Heart failure management in the emergency department observation unit

Clinical and utilization outcomes with short stay units vs hospital admission for lower risk decompensated heart failure: a systematic review and meta-analysis

With over 1 million primary heart failure (HF) hospitalizations annually, nearly 80% of patients who present to the emergency department with decompensated HF (DHF) are hospitalized. Short stay units (SSU) present an alternative to hospitalization, yet the effectiveness of the SSU strategy of care is not well known. This study is to determine the effectiveness of a SSU strategy compared with hospitalization in lower-risk patients with DHF. Our primary outcome was a composite of 30-day mortality and re-hospitalization. Key secondary outcomes included 90-day mortality and re-hospitalization, costs, and 30-day days-alive-and-out-of-hospital (DAOOH). This is a systematic review and meta-analysis, following PRISMA guidelines. MEDLINE, EMBASE, CENTRAL, CINAHL, SCOPUS, and Web of Science were searched from inception through February 2024. Either randomized trials or comparative observational studies were included if they compared outcomes between low-risk ED DHF patients admitted to an SSU (defined as an observation unit with expected stay ≤ 48 h) vs. admitted to the hospital. Two authors independently screened all titles and abstracts and then identified full texts for inclusion. Data extraction and risk of bias assessments were performed by two authors in parallel. The primary outcome was a composite of death or readmission within 30 days, reported as relative risk (RR), where a RR < 1 favored the SSU strategy. Secondary outcomes included 90-day mortality and re-hospitalization, costs, and 1-month days-alive-and-out-of-hospital (DAOOH). Of the 467 articles identified by our search strategy, only 3 full text articles were included. In meta-analysis for the primary outcome of 30-day death or readmission, the RR was 0.95 (95% CI = 0.56 to 1.63; I2 = 0%) for patients randomized to SSU vs hospitalization (2 studies, 241 patients). There were only 2 total deaths at 30 days in the 2 studies (total N = 258) which reported 30-day mortality, both in hospitalized patients. Only one study reported 90-day outcomes, showing no significant differences. Costs were lower in the SSU arm from one study, and 30-day DAOOH also favored SSU based on a single randomized trial. Based on very limited evidence, SSU provides similar efficacy for 30-day and 90-day mortality and readmission compared to hospitalization. An SSU strategy appears safe and may be cost effective.

Cardiac autonomic nerve abnormalities in chronic heart failure are associated with presynaptic vagal nerve degeneration

BACKGROUND

Understanding of the functional and structural disturbances of cardiac autonomic nerves in ventricular hypertrophy and eventual chronic heart failure (CHF) remains unclear.

METHODS AND RESULTS

ECG signals were obtained by a radio transmitter from male Wistar rats that received monocrotaline (MCT) via subcutaneous injection. Heart rate (HR) and HR variability (HRV) were analyzed. The RR interval, total power (TP), low frequency (LF) power, high frequency (HF) power, and LF/HF (L/H) power ratio were measured. Ultrastructural changes in cardiac autonomic nerves at the sinoatrial (SA) node region were studied using an electron microscope. TP and HF powers in MCT-induced right ventricular hypertrophy (RVH) and eventual CHF were significantly decreased, and HR was significantly increased at week 5 or later after the MCT injection. The electron microscopic findings indicated the depletion of neurotransmitter vesicles and degradation of parasympathetic but not sympathetic nerve endings in the SA node region of the heart.

CONCLUSION

MCT-induced RVH and CHF rats showed presynaptic vagal nerve degradation prior to sympathetic nerve derangement in the heart.

Estimating observation unit profitability with options modeling

BACKGROUND

Over the past two decades, the use of observation units to treat such common conditions as chest pain, asthma, and others has greatly increased. These units allow patients to be directed out of emergency department (ED) acute care beds while potentially avoiding inpatient admission. Many studies have demonstrated the clinical effectiveness of care delivered in such a setting compared to the ED or inpatient ward. However, there are limited data published about observation unit finance.

METHODS

Using the economic principles of stock options, opportunity costs, and net present value (NPV), a model that captures the value generated by admitting a patient to an observation unit was derived. In addition, an appendix is included showing how this model can be used to calculate the dollar value of an observation unit admission.

RESULTS

A model is presented that captures more complexity of observation finance than the simple difference between payments and costs. The calculated estimate in the Appendix suggests that the average value of a single observation unit admission was about $2,908, which is about 40% higher than expected.

CONCLUSION

Subtraction of costs from payments may significantly underestimate the financial value of an observation unit admission. However, the positive value generated by an observation unit bed must be considered in the context of other projects available to hospital administrators.

Acute heart failure: new diagnostic perspectives for the emergency physician

The topic of heart failure (HF) in the emergency department is today relevant, since there are new serum markers and imaging techniques that may help in the diagnosis of this disease. Natriuretic peptides have now entered the flowchart for etiologic diagnosis in patients with acute dyspnea, when technical facilities are available. Recently, chest ultrasonography has been shown to be useful for the noninvasive assessment of extravascular lung water. Starting from this practical standpoint, we propose that simple chest ultrasonographic signs can provide a totally noninvasive characterization of pulmonary congestion in patients with HF.

Optimizing treatment and outcomes in acute heart failure: beyond initial triage

Heart failure contributes substantially to health care costs in the United States due to its prevalence and frequent necessity for repeat hospitalizations to manage episodes of acute decompensation. Heart failure overwhelmingly impacts Medicare costs, as the highest proportion of heart failure patients are older than 65 years of age. Efforts to reduce morbidity, mortality, and health care resource utilization have been achieved successfully through emergency department-based heart failure observation units. For select patients, the observation unit can provide care with effective oral agents, including angiotensin-converting enzyme inhibitors, beta-adrenergic receptor blockers, and diuretics, as well as administration of other vasoactive agents, followed by a discharge plan of effective heart failure education and rigorous follow-up management. As advanced pharmacologic and diagnostic therapies continue to emerge, the observation unit staff can play an integral role in the critical education and self-management tools that are needed by the patient to ultimately improve outcomes and quality of life.

Observation unit treatment of heart failure with nesiritide: results from the proaction trial

This was a multicenter, randomized, double-blind, placebo-controlled pilot study, evaluating the safety and efficacy of a standard care treatment regimen with the addition of either nesiritide or placebo (SCP) in 237 Emergency Department (ED)/Observation Unit (OU) patients with decompensated heart failure (HF). Efficacy measures included initial admission, length of hospital stay (LOS), and inpatient rehospitalization through 30 days. Compared to the standard care group, patients who also received nesiritide had 11% fewer inpatient hospital admissions at the index ED visit (55% SCP, 49% nesiritide, p = 0.436), and 57% fewer inpatient hospitalizations within 30 days after discharge from the index hospitalization (23% SCP, 10% nesiritide, p = 0.058). The duration of rehospitalization was shorter for nesiritide patients (median LOS 2.5 vs. 6.5 days, p = 0.032). The incidence of symptomatic hypotension was low and did not differ between the groups. This study showed that nesiritide is safe when used in the emergency department, observation units, or similar settings.

The Utility of Microvascular Perfusion Assessment in Heart Failure: A Pilot Study

BACKGROUND

The evaluation of heart failure is routinely based on subjective patient symptoms and physician examination. We propose the noninvasive evaluation of microvascular and global perfusion can objectify heart failure severity and provide additional prognostic information.

METHODS

A prospective, observational pilot study of patients previously stratified into New York Heart Association (NYHA) heart failure classes and who after a routine cardiology clinic evaluation were felt to be at their stable baseline state. Measurements included: thoracic impedance (Zo), hypothenar tissue hemoglobin oxygen saturation (StO2), and Zo-derived cardiac index (CI). To determine if adverse outcomes (hospitalization or death) occurred, patients or their families were contacted 6 months after enrollment and their charts reviewed. Monitor values between the NYHA classes were compared using analysis of variance. Values of those who later developed adverse outcomes were compared to patients who remained stable using a Student t-test (P < .05 considered significant). A Kaplan-Meier survival curve was used to describe the adverse outcome rate over time, and a Cox's proportional hazards model was used to relate perfusion values to adverse outcomes.

RESULTS

There were no differences in CI (P = .08), Zo (P = .38), or StO2 (P = .14) found between NYHA classes (n = 46). After 6 months, 6 patients required hospitalization for heart failure and 1 died. This group had lower StO2 values compared with the stable group (P = .015). The time course of the adverse events was found not to be due to chance alone when evaluated using a Kaplan-Meier curve and the StO2 was significantly associated with time to adverse outcome (P < .05).

CONCLUSIONS

Outpatient heart failure patients who later develop adverse outcomes have significantly lower StO2 values than those who remain stable. This suggests cardiac performance in stable heart failure patients may be better reflected at the microvascular level using measures such as StO2 as opposed to a global level using the physical exam or impedance cardiography. StO2 may serve as a predictor for future adverse events and as an adjunct to current evaluation techniques.

Nesiritide for the treatment of decompensated heart failure

Heart failure is the leading cause of hospitalizations in the USA, and is associated with significant morbidity, mortality and resource utilization. Established therapies for chronic heart failure have been shown to improve outcomes, but treatment for decompensated heart failure remains largely empiric. Nesiritide (Natrecor) is a synthetic analog of human B-type natriuretic peptide, a peptide released by the ventricular myocardium in response to increased wall tension. The physiologic effects of human B-type natriuretic peptide include natriuresis, vasodilation and neurohormonal modulation. In clinical trials, nesiritide has been shown to decrease cardiac filling pressures, increase cardiac index, and improve the clinical status of patients with acute decompensated heart failure. Compared with other available intravenous agents for heart failure, nesiritide is effective, generally well-tolerated with few adverse effects, and does not require invasive monitoring during administration. Nesiritide has proven to be an effective new treatment for patients with decompensated heart failure.