Author’s Disclosure Statement: Dr. Peacock reports that he has received research grants from Abbott Laboratories, Janssen Pharmaceuticals, Inc, Hoffman LaRoche, and ZS Pharma Inc; serves as a consultant for Bayer Corporation, Beckman Coulter Life Sciences, Boehringer Ingelheim, Instrumentation Laboratory, Janssen Pharmaceuticals, Relypsa Inc, Hoffman LaRoche, and ZS Pharma Inc; has provided expert testimony for Johnson and Johnson; and has ownership interests in Comprehensive Research Associates LLC, Emergencies in Medicine LLC, and Ischemia DX, LLC.
Although a randomized controlled trial on the importance of time to treatment of AHF is unlikely to ever be completed, data suggest that, as in the case of MI, delayed AHF therapy is associated with adverse outcomes. In a study of 499 suspected AHF patients transferred by ambulance, patients randomized to immediate therapy vs those whose therapy was not initiated until hospital arrival (mean delay of 36 minutes), had a 251% increase in survival (P < 0.01).67
Furthermore, the delayed administration of vasoactive agents, defined as medication administered to alter hemodynamics (eg, dobutamine, dopamine, nitroglycerin, nesiritide) is also associated with harm,68 and registry studies demonstrate increased death rates (n = 35,700).69 Finally, another registry (n = 14,900) study demonstrated early IV furosemide is associated with decreased mortality.70 This latter finding was also validated in a prospective observational cohort study (mortality 2.3 vs 6.0 in early vs delayed therapy groups, respectively).71
Patient Disposition
One of the unique features of emergency medicine is the need to determine, with very limited information and time, a patient’s very short-term clinical trajectory. Few physicians are required to have greater accuracy with less information or time than do EPs. Several studies report objective data points and risk scores to assist in this task, but none has been universally adopted, reflecting the challenge of applying population data to individuals.
Short-term Prognosis
In 1,638 patients evaluated for 14-day outcomes, an HR lower than 50% maximal HR (MHR), and an SBP greater than 140 mm Hg were associated with the lowest rate of serious adverse events (SAEs) (6%) and hospitalization (38%).72 An MHR over 75% was associated with the highest SAE rate, although SAEs decreased as SBP increased (30%, 24%, and 21% with SBPs < 120 mm Hg, 120-140 mm Hg, and > 140 mm Hg, respectively).72
Risk Scores
In a prospective, observational cohort study of 1,100 ED patients, the Ottawa Heart Failure Risk Scale, combined with NTproBNP values, had a sensitivity of 95.8%—at the cost of increasing the admission rate (from 60.8% to 88%)—for serious adverse events (defined as death within 30 days), admission to a monitored unit, intubation, NIV, MI, or relapse resulting in hospital admission within 14 days.73
Observation Unit
Overall, 44% of in-patient HF admissions are for less than 3 days (Table 1),2 supporting the practice of managing selected patients in shorter clinical-care environments than in inpatient units. Further, ED patients presenting with moderate dyspnea require both a diagnosis and an evaluation of their therapeutic response to determine the need for hospitalization. However, evaluating therapeutic response requires more time than is available in the typical ED. Thus, an ED OU offers the following:
(1) The OU provides the EP with a longer evaluation time, and therefore a more accurate disposition may be effected;
(2) Costs are significantly lower in patients managed in an ED OU; and
(3) Patient satisfaction may be improved, as most patients prefer home management over hospitalization.
All three of these opportunities are supported by a number of studies,74-78 with validated entry and exclusion criteria, treatment algorithms and discharge metrics. Most recently, in a registry of hospitals in Spain registry, patients presenting to hospitals that had OUs had a 2.2-day shorter LOS, lower 30-day ED revisit rate, and similar mortality rates compared to those in institutions without OUs—although these beneficial effects occurred at the cost of an 8.9% higher admission rate.79
Patient Education
Intuitively, it would be expected that patient education would reduce return visits, 30-day hospitalizations, and AHF-related mortality. Unfortunately, it has not been demonstrated that patient education results in a consistent benefit at hospital discharge, or in the outpatient environment.80-85
Although AHF education in the ED has been poorly studied, areas that have shown promise are education occurring before ED management (ie, in the ED waiting area) in underinsured patients,86 and during ED care for patients with poor health care literacy.87 As educational interventions are both inexpensive and unlikely to result in harm, their implementation should be considered.
Conclusion
The spectrum of HF is a common presentation in the ED. Because HF generally appears as dyspnea, in a cohort with multiple comorbidities, the diagnosis can be challenging. This is complicated by the fact that patients with severe presentations may require life-saving interventions long before a clinical evaluation is completed (or even initiated). The skill of the EP, and his or her ability to improve the clinical condition before intubation is required, will determine the patient’s trajectory. Conversely, as a chronic condition, HF may present with moderate symptoms for which a short diuretic “tune-up” in an observation environment may be appropriate.
How these decisions are made will depend upon the local environment, the availability of outpatient resources, and individual patient choices. There are few chronic diseases that are more complex, are seen more often in the ED, or that require more skill and finesse in management.
