National Heart, Lung, and Blood Institute Working Group on Emergency Department Management of Acute Heart Failure

Peacock, W. Frank; Braunwald, Eugene; Abraham, William T.; Albert, Nancy M.; Burnett, John C.; Christenson, R H; Collins, Sean P.; Diercks, Deborah B.; Fonarow, Gregg C.; Hollander, Judd E.; Kellerman, Art; Gheorghiade, Mihai; Kirk, Doug; Levy, Philip; Maisel, Alan S.; Massie, Barry M.; O’Connor, Christopher M.; Pang, Peter S.; Shah, Monica; Sopko, George; Stevenson, Lynne Warner; Storrow, Alan B.; Teerlink, John R.

doi:10.1016/j.jacc.2010.03.051

Cited by 72 publications

(51 citation statements)

References 54 publications

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“…Initial systolic blood pressure was categorized as <115,115–160, and >160 based on published risk classification for heart failure patients in the ED. 18 Initial heart rate was categorized as <100 and ≥100. Comorbid conditions were based on the Agency for Healthcare Research and Quality (AHRQ) Clinical Classification Software definitions.…”

Section: Methodsmentioning

confidence: 99%

Emergency department visits for heart failure and subsequent hospitalization or observation unit admission

Blecker

Ladapo

Doran

et al. 2014

American Heart Journal

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Background Treatment of acute heart failure in the emergency department (ED) or observation unit is an alternative to hospitalization. Both ED and observation unit management have been associated with reduced costs and may be used to avoid penalties related to rehospitalizations. The purpose of this study was to examine trends in ED visits for heart failure and disposition following such visits. Methods We used the National Hospital Ambulatory Medical Care Survey, a representative sample of ED visits in the United States, to estimate rates and characteristics of ED visits for heart failure between 2002 and 2010. The primary outcome was the discharge disposition from the ED. Regression models were fit to estimate trends and predictors of hospitalization and admission to an observation unit. Results The number of ED visits for heart failure remained stable over the period, from 914,739 in 2002 to 848,634 in 2010 (annual change −0.7%; 95% CI −3.7% – +2.5%). Of these visits, 74.2% led to hospitalization while 3.1% led to observation unit admission. The likelihood of hospitalization did not change during the period (adjusted prevalence ratio 1.00; 95% CI 0.99–1.01 for each additional year) while admission to the observation unit increased annually (adjusted prevalence ratio 1.12; 95% CI 1.01–1.25). We observed significant regional differences in likelihood of hospitalization and observation admission. Conclusions The number of ED visits for heart failure and high proportion of ED visits with subsequent inpatient hospitalization have not changed in the last decade. Opportunities may exist to reduce hospitalizations by increasing short term management of heart failure in the ED or observation unit.

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Section: Methodsmentioning

confidence: 99%

Emergency department visits for heart failure and subsequent hospitalization or observation unit admission

Blecker

Ladapo

Doran

et al. 2014

American Heart Journal

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“…There are 3 million hospitalizations for acute HF annually in the United States, 80% of which arrive through emergency departments. Accordingly, the National Heart, Lung, and Blood Institute published the findings of a working group on emergency department management of acute HF, which outlines the existing opportunities and challenges (46). The search for pharmacological strategies to relieve acute HF continues, including publication of the phase 3 PROTECT (Placebo-Controlled Randomized Study of the Selective A 1 Adenosine Receptor Antagonist Rolofylline for Patients Hospitalized With Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function) trial.…”

Section: Management Of Hfmentioning

confidence: 99%

The Year in Heart Failure

Owens

Jessup

2012

Journal of the American College of Cardiology

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With health care reform and pay-for-performance measures in the near future, the heart failure (HF) community must critically appraise our practice patterns and processes of care. Ideally, our efforts begin with strategies to prevent HF, followed by therapies to treat HF and approaches to improving the cost-effectiveness of care. It is increasingly apparent that our current model is not sustainable, and we look to the scientists and clinicians in our field to provide innovative yet practical solutions. Herein, we discuss the major published clinical advances in HF over the past academicIn the United States, HF incidence approaches 10 per 1,000 population after 65 years of age (29). Efforts to prevent HF focus on the treatment of established risk factors and the development of risk scores to predict incident HF. One risk prediction score, the Health ABC Heart Failure Model, was validated externally in Cardiovascular Health Study participants, confirming the utility of 9 variables to predict incident HF. The strength of the model is its applicability to real-world practice, in which all of the variables are readily available (30). A separate study suggested that including only common cardiovascular risk factors (coronary disease, hypertension, diabetes, atrial fibrillation, valvular disease, and age) can predict incident HF in men and women during 1,015,794 person-years of follow-up (31). Lam et al. (32) showed that after adjustment for cardiac dysfunction, subclinical dysfunction in each noncardiac organ system was associated with a 30% increased risk for HF.Nevertheless, there is an unmet need to predict risk earlier. A small study by Yan et al. (33) reported the use of cardiac magnetic resonance imaging to detect subclinical, regional left ventricular (LV) dysfunction, as an independent predictor for incident HF and cardiovascular events in the asymptomatic, lower risk MESA (Multi-Ethnic Study of Atherosclerosis) cohort. Another investigation of an elderly cohort revealed an increased risk for LV diastolic dysfunction, independent of LV mass and traditional risk factors, that occurred with increased body mass index (34). These studies suggest that lifestyle counts in HF prevention efforts. Indeed, an analysis of almost 60,000 Finnish subjects free of HF at baseline showed that moderate and high levels of occupational and leisure-time physical activity were associated with a reduced risk for HF (35). BiomarkersThis year saw no new evidence that serial biomarker-guided management of HF could reduce morbidity or mortality. In both the STARBRITE (Strategies for Tailoring Advanced HF Regimens in the Outpatient Setting) and PRIMA (Can Pro-Brain-Natriuretic Peptide Guided Therapy of Chronic HF Improve HF Morbidity and Mortality) trials, the use of natriuretic peptide-guided therapy was associated with increased use of evidence-based medications but no improvement in days alive or decrease in HF hospitalizations (36,37).Several biomarker studies focused on predicting HF incidence in the community. Elevated cardiac tro...

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“…8,22,23 It is also an approach advocated by AHFS clinical trialists. Failure to target specific patient subgroups has been suggested as a possible contributor to the disappointing results of AHFS clinical trials seen to date.…”

Section: Future Directionsmentioning

confidence: 99%

“…Cardiac phenotyping with echocardiography has been proposed for this purpose. 23 Advanced echocardiographic techniques allow for detailed assessments of structure, function, hemodynamics, and mechanics. Importantly, repeat assessments at the bedside are possible, capturing the dynamic nature of AHFS.…”

Section: Future Directionsmentioning

confidence: 99%

Classification of Patients With Acute Heart Failure Syndromes in the Emergency Department

Pang¹,

Hoffmann

Shah

2012

Circ: Heart Failure

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H ospitalization for acute heart failure syndromes (AHFS) heralds a grim prognosis: More than one third of patients will be dead or rehospitalized within 90 days postdischarge. 1 Although total hospitalizations for AHFS have decreased over the past decade, rehospitalization rates have not. 2,3 With 1 million hospitalizations annually at an estimated cost exceeding $20 billion, AHFS is a major public health problem. 4 Article see p 17One of the possible contributors to these poor outcomes is our approach to patients with AHFS in the emergency department (ED). Approximately 80% of hospitalized patients initially present to the ED, highlighting the pivotal role of the ED in initial AHFS management. 5 Yet there are no class I, level A guideline recommendations for the initial pharmacological treatment of AHFS. 6 ED treatment today is largely the same as it was 40 years ago and is similar across all patients with AHFS despite the heterogeneity of patients in terms of precipitant, presentation (eg, pulmonary edema, hypertension), phenotype (eg, reduced or preserved ejection fraction), or etiology (ischemic versus nonischemic). 6a,7-9 This management approach and lack of progress is not the fault of frontline caregivers; rather it reflects our limited understanding of the pathophysiology of AHFS and the need for further research, especially in the ED setting.In this issue of Circulation: Heart Failure, Drexler et al 10 address the hypothesis that ED patients with AHFS with an underlying ischemic etiology have a distinct pathophysiology compared to patients with AHFS with a nonischemic etiology. Specifically, they tested whether higher brain natriuretic peptide and troponin levels are present in patients with AHFS with an ischemic etiology versus nonischemic etiology due to greater hemodynamic stress and myocyte damage. The authors contextualize their study by suggesting that knowledge of the etiology would allow for tailoring of both diagnosis and treatment.Drexler et al prospectively enrolled 718 consecutive ED patients with AHFS and validated their findings from a second, independent cohort of 326 patients from a previously conducted multicenter, prospective, observational study. Ischemic etiology was adjudicated from the medical record on the basis of a prespecified definition that included a history of percutaneous coronary intervention; coronary artery bypass graft; acute myocardial infarction; and procedures or tests performed in the past or during hospitalization, such as angiography of myocardial perfusion imaging.Of the 400 (56%) patients with AHFS with an ischemic etiology versus the 318 (44%) patients with a nonischemic etiology, those with an ischemic etiology had higher brain natriuretic peptide, troponin T, and sensitive cardiac troponin I levels. Diagnostic accuracy of each individual marker for an ischemic etiology was poor, however, and did not improve when markers were combined (area under the curve, 0.58; 95% CI, 0.52-0.65). Similar results were noted in the validation cohort. The authors conclude...

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National Heart, Lung, and Blood Institute Working Group on Emergency Department Management of Acute Heart Failure

Cited by 72 publications

References 54 publications

Emergency department visits for heart failure and subsequent hospitalization or observation unit admission

Emergency department visits for heart failure and subsequent hospitalization or observation unit admission

The Year in Heart Failure

Classification of Patients With Acute Heart Failure Syndromes in the Emergency Department

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