Physicians' Academy for Cardiovascular Education

Pre-hospital and early hospital management of acute heart failure

Aug. 13, 2015 - news

 

Recommendations on pre-hospital and early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine – short version

 
Mebazaa A, Yilmaz MB, Levy P, et al.
Eur Heart J 2015 36: 1958-1966
 
Rapid managements of acute heart failure (AHF) requires the cooperation of various disciplines, among which emergency physicians, cardiologists, intensivists and nurses. Experience has been accumulated in different settings of the area of intensive care on AHF. The authors of this consensus document advocate the need of a common working definition of AHF covering all dimensions and modes of presentation. They note that most AHF presentation are either acute decompensations of chronic underlying HF or the abrupt onset of dyspnoea associated with significantly elevated blood pressure (BP). The authors also acknowledge, based on recent data, that AHF may have a ‘time to therapy’ concept, much like acute coronary syndromes, implying an important role for ‘pre-hospital’ management. In addition, patients presenting with normal or high BP who are admitted with signs or symptoms of congestion should be distinguished from those presenting with symptomatic hypotension and hypoperfusion due to low cardiac output. The latter is rare and associated with a particularly poor outcome. In order to appropriately treat a specific AHF phenotype, it is important to be able to appropriately identify it.
 
The current consensus paper is a joint initiative of the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine. It aims to provide contemporary perspective for early hospital management, based on the most recent data, and to provide guidance, based on expert opinions to practicing physicians and other health care professionals. The document benefits from valuable experience obtained at the emergency department through to the coronary care unit/intensive care unit (ICU/CCU).
 
After starting out with a definition and a description of clinical characteristics of AHF patients who were managed in various settings, the document outlines pre-hospital and early management strategies that should be applied. A list is given of initial clinical evaluation steps and investigations that should or may be performed at arrival in the emergency department/ ICU/CCU. The relevant laboratory tests at presentation are also listed. The role of nursing management is also described. Suggestions are given as to when oxygen therapy and/or ventilator support is applicable, as well as early administration of IV diuretics and vasodilators, and which type of drugs need to be used with extra caution in the context of AHF.
Guidance is provided about when a patient can be discharged from the emergency department, and when hospitalisation in the ward or ICU/CCU is indicated. Furthermore, how the patient should be monitored during the hospital stay, and which criteria apply for discharge and how follow-up should be organised during a high-risk period.
A separate section is dedicated to the definition, initial management and monitoring of cardiogenic shock including device therapy.  The document concludes with gaps in the knowledge and perspectives.

Note that a short and extended version of this document are produced.
Find the short version online at Eur Heart J