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GREAT AHF Registry
Emergency Departement
Salvatore Di Somma MD
Emergency Medicine Department
Sant’Andrea Hospital
University of Roma “La Sapienza”
School of Medicine & Psychology
AHF Background (I)
rapid onset of symptoms and signs secondary to abnormal
cardiac function.
•
•occur as the first manifestation of a failing heart (acute de novo heart failure)
or in patients with chronic heart failure (acute decompensated heart failure).
•Or as cardiogenic shock
leading medical cause of hospitalization among people aged > or = 65 years;
More than 1 million hospital admissions occur annually for AHFS both in the United States and
in Europe
outcome: in-hospital mortality 10% (2-20%)
re-hospitalisation >50% within 1 year
ESC guidelines: European Heart Journal (2012) 33, 1787–1847
Gregg C. Fonarow: Am Heart J. 2008 Feb;155(2):200-7
Owais Dar; Martin R. Cowie: Crit Care Med 2008 Vol. 36, No. 1 (Suppl.)
This is the question
• Why we need a new registry in Acute Heart
Failure patients?
Background (II)
- ADHERE (Acute Decompensated Heart Failure National Registry): United States,
2002-2004, 105.388 patients, 274 hospitals (Am Heart J 2005;149:209-16)
- EHFS II (EuroHeart Failure Survey II): Europe, 2004-2005, 3580 patients, 133
hospitals, ICU, CCU, internal medicine and cardiology (European Heart Journal 2006; 27, 2725–
2736)
- ATTEND Registry: Asia and Pacific regions, 2007-2012, 1110 patients, 47 hospitals
(Am Heart J 2010;159:949-955.e1.)
- AHEAD (Acute Heart Failure Database Main registry): Czech Republic, 2006-2009,
4153 patients, 7 hospitals, cardiology departments (Spinar et al. Critical Care 2011, 15:R291)
- Italian Registry
- England and Wales Survey
- Japanese Registry (JCARE-CARD)
- Helsinki-Zurich Study
- New York Registry
- EFICA Study (Etude Française de l’Insuffisance Cardiaque Aiguë)
Why GREAT-AHF Registry?
• Patients with AHF may present in ED insidiously or acutely
with a spectrum of clinical severities ranging from those with
increasing dyspnea to those in extremis with acute pulmonary
edema or cardiogenic shock;
• Actually there are few data about the strategy on treatment
and post-discharge dispositions of AHF patients in ED;
• It’s difficult to evaluate quickly those patients on the basis of
clinical and instrumental exams
Background (III)
• Multicentered hospital-based
registries and surveys can provide
much valuable information about the
syndrome, although they may miss
patients with milder presentations
who are managed in primary care.
Typical AHF patient
the typical patient is >70 yrs of age, with a history of heart failure, coronary
artery disease and hypertension
Owais Dar, Martin R. Cowie: Crit Care Med 2008 Vol. 36, No. 1 (Suppl.)
AHF In-hospital mortality
AHEAD Registry
EuroHeart Failure Survey II
Owais Dar, Martin R. Cowie: Crit Care Med 2008 Vol. 36, No. 1 (Suppl.)
Spinar et al. Critical Care 2011, 15:R291
Predictors of in-hospital mortality:
OPTIMIZE-HF
Abraham et al Predictors of HF Hospital Mortality in the OPTIMIZE-HF
Trial. JACC Vol. 52, No. 5, 2008:347–56
AHF Risk-prediction score
Abraham et al Predictors of HF Hospital Mortality in the OPTIMIZE-HF
Trial. JACC Vol. 52, No. 5, 2008:347–56
new guidelines  new AHF registry
GREAT AHF Registry
“core”
AHF treatment: 2012 guidelines
-
-
Cotter G et al: Randomised trial of high-dose isosorbide dinitrate plus low-dose
furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in
severe pulmonary oedema. Lancet 1998;351:389–393.
Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive
heart failure: a randomized controlled trial. JAMA 2002;287:1531–1540.
Cohn JN et al: Effect of short-term infusion of sodium nitroprusside on mortality rate
in acute myocardial infarction complicated by left ventricular failure: results of a
Veterans Administration cooperative study. N Engl J Med 1982; 306:1129–1135.
ESC guidelines: European Heart Journal (2012) 33, 1787–1847
Vasodilators: 2012 guidelines
ESC guidelines: European Heart Journal (2012) 33, 1787–1847
Medications in AHF
Owais Dar, Martin R. Cowie: Crit Care Med 2008 Vol. 36, No. 1 (Suppl.)
Sato et al: American Heart Journal June 2010
Actually available registries include AHF patients enrolled at the
moment of in-hospital admission (department of cardiology,
intensive care unit, cardiac care unit.…)
Different acute presentation of AHF in emergency department
make each patient a different AHF-patient
NEED for BETTER CHARACTERIZATION of
AHF-PATIENTS in EMERGENCY SETTING
GREAT AHF Registry: Aims
1.
Creating a new International Prospective Registry on Acute Heart Failure
patient presenting in Emergency Department (ED);
2.
Creating a new Global AHF Database for future studies;
3.
Underlining any differences in treatment and management of patients
with acute heart failure in the different countries;
4.
Updating practice of treatment with a focus on the prompt use of
vasodilator drugs at ED arrival;
5.
Indentifying potential predictor variables;
6.
Evaluating the therapeutic and prognostic effects of AHF-patients
management in ED: inhospital mortality and incidence of cardiovascular
events within 30 days
GREAT AHF Registry: Objectives
• Describe the characteristics of patients presenting in ED with AHF
• Describe the prevalence of different kinds of AHF presentation (pulmonary
edema, ADHF, cardiogenic shock, right heart failure, HF-PEF preserved ejection
fraction, etc…)
• Describe current treatment of AHF in ED (pharmacological and/or non
pharmacological treatments)
• Verify the application of the current new Guidelines
• Estimate the outcomes related to treatment (focused on early use of
vasodilators)
• Estimate medical resource use and costs
• Assess 30 days major adverse cardiovascular events
GREAT AHF Registry:
Materials and Methods
- Prospective, international cross sectional registry ( participating
countries: ……………………..).
- ???? centers for Country (extimated …… patients)
- Enrollment period:……….
- ……. days Follow-up
- All data will be collected using a software (i.e. GIPSE) and in a
web-based data collection form
CRF ADHERE
Collection of data in ED
Conclusions:
Why GREAT-AHF Registry?
• Patients with AHF may present in ED insidiously or acutely with a
spectrum of clinical severities ranging from those with increasing dyspnea
to those in extremis with acute pulmonary edema or cardiogenic shock;
• Actually there are few data about the strategy on treatment and postdischarge dispositions of AHF patients in ED;
• It’s difficult to evaluate quickly these patients on the basis of clinical and
instrumental exams;
• For these reasons, a new registry is needed for evaluation of AHF at ED
presentation
• We are trying to create a new global, simple and rapid to perform registry
to be used in ED setting