Algorithm for therapeutic management of acute heart failure syndromes

[Epidemiological and prognostic profile of acute heart failure: experience in the emergency department at the Charles Nicole Hospital of Tunis from 2013 to 2014]

Introduction

l'Insuffisance Cardiaque Aiguë (ICA) correspond à une entité syndromique spécifique, regroupant plusieurs tableaux cliniques hétérogènes; fréquemment rencontrées aux urgences. L'objectif de cette étude a été de décrire les caractéristiques épidémiologiques, cliniques, thérapeutiques et pronostiques des patients admis aux urgences pour ICA.

Méthodes

Nous avons mené une étude prospective descriptive dans un service d'accueil des urgences qui a inclus tous les patients admis pour ICA. Nous avons étudié les caractéristiques épidémiologiques, cliniques, thérapeutiques et pronostiques chez ces patients.

Résultats

Nous avons inclus 180 patients pour ICA ayant entrainé une hospitalisation dans le service d'urgence. Le sexe ratio a été de 1,27. L'âge moyen a été de 66±12 ans. Quatre vingt deux pour cent des patients étaient hypertendus et 69% étaient diabétiques connus. Les étiologies de décompensation étaient essentiellement une poussée hypertensive chez 61,7% des patients, un syndrome coronaire aigu chez 24%. Le support respiratoire a été assuré essentiellement par la CPAP (Continuous Positive Airway Pressure) dans 73,3% des cas. Le traitement pharmacologique a été à base de dérivés nitrés dans 70% et de diurétique dans 40,5% des cas. Le taux de récidive de l'insuffisance cardiaque aiguë à un mois a été de 21,7% (n=39 patients), et celui de la mortalité à 3 mois a été de 13,3%.

Conclusion

l'ICA vue au niveau des urgences est essentiellement sous forme hypertensive. Le traitement est basé essentiellement sur la CPAP, les vasodilatateurs et les diurétiques. Le taux de récidive était important, et la mortalité était aussi élevée.

Diagnosis and management of acute heart failure

Acute heart failure (AHF) is a life threatening clinical syndrome with a progressively increasing incidence in general population. Turkey is a country with a high cardiovascular mortality and recent national statistics show that the population structure has turned to an 'aged' population.As a consequence, AHF has become one of the main reasons of admission to cardiology clinics. This consensus report summarizes clinical and prognostic classification of AHF, its worldwide and national epidemiology, diagnostic work-up, principles of approach in emergency department,intensive care unit and ward, treatment in different clinical scenarios and approach in special conditions and how to plan hospital discharge.

Decompensated heart failure

Heart failure is a disease with high incidence and prevalence in the population. The costs with hospitalization for decompensated heart failure reach approximately 60% of the total cost with heart failure treatment, and mortality during hospitalization varies according to the studied population, and could achieve values of 10%. In patients with decompensated heart failure, history and physical examination are of great value for the diagnosis of the syndrome, and also can help the physician to identify the beginning of symptoms, and give information about etiology, causes and prognosis of the disease. The initial objective of decompensated heart failure treatment is the hemodynamic and symptomatic improvement preservation and/or improvement of renal function, prevention of myocardial damage, modulation of the neurohormonal and/or inflammatory activation and control of comorbidities that can cause or contribute to progression of the syndrome. According to the clinical-hemodynamic profile, it is possible to establish a rational for the treatment of decompensated heart failure, individualizing the proceedings to be held, leading to reduction in the period of hospitalization and consequently reducing overall mortality.

Initial emergency department systolic blood pressure predicts left ventricular systolic function in acute decompensated heart failure

Ejection fraction (EF) is often unknown in patients who present with acute decompensated heart failure (ADHF). The objective of this study was to determine whether a patient's systolic blood pressure is associated with their left ventricular EF. This study was a retrospective chart review of all patients admitted to an emergency department (ED) observation unit from January 2002 to December 2004. A low EF was defined as <40%. Among 475 patients, the median age was 72 years, 53% were men, 40% were white, 59% were black, and 59% had a low EF. Patients with low EFs were more likely male ( P<.0001), with prior congestive heart disease ( P<.0001), longer QRS duration ( P<.0001), left bundle branch block ( P<.0001), and higher B-type natriuretic peptide ( P<.0001). The low EF group was less likely to have diabetes ( P<.0001). Adjusted odds ratios for an EF >or=40% were significant at all systolic blood pressure readings >120 mm Hg. Having an ED systolic BP >120 mm Hg is associated with significantly higher rates of preserved left ventricular systolic function in patients with ADHF.

Diuretic, opiate and nitrate use in severe acidotic acute cardiogenic pulmonary oedema: analysis from the 3CPO trial

BACKGROUND

Drug treatments for acute cardiogenic pulmonary oedema (ACPO) have not been rigorously evaluated and recent observational data suggests some agents are related to poorer outcome.

AIM

We aimed to examine the effect of treatment with diuretics, nitrates and opiates on 7-day mortality, acidosis and respiratory distress in UK Emergency Department (ED) patients with severe acidotic pulmonary oedema.

DESIGN

Analysis of data from the 3CPO trial; a multicentre randomized controlled trial.

METHODS

Data were analysed from patients recruited with severe acidotic pulmonary oedema to the 3CPO trial in 26 UK EDs between 2003 and 2007. The effects of these treatments on 7-day mortality, improvement in acidosis (pH change between baseline and 1 h) and improvement in respiratory distress (patient measured breathlessness using a Visual Analogue Score between baseline and 1 h) were tested using univariate logistic regression analysis, and a regression model used to adjust for confounding baseline differences.

RESULTS

Nitrates were given to 947/1048 (90.4%) patients, diuretics to 934/1049 (89.0%) patients and opiates to 541/1052 patients (51.4%). Adjusted analysis showed that opiate treatment was associated with less improvement in acidosis [difference in improvement in pH -0.022, 95% confidence interval (CI) -0.014 to -0.030, P < 0.001], but no difference in mortality or improvement in respiratory distress. We found no evidence that nitrate or diuretic use were associated with any difference in mortality, improvement in acidosis or respiratory distress.

CONCLUSION

Opiate use is associated with less improvement in acidosis during initial treatment and may attenuate effective treatment of severe acidotic ACPO.