry is that AHF is developed during a ST-elevation myocardial infarction (STEMI), as most of these patients bypass ED and go directly to hemodynamic laboratory. Extensive details of the EAHFE registry have been published elsewhere [ 8 , 16 , 17 ]. For this analysis, we included all patients with sex recorded in the administrative records and with complete data for the variables required to calculate the MEESSI-AHF score. The MEESSI-AHF score incorporates clinical, laboratory, and functional parameters obtained at initial ED assessment, specifically: age, Barthel index, NYHA class, non-STEMI as precipitant of the AHF episode, low output symptoms, oxygen saturation, systolic blood pressure, respiratory rate, potassium, creatinine, troponin, NT-proBNP and left ventricular hypertrophy in the electrocardiogram (ECG) [ 5 ]. In addition to these variables, we also collected other relevant clinical characteristics corresponding to comorbidities, baseline functional status, triggers of decompensation, clinical presentation, vital signs, laboratory results, chest radiography, and ECG. Outcomes We evaluated two sets of outcomes aligned with the study objectives. To assess the reliability of the MEESSI-AHF score in predicting adverse events in men and women, we used 30-day all-cause mortality after the index ED episode, the same endpoint employed for score development in the original study [ 5 ]. To examine whether men and women with the same MEESSI-AHF score are managed similarly, we analyzed three additional outcomes. Regarding ED physicians’ decisions, we assessed hospitalization after ED care and extended ED observation among patients discharged home, defined as > 24 hours before discharge. Regarding hospital physicians’ decisions, we assessed length of stay among patients discharged alive (excluding in-hospital deaths) and defined prolonged hospitalization as > 7 days, a threshold commonly used in acute heart failure studies and roughly corresponding to the upper quartile of hospital stays in previous EAHFE analyses [ 1 ]. Because of their objective nature, outcome adjudication was made locally by the principal investigator of each center, without external review. Statistical analysis Quantitative variables were expressed as medians and interquartile ranges (IQR) and compared between sexes using the Mann–Whitney U test. Categorical variables were reported as absolute frequencies and percentages and compared using the chi-square test. The prognostic performance of MEESSI-AHF was evaluated using the C-statistic (area under the ROC curve) with 95% confidence interval (CI), analyzing discrimination overall and stratified by sex. The comparison of the discriminative capacity between sexes was performed by using McLeod test. To assess the association between sex and death prognostication of MEESSI-AHF as well as between sex and clinical decisions of emergency and hospital physicians, we built logistic regression models and analyses were performed both by risk categories (low, intermediate, high, very high) and associations were expressed as odds ratio (OR) with 95% CI, as well as by treating the MEESSI-AHF score as a continuous variable with restricted cubic splines (RCS) using 5 knots (placed at 5, 25, 50, 75 and 95 percentiles of the MEESSI-AHF score distribution) following Harrell’s recommendations [ 18 ]. For the RCS models, a sensitivity analysis was conducted considering separately patients with preserved (≥50%) and mildly-reduced or reduced LVEF (< 50%). Sex interaction was tested for the relationship between MEESSI-AHF categories or scores and outcomes. A two-sided p value < 0.05 was considered statistically significant. Analyses were performed using IBM SPSS Statistics version 29.0 for Mac (IBM Corp., Armonk, NY, USA) and STATA version 18.0 for Mac (StataCorp, College Station, TX, USA). Ethical considerations This study used anonymized data from the EAHFE registry, and the study protocol was approved by the Clinical Research Ethics Committee of the Central University Hospital of Asturias (Oviedo, Spain, reference numbers 49/2010, 69/2011, 166/13, 160/15 and 205/17) and Hospital Clínic de Barcelona (Barcelona, Spain, reference number 2018/0233) as the lead committees, as well as by the ethics committees of all other participating centers. In accordance with the Declaration of Helsinki and local regulations, the requirement for written informed consent was waived by all ethics committees owing to the retrospective use of fully anonymized routinely collected data; no identifiable personal data were used. Only authorized investigators had access to the anonymized database used for analysis. RESULTS A total of 13,042 patients diagnosed with AHF and treated in EDs were included ( Fig. 1 ) . Median age was 83 years (IQR 75–89), and 56% were women (n = 7,250). Comorbidities were frequent, with hypertension, previous AHF episodes and atrial fibrillation being present in more than 50% of patients. Around two thirds had some functional impairment (Barthel index below 100 points) and nearly one quarter were on NYHA class III or IV. Two thirds of patients were on chronic diuretic treatment. The most frequent precipitants of the AHF episode were infections (39%) and tachyarrhythmia (16%). The rest of clinical, analytical, radiological and ECG data are detailed in Table 1 . Women showed a distinct clinical profile, with significant differences in most of the variables analyzed. Remarkably, women were older than men and with a higher prevalence of hypertension, atrial fibrillation, valvular heart disease, and dementia (all p < 0.001). They also had worse baseline functional status, with lower Barthel Index scores and a higher proportion of NYHA functional class III/IV. In contrast, men more frequently presented with ischemic heart disease, chronic obstructive pulmonary disease, and active neoplasms (all p < 0.001). The rest of comparisons are presented in Table 1 . Table 1 Characteristics of patients included in the present study. All patients N = 13042 n (%) Missing values n (%) Men N = 5792 n (%) Women N = 7250 n (%) p EPIDEMIOLOGICAL DATA Age [median (IQR)] 83 (75–89) 1 (0.0) 80 (13) 84(10) < 0.001 Female sex 7250 (55.6) 0 - - - COMORBIDITIES Hypertension 11046 (85) 48 (0.4) 4758 (82.5) 6288 (87) < 0.001 Previous episodes of acute heart failure 9527 (73.1) 9 (0.1) 4130 (71.3) 5397 (74.5) < 0.001 Atrial fibrillation 6530 (50.3) 48 (0.4) 2777 (48.1) 3753 (51.9) < 0.001 Diabetes mellitus 5482 (42.2) 48 (0.4) 2557 (44.3) 2925 (40.5) 2 mg/dL) 3793 (29.2) 48 (0.4) 1764 (30.6) 2029 (28.1) 0.002 Ischemic heart disease 3548 (27.3) 48 (0.4) 2076 (36) 1472 (20.4) < 0.001 Valvular heart disease 3386 (26.1) 48 (0.4) 1303 (22.6) 2083 (28.8) < 0.001 Chronic obstructive pulmonary disease 3142 (24.2) 48 (0.4) 2008 (34.8) 1134 (15.7) < 0.001 Neoplasm 1752 (14.2) 685 (5.2) 950 (17.3) 802 (11.7) < 0.001 Cerebrovascular disease 1668 (12.8) 48 (0.4) 775 (13.4) 893 (12.4) 0.068 Dementia 1521 (12.3) 683 (5.2) 505 (9.2) 1016 (14.8) < 0.001 BASELINE FUNCTIONAL STATUS NYHA functional class III/IV 3050 (24.1) 405 (3.1) 1229 (21.9) 1821 (25.9) < 0.001 LVEF (%) [median (IQR)] 55 (45–62) 5294 (40.6) 51 (40–60) 56 (50–65) < 0.001 Barthel Index [median (IQR)] 90 (70–100) 590 (4.52) 95 (80–100) 85 (60–100) < 0.001 CHRONIC HOME TREATMENT Loop diuretics 8499 (66.8) 310 (2.4) 3652 (64.5) 4847 (68.5) < 0.001 Renin–angiotensin system inhibitors 3474 (27.3) 310 (2.4) 1412 (25.0) 2062 (29.2) < 0.001 Beta-blockers 5875 (46.1) 310 (2.4) 2662 (47.0) 3213 (45.4) 0.070 Mineralocorticoid receptor antagonists 2074 (16.3) 310 (2.4) 1023 (18.1) 1051 (14.9) < 0.001 Thiazide diuretics 1893 (14.9) 310 (2.4) 765 (13.5) 1128 (15.9) < 0.001 TRIGGERS OF THE EPISODE Infection 4807 (39.3) 807 (6.2) 2153 (39.6) 2654 (39.0) 0.520 Tachyarrhythmia 1905 (15.6) 807 (6.2) 728 (13.4) 1177 (17.3) < 0.001 Anemia 958 (7.8) 807 (6.2) 420 (7.7) 538 (7.7) 0.703 Hypertensive crisis 698 (5.7) 807 (6.2) 269 (4.9) 429 (6.3) < 0.001 Dietary/therapeutic non-adherence 486 (4.0) 807 (6.2) 253 (4.7) 233 (3.4) < 0.001 CLINICAL STATUS Dyspnea on exertion 12042 (92.5) 18 (0.1) 5350 (92.5) 6692 (92.4) 0.839 Pulmonary crackles 9161 (70.3) 18 (0.1) 3960 (68.5) 5201 (71.8) < 0.001 Peripheral edema 8820 (67.7) 18 (0.1) 3937 (68.1) 4883 (67.4) 0.435 Orthopnea 7248 (55.7) 18 (0.1) 3276 (56.6) 3972 (54.9) 0.041 Jugular venous distension 2641 (20.3) 18 (0.1) 1197 (20.7) 1444 (19.9) 0.286 Paroxysmal nocturnal dyspnea 3296 (25.3) 18 (0.1) 1567 (27.1) 1729 (23.9) < 0.001 Signs of low output 1634 (12.5) 0 683 (11.8) 951 (13.1) 0.023 Hepatomegaly 607 (4.7) 18 (0.1) 316 (5.5) 291 (4.0) < 0.001 VITAL SIGNS IN THE ED Systolic blood pressure (mmHg) [median (IQR)] 139 (120–156) 0 135(118–152) 139 (121–158) < 0.001 Heart rate (bpm) [median (IQR)] 84 (70–100) 196 (1.5) 81 (69–99) 85 (71–101) < 0.001 Baseline oxygen saturation (%) [median (IQR)] 94 (91–97) 0 95 (91–97) 94 (90–97) < 0.001 LABORATORY DATA Hemoglobin (g/L) [median (IQR)] 11.9 (10.6.-3.3) 70 (0.53) 12.2 (10.7–13.7) 11.7 (10.5–13) < 0.001 Creatinine (mg/dL) [median (IQR)] 1.20 (0.90–1.64) 143 (1.1) 1.30 (0.99–1.80) 1.10(0.83–1.5) < 0.001 Sodium (mmol/L) [median(IQR)] 139 (136–141) 143 (1.1) 139(136–141) 139(136–141) 0.01 Potassium (mmol/L) [median (IQR)] 4.40 (4-4.80) 2 (0.0) 4.40 (4-4.8) 4.40(4-4.8) 99th percentile) 3652 (48.0) 5431 (41.6) 1792 (51.7) 1860 (44.9) < 0.001 RADIOGRAPHIC DATA Cardiomegaly 6114 (49.3) 648 (5.0) 2617 (47.5) 3497(50.8) < 0.001 Alveolar edema in lung parenchyma 938 (11.7) 5024 (38.5) 412 (11.4) 526 (11.9) 0.446 Pleural effusion 3591 (29.0) 648 (5.0) 1613 (29.3) 1978 (28.7) 0.473 ECG DATA Atrial fibrillation 6408 (49.1) 0 2724 (47.0) 3684 (50.8) < 0.001 Left bundle branch block 1287 (9.9) 0 596 (10.3) 691 (9.5) 0.149 Left ventricular hypertrophy 465 (3.6) 0 221 (3.8) 244 (3.4) 0.168 ED: emergency department; NYHA: New York Health Association; LVEF: left ventricular ejection fraction; IQR: interquartile range; ECG: electrocardiogram. Bold numbers denote statistical significance (p < 0.05) Overall, 30-day mortality was 10.6% and was higher in women (11.2% vs. 9.9%, p = 0.023). Risk scores were estimated using the MEESSI-AHF scale, and overall c-statistic resulted in 0.78 (95% CI: 0.77–0.79), with no differences between sexes (men: 0.77, women: 0.78, p = 0.163), ( Fig. 2 ) . The MEESSI-AHF score classified patients into four categories (low, intermediate, high, and very high risk), with 30-day mortality progressively increased with higher risk categories (2.9% in low; 9.6% in intermediate; 18.2% in high; and 39.7% in very high; global p < 0.001). As shown in Fig. 3 these progressive increases in mortality across risk categories were observed in both, men and women, with no significant differences in predicted 30-day mortality by risk category being observed between women and men in the interaction analysis. Consistently, the odds ratios for 30-day mortality increased across MEESSI-AHF risk categories in both sexes, reaching values of approximately 3.3 for intermediate, 6–8 for high, and 20–23 for very-high risk groups compared with the low-risk reference category ( Table 2 ) . Similarly, continuous analysis using RCS showed parallel trends between sexes in mortality prediction according to the MEESSI-AHF score, with no significant interaction, as illustrated in Fig. 3 . These results were consistent regardless of ejection fraction. Table 2 Interaction analysis of sex and risk group according to the MEESSI-AHF scale for each outcome variable in the present study. Low risk Intermediate risk High risk Very-high risk Events/Total (%) OR (95% CI) Events/Total (%) OR (95% CI)* Events/Total (%) OR (95% CI)* Events/Total (%) OR (95% CI)* 30-day mortality Men 79 / 2489 (3.2) Reference 219 / 2259 (9.7) 3.27 (2.51–4.26) 92 / 525 (17.5) 6.48 (4.72–8.90) 181 / 455 (39.8) 20.2 (15.0–27.0) Women 72 / 2657 (2.7) Reference 276 / 2910 (9.5) 3.76 (2.89–4.90) 153 / 821 (18.6) 8.22 (6.14-11.0) 299 / 755 (39.6) 23.5 (17.9–31.0) P for interaction - - - 0.467 - 0.280 - 0.448 Hospitalization Men 1655 / 2518 (65.7) Reference 1823 / 2278 (80.0) 2.09 (1.83–2.38) 472 /527 (89.6) 4.47 (3.34–5.99) 424 /456 (93.0) 6.91 (4.78–9.99) Women 1718 / 2700 (63.6) Reference 2371 / 2950 (80.4) 2.34 (2.08–2.64) 743 / 830 (89.5) 4.88 (3.86–6.18) 697 / 760 (91.7) 6.32 (4.83–8.28) P for interaction - - - 0.211 - 0.649 - 0.704 Extended observation in the ED (> 24 hours) Men 67 / 844 (7.9) Reference 44 / 443 (9.9) 1.28 (0.86–1.91) 9 / 51 (17.6) 2.48 (1.16–5.32) 3 / 20 (15.0) 2.05 (0.58–7.16) Women 68 / 952 (7.1) Reference 54 / 567 (9.5) 1.37 (0.94–1.99) 9 / 83 (10.8) 1.58 (0.76–3.30) 9 / 40 (22.5) 3.77 (1.73–8.25) P for interaction - - - 0.191 - 0.375 - 0.399 Prolonged hospitalization (> 7 days) Men 728 / 1595 (45.6) Reference 841 /1655 (50.8) 1.23 (1.07–1.41) 216 / 394 (54.8) 1.44 (1.16–1.80) 169 / 293 (57.7) 1.62 (1.26–2.09) Women 662 / 1659 (39.9) Reference 1028 / 2151 (47.8) 1.38 (1.21–1.57) 297 / 634 (46.8) 1.33 (1.10–1.60) 261 / 461 (56.6) 1.96 (1.59–2.42) P for interaction - - - 0.239 - 0.563 - 0.252 *The OR is referred to the low-risk group of the same sex, taken as reference. OR: odds ratio; CI: confidence interval; ED: emergency department. Bold values denote statistical significance (p < 0.05) With respect to clinical decisions made by emergency physicians in the ED, hospitalization was ordered in 76.0% of all patients and extended observation in the ED accounted in 8.7% of patients discharged home, with a proportional relationship with the estimated risk: patients with higher MEESSI-AHF scores were admitted more frequently and extended observation was also more frequent, overall and in both women and men considered individually ( Fig. 4 ) . No significant sex differences were detected in any comparison (Table 2 ). Similarly, continuous analysis using RCS showed parallel trends between sexes in both hospitalization and extended observation in the ED according to the MEESSI-AHF score, with no significant interaction, as illustrated in Fig. 4 . Finally, respect to management of hospitalized patients, prolonged hospitalization was observed in 47.5% of patients, and the higher the patient risk, the more frequent the prolonged hospitalization, irrespective if the patient risk was categorically considered or assessed as a continuous variable ( Fig. 4 ) . No significant sex differences were detected in any comparison (Table 2 and Fig. 4 ). Subgroup analyses based on LVEF revealed no differences in the clinical management of men and women with comparable severity of AHF decompensation as assessed by risk stratification ( Fig. 4 ) . DISCUSSION In this large multicenter cohort of 13,042 patients treated for AHF in Spanish EDs, the MEESSI-AHF score demonstrated robust and comparable prognostic performance in both sexes. The prediction of 30-day mortality according to estimated risk was clear and parallel in women and men, both in categorical and continuous analyses, with no evidence of significant sex interaction. These findings support MEESSI-AHF as a reliable tool irrespective of patient sex, equally applicable to men and women. Although women showed slightly higher crude 30-day mortality than men (11.2% vs. 9.9%), this difference likely reflects their older age, higher prevalence of comorbidities, and worse baseline functional status rather than inequities in care. Importantly, once risk was standardized through the MEESSI-AHF score, mortality prediction and risk gradients were virtually identical across sexes, with no significant sex interaction. Although this might have been anticipated—since sex was evaluated and excluded as a prognostic factor in the pivotal study that developed the MEESSI-AHF score [ 5 ]—we consider it essential that any risk model undergo validation in both sexes to confirm equivalent performance without sex-related differences. This study represents the first formal sex-specific validation of a prognostic scale in AHF, demonstrating that MEESSI-AHF performs equivalently in both women and men. This finding reinforces its utility as an objective, sex-neutral tool for guiding ED clinical decisions, without sex-related bias. It also sets a precedent for other conditions where sex differences are well documented but where no sex-validated risk tools currently exist. In line with our findings, Grilli et al. have recently reported, in a cohort of 7,900 patients (with 6,456 men and 1,444 women), that a sex-recalibrated version of the Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score (S-MECKI) improved risk classification and accuracy in patients with heart failure and reduced LVEF, particularly enhancing prognostic performance in high-risk patients [ 19 ]. Moreover, Vishram-Nielsen et al. evaluated the Seattle Heart Failure Model (SHFM) and the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) scores, both developed to evaluate patients with chronic heart failure, separately in men and women. They found overall similar discriminatory capacity and predicted versus observed risk between sexes, although both scores tended to overestimate mortality in women at 3 years [ 20 ]. In contrast the absence of sex bias in our study may relate to the specific nature of the MEESSI-AHF score, which is based on objective clinical and analytical variables obtained during the acute episode in the emergency department. These parameters reflect physiological severity rather than therapeutic management, and are therefore less influenced by gender-related differences in care or follow-up. These findings collectively underscore that, despite known sex-related differences in clinical presentation (such as older age, higher prevalence of preserved LVEF, and greater comorbidity in women) applying sex-aware recalibration does not compromise, and may even enhance, the performance of prognostic tools. Our validation of MEESSI-AHF in both sexes thus supports a sex-sensitive approach to medicine and advocates for the systematic validation of prognostic models separately in men and women. The second objective of the present study was to determine whether emergency and hospital physicians’ decision-making aligns with patient risk and whether any divergence exists according to patient sex. Risk stratification by MEESSI-AHF was clearly associated with the emergency physicians' decisions to hospitalize the most severely decompensated patients and to extend observation in the ED for high-risk patients discharged directly home. These clinical decisions were proportionally linked to estimated risk regardless of sex, even in subgroups with preserved or reduced LVEF. Notably, despite documented sex-based discrepancies in clinical management in other international contexts [ 21 – 23 ], we observed that in our cohort, ED decisions—such as hospitalization and extended ED observation—were strictly governed by estimated risk and not by patient sex [ 24 ]. This suggests equitable practice in the ED and argues against sex-based bias in AHF management. Although consistency was seen during hospitalization, where prolonged stays were aligned with higher risk scores, we realize this represents only a partial evaluation, as many dimensions of inpatient management remain unexplored. In this regard, our finding is consistent with results reported by Galvão et al., who analyzed over 105,000 AHF admissions from the ADHERE registry and found that, although women were older and received less aggressive interventions, length of stay were similar between sexes after adjustment [ 25 ]. Conversely, Zsilinszka et al. studied over 4,000 patients with heart failure and preserved LVEF presenting to the ED and found no sex differences in management strategies but, after adjustment for clinical differences between sexes, women had a slightly but statistically significant longer hospitalization (+ 0.4 days) [ 26 ]. Together, these data support our observation that high-quality, risk-based management of AHF can and should be delivered equitably, without regard to sex. Limitations Several limitations should be acknowledged. First, the retrospective observational design carries an inherent risk of residual confounding. Second, the analysis was restricted to the Spanish setting, which may limit international generalizability, as AHF management—particularly regarding hospitalization and ED length of stay—can vary widely across countries and even among hospitals within the same country [ 27 ]. Third, some variables, such as LVEF, were incompletely recorded, potentially limiting phenotype-specific analyses. Fourth, the EAHFE registry mainly comprises very elderly patients, which likely reflects the true spectrum of AHF but also introduces specific challenges. Older patients often present with frailty and functional or cognitive impairments, which may influence physicians’ decisions and outcomes [ 28 , 29 ]. Fifth, we did not examine differences in the hospital departments to which patients were admitted, nor the use of less conventional AHF management strategies such as admission in short-stay units or hospital-at-home programs [ 30 , 31 ]. Finally, our analysis was based solely on recorded biological sex, without considering non-binary categories or incorporating gender-related sociocultural determinants, which may also influence clinical management or symptom perception. CONCLUSIONS Overall, this study validates the universal applicability of the MEESSI-AHF scale regardless of sex and underscores the need for future research systematically incorporating sex and gender perspectives into the development and validation of prognostic tools. Furthermore, our findings suggest that once physicians’ decisions are adjusted by the MEESSI-AHF score, the management of patients with AHF in the ED is not influenced by sex-related bias. Declarations Acknowledgements We thank the healthcare professionals working in emergency departments for their professionalism and dedication. Ethical approval The EAHFE registry and this ancillary analysis were approved by the Clinical Research Ethics Committees of Hospital Clínic de Barcelona (ref. 2018/0233), Hospital Universitario Central de Asturias (ref. 205/17), and all participating centers. Consent to participate Given the retrospective use of anonymized registry data (EAHFE), the requirement for written informed consent was waived by all ethics committees; no identifiable patient data were used. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data availability De-identified data are part of the EAHFE registry and are not publicly available due to institutional and ethical restrictions; de-identified data may be available from the corresponding author on reasonable request and with permission from the EAHFE Steering Committee. Author contributions Study conception and design: Òscar Miró, Natalia Miota, Blanca Coll-Vinent. Data collection: Pere Llorens, Víctor Gil, Javier Jacob, Pablo Herrero, Aitor Alquézar-Arbé, Mónica Villar, Cristina Antón, Naila Canadell. Statistical analysis and interpretation: Òscar Miró. Drafting of the manuscript: Natalia Miota, Òscar Miró, Blanca Coll-Vinent. Critical revision for important intellectual content: All authors. All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work . References Llorens P, Escoda R, Miró O, Herrero-Puente P, Martín-Sánchez FJ, Jacob J, et al. Características clínicas, terapéuticas y evolutivas de los pacientes con insuficiencia cardiaca aguda atendidos en servicios de urgencias españoles: Registro EAHFE. Emergencias. 2015;27:11-22. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2016;37:2129-2200. Miró O, García Sarasola A, Fuenzalida C, Calderón S, Jacob J, Aguirre A, et al. Departments involved during the first episode of acute heart failure and subsequent emergency department revisits and rehospitalisations: an outlook through the NOVICA cohort. Eur J Heart Fail. 2019;21:1231-1244. Dharmarajan K, Hsieh AF, Lin Z, Bueno H, Ross JS, Horwitz LI, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309:355-363. Miró O, Rosselló X, Gil V, Martín-Sánchez FJ, Llorens P, Herrero-Puente P, et al. Predicting 30-day mortality for patients with acute heart failure in the emergency department: a cohort study. Ann Intern Med. 2017;167:698-705. Rossello X, Bueno H, Gil V, Jacob J, Martín-Sánchez FJ, et al. MEESSI-AHF risk score performance to predict multiple post-index event and post-discharge short-term outcomes. Eur Heart J Acute Cardiovasc Care. 2021;10:142-152. Miró O, Rosselló X, Gil V, Martín-Sánchez FJ, Llorens P, Herrero-Puente P, et al. The usefulness of the MEESSI score for risk stratification of patients with acute heart failure at the emergency department. Rev Esp Cardiol. 2019;72:198-207. Miró O, Rosselló X, Gil V, Martín-Sánchez FJ, Llorens P, Herrero-Puente P, et al. Analysis of how emergency physicians’ decisions to hospitalize or discharge patients with acute heart failure match the clinical risk categories of the MEESSI-AHF scale. Ann Emerg Med. 2019;74:204-215. Islas Susenán A, et al. Sex and gender differences in heart failure. Int J Heart Fail. 2020;2:123-131. Dorsch MP, Dunlay SM, Roger VL. Sex differences in heart failure. Int J Heart Fail. 2013;1:64-71. Martí-Almor J, et al. Sex differences in the management and outcomes of acute heart failure with preserved ejection fraction in the emergency department. J Card Fail. 2016;22:280-288. Špinar J, Jarkovsky J, Vitovec J, et al. AHEAD registry: Acute Heart Failure Database—main characteristics and hospital outcomes of patients admitted with acute heart failure in the Czech Republic. Eur J Heart Fail. 2011;13:946-952. Lam CSP, Arnott C, Beale AL, et al. Sex differences in heart failure. Eur Heart J. 2019;40:3859-3868. Tan VY, Chan SP, Chia SY, et al. Gender differences in patients with acute decompensated heart failure in Singapore. Int J Cardiol. 2020;313:64-69. Komajda M, Lam CSP. Heart failure with preserved ejection fraction: a clinical dilemma. Eur Heart J. 2021;42:484-493. Jacob J, Llauger L, Herrero-Puente P, Martín-Sánchez FJ, Llorens P, Roset A, et al. Acute heart failure and adverse events associated with the presence of renal dysfunction and hyperkalaemia. Eur J Intern Med. 2019;67:89-96. Miró O, Fortuny MJ, Espinosa B, Alquézar-Arbé A, Jacob J, Trullàs JC, et al. Alkalosis during emergency department evaluation of acute heart failure: Is there an association with mortality? Emergencias. 2025;37:23-30. Harrell FE Jr. Regression Modeling Strategies. 2nd ed. New York: Springer-Verlag; 2015. Grilli G, Salvioni E, Moscucci F, Bonomi A, Sinagra G, Schaeffer M, et al. A matter of sex—persistent predictive value of MECKI score prognostic power in men and women with heart failure and reduced ejection fraction: a multicenter study. Front Cardiovasc Med. 2024;11:1390544. Vishram-Nielsen JKK, Foroutan F, Ross HJ, Gustafsson F, Alba AC. Performance of prognostic risk scores in heart failure patients: do sex differences exist? Can J Cardiol. 2020;36:45-53. Vicent L, García-Cosio M, Amigo JS, Guerra JM, Dolz LM, Farré-López N, et al. Sex and clinical outcomes in new-onset heart failure. Int J Cardiol. 2025;428:133092. Shah KS, Xu H, Matsouaka RA, Bhatt DL, Heidenreich PA, DeVore AD, et al. Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. J Am Coll Cardiol. 2017;70:2476-2486. Parcha V, Patel AP, Kalra R, Arora G, Raza MQ, Davis GM, et al. Equity in heart failure care: a Get With the Guidelines–Heart Failure registry analysis. Circ Heart Fail. 2024;17:e010280. Khera R, Pandey A, Ayers CR, et al. Contemporary sex differences in heart failure management and outcomes after acute coronary syndromes. JACC Adv. 2023;2:100294. Galvão M, Kalman J, DeMarco T, Fonarow GC, Galvin C, Ghali JK, et al. Gender differences in in-hospital management and outcomes in patients with decompensated heart failure: analysis from the Acute Decompensated Heart Failure National Registry (ADHERE). J Card Fail. 2006;12:100-107. Zsilinszka R, Unger JW, Papp Z, Kaldy NB, Papp R, Zemanek D, et al. Sex differences in the management and outcomes of patients with heart failure with preserved ejection fraction admitted to the emergency department. J Card Fail. 2016;22:S183. Miró O, Sánchez C, Gil V, Repullo D, García-Lamberechts EJ, González Del Castillo J, et al. Current Spanish emergency department organization and clinical practices in caring for patients with acute heart failure. Emergencias. 2022;34:85-94. Bima P, Morello F. Elderly frequent visitors to emergency departments: stories of frailty and comorbidity. Emergencias. 2025;37:1-2. Hamada T, Kubo T, Kawai K, Nakaoka Y, Yabe T, Furuno T, et al. Prognostic impact of frailty based on a comprehensive frailty assessment in patients with heart failure. ESC Heart Fail. 2024;11:2076-2085. Bibiano-Guillén C, Mir-Montero M, Rodríguez-Rodríguez B, Vinat-Prado S, Sánchez-Pérez M, Pantoja-Zarza MC. Implementing a virtual home short-stay unit: feasibility, safety, and satisfaction. Emergencias. 2025;37:312-315. Sánchez C, et al. Factores asociados con la necesidad de escalada asistencial en pacientes con insuficiencia cardíaca aguda ingresados directamente desde urgencias en hospitalización a domicilio. Emergencias. 2025;in press. Cite Share Download PDF Status: Published Journal Publication published 17 Mar, 2026 Read the published version in Internal and Emergency Medicine → Version 1 posted Reviewers agreed at journal 06 Jan, 2026 Reviewers invited by journal 06 Jan, 2026 Editor assigned by journal 02 Jan, 2026 First submitted to journal 02 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8480632","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":570117765,"identity":"7e158e51-6b84-4778-bd14-0d4f9a3141b5","order_by":0,"name":"Oscar Miro","email":"","orcid":"","institution":"Hospital Clínic Barcelona: Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Oscar","middleName":"","lastName":"Miro","suffix":""},{"id":570117766,"identity":"d6b6d86e-f71d-4910-82d3-01ac97d70d91","order_by":1,"name":"natalia miota hernández","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAt0lEQVRIiWNgGAWjYFACxgYgYcPAx8zAcIB4LQcY0hjYYFp4iNJ1gOEwAxuMQ1CLudjhxscfas7Ls7HzHjzwg8FO3p6QFsvZic0GB47dNmxj5ks42MOQbNhDSIvB7cQ2iQNstxPYmHkMDgPdyEikln/n4FrsidNysO0AXEsiMVqaDc72JQP9wmNwsMcgObnnAEEt6Q8fVHyzk+fnP2P84UeFnW17AyFr0EwgTfkoGAWjYBSMAhwAAM+JPRmPHDFzAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-9909-446X","institution":"Hospital Clínic Barcelona: Hospital Clinic de Barcelona","correspondingAuthor":true,"prefix":"","firstName":"natalia","middleName":"miota","lastName":"hernández","suffix":""},{"id":570117767,"identity":"1e5bdb0c-33ae-4082-9128-686ddcbfb835","order_by":2,"name":"Pere Llorens","email":"","orcid":"","institution":"Hospital General Universitario Dr Balmis","correspondingAuthor":false,"prefix":"","firstName":"Pere","middleName":"","lastName":"Llorens","suffix":""},{"id":570117768,"identity":"9f8154ca-eb96-4e14-83e3-e22b5da5b2f3","order_by":3,"name":"Víctor Gil","email":"","orcid":"","institution":"Hospital Clínic Barcelona: Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Víctor","middleName":"","lastName":"Gil","suffix":""},{"id":570117769,"identity":"178579af-59f2-4825-b29f-6033124aafde","order_by":4,"name":"Javier Jacob","email":"","orcid":"","institution":"Bellvitge University Hospital: Hospital Universitari de Bellvitge","correspondingAuthor":false,"prefix":"","firstName":"Javier","middleName":"","lastName":"Jacob","suffix":""},{"id":570117770,"identity":"90ac53b1-621b-4d4a-9440-d63d040af205","order_by":5,"name":"Pablo Herrero","email":"","orcid":"","institution":"Hospital General de Asturias: Hospital Universitario Central de Asturias","correspondingAuthor":false,"prefix":"","firstName":"Pablo","middleName":"","lastName":"Herrero","suffix":""},{"id":570117771,"identity":"8ae8512d-62ae-4be6-9282-2e4740ac88dc","order_by":6,"name":"Aitor Alquézar-Arbé","email":"","orcid":"","institution":"Hospital de Sant Pau: Hospital de la Santa Creu i Sant Pau","correspondingAuthor":false,"prefix":"","firstName":"Aitor","middleName":"","lastName":"Alquézar-Arbé","suffix":""},{"id":570117772,"identity":"c7d918ba-60b0-48b3-a840-7565813ba535","order_by":7,"name":"Mónica Villar","email":"","orcid":"","institution":"Hospital Clínic Barcelona: Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Mónica","middleName":"","lastName":"Villar","suffix":""},{"id":570117773,"identity":"bd22555e-1283-42b2-824a-ec40ad7811c7","order_by":8,"name":"Cristina Antón","email":"","orcid":"","institution":"Hospital Clínic Barcelona: Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Cristina","middleName":"","lastName":"Antón","suffix":""},{"id":570117774,"identity":"69f4eebb-b2d8-475a-953e-8b1764b96a1f","order_by":9,"name":"Naila Canadell","email":"","orcid":"","institution":"Hospital Clínic Barcelona: Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Naila","middleName":"","lastName":"Canadell","suffix":""},{"id":570117775,"identity":"1fbe2d27-5e36-473f-b8b9-3249464e9e56","order_by":10,"name":"Blanca Coll-Vinent","email":"","orcid":"","institution":"Hospital Clínic Barcelona: Hospital Clinic de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Blanca","middleName":"","lastName":"Coll-Vinent","suffix":""}],"badges":[],"createdAt":"2025-12-30 11:11:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8480632/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8480632/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11739-026-04319-9","type":"published","date":"2026-03-17T15:59:32+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":100021843,"identity":"7f5da6bc-b89a-45dc-bcee-7657a31e545e","added_by":"auto","created_at":"2026-01-12 08:07:38","extension":"tif","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":440088,"visible":true,"origin":"","legend":"","description":"","filename":"FIGURE1.tif","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/023c26b938ba22eeca475f08.tif"},{"id":100021841,"identity":"a54d0ebf-770b-42eb-9384-1b492fcfa54f","added_by":"auto","created_at":"2026-01-12 08:07:37","extension":"tif","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":165868,"visible":true,"origin":"","legend":"","description":"","filename":"FIGURE2.tif","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/bf75e5bba2aff952190c1f5e.tif"},{"id":100021833,"identity":"2c1ddd41-98ac-488a-be9c-0aca128e0512","added_by":"auto","created_at":"2026-01-12 08:07:36","extension":"tif","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":309844,"visible":true,"origin":"","legend":"","description":"","filename":"FIGURE3.tif","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/4ea53fde17d780733a9a64ca.tif"},{"id":100361951,"identity":"25a12632-eb94-4193-bad2-337a4196eef8","added_by":"auto","created_at":"2026-01-16 07:45:58","extension":"tif","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":946630,"visible":true,"origin":"","legend":"","description":"","filename":"FIGURE4.tif","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/567cfd6fd8606ef7fc6904c1.tif"},{"id":100361541,"identity":"d13b4d8c-73dc-480b-9ca4-da686e5b7829","added_by":"auto","created_at":"2026-01-16 07:45:15","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":14345,"visible":true,"origin":"","legend":"","description":"","filename":"iaemIAEMD2502047.xml","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/81a88f0e78ac070e65822001.xml"},{"id":100021826,"identity":"fe67f6b6-8803-4981-831e-09bb2fc668df","added_by":"auto","created_at":"2026-01-12 08:07:36","extension":"xml","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1484,"visible":true,"origin":"","legend":"","description":"","filename":"IAEMD250204737538.go.xml","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/e24347d4d48c7c319d874dde.xml"},{"id":100021842,"identity":"16c3bd4d-18fe-4b92-9a36-f4cadb9be2ae","added_by":"auto","created_at":"2026-01-12 08:07:37","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":908,"visible":true,"origin":"","legend":"","description":"","filename":"IAEMD2502047Import.xml","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/d14b623070f12e7d735298ac.xml"},{"id":100021839,"identity":"f22db011-25ee-42b3-af7d-55ac0b6cfce4","added_by":"auto","created_at":"2026-01-12 08:07:37","extension":"xml","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":139881,"visible":true,"origin":"","legend":"","description":"","filename":"IAEMD25020470enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/8099c660213e1b407c62b187.xml"},{"id":100362772,"identity":"6b594566-b8e0-46cd-882f-7fe39f514c5d","added_by":"auto","created_at":"2026-01-16 07:48:04","extension":"tif","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":440088,"visible":true,"origin":"","legend":"","description":"","filename":"FIGURE1.tif","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/1651b1a32279107940949b56.tif"},{"id":100021831,"identity":"60593ad3-4475-417d-8bca-b6928a619ebc","added_by":"auto","created_at":"2026-01-12 08:07:36","extension":"tif","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":165868,"visible":true,"origin":"","legend":"","description":"","filename":"FIGURE2.tif","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/358294f00dc6cf0cabeaa23b.tif"},{"id":100021837,"identity":"0dd9d59d-440b-4bdc-8789-f4bb202527bb","added_by":"auto","created_at":"2026-01-12 08:07:36","extension":"tif","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":309844,"visible":true,"origin":"","legend":"","description":"","filename":"FIGURE3.tif","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/43ce0985f7bc4e02fdb5eca4.tif"},{"id":100021840,"identity":"f2904204-b6d6-44fe-939b-0d9a0bdef25d","added_by":"auto","created_at":"2026-01-12 08:07:37","extension":"tif","order_by":23,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":946630,"visible":true,"origin":"","legend":"","description":"","filename":"FIGURE4.tif","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/9d1938d3bbdaefd486af94d1.tif"},{"id":100362819,"identity":"191b0347-8095-426b-ab3a-98a38fb05785","added_by":"auto","created_at":"2026-01-16 07:48:07","extension":"png","order_by":24,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78455,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFIGURE1.png","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/3d1ccf4a96214d158ded8cb2.png"},{"id":100021830,"identity":"ded0d555-c70f-4728-a9df-d5b9e086cebd","added_by":"auto","created_at":"2026-01-12 08:07:36","extension":"png","order_by":25,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":22613,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFIGURE2.png","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/67bc347ce2e9557582a8a8da.png"},{"id":100021828,"identity":"46dc22d9-9f41-4ff9-95b2-025578041236","added_by":"auto","created_at":"2026-01-12 08:07:36","extension":"png","order_by":26,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":46643,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFIGURE3.png","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/3d78f65c855c6d05c538f096.png"},{"id":100362778,"identity":"2ec2f6f6-af11-4f66-86d2-411bc2290764","added_by":"auto","created_at":"2026-01-16 07:48:04","extension":"png","order_by":27,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":71805,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFIGURE4.png","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/1094c1d303a6a29498d84d3d.png"},{"id":100021836,"identity":"fafce5d9-108b-4e95-8de6-0d77aa1d86c1","added_by":"auto","created_at":"2026-01-12 08:07:36","extension":"xml","order_by":28,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":136874,"visible":true,"origin":"","legend":"","description":"","filename":"IAEMD25020470structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/89d7d50899864b23fc13f851.xml"},{"id":100362944,"identity":"72f6f462-f402-4c91-8d1e-6cc702c4f0ec","added_by":"auto","created_at":"2026-01-16 07:48:21","extension":"html","order_by":29,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":153969,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/c25261b8831469922134936b.html"},{"id":100021822,"identity":"322b24de-35fa-4392-8a74-403664ed2f2d","added_by":"auto","created_at":"2026-01-12 08:07:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":267950,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of patient inclusion\u003c/p\u003e","description":"","filename":"FIGURE1.png","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/b84d79013c6d325f49644e23.png"},{"id":100021823,"identity":"8f63bf3a-b3e6-463d-a7b0-5df29f3a98c9","added_by":"auto","created_at":"2026-01-12 08:07:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":61821,"visible":true,"origin":"","legend":"\u003cp\u003eAnalysis by sex of discriminative capacity of MEESSI-AHF score\u003c/p\u003e","description":"","filename":"FIGURE2.png","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/c70e067e528eb9f2f8e3cbca.png"},{"id":100362573,"identity":"67ec23d7-1ca2-4944-ab7c-00c3daf9eb8c","added_by":"auto","created_at":"2026-01-16 07:47:03","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":129400,"visible":true,"origin":"","legend":"\u003cp\u003eThirty-day mortality by sex and MEESSI-AHF risk category (left) and by score as a continuous variable (right), including subgroup analyses by ejection fraction (≥50% vs \u0026lt;50%).\u003c/p\u003e","description":"","filename":"FIGURE3.png","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/56f765e75798c5da39253d00.png"},{"id":100021825,"identity":"5d90809b-9714-44ad-a54f-c9c2ae197692","added_by":"auto","created_at":"2026-01-12 08:07:36","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":426616,"visible":true,"origin":"","legend":"\u003cp\u003eRates of hospitalization, extended ED observation, and prolonged hospitalization by MEESSI-AHF risk category (left) and by score as a continuous variable (right), with subgroup analyses by ejection fraction (≥50% vs \u0026lt;50%).\u003c/p\u003e\n\u003cp\u003e**Abbreviations: MEESSI-AHF = Multiple Estimation of risk based on the Emergency Department Spanish Score in patients with Acute Heart Failure; LVEF = left ventricular ejection fraction; ED = emergency department.\u003c/p\u003e","description":"","filename":"FIGURE4.png","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/509a642498236dfdb05f9ba4.png"},{"id":105224499,"identity":"32cab228-e2ab-43b9-a214-f1cd6f11b25f","added_by":"auto","created_at":"2026-03-23 16:14:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2177158,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8480632/v1/c2d5842f-41ad-47b8-9527-148e0b9ea9fc.pdf"}],"financialInterests":"","formattedTitle":"Influence of patient sex on clinical decision-making in acute heart failure: A risk-adjusted analysis using the MEESSI-AHF score","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAcute heart failure (AHF) is one of the leading causes of hospital emergency department (ED) visits worldwide, associated with high morbidity and mortality and representing a major public health challenge [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Approximately 90% of AHF patients are first managed in the ED [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Data from the EAHFE registry (Epidemiology of Acute Heart Failure in Emergency Departments) show that AHF entails substantial healthcare resource use, with hospitalization rates above 75%, in-hospital mortality near 8%, and one-year mortality around 30% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Moreover, it is associated with frequent revisits and readmissions, making it a syndrome with persistent clinical impact beyond the initial acute episode [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTaken together, these observations emphasize the need for reliable tools to ensure accurate risk stratification and to guide clinical decision-making in the challenging context of emergency care. European Society of Cardiology guidelines for heart failure recommend initial risk stratification of AHF patients upon ED arrival to inform diagnostic and therapeutic decisions and optimize resource allocation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], as accurate early risk assessment is key to reducing adverse outcomes and avoiding unnecessary admissions. In line with these recommendations, early ED management with proper risk estimation is crucial. To this end, the MEESSI-AHF score (Multiple Estimation of risk based on the Emergency Department Spanish Score in patients with AHF) was developed and validated for ED use. It estimates 30-day mortality in AHF patients based on 13 readily available clinical variables, with excellent discrimination (c-statistic\u0026thinsp;\u0026gt;\u0026thinsp;0.8) and good calibration across independent cohorts and care settings [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The MEESSI-AHF score classifies patients into four risk groups (low, intermediate, high, very high), supporting decisions on hospital admission or safe discharge from the ED.\u003c/p\u003e \u003cp\u003eIn recent years, numerous studies have highlighted the importance of incorporating sex and gender perspectives in emergency medicine practice and cardiovascular research, including AHF. Women with AHF show a distinct clinical profile compared with men: older age, higher prevalence of hypertension and elevated blood pressure at presentation, greater frequency of preserved left ventricular ejection fraction (LVEF), more symptoms, and worse functional class [\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Despite these differences, women paradoxically tend to exhibit a favorable long-term prognosis, with similar or slightly better survival and equal or lower readmission rates [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, despite growing evidence of sex-related differences in AHF presentation and outcomes, it remains unclear whether risk stratification tools used in EDs perform equally well in both sexes, or whether clinical decisions derived from their use are based solely on estimated risk without sex-related influence. Understanding this is essential, since sex can affect pathophysiology, treatment response, and prognosis, and unrecognized differences could limit the clinical applicability of risk scores. The aim of this study was to examine whether the MEESSI-AHF score has similar prognostic accuracy in men and women for predicting 30-day mortality (the outcome for which MEESSI-AHF was designed), and whether sex differences exist in decision-making in the ED (to decide hospitalization or extended observation in the ED before discharging patient home without hospitalization) and during the hospitalization (length of stay in hospitalized patients) for men and women with the same MEESSI-AHF score. This analysis seeks to provide evidence on the score\u0026rsquo;s validity in both sexes and to demonstrate equitable, risk-based care in the ED irrespective of patient sex.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and population\u003c/h2\u003e \u003cp\u003eWe conducted a multicenter, retrospective, observational, non-interventional study based on the prospective EAHFE registry, which includes unselected patients diagnosed with AHF and treated in Spanish EDs. The registry prospectively enrolls cases from 52 emergency departments across Spain over intermittent inclusion periods between 2007 and 2022. The only criterion for exclusion to be included in the EAHFE registry is that AHF is developed during a ST-elevation myocardial infarction (STEMI), as most of these patients bypass ED and go directly to hemodynamic laboratory. Extensive details of the EAHFE registry have been published elsewhere [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. For this analysis, we included all patients with sex recorded in the administrative records and with complete data for the variables required to calculate the MEESSI-AHF score. The MEESSI-AHF score incorporates clinical, laboratory, and functional parameters obtained at initial ED assessment, specifically: age, Barthel index, NYHA class, non-STEMI as precipitant of the AHF episode, low output symptoms, oxygen saturation, systolic blood pressure, respiratory rate, potassium, creatinine, troponin, NT-proBNP and left ventricular hypertrophy in the electrocardiogram (ECG) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In addition to these variables, we also collected other relevant clinical characteristics corresponding to comorbidities, baseline functional status, triggers of decompensation, clinical presentation, vital signs, laboratory results, chest radiography, and ECG.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eWe evaluated two sets of outcomes aligned with the study objectives. To assess the reliability of the MEESSI-AHF score in predicting adverse events in men and women, we used 30-day all-cause mortality after the index ED episode, the same endpoint employed for score development in the original study [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. To examine whether men and women with the same MEESSI-AHF score are managed similarly, we analyzed three additional outcomes. Regarding ED physicians\u0026rsquo; decisions, we assessed hospitalization after ED care and extended ED observation among patients discharged home, defined as \u0026gt;\u0026thinsp;24 hours before discharge. Regarding hospital physicians\u0026rsquo; decisions, we assessed length of stay among patients discharged alive (excluding in-hospital deaths) and defined prolonged hospitalization as \u0026gt;\u0026thinsp;7 days, a threshold commonly used in acute heart failure studies and roughly corresponding to the upper quartile of hospital stays in previous EAHFE analyses [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Because of their objective nature, outcome adjudication was made locally by the principal investigator of each center, without external review.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eQuantitative variables were expressed as medians and interquartile ranges (IQR) and compared between sexes using the Mann\u0026ndash;Whitney U test. Categorical variables were reported as absolute frequencies and percentages and compared using the chi-square test. The prognostic performance of MEESSI-AHF was evaluated using the C-statistic (area under the ROC curve) with 95% confidence interval (CI), analyzing discrimination overall and stratified by sex. The comparison of the discriminative capacity between sexes was performed by using McLeod test.\u003c/p\u003e \u003cp\u003eTo assess the association between sex and death prognostication of MEESSI-AHF as well as between sex and clinical decisions of emergency and hospital physicians, we built logistic regression models and analyses were performed both by risk categories (low, intermediate, high, very high) and associations were expressed as odds ratio (OR) with 95% CI, as well as by treating the MEESSI-AHF score as a continuous variable with restricted cubic splines (RCS) using 5 knots (placed at 5, 25, 50, 75 and 95 percentiles of the MEESSI-AHF score distribution) following Harrell\u0026rsquo;s recommendations [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. For the RCS models, a sensitivity analysis was conducted considering separately patients with preserved (\u0026ge;50%) and mildly-reduced or reduced LVEF (\u0026lt;\u0026thinsp;50%). Sex interaction was tested for the relationship between MEESSI-AHF categories or scores and outcomes.\u003c/p\u003e \u003cp\u003eA two-sided p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Analyses were performed using IBM SPSS Statistics version 29.0 for Mac (IBM Corp., Armonk, NY, USA) and STATA version 18.0 for Mac (StataCorp, College Station, TX, USA).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e This study used anonymized data from the EAHFE registry, and the study protocol was approved by the Clinical Research Ethics Committee of the Central University Hospital of Asturias (Oviedo, Spain, reference numbers 49/2010, 69/2011, 166/13, 160/15 and 205/17) and Hospital Cl\u0026iacute;nic de Barcelona (Barcelona, Spain, reference number 2018/0233) as the lead committees, as well as by the ethics committees of all other participating centers. In accordance with the Declaration of Helsinki and local regulations, the requirement for written informed consent was waived by all ethics committees owing to the retrospective use of fully anonymized routinely collected data; no identifiable personal data were used. Only authorized investigators had access to the anonymized database used for analysis.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 13,042 patients diagnosed with AHF and treated in EDs were included \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Median age was 83 years (IQR 75\u0026ndash;89), and 56% were women (n\u0026thinsp;=\u0026thinsp;7,250). Comorbidities were frequent, with hypertension, previous AHF episodes and atrial fibrillation being present in more than 50% of patients. Around two thirds had some functional impairment (Barthel index below 100 points) and nearly one quarter were on NYHA class III or IV. Two thirds of patients were on chronic diuretic treatment. The most frequent precipitants of the AHF episode were infections (39%) and tachyarrhythmia (16%). The rest of clinical, analytical, radiological and ECG data are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Women showed a distinct clinical profile, with significant differences in most of the variables analyzed. Remarkably, women were older than men and with a higher prevalence of hypertension, atrial fibrillation, valvular heart disease, and dementia (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). They also had worse baseline functional status, with lower Barthel Index scores and a higher proportion of NYHA functional class III/IV. In contrast, men more frequently presented with ischemic heart disease, chronic obstructive pulmonary disease, and active neoplasms (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The rest of comparisons are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients included in the present study.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;13042\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMissing values\u003c/p\u003e \u003cp\u003e n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;5792\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;7250\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEPIDEMIOLOGICAL DATA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge [median (IQR)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (75\u0026ndash;89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84(10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7250 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCOMORBIDITIES\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11046 (85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4758 (82.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6288 (87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious episodes of acute heart failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9527 (73.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4130 (71.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5397 (74.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6530 (50.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2777 (48.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3753 (51.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5482 (42.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2557 (44.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2925 (40.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic kidney disease (creatinine\u0026thinsp;\u0026gt;\u0026thinsp;2 mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3793 (29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1764 (30.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2029 (28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIschemic heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3548 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2076 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1472 (20.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValvular heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3386 (26.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1303 (22.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2083 (28.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic obstructive pulmonary disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3142 (24.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2008 (34.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1134 (15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoplasm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1752 (14.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e685 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e950 (17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e802 (11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1668 (12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e775 (13.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e893 (12.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDementia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1521 (12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e683 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e505 (9.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1016 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBASELINE FUNCTIONAL STATUS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNYHA functional class III/IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3050 (24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e405 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1229 (21.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1821 (25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF (%) [median (IQR)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (45\u0026ndash;62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5294 (40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51 (40\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56 (50\u0026ndash;65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarthel Index [median (IQR)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (70\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e590 (4.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95 (80\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85 (60\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCHRONIC HOME TREATMENT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoop diuretics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8499 (66.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e310 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3652 (64.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4847 (68.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenin\u0026ndash;angiotensin system inhibitors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3474 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e310 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1412 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2062 (29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeta-blockers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5875 (46.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e310 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2662 (47.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3213 (45.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.070\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMineralocorticoid receptor antagonists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2074 (16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e310 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1023 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1051 (14.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThiazide diuretics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1893 (14.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e310 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e765 (13.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1128 (15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTRIGGERS OF THE EPISODE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4807 (39.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e807 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2153 (39.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2654 (39.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.520\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTachyarrhythmia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1905 (15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e807 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e728 (13.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1177 (17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e958 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e807 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e420 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e538 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.703\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertensive crisis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e698 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e807 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e269 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e429 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDietary/therapeutic non-adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e486 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e807 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e253 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e233 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCLINICAL STATUS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyspnea on exertion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12042 (92.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5350 (92.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6692 (92.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.839\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary crackles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9161 (70.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3960 (68.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5201 (71.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeripheral edema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8820 (67.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3937 (68.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4883 (67.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.435\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopnea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7248 (55.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3276 (56.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3972 (54.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.041\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJugular venous distension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2641 (20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1197 (20.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1444 (19.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParoxysmal nocturnal dyspnea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3296 (25.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1567 (27.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1729 (23.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSigns of low output\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1634 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e683 (11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e951 (13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.023\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatomegaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e607 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e316 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e291 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVITAL SIGNS IN THE ED\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic blood pressure (mmHg) [median (IQR)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e139 (120\u0026ndash;156)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e135(118\u0026ndash;152)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e139 (121\u0026ndash;158)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart rate (bpm) [median (IQR)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84 (70\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e196 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81 (69\u0026ndash;99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85 (71\u0026ndash;101)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline oxygen saturation (%) [median (IQR)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (91\u0026ndash;97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95 (91\u0026ndash;97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94 (90\u0026ndash;97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLABORATORY DATA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (g/L) [median (IQR)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.9 (10.6.-3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (0.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.2 (10.7\u0026ndash;13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.7 (10.5\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine (mg/dL) [median (IQR)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.20 (0.90\u0026ndash;1.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e143 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.30 (0.99\u0026ndash;1.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.10(0.83\u0026ndash;1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSodium (mmol/L) [median(IQR)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e139 (136\u0026ndash;141)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e143 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e139(136\u0026ndash;141)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e139(136\u0026ndash;141)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePotassium (mmol/L) [median (IQR)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.40 (4-4.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.40 (4-4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.40(4-4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNT-proBNP (pg/mL) [median (IQR)]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4320 (2090\u0026ndash;9595)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5435 (41.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4500 (2090\u0026ndash;10264)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4151 (2094\u0026ndash;8834)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncresased troponin (\u0026gt;\u0026thinsp;99th percentile)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3652 (48.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5431 (41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1792 (51.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1860 (44.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRADIOGRAPHIC DATA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiomegaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6114 (49.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e648 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2617 (47.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3497(50.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlveolar edema in lung parenchyma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e938 (11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5024 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e412 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e526 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.446\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleural effusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3591 (29.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e648 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1613 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1978 (28.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eECG DATA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6408 (49.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2724 (47.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3684 (50.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft bundle branch block\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1287 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e596 (10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e691 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft ventricular hypertrophy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e465 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e221 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e244 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eED: emergency department; NYHA: New York Health Association; LVEF: left ventricular ejection fraction; IQR: interquartile range; ECG: electrocardiogram.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eBold numbers denote statistical significance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOverall, 30-day mortality was 10.6% and was higher in women (11.2% vs. 9.9%, p\u0026thinsp;=\u0026thinsp;0.023). Risk scores were estimated using the MEESSI-AHF scale, and overall c-statistic resulted in 0.78 (95% CI: 0.77\u0026ndash;0.79), with no differences between sexes (men: 0.77, women: 0.78, p\u0026thinsp;=\u0026thinsp;0.163), \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. The MEESSI-AHF score classified patients into four categories (low, intermediate, high, and very high risk), with 30-day mortality progressively increased with higher risk categories (2.9% in low; 9.6% in intermediate; 18.2% in high; and 39.7% in very high; global p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e these progressive increases in mortality across risk categories were observed in both, men and women, with no significant differences in predicted 30-day mortality by risk category being observed between women and men in the interaction analysis. Consistently, the odds ratios for 30-day mortality increased across MEESSI-AHF risk categories in both sexes, reaching values of approximately 3.3 for intermediate, 6\u0026ndash;8 for high, and 20\u0026ndash;23 for very-high risk groups compared with the low-risk reference category \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Similarly, continuous analysis using RCS showed parallel trends between sexes in mortality prediction according to the MEESSI-AHF score, with no significant interaction, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. These results were consistent regardless of ejection fraction.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInteraction analysis of sex and risk group according to the MEESSI-AHF scale for each outcome variable in the present study.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eLow risk\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eIntermediate risk\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eHigh risk\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eVery-high risk\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEvents/Total (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEvents/Total (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR (95% CI)*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEvents/Total (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOR (95% CI)*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEvents/Total (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOR (95% CI)*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e30-day mortality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79 / 2489 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e219 / 2259 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e3.27 (2.51\u0026ndash;4.26)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e92 / 525 (17.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e6.48 (4.72\u0026ndash;8.90)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e181 / 455 (39.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e20.2 (15.0\u0026ndash;27.0)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 / 2657 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e276 / 2910 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e3.76 (2.89\u0026ndash;4.90)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e153 / 821 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e8.22 (6.14-11.0)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e299 / 755 (39.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e23.5 (17.9\u0026ndash;31.0)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP for interaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.467\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.448\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospitalization\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1655 / 2518 (65.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1823 / 2278 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e2.09 (1.83\u0026ndash;2.38)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e472 /527 (89.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e4.47 (3.34\u0026ndash;5.99)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e424 /456 (93.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e6.91 (4.78\u0026ndash;9.99)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1718 / 2700 (63.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2371 / 2950 (80.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e2.34 (2.08\u0026ndash;2.64)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e743 / 830 (89.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e4.88 (3.86\u0026ndash;6.18)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e697 / 760 (91.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e6.32 (4.83\u0026ndash;8.28)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP for interaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.649\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExtended observation in the ED (\u0026gt;\u0026thinsp;24 hours)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 / 844 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 / 443 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.28 (0.86\u0026ndash;1.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9 / 51 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e2.48 (1.16\u0026ndash;5.32)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3 / 20 (15.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2.05 (0.58\u0026ndash;7.16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 / 952 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54 / 567 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.37 (0.94\u0026ndash;1.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9 / 83 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.58 (0.76\u0026ndash;3.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9 / 40 (22.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e3.77 (1.73\u0026ndash;8.25)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP for interaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.375\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.399\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProlonged hospitalization (\u0026gt;\u0026thinsp;7 days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e728 / 1595 (45.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e841 /1655 (50.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e1.23 (1.07\u0026ndash;1.41)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e216 / 394 (54.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e1.44 (1.16\u0026ndash;1.80)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e169 / 293 (57.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1.62 (1.26\u0026ndash;2.09)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e662 / 1659 (39.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1028 / 2151 (47.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e1.38 (1.21\u0026ndash;1.57)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e297 / 634 (46.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e1.33 (1.10\u0026ndash;1.60)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e261 / 461 (56.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1.96 (1.59\u0026ndash;2.42)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP for interaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.563\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.252\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003e*The OR is referred to the low-risk group of the same sex, taken as reference. OR: odds ratio; CI: confidence interval; ED: emergency department. Bold values denote statistical significance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWith respect to clinical decisions made by emergency physicians in the ED, hospitalization was ordered in 76.0% of all patients and extended observation in the ED accounted in 8.7% of patients discharged home, with a proportional relationship with the estimated risk: patients with higher MEESSI-AHF scores were admitted more frequently and extended observation was also more frequent, overall and in both women and men considered individually \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. No significant sex differences were detected in any comparison (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Similarly, continuous analysis using RCS showed parallel trends between sexes in both hospitalization and extended observation in the ED according to the MEESSI-AHF score, with no significant interaction, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Finally, respect to management of hospitalized patients, prolonged hospitalization was observed in 47.5% of patients, and the higher the patient risk, the more frequent the prolonged hospitalization, irrespective if the patient risk was categorically considered or assessed as a continuous variable \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. No significant sex differences were detected in any comparison (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Subgroup analyses based on LVEF revealed no differences in the clinical management of men and women with comparable severity of AHF decompensation as assessed by risk stratification \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this large multicenter cohort of 13,042 patients treated for AHF in Spanish EDs, the MEESSI-AHF score demonstrated robust and comparable prognostic performance in both sexes. The prediction of 30-day mortality according to estimated risk was clear and parallel in women and men, both in categorical and continuous analyses, with no evidence of significant sex interaction. These findings support MEESSI-AHF as a reliable tool irrespective of patient sex, equally applicable to men and women. Although women showed slightly higher crude 30-day mortality than men (11.2% vs. 9.9%), this difference likely reflects their older age, higher prevalence of comorbidities, and worse baseline functional status rather than inequities in care. Importantly, once risk was standardized through the MEESSI-AHF score, mortality prediction and risk gradients were virtually identical across sexes, with no significant sex interaction. Although this might have been anticipated\u0026mdash;since sex was evaluated and excluded as a prognostic factor in the pivotal study that developed the MEESSI-AHF score [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u0026mdash;we consider it essential that any risk model undergo validation in both sexes to confirm equivalent performance without sex-related differences.\u003c/p\u003e \u003cp\u003eThis study represents the first formal sex-specific validation of a prognostic scale in AHF, demonstrating that MEESSI-AHF performs equivalently in both women and men. This finding reinforces its utility as an objective, sex-neutral tool for guiding ED clinical decisions, without sex-related bias. It also sets a precedent for other conditions where sex differences are well documented but where no sex-validated risk tools currently exist. In line with our findings, Grilli et al. have recently reported, in a cohort of 7,900 patients (with 6,456 men and 1,444 women), that a sex-recalibrated version of the Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score (S-MECKI) improved risk classification and accuracy in patients with heart failure and reduced LVEF, particularly enhancing prognostic performance in high-risk patients [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Moreover, Vishram-Nielsen et al. evaluated the Seattle Heart Failure Model (SHFM) and the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) scores, both developed to evaluate patients with chronic heart failure, separately in men and women. They found overall similar discriminatory capacity and predicted versus observed risk between sexes, although both scores tended to overestimate mortality in women at 3 years [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast the absence of sex bias in our study may relate to the specific nature of the MEESSI-AHF score, which is based on objective clinical and analytical variables obtained during the acute episode in the emergency department. These parameters reflect physiological severity rather than therapeutic management, and are therefore less influenced by gender-related differences in care or follow-up.\u003c/p\u003e \u003cp\u003eThese findings collectively underscore that, despite known sex-related differences in clinical presentation (such as older age, higher prevalence of preserved LVEF, and greater comorbidity in women) applying sex-aware recalibration does not compromise, and may even enhance, the performance of prognostic tools. Our validation of MEESSI-AHF in both sexes thus supports a sex-sensitive approach to medicine and advocates for the systematic validation of prognostic models separately in men and women.\u003c/p\u003e \u003cp\u003eThe second objective of the present study was to determine whether emergency and hospital physicians\u0026rsquo; decision-making aligns with patient risk and whether any divergence exists according to patient sex. Risk stratification by MEESSI-AHF was clearly associated with the emergency physicians' decisions to hospitalize the most severely decompensated patients and to extend observation in the ED for high-risk patients discharged directly home. These clinical decisions were proportionally linked to estimated risk regardless of sex, even in subgroups with preserved or reduced LVEF. Notably, despite documented sex-based discrepancies in clinical management in other international contexts [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], we observed that in our cohort, ED decisions\u0026mdash;such as hospitalization and extended ED observation\u0026mdash;were strictly governed by estimated risk and not by patient sex [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This suggests equitable practice in the ED and argues against sex-based bias in AHF management. Although consistency was seen during hospitalization, where prolonged stays were aligned with higher risk scores, we realize this represents only a partial evaluation, as many dimensions of inpatient management remain unexplored. In this regard, our finding is consistent with results reported by Galv\u0026atilde;o et al., who analyzed over 105,000 AHF admissions from the ADHERE registry and found that, although women were older and received less aggressive interventions, length of stay were similar between sexes after adjustment [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Conversely, Zsilinszka et al. studied over 4,000 patients with heart failure and preserved LVEF presenting to the ED and found no sex differences in management strategies but, after adjustment for clinical differences between sexes, women had a slightly but statistically significant longer hospitalization (+\u0026thinsp;0.4 days) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Together, these data support our observation that high-quality, risk-based management of AHF can and should be delivered equitably, without regard to sex.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eSeveral limitations should be acknowledged. First, the retrospective observational design carries an inherent risk of residual confounding. Second, the analysis was restricted to the Spanish setting, which may limit international generalizability, as AHF management\u0026mdash;particularly regarding hospitalization and ED length of stay\u0026mdash;can vary widely across countries and even among hospitals within the same country [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Third, some variables, such as LVEF, were incompletely recorded, potentially limiting phenotype-specific analyses. Fourth, the EAHFE registry mainly comprises very elderly patients, which likely reflects the true spectrum of AHF but also introduces specific challenges. Older patients often present with frailty and functional or cognitive impairments, which may influence physicians\u0026rsquo; decisions and outcomes [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Fifth, we did not examine differences in the hospital departments to which patients were admitted, nor the use of less conventional AHF management strategies such as admission in short-stay units or hospital-at-home programs [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Finally, our analysis was based solely on recorded biological sex, without considering non-binary categories or incorporating gender-related sociocultural determinants, which may also influence clinical management or symptom perception.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eOverall, this study validates the universal applicability of the MEESSI-AHF scale regardless of sex and underscores the need for future research systematically incorporating sex and gender perspectives into the development and validation of prognostic tools. Furthermore, our findings suggest that once physicians\u0026rsquo; decisions are adjusted by the MEESSI-AHF score, the management of patients with AHF in the ED is not influenced by sex-related bias.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the healthcare professionals working in emergency departments for their professionalism and dedication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe EAHFE registry and this ancillary analysis were approved by the Clinical Research Ethics Committees of Hospital Cl\u0026iacute;nic de Barcelona (ref. 2018/0233), Hospital Universitario Central de Asturias (ref. 205/17), and all participating centers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven the retrospective use of anonymized registry data (EAHFE), the requirement for written informed consent was waived by all ethics committees; no identifiable patient data were used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDe-identified data are part of the EAHFE registry and are not publicly available due to institutional and ethical restrictions; de-identified data may be available from the corresponding author on reasonable request and with permission from the EAHFE Steering Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception and design: \u0026Ograve;scar Mir\u0026oacute;, Natalia Miota, Blanca Coll-Vinent.\u003c/p\u003e\n\u003cp\u003eData collection: Pere Llorens, V\u0026iacute;ctor Gil, Javier Jacob, Pablo Herrero, Aitor Alqu\u0026eacute;zar-Arb\u0026eacute;, M\u0026oacute;nica Villar, Cristina Ant\u0026oacute;n, Naila Canadell.\u003c/p\u003e\n\u003cp\u003eStatistical analysis and interpretation: \u0026Ograve;scar Mir\u0026oacute;.\u003c/p\u003e\n\u003cp\u003eDrafting of the manuscript: Natalia Miota, \u0026Ograve;scar Mir\u0026oacute;, Blanca Coll-Vinent.\u003c/p\u003e\n\u003cp\u003eCritical revision for important intellectual content: All authors.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;All authors approved the final version of the manuscript and agree to be accountable for all aspects of the work\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eLlorens P, Escoda R, Mir\u0026oacute; O, Herrero-Puente P, Mart\u0026iacute;n-S\u0026aacute;nchez FJ, Jacob J, et al. Caracter\u0026iacute;sticas cl\u0026iacute;nicas, terap\u0026eacute;uticas y evolutivas de los pacientes con insuficiencia cardiaca aguda atendidos en servicios de urgencias espa\u0026ntilde;oles: Registro EAHFE. Emergencias. 2015;27:11-22.\u003c/li\u003e\n \u003cli\u003ePonikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2016;37:2129-2200.\u003c/li\u003e\n \u003cli\u003eMir\u0026oacute; O, Garc\u0026iacute;a Sarasola A, Fuenzalida C, Calder\u0026oacute;n S, Jacob J, Aguirre A, et al. Departments involved during the first episode of acute heart failure and subsequent emergency department revisits and rehospitalisations: an outlook through the NOVICA cohort. Eur J Heart Fail. 2019;21:1231-1244.\u003c/li\u003e\n \u003cli\u003eDharmarajan K, Hsieh AF, Lin Z, Bueno H, Ross JS, Horwitz LI, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309:355-363.\u003c/li\u003e\n \u003cli\u003eMir\u0026oacute; O, Rossell\u0026oacute; X, Gil V, Mart\u0026iacute;n-S\u0026aacute;nchez FJ, Llorens P, Herrero-Puente P, et al. Predicting 30-day mortality for patients with acute heart failure in the emergency department: a cohort study. Ann Intern Med. 2017;167:698-705.\u003c/li\u003e\n \u003cli\u003eRossello X, Bueno H, Gil V, Jacob J, Mart\u0026iacute;n-S\u0026aacute;nchez FJ, et al. MEESSI-AHF risk score performance to predict multiple post-index event and post-discharge short-term outcomes. Eur Heart J Acute Cardiovasc Care. 2021;10:142-152.\u003c/li\u003e\n \u003cli\u003eMir\u0026oacute; O, Rossell\u0026oacute; X, Gil V, Mart\u0026iacute;n-S\u0026aacute;nchez FJ, Llorens P, Herrero-Puente P, et al. The usefulness of the MEESSI score for risk stratification of patients with acute heart failure at the emergency department. Rev Esp Cardiol. 2019;72:198-207.\u003c/li\u003e\n \u003cli\u003eMir\u0026oacute; O, Rossell\u0026oacute; X, Gil V, Mart\u0026iacute;n-S\u0026aacute;nchez FJ, Llorens P, Herrero-Puente P, et al. Analysis of how emergency physicians\u0026rsquo; decisions to hospitalize or discharge patients with acute heart failure match the clinical risk categories of the MEESSI-AHF scale. Ann Emerg Med. 2019;74:204-215.\u003c/li\u003e\n \u003cli\u003eIslas Susen\u0026aacute;n A, et al. Sex and gender differences in heart failure. Int J Heart Fail. 2020;2:123-131.\u003c/li\u003e\n \u003cli\u003eDorsch MP, Dunlay SM, Roger VL. Sex differences in heart failure. Int J Heart Fail. 2013;1:64-71.\u003c/li\u003e\n \u003cli\u003eMart\u0026iacute;-Almor J, et al. Sex differences in the management and outcomes of acute heart failure with preserved ejection fraction in the emergency department. J Card Fail. 2016;22:280-288.\u003c/li\u003e\n \u003cli\u003e\u0026Scaron;pinar J, Jarkovsky J, Vitovec J, et al. AHEAD registry: Acute Heart Failure Database\u0026mdash;main characteristics and hospital outcomes of patients admitted with acute heart failure in the Czech Republic. Eur J Heart Fail. 2011;13:946-952.\u003c/li\u003e\n \u003cli\u003eLam CSP, Arnott C, Beale AL, et al. Sex differences in heart failure. Eur Heart J. 2019;40:3859-3868.\u003c/li\u003e\n \u003cli\u003eTan VY, Chan SP, Chia SY, et al. Gender differences in patients with acute decompensated heart failure in Singapore. Int J Cardiol. 2020;313:64-69.\u003c/li\u003e\n \u003cli\u003eKomajda M, Lam CSP. Heart failure with preserved ejection fraction: a clinical dilemma. Eur Heart J. 2021;42:484-493.\u003c/li\u003e\n \u003cli\u003eJacob J, Llauger L, Herrero-Puente P, Mart\u0026iacute;n-S\u0026aacute;nchez FJ, Llorens P, Roset A, et al. Acute heart failure and adverse events associated with the presence of renal dysfunction and hyperkalaemia. Eur J Intern Med. 2019;67:89-96.\u003c/li\u003e\n \u003cli\u003eMir\u0026oacute; O, Fortuny MJ, Espinosa B, Alqu\u0026eacute;zar-Arb\u0026eacute; A, Jacob J, Trull\u0026agrave;s JC, et al. Alkalosis during emergency department evaluation of acute heart failure: Is there an association with mortality? Emergencias. 2025;37:23-30.\u003c/li\u003e\n \u003cli\u003eHarrell FE Jr. Regression Modeling Strategies. 2nd ed. New York: Springer-Verlag; 2015.\u003c/li\u003e\n \u003cli\u003eGrilli G, Salvioni E, Moscucci F, Bonomi A, Sinagra G, Schaeffer M, et al. A matter of sex\u0026mdash;persistent predictive value of MECKI score prognostic power in men and women with heart failure and reduced ejection fraction: a multicenter study. Front Cardiovasc Med. 2024;11:1390544.\u003c/li\u003e\n \u003cli\u003eVishram-Nielsen JKK, Foroutan F, Ross HJ, Gustafsson F, Alba AC. Performance of prognostic risk scores in heart failure patients: do sex differences exist? Can J Cardiol. 2020;36:45-53.\u003c/li\u003e\n \u003cli\u003eVicent L, Garc\u0026iacute;a-Cosio M, Amigo JS, Guerra JM, Dolz LM, Farr\u0026eacute;-L\u0026oacute;pez N, et al. Sex and clinical outcomes in new-onset heart failure. Int J Cardiol. 2025;428:133092.\u003c/li\u003e\n \u003cli\u003eShah KS, Xu H, Matsouaka RA, Bhatt DL, Heidenreich PA, DeVore AD, et al. Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. J Am Coll Cardiol. 2017;70:2476-2486.\u003c/li\u003e\n \u003cli\u003eParcha V, Patel AP, Kalra R, Arora G, Raza MQ, Davis GM, et al. Equity in heart failure care: a Get With the Guidelines\u0026ndash;Heart Failure registry analysis. Circ Heart Fail. 2024;17:e010280.\u003c/li\u003e\n \u003cli\u003eKhera R, Pandey A, Ayers CR, et al. Contemporary sex differences in heart failure management and outcomes after acute coronary syndromes. JACC Adv. 2023;2:100294.\u003c/li\u003e\n \u003cli\u003eGalv\u0026atilde;o M, Kalman J, DeMarco T, Fonarow GC, Galvin C, Ghali JK, et al. Gender differences in in-hospital management and outcomes in patients with decompensated heart failure: analysis from the Acute Decompensated Heart Failure National Registry (ADHERE). J Card Fail. 2006;12:100-107.\u003c/li\u003e\n \u003cli\u003eZsilinszka R, Unger JW, Papp Z, Kaldy NB, Papp R, Zemanek D, et al. Sex differences in the management and outcomes of patients with heart failure with preserved ejection fraction admitted to the emergency department. J Card Fail. 2016;22:S183.\u003c/li\u003e\n \u003cli\u003eMir\u0026oacute; O, S\u0026aacute;nchez C, Gil V, Repullo D, Garc\u0026iacute;a-Lamberechts EJ, Gonz\u0026aacute;lez Del Castillo J, et al. Current Spanish emergency department organization and clinical practices in caring for patients with acute heart failure. Emergencias. 2022;34:85-94.\u003c/li\u003e\n \u003cli\u003eBima P, Morello F. Elderly frequent visitors to emergency departments: stories of frailty and comorbidity. Emergencias. 2025;37:1-2.\u003c/li\u003e\n \u003cli\u003eHamada T, Kubo T, Kawai K, Nakaoka Y, Yabe T, Furuno T, et al. Prognostic impact of frailty based on a comprehensive frailty assessment in patients with heart failure. ESC Heart Fail. 2024;11:2076-2085.\u003c/li\u003e\n \u003cli\u003eBibiano-Guill\u0026eacute;n C, Mir-Montero M, Rodr\u0026iacute;guez-Rodr\u0026iacute;guez B, Vinat-Prado S, S\u0026aacute;nchez-P\u0026eacute;rez M, Pantoja-Zarza MC. Implementing a virtual home short-stay unit: feasibility, safety, and satisfaction. Emergencias. 2025;37:312-315.\u003c/li\u003e\n \u003cli\u003eS\u0026aacute;nchez C, et al. Factores asociados con la necesidad de escalada asistencial en pacientes con insuficiencia card\u0026iacute;aca aguda ingresados directamente desde urgencias en hospitalizaci\u0026oacute;n a domicilio. Emergencias. 2025;in press.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"internal-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iaem","sideBox":"Learn more about [Internal and Emergency Medicine](http://link.springer.com/journal/11739)","snPcode":"11739","submissionUrl":"https://www.editorialmanager.com/iaem/default.aspx","title":"Internal and Emergency Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Sex Factors, Risk Assessment, Mortality, Heart Failure, Emergency Service, Hospital","lastPublishedDoi":"10.21203/rs.3.rs-8480632/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8480632/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Risk scores for acute heart failure (AHF) are typically developed without sex-specific models. The MEESSI-AHF score estimates 30-day mortality in patients presenting with AHF to the emergency department (ED). Whether its prognostic accuracy and its influence on clinical decisions are comparable between men and women remains unknown.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe analyzed patients from the EAHFE registry with known sex and complete data to calculate the MEESSI-AHF score. Patients were classified into four risk groups (low, intermediate, high, very high). Sex-based differences were evaluated for 30-day mortality and for ED physicians’ decisions regarding hospitalization and extended (\u0026gt;24 h) ED observation, as well as for hospital physicians’ decisions regarding prolonged hospitalization (\u0026gt;7 days). Logistic regression interaction analyses were performed using both categorical and continuous models (restricted cubic splines).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eWe included 13,042 patients (median age 83 years; 56% women). MEESSI-AHF accurately stratified 30-day mortality overall (2.9%, 9.6%, 18.2%, and 39.7% across risk groups; with a c-statistic of 0.78; p\u0026lt;0.001) and by sex (c-statistics of 0.77 for men and 0.78 for women, p\u0026gt;0.05), with no significant sex interactions in categorical or continuous analyses (all p\u0026gt;0.05). Hospitalization (76%), extended observation in the ED in discharged patients (9%) and prolonged hospitalization (47%) also increased with higher MEESSI-AHF risk, with no evidence of sex interaction in categorical or continuous analyses (all p\u0026gt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe MEESSI-AHF score estimates risk with similar accuracy in men and women. Clinical decisions regarding hospitalization and discharge (from ED and after hospitalization) appear to be made equally in patients of both sexes with comparable MEESSI-AHF-estimated risk.\u003c/p\u003e","manuscriptTitle":"Influence of patient sex on clinical decision-making in acute heart failure: A risk-adjusted analysis using the MEESSI-AHF score","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 08:07:31","doi":"10.21203/rs.3.rs-8480632/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2026-01-06T11:45:17+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-06T10:17:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-03T04:57:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"Internal and Emergency Medicine","date":"2026-01-02T08:00:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"internal-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iaem","sideBox":"Learn more about [Internal and Emergency Medicine](http://link.springer.com/journal/11739)","snPcode":"11739","submissionUrl":"https://www.editorialmanager.com/iaem/default.aspx","title":"Internal and Emergency Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f68d722f-456c-4d78-ae56-3f23c1641b8e","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T16:11:38+00:00","versionOfRecord":{"articleIdentity":"rs-8480632","link":"https://doi.org/10.1007/s11739-026-04319-9","journal":{"identity":"internal-and-emergency-medicine","isVorOnly":false,"title":"Internal and Emergency Medicine"},"publishedOn":"2026-03-17 15:59:32","publishedOnDateReadable":"March 17th, 2026"},"versionCreatedAt":"2026-01-12 08:07:31","video":"","vorDoi":"10.1007/s11739-026-04319-9","vorDoiUrl":"https://doi.org/10.1007/s11739-026-04319-9","workflowStages":[]},"version":"v1","identity":"rs-8480632","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8480632","identity":"rs-8480632","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}