Management of suspected acute heart failure dyspnea in the emergency department: results from the French prospective multicenter DeFSSICA survey

Abstract

BackgroundAn appropriate diagnostic process is crucial for managing patients with acute heart failure (AHF) in emergency department (ED). Our study aims to describe the characteristics and therapeutic management of patients admitted to the ED for dyspnea suspected to have AHF, their in-hospital pathway of care and their in-hospital outcome.MethodsConsecutive patients admitted in 26 French ED for dyspnea suspected to be the consequence of AHF, prior to in hospital diagnostic test, were prospectively included at the time of their admission in the DeFSSICA Survey. Clinical characteristics at admission were recorded by the ED physicians. At discharge from ED, patients were categorized as AHF or non-AHF based on the final diagnosis reported in the discharge summary. The completeness of the data was controlled by the local investigator.ResultsFrom 16/6/2014 to 7/7/2014, 699 patients were included, of whom 537 (77 %) had a final diagnosis of AHF at discharge. Patients with AHF were older (median 83 vs 79 years, p = 0.0007), more likely to have hypertension (71 % vs 57 %, p = 0.002), chronic HF (54 % vs 37 %, p = 0.0004), atrial fibrillation (45 % vs 34 %, p = 0.02) and history of hospitalization for AHF in the previous year (40 % vs 18 %, p < 0.0001) when compared to patients without AHF. Furosemide and oxygen were used in approximately 2/3 of the patients in the ED (respectively 75 and 68 %) whereas nitrates were in 19 % of the patients. Diagnostic methods used to confirm AHF included biochemistry (100 %), pro-B-type natriuretic peptide (90 %), electrocardiography (98 %), chest X-ray (94 %), and echography (15 %) which only 18 % of lung ultrasound.After the ED visit, 13 % of AHF patients were transferred to the intensive care unit, 28 % in cardiology units and 12 % in geriatric units. In-hospital mortality was lower in AHF vs non-AHF patients (5.6 % vs 14 %, p = 0.003).DiscussionDeFSSICA, a large French observational survey of acute HF, provides information on HF presentation and the French pathway of care. Patients in DeFSSICA were elderly, with a median age of 83 years. Compared with the French OFICA study, patients in DeFSSICA were more likely to have hypertension (71 % vs 62 %) and atrial fibrillation (45 % vs 38 %). As atrial fibrillation and a rapid heart rate have been closely linked to mortality, detection of atrial fibrillation should be considered systematically.The limited use of nitrates in DeFSSICA may be related to the median SBP of 140 (121–160) mmHg. However, our use of nitrates was similar to those in the EAHFE (20.7 %) and OPTIMIZE-HF (14.3 %) registries. In line with guidelines, the proportions of patients who underwent ECG, biological analysis, or chest X-ray were all >90 % in DeFSSICA. Similarly, BNP or pro-BNP was measured in 93 % of patients, compared with 82 % of patients in the OFICA study. Although BNP may be helpful when the diagnosis of HF is in doubt, ultrasound remains the gold standard. The use of ultrasound in the ED has been reported to accelerate the diagnosis of HF and the initiation ...

Hyponatraemia, hyperglycaemia and worsening renal function at first blood sample on emergency department admission as predictors of in-hospital death in patients with dyspnoea with suspected acute heart failure: retrospective observational analysis of the PARADISE cohort

“…We believe that the settings in which predictors of outcome are studied is highly relevant for AHF. Indeed, as previously demonstrated by our group in the DEFSICA study, 3 patients admitted for acute dyspnoea in the ED are often older, sicker and have a higher degree of associated comorbidities as well as associated acute dyspnoea aetiology than patients admitted in cardiology wards. Importantly, only a small proportion of our population was admitted to a cardiology ward after ED stay (<20%), clearly underscoring the selection bias derived from data acquired solely in cardiology departments.…”

Impact of renal dysfunction on the management and outcome of acute heart failure: results from the French prospective, multicentre, DeFSSICA survey

“…As such, the data are primarily applicable to the French population, although wider extrapolation is possible due to coherences with similar studies in other geographical regions. The overall DeFSSICA study data are presented elsewhere10 and the present subanalysis reports real-life data from subgroups of patients with AHF with or without concomitant renal dysfunction, based on a CrCl threshold of 60 mL/min. The results show that AHF admissions to EDs are often associated with renal impairment, with almost two-thirds of AHF admissions having CrCl ≤60 mL/min.…”

“…This was a prospective, multicentre study in patients presenting with suspected HF dyspnoea in 26 EDs in academic, community and regional hospitals (the DeFSSICA study) for which the rationale and design are reported elsewhere 10. Written information regarding the objectives of the survey was provided to all patients prior to their inclusion according to French law.…”

“…In this context, a subanalysis was conducted using real-life data from the Description de la Filière de Soins dans les Syndromes d’Insuffisance Cardiaque Aigue (DeFSSICA study), a large-scale, prospective study that was conducted in patients with suspected dyspnoea of cardiac origin in emergency departments (EDs) throughout France 10. The aim of this subanalysis was to compare the management and outcome of patients with CRS to patients with AHF without renal dysfunction in France using novel real-life data, based on the hypothesis that patients with CRS and AHF would have the same outcome if the management of CRS was based on that for patients with AHF without renal dysfunction.…”

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“…However, there is likely room for improving the diagnostic approach to AHF from widely available routine tools including chest radiography (CXR). CXR is a fast and inexpensive method performed systematically in the ED in patients with acute dyspnea [10][11][12]. It is the first-line diagnostic imaging modality advocated in current guidelines [13].…”