provincial clinical knowledge topic · 2018-04-05 · tachyarrythmias (e.g. atrial fibrillation,...

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Provincial Clinical Knowledge Topic Acute Heart Failure, Adult – Emergency

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Important Information Before you Begin

The recommendations contained in this knowledge topic have been provincially adjudicated and are based on best practice and available evidence. Clinicians applying these recommendations should, in consultation with the patient, use independent medical judgment in the context of individual clinical circumstances to direct care. This knowledge topic will be reviewed periodically and updated as best practice evidence and practice change. The information in this topic strives to adhere to Institute for Safe Medication Practices (ISMP) safety standards and align with Quality and Safety initiatives and accreditation requirements such as the Required Organizational Practices. Some examples of these initiatives or groups are: Health Quality Council Alberta (HQCA), Choosing Wisely campaign, Safer Healthcare Now campaign etc.


Goals of Management

1. Correctly make the diagnosis of acute heart failure (HF), and identify the precipitating cause 2. Early treatment of patients with cardiogenic shock, including early identification of

cardiogenic shock complicating STEMI, echocardiography, and vasopressor initiation 3. Ventilatory support (invasive or non-invasive) for acute HF patients with pulmonary edema

and respiratory distress 4. Medical therapy of acute HF should include a loop diuretic and nitroglycerin 5. Appropriate and safe disposition decision making in acute HF patients seen in the ED.

Clinical Decision Support

Key definitions used in this document: ● Acute heart failure (HF): the gradual or rapid deterioration in heart failure signs and

symptoms resulting in the need for urgent therapy. ● Cardiogenic shock: acute HF patients presenting with signs of hypoperfusion and

hypotension (systolic blood pressure [SBP] LESS than 90 mmHg.

Table 1: Signs and symptoms of acute heart failure (HF)4

Pulmonary Systemic Symptoms Dyspnea

Orthopnea Paroxysmal nocturnal dysnpea

Edema Abdominal pain (hepatic swelling) Early satiety

Signs Crackles Wheezing Pleural effusions Hypoxemia Third heart sound (left sided) Worsening mitral regurgitation

Edema Elevated jugular venous pressure (JVP) Hepatic enlargement Ascites Third heart sound (right sided) Worsening tricuspid regurgitation Hepatojugular reflex


Table 2: Precipitating causes of acute heart failure (HF) 4, 9

● Acute coronary syndrome ● Tachyarrythmias (e.g. atrial fibrillation, ventricular tachycardia) ● Excessive rise in blood pressure, uncontrolled hypertension ● Infection (e.g. pneumonia, infective endocarditis, sepsis) ● Non-adherence with salt/fluid intake or medications ● Bradyarrythmia and conduction system abnormalities ● Toxic substance (e.g. alcohol, recreational drug use) ● Medications: NSAIDs, corticosteroids, negative inotropic substances, cardiotoxic

chemotherapies, cardiac depressant medications ● Exacerbation of chronic obstructive pulmonary disease (COPD) ● Pulmonary embolism ● Anemia ● Surgery and perioperative complications ● Increased sympathetic drive, stress related cardiomyopathy ● Metabolic/hormonal derangements (e.g. thyroid dysfunction, diabetic ketosis, adrenal

dysfunction, pregnancy and peripartum related abnormalities). ● Cerebrovascular insult ● Progressive valvular disease ● Acute mechanical cause:

○ Myocardial rupture complicating acute coronary syndrome (ACS) (e.g. free wall rupture, ventricular septal defect, acute mitral regurgitation)

○ Chest trauma or cardiac intervention ○ Acute native or prosthetic valve incompetence secondary to endocarditis, aortic

dissection or thrombosis Table 3: Clinical scoring system for the diagnosis of acute HF: PRIDE Acute Heart Failure Score2

Predictor Possible Score

Age GREATER than 75 years Orthopnea present Lack of cough Current loop diuretic therapy (before presentation) Crackles on exam Lack of fever Elevated NT-proBNP Interstitial edema on chest X-ray

1 2 1 1 1 2 4 2

Likelihood of Acute Heart Failure: Low Intermediate High

Total score (of possible 14) 0 to 5 6 to 8 9 to 14


Table 4: Natiuretic peptides cut points for the diagnosis of heart failure (HF)6

Age, years Chronic Heart Failure (CHF)

unlikely (pg/mL)

Chronic Heart Failure (CHF) possible, other diagnoses need to be considered (pg/mL)

CHF very likely (pg/mL)

BNP All <100 100-500 >500

NT-proBNP <50 <300 300-450 >450

50-75 <300 450-900 >900

>75 <300 900-1800 >1800 Table 5: Causes of elevated BNP (brain natriuretic peptide)9

Cardiac Non-Cardiac ● Heart failure ● Acute coronary syndromes ● Pulmonary embolism ● Myocarditis ● Left ventricular hypertrophy ● Hypertrophic or restrictive

cardiomyopathy ● Valvular heart disease ● Congenital heart disease ● Atrial and ventricular tachyarrhythmias ● Heart contusion ● Cardioversion, ICD shock ● Surgical procedures involving the heart ● Pulmonary hypertension

● Advanced age ● Ischemic stroke ● Subarachnoid hemorrhage ● Renal dysfunction ● Liver dysfunction (mainly liver cirrhosis

with ascites) ● Paraneoplastic syndrome ● Chronic obstructive pulmonary disease ● Severe infections (including pneumonia

and sepsis) ● Severe burns ● Anemia ● Severe metabolic and hormone

abnormalities (e.g. thyrotoxicosis, diabetic ketosis)


Table 6: Contraindications to non-invasive positive pressure ventilation (NIPPV)1

● Cardiac or respiratory arrest ● Hemodynamic instability ● Complicated multiorgan failure ● Impaired consciousness (including agitated/uncooperative patients) ● Upper airway obstruction ● Inability to clear secretions/protect airway ● Pneumothorax ● Facial surgery, trauma, or deformity ● Recent esophageal anastomosis

Table 7: Recommendations for hospitalizing patients with acute heart failure (HF) 4

Recommendation Clinical Circumstances Hospitalization recommended

● Evidence of severely decompensated HF, including: ○ Hypotension ○ Worsening renal function ○ Altered mentation

● Dyspnea at rest ● Oxygen saturation LESS than 90% ● Hemodynamically significant arrhythmia including new onset

of rapid atrial fibrillation ● Acute coronary syndromes ● Elevated cardiac biomarkers

Hospitalization should be considered

● Signs and symptoms of pulmonary or systemic edema ● Major electrolyte disturbance (e.g. hyponatremia,

hyperkalemia) ● Associated comorbid conditions

○ Pneumonia ○ Pulmonary embolus ○ Diabetic ketoacidosis ○ Symptoms suggestive of transient ischemic accident

or stroke ● Repeated implantable cardioverter defibrillator (ICD) firings ● Previously undiagnosed heart failure (HF) with signs and

symptoms of systemic or pulmonary edema


The Ottawa Heart Failure Risk Scale (OHFRS): The OHFRS has recently been prospectively derived and validated as a risk scoring system to guide Emergency Department (ED) admission decisions for acute HF patients12. The authors suggested that an OHFRS score of greater than 1 has the best sensitivity to detect serious adverse events compared with actual practice (92% vs 72%), but would result in increased admission rates (78% vs. 57%). This tool has not yet been prospectively and explicitly evaluated in multiple clinical settings to determine it’s true clinical effectiveness, or impact on admission of acute HF patients. As such, the use of the tool in clinical practice must be applied cautiously. The authors recommend that OHFRS can be used as an adjunct for ED disposition making in acute HF patients, with the scale offering insight into the risks and short-term likelihood of adverse events, but should not explicitly direct whether admission should occur. Table 8: The Ottawa Heart Failure Risk Scale (OHFRS)12

Items Points Initial Assessment: a) History of transient ischemic attack (TIA) or stroke b) History of intubation or respiratory distress c) Heart rate on ED arrival greater than or equal to 110 bpm d) Room air Sa02 LESS than 90% on EMS or ED arrival

1 2 2 1

Investigations: a) ECG has acute ischemic changes b) Urea greater than or equal to 12 mmol/L c) Serum C02 greater than 35 mmol/L d) Troponin I or T elevated to AMI level e) BNP greater than 5000 ng/L **Caution: some areas within AHS use the

NT-ProBNP/BNP assay which may not be compatible with the OHFRS score

2 1 2 2 1

Walk test after ED treatment1:

a) Sa02 LESS than 90% on room air or usual 02, or heart rate greater than 110 bpm, or too ill to walk

1

Heart failure risk category for serious adverse event within 14 days2

Total score Risk (%) Category 0 2.8 Low 1 5.1 Medium 2 9.2 Medium 3 15.9 High 4 26.1 High 5 39.8 Very High 6 55.3 Very High 7 69.8 Very High 8 81.2 Very High 9 89.0 Very High

1Patient walks for 3 minutes at their own pace, with their walking aids as usual, with home 02 at usual oxygen flow level with continuous pulse oximeters measuring heart rate and oxygen saturation levels. 2Death within 30 days, admission to monitored unit, intubation, noninvasive ventilation, myocardial infarction, or relapse resulting in hospital admission within 14 days


Decision Making

Figure 1: Acute Heart Failure Clinical Pathway


1. Correctly make the diagnosis of acute heart failure (HF) in the ED based on a constellation

of clinical findings. If the diagnosis is in doubt, the use of natriuretic peptide (BNP) markers as an adjunct are indicated (see Table 1, Table 3, Table 4).

2. Identify, when possible, the precipitant of acute HF (see Table 2).

○ Routine investigations should include chest X-ray, ECG, CBC, creatinine, urea, electrolytes, glucose, and troponin.

3. Assess the severity of current HF episode (see Figure 1).

4. Identify and manage patients with cardiogenic shock (systolic blood pressure [SBP] LESS

than 90 mmHg and signs of hypoperfusion): ○ Cardiogenic shock may result from low output advanced end-stage chronic HF, or

with acute onset from STEMI, myocarditis, cardiomyopathy, or other etiologies. ○ In patients with suspected cardiogenic shock, immediate ECG and echocardiogram

should be obtained. ○ To address hypotension and improve hypoperfusion, a small fluid challenge (in the

absence of pulmonary edema) +/- vasopressor therapy should be initiated. ○ In patients with cardiogenic shock complicating STEMI, immediate percutaneous

coronary intervention (PCI) is recommended for coronary revascularization (within 2 hours of hospital admission).

5. Initiate mechanical ventilation when indicated:

○ Non-invasive positive pressure ventilation (NIPPV) is of benefit for patients presenting with acute cardiogenic pulmonary edema and respiratory distress. Early initiation of NIPPV in this population reduces in-hospital mortality and endotracheal intubation, and is associated with fewer adverse events compared with standard care. There appears to be no clear difference in 30-day mortality in patients treated with medical care versus NIPPV.

○ Continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) are NIPPV modalities used in acute HF. Either modality is acceptable and are likely equivalent in their outcomes and efficacy in this context 16, 17

○ Invasive ventilation: Consider invasive mechanical ventilation in patients with acute HF with pulmonary edema, that despite treatment is leading, or complicated by respiratory failure, reduced level of consciousness, physical exhaustion, or in the presence of other contraindications to NIPPV (see Table 6).

○ Recognize that invasive ventilation is associated with significant morbidity and mortality, and in patients with cardiogenic shock may worsen hypotension and increase vasopressor requirements.

6. Initiate medical therapy for acute HF patients (see Figure 1)

○ High dose loop diuretic therapy administered intravenously via bolus or continuous infusion. It is reasonable to start with bolus administration, given ease of intermittent


bolus compared to continuous infusion. ○ Nitroglycerin therapy should be used as an adjunct to diuretic therapy in patients

who are not hypotensive. ○ There is no benefit to ACE-inhibitor initiation in the ED, and it is not recommended. ○ There is no role for the use of opiates in the management of HF in the ED. Opiate

use is associated with increased mortality, intubation, and admission to the ICU.

7. Determine patient disposition based on severity of acute HF, response to ED therapy, and individual patient factors (see Table 7).

○ There are currently no national guideline recommendations or prospectively validated tools identifying low risk patients that can safely be discharged home following an ED visit with acute HF. A Canadian multicentre prospective cohort study found that 38.1% of acute HF visits resulted in admission, and that 48% of serious adverse events in this cohort occurred in patients not initially admitted to hospital (Stiell 2013), suggesting that acute HF patients discharged from the ED are at risk for poor outcomes. The decision to safely discharge an acute HF patient home from the ED must rely on clinician judgement, based upon a number of factors 3, 8

▪ The absence of high-risk features (e.g.. hypotension, renal failure, hypoxia, troponin elevation)

▪ Lack of co-morbidities ▪ Good response to initial ED treatment (e.g improvement in oxygenation,

dyspnea, and ambulation) ▪ Patient ability to manage symptoms at home and reliable/able to return if

deteriorates ▪ Availability of close outpatient follow up

8. The Ottawa Heart Failure Risk Scale is an additional tool, meant to be used as an adjunct

for ED disposition decision-making (see Table 8).


Order Set Components Name of Order Set: Acute Heart Failure Adult Emergency Orders Order Set Keywords: CHF, AHF

Goals of Care Designation Conversations leading to the ordering of a Goals of Care Designation (GCD), should take place as early as possible in a patient's course of care. The Goals of Care Designation is created, or the previous GCD is affirmed or changed resulting from this conversation with the patient or, where appropriate, the Alternate Decision-Maker. Complete the Goals of Care Designation (GCD) Order Set within your electronic system, or if using paper process, complete the Provincial Goals of Care Designation (GCD) paper form (http://www.albertahealthservices.ca/frm-103547.pdf) Intravenous Fluids ⬜ Intravenous Cannula – Insert: Initiate IV ⬜ IV Peripheral Saline Flush/Lock: Saline Lock

Maintenance IV Solutions ⬜ 0.9% NaCl infusion at ______mL/hour ⬜ D5W - 0.9% NaCl infusion at ______ mL/hour ⬜ D5W - 0.45% NaCl infusion at ______ mL/hour ⬜ Other: ________________________ at ____________ mL/hour

Laboratory Investigations Hematology ⬜ CBC and differential ⬜ PT(INR) ⬜ PTT Chemistry ⬜ Electrolytes (Na, K, Cl, CO2) ⬜ Glucose Random ⬜ Creatinine ⬜ Urea ⬜ Thyroid Stimulating Hormone (TSH) ⬜ Troponin

⬜ Unit to collect STAT ⬜ Unit to collect timed _____:_____ (hh:mm)

⬜ BNP/NT-proBNP Blood Gases ⬜ Blood Gases Venous

⬜ On current therapy ⬜ On room air

http://www.albertahealthservices.ca/frm-103547.pdf


⬜ Blood Gases Arterial (ABG)

ABG is not needed and should be restricted to patients in whom oxygenation cannot be readily assessed by pulse oximetry. However, ABG may be useful when a precise measurement of O2 and CO2 partial pressures is needed.

⬜ On current therapy ⬜ On room air

Urine Tests ⬜ Pregnancy Test, Urine (POCT if available)

Other Investigations Electrocardiogram (ECG) ⬜ Electrocardiogram - 12 Lead

⬜ Routine ⬜ Time critical _____:_____(hh:mm)

⬜ Electrocardiogram - 15 Lead Diagnostic Imaging General Radiology ⬜ Chest X-ray, 2 Projections (GR Chest PA and Lateral) ⬜ Chest X-ray, 1 Projection portable (GR Chest Portable) Echocardiogram ⬜ Echo Transthoracic Complete Medications

Nitroglycerin Contraindicated if systolic blood pressure (SBP) LESS than 100 mmHg

Choose ONE: ⬜ nitroglycerin SL spray (each spray delivers 0.4 mg nitroglycerin): 1 spray sublingually every

5 minutes for 3 doses; notify authorized prescriber if symptoms persist after 3 doses; HOLD if SBP less than 100 mmHg

⬜ nitroglycerin tab 0.3 mg sublingual every 5 minutes x 3 PRN; notify authorized prescriber if symptoms persist after 3 doses; HOLD if SBP less than 100 mmHg

⬜ nitroglycerin tab 0.6 mg sublingual every 5 minutes x 3 PRN; notify authorized prescriber if

symptoms persist after 3 doses; HOLD if SBP less than 100 mmHg

⬜ nitroglycerin patch ⬜ 0.4 mg/hr topically, apply now, remove at _____:_____ (hh:mm) ⬜ 0.6 mg/hr topically, apply now, remove at _____:_____ (hh:mm) ⬜ 0.8 mg/hr topically, apply now, remove at _____:_____ (hh:mm)

⬜ nitroglycerin IV continuous – dosing as per local institutional practices until provincial

orders available. Target SBP GREATER than _____ mmHg and LESS than _____mmHg


Loop Diuretics

Indicated for use in acute HF patients with signs of volume overload. If not previously on furosemide, start at 40 mg IV or 80 mg IV if renal failure is present. If previously on furosemide, use total daily oral dose as initial dose of IV furosemide. Choose ONE: ⬜ furosemide 40 mg IV once ⬜ furosemide 80 mg IV once ⬜ furosemide ______ mg IV once

If patient remains in the ED awaiting inpatient consultation service and / or admission, ensure ongoing loop diuretic is ordered to prevent further decompensation. Subsequent dosing should be determined by response to the initial dose: ⬜ furosemide 40 mg IV BID ⬜ furosemide 80 mg IV BID ⬜ furosemide _____ mg IV BID

Vasopressors

Norepinephrine may be superior to doPAMine in cardiogenic shock patients ⬜ doPAMine infusion 5 to 20 microgram/kg/min IV; titrate to maintain Mean Arterial Pressure

(MAP) of GREATER than ______ mmHg ⬜ norepinephrine infusion 0.05 to 0.5 microgram/kg/min IV; titrate to maintain Mean Arterial

Pressure (MAP) of GREATER than ______ mmHg

Patient Care Orders

Vital Signs These orders need to be re-evaluated when the patient stabilizes or by two hours, whichever occurs first. ⬜ Vital Signs (respiratory rate, pulse, blood pressure, temperature, oxygen saturation)

⬜ as per provincial guideline (Assessment and Reassessment of Patients guideline, ESCN - HCS-181-01)

⬜ every ______ hour(s) ⬜ every ______ minute(s)

⬜ Bedside Cardiac Monitoring ⬜ Oxygen Saturation Monitoring – Continuous

Respiratory Care If oxygen saturation is already adequate, no supplemental oxygen is required ⬜ O2 Therapy to maintain saturation greater than or equal to 92% for previously healthy patients ⬜ O2 Therapy to maintain saturation greater than or equal to 90% for CO2 retaining / COPD

patient

Intake and Output ⬜ Intake and Output: every 1 hour ⬜ Intake and Output: every ______ hour(s) ⬜ Foley Catheter – Insert: Connect to straight drainage

http://insite.albertahealthservices.ca/assets/policy/clp-ed-assess-reassess-pts-guideline-hcs-181-01.pdf

http://insite.albertahealthservices.ca/assets/policy/clp-ed-assess-reassess-pts-guideline-hcs-181-01.pdf


Weight ⬜ Weigh patient once daily; Obtain patient weight as soon as possible in ED after patient is

stabilized. Important for optimal administration of weight-based medications, and to monitor response to diuretic therapy.

Diet / Nutrition ⬜ NPO ⬜ NPO – May Have Sips, May Take Meds ⬜ Clear Fluids ⬜ Regular Diet ⬜ Sodium 2000 mg ⬜ Other Diet :____________ Consultations ⬜ Consult Respiratory Therapy: Indication: ___________ ⬜ Consult Transition Services: Indication: ___________ ⬜ Consult Hospitalist: Indication: ___________ ⬜ Consult Internal Medicine: Indication: ___________ ⬜ Consult Cardiology: Indication: ___________


Rural Considerations 1. Interfacility transfer:

● Patients with cardiogenic shock should be rapidly transported to a tertiary care centre with cardiac catheterization capability and ICU/CCU care.

2. Access to echocardiography: ● Echocardiogram is recommended for admitted patients with new onset heart failure

during their hospital stay. If no echocardiogram available, consider transferring to alternate centre for diagnostics or ongoing care.

Disposition Planning

1. Considerations for admission: ● Renal dysfunction, low blood pressure, hyponatremia, and elevated cardiac biomarkers

(troponin, BNP) have been consistently associated with an increased risk of mortality and morbidity

● Dyspnea or hypoxemia at rest ● Significant co-morbidities ● Physical condition (frailty, mobility issues) ● Social instability, psychiatric co-morbidity, or substance use

2. Consideration for admission to the Intensive Care/Coronary Care unit:

● Cardiogenic shock requiring vasopressor/inotrope support ● Respiratory failure requiring intubation, or ongoing need for NIPPV

3. Considerations for Discharge/Transfer:

● The absence of high-risk features (e.g. hypotension, renal failure, hypoxia, troponin elevation)

● Lack of co-morbidities ● Good response to initial ED treatment (e.g improvement in oxygenation, dyspnea, and

ambulation) ● Patient able to manage symptoms at home and reliable / able to return if deteriorates ● Availability of close outpatient follow up options ● Initiate therapy for patient to continue after ED visit (e.g. oral diuretic, nitroglycerin

patch) ● Facilitate close follow up with primary care provider, and referral to cardiology or internal

medicine where appropriate ● Include Ottawa score

4. Outpatient follow-up: ● Follow up with family physician in 1 to 2 weeks ● If new onset heart failure diagnosed in the ED, and patient is discharged directly from

the ED, arrange urgent follow up with Internal Medicine or Cardiology


5. Patient and Family education/discharge instructions:

● If questions or concerns call Health Link ● Patient care handouts: heart failure ● Lifestyle Choices to Manage Heart Failure ● Heart and Stroke Foundation

https://myhealth.alberta.ca/search/Pages/results-aftervisits.aspx?k=heart%20failure

https://www.albertahealthservices.ca/assets/info/nutrition/if-nfs-nutrition%20and-lifestyle-choices-to-manage-heart-failure.pdf

http://www.heartandstroke.ca/heart/conditions/heart-failure


Analytics

Outcome Measure#1

Name of Measure

# of times order set/protocol ‘Acute Heart Failure Adult Emergency Orders’ used

Definition For all patients with acute heart failure, number of times orderset ‘Acute Heart Failure Adult Emergency Orders’ is used. Overall, by region, by site, and by unit. Requires: ● Number (%) of ED patients discharged with ICD-10 discharge

diagnosis of heart failure ● Number (%) of ED patients (by site/zone/hospital type or location

[e.g. inner city]) for whom this order set is applied

Rationale Intended to measure if the order set cited in the knowledge topic is being used and what % of time for the indicated disease or condition. May indicate areas with adoption issues or gaps in topic content.

Notes for Interpretation

Health record must have coding for disease/condition, consider timing of roll out of provincial CIS vs paper order sets.

Outcome Measure#2

Name of Measure Reduced adverse events amongst acute heart failure patients

Definition Reduced adverse events amongst acute HF patients discharged from the ED

a. Death within 30 days of ED visit b. Need for mechanical ventilation c. Acute MI

Requires: ● Patient demographics ● CEDIS presenting complaint and CTAS score ● ED diagnoses for heart failure using ICD-10 ● Site and Zone identifiers ● ED time markers (triage to physician, physician to consult and

then to admission or physician to discharge) and outcome markers (consulted for admission, admitted to ICU, OR, or ward, died)

● ED request for consultation of index ED visit ● 14 and 30 day ‘unplanned’ ED return visits for acute heart

failure or related conditions and % of those which were admitted


Outcome Measure#3

Name of Measure Reduced rates of unplanned return to ED and admission to hospital for related medical condition within 14 days

Definition ● Patient demographics ● CEDIS presenting complaint and CTAS score ● ED diagnoses for heart failure using ICD-10 ● Site and Zone identifiers ● ED time markers (triage to physician, physician to

consult and then to admission or physician to discharge) and outcome markers (consulted for admission, admitted to ICU, OR, or ward, died)

● ED length of stay for discharged ED patients with acute heart failure

● ED Length of stay for admitted patients with acute heart failure

● 14 and 30 day ‘unplanned’ ED return visits for acute heart failure or related conditions and % of those which were admitted

Outcome Measure#4

Name of Measure Optimizing utilization of NIPPV in acute HF patients

Definition Requires: ● Patient demographics ● CEDIS presenting complaint and CTAS score ● ED diagnoses for heart failure using ICD-10 ● Site and Zone identifiers ● Number (%) of acute HF patients receiving NIPPV ● Number (%) of acute HF patients receiving

mechanical ventilation

Rationale NIPPV (BiPAP or CPAP) should be initiated in patients with cardiogenic pulmonary edema presenting with respiratory distress without delay at acute presentation. NIPPV reduces in-hospital mortality and endotracheal intubation, and is associated with fewer adverse events compared with standard care.


Outcome Measure#5

Name of Measure Reduced rates of opiate administration in ED patients with acute HF

Definition Requires: ● Patient demographics ● CEDIS presenting complaint and CTAS score ● ED diagnoses for heart failure using ICD-10 ● Site and Zone identifiers ● Use of opiates during ED stay

Rationale There is no role for the use of opiates in the management of HF in the ED. Opiate use is associated with increased mortality, intubation, and admission to the ICU.

Outcome Measure#6

Name of Measure Increase use of appropriate furosemide therapy

Definition Increased rates of appropriate furosemide therapy ● Unless contraindicated, should be used in acute HF with signs

of volume overload o Increased rates of high dose therapy (equivalent to

total daily oral dose) Requires:

● Patient demographics ● CEDIS presenting complaint and CTAS score ● ED diagnoses for heart failure using ICD-10 ● Site and Zone identifiers ● Use of furosemide during ED stay

Rationale Diuretics should be administered intravenously to HF patients with signs of fluid overload early in the course of treatment, as early therapy is associated with better outcomes.

Outcome Measure#7

Name of Measure If discharged, received adequate education regarding heart failure and its management, and when to return to ED for reassessment

Definition Consider patient survey. Requires: ● Discharge destination (home, home care, family physician) ● Discharge medications (diuretics, nitroglycerin)


Clinical Questions & Recommendations

Clinical Question #1: What is the role of B-type natriuretic peptides (BNP) in the diagnosis of heart failure (HF) in the ED? Clinical Statement #1: The use of BNP (BNP/NT-pro-BNP) measurement is recommended to help confirm or rule out a diagnosis of HF in patients in whom a clinical diagnosis is in doubt. BNP also improves the diagnostic accuracy compared to clinical judgement alone in the diagnosis of acute HF.

Quality of Evidence: High Strength of Recommendation: Strong

References: 1. Silvers SM, Howell JM, Kosowsky JM, et al. Clinical Policy: Critical Issues in the Evaluation

and Management of Adult Patients Presenting to the Emergency Department with Acute Heart Failure Syndromes. Ann Emerg Med. 2007;49:627-669.

2. Moe GW, Ezekowitz JA, O’Meara E, et al. The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Focus Update: Anemia, Biomarkers, and Recent Therapeutic Trial Implications. Can J Cardiol. 2015;31:3-16.

Clinical Question #2: Is there a role for scoring systems in the diagnosis of heart failure (HF) in the ED? Clinical Statement #2: In ED patients in whom the diagnosis of acute HF is being considered, the use of a validated scoring system can improve diagnosis and decision-making, as an adjunct to clinical impression alone. A commonly used scoring system is the PRIDE Heart failure score (see Table 3)

Quality of Evidence: Moderate Strength of Recommendation: Strong

References: 1. Moe GW, Ezekowitz JA, O’Meara E, et al. The 2014 Canadian Cardiovascular Society

Heart Failure Management Guidelines Focus Update: Anemia, Biomarkers, and Recent Therapeutic Trial Implications. Can J Cardiol. 2015;31:3-16.

Clinical Question #3: What is the role of non-invasive positive pressure ventilation (NIPPV) in the management of acute heart failure (HF) in the ED? Clinical Statement #3: NIPPV (BiPAP or CPAP) should be initiated in patients with cardiogenic pulmonary edema presenting with respiratory distress without delay at acute presentation. NIPPV reduces in-hospital mortality and endotracheal intubation, and is associated with fewer adverse events compared with standard care. Quality of Evidence: Moderate to High Strength of Recommendation: Strong


References:

1. Silvers SM, Howell JM, Kosowsky JM, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Heart Failure Syndromes. Ann Emerg Med. 2007;49:627-669.

2. Vital FMR, Ladeira MT, Atallah AN. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema (Review). Cochrane Database of Syst Rev. 2013(5):CD005351.

Clinical Question #4: Is there a role for opiates in the management of heart failure (HF) in the ED for symptom management? Clinical Statement #4: There is no role for the use of opiates in the management of HF in the ED. Opiate use is associated with increased mortality, intubation, and admission to the ICU.

Quality of Evidence: Very low Strength of Recommendation: Weak

References: 1. National Institute for Health and Care Excellence (NICE), 2014. Acute heart failure:

diagnosing and managing acute heart failure in adults. London: NICE. https://www.nice.org.uk/guidance/cg187. Accessed May 2017.

Clinical Question #5: What is the role of diuretics in the in the management of acute HF in the ED? Clinical Statement #5: Diuretics should be administered intravenously to HF patients with signs of fluid overload early in the course of treatment, as early therapy is associated with better outcomes.




2. Yancy CW, Jessup M, Butler J, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2013;62:e147-e239.

Clinical Question #6: Which diuretic administration strategy is the most clinically and cost effective in acute heart failure (HF)? Clinical Statement #6: There is no difference in clinically relevant outcomes between continuous infusion and intermittent bolus dosing of diuretics. If patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed their chronic oral daily dose.


https://www.nice.org.uk/guidance/cg187



References:

1. National Institute for Health and Care Excellence (NICE), 2014. Acute heart failure: diagnosing and managing acute heart failure in adults. London: NICE. https://www.nice.org.uk/guidance/cg187. Accessed May 2017.



Clinical Question #7: What is the role of vasodilator therapy in the in the management of acute heart failure (HF) in the ED? Clinical Statement #7: Nitrate use may be considered as an adjunct to diuretic therapy in hemodynamically stable (systolic blood pressure [SBP] GREATER than 100) patients with acute HF. Although nitrates are commonly used in the treatment of acute HF, there is no robust evidence confirming their improvement in dyspnea and global clinical status. There may be a benefit in improving hemodynamic outcomes, and when combined with diuretic therapy.




Clinical Question #8: Is there a benefit to ACE-inhibitor therapy initiation in the ED for acute heart failure (HF) patients? Clinical Statement #8: ACE-inhibitors do not have a role in the initial ED treatment of acute HF. While there is evidence that ACE-inhibitors reduce mortality and re-hospitalization in the long term, and should be initiated before discharge in hospitalized patients, there is no benefit to early ACE-inhibitor initiation, and the Canadian Cardiovascular Society recommends against their early use in acute HF.









Clinical Question #9: Which patients diagnosed with acute heart failure (HF) in the ED can be safely discharged home from the ED? Clinical Statement #9: There are currently no guideline recommendations or prospectively validated tools identifying low risk patients that can safely be discharged home following an ED visit with acute HF. The decision to safely discharge an acute HF patient home from the ED must rely on clinician judgement, based upon a number of factors including: The absence of high-risk features (i.e. hypotension, renal failure, hypoxia, troponin elevation), lack of co-morbidities, good response to initial ED treatment, patient’s ability to manage symptoms at home and reliable / able to return if deteriorates, and availability of close outpatient follow up. The Ottawa Heart Failure Risk Scale (OHFRS) is a tool to provide an estimate of risk for adverse events in ED acute HF patients, to be used as an adjunct for ED disposition decision-making. (see Table 8)

Quality of Evidence: Moderate Strength of Recommendation: Weak

References: 1. Collins SP, Storrow AB, Levy PD et al. Early Management of Patients With Acute Heart

Failure: State of the Art and Future Directions - A Consensus Document from the SAEM/HFSA Acute Heart Failure Working Group. Acad Emerg Med. 2015;22:94-112.

2. Pang PS, Jesse R, Collins SP et al. Patients With Acute Heart Failure in the Emergency Department: Do They All Need to Be Admitted? J Card Fail. 2012;18:900-903.

3. Stiell IG, Clement CM, Brison RJ, et al. A Risk Scoring System to Identify Emergency Department Patients With Heart Failure at High Risk for Serious Adverse Events. Acad Emerg Med. 2013;20(1):17-26.


References

1. Ahn J and Pillow T. Focus on: Noninvasive positive pressure ventilation in the emergency department. ACEP News, March 2010. https://www.acep.org/Clinical---Practice-Management/Focus-On--Noninvasive-Positive-Pressure-Ventilation-In-the-Emergency-Department/. Accessed online March 18, 2017.

2. Baggish AL, Siebert U, Lainchbury JG et al. A validated clinical and biochemical score for the diagnosis of acute heart failure: the ProBNP investigation of dyspnea in the emergency department (PRIDE) acute heart failure score. Am Heart J. 2006;151:48-54.

3. Collins SP, Storrow AB, Levy PD et al. Early Management of Patients With Acute Heart Failure: State of the Art and Future Directions - A Consensus Document from the SAEM/HFSA Acute Heart Failure Working Group. Acad Emerg Med. 2015;22:94-112.

4. Heart Failure Society of America. Heart Failure Society of America (HFSA) Comprehensive Heart Failure Practice Guideline 2010. Section 12: Evaluation and Management of Patients with Acute Decompensated Heart Failure. J Card Fail. 2010;16:e134-e156.

5. McKelvie RS, Moe GW, Ezekowitz JA et al. The 2012 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Acute and Chronic Heart Failure. Can J Cardiol. 2013;29:168-181.


7. National Institute for Health and Care Excellence (NICE), 2014. Acute heart failure: diagnosing and managing acute heart failure in adults. London: NICE. https://www.nice.org.uk/guidance/cg187. Accessed May 2017.

8. Pang PS, Jesse R, Collins SP et al. Patients With Acute Heart Failure in the Emergency Department: Do They All Need to Be Admitted? J Card Fail. 2012;18:900-903.

9. Ponikowski P, Voors AA, Anker SA, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2016;37:2129–2200.

10. Silvers SM, Howell JM, Kosowsky JM, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Heart Failure Syndromes. Ann Emerg Med. 2007;49:627-669.

11. Stiell IG, Clement CM, Brison RJ, et al. A Risk Scoring System to Identify Emergency Department Patients With Heart Failure at High Risk for Serious Adverse Events. Acad Emerg Med. 2013;20(1):17-26.

12. Stiell IG, Perry JJ, Clement CM, et al. Prospective validation of the Ottawa heart failure risk scale, with and without use of quantitative NT-proBNP. Acad Emerg Med. 2017;24:316-327.

13. Vital FMR, Ladeira MT, Atallah AN. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema (Review). Cochrane Database of Syst Rev. 2013(5):CD005351.

14. Yancy CW et al. 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. Circulation. 2016;134:000–000.


16. Allen AL and O’Connor CM. Management of acute decompensated heart failure. CMAJ. 2007;176:797-805.

17. Li H, Hu C, Xia JX et al., A comparison of bilevel and continuous positive airway pressure noninvasive ventilation in acute cardiogenic pulmonary edema. Amer J Emerg Med. 2013;31:1322-1327.

https://www.acep.org/Clinical---Practice-Management/Focus-On--Noninvasive-Positive-Pressure-Ventilation-In-the-Emergency-Department/






Acknowledgements

We would like to acknowledge the contributions of the clinicians who participated in the development of this topic. Your expertise and time spent are appreciated.

Name Title Zone

Knowledge Lead

Chris Hall Physician, Emergency Medicine Provincial

Topic Lead

Jennifer Nicol Physician, Emergency Medicine Calgary Zone

Working Group Members

Shawn Dowling Physician, Emergency Medicine Calgary Zone

Simon Ward Physician, Emergency Medicine Central Zone

Michael Bullard Physician, Emergency Medicine Edmonton Zone

Dan Banmann Physician, Emergency Medicine South Zone

Vincent DiNinno Physician, Emergency Medicine South Zone

Jennifer Evangelista Registered Nurse, Clinical Nurse Educator Calgary Zone

Sarah Halverson Registered Nurse, Clinical Nurse Educator Central Zone

Matthew Douma Registered Nurse, Clinical Nurse Educator Edmonton Zone

Jean Harsch Registered Nurse, Clinical Nurse Educator Edmonton Zone

Dawn Peta Registered Nurse, Clinical Nurse Educator South Zone

Kristen Mackenzie Registered Nurse, Clinical Nurse Educator North Zone

Clinical Support Services

Steven Freriks Pharmacy Information Management Governance Committee (PIM-GC) on behalf of Pharmacy Services

Provincial

James Wesenberg on behalf of Laboratory Services - Provincial Networks Provincial

Bill Anderson on behalf of Diagnostic Imaging Services Provincial

Carlota Basualdo-Hammond & Marlis Atkins

on behalf of Nutrition & Food Services Provincial


SCN or Provincial Committee

Emergency Strategic Clinical Network Core Committee Provincial

Clinical Informatics Lead

Sarah Searle Registered Nurse Provincial

Additional Contributors

Thank you to the following clinicians who participated in the colleague review process. Your time spent reviewing the knowledge topics and providing valuable feedback is appreciated. Catherine Johansen, Steve Carmichael, Craig Curtis, Tony Nickonchuk, Cheryl Gelinas, Rita Muzyka, Margaret Dymond, Brian Holroyd, Mary Gunther, Bre Hutchinson, Brenda Ashman Brian Dufresne, Brian Rowe, Janet Wallace, Teresa Thurber, Shelley O'Neill.

provincial clinical knowledge topic · 2018-04-05 · tachyarrythmias (e.g. atrial fibrillation,...

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