Evaluation and Management of Acutely Decompensated Chronic Heart Failure in the Emergency Department

Abstract

Symptoms of acutely decompensated heart failure commonly cause patients to seek care in the emergency department (ED). Decompensated heart failure can arise de novo-for example, in the setting of acute myocardial infarction (MI). More commonly, however, symptomatic heart failure presents in the context of pre-existing left ventricular dysfunction. An underlying diagnosis of chronic heart failure having already been established, one or more precipitating factors lead to clinical decompensation.Acutely decompensated chronic heart failure is a poorly defined clinical entity, and no universal definition exists. 1 Chronic heart failure is itself a complex and multifaceted clinical syndrome, encompassing conditions of both systolic and diastolic dysfunction. An acute decompensation can manifest over a period of minutes, hours, or days and can range in severity from mild symptoms of volume overload or decreased cardiac output to frank pulmonary edema or cardiogenic shock.However defined, the number of patients who present to the ED with decompensated chronic heart failure is likely to increase over the coming years. With the aging of the United States' population, the overall prevalence of heart failure is rising. 2 At the same time, advances in outpatient therapy are allowing patients with chronic heart failure to live longer with more advanced stages of hemodynamic compromise. Nearly five million Americans with heart failure are alive today, and approximately 550,000 new cases arise each year. Heart failure now accounts for close to one million inpatient admissions annually, is a secondary diagnosis associated with another two million hospitalizations each year, and represents the number one reason for hospital admission among the growing elderly population. 3 Short-term outcomes for patients admitted with decompensated heart failure have remained fairly constant over the past two decades. In-hospital mortality remains at approximately 7%, 4,5 with major adverse events occurring in up to 18% of patients. 6 For those who present with frank pulmonary edema, the corresponding rates of morbidity and mortality are approximately doubled. 7-10 Meanwhile, hospital

Morfin i behandlingen av akutt lungeødem

“…For å oppsummere: Selv om det har vaert beskrevet en viss dilatasjon av blodårene, er det sannsynligvis morfinets angstdempende effekt via redusert sympatikusaktivitet som har størst betydning ved lungeødem, uten at denne mekanismen er fullt klarlagt (4,16,24).…”

Management of Acute Decompensated Heart Failure in the Emergency Department

“…The exclusion criteria for admission to an observation unit are designed to select for patients most likely to benefit from an aggressive diuretic and vasodilation strategy. These include: 74–76 …”

“…Failure to adhere to these clinical predictors may contribute to repeat ED visits, hospital admission (often with prolonged LOS), patient morbidity, and increased overall cost 75,77 . The following criteria have been proposed for use in various combinations of discharge planning, 74–76 but not all of these criteria may be met in an individual patient, and extensive work evaluating these criteria is lacking:…”

Intervenciones educativas de enfermería en pacientes ambulatorios con falla cardiaca

“…Se ha investigado en extenso la fisiopatología, etiología, diagnóstico y tratamiento; sin embargo, en las últimas dos décadas la prevalencia e incidencia de la enfermedad ha aumentado de manera relevante y se ha indicado que la mortalidad a corto y largo plazo asociada a esta entidad en algunos casos supera la tasa observada en algunos cánceres (1) . Además, el descompensamiento de la enfermedad se ha asociado con hospitalizaciones frecuentes, mala calidad de vida, baja adherencia al tratamiento y un exceso en los costos para su manejo (2) .…”