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How could emergency care be improved for patients with acute heart failure? 

Date: 17 May 2014

Professor Sean Collins
Represents the Society for Academic Emergency Medicine
Vanderbilt Medical Center N ashville, Tennessee, US 

“The majority of heart failure patients (HF) attend the emergency department (ED) for symptoms related to acute HF (AHF), such as shortness of breath, weight gain, oedema and fatigue. These patients also have co morbidities, such as coronary artery disease, chronic obstructive pulmonary disease and kidney problems, all of which can precipitate symptoms and an ED visit. In the US there are nearly one million ED visits each year for AHF.
ED treatments for HF have changed very little over the last two decades. Until recently all HF patients were approached in the same way, and treated largely with diuretics. Now preliminary data suggests targeting blood pressure control with vasodilators may also be an important step during initial management, leading to an evolution of treatment from the diuretic-only approach.

Far and away the biggest challenge for ED clinicians is to identify which AHF patients could be safely discharged from the ED without inpatient admission. While extensive guidelines have been developed for AHF by the ESC, HFSA and ACC/AHA, what’s missing from all of these is which patients would be good candidates for early, safe ED discharge. Such omissions are not oversights, but rather highlight the paucity of clinical data in this area. The consequence is that the majority of patients seen in the ED with AHF end up being admitted to hospital for inpatient management. Of the $39.2 billion spent on HF care in the US in 2010, inpatient admissions represented the biggest proportion of expenditure. The multiple barriers that exist to HF patients’ managing their condition in the community include paying for medications, understanding dietary and medication instructions, and having access to care providers The consequence s that preventable reasons for worsening of AHF symptoms are not addressed in a timely manner.

While ED nurses and physicians overall do an outstanding job understanding the complexities of AHF patients, they could undoubtedly play a bigger role in teaching patients how to manage their condition better at home and avoid ending up in the ED. Educational initiatives should be developed to help ED nurses and physicians identify barriers to good
outpatient self-care. Simple questions about patients’ understanding of healthy diet choices and medication adherence, for example, would provide a quick snapshot of their selfmanagement skills. Such approaches could facilitate safe ED discharge and prevent subsequent ED and hospital visits.

Ultimately greater collaborations are needed between ED and HF practitioners to make care transition from the ED to inpatient and outpatient settings more efficient.“

Professor Abdelouahab Bellou
Immediate past-President of the European Society for Emergency Medicine and Head of Emergency Department
University Hospital, Faculty of Medicine, University of Rennes 1, France

“The European Society for Emergency Medicine (EuSEM) was launched in 1994 with the mission of advancing research, education, practice and the standards of the specialty of emergency medicine (EM) throughout Europe. The organization, which currently has 30 European national societies of emergency medicine as members, aims to encourage the development of uniform information systems and data banks in EM throughout Europe and to promote international collaborations.

Patients with acute heart failure (AHF) most frequently end up in the emergency department (ED) due to symptoms of shortness of breath, and less frequently are admitted due to cardiogenic shock or acute heart failure syndrome (AHFS) developing through myocardial infarction (MI).

For most patients with AHFS the ED serves as the initial point of health care contact, and is the place where primary stabilization is achieved. The majority of patients who present with AHF are admitted as inpatients to the hospital due to the challenge of identifying ED patients at low risk for poor outcomes. Risk stratification of patients with AHFS remains problematic due to multiple co morbidities.
Despite heterogeneous clinical profiles suggesting that targeted treatment may be beneficial, the majority of patients with AHF are still treated with homogeneous therapy, namely intravenous diuretics and nitrics. The next logical step for investigators is to determine whether select subsets of patients, classified via reliable objective measures after initial evaluation, would benefit from targeted therapy aimed at their risk profile, AHF aetiology, and reasons for decompensation.

The current evidence base on which acute care for AHF is based remains astonishingly thin. We need clinical research to be undertaken in the ED setting. Since little is known about the epidemiology of dyspnoeic patients in the ED EuSEM this year launched the EUROpean Dyspnoea in the Emergency Departments (EURODEM) pro aject looking at all cause mortality and all cause rehospitalisation. Such information is important since it serves as a barometer of the quality of care: low rates of rehospitalisation reflect high quality of care.

We also need to improve the diagnosis of HF in the ED by boosting the use of biomarkers (such as BNP), echocardiography, and increase the implementation of guidelines. Ultimately we need to find ways to improve AHF treatment by reaching patients much earlier just as they start to decompensate. EuSEM is currently collaborating with the Heart Failure Association (HFA) of the ESC to produce a “Call for Action” consensus document to improve the management of AHF both in pre hospital and in-hospital settings. Through the development of workshops and joint sessions with the ESC at EuSEM congresses we hope to improve the education of clinicians and nurses treating AHF patients in the ED.”