Management of suspected acute heart failure dyspnea in the emergency department: results from the French prospective multicenter DeFSSICA survey (original) (raw)
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Clinical Cardiology, 2021
Background: Acute heart failure (AHF) is a common serious condition that contributes to about 5% of all emergency hospital admissions in Europe. Hypothesis: To assess the type and chronology of the first AHF symptoms before hospitalization and to examine the French healthcare system pathways before, during and after hospitalization. Material and Methods: A retrospective observational study including patients hospitalized for AHF Results: 793 patients were included, 59.0% were men, 45.6% identified heart failure (HF) as the main cause of hospitalization; 36.0% were unaware of their HF. Mean age was 72.9 ± 14.5 years. The symptoms occurring the most before hospitalization were dyspnea (64.7%) and lower limb edema (27.7%). Prior to hospitalization, 47% had already experienced symptoms for 15 days; 32% of them for 2 months. Referral to hospital was made by the emergency medical assistance service (SAMU, 41.6%), a general practitioner (GP, 22.3%), a cardiologist (19.5%), or the patient (16.6%). The modality of referral depended more on symptom acuteness than on type of symptoms. A sudden onset of AHF symptoms led to making an emergency call or to spontaneously attending an emergency room (ER), whereas cardiologists were consulted when symptoms had already been present for over 15 days. Cardiologists referred
Journal of Intensive and Critical Care
Aim: Dyspnea is a common cause of hospital admittance. Preliminary investigations an in pre-hospital phase and in the Emergency Department (ED) should detect the underlying cause. Time is crucial and emergency physicians have few diagnostic tools to manage patients presenting shortness of breath. In this study we assess the performance of lung ultrasound as a diagnostic tool in the evaluation of acute heart failure (AHF), in order to formulate an ultrasound-based diagnostic score. Methods and Results: Over a two-year-period, 236 consecutive patients admitted to our ED for non-traumatic dyspnea were enrolled in the study. All patients underwent lung ultrasound (LU) systematic evaluation reporting B-lines, in addition to standardized work-up. ROC curve showed an AUC=82.3% (95% CI=76.3%-87.9%) and AUC=75.5 (95% CI=68.4%-81.3%) for LU and NT pro-BNP respectively. About 18% of the patients enrolled showed a number of B-Lines >18, which were used as an early diagnostic test to detect patients with AHF: A sensitivity and specificity of 39.8% and 97.0% were found respectively. A score model was designed to diagnose the remaining patients including LU, chest X-Ray and NT-proBNP to supply high diagnostic accuracy (AUC=91.7%). Conclusion: As known, LUS can be a useful tool for a prompt and accurate detection of AHF, allowing chest X-ray and biomarker evaluation to be avoided in a remarkable portion of dyspneic patients, which include about 40% of the actual AHF occurrences. In this way it is possible to reach an accurate diagnosis in a short amount of time, making it possible to start therapy precociously. An integrated approach that includes chest X-ray and NT-proBNP can improve diagnostic capabilities. Our proposed operative protocol minimizes the ratio between time of medical intervention and diagnostic accuracy of AHF, in patients presenting shortness of breath, starting from prehospital phase.
Heart & lung : the journal of critical care, 2017
Dyspnea is the most common presenting symptom in patients with acute heart failure (AHF), but is difficult to quantify as a research measure. The URGENT Dyspnea study compared 3 scales: (1) 10 cm VAS, (2) 5-point Likert, and (3) a 7-point Likert (both VAS and 5-point Likert were recorded in the upright and supine positions). However, the minimal clinically important difference (MCID) to patients has not been well established. We performed a secondary analysis from URGENT Dyspnea, an observational, multi-center study of AHF patients enrolled within 1 h of first physician assessment in the ED. Using the anchor-based method to determine the MCID, a one-category change in the 7-point Likert was used as the criterion standard ('minimally improved or worse'). The main outcome measures were the change in visual analog scale (VAS) and 5-point Likert scale from baseline to 6-h assessment relative to a 1-category change response in the 7-point Likert scale ('minimally worse', ...
Academic Emergency Medicine, 2015
Objective: The primary goal of this study was to determine accuracy for diagnosing acutely decompensated heart failure (ADHF) in the undifferentiated dyspneic ED patient using a Lung and Cardiac Ultrasound (LuCUS) protocol. Secondary objectives were to determine if ultrasound findings acutely change management and if findings are more accurate than clinical gestalt. Methods: This was a prospective, observational study of adult patients presenting to the ED with undifferentiated dyspnea. Intervention consisted of a twelve-view LuCUS protocol performed by experienced emergency physician (EP) sonographers. The primary objective was measured by comparing ultrasound findings to final diagnosis independently determined by two blinded physicians. Acute treatment changes based on ultrasound findings were tracked in real time through a standardized data collection form. Results: We analyzed data on 99 patients; 36% had a final diagnosis of ADHF. The overall sensitivity, specificity, positive and negative likelihood ratios of the LuCUS protocol were 83% (67-93 95% confidence interval [CI]), 83% (70-91 CI), 4.8 (2.7-8.3 CI) and 0.20 (0.09-0.42 CI), respectively. 47% of patients had changes in acute management, and 42% had changes in acute treatment. Observed agreement for the LuCUS protocol was 93% between coinvestigators. Overall, accuracy improved by 20% (83% vs 63%, 8-31 CI of the difference) over clinical gestalt alone.
Approach to undifferentiated dyspnea in emergency department: aids in rapid clinical decision-making
International Journal of Emergency Medicine, 2018
Background: Diagnosis and management of patients presenting with acute dyspnea is one of the major challenges for physicians in emergency department (ED). A correct diagnosis is frequently delayed and difficult to ascertain, and clinical uncertainty is common, explaining the need for rapid diagnosis and a management plan. The primary aim of our study is to assess a diagnostic strategy using multiorgan point of care ultrasonography (USG) to differentiate patients presenting with acute dyspnea to ED into different diagnostic categories for timely management in a resource-limited setting. Methods: This is a prospective cohort study which assessed the diagnostic performance of a strategy in evaluating patients presenting with undifferentiated dyspnea as primary predominant complaint to ED. Focused multiorgan USG which includes cardiac USG for left ventricle systolic function, right ventricle enlargement, and pericardial effusion, inferior vena cava (IVC) diameter and collapsibility, lung USG to identify various patterns (acute interstitial syndrome, pneumothorax, pleural effusion, consolidation, etc.) and renal USG to assess kidney size and echotexture was performed. Later, patients were grouped into one of ten clinical syndromes defined in the study based on USG and clinical patterns. Emergency diagnosis was compared with final hospital diagnosis to assess the accuracy of this strategy. Results: Concordance between ED diagnosis of dyspnea using the diagnostic strategy proposed in the study with final hospital diagnosis was high with agreement in 88% of patients (Kappa statistic = .805, p = .000) which is statistically significant. The most common diagnosis was acute decompensated heart failure (ADHF). Sensitivity and specificity of the diagnostic strategy used in this study to identify ADHF was 97.3 and 93.3%, respectively. On multivariate analysis, jugular venous distension, fever and cough, ejection fraction (by eyeball method), dilated IVC, absent to decreased lung sliding showed independent association in predicting cardiac and non-cardiac diagnosis. Conclusions: The present study concludes that integrating focused multiorgan USG by lung-cardiac-IVC and renal ultrasound into routine clinical evaluation of patients with dyspnea has a higher accuracy for differentiating causes of dyspnea in emergency department. This strategy can be adopted even in resource limited setting.
Relation of dyspnea severity on admission for acute heart failure with outcomes and costs
The American journal of cardiology, 2015
Hospitalization for heart failure (HF) is frequently related to dyspnea, yet associations among dyspnea severity, outcomes, and health care costs are unknown. The aim of this study was to describe the characteristics of patients hospitalized for acute HF by dyspnea severity and to examine associations among dyspnea severity, outcomes, and costs. Registry data for patients hospitalized for HF were linked with Medicare claims to evaluate dyspnea and outcomes in patients ≥65 years of age. We classified patients by patient-reported dyspnea severity at admission. Outcomes included length of stay, mortality 30 days after admission, days alive and out of the hospital, readmission, and Medicare payments 30 days after discharge. Of 48,616 patients with acute HF and dyspnea, 4,022 (8.3%) had dyspnea with moderate activity, 19,619 (40.3%) with minimal activity, and 24,975 (51.4%) at rest. Patients with dyspnea with minimal activity or at rest had greater co-morbidities, including renal insuffi...
BMC Research Notes, 2012
Background: Chronic heart failure (CHF) is a major public health problem characterised by progressive deterioration with disabling symptoms and frequent hospital admissions. To influence hospitalisation rates it is crucial to identify precipitating factors. To characterise patients with CHF who seek an emergency department (ED) because of worsening symptoms and signs and to explore the reasons why they are admitted to hospital. Method: Patients (n = 2,648) seeking care for dyspnoea were identified at the ED, Sahlgrenska University Hospital/ Östra. Out of 2,648 patients, 1,127 had a previous diagnosis of CHF, and of these, 786 were included in the present study with at least one sign and one symptom of worsening CHF. Results: Although several of the patients wanted to go home after acute treatment in the ED, only 2% could be sent home. These patients were enrolled in an interventional study, which evaluated the acute care at home compared to the conventional, in hospital care. The remaining patients were admitted to hospital because of serious condition, including pneumonia/respiratory disease, myocardial infarction, pulmonary oedema, anaemia, the need to monitor cardiac rhythm, pathological blood chemistry and difficulties to communicate. Conclusion: The vast majority of patients with worsening CHF seeking the ED required hospital care, predominantly because of co-morbidities. Patients with CHF with symptomatic deterioration may be admitted to hospital without additional emergency room investigations.
Acute Heart Failure in the Emergency Department: the SAFE-SIMEU Epidemiological Study
The Journal of emergency medicine, 2017
Patients with acute heart failure (AHF) have high rates of attendance to emergency departments (EDs), with significant health care costs. We aimed to describe the clinical characteristics of patients attending Italian EDs for AHF and their diagnostic and therapeutic work-up. We carried out a retrospective analysis on 2683 cases observed in six Italian EDs for AHF (January 2011 to June 2012). The median age of patients was 84 years (interquartile range 12), with females accounting for 55.8% of cases (95% confidence interval [CI] 53.5-57.6%). A first episode of AHF was recorded in 55.3% (95% CI 55.4-57.2%). Respiratory disease was the main precipitating factor (approximately 30% of cases), and multiple comorbidities were recorded in > 50% of cases (history of acute coronary syndrome, chronic obstructive pulmonary disease, diabetes, chronic kidney disease, valvular heart disease). The treatment was based on oxygen (69.7%; 67.9-71.5%), diuretics (69.2%; 67.9-71.5%), nitroglycerin (19...
Characterization of acute heart failure hospitalizations in a Portuguese cardiology department
Revista Portuguesa de Cardiologia, 2013
Aims: We describe the clinical characteristics, management and outcomes of patients hospitalised with acute heart failure (AHF) in a south western European Cardiology Department. We sought to identify the determinants of length of stay (LOS) and heart failure (HF) rehospitalisation or death during a 12-months follow-up period. Methods and Results: This was a retrospective cohort study including all patients admitted during 2010 with either a primary or secondary diagnosis of AHF. Death and readmission were followed through 2011. Amongst the 924 patients admitted, 201 (21%) had AHF, 107 (53%) of which with new-onset AHF. The main precipitating factors were acute coronary syndrome (ACS) (63%) and arrhythmia (14%). The most frequent clinical presentations were heart failure (HF) after ACS (63%), chronic decompensate HF (47%) and acute pulmonary oedema (21%). On admission 73% had left ventricular ejection fraction (LVEF) < 0.50. Median LOS was 11 days and inhospital mortality was 5.5%. Rehospitalisation rate was 21% and 24% at six and 12 months respectively. All-cause mortality was 16% at 12 months. The independent predictors of rehospitalisation or death were HF hospitalisation during previous year (Hazard Ratio-HR-3.177), serum sodium < 135 mmol/L on admission (HR 1.995), atrial fibrillation (HR 1.791) and reduced LVEF (HR 0.518). Conclusions: Our patients more often presented new-onset AHF, due to an ACS, causing reduced LVEF. Several predictive factors of death or rehospitalisation were identified that may help to select high risk patients to be followed in a HF management programme after discharge.