Classification of Patients With Acute Heart Failure Syndromes in the Emergency Department

Ischemic Electrocardiographic Abnormalities and Prognosis in Decompensated Heart Failure

Background—

Identification of coronary ischemia may enable targeted diagnostic and therapeutic strategies for acute heart failure. We determined the risk of 30-day mortality associated with ischemic ECG abnormalities in patients with acute heart failure.

Methods and Results—

Among 8772 patients (53.4% women, median 78 years [Q1, Q3: 68,84]) presenting with acute heart failure to 86 hospital emergency departments in Ontario, Canada, Q-waves, T-wave inversion, or ST-depression were present in 51.8% of subjects. However, presence of ST-depression was the only finding associated with 30-day mortality with adjusted odds ratio 1.24 (95% confidence interval [CI], 1.02–1.50). Using continuous net reclassification improvement, addition of ST-depression to the Emergency Heart failure Mortality Risk Grade model reclassified 16.9% of patients overall, and 29.3% of those with a history of ischemic heart disease (both P <0.001). By adding ST-depression to the model, the Emergency Heart failure Mortality Risk Grade was extended to predict 30-day death with high discrimination ( c -statistic 0.801), with 0.57% mortality rate in the lowest risk decile. Adjusted odds ratios for 30-day mortality were 2.81 (95% CI, 1.48–5.31; P =0.002) in quintile 2, 7.41 (95% CI, 4.13–13.30; P <0.001) in quintile 3, and 14.47 (95% CI, 8.20–25.54; P <0.001) in quintile 4 compared with the lowest risk quintile. When the highest risk quintile was subdivided into 2 equally sized risk strata (deciles 9 and 10), the adjusted odds ratios for 30-day mortality were 27.20 (95% CI, 15.33–48.27; P <0.001) in decile 9 and 58.96 (95% CI, 33.54–103.65; P <0.001) in highest risk decile 10.

Conclusions—

Presence of ST-depression on the ECG reclassified risk of 30-day mortality in patients with acute heart failure, identifying both high- and low-risk subsets.

Treatment of acute heart failure in the emergency department

Millions of patients are hospitalized for acute heart failure (AHF) every year throughout the world. Despite tremendous advances in cardiovascular care, morbidity and mortality for AHF remain high, consuming billions of health care dollars. With the aging of the population, the incidence and prevalence of HF is projected to increase. Yet, initial treatment of AHF today is similar to 40 years ago. Multiple studies have yielded new insights regarding initial management, with regards to both treatment and strategies of care. These advances will be reviewed in the context of initial or early AHF management. There remains, however, an unmet need to improve outcomes for AHF patients.

Acute Heart Failure Treatment

Dyspnea is the predominant symptom for patients with acute heart failure and initial treatment is largely directed towards the alleviation of this. Contrary to conventional belief, not all patients present with fluid overload and the approach to management is rapidly evolving from a solitary focus on diuresis to one that more accurately reflects the complex interplay of underlying cardiac dysfunction and acute precipitant. Effective treatment thus requires an understanding of divergent patient profiles and an appreciation of various therapeutic options for targeted patient stabilization. The key principle within this paradigm is directed management that aims to diminish the work of breathing through situation appropriate ventillatory support, volume reduction and hemodynamic improvement. With such an approach, clinicians can more efficiently address respiratory discomfort while reducing the likelihood of avoidable harm.