Feature: Algorithm may help evaluate, improve outcomes for acute HF
The number of hospital admissions for acute heart failure syndromes (AHFS) has reached 1 million annually across the U.S. and Europe, and despite the fact that patients’ symptoms may improve during hospitalization; the rate of post-discharge readmission within 60 days is still almost 30 percent. Researchers in a commentary published in this week’s Journal of the American Medical Association have proposed an algorithm for evaluating AHFS at presentation, which may be the first step to optimizing treatment.

“An algorithm is needed for evaluation of AHFS at presentation, given the heterogeneity of this patient population,” wrote Mihai Gheorghiade, MD, and Eugene Braunwald, MD, from Northwestern University Feinberg School of Medicine in Chicago, and Brigham and Women’s Hospital and Harvard Medical School in Boston, respectively.  “This paper is not about preventing readmission, but rather a tool, or checklist, to address the initial assessment and management in the emergency department,” Gheorghiade told Cardiovascular Business.

There are three phases of AHFS: urgent treatment and stabilization, in-hospital management and post discharge. “This paper focuses on is the first phase, the assessment and management of acute heart failure syndromes,” Gheorghiade said. “It is all about initial stabilization. Once a patient has been stabilized, a more comprehensive and systematic approach to address underlying cardiac abnormalities [myocardium, valvular disease, coronary artery disease, electrical abnormalities, among others] can be performed.”

The authors outlined a six-axis model, that aids in initial patient assessment: (1) Clinical Severity, (2) Blood Pressure, (3) Heart Rate and Rhythm, (4) Precipitants, (5) Comorbidities, (6) DeNovo or Chronic HF.

In an example of the axis model in action, a hypothetical patient could be described as presenting with:

  • Acute pulmonary edema;
  • High Blood pressure (BP);
  • Atrial fibrillation (AF) with a rapid ventricular response;
  • Myocardial ischemia;
  • Abnormal renal function; and
  • De novo HF.
“Patients with AHFS may present insidiously or acutely with a spectrum of clinical severities ranging from those with increasing dyspnea to those in extremis with acute pulmonary edema or cardiogenic shock,” Gheorghiade and Braunwald wrote. They noted that the severity of presenting symptoms will often dictate whether a patient will need immediate treatment or deferred treatment after a more in-depth assessment of cardiac function takes place.

However, the authors noted that “severity at presentation does not always correlate well with long-term prognosis.” While patients who present with pulmonary edema as a result of severe hypertension may have an “excellent prognosis,” patients presenting with moderate dyspnea and severe left ventricular dysfunction have often have high rates of mortality.

Because there is an inverse association between BP at presentation and in-hospital and post-discharge mortality, the researchers said it is imperative to maintain adequate BP, particularly for obstructive CAD patients who may also have ischemic or hibernating myocardium at risk of necrosis. And while they said most patients with reactive hypertension respond to loop diuretics, when hypertension is the cause of acute HF, a systemic vasodilator may be required.

And because heart rhythms affect myocardial oxygen demands and cardiac output, achieving an optimal heart rate is essential, particularly for HF patients or those with preserved systolic function, CAD or valvular abnormalities. Beta-blockers should be used to achieve rate control in patients with AF.

The authors wrote that it is “of paramount importance to establish the precipitating cause(s), which may have therapeutic and prognostic implications.” The initial therapy should include removing of precipitant(s), and if this occurs, the subsequent course can be stabilized.

For the fifth axis of the model, the authors wrote that it is crucial to pinpoint and properly monitor comorbidities. They noted that clinicians should measure and prevent oxygen saturation levels from dipping below 90 percent, and properly measure plasma glucose levels in diabetic patients.

Lastly, the authors wrote that it is essential to perform Doppler echocardiography for assessment and management of patients with de novo HF because these patients have the potential to benefit from specific therapies or interventions, like valvular surgery.

After the clinician uses these six concepts to stabilize the patient, Gheorghiade said that they should then implement existing guideline-based therapies for HF patients; however, only after an in-depth assessment of cardiac structure and function is performed.

“The overall message is that during hospitalization or soon after discharge ‘fix’ the underlying cardiac problem that can be related to the myocardium, valvular abnormalities, dyssynchrony, coronary artery disease, among others,” Gheorghiade offered. “The term heart failure is the manifestation of specific cardiac abnormalities, which must be addressed.

“This six axis tool allows physicians to develop a clear clinical picture of the problem for individual patients without overlooking important details,” Gheorghiade concluded.