Heart Failure In Emergency Department Research Articles

Abstract 4135726: Prospective validation and implementation pilot study of an emergency department heart failure risk stratification tool: STRIDE-HF

Background: We previously found the STRIDE-HF emergency department (ED) risk tool accurately predicted risk of a 30-day serious adverse event (SAE), including 30-day mortality, cardiopulmonary resuscitation, intra-aortic balloon pump insertion, intubation, new dialysis, myocardial infarction, or coronary revascularization. Research question: We sought to prospectively validate STRIDE-HF and describe safety of the deployed model in a clinical pilot. We hypothesized that performance would decrease slightly with prospective evaluation and that real-time risk display would contribute to safe disposition decisions. Goals: 1) To prospectively validate KPCARES-HF across 21 community EDs among ED patients with acute heart failure (AHF) from January 1, 2023 – December 31 st , 2023; and 2) to describe outcomes among patients predicted to be very low risk and discharged home in the clinical pilot. Methods: For prospective validation, we report 30-day mortality rates by risk strata. We assess model performance using area under the receiver operator curve (AUROC) and sensitivity at a key clinical threshold. We describe rates of 30-day SAE among patients predicted to be very low risk and discharged after ED or observation unit care in the clinical pilot. Results: There were 13,274 ED patients in the prospective validation; median age was 76, 50.8% were female, and 44.5% were non-White. We found 11.4%, 24.8%, 31.9%, and 31.9% of patients were very low, low, moderate, and high risk, respectively, while 21.6%, 15.2% and 63.0% were discharged, observed, and admitted, respectively. Among discharged patients, 29.2% and 13.3% were moderate or high risk, respectively, and 30-day mortality rates among these patients were 2.2% and 8.4%, respectively. Among 8,363 admitted patients, 27.7% were very low or low risk. Conclusions: STRIDE-HF maintained high predictive accuracy with prospective validation in this diverse, multi-center cohort. Our findings suggest that use of STRIDE-HF might help better align risk with admission decision and can be safely used to assist providers in identifying patients who may be stable for outpatient care.

Multimodal deep learning models utilizing chest X-ray and electronic health record data for predictive screening of acute heart failure in emergency department

Background and ObjectivesAmbiguity in diagnosing acute heart failure (AHF) leads to inappropriate treatment and potential side effects of rescue medications. To address this issue, this study aimed to use multimodality deep learning models combining chest X-ray (CXR) and electronic health record (EHR) data to screen patients with abnormal N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in emergency departments. MethodsUsing the open-source dataset MIMIC-IV and MIMICCXR, the study population consisted of 1,432 patients and 1,833 pairs of CXRs and EHRs. We processed the CXRs, extracted relevant features through lung-heart masks, and combined these with the vital signs at triage to predict corresponding NT-proBNP levels. ResultsThe proposed method achieved a 0.89 area under the receiver operating characteristic curve by fusing predictions from single-modality models of heart size ratio, radiomic features, CXR, and the region of interest in the CXR. The model can accurately predict dyspneic patients with abnormal NT-proBNP concentrations, allowing physicians to reduce the risks associated with inappropriate treatment. ConclusionThe study provided new image features related to AHF and offered insights into future research directions. Overall, these models have great potential to improve patient outcomes and reduce risks in emergency departments.

Assessment of venous congestion with venous excess ultrasound score in the prognosis of acute heart failure in the emergency department: a prospective study.

In acute decompensated heart failure (HF), systemic venous congestion contributes to patients' symptoms and hospital admissions. The purpose of our study is to determine if venous congestion, examined using the venous excess ultrasound (VExUS) score, predicts HF-related hospitalization and mortality in patients admitted to the emergency department (ED) with acute decompensated HF. Fifty patients admitted for acute HF in ED underwent ultrasound (US) assessment according to the VExUS score within the first 24 and 72 h. All patients were followed up with a telephone call at 30 and 60 days after hospital discharge. On admission, 56% had a VExUS score of 3. After 72 h, 32% had no more signs of congestion at the Doppler VExUS examination (inferior vena cava < 2 cm, VExUS score of 0); a similar percentage still exhibited a VExUS score of 3 despite therapy. Eighty per cent of patients were hospitalized after admission to the ED, while six (15%) died in-hospital; all exhibited a first-assessment VExUS score of 3. No patient with a VExUS score < 3 died during the study. During short-term follow-up, 18 patients were readmitted to the ED for acute decompensated HF. Ninety-four per cent of the readmitted patients had a VExUS score of 3 at the Doppler assessment at the first ED admission. Severe venous congestion, defined as a VExUS score of 3 at the initial assessment of patients with acute decompensated HF, predicts inpatient mortality, HF-related death, and early readmission.

Association of intravenous digoxin use in acute heart failure with rapid atrial fibrillation and short-term mortality according to patient age, renal function, and serum potassium.

Intravenous digoxin is still used in emergency departments (EDs) to treat patients with acute heart failure (AHF), especially in those with rapid atrial fibrillation. Nonetheless, many emergency physicians are reluctant to use intravenous digoxin in patients with advanced age, impaired renal function, and potassium disturbances due to its potential capacity to increase adverse outcomes. We investigated whether intravenous digoxin used to treat rapid atrial fibrillation in patients with AHF may influence mortality in patients with specific age, estimated glomerular filtration rate (eGFR), and serum potassium classes. A secondary analysis of patients included in in the Spanish EAHFE cohort, which includes patients diagnosed with AHF in the ED. 45 Spanish EDs. Two thousand one hundred ninety-four patients with AHF and rapid atrial fibrillation (heart rate ≥100 bpm) not receiving digoxin at home, divided according to whether they were or were not treated with intravenous digoxin in the ED. The relationships between age, eGFR, and potassium with 30-day mortality were investigated using restricted cubic spline (RCS) models adjusted for relevant patient and episode variables. The impact of digoxin use on such relationships was assessed by checking interaction. The median age of the patients was 82 years [interquartile range (IQR) = 76-87], 61.4% were women, 65.2% had previous episodes of atrial fibrillation, and the median heart rate at ED arrival was 120 bpm (IQR = 109-135). Digoxin and no digoxin groups were formed by 864 (39.4%) and 1330 (60.6%) patients, respectively. There were 191 deaths within the 30-day follow-up period (8.9%), with no differences between patients receiving or not receiving digoxin (8.5 vs. 9.1%, P = 0.636). Although analysis of RCS curves showed that death was associated with advanced age, worse renal function, and hypo- and hyperkalemia, use of intravenous digoxin did not interact with any of these relationships ( P = 0.156 for age, P = 0.156 for eGFR; P = 0.429 for potassium). The use of intravenous digoxin in the ED was not associated with significant changes in 30-day mortality, which was confirmed irrespective of patient age or the existence of renal dysfunction or serum potassium disturbances.

Timing of previous heart failure hospitalization as a prognostic factor for emergency department heart failure patients.

To investigate whether the timing of a previous hospital admission for acute heart failure (AHF) is a prognostic factor for AHF patients revisiting the emergency department (ED) in the subsequent 12-month follow-up. All ED AHF patients enrolled in the previously described EAHFE registry were stratified by the presence or absence of an AHF hospitalization admission in the prior 12months. The primary outcome was 12-month all-cause mortality postED visit. Secondary end points were hospital admission, prolonged hospitalization (> 7days), mortality during hospitalization and a 90-day post-discharge adverse composite event (ACE) rate, defined as ED revisits due to AHF, hospitalizations due to AHF, or all-cause mortality. Outcomes were adjusted for baseline and AHF episode characteristics.Of 5,757 patients included, the median age was 84years (IQR 77-88); 57% were women, and 3,759 (65.3%) had an AHF hospitalization in the previous 12months. The 12-month mortality was 37% (41.7% vs. 28.3% p < 0.001), hospital admission was 76.1% (78.8% vs. 71.1% p < 0.001) ACE was 60.2% (65.1% vs. 50.5% p < 0.001). In the adjusted analysis, patients with AHF hospitalization in the prior 12months had a higher mortality (HR = 1.41; 95% CI 1.27-1.56), 90-day ACE rate (HR = 1.45: 95% CI 1.32-1.59), and more hospital admissions (OR = 1.32; 95% CI 1.16-1.51), with shorter times since the previous hospitalization being related to the outcomes analyzed. One-year mortality, adverse events at 90days, and readmission rates are increased in ED AHF patients previously admitted within the last 12months.

Prognostic impact of metformin in patients with type 2 diabetes mellitus and acute heart failure: Combined analysis of the EAHFE and RICA registries

IntroductionPatients with diabetes mellitus (DM) and heart failure (HF) have a worse prognosis despite therapeutic advances in both diseases. Sodium-glucose co-transporter type 2 and GLP-1 receptor agonists have shown cardiovascular benefits and they have been positioned as the first step in the treatment of DM in patients with HF or high cardiovascular risk. However, in the pivotal trials the majority of patients receive concomitant treatment with metformin. Randomized clinical trials have not yet been developed to assess the prognostic impact of metformin at the cardiovascular level. Our objective has been centered in analyzing whether patients with DM and acute HF who receive treatment with metformin at the time of discharge may have a better prognosis at one year of follow-up. MethodsProspective cohort trial using the combined analysis of the two main Spanish HF registries, the EAHFE Registry (Epidemiology of Acute Heart Failure in Emergency Departments) and the RICA (National Registry of Patients with Heart Failure). Results33% (1453) of a total of 4403 patients with DM type 2 received treatment with metformin. This group presents significantly lower mortality after one year of treatment (22 versus 32%; Log Rank test P < 0.001). In the adjusted analysis of mortality, patients receiving treatment with metformin have lower mortality at one year of follow-up regardless of the rest of the variables (RR 0,814; 95%IC 0,712–0,930; P < 0.01). ConclusionsPatients with DM type 2 and acute HF who receive metformin have a better prognosis after one year of follow-up, so we believe that this drug should continue to be a fundamental pillar in the treatment of these patients.

Acute heart failure in emergency departments: what is new in 2023?

aEmergency Department, Toulouse University Hospital bCERPOP – EQUITY, INSERM, Toulouse cEmergency Medicine Department, CHRU Tours dFaculty of Medicine, University of Tours, Tours, France Received 9 January 2023 Accepted 11 January 2023 Correspondence to Frederic Balen, MD, MSc, Emergency Department, Toulouse University Hospital, 31059 Toulouse, France, E-mail: [email protected]

Doppler alternans in pediatric emergency: correlation between clinical, Doppler waveforms and silent ventricular dysfunction by POCUS echo

Pulsus alternans (PA), reported in nineteenth century, is a subtle abnormality, often missed in emergency situations. However, the significance lies in its association with severe ventricular dysfunction. This case reports an 8-year-old child presenting with heart failure in emergency department. Abdominal aortic Doppler displayed pulsus/Doppler alternans. Step by step investigation of Doppler clue unearthed severe left ventricular dysfunction secondary to systemic arterial hypertension.

Outcomes Of Remote Pulmonary Artery Hemodynamic Monitoring In Heart Failure Patients With Atrial Fibrillation In Male And Female Population

Introduction Pulmonary artery (PA) hemodynamic monitoring using CadioMEMS device has shown to decrease heart failure (HF) readmissions. Atrial fibrillation (AFib) and HF often coexist and AFib can itself cause variations in PA pressures. We studied the impact of remote PA hemodynamic monitoring in reducing HF readmissions in patients with Afib and HF in male and female population. Method Retrospective data was collected for patients with HF who had CardioMEMS device implanted based on FDA indications from April 2015 to August 2020. Data including number of all cause and HF hospitalizations, emergency department (ED) and HF clinic visits was collected for 1-year pre and 1-year post device implantation. Mortality data was collected at 1-year post-implantation. Analysis was done using the median and Kruskal-Wallis test for comparison between different age groups. Mortality was compared using Pearson's chi-squared test. Results CardioMEMS device was implanted in 177 patients during the study period. Of this population, 107 (60%) had AFib. There was a statistically significant decrease in overall mean HF admissions in Afib patients from 1.68 (± 1.34) to 0.63 (± 1.08), (63.1%) p<0.001 and mean HF ED visits 1.38 (± 1.40) to 0.57 (± 1.02), (58.7%) p<0.001 between 1-year pre and post implantation. But there was no statistically significant difference between male and female population in all-cause admissions, HF admissions, ED visits, ED HF visits, HF clinic visits along with mortality at 1-year post-implantation. Conclusion Remote PA hemodynamic monitoring decreases heart failure readmissions and ED visits in patients with AFib and HF and outcomes are similar in male and female population. Pulmonary artery (PA) hemodynamic monitoring using CadioMEMS device has shown to decrease heart failure (HF) readmissions. Atrial fibrillation (AFib) and HF often coexist and AFib can itself cause variations in PA pressures. We studied the impact of remote PA hemodynamic monitoring in reducing HF readmissions in patients with Afib and HF in male and female population. Retrospective data was collected for patients with HF who had CardioMEMS device implanted based on FDA indications from April 2015 to August 2020. Data including number of all cause and HF hospitalizations, emergency department (ED) and HF clinic visits was collected for 1-year pre and 1-year post device implantation. Mortality data was collected at 1-year post-implantation. Analysis was done using the median and Kruskal-Wallis test for comparison between different age groups. Mortality was compared using Pearson's chi-squared test. CardioMEMS device was implanted in 177 patients during the study period. Of this population, 107 (60%) had AFib. There was a statistically significant decrease in overall mean HF admissions in Afib patients from 1.68 (± 1.34) to 0.63 (± 1.08), (63.1%) p<0.001 and mean HF ED visits 1.38 (± 1.40) to 0.57 (± 1.02), (58.7%) p<0.001 between 1-year pre and post implantation. But there was no statistically significant difference between male and female population in all-cause admissions, HF admissions, ED visits, ED HF visits, HF clinic visits along with mortality at 1-year post-implantation. Remote PA hemodynamic monitoring decreases heart failure readmissions and ED visits in patients with AFib and HF and outcomes are similar in male and female population.

Abstracts for the 40th emergencies in medicine conference

Abstracts for the 40^th emergencies in medicine conference

Abstract 10744: Efficacy of Remote Pulmonary Artery Hemodynamic Monitoring in Reducing Heart Failure Readmissions Among Patients with Obstructive Sleep Apnea of Varying Severity

Introduction: Obstructive sleep apnea (OSA) and heart failure (HF) often co-exist. Remote pulmonary artery (PA) hemodynamic monitoring has shown to decrease HF readmissions. However, there is limited data regarding its efficacy in patients with OSA of varying severity. Hypothesis: Outcomes of remote PA hemodynamic monitoring using CardioMEMS device in reducing HF hospitalization in patients with mild [apnea-hypopnea index (AHI)=5-14], moderate (AHI=15-30) and severe OSA (AHI&gt;30). Methods: Retrospective data was collected for HF patients who had CardioMEMS device implanted based on FDA indications from April 2015 to August 2020. Number of hospitalizations, emergency department (ED) and HF clinic visits data was collected for 1-year pre and 1-year post-implantation. Mortality data was collected at 1-year post-implantation. Severity of OSA was based on AHI documented in the sleep study. Analysis was done using Kruskal-Wallis test for comparison between OSA groups. Mortality was compared with Pearson’s chi-squared test. Results: CardioMEMS device was implanted in 177 patients during the study period. Of this, 108(61%) patients had OSA diagnosed at the time of implantation. Among OSA patients, 52(48%) had severe OSA. There was a statistically significant decrease in overall mean HF admissions from 1.80(± 1.55) to 0.62(± 1.07), 65.6%, p&lt;0.001 and mean HF ED visits from 1.37(± 1.50) to 0.5(± 0.95), 63.5%, p&lt;0.001 in 1-year pre-and post-implantation among all OSA patients. When comparing different OSA groups, there was no statistically significant difference between them in all-cause admissions, HF admissions, ED visits, ED HF visits, and HF clinic visits 1-year pre and post-implantation. No statistically significant difference was observed in mortality. Conclusions: PA hemodynamic monitoring using CardioMEMS device had a net benefit in reducing HF admissions and HF ED visits in OSA patients and this benefit remained unchanged across different OSA groups.

Outcomes of remote pulmonary artery hemodynamic monitoring in heart failure patients with obstructive sleep apnea

Abstract Introduction Obstructive sleep apnea (OSA) is often associated with heart failure (HF). Remote pulmonary artery (PA) hemodynamic monitoring has shown to decrease HF related readmissions. However, there is paucity of data regarding its efficacy and mortality in patients with OSA. Purpose Real-world analysis of outcomes of remote PA hemodynamic monitoring using CardioMEMS device in reducing HF hospitalization in patients with OSA [apnea–hypopnea index (AHI) ≥5]. Methods Retrospective data was collected for patients with HF who had CardioMEMS device implanted based on FDA indications from April 2015 to August 2020. The number of hospitalizations, emergency department (ED) and HF clinic visits data was collected for 1-year pre and 1-year post device implantation. Mortality data was also collected at 1-year post-implantation. Patients who were diagnosed with OSA based on AHI ≥5 on sleep study at the time of implantation were included in the study. Analysis was done using Kruskal-Wallis test for comparison between heart failure patients with and without OSA. Mortality was compared with Pearson's chi-squared test. Results CardioMEMS device was implanted in 177 patients during the study period. Of this population, 108 (61%) patients had known OSA at the time of implantation. There was a statistically significant decrease in overall mean HF admissions from 1.80 (± 1.55) to 0.62 (± 1.07), 65.6%, p&amp;lt;0.001 and mean HF ED visits from 1.37 (± 1.50) to 0.5 (± 0.95), 63.5%, p&amp;lt;0.001 in 1-year pre- and post-implantation among OSA patients. When comparing outcomes between HF patients with and without OSA, there was no statistically significant difference observed between them in all-cause admissions, HF admissions, ED visits, ED HF visits, and HF clinic visits 1-year pre and post implantation. Also, no statistically significant difference was observed in mortality between the groups at 1-year post-implantation. Conclusions PA hemodynamic monitoring using CardioMEMS device had a net benefit in reducing HF admissions and HF ED visits in OSA patients which was similar in patients without OSA. Funding Acknowledgement Type of funding sources: None.

Response to “practical implication of nitroglycerin test for diagnosing heart failure in emergency department”

Response to “practical implication of nitroglycerin test for diagnosing heart failure in emergency department”

Predictors of acute kidney injury in patients with acute decompensated heart failure in emergency departments in China.

ObjectiveThis retrospective multicentre observational study was performed to assess the predictors of acute kidney injury (AKI) in patients with acute decompensated heart failure (ADHF) in emergency departments in China.MethodsIn total, 1743 consecutive patients with ADHF were recruited from August 2017 to January 2018. Clinical characteristics and outcomes were compared between patients with and without AKI. Predictors of AKI occurrence and underdiagnosis were assessed in multivariate regression analyses.ResultsOf the 1743 patients, 593 (34.0%) had AKI. AKI was partly associated with short-term all-cause mortality and cost. Cardiovascular comorbidities such as coronary heart disease, diabetes mellitus, and hypertension remained significant predictors of AKI in the univariate analysis. AKI was significantly more likely to occur in patients with a lower arterial pH, lower albumin concentration, higher creatinine concentration, and higher N-terminal pro-brain natriuretic peptide (NT-proBNP) concentration. Patients treated with inotropic agents were significantly more likely to develop AKI during their hospital stay.ConclusionThis study suggests that cardiovascular comorbidities, arterial pH, the albumin concentration, the creatinine concentration, the NT-proBNP concentration, and use of inotropic agents are predictors of AKI in patients with ADHF.

B-PO03-195 OUTCOMES OF REMOTE PULMONARY ARTERY HEMODYNAMIC MONITORING IN HEART FAILURE PATIENTS WITH ATRIAL FIBRILLATION IN DIFFERENT AGE GROUPS

Pulmonary artery (PA) hemodynamic monitoring using CadioMEMS device has shown to decrease heart failure (HF) readmissions. Atrial fibrillation (AFib) and HF often coexist and AFib can itself cause variations in PA pressures. To study the impact of remote PA hemodynamic monitoring in reducing HF readmissions in patients with Afib and HF in different age groups. Retrospective data was collected for patients with HF who had CardioMEMS device implanted based on FDA indications from April 2015 to August 2020. Data including number of all cause and HF hospitalizations, emergency department (ED) and HF clinic visits was collected for 1-year pre and 1-year post device implantation. Mortality data was collected at 1-year post-implantation. Analysis was done using the median and Kruskal-Wallis test for comparison between different age groups. Mortality was compared using Fisher's Exact Test. CardioMEMS device was implanted in 177 patients during the study period. Of this population, 107 (60%) had AFib. There was a statistically significant decrease in overall mean HF admissions in Afib patients from 1.68 (± 1.34) to 0.63 (± 1.08), (63.1%) p<0.001 and mean HF ED visits 1.38 (± 1.40) to 0.57 (± 1.02), (58.7%) p<0.001 between 1-year pre and post-implantation. But there was no statistically significant difference between age groups in all-cause admissions, HF admissions, ED visits, ED HF visits, HF clinic visits along with mortality at 1-year post-implantation. Remote PA hemodynamic monitoring decreases heart failure readmissions and ED visits in patients with AFib and HF and outcomes are similar in different age groups.

The FAST-FURO study: effect of very early administration of intravenous furosemide in the prehospital setting to patients with acute heart failure attending the emergency department.

The effect of early administration of intravenous (IV) furosemide in the emergency department (ED) on short-term outcomes of acute heart failure (AHF) patients remains controversial, with one recent Japanese study reporting a decrease of in-hospital mortality and one Korean study reporting a lack of clinical benefit. Both studies excluded patients receiving prehospital IV furosemide and only included patients requiring hospitalization. To assess the impact on short-term outcomes of early IV furosemide administration by emergency medical services (EMS) before patient arrival to the ED. In a secondary analysis of the Epidemiology of Acute Heart Failure in Emergency Departments (EAHFE) registry of consecutive AHF patients admitted to Spanish EDs, patients treated with IV furosemide at the ED were classified according to whether they received IV furosemide from the EMS (FAST-FURO group) or not (CONTROL group). In-hospital all-cause mortality, 30-day all-cause mortality, and prolonged hospitalization (>10 days) were assessed. We included 12595 patients (FAST-FURO = 683; CONTROL = 11912): 968 died during index hospitalization [7.7%; FAST-FURO = 10.3% vs. CONTROL = 7.5%; odds ratio (OR) = 1.403, 95% confidence interval (95% CI) = 1.085-1.813; P = 0.009], 1269 died during the first 30 days (10.2%; FAST-FURO = 13.4% vs. CONTROL = 9.9%; OR = 1.403, 95% CI = 1.146-1.764; P = 0.004), and 2844 had prolonged hospitalization (22.8%; FAST-FURO = 25.8% vs. CONTROL = 22.6%; OR = 1.189, 95% CI = 0.995-1.419; P = 0.056). FAST-FURO group patients had more diabetes mellitus, ischaemic cardiomyopathy, peripheral artery disease, left ventricular systolic dysfunction, and severe decompensations, and had a better New York Heart Association class and had less atrial fibrillation. After adjusting for these significant differences, early IV furosemide resulted in no impact on short-term outcomes: OR = 1.080 (95% CI = 0.817-1.427) for in-hospital mortality, OR = 1.086 (95% CI = 0.845-1.396) for 30-day mortality, and OR = 1.095 (95% CI = 0.915-1.312) for prolonged hospitalization. Several sensitivity analyses, including analysis of 599 pairs of patients matched by propensity score, showed consistent findings. Early IV furosemide during the prehospital phase was administered to the sickest patients, was not associated with changes in short-term mortality or length of hospitalization after adjustment for several confounders.

Prognostic implications of Anemia in patients with acute heart failure in emergency departments. ANEM-AHF Study.

The presence of anaemia leads to a worse prognosis in patients with heart failure (HF). There are few data on the impact of anaemia on mortality in patients with acute heart failure (AHF), and the studies available are mainly retrospective, and include hospitalised patients. Evaluate the role of anaemia on 30-day and 1-year mortality in patients with AHF attended in hospital emergency departments (HEDs). We performed a multicentre, observational study of prospective cohorts of patients with AHF. The study variables were: Anaemia (haemoglobin <12g/dL in women and <13g/dL in men), mortality at 30days and at 1year, risk factors, comorbidity, functional impairment, basal functional grade for dyspnoea, chronic and acute treatment, clinical and analytical data of the episode, and patient destination. Bivariate analysis and survival analyses using Cox regression. A total of 13454 patients were included, 7662 (56.9%) of whom had anaemia. Those with anaemia were older, had more comorbidity, a worse functional status and New York Heart Association class, greater renal function impairment, and more hyponatraemia. The mortality was higher in patients with anaemia at 30days and 1year: 7.5% vs 10.7% (P<.001) and 21.2% vs 31.4% (P<.001), respectively. The crude and adjusted hazard ratios of anaemia for 30-day mortality were: 1.46 (confidence interval [CI] 95% 1.30-1.64); P<.001 and 1.20 (CI 95% 1.05-1.38); P=.009, respectively, and 1.57 (CI 95% 1.47-1.68) and 1.30 (CI 95% 1.20-1.40) for mortality at 1year. The weight of anaemia on mortality was different in each follow-up period. Anaemia is an independent predictor of mortality at 30days and 1year in patients with AHF attended in HEDs. It is important to study the aetiology of AHF since adequate treatment would reduce mortality.

How Standardization of Diagnosing and Treating Decompensated Heart Failure Affects Emergency Department and Hospital Length of Stay Across a Large Healthcare System

Introduction Heart failure (HF) affects more than 6 million Americans and is the most common discharge diagnosis-related group (DRG) among Medicare patients. As greater than 80% of these patients present via the emergency department (ED), it is imperative that decompensated HF (DHF) be differentiated from other medical conditions as quickly as possible to allow for efficient treatment initiation. In this study, we examined the effect of an ED HF protocol involving the triage, diagnosis, and management of DHF with the goal of improving diagnostic accuracy, time to initial diuresis, and length of stay (LOS). Methods : All patients diagnosed with DHF during an ED visit were studied over a 3-month period at two EDs across the Scripps Healthcare system. Quality metrics collected are listed in the accompanying table. Values were compared to a pre-intervention cohort that was treated for DHF at the same sites the year prior. Patients were evaluated in triage, and the HF protocol was initiated if the patient met screening criteria, which included specific complaints such as shortness of breath and/or leg swelling. Once initiated, “Code CHF” was announced. The protocol included a nurse-driven order set, medication reconciliation, and a prompt to the physician to utilize point of care ultrasound (POCUS). If DHF was diagnosed, a protocol dose of diuretic was ordered. The aforementioned metrics were then calculated post discharge. Results : A total of 485 patients were evaluated using the DHF protocol, and 377 patients were evaluated from the year prior. Mean door-to-diuretic (D2D) time decreased by 35 minutes. Mean ED LOS decreased by 1 hour and 34 minutes. Mean hospital LOS decreased by 5 hours. POCUS use increased by 23%. Lasix dose increased by a mean of 13 mg. Medication reconciliation did not change dramatically between the pre and post period. Conclusions/Discussion : This pilot study demonstrates that implementation of a HF protocol aimed at improving diagnostic accuracy and treatment of DHF is feasible in a real-world community ED. Crucially this translates into important quality, patient experience, and cost metrics. Our results are consistent with prior studies showing that a decrease in D2D time, and increase in initial diuretic dosing, are associated with improved LOS. While promising, the simultaneous implementation of several interventions makes it difficult to discern which had the biggest impact on improving the evaluated metrics. The question of sustainability and follow-up ED and hospital admissions is currently being assessed in follow up studies.

Factors associated with in-hospital mortality and adverse outcomes during the vulnerable post-discharge phase after the first episode of acute heart failure: results of the NOVICA-2 study

To identify patients at risk of in-hospital mortality and adverse outcomes during the vulnerable post-discharge period after the first acute heart failure episode (de novo AHF) attended at the emergency department. This is a secondary review of de novo AHF patients included in the prospective, multicentre EAHFE (Epidemiology of Acute Heart Failure in Emergency Department) Registry. We included consecutive patients with de novo AHF, for whom 29 independent variables were recorded. The outcomes were in-hospital all-cause mortality and all-cause mortality and readmission due to AHF within 90days post-discharge. A follow-up check was made by reviewing the hospital medical records and/or by phone. We included 3422 patients. The mean age was 80years, 52.1% were women. The in-hospital mortality was 6.9% and was independently associated with dementia (OR = 2.25, 95% CI = 1.62-3.14), active neoplasia (1.97, 1.41-2.76), functional dependence (1.58, 1.02-2.43), chronic treatment with beta-blockers (0.62, 0.44-0.86) and severity of decompensation (6.38, 2.86-14.26 for high-/very high-risk patients). The 90-day post-discharge combined endpoint was observed in 19.3% of patients and was independently associated with hypertension (HR = 1.40, 1.11-1.76), chronic renal insufficiency (1.23, 1.01-1.49), heart valve disease (1.24, 1.01-1.51), chronic obstructive pulmonary disease (1.22, 1.01-1.48), NYHA 3-4 at baseline (1.40, 1.12-1.74) and severity of decompensation (1.23, 1.01-1.50; and 1.64, 1.20-2.25; for intermediate and high-/very high-risk patients, respectively), with different risk factors for 90-day post-discharge mortality or rehospitalisation. The severity of decompensation and some baseline characteristics identified de novo AHF patients at increased risk of developing adverse outcomes during hospitalisation and the vulnerable post-discharge phase, without significant differences in these risk factors according to patient age at de novo AHF presentation.

The CRAS-EAHFE study: Characteristics and prognosis of acute heart failure episodes with cardiorenal-anaemia syndrome at the emergency department.

The coexistence of other comorbidities confers poor outcomes in patients with acute heart failure. Our aim was to determine the characteristics of patients with acute heart failure and cardiorenal anaemia syndrome and the relationship between renal dysfunction and anaemia, alone or combined as cardiorenal anaemia syndrome, on short-term outcomes. We analysed the Epidemiology of Acute Heart Failure in Emergency Departments registry (cohort of patients with acute heart failure in Spanish emergency departments). Renal dysfunction was defined by an estimated glomerular filtration rate <60 ml/min/m2, anaemia by haemoglobin values <12/<13 g/dl in women/men, and cardiorenal anaemia syndrome as the presence of both. Comparisons were made according to cardiorenal-anaemia syndrome positive (CRAS+) with respect to the rest of patients (CRAS-) and according the presence of renal dysfunction (RD+) and anaemia (A+), (alone, RD+/A-, RD-/A+) or in combination (RD+/A+; i.e. CRAS+) with respect to patients without renal dysfunction and anaemia (RD-/A-). The primary outcome was 30-day mortality, and the secondary outcomes were need for admission, prolonged hospitalisation (>10 days), in-hospital mortality during the index event, and reconsultation and the combination of 30-day post-discharge reconsultation/death. These short-term outcomes were compared and adjusted for differences among groups. Of the 13,307 patients analysed, CRAS+ (36.4%) was associated with older age, multiple comorbidities, chronic use of loop diuretics, oedemas and hypotension. The 30-day mortality in CRAS+ was greater than in CRAS- (hazard ratio = 1.46, 95% confidence interval = 1.26-1.68) and RD-/A- (hazard ratio = 1.83, 95% confidence interval = 1.46-2.28) control groups. The mortality level was also higher in RD+/A- (hazard ratio = 1.40, 95% confidence interval = 1.10-1.78) and higher, but not statistically significant, in RD-/A+ (hazard ratio = 1.28, 95% confidence interval = 0.99-1.63) with respect to RD-/A-. All of the secondary outcomes, when related to CRAS- and RD-/A- control groups, were worse for CRAS+ and to a lesser extent, RD+/A-, being more rarely observed in RD-/A+. Cardiorenal anaemia syndrome in acute heart failure is related to greater mortality and worse short-term outcomes, and the impact of renal dysfunction and anaemia seems to be additive.