Advice for emergency care for patients with acute heart failure was published for the first time in the European Heart Journal: Acute Cardiovascular Care.
Despite the fact that acute heart failure is associated with a high risk of death, effective care guidelines lag behind nearly 30 years. Only half of patients who are discharged with acute heart failure survive after three years and mortality from it is much higher than that from a heart attack, explains Professor Christian Mueller, chair of the Acute Heart Failure Study Group of the Acute Cardiovascular Care Association (ACCA) of the European Society of Cardiology (ESC).
He points out that unlike heart attack, there are no standard treatment pathways for acute heart failure. The paper published this week is the first step towards catching up and establishing some basic standards for the treatment of acute heart failure.
Acute heart failure is a chronic disorder and the majority of patients usually end up in emergency complaining of sudden and severe shortness of breath. Half of these patients are suffering from chronic heart failure while the other half could either have had a heart attack ten years ago or their condition remains undiagnosed.
"Most patients with acute heart failure cannot be cured," said Professor Mueller. "We can effectively treat the acute flare ups of dyspnoea with vasodilators or diuretics that remove the extra fluid on the lungs. But the underlying progressive disease remains and patients need long term follow up to make sure they are on the correct medication at the right dosages."
The advice published in this paper focuses on the decision to either discharge patients with acute heart failure and treat them as outpatients or to admit them to the hospital. To date, there has been no guidance in this regard and most emergency physicians tend to act conservatively by admitting patients. But as Professor Mueller explains, the hospital may not be the best place for acutely ill patients as they may be at a greater risk of developing infections. In addition, hospitals are already burdened with the need to reduce admissions.
The new advice clearly outlines criteria that would enable clinicians to select patients that can be safely discharged from the emergency department. An algorithm is used to help come to such a decision and accounts for local factors, places of treatment, reimbursement policies and logistics. The paper also emphasises on the importance of long-term follow up whether the patients are discharged directly from the ED or spend some time in the hospital. It is advised that such follow-up planning should be done by the emergency team in collaboration with the GP, cardiologist and other healthcare members involved in the patient's care.
It's never ever possible to treat acute heart failure sufficiently in 24 hours in the emergency department," said Professor Mueller. "Intense follow up will always be needed. It's the task of the emergency department physician to either make the first follow up appointment or to ensure that this will occur. Patients should be seen by their GP within 48 hours to fine tune the number of drugs and their doses, and assess vital signs, blood pressure, electrolytes and kidney function."
He concluded: "Ultimately we hope this guidance will improve the management of patients with acute heart failure and make some inroads towards giving them a better outlook."
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