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

and Initial Triage Results Decision
? Questions

Author:
Òscar Miró, MD, PhD
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

Òscar Miró, MD, PhD

Emergency
Emergency Department,
Department, Hospital
Hospital Clínic
Clínic
(Barcelona,
(Barcelona, Catalonia:
Catalonia: Spain)
Spain)

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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
This is
is the
the ED
ED ofof an
an academic
academic tertiary
tertiary care
care
hospital in a large urban center.
hospital in a large urban center. YouYou
completed
completed training
training as
as a
a board
board certified
certified
internal
internal medicine
medicine physician
physician 5 5 years
years ago
ago
•• You
You have
have 55 residents
residents on
on duty
duty (of
(of different
different
medical
medical specialties,
specialties, but
but none
none ofof emergency
emergency
medicine
medicine because
because this
this specialty
specialty is
is not
not
recognized in your country), a
recognized in your country), a fullfull
complement
complement of of nurses
nurses and
and assistants,
assistants, and
and
24/7 immediate access to image explorations
24/7 immediate access to image explorations
(CT,
(CT, MR,
MR, US)
US)
CT=computed tomography; ED=Emergency Department; MR= magnetic resonance; More
US=ultrasound
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
•• Nobody
Nobody inin the
the ED
ED isis skilled
skilled in
in emergency
emergency
echo
echo and the ED does not have natriuretic
and the ED does not have natriuretic
peptide
peptide availability. Essentially, this ED
availability. Essentially, this ED
handles
handles any
any type
type of
of emergency
emergency
•• You
You are
are also
also in
in charge
charge of of aa 16-bed
16-bed
observation
observation unit,
unit, located
located immediately
immediately
adjacent
adjacent to
to the
the ED,
ED, where
where patients
patients can
can be
be
observed for up to 24 hours.
observed for up to 24 hours.
•• Annual census
Annual census 100,000
100,000 visits/year.
visits/year. Mean
Mean
LOS
LOS 1313 hours
hours (4.3
(4.3 for
for discharged
discharged patients;
patients;
17.1 for admitted patients)
17.1 for admitted patients)
ED=Emergency Department; LOS=length of stay
 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 Past History, Allergy

I History, Medications,
Present Illness HP
and Social History

Chief Complaint Physical

and Vital Signs Examination

CASE DETAILS
AND INITIAL TRIAGE

Author:
Òscar Miró, MD, PhD
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 (11.30 am)

•• A
A 83
83 year-old
year-old woman
woman presents
presents at
at the
the ED
ED by
by
ambulance
ambulance because
because of
of worsening
worsening shortness
shortness
of
of breath
breath

ED=Emergency Department
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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
Vital Signs and Key Data from
Paramedics
•• Paramedic
Paramedic from
from the
the ambulance
ambulance crew
crew reports
reports that
that she
she
has a previous diagnosis of chronic cardiac failure
has a previous diagnosis of chronic cardiac failure
•• Vitals
Vitals en
en route:
route: BP:
BP: 155/70
155/70 mmHg,
mmHg, HR:
HR: 98
98 bpm,
bpm,
RR: 26 brpm, Temperature: 35.9°C / 96.6°F,
RR: 26 brpm, Temperature: 35.9°C / 96.6°F,
O
O22 sat
sat room
room air:
air: 90%
90%
•• Based
Based on
on the
the presence
presence of
of leg
leg edema
edema and
and lung
lung rales
rales
on
on auscultation
auscultation the
the paramedic
paramedic has
has administered
administered
furosemide
furosemide 4040 mg
mg IV
IV and
and provided
provided oxygen
oxygen by
by mask
mask
at a concentration of 28%
at a concentration of 28%

BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; HR=heart rate; RR=respiration rate;
02 sat=oxygen saturation
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

I
HP

CASE DETAILS
AND INITIAL TRIAGE
History of Present Illness
•• Increase
Increase ofof dyspnea
dyspnea over
over last
last 7
7 days,
days, no
no
clear
clear trigger
trigger
•• Intensified
Intensified furosemide
furosemide treatment
treatment from
from
40
40 mg o.d. to 40 mg b.i.d. by her GP
mg o.d. to 40 mg b.i.d. by her GP
3 days ago
3 days ago
•• Last
Last 2
2 days
days sleeping
sleeping seated
seated with
with three
three pillows
pillows
•• No
No chest
chest pain,
pain, no
no fever,
fever, no
no changes
changes in
in
medication other than increase in
medication other than increase in
furosemide
furosemide dosage
dosage
b.i.d.=twice daily; GP=General Practitioner; o.d.=once daily
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
•• Type
Type II
II diabetes
diabetes mellitus
mellitus
–
– metformin 850 mg
metformin 850 mg b.i.d.
b.i.d.
•• Arterial
Arterial hypertension
hypertension
– enalapril
– enalapril 20
20 mg
mg o.d.
o.d.
•• Persistent
Persistent atrial
atrial fibrillation
fibrillation
– dicoumarin*
– dicoumarin*
–
– digoxin
digoxin 0.25
0.25 mg/48
mg/48 h h
•• Ischemic
Ischemic cardiomyopathy
cardiomyopathy
– inferior
– inferior MI
MI 4
4 years
years ago
ago and
and post-infarct
post-infarct angina
angina
–
– Coronary
Coronary artery
artery bypass
bypass 3x
3x (asymptomatic
(asymptomatic since)
since)
– ASA 100 mg o.d. and simvastatin 40
– ASA 100 mg o.d. and simvastatin 40 mg o.d.mg o.d.

*Dose dependent on coagulation test results (international normalized ratio)

More
ASA=acetylsalicylic acid; b.i.d.=twice daily; MI=myocardial infarction; o.d.=once daily
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
•• Chronic
Chronic heart
heart failure
failure
–
– NYHA
NYHA Class
Class II,
II, LVEF
LVEF 38%,
38%, no
no significant
significant
valvular dysfunction
valvular dysfunction
–
– last
last echocardiogram
echocardiogram was was 33 years
years previous
previous
–
– furosemide
furosemide 4040 mg
mg o.d.
o.d.
–
– four
four previous
previous episodes
episodes ofof AHF
AHF in
in past
past
12 months
12 months
•• two
two admitted
admitted toto internal
internal medicine
medicine
ward
ward
•• two
two discharged
discharged directly
directly home
home from
from ED
ED
AHF=acute heart failure; ED=Emergency Department; LVEF=left ventricular ejection fraction;
NYHA=New York Heart Association
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
Allergy History, Medications,
and Social History
Allergies
Allergies Current Medications
•• NKDA
NKDA • Metformin 850 mg b.i.d.
• Enalapril 20 mg o.d.
Social
Social History
History • Dicoumarin and digoxin
•• Is
Is functionally
functionally 0.25 mg/48 h
independent:
independent: Barthel
Barthel • AAS 100 mg o.d.
index: 100 points
index: 100 points
•• • Simvastatin 40 mg o.d.
Intellectually
Intellectually intact:
intact:
mini-mental test: • Furosemide 40 mg o.d.
mini-mental test:
30
30 points
points
•• Is
Is adherent
adherent toto treatment
treatment
•• Lives with her daughter
Lives with her daughter
•• Exercises
Exercises daily
daily (30
(30 min
min walk)
walk)

b.i.d.=twice daily; NKDA=no known drug allergies; o.d.=once daily

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
Physical Examination
•• Vitals
Vitals at
at ED:
ED:
–
– BP:
BP: 152/78
152/78 mmHg
mmHg
–
– HR: 110 bpm (arrhythmic)
HR: 110 bpm (arrhythmic)
– RR:
– RR: 2424 brpm
brpm
–
– Temperature:
Temperature: 36.4°C
36.4°C // 97.5°F
97.5°F
– O sat: 91% (on room
– O22 sat: 91% (on room air)air)
•• No
No cardiac
cardiac murmurs
murmurs
•• Rales on
Rales on both
both pulmonary
pulmonary bases,
bases, clear
clear above
above
•• Mild
Mild edema
edema until
until knees
knees
•• Jugular
Jugular distention: 6
distention: 6 cm
cm
•• Otherwise unremarkable
Otherwise unremarkable
BP=blood pressure; ED=Emergency Department; HR=heart rate; RR=respiration rate; O 2 sat=oxygen saturation
 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) and Initial Plan of Care
Differential Diagnosis

INITIAL DIAGNOSIS
AND CARE PLAN

Author:
Òscar Miró, MD, PhD
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
•• EM
EM consultant
consultant and
and resident
resident concur
concur she
she has
has
acute decompensated heart
acute decompensated heart failurefailure
–
– based
based upon
upon aa history
history of
of chronic
chronic heart
heart
failure
failure and
and recent
recent episodes
episodes of of AHF
AHF
–
– presence
presence ofof leg
leg edema
edema and
and lung
lung rales
rales on
on
admission
admission
–
– other
other possibilities
possibilities are
are considered
considered unlikely
unlikely

AHF=acute heart failure; EM=emergency medicine

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
(12.40
(12.40 pm;
pm; +1.10
+1.10 hours
hours after
after ED
ED arrival)
arrival)
? QUESTION

Treatment
Treatment
•• Maintain
Maintain oxygen
oxygen supplementation
supplementation
•• No
No more
more furosemide
furosemide at
at this
this point
point
Work-up
Work-up
•• Check
Check clinical
clinical response
response
•• Check
Check urine
urine output
output
•• Order
Order X
X ray
ray
•• Order ECG
Order ECG
•• Order
Order laboratory
laboratory tests
tests including
including troponin
troponin
ECG=electrocardiogram; ED=Emergency Department
 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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Lab Results

ECG Chest X ray

DIAGNOSTIC RESULTS

Author:
Òscar Miró, MD, PhD
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: (12.55
(12.55 pm;
pm; +1.25
+1.25 hours
hours after
after ED
ED arrival)
arrival) Click here for
ECG:
Interpretation

ECG=electrocardiogram; ED=Emergency Department

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
•• Mild
Mild tachycardia,
tachycardia, atrial
atrial fibrillation
fibrillation and
and left
left anterior
anterior
hemiblock, with non specific ST changes
hemiblock, with non specific ST 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 (or Point of Care Testing
Results) (1.26
(1.26 am;
am; +1.46
+1.46 hours
hours after
after ED
ED arrival)
arrival)
• Blood Tests (reference range)
– Glucose 201 mg/dL (65–110 mg/dL)
– Creatinine 1.1 mg/dL (0.3–1.3mg/dL)
– eGFR 67 mL/min/1.73 m2 (>60
mL/min/1.73 m2)
– Troponin* <0.017 ng/mL (<0.05 ng/mL)
– Hemogram normal
– INR 2.7
• Gas Blood Analysis (Arterial, Room Air)
– pH 7.42 (7.35–7.45)
– pCO2 43 mmHg (38–48 mmHg)
– pO2 63 mmHg (95–100 mmHg)
• Plasma Digoxin 0.9 ng/mL (0.8–1.8ng/mL)
Levels

*Dimension® EXL LOCI Module (Siemens Diagnostics), Pathological value (99 th percentile)=0.055 ng/mL;
Lowest limit for detection=0.017 ng/mL.
ED=Emergency Department; eGFR=estimated glomerular filtration rate; INR=international normalized ratio
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
•• Previous
Previous sternotomy,
sternotomy, heart
heart enlargement,
enlargement, lung
lung
interstitial
interstitial edema with some patched areas with
edema with some patched areas with
alveolar
alveolar edema
edema
 Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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Revised Clinical
Impression and Next Actions
Differential Diagnoses

REVISED DIAGNOSIS AND

CARE PLAN

Author:
Òscar Miró, MD, PhD
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
•• Complementary
Complementary explorations
explorations support
support initial
initial
diagnosis
diagnosis
•• Tachycardia
Tachycardia was
was considered
considered to
to be
be secondary
secondary to
to AHF
AHF
•• EM
EM consultant
consultant and
and resident
resident concur
concur patient
patient does
does not
not
need
need further
further investigations
investigations to
to confirm
confirm diagnosis
diagnosis
•• Urine output
Urine output 4
4 hours
hours after
after ED
ED arrival:
arrival: 950
950 cc
cc
•• Patient
Patient feeling
feeling comfortable
comfortable sat
sat at
at 45°
45° with
with oxygen
oxygen
supplementation
supplementation
•• EM
EM consultant
consultant and
and resident
resident concur
concur patient
patient does
does not
not
need emergent cardiologist consultation
need emergent cardiologist consultation
AHF=acute heart failure; ED=emergency department; EM=emergency medicine
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
Treatment
Treatment
•• Patient
Patient allocated
allocated to to the
the ED
ED observation
observation unit
unit (maximum
(maximum allowed
allowed
stay: 24 hours; monitoring at bedside possible,
stay: 24 hours; monitoring at bedside possible, but no but no
telemetry)
telemetry)
•• Maintain
Maintain onon oxygen
oxygen supplementation
supplementation
•• Furosemide
Furosemide i.v.,i.v., 40
40 mg/8
mg/8 hh
•• Close
Close renal function monitoring (get
renal function monitoring (get another
another creatinine
creatinine in
in
12–24 hours)
12–24 hours)
•• Maintain
Maintain chronic
chronic HF HF medications
medications and
and the
the remaining
remaining
medications as
medications as usual:usual:
–
– metformin
–
REVISED DIAGNOSIS AND
metformin
dicoumarin
– dicoumarin
–
– digoxin
digoxin CARE PLAN
–
– AAS
AAS
–
– simvastatin
simvastatin
•• Low
Low sodium
sodium diet,
diet, vitals/8
vitals/8 h,
h, capillary
capillary glucose
glucose determination/8
determination/8 h,
h,
urine output quantification
urine output quantification
ED=emergency department; 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
Re-evaluation of the Patient in the
ED Observation Unit
(8.30
(8.30 am;
am; +21
+21 hours
hours after
after ED
ED arrival)
arrival)
•• Total
Total diuresis:
diuresis: 2,100
2,100 mLmL
•• Vitals: BP:
Vitals: BP: 143/69
143/69 mmHg;
mmHg; HR:HR: 90
90 bpm
bpm (arrhythmic),
(arrhythmic),
RR:
RR: 20 brpm (room air), Temperature: 36.0 °C
20 brpm (room air), Temperature: 36.0 °C // 97
97 °F;
°F;
O
O22 sat:
sat: 95%
95% (room
(room air),
air), dyspnea
dyspnea improved
improved onon room
room airair
(qualitative
(qualitative approach)
approach)
•• Able
Able to go to toilet
to go to toilet by
by herself
herself without
without oxygen
oxygen (10
(10 meters)
meters)
•• On
On examination, improvement of lung rales and leg edema,
examination, improvement of lung rales and leg edema,
although some remaining
although some remaining
Blood
REVISED pH DIAGNOSIS AND pCO 40 mmHg
•• Blood gas
gas analysis:
analysis: pH 7.45;
7.45; pO
pO 22 73
73 mmHg;
mmHg; pCO22 40 mmHg
•• Current
CARE PLAN
Current renal
renal function:
function: creatinine
creatinine 1.0
1.0 mg/dL,
mg/dL,
eGFR 75 mL/min/m
eGFR 75 mL/min/m
2
2

•• Patient
Patient wanting
wanting to to go
go home
home
BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; ED=Emergency Department;
eGFR=estimated glomerular filtration rate; HR=heart rate; i.v.=intravenous; O 2 sat=oxygen saturation;
RR=respiration rate
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
•• Discharge
Discharge oror not
not discharge?
discharge?
(that’s the question)
(that’s the question)
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
Assessing Home Setting
•• Patient
Patient understanding:
understanding: fine
fine
•• Patient
Patient independence:
independence: fine
fine
•• Patient
Patient autonomy:
autonomy: fine
fine
•• Dyspnea
Dyspnea atat baseline:
baseline: mild
mild effort
effort (NYHA
(NYHA class
class II)
II)
•• Main
Main caregiver:
caregiver: daughter
daughter
•• Caregiver
Caregiver availability:
availability: 24
24 hours
hours (unemployed)
(unemployed)
•• GP:
GP: patient
patient and
and family
family happy
happy with
with her,
her, has
has had
had the
the
same
same GPGP during
during last
last 15
15 years,
years, easily
easily avalilable
avalilable

EM
EM Consultant
Consultant andand Resident
Resident Final
Final Action
Action
•• Patient
Patient is
is discharged
discharged
EM=emergency medicine; GP=General Practitioner; NYHA=New York Heart Association
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Discussion and
Conclusions

Teaching Points Local Variation

TEACHING POINTS, DISCUSSION

AND CONCLUSIONS

Author:
Òscar Miró, MD, PhD
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
•• Discharge
Discharge is is usually
usually based
based onon physician
physician experience
experience
and judgement (subjective
and judgement (subjective data) data)
•• No
No risk
risk scales
scales are
are currently
currently widely
widely used
used inin the
the ED
ED for
for risk
risk
stratification
stratification
•• There
There is is no
no definition
definition regarding
regarding the
the target
target level
level of
of risk
risk that
that can
can be
be
reasonably assumed when a patient is discharged
reasonably assumed when a patient is discharged directly fromdirectly from
the
the ED
ED
•• Two
Two main
main objectives
objectives should
should be
be achieved
achieved after
after ED
ED discharge:
discharge:
–
– avoid
avoid short-term
short-term mortality
mortality
–
– avoid
avoid short-term ED
short-term ED representation
representation
•• Definition
Definition of
of standards
standards for
for mortality
mortality and
and representation
representation
needed
needed
•• One
One tool
tool that
that could
could be
be used
used to
to assess
assess the
the patient
patient at
at discharge
discharge
is
is the
the EHMRG*
EHMRG* scorescore
–
– classifies
classifies patients
patients as
as ‘low’,
‘low’, ‘intermediate’
‘intermediate’ or
or ‘high’
‘high’ risk
risk for
for
death during the next 7
death during the next 7 days days
–
– this
this patient
patient is
is classified
classified as
as ‘intermediate’
‘intermediate’ risk
risk for
for mortality
mortality

*Available at https://ehmrg.ices.on.ca/#. Please note, the EHMRG Risk Score has not been prospectively
validated. Clinical judgement is important. ED=Emergency Department; EHMRG=Emergency Heart Failure
Mortality Risk Grade
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
•• Patients
Patients with
with a
a well-established
well-established diagnosis
diagnosis of of
chronic heart failure and a good initial clinical
chronic heart failure and a good initial clinical
response
response to
to treatment
treatment can
can bebe safely
safely
discharged
discharged directly
directly from
from the
the ED
ED after
after a a short
short
observation
observation period
period
•• A proper
A proper home
home setting
setting is
is key
key to
to success
success
•• Objective
Objective risk
risk stratification
stratification should
should help
help to
to
minimize risk
minimize risk

ED=Emergency Department
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
Management Considerations
CONCLUSIONS
•• Vasodilators
Vasodilators could could have
have been
been used
used in in present
present case
case (SBP
(SBP
152
152 mmHg at ED arrival): clinical evidence seems to favor
mmHg at ED arrival): clinical evidence seems to favor
but strong scientific data are still
but strong scientific data are still lackinglacking
•• Arterial
Arterial blood
blood gases
gases are are sometimes
sometimes overused
overused in in patients
patients
with
with dyspnea: in the present case, it could probably have
dyspnea: in the present case, it could probably have
been avoided
been avoided
•• Monitoring
Monitoring of of renal
renal function
function (and
(and electrolytes)
electrolytes) in in patients
patients
with
with aa borderline
borderline dysfunction
dysfunction is is crucial,
crucial, especially
especially ifif a
a patient
patient
is discharged home in less than 24 hours. Minimal
is discharged home in less than 24 hours. Minimal worsening worsening
with
with decongestion
decongestion is is acceptable.
acceptable.
•• Atrial
Atrial fibrillation
fibrillation does
does not
not necessarily
necessarily mean mean it
it is
is the
the
precipitant
precipitant ofof the
the AHF
AHF episode
episode andand does
does not
not always
always needneed to to
be treated: this was the case with
be treated: this was the case with our patientour patient

AHF=acute heart failure; bpm=beats per minute; ED=Emergency Department; SBP=systolic 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

TEACHING POINTS,
DISCUSSION AND
Local Variation
CONCLUSIONS
•• AnAn ED
ED observation
observation unitunit is
is highly
highly needed
needed ifif you
you
want to discharge a portion of patients
want to discharge a portion of patients with with
AHF
AHF without
without hospitalization
hospitalization (not
(not present
present inin all
all
countries)
countries)
•• In
In some
some countries,
countries, many
many patients
patients areare assessed
assessed
at
at the
the ED
ED using
using natriuretic
natriuretic peptides
peptides andand echo
echo
•• The
The EHMRG
EHMRG scale scale (used
(used for
for risk
risk stratification)
stratification)
was derivated and validated in a
was derivated and validated in a CanadianCanadian
cohort,
cohort, so
so itit should
should be
be ascertained
ascertained in in other
other
countries
countries

ADHF=acute decompensated heart failure; ED=Emergency Department; EHMRG=Emergency Heart Failure

Mortality Risk Grade
 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