New recommendations across specialties and continents are calling for urgent treatment for acute heart failure.
Patients presenting in the Emergency Department with acute dyspnea still have a high in-house mortality rate, about 10 fold higher than acute chest pain patients. Now, for the first time, new recommendations across specialties and continents are calling for urgent treatment for acute heart failure.
When patients are admitted to the Emergency Department (ED) with angina or chest pains, attending physicians have a clear diagnostic pathway to follow, administering well established tests to detect coronary heart disease and prevent a heart attack or other serious event.
A less clear symptom, however, is dyspnea, or shortness of breath. Although this symptom can suggest acute heart failure, a distressing and life-threatening condition that requires immediate medical attention and usually leads to urgent hospital admission, we have not seen the same efforts to optimize its management. Unfortunately, this can lead to delays in treatment, sub-optimal treatment, and readmissions to the hospital.1, 2
Even for an experienced physician, the underlying cause of dyspnea can be difficult to identify. However, evidence supports the measurement of natriuretic peptide levels in all patients with acute dyspnea and suspected acute heart failure immediately upon admittance to the ED. Natriuretic Peptides have been shown to enhance diagnostic accuracy of acute heart failure and therefore have an established role in aiding diagnosis given their high sensitivity and specificity.
Accurate Brain Natriuretic Peptide (BNP) measurement can be achieved with a point-of-care (POC) device.
Studies have shown the effectiveness and reliability of BNP POC devices in comparison to standard laboratory tests. The clinical utility of the cut-off 100 pg/ml for BNP was first demonstrated using the Alere Triage BNP test in the ‘Breathing Not Properly’ study before a central laboratory assay was available.3 A publication from Basel showed that when BNP testing was added to the ED clinical evaluation protocol, in-patient days were reduced from 11 to eight days, and overall cost was reduced by 26%.4
Most importantly, the study also shows that POC BNP testing reduced the time to initiation of the correct treatment from 90 to 63 minutes.4 This significant reduction in treatment delay directly supports the goals of a novel collaboration between the Heart Failure Association of the European Society of Cardiology (ESC-HFA), the European Society of Emergency Medicine (EuSEM) and the Society for Academic Emergency Medicine (SAEM) in the U.S. This collaboration aims to achieve an improved patient journey by introducing the time to therapy concept along with new medications for Acute Heart Failure. The hope is to achieve significant reductions in mortality and morbidity, as we have seen in acute coronary syndrome patients. A recently published consensus paper in the European Heart Journal provides a contemporary perspective for early hospital management within the context of the most recent data and provides guidance, based on expert opinion, to practicing physicians and other healthcare professionals.5 Most patients with acute heart failure have normal or high blood pressure at presentation. Beside diuretics the use of intravenous vasodilators are recommended for these patients. Their use has shown to be associated with lower mortality. Conversely, a delay in drug administration was associated with higher mortality.
Acute Heart Failure urgently requires rapid diagnosis and appropriate treatment, which is why we believe that “Time is life” – not only for acute coronary syndrome, but also for Acute Heart Failure.
Click on the link below to hear two emergency physicians, Prof. Roland Bingisser (University Hospital Basel, CH) and Dr. David Robinson (Bradford Teaching Hospitals NHS Foundation, UK), and a leading cardiologist, Prof. Christian Müller (Cardiology and Cardiovascular Research Institute Basel, CH) discuss the need for early diagnosis and early initiation of treatment of acute heart failure, starting with a discussion of a patient case.
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