Heart failure diagnosis in acute conditions has high agreement with inpatient diagnosis:

Heart failure care and outcomes in a Tanzanian emergency department: A prospective observational study

BACKGROUND

The burden of heart failure is growing in sub-Saharan Africa, but there is a dearth of data characterizing care and outcomes of heart failure patients in the region, particularly in emergency department settings.

METHODS

In a prospective observational study, adult patients presenting with shortness of breath or chest pain to an emergency department in northern Tanzania were consecutively enrolled. Participants with a physician-documented clinical diagnosis of heart failure were included in the present analysis. Standardized questionnaires regarding medical history and medication use were administered at enrollment, and treatments given in the emergency department were recorded. Thirty days after enrollment, a follow-up questionnaire was administered to assess mortality and medication use. Multivariate logistic regression was performed to identify baseline predictors of thirty-day mortality.

RESULTS

Of 1020 enrolled participants enrolled from August 2018 through October 2019, 267 patients (26.2%) were diagnosed with heart failure. Of these, 139 (52.1%) reported a prior history of heart failure, 168 (62.9%) had self-reported history of hypertension, and 186 (69.7%) had NYHA Class III or IV heart failure. At baseline, 40 (15.0%) reported taking a diuretic and 67 (25.1%) reported taking any antihypertensive. Thirty days following presentation, 63 (25.4%) participants diagnosed with heart failure had died. Of 185 surviving participants, 16 (8.6%) reported taking a diuretic, 24 (13.0%) reported taking an antihypertensive, and 26 (14.1%) were rehospitalized. Multivariate predictors of thirty-day mortality included self-reported hypertension (OR = 0.42, 95% CI: 0.21-0.86], p = 0.017) and symptomatic leg swelling at presentation (OR = 2.69, 95% CI: 1.35-5.56, p = 0.006).

CONCLUSION

In a northern Tanzanian emergency department, heart failure is a common clinical diagnosis, but uptake of evidence-based outpatient therapies is poor and thirty-day mortality is high. Interventions are needed to improve care and outcomes for heart failure patients in the emergency department setting.

Improved cardiac and venous pressures during hospital stay in patients with acute heart failure: an echocardiography and biomarkers study

Aims

Changes in echocardiographic parameters and biomarkers of cardiac and venous pressures or estimated plasma volume during hospitalization associated with decongestive treatments in acute heart failure (AHF) patients with either preserved left ventricular ejection fraction (LVEF) (HFPEF) or reduced LVEF (HFREF) are poorly assessed.

Methods and results

From the metabolic road to diastolic heart failure: diastolic heart failure (MEDIA‐DHF) study, 111 patients were included in this substudy: 77 AHF (43 HFPEF and 34 HFREF) and 34 non‐cardiac dyspnea patients. Echocardiographic measurements and blood samples were obtained within 4 h of presentation at the emergency department and before hospital discharge. In AHF patients, echocardiographic indices of cardiac and venous pressures, including inferior vena cava diameter [from 22 (16–24) mm to 13 (11–18) mm, P = 0.009], its respiratory variability [from 32 (8–44) % to 43 (29–70) %, P = 0.04], medial E/e' [from 21.1 (15.8–29.6) to 16.6 (11.7–24.3), P = 0.004], and E wave deceleration time [from 129 (105–156) ms to 166 (128–203) ms, P = 0.003], improved during hospitalization, similarly in HFPEF and HFREF patients. By contrast, no changes were seen in non‐cardiac dyspnea patients. In AHF patients, all plasma biomarkers of cardiac and venous pressures, namely B‐type natriuretic peptide [from 935 (514–2037) pg/mL to 308 (183–609) pg/mL, P < 0.001], mid‐regional pro‐atrial natriuretic peptide [from 449 (274–653) pmol/L to 366 (242–549) pmol/L, P < 0.001], and soluble CD‐146 levels [from 528 (406–654) ng/mL to 450 (374–529) ng/mL, P = 0.003], significantly decreased during hospitalization, similarly in HFPEF and HFREF patients. Echocardiographic parameters of cardiac chamber dimensions [left ventricular end‐diastolic volume: from 120 (76–140) mL to 118 (95–176) mL, P = 0.23] and cardiac index [from 2.1 (1.6–2.6) mL/min/m² to 1.9 (1.4–2.4) mL/min/m², P = 0.55] were unchanged in AHF patients, except tricuspid annular plane systolic excursion (TAPSE) that improved during hospitalization [from 16 (15–19) mm to 19 (17–21) mm, P = 0.04]. Estimated plasma volume increased in both AHF [from 4.8 (4.2–5.6) to 5.1 (4.4–5.8), P = 0.03] and non‐cardiac dyspnea patients (P = 0.01). Serum creatinine [from 1.18 (0.90–1.53) to 1.19 (0.86–1.70) mg/dL, P = 0.89] and creatinine‐based estimated glomerular filtration rate [from 59 (40–75) mL/min/1.73m² to 56 (38–73) mL/min/1.73m², P = 0.09] were similar, while plasma cystatin C [from 1.50 (1.20–2.27) mg/L to 1.78 (1.33–2.59) mg/L, P < 0.001] and neutrophil gelatinase associated lipocalin (NGAL) [from 127 (95–260) ng/mL to 167 (104–263) ng/mL, P = 0.004] increased during hospitalization in AHF.

Conclusions

Echocardiographic parameters and plasma biomarkers of cardiac and venous pressures improved during AHF hospitalization in both acute HFPEF and HFREF patients, while cardiac chamber dimensions, cardiac output, and estimated plasma volume showed minimal changes.

Acutely decompensated heart failure with preserved and reduced ejection fraction present with comparable haemodynamic congestion

AIMS

Congestion is a central feature of acute heart failure (HF) and its assessment is important for clinical decisions (e.g. tailoring decongestive treatments). It remains uncertain whether patients with acute HF with preserved ejection fraction (HFpEF) are comparably congested as in acute HF with reduced EF (HFrEF). This study assessed congestion, right ventricular (RV) and renal dysfunction in acute HFpEF, HFrEF and non-cardiac dyspnoea.

METHODS AND RESULTS

We compared echocardiographic and circulating biomarkers of congestion in 146 patients from the MEDIA-DHF study: 101 with acute HF (38 HFpEF, 41 HFrEF, 22 HF with mid-range ejection fraction) and 45 with non-cardiac dyspnoea. Compared with non-cardiac dyspnoea, patients with acute HF had larger left and right atria, higher E/e', pulmonary artery systolic pressure and inferior vena cava (IVC) diameter at rest, and lower IVC variability (all P < 0.05). Mid-regional pro-atrial natriuretic peptide (MR-proANP) and soluble CD146 (sCD146), but not B-type natriuretic peptide (BNP), correlated with echocardiographic markers of venous congestion. Despite a lower BNP level, patients with HFpEF had similar evidence of venous congestion (enlarged IVC, left and right atria), RV dysfunction (tricuspid annular plane systolic excursion), elevated MR-proANP and sCD146, and renal impairment (estimated glomerular filtration rate; all P > 0.05) compared with HFrEF.

CONCLUSION

In acute conditions, HFpEF and HFrEF presented in a comparable state of venous congestion, with similarly altered RV and kidney function, despite higher BNP in HFrEF.

Heart failure in patients presenting with dyspnoea to the emergency department in the Asia Pacific region: an observational study

OBJECTIVES

To describe demographic features, assessment, management and outcomes of patients who were diagnosed with heart failure after presenting to an emergency department (ED) with a principal symptom of dyspnoea.

DESIGN

Planned substudy of the prospective, descriptive cohort study: Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM).

SETTING

46 EDs in Australia, New Zealand, Singapore, Hong Kong and Malaysia collected data over 3 72-hour periods in May, August and October 2014.

PARTICIPANTS

Patients with an ED diagnosis of heart failure.

OUTCOME MEASURES

Outcomes included patient epidemiology, investigations ordered, treatment modalities used and patient outcomes (hospital length of stay (LOS) and mortality).

RESULTS

455 (14.9%) of the 3044 patients had an ED diagnosis of heart failure. Median age was 79 years, half were male and 62% arrived via ambulance. 392 (86%) patients were admitted to hospital. ED diagnosis was concordant with hospital discharge diagnosis in 81% of cases. Median hospital LOS was 6 days (IQR 4-9) and in-hospital mortality was 5.1%. Natriuretic peptide levels were ordered in 19%, with lung ultrasound (<1%) and echocardiography (2%) uncommonly performed. Treatment modalities included non-invasive ventilation (12%), diuretics (73%), nitrates (25%), antibiotics (16%), inhaled β-agonists (13%) and corticosteroids (6%).

CONCLUSIONS

In the Asia Pacific region, heart failure is a common diagnosis among patients presenting to the ED with a principal symptom of dyspnoea. Admission rates were high and ED diagnostic accuracy was good. Despite the seemingly suboptimal adherence to investigation and treatment guidelines, patient outcomes were favourable compared with other registries.

Management of suspected acute heart failure dyspnea in the emergency department: results from the French prospective multicenter DeFSSICA survey

BACKGROUND

An appropriate diagnostic process is crucial for managing patients with acute heart failure (AHF) in emergency department (ED). Our study aims to describe the characteristics and therapeutic management of patients admitted to the ED for dyspnea suspected to have AHF, their in-hospital pathway of care and their in-hospital outcome.

METHODS

Consecutive patients admitted in 26 French ED for dyspnea suspected to be the consequence of AHF, prior to in hospital diagnostic test, were prospectively included at the time of their admission in the DeFSSICA Survey. Clinical characteristics at admission were recorded by the ED physicians. At discharge from ED, patients were categorized as AHF or non-AHF based on the final diagnosis reported in the discharge summary. The completeness of the data was controlled by the local investigator.

RESULTS

From 16/6/2014 to 7/7/2014, 699 patients were included, of whom 537 (77 %) had a final diagnosis of AHF at discharge. Patients with AHF were older (median 83 vs 79 years, p = 0.0007), more likely to have hypertension (71 % vs 57 %, p = 0.002), chronic HF (54 % vs 37 %, p = 0.0004), atrial fibrillation (45 % vs 34 %, p = 0.02) and history of hospitalization for AHF in the previous year (40 % vs 18 %, p < 0.0001) when compared to patients without AHF. Furosemide and oxygen were used in approximately 2/3 of the patients in the ED (respectively 75 and 68 %) whereas nitrates were in 19 % of the patients. Diagnostic methods used to confirm AHF included biochemistry (100 %), pro-B-type natriuretic peptide (90 %), electrocardiography (98 %), chest X-ray (94 %), and echography (15 %) which only 18 % of lung ultrasound. After the ED visit, 13 % of AHF patients were transferred to the intensive care unit, 28 % in cardiology units and 12 % in geriatric units. In-hospital mortality was lower in AHF vs non-AHF patients (5.6 % vs 14 %, p = 0.003).

DISCUSSION

DeFSSICA, a large French observational survey of acute HF, provides information on HF presentation and the French pathway of care. Patients in DeFSSICA were elderly, with a median age of 83 years. Compared with the French OFICA study, patients in DeFSSICA were more likely to have hypertension (71 % vs 62 %) and atrial fibrillation (45 % vs 38 %). As atrial fibrillation and a rapid heart rate have been closely linked to mortality, detection of atrial fibrillation should be considered systematically.The limited use of nitrates in DeFSSICA may be related to the median SBP of 140 (121-160) mmHg. However, our use of nitrates was similar to those in the EAHFE (20.7 %) and OPTIMIZE-HF (14.3 %) registries. In line with guidelines, the proportions of patients who underwent ECG, biological analysis, or chest X-ray were all >90 % in DeFSSICA. Similarly, BNP or pro-BNP was measured in 93 % of patients, compared with 82 % of patients in the OFICA study. Although BNP may be helpful when the diagnosis of HF is in doubt, ultrasound remains the gold standard. The use of ultrasound in the ED has been reported to accelerate the diagnosis of HF and the initiation of treatment, and shorten the length of stay. In-hospital mortality of HF patients in DeFSSICA was 6.4 %, slightly lower than in the OFICA study (8.2 %). Improved interdisciplinary cooperation has been highlighted as a key factor for the improvement of HF patient care.

CONCLUSIONS

DeFSSICA shows that patients admitted for dyspnea suspected to be the consequence of AHF are mostly elderly. The diagnosis of AHF is difficult to ascertain based on clinical presentation in patients with dyspnea. Novel diagnostic techniques such as thoracic ultrasound are warranted to provide the right treatment to the right patients in the ED as early as possible.

Clinical benefits of natriuretic peptides and galectin-3 are maintained in old dyspnoeic patients

BACKGROUND

Acute dyspnoea is the leading cause of unscheduled admission of elderly patients. Several biomarkers are used to diagnose acute heart failure (AHF) and assess prognosis of dyspnoeic patients, but their value in elderly patients is unclear.

OBJECTIVE

To compare diagnostic and prognostic performances of conventional and novel cardiovascular biomarkers in 2 age groups: young (<75 years old) vs. old (≥75 years old) dyspnoeic patients.

DESIGN

Prospective observational registry.

SETTING

Emergency department (ED).

SUBJECTS

Acutely dyspnoeic adult patients.

METHODS

Blood samples were collected at ED admission. The diagnostic value of 4 natriuretic peptides (BNP, proBNP, NT-proBNP, MR-proANP) for AHF was tested. We also assessed the prognostic value of same natriuretic peptides and of 3 novel cardiovascular biomarkers (galectin-3, sST2 and proenkephalin), using 1-year all-cause mortality as end-point. Diagnostic or prognostic performances are expressed as area under the receiveroperating characteristic curve (AUC) with 95% confidence interval.

RESULTS

Two hundred one acutely dyspnoeic patients were studied. AHF was the cause of dyspnoea in 57% of old and 44% of young patients, respectively. All 4 natriuretic peptides performed well in diagnosing AHF in both age groups (all AUC>0.7). BNP showed the best diagnostic performance in both old (AUC: 0.98 [0.97-1.00]) and young (AUC 0.98 [0.95-1.00]) patients. Galectin-3 showed the best prognostic performance in both old (AUC 0.74 [0.62-0.87]) and young patients (AUC 0.75 [0.56-0.94]).

CONCLUSIONS

BNP and galectin-3 show good clinical benefits in both oldand young acutely dyspnoeic patients.

Effect of precipitating factors of acute heart failure on readmission and long-term mortality

Aims

Acute heart failure (AHF) is one of the leading causes of unscheduled hospitalization and is associated with frequent readmissions and substantial mortality. Precipitating factors of AHF influence short‐term mortality, but their effect on outcome after hospital discharge is unknown. The present study assessed the effect of precipitating factors on readmission and long‐term survival in the overall population and in patients aged 75 years or younger.

Methods and results

Patients admitted with AHF (n = 755) included in the multicentre cohort ‘Biomarcoeurs’ were included in the study. Precipitating factors of AHF were classified in four main groups: acute coronary syndrome, atrial fibrillation, acute pulmonary disease and other causes. Hospital readmission during 90 days after discharge and survival at 1 year were analysed. Precipitating factors influenced readmissions and survival. Acute pulmonary disease was associated with fewer readmissions (HR 0.61, 95% confidence interval (CI) 0.37–0.99, P = 0.049), especially in patients aged 75 years or younger (HR 0.20, 95% CI 0.06–0.63, P = 0.006), whereas atrial fibrillation (HR 2.23, 95% CI 1.29–3.85, P = 0.004) and acute coronary syndrome (HR 2.23, 95% CI 1.02–4.86, P = 0.044) were associated with more readmissions. Patients with acute pulmonary disease at admission showed higher mortality (HR 1.59, 95% CI 1.04–2.43, P = 0.034), especially in subjects aged 75 years or younger (HR 2.52, 95% CI 1.17–5.41, P = 0.018).

Conclusions

Precipitating factors of AHF substantially influenced outcome after hospitalization. In particular, patients with AHF precipitated by acute pulmonary disease showed fewer readmissions and higher 1 year mortality, especially in patients aged 75 years or younger.

Effect of low-dose diuretics on the level of serum cystatin C and prognosis in patients with asymptomatic chronic heart failure

The aim of the present study was to investigate the effect of low-dose diuretics on the serum cystatin C (CysC) and serum creatinine (Scr) levels, and on the prognosis in patients with asymptomatic chronic heart failure (HF). A total of 66 asymptomatic chronic HF patients were divided into the observation and control groups (n=33 in each group). Patients in the control group were treated with a routine treatment, while the patients in the observation group were treated with the diuretic hydrochlorothiazide along with the same routine treatment as the control group. The left ventricular ejection fraction (LVEF), serum CysC levels, Scr levels, heart function, prognosis, adverse reactions and complications of the patients in the two groups were compared prior to and following treatment. The LVEF increased in the two groups following treatment, while the levels of serum CysC and Scr decreased. The LVEF in the observation group increased following treatment for 1, 3 and 6 months compared with the LVEF values in the control group. In addition, the levels of serum CysC and Scr in the observation group were found to be lower compared with those in the control group (P<0.05). The incidence of adverse prognosis following treatment for 6 months in the observation group was lower compared with that in the control group (P<0.05). The proportion of HF patients with New York Heart Association (NYHA) class I and II increased following treatment for 6 months in the two groups (P<0.05). However, in the observation group, a higher number of patients exhibited class I and II disease after treatment for 6 months compared with the number in the control group (P<0.05). Furthermore, no statistically significant difference was observed between adverse reactions and complications in the two groups (P>0.05). In conclusion, low-dose diuretics may effectively improve the cardiac and renal functions and prognosis in asymptomatic chronic HF patients, without increasing the incidence of side effects.