Bronchodilator Therapy in Acute Decompensated Heart Failure Patients Without a History of Chronic Obstructive Pulmonary Disease

Emergency Department Use of Heart Failure-Exacerbating Medications in Patients with Chronic Heart Failure

BACKGROUND

Use of heart failure-exacerbating medications (HFEMs) may lead to preventable episodes of acute decompensated heart failure (HF). HFEMs use is common in patients with HF, and there may be opportunities to reduce their use from the emergency department (ED).

METHODS

We performed an observational study on patients with HF presenting to EDs within a healthcare system between 1 January 2016 and 31 December 2020. Patients with chronic HF were identified using diagnostic codes within the electronic health record. The cohort was restricted to ambulatory (i.e., discharged to home) ED encounters. Medications, either ordered in the ED or prescribed at ED discharge, were extracted from the medication administration record and identified as potential HFEMs based on the 2016 American Heart Association Scientific Statement. Descriptive statistics were used to summarize the prevalence of HFEM use during ambulatory ED encounters. Exploratory analyses to identify correlates of HFEM use were performed.

RESULTS

The study cohort included 23,907 ED encounters. ED administration or prescription of HFEMs occurred during 20% of ambulatory ED encounters. HFEM administration in the ED (17%) was more common than HFEM prescription at ED discharge (6%). The most common HFEMs administered in the ED included nonsteroidal anti-inflammatory drugs (11%) and albuterol (7%).

CONCLUSION

HFEM use is common in patients with HF seeking ED care, occurring in roughly one-fifth of ambulatory ED encounters. There may be opportunities to optimize medication use among patients with HF in the ED.

Diagnostic accuracy of prehospital lung ultrasound for acute decompensated heart failure: A systematic review and Meta-analysis

BACKGROUND

Lung ultrasound (LUS) reduces time to diagnosis and treatment of acute decompensated heart failure (ADHF) in emergency department (ED) patients with undifferentiated dyspnea. We conducted a systematic review to evaluate the diagnostic accuracy and clinical impact of LUS for ADHF in the prehospital setting.

METHODS

We performed a keyword search of multiple databases from inception through June 1, 2023. Included studies were those enrolling prehospital patients with undifferentiated dyspnea or suspected ADHF, and specifically diagnostic studies comparing prehospital LUS to a gold standard and intervention studies with a non-US comparator group. Title and abstract screening, full text review, risk of bias (ROB) assessments, and data extraction were performed by multiple authors. and adjudicated. The primary outcome was pooled sensitivity, specificity, and diagnostic likelihood ratios (LR) for prehospital LUS. A test-treatment threshold of 0.7 was applied based on prior ADHF literature in the ED. Intervention outcomes included mortality, mechanical ventilation, and time to HF specific treatment.

RESULTS

Eight diagnostic studies (n = 691) and two intervention studies (n = 70) met inclusion criteria. No diagnostic studies were low-ROB. Both intervention studies were critical-ROB, and not pooled. Pooled sensitivity and specificity of prehospital LUS for ADHF were 86.7% (95%CI:70.8%-94.6%) and 87.5% (78.2%-93.2%), respectively, with similar performance by physician vs. paramedic LUS and number of lung zones evaluated. Pooled LR+ and LR- were 7.27 (95% CI: 3.69-13.10) and 0.17 (95% CI: 0.06-0.34), respectively. Area under the summary receiver operating characteristic curve was 0.922. At the observed 42.4% ADHF prevalence (pre-test probability), positive pre-hospital LUS exceeded the 70% threshold to initiate treatment (post-test probability 84%, 80-88%).

CONCLUSIONS

LUS had similar diagnostic test characteristics for ADHF diagnosis in the prehospital setting as in the ED. A positive prehospital LUS may be sufficient to initiate early ADHF treatment based on published test-treatment thresholds. More studies are needed to determine the clinical impact of prehospital LUS.

Prehospital lung ultrasound in acute heart failure: Impact on diagnosis and treatment

OBJECTIVE

Patients with acute heart failure (AHF) are commonly misdiagnosed and undertreated in the prehospital setting. These delays in diagnosis and treatment have a direct negative impact on patient outcomes. The goal of this study was to determine the diagnostic accuracy of paramedics with and without the use of lung ultrasound (LUS) for the diagnosis of AHF in patients with dyspnea in the prehospital setting. Secondarily, we assessed LUS impact on rate of and time to initiation of HF therapies.

METHODS

This was a prospective interventional study on a consecutive sample of patients transported to the hospital by one emergency medical services agency. Adult patients (>18 years) with a chief complaint of dyspnea were included. LUS was performed by trained paramedics and was defined as positive for AHF if both anterior-superior lung zones had greater than or equal to three B-lines or bilateral B-lines were visualized on a four-view protocol. Paramedic diagnosis was compared to hospital discharge diagnosis which served as the criterion standard.

RESULTS

Of the 264 included patients, 94 (35%) had a final diagnosis of AHF. Forty total patients had a LUS performed; 17 of these patients had a final diagnosis of AHF. Sensitivity and specificity for AHF by paramedics were 23% (95% confidence interval [CI] 0.14-0.34) and 97% (95% CI 0.92-0.99) without LUS and 71% (95% CI 0.44-0.88) and 96% (95% CI 0.76-0.99) with the use of LUS. In the 94 patients with AHF, 14% (11/77) received HF therapy prehospital without the use of LUS and 53% (9/17) with the use of LUS. LUS improved frequency of treatment by 39%. Median time to treatment was 21 min with LUS and 169 min without.

CONCLUSIONS

LUS improved paramedic sensitivity and accuracy for diagnosing AHF in the prehospital setting. LUS use led to higher rates of prehospital HF therapy initiation and significantly decreased time to treatment.

Prehospital Diagnosis and Treatment of Patients With Acute Heart Failure

Introduction 

Early diagnosis and optimization of heart failure therapies in patients with acute heart failure (AHF), including in the prehospital setting, is crucial to improving outcomes. However, making the diagnosis of AHF in the prehospital setting is difficult. The goal of this study was to evaluate the accuracy of prehospital diagnosis (AHF versus not heart failure [HF]) in patients with acute dyspnea when compared to final hospital diagnosis.

Methods

We conducted a retrospective study of adult patients transported by emergency medical services (EMS) with a primary or secondary complaint of shortness of breath. Patients were identified through an EMS electronic database (ESO) and matched to their hospital encounter. ESO was reviewed for prehospital diagnosis and management. Hospital electronic medical records were reviewed to determine final hospital diagnosis, management in the emergency department and hospital, disposition, and length of stay. The primary outcome compared prehospital diagnosis to final hospital diagnosis, which served as our criterion standard.

Results

Of 199 included patients, 50 (25%) had a final diagnosis of AHF. Prehospital paramedic sensitivity and accuracy for AHF were 14% (7/50; confidence interval [CI] 0.06-0.26) and 77% (CI 0.70-0.82), respectively. In the 50 patients with AHF, 14 (28%) received nitroglycerin in the prehospital setting, while 27 (54.0%) patients were inappropriately treated with albuterol.

Conclusion

Prehospital paramedics had poor sensitivity and moderate accuracy for the diagnosis of AHF. A small percentage of patients ultimately diagnosed with AHF had HF therapy initiated in the prehospital setting. This data highlights the fact that AHF is difficult to diagnose in the prehospital setting and is commonly missed.

Potentially Inappropriate Prescriptions in Heart Failure with Reduced Ejection Fraction (PIP-HFrEF)

Heart failure (HF) is a chronic debilitating and potentially life-threatening condition. Heart Failure patients are usually at high risk of polypharmacy and consequently, potentially inappropriate prescribing leading to poor clinical outcomes. Based on the published literature, a comprehensive HF-specific prescribing review tool is compiled to avoid medications that may cause HF or harm HF patients and to optimize the prescribing practice of HF guideline-directed medical therapies. Recommendations are made in line with the last versions of ESC guidelines, ESC position papers, scientific evidence, and experts' opinions.

Evaluating the impact of point-of-care ultrasonography on patients with suspected acute heart failure or chronic obstructive pulmonary disease exacerbation in the emergency department: A prospective observational study

Objectives

Acute heart failure and chronic obstructive pulmonary disease (COPD) are sometimes difficult to differentiate in the emergency department (ED). We sought to determine the clinical impact of point-of-care ultrasonography (POCUS) in ED patients with suspected acute heart failure or COPD.

Methods

We conducted a prospectively collected cohort study with health records review with frequency matching at The Ottawa Hospital between March and September 2017. We included patients aged 50 and older with shortness of breath or cough from suspected acute heart failure or COPD. Our primary outcome was ED length of stay. Secondary outcomes were time to disposition decision, time to appropriate treatment, and the incidence of adverse events. We analyzed time-to-event outcomes using Kaplan-Meier analysis and Cox regression analysis with POCUS analyzed as a time-dependent variable, and the incidence of adverse events using logistic regression analyses.

Results

There were 81 patients evaluated with lung POCUS and 243 matched patients who were not. Lung POCUS was not significantly associated with ED length of stay and time to disposition decision; however, patients evaluated with lung POCUS received disease-specific treatment faster compared with the non-POCUS group (adjusted hazard ratio, 1.50 [95% confidence interval, 1.05–2.15], a median time difference of 31 minutes). We found no significant differences in the incidence of adverse events.

Conclusions

In this study, use of lung POCUS resulted in no difference in ED length of stay and time to disposition decision, but was associated with faster administration of disease-specific treatments for elderly patients with suspected acute heart failure or COPD.

Effect of early physician follow-up on mortality and subsequent hospital admissions after emergency care for heart failure: a retrospective cohort study

BACKGROUND

The 1-year mortality rate in patients with heart failure who are discharged from an emergency department is 20%. We sought to determine whether early follow-up after discharge from the emergency department was associated with decreased mortality or subsequent admission to hospital.

METHODS

This retrospective cohort study conducted in Ontario, Canada, included adult patients who were discharged from 1 of 163 emergency departments between April 2007 and March 2014 with a primary diagnosis of heart failure. Using a propensity score-matched landmark analysis, we assessed follow-up in relation to mortality and admissions to hospital for cardiovascular conditions.

RESULTS

Of 34 519 patients, 16 274 (47.1%) obtained follow-up care within 7 days and 28 846 (83.6%) within 30 days. Compared with follow-up between day 8 and 30, patients with follow-up care within 7 days had a lower rate of mortality over 1 year (hazard ratio [HR] 0.92; 95% confidence interval [CI] 0.87-0.97), and a reduced rate of admission to hospital over 90 days (HR 0.87, 95% CI 0.80-0.94) and 1 year (HR 0.92; 95% CI 0.87-0.97); the mortality rate over 90 days in this group trended to a lower rate (HR 0.90, 95% CI 0.10-1.00). Follow-up care within 30 days, compared with patients without 30-day follow-up, was associated with a reduction in 1-year mortality (HR 0.89, 95% CI 0.82-0.97) but not admission to hospital (HR 1.02, 95% CI 0.94-1.10). In this group, there was a trend toward an increase in 90-day admission to hospital (HR 1.14, 95% CI 1.00-1.29).

INTERPRETATION

Follow-up care within 7 days of discharge from the emergency department was associated with lower rates of long-term mortality, as well as subsequent hospital admissions, and a trend to lower short-term mortality rates. Timely access to longitudinal care for patients with heart failure who are discharged from the emergency setting should be prioritized.

CORT-AHF Study: Effect on Outcomes of Systemic Corticosteroid Therapy During Early Management Acute Heart Failure

OBJECTIVES

This study investigated whether systemic corticosteroids (new onset) administered to patients with acute heart failure (AHF) have any association with outcomes, with differentiated analyses for patients with and without chronic obstructive pulmonary disease (COPD) as a comorbidity.

BACKGROUND

Patients with undiagnosed dyspnea frequently receive corticosteroids in emergency departments while determining a final diagnosis, but their effect on the outcomes of patients with AHF without overt COPD exacerbation is unknown.

METHODS

We selected patients with AHF from the EAHFE (Epidemiology of Acute Heart Failure in the Emergency Departments) registry, recording key data (new-onset corticosteroid therapy, COPD condition). Patients with and without COPD were analyzed separately. We calculated unadjusted and adjusted ratios for corticosteroid-treated compared with corticosteroid-untreated patients for 2 coprimary endpoints: 90-day all-cause mortality (from index episode) and 90-day post-discharge combined endpoint (all-cause mortality or readmission for AHF), with intermediate time-point estimations. Other secondary endpoints were calculated, and some sensitive and stratified analyses were performed.

RESULTS

We analyzed 11,356 patients: 8,635 without COPD (841 corticosteroid-treated, 9.7%) and 2,721 with COPD (753 corticosteroid-treated, 27.7%). There were several differences between treated and untreated patients, essentially because corticosteroid-treated patients were sicker. Although unadjusted outcomes were worse in corticosteroid-treated patients, especially in patients without COPD, these differences disappeared after adjustment: hazard ratios for 90-day mortality (without/with COPD) were 0.91 (95% confidence interval (CI): 0.76 to 1.10)/0.99 (95% CI: 0.78 to 1.26), and 1.09 (95% CI: 0.93 to 1.28)/1.02 (95% CI: 0.86 to 1.21) for the post-discharge combined endpoint. Analyses of intermediate time-point coprimary endpoints and secondary outcomes rendered similar estimations. Sensitivity and stratified analysis did not significantly modify these results.

CONCLUSIONS

There is no evidence of harm related to the new onset of systemic corticosteroid therapy during an episode of AHF, either in patients with or without concomitant COPD.

Lung ultrasound for monitoring cardiogenic pulmonary edema

Several studies address the accuracy of lung ultrasound (LUS) in the diagnosis of cardiogenic pulmonary edema (CPE) evaluating the interstitial syndrome, which is characterized by multiple and diffuse vertical artifacts (B-lines), and correlates with extravascular lung water. We studied the potential role of LUS in monitoring CPE response to therapy, by evaluating the clearance of interstitial syndrome within the first 24 h after Emergency Department (ED) admission. LUS was performed at arrival (T0), after 3 (T3) and 24 (T24) hours. Eleven regions were evaluated in the antero-lateral chest; the B-lines burden was estimated in each region (0 = no B-lines, 1 = multiple B-lines, 2 = confluent B-lines/white lung) and a mean score (B-Score, range 0-2) was calculated. Patients received conventional CPE treatment. Blood chemistry, vital signs, blood gas analysis, diuresis at T0, T3, T24 were also recorded. A complete echocardiography was obtained during hospitalization. Forty-one patients were enrolled. Respiratory and hemodynamic parameters improved in all patients between T0 and T3 and between T3 and T24. Mean B-score significantly decreased at T3 (from 1.59 ± 0.40 to 0.73 ± 0.44, P < 0.001) and between T3 and T 24 (from 0.73 ± 0.44 to 0.38 ± 0.33, P < 0.001). B-score was higher in the lower pulmonary regions at any time. At final evaluation (T24) 75 % of apical and only 38 % of basal regions were cleared. LUS allows one to assess the clearance of interstitial syndrome and its distribution in the early hours of treatment of CPE, thus representing a possible tool to guide therapy titration.

Symptom management challenges in heart failure: pharmacotherapy considerations

Heart failure is a chronic, progressive illness that is increasing in prevalence in the USA. Patients with advanced heart failure experience a high symptom burden that is comparable to patients with advanced cancer. Palliative care, however, is underutilized in patients with heart failure, and symptoms may go untreated as the disease progresses. A combination of pharmacologic and non-pharmacologic interventions should be used to address symptoms and maintain quality of life. While there have been significant advances in evidence-based heart failure treatments in recent years, selection of appropriate palliative medications as symptoms progress is challenging due to limited clinical studies in this patient population. Medications that are commonly used for symptom management in other life-limiting illnesses may have little to no evidence in heart failure, or have undesirable cardiac effects that preclude use. Clinicians must extrapolate available clinical evidence and prescribing considerations relevant to heart failure to palliate symptoms as well as possible. The objectives of this paper are to review the most common and distressing symptoms in heart failure, analyze evidence, or lack thereof, for pharmacologic management of symptoms, and provide prescribing considerations based on side effect profiles and comorbid conditions.

Challenges of Treating Acute Heart Failure in Patients with Chronic Obstructive Pulmonary Disease

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) comorbidity poses substantial diagnostic and therapeutic challenges in acute care settings. The specific role of pulmonary comorbidity in the treatment and outcomes of cardiovascular disease patients was not addressed in any short- or long-term prospective study. Both HF and COPD can be interpreted as systemic disorders associated with low-grade inflammation, endothelial dysfunction, vascular remodelling and skeletal muscle atrophy. HF is regularly treated as a broader cardiopulmonary syndrome utilising acute respiratory therapy. Based on observational data and clinical expertise, a management strategy of concurrent HF and COPD in acute settings is suggested. Concomitant use of beta2-agonists and beta-blockers in a comorbid cardiopulmonary condition seems to be safe and effective.

The impact of emergency medical services in acute heart failure

BACKGROUND

Real-life data on the role of emergency medical services (EMS) in acute heart failure (AHF) are scarce. Our aim was to describe prehospital treatment of AHF and to compare patients using EMS with self-presented, non-EMS patients.

METHODS

Data were collected retrospectively from three university hospitals in Helsinki metropolitan area between July 1, 2012 and July 31, 2013. According to the use of EMS, patients were divided into EMS and non-EMS groups.

RESULTS

The study included 873 AHF patients. One hundred were (11.5%) EMS and 773 (88.5%) non-EMS. EMS patients more often had comorbidities. Initial heart rate (HR) and peripheral oxygen saturation (SpO₂) differed between EMS and non-EMS patients; mean HR 89.2 (SD 22.5) vs. 83.7 (21.5)/min (p=0.02) and SpO₂ 90.3 (8.6) vs. 92.9 (6.6)% (p=0.01). However, on presentation to ED EMS patients' vital signs were similar to non-EMS patients'. On presentation to ED 46.0% were normotensive and 68.2% "warm and wet". Thirty-four percentage of EMS patients received prehospital medication. In-hospital mortality was 6.0% and 7.1% (p=0.84) and length of stay (LOS) 7.7 (7.0) and 8.5 (7.9) days (p=0.36) in EMS and non-EMS groups.

CONCLUSION

The use of EMS and administration of prehospital medication was low. EMS patients had initially worse HR and SpO₂ than non-EMS patients. However, EMS patients' signs improved and were similar on presentation to ED. There were no differences in in-hospital mortality and LOS. This underscores the need for equal attention to any AHF patient independent of the arrival mode.

Obstructive Ventilatory Disorder in Heart Failure-Caused by the Heart or the Lung?

Heart failure (HF) is a clinical syndrome frequently associated with airway obstruction, either as a respiratory comorbidity or as a direct consequence of HF pathophysiology. Recognizing the relative contribution of an underlying airway disease as opposed to airway obstruction due to volume overload and left atrial pressure elevation is of importance for the appropriate management of patients affected by HF. This review focuses on "les liaisons dangereuses" between the heart and the lungs, outlying recent advances linking in a vicious circle of chronic obstructive lung disease (COPD) and obstructive sleep apnea (OSA) on one side and HF on the other side. It also discusses the role of pivotal diagnostic tools such as pulmonary function tests and cardiopulmonary exercise test to determine the contribution of HF and COPD to symptoms and clinical status. Treatment implications are discussed as well.

Challenges in the Management of Patients with Chronic Obstructive Pulmonary Disease and Heart Failure With Reduced Ejection Fraction

Chronic obstructive pulmonary disease (COPD) and heart failure with reduced ejection fraction (HFrEF) commonly coexist in clinical practice. The prevalence of COPD among HFrEF patients ranges from 20 to 32 %. On the other hand; HFrEF is prevalent in more than 20 % of COPD patients. With an aging population, the number of patients with coexisting COPD and HFrEF is on rise. Coexisting COPD and HFrEF presents a unique diagnostic and therapeutic clinical conundrum. Common symptoms shared by both conditions mask the early referral and detection of the other. Beta blockers (BB), angiotensin-converting enzyme inhibitors, and aldosterone antagonists have been shown to reduce hospitalizations, morbidity, and mortality in HFrEF while long-acting inhaled bronchodilators (beta-2-agonists and anticholinergics) and corticosteroids have been endorsed for COPD treatment. The opposing pharmacotherapy of BBs and beta-2-agonists highlight the conflict in prescribing BBs in COPD and beta-2-agonists in HFrEF. This has resulted in underutilization of evidence-based therapy for HFrEF in COPD patients owing to fear of adverse effects. This review aims to provide an update and current perspective on diagnostic and therapeutic management of patients with coexisting COPD and HFrEF.

Prehospital lung ultrasound for the diagnosis of cardiogenic pulmonary oedema: a pilot study

BACKGROUND

An improved prehospital diagnostic accuracy of cardiogenic pulmonary oedema could potentially improve initial treatment, triage, and outcome. A pilot study was conducted to assess the feasibility, time-use, and diagnostic accuracy of prehospital lung ultrasound (PLUS) for the diagnosis of cardiogenic pulmonary oedema.

METHODS

A prospective observational study was conducted in a prehospital setting. Patients were included if the physician based prehospital mobile emergency care unit was activated and one or more of the following two were present: respiratory rate >30/min., oxygen saturation <90 %. Exclusion criteria were: age <18 years, permanent mental disability or PLUS causing a delay in life-saving treatment or transportation. Following clinical assessment PLUS was performed and presence or absence of interstitial syndrome was registered. Audit by three physicians using predefined diagnostic criteria for cardiogenic pulmonary oedema was used as gold standard.

RESULTS

A total of 40 patients were included in the study. Feasibility of PLUS was 100 % and median time used was 3 min. The gold standard diagnosed 18 (45.0 %) patients with cardiogenic pulmonary oedema. The diagnostic accuracy of PLUS for the diagnosis of cardiogenic pulmonary oedema was: sensitivity 94.4 % (95 % confidence interval (CI) 72.7-99.9 %), specificity 77.3 % (95 % CI 54.6-92.2 %), positive predictive value 77.3 % (95 % CI 54.6-92.2 %), negative predictive value 94.4 % (95 % CI 72.7-99.9 %).

DISCUSSION

The sensitivity of PLUS is high, making it a potential tool for ruling-out cardiogenic pulmonary. The observed specificity was lower than what has been described in previous studies.

CONCLUSIONS

Performed, as part of a physician based prehospital emergency service, PLUS seems fast and highly feasible in patients with respiratory failure. Due to its diagnostic accuracy, PLUS may have potential as a prehospital tool, especially to rule out cardiogenic pulmonary oedema.

Point-of-Care Multi-Organ Ultrasound Improves Diagnostic Accuracy in Adults Presenting to the Emergency Department with Acute Dyspnea

Introduction

Determining the etiology of acute dyspnea in emregency department (ED) patients is often difficult. Point-of-care ultrasound (POCUS) holds promise for improving immediate diagnostic accuracy (after history and physical), thus improving use of focused therapies. We evaluate the impact of a three-part POCUS exam, or “triple scan” (TS) – composed of abbreviated echocardiography, lung ultrasound and inferior vena cava (IVC) collapsibility assessment – on the treating physician’s immediate diagnostic impression.

Methods

A convenience sample of adults presenting to our urban academic ED with acute dyspnea (Emergency Severity Index 1, 2) were prospectively enrolled when investigator sonographers were available. The method for performing components of the TS has been previously described in detail. Treating physicians rated the most likely diagnosis after history and physical but before other studies (except electrocardiogram) returned. An investigator then performed TS and disclosed the results, after which most likely diagnosis was reassessed. Final diagnosis (criterion standard) was based on medical record review by expert emergency medicine faculty blinded to TS result. We compared accuracy of pre-TS and post-TS impression (primary outcome) with McNemar’s test. Test characteristics for treating physician impression were also calculated by dichotomizing acute decompensated heart failure (ADHF), chronic obstructive pulmonary disease (COPD) and pneumonia as present or absent.

Results

57 patients were enrolled with the leading final diagnoses being ADHF (26%), COPD/asthma (30%), and pneumonia (28%). Overall accuracy of the treating physician’s impression increased from 53% before TS to 77% after TS (p=0.003). The post-TS impression was 100% sensitive and 84% specific for ADHF.

Conclusion

In this small study, POCUS evaluation of the heart, lungs and IVC improved the treating physician’s immediate overall diagnostic accuracy for ADHF, COPD/asthma and pneumonia and was particularly useful to immediately exclude ADHF as the cause of acute dyspnea.

Considerations for initial therapy in the treatment of acute heart failure

The diagnosis of patients presenting to the emergency department with acute heart failure (AHF) is challenging due to the similarity of AHF symptoms to other conditions such as chronic obstructive pulmonary disease and pneumonia. Additionally, because AHF is most common in an older population, the presentation of coexistent pathologies further increases the challenge of making an accurate diagnosis and selecting the most appropriate treatment. Delays in the diagnosis and treatment of AHF can result in worse outcomes and higher healthcare costs. Rapid initiation of treatment is thus necessary for optimal disease management. Early treatment decisions for patients with AHF can be guided by risk-stratification models based on initial clinical data, including blood pressure, levels of troponin, blood urea nitrogen, serum creatinine, B-type natriuretic peptide, and ultrasound. In this review, we discuss methods for differentiating high-risk and low-risk patients and provide guidance on how treatment decisions can be informed by risk-level assessment. Through the use of these approaches, emergency physicians can play an important role in improving patient management, preventing unnecessary hospitalizations, and lowering healthcare costs. This review differs from others published recently on the topic of treating AHF by providing a detailed examination of the clinical utility of diagnostic tools for the differentiation of dyspneic patients such as bedside ultrasound, hemodynamic changes, and interrogation of implantable cardiac devices. In addition, our clinical guidance on considerations for initial pharmacologic therapy in the undifferentiated patient is provided. It is crucial for emergency physicians to achieve an early diagnosis of AHF and initiate therapy in order to reduce morbidity, mortality, and healthcare costs.

Diagnosing acute heart failure in patients with undifferentiated dyspnea: a lung and cardiac ultrasound (LuCUS) protocol

OBJECTIVES

The primary goal of this study was to determine accuracy for diagnosing acutely decompensated heart failure (ADHF) in the undifferentiated dyspneic emergency department (ED) patient using a lung and cardiac ultrasound (LuCUS) protocol. Secondary objectives were to determine if US findings acutely change management and if findings are more accurate than clinical gestalt.

METHODS

This was a prospective, observational study of adult patients presenting to the ED with undifferentiated dyspnea. The intervention consisted of a 12-view LuCUS protocol performed by experienced emergency physician sonographers. The primary objective was measured by comparing US findings to the final diagnosis independently determined by two physicians blinded to the LuCUS result. Acute treatment changes based on US findings were tracked in real time through a standardized data collection form.

RESULTS

Data on 99 patients were analyzed; ADHF was the final diagnosis in 36%. The LuCUS protocol had sensitivity of 83% (95% confidence interval [CI] = 67% to 93%), specificity of 83% (95% CI = 70% to 91%), positive likelihood ratio of 4.8 (95% CI = 2.7 to 8.3), and negative likelihood ratio of 0.20 (95% CI = 0.09 to 0.42). Forty-seven percent of patients had changes in acute management, and 42% had changes in acute treatment. Observed agreement for the LuCUS protocol was 93% between coinvestigators. Overall, accuracy improved by 20% (83% vs. 63%, 95% CI = 8% to 31% for the difference) over clinical gestalt alone.

CONCLUSIONS

The LuCUS protocol may accurately identify ADHF and may improve acute clinical management in dyspneic ED patients. This protocol has improved diagnostic accuracy over clinical gestalt alone.

The epidemiology and outcome of prehospital respiratory distress

OBJECTIVES

Patients with respiratory distress often seek emergency medical care and are transported by emergency medical services (EMS). EMS encounters with patients in respiratory distress have not been well described. The study objective was to characterize the epidemiology of prehospital respiratory distress and subsequent patient outcomes.

METHODS

This was a population-based cohort study of noninjured adults transported by EMS to any of 16 hospitals between 2002 and 2006. EMS records were linked to hospital administrative data for encounters categorized by EMS personnel as primarily "respiratory distress" in nature. The authors described prehospital patient and encounter characteristics, interventions, hospital discharge diagnoses (using ICD-9-CM codes), and patient outcomes. The association between prehospital variables, defined a priori, and hospital admission were described using multivariable logistic regression.

RESULTS

There were 166,908 EMS encounters, of which 19,858 were for respiratory distress (11.9%, 95% confidence interval [CI] = 11.7% to 12.1%). Half of the patients were admitted to the hospital (n = 9,964), one-third of those required intensive care (n = 3,094), and 10% of hospitalized patients died prior to discharge (n = 948). Fifteen percent of hospitalized patients received invasive mechanical ventilation (n = 1,501), over half of whom were intubated during prehospital care (n = 896). The most common primary discharge diagnoses among prehospital respiratory distress patients admitted to the hospital were congestive heart failure (CHF; 16%), pneumonia (15%), chronic obstructive pulmonary disease (COPD; 13%), and acute respiratory failure (13%). Few EMS patients with respiratory distress were coded with a primary diagnosis of acute myocardial infarction (3.5%, n = 350) or underwent percutaneous coronary intervention (0.7%, n = 71). In a multivariable regression model, prehospital factors that were independently associated with hospital admission included initial respiratory rate (odds ratio [OR] = 1.29 for an increase in respiratory rate of five breaths/min, 95% CI = 1.24 to 1.35) and an encounter that originated at a nursing home (OR = 2.80, 95% CI = 2.28 to 3.43).

CONCLUSIONS

In a population-based cohort, EMS personnel commonly encounter prehospital respiratory distress among medical patients, many of whom require hospital admission to the intensive care unit. These data may help to inform targeted therapy or more efficient triage and transport decisions.

Heart failure and chronic obstructive pulmonary disease: the challenges facing physicians and health services

Pulmonary disease is common in patients with heart failure, through shared risk factors and pathophysiological mechanisms. Adverse pulmonary vascular remodelling and chronic systemic inflammation characterize both diseases. Concurrent chronic obstructive pulmonary disease presents diagnostic and therapeutic challenges, and is associated with increased morbidity and mortality. The cornerstones of therapy are beta-blockers and beta-agonists, whose pharmacological properties are diametrically opposed. Each disease is implicated in exacerbations of the other condition, greatly increasing hospitalizations and associated health care costs. Such multimorbidity is a key challenge for health-care systems oriented towards the treatment of individual diseases. Early identification and treatment of cardiopulmonary disease may alleviate this burden. However, diagnostic and therapeutic strategies require further validation in patients with both conditions.

Early emergency management of acute decompensated heart failure

PURPOSE OF REVIEW

Acute decompensated heart failure (ADHF) is characterized by a complex spectrum of pathophysiology that emerges as a common clinical disease state, which manifests as a failure of the circulation to provide for the needs of the body systems. Whereas ADHF is often characterized by the findings of pulmonary congestion and dyspnea, a variety of clinical presentations are possible, with each requiring differing management strategies. This review examines the approach of the four-quadrant clinical profile for differentiation of the ADHF patient during the emergent resuscitative phase of the decompensation.

RECENT FINDINGS

Clinical and diagnostic information can be used to determine the relative degree of pulmonary congestion and peripheral tissue perfusion in patients suspected of ADHF. This information can be used in a four-quadrant approach to differentiate patients into pathophysiologic categories. These profiles can then be translated into management strategies from a physiology based perspective in which the specific mechanisms of the failure are targeted.

SUMMARY

ADHF can present in a variety of clinical forms in the emergent setting. Categorization of the ADHF patient according to their individual hemodynamic profile can assist in management decisions during the emergent resuscitative phase of the decompensation based upon an approach that targets causative pathophysiologic mechanisms.

Pharmacology and therapeutics of bronchodilators

Bronchodilators are central in the treatment of of airways disorders. They are the mainstay of the current management of chronic obstructive pulmonary disease (COPD) and are critical in the symptomatic management of asthma, although controversies around the use of these drugs remain. Bronchodilators work through their direct relaxation effect on airway smooth muscle cells. at present, three major classes of bronchodilators, β(2)-adrenoceptor (AR) agonists, muscarinic receptor antagonists, and xanthines are available and can be used individually or in combination. The use of the inhaled route is currently preferred to minimize systemic effects. Fast- and short-acting agents are best used for rescue of symptoms, whereas long-acting agents are best used for maintenance therapy. It has proven difficult to discover novel classes of bronchodilator drugs, although potential new targets are emerging. Consequently, the logical approach has been to improve the existing bronchodilators, although several novel broncholytic classes are under development. An important step in simplifying asthma and COPD management and improving adherence with prescribed therapy is to reduce the dose frequency to the minimum necessary to maintain disease control. Therefore, the incorporation of once-daily dose administration is an important strategy to improve adherence. Several once-daily β(2)-AR agonists or ultra-long-acting β(2)-AR-agonists (LABAs), such as indacaterol, olodaterol, and vilanterol, are already in the market or under development for the treatment of COPD and asthma, but current recommendations suggest the use of LABAs only in combination with an inhaled corticosteroid. In addition, some new potentially long-acting antimuscarinic agents, such as glycopyrronium bromide (NVA-237), aclidinium bromide, and umeclidinium bromide (GSK573719), are under development, as well as combinations of several classes of long-acting bronchodilator drugs, in an attempt to simplify treatment regimens as much as possible. This review will describe the pharmacology and therapeutics of old, new, and emerging classes of bronchodilator.

Prehospital lung ultrasound in the distinction between pulmonary edema and exacerbation of chronic obstructive pulmonary disease

We present 2 cases of dyspneic patients, where prehospital lung ultrasound helped to distinguish between pulmonary edema and acute exacerbation of chronic obstructive pulmonary disease.

Bibliography. Current world literature

This bibliography is compiled by clinicians from the journals listed at the end of this publication. It is based on literature entered into our database between 1 November 2007 and 31 October 2008 (articles are generally added to the database about two and a half months after publication). In addition, the bibliography contains every paper annotated by reviewers; these references were obtained from a variety of bibliographic databases and published between the beginning of the review period and the time of going to press. The bibliography has been grouped into topics that relate to the reviews in this issue.

Combination of quantitative capnometry, N-terminal pro-brain natriuretic peptide, and clinical assessment in differentiating acute heart failure from pulmonary disease as cause of acute dyspnea in pre-hospital emergency setting: study of diagnostic accuracy

AIM

To determine the diagnostic accuracy of the combination of quantitative capnometry (QC), N-terminal pro-brain natriuretic peptide (NT-proBNP), and clinical assessment in differentiating heart failure (HF)-related acute dyspnea from pulmonary-related acute dyspnea in a pre-hospital setting.

METHODS

This prospective study was performed in the Center for Emergency Medicine Maribor, Slovenia, January 2005-June 2007. Two groups of patients with acute dyspnea apnea were compared: HF-related acute dyspnea group (n = 238) vs pulmonary-related acute dyspnea (asthma/COPD) group (n = 203). The primary outcome was the comparison of combination of QC, NT-proBNP, and clinical assessment vs NT-proBNP alone or NT-proBNP in combination with clinical assessment, in differentiating HF-related acute dyspnea from pulmonary-related acute dyspnea (asthma/COPD) in pre-hospital emergency setting, using the area under the receiver operating characteristic curve (AUROC). The secondary outcomes end points were identification of independent predictors for final diagnosis of acute dyspnea (caused by acute HF or pulmonary diseases), and determination of NT-proBNP levels, as well as capnometry, in the subgroup of patients with a previous history of HF and in the subgroup of patients with a previous history of pulmonary disease.

RESULTS

In differentiating between cardiac and respiratory causes of acute dyspnea in pre-hospital emergency setting, NT-proBNP in combination with PetCO2 and clinical assessment (AUROC, 0.97; 95% confidence interval [CI], 0.90-0.99) was superior to combination of NT-proBNP and clinical assessment (AUROC, 0.94; 95% CI, 0.88-0.96; P = 0.006) or NT-proBNP alone (AUROC, 0.90; 95% CI, 0.85-0.94; P = 0.005). The values of NT-proBNP> or = 2000 pg/mL and PetCO2 < or = 4 kPa were strong independent predictors for acute HF. In the group of acute HF dyspneic patients, subgroup of patients with previous COPD/asthma had significantly higher PetCO2 (3.8 +/- 1.2 vs 5.8 +/- 1.3 kPa, P = 0.009). In the group of COPD/asthma dyspneic patients, NT-proBNP was significantly higher in the subgroup of patients with previous HF (1453.3 +/- 552.3 vs 741.5 +/- 435.5 pg/mL, P = 0.010).

CONCLUSION

In differentiating between cardiac and respiratory causes of acute dyspnea in pre-hospital emergency setting, NT-proBNP in combination with capnometry and clinical assessment was superior to NT-proBNP alone or NT-proBNP in combination with clinical assessment.

Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure

OBJECTIVES

Sonographic thoracic B-lines and N-terminal pro-brain-type natriuretic peptide (NT-ProBNP) have been shown to help differentiate between congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The authors hypothesized that ultrasound (US) could be used to predict CHF and that it would provide additional predictive information when combined with NT-ProBNP. They also sought to determine optimal two- and eight-zone scanning protocols when different thresholds for a positive scan were used.

METHODS

This was a prospective, observational study of a convenience sample of adult patients presenting to the emergency department (ED) with shortness of breath. Each patient had an eight-zone thoracic US performed by one of five sonographers, and serum NT-ProBNP levels were measured. Chart review by two physicians blinded to the US results served as the criterion standard. The operating characteristics of two- and eight-zone thoracic US alone, compared to, and combined with NT-ProBNP test results for predicting CHF were calculated using both dichotomous and interval likelihood ratios (LRs).

RESULTS

One-hundred patients were enrolled. Six were excluded because of incomplete data. Results of 94 patients were analyzed. A positive eight-zone US, defined as at least two positive zones on each side, had a positive likelihood ratio (LR+) of 3.88 (99% confidence interval [CI] = 1.55 to 9.73) and a negative likelihood ratio (LR-) of 0.5 (95% CI = 0.30 to 0.82), while the NT-ProBNP demonstrated a LR+ of 2.3 (95% CI = 1.41 to 3.76) and LR- of 0.24 (95% CI = 0.09 to 0.66). Using interval LRs for the eight-zone US test alone, the LR for a totally positive test (all eight zones positive) was infinite and for a totally negative test (no zones positive) was 0.22 (95% CI = 0.06 to 0.80). For two-zone US, interval LRs were 4.73 (95% CI = 2.10 to 10.63) when inferior lateral zones were positive bilaterally and 0.3 (95% CI = 0.13 to 0.71) when these were negative. These changed to 8.04 (95% CI = 1.76 to 37.33) and 0.11 (95% CI = 0.02 to 0.69), respectively, when congruent with NT-ProBNP.

CONCLUSIONS

Bedside thoracic US for B-lines can be a useful test for diagnosing CHF. Predictive accuracy is greatly improved when studies are totally positive or totally negative. A two-zone protocol performs similarly to an eight-zone protocol. Thoracic US can be used alone or can provide additional predictive power to NT-ProBNP in the immediate evaluation of dyspneic patients presenting to the ED.

Evaluation of a thoracic ultrasound training module for the detection of pneumothorax and pulmonary edema by prehospital physician care providers

BACKGROUND

While ultrasound (US) has continued to expedite diagnosis and therapy for critical care physicians inside the hospital system, the technology has been slow to diffuse into the pre-hospital system. Given the diagnostic benefits of thoracic ultrasound (TUS), we sought to evaluate image recognition skills for two important TUS applications; the identification of B-lines (used in the US diagnosis of pulmonary edema) and the identification of lung sliding and comet tails (used in the US diagnosis of pneumothorax). In particular we evaluated the impact of a focused training module in a pre-hospital system that utilizes physicians as pre-hospital providers.

METHODS

27 Paris Service D'Aide Médicale Urgente (SAMU) physicians at the Hôpital Necker with varying levels of US experience were given two twenty-five image recognition pre-tests; the first test had examples of both normal and pneumothorax lung US and the second had examples of both normal and pulmonary edema lung US. All 27 physicians then underwent the same didactic training modules. A post-test was administered upon completing the training module and results were recorded.

RESULTS

Pre and post-test scores were compared for both the pneumothorax and the pulmonary edema modules. For the pneumothorax module, mean test scores increased from 10.3 +/- 4.1 before the training to 20.1 +/- 3.5 after (p < 0.0001), out of 25 possible points. The standard deviation decreased as well, indicating a collective improvement. For the pulmonary edema module, mean test scores increased from 14.1 +/- 5.2 before the training to 20.9 +/- 2.4 after (p < 0.0001), out of 25 possible points. The standard deviation decreased again by more than half, indicating a collective improvement.

CONCLUSION

This brief training module resulted in significant improvement of image recognition skills for physicians both with and without previous ultrasound experience. Given that rapid diagnosis of these conditions in the pre-hospital system can change therapy, especially in systems where physicians can integrate this information into treatment decisions, the further diffusion of this technology would seem to be beneficial and deserves further study.

Illicit stimulant use in a United States heart failure population presenting to the emergency department (from the Acute Decompensated Heart Failure National Registry Emergency Module)

Illicit stimulant drug use may have a profound clinical impact in acute decompensated heart failure (ADHF). The chronic use of cocaine and methamphetamine may lead to overt cardiomyopathy and ADHF. The Acute Decompensated Heart Failure National Registry Emergency Module (ADHERE-EM) collected data on patients presenting to emergency departments with ADHF at 83 geographically dispersed hospitals in the United States. This registry was queried to determine the rate of self-reported illicit drug use in emergency department patients presenting with ADHF and compare these patients with those without illicit drug use. The registry enrolled 11,258 patients with ADHF with drug use data from January 2004 to March 2006. Of these patients, 594 (5.3%) self-reported current or past stimulant drug use. Compared with nonusers, these patients were more likely to be younger (median age 49.7 vs 76.1 years), to be African American (odds ratio 11.9, 95% confidence interval 9.8 to 14.4), and to have left ventricular ejection fractions <40% (odds ratio 3.4, 95% confidence interval 2.8 to 4.2). Admitted users had no difference in mortality (adjusted odds ratio 0.83, 95% confidence interval 0.25 to 2.72) compared with nonusers. In conclusion, data from ADHERE-EM suggest that a clinically important percentage of patients with ADHF report the use of illicit stimulant drugs. Although these patients are younger with a greater degree of LV dysfunction, they did not have greater risk-adjusted mortality.