As you arrive for your ED shift, an ambulance pulls in, carrying a patient struggling to breathe. The paramedics quickly brief you: your patient is a 76-year-old woman with a history of heart failure. She has been compliant with all of her medications but has had progressively worsening, difficult breathing. You notice coarse, wet-sounding lungs with poor air movement at the lung bases. You also notice significant pitting edema in both of her legs. She describes orthopnea and states that she has been sitting up in a chair to sleep for “a while.” When you examine her medications, you note that she is on a low dose of a beta blocker and an ACE inhibitor, despite a stated history of low blood pressure. She was also prescribed spironolactone and furosemide, and you can feel an implant under the skin of her left chest wall, which she confirms as an AICD. You attach your patient to the cardiac monitor and notice she is tachycardic, with a heart rate of 115 beats/min, and her blood pressure is 80/40 mm Hg. You wonder if she would be best treated with fluids or diuretics, and your medical student asks, “How do we decide?”
While nurses are establishing IV access for your first patient, another nurse pulls you into a nearby room with a patient who just arrived via EMS. The patient is an overweight middle-aged man who is also struggling to breathe. Paramedics report that his blood pressure was 220/130 mm Hg at the scene. You immediately attach the patient to the cardiac monitor and obtain vital signs. His blood pressure is now 240/140 mm Hg. You listen to his lungs and again notice coarse, wet breath sounds. Your patient is tachypneic, leaning forward in bed, and saturating 70% on room air. His oxygen saturation improves to 88% on a 100% nonrebreather mask. His legs are edematous, and he has marked conversational dyspnea. Respiratory failure seems certain unless appropriate action is taken, and you wonder if there is anything that can change this patient’s course.
The incidence of in-hospital mortality among patients admitted to the hospital for decompensated heart failure is 6.4%.1 Although there are many management options available, some therapies offer innovative approaches to improve patient outcomes, while others may increase cost without improving outcomes.
In the United States, acute decompensated heart failure (ADHF) is the number one cause of hospital admission in patients over the age of 65 and accounts for more than 1 million hospital admissions and $30.7 billion in healthcare expenditure annually.2 In individuals aged 65 to 69 years, the prevalence of heart failure is roughly 20 per 1000, and prevalence jumps to more than 80 per 1000 in individuals older than 85 years.3 The prevalence of heart failure varies by sex and ethnicity, with men demonstrating a higher prevalence than women, and blacks having a higher prevalence than whites.2 With the aging of the United States population, heart failure is expected to become a more common emergency department (ED) presentation. Projections estimate an increase in the prevalence of heart failure by 46% from 2012 to 2030, with a predicted 8 million adult cases in the United States by 2030.2
Not all heart failure is the same. Heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) represent distinct underlying pathophysiologies that require different approaches in treatment. HFpEF and HFrEF are essentially equal in terms of occurrence, morbidity, and mortality.4 The underlying volume status of heart failure patients is difficult to assess, yet time is often limited, and the interventions chosen can change the course for better or for worse. In addition, ADHF patients may present with either hypertension or hypotension, which can make management challenging.
This issue of Emergency Medicine Practice examines the medical management of ADHF, with a focus on new therapies that may alter conventional management. This issue will enable the emergency clinician to quickly recognize the clinical presentations of the varying types of decompensated heart failure, understand the underlying pathophysiology, and formulate the most appropriate management plan.
A literature search was performed via PubMed using the terms acute heart failure and decompensated heart failure. The search returned 1710 articles; 350 articles from 2014 to present were screened for relevance, and a total of 190 were reviewed based on clinical applicability in the ED. The Cochrane Database of Systematic Reviews was searched for reviews using the terms decompensated heart failure and acute heart failure, which identified 10 reviews; 108 were identified with the more general search terms of heart failure. The majority of these reviews focused on chronic heart failure management and were excluded. Guidelines released jointly by the American Heart Association and American College of Cardiology Foundation were also reviewed.
The available data that focus on the management of ADHF are, overall, of lower quality than that for chronic heart failure management, and the literature behind newer interventions is even more limited. Studies looking at newer treatment modalities would benefit from the improved generalizability associated with multicenter studies that enroll larger patient populations. The paucity of data on the vasodilator nesiritide is a prime example – the only available studies are small, underpowered, and tend to show nonsignificant trends in terms of efficacy and harm compared with older modalities.5,6 Even basic interventions (such as nitrate administration) have limited data supporting their use.7 Less commonly performed rescue therapies, such as extracorporeal membrane oxygenation (ECMO), have even lower-quality data supporting their use, largely due to small sample sizes.8 The literature behind the management of HFpEF is also weaker than that supporting the management of HFrEF.
1. “The patient looked comfortable, so I didn’t immediately check his pulse oximetry.”
Vital signs are truly vital in these patients. Blood pressure and pulse oximetry must be checked immediately. A low pulse oximetry level requires immediate intervention with supplemental oxygen or respiratory support.
2. “I wasn’t sure what was going on, but I didn’t know how to use the ultrasound machine.”
Bedside echocardiogram is a crucial diagnostic tool to help confirm the diagnosis of heart failure. The onus is on the emergency clinician to learn to use ultrasound as a diagnostic tool for diagnosis of heart failure and other ED presentations.
3. “The patient was short of breath, so I started treatment for heart failure.”
There are many diagnostic entities that can cause dyspnea and mimic the symptoms of heart failure. Particularly in obese patients who are poorly conditioned at baseline, many other causes of dyspnea can be mistaken for heart failure. Examples include pulmonary embolism, pneumonia, pericardial effusion, and COPD. Treatment can be started quickly if the diagnosis is clear, but alternative etiologies should be actively sought.
4. “The patient was wheezing, so I knew it was COPD and did not worry about heart failure.”
While heart failure traditionally presents with rales on the pulmonary examination, cardiac wheezes can also occur and are not necessarily indicative of obstructive pulmonary disease as the primary etiology. Additionally, patients may have coexisting obstructive pulmonary disease and heart failure, which can complicate the clinical picture.
5. “There was a focal infiltrate on the chest x-ray, so I knew it couldn’t be heart failure.”
Patients can present with multiple coexisting etiologies, and heart failure can be exacerbated by secondary assaults, such as sepsis. Additionally, pulmonary congestion can present as bilateral consolidation on chest x-ray.
6. “The patient had chest pain and obvious heart failure, so we treated for heart failure but did not do any additional diagnostic testing.”
Don’t miss secondary causes of heart failure. Coronary ischemia, pulmonary embolism, and pericardial effusion can all contribute to the heart's inability to pump effectively. These secondary reversible or treatable causes are crucial to identifying and effectively managing these patients.
7. “The patient was hypotensive but had a history of heart failure, so I did not give any IV fluids.”
Patients with heart failure can be intravascularly depleted and may require gentle fluid resuscitation in the setting of hypotension. The fluids should be given in smaller aliquots, but fluid should not be withheld in these patients, particularly in hypotensive patients who do not look grossly fluid overloaded.
8. “I wasn’t sure what to do for my unstable patient, so I just gave furosemide and waited.”
These patients respond well to aggressive, early interventions. Failure to quickly intervene can allow clinical deterioration, requiring more-invasive airway and circulatory support. Furosemide is an inadequate sole intervention in an unstable patient.
9. “My patient was having difficulty breathing, so I immediately intubated.”
While the decision to intubate is always a clinical one, a trial of NIPPV is often appropriate in patients with ADHF. NIPPV is a useful temporizing measure that can stabilize the patient until more definitive interventions have taken effect. The appropriate contraindications for NIPPV should always be considered, but in the appropriate patient, it can be a useful adjunct.
10. “My patient was looking much better on the nitroglycerin drip, so I weaned her off and discharged her home.”
Heart failure patients have a high risk of clinical deterioration and require close observation. Patients requiring nitroglycerin or pressor drips require ICU-level care and close monitoring. Any patient with respiratory symptoms should be admitted for diuresis and close observation.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
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Jeff:Welcome back to the May 2017 episode of EMPlify, the podcast corollary to EB Medicine’s Emergency Medicine Practice.
Nachi: This month, we are talking about acute decompensated heart failure. We’ll be covering all aspects of the acute management, from initial ED diagnosis and treatment to novel biomarkers and new and controversial therapies.
Jeff: As always… you all should know the drill by now… We must start by acknowledging this month’s co-authors: Drs. Emily Singer Fischer and Boyd Burns of the University of Oklahoma School of Community Medicine, for all of their diligent work they put into this month’s issue. It covers 190 articles, and 10 reviews from the Cochrane database as well as the most updated guidelines from the American Heart Association and the American College of Cardiology Foundation. Not bad.
Emily Singer Fisher, MD; Boyd Burns, DO, FACEP, FAAEM
May 1, 2017
May 31, 2020
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 1.5 Pharmacology CME credits
Upon competion of this article, you should be able to:
Date of Original Release: May 1, 2017. Date of most recent review: April 10, 2017. Termination date: May 1, 2020.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Medical Journal activity, Emergency Medicine Practice, has been reviewed and is acceptable for up to 48 Prescribed credits by the American Academy of Family Physicians per year. AAFP accreditation begins July 1, 2016. Term of approval is for one year from this date. Each issue is approved for 4 Prescribed credits. Credit may be claimed for one year from the date of each issue. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 1.5 Pharmacology CME credits, subject to your state and institutional approval.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
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Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.
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