Clinical assessment of acute heart failure syndromes: emergency department through the early post-discharge period

Abstract

Acute heart failure syndromes (AHFS) are defined as a rapid change in heart failure signs and symptoms in patients with chronic or de novo heart failure, who require urgent or emergent therapy.w1 w2 These symptoms are predominantly the result of systemic and pulmonary congestion due to elevated left ventricular (LV) filling pressures. AHFS are known to occur in patients with preserved or reduced LV ejection fraction (LVEF) and are an increasingly common cause of hospitalisation and mortality in the USA and worldwide.w3 In the USA, heart failure as the primary or secondary cause resulted in almost 3.6 million hospitalisations annually with an estimated cost of $39–$56 billion (£25–£35 billion, €28–€40 billion). In other developed countries, total expenditures on heart failure ranges between 1–2% of the total healthcare budget, with ∼75% due to hospitalisation for heart failure. Hospitalisation for AHFS independently portends a poor prognosis.w4–w7 Despite multiple trials aimed at improving outcomes, post-discharge event (death or rehospitalisation) rates can be as high as 20–30% within the subsequent 60–90 day period and 50% at 1 year.w8 1 AHFS present with a wide range of signs and symptoms, often in the setting of other cardiovascular diseases such as coronary artery disease (CAD), hypertension, valvular heart disease, atrial fibrillation, as well as other non-cardiac conditions, including renal dysfunction, pulmonary disease, anaemia, and diabetes.w2 Current practice guidelines recommend the selective use of biomarkers as well as non-invasive and invasive techniques for the initial assessment of AHFS. However, the selection and timing of tests are not well delineated.2 w9 This document proposes a consensus recommendation regarding a complete assessment of patients initially presenting to the emergency department with AHFS through hospitalisation (figure 1) and the early post-discharge period. Three phases of assessment are proposed: (1) immediate (emergency department); (2) in-hospital; and (3) …