Diuretics for Acute HF Can Depend on Specialty of Physician

September 20, 2011

September 20, 2011 (Boston, Massachusetts) — Internal-medicine (IM) physicians were seven times more likely than emergency-medicine (EM) specialists to treat patients with acute decompensated heart failure with IV diuretics and were less likely to use nitrates, in an analysis based on the experience at one urban center [1].

Dr Ankitkumar K Patel

Possible reasons for the disparities, according to the authors: EM physicians may less often pick up volume overload, and they may tend to treat such patients as if they had hypertensive heart failure with preserved ejection fraction.

"They underdiagnose volume-overload heart failure, and by not recognizing it, they're less inclined to treat with diuretics in the acute setting. I think that's the core difference," according to Dr Ankitkumar K Patel (Cooper University Hospital, Camden, NJ), who presented the analysis here at the Heart Failure Society of America 2011 Scientific Meeting.

Whatever the reasons for the disparity, they seem to stem from differences in the questions the two kinds of specialists ask when taking the patient's history. "In the emergency room, they're pressured to take a very concise history, and I think in internal medicine, we can take a little more time," Patel said to heartwire .

When he and his colleagues reviewed specific items included in the history-taking by EM and IM doctors from 168 patients admitted for acute HF over two months in 2010, "the information the EM physicians most often didn't acquire was whether or not there was medication noncompliance or a dietary indiscretion [like a salty meal]," he said.

I think EM physicians are basing their clinical decisions on a different cohort.

In such cases, natriuretic-peptide levels and signs of pulmonary edema tended to be consistent with volume overload, which IM doctors were more likely to catch, "potentially explaining the initial management differences."

The analysis focused on how often seven factors were queried in the history-taking (shortness of breath, chest pain, abdominal pain, weight change, lower extremity edema, medication noncompliance, and dietary indiscretion) and the frequency of looking for five items in the physical examination (jugular venous distension, S3 heart sound [suggesting ventricular distention], crackles [suggesting pulmonary edema], pedal edema, and ascites).

Comparison of Evaluation and Management of 168 Patients With Acute Decompensated Heart Failure by Emergency Medicine (EM) and Internal Medicine (IM) Physicians

Evaluation or management EM IM p
Items included in history taking (n, mean) 4.01 4.64 <0.001
Items included at physical exam (n, mean) 4.26 4.22 0.65
Use of diuretics (% of cohort) 10.7 80.9 <0.001
Use of nitroglycerin (% of cohort) 17.3 9.5 <0.05
Oxygen (% of cohort) 33.3 36.9 0.284
BiPAP/intubation (% of cohort) 13.1 10.7 0.306

BPAP=bilevel positive airway pressure

According to Patel, some emergency-medicine literature suggests that much heart failure treated by EM physicians is approached as if the patient is hypertensive with preserved diastolic function and that diuretic use for their acute management can increase the risk of respiratory distress.

"Based on that, [EM physicians] may think that giving nitrates is a better option than giving them diuretics," he said, adding that in such cases, that's a "quite reasonable" approach.

"But the patients we generally see in our emergency room are volume-overloaded, [often] due to medication noncompliance or dietary indiscretion," according to Patel. In the current analysis, diuretic use did not increase the risk of respiratory failure. "I think [EM doctors] are basing their clinical decisions on a different cohort."

Patel and his coauthors had no disclosures.

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