Urgent Diagnosis, Treatment for Acute HF Recommended for First Time in Joint Consensus Paper

Deborah Brauser

June 04, 2015

SEVILLE, SPAIN — Newly released joint recommendations from three societies stress, for the first time, the importance of quickly diagnosing and treating acute heart failure[1].

The European Society of Cardiology Heart Failure Association (ESC-HFA), the European Society for Emergency Medicine, and the US Society for Academic Emergency Medicine collaborated on a consensus paper that not only calls for the addition of an urgent time element to acute HF care but also provides an algorithm for more streamlined management of the disease.

This includes recommendations on how to better involve nurses, how to use oxygen therapy and/or ventilatory support, how to manage treatments, criteria for emergency-department or hospital discharge, and ways to keep this high-risk population from becoming rehospitalized within 30 days—which is an all-too-common occurrence, say the organizations.

They add that the consensus paper was not created to replace current guidelines "but to provide contemporary perspective" and guidance based on the most recent data. The recommendations were published online May 22, 2015 in the European Heart Journal to coincide with the start of the Heart Failure Congress 2015 of the ESC-HFA.

Prof Alexandre Mebazaa

Lead author Prof Alexandre Mebazaa (Paris Diderot University, France) told heartwire from Medscape that acute HF, like acute coronary syndrome, has a "time-to-therapy concept," meaning every minute is important for improved outcomes.

"In this paper, we insisted that treatment of these patients should be done as early as possible—as soon as the patient arrives," said Mebazaa, who is also an HFA board member. In addition, "for the first time, nurses are playing an important role in the triage, determining whether the condition is severe or not severe and then following the symptoms."

Overall, "we describe the journey of these patients, give indications on when the patient can leave, and stress that we need to see these patients again within days and repeatedly until they are out of harm's way."

Critical Steps

When it comes to patients with acute HF, the authors write that clinicians often have to "make treatment decisions without adequate evidence." They note that it is important for cardiologists, emergency physicians, nurses, and other healthcare providers to cooperate not only to share expertise but to provide rapid benefits to patients.

In fact, "investigation and treatment should be started immediately and concomitantly" upon the patient's arrival at an emergency department, intensive care unit, or coronary care unit, write the authors. Some of the important steps they list include the following:

  • Determining the severity of cardiopulmonary instability, then searching for congestion and conducting additional testing as needed.

  • Doing immediate echocardiography at this stage only if hemodynamic instability is present, otherwise after stabilization.

  • Avoiding urinary catheterization, if possible.

  • Measuring plasma natriuretic-peptide levels, as well as troponin, BUN, creatinine, electrolytes, glucose, and complete blood count.

  • Considering oxygen therapy for acute-HF patients with peripheral capillary oxygen saturation (SpO2)<90%.

  • Beginning noninvasive ventilation as soon as possible if the patient is in respiratory distress.

  • Upon discharge, patients should immediately enroll in a disease-management program, make an appointment with their general practitioner within 1 week, and see their cardiology team within 2 weeks.

"We're really insisting that this is a very vulnerable phase. When a patient leaves the hospital, the heart failure is still there, and we need to remove water to improve heart condition. Also there is a 'posthospital syndrome,' where the patient probably needs some psychological support," said Mebazaa.

The authors write that further investigation is now needed into the use of biomarkers, ways to better determine clinical improvement, and whether home visits by HF teams could decrease the number of emergency-department and hospital visits for these patients.

For now, it is important to "think of the right strategy but start it as early as possible, stay close to the patient, and then reassess the condition to change the strategy quickly if needed," said Mebazaa.

"The ESC-HFA guidelines came out in 2012. And we wanted to complement those guidelines, with some added details and issues. These are basically recommendations from experts," he said.

Mebazaa has received speaker's honoraria from Alere, Bayer, Edwards Science Life, the Medicines Company, Novartis, Orion, Servier, Thermofisher, and Vifor Pharma and received fees as a member of advisory boards and/or steering committees for Bayer, Cardiorentis, the Medicines Company, and Critical Diagnostics. Disclosures for the coauthors are listed in the article.

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