Death risk higher than heart attack but care lags 30 years behind.
The first European advice on emergency care for patients with acute heart failure is published in European Heart Journal: Acute Cardiovascular Care. Acute heart failure carries a higher risk of death than heart attack but care lags 30 years behind.
"Only half of patients discharged with acute heart failure are alive in three years."
"Mortality from acute heart failure is even higher than from a heart attack so it is an urgent situation," said 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).
"Only half of patients discharged from hospital with acute heart failure are alive in three years, even though they felt fine," he continued. "Despite the severity of the condition there are no standard treatment pathways, whereas these were agreed across Europe for heart attack 30 years ago. The paper published today is the first step towards catching up with heart attack care and establishing similar standards for acute heart failure."
Acute heart failure is a chronic disorder that flares up and leads to emergency visits. The vast majority of patients present to an emergency department with sudden and severe shortness of breath (called acute dyspnoea) at rest. In 50% of patients the underlying condition is chronic heart failure. The other 50% could have had a heart attack ten years ago, or their underlying heart condition is 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 paper published today focuses on the pivotal decision of whether to discharge patients with acute heart failure from the emergency department and see them as outpatients, or to admit them to hospital. Until now there was no guidance on this issue. The result is that emergency physicians have tended to act conservatively and admit patients to hospital.
"The hospital is not always the best place to care for acutely ill patients," said Professor Mueller. "While in hospital, patients with acute heart failure - who are 78 years old on average - are at risk of developing infections and they have problems sleeping. There is also pressure on hospitals to avoid expensive admissions when possible. But patients do benefit from more intense follow up while in hospital."
The paper outlines criteria to help clinicians select patients that can be safely discharged from the emergency department. A novel algorithm shows the order of decisions to be made and what to consider at each step.
Professor Mueller said: "The paper aims to kick start the process of emergency medicine physicians and cardiologists joining forces to apply or adjust the algorithm so that it works locally. The patient pathway and decisions on place of treatment will vary depending on reimbursement policies and logistics."
The importance of long term follow up is emphasised, regardless of whether patients are discharged directly from the emergency department or spend a period in hospital before being sent home. Follow up planning should be done by the emergency team in collaboration with the general practitioner (GP), cardiologist, and others involved in the patient's long term 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."