Managing Acute Heart Failure in the Emergency DepartmentPatient Case Study

1

Case Introduction

3

Initial Diagnosis and Care Plan

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Case Details and Initial Triage

5

Revised Diagnosisand Care Plan

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Teaching PointsDiscussion and Conclusions

4

DiagnosticResults

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DispositionDecision

Phillip Levy, MD, MPH

Author:

Glossary

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Phillip Levy, MD, MPHAssociate Professor, Wayne State University School of Medicine (Detroit, MI; USA)

• Assistant Director, Clinical Research, Cardiovascular Research Institute

• Associate Director, Clinical Research, Department of Emergency Medicine

• Director, Clinical Research Center, Office of the Vice President of Research

CASE INTRODUCTION

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CaseIntroduction

Initial Diagnosis and Care Plan

Case Details and Initial Triage

Revised Diagnosisand Care Plan

Teaching PointsDiscussion and Conclusions

DiagnosticResults

DispositionDecision

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Background• This is the ER of an academic, tertiary care

hospital in a large urban center. You are a board certified emergency physician with 2 years of experience

• You have 2 residents on duty, a full complement of nurses and assistants, and ready access to a wide range of in-house consultative services, including interventional cardiology 24/7

CASE INTRODUCTION

ER=emergency room

CaseIntroduction

Initial Diagnosis and Care Plan

Case Details and Initial Triage

Revised Diagnosisand Care Plan

Teaching PointsDiscussion and Conclusions

DiagnosticResults

DispositionDecision

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Chief Complaint and Vital Signs

History of Present Illness and Review of systems

Past History, Allergy History, Medications, and Social History

Physical Examination

CASE DETAILS AND INITIAL TRIAGE

HPI

CaseIntroduction

Initial Diagnosis and Care Plan

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Revised Diagnosisand Care Plan

Teaching PointsDiscussion and Conclusions

DiagnosticResults

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Phillip Levy, MD, MPH

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Chief Complaint“I am short of breath and my body is swollen”

• Triage time: 17.25• Mode of arrival: EMS

EMS=emergency medical services

CASE DETAILS AND INITIAL TRIAGE

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CaseIntroduction

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Vital Signs• BP: 194/122 mmHg• HR: 65 bpm• RR: 18 brpm• Temperature: 36.5°C / 98 °F• O2 sat: 96% room air

CASE DETAILS AND INITIAL TRIAGE

BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; HR=heart rate; O2 sat=oxygen saturation; RR=respiration rate

CaseIntroduction

Initial Diagnosis and Care Plan

Case Details and Initial Triage

Revised Diagnosisand Care Plan

Teaching PointsDiscussion and Conclusions

DiagnosticResults

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History of Present Illness• 49-year-old black male with a history of

chronic heart failure (reduced EF), presents because of shortness of breath and body swelling, particularly in his legs

• Symptoms have been worsening over the last 3 weeks to the point where he is now having trouble walking across the room without getting very short of breath

• Difficulty breathing is exacerbated by lying down flat

• Patient states he has been intermittently compliant with his medications

EF=ejection fraction

HPI

CASE DETAILS AND INITIAL TRIAGE

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CaseIntroduction

Initial Diagnosis and Care Plan

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Revised Diagnosisand Care Plan

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Review of SystemsDenies• Chest pain• Recent upper respiratory illness symptoms• Fevers or chill

CASE DETAILS AND INITIAL TRIAGE

CaseIntroduction

Initial Diagnosis and Care Plan

Case Details and Initial Triage

Revised Diagnosisand Care Plan

Teaching PointsDiscussion and Conclusions

DiagnosticResults

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Past HistoryPast Medical History• Heart failure with reduced ejection fraction

– last admission for acute heart failure ≈ 6 weeks prior

• Hypertension• Coronary artery disease• Diabetes mellitus• Gout• Stage 1 chronic kidney disease

Past Surgical History• Cardiac catheterization

CASE DETAILS AND INITIAL TRIAGE

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CaseIntroduction

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Allergy History, Medications, and Social HistoryAllergy History• None

Social History• No cigarettes• No regular alcohol • No illicit drugs

Current MedicationsDiltiazem ER 120 mg 1 cap dailyFurosemide 40 mg 1 tab twice a dayHydralazine 50 mg 2 tabs four times a dayIsosorbide 60 mg 2 tabs in the mononitrate ER morningLisinopril 40 mg 1 tab daily Losartan 50 mg 2 tab dailyMetoprolol 50 mg 2 tabs twice a dayMinoxidil 2.5 mg 2 tabs twice a day Glipizide 5 mg 1 tab twice a dayMetformin 500 mg 1 tab twice a day Ranitidine 150 mg 1 tab twice a day

CASE DETAILS AND INITIAL TRIAGE

CaseIntroduction

Initial Diagnosis and Care Plan

Case Details and Initial Triage

Revised Diagnosisand Care Plan

Teaching PointsDiscussion and Conclusions

DiagnosticResults

DispositionDecision

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Physical Examination (Focused Exam)• Neck

– elevated jugular venous pressure noted• Respiratory

– equal excursion bilateral; basilar crackles with no wheezing or rhonchi• Cardiovascular

– regular rate and rhythm, S1/S2 auscultated, no murmurs, gallops, rubs, or thrills; pulses palpated and equal in all 4 extremities

• Gastrointestinal– bowel sounds normal, abdomen soft, non-tender, non distended

• Extremities– 2+ pitting edema to the mid thigh bilateral; no erythema, warmth or

tenderness appreciated• Skin

– warm, dry, intact, no rashes; well-perfused• Neurological

– alert and oriented to person, place and time; no global or focal deficits appreciated

CASE DETAILS AND INITIAL TRIAGE

CaseIntroduction

Initial Diagnosis and Care Plan

Case Details and Initial Triage

Revised Diagnosisand Care Plan

Teaching PointsDiscussion and Conclusions

DiagnosticResults

DispositionDecision

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Initial Plan of Care

INITIAL DIAGNOSIS AND CARE PLAN

Clinical Impression (Initial Diagnosis)

and Differential Diagnosis

CaseIntroduction

Initial Diagnosis and Care Plan

Case Details and Initial Triage

Revised Diagnosisand Care Plan

Teaching PointsDiscussion and Conclusions

DiagnosticResults

DispositionDecision

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Phillip Levy, MD, MPH

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Clinical Impression (Initial Diagnosis)and Differential Diagnosis Primary diagnosis• Acute (on chronic) heart failure

Things to differentiate• Hypertension vs fluid overload as the primary

precipitant • Potential contribution of acute kidney injury

and myocardial ischemia

INITIAL DIAGNOSIS AND CARE PLAN

CaseIntroduction

Initial Diagnosis and Care Plan

Case Details and Initial Triage

Revised Diagnosisand Care Plan

Teaching PointsDiscussion and Conclusions

DiagnosticResults

DispositionDecision

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Initial Plan of CareTreatment• Furosemide 40 mg by i.v. bolus• Aspirin 325 mg by mouth

Work-up• ECG• Laboratory analysis• Chest X ray

INITIAL DIAGNOSIS AND CARE PLAN

ECG=electrocardiogram; i.v.=intravenous

CaseIntroduction

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DiagnosticResults

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DIAGNOSTIC RESULTS

Lab Results

Ancillary Imaging

Chest X ray

ECG

CaseIntroduction

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Phillip Levy, MD, MPH

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ECGDIAGNOSTIC RESULTS Click here for

ECG: Interpretation

ECG=electrocardiogram

CaseIntroduction

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ECG: Interpretation

• Normal sinus rhythm with no evidence of ST segment elevation

• ST segment depression <1 mm noted in leads I, II, aVF, V5, and V6

• Poor R wave progression• No left ventricular hypertrophy by Cornell voltage

criteria criteria

DIAGNOSTIC RESULTS

CaseIntroduction

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DiagnosticResults

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Lab results• Sodium 145 mmol/L • Potassium 3.4 mmol/L • Chloride 108 mmol/L • Carbon Dioxide 30 mmol/L • Anion Gap 7 mmol/L • Glucose 118 mg/dL • BUN 18 mg/dL • Creatinine 1.9 mg/dL • eGFR* 46 mL/min/1.73m2 • Calcium 8.8 mg/dL • Magnesium 2.0 mg/dL

• Troponin I** 0.032 ng/mL (32 pg/mL)• NT-proBNP*** 5,781 pg/mL

• WBC 6.8 K/CUMM • Hemoglobin 13.2 g/dL• Hematocrit 39.7% • MCV

94.5 FL • RDW 12.2 % • Platelets 172 K/CUMM

• PTT 28.1 Seconds

• PT11.4 Seconds

• INR1.06

*Calculated using Cockroft-Gault equation; **Siemens Vista assay 99th percentile cut-point = 0.057 ng/mL. Highest value:40.0 ng/mL; Lowest value:<0.017. Negative:<0.057 ng/mL; indeterminate:0.057–0.19ng/mL; Positive:>0.020ng/mL. ***Roche Cobas assay. Highest value: >35000 pg/mL; Lowest value: 5 pg/mL. Normal range: <450pg/mL, <900pg/mL , and <1800g/mL for <50 years of age, 50–75 years of age; and >75 years of age, respectively.BUN=blood urea nitrogen; eGFR=estimated glomerular filtration rate; INR=international normalized ratio; MCV=mean corpuscular volume; NT-proBNP=N-terminal pro-B-type natriuretic peptide; PT=prothrombin time; PTT=partial thromboplastin time; RDW=red cell distribution width; WBC=white blood cell count

DIAGNOSTIC RESULTS

CaseIntroduction

Initial Diagnosis and Care Plan

Case Details and Initial Triage

Revised Diagnosisand Care Plan

Teaching PointsDiscussion and Conclusions

DiagnosticResults

DispositionDecision

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Click here forLab results:Reference Ranges

Chest X rayDIAGNOSTIC RESULTS Click here for

Chest X ray: Interpretation

CaseIntroduction

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Chest X ray: Radiology InterpretationTechnique• Upright PA and lateral views of the chest

Findings• The heart is moderately enlarged. The trachea is

midline. There is mild pulmonary vascular congestion. There is small left pleural effusion. There is no pneumothorax. There is no focal area of airspace opacity 

• There is no significant change in the osseous structures. The visualized upper abdomen is unremarkable

Impression• Moderate cardiomegaly with mild pulmonary vascular

congestion and small left pleural effusion

PA=posterior-anterior

DIAGNOSTIC RESULTS

CaseIntroduction

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DiagnosticResults

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Ancillary ImagingNone obtained from the ER

Contrast enhanced TTE from ≈ 6 weeks prior • Normal left ventricular size and wall thickness • Mildly reduced systolic function (EF 50–55%) with severe

inferior and inferolateral wall hypokinesis• Abnormal left ventricular diastolic function

– lateral e’ – 4.12 cm/s – E/e’ ratio = 16.34

• Severe left atrial dilatation– left atrial volume index 50.9 mL/m²

• The right ventricle is suboptimally visualized, appears dilated

• Moderate to severe right atrial dilatation (diameter=6.5 cm) with significantly elevated right atrial pressure (15 mmHg)

• Pulmonary hypertension is present (PASP=47.8 mmHg)

DIAGNOSTIC RESULTS

EF=ejection fraction; PASP=pulmonary artery systolic pressure; TTE=transthoracic echocardiogram

CaseIntroduction

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Next Actions

REVISED DIAGNOSIS AND CARE PLAN

Revised Clinical Impression and

Differential Diagnoses

CaseIntroduction

Initial Diagnosis and Care Plan

Case Details and Initial Triage

Revised Diagnosisand Care Plan

Teaching PointsDiscussion and Conclusions

DiagnosticResults

DispositionDecision

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Phillip Levy, MD, MPH

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REVISED DIAGNOSIS AND CARE PLAN

Revised Clinical Impression and Differential DiagnosesPrimary Diagnosis• Acute heart failure with volume overload and worsening renal

function (patient had history of Stage I kidney disease)– markedly elevated NT-proBNP– evidence of Stage III chronic kidney disease (baseline

Stage I)

Secondary Diagnosis• Poorly controlled chronic hypertension • No evidence of myocardial injury on ECG or lab analysis

REVISED DIAGNOSIS AND CARE PLAN

ECG=electrocardiogram; NT-proBNP=N-terminal pro-B-type natriuretic peptide

CaseIntroduction

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Next actionsTreatment• Antihypertensive therapy added

– metoprolol 50 mg given by mouth

• Additional dose of furosemide (20 mg i.v. bolus) given

REVISED DIAGNOSIS AND CARE PLAN

? QUESTION

i.v.=intravenous

CaseIntroduction

Initial Diagnosis and Care Plan

Case Details and Initial Triage

Revised Diagnosisand Care Plan

Teaching PointsDiscussion and Conclusions

DiagnosticResults

DispositionDecision

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Disposition• Patient feeling better• Admitted to PCP with cardiology and

nephrology consultation– continued diuresis – antihypertensive and chronic heart failure meds

reinitiated

• Disposition time – 19.42

DISPOSITIONDECISION

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PCP=primary care physician

CaseIntroduction

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Local Variation

TEACHING POINTS, DISCUSSION AND CONCLUSIONS

Discussion and Conclusions

Teaching Points

CaseIntroduction

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Phillip Levy, MD, MPH

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Teaching Points• Important to distinguish when elevated blood

pressure is a precipitant to AHF or simply a marker of poorly controlled chronic hypertension– protracted symptom onset with evidence of fluid

overload suggest the latter (though this can be difficult to determine)

• Chronic oral therapy should be initiated once patient is stabilized– be sure to avoid concurrent ACEI and ARB

therapy…• Need to adequately dose initial i.v. diuretic

therapy when fluid overload is present – target 2–2.5 x daily oral dosing divided for q12

administration

TEACHING POINTS, DISCUSSION AND

CONCLUSIONS

ACEI = angiotensin converting enzyme inhibitor; AHF=acute heart failure; ARB = angiotensin receptor blocker; i.v.=intravenous

CaseIntroduction

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Discussion and ConclusionsShould this patient have received nitrates?• Not based on his symptoms

– respiratory status was mildly compromised on arrival and symptoms improved with diuretic therapy

• Not based solely on BP either– no evidence to suggest clinical benefit with routine BP reduction

in hypertensive patients• Trial of sublingual NTG is not unreasonable

– unclear what end-point would be targeted– Venous congestion leading to renal congestion may improve with

vasodilator therapyWhat else could have been done in the ER?• More aggressive BP control using oral agents (lisinopril,

hydralazine)– metoprolol is a poor first choice for this purpose– Start with patients chronic medications given history of

intermittent compliance

TEACHING POINTS, DISCUSSION AND

CONCLUSIONS

BP=blood pressure; ER=emergency room; NTG = nitroglycerin

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Blood Pressure: Arrival Through Day 2TEACHING POINTS, DISCUSSION AND

CONCLUSIONS

CaseIntroduction

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Local Variation• General underuse of nitrates in the US

compared to Europe1

– may be driven by regional differences in directed resource utilization (i.e., nitrate infusions often require ICU or step-down unit admission in the US) or differential understanding of disease process

• Focus on rapid throughput in this hospital– door to disposition=137 minutes

TEACHING POINTS, DISCUSSION AND

CONCLUSIONS

1. Collins et al. Eur J Heart Fail 2010;12:1253–60ICU=Intensive Care Unit.

CaseIntroduction

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Glossary of termsAcute MedicineAlso known as emergency medicine ward

CHA2DS2-VASCA clinical prediction rule for estimation ofstroke risk in patients with atrial fibrillation

CHEM7US terminology. A basic metabolic panelincluding Na, K, Cl−, HCO3

− or CO2, bloodurea nitrogen, creatinine and glucose

Community heart failure teamUK terminology. A specialist communityheart failure nursing service working inpartnership with Hospital Trusts

ConsultantUK terminology. The equivalent role in theUS would be an attending/staff physician

C/OComplaining of

EHMRGEmergency Heart Failure Mortality Risk Grade. A tool that could be used to assess mortality risk at discharge. Note, this tool has not been prospectively validated. Clinical judgement is important

GPGeneral practitioner. UK terminology.The equivalent role in the US would be family physician

R/ORuled out

Statstatim (Latin) referring to speed

Specialist UK terminology. See consultant

Lab results: Reference Ranges1,2DIAGNOSTIC RESULTS

Hematology• D-Dimer <500 μg/L (0.5 mg/L)• Hematocrit 

    Male 41%–51%    Female 36%–47%

• Hemoglobin, blood    Male 14–17 g/dL

(140–170 g/L)    Female 12–16 g/dL

(120–160 g/L)

• Platelets 150,000–350,000/µL

(150–350 x 109/L)

Blood, plasma and serum chemistry• Albumin, serum 3.5–5.5 g/dL

(35–55 g/L)

• ALT 0–35 units/L*

• AST 0–35 units/L*

* Test performed at 37oC3

1. American College of Physicians, Laboratory Reference Values; 2. McMurray et al. Eur Heart J 2012:33;1787–1847; 3. http://www.surgeryencyclopedia.com/La-Pa/Liver-Function-Tests.html [accessed 20th February 2015]ALT=aminotransferase, alanine; AST=aminotransferase, aspartate; BNP=B-type natriuretic peptide; BUN=blood urea nitrogen; CRP=c-reactive protein

• Blood gases, arterial (ambient air)      pH 7.38–7.44      pCO2 35–45 mm Hg

(4.7–6.0 kPa)     pO2 80–100 mm Hg

(10.6–13.3 kPa)     O2 sat ≥95%

• BNP, blood <100 pg/mL• BUN 8–

20 mg/dL

(2.9–7.1 mmol/L)• CRP

0.0–0.8 mg/dL

(0.0–8.0 mg/L)• Ca, serum 9–10.5 mg/dL

(2.2–2.6 mmol/L)More

Lab results: Reference Ranges1,2DIAGNOSTIC RESULTS

• Urea nitrogen, blood8–

20 mg/dL

(2.9–7.1 mmol/L)• Uric acid, serum

2.5–8 mg/dL

(0.15–0.47 mmol/L)

Urine• GFR, normal

Male 130 mL/min/1.73 m2

Female 120 mL/min/1.73 m2

Blood, plasma and serum chemistry(cont’d)• Creatinine, serum

0.7–1.3 mg/dL (61.9–115 µmol/L)

• Electrolytes, serum     Na136–145 meq/L

(136–145 mmol/L)     K3.5–5.0 meq/L

(3.5–5.0 mmol/L)     Cl‾ 98–106 meq/L

(98–106 mmol/L)    HCO3 23–28 meq/L

(23–28 mmol/L)• Glucose, plasma*

70–100 mg/dL

(3.9–5.6 mmol/L)

• Lactic acid, venous blood6-

16 mg/dL (0.67-1.8 mmol/L)

1. American College of Physicians, Laboratory Reference Values; 2. McMurray et al. Eur Heart J 2012:33;1787–1847GFR=glomerular filtration rate. *Fasting.