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- A PAGE 2| Introduction To The Guidelines: Heart Failure PAGE 3| Guest Editor Comment PAGE 4| Assessment Of The Guideline Methodology PAGE 5 | Selected Guideline Recommendations, With Discussion PAGE 12| References PAGE 13| CME Questions Current Guidelines For The Evaluation And Management Of Heart Failure T his issue of EM Practice Guidelines Update reviews 2 recently updated guidelines on the evaluation and management of heart failure (HF). The European Society of Cardiology (ESC) guideline is an update of their 2008 issue and provides practical, evidence-based guidelines for the diagnosis and treatment of acute and chronic HF. The joint American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guideline is an update of their 2009 publication that is primarily focused on chronic HF. The focus of this review is on the recommendations most relevant to emergency medicine practice—the assessment and treatment of acute HF. Practice Guideline Impact • Editor’s Note: To read more about this publication and the background and methodologies for practice guideline development, go to: http://www.ebmedicine.net/introduction B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements are useful to support clinical judgment for the diagnosis of acute HF, especially in the setting of clinical uncertainty. January/February 2014 Volume 6, Number 1 Author Trevor Lewis, MD, FACEP Medical Director, Emergency Department, Cook County Hospital; Associate Professor of Emergency Medicine, Rush Medical College, Chicago, IL Guest Editor Deborah B. Diercks, MD Professor and Vice Chair of Research, Department of Emergency Medicine, University of California, Davis, Davis, CA Editor-In-Chief Sigrid Hahn, MD, MPH Associate Professor of Emergency Medicine, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY Editorial Board Luke K. Hermann, MD Associate Professor of Emergency Medicine, Director of Quality and Finance, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY Andy Jagoda, MD, FACEP Professor and Chair, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY Eddy S. Lang, MDCM, CCFP (EM), CSPQ Senior Researcher, Alberta Health Services; Associate Professor, University of Calgary; Adjunct Professor, McGill University, Montreal, Quebec, Canada Trevor Lewis, MD, FACEP Medical Director, Emergency Department, Cook County Hospital; Associate Professor of Emergency Medicine, Rush Medical College, Chicago, IL Gregory M. Press, MD, RDMS Emergency Ultrasound Director, Hutt Valley Hospital, Lower Hutt, New Zealand Christopher Tainter, MD, RDMS • A completely normal electrocardiogram (ECG) indicates that HF is unlikely. Critical Care Fellow, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA • Patients with acute HF should be treated promptly with intravenous (IV) diuretics to reduce morbidity. Chair, Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL • • Vasodilators may be used as an adjunct to diuretic therapy in an effort to reduce dyspnea, but they do not improve major outcomes. Drugs that are potentially harmful in patients with a reduced ejection fraction include most antiarrhythmic drugs, most calcium-channel-blocking drugs (except amlodipine), and nonsteroidal anti-inflammatory drugs (NSAIDs). Scott M. Silvers, MD Scott D. Weingart, MD, FCCM Associate Professor, Department of Emergency Medicine, Director, Division of ED Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY Prior to beginning this activity, see “CME Information” on page 14. | print | SUBSCRIBE | WEBSITE Current Guidelines For The Evaluation And Management Of Heart Failure Introduction To The Guidelines: Heart Failure T “heart failure with a reduced ejection fraction” (HFrEF), defined as an EF ≤ 40%.4 The ESC uses similar definitions, but considers a reduced EF to be ≤ 35%.5 EFs of 35% to 50% encompass a gray area, and most likely represent patients with mild systolic dysfunction. There is also no standardized terminology to describe acutely or subacutely worsened HF, and the terms “acute heart failure,” “acute heart failure syndromes,” and “acutely decompensated heart failure” have been used by various authors and organizations. The ACCF/AHA suggests that the use of clinical descriptors can help subclassify patients with acute HF as congested or not (“wet” or “dry”) and/or as being wellperfused or not (“warm” or “cold”). his issue of EM Practice Guidelines Update reviews 2 recently published guidelines on the evaluation and management of HF: 1. “ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012,” published by the European Society of Cardiology (ESC), available at: http://eurheartj.oxfordjournals.org/content/33/14/1787.full.pdf 2. “2013 ACCF/AHA Guideline for the Management of Heart Failure: a Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines,” published by the American Heart Association (AHA), available at: http://circ.ahajournals.org/content/early/2013/06/03/ CIR.0b013e31829e8776.full.pdf This issue of EM Practice Guidelines Update will inform the emergency clinician of the new and updated guidelines in the diagnosis and care of patients with HF. Faced with the pressures of managing patients with acute HF or HF as a comorbidity, reducing admission rates for acute HF, and determining the often subtle presentations of new-onset HF in the ED, the emergency clinician must be well-versed in the acute treatment guidelines, chronic treatment regimens, and approaches to diagnosis. Many of the recommendations in the full guidelines apply to the outpatient setting, and only those that are applicable to the care of the ED patient will be reviewed here. The ACCF/AHA guidelines are more focused on the United States population and much broader in their discussion of outpatient management and chronic congestive HF. The ESC recommendations apply to a more global population, with a greater focus on acute care. HF is a common condition affecting approximately 1% to 2% of the adult population, with a prevalence of ≥ 10% in patients aged > 70 years.1 Survival for HF patients has improved, but absolute mortality rates remain at approximately 50% at 5 years for all-cause HF.2 There is some evidence that the number of hospitalizations attributed primarily to HF is declining; however, there has been an increase in the number of hospitalizations of patients with a diagnosis of chronic HF.3 HF is a heterogeneous clinical syndrome caused by structural and functional impairment of ventricular filling or ejection of blood, resulting primarily in dyspnea and fatigue with or without symptoms of volume overload.4 There is no definitive diagnostic test for HF. As a result, there is considerable variability in the definitions and terminology used to describe HF. The AHA recommends against use of the term “congestive heart failure,” as fluid overload need not be present, and prefers the term “heart failure.” The ACCF/AHA guideline writing committee used the terms “heart failure with a preserved ejection fraction” (HFpEF), defined as an ejection fraction (EF) ≥ 50%; and EM Practice Guidelines Update © 2014 —Trevor Lewis, MD 2 www.ebmedicine.net • January/February 2014 | print | SUBSCRIBE | WEBSITE Current Guidelines For The Evaluation And Management Of Heart Failure Guest Editor Comment: Deborah Diercks, MD For the emergency clinician, an ideal guideline on HF would provide clear recommendations for decsions regarding ED-based diagnostics, treatment, and disposition. These 2 recently published guidelines by the major American and European cardiology societies focus largely on the care of chronic HF, but they also provide guidance for patients presenting with acute HF. The ACCF/AHA HF guideline covers acute care under the section entitled “The Hospitalized Patient." It does not explicitly address the ED setting (not surprising, perhaps, as no emergency physicians were included on the writing panel). a randomized controlled trial (RCT) from 2008 did not show positive results;6 however, readers should be reminded of the 2013 Cochrane review (which included this RCT) that showed a reduction in mortality, a reduction in the need for endotracheal intubation, as well as a reduction in the number of days spent in the intensive care unit without increasing the risk of having a heart attack during or after treatment.7 Overall, the treatment guidelines are relatively consistent with current practices in the ED, so they may provide reassurance to ED clinicians that their current management plan is sufficient. However, these guidelines also highlight important regulatory benchmarks that are tracked on HF patients, and these are relevant, as emergency clinicians are taking a more comprehensive role in the management of acute HF patients. The outcome measures of admission rates and 30-day riskstandardized HF readmission rates are clearly in the domain of the emergency clinician. Currently, there are approximately 700,000 ED visits for acute HF per year in the United States, approximately 80% of which result in admission.8 Despite this (and perhaps because the ACCF/AHA writing committee did not focus on the ED setting), the question of risk stratification and potential discharge from the ED is not addressed. The ACCF/AHA continues to suggest categorization of acute HF patients by their hemodynamic status and degree of congestion. Diagnostic tests (eg, chest x-ray and natriuretic peptide levels) can be used to assist in this assessment. For patients with congestion who are hemodynamically stable, the Class I recommendation is to use loop diuretics as part of the initial management (“...to be given in the ED”). Adjuncts to diuretics that are also suggested (with Class IIb recommendations) include low-dose dopamine, ultrafiltration, IV vasodilators (nitroglycerin, nitroprusside, nesiritide), and vasopressin receptor antagonists (for patients with severe hyponatremia). Ultrafiltration may not be relevant to emergency clinicians outside of specialized healthcare settings, as it requires resources that are limited in the ED setting. Surprisingly, the ACCF/AHA guidelines do not address the use of noninvasive ventilation (NIV). Unlike ultrafiltration, NIV is widely available and in common use in the ED. The recommendations in the ACCF/AHA guidelines for management of acute HF are somewhat difficult to locate within the document; however, the ESC guidelines present the information in a clear format. The best use of the ACCF/AHA guidelines is as a reference for specific issues. For the emergency clinician seeking to practice guideline-based therapy and utilize algorithms, the ESC guidelines are much more useful. ■ In contrast to the ACCF/AHA guidelines, the ESC HF guidelines present more comprehensive and user-friendly recommendations for patients presenting with acute HF. These guidelines present algorithms for diagnosis and management, and, unlike the ACCF/AHA guidelines that suggest treatment based on assessment of perfusion and congestion, these guidelines recommend treatment based on blood pressure and oxygenation in patients with pulmonary congestion. The actual treatment recommendations differ very little between the guidelines. The ESC does address NIV, endorsing it with a IIB recommendation based on class B evidence. In their discussion, they cite concern that EM Practice Guidelines Update © 2014 3 www.ebmedicine.net • January/February 2014 | print | SUBSCRIBE | WEBSITE Current Guidelines For The Evaluation And Management Of Heart Failure Assessment Of The Guideline Methodology A committee appointed by the ACCF/AHA Task Force on Practice Guidelines authored the ACCF/AHA guidelines. The definitions and levels of recommendations are noted in Table 1. Members of the ESC Task Force were selected by the ESC to write the guideline in accordance with the ESC Committee for Guidelines Policy. The same definitions for the recommendations were utilized as noted in Table 1. Table 1. Definition Of Classes And Levels Of Evidence Used In American Heart Association Recommendations Level of Evidence A Data derived from multiple sources B Data derived from a single randomized trial or nonrandomized studies C Consensus opinion of experts Classes of Recommendation The authors of this issue of EM Practice Guidlines Update, Trevor Lewis, MD and Editor-in-Chief Sigrid Hahn, MD, MPH graded this guideline using the Appraisal of Guidelines for Research and Education (AGREE) II instrument (available at http://www.agreetrust.org/). This instrument is a checklist that allows users to grade a guideline on 23 items in 6 domains, reflecting the degree to which the guideline developers used unbiased, best-practice methodology in developing the guideline and writing the recommendations. The results of the AGREE instrument are presented in Figure 1, with a percentile calculated and assigned for each domain (maximum score of 100%). The score for relevance to emergency medicine is not part of the AGREE instrument, but reflects the judgment of the author and editor of this issue Class I Conditions for which there is conflicting evidence for and/or general agreement that the procedure or treatment is useful and effective Class II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment Class IIa The weight of evidence or opinion is in favor of the procedure or treatment Class IIb Usefulness/efficacy is less well established by evidence or opinion Class III Conditions for which there is evidence and/or general agreement that the procedure or treatment is not useful/effective and in some cases may be harmful | PRINT | SUBSCRIBE | WEBSITE Figure 1. AGREE Criteria For Heart Failure Guidelines Scope and purpose —Trevor Lewis, MD; and Sigrid Hahn, MD, MPH Stakeholder involvement Rigor of development n ESC Clarity of presentation n ACCF/AHA Applicability Editorial independence Overall guideline quality Relevance to emergency medicine 0 Abbreviation: AGREE, Appraisal of EM Practice Guidelines Update © 2014 4 20 40 60 Percentile Score Guidelines for Research and 80 100 Education. www.ebmedicine.net • January/February 2014 | print | SUBSCRIBE | WEBSITE Current Guidelines For The Evaluation And Management Of Heart Failure Selected Guideline Recommendations, With Discussion T he recommendations excerpted here are presented as they appear in the original guidelines, including the strength of the recommendation and the level of evidence. Recommendations on the same clinical topic from the 2 guidelines are presented sideby-side to facilitate comparison. However, when there is overlap and no significant discrepancy, only 1 of the 2 guideline recommendations are presented, in the interest of brevity. Disease prevention, nonsurgical device implantation, and surgical options are not reviewed, as they have limited relevance to the emergency clinician. markers, including cardiac troponin testing, and treated optimally as appropriate to the overall condition and prognosis of the patient. (ACCF/AHA, Class I, Level C) Electrocardiogram • A 12-lead ECG is recommended to determine heart rhythm, heart rate, QRS morphology, and QRS duration, and to detect other relevant abnormalities. This information also assists in planning treatment and is of prognostic importance. A completely normal ECG makes systolic HF unlikely. (ESC, Class I, Level C) Initial Assessment Of Suspected Acute Heart Failure • Common precipitating factors for acute HF should be considered during initial evaluation, as recognition of these conditions is critical to guide appropriate therapy. (ACCF/AHA, Class I, Level C) • Common factors that precipitate acute decompensated HF include: ◦◦ Nonadherence with medication regimen, sodium and/or fluid restriction ◦◦ Acute myocardial ischemia ◦◦ Uncorrected high blood pressure ◦◦ Atrial fibrillation and other arrhythmias ◦◦ Recent addition of negative inotropic drugs (eg, verapamil, nifedipine, diltiazem, beta blockers) ◦◦ Pulmonary embolus ◦◦ Initiation of drugs that increase salt retention (eg, steroids, thiazolidinediones, NSAIDs) ◦◦ Excessive alcohol or illicit drug use ◦◦ Endocrine abnormalities (eg, diabetes mellitus, hyperthyroidism, hypothyroidism) ◦◦ Concurrent infections (eg, pneumonia, viral illnesses) ◦◦ Additional acute cardiovascular disorders (eg, valve disease endocarditis, myopericarditis, aortic dissection) • Acute coronary syndromes (ACS) precipitating acute HF decompensation should be promptly identified by ECG and serum bio- EM Practice Guidelines Update © 2014 Chest X-Ray • Patients with suspected or new-onset HF or patients presenting with acute decompensated HF, should undergo a chest x-ray to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient’s symptoms. (ACCF/AHA, Class I, Level C) Editorial Comment: Trevor Lewis, MD Several points are worth highlighting: (1) Heart failure is very unlikely in patients with a normal ECG; (2) A normal chest x-ray does not exclude pulmonary edema and is better for identifying an alternative diagnosis than for ruling in acute HF; (3) Although ESC does not make a formal recommendation about the role of echocardiography in the ED (the recommendations about echocardiography refer to the ambulatory setting), they incorporate echocardiography in their diagnostic algorithm for acute HF. They endorse early echocardiography for patients presenting to the ED with suspected acute HF (immediate echocardiography is recommended in shocked or severely hemodynamically compromised patients). Neither organization discusses the role of bedside echocardiography. (See Figure 2, page 6.) 5 www.ebmedicine.net • January/February 2014 Current Guidelines For The Evaluation And Management Of Heart Failure | print | SUBSCRIBE| WEBSITE | WEBSITE | PRINT | SUBSCRIBE Figure 2. European Society Of Cardiology Recommended Diagnostic Testing For Acute Heart Failure Suspected heart failure of acute onset • ECG • Chest x-ray • BNP/NT-proBNP* ECG abnormal or NT-proBNP ≥ 300 pg/mL† or BNP ≥ 100 pg/mL† ECG normal and NT-proBNP < 300 pg/mL or BNP < 100 pg/mL Echocardiogram Heart failure unlikely‡ If heart failure is confirmed, determine etiology and start appropriate treatment *In the acute setting, MR-proANP may also be used (cut-off point < 120 pmol/L; ie, < 120 pmol/L = heart failure unlikely). † Other causes of elevated natriuretic peptide levels in the acute setting are an acute coronary syndromes, atrial or ventricular arrhythmias, pulmonary embolism, and severe chronic obstructive pulmonary disease with elevated right heart pressure, renal failure, and sepsis. Other causes of an elevated natriuretic level in the nonacute setting are: old age (> 75 years), atrial arrhythmias, left ventricular hypertrophy, chronic obstructive pulmonary disease, and chronic kidney disease. ‡ Treatment may reduce natriuretic peptide concentration, and natriuretic concentrations may not be markedly elevated in patients with HF-PEF. Abbreviations: BNP, B-type natriuretic peptide; ECG, electrocardiogram; HF-pEF, heart failure with preserved ejection fraction; MR-proANP, midregional pro-atrial natriuretic peptide; NT-proBNP, N-terminal B-type natriuretic peptide. EM Practice Practice Guidelines Guidelines Update Update © © 2011 2014 EM 2 6 www.ebmedicine.net • January/February 2014 ebmedicine.net • April 2012 | print | SUBSCRIBE | WEBSITE Current Guidelines For The Evaluation And Management Of Heart Failure Treatment Of Acute Heart Failure Without Shock Oxygen High-flow oxygen is recommended in patients with a capillary oxygen saturation < 90% or PaO2 < 60 mm Hg (8.0 kPa) to correct hypoxemia. (ESC, Class I, Level C) Laboratory Testing • Measurement of BNP or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis. (ACCF/AHA, Class I, Level A; revised from previous guidelines)9 • Measurement of BNP or NT-proBNP and/or cardiac troponin is useful for establishing prognosis or disease severity in acutely decompensated HF. (ACCF/AHA, Class I, Level A; revised from previous guidelines)9 • The usefulness of BNP- or NT-proBNP-guided therapy for acutely decompensated HF is not well established. (ACCF/AHA, Class IIb, Level C, new recommendation) • Measurement of other clinically available tests (such as biomarkers of myocardial injury or fibrosis) may be considered for additive risk stratification in patients with acutely decompensated HF. (ACCF/ AHA, Class IIb, Level A, new recommendation) • Measurement of natriuretic peptide (BNP, NT-proBNP, or midregional pro-atrial natriuretic peptide [MR-proANP]) should be considered to: ◦◦ Exclude alternative causes of dyspnea (if the level is below the exclusion cut-point, HF is very unlikely) (ESC, Class IIb, Level C) ◦◦ Obtain prognostic information (ESC, Class IIb, Level C) Editorial Comment: Trevor Lewis, MD Oxygen should not be used routinely in nonhypoxic patients as it causes vasoconstriction and reduced cardiac output. Noninvasive Ventilation NIV (eg, CPAP) should be considered in dyspneic patients with pulmonary edema and a respiratory rate > 20 breaths/min to improve breathlessness and reduce hypercapnia and acidosis. NIV can reduce blood pressure and should not generally be used in patients with a systolic blood pressure (SBP) < 85 mm Hg (and blood pressure should be monitored regularly when this treatment is used). (ESC, Class IIa, Level B) Editorial Comment: Trevor Lewis, MD The use of NIV has become routine in the management of patients presenting to the ED with acute HF. As previously noted, a 2013 Cochrane meta-analysis found a reduction in hospital mortality and the need for intubation with NIV.7 The ESC guideline authors, however, cite an RCT (also included in the meta-analysis) that demonstrated that neither continuous positive airway pressure (CPAP) nor noninvasive positive pressure ventilation (NIPPV) reduced mortality or the rate of endotracheal intubation when compared with standard therapy.6 This appears to be why they describe NIV as an “adjunct” therapy for patients who are not improving with pharmacologic therapy or who are in severe distress, rather than as a Class I, first-line therapy. Editorial Comment: Trevor Lewis, MD Routine laboratory testing can help elucidate possible causes of acute HF (such as anemia). The ACCF/AHA guideline newly recommends measuring troponin for “additive risk stratification” in acute HF, and comments that the measurement of troponins should be routine in patients presenting with acute HF. The ESC suggests only that troponins “may be indicated” in the ED patient. The ACCF/AHA has revised its recommendations regarding the use of BNP and provides a strong recommendation in support of the role of BNP in cases of diagnostic uncertainty (much stronger than the ESC). The ESC guideline emphasizes the ability of a BNP measurement to exclude acute HF in the ED patient if NTproBNP is < 300 pg/mL or BNP is < 100 pg/mL. BNP also has obvious prognostic value, but no established value in guiding treatment. The role of BNP in the diagnostic workup of acute HF is shown in the algorithm from the ESC guideline. (See Figure 2, page 6.) EM Practice Guidelines Update © 2014 7 www.ebmedicine.net • January/February 2014 | print | SUBSCRIBE | WEBSITE Current Guidelines For The Evaluation And Management Of Heart Failure Treatment Of Acute Heart Failure Without Shock (Continued) Diuretics • Patients with HF admitted with evidence of significant fluid overload should be promptly treated with IV loop diuretics to reduce morbidity. (ACCF/AHA, Class I, Level B) • If patients are already receiving loop diuretic therapy, the initial IV dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or as a continuous infusion. Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension. (ACCF/AHA, Class I, Level B; revised from previous guideline)9 • An IV loop diuretic is recommended to improve breathlessness and relieve congestion. Symptoms, urine output, renal function, and electrolytes should be monitored regularly during use of IV diuretics (ESC, Class I, Level B) • Low-dose dopamine infusion may be considered in addition to loop diuretic therapy to improve diuresis and to better preserve renal function and renal blood flow. (ACCF/AHA, Class IIb, Level B) Vasodilators • If symptomatic hypotension is absent, IV nitroglycerin, nitroprusside, or nesiritide may be considered an adjuvant to diuretic therapy for relief of dyspnea in patients admitted with acutely decompensated HF. (ACCF/AHA, Class IIb, Level B) • An IV infusion of a nitrate should be considered in patients with pulmonary congestion/edema and a SBP > 110 mm Hg who do not have severe mitral or aortic stenosis, to reduce pulmonary capillary wedge pressure and systemic vascular resistance. Nitrates may also relieve dyspnea and congestion. Symptoms and blood pressure should be monitored frequently during administration of IV nitrates. (ESC, Class IIa, Level B) • An IV infusion of sodium nitroprusside may be considered in patients with pulmonary congestion/edema and a SBP > 110 mm Hg who do not have severe mitral or aortic stenosis, to reduce pulmonary capillary wedge pressure and systemic vascular resistance. Caution is recommended in patients with acute myocardial infarction. Nitroprusside may also relieve dyspnea and congestion. Symptoms and blood pressure should be monitored frequently during administration of IV nitroprusside. (ESC, Class IIa, Level B) Editorial Comment: Trevor Lewis, MD Both guidelines conclude that diuretics are a cornerstone of therapy for acute HF. The AHA guidelines codify what has already been a common ED dosing regimen for years, and they recommend starting diuretics in the ED without delay, in an effort to improve outcomes (although their impact on mortality is not well established). The ESC guideline does not specify dosing, noting the lack of good evidence for the use of high-dose over low-dose loop diuretics and tradeoffs that include transiently worsened renal function. The addition of a thiazide diuretic is a good option to remember when initial aggressive furosemide dosing is inadequate. The weak recommendation to consider dopamine is added in this section for reader interest; however, it should be noted that this is based on a single study and the guideline authors remarked that more data are needed. Editorial Comment: Trevor Lewis, MD Both guideline writing committees conclude that, overall, there are no data to suggest that IV vasodilators improve major outcomes in the patient hospitalized with HF. IV vasodilators may help relieve dyspnea. The ACCF/AHA guideline also cautions that IV vasodilators should be administered with caution in patients with HFpEF, as these patients are typically more volume sensitive. EM Practice Guidelines Update © 2014 Opiates An IV opiate (along with an antiemetic) should be considered in particularly anxious, restless, or distressed patients to relieve these symptoms and improve breathlessness. Alertness and ventilatory effort should be monitored frequently after administration because opiates can depress respiration. (ESC, Class IIa, Level C) 8 www.ebmedicine.net • January/February 2014 | print | SUBSCRIBE | WEBSITE Current Guidelines For The Evaluation And Management Of Heart Failure Treatment Of Acute Heart Failure Without Shock (Continued) Inotropes And Vasopressors • Inotropic agents are NOT recommended unless the patient is hypotensive (SBP < 85 mm Hg), hypoperfused, or shocked because of safety concerns (atrial and ventricular arrhythmias, myocardial ischemia, and death). (ESC, Class III, Level C) • Use of parenteral inotropic agents in hospitalized patients without documented severe systolic dysfunction, low blood pressure, or impaired perfusion and evidence of significantly depressed cardiac output, with or without congestion, is potentially harmful. (ACCF/ AHA, Class III, Level B) • • Editorial Comment: Trevor Lewis, MD Inotropes or vasopressors are only potentially appropriate in patients with significant hypoperfusion or cardiogenic shock. (See discussion following.) • Treatment Of Acute Heart Failure With Hypotension, Hypoperfusion, Or Shock Cardioversion • Electrical cardioversion is recommended if an atrial or ventricular arrhythmia is thought to be contributing to the patient’s hemodynamic compromise in order to restore sinus rhythm and improve the patient’s clinical condition. (ESC, Class I, Level C) Editorial Comment: Trevor Lewis, MD Patients with acute HF and shock have severely compromised circulatory status, and the use of inotropes and vasopressors requires an assessment of the tradeoff between potential benefits and risks (including myocardial ischemia and arrhythmias) in these critically ill patients. Despite improving hemodynamic status, inotropes have not been shown to improve patient outcomes. Of note, many of the studies focus on end-stage chronic HF patients, which may not be applicable to the acute presentation of the ED patient. Inotropes And Vasopressors • Short-term, continuous IV inotropic support may be reasonable in hospitalized patients presenting with documented severe systolic dysfunction who present with low blood pressure and significantly depressed cardiac output to maintain systemic perfusion and preserve end-organ performance (ACCF/AHA, Class IIb, Level B; revised from previous guideline)9 • Until definitive therapy (eg, coronary revascularization, mechanical circulatory support, heart transplantation) or resolution of the acute precipitating problem, patients with cardiogenic shock should receive temporary IV inotropic support to maintain systemic perfusion and preserve end-organ performance. (ACCF/AHA, Class I, Level C) EM Practice Guidelines Update © 2014 An IV infusion of an inotrope (eg, dobutamine) should be considered in patients with hypotension (SBP < 85 mm Hg) and/or hypoperfusion to increase cardiac output, increase blood pressure, and improve peripheral perfusion. The ECG should be monitored continuously because inotropic agents can cause arrhythmias and myocardial ischemia. (ESC, Class IIa, Level C) A vasopressor (eg, dopamine or norepinephrine) may be considered in patients who have cardiogenic shock, despite treatment with an inotrope, to increase blood pressure and vital organ perfusion. The ECG should be monitored, as these agents can cause arrhythmias and/or myocardial ischemia. Intra-arterial blood pressure measurement should be considered. (ESC, Class IIb, Level C) An IV infusion of levosimendan (or a phosphodiesterase inhibitor) may be considered to reverse the effect of beta blockade if beta blockade is thought to be contributing to hypoperfusion. The ECG should be monitored continuously because inotropic agents can cause arrhythmias and myocardial ischemia, and, as these agents are also vasodilators, blood pressure should be monitored carefully. (ESC, Class IIb, Level C) 9 www.ebmedicine.net • January/February 2014 | print | SUBSCRIBE | WEBSITE Current Guidelines For The Evaluation And Management Of Heart Failure ST-segment elevated myocardial infarction (NSTEMI) is complicated by the fact that patients both with and without coronary artery disease often have elevated troponin levels in the setting of acute HF. Treatment Of Acute Heart Failure With Hypotension, Hypoperfusion, Or Shock (Continued) Mechanical Circulatory Support • Short-term mechanical circulatory support should be considered (as a “bridge to recovery”) in patients remaining severely hypoperfused despite inotropic therapy and with a potentially reversible cause (eg viral myocarditis) or a potentially surgically correctable cause (eg acute interventricular septal rupture). (ESC, Class IIa, Level C) • Short-term mechanical circulatory support may be considered (as a ‘bridge to decision’) in patients deteriorating rapidly before a full diagnostic and clinical evaluation can be made. (ESC, Class IIb, Level C) Treatment Of Acute Heart Failure With An Arrhythmia • Electrical cardioversion is recommended in patients hemodynamically compromised by atrial fibrillation and in whom urgent restoration of sinus rhythm is required to improve the patient’s clinical condition rapidly. (ESC, Class I, Level C) • Patients should be fully anticoagulated (eg, with IV heparin), if not already anticoagulated and with no contraindication to anticoagulation, as soon as atrial fibrillation is detected to reduce the risk of systemic arterial embolism and stroke. (ESC, Class I, Level A) • Electrical cardioversion or pharmacological cardioversion with amiodarone should be considered in patients when a decision is made to restore sinus rhythm nonurgently (“rhythm control” strategy). This strategy should only be employed in patients with a first episode of atrial fibrillation of < 48 hours’ duration (or in patients with no evidence of left atrial appendage thrombus on transesophageal echocardiogram). (ESC, Class I, Level C) Treatment Of Acute Heart Failure Due To Acute Coronary Syndromes • Immediate primary percutaneous coronary intervention (PCI) (or coronary artery bypass graft [CABG] in selected cases) is recommended if there is an ST elevation or a new left bundle branch block ACS in order to reduce the extent of myocyte necrosis and reduce the risk of premature death. (ESC, Class I, Level A; revised from previous guideline)10 • Alternative to PCI or CABG: IV thrombolytic therapy is recommended if PCI/CABG cannot be performed, or if there is ST-segment elevation or new left bundle branch block, to reduce the extent of myocyte necrosis and reduce the risk of premature death. (ESC, Class I, Level A; revised from previous guideline)10 • Early PCI (or CABG in selected patients) is recommended if there is non-ST elevation ACS in order to reduce the risk of recurrent ACS. Urgent revascularization is recommended if the patient is hemodynamically unstable. (ESC, Class I, Level A; revised from previous guideline)10 Editorial Comment: Trevor Lewis, MD The ACCF/AHA guideline defers to the 2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation guideline (available at http://circ.ahajournals.org/content/123/1/104.extract) for treatment of patients with HF and arrhythmia. The ESC guideline comments on the use of urgent heparin for patients who are not currently anticoagulated. In addition, the guidelines mirror the current Advanced Cardiac Life Support (ACLS) recommendations to cardiovert the unstable patient. Care must be employed in interpreting what constitutes an "unstable" patient, especially in the setting of unknown duration of AF with the potential for atrial clot. A fully revised atrial fibrillation guideline, which will include updated recommendations on HF with atrial fibrillation, is in development by the ACCF/AHA, with publication expected in 2014. Editorial Comment: Trevor Lewis, MD Management of patients with ST-segment elevated myocardial infarction (STEMI) and HF is straightforward, as these patients need immediate cardiac intervention. In contrast, the diagnosis and management of non- EM Practice Guidelines Update © 2014 10 www.ebmedicine.net • January/February 2014 | print | SUBSCRIBE | WEBSITE Current Guidelines For The Evaluation And Management Of Heart Failure Treatments That May Cause Harm • Drugs known to adversely affect the clinical status of patients with current or prior symptoms of HFrEF are potentially harmful and should be avoided or withdrawn whenever possible (eg, most antiarrhythmic drugs, most calcium-channel-blocking drugs [except amlodipine], NSAIDs, or thiazolidinediones). (ACCF/AHA, Class III, Level B) • Thiazolidinediones (glitazones) should not be used, as they cause worsening HF and increase the risk of HF hospitalization. (ESC, Class III, Level A) • Most calcium-channel blockers (with the exception of amlodipine and felodipine) should not be used, as they have a negative inotropic effect and can cause worsening HF. (ESC, Class III, Level B) • NSAIDs and cyclooxygenase-2 (COX-2) inhibitors should be avoided, if possible, as they may cause sodium and water retention, worsening renal function, and worsening HF. (ESC, Class III, Level B) Summary Of Guideline-Directed Medical Therapy For The Emergency Physician: Trevor White, MD The ACCF/AHA guideline emphasizes the importance of “guideline-directed medical therapy," and both they and the ESC spend much time discussing the appropriate outpatient regimen for the management of chronic HF. An understanding of these medications is useful for the emergency clinician when managing HF patients in the ED, whether they have an acute decompensation or not. Both angiotensin-converting enzyme (ACE) inhibitors and beta blockers have been cornerstones of HFrEF treatment for years. Key trials have included the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS) and Studies of Left Ventricular Dysfunction (SOLVD), which have shown reductions in mortality of 27% and 16%, respectively, with the use of these drugs.11-13 The primary role of angiotensin-receptor blockers (ARBs) still appears to be as a substitute for patients who are intolerant to ACE inhibitors. The expansion of the role of mineralocorticoid/aldosterone-receptor antagonists has come from recent RCTs, including the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF), which found that patients already taking ACE inhibitors and beta blockers had a decrease in hospitalizations and death.14,15 The bottom line is that the use of ACE inhibitors, beta blockers, and mineralocorticoid/aldosterone-receptor antagonists is fundamentally important in improving the course of systolic HF and should, at least, be considered in every patient. The utility of digoxin still remains more of an additive medication after the implementation of other first-line therapies. ■ Editorial Comment: Trevor Lewis, MD These recommendations are new in the current guidelines. They provide a useful summary of drugs for emergency clinicians to avoid when managing HF. Reviewing a patient’s medication list can provide clues to reasons for their decompensation. Commonly prescribed diabetes medications, such as pioglitazone (Actos®) and rosiglitazone (Avandia®) should be avoided in HF patients. More important for emergency medicine practice is the avoidance of NSAIDs and COX-2 selective inhibitor medications in HF. These are commonly prescribed medications in the ED and often given to this subset of patients. EM Practice Guidelines Update © 2014 11 www.ebmedicine.net • January/February 2014 | print | SUBSCRIBE | WEBSITE Current Guidelines For The Evaluation And Management Of Heart Failure References 1. Mosterd A, Hoes AW. Clinical epidemiology of heart failure. Heart. 2007;93(9):1137-1146. (Review) 9. Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the International Society for Heart and Lung Transplantation. J Am Coll Cardiol. 2009;53(15):e1-e90. (Guidelines) 2. Roger VL, Weston SA, Redfield MM, et al. Trends in heart failure incidence and survival in a community-based population. JAMA. 2004;292(3):344-350. (Population-based cohort study; 4537 patients) 10.Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail. 2008;10(10):933-989. (Guidelines) 3. Blecker S, Paul M, Taksler G, et al. Heart failure-associated hospitalizations in the United States. J Am Coll Cardiol. 2013;61(12):12591267. (Nationwide inpatient sample) 4. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128(16):e240-e319. (Guidelines) 11. Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). The CONSENSUS Trial Study Group. N Engl J Med. 1987;316(23):1429-1435. (Randomized double-blind study; 253 patients) 5. McMurray JJ, Adamopoulos S, Anker SD, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2012;14(8):803-869. (Guidelines) 12.Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. The SOLVD Investigators. N Engl J Med. 1992;327(10):685-691. (Randomized double-blind trial; 4228 patients) 6. Gray A, Goodacre S, Newby DE, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med. 2008;359(2):142151. (Multicenter open prospective randomized controlled trial; 1069 patients) 13.Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators. N Engl J Med. 1991;325(5):293-302. (Randomized doubleblind trial; 2569 patients) 7. Vital FM, Ladeira MT, Atallah AN. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev. 2013;5:CD005351. (Systematic review; 32 blinded or unblinded randomized or quasi-randomised studies; 2916 participants) 14.Zannad F, McMurray JJ, Krum H, et al. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med. 2011;364(1):11-21. (Randomized double-blind trial; 2737 patients) 15.Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 2003;348(14):1309-1321. (Randomized trial; 6632 patients) 8. Collins SP, Storrow AB. Moving toward comprehensive acute heart failure risk assessment in the emergency department: the importance of self-care and shared decision making. JACC Heart Fail. 2013;1(4):273-280. (Assessment) EM Practice Guidelines Update © 2014 12 www.ebmedicine.net • January/February 2014 | print | SUBSCRIBE | WEBSITE Current Guidelines For The Evaluation And Management Of Heart Failure CME Questions To take the CME test, visit: www.ebmedicine.net/G0114 or scan the QR code below with a smartphone: 1. BNP may be helpful for all of the following clinical scenarios except to: a. b. c. d. Support a clinical diagnosis in the setting of suspected acute HF Provide prognostic information in patients with acute HF Guide therapy for patients with acute HF Establish disease severity in patients with acute HF 2. The ACCF/AHA guideline gives the strongest recommendation to which of the following treatments for acute HF? a. b. c. d. IV vasodilators IV diuretics NIV IV opiates 3. Which of the following treatment options is generally contraindicated in the severely hypotensive patient with acute HF? a. b. c. d. NIV Inotropes Vasopressors Mechanical circulatory support 4. Which of the following classes of medications is generally contraindicated in patients with HFrEF? a. ACE inhibitors b. Beta blockers c.MRAs d. NSAIDs EM Practice Guidelines Update © 2014 13 www.ebmedicine.net • January/February 2014 | print | SUBSCRIBE | WEBSITE Current Guidelines For The Evaluation And Management Of Heart Failure CME information for EM Practice Guidelines Update To take the CME test, visit: www.ebmedicine.net/G0114 To contact the Editor-In-Chief, email Sigrid Hahn, MD, MPH at: [email protected] Date of Original Release: January 1, 2014. Date of most recent review: December 15, 2013. Termination date: January 1, 2017. Accreditation: EB Medicine is accredited by the Accrediting Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the ACCME. EM Practice Guidelines Update (ISSN Online: 1949-8314) is published bimonthly (6 times per year) by EB Medicine 5550 Triangle Parkway, Suite 150; Norcross, GA 30092 Telephone: 1-800-249-5770 or 1-678-366-7933; Fax: 1-770-500-1316 Email: [email protected] Website: www.ebmedicine.net Credit Designation: EB Medicine designates this enduring material for a maximum of 2 AMA PRA Category 1 Credits™. Physicians should claim only credit commensurate with the extent of their participation in the activity. Needs Assessment: The need for this educational activity was determined by a survey of practicing emergency physicians and the editorial board of this publication; knowledge and competency surveys; and evaluation of prior activities for emergency physicians. Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents. CEO and Publisher: Stephanie Williford Director of Editorial: Dorothy Whisenhunt Content Editors: Erica Carver, Lesley Wood Editorial Projects Manager: Kay LeGree Director of Member Services: Liz Alvarez Member Services Representatives: Kiana Collier, Paige Banks Director of Marketing: Robin Williford Marketing Coordinator: Katherine Johnson Marketing Communications Specialist: Aron Dunn Goals: Upon completion of this article, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence, (2) cost-effectively diagnose and treat the most critical ED presentations, and (3) describe the most common medicolegal pitfalls for each topic covered. Objectives: Upon completion of this article, you should be able to: (1) cite recommendations for the evaluation of the patient with suspected acute HF in the ED; (2) describe recommendations for the treatment of the patient with suspected acute HF in the ED; (3) name medications that are contraindicated in patients with acute HF; and (4) name medications used for the outpatient management of chronic HF. Discussion of Investigational Information: As part of the newsletter, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration-approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product. Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Lewis, Dr. Diercks, Dr. Hahn, Dr. Jagoda, and their related parties reported no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended to supplement, rather than substitute, for professional judgment. 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Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit: http://www.ebmedicine.net/policies. 14 www.ebmedicine.net • January/February 2014 | print | SUBSCRIBE | WEBSITE Current Guidelines For The Evaluation And Management Of Heart Failure Check Out The EM Practice Guidelines Update Archives Publication Date Issue Title Link # Free CME Credits January 2012 Current Emergency Medical Services Guidelines: Traumatic Cardiopulmonary Arrest And Prehospital Airway Management (Trauma CME) www.ebmedicine.net/CPR 2 February 2012 Low-Risk Chest Pain In The ED: Current Guidelines www.ebmedicine.net/ChestPain 2 March 2012 Neck Trauma: Current Guidelines For Emergency Clinicians www.ebmedicine.net/NeckTrauma 2 April 2012 Unstable Angina And Non-ST-Elevation Myocardial Infarction In The ED: Current Guidelines www.ebmedicine.net/NSTEMI 2 May 2012 Current Guidelines On Atrial Fibrillation In The ED www.ebmedicine.net/Afib 2 June 2012 Current Guidelines For The Management Of Hypertension In The ED www.ebmedicine.net/Hypertension 2 July 2012 Current Guidelines For The Management Of Pneumothorax In The ED www.ebmedicine.net/Pneumothorax 2 August 2012 Guidelines For The Management Of Cystitis And Pyelonephritis In The ED www.ebmedicine.net/Cystitis 2 September 2012 Current Guidelines For Management of Acute Altitude Illness, Frostbite, And Snake Envenomation (Trauma CME) www.ebmedicine.net/Envenomation 2 October 2012 American Heart Association Guidelines For The Emergency Clinician: Cardiac Arrest In Special Situations And First Aid (Trauma CME) www.ebmedicine.net/CardiacArrest 2 November 2012 Percutaneous Coronary Intervention: Current Guidelines For The ED www.ebmedicine.net/PCI 2 December 2012 Current Guidelines For Evaluating And Managing Symptomatic Early Pregnancy In The ED www.ebmedicine.net/EarlyPregnancy 2 January 2013 Current Guideline For The Neurodiagnostic Evaluation Of The Child With A Simple Febrile Seizure www.ebmedicine.net/PedFebSeizure 2 February 2013 Current Guidelines For The Evaluation And Management Of Community-Acquired Pneumonia In The ED www.ebmedicine.net/CAP 2 March 2013 Current Guidelines For Management Of Bell Palsy And Herpes Zoster In The ED www.ebmedicine.net/BellPalsy 2 April 2013 Current Guidelines For The Management Of Severe Sepsis And Septic Shock www.ebmedicine.net/Sepsis 2 May 2013 Current Guidelines For The Management Of Community-Acquired Pneumonia In Children www.ebmedicine.net/PedCAP 2 June 2013 Guidelines For The Evaluation And Management Of Upper Gastrointestinal Bleeding www.ebmedicine.net/UGIBleeding 2 July 2013 Guidelines For The Evaluation And Management Of Acute Cerebrovascular Syndrome Part I: Diagnosis And Evaluation Of Transient Ischemic Attack (Stroke CME) www.ebmedicine.net/TIA 2 August 2013 Guidelines For The Evaluation And Management Of Acute Cerebrovascular Syndromes Part II: Evaluation And Management Of Acute Ischemic Stroke (Stroke CME) www.ebmedicine.net/Stroke 2 September 2013 Guidelines For The Management Of Pediatric Severe Sepsis And Septic Shock www.ebmedicine.net/PedSepsis 2 October 2013 Current Guidelines On HIV Postexposure Prophylaxis For Nonoccupational Exposures, Including Sexual Assault www.ebmedicine.net/HIVPostexposure 2 Nov/Dec 2013 Current Guidelines For The Evaluation And Management Of Concussion In Sport www.ebmedicine.net/SportConcussion 2 EM Practice Guidelines Update © 2014 15 www.ebmedicine.net • January/February 2014 | print | SUBSCRIBE|| WEBSITE | WEBSITE || PRINT || SUBSCRIBE PRINT SUBSCRIBE WEBSITE Current Guidelines For The Evaluation And in Management Of Heart Failure Benign Benign Paroxysmal Positional Vertigo and Acute Otitis Externa the Benign Paroxysmal Positional Vertigo And Acute Otitis Externa IninThe The ED: Current Current Guidelines Guidelines BenignParoxysmal ParoxysmalPositional PositionalVertigo VertigoAnd andAcute AcuteOtitis OtitisExterna ExternaIn the ED: Want to receive EM Practice Guidelines Update free? Years Subscribe Subscribe to to Emergency Emergency Medicine Medicine Practice Practice and and you’ll you’ll receive receive EM EM Practice Practice Guidelines Guidelines Update Update at at no no additional additional charge! charge! Plus, Plus, you you receive receive all all the the benefits benefits of of Emergency Emergency Medicine Medicine Practice: Practice: • • Achief-complaintfocus:Everyissuestartswithapatientcomplaint—justlikeyourdailypractice.You’reguidedstep-by-step A chief-complaint focus: Every issue starts with a patient complaint — just like your daily practice. You’re guided step-by-step inreachingthediagnosis—oftenthemostchallengingpartofyourjob. in reaching the diagnosis — often the most challenging part of your job. • • Anevidence-basedmedicineapproach:Thedegreeofacceptanceandscientificvalidityofeachrecommendationisassessed An evidence-based medicine approach: The degree of acceptance and scientific validity of each recommendation is assessed basedonstrengthofevidence. based on strength of evidence. • Diagnosisandtreatmentrecommendationssolidlybasedinthecurrentliterature. • Diagnosis and treatment recommendations solidly based in the current literature. 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Decker, Departme and Associat c Affairs, tor Argentina Argentina Mount Sinai r, , Aires, Aires, ent nt Beston, Sinai School Inc, Inova of Academic MD of of DC;Director Thomas Emergency Emergen Practices Chair and e Professo Emergen Medicine Schoolofof Medicine Thomas Jefferson Fairfax Affairs, cy Medicine r of cy Medicine , Associate Medicine, ,, New New York, Hospital, Jefferson University Maarten Best Inc, Inova Maarten Church, York, NY Practices Philadelp , Resea , MayoProfessor CollegeEmergen Falls NY Simons, University, , Philadelp VA Simons, Fairfax Hospital, cy Medicine Clinic of , of Medicine Research MD, MD, Church, hia,hia, Emergen PhD rch Editor Emergen PhD , Mayo Clinic PAPA College Falls , Rocheste Editorss cycy Medicine of Medicine Medicine Francis M. r, MN Keith A. Marill,VA Scott Silvers, Scott Director, Residenc , Rocheste Director, Residenc Silvers, MD, MD Fesmire, Keith A. 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