Moving toward comprehensive acute heart failure risk assessment in the emergency department: the importance of self-care and shared decision making

Holistic approach to drug therapy in a patient with heart failure

Heart failure (HF) is a growing global public health problem affecting at least 26 million people worldwide. The evidence-based landscape for HF treatment has changed at a rapid rate over the last 30 years. International guidelines for the management of HF now recommend the use of four pillars in all patients with reduced ejection fraction: angiotensin receptor neprilysin inhibitors or ACE inhibitors, beta blockers, mineralocorticoid receptor antagonists and sodium-glucose co-transporter-2 inhibitors. Beyond the main four pillar therapies, numerous further pharmacological treatments are also available in specific patient subtypes. These armouries of drug therapy are impressive, but where does this leave us with individualised and patient-centred care? This paper reviews the common considerations needed to provide a holistic, tailored and individual approach to drug therapy in a patient with HF with reduced ejection fraction, including shared decision making, initiating and sequencing of HF pharmacotherapy, drug-related considerations, polypharmacy and adherence.

Retrospective validation of acute heart failure risk stratification in the emergency department

BACKGROUND

Heart Failure (HF) is a primary diagnosis for hospital admission from the Emergency Department (ED), although not all patients require hospitalization. The Emergency Heart Failure Mortality Risk Grade (EHMRG) estimates 7-day mortality in patients with acute HF in ED settings, but further validation is needed in the United States (US).

OBJECTIVES

To validate EHMRG scores by risk-stratifying patients with acute HF in a large tertiary healthcare center in the US and analyze outcome measures to determine if EHMRG risk scores safely identify low-risk groups that may be discharged or managed in ED observation units (EDOUs).

METHODS

A retrospective cohort analysis of 304 patients with acute HF presenting to an ED at a large, tertiary healthcare center was completed. EHMRG scores were calculated to stratify patients according to published thresholds. Mortality and major adverse cardiac event (MACE) rates were analyzed.

RESULTS

No deaths occurred in very low and low-risk EHMRG groups at 7 days post discharge. 30-day mortality was significantly less in the lower risk groups (3.1%) when compared to all other patients (11.1%). MACE rates at 30 days in the very low risk group (15%) were significantly less when compared to all other patients (31.3%). Hospitalizations occurred in 23.4% of patients in lower risk groups.

CONCLUSIONS

ED risk stratification with EHMRG differentiates high-risk patients requiring hospitalization from lower risk patients who can be safely managed in alternative settings with good outcomes. Data supports improved pathways for patients with acute HF during a time of high hospital volumes.

Emergency department risk assessment and disposition of acute heart failure patients: existing evidence and ongoing challenges

Heart failure (HF) is a global public health burden, characterized by frequent emergency department (ED) visits and hospitalizations. Identifying successful strategies to avoid admissions is crucial for the management of acutely decompensated HF, let alone resource utilization. The primary challenge for ED management of patients with acute heart failure (AHF) lies in the identification of those who can be safely discharged home instead of being admitted. This is an elaborate decision, based on limited objective evidence. Thus far, current biomarkers and risk stratification tools have had little impact on ED disposition decision-making. A reliable definition of a low-risk patient profile is warranted in order to accurately identify patients who could be appropriate for early discharge. A brief period of observation can facilitate risk stratification and allow for close monitoring, aggressive treatment, continuous assessment of response to initial therapy and patient education. Lung ultrasound may represent a valid bedside tool to monitor cardiogenic pulmonary oedema and determine the extent of achieved cardiac unloading after treatment in the observation unit setting. Safe discharge mandates multidisciplinary collaboration and thoughtful assessment of socioeconomic and behavioural factors, along with a clear post-discharge plan put forward and a close follow-up in an outpatient setting. Ongoing research to improve ED risk stratification and disposition of AHF patients may mitigate the tremendous public health challenge imposed by the HF epidemic.

Incidence of Timely Outpatient Follow-Up Care After Emergency Department Encounters for Acute Heart Failure

BACKGROUND

Patients who are discharged from the emergency department (ED) after an encounter for acute heart failure are at high risk for return hospitalization. These patients may benefit from timely outpatient follow-up care to reassess volume status, adjust medications, and reinforce self-care strategies. This study examines the incidence of outpatient follow-up care after ED encounters for acute heart failure and describes patient characteristics associated with obtaining timely follow-up care.

METHODS

We conducted a retrospective cohort study using an administrative claims database for a large US commercial insurer, from January 1, 2012 to June 30, 2019. Participants included adult patients discharged from the ED with principal diagnosis of acute heart failure. The primary outcome was obtaining an in-person outpatient clinic visit for heart failure within 30 days. We also examined the competing risk of all-cause hospitalization within 30 days and without an intervening outpatient clinic visit. We estimated competing risk regression models to identify patient characteristics associated with obtaining outpatient follow-up and report cause-specific hazard ratios.

RESULTS

The cohort included 52 732 patients, with mean age of 73.9 years (95% CI, 73.8-74.0) and 27 395 (52.0% [95% CI, 51.5-52.4]) female patients. Within 30 days of the ED encounter, 12 279 (23.2%) patients attended an outpatient clinic visit for heart failure, with 8382 (15.9%) patients hospitalized before they could obtain an outpatient clinic visit. In the adjusted analysis, patients that were younger, women, reporting non-Hispanic Black race, and had fewer previous clinic visits were less likely to obtain outpatient follow-up care.

CONCLUSIONS

Few patients obtain timely outpatient follow-up after ED visits for heart failure, although nearly 20% require hospitalization within 30 days. Improved transitions following discharge from the ED may represent an opportunity to improve outcomes for patients with acute heart failure.

Improvement in Kansas City Cardiomyopathy Questionnaire Scores After a Self-Care Intervention in Patients With Acute Heart Failure Discharged From the Emergency Department

BACKGROUND

We conducted a secondary analysis of changes in the Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 over 30 days in a randomized trial of self-care coaching versus structured usual care in patients with acute heart failure who were discharged from the emergency department.

METHODS

Patients in 15 emergency departments completed the KCCQ-12 at emergency department discharge and at 30 days. We compared change in KCCQ-12 scores between the intervention and usual care arms, adjusted for enrollment KCCQ-12 and demographic characteristics. We used linear regression to describe changes in KCCQ-12 summary scores and logistic regression to characterize clinically meaningful KCCQ-12 subdomain changes at 30 days.

RESULTS

There were 350 patients with both enrollment and 30-day KCCQ summary scores available; 166 allocated to usual care and 184 to the intervention arm. Median age was 64 years (interquartile range, 55-70), 37% were female participants, 63% were Black, median KCCQ-12 summary score at enrollment was 47 (interquartile range, 33-64). Self-care coaching resulted in significantly greater improvement in health status compared with structured usual care (5.4-point greater improvement, 95% CI, 1.12-9.68; P=0.01). Improvements in health status in the intervention arm were driven by improvements within the symptom frequency (adjusted odds ratio, 1.62 [95% CI, 1.01-2.59]) and quality of life (adjusted odds ratio, 2.39 [95% CI, 1.46-3.90]) subdomains.

CONCLUSIONS

In this secondary analysis, patients with acute heart failure who received a tailored, self-care intervention after emergency department discharge had clinically significant improvements in health status at 30 days compared with structured usual care largely due to improvements within the symptom frequency and quality of life subdomains of the KCCQ-12. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02519283.

First symptoms and health care pathways in hospitalized patients with acute heart failure: ICPS2 survey. A report from the Heart Failure Working Group (GICC) of the French Society of Cardiology

BACKGROUND

Acute heart failure (AHF) is a common serious condition that contributes to about 5% of all emergency hospital admissions in Europe.

HYPOTHESIS

To assess the type and chronology of the first AHF symptoms before hospitalization and to examine the French healthcare system pathways before, during and after hospitalization.

MATERIAL AND METHODS

A retrospective observational study including patients hospitalized for AHF RESULTS: 793 patients were included, 59.0% were men, 45.6% identified heart failure (HF) as the main cause of hospitalization; 36.0% were unaware of their HF. Mean age was 72.9 ± 14.5 years. The symptoms occurring the most before hospitalization were dyspnea (64.7%) and lower limb edema (27.7%). Prior to hospitalization, 47% had already experienced symptoms for 15 days; 32% of them for 2 months. Referral to hospital was made by the emergency medical assistance service (SAMU, 41.6%), a general practitioner (GP, 22.3%), a cardiologist (19.5%), or the patient (16.6%). The modality of referral depended more on symptom acuteness than on type of symptoms. A sudden onset of AHF symptoms led to making an emergency call or to spontaneously attending an emergency room (ER), whereas cardiologists were consulted when symptoms had already been present for over 15 days. Cardiologists referred more patients to cardiology departments and fewer patients to the ER than general practitioners or the SAMU.

CONCLUSION

This study described the French healthcare system pathways before, during and after hospitalization AHF. AHF clinic network should be developed to provide adequate care for all HF patients and create awareness regarding AHF symptoms.

TACIT (High Sensitivity Troponin T Rules Out Acute Cardiac Insufficiency Trial)

BACKGROUND

Identifying low-risk acute heart failure patients safe for discharge from the emergency department is a major unmet need.

METHODS AND RESULTS

A prospective, observational, multicenter pilot study targeting lower risk acute heart failure patients to determine whether hsTnT (high-sensitivity troponin T) identifies emergency department acute heart failure patients at low risk for rehospitalization and mortality. hsTnT was drawn at baseline and 3 hours. Phone follow-up occurred at 30 and 90 days. The primary end point composite of all-cause mortality, rehospitalization, and emergency department visits at 90 days (changed from 30 days because of lack of mortality events), analyzed using logistic regression. Secondary end points: 30- and 90-day all-cause mortality. hsTnT values less than the 99th percentile were defined as low hsTnT. Out of 527 enrolled patients, 499 comprised the initial analysis set. Of these, 332 had both 0- and 3-hour hsTnT drawn, of whom 319 completed 30 day follow-up. The average age was 62, 60% male, and 57% black. Median hsTnT was 26.4 ng/L (interquartile range, 15.1-44.3). There were 99 (21%) 30-day composite events, 13 (2.7%) deaths at 30 days, and 25 deaths (8.2%) at 90 days. Serial hsTnT values below the 99th percentile were not associated with a lower risk for the 90-day primary composite end point (odds ratio, 0.79; 95% CI, 0.42-1.50; P=0.4736). However, no deaths occurred in the low hsTnT group at 30 days with 1 death at 90 days.

CONCLUSIONS

hsTnT did not identify patients at low risk for the primary outcome of rehospitalization, emergency department visits, and mortality at 90 days.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02592135.

Acute Heart Failure in the Emergency Department: Respiratory Rate as a Risk Predictor

BACKGROUND/AIM

Several risk scores can stratify patients with acute heart failure (AHF) at the Emergency Department (ED). Registration of vital signs, such as blood pressure (BP), heart rate (HR) and respiratory rate (RR) upon admission is mandatory. Nevertheless, measurement of RR remains neglected worldwide.

PATIENTS AND METHODS

The predictive value of RR in classifying patients with AHF was investigated by processing several vital signs recorded in the ED.

RESULTS

HR and RR individually did not discriminate patients according to hospitalization length, Intensive Care Unit (ICU) admittance, mechanical respiratory support or death. The derivative indices, HR:RR and Respiratory Efficacy Index (REFI) (=RR×100/SatO₂), differentiated study patients regarding hospitalization length. Receiver operating characteristic curves predicting mortality and ICU admission for REFI and HR:RR revealed high accuracy, sensitivity and specificity for cut-off values of REFI >27 and HR:RR ≥4.

CONCLUSION

The RR and its derivative indices are easily accessible vital signs monitored at the ED which merit 'revitalization'.

Acute Heart Failure in the Emergency Department: Respiratory Rate as a Risk Predictor

BACKGROUND/AIM

Several risk scores can stratify patients with acute heart failure (AHF) at the Emergency Department (ED). Registration of vital signs, such as blood pressure (BP), heart rate (HR) and respiratory rate (RR) upon admission is mandatory. Nevertheless, measurement of RR remains neglected worldwide.

PATIENTS AND METHODS

The predictive value of RR in classifying patients with AHF was investigated by processing several vital signs recorded in the ED.

RESULTS

HR and RR individually did not discriminate patients according to hospitalization length, Intensive Care Unit (ICU) admittance, mechanical respiratory support or death. The derivative indices, HR:RR and Respiratory Efficacy Index (REFI) (=RR×100/SatO₂), differentiated study patients regarding hospitalization length. Receiver operating characteristic curves predicting mortality and ICU admission for REFI and HR:RR revealed high accuracy, sensitivity and specificity for cut-off values of REFI >27 and HR:RR ≥4.

CONCLUSION

The RR and its derivative indices are easily accessible vital signs monitored at the ED which merit 'revitalization'.

An East-West comparison of self-care barriers in heart failure

BACKGROUND

Barriers in heart failure self-care contribute to heart failure hospitalizations, but geographic differences have not been well-studied. We aimed to compare self-care barriers in heart failure patients managed at tertiary centers in an Eastern (Singapore) versus a Western (USA) nation.

METHODS

Acute heart failure patients were prospectively assessed with a standardized instrument comprising of 47 distinct self-care barriers. The multi-equation generalized structural equation model was used to evaluate for geographic differences in barriers experienced, and association of barriers with outcomes.

RESULTS

Patient-related factors accounted for six out of 10 most prevalent self-care barriers among the 90 patients, with a median number of 11 barriers reported per patient. The Western patients reported a higher level of barriers when compared with their Eastern counterparts (median (interquartile range) 15 (9-24) versus 9 (4-16), p=0.001), after adjusting for demographics and co-morbidities. Many of these differences could be explained by geographic differences between the countries. There was no significant difference identified in all-cause mortality (19.4% versus 10.2%) and heart failure re-hospitalization (41.9% versus 45.8%) at six months between the groups.

CONCLUSIONS

Self-care barriers are highly prevalent among acute heart failure patients, and differ substantially between East and West, but were not associated with geographic differences in outcomes.

Lay Consultations in Heart Failure Symptom Evaluation

PURPOSE

Lay consultations can facilitate or impede healthcare. However, little is known about how lay consultations for symptom evaluation affect treatment decision-making. The purpose of this study was to explore the role of lay consultations in symptom evaluation prior to hospitalization among patients with heart failure.

METHODS

Semi-structured interviews were conducted with 60 patients hospitalized for acute decompensated heart failure. Chi-square and Fisher's exact tests, along with logistic regression were used to characterize lay consultations in this sample.

RESULTS

A large proportion of patients engaged in lay consultations for symptom evaluation and decision-making before hospitalization. Lay consultants provided attributions and advice and helped make the decision to seek medical care. Men consulted more often with their spouse than women, while women more often consulted with adult children.

CONCLUSIONS

Findings have implications for optimizing heart failure self-management interventions, improving outcomes, and reducing hospital readmissions.

Self Managing Heart Failure in Remote Australia - Translating Concepts into Clinical Practice

Congestive heart failure (CHF) is an ambulatory health care condition characterized by episodes of decompensation and is usually without cure. It is a leading cause for morbidity and mortality and the lead cause for hospital admissions in older patients in the developed world. The long-term requirement for medical care and pharmaceuticals contributes to significant health care costs. CHF management follows a hierarchy from physician prescription to allied health, predominately nurse-led, delivery of care. Health services are easier to access in urban compared to rural settings. The differentials for more specialized services could be even greater. Remote Australia is thus faced with unique challenges in delivering CHF best practice. Chronic disease self-management programs (CDSMP) were designed to increase patient participation in their health and alleviate stress on health systems. There have been CDSMP successes with some diseases, although challenges still exist for CHF. These challenges are amplified in remote Australia due to geographic and demographic factors, increased burden of disease, and higher incidence of comorbidities. In this review we explore CDSMP for CHF and the challenges for our region.

Dissemination and Implementation of Shared Decision Making Into Clinical Practice: A Research Agenda

Shared decision making (SDM) is essential to advancing patient-centered care in emergency medicine. Despite many documented benefits of SDM, prior research has demonstrated persistently low levels of patient engagement by clinicians across many disciplines, including emergency medicine. An effective dissemination and implementation (D&I) framework could be used to alter the process of delivering care and to facilitate SDM in routine clinical emergency medicine practice. Here we outline a research and policy agenda to support the D&I strategy needed to integrate SDM into emergency care.

Plasma bioactive adrenomedullin as a prognostic biomarker in acute heart failure

OBJECTIVE

The objective was to evaluate the prognostic performance of a new biomarker, plasma bioactive adrenomedullin (bio-ADM), for short-term clinical outcomes in acute heart failure.

METHODS

A multicenter prospective cohort study of adult emergency department (ED) patients suspected of having acute heart failure was conducted to evaluate the association between plasma bio-ADM concentration and clinical outcomes. The primary outcome was a composite of the following within 30 days: death, cardiac arrest with resuscitation, respiratory failure, emergency dialysis, acute coronary syndrome, hospitalization >5 days, and repeat ED visit or hospitalization. Prognostic accuracy was evaluated with a nonparametric receiver operating characteristic curve. In addition, a multivariable logistic regression model was constructed to assess the additive prognostic performance of bio-ADM while adjusting for other biomarkers routinely used clinically, including B-type natriuretic peptide, cardiac troponin I, creatinine, and sodium concentration.

RESULTS

Two hundred forty-six patients were enrolled, including 85 (34.6%) patients with the primary outcome. Plasma bio-ADM concentrations were higher among patients who experienced the primary outcome (median, 80.5 pg/mL; interquartile range [IQR], 53.7-151.5 pg/mL) compared with those who did not (median, 54.4 pg/mL; IQR, 43.4-78.4 pg/mL) (P < .01). Area under the receiver operating characteristic curve was 0.70 (95% confidence interval, 0.63-0.75). After adjusting for the other biomarkers, plasma bio-ADM remained a strong predictor of the primary outcome (adjusted odds ratio per IQR change, 2.68; 95% confidence interval, 1.60-4.51).

CONCLUSIONS

Bioactive adrenomedullin concentrations at the time of ED evaluation for acute heart failure were predictive of clinically important 30-day outcomes, suggesting that bio-ADM is a promising prognostic marker for further study.

Identification of Emergency Department Patients With Acute Heart Failure at Low Risk for 30-Day Adverse Events: The STRATIFY Decision Tool

OBJECTIVES

No prospectively derived or validated decision tools identify emergency department (ED) patients with acute heart failure (AHF) at low risk for 30-day adverse events who are thus potential candidates for safe ED discharge. This study sought to accomplish that goal.

BACKGROUND

The nearly 1 million annual ED visits for AHF are associated with high proportions of admissions and consume significant resources.

METHODS

We prospectively enrolled 1,033 patients diagnosed with AHF in the ED from 4 hospitals between July 20, 2007, and February 4, 2011. We used an ordinal outcome hierarchy, defined as the incidence of the most severe adverse event within 30 days of ED evaluation (acute coronary syndrome, coronary revascularization, emergent dialysis, intubation, mechanical cardiac support, cardiopulmonary resuscitation, and death).

RESULTS

Of 1,033 patients enrolled, 126 (12%) experienced at least one 30-day adverse event. The decision tool had a C statistic of 0.68 (95% confidence interval: 0.63 to 0.74). Elevated troponin (p < 0.001) and renal function (p = 0.01) were significant predictors of adverse events in our multivariable model, whereas B-type natriuretic peptide (p = 0.09), tachypnea (p = 0.09), and patients undergoing dialysis (p = 0.07) trended toward significance. At risk thresholds of 1%, 3%, and 5%, we found 0%, 1.4%, and 13.0% patients were at low risk, with negative predictive values of 100%, 96%, and 93%, respectively.

CONCLUSIONS

The STRATIFY decision tool identifies ED patients with AHF who are at low risk for 30-day adverse events and may be candidates for safe ED discharge. After external testing, and perhaps when used as part of a shared decision-making strategy, it may significantly affect disposition strategies. (Improving Heart Failure Risk Stratification in the ED [STRATIFY]; NCT00508638).

Self-care Barriers Reported by Emergency Department Patients With Acute Heart Failure: A Sociotechnical Systems-Based Approach

STUDY OBJECTIVE

We pilot tested a sociotechnical systems-based instrument that assesses the prevalence and nature of self-care barriers among patients presenting to the emergency department (ED) with acute heart failure.

METHODS

A semistructured instrument for measuring self-reported self-care barriers was developed and administered by ED clinicians and nonclinician researchers to 31 ED patients receiving a diagnosis of acute heart failure. Responses were analyzed with descriptive statistics and qualitative content analysis. Feasibility was assessed by examining participant cooperation rates, instrument completion times, item nonresponse, and data yield.

RESULTS

Of 47 distinct self-care barriers assessed, a median of 15 per patient were indicated as "sometimes" or "often" present. Thirty-four specific barriers were reported by more than 25% of patients and 9 were reported by more than 50%. The sources of barriers included the person, self-care tasks, tools and technologies, and organizational, social, and physical contexts. Seven of the top 10 most prevalent barriers were related to patient characteristics; the next 3, to the organizational context (eg, life disruptions). A preliminary feasibility assessment found few item nonresponses or comprehension difficulties, good cooperation, and high data yield from both closed- and open-ended items, but also found opportunities to reduce median administration time and variability.

CONCLUSION

An instrument assessing self-care barriers from multiple system sources can be feasibly implemented in the ED. Further research is required to modify the instrument for widespread use and evaluate its implementation across institutions and cultural contexts. Self-care barriers measurement can be one component of broader inquiry into the distributed health-related "work" activity of patients, caregivers, and clinicians.

Challenges in acute heart failure clinical management: optimizing care despite incomplete evidence and imperfect drugs

Acute heart failure is a common condition associated with considerable morbidity, mortality, and cost. However, evidence-based data on treating heart failure in the acute setting are limited, and current individual treatment options have variable efficacy. The healthcare team must often individualize patient care in ways that may extend beyond available clinical guidelines. In this review, we address the question, "How do you do the best you can clinically with incomplete evidence and imperfect drugs?" Expert opinion is provided to supplement guideline-based recommendations and help address the typical challenges that are involved in the management of patients with acute heart failure. Specifically, we discuss 4 key areas that are important in the continuum of patient care: differential diagnosis and risk stratification; choice and implementation of initial therapy; assessment of the adequacy of therapy during hospitalization or observation; and considerations for discharge/transition of care. A case study is presented to highlight the decision-making process throughout each of these areas. Evidence is accumulating that should help guide patients and healthcare providers on a path to better quality of care.

An early warning scoring system for the prevention of acute heart failure

BACKGROUND

Early prediction and identification of the onset of acute heart failure (AHF) in high-risk patients are of great significance for preemptive treatment and a better prognosis. We sought to find a scoring system to predict the onset of AHF in patients in the acute heart failure unit (AHFU).

METHODS

Data for 433 patients at of AHF in the AHFU were analyzed. We recorded sex, age, history of coronary artery disease, hypertension, diabetes, and primary percutaneous coronary intervention. We also reviewed temperature, pulse, SpO₂, respiratory rate, urine volume, and emotional state every hour before the onset of AHF. All admission and follow-up data were retrieved from hospital charts. Factors were analyzed using a binary logistic regression model to create the SUPER (SpO₂, urine volume, pulse, emotional state, and respiratory rate) scoring model. We divided the scoring system into four levels: low-, intermediate-, high-, and extremely high-risk. Patients fitting the four risk levels were followed up for 6 to 24 months.

RESULTS

SpO₂, hourly urine volume, pulse, emotional state and respiratory rates were associated with an independent increased risk for the onset of AHF. The SUPER score for the patients in the AHFU predicted the onset of AHF 3.90 ± 1.94 h (1-17 h) earlier. The areas under the ROC curve for the SUPER score and the modified early warning score were 0.811 and 0.662 (p<0.05), indicating that the SUPER score provided a better warning of the AHF. A low-, intermediate-, high-, and very high-risk SUPER predicted the likelihood of AHF at 17.3%, 61.3%, 84.4%, and 94.0%, respectively. The differences in mortality rates between the four levels were statistically significant (p<0.05).

CONCLUSIONS

In patients at high risk of AHF, the SUPER scoring system could predict the onset of AHF 2 to 6h earlier. Preemptive treatment according to the SUPER score may prevent or delay AHF occurrence to improve quality of life and reduce mortality.

Early management of patients with acute heart failure: state of the art and future directions. A consensus document from the society for academic emergency medicine/heart failure society of America acute heart failure working group

Heart failure (HF) afflicts nearly 6 million Americans, resulting in one million emergency department (ED) visits and over one million annual hospital discharges. An aging population and improved survival from cardiovascular diseases is expected to further increase HF prevalence. Emergency providers play a significant role in the management of patients with acute heart failure (AHF). It is crucial that emergency physicians and other providers involved in early management understand the latest developments in diagnostic testing, therapeutics and alternatives to hospitalization. Further, clinical trials must be conducted in the ED in order to improve the evidence base and drive optimal initial therapy for AHF. Should ongoing and future studies suggest early phenotype-driven therapy improves in-hospital and post-discharge outcomes, ED treatment decisions will need to evolve accordingly. The potential impact of future studies which incorporate risk-stratification into ED disposition decisions cannot be underestimated. Predictive instruments that identify a cohort of patients safe for ED discharge, while simultaneously addressing barriers to successful outpatient management, have the potential to significantly impact quality of life and resource expenditures.

Early management of patients with acute heart failure: state of the art and future directions--a consensus document from the SAEM/HFSA acute heart failure working group

Heart failure (HF) afflicts nearly 6 million Americans, resulting in 1 million emergency department (ED) visits and over 1 million annual hospital discharges. The majority of inpatient admissions originate in the ED; thus, it is crucial that emergency physicians and other providers involved in early management understand the latest developments in diagnostic testing, therapeutics, and alternatives to hospitalization. This article discusses contemporary ED management as well as the necessary next steps for ED-based acute HF research.

The burden of acute heart failure on U.S. emergency departments

OBJECTIVES

The goal of this study was to examine 2006 to 2010 emergency department (ED) admission rates, hospital procedures, lengths of stay, and costs for acute heart failure (AHF).

BACKGROUND

Patients with AHF are often admitted and are associated with high readmissions and cost.

METHODS

We utilized Nationwide Emergency Department Sample AHF data from 2006 to 2010 to describe admission proportion, hospital length of stay (LOS), and ED charges as a surrogate for resource utilization. Results were compared across U.S. regions, patient insurance status, and hospital characteristics.

RESULTS

There were 958,167 mean yearly ED visits for AHF in the United States. Fifty-one percent of the patients were female, and the median age was 75.1 years (interquartile range [IQR]: 62.5 to 83.7 years). Overall, 83.7% (95% confidence interval: 83.1% to 84.2%) were admitted; the median LOS was 3.4 days (IQR: 1.9 to 5.8 days). Comparing 2006 with 2010, there was a small decrease in median LOS (0.09 days), but the proportion admitted did not change. Odds of admission, adjusting for age, sex, hospital characteristic (academic and safety net status), and insurance (Medicare, Medicaid, private, self-pay/no charge) were highest in the Northeast. Median ED charges were $1,075 (IQR: $679 to $1,665) in 2006 and $1,558 (IQR: $1,018 to $2,335) in 2010. Patients without insurance were more likely to be discharged from the ED, but when admitted, were more likely to receive a major diagnostic or therapeutic procedure.

CONCLUSIONS

A very high proportion of ED patients with AHF are admitted nationally, with significant variation in disposition and procedural decisions based on region of the country and type of insurance, even after adjusting for potential confounding.

Implementing guideline based heart failure care in the Northern Territory: challenges and solutions

The Northern Territory of Australia is a vast area serviced by two major tertiary hospitals. It has both a unique demography and geography, which pose challenges for delivering optimal heart failure services. The prevalence of congestive heart failure continues to increase, imposing a significant burden on health infrastructure and health care costs. Specific patient groups suffer disproportionately from increased disease severity or service related issues often represented as a "health care gap". The syndrome itself is characterised by ongoing symptoms interspersed with acute decompensation requiring lifelong therapy and is rarely reversible. For the individual client the overwhelming attention to heart failure care and the impact of health care gaps can be devastating. This gap may also contribute to widening socio-economic differentials for families and communities as they seek to take on some of the care responsibilities. This review explores the challenges of heart failure best practice in the Northern Territory and the opportunities to improve on service delivery. The discussions highlighted could have implications for health service delivery throughout regional centres in Australia and health systems in other countries.