CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 1, January – April 2024 AFRICA 41 with malignancies; patients with severe liver or kidney diseases; or those with incomplete medical data. This study was approved by the ethics committee of our hospital. All patients and their families gave informed consent. The clinical data, such as age, gender, smoking and drinking habits, diabetes mellitus, hypertension, coronary heart disease and indices after admission, such as troponin I (cTnI), B-type natriuretic peptide (BNP), six-minute walking distance (6MWD) and left ventricular ejection fraction (LVEF), were collected. The severity of CHF was assessed using the MEWS. Systolic blood pressure, heart and respiration rate, body temperature and consciousness were measured and scored 0–3 points for each. The total score (0–14 points) of the five indices was the MEWS. The higher MEWS points corresponded to a more severe condition of disease. The MEWS scoring criteria15 are shown in Table 1. CHF patients were followed up for three years by the out-patient clinic, rehospitalisation and telephone, and the clinical outcome during follow up was recorded, based on which the patients were divided into a survival group and non-survival group. The MEWS was compared among the four NYHA groups on admission and discharge, and the predictive value of the MEWS for the severity of disease and long-term prognosis was observed. Statistical analysis SPSS22.0 software was used for statistical analysis. Numerical data are expressed as numbers and percentage, and measurement data are expressed as mean and standard deviation. The t-test or chi-squared test was performed for univariate analysis, and Spearman’s correlation analysis was conducted. Long-term prognosis was assessed using receiver operator characteristic (ROC) curve analysis, and the area under curve (AUC) ≥ 0.70 indicated certain accuracy. The Youden index was calculated and the cut-off value was determined based on the sensitivity and specificity. A p < 0.05 was considered to be statistically significant. Results There were 102 males and 78 females aged 65–81 years old, with an average of 70.36 ± 10.41 years. They were divided into a grade I group (n = 28), a grade II group (n = 37), a grade III group (n = 68) and a grade IV group (n = 47) according to their New York Heart Association (NYHA) functional classification. The general data such as age, gender and history of disease had no statistically significant differences among the groups (p > 0.05). The MEWS on discharge was significantly lower than that on admission in the four groups, and the higher the NYHA grade, the higher the MEWS value (p < 0.05) (Table 2). After a three-year follow up, 48 out of the 180 patients had died, with a death rate of 26.67%. There were no statistically significant differences in age, gender, smoking, drinking, diabetes, hypertension and coronary heart disease between the non-survival and survival groups (p > 0.05). cTnI, BNP, 6MWD, LVEF, NYHA grade and the MEWS affected the clinical outcomes of patients. Compared with the survival group, the MEWS, cTnI and BNP levels of the non-survival group were significantly higher, and the 6MWD and LVEF were lower (p < 0.05) (Table 3). Different clinical outcomes were positively correlated with NYHA grade, MEWS, 6MWD and LVEF (r = 0.368, r = 0.471, r = 0.387, r = 0.423, p < 0.05), and negatively correlated with cTnI and BNP values (r = –0.411, r = –0.425). To further evaluate the assessment value of the MEWS for the long-term prognosis of patients, MEWS was subjected to ROC curve analysis. It was found that the AUC was 0.852 (95% CI 0.785–0.919, p < 0.001), indicating higher accuracy. The optimal cut-off value of the MEWS in judging the condition of patients was 5.6 points, in which case the Youden index was the highest (0.65), and the corresponding sensitivity and specificity were 0.854 and 0.797%, respectively. The AUC of cTnI was 0.845 (95% CI 0.764–0.904, p < 0.001), the optimal cut-off value was 2.05 ng/ml, the Youden index was 0.62, the sensitivity was 0.842%, and the specificity was 0.775%. Table 1. MEWS scoring criteria Variables 0 points 1 point 2 points 3 points Systolic blood pressure (mmHg) 101–199 81–100 ≥ 200 or 71–80 ≤ 70 Heart rate (beats/min) 51–100 41–50 or 101–110 ≤ 40 or 111–129 ≥ 130 Respiration (times/min) 9–14 15–20 21–29 or < 9 ≥ 30 Body temperature (°C) 35 35–38.4 < 35 or ≥ 38.5 Consciousness Clear Respond to sound Respond to pain No response MEWS: modified early warning score. Table 2. MEWS of four groups NYHA class n MEWS on admission (mean ± SD) MEWS on discharge (mean ± SD) t/p-value (admission and discharge) I 28 1.25 ± 0.84 0.78 ± 0.75 2.209/0.031 II 37 3.47 ± 0 .981 2.28 ± 0.961 5.276/0.000 III 68 5.48 ± 0.941,2 4.23 ± 1.241,2 6.624/0.000 IV 47 7.78 ± 2.141,2,3 6.58 ± 1.871,2,3 2.895/0.005 1p < 0.05 vs grade I, 2p < 0.05 vs grade II, 3p < 0.05 vs grade III. MEWS: modified early warning score; NYHA: New York Heart Association. Table 3. General data of patients with different clinical outcomes Variables Non-survival group (n = 48) Survival group (n = 132) t/χ2 p-value Age (years), mean ± SD 71.52 ± 10.24 69.94 ± 9.47 0.968 0.334 Gender (male/female) 25/77 23/55 0.560 0.454 Smoking (yes), n (%) 13 (27.08) 32 (24.24) 1.402 0.237 Drinking (yes), n (%) 10 (20.83) 25 (18.94) 0.081 0.776 Diabetes mellitus (yes), n (%) 17 (35.42) 31 (23.48) 2.563 0.109 Hypertension (yes), n (%) 15 (31.25) 36 (27.27) 0.274 0.601 Coronary heart disease (yes), n (%) 19 (39.58) 35 (26.51) 2.863 0.091 NYHA class, n (%) 28.540 0.000 I 2 (7.14) 26 (92.86) II 6 (16.22) 31 (83.78) III 14 (20.59) 54 (79.41) IV 26 (55.32) 21 (44.68) MEWS, mean ± SD 7.52 ± 2.31 4.30 ± 2.27 8.377 0.000 cTnI (ng/ml), mean ± SD 2.52 ± 0.48 1.72 ± 0.45 10.361 0.000 BNP (ng/ml), mean ± SD 447.79 ± 27.33 359.18 ± 30.78 17.578 0.000 6MWD (min), mean ± SD 311.28 ± 19.30 375.37 ± 21.02 18.477 0.000 LVEF (%), mean ± SD 43.31 ± 3.09 50.28 ± 4.76 9.438 0.000 6MWD: six-minute walking distance; BNP: B-type natriuretic peptide; cTnI: troponin I; LVEF: left ventricular ejection fraction; MEWS: modified early warning score; NYHA: New York Heart Association.
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