Departments involved during the first episode of acute heart failure and subsequent emergency department revisits and rehospitalisations: an outlook through the NOVICA cohort

Abstract

ObjectivesWe investigated the natural history of patients after a first episode of acute heart failure (FEAHF) requiring emergency department (ED) consultation, focusing on: the frequency of ED visits and hospitalisations, departments admitting patients during the first and subsequent hospitalisations, and factors associated with difficult disease control.We included consecutive patients diagnosed with FEAHF (either with or without previous heart failure diagnosis) in four EDs during 5 months in three different time periods (2009, 2011, 2014). Diagnosis was adjudicated by local principal investigators. The clinical characteristics of the index event were prospectively recorded, and all post-discharge ED visits and hospitalisations [related/unrelated to acute heart failure (AHF)], as well as departments involved in subsequent hospitalisations were retrospectively ascertained. 'Uncontrolled disease' during the first year after FEAHF was considered if patients were attended at ED (≥ 3 times) or hospitalised (≥ 2 times) for AHF or died. Overall, 505 patients with FEAHF were included and followed for a mean of 2.4 years. In-hospital mortality was 7.5%. Among 467 patients discharged alive, 288 died [median survival 3.9 years, 95% confidence interval (CI) 3.5-4.4], 421 (90%) revisited the ED (2342 ED visits; 42.4% requiring hospitalisation, 34.0% AHF-related) and 357 Ò. Miró et al.(77%) were hospitalised (1054 hospitalisations; 94.1% through ED, 51.4% AHF-related). AHF-related hospitalisations were mainly in internal medicine (28.0%), short-stay unit (26.3%), cardiology (20.8%), and geriatrics (14.1%). Only 47.4% of AHF-related hospitalisations were in the same department as the FEAHF, and internal medicine involvement significantly increased with subsequent hospitalisations (P = 0.01). Uncontrolled disease was observed in 31% of patients, which was independently related to age > 80 years [odds ratio (OR) 1.80, 95% CI 1.17-2.77], systolic blood pressure < 110 mmHg at ED arrival (OR 2.61, 95% CI 1. 26-5.38) and anaemia (OR 2.39, 95% CI

Risk stratification scores for patients with acute heart failure in the Emergency Department: A systematic review

“…Among the 761 screened citations, 28 studies published over the last 10 years 8,20,24,35–59 met the inclusion criteria after full-text review (Figure 1). These 28 studies included 19 different risk models that had been used in AHF patients in the ED setting to predict clinical outcomes (Table 1).…”

“…4 In AHF patients, the cause of rehospitalization within 30 days is attributable to further worsening of HF in only 16–37% of cases. 5–8…”

De novo heart failure: where the journey begins

“…However, introduction and uptitration of these therapies among older hospitalized HF patients may be complex, especially when used together with other treatments targeting co-morbidities. It is thus reassuring that in the Spanish experience by Miró et al, 5 discharge prescription of core elements of guideline-directed medical therapy (GDMT) for HFrEF was comparable irrespective of treating department or if the patient was treated and discharged from the emergency department.…”

“…In this issue of the Journal, Miró et al 5 present observations from NOVICA-3, a longitudinal cohort of 505 unselected patients hospitalized with apparently new HF. Patients were carefully tracked after their initial presentation to four emergency departments in Barcelona, Spain from 2009 to 2014.…”

“…The study of Miró et al 5 also emphasizes the severity and prognostic significance of sentinel HF hospitalizations; 8% died during the index hospitalization and, among survivors, median survival was only 4 years. Data from the US-based Get With The Guidelines-Heart Failure registry consistently showed dismal prognosis among hospitalized HF patients with average life expectancy of ∼2 years with 75% mortality rates at 5 years, irrespective of ejection fraction.…”