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KAMC Emergency
Heart Failure Services Holy Makkah
Dr Asadullah Khan Soomro
Adult Cardiologist
King Abdullah Medical City Holy Makkah
Email; hssbasadsoomro@gmail.com
Emergency Heart Failure Services
Introduction
Acute HF is a gradual or rapid decompensation in symptoms and
hemodynamics , requiring urgent management .it covers large spectrum of
disease ranging from mild exacerbation with gradual increases in edema to
cardiogenic shock.
With the result millions are visiting emergency department, and indeed
80% admissions are through the emergency .
HF has significant economic burden and is expected to increase all over
the world, because cardiology community has not ,is not and in near future
will not spent money , time and pay attention on these 60-70% stage A and B
heart failure before overt symptoms .
Remaining 30% patients with stage C and stage D heart failure patients are
visiting emergency department ,community clinics and are vulnerable for
first admission and readmission in different hospitals .
Emergency Heart Failure Services
Introduction
We do not know exactly , how many stage C symptomatic heart failure
patients FC 1 &11 are in compensated phase and are non vulnerable
for hospitalization .
Unfortunately most of the hospitals , pharmaceutical and device industry
are spending lot of resources on this compensated population ,who
are occupying the HF out patient appointment slots , so essentially
nothing is left for minority of HF patients with de-novo and post
discharge stage C and D ambulatory heart failure patients .
No alternative for such patients , therefore only option for them is to
go to Emergency at any time and are inappropriately readmitted .
So what are alternatives for them ??
Emergency Heart Failure
Services
Which Heart failure Patients are visiting Emergency Department
( 70% are with ADCHF, 15-20% are with de-novo and around 5 - 10% are in advanced HF )
Acute Heart
Failure Syndromes
De –Novo
First time with
moderate to
severe
symptoms of
Heart failure.
Acute decompensated
Chronic heart failure
Stage C to stage D ( advanced HF FC 111 & 1V )
heart failure patients frequently visit emergency
department for decompensation of previously
compensated heart failure, especially post
discharge from hospital in vulnerable phase .
( first 30 days or those in transitional phase
of stage D heart failure patient.
Advanced heart
failure Stage D .
Tiny group of Post transplant,
post LVAD, CRTD ,mitral clip
Associated co morbid
conditions.
Some times Post cardiac
surgery , post PCI , cancer
with cardio-toxicity cardiac
tamponad ,stent
thrombosis presenting
with heart failure.
Emergency Heart Failure
Services
There is another way of classifying acute Heart Failure in Emergency department
Based on hemodynamic status , Perfusion and blood pressure.
Acute Heart Failure
Syndromes
Wet & Warm Dry & Warm
Dry & Cold
Wet & Cold
Hypertensive Form 25% ( Systolic BP > 140 mm ) common in elderly with perserved systolic function
Associated with acute pulmonary edema, may occur rapidly as flash pulmonary edema.
Hypotensive < 8%
Acute HF is associated with
Cardiogenic shock and major organ
Hypoperfusion. Minimal systemic
and pulmonary edema
Normotensive 50%
Most Common, with
progressive worsening of
symptoms and lot of systemic
edema.
HF with Coronary syndromes has 4 heterogenous manifestations ( HF without MI and without typical
angina is rare but usually misinterpretated untill CAG is done) Last not the least predominant right
heart failure with lot of systemic congestion, rafractory ascites, hernias and scrotal edema .
oomro’s ion of Heart Syndromes
.
Chronic Advanced heart
failure journey stage D.
Their journey starts from de-novo
heart failure, then progressed to
chronic heart failure ,followed by
recurrent episodes of acute on chronic
decompensation of heart failure , they
usually shuttle from ER to hospital
admission, progress to advanced HF
stage D , with major organ dysfunction,
Persistently raised BNP recurrent ER
Visits and prolong hospitalizations,
until die suddenly or in hospital with
pump failure .
Heart Failure journey from symptoms till death
Orange is ER Visit
Green & Red is Hospital ist
admission and readmissions
Emergency Heart Failure
Services
Death
ER
VISITS
Last Admission
Ist
A
D
M
I
S
I
O
N
“ Which Patients are vulnerable
for ER visits & readmission”
1) Heart failure stage C,& stage D , discharged without establishing HF etiology and
precipitants , especially ischemic heart failure without angina and documented MI/
uncorrected structural heart defects. ( HF managed without heart failure programme ,
unfortunately bitter truth )
2) Patients who are discharged prematurely, without fulfilling discharge criteria.
3) Who have Subclinical congestion, & No post discharge transitional care ( hospital to home)
4) Acute heart failure who stay in hospital for more than 7 days .
5) ADCHF in whom precipitants are not addressed appropriately. ( like ischemia & infections )
6) Acute heart failure with major organ dysfunction ,like creatinine > 2.5 or with passive liver
congestion.
7) Persistently raised BNP > 1000.
8) Heart failure with uncontrolled blood pressure ,heart rate and rhythm.
9) Those on inadequate diuretic dose and non adherent to follow up/ dietary advise. Poor
heart failure education and self care HF zones.
Heart Failure Syndromes
“Emergency Admission Criteria ”
1) Heart failure with New evidence of
simultaneous congestion and hypo
perfusion ( Wet & cold ).
2) Heart failure with New development of
major organ dysfunction ( Acute
liver & renal injury )
3) Acute decompensation of chronic heart
failure with cardiac ( ischemia
,dysrrhythmias) & non cardiac
precipitating factors ( infections
,anemia, COPD, thyroid dysfunction etc) .
1)
1)Pulmonary edema or respiratory
distress even in sitting position.
2) Arterial desaturation < 90% in
absence of known hypoxia . ( COPD,CHD).
3) Heart failure with hypotension ,systolic
BP < 75mm hg.
4) Heart failure with decreased
mentation due to hypoperfusion .
5) Heart failure with persistent
tachycardia ,rate above 120 per min.
Need for urgent hospitalization Need for immediate Hospitalization
Heart Failure Syndromes
“Emergency Admission Criteria ”
1) Symptomatic arrhythmias,
syncope, pre syncope, cardiac
arrest.
2) Multiple discharges of ICD.
3) HF with New MI or Ischemia
4) Rapid onset of new
symptoms of Heart Failure.
1) Rapid fall in serum sodium
< 130 mg/l
2) Rising serum creatinine at
least two fold or > 2.5. mg/dl
3) Persistent symptoms of
resting congestion despite
repeated out -patient clinic
visits.
Suggested Indications for heart failure admissions Consider Hospitalization
Emergency Heart Failure Services
Is HF hospitalization necessary ?
Does post discharge HF rehospitalization predict
a worse out come ?
Is hospitalization, a marker of high risk ?
To dispose from ED or admit have impact on
outcomes at all ?
Need extensive research to answer these burning
questions.
Emergency Heart Failure Services
Is HF hospitalization necessary ?
Several registry findings suggest that, for some patients
hospitalization may not significantly impact on high event rate .
Many HF hospitalizations are driven by gaps in process of care
rather than worsening pathophysiology. Like,
First ,the majority of patients are not in need of an acute
intervention beyond decongestion, yet most are admitted solely
for I/V diuretics.2nd only few patients during hospitalization require
diagnostic tests or therapeutic procedures.
3rd only minority of HF admissions require I/V ionotropes, mechanical
support, or hemodynamic monitoring.
Thus, a large subset of HF readmissions at rampant cost do not need it
Early clinical Management
of Acute Heart Failure
• First 6 hours
• Priority is stabilization and
treating life –threatening
complications of acute heart
failure ( like ACS and AHF ).
• Goals are to improve
congestion and hemodynamics.
• Initiation of I/V diuretics and
vasodilators.
• In select patients ,If heart
failure is moderate to
severe and do not need
acute intervention can keep
him in observation unit ( if
available ) for 24 to 48
hours.
*
*Around 6 to 24 hours after
presentation .
• Priority is early initiation of I/V
diuretics and vasoactive agents if
needed.
• Goals are to review old record, to
prevent unnecessary tests ,avoid
long stay and emphasize on heart
failure education and precipitants
to improve long term outcomes.
• Initiate guide line directed therapy ,
( GDMT) if non adherent ,educate
significance to patient and family .
* If already on GDMT titrate dose who
so ever can tolerate.
Early post dispose Follow up on same
day HF clinic for continuation of care.
• Patients with moderate acute HF
symptoms are referred from
community clinics or walk in to ER
( usually do not require or refuse
admission (DAMA) but need
alternative .
• Goals are to manage acute
symptoms and refer to RAHFC .
• Priority is for low risk patients
( according to score) who require
short I/V diuretics.
• Out patient Rapid access HF clinic
( RAHFC ) or same day access clinic
( SDAHFC ) without appointment is
an alternative for low risk HF
patients disposed from ER or HF
observation unit.
• This novel OPD facility is utilized for
I/V bolus or 3-4 hours infusion of
diuretics in selected patients .
Emergency Management Early Hospital/ OBU Management Same day Access HF Clinic
Risk Stratification after initial
Heart Failure treatment in ER/OBU
Careful history, thorough
physical examination and
simple diagnostic tests .
Response to ED
treatment like I/V
diuretics & S/L nitrates
comprised of low risk,
they return quickly to
their baseline and do not
exhibit high risk features.
After brief observation,
may be eligible for
discharge
Emergency department HF
patients ,who partially
respond to initial therapy ,in
which symptoms improve
partially with no high risk
features may require
continued treatment and
observation in ED based
observation unit.
If they improve book them
to alternative to
hospitalization on same day
heart failure clinic in OPD.
They represent around 20% of
all emergency department HF
patients, who develop
worsening clinical profile
after therapy ,which
includes, symptoms,
hypotension, major organ
dysfunction ,significantly
raised troponin and BNP
are poor candidates to dispose
from ED/OBU and should be
promptly triaged to an
inpatient heart failure unit
for early intervention and
further care
1) Low Risk 3) Intermediate Risk 2) High Risk
Alternatives to HF Hospitalizations
“ Inpatient equivalent “
Emergency based heart failure observation unit ( OU )
This is the novel area where acute therapy of heart failure
can be delivered ,inexpensive testing can be done ,and
effective care transition planned to avoid inpatient
hospitalization .
Investing in this new ED approach to patients
with HF is instrumental ,if we are really serious to
hospital ist admission and readmissions.
This service is only beneficial for low & intermediate risk
80%
HF admissions
&
Readmissions
Originate in
ED
50%
Heart Failure
Can be safely
Discharged
after
Observation
75% patients in OU
who responded
treatment have no
high risk features
The Purpose of an OU is to simultaneously
treat and risk-stratify the need for hospitalization
Emergency
Physicians are
Key Stake holders
Alternatives to HF Hospitalizations
“ Inpatient equivalent “
Emergency based heart failure observation unit ( OU )
Why cant we implement ,if observation unit HF
management is not complex or costly , and in fact
,conserve significant resources compared to admissions .
Its safe, efficient and minimizes healthcare expenditure.
May be Implementation need skillful coordination
of the transition of care and robust database, which
is bit difficult but not impossible ?
Emergency department for heart failure patients is bit neglected, despite
it’s the point of triage and disposition for the majority of HF
patients who are considered for admission .
We can do better by using novel management strategies.
After
Symptom
Resolutio
n
Work
Out
On
Post
ED
Disch
arge
Event
Rate.
ED
Heart
Failure
Complex
Population
Complex
Problems
&
Complex
Solutions
But ?????
Alternatives to HF Hospitalizations
“ Inpatient equivalent “
Emergency based heart failure observation unit ( OU )
Observation Unit HF management
is compelling for several reasons & is ideal place to address many issues.
1) High proportion of patients experience improvement in
breathlessness & congestion.
2)Many have complete resolution of congestion in 24 hours
3) Monitoring of Vitals, Weight,& urinary output in OU is possible.
4) Routine labs, serial troponin, BNP ,EKG ,Echo in selective cases
are possible.
5) Last not the least HF education & OPD SDAHF clinic follow –up
are key factors in OU management.
Emergency Heart Failure Services
“Alternatives to Hospitalization”
• Historically heart failure clinics were mainly for
stable patients with chronic heart failure, mostly
reserved for patients already stabilized after
hospitalization or emergency department
visit. They occupy the appointment slots and
consume lot of hospital resources despite being
non vulnerable for readmission syndromes.
Most of these patients fulfil the dispose criteria
from HF clinic, therefore can follow at developed
community heart failure clinic/ or newly
emerged Virtual clinics as part of HF programme
• Patients hospitalized for acute heart failure
remain at significant risk for readmission and
mortality ( 25-30% especially vulnerable
patients in first 30-60 days of vulnerable
phase ).
• Patients with acute heart failure with established
etiology and underlying structural heart defects despite
revascularization and corrective surgery/ uncorrected
high risk stage C to D HF patients .
• Most of them have multiple co morbidities and
precipitating factors hence recurrent hospitalizations
and visits to emergency department ,consume hospital
resources and costly business indeed .
• Post hospital discharge and those disposed from ER need some
evidence base suitable alternative ,like post discharge early
HF review /same day access HF clinic . This is a novel
multidisciplinary integrated outpatient service can cover up
many gaps to facilitate post discharge follow-up for
vulnerable patients in vulnerable phase.
• Many of these recurrent ER visitors have congestion problem
and need I/V bolus or short infusion for diuresis. SDAHFC can
be utilized safely and potentially cost-effective to reduce
ER visits and unplaned hospitalization.
Out patient same Day Access HF Clinic ( SDAHFC)
Emergency Heart Failure Services
Emergency Observation Unit interventions to facilitate safe and early
discharge and avoid inpatient admission.
Issue to be addressed Method
1) Observe response to therapy Vital signs, dyspnea response ,urine output and weight
2) Identify high risk features Serial Troponin, EKG changes, major organ function &electrolytes
3) Routine diagnostic Testing Echocardiography as gold standard in selective patients
4) HF education, self care & HF Zones Educational pamphlets in local language ,Videos and councelling by HF trained
nurse.
5) Guideline directed medical therapy
For HF ( GDMT)
a) ARNI/ACE/ARB b ) Beta blockers
b) Aldosterone antagonists d) Oral loop diuretics
Refilling of medications prior to discharge ,documented plan for dose titration and
provision of close monitoring
6) Arrange Post discharge follow up Co ordinate with HF team for post discharge ( SDAHFC ) with in 7 days according to
ED physician recommendation .
Emergency Heart Failure Services
Recommendations for appropriate candidate
for Observation Unit / safely discharged to home.
Absence of High Risk
features
Absence of high risk features does not ,
by default define low risk patients
Acute HF syndromes in emergency
department rarely enrolled in trial. So depends
on ED clinician gestalt “ Science & Art “
( Zero score does not mean zero risk) but can be safely
discharged from ED or considered for OBU management.
Blood pressure SBP > 100mm Hg / > 120 mm
Respiratory rate < 32 breaths /min
Renal Function BUN < 40 mg/dl Creatnine < 3.0 mg/dl , Sodium > 130
ACS features No New ischemic EKG changes or rise in troponin to ACS level
BNP / Pro BNP level Suggested <1000 or Pro BNP < 5000
Ottawa Heart Failure Risk Categories for
Serious Adverse Events within 14 days
Items Points
1) Initial assessment
a) History of stroke/TIA ( 1 )
b) H/O intubation for resp distress ( 2 )
c) Heart Rate on ED arrival > 110 ( 2 )
d) Room air saturation < 90% on Ed arrival ( 1 )
Items Points
2) Investigations
a) Acute EKG changes ( 2 )
b) Urea > 12 mmol/L ( 1 )
c) Serum Co2 > 35 mmol/L ( 2 )
d) Raised troponin to MI level ( 2 )
e) BNP> 1000 NT-Pro BNP > 5000 ng/L ( 1 )
3) Walk test after ED treatment
a) O2 saturation < 90 % on room air or heart rate >
110 during 3 min walk test or too ill to walk ( 1 )
Total Score ( 0 – 15 )
Ottawa Heart Failure Risk Categories for
Serious Adverse Events within 14 days
Total Score Risk Category
0 2.8 Low
1 5.1 Medium
2 9.2 Medium
3 15.9 High
4 26.1 High
5 39.8 Very High
6 55.3 Very High
7 69.8 Very High
8 81.2 Very High
9 89.0 Very High
Without an RCT, we
don’t know the true
benefits and harms.
The decision to admit
or dispose acute heart
failure patients from
ED is highly variable.
This score might be
valuable in some
settings. “May or may
not “ Depend on ED
physicians
circumstances and
wisdom indeed.
Until local RCT
demonstrate
benefits of our
patients ( not just
prevention of
readmissions ).
Scores and guide
lines are to guide us
,but we should have
our own clinical
judgement to make
decisions.
Personally, I think cocktail of different
scores are worth looking, we are
lucky, most of the components are
available in our ED. The walk test
may be “difficult but not impossible”,
But seems most valuable piece of
information to apply practically in ED.
Heart Failure Self Care
“When to contact physician or visit ER ”
Every heart failure patient,
family ,paramedical personnel
and community physicians
indeed should be aware of heart
failure Zones .
Ideally every patient ,every
day should be green
“ Ever Green”
Score Zero
Yellow
Zone
Get alert ,
Warning Signs
( Number 1 to 5)
Adjust your fluid,
salt, diuretic or call
your physician
Red
Zone
Emergency
( Call ambulance
To visit ER.
If number
6 to 10 )
Heart failure Zones
Heart Failure Self Care
“When to contact physician or visit ER ”
1) When you gain ( from dry weight ) more than 2 pounds /one
kilogram weight in a day or 5 lb/2kg in a week .
2 ) Worsening of dry hacking cough in lying down get better in
sitting down with pink foamy spit or sputum with or without fever.
3) Increase in swealling of our feet, ankles , legs and scrotum
4) Recurrent abdominal especially right hypochondrial pain with
tenderness with or without abdominal fullness and jaundice
5) Extreme tiredness or weakness FC 111 ,1V. If you think your
symptoms are related with medications
Heart Failure Self Care
“When to contact physician or visit ER ”
6) Sudden Shortness of breath FC 111/1V or orthopnea or PND
( shortness of breath in lying down / need more pillows at night or
wake from sleep at mid night ).
7) Sudden or recurrent dizziness with syncope / fall down sustain
injury.
8) Sudden or worsening of retrosternal chest pain /pressure
( Typical ischemic Pain) .
9) If your pulse or heart beat gets very slow or very fast with low
blood pressure with or without dizziness/ syncope.
10) If you think your symptoms are related to new procedure
( PCI/cardiac surgery ) or device implantation ( fever
/inappropriate shocks.
KAMC NEW ONSET
HEART FAILURE Clinical Pathway
RAHFC
( RAPID ACCESS HEART FAILURE CLINIC )
Patients with severe symptoms
Before diagnosis of Heart Failure
Patients with Mild to moderate symptoms
Before diagnosis of Heart Failure
POST DISCHARGE
With in 7-14 days
Out Patient Multi disciplinary
Clinic
Phased based Inpatient
Care
Heart Failure Clinic Community HF Clinic
Long Term Heart Failure Management Programe NO
Heart Failure
Disposed
Or
Stage A& B
Heart failure
Cath
Lab
OR
CCU
Ward
Treated
Or DAMA
Admission
Primary/secondary care centers
Conclusions
1) Optimal management & risk stratification of acute heart failure is
traditionally problematic , & challenging to identify low risk
Patients for disposition .
2) Often Patients are complex with multiple complex Cardio Vascular
and non CV comorbidities & complex solutions indeed.
3) Patients with new onset heart failure or acute decompensation of
chronic heart failure ( ADCHF) with diverse HF etiologies and
precipitants , usually require heterogeneous and multidisciplinary
group of providers, since services are fragmented so they go to
emergency.
4) In ER most of such patients are seen by non heart failure cardiologists
/interventionists ,so they are either irrationally disposed or admitted
with out risk stratification.( Risk Intolerance).
Conclusions
5) Last not the least If we prepare clinical pathways, risk score
system and creat an education and awareness amongst
Emergency Department physicians, with alternatives to
hospitalization , many of these patients can be kept in HF
observation unit for 24-48 hours or book for specialized same
day access HF ( SDHFC ) out patient clinic .
Both of these novel services pose an exciting area of growth
and can significantly reduce ED visits and hospitalization
for acute heart failure patients.
THANK YOU
Living Longer, Living Well

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Emergency HF service

  • 1. KAMC Emergency Heart Failure Services Holy Makkah Dr Asadullah Khan Soomro Adult Cardiologist King Abdullah Medical City Holy Makkah Email; hssbasadsoomro@gmail.com
  • 2. Emergency Heart Failure Services Introduction Acute HF is a gradual or rapid decompensation in symptoms and hemodynamics , requiring urgent management .it covers large spectrum of disease ranging from mild exacerbation with gradual increases in edema to cardiogenic shock. With the result millions are visiting emergency department, and indeed 80% admissions are through the emergency . HF has significant economic burden and is expected to increase all over the world, because cardiology community has not ,is not and in near future will not spent money , time and pay attention on these 60-70% stage A and B heart failure before overt symptoms . Remaining 30% patients with stage C and stage D heart failure patients are visiting emergency department ,community clinics and are vulnerable for first admission and readmission in different hospitals .
  • 3. Emergency Heart Failure Services Introduction We do not know exactly , how many stage C symptomatic heart failure patients FC 1 &11 are in compensated phase and are non vulnerable for hospitalization . Unfortunately most of the hospitals , pharmaceutical and device industry are spending lot of resources on this compensated population ,who are occupying the HF out patient appointment slots , so essentially nothing is left for minority of HF patients with de-novo and post discharge stage C and D ambulatory heart failure patients . No alternative for such patients , therefore only option for them is to go to Emergency at any time and are inappropriately readmitted . So what are alternatives for them ??
  • 4. Emergency Heart Failure Services Which Heart failure Patients are visiting Emergency Department ( 70% are with ADCHF, 15-20% are with de-novo and around 5 - 10% are in advanced HF ) Acute Heart Failure Syndromes De –Novo First time with moderate to severe symptoms of Heart failure. Acute decompensated Chronic heart failure Stage C to stage D ( advanced HF FC 111 & 1V ) heart failure patients frequently visit emergency department for decompensation of previously compensated heart failure, especially post discharge from hospital in vulnerable phase . ( first 30 days or those in transitional phase of stage D heart failure patient. Advanced heart failure Stage D . Tiny group of Post transplant, post LVAD, CRTD ,mitral clip Associated co morbid conditions. Some times Post cardiac surgery , post PCI , cancer with cardio-toxicity cardiac tamponad ,stent thrombosis presenting with heart failure.
  • 5. Emergency Heart Failure Services There is another way of classifying acute Heart Failure in Emergency department Based on hemodynamic status , Perfusion and blood pressure. Acute Heart Failure Syndromes Wet & Warm Dry & Warm Dry & Cold Wet & Cold Hypertensive Form 25% ( Systolic BP > 140 mm ) common in elderly with perserved systolic function Associated with acute pulmonary edema, may occur rapidly as flash pulmonary edema. Hypotensive < 8% Acute HF is associated with Cardiogenic shock and major organ Hypoperfusion. Minimal systemic and pulmonary edema Normotensive 50% Most Common, with progressive worsening of symptoms and lot of systemic edema. HF with Coronary syndromes has 4 heterogenous manifestations ( HF without MI and without typical angina is rare but usually misinterpretated untill CAG is done) Last not the least predominant right heart failure with lot of systemic congestion, rafractory ascites, hernias and scrotal edema .
  • 6. oomro’s ion of Heart Syndromes . Chronic Advanced heart failure journey stage D. Their journey starts from de-novo heart failure, then progressed to chronic heart failure ,followed by recurrent episodes of acute on chronic decompensation of heart failure , they usually shuttle from ER to hospital admission, progress to advanced HF stage D , with major organ dysfunction, Persistently raised BNP recurrent ER Visits and prolong hospitalizations, until die suddenly or in hospital with pump failure . Heart Failure journey from symptoms till death Orange is ER Visit Green & Red is Hospital ist admission and readmissions Emergency Heart Failure Services Death ER VISITS Last Admission Ist A D M I S I O N
  • 7. “ Which Patients are vulnerable for ER visits & readmission” 1) Heart failure stage C,& stage D , discharged without establishing HF etiology and precipitants , especially ischemic heart failure without angina and documented MI/ uncorrected structural heart defects. ( HF managed without heart failure programme , unfortunately bitter truth ) 2) Patients who are discharged prematurely, without fulfilling discharge criteria. 3) Who have Subclinical congestion, & No post discharge transitional care ( hospital to home) 4) Acute heart failure who stay in hospital for more than 7 days . 5) ADCHF in whom precipitants are not addressed appropriately. ( like ischemia & infections ) 6) Acute heart failure with major organ dysfunction ,like creatinine > 2.5 or with passive liver congestion. 7) Persistently raised BNP > 1000. 8) Heart failure with uncontrolled blood pressure ,heart rate and rhythm. 9) Those on inadequate diuretic dose and non adherent to follow up/ dietary advise. Poor heart failure education and self care HF zones.
  • 8. Heart Failure Syndromes “Emergency Admission Criteria ” 1) Heart failure with New evidence of simultaneous congestion and hypo perfusion ( Wet & cold ). 2) Heart failure with New development of major organ dysfunction ( Acute liver & renal injury ) 3) Acute decompensation of chronic heart failure with cardiac ( ischemia ,dysrrhythmias) & non cardiac precipitating factors ( infections ,anemia, COPD, thyroid dysfunction etc) . 1) 1)Pulmonary edema or respiratory distress even in sitting position. 2) Arterial desaturation < 90% in absence of known hypoxia . ( COPD,CHD). 3) Heart failure with hypotension ,systolic BP < 75mm hg. 4) Heart failure with decreased mentation due to hypoperfusion . 5) Heart failure with persistent tachycardia ,rate above 120 per min. Need for urgent hospitalization Need for immediate Hospitalization
  • 9. Heart Failure Syndromes “Emergency Admission Criteria ” 1) Symptomatic arrhythmias, syncope, pre syncope, cardiac arrest. 2) Multiple discharges of ICD. 3) HF with New MI or Ischemia 4) Rapid onset of new symptoms of Heart Failure. 1) Rapid fall in serum sodium < 130 mg/l 2) Rising serum creatinine at least two fold or > 2.5. mg/dl 3) Persistent symptoms of resting congestion despite repeated out -patient clinic visits. Suggested Indications for heart failure admissions Consider Hospitalization
  • 10. Emergency Heart Failure Services Is HF hospitalization necessary ? Does post discharge HF rehospitalization predict a worse out come ? Is hospitalization, a marker of high risk ? To dispose from ED or admit have impact on outcomes at all ? Need extensive research to answer these burning questions.
  • 11. Emergency Heart Failure Services Is HF hospitalization necessary ? Several registry findings suggest that, for some patients hospitalization may not significantly impact on high event rate . Many HF hospitalizations are driven by gaps in process of care rather than worsening pathophysiology. Like, First ,the majority of patients are not in need of an acute intervention beyond decongestion, yet most are admitted solely for I/V diuretics.2nd only few patients during hospitalization require diagnostic tests or therapeutic procedures. 3rd only minority of HF admissions require I/V ionotropes, mechanical support, or hemodynamic monitoring. Thus, a large subset of HF readmissions at rampant cost do not need it
  • 12. Early clinical Management of Acute Heart Failure • First 6 hours • Priority is stabilization and treating life –threatening complications of acute heart failure ( like ACS and AHF ). • Goals are to improve congestion and hemodynamics. • Initiation of I/V diuretics and vasodilators. • In select patients ,If heart failure is moderate to severe and do not need acute intervention can keep him in observation unit ( if available ) for 24 to 48 hours. * *Around 6 to 24 hours after presentation . • Priority is early initiation of I/V diuretics and vasoactive agents if needed. • Goals are to review old record, to prevent unnecessary tests ,avoid long stay and emphasize on heart failure education and precipitants to improve long term outcomes. • Initiate guide line directed therapy , ( GDMT) if non adherent ,educate significance to patient and family . * If already on GDMT titrate dose who so ever can tolerate. Early post dispose Follow up on same day HF clinic for continuation of care. • Patients with moderate acute HF symptoms are referred from community clinics or walk in to ER ( usually do not require or refuse admission (DAMA) but need alternative . • Goals are to manage acute symptoms and refer to RAHFC . • Priority is for low risk patients ( according to score) who require short I/V diuretics. • Out patient Rapid access HF clinic ( RAHFC ) or same day access clinic ( SDAHFC ) without appointment is an alternative for low risk HF patients disposed from ER or HF observation unit. • This novel OPD facility is utilized for I/V bolus or 3-4 hours infusion of diuretics in selected patients . Emergency Management Early Hospital/ OBU Management Same day Access HF Clinic
  • 13. Risk Stratification after initial Heart Failure treatment in ER/OBU Careful history, thorough physical examination and simple diagnostic tests . Response to ED treatment like I/V diuretics & S/L nitrates comprised of low risk, they return quickly to their baseline and do not exhibit high risk features. After brief observation, may be eligible for discharge Emergency department HF patients ,who partially respond to initial therapy ,in which symptoms improve partially with no high risk features may require continued treatment and observation in ED based observation unit. If they improve book them to alternative to hospitalization on same day heart failure clinic in OPD. They represent around 20% of all emergency department HF patients, who develop worsening clinical profile after therapy ,which includes, symptoms, hypotension, major organ dysfunction ,significantly raised troponin and BNP are poor candidates to dispose from ED/OBU and should be promptly triaged to an inpatient heart failure unit for early intervention and further care 1) Low Risk 3) Intermediate Risk 2) High Risk
  • 14. Alternatives to HF Hospitalizations “ Inpatient equivalent “ Emergency based heart failure observation unit ( OU ) This is the novel area where acute therapy of heart failure can be delivered ,inexpensive testing can be done ,and effective care transition planned to avoid inpatient hospitalization . Investing in this new ED approach to patients with HF is instrumental ,if we are really serious to hospital ist admission and readmissions. This service is only beneficial for low & intermediate risk 80% HF admissions & Readmissions Originate in ED 50% Heart Failure Can be safely Discharged after Observation 75% patients in OU who responded treatment have no high risk features The Purpose of an OU is to simultaneously treat and risk-stratify the need for hospitalization Emergency Physicians are Key Stake holders
  • 15. Alternatives to HF Hospitalizations “ Inpatient equivalent “ Emergency based heart failure observation unit ( OU ) Why cant we implement ,if observation unit HF management is not complex or costly , and in fact ,conserve significant resources compared to admissions . Its safe, efficient and minimizes healthcare expenditure. May be Implementation need skillful coordination of the transition of care and robust database, which is bit difficult but not impossible ? Emergency department for heart failure patients is bit neglected, despite it’s the point of triage and disposition for the majority of HF patients who are considered for admission . We can do better by using novel management strategies. After Symptom Resolutio n Work Out On Post ED Disch arge Event Rate. ED Heart Failure Complex Population Complex Problems & Complex Solutions But ?????
  • 16. Alternatives to HF Hospitalizations “ Inpatient equivalent “ Emergency based heart failure observation unit ( OU ) Observation Unit HF management is compelling for several reasons & is ideal place to address many issues. 1) High proportion of patients experience improvement in breathlessness & congestion. 2)Many have complete resolution of congestion in 24 hours 3) Monitoring of Vitals, Weight,& urinary output in OU is possible. 4) Routine labs, serial troponin, BNP ,EKG ,Echo in selective cases are possible. 5) Last not the least HF education & OPD SDAHF clinic follow –up are key factors in OU management.
  • 17. Emergency Heart Failure Services “Alternatives to Hospitalization” • Historically heart failure clinics were mainly for stable patients with chronic heart failure, mostly reserved for patients already stabilized after hospitalization or emergency department visit. They occupy the appointment slots and consume lot of hospital resources despite being non vulnerable for readmission syndromes. Most of these patients fulfil the dispose criteria from HF clinic, therefore can follow at developed community heart failure clinic/ or newly emerged Virtual clinics as part of HF programme • Patients hospitalized for acute heart failure remain at significant risk for readmission and mortality ( 25-30% especially vulnerable patients in first 30-60 days of vulnerable phase ). • Patients with acute heart failure with established etiology and underlying structural heart defects despite revascularization and corrective surgery/ uncorrected high risk stage C to D HF patients . • Most of them have multiple co morbidities and precipitating factors hence recurrent hospitalizations and visits to emergency department ,consume hospital resources and costly business indeed . • Post hospital discharge and those disposed from ER need some evidence base suitable alternative ,like post discharge early HF review /same day access HF clinic . This is a novel multidisciplinary integrated outpatient service can cover up many gaps to facilitate post discharge follow-up for vulnerable patients in vulnerable phase. • Many of these recurrent ER visitors have congestion problem and need I/V bolus or short infusion for diuresis. SDAHFC can be utilized safely and potentially cost-effective to reduce ER visits and unplaned hospitalization. Out patient same Day Access HF Clinic ( SDAHFC)
  • 18. Emergency Heart Failure Services Emergency Observation Unit interventions to facilitate safe and early discharge and avoid inpatient admission. Issue to be addressed Method 1) Observe response to therapy Vital signs, dyspnea response ,urine output and weight 2) Identify high risk features Serial Troponin, EKG changes, major organ function &electrolytes 3) Routine diagnostic Testing Echocardiography as gold standard in selective patients 4) HF education, self care & HF Zones Educational pamphlets in local language ,Videos and councelling by HF trained nurse. 5) Guideline directed medical therapy For HF ( GDMT) a) ARNI/ACE/ARB b ) Beta blockers b) Aldosterone antagonists d) Oral loop diuretics Refilling of medications prior to discharge ,documented plan for dose titration and provision of close monitoring 6) Arrange Post discharge follow up Co ordinate with HF team for post discharge ( SDAHFC ) with in 7 days according to ED physician recommendation .
  • 19. Emergency Heart Failure Services Recommendations for appropriate candidate for Observation Unit / safely discharged to home. Absence of High Risk features Absence of high risk features does not , by default define low risk patients Acute HF syndromes in emergency department rarely enrolled in trial. So depends on ED clinician gestalt “ Science & Art “ ( Zero score does not mean zero risk) but can be safely discharged from ED or considered for OBU management. Blood pressure SBP > 100mm Hg / > 120 mm Respiratory rate < 32 breaths /min Renal Function BUN < 40 mg/dl Creatnine < 3.0 mg/dl , Sodium > 130 ACS features No New ischemic EKG changes or rise in troponin to ACS level BNP / Pro BNP level Suggested <1000 or Pro BNP < 5000
  • 20. Ottawa Heart Failure Risk Categories for Serious Adverse Events within 14 days Items Points 1) Initial assessment a) History of stroke/TIA ( 1 ) b) H/O intubation for resp distress ( 2 ) c) Heart Rate on ED arrival > 110 ( 2 ) d) Room air saturation < 90% on Ed arrival ( 1 ) Items Points 2) Investigations a) Acute EKG changes ( 2 ) b) Urea > 12 mmol/L ( 1 ) c) Serum Co2 > 35 mmol/L ( 2 ) d) Raised troponin to MI level ( 2 ) e) BNP> 1000 NT-Pro BNP > 5000 ng/L ( 1 ) 3) Walk test after ED treatment a) O2 saturation < 90 % on room air or heart rate > 110 during 3 min walk test or too ill to walk ( 1 ) Total Score ( 0 – 15 )
  • 21. Ottawa Heart Failure Risk Categories for Serious Adverse Events within 14 days Total Score Risk Category 0 2.8 Low 1 5.1 Medium 2 9.2 Medium 3 15.9 High 4 26.1 High 5 39.8 Very High 6 55.3 Very High 7 69.8 Very High 8 81.2 Very High 9 89.0 Very High Without an RCT, we don’t know the true benefits and harms. The decision to admit or dispose acute heart failure patients from ED is highly variable. This score might be valuable in some settings. “May or may not “ Depend on ED physicians circumstances and wisdom indeed. Until local RCT demonstrate benefits of our patients ( not just prevention of readmissions ). Scores and guide lines are to guide us ,but we should have our own clinical judgement to make decisions. Personally, I think cocktail of different scores are worth looking, we are lucky, most of the components are available in our ED. The walk test may be “difficult but not impossible”, But seems most valuable piece of information to apply practically in ED.
  • 22. Heart Failure Self Care “When to contact physician or visit ER ” Every heart failure patient, family ,paramedical personnel and community physicians indeed should be aware of heart failure Zones . Ideally every patient ,every day should be green “ Ever Green” Score Zero Yellow Zone Get alert , Warning Signs ( Number 1 to 5) Adjust your fluid, salt, diuretic or call your physician Red Zone Emergency ( Call ambulance To visit ER. If number 6 to 10 ) Heart failure Zones
  • 23. Heart Failure Self Care “When to contact physician or visit ER ” 1) When you gain ( from dry weight ) more than 2 pounds /one kilogram weight in a day or 5 lb/2kg in a week . 2 ) Worsening of dry hacking cough in lying down get better in sitting down with pink foamy spit or sputum with or without fever. 3) Increase in swealling of our feet, ankles , legs and scrotum 4) Recurrent abdominal especially right hypochondrial pain with tenderness with or without abdominal fullness and jaundice 5) Extreme tiredness or weakness FC 111 ,1V. If you think your symptoms are related with medications
  • 24. Heart Failure Self Care “When to contact physician or visit ER ” 6) Sudden Shortness of breath FC 111/1V or orthopnea or PND ( shortness of breath in lying down / need more pillows at night or wake from sleep at mid night ). 7) Sudden or recurrent dizziness with syncope / fall down sustain injury. 8) Sudden or worsening of retrosternal chest pain /pressure ( Typical ischemic Pain) . 9) If your pulse or heart beat gets very slow or very fast with low blood pressure with or without dizziness/ syncope. 10) If you think your symptoms are related to new procedure ( PCI/cardiac surgery ) or device implantation ( fever /inappropriate shocks.
  • 25. KAMC NEW ONSET HEART FAILURE Clinical Pathway RAHFC ( RAPID ACCESS HEART FAILURE CLINIC ) Patients with severe symptoms Before diagnosis of Heart Failure Patients with Mild to moderate symptoms Before diagnosis of Heart Failure POST DISCHARGE With in 7-14 days Out Patient Multi disciplinary Clinic Phased based Inpatient Care Heart Failure Clinic Community HF Clinic Long Term Heart Failure Management Programe NO Heart Failure Disposed Or Stage A& B Heart failure Cath Lab OR CCU Ward Treated Or DAMA Admission Primary/secondary care centers
  • 26. Conclusions 1) Optimal management & risk stratification of acute heart failure is traditionally problematic , & challenging to identify low risk Patients for disposition . 2) Often Patients are complex with multiple complex Cardio Vascular and non CV comorbidities & complex solutions indeed. 3) Patients with new onset heart failure or acute decompensation of chronic heart failure ( ADCHF) with diverse HF etiologies and precipitants , usually require heterogeneous and multidisciplinary group of providers, since services are fragmented so they go to emergency. 4) In ER most of such patients are seen by non heart failure cardiologists /interventionists ,so they are either irrationally disposed or admitted with out risk stratification.( Risk Intolerance).
  • 27. Conclusions 5) Last not the least If we prepare clinical pathways, risk score system and creat an education and awareness amongst Emergency Department physicians, with alternatives to hospitalization , many of these patients can be kept in HF observation unit for 24-48 hours or book for specialized same day access HF ( SDHFC ) out patient clinic . Both of these novel services pose an exciting area of growth and can significantly reduce ED visits and hospitalization for acute heart failure patients.