Bridging the gap between evidence and practice in acute decompensated heart failure management

Abstract

Registry data indicate a gap between evidence-based guidelines and current management of patients with acute decompensated heart failure (ADHF). Bridging this gap is crucial given the frequency and cost of hospitalization for this disorder. Patients with ADHF require rapid assessment to determine appropriate treatment location and initial therapy. Patients with impending respiratory failure or cardiogenic shock should be managed in an intensive care setting, patients with congestion that is expected to require prolonged intravenous therapy should be admitted to the hospital, and patients with congestion that is likely to respond within 12-24 hours can be managed in an observation unit. Clinical status should guide selection of initial therapy. Initially, therapeutic response should be assessed every couple of hours. Once effective acute therapy has been established, it is important to implement strategies to improve long-term outcomes.These strategies include ensuring that care complies with established core performance measures, providing patient education in a manner suited to ensure comprehension and retention, and arranging for appropriate outpatient followup, ideally in a comprehensive heart failure disease management program. The purpose of this review is (1) to examine evidence-based guidelines for the treatment of ADHF, (2) to present a practical algorithm for patient assessment and treatment derived from these guidelines and personal experience, and (3) to discuss systems to enhance the ultimate transition of patient care from the inpatient to outpatient setting. Journal of Hospital Medicine 2008;3(Suppl 6):S7-S15.

Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting

“…The early and correct diagnosis presents a significant clinical challenge and is of primary importance, as misdiagnosis can result in deleterious consequences to patients [4-6]. Rapid bedside tests, especially brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP), help in determining the cause of acute dyspnea in the prehospital setting [2,7].…”

A Phased Cluster-randomized Trial of Rural Hospitals Testing a Quality Collaborative to Improve Heart Failure Care

“…Establishing effective care processes in acute care is essential, but needs to be extended into the outpatient and home settings. 28 Long-term patient outcomes such as functional status, self-management, or physiological measures (eg, B-type natriuretic peptide) may better represent improvements benefiting the target population.…”

Observation Units in the Management of Acute Heart Failure Syndromes

“…They can coordinate the transition to outpatient care and manage comorbid conditions. The patients' cardiologists can serve as consultants in this model, managing advanced therapies such as vasoactive agents or ultrafiltration therapy, although these therapies may require transfer to a specialized care unit [20,22].…”