Heart Failure In Emergency Department Research Articles

B-Type natriuretic peptide trends correlate with clinical events in heart failure patients discharged from an observation unit

Study objectives: B-type natriuretic peptide (BNP) has been evaluated extensively as a diagnostic marker in dyspneic emergency department (ED) patients, but changes in BNP during treatment are less well understood. We hypothesize that changes in BNP levels will predict treatment failures in heart failure patients treated in an observation unit. Methods: We performed a retrospective medical record review of heart failure patients treated in the observation unit between February 2003 and March 2004. Those patients discharged directly from the observation unit were the focus of this analysis. All patients were required to have a minimum of 2 BNP values drawn as part of their observation unit management, with the last BNP performed just before observation unit disposition. Thirty-day heart failure event rates included an ED visit for heart failure, an observation unit readmission for heart failure, a hospital readmission for heart failure, and death. Event rates were not counted twice (ie, an ED visit for heart failure resulting in a hospital admission counted as only 1 event). The Mann-Whitney U test was used to compare continuous variables. Results: Thirty-two patients discharged directly from the observation unit fulfilled inclusion criteria. These patients had a mean age of 54.8 years, 59.4% were men, and 83.1% were black. Eight of the 32 patients discharged from the observation unit experienced 30-day events: 0 deaths, 7 ED heart failure visits, 1 observation unit heart failure readmission, and 6 hospital heart failure readmissions. Patients whose BNP levels increased despite apparent clinical improvement experienced more 30-day events (44.4%) than those patients whose BNP levels decreased with treatment (17.4%). Although there was no significant difference in initial BNP levels between the 2 groups (1,436±940 pg/mL versus 1,025±1,029 pg/mL; P =.124), the absolute value of the final BNP drawn was higher in those with events (1,620±854 pg/mL) than those without events (785±626 pg/mL; P =.033). Conclusion: This pilot study suggests that discharged observation unit patients with heart failure whose BNP decreases with treatment have a better prognosis than those patients whose BNP increases with treatment.

Primary results of the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT): A multicenter study of B-type natriuretic peptide levels, emergency department decision making, and outcomes in patients presenting with shortness of breath

ObjectivesThe purpose of this study was to examine the relationships among B-type natriuretic peptide (BNP) levels within the diagnostic range, perceived congestive heart failure (CHF) severity, clinical decision making, and outcomes of the CHF patients presenting to emergency department (ED). BackgroundSince BNP correlates with the presence of CHF, disease severity, and prognosis, we hypothesized that BNP levels in the diagnostic range offer value independent of physician decision making with regard to critical outcomes in emergency medicine. MethodsThe Rapid Emergency Department Heart failure Outpatient Trial (REDHOT) study was a 10-center trial in which patients seen in the ED with shortness of breath were consented to have BNP levels drawn on arrival. Entrance criteria included a BNP level >100 pg/ml. Physicians were blinded to the actual BNP level and subsequent BNP measurements. Patients were followed up for 90 days after discharge. ResultsOf the 464 patients, 90% were hospitalized. Two-thirds of patients were perceived to be New York Heart Association (NYHA) functional class III or IV. The BNP levels did not differ significantly between patients who were discharged home from the ED and those admitted (976 vs. 766, p = 0.6). Using logistic regression analysis, an ED doctor's intention to admit or discharge a patient had no influence on 90-day outcomes, while the BNP level was a strong predictor of 90-day outcome. Of admitted patients, 11% had BNP levels <200 pg/ml (66% of which were perceived NYHA functional class III or IV). The 90-day combined event rate (CHF visits or admissions and mortality) in the group of patients admitted with BNP <200 pg/ml and >200 pg/ml was 9% and 29%, respectively (p = 0.006). ConclusionsIn patients presenting to the ED with heart failure, there is a disconnect between the perceived severity of CHF by ED physicians and severity as determined by BNP levels. The BNP levels can predict future outcomes and thus may aid physicians in making triage decisions about whether to admit or discharge patients. Emerging clinical data will help further refine biomarker-guided outpatient therapeutic and monitoring strategies involving BNP.

1001-25 Primary results of the rapid emergency department heart failure outpatient trial (REDHOT): A multicenter trial examining B-type natriuretic peptide levels, emergency physician decision making and outcomes in patients presenting with shortness of breath

1001-25 Primary results of the rapid emergency department heart failure outpatient trial (REDHOT): A multicenter trial examining B-type natriuretic peptide levels, emergency physician decision making and outcomes in patients presenting with shortness of breath

Management of Acute Decompensated Heart Failure in the Emergency Department

Heart failure, a disease of epidemic proportions, has a tremendous clinical and financial impact on the US health care system. With more than 5 million Americans diagnosed with heart failure and 5-year mortality approaching 50%, it is the most common cause of hospitalization in patients older than 65 years and is the single most expensive diagnosis in the US health care system. Because the average US hospital loses more than 1000 dollars per heart failure admission, effective therapies that decrease length of stay, reduce hospital costs, and prevent 30-day readmissions are needed. This article reviews the relevant pathophysiology of heart failure, discusses the newest diagnostic strategies for emergency department diagnoses, evaluates recent advances and effects of early aggressive therapies, and presents a suggested algorithm for the treatment of acutely decompensated heart failure in emergency departments.

Effective observation unit treatment of decompensated heart failure.

There is little information on the effectiveness of emergency department (ED) observation unit (OU) heart failure (HF) therapy. The authors' objective was to evaluate outcomes after implementation of an ED-OU treatment protocol for HF exacerbation. Unblinded assessment of the effectiveness of an HF protocol was performed, controlled by outcome for 9 months prior to implementation. This included diagnostic and therapeutic algorithms, cardiology consultation, close monitoring, patient education, and discharge planning. Adverse outcomes were defined as the 90-day rates of ED HF revisits, hospital HF readmissions, or death, as determined by chart review, computer database search, and phone follow-up. One hundred fifty-four patients were enrolled; 50 entered before, and 104 after protocol implementation. Only six (12%) in the preprotocol and one (1%) of the postprotocol group were lost to follow-up. After an OU visit, postprotocol 90-day ED HF revisit rates declined 56% (0.90-0.51; p<0.0000) and the 90-day HF rehospitalization rate decreased 64% (0.77-0.50; p=0.007). The 90-day rates of death and OU HF readmission decreased from 4% to 1% (p=0.096) and 18% to 11% (p=0.099), respectively. An intensive outpatient ED OU HF management protocol safely decreases 90-day rates of emergency department visits and inpatient hospitalizations.

Dyspnea duration, distress, and intensity in emergency department visits for heart failure

Background: Dyspnea is the most common symptom among patients with heart failure (HF) who present to the emergency department (ED), but it is not clear which dimensions of the symptom prompt ED visits, or whether dyspnea characteristics are related to visit disposition. Purpose: The goal of this study was to explore the influence of dyspnea duration, distress, and intensity on decisions of patients with HF to come to an ED and the disposition of visits. Methods: The study population consisted of patients treated for HF in an urban university hospital ED (N = 57) who were interviewed retrospectively. Open-ended questions pertained to symptoms in general and dyspnea at the time of the visit. Subjects rated recalled dyspnea distress (0 = not at all bothered by breathing; 4 = bothered very much by breathing) for when they decided to come to the ED (Decision) and a week before the visit (Week Before), as well as duration—the number of days before the visit that dyspnea was recalled as having been as severe as at Decision. After the interviews, a subsample (n = 34) rated the intensity of a set of dyspnea sensory quality descriptors for Decision and Week Before (0 = not endorsed; 1 = very mild; 10 = very severe). Charts were also reviewed. Results: Seventy percent recalled dyspnea as the most distressing symptom at Decision, or the primary reason for the visit; 88% were admitted. Dyspnea duration was unrelated to admission. Duration was 3 days or less for 65% of the sample, but 6 days or more for 35%. There was no duration-related difference in dyspnea distress or intensity at Decision, but subjects with a duration ≤3 days reported lower levels of both dimensions for Week Before with significant increases from Week Before to Decision. Those with longer episodes reported high levels of distress and intensity in both time frames with no significant change in either dimension. Conclusion: Subjects reported high levels of distress and intensity at Decision, regardless of dyspnea duration. Differences in recalled duration were associated with 2 distinct patterns in distress and intensity ratings but were not associated with admission. Dyspnea duration does not appear to be a valid criterion for judging condition severity in HF-related visits to the ED. (Heart Lung® 2001;30:47-56.)