Managing Acute Heart Failure in the Emergency Department

Patient Case Study

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Initial Diagnosis Revised Diagnosis Teaching Points

Case Introduction and Care Plan and Care Plan Discussion and Conclusions

1 3 5 7

2 4 6

Glossary

Case Details Diagnostic Disposition ? Questions

and Initial Triage Results Decision

Author:
Martin Möckel, MD, PhD, FESC, FAHA
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE INTRODUCTION

Martin Möckel, MD, PhD, FESC, FAHA

Professor, Charité–Universitätsmedizin Berlin,
(Berlin; Germany)

• Head, Division of Emergency Medicine,

Campus Virchow and Mitte
• Professor of Medicine, Department of
Cardiology, Campus Virchow

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Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE INTRODUCTION
Background
• This is the ED of a university tertiary care
hospital in a large urban center. The ER is 1
of 3 sites which form the division of EM for
adult patients. You are the consultant on duty

• In this respective site there are at least 2

residents and 1 consultant on duty, a full
complement of nurses, and 24/7 immediate
(less than 30 minute) echo capability

• Essentially, this ER handles any type of

internal medicine, neurology and gynecology
adult emergency, approximately 28,000 cases
per year

echo=echocardiogram; ED=Emergency Department; EM=emergency medicine; ER=emergency room

 Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

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History of Present Illness Past History, Allergy

and Review of systems History, Medications,
and Social History

Chief Complaint Physical

and Vital Signs Examination

CASE DETAILS
AND INITIAL TRIAGE

Author:
Martin Möckel, MD, PhD, FESC, FAHA
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE

Chief Complaint
“My mother can’t talk.”

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Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE Chief Complaint (cont)
• 51 year old female
• The daughter contacted the emergency
services:
– the patient was brought in by ambulance and
paramedics suspected a stroke
– the patient could barely speak (due to severe
dyspnea)
• Symptom onset was 1 day earlier, starting
with fatigue
– at admission severe dyspnea but no focal
neurological deficit was detected
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Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE Vital Signs
• BP: 101/68 mmHg at triage
• HR: 118 bpm
• RR: >30 brpm
• Temperature: no fever
• O2 sat: 77% room air

BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; HR=heart rate;
O2 sat= oxygen saturation; RR=respiratory rate
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Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

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CASE DETAILS
AND INITIAL TRIAGE
Immediate next actions
Given the patients severe presentation…
• Oxygen is provided via non re-breather
• Peripheral i.v. access is obtained and blood
for lab work is drawn
• Patient is placed on cardiac monitor
• All of this occurs simultaneously as initial
history and examination takes place
i.v.=intravenous
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE History of Present Illness
• Due to the patients condition, she is not able
to report any details of history
• Her daughter states that her mother was very
tired for the last 24 hours, with speech that
was unclear and complaints of fatigue
• Paramedics were called today when she
developed severe dyspnea

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Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE Review of Systems
• No cough, no fever
• No black or bloody stools
• No nausea or vomiting
• No back, abdominal or chest pain
• No palpitations
• Severe shortness of breath
• Fatigue
• No rash or temperature intolerance
• No syncope or drowsiness
• No edema
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE
Past History
• Arterial hypertension
• Depression (bipolar disorder)

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CASE DETAILS
AND INITIAL TRIAGE Allergy History, Medications,
and Social History
Allergies
• None

Current Medications
• Torasemide
• Amlodipine

Social History (via daughter)

• Married
• No tobacco
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
Physical Examination (Focused Exam)
AND INITIAL TRIAGE
• Heart:
– no murmurs, but hard to examine due to severe
tachypnea
• Lungs: ? QUESTION
– significant tachypnea
– respiratory distress
– rales over both sides, diffuse. No wheezing
• Abdomen:
– normal
• Glasgow Coma Scale:
– 15
• Remainder of exam is unremarkable. Importantly, there
are no focal neurologic deficits

BP=blood pressure
 Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

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Clinical Impression
(Initial Diagnosis)
Initial Plan of Care
and Differential
Diagnosis

INITIAL DIAGNOSIS
AND CARE PLAN

Author:
Martin Möckel, MD, PhD, FESC, FAHA
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

INITIAL DIAGNOSIS
AND CARE PLAN
Clinical Impression
(Initial Diagnosis)
and Differential Diagnosis
• Pulmonary edema (severe dyspnea, rales)

• Suspected pneumonia (hypotension, no

history of HF) in elderly patient

• Acute coronary syndrome

HF= heart failure
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

INITIAL DIAGNOSIS
AND CARE PLAN
Initial Plan of Care
• Noninvasive ventilation
? QUESTION
• Furosemide 40 mg i.v. (on the basis of initial BP)
• Within 60 minutes after presentation, blood
pressure drops to 66/45mmH
• Norepinephrine infusion (0.1 mg/h, after BP
drop)

BP=blood pressure; i.v.=intravenous

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Lab Results Chest X ray

ECG
DIAGNOSTIC RESULTS Ancillary Imaging

Author:
Martin Möckel, MD, PhD, FESC, FAHA
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DIAGNOSTIC
RESULTS ECG Click here for
ECG:
Interpretation
• Performed 10 min after admission
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DIAGNOSTIC
RESULTS

ECG: Interpretation
• Sinus rhythm, tachycardia, no significant
ST-T-segment changes
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DIAGNOSTIC
RESULTS Lab Results (Available Within 30–60 min)
(Reference range)
• Sodium 124 mmol/L (131–146 mmol/L)
• Potassium 3.8 mmol/L (3.5–5.1 mmol/L)
• Creatinine 2.77 mg/dL (0.7–1.2 mg/dL)
• hsTnT* 21 ng/L (<14/50 ng/L)
• CK 1976 U/L (<190 U/L)
• NT-proBNP** 3765 ng/L (<121 ng/L)
• CRP 531.3 mg/L (<5.0 mg/L)
• Procalcitonin 21.96 µg/L (<0.5 µg/L)
• WBC 12.73/nL (3.9–10.5/nL)
• Platelets 122/nL (150–370/nL)
• Hemoglobin 14.3 g/dL (12.5–17.2g/dL)

*Roche Cobas assay. 99th percentile/local cut-off for acute myocardial infarction (grey zone in between).
**Roche Cobas assay, normal reference. Cut-offs for decision making differ.
CK=creatinine kinase; CRP=c-reactive protein; hsTnT=high sensitivity troponin; NT-proBNP=N-terminal B-type natriuretic
peptide; WBC = white blood cell count
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DIAGNOSTIC
RESULTS Chest X ray
Click here for
Chest X ray:
Interpretation
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DIAGNOSTIC
RESULTS Chest X ray: Radiology Interpretation
• a.p. in bed
• Severe bilateral infiltration mild congestion, left
pleural effusion

a.p=anterior-posterior
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DIAGNOSTIC
RESULTS
Ancillary Imaging
• Performed 20 minutes after admission
• Emergency echocardiography indicated:
– LV hypertrophy ? QUESTION

– moderately reduced LV function

– slightly dilated RV
– dilatation of LA and RA
– aortic valve sclerosis, mild MR
– no PE

LA=left atrial; LV=left ventricular; MR=mitral valve regurgitation; RA=right atrial; RV=right ventricle; PE=pulmonary embolism
 Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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Next Actions

Revised Clinical REVISED DIAGNOSIS

Impression and AND CARE PLAN Ancillary Imaging
Differential Diagnoses

Author:
Martin Möckel, MD, PhD, FESC, FAHA
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

REVISED DIAGNOSIS
AND CARE PLAN Revised Clinical Impression
and Differential Diagnoses
• High PCT and CRP in combination with only
moderately reduced LV function and shock led to
suspicion of sepsis (septic shock) leading to AHF

AHF=acute heart failure; CRP=c-reactive protein; LV=left ventricular; PCT=procalcitonin

Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

REVISED DIAGNOSIS
AND CARE PLAN
Next Actions
• CT-scan of thorax in the ER on search for source of infection
shows bilateral pneumonic infiltrations, moderate pleural
effusion and mild congestion
? QUESTION

• Start with i.v. antibiotics

• Continuous monitoring of vital signs and BP
• Start with moderate crystalloid fluid infusion (100 mL/hour)

BP=blood pressure; CT=computer tomography; ER=emergency room; i.v.=intravenous

Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

REVISED DIAGNOSIS
AND CARE PLAN Ancillary Imaging
• CT-scan of thorax
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

DISPOSITION
DECISION Disposition
• Transferred to intensive care unit
• After initial successful NIV, secondary intubation and
mandatory ventilation was necessary for 9 days
• The patient had acute renal failure and paroxysmal
atrial fibrillation
• The patient was discharged home 15 days after the
index event

NIV=non-invasive ventilation
 Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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Discussion and
Conclusions

Local Variation
Teaching Points

TEACHING POINTS, DISCUSSION

AND CONCLUSIONS

Author:
Martin Möckel, MD, PhD, FESC, FAHA
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

TEACHING POINTS,
DISCUSSION AND Teaching Points
CONCLUSIONS

• Acute (pulmonary) infection and sepsis are the

most important differential diagnoses in AHF
• Mild heart failure worsens significantly due to
infection and may initially dominate the clinical
picture
• Early decision making is significantly assisted
by procalcitonin and early echo (EF, LV
function [cardiac output], exclusion of relevant
right heart failure due to PE, exclusion of
pericardial effusion)
• Patients may present without fever even in
septic pneumonia; this is more common in
the elderly

AHF=acute heart failure; EF=ejection fraction; LV=left ventricle; PE=pulmonary embolism

Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

TEACHING POINTS,
DISCUSSION AND Discussion and Conclusions
CONCLUSIONS

• The case has been managed adequately

– upon reflection, pre-hospital airway management could
have further improved, and shortened, the clinical course
• Psychiatric disorders often make it difficult to interpret
history
– communication with relatives is crucial in these cases
• In our ED early echo and PCT measurement are
increasingly utilized
– echo helps as outlined earlier
– PCT helps to decide on antibiotic treatment and should be
tested at admission and 12–24h later

ED=Emergency Department; PCT=procalcitonin

Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

TEACHING POINTS,
DISCUSSION AND
CONCLUSIONS
Local Variation
• The availability of echo 24/7 within 30 min;
specifically small ERs with limited specialist
availability should consider establishing a full
emergency sonography (echo, lung, FAST,
veins) program
• NIV capability within the ED
• Full labs within 60 min, troponin POCT
(immunoassay analyzer, radiometer,
troponin T)
ED=Emergency Department; FAST=focussed assessment with sonography in trauma; NIV=non-invasive
ventilation; POCT=point of care testing
 Glossary of terms
Acute Medicine
Also known as emergency medicine ward
CHA2DS2-VASC
A clinical prediction rule for estimation of
stroke risk in patients with atrial fibrillation
EHMRG
Emergency Heart Failure Mortality Risk Grade. A
tool that could be used to assess mortality risk at
discharge. Note, this tool has not been
prospectively validated. Clinical judgement is
important

CHEM7 GP
US terminology. A basic metabolic panel General practitioner. UK terminology.
including Na, K, Cl−, HCO3− or CO2, blood The equivalent role in the US would be family
urea nitrogen, creatinine and glucose physician

Community heart failure team R/O

UK terminology. A specialist community Ruled out
heart failure nursing service working in
partnership with Hospital Trusts Stat
statim (Latin) referring to speed
Consultant
UK terminology. The equivalent role in the Specialist
US would be an attending/staff physician UK terminology. See consultant

C/O
Complaining of