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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