Validation and implementation of the FLHASc score for risk stratification of patients with hemoptysis in the emergency department.

BACKGROUND

Hemoptysis is a potentially life-threatening symptom that often prompts emergency department (ED) evaluation and hospitalization. Reliable prognostic tools to guide clinical decision-making and optimize resource use are currently lacking.

OBJECTIVE

To prospectively validate the Florence Hemoptysis Assessment Score (FLHASc) in patients presenting with hemoptysis to the ED, and to eventually derive and validate an improved version of the score (FLHASc2).

METHODS

We analyzed data from the POPEIHE study (NCT06067997), a multicenter prospective cohort of 546 consecutive adult patients presenting with hemoptysis to 9 Italian EDs. The primary outcome was a composite of in-hospital death, need for ventilatory support, intensive care unit (ICU) admission, blood transfusion, or invasive hemostatic procedures. We evaluated the prognostic performance of the original FLHASc, then derived a new model (FLHASc2) using multivariate logistic regression in a randomly selected derivation cohort (n = 321) and validated it in the remaining cohort (n = 225). A simplified version of the score was also tested.

RESULTS

The original FLHASc demonstrated moderate discriminatory ability (AUC 0.71; 95% CI: 0.65-0.76) and suboptimal calibration. The FLHASc2 showed improved performance (AUC 0.79, 95% CI: 0.73-0.87 in derivation and 0.81, 95% CI: 0.73-0.88, in validation cohorts; Brier score < 0.10 in both). The simplified FLHASc2 (sFLHASc2), assigning one point per variable, maintained comparable accuracy (AUC 0.80, 95% CI: 0.72-0.87) and identified 47.8% of patients as low risk (2.7% event rate). When combined with a negative chest X-ray, the observed event rate in this subgroup dropped to 0.87%, with a negative predictive value of 99.1% (CI 95%, 96.5-100%).

CONCLUSIONS

The FLHASc2 and its simplified version are accurate prognostic tools for identifying hemoptysis patients at low risk of short-term adverse outcomes. Use of the sFLHASc2 combined with chest X-ray may allow safe ED discharge in nearly half of cases. A prospective management trial is warranted to confirm its clinical impact.

TRIAL REGISTRATION NUMBER: NCT06067997.