Download Characteristics and clinical course of patients with acute heart failure

Emergencias 2015;27:11-22
ORIGINAL ARTICLE
Characteristics and clinical course of patients with acute
heart failure and the therapeutic measures applied in
Spanish emergency departments: based on the EAHFE
registry (Epidemiology of Acute Heart Failure in
Emergency Departments)
Pere Llorens1, Rosa Escoda2, Òscar Miró2, Pablo Herrero-Puente3, Francisco Javier Martín-Sánchez4,
Javier Jacob5, José Manuel Garrido6, María José Pérez-Durá7, Cristina Gil8, Marta Fuentes8, Héctor
Alonso9, Christian Muller10, Alexander Mebazaa11, en representación de los participantes del
estudio del grupo de trabajo ICA-SEMES (Anexo 1)
Objectives. To analyze data recorded in the EAHFE registry (Epidemiology of Acute Heart Failure in Emergency Departments), which collects information on the clinical characteristics and laboratory findings of patients with acute
heart failure (AHF) treated in 29 Spanish hospital emergency departments (EDs) as well as therapies used and clinical
course. We analyzed changes in management observed over time and compared the results with data recorded in
other AHF registries.
Material and methods. Prospective multicenter cohort study of consecutive patients treated in 3 different years:
2007, 2009, and 2011. We collected demographic, clinical, and laboratory data; medications taken prior to the emergency and in the ED; and outcome variables (in-hospital and 30-day and 1-year mortality rates, readmissions within
30 days). Changes in therapy and course in the 3 years were analyzed. The literature was reviewed to find other national and international AHF registries.
Results. A total of 5845 patients were included (2007, 948; 2009, 1483; 2011, 3414). The mean age was 79 years
and 56% were women. The AHF episode registered was the first experienced by 34.6% of the patients. Comorbidity
was high: 82% had hypertension, 42.3% had diabetes mellitus, and 47.7% had atrial fibrillation. Severe or total functional dependence was observed in 21.9%, and 57.3% had systolic dysfunction (left ventricular ejection fraction,
38.3%). The main treatments administered consisted in diuretics (96.8%), endovenous nitroglycerine (20.7%), noninvasive ventilation (6.4%), and inotropic agents or vasopressors (3.6%). The glomerular filtration rate was low in 57%.
Troponin and natriuretic peptide levels were measured in the EDs in 49.1% and 42.4% of the cases, respectively. Patients presented as normotensive in 66.4% of the cases, hypertensive in 23.5%, and hypotensive in 4.6% (0.7% in
shock); 76.1% were admitted (1.9% to the ICU). The median hospital stay was 7 days and 23.9% were discharged
from the ED. In-hospital mortality was 7.6%; 30-day mortality was 9.4% and 1-year mortality 29.5%. Orders for troponin and natriuretic peptide determinations increased over the 3 study periods, and the intravenous infusion of diuretics and inotropic agents and vasoconstrictors decreased (P < 0.001, all comparisons). Revisits within 30 days also
decreased (P = 0.004). No changes were observed in in-hospital or 30-day mortality rates between 2007 and 2011.
We reviewed 14 previously published registry reports (8 compiled prospectively); only 2 of the registries included ED
patients.
Conclusions. The EAHFE registry describes the characteristics of AHF in a cohort that resembles the universe of our
patients with AHF. Significant changes were observed over time in some aspects of AHF management. Revisits decreased, but mortality rates remained unchanged. Only 2 other previously analyzed registries included patients with
AHF treated in hospital EDs.
Keywords: Acute heart failure. Hospital emergency health services. Therapy. Clinical course. Registries.
Características clínicas, terapéuticas y evolutivas de los pacientes con
insuficiencia cardiaca aguda atendidos en servicios de urgencias españoles:
Registro EAHFE
Affiliation of authors:
Emergency Service, Short Stay
Unit and Home Care Unit,
University Hospital General de
Alicante, Alicante, Spain.
2
Emergency Service, Hospital
Clinic of Barcelona, Research
Group "ER: processes and
pathologies", IDIBAPS, Barcelona,
Spain.
3
Emergency Service, Hospital
Universitario Central de Asturias,
Research Group ER-HUCA,
Oviedo, Spain.
4
Emergency Service and Short
Stay Unit, Hospital Clinico San
Carlos, Madrid, Spain.
5
Emergency Service, Hospital
Universitario de Bellvitge,
Barcelona, Spain.
6
Emergency Service, Hospital
Virgen de la Macarena, Sevilla,
Spain.
7
Emergency Department,
Polytechnic Hospital La Fe,
Valencia, Spain.
8
Emergency Service, Hospital
Universitario de Salamanca,
Salamanca, Spain.
9
Emergency Service, Hospital
Marqués de Valdecilla, Santander,
Spain.
10
Cardiology Department,
University Hospital of Basel, Basel,
Switzerland.
11
Department of Anaesthesia and
Intensive Care, INSERM UMR 942,
Lariboisière Hospital, University of
Paris - Diderot, Paris, France.
1
Corresponding author:
Pere Llorens
General Emergency Service.
General Hospital of Alicante
C / Pintor Baeza 12.
03010 Alicante, Spain
Email:
[email protected]
Item Information:
Received: 11/11/2014
Accepted: 12/26/2014
Online: 02/11/2015
Objetivos. Presentación de los resultados del Registro EAHFE (Epidemiology of Acute Heart Failure in Emergency
Departments) que recoge las características clínicas, de laboratorio, terapéuticas y la evolución de los pacientes
con insuficiencia cardiaca aguda (ICA) atendidos en 29 servicios de urgencias hospitalarios (SUH) españoles. Se
analizan los cambios de manejo a lo largo del tiempo; y se comparan los resultados con los de otros registros
de ICA.
Material y métodos. Estudio multicéntrico, de cohortes, prospectivo, de inclusión consecutiva, realizado en tres periodos (2007, 2009 y 2011). Se recogieron datos demográficos, clínicos, de laboratorio, del tratamiento farmacológi-
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Llorens P, et al. Emergencias 2015;27:11-22
co previo y el administrado en SUH y variables evolutivas (mortalidad intrahospitalaria y a los 30 días y al año, reingreso a 30 días). Se analizaron los cambios terapéuticos y evolutivos a lo largo de estos 3 periodos. Se revisó la literatura para identificar registros previos de ICA de carácter nacional o internacional.
Resultados. Se incluyeron 5.845 pacientes (2007: 948, 2009: 1.483, 2011: 3.414), con edad media de 79 años y
56% mujeres. Un 34,6% era un primer episodio de ICA. Presentaron elevada comorbilidad (82% hipertensión,
42,3% diabetes mellitus, 47,7% fibrilación auricular). Un 21,9% tenía dependencia funcional grave o total. El
57,3% tenía una disfunción sistólica (FEVI 38,3%). Los principales tratamientos administrados en urgencias consistieron en diuréticos (96,8%), nitroglicerina endovenosa (20,7%), ventilación no invasiva (6,4%) y fármacos inotrópicos o vasopresores (3,6%). El 57% presentaba una tasa de filtrado glomerular disminuida. Las troponinas y los
péptidos natriuréticos se determinaron en urgencias en un 49,1% y 42,4% de casos, respectivamente. Las formas
de presentación se clasificaron como: normotensiva (66,4%), hipertensiva (23,5%), hipotensiva (4,6%, 0,7% con
shock). El 76,1% fue ingresado (1,9% en intensivos), con una mediana de estancia hospitalaria de 7 días, y el
23,9% dado de alta desde urgencias. La mortalidad intrahospitalaria fue 7,6%, a 30 días 9,4% y al año 29,5%. A
lo largo del periodo estudiado, ha aumentado la solicitud de troponinas (p < 0,001) y péptidos natriuréticos
(p < 0,001) en urgencias, ha disminuido el uso de diuréticos en perfusión (p < 0,001) y de inotropos/vasoconstrictores (p < 0,001) y ha disminuido el porcentaje de reconsulta a 30 días (p = 0,004). No se observaron cambios en
la mortalidad intrahospitalaria y a los 30 días entre el periodo 2007-2011. Se han revisado 14 registros anteriores
(8 prospectivos), y solo en 2 la inclusión de pacientes se hizo desde el SUH.
Conclusiones. El Registro EAHFE describe las características de la ICA a partir de una cohorte que se aproxima al
universo de pacientes con ICA. Con el paso del tiempo se observan cambios significativos en algunos aspectos del
manejo de la ICA; las revisitas han disminuido, aunque la mortalidad no se ha modfiicado. Aparte del Registro
EAHFE, solo existen otros 2 registros previos en el mundo que hayan incluido pacientes con ICA atendidos en urgencias.
Palabras clave: Insuficiencia cardiaca aguda. Servicios de Urgencias Hospitalarios. Características. Manejo. Evolución. Registro.
Introduction
Acute heart failure (AHF) is one of the leading causes
of hospitalization and represents a major economic and
medical burden in any public health system. It is associated with increased hospital mortality after discharge, as
well as high rates of readmission1. The diagnosis, management and treatment of AHF in routine clinical practice is
based on data from different observational epidemiological studies, clinical trials and expert consensus documents.
All this information is reflected in the guidelines of different societies and countries2-4. However, the records from
different countries show discrepancies, sometimes substantial, between actual therapies and guideline indications5 and the results in terms of morbidity and mortality
are often very different between hospital centers. In addition, geographical variations depending on the location
of the study may include differences in age, race, ethnicity, culture, social and economic circumstances, health
resources and health systems that affect the management
and even the course of the disease6.
Hospital emergency departments (EDs) and observation units (OU), where patients are usually located for
periods of less than 24 hours, play a central role in the
management of AHF. In Spain, as in most countries
with a public health system, the vast majority of these
patients are initially treated in the ED. The care provided there is a key factor, since rapid identification of
the different scenarios and complications of AHF and its
proper treatment determine short and medium term
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prognosis4,7. Additionally, proper risk stratification in the
ED may help select patients at low or intermediate risk,
some of whom may be discharged directly from the ED
thus avoiding unnecessary hospital admissions8. Data
from different countries indicate that this percentage
ranges between 20% and 40%9,10.
EDs, on attending most patients with AHF, allow a
more global view, which approximates the reality of the
disease. However, most AHF records describe hospitalized patients or those managed in specialized units,
which excludes the proportion of patients discharged
directly from the ED10-24. In addition, most records are
cross-sectional and analyze the management of AHF in
a cohort of the population attended at a particular moment of time. This prevents assessing the degree of adherence of the professionals caring for AHF patients to
current management guidelines, and the effect of training programs designed to correct deviations, which
are only identifiable through studies with a longitudinal
design25. For the first time, the present study describes
overall results from the EAHFE Registry (Epidemiology of
Acute Heart Failure in Emergency Departments), whose
general objective was to remedy the above-mentioned
limitations. In particular, the three specific objectives of
this paper were: 1) to describe the clinical characteristics, laboratory findings, treatment and outcome of AHF
patients seen in Spanish EDs; 2) to detect changes in
the management of these patients in such EDs over time; and 3) compare the results of this registry with
those of other published AHF registries.
Llorens P, et al. Emergencias 2015;27:11-22
Method
The EAHFE26 Registry is a multipurpose, multicenter, non-interventional analytical cohort study with
prospective follow-up. The EAHFE Registry has had
three phases of patient inclusion to date: the first
(EAHFE-1), from April 15 to May 15, 2007 (1 month
in 10 EDs); the second (EAHFE-2) was conducted between 1 and 30 June 2009 (1 month, 19 EDs) and the
third (EAHFE-3) between November 7, 2011 and January 7, 2012 (2 months, 29 EDs). Participating hospitals are widely distributed in Spain and include university hospitals, referral hospitals and community
hospitals (see list of centers in the Annex on participating centers). During these periods, participating EDs
included all consecutive AHF patients. The diagnostic
criteria are based on the presence of symptoms
(dyspnea, orthopnea, paroxysmal nocturnal dyspnea)
and acute signs of AHF (third heart sound, pulmonary
rales, jugular venous pressure greater than 4 cm, sinus
tachycardia at rest, edema, hepatomegaly, hepatojugular reflux) and radiological evidence of pulmonary
congestion.
The only exclusion criterion is a diagnosis of acute
myocardial infarction with ST elevation as the primary
diagnosis and concomitantly development of AHF. All
participating EDs have a principal investigator, and all
principal investigators meet one month before starting
the inclusion period to agree and unify criteria. Subsequently, and prior to the patient inclusion period,
each principal investigator meets with his/her ED
physicians to explain the protocol, since they all participate in the detection of patients with AHF. When a
case is detected, the principal investigator checks that
the patient meets the inclusion criteria, in which case
all the variables are recorded on a specific data sheet.
The variables have not differed substantially between
periods. This action protocol was the same in all three
periods of recruitment for the EAHFE registry, and at
no time was there any intervention, since all management is provided by the medical team responsible
with their usual care procedures.
The registry is prepared in accordance with the
Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, and patients
give their informed consent to participate. The full
protocol was approved by the ethics and clinical research committees of the participating hospitals.
Part 1: Descriptive analysis of the EAHFE Registry
Baseline patient data include demographics (age and
sex), comorbidity (history of hypertension, diabetes mellitus, dyslipidemia, coronary artery disease, valvular heart
disease, atrial fibrillation, chronic renal failure - creatinine
higher than 2 mg / dL, stroke, chronic obstructive pulmonary disease -COPD-, peripheral artery disease, diagnosis of dementia and previous episodes of AHF), baseline functional status (functional dyspnea according to the
New York Heart Association -NYHA-), echocardiographic
data in the event of having had an echocardiogram performed in the year before the ED visit, baseline functional status, measured by the Barthel27 index, (0-20 points:
total dependence; 21-60: severe dependence; 61-90:
moderate dependence, 91-99: little or mild dependence,
and 100: independence), and treatment prior to the ED
visit (diuretics, beta blockers, angiotensin converting
enzyme inhibitors – ACEI - angiotensin receptor antagonists of angiotensin II - ARA-II, calcium channel blockers,
aldosterone inhibitors, anticoagulants, antiplatelet agents,
digoxin and cardiac resynchronization therapy).
Data from the acute episode of AHF include vital
signs on ED arrival (systolic blood pressure or SBP, heart
rate – HR - and respiratory rate - RR), analytical data (hemoglobin with anemia defined according to recommendations of the WHO, glucose, creatinine, urea, estimated
glomerular filtration test - eGF- using the abbreviated formula of the study Modification of Diet in Renal Disease MDRD28-, sodium, troponin and natriuretic peptides, although the latter are not available in all EDs), ECG data,
treatment administered in the ED and the destination of
the patient after ED care (discharge or admission, and
the hospital department in the latter case).
With existing clinical history data, the principal investigator of each center performed two independent classifications of the episode. On the one hand, the episode of
AHF was classified as hypertensive, normotensive, hypotensive, pulmonary edema, cardiogenic shock and isolated right heart failure. This classification was performed
with EAHFE patients included in periods 2 and 32. On the
other hand, for the EAHFE periods 1 and 3, the researcher classified each episode depending on whether there
was any trigger for the AHF, judging by the data collected and the comments made in the clinical history by
the medical care team, and what this factor was. In the
latter case, more than one episode triggering factor
could be assigned.
Finally, the EAHFE Register also collects data from patient follow-up, consisting of the total hospital stay when
appropriate, hospital mortality and follow-up mortality,
as well as ED revisits for a new episode of AHF within 30
days. This was done through a phone call or by consulting the clinical history or primary care consultation 3060 days after the index event. In addition, a new phone
call or consultation within one year from the index event
was used to assess the long-term mortality.
Part 2: Evolutionary analysis
To compare possible changes over time in the management of AHF in Spanish ED patients, we analyzed
data from the 8 EDs who had participated in all three
periods of recruitment: EAHFE-1 in 2007, EAHFE-2 in
2009 and EAHFE-3 in 2011 (Hospital Marqués de Valdecilla in Santander, University Hospital of Salamanca,
Hospital de Bellvitge in L'Hospitalet de Llobregat, Hospital Clinic of Barcelona, Hospital Universitario Central de
Asturias in Oviedo, Hospital Clinico San Carlos in Madrid, Hospital La Fe in Valencia and Alicante General
Hospital). For each of these patients we analyzed the
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Llorens P, et al. Emergencias 2015;27:11-22
emergency physicians approach to the application of
troponin and natriuretic peptide in the ED, the treatment administered in such EDs, and patient willingness.
Additionally, in these centers we investigated the evolution of in-hospital 30-day mortality and 30-day revisits
to the ED.
Part 3: Review of previous AHF records
Se compararon las principales características de los
pacWe compared the main characteristics of EAHFE registry patients with those reported in other published
registries. Medline was used as a search engine, with the
words "Acute Heart Failure" and "Registry" as descriptors
for review of the literature. Abstracts of papers were reviewed and those that met all the following criteria were
chosen: main registries, multicenter, nationwide or international collaboration in which AHF was the principal
diagnosis, analysis of aspects of care in the ED or during
hospitalization concerning the acute episode, and intensive care units (ICU) were not the primary destination of
patients. Papers that met these criteria were reviewed in
full text. In addition, cross-references that appeared in
these articles were reviewed.
Statistical analysis
Qualitative variables are expressed as frequencies
and percentages, and continuous variables as means
and standard deviation (SD). Tables and survival curves
were elaborated using Kaplan-Meier method. Chi-square test for linear trend was used to compare possible
changes in the management of patients with AHF in
the ED over time. Differences with a p value less than
0.05 were considered significant. All analyses were performed using SPSS 18.0..
Results
Part 1: Patient characteristics Registry EAHFE
The EAHFE registry included 5,845 patients with AHF
(EAHFE-1: 948, EAHFE-2: 1,483, EAHFE-3: 3,414 patients). The average age was 79 years (SD 10) and 56%
were women; 34.6% of the cases were first episodes of
AHF (de novo). Regarding comorbidity, 82% had hypertension, 42.3% diabetes mellitus, 47.7% atrial fibrillation
and 24.6% COPD. Almost a quarter (22.6%) were NYHA
functional class I at baseline and 37.5% had functional
independence (Barthel 100 points). At the other extreme, 25.1% of patients had a functional class NYHA III-IV
and 21.9% had severe or total functional dependence
(Barthel  60 points). 38.1% had an echocardiogram,
which showed systolic dysfunction in 57.3% of cases.
Left ventricle ejection fraction (LVEF) was 50.6% (38.3%
for the subgroup of patients with systolic dysfunction).
The main treatments that patients received chronically
for their heart failure were loop diuretics 67.2% ACE inhibitors or ARBs 55.9% and beta-blockers 32.7%. Other
baseline characteristics are shown in Table 1.
14
The data collected during the acute episode is reported in Table 2. Notably, we observed anemia in 57.1%
of patients, blood glucose greater than 180 mg / dl in
20.6%, natremia lower than 135 mEq / L 20.8% and
GFR lower than 60 mL / h / m2 1.73 in 57%. Troponins
and natriuretic peptides were determined in the ED in
49.1% and 42.4% of patients, respectively. Regarding
treatment, we would highlight the predominant use of
diuretics (96.8%; mainly in bolus form) and noninvasive
ventilation (NIV) in 6.4% and inotropes or vasopressors
in 3.6%.
The predominant form of presentation, observed in
two thirds of cases, was normotensive AHF, followed by
hypertensive AHF, which was observed in almost a quarter of patients. Only 0.7% of AHF presented with shock
(Figure 1). In 523 cases (11%), the clinical diagnosis was
acute pulmonary edema (EAP). Furthermore, in 77% of
patients we were able to identify at least one trigger,
most frequently infection (41.6% of patients where a
triggering factor was identified). The remaining factors
are detailed in Table 3. After treatment in the ED,
76.1% of patients with AHF were admitted to wards
(1.9% admitted to ICU) and 23.9% were discharged directly from the ED or OU (Figure 2).
The average stay for hospitalized patients was 9 (SD
15) days, with a median of 7 days (IQR: 7). Hospital
mortality was7.6%, overall mortality at 30 days was
9.4% and the rate of revisits within 30 days was 20%.
Figure 3 shows the survival curve for mortality at one
year, reaching 29.5%.
Part 2: Evolutionary analysis.
Comparison between EAHFE Registries 1, 2 and 3
The 8 EDs that participated in the three EAHFE phases contributed a total of 2,865 patients (EAHFE 1: 825;
EAHFE 2: 722; EAHFE 3: 1318). The determination of troponins and natriuretic peptides in the ED during the period increased (Table 4). As for treatment in the ED, we
observed highlights a significant decrease in the use of
diuretics in perfusion and inotropes and vasopressors.
However, ED use of intravenous nitroglycerin has not
changed significantly over time. The ratio of patients
hospitalized and discharged from the ED has not changed significantly. Regarding follow-up data of these patients, neither in-hospital mortality nor 30-day mortality
changed significantly over time changes, but the rate of
return visits to the ED for AHF within 30 days showed a
significant decrease (Figure 4).
Part 3: Review of previous AHF records
Of 76 studies initially identified, 13 met the criteria
for inclusion. The complete review of these items resulted in four exclusions since they were sub-studies, so 9
studies were analyzed. In addition, through cross references, another 5 items were identified and finally included, so that 14 studies were finally reviewed (Table
5). Of these, 9 registries were prospective and 6 retrospective; in 12 of them, patients were hospitalized (6
Llorens P, et al. Emergencias 2015;27:11-22
Table 1. Baseline characteristics of patients with acute heart
failure
Total
n (%)
Table 2. Characteristics of acute episode of heart failure
Total
n (%)
Epidemiological data
Age,
Edad,years
años[mean
[media(SD)]
(DE)]
79.3 (10.4)
Female
sex
Sexo mujer
3,304 (56.5)
Medical history
Hypertension
Hipertensión arterial
4,824 (82.7)
Diabetes mellitus
2,464 (42.3)
Dyslipidemia
Dislipemia
2,235 (38.3)
Ischemic
heart
disease
Cardiopatía
isquémica
1,785 (30.6)
Chronic
renalrenal
failure
Insuficiencia
crónica
1,302 (22.3)
Cerebrovascular
disease
Enfermedad cerebrovascular
736 (12.6)
AF
Fibrilación auricular
2,780 (47.7)
Valve
disease
Valvulopatía
1,536 (26.4)
Peripheral
disease
Arteriopatíaartery
periférica
467 (8.0)
COPD
EPOC
1,432 (24.6)
Dementia
Demencia
451 (7.7)
Neoplasia
512 (8.8)
Cirrhosis
Cirrosis
66 (1.1)
Previous
heartcardiaca
failure previa
Insuficiencia
3,695 (65.4)
Baseline data
Cardiorespiratory
(stage
NYHA)
Cardiorrespiratoria
(estadio
de la NYHA)
II
1,220 (22.6)
IIII
2,822 (52.3)
IIIIII
1,261 (23.4)
IVIV
92 (1.7)
Functional(Índice
(BarthelBarthel)
Index)
Funcional
Functional independence
(100puntos)
points)
Independencia
funcional (100
1,931 (37.5)
Mild
dependence
Dependencia
leve(91-99
(91-99points)
puntos)
269 (5.2)
Moderate
dependence
(61-90
points)
Dependencia
moderada
(61-90
puntos)
1,680 (32.6)
Severe
dependence
Dependencia
grave (21-60
(21-60 points)
puntos)
944 (18.3)
Total
dependence
Dependencia
total(0-20
(0-20points)
puntos)
332 (6.4)
Type de
echocardiographic
dysfunction(n
(n==2226)
2226)
Tipo
disfunción ecocardiográfica
systolic
Sistólica
1,275 (57.3)
diastolic
Diastólica
930 (41.8)
mixed
Mixta
21 (0.9)
Left ventricular
ejection
fraction [mean
(SD)]
Fracción
eyección
del ventrículo
izquierdo
[media (DE)]
All
patients
Todos
los pacientes
50.6 (15.9)
Patients
with
dysfunction
Pacientes
consystolic
disfunción
sistólica
38.3 (12.6)
Pre-hospital treatment
Diuretics ASA
Diuréticos
ASA
3,860 (67.2)
ACE inhibitors and ARBs
IECA-ARAII
3,266 (55.9)
Beta blockers
Betabloqueantes
1,878 (32.7)
Aldosterone antagonists
Antagonistas
de la aldosterona
961 (16.7)
Digoxin
Digoxina
1,132 (19.7)
CRT
Dispositivos
TRC
472 (8.2)
SD: standard deviation; COPD, chronic obstructive pulmonary disease;
NYHA, New York Heart Association; SBP, systolic blood pressure. ACEI
ARBs: angiotensin converting enzyme / angiotensin-II receptor antagonists; CRT: cardiac resynchronization therapy.
Vital Signs
Systolic arterial
blood pressure
Presión
sistólica (mmHg) [mean
[media(SD)]
(DE)]
142 (29)
<140
< 140mmHg
mmHg
2.775 (66.4)
<120
< 120mmHg
mmHg
1.167 (20)
<100
< 100mmHg
mmHg
271 (4.8)
<80
< 80mmHg
mmHg
23 (0.4)
Diastolicarterial
blood diastólica
pressure (mmHg)
Presión
(mmHg)[mean
[media(SD)]
(DE)]
77 (17)
Heart rate (bpm)
[Mean
Frecuencia
cardiaca
(lpm)(SD)]
[media (DE)]
90,1 (24.7)
Respiratory respiratoria
rate (bpm) (rpm)
[mean[media
(SD)] (DE)]
Frecuencia
23 (7)
Oxygen saturation
Saturación
basal de on
o] arrival (%) [mean (SD)]
92 (7)
Electrocardiogram
AF
Fibrilación
auricular
2.342 (40.1)
Left ventricular
hypertrophy
Hipertrofia
ventricular
izquierda
293 (5)
Left bundle
branch
block
Bloqueo
de rama
izquierda
521 (8.9)
Laboratory data
Hemoglobina(g(g/dl)
(DE)]
11,8 (2.0)
Hemoglobin
/ dl) [media
[mean (SD)]
(< 12inenwomen
mujeres,
< 13
en hombres)
3.216 (57.1)
Anemia (<12
<13
in men)
Glucemia(mg
(mg/dl)
[media(SD)]
(DE)]
143 (73)
Glucose
/ dl) [mean
110
2.980 (64.2)
>>110
140
1.519 (37.2)
>>140
180
841 (20.6)
>>180
Creatinina (mg
(mg/dl)
1.3 (0.8)
Creatinine
/ dl)[media
[mean(DE)]
(SD)]
2
[media
(DE)]
Filtrado glomerular
(ml/min/1,73
m2) m
) [mean
(SD)] 58.2 (26,4)
Glomerular
filtration rate
(ml / min / 1.73
< 60
4.149 (57)
<60
< 30
771 (14)
<30
< 15
133 (2.4)
<15
Sodio (mEq/L)
(DE)]
137 (5)
Sodium
(mEq /[media
L) [mean
(SD)]
< 135
1.152 (20.8)
<135
< 130
330 (6.0)
<130
< 125
114 (2)
<125
< 115
13 (0.2)
<115
Péptidos natriuréticos
[mediana
(RIC)]
Natriuretic
peptides [median
(IQR)]
NT-proBNP(pg
(pg/mL)
4.010 (6.847)
NT-proBNP
/ mL)(n
(n==2.096)
2,096)
BNP(pg
(pg/mL)
698 (1.354)
BNP
/ mL)(n
(n==382)
382)
Troponinas(n(n= =2,869)
2.869)
Troponins
Positivas*
1.309 (45)
Positive
*
Positivastroponin
de la troponina
T de 4ª generación
(n = 523 181 (34.6)
Positive
T 4th generation
(n = 523)
Positivasultrasensitive
de la troponina
T ultrasensible
(n = 887)
724 (81.3)
Positive
troponin
T (n = 887)
Positivastroponin
de la troponina
I (n = 1.458)
404 (27.8)
Positive
I (n = 1,458)
Treatment
Oxygen
Oxigenoterapia
4.519 (78.5)
Non-invasive
Ventilación noventilation
invasiva
377 (6.4)
Bolus
intravenous
diuretics
Diuréticos
intravenosos
bolo
5.069 (86.7)
Diuretics
intravenousperfusión
infusion
Diuréticosbyintravenosos
591 (10.1)
Intravenous
nitroglycerin
Nitroglicerina
intravenosa
1.190 (20.7)
Inotropic
or ovasopressor
treatment
Inotrópicos
vasopresores
207 (3.6)
Digoxin
Digoxina
1.014 (17.6)
*Cut-off percentile 99. SD: standard deviation.
cardiology, 1 internal medicine, and the rest in any
ward) and 2 studies included patients seen in the ED.
Mean age varied from 69-77 years and the percentage
of women varied between 39% and 62.4%. Comorbidity was present in very different ways. So, for major
comorbidities, ischemic heart disease was present in
28% to 65%, hypertension between 57.8 and 83.7%,
diabetes mellitus between 31 and 45.3%, atrial fibrillation between 31 and 53.1%, and previous episodes of
AHF between 37 and 88%.
Regarding baseline data, between 51.3 to 72.5%
of patients received chronic treatment with ACE inhibitors or ARBs and beta-blockers between 40 and
53.1%. Presentation in the form of acute pulmonary
edema varied between 16 and 49.6%, and shock bet-
ween 2 and 14.5%. The presence of an infection as a
precipitating factor was recorded in 15-27%, although
this was contained in only 4 of the 14 records. LVEF
ranged between 34 and 42%. Mean SBP of acute episodes varied between 130 and 147 mmHg, HR between 88 and 110 bpm, creatinine between 0.76 and 1.8
mg / dL, anemia between 14.4 and 46% of patients
and only 3 records showed the percentage of patients
with hyponatremia, ranging between 5% (sodium
<130 mmEq / L) and 45% (sodium <136 mmEq / L).
The application of natriuretic peptides varied between
8 and 82%. As for treatments for AHF episodes, NIV
was used in 8.9-36.1%, diuretics in 80-99%, vasodilators in 14.3-51.3% and inotropes in 10.5-29.8%. The
average hospital stay for patients admitted varied bet-
15
Llorens P, et al. Emergencias 2015;27:11-22
858 patients;
15.1%
31 patients;
0.7%
265 patients;
4.7%
896 patients;
15.7%
134 patients;
2.8%
372 patients;
6.5%
125 patients;
2.6%
3,159 patients;
66.4%
1850 patients;
32.5%
Normotensive
AHF
ICA normotensiva
Hypertensive
AHF
ICA hipertensiva
Hypertensive
AHF
(no
shock)
ICA hipotensiva
(sin
shock)
Hypertensive
AHF
(with
shock)
ICA hipotensiva
(con
shock)
ACS
withinsuficiencia
heart failurecardiaca
SCA con
Right heart failure
Insuficiencia
cardiaca derecha
The main findings of this study can be summarized
under three headings. First, we describe a large series
of patients with AHF collected prospectively during care
in the ED. If we accept that this is the scenario that
most closely reflects the reality of patients with AHF, its
findings can be considered representative and reliable
for the global spectrum of this syndrome. In general,
this is usually an aging and functionally dependent population compared to that often seen in clinical trials
and even in other similar records. Their clinical management, both chronic and acute, is suboptimal in rela-
tion to guideline recommendations. A quarter of patients are discharged from the ED without hospitalization, and their short and long term outcomes can clearly be improved. Second, this work shows discrete but
significant changes over time in some aspects of the
management of these patients in the ED. These changes tend to compliance with the treatment guidelines
for AHF, but not optimally. They therefore deserve to be
analyzed to identify areas for improvement in the treatment and prognosis of AHF. Third, analysis of the main
published AHF records shows that most involved inpatients, the results are quite heterogeneous, and are not
directly comparable with those of the EAHFE registry.
Indeed, we only found 2 studies, the ADHERE-EM12 conducted in the US and the Canadian Cohort Study 24,
which included ED patients. The EAHFE Registry com-
Table 3. Distribution of episodes of acute heart failure
depending on the trigger *
1.0
16.9%
Total
n (%)
16
981 (23.0)
3,287 (77.0)
1,370 (32.1)
637 (37.2)
263 (6.2)
255 (6.0)
167 (3.9)
112 (2.6)
802 (18.8)
registries (n =
22.6%
0.8
Cumulative
survival
Time in days
Presence of trigger
No
Yes
Precipitating factors identified
Infection
Rapid atrial fibrillation
Anemia
Hypertensive emergency
Therapeutic failure
Coronary ischemia
Other
*The data were collected in EAHFE-1 and EAHFE-3
4,268).
9.4%
29.5%
0.6
0.4
6 Months
Discussion
Figure 2. Destination of patients with acute heart failure treated in the emergency department. ED: hospital emergency
department.
3 Months
ween 3.8 and 17.8 days, ICU admission between 17
and 69% and hospital mortality varied between 3.8
and 17.8%.
1357; 23.9%
Direct
discharge
home desde
from the
ED
a domicilio
el SUH
Alta directa
Internal
Medicinamedicine
interna
Cardiology
Cardiología
Short
Unidadstay
de unit
corta estancia
Geriatric
Geriatría ward
Intensive
unit intensivos
Unidad decare
cuidados
Other
Otros
1 Month
Figure 1. Distribution of episodes of acute heart failure in
EAHFE-2 and EAHFE-3 registries (n = 4,753). AHF: acute heart
failure. ACS: acute coronary syndrome.
91 patients;
1.6%
12 Months
1,119 patients;
23.5%
186 patients;
3.9%
0.2
0.0
0
365
Timesurvival
in days(days)
Cumulative
Figure 3. Survival curve corresponding to the mortality of
patients enrolled in the EAHFE study.
Llorens P, et al. Emergencias 2015;27:11-22
Table 4. Comparison of ED management of acute heart failure over time*
Lab tests requested in the ED
Determination of natriuretic peptides
Determination of troponin
ED treatment
Oxygen
Non-invasive ventilation
Bolus intravenous diuretics
Diuretics by intravenous infusion
Intravenous nitroglycerin
Inotropic-vasopressor treatment
Destination
Direct discharge from the ED
* Results from 2865 patients with AHF corresponding
EAHFE-1
N = 825
n (%)
EAHFE-2
N = 722
n (%)
EAHFE-3
N = 1318
n (%)
59 (7.2)
403 (48.8)
279 (38.6)
356 (49.3)
628 (47.6)
823 (62.4)
< 0.001
< 0.001
675 (81.8)
26 (3.2)
687 (83.3)
169 (20.5)
176 (21.3)
36 (4.4)
570 (85.5)
43 (6)
631 (87.4)
69 (9.6)
173 (25.9)
26 (3.6)
1.049 (79.8)
59 (4.5)
1.146 (86.9)
84 (6.4)
307 (23.3)
43 (3.3)
0.13
0.24
< 0.05
< 0.001
0.389
< 0.001
167 (20.2)
168 (23.3)
282 (21.2)
to the 8 hospitals participating in the EAHFE Records 1, 2 and 3.
plements these and can be directly compared with
them. Below we discuss this with the EAHFE findings.
It is noteworthy that EAHFE Registry patients are
those with a higher mean age (79 years), and in some
cases by more than 10 years of age compared with
other registries, especially those not conducted in EDs.
The difference in age between the population with a
disease and the population included in clinical trials has
been highlighted in many studies29-33. In part this may
be because the inclusion of patients in many cases is
made from cardiology wards, where the age of patients
admitted is usually lower. Therefore, this difference
could be reduced in part with greater involvement and
participation of EDs in clinical trials34,35. Advanced age
possibly determines greater comorbidities, functional
dependency and preserved LVEF, as found in the EAHFE
Registry. This can influence the application of the results of clinical trials to the general population or sometimes give rise to unexpected results.
The guidelines recommend troponin determination
in all ED patients with AHF, to establish the prognosis
Percentage
p= 0.004
p= 0.87
p= 0.44
Hospital mortality
Mortality at 30 days
ED revisits within 30 days
Figure 4. Comparison over time of mortality and revisits to
the ED in 2,865 patients with acute heart failure corresponding to the 8 hospitals participating in the EAHFE Registries 1,
2 and 3. ED: hospital emergency department.
p
linear trend
0.60
and in some cases it may be diagnostic of the trigger if
the clinical symptoms are compatible with acute coronary syndrome (ACS)36. This recommendation is not followed in more than half the cases. It is noteworthy
that, when determined, the result is positive in 45% of
cases. This percentage is high, possibly biased by the
fact that troponin tests were perhaps requested in more
severe cases or in patients with symptoms suggestive of
ACS. In this regard, it is remarkable in those centers
using the new ultrasensitive test, positivity exceeds
80%, and this poses a challenge in the differential diagnosis of ACS, since ischemic heart disease is present in
a large number of cases of AHF, and although clinical
symptoms are most useful, cardiac catheterization may
be necessary in many cases for confirmation.
The determination of natriuretic peptides in the ED
in our study (34%) was very similar to that reported by
the European ESC-HF Pilot registry19 and the Italian registry IN-HF21 (37% and 30% respectively), but well below that shown in the ADHERE 11 registry in the US
(63%) or the French registry OFAHF23 (82%). However,
these studies do not specify whether they were requested on ED arrival or during hospitalization, and the
EAHFE registry did not include many of the patients
with natriuretic peptide determination during hospitalization. In this case, the recommendation for urgent determination in the ED is not as strong as for troponins.
However, their availability in the ED has been increasing, which has been associated with an increasing percentage of patients whose values are determined, as seen in this study. Thus, although it is routinely
recommended during hospitalization of patients with
AHF to stratify risk and as a prognostic marker37, the benefits of its determination in the ED in terms of indicating likely revisits or mortality are unclear38. We have seen that neither the determination of natriuretic
peptides in an individual patient or the fact that ED have this test available is associated with better prognosis
in terms of mortality or revisits, either for inpatients or
those discharged from the ED39. This may be related to
the absence of recommendations regarding the intensity or type of therapy to follow according to test values, or the degree or type of control to be performed
17
18
ND
79
45
32.5
33.5
8∞
76
ND
ND
ND
ND
ND
ND
ND
ND
ND
ND
89
1.8
ND
ND
ND
38
65
73
44
31
ND
30
65
53
70
48
28
ND
ND
ND
ND
ND
144
ND
1.8
ND
ND
63
34
USA
143
87
1.8
ND
ND
8
39
ND
ND
ND
ND
15
51.3
65.7
53.1
23.4
46
71
41
31
28
19.6
88
USA
OPTIMIZEDHF13
147
99
1.4
ND
ND
ND
ND
ND
ND
ND
DD
ND
60
45
40
20
33
71
34
40
9
A
37
Japan
ATTEND14
AHEAD15
RO-AHFS16
EHFS I17
EHFS II18
ESC HF
pilot19
ALARMHF20
IN-HF21
Italian S22
OFICA23
Canadian
RICA24
Cohort Study10*
EAHFE
135
90
1.2
35.1‡
5**
ND
37
14.5
18.4
3.8
36.2
ND
59.8
55
51
16.9
51
73.1
42.6
26.5
16.2
ND
41.7
143
98
1.3
ND
ND
ND
38
5
29
4
11.3
ND
52.9
69.3
44.5
35
61
67
33
44
ND
ND
88
ND
ND
ND
ND
20.5
20
ND
<1
ND
ND
19
17
ND
ND
ND
ND
51””
53
27
ND
ND
18
83
135
95
ND
14.7¶
ND
16
38
4
16
3
30
17.6
63.1
71.2
43.2
26.6
53.6
62.5
32.8
38.7
19.3
16.8
62.9
141
97
1.7
46§
45~
ND
37
72.5
81
32
ND
46
65.6
38.4
28.4
29.7
24.7
56
133 130 (novo) 130 (ICC) 134
88 107 (ICC) 110 (novo) 93
ND
ND
1.5
31.4§
14.4¶
38.7§
ND
ND
18.8~
37
ND
30
40 (novo) 37 (ICC)
38
38
59
64
41
16
42.3
57.8
40.4
37.7
30.1
32.5
57
7.7
49.6
ND
33
ND
11.7
36.7
4.5
36.9
16.3
ND
ND
ND
ND
30.7
70.2
45.3
24.4
24.8
21.4
63.8
2
27
9
13
ND
2
ND
ND
ND
ND
60
68
62
21
51
62
35
44
ND
26
ND
130
89
1.5
ND
ND
82
42
6
38
6
13
27
ND
ND
ND
ND
44
62
31
38
20.9
15
72
146
89
0.76
ND
ND
ND
ND
ND
ND
ND
ND
ND
58.2
54.5
46.4
18.7
51.8
63.8
38.2
ND
22.2
ND
ND
ND
ND
ND
45.1§
ND
ND
50
ND
ND
ND
ND
ND
80.3ˆ
85.4ˆ
57.4ˆ
28.8ˆ
28
83.7
44.7
53.1
27.5
59.2
66.6
142
90
1.3
57.1‡
5.9**; 20.8~
34
50
0.7
11
2.6
2.8
32.1
55.9
67.2
32.7
19.7
30.5
82.5
42.2
47.6
24.5
22.3
63.2
Czech
Rumania
Europe
Europe
Europe Europa, Turkey,
Italy
Italy
Italy
Canada
Spain
Spain
Republic
Australia, Mexico
274
83
259
32
7
13
115
133
136
668
61
206
170
86
52
29
2001-4 (36) 2004-5 (21) 2003-4 (22) 2007-9 (27) 2006-9 (38) 2008-9 (12) 2000-1 (1.5) 2004-5 (10) 2009-10 (8) 2006-7 (6) 2007-9 (23) 2004 (3) 2009 (1 day) 2004-7 (36) 2008-9 (10) 2007-11 (4)
R
R
R
P
R
P
P
P
P
R
P
P
P
R
P
P
Hosp.
SUH
Hosp.
Hosp. Hosp./Card. Hosp./Card. Hosp.
Hosp. Hosp./Card.
Hosp.
Hosp./Card.Hosp./Card.Hosp./Card. SUH
Hosp./MI
SUH
105,388
10,984
48,612
2,867
4,153
3,224
46,788
3,580
1,892
4,953
1,855
2,807
1,648
12,591
1,172
5,845
72 (14)
73 (14)
73 (14)
73 (14)
71 (12)
69 (22)
71 (ND)
71 (ND)
70 (13)
66-70
70 (13) 73 (11)
76 (13)
75 (11)
77 (8)
79 (10)
52
52.2
52
41
42.4
44
47
39
37
62.4
40
39.5
46
48.5
54.9
56.5
USA
ADHEREEM12
Treatment of acute episode (%)
NIV
VNI
ND
ND
ND
36.1
8.9
ND
ND
13.9
ND
9.6
ND
ND
12.4
ND
ND
6.4
Diuretics
Diuréticos
ND
ND
ND
80.4
ND
80
ND
84.4
84.6
89.7
99
95.3
ND
ND
ND
96.8
Vasodilators
Vasodilatores
21
ND
14.3
45.8
ND
33
ND
38.7
18.5
41.1
29.9
51.3
ND
ND
ND
20.7
Inotropics
Inotrópicos
15
ND
10.9
20.7
22.3
18
ND
29.8
10.5
39
19.4
24.6
13.8
ND
ND
2.1
Evolution
Días hospitalizado
(mediana/media)
4.3/ND
ND/ND
4/5.7
21/31
7.1/ND
ND/8.4
11/ND
ND/9
ND/ND
6/ND
10/ND
9/ND
13/ND
ND/ND
ND/ND
7/9.4
Inpatient
days (median
/ mean)
ICU
admission
(%)(%)
Ingreso
en la UCI
18.7
ND
ND
ND
ND
ND
ND
51
48
17
51.9
69
43
ND
ND
1.9
Hospital
Mortality
(%)
Mortalidad
Intrahospitalaria
(%)
4
5.8
3.8
7.7
12.7
7.7
6.9
7.3
3.8
17.8
6.4
7.3
8.2
ND†
ND
7.6
CHF: chronic heart failure. R: Retrospective. P: Prospective. Hosp .: hospital. Card .: cardiology. ED: hospital emergency department. IM: internal medicine. NA: data not reported in the study. COPD,
chronic obstructive pulmonary disease. ACEI / ARBs angiotensin converting enzyme inhibitors / angiotensin-II receptor blockers. LVEF, Left ventricular ejection. SBP, systolic blood pressure. HR: heart rate.
BNP: natriuretic peptides. NIV: noninvasive ventilation. ICU: intensive care unit. * Data were obtained from the sum of the derivation cohort and the validation cohort. † Mortality at 7 days: 2%. ‡ Hemoglobin <12 in men and <13 g / dl in men. §Hemoglobin <12 g / dl. ¶limit unavailable. ** Sodium <130 mmEq / L. ~ Sodium <136 mmEq / L. ∞ Chronic dialysis. Estimated glomerular filtration rate
<60 ml / min. Medication at discharge. ¥ Data obtained from a substudy. "" History of stable or unstable angina. ⁺Serum creatinine 150 µmol / l: 16% 200 µmol / l: 20%. ⁺⁺16% men and 23% women, hemoglobin <11 g / dl. ⁺⁺⁺Sodium <135 mmEq / L. ⁿFEVI <40% in 45% of cases.
Participating
centers
Centros participantes
Year
of study
(total
months)
Año del
estudio
(meses
totales)
Type
of study
Tipo de
estudio
Scope
Ámbito
Patients
Pacientesincluded
incluidos
Age,
Edad,years,
años,mean
media(SD)
(DE)
Women (%)
Comorbidity (%)
Ischemic
heart
disease
Cardiopatía
isquémica
Hypertension
Hipertensión
Diabetes mellitus
AF
Fibrilación auricular
COPD
EPOC
Chronic
kidney
disease
Enfermedad
renal
crónica
Chronic
heartcardiaca
failure crónica
Insuficiencia
Usual care (%)
ACEI
/ ARBs
IECA/ARA-II
Diuretics
Diuréticos
Beta-blockers
Beta-bloqueantes
Digoxin
Digoxina
Presentation (%)
Shock cardiogénico
Cardiogenic
shock
Acute
Edemapulmonary
agudo de edema
pulmón
Right
heart failure
Insuficiencia
cardiaca derecha
Acute
coronary
syndrome
Síndrome
coronario
agudo
Infection Precipitating factor
Physical and laboratory findings
SBP
PAS (mmHg)
(mmHg) (average)
(media)
HR
(bpm)(media)
(mean)
Fc (lpm)
Creatinine
/ dL)(media)
(mean)
Creatinina (mg
(mg/dL)
Anemia
Anemia (%)
(%)
Hyponatremia
(%)
Hiponatremia (%)
BNP
BNP (%)
realizado (%)
Mean LVEF (%)
Epidemiology
Country
ADHERE11
Table 5. Comparison of the EAHFE Register with other major registries of acute heart failure
Llorens P, et al. Emergencias 2015;27:11-22
Llorens P, et al. Emergencias 2015;27:11-22
after discharge (early follow-up, specialized consultations, phone monitoring, telemonitoring).
Regarding the treatment performed in the ED, the
use of NIV was lower (6.5%) than in other studies, with
8.9% in AHEAD15 and 9.6% in ALARM-HF20 and up to
36% in the Japanese study ATTEND14. And despite the
various benefits of using NIV39,40, we have not observed
an increase in use over time. We believe the percentage
of utilization is low, because the EAHFE Registry itself
provides 11% of patients with the classic form of acute
pulmonary edema. As for treatment with intravenous
nitrates, these are considered the most rational therapy
in the management of the AHF4. Their use in the EAHFE
study (20.7%) was similar to the North American ADHERE11 21% and OPTIMIZE-HF13 14.3% and the European ESF HF pilot study19 with 18.5%), and less than the
Italian S22 (51%). ED Your prescription has remained without significant changes over time in Spain. We believe that this may be partly related to the limited evidence of its effect on the improvement in dyspnea or
evolutionary parameters3. Again, this percentage must
be considered low, as the hypertensive form of AHF involves 23.5% of patients and the normotensive form
with SBP above 120 mmHg involves 63.3% of all normotensive forms. So, overall, 57.6% of patients in the
EAHFE registry present a clinical picture where vasodilators clearly have a therapeutic role. Inotropes and vasopressors were used in our EDs much less than elsewhere, probably due to the inclusion of all patients
attending the ED, including those that are discharged.
Furthermore, our results show progressively less use
over time. This may reflect special caution (or fear) for
use in the ED because their frequent use has been associated with worse prognosis in these patients and the
occurrence of adverse events2. Currently, in the ED, we
should limit its use as a bridge to transplantation therapy or myocardial recovery, as palliative treatment in
non-transplant candidates or in patients with hemodynamic instability4.
Furosemide deserves special mention, as it is the
most common treatment. Although its use is recommended to ensure infusion plasma level and a continuous effect, and it may be less damaging to the kidney, the fact is that its use is low (10.1%) and has
decreased over time (from 20.5% to 6.4%). The fact
that recent clinical trials have shown limited utility41-43
may have contributed to this decline, as well as patient
discomfort, increased workload and nursing time, and
the difficulty of moving the patient to a general ward
which involves the use of continuous infusion equipment.
The rates of ED discharge home of patients with
AHF vary widely. In ADHEREEM 12 , this was 7% of
11,258 patients, and in Lee et al. 10 it was 30% of
12,591 patients which is closer to our rate (23.9%).
These oscillations reflect differences in health systems,
health resources and ED organization. Regarding the
latter, there are countries where there is a time limit of
ED stay (the 4-hour rule in the UK, for example), making it harder to decide on discharge home44. Indeed,
the possibility of an ED discharge is mainly affected by
two characteristics: the availability of an observation
unit in the ED (which facilitate longer ED stay and allow
this observation by emergency physicians) and the selection of patients suitable for discharge after a short
period of observation (less than 24 hours).
Different studies show a continuous increase in readmission rates, between 24-27% at 30 days and approximately 30% at 60-90 days after discharge45. In our
series, revisits to the ED during the first 30 days after
discharge for a new episode of AHF was 20% and there
has been a decrease in this percentage over time. In
this regard, there are few studies (including those in
which a rapid improvement in dyspnea, decreased episodes of worsening, or mortality)46 that have shown an
effect on readmissions within 30-60 days of the index
episode.
The possible reasons for not being able to reduce
revisits are manifold: rapid reduction of dyspnea and
preventing worsening of heart failure may induce faster
discharge, which shortens the hospital stay but negatively affect readmissions. However, we believe that aspects of the medical organization dealing with AHF
may also play an important role. Many patients with
AHF leave the hospital or ED without appropriate recommendations on what to do: they do not get the disease modifying drugs (or the doses are not properly titrated), they do not receive adequate education
regarding important aspects of their disease (alarm
symptoms, treatments, prognosis) and there may not
be good coordination among the various professionals
who treat patients with AHF8. In this regard, ambulatory control programs for chronic patients should improve many of these issues and result in better outpatient and home control and, to some extent, reduce ED
visits and hospital admissions47,48.
This study has certain limitations. First, AHF management policies (therapeutic protocols, discharge or admission criteria - in OU, wards or ICUs, requests for laboratory tests) may differ in each center, despite
adherence to treatment guidelines at all times, as each
center has an AHF coordinator. Second, the EAHFE data
come from Spanish EDs and may not represent management in other countries. Third, although the inclusion of patients was consecutive, some patients may
have been missed. Fourth, the classification of AHF presentation, as well as determining the existence of a trigger, were retrospectively analyzed by the principal investigator, so there may have been some overlapping
or misclassified cases. Fifth, the diagnosis of AHF was
based on clinical data without laboratory data for confirmation in some cases, so this is a possible source of
error, but it also the dynamics of ED care in general.
However, we believe the EAHFE Register provides reliable data about a population of patients with AHF, concerning both the acute episode and ED management
trends, which probably includes most of the spectrum
of this syndrome. Assessed in the context of other major published registries, it can contribute to better identify areas for improvement and steps to improve the
19
Llorens P, et al. Emergencias 2015;27:11-22
management of the AHF in the ED as well as in outpatient or hospital contexts.
Financing
This study was partially funded by the projects PI10
/ 01918 and PI11 / 01021 of the Institute of Health
Carlos III and FEDER funds. The Research Group "ED:
processes and pathologies", IDIBAPS, receives funding
from the Government of Catalonia for consolidated research groups (GRC 2009-2013 and 2014-2016). The
AHF-SEMES group has received unconditional support
from Orion Pharma, Otsuka and Novartis.
Conflict of interest
The author declares no conflict of interest in relation
to the present article.
Acknowledgements
We thank Alicia Diaz for invaluable assistance in the
administration and maintenance of the database.
Addendum
Co-investigadores del Registro EAHFE-Grupo de Trabajo de Insuficiencia Cardiaca Aguda de la Sociedad Española de Emergencias
(Grupo ICA-SEMES): Cristina Gil (Hospital Universitario de Salamanca).
José Vallés (Hospital La Fe de Valencia).Víctor Gil (Hospital Clinic de Barcelona). José Pavón, Ana Bella Álvarez (Hospital Dr. Negrín de Las Palmas de Gran Canaria). Antonio Noval (Hospital Insular de Las Palmas de
Gran Canaria). José M. Torres (Hospital Reina Sofía de Córdoba). María
Luisa López-Grima, Amparo Valero (Hospital Dr. Peset de Valencia). Alfons Aguirre (Hospital del Mar de Barcelona). María Isabel Alonso, Helena Sancho, Francisco Ruiz (Hospital de Valme de Sevilla). Antonio Giménez, José Miguel Franco (Hospital Miguel Servet de Zaragoza). Sergio
Pardo (Hospital San Juan de Alicante). Ana Belén Mecina (Hospital de
Alcorcón). Josep Tost (Consorci Sanitari de Terrassa). Jordi Fabregat
(Hospital Mutua de Terrasa). Francisco Epelde (Consorci Sanitari i Universitari Parc Taulí en Sabadell). Susana Sánchez (Hospital Río Ortega de
Valladolid). Pascual Piñera (Hospital Reina Sofía de Murcia). Raquel Torres Gárate (Hospital Severo Ochoa). Aitor Alquezar, Miguel Alberto Rizzi (Hospital San Pau de Barcelona). Fernando Richard (Hospital de Burgos). Javier Lucas (Hospital General de Albacete). Irene Cabello
(Hospital Universitari de Bellvitge, Barcelona).
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