Managing the Patient with Heart Failure in the Emergency Department

CardioPulse 3493 doi:10.1093/eurheartj/ehy615 Managing the Patient with Heart Failure in the Emergency Department (1) (2) (3) Establishing the diagnosis of HF as the cause for symptoms and ruling out alternative diagnoses. Evaluating for precipitating factors. Risk stratification to aid correct disposition. The diagnosis of HF in the ED needs to be performed rapidly but accurately, simultaneously with therapeutic interventions. The ED physician (consulting a cardiologist as needed) must determine the aetiology of symptoms in patients with suspected HF based on the initial history, physical examination, diagnostic studies (laboratory data, electrocardiogram, and radiography), and the response to empiric therapy. The most common symptom is dyspnoea but differentiating pulmonary from cardiac cause may be difficult. As many as 20% of the patients admitted with HF have chronic lung disease.7 Jugular venous distention has the best diagnostic value to assess congestion with a predictive accuracy of about 80%.9 Laboratory evaluation in the ED usually includes complete blood count, serum electrolytes, blood urea nitrogen (BUN), creatinine, thyroid function, troponin (T or I) and brain natriuretic peptide (BNP), or it’s N terminal (NT-proBNP). Additional testing such as D-dimer, digoxin blood level, and urinary toxic screen may be added. Natriuretic peptides (both BNP and NT-proBNP) are of special interest to aid the diagnosis. Given a high specificity (above 90%) but modest sensitivity (70–80%), they are better utilized to rule out the disease.10 Additional testing includes an electrocardiogram and chest radiograph.11 However, chest radiography does not show signs of congestion in 18% of admissions.12 The overall sensitivity of HF diagnosis in the ED is only 65%.13 By incorporating patients age, NTproBNP as a continuous variable and pre-test probability for HF, HF ED diagnosis was redirected in 48% with 95% accuracy.14 New diagnostic tools include lung ultrasound and ED echocardiography. Identification and quantification of B-lines with lung ultrasound can aid in ruling in or excluding pulmonary congestion.15 Echocardiography is integral to the diagnosis of HF.16 If formal echocardiography isn’t available rapidly, focused cardiac ultrasound can be performed by ED personal to assess global left ventricular systolic function, restrictive mitral inflow pattern,17 valve malfunction, right ventricular dysfunction and inferior vena cava distension, and may be combined with pulmonary ultrasonography to improve specificity of HF diagnosis.18 It is important to identify and treat precipitating factors early. The 2016 European Society of Cardiology (ESC) HF Guidelines highlight coronary disease, hypertension, arrhythmia, mechanical complications, and pulmonary emboli (acronym CHAMP) as diagnoses which need to be ruled out early in the evaluation. While coronary artery disease is common among patients with decompensated HF,19 testing for ischaemia in patients with new-onset HF is underutilized.20 Other causes for decompensation such as bleeding, infection, and thyroid dysfunction should also be identified promptly and treated. The treatment of HF in the ED involves simultaneous ‘generic’ HF treatment and consideration of the precipitating factors. After initial stabilization current guidelines suggest treatment with diuretics, vasodilators, or inotropes based on clinical haemodynamic profiles (wet vs. dry and warm vs. cool).16 Evidence base for acute HF treatment is limited and currently the only Class I recommendation for medical therapy in acute HF is intravenous loop diuretics in patients with fluid overload (LOE C). In patients without hypotension intravenous vasodilators (such as nitroglycerine) should be considered and may be first line in those with hypertension (Class IIa LOE B).16 An important aspect of the treatment in the ED, after the diagnosis and initiation of treatment is the decision on appropriate disposition (Figure 2). This should be based on the individual patient risk stratification. To aid this evaluation, the ED physician can consult the cardiologist, preferably a HF specialist. Additional valuable information may be gathered by direct contact with the primary care physician or referring cardiologist. Heart failure (HF) is a global public health problem affecting an estimated 26 million people worldwide. It is the leading cause of hospitalization in the USA and Europe.1,2 Patients hospitalized with HF have a higher in-hospital3 and post-discharge4 mortality as well as an increased rate of rehospitalizations.3,4 As many as 77% of these patients initially present to the emergency department (ED),5 posing several challenges. These include the need for rapid diagnosis integrated with early delivery of appropriate therapy together with risk stratification to aid the correct patient disposition.6 Heart failure patients may present to the ED with varying clinical scenarios, each associated with specific clinical characteristics (Figure 1). Acute HF, defined as the rapid onset of symptoms and signs secondary to abnormal cardiac function, may present as acute pulmonary oedema and hypertension (vasoactive), shock, shortness of breath, or oedema with fluid overload. Cardiac dysfunction can be related to systolic or diastolic dysfunction, valvular dysfunction, or as isolated right ventricular dysfunction. While acute HF can present without previously known cardiac dysfunction, 63%7 to 75%5 have a diagnosis of HF prior to presentation. Ancillary conditions or precipitating factors may cause destabilization of HF. In the OPTIMIZE HF registry, a precipitating factor was identified in 61.3% of hospitalized HF patients. These include lung infection (15.3%), ischaemia (14.7%), arrhythmia (13.5%), poorly controlled hypertension (10.7%), and medication non-compliance (8.9%).8 The precipitant may dominate the clinical presentation such as with overt infection or acute coronary syndrome or can be subtle and necessitate in-depth investigation. Another clinical scenario often neglected by HF registries is the patient with a history of HF and a seemingly unrelated ED referral. These are probably common and may be mixed with the other patients with acute HF. As an example, in the European HF survey, the principal reason for admission to the hospital was HF in only 40%.2 Little information is available about the implications on the treatment and suggested disposition of these patients. For the evaluation of the patient with HF, three efforts are required (Figure 2): 3494 CardioPulse Stabilizaon Hemodynamic Venlatory support Diagnosis Heart failure treatment Precipitant treatment Cardiology consultaon Heart failure; Precipitants Risk straficaon Low Intermediate High Observaon Hospitalizaon Discharge Outpaent care Figure 2 Management and triage of heart failure patients in the emergency department. Hospitalization in HF can be used for diagnostic workup, improvi (...truncated)