Editor’s Choice-The role of the emergency department in the management of acute heart failure: An international perspective on education and research

Abstract

Emergency departments are a major entry point for the initial management of acute heart failure (AHF) patients throughout the world. The initial diagnosis, management and disposition - the decision to admit or discharge - of AHF patients in the emergency department has significant downstream implications. Misdiagnosis, under or overtreatment, or inappropriate admission may place patients at increased risk for adverse events, and add costs to the healthcare system. Despite the critical importance of initial management, data are sparse regarding the impact of early AHF treatment delivered in the emergency department compared to inpatient or chronic heart failure management. Unfortunately, outcomes remain poor, with nearly a third of patients dying or re-hospitalised within 3 months post-discharge. In the absence of robust research evidence, consensus is an important source of guidance for AHF care. Thus, we convened an international group of practising emergency physicians, cardiologists and advanced practice nurses with the following goals to improve outcomes for AHF patients who present to the emergency department or other acute care setting through: (a) a better understanding of the pathophysiology, presentation and management of the initial phase of AHF care; (b) improving initial management by addressing knowledge gaps between best practices and current practice through education and research; and

Early identification of acute heart failure at the time of presentation: do natriuretic peptides make the difference?

“…Therefore, clinicians need to be aware that the prognostically most important disease in a certain patient with dyspnea and high NP is not AHF. The actual heart failure guidelines of the European Society of Cardiology (ESC) have already anticipated this partly with the CHAMP‐concept which helps to identify an acute etiology (acute Coronary syndrome, Hypertension emgerency, Arrhythmia, acute Mechanical cause, Pulmonary embolism),1 and an expert paper about AHF in the ED focused on the so‐called precipitants,5 which are sometimes the cause of a syndrome with dyspnea and high NPs that need primarily therapy of the underlying disease. Therefore, the future view on the syndrome of AHF should involve always the underlying disease, and therefore, a wording like ‘AHF on the basis of pulmonary infection’ or ‘AHF on the basis of acute coronary syndrome’ seem to be appropriate.…”

“…Several opinion papers have been published in recent years with expert recommendations about the early assessment of patients with suspected HF 5, 6. In a literature overview, Pang et al .…”

IMPROV-ED study: outcomes after discharge for an episode of acute-decompensated heart failure and comparison between patients discharged from the emergency department and hospital wards

“…Therefore, follow-up arrangements after hospital discharge may have been better than those made after ED discharge, and could account, at least in part, for these differences. Failure to initiate guideline-directed medical therapy and the lack of timely, outpatient follow-up post-discharge are two variables that repeatedly appear to be particularly important in the determination of patient outcome [17][18][19]. Alternatively to poorer ED management, increased ED revisit by patients discharged from the ED could be due, at least to some extent, by some patients possibly using the ED as a substitute for primary care physicians either because they believe they receive better service, or because they are illeducated.…”

Acute heart failure facts and numbers: acute heart failure populations

“…Pang et al . recently published an educational consensus paper for which an international group of experts had convened to provide guidance for AHF care . The authors analyse a large set of AHF registries with respect to origin, setting, patient characteristics, treatment, and outcome.…”

“…The mean age of patients ranges between 69 and 79 years, whilst the proportion of women ranges between 37 and 62%. Inhospital mortality also varies widely with proportions between 3.8 and 17.8% . In summary, AHF cohorts in international registries are extremely varied and do not describe comparable patient groups, owing not only to the different healthcare systems, but also to different patient selection based on different definitions of AHF.…”