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Test your knowledge on Acute Heart Failure

Acute heart failure (AHF) is the leading cause of hospitalization for subjects >65 years old. It is a life- threatening condition with a high in-hospital mortality (6–7% in Europe) and exceedingly  high post-discharge mortality and rehospitalization rates (10-20% and 30-40%, respectively) in the 6 months after discharge). The survey by the Acute Cardiovascular Care Association (ACCA) of the European Society of Cardiology (ESC) is therefore particularly welcome. Seven hundred physicians have answered making this quite a representative sample. I report here my comments about the main results regarding each of the 5 questions.


Results from the audiance:

Which statement(s) regarding acute dyspnoea as the leading symptom in the emergency department is/are true?
Acute dyspnea has more than 10 differential diagnosis 94,4%
Acute heart failure is a rare cause of acute dyspnea in the ED 1,2%
Most patients suffer from pulmonary disease 4,4%

94.4% of the participants chose  the statement that “acute dyspnea has more than 10 differential diagnosis”. I agree. In addition to AHF, diseases of the airways, lung parenchyma and pleura, anemia, metabolic disorders (i.e. hypothyroidism), disorders of the breathing nerves and muscles, anxiety can be the cause of dyspnea. Differential diagnosis is not an easy task. Laboratory exams and, namely, plasma levels of brain natriuretic peptides (BNP) and echocardiography are of major help. However, they cannot differentiate between AHF and a pre-existing cardiac disease, which is not causing symptoms. Clinical skills and clinical experience remain the mainstay of AHF diagnosis.

What is the sensitivity of lower extremity edema for the diagnosis of acute heart failure?
80% / 10,3%
90% 6,7%
60-70% 83%

Also in this case I agree with what answered by the majority. 83% of the participants chose the lowest sensitivity: 60-70% for the diagnosis of AHF. This is in agreement with the existing literature and is consistent with the finding that AHF may occur in the absence of peripheral edema, fluid retention and weight gain with fluid redistribution to the lungs and increased left ventricular afterload as the main pathogenetic mechanisms.

What is the systolic blood pressure which usually requires the cessation of nitroglycerin infusion during acute heart failure drip?
<110mmHg 13%
<120mmHg 3%
<90mmHg 68%

This question moves us from diagnosis to treatment. In this case, the answers are more differentiated with 68% indicating <90 mmhg, 13% <110 mmHg and 3% <120 mmhg. This answer reflects our confidence with continuous nitroglycerin infusion as a major treatment tool for AHF, independently from the studies showing that its continuous infusion may cause increased oxidative stress and endothelial dysfunction. Second, this answer shows our relative lack of concern that a systolic blood pressure between 90 and 110 mmhg my be associated with harmful effects related with end-organ hypoperfusion and this occurs despite the fact that current ESC guidelines strongly recommend to avoid hypotension and state that vasodilators “… should be avoided in patients with a systolic blood pressure <110 mmHg.” This threshold is accepted by only 13% of the participants whereas the vast majority of the participants considered 90 mmHg

Which statement(s) regarding the initial management of patients with acute dyspnoea in the emergency department is/are true?

ECG and BNP testing should complement clinical assessment in the vast majority of patients
80%
Therapy including oxygen or non-invasive ventilation can only be initiated once the underlying diagnosis is confirmed 6.5%
Vital signs are often 6.5% very helpful in the differential diagnosis 6.5%

80% of the participants answered “ECG and BNP testing should complement clinical assessment in the vast majority of the patients”. Only a minority indicated that they would initiate oxygen or noninvasive ventilation or that vital signs are very helpful for the diagnosis (6.5% in both cases). The sentence about the usefulness of BNP testing and ECG can, however, be discussed. The role of the ECG for the diagnosis of a concomitant arrhythmia and to exclude an acute coronary syndrome is unquestioned. However, it may be discussed whether BNP testing must complement clinical exam in all the patients with acute dyspnea.

What is the preferred initial agent to lower heart rate in acute heart failure with concomitant tachycardiac atrial fibrillation (heart rate 150 per min) in a patient with a systolic blood pressure of about 120mmHg?

IV Betablocker 28%

 

I agree with the choice of the majority of the participants (65%) as I would use IV digoxin as well. An IV betablocker was chosen by 28% and IV verapamil by 7% of the participants. However, the acute negative inotropic effects of these agents may make them less tolerated, if not detrimental, in an AHF setting.

 

Acute Coronary Syndromes (ACS)


The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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