Emergency Diagnosis and Treatment of Acute Decompensated

Transcription

Emergency Diagnosis and Treatment of Acute Decompensated
EMERGENCY DIAGNOSIS AND TREATMENT OF ACUTE DECOMPENSATED HEART FAILURE (ADHF) - MARCH 2005
Produced by
© 2005 EMCREG-International
www.emcreg.org
EMERGENCY DIAGNOSIS
AND TREATMENT OF
ACUTE DECOMPENSATED
HEART FAILURE (ADHF)
IN THIS ISSUE
CME Monograph
from the ACEP 2005
Spring Congress Satellite
Symposium
Orlando, Florida
March 4, 2005
EMCREG-International
This educational monograph was supported in part by
an unrestricted educational grant from Scios.
Printed in t h e U S A
Produced by
%-%2'%.#9
$)!'./3)3!.$
42%!4-%.4/&!#54%
$%#/-0%.3!4%$
(%!24&!),52%!$(&
ʜ˜œ}À>«…
vÀœ“Ê̅iÊ
*ÊÓääx
-«Àˆ˜}Ê
œ˜}ÀiÃÃÊÊ
->ÌiˆÌiÊ-ޓ«œÃˆÕ“
"À>˜`œ]ʏœÀˆ`>
>ÀV…Ê{]ÊÓääx
%DITEDBY
!NDRA,"LOMKALNS-$
!SSISTANT0ROFESSOR2ESIDENCY$IRECTOR
$EPARTMENTOF%MERGENCY-EDICINE
5NIVERSITYOF#INCINNATI
#INCINNATI/(53!
$IRECTOR#-%AND%NDURING-ATERIALS
%-#2%')NTERNATIONAL
*Àœ`ÕVi`ÊLÞÊ
,‡˜ÌiÀ˜>̈œ˜>Ê
Q“iÀ}i˜VÞÊi`ˆVˆ˜iÊ
>À`ˆ>VÊ,iÃi>ÀV…Ê
>˜`Ê`ÕV>̈œ˜ÊÀœÕ«R
7"RIAN'IBLER-$
)NTERNATIONAL
W W W E M C R E G O R G
0ROFESSOR#HAIRMAN
$EPARTMENTOF%MERGENCY-EDICINE
5NIVERSITYOF#INCINNATI
#INCINNATI/(53!
0RESIDENT%-#2%')NTERNATIONAL
)NTERNATIONAL
>ÞÊÓääx
i>ÀÊ
œi>}ÕiÃ\
>V…ÊÞi>À]ʘi>ÀÞʜ˜iʓˆˆœ˜Ê«>̈i˜ÌÃʈ˜Ê̅iÊ1˜ˆÌi`Ê-Ì>ÌiÃÊ>ÀiʅœÃ«ˆÌ>ˆâi`Ê܈̅Ê>VÕÌiÊ`iVœ“«i˜Ã>Ìi`ʅi>ÀÌÊv>ˆÕÀiÊ­®°Ê˜Ê̅iÊ
«>ÃÌ]Ê̅iÀiʅ>ÛiÊLii˜Êˆ“ˆÌi`Ê«À>V̈ViÊ}Ո`iˆ˜iÃÊvœÀÊ̅iÊi“iÀ}i˜VÞʓ>˜>}i“i˜ÌʜvÊ̅ˆÃÊVœ˜`ˆÌˆœ˜°Ê>Ì>ÊvÀœ“Ê̅iÊ,ʭ̅iÊ
VÕÌiÊiVœ“«i˜Ã>Ìi`Êi>ÀÌÊ>ˆÕÀiÊ >̈œ˜>Ê,i}ˆÃÌÀÞ®]ʈ˜`ˆV>ÌiÊ̅>ÌÊÊ«>̈i˜ÌÃÊ>ÀiÊÀi«i>Ìi`ÞʅœÃ«ˆÌ>ˆâi`]Ê>˜`ʜ̅iÀ܈Ãiʅ>ÛiÊ
>ÊÛiÀÞʅˆ}…ÊÀ>ÌiʜvʓœÀLˆ`ˆÌÞÊ>˜`ʓœÀÌ>ˆÌÞ°Ê/…iʓ>˜>}i“i˜ÌÊ>˜`ÊV>ÀiʜvÊ̅ˆÃÊ«>̈i˜ÌÊ}ÀœÕ«ÊÀi“>ˆ˜ÃÊÃÕLœ«Ìˆ“>°Ê/…ˆÃÊVœ“«Ài…i˜ÃˆÛiÊ
>˜`Ê«Àœ}ÀiÃÈÛiʓœ˜œ}À>«…Ê܈ÊÀiۈiÜÊ̅iʏ>ÌiÃÌÊ`ˆ>}˜œÃ̈VÊ>˜`Ê̅iÀ>«iṎVʓœ`>ˆÌˆiÃÊvœÀÊÊ>˜`ÊÃÕ}}iÃÌʓi̅œ`ÃÊ̜ʈ“«ÀœÛiÊ
̅iÊV>ÀiÊvœÀÊ̅iÃiÊ«>̈i˜ÌÃÊ>ÌÊޜÕÀʈ˜Ã̈ÌṎœ˜°Ê˜Ãˆ}…ÌÃÊ>˜`ʏiÃܘÃÊvÀœ“Ê,Ê܈Ê>ÃœÊLiÊÀiۈiÜi`Ê>˜`Ê`ˆÃVÕÃÃi`°
/…iʓiÀ}i˜VÞÊi`ˆVˆ˜iÊ
>À`ˆ>VÊ,iÃi>ÀV…Ê>˜`Ê`ÕV>̈œ˜ÊÀœÕ«‡˜ÌiÀ˜>̈œ˜>Ê­
,®ÊˆÃÊ«i>Ãi`Ê̜ʫÀiÃi˜ÌÊ̅ˆÃÊi`ÕV>̈œ˜>Ê
“œ˜œ}À>«…Ê ÃՓ“>Àˆâˆ˜}Ê œÕÀÊ ÓääxÊ ,Ê -ޓ«œÃˆÕ“Ê œ˜Ê ̅iÊ “iÀ}i˜VÞÊ i«>À̓i˜ÌÊ ˆ>}˜œÃˆÃÊ >˜`Ê /Ài>̓i˜ÌÊ œvÊ
Ê …i`Ê ˆ˜Ê "À>˜`œ]Ê œÀˆ`>°Ê Ê /…ˆÃÊ «Àœ}À>“Ê ˆÃÊ >ÃœÊ >Û>ˆ>LiÊ >ÃÊ >˜Ê œ˜‡`i“>˜`Ê ÜiLÊ V>ÃÌÊ œ˜Ê ̅iÊ ˆ˜VÕ`i`Ê ‡,"Ê >˜`Ê >ÌÊÊ
…ÌÌ«\ÉÉ>`…v°`ˆ}ˆÃVÀˆ«Ì°Vœ“ÊLi}ˆ˜˜ˆ˜}Ê՘iÊÓääx°ÊÌʈÃʜÕÀʅœ«iÊ̅>ÌÊ̅ˆÃʓ>ÌiÀˆ>Ê܈Ê«ÀœÛˆ`iÊi“iÀ}i˜VÞÊ«…ÞÈVˆ>˜ÃÊ܈̅ʈ˜vœÀ“>̈œ˜Ê
˜iViÃÃ>ÀÞÊ̜ʈ“«ÀœÛiÊ>˜`Êv>VˆˆÌ>ÌiÊV>ÀiÊvœÀÊ̅ˆÃÊ՘ˆµÕiÊ«>̈i˜ÌÊ«œ«Õ>̈œ˜°
,Ê`ÕV>̈œ˜>ÊˆÃȜ˜
/…iÊ “ˆÃȜ˜Ê œvÊ ,‡˜ÌiÀ˜>̈œ˜>Ê ˆÃÊ ÌœÊ «ÀœÛˆ`iÊ Õ«‡Ìœ‡`>Ìi]Ê iۈ`i˜ViÊ L>Ãi`]Ê >˜`Ê Vˆ˜ˆV>ÞÊ ÕÃivÕÊ i`ÕV>̈œ˜>Ê “>ÌiÀˆ>ÃÊ ÌœÊ
…i>Ì…V>ÀiÊ«ÀœÛˆ`iÀÃʈ˜ÛœÛi`ʈ˜Ê̅iÊV>ÀiʜvÊi“iÀ}i˜VÞÊVœ˜`ˆÌˆœ˜Ã°Ê7iÊÌ>ŽiÊ}Ài>ÌÊ«Àˆ`iÊ>˜`ÊivvœÀÌÊ̜ʫÀœÛˆ`iÊ̅iÃiʓ>ÌiÀˆ>ÃÊvÀiiÊ
œvÊVœ““iÀVˆ>ÊLˆ>ðÊ7…ˆiÊ̅iÃiÊi`ÕV>̈œ˜>Êi˜`i>ۜÀÃÊ>ÀiÊ뜘ÜÀi`ʈ˜Ê«>ÀÌÊLÞʈ˜`ÕÃÌÀÞ]Êëi>ŽiÀʜÀÊVœ˜ÌÀˆLÕ̜Àʈ˜yÕi˜ViʜÀÊ
Lˆ>ÃʈÃÊV>ÀivՏÞÊÀiۈiÜi`Ê>˜`ÊÃÌÀˆV̏ÞÊ«Àœ…ˆLˆÌi`°ÊÊ
œ““i˜ÌÃÊÀi}>À`ˆ˜}Ê>˜ÞʜvʜÕÀÊi`ÕV>̈œ˜>Ê“>ÌiÀˆ>ÃÊV>˜ÊLiÊÀiviÀÀi`Ê`ˆÀiV̏ÞÊ
̜ʘ`À>ʰʏœ“Ž>˜Ã]Ê]ʈÀiV̜ÀʜvÊ
Ê>˜`ʘ`ÕÀˆ˜}Ê>ÌiÀˆ>ÃÊ>ÌÊÃÕ««œÀÌJi“VÀi}°œÀ}°
-ˆ˜ViÀiÞ]
Ê
Ê
Ê
Ê
Ê
Ê
Ê
˜`À>ʰʏœ“Ž>˜Ã]ÊÊ
ÃÈÃÌ>˜ÌÊ*ÀœviÃÜÀ]Ê,iÈ`i˜VÞʈÀiV̜ÀÊ
i«>À̓i˜ÌʜvʓiÀ}i˜VÞÊi`ˆVˆ˜iÊ
1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈ÊÊ
ˆ˜Vˆ˜˜>̈]Ê"Ê
ˆÀiV̜À]Ê
Ê>˜`ʘ`ÕÀˆ˜}Ê>ÌiÀˆ>ÃÊ
,‡˜ÌiÀ˜>̈œ˜>
7°ÊÀˆ>˜ÊˆLiÀ]ÊÊ Ê
*ÀœviÃÜÀÊ>˜`Ê
…>ˆÀ“>˜Ê
Ê
i«>À̓i˜ÌʜvʓiÀ}i˜VÞÊi`ˆVˆ˜i
1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈Ê
ˆ˜Vˆ˜˜>̈]Ê"
*ÀiÈ`i˜Ì]Ê
,‡˜ÌiÀ˜>̈œ˜>Ê
Ê
VVÀi`ˆÌ>̈œ˜\Ê/…iÊ1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈Ê
œi}iʜvÊi`ˆVˆ˜iÊ`iÈ}˜>ÌiÃÊ̅ˆÃÊi`ÕV>̈œ˜>Ê>V̈ۈÌÞÊvœÀÊ>ʓ>݈“Õ“ÊœvÊÓʅœÕÀÃʜvÊ
>Ìi}œÀÞÊ£ÊVÀi`ˆÌÊ
̜Ü>À`ÃÊ̅iÊÊ*…ÞÈVˆ>˜½ÃÊ,iVœ}˜ˆÌˆœ˜ÊÜ>À`°Ê>V…Ê«…ÞÈVˆ>˜ÊŜՏ`ÊV>ˆ“Êœ˜ÞÊ̅œÃiʅœÕÀÃÊ̅>ÌʅiÉÅiÊ>VÌÕ>ÞÊëi˜Ìʜ˜Ê̅iÊi`ÕV>̈œ˜>Ê>V̈ۈÌÞ°Ê
/…iÊ1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈ʈÃÊ>VVÀi`ˆÌi`ÊLÞÊ̅iÊVVÀi`ˆÌ>̈œ˜Ê
œÕ˜VˆÊvœÀÊ
œ˜Ìˆ˜Õˆ˜}Êi`ˆV>Ê`ÕV>̈œ˜Ê­
®Ê̜ÊÃÕ««œÀÌÊVœ˜Ìˆ˜Õˆ˜}ʓi`ˆV>Ê
i`ÕV>̈œ˜ÊvœÀÊ«…ÞÈVˆ>˜Ã°Ê
/…ˆÃÊi`ÕV>̈œ˜>Ê“œ˜œ}À>«…ÊÜ>ÃÊÃÕ««œÀÌi`ʈ˜Ê«>ÀÌÊLÞÊ>˜Ê՘ÀiÃÌÀˆVÌi`Êi`ÕV>̈œ˜>Ê}À>˜ÌÊvÀœ“Ê-VˆœÃ°
/…ˆÃÊ`œVՓi˜ÌʈÃÊ̜ÊLiÊÕÃi`Ê>ÃÊ>ÊÃՓ“>ÀÞÊ>˜`ÊVˆ˜ˆV>ÊÀiviÀi˜ViÊ̜œÊ>˜`Ê "/Ê>ÃÊ>ÊÃÕLÃ̈ÌÕÌiÊvœÀÊÀi>`ˆ˜}Ê̅iÊÛ>Õ>LiÊ>˜`ʜÀˆ}ˆ˜>ÊÜÕÀViÊ`œVՓi˜ÌðÊÊ
,Ê܈Ê˜œÌÊLiʏˆ>LiÊ̜ÊޜÕʜÀÊ>˜Þœ˜iÊiÃiÊvœÀÊ>˜ÞÊ`iVˆÃˆœ˜Ê“>`iʜÀÊ>V̈œ˜ÊÌ>Ži˜Ê­œÀʘœÌÊÌ>Ži˜®ÊLÞÊޜÕʈ˜ÊÀiˆ>˜Viʜ˜Ê̅iÃiʓ>ÌiÀˆ>Ã°ÊÊ/…ˆÃÊ
`œVՓi˜ÌÊ`œiÃʘœÌÊÀi«>Viʈ˜`ˆÛˆ`Õ>Ê«…ÞÈVˆ>˜ÊVˆ˜ˆV>ÊÕ`}“i˜Ì°
ˆ˜ˆV>ÊÕ`}“i˜ÌʓÕÃÌÊ}Ո`iÊi>V…Ê«ÀœviÃȜ˜>Êˆ˜ÊÜiˆ}…ˆ˜}Ê̅iÊLi˜iwÌÃʜvÊÌÀi>̓i˜ÌÊ>}>ˆ˜ÃÌÊ̅iÊÀˆÃŽÊœvÊ̜݈VˆÌÞ°ÊʜÃiÃ]ʈ˜`ˆV>̈œ˜ÃÊ>˜`ʓi̅œ`ÃʜvÊ
ÕÃiÊvœÀÊ«Àœ`ÕVÌÃÊÀiviÀÀi`Ê̜ʈ˜Ê̅ˆÃÊ«Àœ}À>“Ê>ÀiʘœÌʘiViÃÃ>ÀˆÞÊ̅iÊÃ>“iÊ>Ãʈ˜`ˆV>Ìi`ʈ˜Ê̅iÊ«>VŽ>}iʈ˜ÃiÀÌÊ>˜`ʓ>ÞÊLiÊ`iÀˆÛi`ÊvÀœ“Ê̅iÊ«ÀœviÃȜ˜>Ê
ˆÌiÀ>ÌÕÀiʜÀʜ̅iÀÊVˆ˜ˆV>ÊVœÕÀÃiðÊÊ
œ˜ÃՏÌÊVœ“«iÌiÊ«ÀiÃVÀˆLˆ˜}ʈ˜vœÀ“>̈œ˜ÊLivœÀiÊ>`“ˆ˜ˆÃÌiÀˆ˜}°Ê
I
ÊÊ/>LiʜvÊ
œ˜Ìi˜ÌÃ
ˆ>}˜œÃˆÃʜvÊVÕÌiÊiVœ“«i˜Ã>Ìi`Êi>ÀÌÊ>ˆÕÀiʈ˜Ê̅iÊÊ°°°°°°°°°°°°°°°°°°°°°°°°°°°°° £
Õ``ʰʜ>˜`iÀ]Ê
*ÀœviÃÜÀ
i«>À̓i˜ÌʜvʓiÀ}i˜VÞÊi`ˆVˆ˜i
1˜ˆÛiÀÈÌÞʜvÊ*i˜˜ÃޏÛ>˜ˆ>]Ê*…ˆ>`i«…ˆ>]Ê*
/Ài>̓i˜ÌʜvÊVÕÌiÊiVœ“«i˜Ã>Ìi`Êi>ÀÌÊ>ˆÕÀiʈ˜Ê̅iÊÊ°°°°°°°°°°°°°°°°°°°°°°°°°°°° x
œÕ}>ÃÊ°Ê
…>À]Ê
ÃÈÃÌ>˜ÌÊ*ÀœviÃÜÀ
ˆÛˆÃˆœ˜ÊœvʓiÀ}i˜VÞÊi`ˆVˆ˜i
7>ň˜}̜˜Ê1˜ˆÛiÀÈÌÞ]Ê-̰ʜՈÃ]Ê"
/…iÊۜÛˆ˜}Ê,œiʜvÊ *ʈ˜Ê̅iʈ>}˜œÃˆÃÊ>˜`Ê/Ài>̓i˜ÌʜvÊ
\ÊÊ
Ê-Փ“>ÀÞʜvÊ̅iÊ *Ê
œ˜Ãi˜ÃÕÃÊ*>˜iÊ,i«œÀÌÊ°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°° £Ç
7°ÊÀ>˜ŽÊ*i>VœVŽ]Ê
*ÀœviÃÜÀ
6ˆVi‡
…>ˆÀ]Ê,iÃi>ÀV…]Êi«>À̓i˜ÌʜvʓiÀ}i˜VÞÊi`ˆVˆ˜i
/…iÊ
iÛi>˜`Ê
ˆ˜ˆV]Ê
iÛi>˜`]Ê"
>VŽ}ÀœÕ˜`Ê>˜`ʈ˜`ˆ˜}ÃÊÀœ“Ê̅iÊ,Ê /" Ê,-/,9Ê°°°°°°°°°°°°°°°°°° ÓÇ
7ˆˆ>“Ê/°ÊLÀ>…>“]Ê
*ÀœviÃÜÀ
…ˆiv]ʈۈȜ˜ÊœvÊ
>À`ˆœÛ>ÃVՏ>ÀÊi`ˆVˆ˜i
/…iÊ"…ˆœÊ-Ì>ÌiÊ1˜ˆÛiÀÈÌÞ]Ê
œÕ“LÕÃ]Ê"
ˆÃi>ÃiÊ>˜>}i“i˜ÌʜvÊVÕÌiÊiVœ“«i˜Ã>Ìi`Êi>ÀÌÊ>ˆÕÀi\Ê/…iÊ,Ê
“iÀ}i˜VÞÊi`ˆVˆ˜iʜ`ՏiÊÊ°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°° ÎÎ
,ˆV…>À`Ê°Ê-Փ“iÀÃ]Ê
*ÀœviÃÜÀ
i«>À̓i˜ÌʜvʓiÀ}i˜VÞÊi`ˆVˆ˜i
1˜ˆÛiÀÈÌÞʜvʈÃÈÃÈ««ˆÊi`ˆV>Ê
i˜ÌiÀ]Ê>VŽÃœ˜]Ê-
VÕÌiÊiVœ“«i˜Ã>Ìi`Êi>ÀÌÊ>ˆÕÀiʈÃi>ÃiÊ>˜>}i“i˜ÌÊ/œœÃÊ°°°°°°°°°°°°°°°°°°° Ι
-i>˜Ê*°Ê
œˆ˜Ã]Ê
ÃÈÃÌ>˜ÌÊ*ÀœviÃÜÀ
i«>À̓i˜ÌʜvʓiÀ}i˜VÞÊi`ˆVˆ˜i
1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈]Ê
ˆ˜Vˆ˜˜>̈]Ê"
œ˜Ìˆ˜Õˆ˜}Êi`ˆV>Ê`ÕV>̈œ˜Ê+ÕiÃ̈œ˜ÃÊ°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°° {Ç
II
œ˜ÌÀˆLṎ˜}ÊÕ̅œÀÃ
7ˆˆ>“Ê/°ÊLÀ>…>“]Ê
*ÀœviÃÜÀ
…ˆiv]ʈۈȜ˜ÊœvÊ
>À`ˆœÛ>ÃVՏ>ÀÊi`ˆVˆ˜i
/…iÊ"…ˆœÊ-Ì>ÌiÊ1˜ˆÛiÀÈÌÞ
œÕ“LÕÃ]Ê"…ˆœÊ
œÕ}>ÃÊ°Ê
…>À]Ê
ÃÈÃÌ>˜ÌÊ*ÀœviÃÜÀ
7>ň˜}̜˜Ê1˜ˆÛiÀÈÌÞ
-̰ʜՈÃ]ʈÃÜÕÀˆÊ
ÃÈÃÌ>˜ÌÊ*ÀœviÃÜÀ
1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈
ˆ˜Vˆ˜˜>̈]Ê"…ˆœ
7°ÊÀ>˜ŽÊ*i>VœVŽ]Ê
*ÀœviÃÜÀ
/…iÊ
iÛi>˜`Ê
ˆ˜ˆVÊ
iÛi>˜`]Ê"…ˆœ
Õ``ʰʜ>˜`iÀ]Ê
*ÀœviÃÜÀ
1˜ˆÛiÀÈÌÞʜvÊ*i˜˜ÃޏÛ>˜ˆ>
*…ˆ>`i«…ˆ>]Ê*i˜˜ÃޏÛ>˜ˆ>
,ˆV…>À`Ê°Ê-Փ“iÀÃ]Ê
*ÀœviÃÜÀ
1˜ˆÛiÀÈÌÞʜvʈÃÈÃÈ««ˆÊ
>VŽÃœ˜]ʈÃÈÃÈ««ˆ
-i>˜Ê*°Ê
œˆ˜Ã]Ê
,Êi“LiÀÃ
7°ÊÀˆ>˜ÊˆLiÀ]Ê]Ê*ÀiÈ`i˜Ì
1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈
ˆ˜Vˆ˜˜>̈]Ê"…ˆœ
iÀ“>˜Ê°Êiœœâ]Ê
1˜ˆÛiÀÈÌÞʜëˆÌ>Ê>Ã̅ՈÃLiÀ}
iÕÛi˜]Êi}ˆÕ“
-…ˆ˜}œÊœÀˆ]Ê
iˆœÊ1˜ˆÛiÀÈÌÞ
/œŽÞœ]Ê>«>˜
À̅ÕÀÊ°Ê*>˜Vˆœˆ]Ê
1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈
ˆ˜Vˆ˜˜>̈]Ê"…ˆœ
6°Ê˜>˜Ì…>À>“>˜]Ê
-ˆ˜}>«œÀiÊi˜iÀ>ÊœÃ«ˆÌ>
-ˆ˜}>«œÀi
iLœÀ>…Ê-°ÊˆiÀVŽÃ]Ê
1°
°Ê>ۈÃÊi`ˆV>Ê
i˜ÌiÀ
->VÀ>“i˜Ìœ]Ê
>ˆvœÀ˜ˆ>
`Ü>À`Ê
°Ê>ÕV…]Ê
1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈
ˆ˜Vˆ˜˜>̈]Ê"…ˆœ
7°ÊÀ>˜ŽÊ*i>VœVŽ]Ê
/…iÊ
iÛi>˜`Ê
ˆ˜ˆVÊ
iÛi>˜`]Ê"…ˆœ
/œ“Ê*°ÊÕv`iÀ…iˆ`i]Ê
i`ˆV>Ê
œi}iʜvÊ7ˆÃVœ˜Ãˆ˜
ˆÜ>Վii]Ê7ˆÃVœ˜Ãˆ˜
Ài}œÀÞÊ°ÊiÀ“>˜˜]Ê
1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈
ˆ˜Vˆ˜˜>̈]Ê"…ˆœ
,>ޓœ˜`Ê°Ê>VŽÃœ˜]Ê
7ˆˆ>“Êi>Փœ˜ÌʜëˆÌ>
,œÞ>Ê">Ž]ʈV…ˆ}>˜
…>ÀiÃÊ6°Ê*œ>VŽ]Ê
1˜ˆÛiÀÈÌÞʜvÊ*i˜˜ÃޏÛ>˜ˆ>ʜëˆÌ>
*…ˆ>`i«…ˆ>]Ê*i˜˜ÃޏÛ>˜ˆ>
,œLiÀ̜Ê>ÃÃ>˜]Ê
*Àœ‡
>À`ˆ>VœÊœÃ«ˆÌ>
,ˆœÊ`iÊ>˜iˆÀœ]ÊÀ>∏
À>˜VˆÃÊ°ÊiӈÀi]Ê
À>˜}iÀÊi`ˆV>Ê
i˜ÌiÀ
…>ÌÌ>˜œœ}>]Ê/i˜˜iÃÃii
°ÊœÕ}>ÃʈÀŽ]Ê
1°
°Ê>ۈÃÊi`ˆV>Ê
i˜ÌiÀ
->VÀ>“i˜Ìœ]Ê
>ˆvœÀ˜ˆ>
>ÀÀÞÊ-iÛiÀ>˜Vi]Ê
ՎiÊ1˜ˆÛiÀÈÌÞÊi`ˆV>Ê
i˜ÌiÀ
ÕÀ…>“]Ê œÀ̅Ê
>Àœˆ˜>
˜`À>ʰʏœ“Ž>˜Ã]Ê
1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈
ˆ˜Vˆ˜˜>̈]Ê"…ˆœ
°ÊiiÊ>ÀÛiÞ]Ê
>Àœˆ˜>ÃÊi`ˆV>Ê
i˜ÌiÀ
…>ÀœÌÌi]Ê œÀ̅Ê
>Àœˆ˜>
…ÀˆÃ̜«…iÀʰʈ˜`Ãi]Ê*…
1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈
ˆ˜Vˆ˜˜>̈]Ê"…ˆœ
7>ÌiÀÊ°Ê-V…À>`ˆ˜}]Ê
9œÀŽÊœÃ«ˆÌ>
9œÀŽ]Ê*i˜˜ÃޏÛ>˜ˆ>
iÀ>`Ê8°ÊÀœ}>˜]Ê
œÀ̅Ê-…œÀiÊ1˜ˆÛiÀÈÌÞʜëˆÌ>
*>ˆ˜ÛˆiÜ]Ê iÜÊ9œÀŽ
>ÀÞÊ°ÊÀii˜]Ê
œ…˜Ãʜ«Žˆ˜ÃÊi`ˆV>Ê
˜Ã̈ÌṎœ˜Ã
>Ìˆ“œÀi]Ê>Àޏ>˜`
Û>˜`ÀœÊiõՈÌ>]Ê
*Àœ‡
>À`ˆ>VœÊœÃ«ˆÌ>
,ˆœÊ`iÊ>˜iˆÀœ]ÊÀ>∏
œÀiÞÊ°Ê-œÛˆÃ]Ê
6>˜`iÀLˆÌÊ1˜ˆÛiÀÈÌÞ
>Åۈi]Ê/i˜˜iÃÃii
,ˆV…>À`Ê°Ê œÜ>Ž]Ê
i˜ÀÞʜÀ`ʜëˆÌ>
iÌÀœˆÌ]ʈV…ˆ}>˜
,ˆV…>À`Ê°Ê-Փ“iÀÃ]Ê
1˜ˆÛiÀÈÌÞʜvʈÃÈÃÈ««ˆÊÊ
>VŽÃœ˜]ʈÃÈÃÈ««ˆ
>Ã>̜ňÊ"L>]Ê
ÕÀՎ>Ü>Ê
ˆÌÞʜëˆÌ>
>«>˜
Àˆ>˜Ê,°Ê/ˆvv>˜Þ]Ê
>ÀˆVœ«>Êi`ˆV>Ê
i˜ÌiÀ
*…œi˜ˆÝ]ÊÀˆâœ˜>
Àˆ>˜Ê°Ê"½ iˆ]Ê
->ˆ˜Ìʜ…˜ÃʜëˆÌ>
iÌÀœˆÌ]ʈV…ˆ}>˜
>“iÃÊ°Ê7iLiÀ]Ê
1˜ˆÛiÀÈÌÞʜvʈV…ˆ}>˜
ˆ˜Ì]ʈV…ˆ}>˜
œÃi«…Ê*°Ê"À˜>̜]Ê
i`ˆV>Ê
œi}iʜvÊ6ˆÀ}ˆ˜ˆ>
,ˆV…“œ˜`]Ê6ˆÀ}ˆ˜ˆ>
,œLiÀÌÊ°Ê<>i˜ÃŽˆ]Ê
7>ޘiÊ-Ì>ÌiÊ1˜ˆÛiÀÈÌÞ
iÌÀœˆÌ]ʈV…ˆ}>˜
>ۈ`Ê°Ê°ÊÀœÜ˜]Ê
>ÃÃ>V…ÕÃiÌÌÃÊi˜iÀ>ÊœÃ«ˆÌ>
œÃ̜˜]Ê>ÃÃ>V…ÕÃiÌÌÃ
III
ˆ˜Ê°Ê>˜]Ê
1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈
ˆ˜Vˆ˜˜>̈]Ê"…ˆœ
œÕ}>ÃÊ°Ê
…>À]Ê
7>ň˜}̜˜Ê1˜ˆÛiÀÈÌÞÊ-V…œœÊœvÊ
i`ˆVˆ˜i
-̰ʜՈÃ]ʈÃÜÕÀˆÊ
>“iÃÊ7°ÊœiŽÃÌÀ>]Ê
7>ŽiʜÀiÃÌÊ1˜ˆÛiÀÈÌÞ
7ˆ˜Ã̜˜Ê->i“]Ê œÀ̅Ê
>Àœˆ˜>
>“iÃÊ°Ê
…ÀˆÃÌi˜Ãœ˜]Ê
-Ì°Ê*>Տ½ÃʜëˆÌ>
6>˜VœÕÛiÀ]ÊÀˆÌˆÃ…Ê
œÕ“Lˆ>
Õ``ʰʜ>˜`iÀ]Ê
1˜ˆÛiÀÈÌÞʜvÊ*i˜˜ÃޏÛ>˜ˆ>
*…ˆ>`i«…ˆ>]Ê*i˜˜ÃޏÛ>˜ˆ>
-i>˜Ê*°Ê
œˆ˜Ã]Ê
1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈
ˆ˜Vˆ˜˜>̈]Ê"…ˆœ
Àˆ>˜Ê,°ÊœÀœÞ`]Ê
1˜ˆÛiÀÈÌÞʜvʏLiÀÌ>ʜëˆÌ>Ã
`“œ˜Ìœ˜]ʏLiÀÌ>]Ê
>˜>`>
"--Ê"Ê
1/Ê
"* -/Ê
,/Ê1,Ê Ê/Ê
*UDD%(OLLANDER-$
$EPARTMENTOF%MERGENCY-EDICINE5NIVERSITYOF0ENNSYLVANIA
0HILADELPHIA0!
"
/6-\
£°Ê iw˜iÊ̅iÊÕÃiʜvÊ *Ê̜Ê`ˆÃ̈˜}ՈÅʅi>ÀÌÊv>ˆÕÀiÊvÀœ“ʜ̅iÀÊœ}ˆiÃʜvÊŜÀ̘iÃÃʜvÊ
LÀi>̅
Ó°Ê iˆ˜i>ÌiÊ̅iÊÀœiʜvÊ *ÊvœÀÊÀˆÃŽÊÃÌÀ>̈vވ˜}Ê«>̈i˜ÌÃÊ܈̅ʅi>ÀÌÊv>ˆÕÀi
/,"1
/"
!SWEHAVEIMPROVEDTHECAREOFPATIENTSWITHACUTECORONARYSYNDROMES!#3PA
TIENTSWITHCARDIOVASCULARDISEASEARELIVINGLONGERTHANEVER%FFECTIVEINTERVENTIONSTO
DECREASEMORTALITYOFPATIENTSWITH!#3HAVEINCREASEDTHEINCIDENCEOFHEARTFAILURE
4HECOSTOFHEARTFAILURENOWEXCEEDSBILLIONAYEARMOSTOFWHICHISDUETOHOS
PITALIZATION5NFORTUNATELYHEARTFAILUREISACHRONICCONDITIONANDNEARLYHALFOFPA
TIENTSADMITTEDTOTHEHOSPITALAREREADMITTEDWITHINSIXMONTHS4ODETERMINEOPTIMAL
THERAPYFORPATIENTSWITHACUTEDECOMPENSATEDHEARTFAILURE!$(&THEEMERGENCY
PHYSICIANMUSTBEABLETOCONlDENTLYDIAGNOSEPATIENTSWITHHEARTFAILURE4HISREQUIRES
KNOWLEDGEOFTHEDIAGNOSTICMETHODSUSEDTOIDENTIFYPATIENTSWITHHEARTFAILUREASWELL
ASKNOWLEDGEOFTHEDIFFERENTETIOLOGIESOFHEARTFAILURE
3ORTING/UTTHE%TIOLOGYOF(EART
&AILURE
4HE POTENTIAL ETIOLOGIES OF ACUTE HEART
FAILURE ARE MULTIFACTORIAL AND SHOULD
BE BROADLY DIVIDED INTO TWO CATEGORIES
THE UNDERLYING ETIOLOGY OF THE HEART
FAILUREANDTHEETIOLOGYOFTHEACUTE
PRECIPITANTTHATRESULTSINWORSENINGFROM
THECHRONICCOMPENSATEDSTATE&ORSOME
PATIENTSPARTICULARLYTHOSEPRESENTINGFOR
THElRSTTIMETHESETWOCOMPONENTSMAY
BE IDENTICAL 4HE MOST COMMON ETIOLO
GIES OF HEART FAILURE ARE CORONARY ARTERY
DISEASE AND LONGSTANDING HYPERTENSION
/THER POTENTIAL ETIOLOGIES INCLUDE DI
LATED HYPERTROPHIC AND RESTRICTIVE CAR
DIOMYOPATHIES MYOCARDITIS PERICARDIAL
TAMPONADE VALVULAR HEART DISEASE AND
SECONDARYEFFECTSOFPULMONARYDISEASES
ORMETABOLICDISORDERS
!LTHOUGHINVESTIGATIONOFTHEUNDERLYING
ETIOLOGY IS IMPORTANT TO HELP DETERMINE
WHETHERTHEREISAREVERSIBLECOMPONENT
OFTHEDISEASETHISISUSUALLYBEYONDTHE
SCOPEOFTHEEMERGENCYPHYSICIAN4HERE
AREHOWEVERSEVERALETIOLOGIESFORHEART
FAILURE THAT THE EMERGENCY PHYSICIAN
SHOULDBEAWAREOFASTHEYMAYREQUIRE
MODIlCATIONOFINITIALTHERAPY4HESEARE
SEVERE AORTIC STENOSIS IDIOPATHIC HYPER
TROPHICSUBAORTICSTENOSISORHYPERTROPHIC
OBSTRUCTIVECARDIOMYOPATHYANDPULMO
NARY HYPERTENSION )DENTIlCATION OF PA
TIENTSWITHTHESECONDITIONSISIMPORTANT
BECAUSEAGGRESSIVEPRELOADANDAFTERLOAD
REDUCTIONCANLEADTOCARDIOVASCULARCOL
LAPSESINCETHESEPATIENTSCANNOTINCREASE
THEIR FORWARD BLOOD mOW THROUGH THE
lXEDMECHANICALLESIONSUCHASAmOW
RESTRICTEDAORTICVALVE
/…iÊ«œÌi˜Ìˆ>Êœ}ˆiÃÊ
œvÊ>VÕÌiʅi>ÀÌÊv>ˆÕÀiÊ
>ÀiʓՏ̈v>V̜Àˆ>Ê>˜`Ê
ŜՏ`ÊLiÊLÀœ>`ÞÊ
`ˆÛˆ`i`ʈ˜ÌœÊÌܜÊ
V>Ìi}œÀˆiÃ\Ê­£®Ê̅iÊ
՘`iÀÞˆ˜}Êœ}ÞʜvÊ
̅iʅi>ÀÌÊv>ˆÕÀi]Ê>˜`Ê
­Ó®Ê̅iÊœ}ÞʜvÊ̅iÊ
>VÕÌiÊ«ÀiVˆ«ˆÌ>˜ÌÊ̅>ÌÊ
ÀiÃՏÌÃʈ˜ÊܜÀÃi˜ˆ˜}Ê
vÀœ“Ê̅iÊV…Àœ˜ˆVÊ
Vœ“«i˜Ã>Ìi`ÊÃÌ>Ìi°Ê
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
3EPARATEANDDISTINCTFROMTHEINITIALETI
OLOGY IS THE CAUSE OF THE ACUTE PRECIPI
TANT#ONGESTIVEHEARTFAILURECANBEEX
ACERBATEDBYWORSENINGOFTHEUNDERLYING
CONDITIONBYMEDICATIONORDIETARYNON
COMPLIANCE OR BY DEVELOPMENT OF NEW
ORCOMPLICATINGMEDICALCONDITIONSEG
ISCHEMIADYSRHYTHMIASPULMONARYEM
BOLUSORINFECTION!PPROXIMATELY
OF PATIENTS PRESENTING TO THE EMERGENCY
DEPARTMENT%$WITHHEARTFAILUREHAVE
APRIORDIAGNOSISOFHEARTFAILURE
,iˆ>˜ViÊÕ«œ˜ÊVˆ˜ˆV>Ê
ˆ“«ÀiÃȜ˜Ê>œ˜iÊ
i>`ÃÊ̜Ê`ˆ>}˜œÃ̈VÊ
՘ViÀÌ>ˆ˜ÌÞÊLiV>ÕÃiÊ̅iÊ
È}˜ÃÊ>˜`ÊÃޓ«Ìœ“ÃÊ
œvʅi>ÀÌÊv>ˆÕÀiÊ>ÀiÊ
Ài>̈ÛiÞʘœ˜Ã«iVˆwV°
qqqqqqq
/…iÊÀi>̅ˆ˜}Ê
œÌÊ*Àœ«iÀÞÊ/Àˆ>Ê
`i“œ˜ÃÌÀ>Ìi`Ê̅>ÌÊÊ
*ʈÃÊÕÃivՏÊvœÀÊÊ
̅iÊ`ˆ>}˜œÃˆÃʜvÊ
ÊÊ
ˆ˜Ê̅iÊ°Ê
0ROGRESSINTHE$IAGNOSISOF(EART&AILURE
4HE DIAGNOSIS OF HEART FAILURE HAS TRADI
TIONALLYBEENCHALLENGING2ELIANCEUPON
CLINICAL IMPRESSION ALONE LEADS TO DIAG
NOSTIC UNCERTAINTY BECAUSE THE SIGNS AND
SYMPTOMS OF HEART FAILURE ARE RELATIVELY
NONSPECIlC+EYSYMPTOMSSUCHASSHORT
NESSOFBREATHARENONSPECIlCINPATIENTS
WITH COMORBIDITIES SUCH AS REACTIVE AIR
WAYDISEASE,IKEWISEROUTINELABORATORY
TESTSELECTROCARDIOGRAMSANDRADIOGRAPHS
CANNOTBERELIEDUPONTOALWAYSGUIDEAN
ACCURATEANDAPPROPRIATEDIAGNOSIS
$ESPITE THESE CHALLENGES DIAGNOSTIC CA
PABILITIESINHEARTFAILUREHAVEIMPROVED
IN RECENT YEARS WITH RECOGNITION OF THE
ROLETHAT"TYPENATRIURETICPEPTIDE".0
PLAYSINTHEDISEASE)NADDITIONTOBEING
APUMPTHEHEARTISANENDOCRINEORGAN
THATFUNCTIONSTOGETHERWITHOTHERPHYSI
OLOGICALSYSTEMSTOCONTROLmUIDVOLUME
4HE MYOCARDIUM PRODUCES NATRIURETIC
PEPTIDESONEOFWHICHIS".0AHORMONE
WITH DIURETIC NATRIURETIC AND VASCULAR
SMOOTHMUSCLERELAXINGACTIONS".0IS
A NATURAL ANTAGONIST FOR THE SYMPATHETIC
NERVOUS SYSTEM AND THE RENINANGIOTEN
SINALDOSTERONEAXIS".0ISSECRETEDIN
RESPONSE TO WALL STRETCH VENTRICULAR DI
LATIONANDORINCREASEDlLLINGPRESSURES
-EASUREMENTOFENDOGENOUS".0ISTHUS
ACLINICALLYSENSIBLEWAYTOASSESSWHETH
ERAPARTICULARPATIENTHASHEARTFAILURE
4HE "REATHING .OT 0ROPERLY STUDY OF
PATIENTSWHOPRESENTEDTO%$SWITH
SHORTNESSOFBREATHSHOWEDTHAT".0LEV
ELS ALONE WERE MORE ACCURATE PREDICTORS
OFTHEPRESENCEORABSENCEOFHEARTFAILURE
THANANYHISTORICALFACTORSPHYSICALlND
INGS OR LABORATORY VALUES ".0 LEVELS
WEREMUCHHIGHERINPATIENTSWHOWERE
SUBSEQUENTLY DIAGNOSED WITH HEART FAIL
URETHANINTHOSEDIAGNOSEDWITHNONCAR
DIACDYSPNEAPGD,VSPGD,
! ".0 CUTOFF VALUE OF PGM, HAD
ASENSITIVITYOFANDASPECIlCITYOF
FORDIFFERENTIATINGHEARTFAILUREFROM
OTHERCAUSESOFDYSPNEAANDACUTOFFOF
PGM,HADANEGATIVEPREDICTIVEVAL
UE OF 7ITHOUT KNOWLEDGE OF ".0
LEVELSEMERGENCYPHYSICIANSHADA
INDECISIONRATEINTRYINGTOMAKEADIAG
NOSIS".0LEVELSADDEDSIGNIlCANTLYTO
THE CLINICAL IMPRESSION AS IT WAS FOUND
THATCLINICALDECISIONMAKINGINCONJUNC
TIONWITH".0LEVELSCOULDHAVEREDUCED
THEDIAGNOSTICINDECISIONRATETO)N
MULTIVARIATEANALYSES".0LEVELSALWAYS
CONTRIBUTED TO THE DIAGNOSIS EVEN AFTER
TAKING INTO ACCOUNT lNDINGS FROM THE
HISTORY AND PHYSICALEXAMINATION4HUS
THE"REATHING.OT0ROPERLYTRIALDEMON
STRATED THAT ".0 LEVELS HAVE SIGNIlCANT
CLINICAL UTILITY FOR BOTH THE DIAGNOSIS
AND RISK STRATIlCATION OF HEART FAILURE
PATIENTS IN THE %$ "OTH DIASTOLIC AND
SYSTOLIC DYSFUNCTION ARE ASSOCIATED WITH
HIGH".0LEVELSOFMOREORLESSTHESAME
DEGREE
"--Ê"Ê
1/Ê
"* -/Ê
,/Ê1,Ê Ê/Ê
".0MUSTBEUSEDWITHCAUTIONINCERTAIN
POPULATIONS!LTHOUGH".0CANHELPDIF
FERENTIATEPULMONARYFROMCARDIACETIOLO
GIESOFDYSPNEASOMETYPESOFLUNGDIS
EASE SUCH AS COR PULMONALE AND PULMO
NARYEMBOLISMHAVEELEVATED".0LEVELS
HOWEVER".0ISNOTUSUALLYELEVATEDASTO
ASHIGHALEVELASITISINPATIENTSWITHHEART
FAILURE )N A SUBGROUP OF PATIENTS WITH A
HISTORY OF REACTIVE AIRWAY DISEASE IN THE
"REATHING.OT0ROPERLYTRIALOFSUB
JECTSWITHAHISTORYOFASTHMAORCHRONIC
OBSTRUCTIVE PULMONARY DISEASE WITHOUT A
HISTORYOF#(&WEREFOUNDTOHAVE
NEWLY DISCOVERED #(& /NLY WERE
IDENTIlED IN THE %$ WHILE A ".0 PGM,IDENTIlED!DDITIONALLY".0
LEVELS PGM, PROVIDED DIAGNOSTIC
INFORMATIONBEYONDTHATOBTAINEDFROMIN
DIVIDUALCHESTRADIOGRAPHICINDICATORS
4HERE IS A SIGNIlCANT INVERSE RELATIONSHIP
BETWEEN BODY WEIGHT BODY MASS INDEX
AND ".0 LEVELS4HIN PATIENTS WITH HEART
FAILUREAREMORELIKELYTOHAVEELEVATED".0
VALUESINTHEABSENCEOFHEARTFAILURE#ON
VERSELY OBESE PATIENTS ARE MORE LIKELY TO
HAVELOWERLEVELSOF".0FORANYGIVENSE
VERITYOFHEARTFAILURE!SARESULT".0LEV
ELSSHOULDBEUSEDWITHCAUTIONINPATIENTS
WITHOBESITYUNLESSOFCOURSEBASELINE".0
VALUES ARE KNOWN 4HEN THE OBESE PATIENT
CANBEFOLLOWEDFORDECOMPENSATION
4HE "REATHING .OT 0ROPERLY 4RIAL DEM
ONSTRATEDTHAT".0ISUSEFULFORTHEDIAG
NOSIS OF #(& IN THE %$ 4HE 2%$(/4
3TUDY SUGGESTS THAT ".0 MIGHT ALSO BE
USEFULTOIMPROVETRIAGEANDDISPOSITIONOF
PATIENTSWHOPRESENTTOTHE%$WITHHEART
FAILURE4HISTRIALDEMONSTRATEDAhDISCON
NECTvBETWEENTHEPHYSICIANPERCEPTIONOF
THESEVERITYOFHEARTFAILUREANDTHEACTUAL
".0VALUE)NTHElRSTPHASEPATIENTS
VISITING %$S WITH COMPLAINTS OF BREATH
ING DIFlCULTY HAD ".0 MEASUREMENTS
TAKENONARRIVAL0HYSICIANSWEREBLINDED
TO".0RESULTSHOWEVERINCLUSIONINTHE
TRIALREQUIREDA".0PGML0ATIENTS
DISCHARGEDFROMTHE%$HADHIGHER".0
LEVELSTHANTHOSEADMITTEDTOTHEHOSPITAL
PGMLVSPGML7ITHRESPECTTO
THEADMITTEDPATIENTSHAD".0LEV
ELSPGMLWHICHISINDICATIVEOFLESS
SEVERE#(&-OSTOFTHESEPATIENTSWERE
PERCEIVEDTOHAVECLASS)))OR)6HEARTFAIL
URE-ORTALITYFORTHESEPATIENTSWASAT
DAYSANDONLYATDAYSSUGGESTING
THATPATIENTSWITHHEARTFAILUREANDLOWLEV
ELSOF".0MIGHTHAVEACTUALLYBEENSAFE
FORDISCHARGE7ITHRESPECTTOPATIENTSTHAT
WERE ACTUALLY DISCHARGED HAD ".0
LEVELSPGM,!TDAYSMORTALITY
WAS4HEREWASNOMORTALITYOFTHOSE
DISCHARGEDWITH".0LEVELSPGM,
4HISSUGGESTSTHATUSEOF".0INTHE%$
MIGHTALSOHELPDETERMINEWHICHWELLAP
PEARINGPATIENTSAREHIGHRISKFORABADOUT
COMEOVERTHESHORTTERMDAYS
iÛ>̈œ˜ÃʜvÊ *Ê>ÀiÊ
ÕÃivՏÊvœÀÊ>ÃÃiÃȘ}Ê
ÀˆÃŽÊÃÌÀ>̈wV>̈œ˜Ê>˜`Ê
«Àœ}˜œÃˆÃʈ˜Ê«>̈i˜ÌÃÊ
܈̅ʅi>ÀÌÊv>ˆÕÀi°
%LEVATED ".0 LEVELS ARE USEFUL FOR AS
SESSING RISK STRATIlCATION AND PROGNOSIS
INPATIENTSWITHHEARTFAILURE".0LEVELS
ARE RELATED TO CHANGES IN LIMITATIONS OF
PHYSICAL ACTIVITIES AND FUNCTIONAL STATUS
(ARRISONETALFOLLOWEDPATIENTSFOR
MONTHSAFTERANINDEXVISITTOTHE%$FOR
DYSPNEA (IGHER ".0 LEVELS WERE ASSO
CIATED WITH A PROGRESSIVELY WORSE PROG
NOSIS 4HE RELATIVE RISK OF MONTH #(&
ADMISSIONORDEATHINPATIENTSWITH".0
LEVELSPGM,WASTIMESTHERISK
OFPATIENTSWITHLEVELSLESSTHAN7HEN
COMBINEDWITHTROPONIN)BOTHTROPONIN)
AND".0ALONEANDINCOMBINATIONPRE
DICTSURVIVALIN#(&"OTHTOGETHERHAVE
ADDITIVEPROGNOSTICRISK
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
4HE UTILITY OF ".0 TO DIAGNOSIS #(& IS WELL ESTAB
LISHEDHOWEVERITSABILITYTODRIVETREATMENTISSTILL
UNDERSTUDY2%$(/4))ISARANDOMIZEDCONTROLLED
TRIAL COMPARING TREATMENT AND OUTCOMES OF PATIENTS
WHERETHERAPYISGUIDEDBYSERIAL".0MEASUREMENTS
IN THE EXPERIMENTAL GROUP 4HIS STUDY SHOULD SHED
SOMELIGHTONTHEUTILITYOF".0TODRIVETREATMENT
$UETOTHEVOLUMINOUSDATAONTHECLINICALUTILITYOF
".0CONSENSUSPANELGUIDELINESWERERECENTLYPUB
LISHED4HESERECOMMENDATIONSSTATE
% -ANYPATIENTSPRESENTINGTOEMERGENCYSERVICES
WITH DYSPNEA A HISTORY PHYSICAL EXAMINATION
ANDACHESTXRAYAND%#'SHOULDBEUNDERTAKEN
TOGETHER WITH LABORATORY MEASUREMENTS THAT
INCLUDE".0
% !S".0LEVELSRISEWITHAGEANDAREAFFECTEDBY
GENDERCOMORBIDITYANDDRUGTHERAPYTHEPLASMA
".0MEASUREMENTSHOULDNOTBEUSEDINISOLATION
FROMTHECLINICALCONTEXT
% )F THE ".0 IS PGM, THEN HEART FAILURE IS
HIGHLYUNLIKELYNEGATIVEPREDICTIVEVALUE
% )F THE ".0 LEVEL IS PGM, THEN #(& IS
HIGHLYLIKELYPOSITIVEPREDICTIVEVALUE
% &OR".0LEVELSOFnONESHOULDCONSIDER
THE FOLLOWING CONDITIONS IN THE DIFFERENTIAL
DIAGNOSIS
A "ASELINE".0VALUEDUETOSTABLEUNDERLYING
DYSFUNCTION
B 2IGHTVENTRICULARFAILUREFROMCOR
PULMONALE
C !CUTEPULMONARYEMBOLISM
D 2ENALFAILURE
s 0ATIENTSMAYPRESENTWITH#(&WITHNORMAL
".0 LEVELS OR WITH LEVELS BELOW WHAT
MIGHTONEEXPECTCANOCCURINTHEFOLLOWING
SITUATIONS
A &LASHPULMONARYEDEMAnHOURS
B (EART FAILURE UPSTREAM FROM THE LEFT
VENTRICLE IE ACUTE MITRAL REGURGITATION
FROMPAPILLARYMUSCLERUPTURE
C /BESE PATIENTS BODY MASS INDEX KGM
,, -AISEL!3+RISHNASWAMY0.OWAK2-ETAL2APID
MEASUREMENTOF"TYPENATRIURETICPEPTIDEINTHEEMERGENCY
DIAGNOSISOFHEARTFAILURE.%NGL*-ED
-C#ULLOUGH0!.OWAK2--C#ORD*ETAL"TYPENATRIURETIC
PEPTIDEANDCLINICALJUDGMENTINEMERGENCYDIAGNOSISOFHEART
FAILUREANALYSISFROM"REATHING.OT0ROPERLY".0-ULTINATIONAL
3TUDY#IRCULATION
-AISEL!3-C#ORD*.OWAK2-(OLLANDER*%7U!("
$UC0/MLAND43TORROW!"+RISHNASWAMY0!BRAHAM74
#LOPTON03TEG0'!UMONT-#7ESTHEIM!+NUDSEN#7
0EREZ!+AMIN2+AZANEGRA2(ERRMANN(#-C#ULLOUGH0!
FORTHE".0-ULTINATIONAL3TUDY)NVESTIGATORS"EDSIDE"TYPE
NATRIURETICPEPTIDEINTHEEMERGENCYDIAGNOSISOFHEARTFAILUREWITH
REDUCEDORPRESERVEDEJECTIONFRACTION2ESULTSFROMTHE"REATHING
.OT0ROPERLY".0-ULTINATIONAL3TUDY*!M#OLL#ARDIOL
-C#ULLOUGH0!(OLLANDER*%.OWAK2-ETAL5NCOVERING
HEARTFAILUREINPATIENTSWITHAHISTORYOFPULMONARYDISEASE
RATIONALEFORTHEEARLYUSEOF"TYPENATRIURETICPEPTIDEINTHE
EMERGENCYDEPARTMENT!CAD%MERG-ED
+NUDSEN#7/MLAND4#LOPTON07ESTHEIM!!BRAHAM
743TORROW!"-C#ORD*.OWAK2-!UMONT-#$UC0
(OLLANDER*%7U!("-C#ULLOUGH0!-AISEL!3$IAGNOSTIC
VALUEOF"TYPENATRIURETICPEPTIDEANDCHESTRADIOGRAPHIClNDINGS
INPATIENTSWITHACUTEDYSPNEA!M*-ED
-C#ORD*-UNDY"*(UDSON-0-AISEL!3(OLLANDER*%
!BRAHAM743TEG0'/MLAND4+NUDSEN#73ANDBERG+2
-C#ULLOUGH0!FORTHE"REATHING.OT0ROPERLY-ULTINATIONAL
3TUDY)NVESTIGATORS2ELATIONSHIPBETWEENOBESITYANDBTYPE
NATRIURETICPEPTIDELEVELS!RCH)NTERN-ED
-AISEL!(OLLANDER*%'USS$ETAL0RIMARYRESULTSOFTHERAPID
EMERGENCYDEPARTMENTHEARTFAILUREOUTPATIENTTRIAL2%$(/4A
MULTICENTERSTUDYOFBTYPENATRIURETICPEPTIDELEVELSEMERGENCY
DEPARTMENTDECISIONMAKINGANDOUTCOMESINPATIENTSPRESENTING
WITHSHORTNESSOFBREATH*!MER#OLL#ARDIOL
(ARRISON!-ORRISON,++RISHNASWAMY0ETAL"TYPE
NATRIURETICPEPTIDE".0PREDICTSFUTURECARDIACEVENTSINPATIENTS
PRESENTINGTOTHEEMERGENCYDEPARTMENTWITHDYSPNEA!NN%MERG
-EDn
(ORWICH4"0ATEL*-AC,ELLAN27ETAL#ARDIACTROPONIN
)ISASSOCIATEDWITHIMPAIREDHEMODYNAMICSPROGRESSIVELEFT
VENTRICULARDYSFUNCTIONANDINCREASEDMORTALITYINADVANCEDHEART
FAILURE#IRCULATION
3ILVER-!-AISEL!9ANCY#7-C#ULLOUGH0!"URNETT*#
&RANCIS'3-EHRA-20EACOCK7&&ONAROW''IBLER7"
-ORROW$!(OLLANDER*".0#ONSENSUS0ANEL!CLINICAL
APPROACHFORTHEDIAGNOSTICPROGNOSTICSCREENINGTREATMENT
MONITORINGANDTHERAPEUTICROLESOFNATRIURETICPEPTIDESIN
CARDIOVASCULARDISEASES#ONG(EART&AILURE
SUPPL
#OPYRIGHT%-#2%')NTERNATIONAL
/,/ /Ê"Ê
1/Ê
"* -/Ê,/Ê
1,Ê Ê/Ê, 9Ê*,/ /
$OUGLAS-#HAR-$
$IVISIONOF%MERGENCY-EDICINE7ASHINGTON5NIVERSITY
3T,OUIS-/
"
/6-\
£°Ê iÃVÀˆLiÊ>Êȓ«iÊÌܜÊÃÌi«Ê>««Àœ>V…Ê̜Ê>ÃÃiÃȘ}Ê̅iÊVˆ˜ˆV>ÊÃÌ>ÌÕÃʜvÊÊ«>̈i˜ÌÃÊ܈̅Ê
Ó°Ê iw˜iÊ̅iÊÀœiʜvÊÛ>Ü`ˆ>̜ÀÃÊ>ÃÊ̅iʓ>ˆ˜ÃÌ>ÞʜvÊ̅iÀ>«ÞÊvœÀÊ
/,"1
/"
!CUTELYDECOMPENSATEDHEARTFAILURE!$(&ISACOMMONREASONFORPATIENTSSEEKING
EMERGENCYDEPARTMENT%$CAREANDTHELEADING-EDICAREDIAGNOSISFORHOSPITALIZED
PATIENTS OVER THE AGE OF (OSPITAL READMISSION FOR HEART FAILURE IS COMMON AP
PROXIMATELYOFPATIENTSAREREADMITTEDWITHINDAYSANDWITHINMONTHS
2ECENTADVANCESINTHEUNDERSTANDINGOFTHECOMPLEXPATHOPHYSIOLOGICPROCESSTHAT
EXACERBATEHEARTFAILUREHASLEDTOIMPROVEDDIAGNOSESANDEFFECTIVE%$TREATMENTOF
THISCLINICALENTITY
0ATHOPHYSIOLOGYAND(EMODYNAMIC
!SSESSMENT
)N THE PAST DECOMPENSATED HEART FAILURE
WAS FELT TO BE DUE TO VOLUME OVERLOAD
AND IMPAIRED FORWARD mOW 4REATMENT
WASFOCUSEDONMAXIMIZINGCARDIACOUT
PUT)THASNOWBECOMEAPPARENTTHATIN
MOST !$(&PULMONARY EDEMA THERE IS
INCREASED SYSTEMIC VASCULAR RESISTANCE
SUPERIMPOSEDONREDUCEDMYOCARDIALRE
SERVEBOTHSYSTOLICANDDIASTOLIC-ANY
VARIABLESPLAYAROLEIN!$(&THATEXAC
ERBATE LEFT VENTRICULAR ,6 DYSFUNCTION
AND LEAD TO DETERIORATION ,OW CARDIAC
OUTPUTRESULTSINDECREASEDRENALmOWAND
STIMULATESNEUROHORMONALACTIVATIONIN
CLUDINGTHERELEASEOFANGIOTENSIN))$E
CREASEDCARDIACOUTPUTCAUSESPROGRESSIVE
BLOODVOLUMEEXPANSIONFURTHERINCREAS
ING ,6 lLLING PRESSURES AND MYOCARDIAL
OXYGENCONSUMPTION(YPOTENSIONPRO
MOTES BARORECEPTOR ACTIVATION LEADING
TOINCREASEDSYMPATHETICTONEANDVASO
CONSTRICTIONWHICHFURTHERINCREASESSYS
TEMIC VASCULAR RESISTANCE COMPROMISING
SYSTOLIC PERFORMANCE 4HERE IS MARKED
UPREGULATIONOFVASOCONSTRICTORSINCLUD
ING NOREPINEPHRINE ANGIOTENSIN )) AND
ENDOTHELINALDOSTERONEANDARGININEVA
SOPRESSINRISECONTRIBUTINGTOTHESALTAND
WATERRETENTION
4OCOUNTERBALANCETHEEFFECTSOFNEURO
HORMONES RELEASED BY THE SYMPATHETIC
NERVOUS SYSTEM AND THE RENINANGIOTEN
SINALDOSTERONE SYSTEM 2!!3 AND TO
MAINTAIN CIRCULATORY HOMEOSTASIS THE
BODY PRODUCES A FAMILY OF VASODILATOR
ANTIPROLIFERATIVENATRIURETICPEPTIDESTHAT
PLAY AN IMPORTANT ROLE IN HEART FAILURE
!TRIAL AND "TYPE NATRIURETIC PEPTIDES
ARERELEASEDFROMTHEMYOCARDIUMINRE
SPONSETOINCREASEDATRIALNATRIURETICPEP
TIDE AND VENTRICULAR "TYPE NATRIURETIC
/…iÊÀii>ÃiÊ>˜`Ê
«Àœ`ÕV̈œ˜ÊœvÊÃ̜Ài`Ê
˜>ÌÀˆÕÀïVÊ«i«Ìˆ`iÃÊ>ÀiÊ
ˆ˜ÃÕvwVˆi˜ÌÊ̜ÊL>>˜ViÊ
̅iÊyՈ`ÊÀiÌi˜Ìˆœ˜ÊÊ
œvÊ̅iÊ,-°
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
ˆ}ÕÀiÊ£°Ê
(YLGHQFHIRU/RZ3HUIXVLRQ
1DUURZ3XOVH3UHVVXUH
3XOVXV$OWHUDWLRQV
&RRO)RUHDUPVDQG/HJV
0D\EH6OHHS\2EWXQGHG
$&6,QKLELWRU5HODWHG
6\PSWRPDWLF+\SRWHQVLRQ
'HFOLQLQJ6HUXP6RGLXP/HYHO
:RUVHQLQJ5HQDO)XQFWLRQ
/RZ3HUIXVLRQDW5HVW"
$IAGRAMINDICATINGXTABLEOFHEMODYNAMICPROlLESFORPATIENTS
PRESENTING WITH HEART FAILURE -OST PATIENTS CAN BE CLASSIlED IN A
MINUTEBEDSIDEASSESSMENTACCORDINGTOTHESIGNSANDSYMPTOMS
SHOWNALTHOUGHINPRACTICESOMEPATIENTSMAYBEONTHEBORDERBE
TWEENTHEWARMANDWETANDCOLDANDWETPROlLES4HISCLASSIlCATION
HELPSGUIDEINITIALTHERAPYANDPROGNOSISFORPATIENTSPRESENTINGWITH
ADVANCEDHEARTFAILURE!LTHOUGHMOSTPATIENTSPRESENTINGWITHHYPO
PERFUSIONALSOHAVEELEVATEDlLLINGPRESSURESCOLDANDWETPROlLE
MANYPATIENTSPRESENTWITHELEVATEDlLLINGPRESSURESWITHOUTMAJOR
REDUCTION IN PERFUSION WARM AND WET PROlLE 0ATIENTS PRESENTING
WITHSYMPTOMSOFHEARTFAILUREATRESTORMINIMALEXERTIONWITHOUT
CLINICALEVIDENCEOFELEVATEDlLLINGPRESSURESORHYPOPERFUSIONWARM
ANDDRYPROlLESHOULDBECAREFULLYEVALUATEDTODETERMINEWHETHER
THEIRSYMPTOMSRESULTFROMHEARTFAILURE
1R
<HV
PEPTIDE".0STRESS4HEYINCREASEGLOMERULARlL
TRATION RATE '&2 INHIBIT SODIUM REABSORPTION AND
REDUCEVASCULARSMOOTHMUSCLETONECAUSINGADIURE
SISNATRIURESISANDBALANCEDARTERIALANDVENOUSDILA
TION!LLTHESEEFFECTSCONTRIBUTETOREDUCEDPLASMA
VOLUMEBLOODPRESSUREANDVENTRICULARPRELOAD".0
HASLUSITROPICRELAXINGEFFECTSANDMAYBEANTIlBROT
IC AND ANTIPROLIFERATIVE )N!$(& THE RELEASE AND
PRODUCTION OF STORED NATRIURETIC PEPTIDES ARE INSUFl
CIENTTOBALANCETHEmUIDRETENTIONOFTHE2!!3
2APID BEDSIDE ASSESSMENT OF!$(& CAN BE SIMPLI
lEDBYPLACINGTHEPATIENTINTOONEOFFOURHEMODY
NAMICPROlLESQˆ}ÕÀiÊ £R4WOKEYHEMODYNAMIC
PARAMETERS ARE THE PRESENCE OR ABSENCE OF ELEVATED
lLLINGPRESSURESWETORDRYANDADEQUACYOFPERFU
SIONWARMORCOLD#ONGESTIONCORRESPONDSTOEL
EVATEDPULMONARYCAPILLARYWEDGEPRESSURE0#70
/ܜ‡ˆ˜ÕÌiÊÃÃiÃÓi˜ÌʜvÊi“œ`ޘ>“ˆVÊ
*Àœwi°Ê,i«Àœ`ÕVi`Ê>˜`ÊÀi«Àˆ˜Ìi`Ê܈̅Ê
«iÀ“ˆÃȜ˜ÊvÀœ“Ê œ…Àˆ>Ê]Êi܈ÃÊ]Ê
-ÌiÛi˜Ãœ˜Ê7°ÊÊÓääÓÆÓnÇ\ÈÓn‡È{ä°
(YLGHQFHIRU&RQJHVWLRQ
(OHYDWHG)LOOLQJ3UHVVXUH
2UWKRSQHD
+LJK-XJXODU9HQRXV3UHVVXUH
,QFUHDVLQJ6
/RXG3
(GHPD
$VFLWHV
5DOHV8QFRPPRQ
$EGRPLQRMXJXODU5HIOX[
9DOVDOYD6TXDUH:DYH
&RQJHVWLRQDW5HVW"
1R
<HV
:DUPDQG'U\
:DUPDQG:HW
$
%
&ROGDQG'U\
&ROGDQG:HW
/
&
ANDIMPAIREDPERFUSIONISSUGGESTEDBYALOWCARDIAC
INDEX'REATERTHANOFPATIENTSPRESENTINGWITH
!$(&ARECONGESTEDWET4HEYMAYHAVEADEQUATE
ORREDUCEDPERFUSIONWITHTHEMAJORITYEXPERIENCING
ELEVATED SYSTEMIC VASCULAR RESISTANCE #ONGESTION
ELEVATED lLLING PRESSURE IN !$(& IS REPRESENTED
BY DYSPNEA AND ORTHOPNEA AND ELEVATED JUGULAR VE
NOUSPRESSURE2ALESWHILEAHELPFULSIGNAREABSENT
IN OF PATIENTS WITH CHRONICALLY ELEVATED lLLING
PRESSURESDUETOPULMONARYLYMPHATICCOMPENSATION
0ERIPHERALEDEMAISRELATIVELYINSENSITIVETOELEVATED
lLLINGPRESSURESANDASSOCIATEDWITHMANYNONCARDI
ACCAUSES4HETHIRDHEARTSOUND3WHILEASENSITIVE
MARKERISRARELYAPPRECIATED4HEMOSTREADILYAVAIL
ABLEINDICATOROFPERFUSIONISBLOODPRESSUREANDPULSE
PRESSURE4HISRAPIDASSESSMENTSYSTEMALLOWSFORAP
PROPRIATETARGETINGOFTHERAPYIN!$(&PATIENTS
/,/ /Ê"Ê
1/Ê
"* -/Ê,/Ê
1,Ê Ê/Ê, 9Ê*,/ /
$ETERMININGTHE%TIOLOGYOF!CUTE
$ECOMPENSATIONAND3ETTING
4REATMENT'OALS
4HEETIOLOGIESOF!$(&AREMULTIFACTORI
ALBUTCANBEDIVIDEDINTOTWOCATEGORIES
THE UNDERLYING THE HEART FAILURE AND
THEACUTEPRECIPITANTTHATRESULTSINDE
TERIORATIONFROMTHECHRONICCOMPENSATED
STATE)NPATIENTSPRESENTINGFORTHElRST
TIME THE TWO COMPONENTS ARE IDENTICAL
4HE MOST COMMON CAUSES OF HEART FAIL
UREARECORONARYARTERYDISEASEANDLONG
STANDINGHYPERTENSION/THERETIOLOGIES
INCLUDEDILATEDHYPERTROPHICANDRESTRIC
TIVECARDIOMYOPATHIESMYOCARDITISPERI
CARDIALTAMPONADEVALVULARHEARTDISEASE
ANDSECONDARYEFFECTSOFPULMONARYAND
METABOLICDISORDERS5NDERSTANDINGTHE
UNDERLYINGETIOLOGYISIMPORTANTINHELP
ING TO DETERMINE IF THERE IS A REVERSIBLE
COMPONENTPRESENT4HEEMERGENCYPHY
SICIANMUSTBEAWAREOFNUMBEROFSPE
CIAL CAUSES OF HEART FAILURE THAT REQUIRE
CONSIDERATION WHEN MAKING THERAPEUTIC
DECISIONS )N SEVERE AORTIC STENOSIS ID
IOPATHIC HYPERTROPHIC SUBAORTIC STENOSIS
OR HYPERTROPHIC OBSTRUCTIVE CARDIOMY
OPATHYANDPULMONARYHYPERTENSIONAG
GRESSIVE AFTERLOAD REDUCTION CAN LEAD TO
CARDIOVASCULARCOLLAPSEASTHESEPATIENTS
CANNOTINCREASETHEIRFORWARDBLOODmOW
INTHEFACEOFAlXEDMECHANICALLESION
'REATERTHANOFPATIENTSPRESENTING
TOTHE%$WITH!$(&HAVEAPRIORDIAG
NOSISOFHEARTFAILURE!NACUTEPRECIPI
TANT CAN OFTEN BE IDENTIlED %XACERBA
TIONORWORSENINGOFTHEUNDERLYINGCON
DITIONCANBEDUETOMEDICATIONORDIETARY
NONCOMPLIANCEORTHEDEVELOPMENTOFA
NEW OR COMPLICATING MEDICAL CONDITION
SUCH AS ISCHEMIA DYSRHYTHMIA PULMO
NARY EMBOLUS OR INFECTION 4REATMENT
DEPENDSONTHESEVERITYOFTHESYMPTOMS
ANDDECOMPENSATIONTIMECOURSE
4HERAPEUTICGOALSIN!$(&PATIENTSCAN
BEDIVIDEDINTHREEPHASES4HEPRIMARY
GOALINTHE%$ISRESTORATIONOFOXYGEN
ATION ORGAN PERFUSION AND TOTAL BODY
mUID BALANCE 4HIS IS ACCOMPLISHED BY
REVERSINGACUTEHEMODYNAMICABNORMAL
ITIESANDRELIEVINGSYMPTOMS)NTERMEDI
ATE GOALS INCLUDE MINIMIZING ENDORGAN
DAMAGE REDUCING HOSPITALIZATION DURA
TION AND INITIATION OF BENElCIAL MEDICAL
THERAPIES AND SHOULD COMMENCE IN THE
%$,ONGTERMGOALSFOCUSONREDUCING
READMISSION AND IMPROVING LONGTERM
SURVIVAL WITH TREATMENT THAT DECREASES
DISEASEPROGRESSION4HISOCCURAFTERTHE
PATIENT LEAVES THE %$ 7HILE NATIONAL
GUIDELINES EXIST FOR MANY ACUTE CARDIO
VASCULARCONDITIONSTHEREARENOCONSEN
SUS GUIDELINES FOR THE MANAGEMENT OF
!$(& 'IVEN THE LACK OF RANDOMIZED
CONTROLLEDTRIALSCONSENSUSTHATINCORPO
RATESEVIDENCEBASEDLITERATUREANDEXPERT
OPINIONSHOULDBEUSEDASGUIDELINES
/ܜʎiÞʅi“œ`ޘ>“ˆVÊ
«>À>“iÌiÀÃÊ>ÀiÊ̅iÊ
«ÀiÃi˜ViʜÀÊ>LÃi˜ViÊÊ
œvÊiiÛ>Ìi`Êwˆ˜}Ê
«ÀiÃÃÕÀiÃÊ­ÜiÌʜÀÊ`ÀÞ®Ê
>˜`Ê̅iÊ>`iµÕ>VÞÊÊ
œvÊ«iÀvÕȜ˜ÊÊ
­Ü>À“ÊœÀÊVœ`®°
!PPROACHTO)NITIAL4REATMENT
/URIMPROVEDUNDERSTANDINGOFTHEETIOL
OGYOFHEARTFAILUREANDITSPROGRESSIONHAS
IDENTIlEDTHE2!!3ANDNEUROHORMONAL
PATHWAYSASTARGETSOFTHERAPYANDMAY
EXPLAIN THE BENElTS OF NEUROHORMONAL
BLOCKERS SUCH AS ANGIOCONVERTING EN
ZYME!#%INHIBITORSBETABLOCKERSAL
DOSTERONEBLOCKERSEGSPIRONOLACTONE
ANDSUPRAPHYSIOLOGICDOSESOFNATRIURETIC
PEPTIDESSUCHAS!.0AND".0INTHE
TREATMENTOFHEARTFAILURE
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
)NITIALTHERAPYSHOULDBEGUIDEDBYTHEPATIENTS
HEMODYNAMICPROlLEQˆ}ÕÀiÊÓR &ORPATIENTS
WITHOUTEVIDENCEOFELEVATEDlLLINGPRESSURESOR
HYPOPERFUSION DRY AND WARM NO IMMEDIATE
INTERVENTION IS NEEDED #ARE SHOULD FOCUS ON
MAINTAININGSTABLEVOLUMESTATUSANDPREVENTING
DISEASEPROGRESSION4HESEPATIENTSRARELYPRES
ENT TO THE %$ )N PATIENTS WITH ELEVATED lLLING
PRESSURESBUTADEQUATEPERFUSIONWETANDWARM
THERAPY AIMS TO DIURESE !SSUMING THEY ARE AL
READYRECEIVING!#%INHIBITORSTHEGOALISTOEN
HANCETHEIRDIURETICREGIMEN)NMOREADVANCED
CASES THE USE OF INTRAVENOUS LOOP DIURETICS AND
VASODILATORS SUCH AS NITROGLYCERIN OR NESIRITIDE
CAN ACCELERATE SYMPTOM RESOLUTION 4HE MAIN
CHALLENGE IS AVOIDING HYPOTENSION )N THIS SITU
ATION INOTROPIC THERAPY IS CONTRAINDICATED &OR
CONGESTEDELEVATEDlLLINGPRESSUREPATIENTSWITH
CLINICALHYPOPERFUSIONWETANDCOLDITISUSUALLY
NECESSARYTOhWARMUPINORDERTODRYOUTv&OR
THESEPATIENTSINWHOMREmEXRESPONSESSUPPORT
THEFAILINGCIRCULATION`BLOCKERSAND!#%INHIB
ITORSMAYNEEDTOBEWITHDRAWNUNTILSTABILIZATION
ISACHIEVED,OWCARDIACOUTPUTISOFTENASSOCI
ATEDWITHHIGHSYSTEMICVASCULARRESISTANCEAND
ˆ}ÕÀiÊÓ°Ê
VÕÌiÊ`iVœ“«i˜Ã>Ìi`ʅi>ÀÌÊv>ˆÕÀiÊ­®ÊÌÀi>̓i˜ÌÊÊ
>}œÀˆÌ…“°ÊÊ,i«Àˆ˜Ìi`Ê܈̅ʫiÀ“ˆÃȜ˜ÊvÀœ“ʈœ“i˜ˆ‡
VœÊiÌÊ>°Ê˜˜Ê*…>À“>VœÌ…iÀ°ÊÓää{ÆÎn\È{™‡ÈÈä
$IWHUGLDJQRVLVRI$'+)LQLWLDWHWKHUDS\EDVHGRQSUHVHQWLQJVLJQVDQGV\PSRPV
$6LJQVDQG6\PSRPVRI9ROXPH2YHUORDG
2UWKRSQHD31'
,QFUHDVHG-9'
'2(62%
6RU6
3LWWLQJHGHPD
5DOHV
&KHVW[UD\SXORQDU\
+-5$-5
FRQJHVWLRQ
l%13
5HFHQWZHLJKWJDLQ
&0LOG
YROXPH
RYHUORDG
%6LJQVDQG6\PSRPVRI/RZ&DUGLDF2XWSXW
1DUURZSXOVHSUHVVXUH
$OWHUHGPHQWDOVWDWXV
3UHUHQDOD]RWHPLD
&RROH[WUHPLWLHV
*0LOG0RGHUDWH
(0RGHUDWH6HYHUH9ROXPH2YHUORDG
,QDGHTXDWHUHVSRQVHWR,9GLXUHWLFV
3UHUHQDOD]RWHPLD
,QFUHDVHGR[\JHQUHTXLUHPHQWV
&3$3RU%L3$3UHTXLUHPHQWV
)DWLJXH
,QSDWLHQWGLVSRVLWLRQXQFOHDU
2XWSDWLHQWIXURVHPLGHGRVH!PGGDLO\
6%3!PP+*
',9'LXUHWLFV
,9IXURVHPLGH
Ɣ2QSRIXURVHPLGHDWKRPH"
*LYHWRWDOGRVHDV,9EROXV
PD[PJ
Ɣ1RSRIXURVHPLGHDWKRPH"
6&UVWDUWZLWKPJ,9SXVK
6&U!VWDUWZLWKPJ,9SXVK
'HFUHDVHGXULQHRXWSXW
,QDGHTXDWHUHVSRQVHWR
,9GLXUHWLFV
6%3!PP+J
-9HU\/RZ
&DUGLDF2XWSXW
.O
9ES
2QDBEORFNHU
FKURQLFDOO\"
9ES
3XOPRQDU\DUWHU\
FDWKHWHUSODFHG
+LJK695
+LJK3&:3
/RZ&,
6%3!PP+J
&RQVLGHUYDVRGLODWRUV
DIWHULQLWLDWLRQRI
LQRWURSLFVXSSRUW
.O
,0LOULQRQH
,'REXWDPLQH
‡MJNJPLQ
LQIXVLRQ
‡$GMXVWGRVHUHQDOO\
‡MJNJPLQLQIXVLRQ
‡0D\DOVRUHTXLUH
YDVRSUHVVRUVIRU%3
VXSSRUW
,QDGHTXDWH5HVSRQH
P/ZLWKLQKRXUV
,QDGHTXDWH5HVSRQH
&RQVLGHU0RGHUDWH6HYHUH
9ROXPH2YHUORDG(RU
/RZ&DUGLDF2XWSXW%
&RQVLGHU9HU\/RZ&DUGLDF2XWSXW-
),9'LXUHWLFV,99DVRGLODWRUV
!*2 ABDOMINAL JUGULAR REmEX "I0!0 BILEVEL POSITIVE AIRWAY
PRESSURE ".0 BNATRIURETIC PEPTIDE #) CARDIAC INDEX
#0!0 CONTINUOUS POSITIVE AIRWAY PRESSURE $/% DYSPNEA ON
EXERTION(*2HEPATOJUGULARREmEX*6$JUGULARVENOUSDISTENTION
0#70 PULMONARY CAPILLARY WEDGE PRESSURE 0.$ PAROXYSMAL
NOCTURNAL DYSPNEA 3"0 SYSTOLIC BLOOD PRESSURE 3#R SERUM
CREATININE 3/" SHORTNESS OF BREATH 362 SYSTEMIC VASCULAR
RESISTANCE
MAYIMPROVEWITHVASODILATORTHERAPYALONE4HERE
REMAINSCONTROVERSYABOUTTHEROLEOFINOTROPICVASO
DILATORAGENTSSUCHASDOBUTAMINEANDMILRINONEDUE
TOTHEINCREASEDRISKFORISCHEMICEVENTSANDTACHYAR
RHYTHMIAS0ATIENTSWITHLOWCARDIACOUTPUTWITHOUT
EVIDENCE OF ELEVATED lLLING PRESSURE COLD AND DRY
,9IXURVHPLGH
‡,IIXURVHPLGHJLYHQSUHYLRXVO\GRXEOHSUHYLRXV,9GRVHPD[PJ
‡,IQRIXURVHPLGHJLYHQSUHYLRXVO\DQGVLJQVV\PSWRPVRIYROXPHRYHUORDG
JLYHPJ,9DVGHVFULEHGDERYH
3/86
1HVLULWLGHMJNJ,9SXVKWKHQMJNJYHLQLQIXVLRQ
25
1LWURJO\FHULQSJPLQLQIXVLRQ
‡WRDFKLHYHGHFUHDVHLQ3&:3GRVHRIMJPLQPD\EH
QHFHVVDU\
MAY BE SURPRISINGLY STABLE AND DO NOT PRESENT WITH
URGENTSYMPTOMS5NLESSTHEYHAVESUBNORMALlLLING
PRESSURESVOLUMEDEPLETEDOREXCESSIVEVASODILATION
THEYOFTENDONOTIMPROVEACUTELY)NOTROPICINFUSION
WHILEHELPINGTHESYMPTOMSMAYLEADTODEPENDENCY
ANDTACHYPHYLAXIS
/,/ /Ê"Ê
1/Ê
"* -/Ê,/Ê
1,Ê Ê/Ê, 9Ê*,/ /
0HARMACOLOGIC/PTIONS
!NIDEALAGENTFOR!$(&WOULDBEONE
THATRAPIDLYREDUCES0#7RELIEVINGSYMP
TOMSANDHYPOXIAINDUCESBALANCEDARTE
RIAL AND VENOUS DILATION LACKS POSITIVE
INOTROPIC EFFECTS PROMOTES NATRIURESIS
ANDDOESNTCAUSEREmEXNEUROENDOCRINE
ACTIVATION
$IURETICSARETRADITIONALLYUSEDTOREDUCE
PRELOADTHEREBYIMPROVINGSYMPTOMSIN
!$(& PATIENTS 4HEY DO NOT HAVE ANY
DIRECTMYOCARDIALBENElTBUTACTIVATETHE
NEUROHORMONALSYSTEMLEADINGTOALDOSTE
RONEELEVATION$IURETICSHAVEBEENUSED
FORDECADESANDMOSTPROVIDERSAREVERY
COMFORTABLE WITH THEM DESPITE THE FACT
THAT THEY LACK OF EVIDENCE OF IMPROVED
MORTALITY)NTRAVENOUSFUROSEMIDECAUSES
ADECREASEIN0#70ANDRIGHTATRIALPRES
SUREASARESULTOFVENODILATIONANDDIURE
SIS4HEREISACONCOMITANTDECREASEIN
STROKEVOLUMEINCREASEINSYSTEMICVAS
CULARRESISTANCEANDPRONOUNCEDSPIKEIN
NEUROHORMONAL ACTIVATION )NCREASES IN
THE2!!3ANDSYMPATHETICNERVOUSSYS
TEM ACTIVATION NOREPINEPHRINE LEVELS
CANBESEENSHORTLYAFTERFUROSEMIDEIN
FUSION
)N ONE TRIAL OF HIGHDOSE LOOP DIURETICS
COMPARED TO LOW DOSE DIURETICS COM
BINED WITH INTRAVENOUS VASODILATORS
PATIENTS TREATED WITH HIGHDOSE FUROSE
MIDE DID SIGNIlCANTLY WORSE IN ALL OUT
COME MEASURES ! RECENT ANALYSIS OF
EIGHT SMALL TRIALS FOUND THAT THERE WAS
GREATER DIURESIS AND A BETTER SAFETY PRO
lLEIFDIURETICSWEREGIVENASACONTINU
OUS INSTEAD OF BOLUS INFUSION 7HILE
INTRAVENOUSDIURETICSPROMOTENATRIURESIS
ANDDIURESISTHEYDOSOATTHEEXPENSEOF
NEUROHORMONAL ACTIVATION AND SYSTEMIC
VASOCONSTRICTION THAT PREVENTS REDUCTION
OF VENTRICULAR lLLING PRESSURES $IURETIC
RESISTANCE IS A CLINICAL STATE IN WHICH
DIURETIC RESPONSE IS DIMINISHED OR LOST
4HIS MAY BE CAUSED BY PRERENAL AZOTE
MIA HYPONATREMIA SODIUM RETENTION OR
ALTEREDDIURETICPHARMACOKINETICS4HERE
ISACYCLEOFLOWCARDIACOUTPUTLEADINGTO
DIMINISHEDRENALPERFUSIONWHICHINTURN
PRODUCES VOLUME OVERLOAD AND WORSENS
HEART FAILURE 4HESE DELETERIOUS EFFECTS
ARE EVEN MORE PRONOUNCED IN PATIENTS
WITH UNDERLYING RENAL INSUFlCIENCY $I
URETICREQUIREMENTSINCREASEASTHEHEART
FAILUREPROGRESSES
!RGININEVASOPRESSINISANEUROHORMONE
PRODUCEDBYTHECENTRALNERVOUSSYSTEMIN
RESPONSETOCHANGESINSERUMOSMOLARITY
SEVEREHYPOVOLEMIAORHYPOTENSION/NE
APPROACH TO ANTAGONIZING VASOPRESSINS
ACTIONISTOSELECTIVELYBLOCKITSRECEPTOR
RESULTINGINAQUARESISWITHOUTELECTROLYTE
IMBALANCES OR NEUROHORMONAL STIMULA
TION 4HE NOVEL COMPOUND TOLVAPTAN IS
ANANTAGONISTTHATCAUSESINCREASEDURINE
OUTPUT AND DECREASES BODY WEIGHT AND
EDEMA /NE STUDY LOOKED AT WEIGHT RE
DUCTIONFOLLOWINGHOURSOFINFUSIONIN
PATIENTS WITH IMPAIRED VENTRICULAR FUNC
TION%&4HEREWASNODIFFERENCE
IN INHOSPITAL MORTALITY OR WORSENING OF
HEART FAILURE 4HIS NOVEL AGENT SHOWS
PROMISEOFFACILITATINGmUIDLOSSWITHOUT
ADVERSESEQUELAEINPATIENTSWITHREDUCED
SYSTOLICFUNCTION
˜ˆÌˆ>Ê̅iÀ>«ÞÊŜՏ`ÊLiÊ
}Ո`i`ÊLÞÊ̅iÊ«>̈i˜Ì½ÃÊ
…i“œ`ޘ>“ˆVÊ«Àœwi°
qqqqqqq
ˆÕÀïVÃʅ>ÛiÊLii˜Ê
ÕÃi`ÊvœÀÊ`iV>`iÃÊ>˜`Ê
“œÃÌÊ«ÀœÛˆ`iÀÃÊ>ÀiÊÛiÀÞÊ
Vœ“vœÀÌ>LiÊ܈̅Ê̅i“Ê
`iëˆÌiÊ̅iÊv>VÌÊ̅>ÌÊ
̅iÞʏ>VŽÊœvÊiۈ`i˜ViʜvÊ
ˆ“«ÀœÛi`ʓœÀÌ>ˆÌÞ°
)NOTROPESHAVEBEENAMAINSTAYOFTHERA
PYFOR!$(&BECAUSEOFTHEIRBENElCIAL
EFFECTS ON HEMODYNAMIC PARAMETERS
NAMELY INCREASING CARDIAC CONTRACTILITY
WHICHIMPROVESCARDIACOUTPUT)NOTRO
PESAREUSEDINFREQUENTLYINTHE%$DUE
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
PRIMARILYTOLOGISTICALCONCERNS2ECENTLARGESTUDIES
DEMONSTRATED A LACK OF EFlCACY IN MANY!$(& PA
TIENTSANDEXPOSEDSAFETYCONCERNS)NOTROPESINCREASE
HEARTRATEANDMYOCARDIALOXYGENDEMANDAGGRAVATE
ISCHEMIAPRECIPITATEARRHYTHMIASANDCANCAUSEHY
POTENSION!TRIALCOMPARINGDOBUTAMINEVERSUSNE
SIRITIDEDEMONSTRATEDTHATDOBUTAMINEINCREASESVEN
TRICULAR ECTOPY AND VENTRICULAR TACHYCARDIA -ILRI
NONEFAILEDTODEMONSTRATESIGNIlCANTIMPROVEMENTS
INLENGTHOFHOSPITALIZATIONSYMPTOMRELIEFORMORTAL
ITYCOMPAREDTOPLACEBO)TWASHOWEVERASSOCIATED
WITHSUSTAINEDHYPOTENSIONANDTACHYARRHYTHMIASIN
THE/04)-%#(&TRIAL$OBUTAMINEISPREFERRED
IN PATIENTS WHO ARE HYPOTENSIVE SYSTOLIC "0 MM (G SINCE IT EXERTS ITS EFFECTS BY STIMULATING `
ADRENERGICRECEPTORS(IGHERDOSESAREOFTENREQUIRED
IN PATIENTS ON CHRONIC `BLOCKER THERAPY -ILRINONE
ISAPHOSPHODIESTERASEINHIBITORANDITSACTIONISNOT
IMPACTED BY CONCOMITANT `BLOCKER USE -ILRINONE
DOESNT INCREASE MYOCARDIAL OXYGEN CONSUMPTION
OR EFFECT HEART RATE TO THE SAME DEGREE THAT DOBUTA
MINEDOES)NGENERALGIVENTHEIRINABILITYTOAFFECT
OUTCOMEANDINCREASEDINCIDENCEOFADVERSEEFFECTS
INOTROPICSUPPORTSHOULDBERESERVEDFORPATIENTSWITH
VERYLOWCARDIACOUTPUT4HEYSHOULDONLYBEUSEDIN
THE%$SETTINGONPATIENTSWITHSYMPTOMATICHYPOTEN
SIONUNTILFURTHERTHERAPYINTRAAORTICBALLOONPUMP
CANBEINSTITUTED
#ALCIUM SENSITIZERS SUCH AS LEVOSIMENDAN PRODUCE
INCREASED INOTROPY IN A CYCLIC !-0INDEPENDENT
FASHIONBYINCREASINGTHESENSITIVITYOFTROPONIN#TO
INTRACELLULAR IONIZED CALCIUM AS WELL AS PERIPHERAL
VASODILATION THROUGH THE VASCULAR +!40ASE CHAN
NELS !N EFFECTIVE POSITIVE INOTROPE LEVOSIMENDAN
INCREASESINSTROKEVOLUMEANDCARDIACINDEXANDDE
CREASES 0#70 RIGHT ATRIAL PRESSURES PULMONARY AR
TERIALPRESSURESANDMEANARTERIALPRESSURES)NTHIS
STUDYTHEHEMODYNAMICEFFECTSWEREMAINTAINEDDUR
INGAHOURINFUSIONANDFORATLEASTHOURSAFTER
DISCONTINUATION 7HEN LEVOSIMENDAN WAS ADDED TO
DOBUTAMINEIN.EW9ORK(EART!SSOCIATIONCLASS)6
PATIENTS REFRACTORY TO DOBUTAMINE AND FUROSEMIDE
OFPATIENTSGETTINGALLTHREEAGENTSCOMPAREDTO
NONE IN THE STANDARD GROUP EXPERIENCED A IN
CREASEINCARDIACINDEX4HISEXCITINGAGENTISINTHE
EARLYCLINICALTRIALS
6ASODILATORSREDUCEPRELOADANDAFTERLOADENHANCING
VENTRICULARFUNCTIONANDCARDIACOUTPUTBYIMPROVING
RESTING HEMODYNAMICS6ASODILATORS REDUCE VENTRIC
ULAR lLING PRESSURES 0#70 AND PRELOAD AND OVER
TIMEMYOCARDIALOXYGENCONSUMPTION6ASODILATORS
ALSO DECREASE SYSTEMIC VASCULAR RESISTANCE 362 OR
AFTERLOAD REDUCE VENTRICULAR WORKLOAD INCREASE
STROKEVOLUMEANDIMPROVECARDIACOUTPUT
.ITRATES IN PARTICULAR NITROGLYCERIN HAVE BEEN THE
lRSTLINEPREHOSPITALAND%$THERAPYFORPATIENTSWITH
SEVERESYMPTOMS.ITRATESNITROGLYCERINANDNITRO
PRUSSIDE ACT BY INCREASING CYCLIC GUANOSINE MONO
PHOSPHATEINTHEVASCULARSMOOTHMUSCLELEADINGTO
VASODILATION4HEY IMPROVE SYMPTOMS AND DECREASE
0#70RELATIVELYQUICKLY.ITROGLYCERINUSEISLIMITED
BYFEAROFHYPOTENSIONANDNEEDFORTITRATIONSECOND
ARY TACHYPHYLAXIS YET IT IS FREQUENTLY UNDERDOSED
.ITROGLYCERINHASDIRECTAFFECTSONLARGECORONARYAR
TERIESANDINCREASESCOLLATERALmOWMAKINGITAUSEFUL
INPATIENTSWITHMYOCARDIALISCHEMIA(OWEVERTHERE
ARE NO TRIALS LOOKING AT ITS OUTCOME EFlCACY .ITRO
PRUSSIDE WHILE EFlCACIOUS IS USED INFREQUENTLY DUE
TOCONCERNSABOUTTHIOCYANATETOXICITYESPECIALLYIN
THEFACEOFHEPATICORRENALHYPOPERFUSIONDYSFUNC
TION )T CAN ALSO PRECIPITATE PROFOUND HYPOTENSION
EXACERBATEISCHEMIABYINDUCINGCORONARYSTEALAND
REQUIRES INVASIVE MONITORING "OTH OF THESE AGENTS
CAUSEREmEXACTIVATIONOFTHE2!!3ANDSYMPATHETIC
NERVOUSSYSTEMWHICHLIMITSTHEIRLONGTERMUSE
!NGIOTENSINCONVERTING ENZYME !#% INHIBITION
BLOCKSCONVERSIONOFANGIOTENSIN)INTOANGIOTENSIN))
RESULTINGINDIMINISHEDSYSTEMICVASCULARRESISTANCE
BLOODPRESSUREPRELOADANDAFTERLOAD!#%INHIBITORS
ALSOBLOCKTHEDEGRADATIONOFBRADYKININSANATURAL
/,/ /Ê"Ê
1/Ê
"* -/Ê,/Ê
1,Ê Ê/Ê, 9Ê*,/ /
LY OCCURRING VASODILATOR !#% INHIBITOR
THERAPYINCREASESRENALPERFUSIONANDDE
CREASE RENAL VASCULAR RESISTANCE IMPROV
INGGLOMERULARlLTRATIONRATEBYINDUCING
VASODILATIONINBOTHAFFERENTANDEFFERENT
ARTERIOLES4HEMAJORDRAWBACKTOTHEUSE
OF INTRAVENOUS !#% INHIBITORS SUCH AS
ENALAPRILATINTHEACUTESETTINGISITSPRO
PENSITYTOINDUCEHYPOTENSION)NTHESTA
BLEPATIENT THEAGENTSMAJOR LIMITATIONS
ARE RENAL INSUFlCIENCY AND ANGIOEDEMA
%NALAPRILAT HAS BEEN USED IN THE SETTING
OF!$(&SECONDARYTOUNCONTROLLEDHY
PERTENSION/RAL!#%INHIBITORSAREREC
OMMENDED EARLY OUT FOR THOSE PATIENTS
NOTALREADYRECEIVINGTHEM(OWEVERTHE
PATIENTMUSTBEHEMODYNAMICALLYSTABLE
BEFORETHESEAGENTSAREINITIATEDANDTHIS
LIMITSTHEIRAGGRESSIVEUPFRONTUSEINTHE
%$!NGIOTENSINRECEPTORBLOCKERCANBE
SUBSTITUTEDINPATIENTSWHOCANTTOLERATE
!#%INHIBITORS
2ECENTATTENTIONHASBEENFOCUSEDONTHE
ACUTE BLOCKADE OF DELETERIOUS NEUROHOR
MONES %NDOTHELIN %4 IS A VASOCON
STRICTOR PEPTIDE RELEASED FROM VASCULAR
ENDOTHELIUM AND SMOOTH MUSCLE OF THE
RENALANDPULMONARYSYSTEMS4EZOSEN
TAN IS A HIGHLY SPECIlC AND POTENT %4
RECEPTORANTAGONIST4HEREISADOSEDE
PENDENTINCREASEINCARDIACINDEXDUETO
VASODILATIONANDDECREASEIN0#70)N
THE 2)4: PROJECT TEZOSENTAN IMPROVED
HEMODYNAMICBUTNOTCLINICALOUTCOMEOF
PATIENTSWITHACUTEHEARTFAILURE!RECENT
TRIALEVALUATINGLOWERDOSESINHOSPITAL
IZED!$(&PATIENTSWITHDYSPNEADESPITE
INITIAL TREATMENT SHOWED INCREASED CAR
DIAC INDEX AND DECREASED 0#70 WITHIN
HOURSATTHEMGHOURANDMGHOUR
TREATMENTGROUPSANDBYHOURSINTHE
MGHOURCOHORT4HEEFFECTCONTINUED
BEYOND TREATMENT DISCONTINUATION IN THE
MGHOUR GROUP %NDOTHELIUM LEVELS
WEREINCREASEDINTHEHIGHERDOSEGROUPS
SUGGESTING SYMPATHETIC NERVOUS SYSTEM
ACTIVATIONBUTNOTINTHEMGHOURSUB
SET 4EZOSENTANS EFFECT WHILE CLINICALLY
SIGNIlCANT IS NOT PRESENTLY APPROPRIATE
FORTHE%$GIVENITSDELAYEDONSET
4HE NATRIURETIC PEPTIDE FAMILY CONSISTS OF
FOUR DISTINCT PEPTIDES !TRIAL NATRIURETIC
PEPTIDES!.0AND"TYPENATRIURETICPEP
TIDES".0ARESTRUCTURALLYSIMILAR#TYPE
NATRIURETICPEPTIDES#.0AND$TYPENA
TRIURETICPEPTIDES$.0ARELESSWELLCHAR
ACTERIZED!TRIALAND"TYPENATRIURETICPEP
TIDESHAVEIMPORTANTCENTRALANDPERIPHERAL
SYMPATHOINHIBITORYEFFECTS$AMPENINGOF
THE BARORECEPTORS SUPPRESSED RELEASE OF
CATECHOLAMINEFROMAUTONOMICNERVElND
INGS AND ESPECIALLY SUPPRESSION OF SYM
PATHETIC OUTmOW FROM THE CENTRAL NERVOUS
SYSTEMHAVEALLBEENREPORTED
4HE LONGTERM CONTINUOUS INFUSION OF
!.0 HAS BEEN SHOWN TO BE CLINICALLY
USEFULINPATIENTSWITHSEVEREACUTEHEART
FAILURE (EMODYNAMIC MEASUREMENTS
EVALUATEDBY3WAN'ANZCATHETERSIGNIl
CANTLY IMPROVED WITH!.0 )N A RECENT
STUDY HEMODYNAMIC INDICES CHARACTER
IZED BY DECREASES IN RIGHT ATRIAL PRES
SURE MEAN PULMONARY ARTERIAL PRESSURE
AND 0#70 AND AN INCREASE IN CARDIAC
INDEX WERE OBSERVED AFTER !.0 INFU
SION ,EFT VENTRICULAR PERFORMANCE WAS
ENHANCED WITHOUT THE DEVELOPMENT OF
TOLERANCE 4HE ACTIVATION OF THE 2!!3
PROMOTES STRUCTURAL REMODELING OF THE
HEART AND PROGRESSION OF HEART FAILURE
!.0 THEREBY IMPROVED LEFT VENTRICULAR
ˆÛi˜Ê̅iˆÀʈ˜>LˆˆÌÞÊ̜Ê
>vviVÌʜÕÌVœ“iÊ>˜`Ê
ˆ˜VÀi>Ãi`ʈ˜Vˆ`i˜ViÊ
œvÊ>`ÛiÀÃiÊivviVÌÃ]Ê
ˆ˜œÌÀœ«ˆVÊÃÕ««œÀÌÊÊ
ŜՏ`ÊLiÊÀiÃiÀÛi`ÊÊ
vœÀÊ«>̈i˜ÌÃÊ܈̅ÊÛiÀÞÊ
œÜÊV>À`ˆ>VʜÕÌ«ÕÌ°
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
FUNCTIONPOSSIBLYBYBLUNTINGMYOCARDIAL
REMODELING7HILEAVAILABLEIN!SIA
AND%UROPE!.0ISNOTAPPROVEDFORUSE
INTHE5NITED3TATES
*>̈i˜ÌÃÊÌÀi>̓i˜ÌÊ
i>ÀÞʜ˜ÊÌi˜`Ê̜ʅ>ÛiÊ
ŜÀÌiÀʅœÃ«ˆÌ>ÊÊ
ÃÌ>ÞÃÊ>˜`ÊLiÌÌiÀÊ
œÕÌVœ“iÃÊ̅>˜Ê̅œÃiÊ
܅œÃiʈ˜ÌiÀÛi˜Ìˆœ˜ÊÊ
Ü>ÃÊ`i>Þi`°
".0 IS AN ENDOGENOUS NEUROHORMONE
PRODUCEDINTHEVENTRICLESINRESPONSETO
INCREASEDWALLSTRESSTHATOCCURSFROMVOL
UMEOVERLOADIN!$(&PATIENTS.ESIRIT
IDEISTHElRSTNATRIURETICPEPTIDEIDENTI
CALTOENDOGENOUS".0TOBEAVAILABLE
INTHE5NITED3TATESFORTHETREATMENTOF
!$(& 7ITHIN MINUTES OF ADMINISTRA
TIONNESIRITIDEPRODUCESSIGNIlCANTREDUC
TIONSIN0#70RIGHTATRIALPRESSUREAND
SYSTEMIC VASCULAR RESISTANCE AS WELL AS
CONCOMITANT INCREASES IN STROKE VOLUME
ANDCARDIACOUTPUT.ESIRITIDEHASADDI
TIONALADVANTAGESOVEROTHERVASODILATORS
SUCHASNITROGLYCERININCLUDINGDIURESIS
NATRIURESISANDLUSITROPY4HEBENElCIAL
CORONARY ARTERY EFFECTS OF NITROGLYCERIN
AREALSOPRESENTINNESIRITIDE!DDITION
ALLY NESIRITIDE LACKS THE PROARRHYTHMIC
ANDTACHYCARDIASEENWITHINOTROPESAND
MANYVASODILATORS
4HE6ASODILATION IN THE -ANAGEMENT OF
!CUTE#ONGESTIVE(EAR&AILURE6-!#
TRIAL COMPARED THE USE OF NESIRITIDE NI
TROGLYCERINORPLACEBOINADDITIONTOSTAN
DARDTHERAPYINPATIENTSWITH!$(&
4HIS SAFETY AND EFlCACY TRIAL FOUND THAT
NESIRITIDE REDUCED 0#70 MORE THAN EI
THER NITROGLYCERIN OR PLACEBO AT HOURS
ANDHOURS)MPROVEMENTSINDYSPNEA
AND GLOBAL CLINICAL STATUS IN THE NESIRIT
IDETREATED PATIENTS WERE GREATER THAN
THOSEINTHEPLACEBORECIPIENTSANDSIMI
LAR TO THOSE IN THE NITROGLYCERIN GROUP
.ESIRITIDESHEMODYNAMICEFFECTERSWERE
LONGLASTINGWITHOUTTHENEEDFORUPWARD
TITRATIONWHEREASTITRATIONWASNECESSARY
IN ORDER TO MAINTAIN NITROGLYCERINS EF
FECT4HISWASMOSTSTRIKINGINTHESUBSET
OF PATIENTS WITH RIGHT HEART CATHETERS ON
A CONSTANT DOSE OF NITROGLYCERIN WHERE
RAPIDATTENUATIONOFTHEDESIREDEFFECTAND
RISEIN0#70WASSEENATHOURS
".0 DOESNT INCREASE HEART RATE OR PRO
VOKE ARRHYTHMIAS AND HAS NO INOTROPIC
EFFECTS 4HIS LACK OF ARRHYTHMOGENICITY
IS ESPECIALLY IMPORTANT IN HEART FAILURE
PATIENTSWITHATRIALlBRILLATIONANDTHOSE
PREDISPOSED TO VENTRICULAR TACHYCARDIA
4HE 02%#%$%.4 STUDY COMPARED THE
PROARRHYTHMICEFFECTSOFDOBUTAMINEVER
SUSDOSESOFNESIRITIDEINPATIENTS
$OBUTAMINESIGNIlCANTLYINCREASEDVEN
TRICULAR TACHYCARDIA EVENTS .ESIRITIDE
DIDNOTINCREASEHEARTRATEDESPITEGREATER
REDUCTIONINBLOODPRESSURE"OTHAGENTS
WEREEQUALLYEFFECTIVEINIMPROVINGSIGNS
ANDSYMPTOMSOFHEARTFAILURE#OMPARED
TODOBUTAMINENESIRITIDEREDUCEDDAY
HOSPITALREADMISSIONSFORHEARTFAILUREAND
HADLOWERMONTHMORTALITY
)NTHE0ROSPECTIVE2ANDOMIZED/UTCOMES
3TUDY OF !CUTELY $ECOMPENSATED #ON
GESTIVE (EART &AILURE 4REATED )NITIALLY
IN /UTPATIENTS WITH .ATRECOR 02/!#
4)/.STUDYPATIENTSWERERANDOM
IZEDTOSTANDARDCAREORATLEASTHOURS
OF NESIRITIDE INFUSION IN AN %$ OBSERVA
TIONSETTING)MPORTANTLYNONEOFTHESEPA
TIENTSWASSUBJECTTOINVASIVEOR)#5LEVEL
MONITORINGINTHE%$YETDIDWELL-OR
TALITYRATESANDCOMPLICATIONSWERESIMILAR
/,/ /Ê"Ê
1/Ê
"* -/Ê,/Ê
1,Ê Ê/Ê, 9Ê*,/ /
BETWEEN THE TWO GROUPS .ESIRITIDE WAS
ASSOCIATEDWITHAREDUCTIONINHOSPI
TALREADMISSIONWITHINDAYSCOMPARED
WITH STANDARD THERAPY AND A SUBSTANTIAL
DECREASE IN TOTAL LENGTH OF STAY OVER THE
ENSUINGMONTHSAFTERTHEINDEXVISIT
)N A POOLED ANALYSIS FROM THE 02/!#
4)/. 6-!# AND .3'%4 TRIALS
THESHORTTERMRISKOFDEATHFROMNESIRIT
IDE WAS INVESTIGATED !S NONE OF THE
STUDIES INCLUDED IN THE POOLED ANALYSIS
WEREPOWEREDTODETERMINEMORTALITYDIF
FERENCESTHEREISNOCONCLUSIVEEVIDENCE
OFHARM4HEMANUSCRIPTCONCLUDEDTHAT
WHEN COMPARED TO NONIONOTROPIC BASED
THERAPYNESIRITIDEMAYBEASSOCIATEDWITH
ANINCREASEDRISKOFDEATH&URTHERSTUDY
WITH MORTALITY OUTCOMES OF NESIRITIDE
COMPARED TO CONVENTIONAL THERAPY HAVE
YET TO OCCUR !S WITH ANY NEW THERAPY
THEFAVORABLEATTRIBUTESMUSTBEWEIGHED
AGAINSTTHEPOTENTIALRISKS
%ARLY'OAL$IRECTED4HERAPY
%ARLYGOALDIRECTEDTHERAPY%'$4AP
PROACH EMPHASIZES AGGRESSIVE UPFRONT
TREATMENT BECAUSE PRELIMINARY EVALU
ATIONS HAVE SHOWN THAT PATIENTS TREATED
EARLY OUT TEND TO HAVE SHORTER HOSPITAL
STAYS AND BETTER OUTCOMES THAN THOSE
WHOSE INTERVENTION IS DELAYED )T AIMS
TO ACHIEVE HEMODYNAMIC AND RESPI
RATORY IMPROVEMENT PROMPT RELIEF OF
SYMPTOMSENHANCEDDECISIONMAKING
IN THE %$ WITH AN EMPHASIS ON TIMELY
TRANSITIONTOINPATIENTCAREIFINDICATED
EARLYINITIATIONOFTHERAPYALSOFACILITATES
HOSPITAL DISCHARGE AND AVOIDANCE OF
HIGHRESOURCEUTILIZATION#ARENEEDS
TO FOCUS ON RAPID INITIATION OF PROVEN
THERAPIES THAT IMPROVE PATIENT SYMPTOM
AND CARDIORESPIRATORY STATUS WITHOUT
PLACINGTHEPATIENTATRISKFORIMMEDIATE
ARRHYTHMIAHYPOTENSIONISCHEMIAAND
DELAYED WORSENING RENAL INSUFlCIENCY
TOXICITYADVERSEEVENTS4HEREISGROW
INGEVIDENCETHAT%'$4HASBOTHCLINICAL
ANDECONOMICADVANTAGESOVERMORECON
SERVATIVETREATMENTAPPROACHES
4HERE IS A SUBPOPULATION OF PATIENTS
MODERATELY SICK REQUIRING MORE THAN A
FEWHOURSOFCAREWHODONTNECESSARILY
NEEDHOSPITALADMISSION4HEAVAILABILITY
OF AN %$ OBSERVATION UNIT MAKES GOOD
CLINICALANDECONOMICSENSE%'$4CAN
BE INITIATED AND PATIENTS MONITORED FOR
IMPROVEMENT 0ATIENT SELECTION IS CRITI
CALLYIMPORTANTINDETERMININGWHOWILL
MOST BENElT FROM AN OBSERVATION UNIT
STAYMATCHINGACUITYWITHAVAILABLESER
VICES'ENERALSELECTIONCRITERIAINCLUDE
THEFOLLOWING
ADEQUATESYSTEMICPERFUSIONNORMAL
MENTALSTATUS
EVIDENCEOFREASONABLE
HEMODYNAMICSTABILITY(2AND
BEATSMINSYSTOLIC"0
ANDMM(GOXYGENSATURATION
NOEVIDENCEOFACUTECARDIAC
ISCHEMIABY%#'ORBIOMARKERS
CHESTXRAYlNDINGSCOMPATIBLEWITH
THEDIAGNOSISOFHEARTFAILURE
DIAGNOSISOF(&".0PG
M,WITHOUTOTHERCONFOUNDING
MORBIDITIES
6>Ü`ˆ>̜ÀÃÊÀi`ÕViÊ
«Àiœ>`Ê>˜`Ê>vÌiÀœ>`]Ê
i˜…>˜Vˆ˜}ÊÛi˜ÌÀˆVՏ>ÀÊ
v՘V̈œ˜Ê>˜`ÊV>À`ˆ>VÊ
œÕÌ«ÕÌÊLÞʈ“«ÀœÛˆ˜}Ê
ÀiÃ̈˜}ʅi“œ`ޘ>“ˆVð
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
)NITIAL TREATMENT OF !$(& IS GENERALLY
BASEDONTHEPRESENCEORABSENCEOFPUL
MONARY CONGESTION VOLUME OVERLOAD
ANDANASSESSMENTOFPERFUSIONCARDIAC
OUTPUTQˆ}ÕÀiÊ ÎR7HILETREATMENTAL
GORITHMS FOCUS ON PARENTAL THERAPY DUR
ING THE EARLY PHASE CONTINUATION OF THE
PATIENTS CHRONIC HEART FAILURE MEDICA
TION INCLUDING ”BLOCKERS AND !#% IN
HIBITORSAREIMPORTANT-ILDCONGESTION
IMPROVES WITH INTRAVENOUS DIURETICS
-ONITORINGOFURINEOUTPUTISCRITICAL&OR
THOSEWITHNORMALRENALFUNCTIONAGOALOF
MLHRISACCEPTABLE0ATIENTSWITHIN
ADEQUATERESPONSETOFUROSEMIDESHOULD
BEASSESSEDFORTHEPRESENCEOFMODERATE
TOSEVEREVOLUMEOVERLOADANDVASODILA
TOR THERAPY SHOULD BE CONSIDERED )NTRA
VENOUSNITROGLYCERINORNESIRITIDESHOULD
BESTARTEDINPATIENTSWITHADEQUATEBLOOD
PRESSURE TO SPEED RELIEF OF CONGESTION
)FNITROGLYCERINISUSEDITWILLBENECES
SARYTOUPTITRATETHEINFUSIONFREQUENTLY
0ATIENTSWITHEVIDENCEOFPOORPERFUSION
ˆ}ÕÀiÊΰÊ
*Àˆ“>ÀÞÊ/>À}iÌÃʜvÊ/Ài>̓i˜Ìʈ˜Êi>ÀÌÊ>ˆÕÀi°ÊÊ
,i«Àœ`ÕVi`Ê>˜`ÊÀi«Àˆ˜Ìi`Ê܈̅ʫiÀ“ˆÃȜ˜ÊvÀœ“ÊiÃÃÕ«Ê
]ÊÀœâi“>Ê-°Ê ʘ}ÊÊi`ÊÓääÎÆÎ{n\ÓääLJÓä£n°Ê
œ«ÞÀˆ}…ÌÊ^ÊÓääÎÊ>ÃÃ>V…ÕÃiÌÌÃÊi`ˆV>Ê-œVˆiÌÞ°
%HWDEORFNHUV
+($57
'LJR[LQ
LQRWURSHV
&DUGLDF
UHV\QFKURQL]DWLRQ
WKHUDS\
$&(LQKLELWRUV
DQJLRWHQVLQUHFHSWRUEORFNHUV
DOGRVWHURQHDQWDJRQLVWV
'LXUHWLFV
DOGRVWHURQH
DQWDJRQLVWV
QHVLULWLGH
.LGQH\
$&(LQKLELWRUV
3HULSKHUDO
DQJLRWHQVLQUHFHSWRUEORFNHUV
4REATMENTOPTIONSFORPATIENTSWITHHEARTFAILUREAFFECT
DUWHULHV
YDVRGLODWRUVDOSKDEORFNDGH
THEPATHOPHYSIOLOGICALMECHANISMSTHATARESTIMULATED
QHVLULWLGHH[HUFLVH
IN HEART FAILURE !NGIOTENSINCONVERTINGnENZYME !#%
INHIBITORS AND ANGIOTENSINRECEPTOR BLOCKERS DECREASE
AFTERLOADBYINTERFERINGWITHTHERENINnANGIOTENSINnALDOSTERONESYSTEMRESULTINGINPERIPHERALVASODILATATION4HEYALSO
AFFECTLEFTVENTRICULARHYPERTROPHYREMODELINGANDRENALBLOODmOW!LDOSTERONEPRODUCTIONBYTHEADRENALGLANDSIS
INCREASEDINHEARTFAILURE)TSTIMULATESRENALSODIUMRETENTIONANDPOTASSIUMEXCRETIONANDPROMOTESVENTRICULARAND
VASCULARHYPERTROPHY!LDOSTERONEANTAGONISTSCOUNTERACTTHEMANYEFFECTSOFALDOSTERONE$IURETICSDECREASEPRELOAD
BYSTIMULATINGNATRIURESISINTHEKIDNEYS$IGOXINAFFECTSTHE.A+n!40ASEPUMPINTHEMYOCARDIALCELLINCREASING
CONTRACTILITY )NOTROPES SUCH AS DOBUTAMINE AND MILRINONE INCREASE MYOCARDIAL CONTRACTILITY "ETABLOCKERS INHIBIT THE
SYMPATHETICNERVOUSSYSTEMANDADRENERGICRECEPTORS4HEYSLOWTHEHEARTRATEDECREASEBLOODPRESSUREANDHAVE
ADIRECTBENElCIALEFFECTONTHEMYOCARDIUMENHANCINGREVERSEREMODELING3ELECTEDAGENTSTHATALSOBLOCKTHEALPHA
ADRENERGICRECEPTORSCANCAUSEVASODILATATION6ASODILATORTHERAPYSUCHASCOMBINATIONTHERAPYWITHHYDRALAZINEAND
ISOSORBIDEDINITRATEDECREASESAFTERLOADBYCOUNTERACTINGPERIPHERALVASOCONSTRICTION#ARDIACRESYNCHRONIZATIONTHERAPY
WITHBIVENTRICULARPACINGIMPROVESLEFTVENTRICULARFUNCTIONANDFAVORSREVERSEREMODELING.ESIRITIDEBRAINNATRIURETIC
PEPTIDEDECREASESPRELOADBYSTIMULATINGDIURESISANDDECREASESAFTERLOADBYVASODILATATION%XERCISEIMPROVESPERIPH
ERALBLOODmOWBYEVENTUALLYCOUNTERACTINGPERIPHERALVASOCONSTRICTION)TALSOIMPROVESSKELETALMUSCLEPHYSIOLOGY
/,/ /Ê"Ê
1/Ê
"* -/Ê,/Ê
1,Ê Ê/Ê, 9Ê*,/ /
SHOULDBECONSIDEREDFORINOTROPICSUPPORT$OBUTA
MINE SHOULD BE STARTED IN PATIENTS WITH LOW CARDIAC
OUTPUTANDSYSTOLICBLOODPRESSUREMM(G4HEY
MAY REQUIRE VASOPRESSOR SUPPORT IF HYPOTENSION DE
VELOPS0ATIENTSWITHLOWCARDIACOUTPUTBUTADEQUATE
BLOODPRESSUREMAYBENElTFROMMILRINONEESPECIAL
LYIFTHEYAREALREADYTAKINGBETABLOCKERS4HOSERE
QUIRINGINOTROPICSUPPORTWILLREQUIREADMISSIONTOAN
INTENSIVECAREUNIT4HOSERECEIVINGVASODILATORSCAN
OFTENBEMANAGEDINALESSACUTESETTINGTELEMETRYOR
%$OBSERVATIONUNIT0RELIMINARYANALYSISFROMTHE
!$(%2% REGISTRY INDICATED THAT LENGTH OF STAY WAS
REDUCED BY UP TO A THIRD IN PATIENTS RECEIVING VASO
ACTIVEAGENTSVASODILATORSNESIRITIDEORINOTROPESIN
THE %$ OR OBSERVATION UNIT COMPARED WITH PATIENTS
WHOHADVASOACTIVETHERAPYINITIATEDINTHEHOSPITAL
4HISEARLYINITIATIONOFEMERGENCYDEPARTMENTTHERAPY
ISASSOCIATEDWITHLOWERHOSPITALMORTALITYDECREASED
FREQUENCYOFINVASIVEPROCEDURESANDDECREASED)#5
LENGTHOFSTAY4HUSEARLYTARGETEDVASOACTIVETHERAPY
INTHE!$(&PATIENTSEEMSTOBEVERYPROMISING
.EWPHARMACOLOGICALAGENTSUNDERINVESTIGATION AT
TEMPT TO ENHANCE OUR UNDERSTANDING OF ABNORMAL
NEUROENDOCRINEFUNCTIONINHEARTFAILURE"YSPECIl
CALLYTARGETINGKEYPOINTSSUCHASTHEACTIVATIONAND
FEEDBACKPROCESSTHEYMAYPREVENTDISEASEPROGRES
SION AND ACUTE DECOMPENSATION 7HILE WE AWAIT
NEW TREATMENT MODALITIES CURRENT %$ EFFORTS MUST
FOCUSONTHEEARLYIMPLEMENTATIONOFEFFECTIVESTRATE
GIESTOIMPROVESYMPTOMSANDCORRECTTHEUNDERLYING
PHYSIOLOGY
-1,9
)NTHEMAJORITYOFPATIENTSWHOPRESENTTOTHE%$WITH
!$(&INITIALTHERAPYWITHOXYGENANDDIURETICSWILL
NOT ADEQUATELY REDUCE lLLING PRESSURES OR IMPROVE
CARDIACOUTPUTENOUGHTOIMPROVESYMPTOMS)NOTRO
PESIMPROVESYMPTOMSINTHESHORTTERMBUTAREDEL
ETERIOUS IN THE LONGRUN6ASODILATORS ARE FREQUENTLY
NECESSARY AS THEY ADDRESS THE PRIMARY UNDERLYING
PATHOPHYSIOLOGYOFHEARTFAILURE.ITROGLYCERINAND
NITROPRUSSIDEAREEFFECTIVEBUTTHEIRUSEISHAMPERED
BY ADVERSE EFFECTS AND LIMITATIONS .ATRIURETIC PEP
TIDES SUCH AS NESIRITIDE WITH THEIR NEUROHORMONAL
ANTAGONISMMAYOFFERSEVERALBENElTSOVERCONVEN
TIONALVASODILATORSANDINOTROPESFORTHETREATMENTOF
!$(&)THASBEENSHOWNTHATNESIRITIDECANBEUSED
SAFELYINTHE%$ANDUPFRONTUSECANREDUCEHOSPITAL
LENGTHOFSTAY
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
,, -
+IVIKKO-,EHTONEN,#OLUCCI733USTAINEDHEMODYNAMIC
EFFECTSOFINTRAVENOUSLEVOSIMENDAN#IRCULATION
!GHABABIAN26!CUTELYDECOMPENSATEDHEARTFAILURE
OPPORTUNITIESTOIMPROVECAREANDOUTCOMESINTHEEMERGENCY
DEPARTMENT2EV#ARDIOVASC-EDSUPPL3
-AGNER**2OYSTON$(EART&AILURE"R*!NESTH
.ANAS*.0APAZOGLOU004ERROVITIS*6ETAL(EMODYNAMIC
EFFECTSFLEVOSIMENDANADDEDTODOBUTAMINEINPATIENTSWITH
DECOMPENSATEDADVANCEDHEARTFAILUREREFRACTORYTODOBUTAMINE
ALONE!M*#ARDIOL
&ONAROW'#4HETREATMENTTARGETSINACUTEDECOMPENSATEDHEART
FAILURE2EV#ARDIOVASC-ED3
.OHRIA!,EWIS%3TEVENSON,7-EDICALMANAGEMENTOF
ADVANCEDHEARTFAILURE*!-!
6ANDERHEYDEN-"ARTUNEK*'OETHALS-"RAINANDOTHER
NATRIURETICPEPTIDESMOLECULARASPECTS%UR*(EART&AIL
3TRAIN7$4HEUSEOFRECOMBINANTHUMAN"TYPENATRIURETIC
PEPTIDEINTHEMANAGEMENTOFACUTEDECOMPENSATEDHEARTFAILURE
)NT*#LIN0RACT
(OLLANDER*0HARMACOLOGICMANAGEMENTOPTIONSINTHEEMERGENCY
DEPARTMENT!DVIN(EART&AIL
6ANDER7AL-(*AARSMA4VAN6ELDHUISEN$*.ONCOMPLIANCE
INPATIENTSWITHHEARTFAILUREHOWCANWEMANAGEIT%UR*(EART
&AIL
7ELSCH*D(EISER2-3CHOOLER-0ETAL#HARACTERISTICS
ANDTREATMENTOFPATIENTSWITHHEARTFAILUREINTHEEMERGENCY
DEPARTMENT*%MERG.URS
3HARMA-4EERLINK*2!RATIONALAPPROACHFORTHETREATMENTOF
ACUTEHEARTFAILURECURRENTSTRATEGIESANDFUTUREOPTIONS#URR/PIN
#ARDIOL
-OAZEMI+#HANA*7ILLARD!-+OCHERIL!')NTRAVENOUS
VASODILATORTHERAPYINCONGESTIVEHEARTFAILURE$RUGS!GING
4ORRE!MIONE'9OUNG*"#OLUCCI73ETAL(EMODYNAMIC
ANDCLINICALEFFECTSOFTEZOSENTANANINTRAVENOUSDUALENDOTHELIN
RECEPTORANTAGONISTINPATIENTSHOSPTIALIZEDFORACUTE
DECOMPENSATEDHEARTFAILURE*!M#OLLL#ARDIOL
#OTTER'+ALUSKI%3TANGL+ETAL4HEHEMODYNAMICAND
NEUROHORMONALEFFECTSOFLOWDOSETEZOSENTANANENDOTHELIN!"
RECEPTORANTAGONISTINPATIENTSWITHACUTEHEARTFAILURE%UR*(EART
&AIL
DE$ENUS30(ARAND#7ILLIAMSON$2"RAIN.ATRIURETICPEPTIDE
INTHEMANAGEMENTOFHEARTFAILURE#HEST
+ASAMA34OYAMA4+UMAKURA(ETAL%FFECTSOFINTRAVENOUS
ATRIALNATRIURETICPEPTIDEONCARDIACSYMPATHETICNERVEACTIVITYIN
PATIENTSWITHDECOMPENSATEDCONGESTIVEHEARTFAILURE*.UCL-ED
#OHN*.&ERRARI23HARPE.#ARDIACREMODELINGCONCEPTSAND
CLINICALIMPLICATIONSnACONSENSUSPAPERFROMANINTERNATIONAL
FORUMONCARDIACREMODELING*!M#OLL#ARDIOL
$I$OMENICO2*0ARK(93OUTHWORTH-2ETAL'UIDELINESFOR
ACUTEDECOMPENSATEDHEARTFAILURETREATMENT!NN0HARMACOTHER
6-!#INVESTIGATORS)NTRAVENOUSNESIRITIDEVSNITROGLYCERINFOR
TREATMENTOFDECOMPENSATEDCONGESTIVEHEARTFAILUREARANDOMIZED
CONTROLLEDTRIAL*!-!
#ODY2#LINICALTRAILSOFDIURETICTHERAPYINHEARTFAILURE
RESEARCHDIRECTIONSANDCLINICALCONSIDERATIONS*!M#OLL
#ARDIOL!!
3ILVER-!(ORTON$0#HALI*+%LKAYAM5%FFECTOFNESIRITIDE
VERSUSDOBUTAMINEONSHORTTERMOUTCOMESINTHETREATMENTOF
PATIENTSWITHACTUELYDECOMPENSATEDHEARTFAILURE!M*#OLL
#ARDIOL
+UBO3(#LARK-,ARAGH*(ETAL)DENTIlCATIONOFNORMAL
NEUROHORMONALACTIVITYINMILDCONGESTIVEHEARTFAILUREAND
STIMULATINGEFFECTOFUPRIGHTPOSTUREANDDIURETICS!M*#ARDIOL
#OTTER'-ETZKOR%+ALUSKI%ETAL2ANDOMIZEDTRIALOF
HIGHDOSEISOSORBIDEDINITRATEPLUSLOWDOSEFUROSEMIDEVERSUS
HIGHDOSEFUROSEMIDEPLUSLOWDOSEISOSORBIDEDINITRATEINSEVERE
PULMONARYEDEMA,ANCET
3ALVADOR$2+2EY.22AMOS'#0UNZALAN&%2#ONTINUOUS
INFUSIONVERSUSBOLUSINJECTIONOFLOOPDIURETICSINCONGESTIVEHEART
FAILURE#OCHRANE$ATABASE3YSTEMATIC2EVIEWS#$
'HEORGHIADE-.IAZI)/UYANG*ETAL6ASOPRESSIN6RECEPTOR
BLOCKADEWITHTOLVAPTANINPATIENTSWITHCHRONICHEARTFAILURE
RESULTSFROMADOUBLEBLINDRANDOMIZEDTRIAL#IRCULATION
3TEVENSON,7#LINICALUSEOFINOTROPICTHERAPYFORHEARTFAILURE
LOOKINGBACKWARDORFORWARD#IRCULATION
"URGER!*(ORTON$0,E*EMETEL4ETAL%FFECTOFNESIRITIDE
ANDDOBUTAMINEONVENTRICULARARRHYTHMIASINTHETREATMENTOF
PATIENTSWITHACUTELYDECOMPENSATEDCONGESTIVEHEARTFAILURETHE
02%#%$%.4STUDY!M(EART*
#UFFE-3#ALIFF2-!DAMS+&ETAL3HORTTERMINTRAVENOUS
MILRINONEFORACUTEEXACERBATIONOFCHRONICHEARTFAILURE*!-!
0EACOCK7&%MERMAN#,THE02/!#4)/.STUDYGROUP3AFETY
ANDEFlCACYOFNESIRITIDEINTHETREATMENTOFDECOMPENSATEDHEART
FAILUREINOBSERVATIONPATIENTS*!M#OLL#ARDIOL!
#OLUCCI73%LKAYAM5(ORTON$ETAL)NTRAVENOUSNESIRITIDEA
NATRIURETICPEPTIDEINTHETREATMENTOFDECOMPENSATEDCONGESTIVEHEART
FAILURE.ESIRITIDE3TUDY'ROUP.%NGL*-ED
3ACKNER"ERNSTEIN*$+OWALSKI-&OX-ETAL3HORTTERM2ISK
OF$EATH!FTER4REATMENT7ITH.ESIRITIDEFOR$ECOMPENSATED
(EART&AILURE!0OOLED!NALYSISOF2ANDOMIZED#ONTROLLED4RIALS
*!-!
3ALTZBERG-4"ENElCIALEFFECTSOFEARLYINITIATIONOFVASOACTIVE
AGENTSINPATIENTSWITHACUTEDECOMPENSATEDHEARTFAILURE2EV
#ARDIOVASC-EDSUPPL
0EACOCK7&(EART&AILURE-ANAGEMENTINTHEEMERGENCY
DEPARTMENTOBSERVATIONUNIT0ROGIN#ARDIOVAS$IS
%MERMAN#,0EACOCK7&THE!$(%2%INVESTIGATORS%VOLVING
PATETERSOFCAREFORDECOMPENSATEDHEARTFAILUREIMPLICATIONSFROM
THE!$(%2%REGISTRYDATABASE!CAD%MERG-ED
9OUNG*".EWTHERAPEUTICCHOICESINTHEMANAGEMENTOFACUTE
CONGESTIVEHEARTFAILURE2EV#ARDIOVASC-ED3
#OPYRIGHT%-#2%')NTERNATIONAL
/Ê6"6 Ê,"Ê"Ê *Ê Ê/Ê "--Ê Ê/,/ /Ê
"Ê
\ÊÊÊ-1,9Ê"Ê/Ê *Ê
" - -1-Ê* Ê,*",/
7&RANK0EACOCK-$
$EPARTMENTOF%MERGENCY-EDICINE4HE#LEVELAND#LINIC&OUNDATION
#LEVELAND/(
"
/6-\
$ISCUSSTHEAPPLICATIONANDLIMITATIONSOF".0TESTINGINTHEEMERGENCYSETTING
$ESCRIBETHEAPPROPRIATECANDIDATEFOR".0THERAPY
/,"1
/"
!".0EXPERTCONSENSUSPANELCONSISTINGOFINDIVIDUALSWITHBASICMETHODOLOGICAND
CLINICALEXPERTISEWASCONVENEDINTOCREATEASUMMARYDOCUMENTTOHELPGUIDE
THECLINICIANONTHERECENTEXPLOSIONOFNATRIURETICPEPTIDE.0DATA4HISDOCUMENT
CONTAINS THE DATA FROM THEIR RECOMMENDATIONS MOST APPLICABLE TO THE EMERGENCY
PHYSICIAN
.ATRIURETIC0EPTIDE0HYSIOLOGY
-ORETHANAPUMPTHEHEARTISACRITICAL
ENDOCRINE ORGAN FUNCTIONING WITH OTHER
PHYSIOLOGICAL SYSTEMS TO CONTROL mUID
VOLUME -YOCYTES MANUFACTURE A FAM
ILYOFPEPTIDEHORMONESTERMEDTHE.0S
REPRESENTED BY ATRIAL NATRIURETIC PEPTIDE
!.0 AND "TYPE NATRIURETIC PEPTIDE
".02ELEASEOFTHE.0SISSTIMULATED
BY VOLUME OVERLOAD AND PHYSIOLOGI
CALLY THEY HAVE POWERFUL DIURETIC NATRI
URETICANDVASCULARSMOOTHMUSCLERELAX
ING ACTIONS )MPORTANTLY THEY ALSO SERVE
ASANTAGONISTSTOTHESYMPATHETICNERVOUS
SYSTEM AND THE RENINANGIOTENSINALDO
STERONE AXIS 2!!3 2ELEASE OF .0S
RESULTSFROMCARDIACWALLSTRETCHVENTRIC
ULARDILATIONORINCREASEDPRESSURESFROM
CIRCULATORYVOLUMEOVERLOAD4HEEFFECTS
OF.0SRESULTINLOWERINGBLOODVOLUME
ANDPRESSURE
".0 IS DERIVED FROM A PRECURSOR PRE
PRO".0WHICHUNDERGOESSEVERALCLEAV
AGES 4HE ASSAY RELEVANT PRODUCTS ARE
THE INERT .TERMINAL PRO".0 FRAGMENT
AND PHYSIOLOGICALLY ACTIVE ".0 ".0S
AREPREFERENTIALLYPRODUCEDANDSECRETED
BYTHECARDIACVENTRICLESALTHOUGHmUID
OVERLOADMAYCAUSERAPID".0MANUFAC
TUREINBOTHHEARTCHAMBERS4HEPRIMARY
FUNCTIONOF.0SISTODEFENDAGAINSTVOL
UMEOVERLOAD!FTERRELEASEINTOCIRCULA
TION".0ACTIONSAREMODULATEDATTARGET
SITES BY SPECIlC CELL MEMBRANE RECEP
TORSTERMED!"AND#WHICHMEDIATE
PHYSIOLOGICAL ACTIONS BY CYCLIC '-0
#YCLIC'-0HASPOTENTVASODILATORYAC
TIONS ".0 ALSO CAUSES AN INTRAVASCULAR
mUIDSHIFTFROMTHECAPILLARYBEDINTOTHE
INTERSTITIUM WHICH CONTRACTS INTRAVASCU
LARVOLUMEANDDECREASES"0)NADDI
TION".0ISA2!!3ANTAGONISTWHEREIT
COUNTERACTS SODIUM CONSERVATION VASO
CONSTRICTIONANDVOLUMERETENTION".0
ALSO INHIBITS THE RELEASE OF RENIN FROM
KIDNEY CELLS AND ALDOSTERONE FROM ADRE
/…iÊivviVÌÃʜvÊ *½ÃÊÊ
ÀiÃՏÌʈ˜ÊœÜiÀˆ˜}ÊÊ
Lœœ`ÊۜÕ“iÊÊ
>˜`Ê«ÀiÃÃÕÀi°
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
NALCELLS".0ISPRIMARILYMETABOLIZEDBYTHE.02#
RECEPTORALTHOUGHSOMEADDITIONALDEGRADATIONMAY
OCCURBYNEUTRALENDOPEPTIDASE.EUTRALENDOPEP
TIDASE HAS A WIDE TISSUE DISTRIBUTION INCLUDING ADI
POSEKIDNEYSLUNGANDBRAIN­ˆ}ÕÀiÊ£®
ˆ}ÕÀiÊ£°Ê
*Ê
/-
, 6
5z
6
'z z
z
z
6
z
0
6
z
z
.
*
z
z
5
z*
/
z
+
z
*
z
z
5
)
z
z& z
&
6 z
5
6 z
/z
. 9z
z
zz
*
z
3 . 0
6 zz
6
z
zz
9 4 *z
zz
&DUGLDF
Ɣ /XVLWURSLF Ɣ $QWLILEURWLF Ɣ $QWLUHPRGHOLQJ 0DUFXV/6HWDO&LUFXODWLRQ
=HOOQHU&HWDO$P-3K\VLROSW++
$EUDKDP:7HWDO-&DUG)DLO
&ODUNVRQ3%0HWDO&LUFXODWLRQ
7DPXUD1HWDO3URF1DWO$FDG6FL86$
+HPRG\QDPLF
%DODQFHGYDVRGLODWLRQ
Ɣ 9HLQV Ɣ $UWHULHV Ɣ &RURQDU\DUWHULHV 1HXURKXPRUDO
$OGRVWHURQH (QGRWKHOLQ 1RUHSLQHSKULQH 5HQDO 'LXUHVLV
1DWULXUHVLV
"IOLOGIC$ETERMINANTSON".0-EASUREMENTS
"LOODLEVELSOF.0SAREAFFECTEDBYAVARIETYOFFACTORS
INCLUDING CIRCADIAN RHYTHM AGE EXERCISE AND BODY
POSTURE-ANYDRUGSINCLUDINGDIURETICSANGIOTENSIN
CONVERTINGENZYMEINHIBITORSADRENERGICAGONISTSSEX
ANDTHYROIDHORMONESGLUCOCORTICOIDSSODIUMINTAKE
ANDOTHERCONDITIONSIMPACTLEVELS".0INCREASESWITH
AGE AND GENDER "ASELINE AND PATHOLOGIC LEVELS ARE
HIGHER IN WOMEN4HE AGE INDUCED ".0 INCREASE
MAYBEDUETOTHEDECLINEINMYOCARDIALFUNCTIONOR
TODECREASEDCLEARANCE
".0!SSAY
)TSHOULDBEMADECLEARTHATTHE".0ASSAYISNOTA
STANDALONETEST)TSGREATESTVALUEISWHENITISUSED
WITHTHEPHYSICIANSCLINICALJUDGMENTANDWITHOTHER
APPROPRIATETESTING4HE4RIAGE".0ASSAYSYSTEMIS
THE ONLY &$! APPROVED POINTOF CARE ASSAY )T RE
QUIRESMINUTESTOPERFORMANDREPORTS".0LEVELS
FROM TO PGM,4HIS ASSAY IS RATED AS MOD
ERATELY COMPLEX ASSAY PER #LINICAL ,ABORATORY )M
PROVEMENT!MENDMENTS#,)!REGULATIONS
".0FOR$IAGNOSISOF(EART
&AILURE
$ESPITE ADVANCES IN OUR UNDER
STANDING OF HEART FAILURE (&
PATHOPHYSIOLOGY DIAGNOSIS IS
STILL DIFlCULT 7HILE EMERGEN
CY DEPARTMENT %$ DIAGNOSIS
NEEDSTOBERAPIDANDACCURATE
THE SIGNS AND SYMPTOMS OF (&
ARE NONSPECIlC 2ESPIRATORY
DISTRESS CAN PRECLUDE OBTAINING
THEHISTORYANDDYSPNEAISNON
SPECIlCINTHEELDERLYOROBESE
2OUTINE LABS %#' AND XRAYS
ARE ALSO NOT ACCURATE ENOUGH TO
ALWAYSMAKETHECORRECTDIAGNO
SIS
#/.3%.35334!4%-%.43
'%.%2!,#/--%.43
4HELABORATORYSHOULDPERFORM".0TESTING
ONACONTINUOUSHOURBASISWITHA
TURNAROUNDTIME4!4OFMINUTESOR
LESS4HE4!4ISDElNEDASTHETIMEFROM
BLOODCOLLECTIONTONOTIlCATIONOFRESULT
TOPHYSICIANORCAREGIVER%ITHERCENTRAL
LABORATORYINSTRUMENTATIONORPOINTOFCARE
TESTINGSYSTEMSAREACCEPTABLE
% )NCONSIDERING.0MEASUREMENTSONE
NEEDSTOCAREFULLYCONSIDERLABORATORY
ANDBIOLOGICVARIATIONINCLUDINGGENDER
SEXOBESITYANDRENALFUNCTION
% 4HERESULTSOFNATRIURETICTESTINGIS
DEPENDENTONTHETYPEOFTESTYOUARE
OBTAINING.TERMINALPRO".0AND
BIOACTIVE".0ARE./4INTERCHANGEABLE
/Ê6"6 Ê,"Ê"Ê *Ê Ê/Ê "--Ê Ê/,/ /Ê
"Ê
\ÊÊÊ-1,9Ê"Ê/Ê *Ê
" - -1-Ê* Ê,*",/
4HE"REATHING.OT0ROPERLYSTUDYWASALARGEMUL
TINATIONAL PROSPECTIVE STUDY USING ".0 TO EVALUATE
DYSPNEA IN DYSPNEIC %$ PATIENTS ".0 LEVELS
WERE MEASURED ON ARRIVAL AND PHYSICIANS ASSESSED
THEPROBABILITYOFTHEPATIENTHAVING(&4WOCARDI
OLOGISTSBLINDEDTOTHE".0LEVELREVIEWEDALLDATA
AFTER HOSPITALIZATION TO PRODUCE A hGOLD STANDARDv
CLINICALDIAGNOSIS".0LEVELSALONEMOREACCURATELY
PREDICTEDTHEPRESENCEORABSENCEOF(&THANANYOTH
ERlNDING4HEPGM,CUTPOINTHADASEN
SITIVITY AND SPECIlCITY FOR A (& DIAGNOSIS )N
MULTIVARIATEANALYSIS".0LEVELSALWAYSCONTRIBUTED
TOTHEDIAGNOSISEVENAFTERCONSIDERINGFEATURESOFTHE
HISTORYANDPHYSICALEXAMINATION
".0 LEVELS MAY ALSO HELP IN DISPOSITION DECISIONS
4HE2APID%MERGENCY$EPARTMENT(EART&AILURE/UT
PATIENT2%$(/44RIALDEMONSTRATEDAhSTRONGDIS
CONNECTv BETWEEN THE PERCEIVED SEVERITY OF (& AND
ILLNESS SEVERITY AS DETERMINED BY ".0 /N AVERAGE
PATIENTS DISCHARGED FROM THE %$ HAD A HIGHER ".0
THANTHOSEADMITTEDPGM,VERSUSPGM,
RESPECTIVELY".0ALSOPREDICTEDOUTCOMESOFPATIENTS
DISCHARGEDHADA".0PGM,HOWEVER
THEREWASNOMORTALITYATDAYSIFTHE".0WASLESS
THANPGM,
4HE3WISS"!3%,3TUDYEXAMINED COSTEFFECTIVE
NESSOFUSING".0THROUGHTHEDIAGNOSISANDHOSPITAL
IZATIONINACUTEDECOMPENSATEDHEARTFAILURE!$(&
)NPATIENTS%$MEASUREMENTOF".0WASASSO
CIATED WITH A DECREASE IN HOSPITAL ADMISSIONS
ADAYDECLINEINLENGTHOFSTAYANDANSAV
INGSWITHNOEFFECTSONMORTALITYORREHOSPITALIZATION
RATES
".0AND2ENAL&AILURE
#HRONIC KIDNEY DISEASE #+$ INmUENCES THE CUT
POINTFOR".0)NGENERALAS#+$ADVANCESAHIGHER
".0 CUTPOINT IS IMPLIED ! CUTPOINT OF APPROXI
MATELY PGM, IS REASONABLE FOR THOSE WITH AN
#/.3%.35334!4%-%.453).'".04/
(%,042)!'%%$0!4)%.437)4($930.%!
".0ISOFDIAGNOSTICUTILITYINTHEEVALUATION
OFPATIENTSWITHACUTEDYSPNEA4HUSIN
NEWPATIENTSPRESENTINGWITHDYSPNEATO
ANEMERGENCYSETTINGAHISTORYPHYSICAL
EXAMINATIONCHESTXRAYAND%#'SHOULD
BEUNDERTAKENTOGETHERWITHLABORATORY
MEASUREMENTSTHATINCLUDE".0#URRENT
DATASUGGESTTHEFOLLOWINGGUIDELINES
% !S".0RISESWITHAGEANDISAFFECTED
BYGENDERCOMORBIDITYANDDRUGUSEIT
SHOULDNOTBEUSEDINISOLATIONFROMTHE
CLINICALCONTEXT
% )FTHE".0ISPGM,THEN(&IS
HIGHLYUNLIKELY.06
% )FTHE".0ISPGM,THEN(&IS
HIGHLYLIKELY006
% )FTHE".0ISnPGM,CONSIDER
ABASELINE".0ELEVATEDDUETOSTABLE
UNDERLYINGDYSFUNCTIONRIGHTVENTRICULAR
FAILUREFROMCORPULMONALEACUTE
PULMONARYEMBOLISMORRENALFAILURE
% 0ATIENTSMAYPRESENTWITH(&ANDA
NORMAL".0ORWITHLEVELSBELOWWHAT
ISEXPECTEDINTHEFOLLOWINGSITUATIONS
mASHPULMONARYEDEMAnHOURS(&
UPSTREAMFROMTHELEFTVENTRICLESUCH
ASWITHACUTEMITRALREGURGITATIONFROM
PAPILLARYMUSCLERUPTUREANDOBESE
PATIENTSBODYMASSINDEX;"-)=
ESTIMATED GLOMERULAR lLTRATION RATE '&2 M,
MINM5SINGTHISAPPROACH".0MAINTAINSA
HIGHLEVELOFDIAGNOSTICUTILITYWITHANAREAUNDERTHE
2/#CURVEOFACROSSALL#+$GROUPS
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
#/.3%.35334!4%-%.43#/-/2")$)4)%3
!.$30%#)!,)335%34(!4).&,5%.#%4(%
).4%202%4!4)/./&".0,%6%,3
% ".0ISALTEREDWITHCHRONICRENAL
INSUFlCIENCYESTIMATED'&2M,
MINWITHARECALIBRATIONOFTHECUTOFF
VALUETOPGM,
% ".0ISHELPFULINTHEEVALUATIONOF
DYSPNEAWHENITISVERYLOWORHIGH.4
PRO".0HASGREATERCORRELATIONWITH
E'&2THAN".0HENCELEVELSCANBE
ELEVATEDEVENWITHTHENORMALAGERELATED
DECLINEOFRENALFUNCTIONINTHEE'&2
M,MINRANGE
% 7HENTHEE'&2ISBELOWM,MIN.
TERMINALPRO".0CANBECONSIDERABLY
ELEVATEDANDINTHISSETTINGITSUTILITYIN
THEEVALUATIONOF(&ISUNKNOWN
% "ASELINE".0LEVELSMIGHTTHEREFOREBE
IMPORTANTINDIALYSISPATIENTSASCHANGES
MOSTLIKELYREmECTVOLUMESTATUS4HUS
APREDIALYSIS".0MAYHELPDETERMINE
THEAMOUNTOFVOLUMEWHICHSHOULDBE
REMOVED
#ARDIOPULMONARY$ISEASE
3OME NON(& CARDIOPULMONARY DISEASE MAY CAUSE
".0 ELEVATIONS 4HESE INCLUDE COR PULMONALE LUNG
CANCER PULMONARY EMBOLISM 0% AND PRIMARY PUL
MONARYHYPERTENSION)NTHESE".0MAYBEELEVATED
BUTNOTTOTHEEXTENTFOUNDIN!$(&)N0%".0MAY
BEPROGNOSTICSINCEPATIENTSWITHA".0INTHEUPPER
NORMALRANGEORPGM,HAVEAHIGHERMORTAL
ITYRATE!LTHOUGH".0ISNOTANADEQUATESCREENING
TESTFOR0%INTHESETTINGOFASUSPECTEDORCONlRMED
EMBOLICEVENTA".0ELEVATIONIMPLIES26PRESSURE
OVERLOADANDINCREASEDMORTALITYRISK&INALLYINPRI
MARY PULMONARY HYPERTENSION ".0 ELEVATIONS PAR
ALLELTHEEXTENTOFPULMONARYHEMODYNAMICCHANGES
ANDRIGHT(&
#/.3%.35334!4%-%.4".0).
05,-/.!29!.$!33/#)!4%$#!2$)!#
$)3%!3%
% )NAPPROXIMATELYOFPATIENTSWITH
PULMONARYDISEASE".0ISELEVATED
IMPLYINGCOMBINED(&ANDLUNGDISEASE
CORPULMONALEORAMISDIAGNOSISWHEN
THETRUEETIOLOGYOFDYSPNEAIS(&
% )NTHESETTINGOF0%".0ISELEVATEDIN
OFCASESANDISASSOCIATEDWITH26
PRESSUREOVERLOADANDAHIGHERMORTALITY
".0ISNOTDIAGNOSTICFORACUTE0%
% 0ULMONARYDISEASEWHICHRESULTS
INPULMONARYHYPERTENSIONAND26
PRESSUREORVOLUMEOVERLOADCANLEADTO
ELEVATED".0LEVELSUSUALLYINTHERANGE
OFPGM,
0RESERVED3YSTOLIC&UNCTION03&(EART&AILURE
$IASTOLICMYOCARDIALDYSFUNCTIONALSOKNOWNAS03&
ISTHECAUSEOF(&INASMANYOFOFCASESAND
ISALSOASSOCIATEDWITHHIGH".0".0HASBEEN
FOUNDTOBEAPPROXIMATELYHALFASHIGHIN03&ASIN
CASESOFSYSTOLICDYSFUNCTION
#/.3%.35334!4%-%.4".0).
$)!34/,)#$93&5.#4)/.
% ".0MIGHTBEUSEDTODETECTPATIENTS
WITHDIASTOLICDYSFUNCTION
% ".0CONCENTRATIONSABOVEAGEADJUSTED
CUTPOINTSMAYIDENTIFYELDERLYPATIENTS
WITHDIASTOLICDYSFUNCTION
/Ê6"6 Ê,"Ê"Ê *Ê Ê/Ê "--Ê Ê/,/ /Ê
"Ê
\ÊÊÊ-1,9Ê"Ê/Ê *Ê
" - -1-Ê* Ê,*",/
/BESITY
/BESITY IS AN IMPORTANT RISK FACTOR FOR CORONARY AR
TERYDISEASEAND(&0HYSIOLOGICALLYADIPOSETIS
SUEISRELATEDTOTHENATRIURETICCLEARANCERECEPTOR
AND OBESITY CAN INTERFERE WITH THE USUAL DIAGNOSTIC
APPROACHTO(&-EHRADOCUMENTEDANINVERSERE
LATIONSHIPBETWEEN"ASAL-ETABOLIC)NDEX"-)AND
".0,OWERLEVELSOF".0INTHEOBESE"-)+G
-WERENOTEDDESPITESIMILARSEVERITYOF(&COM
PAREDTOALEANCOHORTANDNEARLYOFOBESEPA
TIENTSHAD".0PGM,
GROUPEDINTO".0QUARTILESHOURSAFTER!#3ONSET
AN INCREASING ".0 WAS ASSOCIATED WITH HIGHER MONTHMORTALITYANDTHISRELATIONSHIPPERSISTEDEVEN
WITHOUTEVIDENCEOF(&ORMYOCARDIALNECROSIS
#/.3%.35334!4%-%.4".0).35$$%.
$%!4(!#3!.$#!$
7HEN USED TOGETHER ".0 AND CARDIAC
TROPONIN PROVIDE A MORE EFFECTIVE TOOL
FOR IDENTIFYING PATIENTS AT INCREASED RISK
FORCLINICALLYIMPORTANTCARDIACEVENTSRE
LATEDTO(&AND!#3-ULTIMARKERPANELS
WITH".0ANDTROPONINARENOWAVAILABLE
WHERE EACH OF THESE MARKERS PROVIDE
UNIQUEANDINDEPENDENTOUTCOMEDATA
#/.3%.35334!4%-%.4".0)./"%3)49
% 3INCEOBESEPATIENTSBODYMASS
INDEX;"-)=KGMEXPRESSLOWER
LEVELSOF".0FORANYGIVENSEVERITY
OF(&CAUTIONSSHOULDBEEXERCISEDIN
INTERPRETING".0LEVELSINSUCHPATIENTS
".0AND!CUTE#ORONARY3YNDROMES!#3
,ARGESTUDIESREPORT.0ELEVATIONSINUNSTABLEANGINA
WITHOUTMYOCARDIALNECROSIS!SISCHEMIAMAYRE
SULTINONLYSMALL.0ELEVATIONSTHEIRSENSITIVITYAND
SPECIlCITYAREINADEQUATEASAhRULEOUTvTOOL(OW
EVERIFPRESENTANELEVATIONOF.0IN!#3ISAPOW
ERFULPREDICTOROFADVERSEEVENTS)NPATIENTS
".0AND0ROGNOSIS
".0ELEVATIONISAPOWERFULMARKEROF(&PROGNOSIS
)N PATIENTS FOLLOWED FOR MONTHS AFTER AN %$
VISITFORDYSPNEATHERELATIVERISKOFMONTH(&AD
MISSIONORDEATHWASTIMESHIGHERIFTHE".0WAS
PGM,­ˆ}ÕÀiÊÓ®4HISWASCONlRMEDBYTHE
6AL(E&4TRIALWHERETHELOWESTQUARTILEOF".0
PGM,HADTHELOWESTALLCAUSEMORTALITYANDTHE
HIGHESTQUARTILEPGM,HADTHEHIGHESTMOR
TALITYATMONTHS­ˆ}ÕÀiÊÓ®
ˆ}ÕÀiÊÓ°Ê
,i>̈œ˜Ã…ˆ«Ê œvÊ *Ê `iÌiÀ“ˆ˜i`Ê
ˆ˜Ê i“iÀ}i˜VÞÊ `i«>À̓i˜ÌÊ V>ÀiÊ ÌœÊ
`i>̅ʜÀʅi>ÀÌÊv>ˆÕÀiʅœÃ«ˆÌ>ˆâ>̈œ˜°Ê
,i«Àˆ˜Ìi`Ê܈̅ʫiÀ“ˆÃȜ˜ÊvÀœ“ʘ˜Ê
“iÀ}Êi`°ÊÓääÓÆΙ\£Î£‡£În°
".0PGM,
".0PGM,
".0PGM,
$AYS
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
ˆÛˆ˜}Ê *]ʈ˜Ê̅iÊ
".0AS4HERAPY
7HEN!$(&OCCURSTHEBALANCEBETWEEN
VASOCONSTRICTORSANDENDOGENOUSVASODI
LATORS IS DISTURBED 4HIS FORMS THE BASIS
AS TO WHY EXOGENOUS ".0 IS GIVEN AS
THERAPY DESPITE HIGH ENDOGENOUS LEVELS
ISANALOGOUSTOGIVINGINSULINFORINSULIN
RESISTANCE)N!$(&HIGHLEVELSOF".0
OCCURASAhDISTRESSHORMONEvWHERESU
PRANORMALLEVELSARENOLONGEREFFECTIVE
AT MAINTAINING THE BALANCE OF VASOCON
STRICTION AND VASODILATION (ENCE GIVING
".0INTHEFORMOFNESIRITIDECANRESTORE
NEUROHORMONALHOMEOSTASIS
vœÀ“ÊœvʘiÈÀˆÌˆ`i]ÊV>˜Ê
ÀiÃ̜ÀiʘiÕÀœ…œÀ“œ˜>Ê
…œ“iœÃÌ>ÈÃÊ>˜`ʈÃÊ
>ÃÜVˆ>Ìi`Ê܈̅ÊÀi`ÕVi`Ê
wˆ˜}Ê«ÀiÃÃÕÀiÃ]Ê
`iVÀi>Ãi`ʫՏ“œ˜>ÀÞÊ
Û>ÃVՏ>ÀÊÀiÈÃÌ>˜Vi]Ê
œÜiÀi`ÊVi˜ÌÀ>ÊÊ
Ûi˜œÕÃÊ«ÀiÃÃÕÀiÃ]ÊÊ
>˜`ÊÀi`ÕV̈œ˜Êˆ˜Ê
ÃÞÃÌi“ˆVÊ*°
.0 ARE MUCH CLOSER TO IDEAL DRUGS FOR
!$(&THANOTHERAGENTS4HEUSEOFNE
SIRITIDEISASSOCIATEDWITHREDUCEDlLLING
PRESSURES DECREASED PULMONARY VASCU
LAR RESISTANCE LOWERED CENTRAL VENOUS
PRESSURESANDREDUCTIONINSYSTEMIC"0
4HEREISALSOINCREASEDCARDIACOUTPUTDUE
TOTHEUNLOADINGEFFECTOFVASODILATATION
BUTWITHOUTREmEXTACHYCARDIA-OREOVER
REDUCING PRELOAD AND AFTERLOAD WITHOUT
INCREASING HEART RATE IS CONSISTENT WITH
DECREASEDMYOCARDIALOXYGENCONSUMP
TION AND A DECREASE IN VENTRICULAR STRESS
A STIMULUS PRESUMED TO DRIVE THE NEU
ROHORMONAL ACTIVATION OF!$(& ,ASTLY
TOLERANCETOTHESEEFFECTSDOESNOTOCCUR
ANDTHESECHANGESINHEMODYNAMICSARE
PRESENTANDPERSISTENTTHROUGHOUTTHEAD
MINISTRATIONOFNESIRITIDE
4ODATENESIRITIDEISTHEONLYNATRIURETIC
PEPTIDEAVAILABLEINTHE53FOR)6THERA
PY#OLUCCIETALINTHE%FlCACY4RIAL
SHOWED THAT NESIRITIDE CAUSES A DOSERE
LATED DECREASE IN 0#70 SYSTEMIC VAS
CULARRESISTANCEMEANRIGHTARTERIALPRES
SURE DYSPNEA FATIGUE A SIGNIlCANT IN
CREASEINCARDIACINDEXANDANIMPROVE
MENTINGLOBALSTATUS4HEMOSTCOMMON
SIDE EFFECT WAS DOSERELATED HYPOTENSION
4HE #OMPARATIVE 4RIAL EVALUATED NE
SIRITIDE VERSUS MANY OTHER CARDIOVASCULAR
AGENTS INCLUDING DOBUTAMINE MILRINONE
NITROGLYCERIN DOPAMINE AND AMRINONE
'LOBAL CLINICAL STATUS FATIGUE AND DYS
PNEAIMPROVEDINALLGROUPSWITHNOSIG
NIlCANTDIFFERENCESBETWEENNESIRITIDEAND
STANDARDTHERAPY4HEMOSTCOMMONSIDE
EFFECTSWEREBRADYCARDIAANDDOSERELATED
HYPOTENSION
)N "URGER ET AL CONDUCTED THE
02%#%$%.4 STUDY )TS PRIMARY OBJEC
TIVE WAS TO COMPARE HEART RATE AND AR
RHYTHMIAS WITH TWO DOSES OF NESIRITIDE
OR§GKGMINTODOBUTAMINE
4HEY CONCLUDED THAT ALTHOUGH INOTROPIC
(&THERAPIESINCLUDINGDOBUTAMINEAND
MILRINONEAREASSOCIATEDWITHFAVORABLE
HEMODYNAMIC AND SYMPTOMATIC EFFECTS
THEY CAUSE ARRHYTHMIAS AND TACHYCARDIA
WHICH MAY INCREASE MYOCARDIAL OXYGEN
DEMAND ISCHEMIA AND MORTALITY 4HEY
DEMONSTRATED FEWER ARRHYTHMIAS AND NO
HEART RATE INCREASE WITH NESIRITIDE &UR
THERMORE THE RATES OF DAY READMIS
SIONANDMONTHMORTALITYWEREHIGHER
WITHDOBUTAMINE4HEAUTHORSCONCLUDED
THAT NESIRITIDE IS SAFER THAN DOBUTAMINE
FORSHORTTERM!$(&MANAGEMENT
4HE6-!# TRIAL WAS A SAFETY AND EF
lCACY STUDY OF INTRAVENOUS NESIRITIDE
VERSUS INTRAVENOUS NITROGLYCERIN OR PLA
CEBOIN!$(&PATIENTSWITHDYSPNEA
AT REST 3WAN 'ANZ CATHETERIZATION WAS
PERFORMEDINROUGHLYHALFATTHEPHYSI
CIANSCHOICE0ATIENTSWERERANDOMIZED
INTOFOURBLINDEDGROUPSEACHRECEIVING
STANDARDTHERAPYANDlXEDDOSENESIRIT
IDE TITRATABLE NESIRITIDE TITRATABLE NITRO
/Ê6"6 Ê,"Ê"Ê *Ê Ê/Ê "--Ê Ê/,/ /Ê
"Ê
\ÊÊÊ-1,9Ê"Ê/Ê *Ê
" - -1-Ê* Ê,*",/
GLYCERIN OR PLACEBO .ESIRITIDE HAD A FASTER ONSET
AND GREATER REDUCTION IN 0#70 THAN NITROGLYCERIN
4HEIMPROVEMENTINCLINICALSTATUSANDDYSPNEAWAS
SIMILAR IN BOTH GROUPS ­ˆ}ÕÀiÊ Î®4HEY CONCLUDED
THATWHENADDEDTOSTANDARDCARENESIRITIDEIMPROVES
HEMODYNAMIC FUNCTION MORE EFFECTIVELY THAN )6 NI
TROGLYCERINORPLACEBO
YIELDANINTUITIVERATIONALEANDAREASONABLEEVIDENCE
BASED APPROACH FOR !$(& ASSESSMENT AND MANAGE
MENT/NEOFTHEMOSTVALUABLElNDINGSISTHATBEGIN
NINGVASOACTIVETHERAPYINTHE%$ISASSOCIATEDWITHA
DAYREDUCTIONINHOSPITALLENGTHOFSTAYCOMPARED
TO THERAPIES NOT INITIATED UNTIL AFTER ADMISSION 4HIS
SUGGESTSTHATTHECHOICEOFTHERAPYINTHE%$MAYCRITI
CALLYIMPACTTHECOURSEOFTHEPATIENT
)NANOTHEREVALUATIONARISKADJUSTEDCOMPARISONOF
OUTCOMES FROM THE!$(%2% REGISTRY OF MORE THAN
!$(&PATIENTSFOUNDIMPROVEDSURVIVALWITH
VASODILATORSCOMPAREDTOINOTROPES7HENCOMPARING
VASODILATORSTHEREARESIMILAROUTCOMESBETWEENNE
SIRITIDEANDNITROGLYCERIN
).4%'2!4).'".0,%6%,3).4/!
2!4)/.!,53%/&.%3)2)4)$%
7HILE".0ISAPPROVEDBYTHE&$!FOR(&DIAGNOSIS
ITSUSEFULNESSTOMONITORTREATMENTISSTILLUNDERSTUDY
(OWEVERSOMESUGGESTIONSCANBEMADE7EBELIEVE
THATONECANSTRATIFYPATIENTSTOTHEHIGHRISKCATEGORYIN
PARTBYUSING".0LEVELS&ONOROWRECENTLYANALYZED
THE!$(%2%DATABASEANDFOUNDTHATHIGH"5.LEVELS
PROVIDEAPOORPROGNOSISFORPATIENTSIN!$(&4HUS
4HE CURRENT APPROVED USE OF NESIRITIDE IS FOR!$(&
!LTHOUGHGUIDELINESTATEMENTSARELACKINGTHETOTALITY
OFDIAGNOSTICANDTHERAPEUTICDATAREGARDINGNESIRITIDE
S
3ODFHER
0HDQ2EVHUYHGYDOXHPP+J
s
S
s
S
S
S
1HVLULWLGH
0HDQ&KDQJHPP+J
s
1LWURJO\FHULQ
S
ss
s
S
s
S
s
S
s
S
S
S
S
s s
s
KU
KU
s
%/ P
P
KU
KU
KU
%/ P
P
KU
SYVSODFHER
SYV17*
ˆ}ÕÀiÊΰ
6>Ü`ˆ>̈œ˜Êˆ˜Ê̅iÊ>˜>}i“i˜ÌʜvÊVÕÌiÊ
Ê­6
®ÊÌÀˆ>\Ê*Àˆ“>ÀÞÊi˜`Ê«œˆ˜ÌʈÃÊ
«Õ“œ˜>ÀÞÊV>«ˆ>ÀÞÊÜi`}iÊ«ÀiÃÃÕÀiÊV…>˜}iÃʜÛiÀÊÎʅœÕÀð{È
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
THECOMBINATIONOFHIGH".0ANDPOORRENALFUNCTION
IDENTIlESHIGHRISKPATIENTS­ˆ}ÕÀiÊ{®
)FPATIENTSAREADMITTEDWITH".0LEVELSPGM,
AND"5.LEVELSARELOWERRISKONECANOFTEN
STARTTREATMENTWITHPARENTERALDIURETICS3UBSEQUENTLY
THEYCANBERECLASSIlEDINTOLOWORHIGHRISKGROUPS
BASED ON THEIR RESPONSE OVER THE NEXT n HOURS
4HOSEWITHANADEQUATEDIURESISAFALLIN".0AND
NODETERIORATIONINRENALFUNCTIONMAYBECANDIDATES
FOR CONTINUED DIURETICSVASODILATORS UNTIL EUVOLEMIA
IS REACHED (OPEFULLY THIS WILL LEAD TO A ".0 LEVEL
PGM,INTHESEPATIENTS)NONESTUDYPATIENTS
WHOSEDISCHARGE".0LEVELSWEREPGM,HADA
REASONABLELIKELIHOODOFNOTBEINGREADMITTEDWITHIN
THEFOLLOWINGDAYS)FTHE".0LEVELWAS
PGM, THE VOLUME STATUS REQUIRED REEVALUATION )F
THEPATIENTISNOTYETEUVOLEMICNESIRITIDEMIGHTBE
CONSIDEREDFORHOURS
)F PATIENTS AFTER RECEIVING n HOURS OF INTRAVENOUS
DIURETICSHAVEANINADEQUATEDIURESISNOCHANGEORAN
INCREASE IN ".0 AND WORSENING RENAL FUNCTION THEY
SHOULDBECONSIDEREDATHIGHRISK)FTHEIRSYSTOLIC"0
ISATLEASTMM(GTHEYCANBEGIVENnDAYSOF
*,&',(),#('+*#
"!&%('"%"!%+&+!%" &
,#',)*+',#'!/#,"1+)'
"1+#%0&#',#('
"+,0*1%.%
NESIRITIDEWITHIVDIURETICS".0CANTHENBECHECKED
HOURSAFTERCESSATIONOFNESIRITIDEANDORALVASODILATORS
ANDDIURETICSCANBEUSEDUNTILEUVOLEMIAISACHIEVED
0ATIENTSWITHSYSTOLIC"0SMM(GOFTENNEEDVA
SOPRESSORSANDORINOTROPESSOMETIMESUNDER3WAN
'ANZ GUIDANCE )N OUR EXPERIENCE AT THE #LEVELAND
#LINICIFTHESEINDIVIDUALSSHOWIMPROVEMENTIN"0
ANDSYMPTOMSWEWILLTHENTRANSITIONTHEIRTHERAPY
TO NESIRITIDE )F THERE IS NO IMPROVEMENT ON INOTRO
PESORPRESSORSFURTHERINVASIVESTRATEGIESSHOULDBE
CONSIDERED&INALLYITISCONCEIVABLETHATINPATIENTS
WHOAREADMITTEDWITHVERYHIGH".0LEVELSORHAVE
IMPAIRED RENAL FUNCTION NESIRITIDE MIGHT BE STARTED
IMMEDIATELY
-1,9
)NSUMMARYTHE".0#ONSENSUS0ANELOFHAS
PROVIDEDCONSENSUSAPPROACHESFORTHEUSEOF".0
FORTHEDIAGNOSISANDTREATMENTOF(&)DEALLYTHE
USEOFTHESERECOMMENDATIONSWILLIMPROVETHECARE
OFYOURPATIENTS
*,&',(),#('+ (*
/#,"(%'&#(&!&%'
&#+*'%"!!+&&
!#( "!%+"!&'"!
"!&%!
)&"'"%&+#%'!&)
"!&%
!!"'%"#&"%#""%#%(&"!
)!&
)!&
)!&
.*1-')*(%
%#'#%+-+)##('( (*
)+,"#+,(*1( .*1)*(%
)*(%
*,&',(),#('+'('*#
"!&%
#("!%+ "& &' #!( "!
&#&&
*,&',(),#('+(%'&&%$(%
"!&%!&%'#( "!%+"!&'"!
"%"%"%%! "+! !&''+
%'!! % !
*,&',(),#('+ (*
/#,"(*+"($
(%'&!"'%"#&)&"'"%&
!"%!&%''"""*
ˆ}ÕÀiÊ{°Ê
*Ê
œ˜Ãi˜ÃÕÃÊ
}œÀˆÌ…“
/Ê6"6 Ê,"Ê"Ê *Ê Ê/Ê "--Ê Ê/,/ /Ê
"Ê
\ÊÊÊ-1,9Ê"Ê/Ê *Ê
" - -1-Ê* Ê,*",/
,, -Ê
3ILVER7-AISEL!9ANCY#7-C#ULLOUGH0!"URNETT*#
&RANCIS'3-EHRA-20EACOCK7&&ONOROW''IBLER"
-ORROW$!(OLLANDER*".0#ONSENSUS0ANEL!#LINICAL
!PPROACHFORTHE$IAGNOSTIC0ROGNOSTIC3CREENING4REATMENT
-ONITORINGAND4HERAPEUTIC2OLESOF.ATRIURETIC0EPTIDESIN
#ARDIOVASCULAR$ISEASES#(&3UPPLn
#LERICO!)ERVASI'-ARIANI'#LINICALRELEVANCEOFTHE
MEASUREMENTOFCARDIACNATRIURETICPEPTIDEHORMONESINHUMANS
(ORM-ETAB2ESn
7IECZOREK3*7U!(#HRISTENSON2ETAL!RAPID"TYPE
NATRIURETICPEPTIDEASSAYACCURATELYDIAGNOSESLEFTVENTRICULAR
DYSFUNCTIONANDHEARTFAILUREAMULTICENTEREVALUATION!M(EART
*n
2EDlELD--2ODEHEFFER2**ACOBSEN3*ETAL0LASMABRAIN
NATRIURETICPEPTIDECONCENTRATIONIMPACTOFAGEANDGENDER*!M
#OLL#ARDIOLn
&RIESINGER'#&RANCIS*0ROMISESANDPERILSOFMANAGEDCAREFOR
OLDERPATIENTSWITHCARDIACDISEASE#ARDIOL#LINn
-AISEL!"TYPENATRIURETICPEPTIDELEVELSAPOTENTIALNOVEL
hWHITECOUNTvFORCONGESTIVEHEARTFAILURE*#ARD&AIL
n
"OOMAMA&6ANDER-EIRACKER!(0LASMA!AND"TYPE
NATRIURETICPEPTIDESPHYSIOLOGYMETHODOLOGYANDCLINICALUSE
#ARDIOVASC2ESn
4HE3/,6$)NVESTIGATORS%FFECTOFENALAPRILONMORTALITYAND
THEDEVELOPMENTOFHEARTFAILUREINASYMPTOMATICPATIENTSWITH
REDUCEDVENTRICULAREJECTIONFRACTIONSANDCONGESTIVEHEARTFAILURE
.%NGL*-EDn
-AIR*(AMMERER,ERCHER!0UCHENDORF"4HEIMPACTOFCARDIAC
NATRIURETICPEPTIDEDETERMINATIONONTHEDIAGNOSISANDMANAGEMENT
OFHEARTFAILURE#LIN#HEM,AB-EDn
3TEVENSON,74HELIMITEDAVAILABILITYOFPHYSICALSIGNSFOR
ESTIMATINGHEMODYNAMICSINCHRONICHEARTFAILURE*!-!
n
,UCHNER!3TEVENS4,"ORGESON$$ETAL$IFFERENTIALATRIAL
ANDVENTRICULAREXPRESSIONOFMYOCARDIAL".0DURINGEVOLUTIONOF
HEARTFAILURE!M*0HYSIOL(n(
(YPERTENSIONANDGENERALPOPULATIONRESEARCH(YPERTENSION
PT))n))
3TEIN",EVIN2.ATRIURETICPEPTIDESPHYSIOLOGYTHERAPEUTIC
POTENTIALANDRISKSTRATIlCATIONINISCHEMICHEARTDISEASE!M
(EART*n
7EIDMANN0(ASLER,'NADINGER-0ETAL"LOODLEVELSANDRENAL
EFFECTSOFATRIALNATRIURETICPEPTIDEINNORMALMAN*#LIN)NVEST
n
#HARLES#*%SPINER%!2ICHARDS!-#ARDIOVASCULARACTIONSOF
!.&CONTRIBUTIONSOFRENALNEUROHUMORALANDHEMODYNAMIC
FACTORSINSHEEP!M*0HYSIOL2n2
(UNT0*%SPINER%!.ICHOLLS-'ETAL$IFFERINGBIOLOGICAL
EFFECTSOFEQUIMOLARATRIALANDBRAINNATRIURETICPEPTIDEINFUSIONSIN
NORMALMAN*#LIN%NDOCRINOL-ETABn
-UKOYAMA-.AKAO+(OSODA+ETAL"RAINNATRIURETICPEPTIDE
ASANOVELCARDIACHORMONEINHUMANS%VIDENCEFORANEXQUISITE
DUALNATRIURETICPEPTIDESYSTEMATRIALNATRIURETICPEPTIDEANDBRAIN
NATRIURETICPEPTIDE*#LIN)NVESTn
$AVIDSON.#3TRUTHERS!$"RAINNATRIURETICPEPTIDE*
(YPERTENSIONn
3AGNELLA'!-EASUREMENTANDIMPORTANCEOFPLASMABRAIN
NATRIURETICPEPTIDEANDRELATEDPEPTIDES!NN#LIN"IOCHEM
n
#LERICO!)ERVASI'-ARIANI'#LINICALRELEVANCEOFTHE
MEASUREMENTOFCARDIACNATRIURETICPEPTIDEHORMONESINHUMANS
(ORM-ETAB2ESn
".0TESTFORRAPIDQUANTIlCATIONOF"TYPENATRIURETICPEPTIDE
;PACKAGEINSERT=3AN$IEGO#ALIF"IOSITE$IAGNOSTICS
7UERZ2#-EADOR3!%FFECTSOFPREHOSPITALMEDICATIONS
ONMORTALITYANDLENGTHOFSTAYIN(&!NN%MERG-ED
n
$EVERAUX2",IEBSON02(ORAN-*2ECOMMENDATIONS
CONCERNINGUSEOFECHOCARDIOGRAPHYINHYPERTENSIONANDGENERAL
POPULATIONRESEARCH(YPERTENSIONPT))n))
$AVIE!0&RANCIS#-,OVE-0ETAL6ALUEOFTHE
ELECTROCARDIOGRAMINIDENTIFYINGHEARTFAILUREDUETOLEFTVENTRICULAR
SYSTOLICDYSFUNCTION"-*
-AISEL!+RISHNASWAMY0.OWAK2-ETAL2APIDMEASUREMENT
OF"TYPENATRIURETICPEPTIDEINTHEEMERGENCYDIAGNOSISOFHEART
FAILURE.%NGL*-EDn
-UELLER#3CHOLER!,AULE+ILIAN+ETAL5SEOF"TYPE
NATRIURETICPEPTIDEINTHEEVALUATIONANDMANAGEMENTOFACUTE
DYSPNEA.%NGL*-EDn
7OLDE-4ULEVSKI))-ULDER*7ETAL"RAINNATRIURETICPEPTIDE
ASAPREDICTOROFADVERSEOUTCOMEINPATIENTSWITHPULMONARY
EMBOLISM#IRCULATION
,EUCHTE(((OLZAPFEL-"AUMGARTNER2!ETAL#LINICAL
SIGNIlCANCEOFBRAINNATRIURETICPEPTIDEINPRIMARYPULMONARY
HYPERTENSION*!##n
,UBIEN%$E-ARIA!+RISHNASWAMY0ETAL5TILITYOF"
NATRIURETIC0EPTIDE".0INDIAGNOSINGDIASTOLICDYSFUNCTION
#IRCULATIONn
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
+RISHNASWAMY0,UBIEN%#LOPTON0ETAL5TILITYOF"NATRIURETIC
PEPTIDE".0INELUCIDATINGLEFTVENTRICULARDYSFUNCTIONSYSTOLIC
ANDDIASTOLICINPATIENTSWITHANDWITHOUTSYMPTOMSOFCONGESTIVE
HEARTFAILUREATAVETERANSHOSPITAL!M*-EDn
-AISEL!3-C#ORD*-.OWAK2-ETAL"EDSIDE"TYPE
NATRIURETICPEPTIDEINTHEEMERGENCYDIAGNOSISOFHEARTFAILUREWITH
REDUCEDORPRESERVEDEJECTIONFRACTIONRESULTSFROMTHE"REATHING
.OT0ROPERLY".0MULTINATIONALSTUDY*!M#OLL#ARDIOL
n
(UBERT("&EINLEIB--C.AMARA0-AND#ASTELLI70
/BESITYASANINDEPENDENTRISKFACTORFORCARDIOVASCULAR
DISEASEAYEARFOLLOWUPOFPARTICIPANTSINTHE&RAMINGHAM
(EART3TUDY#IRCULATION-%$,).%
%CKEL2("AROUCH77%RSHOW!'2EPORTOFTHE.ATIONAL
(EART,UNGAND"LOOD)NSTITUTE.ATIONAL)NSTITUTEOF$IABETES
AND$IGESTIVEAND+IDNEY$ISEASES7ORKING'ROUPONTHE
0ATHOPHYSIOLOGYOF/BESITY!SSOCIATED#ARDIOVASCULAR$ISEASE
#IRCULATIONn
!LPERT-!,AMBERT#2AND0ANAYIOTOU(ETAL
2ELATIONOFDURATIONOFMORBIDOBESITYTOLEFTVENTRICULARMASS
SYSTOLICFUNCTIONANDDIASTOLIClLLINGANDEFFECTOFWEIGHTLOSS
!M*#ARDIOL-%$,).%
+ENCHAIAH3%VANS*#AND,EVY$ETAL/BESITYAND
THERISKOFHEARTFAILURE.%NGL*-ED
3ARZANI2$ESSI&ULGHERI00ACI6-%SPINOSA%AND
2APPELLI!*%XPRESSIONOFNATRIURETICPEPTIDERECEPTORSIN
HUMANADIPOSEANDOTHERTISSUES*%NDOCRINOL)NVEST
-%$,).%
3ENGENES#"ERLAN-$E'LISEZINSKI),AFONTAN-AND
'ALITZKY*.ATRIURETICPEPTIDESANEWLIPOLYTICPATHWAYIN
HUMANADIPOCYTES&!3%"*-%$,).%
-EHRA-25BER0!0ARK-ETAL/BESITYANDSUPPRESSED"TYPE
NATRIURETICPEPTIDELEVELSINHEARTFAILURE*!##n
+IKUTA+9ASUE(9OSHIMURA-ETAL)NCREASEDPLASMALEVELS
OF"TYPENATRIURETICPEPTIDEINPATIENTSWITHUNSTABLEANGINA!M
(EART*n
4ALWAR33QUIRE)"$OWNIE0&ETAL0LASMA.TERMINALPRO
BRAINNATRIURETICPEPTIDEANDCARDIOTROPHINARERAISEDINUNSTABLE
ANGINA(EARTn
DE,EMOS*!-ORROW$!"ENTLEY*(ETAL4HEPROGNOSTIC
VALUEOF"TYPENATRIURETICPEPTIDEINPATIENTSWITHACUTECORONARY
SYNDROMES.%NGL*-EDn
(ARRISON!-ORRISON,++RISHNASWAMY0ETAL"TYPE
NATRIURETICPEPTIDE".0PREDICTSFUTURECARDIACEVENTSINPATIENTS
PRESENTINGTOTHEEMERGENCYDEPARTMENTWITHDYSPNEA!NN%MERG
-EDn
#OLUCCI7%LKAYAM5(ORTON$ETAL)NTRAVENOUSNESIRITIDEA
NATRIURETICPEPTIDEINTHETREATMENTOFDECOMPENSATEDCONGESTIVE
HEARTFAILURE.%NGL*-EDn
3ILVER-!(ORTON$0'HALI*+ETAL%FFECTOFNESIRITIDEVERSUS
DOBUTAMINEONSHORTTERMOUTCOMESINTHETREATMENTOFPATIENTS
WITHACUTELYDECOMPENSATEDHEARTFAILURE*!M#OLL#ARDIOL
n
"URGER!(ORTON$,E*EMTEL4%FFECTSOFNESIRITIDE"TYPE
NATRIURETICPEPTIDEANDDOBUTAMINEONVENTRICULARARRHYTHMIAS
INTHETREATMENTOFPATIENTSWITHACUTELYDECOMPENSATED
CONGESTIVEHEARTFAILURETHE02%#%$%.4STUDY!M(EART*
n
0UBLICATION#OMMITTEEFORTHE6-!#)NVESTIGATORS6ASODILATORS
INTHE-ANAGEMENTOF!CUTE(&)NTRAVENOUSNESIRITIDEVS
NITROGLYCERINFORTREATMENTOFDECOMPENSATEDCONGESTIVEHEART
FAILUREARANDOMIZEDCONTROLLEDTRIAL*!-!n
!$(%2%3CIENTIlC!DVISORY#OMMITTEE4HE!CUTE
$ECOMPENSATED(EART&AILURE.ATIONAL2EGISTRY!$(%2%
OPPORTUNITIESTOIMPROVECAREOFPATIENTSHOSPITALIZEDWITHACUTE
DECOMPENSATEDHEARTFAILURE2EV#ARDIOVASC-EDSUPPL
3n3
-EHRA-25BER0!0OTLURI36ENTURA(/3COTT2,0ARK-(
5SEFULNESSOFANELEVATEDBTYPENATRIURETICPEPTIDETOPREDICT
ALLOGRAFT
#HENG6,+RISHNASWAMY0+AZANEGRA2ETAL!RAPIDBEDSIDE
TESTFOR"TYPENATRIURETICPEPTIDEPREDICTSTREATMENTOUTCOMESIN
PATIENTSADMITTEDWITHDECOMPENSATEDHEARTFAILURE*!M#OLL
#ARDIOLn
#OPYRIGHT%-#2%')NTERNATIONAL
,"1 Ê Ê -Ê,"ÊÊ
/Ê,Ê /" Ê,-/,9
7ILLIAM4!BRAHAM-$
#HIEF$IVISIONOF#ARDIOVASCULAR-EDICINE
4HE/HIO3TATE5NIVERSITY#OLLEGEOF-EDICINE
#OLUMBUS/(
"
/6-\
£°Ê iÃVÀˆLiÊ̅iʓi̅œ`ÃÊ>˜`Ê«ÀœViÃÃʜvÊ̅iÊ,ÊÀi}ˆÃÌÀÞ
Ó°Ê iÃVÀˆLiʅœÜÊw˜`ˆ˜}ÃʜvÊ̅iÊ,ÊÀi}ˆÃÌÀÞÊV>˜ÊLiÊÕÃi`Ê̜Ê`ˆÀiVÌÊ>˜`ʈ“«ÀœÛiÊV>ÀiÊ
vœÀÊÊ«>̈i˜ÌÃ
/,"1
/"
!CUTEDECOMPENSATEDHEARTFAILURE!$(&REPRESENTSAMAJORPUBLICHEALTHPROBLEM
)NTHE5NITED3TATESTHEREAREAPPROXIMATELYMILLIONHOSPITALIZATIONSANNUALLYWITH
APRIMARYDISCHARGEDIAGNOSISOF!$(&.EARLYTWICEASMANYHOSPITALIZATIONSAREAS
SOCIATEDWITHHEARTFAILUREASASECONDARYDIAGNOSIS4HESENUMBERSAREEXPECTEDTO
INCREASEOVERTHENEXTTWODECADES(EARTFAILURETAKESAPARTICULARLYHIGHTOLLONTHE
ELDERLY3INCETHEEARLYS!$(&HASBEENTHELEADINGCAUSEOFHOSPITALIZATIONIN
PERSONSOVERTHEAGEOFYEARS2EPORTEDDEATHRATESAPPEAREXCESSIVEBOTHDURING
ANDAFTERHOSPITALIZATIONANDHIGHREADMISSIONRATESSUGGESTTHATINPATIENTCAREDOESNOT
RESULTINEFFECTIVELONGTERMMANAGEMENT4HEENORMOUSDIRECTCOSTSASSOCIATEDWITH
TREATINGTHEMILLION!MERICANSWITHCHRONICHEARTFAILUREAREMOSTLYATTRIBUTABLETO
THEINPATIENTMANAGEMENTOFEPISODESOFDECOMPENSATION)THASBEENPROPOSEDTHAT
THESEDISMALSTATISTICSEXISTINPARTDUETOAPOORUNDERSTANDINGOFTHECHARACTERISTICS
OFPATIENTSADMITTEDWITH!$(&ANDHOWTOTREATTHEM)NTHISREGARDMOSTINFORMA
TIONABOUT!$(&ISDERIVEDFROMCLINICALTRIALSTHATARESMALLHUNDREDSOFPATIENTS
ANDPOORLYREPRESENTATIVEOFPATIENTSHOSPITALIZEDFOR!$(&DUETOTHEMANYINCLUSION
ANDEXCLUSIONOFSUCHTRIALS
!FEWREGISTRIESHAVEBEENDEVELOPEDTOEVALUATECHRONICHEARTFAILUREINTHEOUTPA
TIENTCOMMUNITYSETTING4HE!CUTE$ECOMPENSATED(EART&AILURE.ATIONAL2EGISTRY
!$(%2%WASDEVELOPEDTOPROVIDEALARGENATIONALDATABASEDESCRIBINGTHECLINICAL
CHARACTERISTICS PHYSICIAN PRACTICE AND TREATMENT PATTERNS AND OUTCOMES OF PATIENTS
HOSPITALIZEDWITH!$(&
-ETHODOLOGYOF!$(%2%
!$(%2% IS A LARGE MULTICENTER REG
ISTRY DESIGNED TO AMASS A LARGE CLINICAL
DATABASE ON THE CLINICAL CHARACTERISTICS
MANAGEMENT AND OUTCOMES OF PATIENTS
HOSPITALIZEDFOR!$(&ACROSSTHE5NITED
3TATES$ATAARECOLLECTEDONTHEEPISODE
OF HOSPITALIZATION BEGINNING WITH THE
POINTOFINITIALCAREANDENDINGWITHTHE
PATIENTS DISCHARGE TRANSFER OUT OF THE
HOSPITAL OR INHOSPITAL DEATH!$(%2%
IS SPONSORED BY 3CIOS )NC &REMONT
/…iÊVÕÌiÊ
iVœ“«i˜Ã>Ìi`Ê
i>ÀÌÊ>ˆÕÀiÊ >̈œ˜>Ê
,i}ˆÃÌÀÞÊ­,®Ê
Ü>ÃÊ`iÛiœ«i`Ê̜Ê
«ÀœÛˆ`iÊ>ʏ>À}i]ʘ>̈œ˜>Ê
`>Ì>L>ÃiÊ`iÃVÀˆLˆ˜}Ê̅iÊ
Vˆ˜ˆV>ÊV…>À>VÌiÀˆÃ̈VÃ]Ê
«…ÞÈVˆ>˜Ê«À>V̈ViÊ>˜`Ê
ÌÀi>̓i˜ÌÊ«>ÌÌiÀ˜Ã]Ê
>˜`ʜÕÌVœ“iÃʜvÊ
«>̈i˜ÌÃʅœÃ«ˆÌ>ˆâi`Ê
܈̅ʰ
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
#ALIFORNIA4HESPECIlCOBJECTIVESOF!$(%2%ARE
TODESCRIBETHEDEMOGRAPHICANDCLINICALCHARAC
TERISTICSOFPATIENTSWHOAREHOSPITALIZEDWITH!$(&
INCLUDINGSPECIlCSUBGROUPSOFINTERESTTOCHAR
ACTERIZETHEINITIALEMERGENCYDEPARTMENTEVALUATION
AND SUBSEQUENT INPATIENT MANAGEMENT OF PATIENTS
HOSPITALIZEDWITH!$(&TOIDENTIFYPATIENTCHAR
ACTERISTICSANDMEDICALCAREPRACTICESASSOCIATEDWITH
IMPROVED HEALTH OUTCOMES IN PATIENTS HOSPITALIZED
WITH!$(& TO CHARACTERIZE TRENDS OVER TIME IN
THEMANAGEMENTOF!$(&ANDTOASSISTHOSPITALS
IN EVALUATING AND IMPROVING QUALITY OF CARE FOR PA
TIENTSHOSPITALIZEDWITHHEARTFAILURE!DDITIONALGOALS
OF!$(%2%INCLUDEDEVELOPMENTOFPREDICTIVEMOD
ELS FOR MORTALITY COMPLICATIONS AND LENGTH OF HOS
PITALSTAYANDTOLINKWITHDEIDENTIlEDDATAONLON
GITUDINALTRENDSINTHECLINICALCAREANDOUTCOMESOF
REGISTRYPATIENTS!GGREGATEDATAFROMTHE!$(%2%
DATABASE IS ALSO USED FOR THE OBSERVATIONAL STUDY OF
TREATMENTEFFECTS
3ITES WERE SELECTED TO REPRESENT THE hREAL WORLDv OF
!$(& 3ITES INCLUDED BOTH ACADEMIC HOSPITALS
ANDNONACADEMICHOSPITALSHOSPITALSANDWERE
GEOGRAPHICALLY DIVERSE INCLUDING HOSPITALS IN THE
.ORTHEASTERN5NITED3TATESHOSPITALSINTHE3OUTH
HOSPITALSINTHE-IDWESTHOSPITALSINTHE7EST
ANDHOSPITALSINTHE-ID!TLANTICREGION3OMEOF
THE LARGEST ACUTE CARE HOSPITALS IN THE 5NITED 3TATES
AREPARTICIPATINGBUTSITESAREDIVERSEINSIZERANGING
FROMTOBEDS3ITESAREREIMBURSEDANOMINAL
FEEFOREACHCOMPLETEDCASEREPORTFORM
&ORTHEPURPOSEOFTHISREGISTRY!$(&ISDElNEDAS
EITHER NEWONSET HEART FAILURE OR DECOMPENSATION OF
CHRONICESTABLISHEDHEARTFAILUREWITHSYMPTOMSSUF
lCIENT TO WARRANT HOSPITALIZATION 0ATIENTS ARE IDEN
TIlED FOR INCLUSION IN THE REGISTRY FROM ADMISSIONS
GIVENADISCHARGEDIAGNOSISOFHEARTFAILUREBASEDON
)NTERNATIONAL#LASSIlCATIONOF$ISEASES.INTH2EVI
SION)#$CODING%LIGIBILITYISNOTCONTINGENTON
THEUSEOFANYPARTICULARTHERAPEUTICAGENTORREGIMEN
0ATIENTSMAYBEMALEORFEMALEANDMUSTBEATLEAST
YEARS OLD AT THE TIME OF HOSPITAL ADMISSION 4HE
REGISTRYISACCUMULATINGDATAONINDIVIDUALHOSPITAL
IZATIONSNOTINDIVIDUALPATIENTSANDITISPOSSIBLETHAT
SOME PATIENTS MAY BE ENROLLED IN THE REGISTRY MORE
THANONCE4HEGOALOFTHEREGISTRYISTOENROLLAREPRE
SENTATIVEPATIENTSAMPLE3ITESAREENCOURAGEDTOENROLL
ADMISSIONSMEETINGENTRYCRITERIAASCONSECUTIVELYAS
POSSIBLE(OSPITALSWITHMORETHANELIGIBLEPATIENTS
INAMONTHAREALLOWEDTOENROLLARANDOMSAMPLEOF
THESECONSECUTIVEADMISSIONSUSINGA*OINT#OMMIS
SION FOR !CCREDITATION OF (EALTHCARE /RGANIZATIONS
*#!(/nAPPROVEDSAMPLINGMETHOD3PECIlCATIONS
-ANUALFOR.ATIONAL)MPLEMENTATIONOF(OSPITAL#ORE
-EASURES*#!(/SECTION
$ATAARECOLLECTEDBYCHARTREVIEWANDENTEREDUSING
A WEBBASED ELECTRONIC DATA CAPTURE %$# SYSTEM
DESIGNEDBY0HASE&ORWARD7ALTHAM-ASSANDLI
CENSED BY THE STUDY CONTRACT RESEARCH ORGANIZATION
0HARMA,INK&()2ESEARCH4RIANGLE.#$ATAARE
RECORDED CONCERNING DEMOGRAPHICS MEDICAL HIS
TORY NONINTRAVENOUS AND INTRAVENOUS CARDIOVASCU
LAR MEDICATIONS INITIAL EVALUATION AT SITE HOSPITAL
CHRONICINFUSIONTHERAPYHOSPITALCOURSEDISPOSITION
AND PROCEDURES )NFORMATION RELATED TO FOUR SPECIlC
ASPECTSOFTHE*#!(/QUALITYIMPROVEMENTINITIATIVE
FORHEARTFAILUREAREALSOCAPTUREDPATIENTINSTRUC
TIONONDIETWEIGHTANDMEDICATIONMANAGEMENTAT
DISCHARGEASSESSMENTOFLEFTVENTRICULARSYSTOLIC
FUNCTION DOCUMENTED OR SCHEDULED ANGIOTENSIN
CONVERTINGENZYME!#%INHIBITORUSEATDISCHARGE
IN PATIENTS CONSIDERED CANDIDATES FOR THIS THERAPY
BASEDONACCEPTEDCLINICALCRITERIAANDCOUNSEL
INGONSMOKINGCESSATIONINCURRENTSMOKERS(UMAN
SUBJECTS CONSIDERATIONS PATIENT CONlDENTIALITY SITE
MONITORINGANDOTHERSPECIlCMETHODOLOGICALISSUES
HAVEBEENPREVIOUSLYOUTLINEDINDETAILELSEWHERE
,"1 Ê Ê -Ê,"ÊÊ
/Ê,Ê /" Ê,-/,9
)NSIGHTSFROM!$(%2%
&ROM/CTOBERTHROUGH$ECEMBER
HEART FAILURE DISCHARGES WERE ENROLLED IN!$(%2%
4HE MEAN AGE OF PATIENTS WAS YEARS AND WEREWOMEN-OSTPATIENTSWEREWHITEORBLACK
AND WERE COVERED BY -EDICARE OR -EDICAID
3EVENTYSIXPERCENTOFPATIENTSENROLLEDHADA
PRIORHISTORYOFHEARTFAILUREANDONETHIRDHADAHISTO
RYOFADMISSIONFOR!$(&WITHINTHEPRIORMONTHS
!HISTORYOFHYPERTENSIONWASCOMMONASWAS
CORONARY ARTERY DISEASE AND DIABETES /THER IMPORTANT OR COMMON COMORBID CONDITIONS
INCLUDED HISTORY OF ATRIAL lBRILLATION CHRONIC
OBSTRUCTIVE PULMONARY DISEASE OR ASTHMA ANDCHRONICRENALINSUFlCIENCY-OSTPATIENTS
PRESENTEDWITHDYSPNEA2ALESANDPERIPHERAL
EDEMA WERE PRESENT IN AND OF THE CASES
RESPECTIVELY /F PATIENTS WITH DOCUMENTED LEFT VEN
TRICULAREJECTIONFRACTIONPRIORTOADMISSIONHAD
PRESERVEDORONLYMILDLYDEPRESSEDSYSTOLICFUNCTION
4HECHARACTERISTICSOFPATIENTSENROLLEDIN!$(%2%
AREVERYDIFFERENTFROMTHOSEOFPATIENTSINCLUDEDIN
CLINICALTRIALSQ/>LiÊ£R
/>LiÊ£°ÊÊ
œ“«>ÀˆÃœ˜ÊœvÊ*>̈i˜ÌÃʘÀœi`ʈ˜Ê,>˜`œ“ˆâi`Ê
œ˜ÌÀœi`Ê/Àˆ>ÃʜvÊÊ6iÀÃÕÃÊ,°
4HEMEDIANLENGTHOFSTAYFORALLHOSPITALIZEDPATIENTS
WASDAYSMEANDAYS4HEINHOSPITALMORTAL
ITY RATE WAS FOR PATIENTS WHO RECEIVED
TREATMENT IN AN INTENSIVE CARE UNIT )#5 2EGISTRY
DATAONTHE*#!(/QUALITYOFCAREINDICATORSSHOWED
THAT ONLY OF PATIENTS WERE GIVEN INSTRUCTION ON
DIET WEIGHT MONITORING ACTIVITY LEVEL WORSENING
SYMPTOMS FOLLOWUP APPOINTMENTS AND MEDICATION
MANAGEMENT AT DISCHARGE !SSESSMENT OF LEFT VEN
TRICULAR SYSTOLIC FUNCTION WAS EITHER DOCUMENTED OR
SCHEDULEDINOFPATIENTS!TOTALOFOFTHE
PATIENTS JUDGED ELIGIBLE TO RECEIVE AN!#% INHIBITOR
BYSTANDARDCLINICALCRITERIAWEREDISCHARGEDONTHIS
MEDICATION#OUNSELINGONSMOKINGCESSATIONFORCUR
RENTSMOKERSWASGIVENTOOFELIGIBLEPATIENTS
!$(%2%-ORTALITY!NALYSES
4ODATETWOPRIMARYANALYSESOFMORTALITYHAVEBEEN
PERFORMEDON!$(%2%4HESEINCLUDEACLASSIlCATION
ANDREGRESSIONTREE#!24ANALYSISINALLPATIENTSTO
DElNECOVARIATEADJUSTEDODDSRATIOSOFDEATHAND
AMULTIVARIABLEREGRESSIONANDPROPENSITYANALYSISIN
PATIENTS RECEIVING )6 VASOACTIVE MEDICATIONS TO DE
lNECOVARIATEADJUSTEDPROBABILITYOFTREATMENT
4HEFORMERANALYSISALLOWSTHEDEVELOPMENTANDVALI
DATIONOFAPREDICTIVEMODELFORINHOSPITALMORTALITY
BASEDONPATIENTCHARACTERISTICSDISCERNEDATTHETIME
#HARACTERISTIC
#LINICAL4RIALS
!$(%2%
!VERAGE!GEYEARS
'ENDER7OMEN
)SCHEMIC%TIOLOGY
2ENAL)NSUFlCIENCY
5SUALLYEXCLUDED
0RESERVED,63YSTOLIC&UNCTION
5SUALLYEXCLUDED
!TRIAL&IBRILLATION
$IABETES
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
OFPRESENTATION4HATISTHE#!24ANALYSISPROVIDES
nFORTHElRSTTIMEnAWAYTOSTRATIFYPATIENTSFORRISK
OF INHOSPITAL MORTALITY 4HE LATTER ANALYSIS PERMITS
THECOMPARISONOFTREATMENTCHOICEONOUTCOME3PE
CIlCALLYTHECOVARIATEANDPROPENSITYSCOREADJUSTED
RISKOFINPATIENTMORTALITYWASEVALUATEDBYTREATMENT
STATUSCOMPARINGINTRAVENOUSDOBUTAMINEMILRINONE
NESIRITIDEANDNITROGLYCERINE
)NORDERTODEVELOPAPRACTICALUSERFRIENDLYBEDSIDE
TOOL FOR RISK STRATIlCATION FOR PATIENTS HOSPITALIZED
WITH!$(& #!24 ANALYSIS OF THE!$(%2% DATA
BASEWASPERFORMEDUSINGTHElRSTDISCHARGES
ENROLLED 4HE lRST HOSPITALIZATIONS FROM
/CTOBERTHROUGH&EBRUARYSERVEDASTHE
DERIVATION COHORT AND WERE ANALYZED TO DEVELOP THE
RISKPREDICTIONMODEL4HENTHEVALIDITYOFTHEMODEL
WASPROSPECTIVELYTESTEDUSINGDATAFROMSUB
SEQUENT HOSPITALIZATIONS VALIDATION COHORT ENROLLED
IN!$(%2%FROM-ARCHTHROUGH*ULY)N
HOSPITALMORTALITYWASSIMILARINTHEDERIVATION
ANDVALIDATIONCOHORTS2ECURSIVEPARTITIONING
OFTHEDERIVATIONCOHORTFORVARIABLESINDICATEDTHAT
THE BEST SINGLE PREDICTOR FOR MORTALITY WAS HIGH AD
MISSIONLEVELSOFBLOODUREANITROGEN*MGD,
ˆ}ÕÀiÊ£°ÊÊ
,Ê,ˆÃŽÊ
ÃÃiÃÓi˜ÌÊ/ÀiiÊvÀœ“Ê
,/ʘ>ÞÈðÊÊ`>«Ìi`Ê
vÀœ“Êœ˜>ÀœÜÊiÌÊ>]Ê
°ÊÓääxÆәÎ\xÇӇ
xnäÊ܈̅ʫiÀ“ˆÃȜ˜Ê
vÀœ“Ê̅iʓiÀˆV>˜Ê
i`ˆV>ÊÃÜVˆ>̈œ˜°
FOLLOWED BY LOW ADMISSION SYSTOLIC BLOOD PRESSURE
MM (G AND THEN BY HIGH LEVELS OF SERUM
CREATININE*MGD,!SIMPLERISKTREEIDENTI
lEDPATIENTGROUPSWITHMORTALITYRANGINGFROM
TO ­ˆ}ÕÀiÊ £® 4HE ODDS RATIO FOR MORTALITY
BETWEENPATIENTSIDENTIlEDASHIGHANDLOWRISKWAS
CONlDENCEINTERVALANDSIMI
LARRESULTSWERESEENWHENTHISRISKSTRATIlCATIONWAS
APPLIEDPROSPECTIVELYTOTHEVALIDATIONCOHORT4HESE
RESULTS SUGGEST THAT!$(& PATIENTS AT LOW INTERME
DIATE AND HIGH RISK FOR INHOSPITAL MORTALITY CAN BE
EASILYIDENTIlEDUSINGVITALSIGNANDLABORATORYDATA
OBTAINED ON HOSPITAL ADMISSION 4HE!$(%2% RISK
ASSESSMENTTOOLPROVIDESCLINICIANSWITHAVALIDATED
PRACTICALBEDSIDEINSTRUMENTFORMORTALITYRISKSTRATI
lCATION3IMILARTOTHECONTEMPORARYAPPROACHTOTHE
TRIAGEANDMANAGEMENTOFCHESTPAINPATIENTSBASEDON
RISKASSESSMENTATPRESENTATIONTHE!$(%2%#!24
ANALYSISMAYULTIMATELYHELPDIRECTTHEPLACEMENTAND
THERAPYOFPATIENTSPRESENTINGWITH!$(&
4O COMPARE INHOSPITAL MORTALITY OF!$(& PATIENTS
RECEIVINGPARENTERALTREATMENTWITHONEOFFOURINTRA
VENOUSVASOACTIVEMEDICATIONSARETROSPECTIVEANAL
YSIS OF DATA FROM !$(%2% WAS PERFORMED $ATA
,"1 Ê Ê -Ê,"ÊÊ
/Ê,Ê /" Ê,-/,9
WITH MILRINONE AND DOBUTAMINE RESPECTIVELY 4HE
CORRESPONDING VALUES FOR NESIRITIDE COMPARED WITH
MILRINONE AND DOBUTAMINE WERE n P
)ANDnP)RESPECTIVELY
4HEADJUSTED/2FORNESIRITIDECOMPAREDWITHNITRO
GLYCERINWASnP4HUSTHERA
PYWITHEITHERANATRIURETICPEPTIDEORVASODILATORWAS
ASSOCIATED WITH SIGNIlCANTLY LOWER INHOSPITAL MOR
TALITY THAN POSITIVE INOTROPIC THERAPY IN HOSPITALIZED
!$(&PATIENTSIN!$(%2%4HERISKOFINHOSPITAL
MORTALITYWASSIMILARFORNESIRITIDEANDNITROGLYCERIN
­/>LiÊ Ó® 4HESE OBSERVATIONS ARE CONSISTENT WITH
lNDINGS FROM RANDOMIZED CONTROLLED TRIALS AND SUP
PORT THE USE OF VASODILATORS NESIRITIDE OR NITROGLYC
ERINASlRSTLINEINTRAVENOUSAGENTSFORTHETREATMENT
OF!$(&4HESELECTIONOFASPECIlCINTRAVENOUSVA
SODILATORMAYBEGUIDEDBYTHERESULTSOFRANDOMIZED
CONTROLLEDTRIALS/FCOURSEINOTROPESMAYSTILLPLAY
AROLEFORTHOSEWHOPRESENTINORINIMPENDINGCAR
DIOGENICSHOCK
FROMTHElRSTPATIENTEPISODESFROM/CTOBER
THROUGH*ULYWEREINCLUDEDINTHISANALY
SIS #ASES IN WHICH PATIENTS RECEIVED NITROGLYCERIN
NESIRITIDE MILRINONE OR DOBUTAMINE WERE IDENTIlED
ANDREVIEWEDNTODETERMINEIFTHECHOICE
OFINTRAVENOUSVASOACTIVETHERAPYAFFECTEDINHOSPITAL
MORTALITY3INCETHECHOICEOFTHERAPYWASNOTDIRECT
EDBYAPROTOCOLBUTBYCLINICIANJUDGMENTORPREFER
ENCEPROPERADJUSTMENTBASEDONFACTORSINmUENCING
TREATMENT DECISION USING ADJUSTMENT FOR COVARIATES
ANDPROPENSITYSCORINGWEREMADE2ISKFACTORAND
PROPENSITY SCOREADJUSTED ODDS RATIOS /2S FOR IN
HOSPITALMORTALITYWERECALCULATED
0ATIENTS WHO RECEIVED INTRAVENOUS NITROGLYCERIN OR
NESIRITIDEHADLOWERINHOSPITALMORTALITYTHANTHOSE
TREATEDWITHDOBUTAMINEORMILRINONE4HERISKFACTOR
ANDPROPENSITYSCOREADJUSTED/2SFORNITROGLYCERIN
WERECONlDENCEINTERVAL;#)=n
P)ANDnP)COMPARED
/>LiÊÓ°Ê
œÀÌ>ˆÌÞÊ"``ÃÊ,>̈œÃʈ˜Ê*>ˆÀ‡7ˆÃiÊ/Ài>̓i˜ÌÊ
œ“«>ÀˆÃœ˜Ãʈ˜Ê̅iÊ,Ê,i}ˆÃÌÀÞ°ÊÊ
,i«Àˆ˜Ìi`Ê܈̅ʫiÀ“ˆÃȜ˜ÊvÀœ“ÊLÀ>…>“ÊiÌÊ>]Ê
ÊÓääxÊ­˜Ê*ÀiÃî°
!NALYSIS
.4'N
VS
-),N
.4'N
VS
$/"N
.%3N
VS
-),N
.%3N
VS
$/"N
.%3N
VS
.4'N
$/"N
VS
-),N
5NADJUSTED
o
o
o
o
o
o
!DJUSTEDFORCOVARIATES\\
o
o
o
o
p
e
!DJUSTEDFORCOVARIATES
ANDPROPENSITYSCOREr
o
o
o
o
p
e
XCLUDEFROMAHPI TNSKGBW 0
WISEANLY
ATIONDYSPE123MUR 6%& 5.," 3"0 -), .4'VS
o
P p
P e
P OR F AR ITE V CO ADJUSTMEN AND OR F AR ITE V CO AND
SCORE
ADJUSTMEN
SODIUM5.CREATN" \ $"0 X3"0ASERITNCLUDGV#O
AND YSP E r
YTREAMNCOPISLUDHBV#
6%& EIGHT,WA5.CRNSODUM" 3"0 $/ .%VS
EIGHTDYSPNAW 6%& ,AGE 3"0 -), .%VS
ATSYMPODUR 6%& 5.HEARSODIUM",T 3"0 $/ .4'VS
PROENSITY
HEAR T
ISONARE
ED MA
ION
ASCULRIZTONVEP
EDNOITARUMPYS &%6 ,ENITARC.5" 0"3 '4. SV3%
123MS
64&HEMOGLBINARDYSPT 3"0 -), $/VS
.OTE
W(OSMER,H GDNFlT ES NOT SIGlCA T ELV
MODELS ADJUSTE ORF RISK ACTOF ANDOR PROENSITYXC F
$/"COMPAR!EISNUDWHT.4V'
U L T I" PE C A S RO F W M N H G
ERONICTSDGlAU"FW
5." LODB UREA NITOG$"0 DIASTOLC B PRESU$/"
-), MILRNOE .%3 NESIRTD .4' NITROGLYCE /2 OD
YCARDIlBLTENUH64&V LODPRSYTICB
MS
RPAM &( OI
S ORF THE
ARITEDJUSVCO
ATORPECUV
AL U E S Y P V
UTAMINE DOB
DS ATIO R 3"0 ION
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
-1,9
,, -
2EGISTRIES SUCH AS !$(%2% MAY PROVIDE INSIGHTS
THATCANNOTBEDISCERNEDFROMRANDOMIZEDCONTROLLED
TRIALS(EARTFAILUREPATIENTSENROLLEDINCLINICALTRIALS
ARE VERY DIFFERENT THAN HEART FAILURE PATIENTS IN THE
COMMUNITY AS DEMONSTRATED BY THE CHARACTERISTICS
OF MORE THAN DISCHARGES FOR!$(& IN!$
(%2% 4HE !$(%2% REGISTRY PROVIDES IMPORTANT
INSIGHTSINTO!$(&TREATMENTANDOUTCOMESTHATMAY
FAVORABLYIMPACTFUTURECARE3PECIlCALLYITPROVIDES
USWITHAVALUABLERISKASSESSMENTTOOLANDWITHIN
SIGHTSINTOTHEEFFECTSOFTREATMENTSELECTIONONOUT
COMESIN!$(&PATIENTS
"ONNEUX,"ARENDREGT**-EETER+ETAL%STIMATINGCLINICAL
MORBIDITYDUETOISCHEMICHEARTDISEASEANDCONGESTIVEHEART
FAILURETHEFUTURERISEOFHEARTFAILURE!M*0UBLIC(EALTH
'HALI*+#OOPER2&ORD%4RENDSINHOSPITALIZATIONRATES
FORHEARTFAILUREINTHE5NITED3TATESEVIDENCEFOR
INCREASINGPOPULATIONPREVALENCE!RCH)NTERN-ED
!MERICAN(EART!SSOCIATIONHEARTANDSTROKESTATISTICAL
UPDATE$ALLAS4EX!MERICAN(EART!SSOCIATION
#UFFE-3#ALIFF2-!DAMS+&ETAL3HORTTERMINTRAVENOUS
MILRINONEFORACUTEEXACERBATIONOFCHRONICHEARTFAILUREA
RANDOMIZEDCONTROLLEDTRIAL*!-!
+RUMHOLZ(-0ARENT%-4U.ETAL2EADMISSIONAFTER
HOSPITALIZATIONFORCONGESTIVEHEARTFAILUREAMONG-EDICARE
BENElCIARIES!RCH)NTERN-ED
/#ONNELL*"4HEECONOMICBURDENOFHEARTFAILURE#LIN#ARDIOL
3UPPL)))
4HE3/,6$)NVESTIGATORS3TUDIESOFLEFTVENTRICULARDYSFUNCTION
3/,6$ˆRATIONALEDESIGNANDMETHODSTWOTRIALSTHATEVALUATE
THEEFFECTOFENALAPRILINPATIENTSWITHREDUCEDEJECTIONFRACTION
!M*#ARDIOL
&RANCIOSA*!!BRAHAM74&OWLER-ETAL2ATIONALEDESIGNAND
METHODSFORACOREGCARVEDILOLHEARTFAILUREREGISTRY#/(%2%
*#ARD&AIL
!DAMS+&/#ONNOR#-/REN2-ETAL$EVELOPMENTOFA
MULTICENTERHEARTFAILUREDATABASEINITIALREPORTFROMTHEUNITED
INVESTIGATORSTOEVALUATEHEARTFAILURE*#ARD&AIL
!CKNOWLEDGMENTS
4HE!$(%2%3CIENTIlC!DVISORY#OMMITTEE!$(%2%
)NVESTIGATORSAND#OORDINATORSAND3CIOS)NC-EMBERSOF
THE!$(%2%3CIENTIlC!DVISORY#OMMITTEEARE7ILLIAM
4!BRAHAM-$&!#0&!##4HE/HIO3TATE5NIVERSITY
(EART#ENTER#OLUMBUS/(+IRKWOOD&!DAMS*R-$
5NIVERSITYOF.ORTH#AROLINA#HAPEL(ILL.#2OBERT,
"ERKOWITZ -$ 0H$ (ACKENSACK 5NIVERSITY (OSPITAL
(ACKENSACK.*-ARIA2OSA#OSTANZO-$-IDWEST(EART
3PECIALISTS.APERVILLE),4ERESA$E-ARCO-$5NIVER
SITYOF#ALIFORNIA3AN&RANCISCO#!#HARLES,%MERMAN
-$#LEVELAND#LINIC#LEVELAND/('REGG#&ONAROW
-$!HMANSON5#,!#ARDIOMYOPATHY#ENTER,OS!N
GELES#!-ARIE'ALVAO-3.!.0#-ONTElORE-EDI
CAL#ENTER"RONX.9*4HOMAS(EYWOOD-$&!##
,OMA,INDA5NIVERSITY-EDICAL#ENTER,OMA,INDA#!
4HIERRY(,E*EMTEL-$!LBERT%INSTEIN(OSPITAL"RONX
.9,YNNE7ARNER3TEVENSON-$"RIGHAMAND7OMENS
(OSPITAL"OSTON-!AND#LYDE79ANCY-$&!##
5NIVERSITYOF4EXAS3OUTHWESTERN-EDICAL#ENTER-EDICAL
#ENTER$ALLAS48
!DAMS+&&ONAROW'#%MERMAN#,ETALFORTHE!$(%2%
3CIENTIlC!DVISORY#OMMITTEEAND)NVESTIGATORS#HARACTERISTICS
ANDOUTCOMESOFPATIENTSHOSPITALIZEDFORHEARTFAILUREINTHE
5NITED3TATESRATIONALEDESIGNANDPRELIMINARYOBSERVATIONS
FROMTHElRSTCASESINTHE!CUTE$ECOMPENSATED(EART
&AILURE.ATIONAL2EGISTRY!$(%2%!M(EART*
&ONAROW'#!DAMS+&!BRAHAM749ANCY#7FORTHE
!$(%2%3CIENTIlC!DVISORY#OMMITTEEAND3TUDY'ROUP2ISK
STRATIlCATIONFORINHOSPITALMORTALITYINACUTELYDECOMPENSATED
HEARTFAILURECLASSIlCATIONANDREGRESSIONTREE#!24ANALYSISOF
THE!$(%2%2EGISTRY*!-!
!BRAHAM74!DAMS+&&ONAROW'#ETALFORTHE!$(%2%
3CIENTIlC!DVISORY#OMMITTEEAND)NVESTIGATORSANDTHE!$(%2%
3TUDY'ROUP)NHOSPITALMORTALITYINPATIENTSWITHACUTE
DECOMPENSATEDHEARTFAILURETREATEDWITHINTRAVENOUSVASOACTIVE
MEDICATIONSANANALYSISFROMTHE!$(%2%2EGISTRY*!M#OLL
#ARDIOLINPRESS
0UBLICATION#OMMITTEEFORTHE6-!#)NVESTIGATORS)NTRAVENOUS
NESIRITIDEVSNITROGLYCERINFORTREATMENTOFDECOMPENSATED
CONGESTIVEHEARTFAILUREARANDOMIZEDCONTROLLEDTRIAL*!-!
#OPYRIGHT%-#2%')NTERNATIONAL
--Ê /Ê"Ê
1/Ê
"* -/Ê,/Ê
1,\Ê/Ê,Ê, 9Ê
Ê"1
2ICHARD,3UMMERS-$
$EPARTMENTOF%MERGENCY-EDICINE5NIVERSITYOF-ISSISSIPPI-EDICAL#ENTER
*ACKSON-3
"
/6-\
£°Ê ,iۈiÜÊ̅iʘiViÃÃ>ÀÞÊii“i˜ÌÃÊ>˜`Ê«ÀœViÃÃÊÀiµÕˆÀi`ÊvœÀÊ>ÊÜi‡œÀV…iÃÌÀ>Ìi`Ê`ˆÃi>ÃiÊ
“>˜>}i“i˜ÌÊ«Àœ}À>“
Ó°Ê ˆÃVÕÃÃÊ̅iʜLiV̈ÛiÃ]Ê`iÈ}˜Ê>˜`ʏœ}ˆÃ̈VÃʜvÊ̅iÊ,ʓiÀ}i˜VÞÊi`ˆVˆ˜iʜ`Տi
/,"1
/"
!MAJORFACTORLIMITINGTHELONGTERMEFlCACYOFCURRENTCONGESTIVEHEARTFAILURE#(&
TREATMENT STRATEGIES IS A LACK OF COMPELLING DATA CONlRMING WHICH APPROACHES AND
THERAPIESWORKBESTINMOSTCLINICALSITUATIONS3TUDIESHAVESHOWNTHATTHECAREGIVEN
TO#(&PATIENTSVARIESWIDELYBASEDONTHELOCATIONWHEREPATIENTSRECEIVETREATMENT
ANDTHESPECIALTYOFTHEPHYSICIANWHOTREATSTHEM)NTHEABSENCEOFANYESTABLISHED
STANDARDSORBESTPRACTICEGUIDELINESPHYSICIANSHAVELITTLEEVIDENCEONWHICHTOBASE
TREATMENTDECISIONS"ECAUSEOFTHISLACKOFCONSENSUSSTANDARDSMANY#(&PATIENTS
RECEIVE LESS THAN OPTIMAL CARE4HE .ATIONAL 2EGISTRY!$(%2% IS THE lRST NATIONAL
REGISTRYTHATPROSPECTIVELYCOLLECTSOBSERVATIONALDATAFROMACROSSTHE5NITED3TATESIN
ORDERTOTRACKANDSTUDYTHEMEDICALMANAGEMENTOFPATIENTSHOSPITALIZEDWITHACUTE
DECOMPENSATEDHEARTFAILURE!$(&!$(%2%ISSPONSOREDBY3CIOSANDOVERSEEN
BYANINDEPENDENTSCIENTIlCADVISORYCOMMITTEEOFNATIONALLYRECOGNIZEDHEARTFAILURE
EXPERTS4ODATEMORETHANHOSPITALSANDMORETHANPATIENTCASESHAVE
BEENENTEREDINTOTHE!$(%2%REGISTRYMAKINGITTHELARGESTMOSTEXTENSIVEREGISTRY
OFITSKIND
/…iÊ >̈œ˜>Ê,i}ˆÃÌÀÞÊ
,ʈÃÊ̅iÊwÀÃÌÊ
˜>̈œ˜>ÊÀi}ˆÃÌÀÞÊ̅>ÌÊ
«ÀœÃ«iV̈ÛiÞÊVœiVÌÃÊ
4HEORIGINALREGISTRYISREFERREDTOASTHE
#ORE 2EGISTRY !S INTEREST IN THE LONG
TERMOUTCOMESOFTHESEPATIENTSEMERGED
THE,ONGITUDINAL-ODULEWASDEVELOPED
TO FOLLOW THE COURSE OF THESE PATIENTS
BEYOND THE IMMEDIATE HOSPITALIZATION
AND INTO THE OUTPATIENT SETTING -ORE
RECENTLYTHE!$(%2%$ISEASE-ANAGE
MENT 1UALITY )NITIATIVE FOR #ARE "EGIN
NINGINTHE%MERGENCY$EPARTMENT-OD
ULE!$(%2%%$$-WASINITIATEDTO
GIVE INSIGHT INTO THE TREATMENT PATTERNS
AND OVERALL QUALITY OF DISEASE MANAGE
MENT $- OF!$(& IN THE EMERGENCY
SETTING
$ISEASE-ANAGEMENT
4RADITIONAL APPROACHES TO THE TREATMENT
OFDISEASEHAVEBEENAhCOMPONENTBASED
MANAGEMENT MODELv WHEREBY SELECTED
PORTIONS OF THE DISEASE ARE MANAGED BY
CERTAIN SPECIALISTS THAT ADDRESS SPECIlC
ASPECTS OF THE PATIENTS ILLNESS )N THIS
SYSTEM THE INTERNIST OR CARDIOLOGIST FO
CUSES ON THE LONGTERM MANAGEMENT OF
#(&WHEREASTHEEMERGENCYPHYSICIANIS
CONCERNEDWITHTHEACUTESTABILIZATIONOF
ADECOMPENSATEDSTATE4HENEWERCON
CEPTSOFDISEASEMANAGEMENTINCORPORATE
THE ENTIRE SPECTRUM OF PATIENT CARE AND
INCLUDE THE FULL USE OF ANCILLARY HEALTH
œLÃiÀÛ>̈œ˜>Ê`>Ì>Ê
vÀœ“Ê>VÀœÃÃÊ̅iÊ1˜ˆÌi`Ê
-Ì>ÌiÃʈ˜ÊœÀ`iÀÊ̜Ê
ÌÀ>VŽÊ>˜`ÊÃÌÕ`ÞÊ̅iÊ
“i`ˆV>Ê“>˜>}i“i˜ÌÊ
œvÊ«>̈i˜ÌÃÊ
…œÃ«ˆÌ>ˆâi`Ê܈̅Ê>VÕÌiÊ
`iVœ“«i˜Ã>Ìi`ʅi>ÀÌÊ
v>ˆÕÀiÊ­®°
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
CAREANDSOCIALSERVICES"ECAUSE!$(&PATIENTSHAVE
ACOMBINATIONOFBOTHANACUTEANDCHRONICCONDITIONIT
ISIMPORTANTTOBEGINTOCONSIDERTHELONGITUDINALCOURSE
OFTHEIRMANAGEMENTEVENASWEBEGINTHESTABILIZATION
PROCESSINTHEEMERGENCYDEPARTMENT%$4HISCON
SIDERATIONHASBECOMEMOREIMPORTANTINRECENTYEARS
ASTHE%$HASBECOMETHESAFETYNETANDPRIMARYCARE
PROVIDERFORMANYOFTHESEPATIENTS)TISNOTUNCOM
MONFOR!$(&PATIENTSTOBECOMEFREQUENTPATIENTS
INOUREMERGENCYDEPARTMENTS"YDEFAULTTHEEMER
GENCY PHYSICIAN THEN BECOMES RESPONSIBLE FOR THEIR
OVERALLCAREANDMUSTCONSIDERISSUESSUCHASACCESSTO
OUTPATIENTMEDICATIONSTHERAMIlCATIONSOFTHEIRINPA
TIENTMANAGEMENTANDTHELONGITUDINALIMPACTOFEARLY
TREATMENT DECISIONS WITHIN THE EMERGENCY SETTING
4HEREISCONSIDERABLEEVIDENCETOSUGGESTTHATTHETREAT
MENTPLANINITIATEDBYTHEEMERGENCYPHYSICIANHASA
SIGNIlCANTIMPACTONTHELONGTERMOUTCOMESOFOTHER
COMMON DISEASE PROCESSES SUCH AS PNEUMONIA AND
ACUTE CORONARY SYNDROMES )T IS REASONABLE TO EXPECT
THATTHESAMEWOULDBETRUEINTHETREATMENTOF!$(&
4HERE ARE TYPICALLY THREE COMMON ELEMENTS TO ANY
WELLORCHESTRATEDDISEASEMANAGEMENTPROGRAM
)DENTIFYPATIENTSATELEVATEDRISKOFADVERSE
OUTCOMES
)NTERVENTIONTOREDUCETHOSERISKS
3YSTEMATICEVALUATIONTOASSESSTHEIMPACTOFTHE
INTERVENTION
ˆ}ÕÀiÊ£°Ê
/…iÊVœ˜}iÃ̈œ˜Ê>˜`ÊyՈ`ÊÀiÌi˜Ìˆœ˜Ê
œvÊ̅iʅi>ÀÌÊv>ˆÕÀiÊÃÌ>ÌiʈÃÊ>Ê
˜>ÌÕÀ>Ê«…ÞȜœ}ˆVÊ>`ÕÃ̓i˜ÌÊ̜Ê
>Ê`ÞÃv՘V̈œ˜>Ê-Ì>Àˆ˜}‡6i˜œÕÃÊ
,iÌÕÀ˜ÊÀi>̈œ˜Ã…ˆ«°Ê
"ÊrÊV>À`ˆ>VÊ
œÕÌ«ÕÌ°Ê6,ÊrÊÛi˜œÕÃÊÀiÌÕÀ˜
'OODDISEASEMANAGEMENTPRACTICEALSOREQUIRESTHE
PHYSICIANTOTHINKABOUTTHEPATIENTSPATHOLOGYFROM
BOTHTHESHORTTERMANDLONGTERMMANAGEMENTPER
SPECTIVES4HIS IS PARTICULARLY IMPORTANT WHEN TREAT
ING CHRONIC DISEASES SUCH AS #(& DUE TO THE DIFFER
ENCES IN THE PATHOPHYSIOLOGIC MECHANISMS INVOLVED
IN THE ACUTE AND CHRONIC PRESENTATIONS #(& IN ITS
ACUTELY DECOMPENSATED FORM IS PRIMARILY A PROBLEM
OFPLUMBING7ITHINTHEVASCULARCONDUITSINVOLVED
IN!$(&THEREISAMISMATCHINTHEPRESSURESRESIS
TANCESANDmUIDVOLUMESREQUIREDTOMAINTAINBLOOD
mOWORCARDIACOUTPUTWHICHFURTHERRESULTSINACON
GESTIVE STATE THAT LIMITS OXYGENATION BY THE LUNGS
4HISCONDITIONHASTHEPOTENTIALFORPOSITIVEFEEDBACK
ANDCANRAPIDLYSPIRALTOANUNSTABLESTATE4RADITIONAL
THERAPIESSUCHASNITROGLYCERINMORPHINEANDDIURET
ICS CAN AMELIORATE THE CONGESTION BY MANIPULATION
OFTHEACUTEPLUMBINGDERANGEMENT4HERESULTISA
DRAMATIC CHANGE IN THE IMMEDIATE CLINICAL SITUATION
ANDTHEPATIENTOFTENAPPEARSALMOSTBACKTONORMAL
INTERMSOFSYMPTOMS(OWEVERDESPITETHISILLUSION
OFSTABILITYTHECHRONICPATHOPHYSIOLOGYOF#(&AND
THE UNDERLYING CAUSE OF THE DECOMPENSATION IS STILL
PRESENT4HECONGESTIONANDmUIDRETENTIONOFTHE
HEARTFAILURESTATEISANATURALPHYSIOLOGICADJUSTMENT
TO A DYSFUNCTIONAL 3TARLING6ENOUS 2ETURN RELATION
SHIPANDISNECESSARYTOBRINGCARDIACOUTPUTBACKTO
NORMAL­ˆ}ÕÀiÊ£® 4HECOSTOFTHISADJUSTMENTIS
--Ê /Ê"Ê
1/Ê
"* -/Ê,/Ê
1,\Ê/Ê,Ê, 9Ê
Ê"1
HIGHER ATRIAL PRESSURES THAT CAN LEAD TO
PULMONARY EDEMA AND DYSPNEA WHICH
BRINGS THE PATIENT ACUTELY TO THE %$ )F
THISMECHANISMISNOTTAKENINTOCONSID
ERATION IN THE DISPOSITION OF STABILIZED
!$(& PATIENT THEN THERE IS TREMENDOUS
POTENTIAL FOR OVERALL TREATMENT FAILURE
0ROPERDISEASEMANAGEMENTALSOREQUIRES
AGLOBALPERSPECTIVEOFALLASPECTSOFTHE
PATIENTSPATHOPHYSIOLOGYTOBESUCCESS
FUL
)N THE PAST FEW DECADES WE SAW AN EM
PHASISONANEVIDENCEBASEDAPPROACHTO
$-WITHAFOCUSONUTILIZINGRESULTSFROM
CLINICALTRIALSTODICTATETHEBESTTREATMENT
OPTIONSFORPATIENTSWITHSPECIlCDISEASE
STATES OR PRESENTATIONS -ORE RECENTLY
WEHAVEBEGUNTOREALIZETHENECESSITYOF
BALANCING THIS POPULATIONBASED PROBA
BILISTIC VIEW OF TREATMENT WITH A SCIEN
TIlCORIENTEDANALYSISOFTHEPHYSIOLOGIC
NUANCES OF THE INDIVIDUAL PATIENT IN A
GOALDIRECTEDAPPROACHTOMANAGEMENT
!$(&$-ISESPECIALLYAMENABLETOTHIS
NOTIONSINCETHEREISLITTLECURRENTTRIALS
BASED INFORMATION AND THE PATHOPHYSI
OLOGIC SPECTRUM OF DISEASE PRESENTATION
IS VARIED (OWEVER AS WE DEVELOP AN
EMERGENCYMEDICINE!$(&$-STRATEGY
ITISIMPORTANTTHATWELOOKATTHEPROCESS
AS A WHOLE AND THE IMPACT OF TREATMENT
PLANSONOUTCOMES
&ORALLTHESEREASONSAREGISTRYTHATTRACKS
THE COURSE OF PATIENTS WITH!$(& FROM
THEEMERGENCYMEDICINEPERSPECTIVECAN
BEINSTRUMENTALINDElNINGTHEBESTPRAC
TICESFORFUTURE$-
!$(%2%%MERGENCY-EDICINE
-ODULE
4HE !$(%2% %MERGENCY -EDICINE
-ODULE IS EXPECTED TO BE THE VEHICLE
THROUGH WHICH A COMPREHENSIVE DISEASE
MANAGEMENT PROCESS IS DEVELOPED FROM
THE UNIQUE PERSPECTIVE OF EMERGENCY
MEDICINEASASPECIALTY"UILDINGONPRIOR
!$(%2%PROGRAMSTHISMODULEWASDE
SIGNEDBYEMERGENCYPHYSICIANSWITHTHE
INTENTIONOFANSWERINGSPECIlCQUESTIONS
OFINTERESTTOTHOSEMANAGING!$(&PA
TIENTSTHATPRESENTTOTHE%$ANDFOLLOWS
THEIRHOSPITALCOURSEANDOUTCOMES
0ROGRAM/BJECTIVES
4HEMAINOBJECTIVESOF!(%2%%$$-
ARE
$EVELOPALARGECLINICAL!$(&
DATABASEFROMACUTECAREHOSPITALS
ACROSSTHE5NITED3TATES
%XAMINETHECURRENTNATIONALSTATE
OFMEDICALMANAGEMENTOFPATIENTS
PRESENTINGTOTHE%$FOR!$(&
#OMPAREPREPOSTOUTCOMESOF
IMPLEMENTATIONOFA$ISEASE
-ANAGEMENTPROGRAMFOR%$
PRESENTATIONSOF!$(&
ÃÊÜiÊ`iÛiœ«Ê>˜Ê
i“iÀ}i˜VÞʓi`ˆVˆ˜iÊ
ÊÊÃÌÀ>Ìi}ÞʈÌʈÃÊ
ˆ“«œÀÌ>˜ÌÊ̅>ÌÊÜiʏœœŽÊ
>ÌÊ̅iÊ«ÀœViÃÃÊ>ÃÊ>Ê
܅œiÊ>˜`Ê̅iÊÊ
ˆ“«>VÌʜvÊÌÀi>̓i˜ÌÊ
«>˜Ãʜ˜ÊœÕÌVœ“ið
3OMEOFTHESECONDARYOBJECTIVESINCLUDE
!SSISTHOSPITALSINEVALUATINGAND
IMPROVINGQUALITYOFCAREBY
A TRACKINGQUALITYINDICATORS
B PROVIDINGMONTHLYANDQUARTERLY
SITESPECIlCAND5NITED3TATES
BENCHMARKDATA
#HARACTERIZETRENDSOVERTIMEINTHE
MANAGEMENTOF!$(&
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
&ORTHE!$(&PATIENTINAN%$
SETTING
A $ESCRIBEDEMOGRAPHICANDCLINI
CALCHARACTERISTICSOF!$(&
B #HARACTERIZETHEINITIAL%$
EVALUATIONSUBSEQUENTMAN
AGEMENT
C )DENTIFYCHARACTERISTICSAND
MEDICALCAREASSOCIATEDWITH
IMPROVEDOUTCOMES
œ“«œ˜i˜ÌÃʜvÊ̅iÊÊ
Ê«Àœ}À>“ʈ˜VÕ`i\
£°Ê /Ài>̓i˜ÌÊ>}œÀˆÌ…“ÃÊ
Ó°Ê "À`iÀÊ-iÌÃ
Î°Ê *…ÞÈVˆ>˜É, Ê
i`ÕV>̈œ˜
{°Ê *>̈i˜ÌÊ`ÕV>̈œ˜
x°Ê ˆÃV…>À}iʘÃÌÀÕV̈œ˜Ã
È°Ê ii`L>VŽÊœœ«Ê­`>Ì>Ê
“œ˜ˆÌœÀˆ˜}Ê̜œÃ®
0ROGRAM$ESIGN
/VERVIEW4HE STUDY DESIGN IS THAT OF A
MULTICENTER CONTINUOUS OBSERVATIONAL
QUALITY IMPROVEMENT INITIATIVE FOCUSING
ON THE MANAGEMENT OF PATIENTS TREATED
IN THE HOSPITAL FOR!$(& IN THE 5NITED
3TATES WITH AN EMPHASIS ON EMERGENCY
MEDICAL CARE )T IS EXPECTED THAT THERE
WILLAPPROXIMATELYHOSPITALSPARTICI
PATING CONTINUOUSLY ENROLLING PATIENTS
FORABOUTMONTHSORUPTOPA
TIENTEPISODES3ITESAREELIGIBLETOPAR
TICIPATE IF THEY ARE A CURRENT !$(%2%
SITEORIFTHEYAREINTHETOPLARGEST
5NITED3TATESACUTECAREHOSPITALSWITHA
MEDIANNUMBEROFANNUAL(&DISCHARGES
OF^PATIENTS3ELECTEDACADEMICAND
COMMUNITYHOSPITALSWILLBEEQUALLYDIS
TRIBUTEDALONGTHESPECTRUMOF(&PATIENT
VOLUMEANDGEOGRAPHY#OMPONENTSOF
THE%$$-PROGRAMINCLUDE
4REATMENTALGORITHMS
/RDER3ETS
0HYSICIAN2.EDUCATION
0ATIENT%DUCATION
$ISCHARGE)NSTRUCTIONS
&EEDBACKLOOPDATAMONITORING
TOOLS
0ATIENTPOPULATION0ATIENTELIGIBILITYIS
NOTLINKEDTOASPECIlCTHERAPEUTICAGENT
OR REGIMEN 0ATIENTS ELIGIBLE FOR ENTRY
INTOTHE!$(%2%2EGISTRYINCLUDETHOSE
OVER THE AGE OF ADMITTED TO AN ACUTE
CARE HOSPITAL AND TREATED ACTIVELY FOR
!$(&EITHERASANEWONSETWITHDECOM
PENSATIONORASCHRONICHEARTFAILUREWITH
DECOMPENSATION4HISWOULDINCLUDETHOSE
PATIENTS WHO RECEIVE A PRINCIPAL %$ OR
HOSPITALDISCHARGEDIAGNOSISOF!$(&OR
ISDIAGNOSEDCLINICALLYANDISDOCUMENTED
INTHE$2'CODES0ATIENTSAREEXCLUDED
IF!$(&ISACOnMORBIDCONDITIONBUTIS
NOTAPRINCIPALFOCUSOFDIAGNOSISORTREAT
MENTDURINGTHE%$ORHOSPITALEPISODE
3TAFFAND)NSTITUTIONALREQUIREMENTS
3ITESMUSTCOMMITTOUTILIZINGA
$-STRATEGYANDWILLBEREQUIRED
TOIMPLEMENTATLEASTTHREEOFlVE
COMPONENTSLISTEDBELOW
%ACHSITEMUSTHAVE
s /NE%$0HYSICIANASTHE0RINCIPAL
OR#OPRINCIPALINVESTIGATOR
s /NEDEDICATED2EGISTRY
#OORDINATOR
A 2EQUIRESACCESSTOALL%$AND
HOSPITALCHARTDATA
B #ANPERFORMELECTRONICDATA
CAPTURE%$#ENTRY
s )NPATIENTPHYSICIANSSUCHAS
CARDIOLOGISTS
A %NCOURAGEDTOPARTICIPATEAS
A#OPRINCIPALINVESTIGATOR
TOFACILITATEAFULLYINTEGRATED
$-1UALITY)MPROVEMENT
PROGRAM
s %$(&ALGORITHM
s (&ADMISSIONORDERS
--Ê /Ê"Ê
1/Ê
"* -/Ê,/Ê
1,\Ê/Ê,Ê, 9Ê
Ê"1
s 0ATIENTDISCHARGEINSTRUCTIONS
s 0HYSICIAN(&EDUCATION
s 0ATIENT(&EDUCATION
$ATA#OLLECTION4HE!$(%2%2EGISTRYISALARGE
DATABASEOFPRIMARYCLINICALINFORMATIONCOLLECT
EDFROMHOSPITALRECORDSOFPATIENTSATSELECTIN
STITUTIONSNATIONWIDE.OPRIORREGISTRYHASCON
DUCTEDRESEARCHATTHISLEVELONTHECLINICALCARE
OF PATIENTS WITH!$(& 5SING MEDICAL RECORDS
DATA ARE COLLECTED FROM THE POINT OF INITIAL CARE
THROUGHPATIENTDISCHARGEFROMTHEHOSPITAL4HE
REGISTRY IS COMPLETELY CONlDENTIAL AND ALL PA
TIENTDATAAREKEPTANONYMOUSTHROUGHENCRYPTED
TREATMENT$ATAINCLUDE
%
%
%
%
%
%
%
%
$EMOGRAPHICS
%-3DATA
-EDICALHISTORY
)NITIALMEDICALEVALUATION
(OSPITALCOURSE
-EDICATIONS
0ROCEDURES
% %$#SYSTEMACCESSISCONTROLLEDBYTHEDATA
COORDINATIONCENTERANDSYSTEMENTRYISLIMITED
BYUSERNAMEPASSWORDnPROTECTEDLOGON
PROCEDURES
% (OSPITALSWILLBEPREVENTEDFROMACCESSING
ELECTRONICCASEREPORTFORMSORAGGREGATEDATA
FROMANYHOSPITALOTHERTHANTHEIROWN
4OFOLLOWTHEPATIENTACROSSRECURRINGVISITSTHE,ON
GITUDINAL 5NIQUE )DENTIlER ,5)$ SYSTEM WILL BE
UTILIZEDFORCONlDENTIALITY
s
s
s
$ISPOSITION
4HEPROGRAMISDESIGNEDTOCOLLECTDATASURROUNDING
THEEPISODEOFHOSPITALCARETHATBEGINSINTHE%$AS
THEPOINTOFINITIALCAREANDENDSWITH%$ORHOSPITAL
DISCHARGETRANSFERORDEATH)FTHEINSTITUTIONISALSO
APARTOFTHE!$(%2%CORETHEPATIENTMAYTRACKED
UP TO DAYS AFTER ADMISSION $ATA ARE COLLECTED
THROUGHAN)NTERNETBASED%$#SYSTEM0ARTICIPATING
INSTITUTIONSENTERDATAUSINGASTANDARDWEBBROWSER
CONNECTEDTOAN%$#SYSTEMCUSTOMIZEDFORTHE!$
(%2%REGISTRY4HESYSTEMHASBEENFULLYTESTEDAND
ISCOMPLIANTWITHFEDERALREGULATIONS
% #&2'UIDANCEON#OMPUTERIZED3YSTEMS
USEDIN#LINICAL4RIALSAND)#('#0GUIDELINES
% !LLSITESTAFFWILLBETRAINEDONTHESEREGULATIONS
s
#OMPUTERGENERATEDUNIQUEIDENTIlER
A ,5)$ENCRYPTIONUSESTHE53&EDERAL
3TANDARD3(!
B 4HE,5)$ALGORITHMWILLBEINDEPENDENTLY
VALIDATEDBY"OOZ!LLEN(OMELAND3ECURITY
)NFORMATION!SSURANCE#IVIL"USINESS
3EGMENT
7ITHAGIVENSETOFVARIABLESA,5)$IS
GENERATEDTHATCANNOTBERELATEDBACKTOAN
INDIVIDUAL
0ATIENTLEVELVARIABLESUSEDTOCONSTRUCTTHE
,5)$ARENOTSTOREDINTHESYSTEMANDTHIS
INFORMATIONCANNOTBEDEENCRYPTEDFROMTHE
,5)$STOREDINTHEDATABASE
4HE,5)$ISSTOREDINTHEDATABASEALONGWITH
PATIENTDATAANDALLOWSFORLONGITUDINALTRACKING
OFHOSPITALREADMISSIONSANDPATIENTOUTCOMES
%NDPOINTS )N ORDER TO MEET THE OVERALL OBJECTIVES
OF THE 0ROGRAM A NUMBER OF SPECIlC ENDPOINTS ARE
TARGETEDFROMWITHINTHEDATACOLLECTIONPROCESS4HE
MOSTIMPORTANTOFTHESEAREASOFFOCUSINCLUDE
)MPACTOF$ISEASE-ANAGEMENT4OOLSON/UTCOMES
s ,ENGTHOFSTAYSYMPTOMATOLOGY
s 2ECIDIVISMTIMETOTREATMENT
$ISPOSITIONOF0ATIENT
s BASEDONPRESENTATIONPARAMETERSIE
#R
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
)MPACTOFDIURETICSRELATIVETOOUTCOMES
s $OSEANDTIMING
s $ElNINGWHICHPATIENTSARERESPONDERS
"I0!0#0!0
s )MPACTONDRUGTHERAPY
s )MPACTONSYMPTOMSOUTCOMES
s /XYGEN3ATURATIONS
2ESOURCEUTILIZATION
s "ENElTOFOBSERVATIONUNITS
4REATING0HYSICIANS
s 0RIMARY#ARE3PECIALISTSAND#ONSULTANTS
1UALITY )NITIATIVE 4HE!$(%2% 2EGISTRY ISSUES A
"ENCHMARK2EPORTEACHQUARTERTOPARTICIPATINGCLIN
ICS AND HOSPITALS 4HESE REPORTS SUMMARIZE REGISTRY
DATACOLLECTEDONACUTEHEARTFAILURETREATMENTDURING
THE PREVIOUS YEAR 4HE REPORTS ALSO MAKE AVAILABLE
INSTITUTIONSPECIlC REGIONAL AND NATIONAL STATISTICS
SUCHASQUALITYINDICATORSTOPARTICIPATINGHOSPITALS
INORDERTOHELPTHEMEVALUATEANDIMPROVETHECARE
THEYPROVIDETOPATIENTS4HEGOALISFORTHEINDIVIDUAL
HOSPITALTOUTILIZETHISINFORMATIONTOEFFECTCHANGEIN
ORDERTOOPTIMIZEOVERALLDISEASEMANAGEMENT
,, &ONAROW'#!$(%2%3CIENTIlC!DVISORY#OMMITTEE4HE!CUTE
$ECOMPENSATED(EART&AILURE.ATIONAL2EGISTRY!$(%2%
OPPORTUNITIESTOIMPROVECAREOFPATIENTSHOSPITALIZEDWITHACUTE
DECOMPENSATEDHEARTFAILURE2EV#ARDIOVASC-ED
3UPPL3
0EACOCK7&2APIDOPTIMIZATIONSTRATEGIESFOROPTIMALCAREOF
DECOMPENSATEDCONGESTIVEHEARTFAILUREPATIENTSINTHEEMERGENCY
DEPARTMENT2EV#ARDIOVASC-ED3UPPL3
%MERMAN#,#OSTANZO-2"ERKOWITZ2,#HENG-!$(%2%
3CIENTIlC!DVISORY#OMMITTEE%ARLYINITIATIONOF)6VASOACTIVE
THERAPYIMPROVESHEARTFAILUREOUTCOMESANANALYSISFROMTHE
!$(%2%2EGISTRYDATABASE!NN%MERG-ED
0EACOCK7&(EARTFAILUREMANAGEMENTINTHEEMERGENCY
DEPARTMENTOBSERVATIONUNIT0ROG#ARDIOVASC$IS
'UYTON!#0HYSIOLOGYOFHEARTFAILURE4RANS!M#OLL#ARDIOL
(ALL*%'UYTON!#-IZELLE(,2OLEOFTHERENINANGIOTENSIN
SYSTEMINCONTROLOFSODIUMEXCRETIONANDARTERIALPRESSURE!CTA
0HYSIOL3CAND3UPPL
3UMMERS2,%VIDENCEDBASEDMEDICINEVSSCIENTIlCREASONING
!CAD%MERG-ED
0EACOCK7&!LLEGRA*!NDER$#OLLINS3$IERCKS$%MERMAN
#+IRK*$3TARLING23ILVER-3UMMERS2,-ANAGEMENT
OF!CUTE$ECOMPENSATED(EART&AILUREINTHE%MERGENCY
$EPARTMENT#ONG(EART&AILSUPPL
-1,9\
!$(& IS EXPECTED TO BECOME ON THE MOST DIFlCULT
MEDICALANDlNANCIALPROBLEMSFACINGOURHEALTHCARE
SYSTEMS 0RELIMINARY EVIDENCE FROM THE !$(%2%
#ORE 2EGISTRY AND A NUMBER OF OTHER CLINICAL TRIALS
INDICATETHATTHEEMERGENCYDEPARTMENTSHOULDBETHE
FOCAL POINT FOR THE DISEASE MANAGEMENT PROCESS OF
!$(&4HE!$(%2%%$$-PROGRAMPRESENTSA
REALOPPORTUNITYFORTHEEMERGENCYMEDICINECOMMU
NITYTOBETTERUNDERSTANDTHEISSUESSURROUNDINGTHIS
DISEASESTATEANDTOOBJECTIVELYOUTLINETHEBESTCOURSE
FOROVERALLDISEASEMANAGEMENT
#OPYRIGHT%-#2%')NTERNATIONAL
1/Ê
"* -/Ê,/Ê1,ÊÊ
--Ê /Ê/""3EAN0#OLLINS-$
$EPARTMENTOF%MERGENCY-EDICINE5NIVERSITYOF#INCINNATI#OLLEGEOF-EDICINE
#INCINNATI/(
"
/6-\
£°Ê ˆÃVÕÃÃÊVœ“«œ˜i˜ÌÃʜvÊi“iÀ}i˜VÞÊ`i«>À̓i˜Ìʅi>ÀÌÊv>ˆÕÀiÊ`ˆÃi>Ãiʓ>˜>}i“i˜ÌÊ̜œÃ
Ó°Ê /œÊ՘`iÀÃÌ>˜`ʅœÜÊ`ˆÃi>Ãiʓ>˜>}i“i˜ÌÊ̜œÃÊVœÕ`ʈ“«ÀœÛiÊ̅iÊV>ÀiʜvÊi“iÀ}i˜VÞÊ
`i«>À̓i˜ÌÊ«>̈i˜ÌÃÊ܈̅ʅi>ÀÌÊv>ˆÕÀi
/,"1
/"
4HERISINGPREVALENCEANDCOSTOFCAREFORHEARTFAILUREISSTAGGERING!LMOSTMILLION
!MERICANSHAVEHEARTFAILUREWITHNEWCASESDIAGNOSEDEACHYEARATATOTAL
COSTOFBILLION4HEINCIDENCEISEXPECTEDTOCONTINUETOINCREASEDRAMATICALLY
DUETOOURAGINGPOPULATIONPREVALENCEOFHEARTFAILUREININDIVIDUALSOVERAGE
IMPROVEDSURVIVALFROMACUTECORONARYSYNDROMES!#3ANDMANAGEMENTAD
VANCES IN CARDIOVASCULAR DISEASES (OSPITALIZATION ACCOUNTS FOR OVER OF HEART
FAILURECOSTS /VERHALFOFPATIENTSOLDERTHANYEARSWITHCONGESTIVEHEARTFAILURE
#(&AREREADMITTEDWITHINMONTHSOFHOSPITALDISCHARGE
7HILEMEDICALRISKFACTORSAREWELLKNOWTOBEASSOCIATEDWITHHOSPITALREADMISSIONAGE
INCREASEDLENGTHOFSTAYANDNUMBEROFCOMORBIDITIESOFTENOVERLOOKEDSOCIALFACTORS
SUCHASSINGLEMARITALSTATUSREADINESSFORDISCHARGEMEDICATIONANDDIETARYNONCOM
PLIANCEALSOINmUENCETHECHANCEOF#(&READMISSION(EARTFAILUREDISEASEMAN
AGEMENT$-PROGRAMSAREDESIGNEDTOTARGETSOCIALRISKFACTORSRESULTINGINDECREASED
RECIDIVISM
(EART&AILURE$ISEASE-ANAGEMENT
(EARTFAILURE$-PROGRAMSHAVEPROVEN
TO BE EFFECTIVE AT REDUCING SUBSEQUENT
READMISSIONSINTHOSEDISCHARGEDAFTERA
#(&ADMISSION)THASBEENSUGGEST
EDTHAT$-PROGRAMSARENEARLYASEFFEC
TIVE AS THAT SEEN WITH ANGIOTENSINCON
VERTINGENZYMEINHIBITORSBETABLOCKERS
OR DIGOXIN $- PROGRAMS STRESS THE
NEED FOR COORDINATED COMPREHENSIVE
CARE BOTH DURING HOSPITALIZATION AND AF
TERDISCHARGE4HEYGENERALLYCONSISTOFA
MULTIFACETEDAPPROACHINCLUDINGPATIENT
EDUCATION AND TEACHING DIETARY ASSESS
MENTMEDICATIONANALYSISANDSOCIALSER
VICESCONSULTATION4HESEPROCESSESHAVE
TRADITIONALLYOCCURREDONCETHEPATIENTIS
HOSPITALIZED
i>ÀÌÊv>ˆÕÀiÊÊ
«Àœ}À>“Ãʅ>ÛiÊ«ÀœÛi˜Ê
̜ÊLiÊivviV̈ÛiÊ>ÌÊ
Ài`ÕVˆ˜}ÊÃÕLÃiµÕi˜ÌÊ
Ài>`“ˆÃȜ˜Ãʈ˜Ê̅œÃiÊ
`ˆÃV…>À}i`Ê>vÌiÀÊ>ÊÊ
Ê>`“ˆÃȜ˜°
7HY$ISEASE-ANAGEMENTINTHE%$
"ECAUSETHEEMERGENCYDEPARTMENT%$
ISTHEPORTALFOROFHOSPITALADMIS
SIONS FOR HEART FAILURE IT REPRESENTS AN
IDEALPLACETOBEGINA$-PROGRAM#(&
PATIENTS DISCHARGED DIRECTLY FROM THE
%$ HAVE A HIGH RATE OF RECIDIVISM AND
DISEASE MANAGEMENT MAY HELP AVOID
UNNECESSARY READMISSIONS 4HOSE PA
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
TIENTS MANAGED IN AN OBSERVATION UNIT
/5 RECEIVE DElNITIVE CARE INCLUDING
MEDICATIONADJUSTMENTANDFOLLOWUPAR
RANGEMENTSAND$-HASBEENSUGGESTED
TOIMPACTRECIDIVISMINTHESEPATIENTS
7HETHERITISINITIATIONOF#(&STANDARD
IZEDORDERSFORANINPATIENTADMISSIONOR
COMPREHENSIVEEDUCATIONANDTEACHINGIN
THEPATIENTDISCHARGEDFROMTHE%$OR/5
DISEASE MANAGEMENT CAN BE POTENTIALLY
INITIATEDONEVERY%$PATIENTWITH#(&
HOURSOFHOSPITALADMISSIONHAVEADECREASEDLIKELIHOODOFINHOSPITAL
MORBIDITYANDMORTALITYCOMPAREDWITHTHOSEPATIENTSTHATRECEIVETREAT
MENTAFTERHOURSP­/>LiÊ £®0ATIENTSWITHPNEUMONIA
THATRECEIVEANTIBIOTICSWITHINHOURSOFHOSPITALARRIVALHAVEAREDUCED
HOSPITAL LENGTHOFSTAY ,/3 AND INHOSPITAL MORTALITY ­/>LiÊ Ó® !
SEPARATEANALYSISFOUNDTHATAFTERADJUSTMENTFORCLINICALANDDEMOGRAPHIC
VARIABLES INITIAL ANTIBIOTIC ADMINISTRATION IN THE %$ AND DOORTONEEDLE
TIMEWASASSOCIATEDWITHREDUCED,/3
4HEIMPACTOFEARLY%$INTERVENTIONAND
TREATMENTHASBEENSEENINOTHERDISEASE
PROCESSES SUCH AS PNEUMONIA AND!#3
4HE#253!$%INITIATIVEHASSUGGESTED
THATTHOSEPATIENTSWITHNON34SEGMENT
ELEVATION MYOCARDIAL INFARCTION .34%
-) THAT RECEIVE TREATMENT WITH GLYCO
PROTEIN '0 ))B)))A INHIBITORS WITHIN
,QKRVSLWDORXWFRPHVVWUDWLILHGE\WLPHWR,,E,,,DLQKLELWRUWUHDWPHQW
/>LiÊ£°
*3,,%,,,$K
1R*3,,E,,,DK
Q Q 3
'HDWK
5H,QIDUFWLRQ
&DUGLRJHQLF6KRFN
&+)
5%&WUDQVIXVLRQ
/>LiÊÓ°
$QWLELRWLFDGPLQLVWUDWLRQZLWKLQKRXUVRIDUULYDODQGSDWLHQWRXWFRPHV
VWUDWLILHGE\ULVNFODVVHV
$GMXVWHGÁ
$QWLELRWLF:LWKLQ
K&,
$QWLELRWLF$IWHU
K&,
$25&,
39DOXH
GPRUWDOLW\
,QKRVSLWDOPRUWDOLW\
/HQJWKRIVWD\aG
GUHDGPLVVLRQ
36,ULVNFODVVHV,,DQG,,,
GPRUWDOLW\
,QKRVSLWDOPRUWDOLW\
/HQJWKRIVWD\aG
GUHDGPLVVLRQ
2XWFRPH0HDVXUHV
$OOSDWLHQWV
36,ULVNFODVVHV,9DQG9
GPRUWDOLW\
,QKRVSLWDOPRUWDOLW\
/HQJWKRIVWD\aG
GUHDGPLVVLRQ
!BBREVIATIONS!/2ADJUSTEDODDSRA
TIO #) CONlDENCE INTERVAL /2 ODDS
RATIO03)0NEUMONIA3EVERITY)NDEX
0ATIENTS WITHOUT PREHOSPITAL ANTIBI
OTICTREATMENT
o5NIVARIATE ANALYSIS COMPARING THE
ANTIBIOTICTIMINGSUBGROUPShWITHIN
HvVShAFTERHv
p-ULTIVARIATE ANALYSIS COMPARING THE
ANTIBIOTICTIMINGSUBGROUPShWITHIN
HvVShAFTERHvUSINGLOGISTICREGRES
SION 4HE LOGISTIC REGRESSION MODEL
INCLUDEDTHETIMINGOFINITIALANTIBIOTIC
03) ADMISSION TO THE INTENSIVE CARE
UNITCENSUSREGIONSOFHOSPITALIZATION
RACEETHNICITYANDOTHERPROCESSESOF
CAREOXYGENATIONASSESSMENTBLOOD
CULTUREWITHINHOURSANDINITIALAN
TIBIOTICCONSISTENTWITHCURRENTGUIDE
LINES !DAPTED AND REPRINTED WITH
PERMISSION FROM (OUCK ET AL !RCH
)NTERN-ED
1/Ê
"* -/Ê,/Ê1,ÊÊ
--Ê /Ê/""-
%$(EART&AILURE$ISEASE-ANAGEMENT4OOLS
4HEREARESEVERALASPECTSTO%$DISEASEMANAGEMENT4HElRSTCOMPONENTISIMPLE
MENTINGAN%$HEARTFAILURETREATMENTALGORITHM­ˆ}ÕÀiÊ £®#ATEGORIZINGAPATIENT
BASED ON THEIR PERFUSION STATUS WARM VERSUS COLD mUID STATUS HYPERVOLEMIC EU
VOLEMICHYPOVOLEMICANDLEVELOFDISEASESEVERITYWILLHELPDICTATEINITIALTHERAPY
4HEMAJORITYOFPATIENTSWILLBEHYPERVOLEMICANDWELLPERFUSEDANDWILLRESPONDTO
DIURETICSANDVASODILATORS
4HESECONDCOMPONENTOF$-ISTHEINTRODUCTIONOF%$#(&ADMISSIONORDERS!D
MISSIONORDERSENSURECONTINUITYOFCAREFROMTHE%$TOTHEINPATIENTWARDWITHREGARD
TOMEDICATIONSLABSANDANCILLARYTESTS)TALSOENSURESTHATTHEPATIENTTHATSPENDSSEV
ERALHOURSINTHE%$WAITINGFORANINPATIENTBEDISAPPROPRIATELYMANAGEDWHILECARE
6WDW('+)&RQVHQVXV3DQHO
(PHUJHQF\'HSDUWPHQW3DWLHQWZLWK6XVSHFWHG
$FXWHRU'HFRPSHQVDWHG+HDUW)DLOXUH
,PPLQHQW5HVSLUDWRU\)DLOXUH$QWLFLSDWHG
<(6
2SWLRQV
",QRWURSHV
"&RQVLGHU+HPRG\QDPLF
0RQLWRULQJ
",&8$GPLVVLRQ
iV>ÕÃiÊ̅iÊi“iÀ}i˜VÞÊ
<(6
&DUGLRJHQLF6KRFNRU
6\PSWRPDWLF+\SRWHQVLRQ"
3HUIRUP+LVWRU\DQG3K\VLFDO([DP
`i«>À̓i˜ÌʈÃÊ̅iÊ
2SWLRQV
<(6
"%L3$3&3$37ULDO
"(QGRWUDFKHDO
,QWXEDWLRQ
",I%3HOHYDWHG
&RQVLGHU5DSLG
9DVRGLODWLRQ
ZLWK1LWURJO\FHULQ
RU1LWURSUXVVLGH
",&8$GPLVVLRQ
«œÀÌ>ÊvœÀÊnä¯ÊÊ
œvʅœÃ«ˆÌ>Ê>`“ˆÃȜ˜ÃÊ
vœÀʅi>ÀÌÊv>ˆÕÀi]ʈÌÊ
+\SRSHUIXVLRQFRROH[WUHPLWLHV
RU$OWHUHG0HQWDO6WDWXV
12
&RQVLGHU2WKHU'LDJQRLVLV
DQG7UHDWPHQW
12
'HFRPSHQVDWHG+HDUW)DLOXUH
/LNHO\"
<(6
7KH(VWLPDWHRI6HYHULW\
,V,QFUHDVHGE\
"$EGRPLQDO6LJQVRI2[LPHWU\
"+LVWRU\RI0XOWLSOH+)$GPLWV
"%81!PJG/
"6%3PP+J
"&UHDWLQLQH!PJG/
":HLJKW$ERYH1RUPDO'U\:HLJKW
"(&*ZLWK/9+(OHYDWHG%3
"l%81+\SRQDWUHPLD
".QRZQ/RZ(MHFWLRQ)UDFWLRQ
"3RRU5HVSRQVHWR7KHUDS\
&ULWLFDO6HYHULW\
aRIDOO+)SDWLHQWV
"2[\JHQ
"/RRS'LXUHWLF
"1HVLULWLGH1LWURJO\FHULQ
RU1LWURSUXVVLGH
Ài«ÀiÃi˜ÌÃÊ>˜Êˆ`i>Ê
3HUIRUP:RUNXS
"%13
"(&*
"&;5
"26$7
"&DUGLDF0DUNHUV
"&%&
"(OHFWURO\WHV
«>ViÊ̜ʈ˜ˆÌˆ>ÌiÊ>ÊÊ
Ê«Àœ}À>“°Ê
&RQFXUUHQW
ZLWK:RUNXS
,QLWLDWH(DUO\('
7KHUDS\%DVHGRQ
&OLQLFDO(VWLPDWH
RI6HYHULW\
0RGHUDWH6HYHULW\
aRIDOO+)SDWLHQWV
/RZ6HYHULW\
aRIDOO+)SDWLHQWV
"2[\JHQ
"/RRS'LXUHWLF
"1HVLULWLGH
"1LWURSDVWHRU6/
1LWURJO\FHULQSUQ
"3DWLHQW(GXFDWLRQ
"2[\JHQ
"1LWURSDVWHRU6/
1LWURJO\FHULQSUQ
"/RRS'LXUHWLFV7ULDO
"3DWLHQW(GXFDWLRQ
,&8
ˆ}ÕÀiÊ£°Ê
Ê/Ài>̓i˜Ìʏ}œÀˆÌ…“°ÊՈ`iˆ˜iÃÊ
vœÀÊ̅iÊi>ÀÞÊÃÌ>Lˆˆâ>̈œ˜Ê>˜`Ê`ˆÃ«œÃˆÌˆœ˜Ê
œvÊ>VÕÌiÊ`iVœ“«i˜Ã>Ìi`ʅi>ÀÌÊv>ˆÕÀiÊ
ˆ˜Ê̅iÊi“iÀ}i˜VÞÊ`i«>À̓i˜Ì°
7HOHPHWU\RU2EVHUYDWLRQ8QLW
2EVHUYDWLRQ8QLWRU0HGLFDO)ORRU
'LVFKDUJH+RPH
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
ISTRANSITIONINGFROMTHEEMERGENCYPHYSICIANTOTHE
ADMITTING TEAM4HERE ARE OTHER ADVANTAGES TO STAN
DARDIZEDORDERS4HEAMOUNTOFEVOLVINGLITERATUREIS
OVERWHELMING IN THERE WERE RANDOM
IZED CONTROLLED TRIALS PUBLISHED 3TANDING ORDERS
ENSUREGUIDELINECOMPLIANCEFROMTHELITERATUREYET
ALLOWPHYSICIANSSOMEAUTONOMYBYALLOWINGFORIN
DIVIDUALPATIENTADJUSTMENTS
4HETHIRDCOMPONENTOF$-ISTHECOMPLETIONOFAPA
TIENTDISCHARGECHECKLIST4HISCHECKLISTISAMETHODOF
ENSURINGTHOSEPATIENTSTHATMEETCRITERIAFORSPECIlC
INTERVENTIONS MEDICATIONS SMOKING CESSATION CAR
DIACREHABILITATIONAREGIVENTHEAPPROPRIATEMEDICA
TIONSANDINSTRUCTIONSUPONDISCHARGE4HEINSTITUTION
OFADISCHARGEMEDICATIONPROGRAMATHOSPITALSIN
5TAHWASASSOCIATEDWITHDRAMATICIMPROVEMENTSIN
APPROPRIATE DISCHARGE PRESCRIPTIONS AND THE RELATIVE
RISKOFDEATHANDREADMISSIONATDAYSANDYEAR
AFTERHOSPITALDISCHARGE­ˆ}ÕÀiÃÊ ÓÊ >˜`Ê Î®4HIS
PROGRAM FOCUSED ON NURSINGINITIATED DOCUMENTA
TIONOFAPPROPRIATEMEDICATIONSUPONDISCHARGEFROM
THEHOSPITAL7HENANAPPROPRIATEMEDICINEWASNOT
PRESCRIBEDATDISCHARGETHEDISCHARGEPLANNINGNURSE
ˆ}ÕÀiÊÓ°Ê
*Àœ«œÀ̈œ˜Ê œvÊ «>̈i˜ÌÃÊ ÀiViˆÛˆ˜}Ê Ì…iÊÊ
>««Àœ«Àˆ>ÌiÊ`ˆÃV…>À}iÊ«ÀiÃVÀˆ«Ìˆœ˜Ã°
/…iÊ xÊ Ì>À}iÌi`Ê “i`ˆV>̈œ˜ÃÊ ÜiÀiÊ
}ˆÛi˜Ê >ÃÊ ˆ˜`ˆV>Ìi`Ê ÌœÊ «>̈i˜ÌÃÊ
܈̅œÕÌÊ`œVՓi˜Ìi`ÊVœ˜ÌÀ>ˆ˜`ˆV>̈œ˜ÃÊ
LivœÀiÊ >˜`Ê “œÀiÊ Ì…>˜Ê ÎÊ Þi>ÀÃÊ >vÌiÀÊ
ˆ“«i“i˜Ì>̈œ˜Ê œvÊ̅iÊ `ˆÃV…>À}iÊ
“i`ˆV>̈œ˜Ê «Àœ}À>“Ê ­£™™nÊ >˜`Ê
ÓääÓ]Ê ÀiëiV̈ÛiÞ®°Ê >Ì>Ê vœÀÊ £™™nÊ
>˜`ÊÓääÓÊÜiÀiÊVœiVÌi`Ê̅ÀœÕ}…Ê̅iÊ
Ã>“iÊ «ÀœViÃÃ°Ê ÊrÊ>˜}ˆœÌi˜Ãˆ˜‡
Vœ˜ÛiÀ̈˜}Ê i˜âޓi°Ê Ê ,i«Àˆ˜Ìi`Ê ÜˆÌ…Ê
«iÀ“ˆÃȜ˜Ê vÀœ“Ê >««iÊ iÌÊ >°Ê ˜˜Ê
˜ÌiÀ˜Êi`ÊÓää{ÆÊ£{£­È®\{{È°
CONTACTEDTHEATTENDINGPHYSICIANORRESIDENTDIRECTLY
AFTERWHICHTHEMISSINGMEDICATIONCOULDBEADDEDTO
THEDISCHARGELISTIFTHEREWERENOCONTRAINDICATIONS
4HE lNAL COMPONENT OF $- IS PATIENT EDUCATION
5NLIKEOTHERACUTEINPATIENTDISEASEPROCESSSUCHAS
PNEUMONIA AND PYELONEPHRITIS ACUTE #(& EXACER
BATIONS ARE TREATED UNTIL THE SUBJECT IS BACK TO THEIR
BASELINE COMPENSATED STATE THE UNDERLYING DISEASE
PROCESSISNEVERCOMPLETELYCURED!SARESULTPATIENT
BEHAVIORAFTERHOSPITALIZATIONMAYHAVEATREMENDOUS
INmUENCEONTHEPROGRESSIONOFTHEIRDISEASEPROCESS
ANDSUBSEQUENTMORBIDITYANDMORTALITY)THASBEEN
SUGGESTED THAT OVER OF READMISSIONS ARE POSSI
BLYORPROBABLYPREVENTABLEANDTHATMEDICATIONAND
DIETARY NONCOMPLIANCE INADEQUATE DISCHARGE PLAN
NINGORFOLLOWUPFAILEDSOCIALSUPPORTANDNOTREC
OGNIZINGSYMPTOMRECURRENCEWEREABIGCONTRIBUTOR
TOTHESEPREVENTABLEREADMISSIONS !$-PROGRAM
THATEMPOWERSTHEPATIENTWITHKNOWLEDGEABOUTTHEIR
DISEASEPROCESSAPPROPRIATEFOLLOWUPANDSIGNSOF
DECOMPENSATIONINCREASESTHELIKELIHOODOFAVOIDING
READMISSIONS
1/Ê
"* -/Ê,/Ê1,ÊÊ
--Ê /Ê/""-
ˆ}ÕÀiÊΰ
DAYS
(&
#($
-)
#!"'
(&
9EAR
#($
-)
#!"'
2ELATIVE2ISKFOR$EATH
(&
`ÕÃÌi`ÊÀi>̈ÛiÊ
ÀˆÃŽÊvœÀÊi>̅Ê>˜`Ê
,i>`“ˆÃȜ˜Ê>ÌÊÎäÊ
`>ÞÃÊ>˜`Ê£ÊÞi>ÀÊvœÀÊ
«>̈i˜ÌÃÊLivœÀiÊ>˜`Ê
>vÌiÀʈ“«i“i˜Ì>̈œ˜Ê
œvÊ̅iÊ`ˆÃV…>À}iÊ
“i`ˆV>̈œ˜Ê«Àœ}À>“°Ê
,i«Àœ`ÕVi`Ê>˜`Ê
Ài«Àˆ˜Ìi`Ê܈̅Ê
«iÀ“ˆÃȜ˜ÊvÀœ“Ê
>««iÊiÌÊ>°Ê˜˜Ê
˜ÌiÀ˜Êi`ÊÓää{ÆÊ
£{£­È®\{{È°
DAYS
#($
/…iÃiÊÀiÃՏÌÃÊÌiÃ̈vÞÊ
̜Ê̅iÊv՘`>“i˜Ì>Ê
-)
Vœ˜ÌÀˆLṎœ˜Ê>ÊÊ
#!"'
«Àœ}À>“ÊV>˜Ê“>ŽiÊ̜Ê
(&
9EAR
̅iʓ>˜>}i“i˜ÌʜvÊ̅iÊ
#($
-)
#!"'
…i>ÀÌÊv>ˆÕÀiÊ«>̈i˜ÌÆʈ˜Ê
2ELATIVE2ISKFOR2EADMISSION
̅ˆÃÊ«Àiˆ“ˆ˜>ÀÞÊÃÌÕ`Þ]Ê
V…>À}iÃÊÜiÀiʅ>Ûi`ÊLÞÊ
˜œÌÊ>`“ˆÌ̈˜}Ê>Ê«>̈i˜Ì]Ê
!0RACTICAL%XAMPLE$ISEASE-ANAGEMENTINTHE/BSERVATION5NIT
)N*ANUARYTHE5NIVERSITYOF#INCINNATI$EPARTMENTOF%MERGENCY-EDICINEINI
TIATEDANACUTEDECOMPENSATEDHEARTFAILUREOBSERVATIONUNIT/5PROTOCOL4HEPROTO
COLSELECTSNONHIGHRISKPATIENTSFORMANAGEMENTOVERAHOURPERIOD$URINGTHIS
TIMEPATIENTSRECEIVEVASODILATORSANDDIURETICSASWELLASFURTHEREVALUATIONINCLUDING
ECHOCARDIOGRAPHYAND!#3RISKSTRATIlCATIONEVALUATIONSERIALCARDIACMARKERSWITH
THEOPTIONFORRESTISCHEMIAIMAGING­ˆ}ÕÀiÊ{®!NEDUCATIONALVIDEOHASBEENDE
VELOPEDTHATINSTRUCTSTHEPATIENTSABOUTTHEIRDISEASEPROCESSDIETMEDICATIONSAND
WARNING SIGNS THAT THEIR HEART FAILURE MAY BE WORSENING $ISCHARGE PLANNING OCCURS
THROUGHACOMBINATIONOFCARDIOLOGYNURSEPRACTITIONEREVALUATIONASWELLASFOLLOW
UPINTHEHEARTFAILUREANDGENERALINTERNALMEDICINECLINIC
>˜`Ê>˜Ê>ÛiÀ>}iʜvʜ˜iÊ
Li`‡`>ÞÊÜ>ÃÊÃ>Ûi`Ê
«iÀʜLÃiÀÛ>̈œ˜>Ê
՘ˆÌÊ«>̈i˜Ì°
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
ˆ}ÕÀiÊ{°Ê
)NCLUSION%XCLUSION#RITERIA&ULFILLED
1˜ˆÛiÀÈÌÞʜvÊ
ˆ˜Vˆ˜˜>̈Ê
Ê«>̅Ü>Þ°
)6DIURETICEQUIVALENTTOHOMEDAILYDOSE
2ESTARTHOME!#%)p)6!#%)
.ITRATES
%LECTROLYTESSTANDING
REPLACEMENT
".0LEVELS
HOURREASSESSMENT
5/*6$DYSPNEA63".0
.ITRATE$IURETIC!#%)
0ATHWAY
$IAGNOSTICS
HOURCARDIACENZYMES
%CHOCARDIOGRAPHY
2ESTPERFUSIONSCAN
.ITRATE$IURETIC
0ATHWAY
2EASSESSEVERYHOURS
(&EDUCATIONVIDEO
$ISCHARGECRITERIAMET
#ARDIOLOGISTCONSULT
$ISCHARGEHOME
&5INDAYS
9%3
./
7EEVALUATEDTHEEFFECTIVENESSOFTHE/5PROTOCOLBY
COMPARINGPATIENTSMANAGEDINTHE/5WITHASIMILAR
RISKMATCHED COHORT OF INPATIENTS /VERALL PA
TIENTSWHOWEREBEINGADMITTEDTOTHEHOSPITALWITH
PRESUMEDDECOMPENSATEDHEARTFAILUREWEREENROLLED
INTHESTUDY!LLPATIENTSHADAHISTORYOFHEARTFAILURE
ANDSATISlEDTWOMAJORORONEMAJORANDTWOMINOR
MODIlED&RAMINGHAM#RITERIA)NCLUSIONANDEXCLU
SIONCRITERIAWERESELECTEDBASEDUPONPRIORRISKSTUD
IES SO AS TO IDENTIFY WHAT CURRENT PRACTICE INDICATES
IS A LOW TO MODERATE RISK PATIENT 0ATIENTS CURRENTLY
BELIEVEDTOBEATHIGHRISKANDPATIENTSWITHNEWONSET
HEARTFAILUREWERENOTINCLUDED
/NE PATIENT WAS FOUND TO HAVE NO PRIOR HISTORY OF
HEARTFAILUREANDTWOPATIENTSLEFTTHEINPATIENTSETTING
AGAINST MEDICAL ADVICE )NCLUSION OF THESE SUBJECTS
MAY AFFECT THE DATA BUT THIS REPRESENTS THE CLINICAL
SCENARIOANDITISIMPORTANTTOINCLUDETHESESOURCES
OF ERROR IN OUTCOMES ANALYSIS 4HIRTYTWO PATIENTS
!DMIT
WEREADMITTEDTOHOSPITALWHILEWEREPLACEDINTHE
OBSERVATIONUNIT%IGHT/5PATIENTSREQUIRED
SUBSEQUENTADMISSION
/UTCOMES MEASURED IN THIS STUDY INCLUDED READ
MISSIONS FOR #(& REPEAT VISITS TO THE %$ FOR HEART
FAILURE AND DEATH 4HERE WERE EVENTS AMONG AD
MITTEDPATIENTSANDEVENTSAMONG/5PA
TIENTS !NY DIFFERENCE WAS NOT SIGNIlCANT
P!LLEVENTSINCLUDEDAREADMISSIONFORHEART
FAILURE!LLBUTONEEVENTINCLUDEDAHEARTFAILURERE
LATED%$VISIT7EALSOCOMPAREDCRUDEESTIMATESOF
BEDHOURSANDCOSTSBETWEENTHETWOGROUPS5SEOF
THE/5AVOIDEDADMISSIONINOFCASES-EDIAN
TIME FROM TRIAGE TO DISCHARGE FOR /5 PATIENTS WAS
HOURSRANGEnHOURSWHILEPATIENTS
ADMITTED DIRECTLY FROM THE %$ HAD A MEDIAN LENGTH
OFSTAYOFHOURSRANGEnHOURS4HE
LENGTH OF HOSPITAL STAY WAS SIGNIlCANTLY SHORTER FOR
/5 PATIENTS THAN FOR ADMITTED PATIENTS P
1/Ê
"* -/Ê,/Ê1,ÊÊ
--Ê /Ê/""-
#HARGES FOR THE TWO GROUPS OF PATIENTS
WEREOBTAINEDCATEGORIZEDBYTHESOURCE
OFTHECHARGEˆ}ÕÀiÊxSHOWSTHESOURCE
OFCHARGESFORADMITTEDAND/5PATIENTS
OUTLIERSNOTSHOWN
4HE TOTAL CHARGE WAS SIGNIlCANTLY LOW
ER FOR THE /5 PATIENTS -EDIAN 2ANGEnTHANFORADMIT
TEDPATIENTS-EDIANRANGE
n 0 )NPATIENT CHARGES
AND PHARMACY CHARGES WERE DIFFERENT
BETWEEN THE TWO GROUPS 0 AND
0 RESPECTIVELY 4HESE RESULTS
TESTIFYTOTHEFUNDAMENTALCONTRIBUTIONA
$- PROGRAM CAN MAKE TO THE MANAGE
MENT OF THE HEART FAILURE PATIENT IN THIS
PRELIMINARY STUDY CHARGES WERE HALVED
BYNOTADMITTINGAPATIENTANDANAVERAGE
OFBEDDAYWASSAVEDPER/5PATIENT
! COMBINATION OF A TREATMENT PATHWAY
PATIENTEDUCATIONANDDISCHARGEPLANNING
ARE INTEGRAL COMPONENTS IN MAKING /5
TREATMENTSUCCESSFUL
-1,9
$ISEASEMANAGEMENTISANINTEGRALCOM
PONENTINTHECOMPREHENSIVECAREOFHEART
FAILURE PATIENTS AND HAS BEEN SHOWN TO
REDUCEREADMISSIONSANDTHEOVERALLCOST
OFCARE4HE%$ACTSASAMAJORPORTAL
FORHEARTFAILUREADMISSIONSANDBECAUSE
OF THIS EMERGENCY PHYSICIANS HAVE THE
POTENTIALTOSIGNIlCANTLYIMPACTTHECARE
OF (& PATIENTS4HE MAJORITY OF %$ PA
TIENTSWHETHERADMITTEDMANAGEDINAN
/5ORDISCHARGEDHOMEWILLLIKELYBEN
ElTFROMONEORMOREOFTHECOMPONENTS
OF$-
/…iʓ>œÀˆÌÞʜvÊÊ
«>̈i˜ÌÃ]Ê܅i̅iÀÊ
>`“ˆÌÌi`]ʓ>˜>}i`ʈ˜Ê
>˜Ê"1]ʜÀÊ`ˆÃV…>À}i`Ê
…œ“i]Ê܈ÊˆŽiÞÊLi˜iwÌÊ
vÀœ“Êœ˜iʜÀʓœÀiʜvÊ
#HARGES$OLLARS
!DMITTED
/5
̅iÊVœ“«œ˜i˜ÌÃʜvÊ°
ˆ}ÕÀiÊx°
,ABORATORY
)NPATIENT
%$
0HARMACY
œÝ«œÌÃÊŜ܈˜}Ê̅iÊÜÕÀViÊ
>˜`Ê>“œÕ˜ÌʜvÊV…>À}iÃÊvœÀÊ
œLÃiÀÛ>̈œ˜Ê՘ˆÌÊ>˜`Ê>`“ˆÌÌi`Ê
«>̈i˜ÌðÊÊ­Iʈ˜`ˆV>ÌiÃÊ>Ê
È}˜ˆwV>˜ÌÊ`ˆvviÀi˜ViÊ®
%MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
,, !SSOCIATION!((EARTDISEASEANDSTROKESTATISTICSUPDATE
/#ONNELL*"4HEECONOMICBURDENOFHEARTFAILURE#LIN#ARDIOL
)))
#ROFT*"'ILES7(0OLLARD2!+EENAN.,#ASPER-,!NDA
2&(EARTFAILURESURVIVALAMONGOLDERADULTSINTHEUNITEDSTATES
!POORPROGNOSISFORANEMERGINGEPIDEMICINTHEMEDICARE
POPULATION!RCH)NTERN-ED
-C#ULLOUGH0!0HILBIN%&3PERTUS*!+AATZ33ANDBERG+2
7EAVER7$#ONlRMATIONOFAHEARTFAILUREEPIDEMIC&INDINGS
FROMTHERESOURCEUTILIZATIONAMONGCONGESTIVEHEARTFAILURE
REACHSTUDY*!M#OLL#ARDIOL
2AME*%3HEFlELD-!$RIES$,'ARDNER%"4OTO+(
9ANCY#7$RAZNER-(/UTCOMESAFTEREMERGENCYDEPARTMENT
DISCHARGEWITHAPRIMARYDIAGNOSISOFHEARTFAILURE!M(EART*
0EACOCK7&T2EMER%%!PONTE*-OFFA$!%MERMAN#%
!LBERT.-%FFECTIVEOBSERVATIONUNITTREATMENTOFDECOMPENSATED
HEARTFAILURE#ONGEST(EART&AIL
3TORROW!"#OLLINS30,INDSELL#*%MERGENCYDEPARTMENT
OBSERVATIONOFHEARTFAILUREISSAFEANDCOSTEFFECTIVE!CAD%MERG
-ED
(OEKSTRA*2OE-40ETERSON%-6*-0OLLACK#6*R-ILLER
#40(ARRINGTON2!/HMAN%-'IBLER7"%ARLYGLYCOPROTEIN
IIBIIIAINHIBITORUSEFORNONSTSEGMENTELEVATIONACUTECORONARY
SYNDROMES0ATIENTSELECTIONANDASSOCIATEDTREATMENTPATTERNS
!CAD%MERG-EDINPRESS
/#ONNELL*""-%CONOMICIMPACTOFHEARTFAILUREINTHEUNITED
STATES!TIMEFORADIFFERENTAPPROACH*(EART,UNG4RANS
33
0HILLIPS#/7RIGHT3-+ERN$%3INGA2-3HEPPERD32UBIN
(2#OMPREHENSIVEDISCHARGEPLANNINGWITHPOSTDISCHARGESUPPORT
FOROLDERPATIENTSWITHCONGESTIVEHEARTFAILURE!METAANALYSIS
*AMA
(OEKSTRA*-69,2OE-40ETERSON%0OLLACK#6*R40
"RINDIS2''IBLER7"/HMAN%-%ARLYGPIIBIIIAINHIBITORUSE
INNONSTELEVATIONACUTECORONARYSYNDROMESISASSOCIATEDWITH
LOWERMORTALITYINTROPONINPOSITIVEPATIENTS*!M#OLL#ARDIOL
3UPPL)6
+RUMHOLZ(-0ARENT%-4U.6ACCARINO67ANG92ADFORD
-*(ENNEN*2EADMISSIONAFTERHOSPITALIZATIONFORCONGESTIVE
HEARTFAILUREAMONGMEDICAREBENElCIARIES!RCH)NTERN-ED
(OUCK0-"RATZLER$7.SA7-A!"ARTLETT*'4IMINGOF
ANTIBIOTICADMINISTRATIONANDOUTCOMESFORMEDICAREPATIENTS
HOSPITALIZEDWITHCOMMUNITYACQUIREDPNEUMONIA!RCH)NTERN
-ED
#HIN-('OLDMAN,#ORRELATESOFEARLYHOSPITALREADMISSION
ORDEATHINPATIENTSWITHCONGESTIVEHEARTFAILURE!M*#ARDIOL
6INSON*-2ICH-73PERRY*#3HAH!3-C.AMARA4%ARLY
READMISSIONOFELDERLYPATIENTSWITHCONGESTIVEHEARTFAILURE*!M
'ERIATR3OC
"ATTLEMAN$3#ALLAHAN-4HALER(42APIDANTIBIOTICDELIVERY
ANDAPPROPRIATEANTIBIOTICSELECTIONREDUCELENGTHOFHOSPITAL
STAYOFPATIENTSWITHCOMMUNITYACQUIREDPNEUMONIA,INK
BETWEENQUALITYOFCAREANDRESOURCEUTILIZATION!RCH)NTERN-ED
+OSSOVSKY-03ARASIN&00ERNEGER46#HOPARD03IGAUD0
'ASPOZ*5NPLANNEDREADMISSIONSOFPATIENTSWITHCONGESTIVE
HEARTFAILURE$OTHEYREmECTINHOSPITALQUALITYOFCAREORPATIENT
CHARACTERISTICS!M*-ED
2ICH-7"ECKHAM67ITTENBERG#,EVEN#,&REEDLAND
+%#ARNEY2-!MULTIDISCIPLINARYINTERVENTIONTOPREVENTTHE
READMISSIONOFELDERLYPATIENTSWITHCONGESTIVEHEARTFAILURE.
%NGL*-ED
2ICH-76INSON*-3PERRY*#3HAH!33PINNER,2#HUNG
-+$AVILA2OMAN60REVENTIONOFREADMISSIONINELDERLY
PATIENTSWITHCONGESTIVEHEARTFAILURE2ESULTSOFAPROSPECTIVE
RANDOMIZEDPILOTSTUDY*'EN)NTERN-ED
#HASSIN-2)SHEALTHCAREREADYFORSIXSIGMAQUALITY-ILBANK
1
,APPE*--UHLESTEIN*",APPE$,"ADGER23"AIR4,
"ROCKMAN2&RENCH4+(OFMANN,#(ORNE"$+RALICK
'OLDBERG3.ICPONSKI./RTON*!0EARSON222ENLUND$'
2IMMASCH(2OBERTS#!NDERSON*,)MPROVEMENTSINYEAR
CARDIOVASCULARCLINICALOUTCOMESASSOCIATEDWITHAHOSPITALBASED
DISCHARGEMEDICATIONPROGRAM!NN)NTERN-ED
#OLLINS30,INDSELL#*,YONS-3'IBLER7"3TORROW!"
"NPLEVELSARERELATEDTODAYEVENTSINHEARTFAILUREPATIENTS
DISCHARGEDFROMANOBSEVATIONUNIT!MERICAN#OLLEGEOF
%MERGENCY0HYSICIANS
'ONSETH*'UALLAR#ASTILLON0"ANEGAS*22ODRIGUEZ!RTALEJO
&4HEEFFECTIVENESSOFDISEASEMANAGEMENTPROGRAMMESIN
REDUCINGHOSPITALREADMISSIONINOLDERPATIENTSWITHHEARTFAILURE
!SYSTEMATICREVIEWANDMETAANALYSISOFPUBLISHEDREPORTS%UR
(EART*
#OPYRIGHT%-#2%')NTERNATIONAL
Ê Ê œ˜Ìˆ˜Õˆ˜}Êi`ˆV>Ê`ÕV>̈œ˜Ê*œÃ̇/iÃÌ
"ASEDONTHEINFORMATIONPRESENTEDINTHISMONOGRAPHPLEASECHOOSEONECORRECTRESPONSEFOREACHOFTHEFOLLOWING
QUESTIONSORSTATEMENTS2ECORDYOURANSWERSONTHEANSWERSHEETONPAGE4ORECEIVE#ATEGORY)CREDITCOMPLETE
THEPOSTTESTANDRECORDYOURRESPONSESONTHEANSWERSHEET-AILINTHERETURNENVELOPENOLATERTHAN*UNE!
PASSINGGRADEOFISNEEDED!CERTIlCATEWILLBESENTTOYOUUPONYOURSUCCESSFULCOMPLETIONOFTHEPOSTTEST
ˆ>}˜œÃˆÃʜvÊVÕÌiÊiVœ“«i˜Ã>Ìi`Êi>ÀÌÊ
>ˆÕÀiʈ˜Ê̅iÊ
!YEAROLDMALETOBACCOSMOKERWITHAHISTORY
OFASTHMAPRESENTSTOTHEEMERGENCYDEPARTMENT
WITHSHORTNESSOFBREATHOFDAYSDURATION(E
HASEXERTIONALDYSPNEAORTHOPNEAANDHEARS
SOMEWHEEZINGWHENHEISBREATHING0HYSICAL
EXAMINATIONREVEALSSCANTCRACKLESATTHEBASES
BILATERALLYWITHCMOFJUGULARVENOUSDISTENTION
AN3HEARTSOUNDANDNOMURMUR7HICHOFTHE
FOLLOWINGBESTSUPPORTSADIAGNOSISOFCONGESTIVE
HEARTFAILURE
A #ARDIOMEGALYONCHESTRADIOGRAPHY
B !".0LEVELOFPGD,
C .ORMALCHESTRADIOGRAPHY
D !".0LEVELOFPGD,
7HICHOFTHEFOLLOWINGDISEASESCANRESULTINLOW
GRADE".0ELEVATIONSPGDL
A 2IGHTVENTRICULARFAILUREFROMCORPULMONALE
B !CUTEPULMONARYEMBOLISM
C #(&INANOBESEPATIENT
D #(&INAPATIENTWITHNORMALBODYMASSINDEX
E !LLOFTHEABOVE
/Ài>̓i˜ÌʜvÊVÕÌiÊiVœ“«i˜Ã>Ìi`Êi>ÀÌÊ
>ˆÕÀiʈ˜Ê̅iʓiÀ}i˜VÞÊi«>À̓i˜Ì
4HEPATIENTSCLINICALSTATUSCANBEDETERMINEDBY
ASSESSINGTHENFORWHICHOFTHEFOLLOWING
A $EGREEOFCARDIACPERFUSIONANDPRESENCEOF
CONGESTION
B $EGREEOFCARDIACPERFUSIONANDBLOODPRESSURE
C "LOODPRESSUREANDPRESENCEOFCONGESTION
D 2ENALFUNCTIONANDVOLUMESTATUS
E 2ENALFUNCTIONANDPERIPHERALEDEMA
7HICHOFTHEFOLLOWINGISNOTTRUEABOUTTHEROLEOF
VASODILATORSINACUTELYDECOMPENSATEDHEART
A 4HEYREDUCEPRELOADANDAFTERLOAD
B -YOCARDIALOXYGENCONSUMPTIONISOFTEN
INCREASED
C 4HEYINCREASESTROKEVOLUMEANDIMPROVE
CARDIACOUTPUT
D 4HEYMAYCAUSEHYPOTENSION
E 4HEBESTHEMODYNAMICINDICATOROFVASODILATOR
THERAPYRESPONSEISADROPINTHEPULMONARY
CAPILLARYWEDGEPRESSURE
*iÀ̈˜i˜ÌÊ *Ê
œ˜Ãi˜ÃÕÃÊ*>˜iÊ
,iVœ““i˜`>̈œ˜Ã
)NANANALYSISOFMORETHANPATIENTSENROLLED
INTHE!$(%2%REGISTRYTHE%$USEOFVASOACTIVE
THERAPYASCOMPAREDTODELAYEDUSAGEONTHE
INPATIENTUNITWASASSOCIATEDWITHWHICHOFTHE
FOLLOWING
A DECREASEDMORTALITY
B LOWER)#5ADMISSIONRATE
C SHORTERHOSPITALIZATIONS
D FEWERINVASIVEPROCEDURES
E ALLOFTHEABOVE
!NELEVATEDTROPONININTHESETTINGOFACUTE
DECOMPENSATEDHEARTFAILUREISASSOCIATEDWITH
A LONGER)#5HOSPITALIZATION
B INCREASEDMORTALITY
C LONGERHOSPITALIZATION
D AHIGHERRATEOFINTUBATIONANDBALLOONPUMP
USAGE
E ALLOFTHEABOVE
Ê œ˜Ìˆ˜Õˆ˜}Êi`ˆV>Ê`ÕV>̈œ˜Ê*œÃ̇/iÃÌÊ­Vœ˜Ì°®
>VŽ}ÀœÕ˜`Ê>˜`ʈ˜`ˆ˜}ÃÊvÀœ“Ê̅iÊ
,Ê >̈œ˜>Ê,i}ˆÃÌÀÞ
7HENDESCRIBINGTHEPATIENTPOPULATIONINTHE
!$(%2%REGISTRYINCOMPARISONTOOTHER!$(&
TRIALSALLOFTHEFOLLOWINGARETRUE%8#%04
A 0ATIENTSIN!$(%2%TENDTOBEOLDER
B !BOUTHALFTHEPATIENTSIN!$(%2%AREWOMEN
C 2ENALINSUFlCIENCYPATIENTSAREEXCLUDEDFROM
!$(%2%
D 4HE!$(%2%POPULATIONINCLUDESACADEMICAND
COMMUNITYCENTER
E !LLOFTHEABOVEARETRUE
)NTHE!$(%2%INTRAVENOUSVASOACTIVEMORTALITY
ANALYSISWHICHOFTHEFOLLOWINGSTATEMENTSARETRUE
A 0ATIENTSWHORECEIVEDINHOSPITALNITROGLYCERIN
HADLOWERINHOSPITALMORTALITY
B 0ATIENTSWHORECEIVEDINTRAVENOUSNESIRITIDEHAD
LOWERINHOSPITALMORALITY
C 0ATIENTSTREATEDWITHDOBUTAMINEORMILRINONE
HADHIGHERINHOSPITALMORTALITY
D !AND#ARECORRECT
E !"AND#ARECORRECT
ˆÃi>ÃiÊ>˜>}i“i˜ÌʜvÊVÕÌiÊ
iVœ“«i˜Ã>Ìi`Êi>ÀÌÊ>ˆÕÀi\Ê/…iÊ
,ʓiÀ}i˜VÞÊi`ˆVˆ˜iʜ`Տi
7HICHOFTHEFOLLOWINGAREREQUIREDFORASUCCESSFUL
POINTOFCAREPROGRAM
A 1UALITYCONTROL
B %DUCATIONOFPHYSICIANS
C ,ABORATORYACCREDITATIONANDREGULATION
D $ElNEDANDREGULATEDTESTINGPROCEDURES
E !LLOFTHEABOVE
&ACTORSTHATSHOULDBECONSIDEREDINTHECOSTANALYSIS
OFAPOINTOFCARETESTINGPROGRAMINCLUDEALLOFTHE
FOLLOWING%8#%04
A ,ABORATORYRESULTTURNAROUNDTIME4!4
B 4IMETODISPOSITION
C 0ATIENTANDPHYSICIANCONSUMERDEMAND
D #OSTOFTESTINGPLATFORMANDREAGENTS
E !LLOFTHEABOVEARECORRECT
VÕÌiÊiVœ“«i˜Ã>Ìi`Êi>ÀÌÊ>ˆÕÀiʈÃi>ÃiÊ
>˜>}i“i˜ÌÊ/œœÃ
4HECOMPONENTSOFDISEASEMANAGEMENTINCLUDEALL
OFTHEFOLLOWINGEXCEPT
A 4REATMENTALGORITHM
B !DMISSIONORDERS
C 0ATIENTDISCHARGECHECKLIST
D 0ATIENTEDUCATION
E !LLOFTHEABOVE
0ATIENTEDUCATIONANDADISCHARGECHECKLISTARETWO
DISEASEMANAGEMENTTOOLSTHATAREUSEDTOIMPROVE
MEDICATIONANDDIETARYCOMPLIANCEINANEFFORTTO
DECREASEDAYHOSPITALREADMISSION4HECURRENT
DAYREADMISSIONRATEFORHEARTFAILUREPATIENTS
DISCHARGEDFROMTHEHOSPITALISAPPROXIMATELY
A B C D %MERGENCY$IAGNOSISAND4REATMENTOF
!CUTE$ECOMPENSATED(EART&AILURE!$(&
œ˜Ìˆ˜Õˆ˜}Êi`ˆV>Ê`ÕV>̈œ˜Ê *œÃ̇/iÃÌʘÃÜiÀʜÀ“Ê>˜`ÊÛ>Õ>̈œ˜
!FTERYOUHAVEREADTHEMONOGRAPHCAREFULLYRECORD
YOURANSWERSBYCIRCLINGTHEAPPROPRIATELETTERFOREACH
QUESTIONANDCOMPLETETHEEVALUATIONQUESTIONNAIRE
61/" Ê+1-/"
-AILTHEANSWERSHEETTO
,
/NASCALEOFTOWITHBEINGHIGHLYSATISlEDAND
BEINGHIGHLYDISSATISlEDPLEASERATETHISPROGRAMWITH
RESPECTTO
(IGHLYSATISlED (IGHLYDISSATISlED
/FlCEOF#ONTINUING-EDICAL%DUCATION
5NIVERSITYOF#INCINNATI#OLLEGEOF-EDICINE
0/"OX
#INCINNATI/(
/VERALLQUALITYOFMATERIAL
#ONTENTOFMONOGRAPH
/THERSIMILAR#-%PROGRAMS
(OWWELLCOURSEOBJECTIVESWEREMET
#-%EXPIRATIONDATE*UNE
D
7HATTOPICSWOULDBEOFINTERESTTOYOUFORFUTURE#-%
PROGRAMS
????????????????????????????????????????????? ?????????????????????????????????????????????
D
????????????????????????????????????????????? ?????????????????????????????????????????????
A
A
B
B
C
C
E
A
B
C
D
E
A
B
C
D
E
A
B
C
D
E
A
B
C
D
E
A
B
C
D
E
A
B
C
D
E
A
B
C
D
E
A
B
C
D
E
A
B
C
D
E
A
B
C
D
7ASTHERECOMMERCIALORPROMOTIONALBIASINTHE
PRESENTATIONQ9%3Q./)F9%3PLEASEEXPLAIN
????????????????????????????????????????????? ????????????????????????????????????????????? ????????????????????????????????????????????? ?????????????????????????????????????????????
(OWLONGDIDITTAKEFORYOUTOCOMPLETETHISMONOGRAPH
????????????????????????????????????????????? ????????????????????????????????????????????? .AME0LEASEPRINTCLEARLY?????????????????????? ?????????????????????????????????????????????
$EGREE ?????????????????????????????????????? ?????????????????????????????????????????????
3PECIALTY?????????????????????????????????????
!CADEMIC!FlLIATIONIFAPPLICABLE ??????????????? ????????????????????????????????????????????? ????????????????????????????????????????????? !DDRESS ?????????????????????????????????????
?????????????????????????????????????????????
#ITY ??????????????3TATE??? :IP#ODE?????????
4ELEPHONE.UMBER ??????????????????????
Ê ˆÃVœÃÕÀiʜvÊ>VՏÌÞɘ`ÕÃÌÀÞÊ,i>̈œ˜Ã…ˆ«Ã
)NACCORDANCEWITH#-%3TANDARDSFOR#OMMERCIAL3UPPORTOF#-%THEAUTHORSHAVEDISCLOSEDTHEFOLLOWING
RELEVANTRELATIONSHIPSWITHPHARMACEUTICALORDEVICEMANUFACTURERS
*UDD%(OLLANDER-$
2ESEARCH'RANTS#ONSULTANT"IOSITE#ONSULTANT3CIOS
$OUGLAS-#HAR-$ #ONSULTANT3CIOS
7&RANK0EACOCK-$ 'RANT2ESEARCH#ONSULTANT3CIOS
7ILLIAM!BRAHAM-$
2ICHARD,3UMMERS-$ #ONSULTANTANDSPEAKERSBUREAU3CIOS
3EAN0#OLLINS-$
3PEAKERHONORARIARESEARCHGRANTSANDCONSULTINGFEESFOR3CIOS
.ONE
Ê "vv‡>LiÊˆÃVœÃÕÀiÃ
&ACULTYMEMBERSAREREQUIREDTOINFORMTHEAUDIENCEWHENTHEYAREDISCUSSINGOFFLABELUNAPPROVEDUSES
OFDEVICESANDDRUGS0HYSICIANSSHOULDCONSULTFULLPRESCRIBINGINFORMATIONBEFOREUSINGANYPRODUCT
MENTIONEDINTHISMONOGRAPH
4HISEDUCATIONALMONOGRAPHWASSUPPORTEDINPARTBYANUNRESTRICTEDEDUCATIONALGRANTFROM3CIOS
#OPYRIGHT%-#2%')NTERNATIONAL
)NTERNATIONAL
W W W E M C R E G O R G
0RODUCEDBY
^ÊÓääxÊ
,‡˜ÌiÀ˜>̈œ˜>
ÜÜÜ°i“VÀi}°œÀ}
/…ˆÃÊi`ÕV>̈œ˜>Ê“œ˜œ}À>«…ÊÜ>ÃÊÃÕ««œÀÌi`ʈ˜Ê«>ÀÌÊLÞÊ
>˜Ê՘ÀiÃÌÀˆVÌi`Êi`ÕV>̈œ˜>Ê}À>˜ÌÊvÀœ“Ê-VˆœÃ°
0R INTE DIN TH E 5 3!