ADHERE Risk Model

ADHERE Risk Model

The ADHERE Risk Model is a validated risk stratification tool used to predict in-hospital mortality in patients with acute decompensated heart failure (ADHF). This model was developed using data from the Acute Decompensated Heart Failure National Registry (ADHERE) and provides clinicians with a simple, bedside risk assessment tool.

Model Development

The ADHERE Risk Model was developed using data from 33,046 patients hospitalized with ADHF across 263 hospitals in the United States. The model identifies five key variables that independently predict in-hospital mortality:

Scoring Criteria

The ADHERE Risk Model assigns points based on five clinical variables:

Variable	Points
Blood Urea Nitrogen (BUN)
< 20 mg/dL	0
20-29 mg/dL	1
30-39 mg/dL	2
≥ 40 mg/dL	3
Systolic Blood Pressure
≥ 130 mmHg	0
110-129 mmHg	1
90-109 mmHg	2
< 90 mmHg	3
Serum Creatinine
< 1.0 mg/dL	0
1.0-1.4 mg/dL	1
1.5-1.9 mg/dL	2
≥ 2.0 mg/dL	3
Heart Rate
< 70 bpm	0
70-89 bpm	1
≥ 90 bpm	2
Serum Sodium
≥ 135 mEq/L	0
130-134 mEq/L	1
< 130 mEq/L	2

Risk Stratification and In-Hospital Mortality

Score Range	Risk Level	In-Hospital Mortality	Clinical Implication
0-3	Low	2.1%	Standard management
4-6	Medium	6.4%	Close monitoring
7-9	High	13.6%	Intensive care
≥ 10	Very High	27.7%	Critical care

Clinical Applications

The ADHERE Risk Model is used for:

• Risk stratification: Identifying patients at high risk of in-hospital mortality
• Resource allocation: Guiding decisions about level of care and monitoring
• Treatment intensity: Determining aggressiveness of therapy
• Discharge planning: Assessing readiness for discharge
• Family counseling: Providing prognostic information to patients and families

Management Recommendations by Risk Level

Low Risk (Score 0-3)

• In-hospital mortality: 2.1%
• Management:
  • Standard heart failure management
  • Regular monitoring
  • Consider early discharge planning
  • Optimize medical therapy

Medium Risk (Score 4-6)

• In-hospital mortality: 6.4%
• Management:
  • Close monitoring required
  • Consider telemetry monitoring
  • Aggressive medical therapy
  • Consider intensive care if clinical status deteriorates

High Risk (Score 7-9)

• In-hospital mortality: 13.6%
• Management:
  • Intensive monitoring and aggressive therapy
  • Consider ICU admission
  • Hemodynamic monitoring
  • Consider advanced therapies (inotropes, mechanical support)

Very High Risk (Score ≥ 10)

• In-hospital mortality: 27.7%
• Management:
  • Critical care management
  • ICU admission recommended
  • Consider advanced therapies
  • Palliative care consultation
  • Family discussions about goals of care

Validation and Performance

The ADHERE Risk Model has been extensively validated:

• Discrimination: Good ability to distinguish between patients with different mortality risks (C-statistic 0.74)
• Calibration: Well-calibrated across different populations
• External validation: Validated in multiple cohorts
• Clinical utility: Shown to improve clinical decision-making

Advantages of the ADHERE Model

• Simple: Easy to calculate at the bedside
• Rapid: Can be calculated quickly using readily available data
• Validated: Extensively validated in large populations
• Practical: Uses commonly measured laboratory values
• Prognostic: Provides accurate mortality risk assessment

Limitations and Considerations

The ADHERE Risk Model has several limitations:

• Static prediction: Does not account for changes in clinical status during hospitalization
• Population-based: May not apply to individual patients
• Not a treatment guide: Should be used with clinical judgment
• Evolving therapies: May not reflect benefits of newer treatments
• Regional differences: May need adjustment for different populations

Integration with Clinical Practice

The ADHERE Risk Model should be used as part of a comprehensive clinical assessment:

• Combine with other clinical parameters and judgment
• Consider patient preferences and values
• Regular reassessment as clinical status changes
• Use in shared decision-making with patients and families
• Follow institutional protocols and guidelines

Comparison with Other Risk Models

The ADHERE Risk Model offers several advantages:

• Simplicity: Only five variables required
• Speed: Can be calculated immediately upon admission
• Validation: Developed and validated in large, diverse populations
• Practicality: Uses routinely available clinical data
• Prognostic accuracy: Good discrimination for in-hospital mortality

The ADHERE Risk Model is a valuable tool in the management of acute decompensated heart failure, providing clinicians with objective risk stratification to guide treatment decisions, resource allocation, and patient counseling.