Early changes in clinical characteristics after emergency department therapy for acute heart failure syndromes: identifying patients who do not respond to standard therapy

Abstract

Aims Clinical trials for acute heart failure syndromes (AHFS) have traditionally enrolled patients well after emergency department (ED) presentation. We hypothesized a large proportion of patients would undergo changes in clinical profiles during the first 24 hours of hospitalization and these changes would be associated with adverse events. Methods We evaluated a prospective cohort of patients with clinical data available at ED presentation and 12–24 hours after ED treatment for AHFS. Patients were categorized into distinct clinical profiles at these time points based on: 1) systolic blood pressure- a. hypertensive [>160 mmHg]; b. normotensive [100–159 mmHg]; or c. hypotensive [<100 mmHg]; 2) moderate to severe renal dysfunction [GFR ≤ 60 ml/min/1.73 m2]; and 3) presence of troponin positivity. A composite outcome of 30-day cardiovascular events was determined by phone follow-up. Results In the 370 patients still hospitalized with data available at the 12–24 hour time point, 196 (53.0%) had changed their clinical profiles, with 117 (59.7%) improving and 79 (40.3%) worsening. The composite 30-day event rate was 16.9%. Patients whose clinical profile started and stayed abnormal had a significantly greater proportion of events than those who started and stayed normal (26.1% vs. 11.3%; p=0.03). Conclusion Patients with abnormal clinical profiles at presentation that remain abnormal throughout the first 12–24 hours of hospitalization are at increased risk of 30-day adverse events. Future clinical trials may need to consider targeting these patients, as they may be the most likely to benefit from experimental therapy.

Current management and future directions for the treatment of patients hospitalized for heart failure with low blood pressure

“…The general approach to the assessment of patients with HF-LBP is similar to HF in general [62], but with several additional key elements. Evaluation should begin promptly in the Emergency Department to facilitate early diagnosis, management and disposition [20,63,64]. This initial assessment should assess fluid status (dehydration versus congestion), the severity (e.g., cardiogenic shock or flash pulmonary edema), BP with or without signs of hypoperfusion, heart rate, rhythm, precipitants, comorbidities and whether the HF is chronic or de novo [20].…”

Additive diagnostic and prognostic value of Bioelectrical Impedance Vector Analysis (BIVA) to brain natriuretic peptide ‘grey-zone’ in patients with acute heart failure in the emergency department

“…6,7 Bioimpedance vector analysis (BIVA) is a non-invasive technique to estimate body water content that has been recently demonstrated of utility in evaluating total fluid congestion in AHF patients. 8,9 Moreover, in decompensated HF patients, BIVA has been shown to be strongly related to brain natriuretic peptide (BNP) values, 10 NYHA functional classes 11 and central venous pressure, 12 and allows physicians to detect fluid accumulation even before the appearance of oedema. 13 In patients referring to ED for shortness of breath, BIVA assessment has been demonstrated to be useful in distinguishing cardiogenic from non-cardiogenic dyspnoea 14 and the combined use of both BIVA and BNP seems to improve the management of AHF patients.…”

Moving From Heart Failure Guidelines to Clinical Practice: Gaps Contributing to Readmissions in Patients With Multiple Comorbidities and Older Age

“…How resources are allocated within the 8 categories and 34 subdomains of a disease management taxonomy could influence readmissions. 11,89 A summary of some of these factors include: firstly there are varying complexities in CHF cohort including hospitalization, complexities of comorbidities or risk factors including male sex, advanced age, or disease (eg, low systolic blood pressure), cardiac comorbidity (myocardial ischemia, AF), noncardiac comorbidity burden (CRI, DM, anemia, COPD, hyponatremia), psychosocial well-being (depression, social support, literacy), noncardiac illnesses (respiratory tract infection, falls, and fractures), history and frequency of prior hospitalization, prescription of prognostic medications, patient-related/compliance factors (nonadherence, dietary indiscretion with salt and water with weight gain, and drug and alcohol abuse), iatrogenic factors (eg, use of nonsteroidal anti-inflammatory drugs), and system-related factors (insufficient access to follow-up care and rehabilitation, poor transitions of care); 27,28,30,41–46,91,110–123 secondly poor correlation between existing readmission risk scores and translation in the clinical domain; 92–97 thirdly, the finding that phenotypic variables other than EF, such as comorbidity or female sex, can determine outcomes, raising questions to broaden HF classification beyond left ventricular EF (LVEF). 17,31,124…”