Current Emergency Department Disposition of Patients With Acute Heart Failure: An Opportunity for Improvement

Emergency department (ED) providers play a critical role in the stabilization and diagnostic evaluation of patients presenting with acute heart failure (AHF), and EDs are key areas for establishing current best practices and future considerations for the disposition of and decision making for patients with AHF. These elements include accurate risk assessment; response to initial treatment and shared decision making concerning optimal venue of care; reframing of physicians’ risk perceptions for patients presenting with AHF; exploration of alternative venues of care beyond hospitalization; population-level changes in demographics, management and outcomes of HF patients; development and testing of data-driven pathways to assist with disposition decisions in the ED; and suggested outcomes for measuring success.     

Emergency Department Management of Patients with Acute Decompensated Heart Failure

The Acute Decompensated HEart Failure National REgistry (ADHERE®) confirms that the management of decompensated heart failure is an emergency department (ED) problem, as more than 75% of patients admitted to the hospital with heart failure arrive through the ED. This emphasizes the need for collaboration among emergency medicine, cardiology, nephrology, and hospitalists in the management of acute decompensated heart failure. Such collaboration is important for several reasons, including the enhancement of patient care. It is also known that most hospitals lose money on heart failure admissions. Strategies that can be employed to limit hospital losses on heart failure include reducing admissions from the ED; decreasing the length of hospital stay; increasing the use of the observation unit; reducing re-admissions, particularly through the first 30 days; and reducing the use of high-resource areas such as the intensive care unit (ICU). This article will focus on initiatives that can be implemented in the ED to help with these strategies. In particular, we will discuss early initiation of therapy and its ability to improve length of stay, reduce re-admissions, and reduce ICU admissions. Use of the observation unit for the management of heart failure will also be discussed as a way of decreasing admissions from the ED.Supported by an unrestricted educational grant from Scios Inc.     

Predicting Long-Term Mortality in Patients With Acute Heart Failure by Using Machine Learning

BackgroundHigh mortality rates in patients with acute heart failure (AHF) necessitate proper risk stratification. However, risk-assessment tools for long-term mortality are largely lacking. We aimed to develop a machine-learning (ML)-based risk-prediction model for long-term all-cause mortality in patients admitted for AHF.Methods and ResultsThe ML model, based on boosted a Cox regression algorithm (CoxBoost), was trained with 2704 consecutive patients hospitalized for AHF (median age 73 years, 55% male, and median left ventricular ejection fraction 38%). We selected 27 input variables, including 19 clinical features and 8 echocardiographic parameters, for model development. The best-performing model, along with pre-existing risk scores (BIOSTAT-CHF and AHEAD scores), was validated in an independent test cohort of 1608 patients. During the median 32 months (interquartile range 12–54 months) of the follow-up period, 1050 (38.8%) and 690 (42.9%) deaths occurred in the training and test cohorts, respectively. The area under the receiver operating characteristic curve (AUROC) of the ML model for all-cause mortality at 3 years was 0.761 (95% CI: 0.754–0.767) in the training cohort and 0.760 (95% CI: 0.752–0.768) in the test cohort. The discrimination performance of the ML model significantly outperformed those of the pre-existing risk scores (AUROC 0.714, 95% CI 0.706–0.722 by BIOSTAT-CHF; and 0.681, 95% CI 0.672–0.689 by AHEAD). Risk stratification based on the ML model identified patients at high mortality risk regardless of heart failure phenotypes.ConclusionsThe ML-based mortality-prediction model can predict long-term mortality accurately, leading to optimal risk stratification of patients with AHF.     

Acute Emergency Department Management of Heart Failure

The Emergency Department (ED) is a common location for acutely decompensated Heart Failure (HF) patients to seek care. Consequently, there is the opportunity for significant clinical benefits when care is managed appropriately. This article reviews the importance of an accurate diagnosis, the necessity to search for underlying precipitants of the HF decompensation, and the impact of early treatment on the subsequent length of hospitalization. It also discusses the value of the ED observation unit for short intensive management of HF, the potential financial benefits of this strategy, and the ability of nesiritide to decrease future revisits when used in this environment.     

Use of the HEAR Score for 30-Day Risk-Stratification in Emergency Department Patients

BackgroundThe 2021 American College of Cardiology/American Heart Association chest pain guidelines recommend risk scores such as HEAR (History, Electrocardiogram, Age, Risk factors) for short-term risk stratification, yet limited data exist integrating them with high-sensitivity cardiac troponin T (hs-cTnT).MethodsRetrospective, multicenter (n = 2), observational, US cohort study of consecutive emergency department patients without ST-elevation myocardial infarction who had at least one hs-cTnT (limit of quantitation [LoQ] <6 ng/L, and sex-specific 99th percentiles of 10 ng/L for women and 15 ng/L for men) measurement on clinical indications in whom HEAR scores (0-8) were calculated. The composite major adverse cardiovascular event (MACE) outcome was 30-day prognosis.ResultsAmong 1979 emergency department patients undergoing hs-cTnT measurement, 1045 (53%) were low risk (0-3), 914 (46%) intermediate risk (4-6), and 20 (1%) high risk (7-8) based on HEAR scores. HEAR scores were not associated with increased risk of 30-day MACE in adjusted analyses. Patients with quantifiable hs-cTnT (LoQ-99th) had an increased risk for 30-day MACE (3.4%) irrespective of HEAR scores. Those with serial hs-cTnT <99th percentile remained at low risk (range 0%-1.2%) across all HEAR score strata. Higher scores were not associated with long-term (2-year) events.ConclusionsHEAR scores are of limited value in those with baseline hs-cTnT <LoQ or hs-cTnT >99^th percentile to define short-term prognosis. In those with baseline quantifiable hs-cTnT within the reference range (<99^th percentile), a higher risk (>1%) for 30-day MACE exists even in those with low HEAR scores. With serial hs-cTnT measurements, HEAR scores overestimate risk when hs-cTnT remains <99th percentile.     

Prediction of Early Adverse Events in Emergency Department Patients With Acute Heart Failure: A Systematic Review

Background

Acute heart failure (AHF) accounts for a substantial proportion of Emergency Department (ED) visits and hospitalizations. Previous studies have shown that emergency physicians' clinical gestalt is not sufficient to stratify patients with AHF into severe and requiring hospitalization vs nonsevere and safe to be discharged. Various prognostic algorithms have been developed to risk-stratify patients with AHF, however there is no consensus as to the best-performing risk assessment tool in the ED.

The Usefulness of the MEESSI Score for Risk Stratification of Patients With Acute Heart Failure at the Emergency Department

Introduction and objectives

The MEESSI scale stratifies acute heart failure (AHF) patients at the emergency department (ED) according to the 30-day mortality risk. We validated the MEESSI risk score in a new cohort of Spanish patients to assess its accuracy in stratifying patients by risk and to compare its performance in different settings.

Cardiology Consultation in the Emergency Department Reduces Re-hospitalizations for Low-Socioeconomic Patients with Acute Decompensated Heart Failure

Background

Re-hospitalization after discharge for acute decompensated heart failure is a common problem. Low-socioeconomic urban patients suffer high rates of re-hospitalization and often over-utilize the emergency department (ED) for their care. We hypothesized that early consultation with a cardiologist in the ED can reduce re-hospitalization and health care costs for low-socioeconomic urban patients with acute decompensated heart failure.

Emergency Department Visits Versus Hospital Readmissions Among Patients Hospitalized for Heart Failure

BackgroundWorsening heart failure (HF) often requires hospitalization but in some cases may be managed in the outpatient or emergency department (ED) settings. The predictors and clinical significance of ED visits without admission vs hospitalization are unclear.MethodsThe ASCEND-HF trial included 2661 US patients hospitalized for HF with reduced or preserved ejection fraction. Clinical characteristics were compared between patients with a subsequent all-cause ED visit (with ED discharge) within 30 days vs all-cause readmission within 30 days. Factors associated with each type of care were assessed in multivariable models. Multivariable models landmarked at 30 days evaluated associations between each type of care and subsequent 150-day mortality.ResultsThrough 30-day follow-up, 193 patients (7%) had ED discharge, 459 (17%) had readmission, and 2009 (76%) had neither urgent visit. Patients with ED discharge vs readmission were similar with respect to age, sex, systolic blood pressure, ejection fraction, and coronary artery disease, whereas ED discharge patients had a modestly lower creatinine (P < .01). Among patients with either event within 30 days, a higher creatinine and prior HF hospitalization were associated with a higher likelihood of readmission, as compared with ED discharge (P < .02). Landmarked at 30 days, rates of death during the subsequent 150 days were 21.0% for patients who were readmitted and 11.4% for patients discharged from the ED. Compared with patients who were readmitted, ED discharge was independently associated with lower 150-day mortality (adjusted hazard ratio 0.58, 95% confidence interval 0.36–0.92, P = .02).ConclusionsIn this cohort of US patients hospitalized for HF, worse renal function and prior HF hospitalization were associated with a higher likelihood of early postdischarge readmission, as compared with ED discharge. Although subsequent mortality was high after discharge from the ED, this risk of mortality was significantly lower than patients who were readmitted to the hospital.     

Early Identification of Patients With Acute Decompensated Heart Failure

Background

Interventions to reduce readmissions after acute heart failure hospitalization require early identification of patients. The purpose of this study was to develop and test accuracies of various approaches to identify patients with acute decompensated heart failure (ADHF) with the use of data derived from the electronic health record.

静脉注射β受体阻滞剂治疗缺血性心脏病慢性心力衰竭急性加重临床经验总结

目的:观察静脉注射β受体阻滞剂对缺血性心脏病慢性心力衰竭(心衰)患者发生心衰急性加重时的临床疗效。方法:观察2例缺血性心脏病慢性心衰患者发生心衰急性加重后,在常规急性心衰治疗的同时,应用静脉注射β受体阻滞剂后,患者的临床症状、体征、心电图及X线胸片的变化。结果:2例缺血性心脏病慢性心衰急性加重的患者,在常规急性心衰治疗效果不佳的前提下,应用静脉注射β受体阻滞剂,治疗后患者的临床症状明显缓解,肺部啰音减少,心电图示心肌缺血改善,X线胸片示肺淤血明显减轻。结论:对于缺血性心脏病慢性心衰患者病程中发生的,以缺血为诱因的心衰急性加重,在常规急性心衰治疗效果不佳时,应用静脉β受体阻滞剂可能获得良好的疗效。