Managing Acute Heart Failure in the Emergency Department

Patient Case Study

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Initial Diagnosis Revised Diagnosis Teaching Points

Case Introduction and Care Plan and Care Plan Discussion and Conclusions

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2 4 6

Glossary

Case Details Diagnostic Disposition ? Questions

and Initial Triage Results Decision

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE INTRODUCTION

Salvatore Di Somma , MD PhD

Emergency Medicine Department,
Sant’ Andrea Hospital,
School of Medicine and Psychology,
University of Roma “Sapienza”
(Rome; Italy)

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Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE INTRODUCTION

Background
• This is the ED of an academic tertiary care hospital in
a large urban city in Europe
• Overall the ED has 9 residents, a full complement of
nurses (110), MD assistants (36) and 12 fellows. This
personnel fully take care of the patients in the ED,
Intensive Short Observation Unit (8 beds) and
Emergency Medicine ward (Acute Medicine, 32 beds)
• The ED has 24/7 ECG, echo, biomarkers data and
chest X ray immediately available
• The hospital has a cath lab

ECG=electrocardiogram; ED=emergency department; MD=medical doctor

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History of Past History, Allergy

I History, Medications,
Present Illness HP
and Social History

Chief Complaint Physical

and Vital Signs Examination

CASE DETAILS
AND INITIAL TRIAGE

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE

Chief Complaint
• Male, 63 years old, who complains of
worsening breathlessness with exertion and
palpitations

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CASE DETAILS
AND INITIAL TRIAGE
Vital Signs
• BP: 95/60 mmHg
• HR: 140 bpm
• RR: 26 brpm
• Temperature: 36°C / 96.8°F
• O2 sat: 98%

BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; HR=heart rate; O2 Sat= oxygen saturation;
RR=respiratory rate
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

I
HP

CASE DETAILS
AND INITIAL TRIAGE History of Present Illness
• 63 year old male with a history of chronic HF
who reports progressive dyspnea on exertion
over the last 7 days. He also notes
palpitations and decreased urinary output.
His legs have become more swollen during
this episode in addition to increased fatigue
• He denies chest pain, fevers, or cough

HF=heart failure
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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CASE DETAILS
AND INITIAL TRIAGE Past History
• Hypertension
• Diabetes mellitus type 2
• Dyslipidemia
• Tobacco addiction and COPD
• Chronic ischemic heart disease
• NSTEMI in 2008 (triple bypass)
• Right leg vein insufficiency
• Recent mitral valvuloplasty
• No previous history of atrial fibrillation
• LVEF 30% (echocardiogram of 2008)
• Functional capacity: NYHA II

COPD=chronic obstructive pulmonary disease; LVEF=left ventricular ejection fraction;

NSTEMI=non-ST segment elevation myocardial infarction; NYHA=New York Heart More
Association
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

CASE DETAILS
AND INITIAL TRIAGE Allergy History, Medications,
and Social History
Allergies Current Chronic Medications
• No history of drug • Aspirin 100 mg/day
allergy • Furosemide 50 mg/day
• Spironolactone 50 mg/day
Social History
• Ramipril 2.50 mg/day
• Smoker
• Digoxin 0.125 mg/day
• No illicit drug use
• Carvedilol 12.50 mg/day
• Human Insulin 15 IU/day
• Glargine 7 IU/day
• Omeprazole 20 mg/day
• Atorvastatin 20 mg/day

COPD=chronic obstructive pulmonary disease; EF=ejection fraction; NSTEMI=non-ST segment

elevation myocardial infarction; NYHA=New York Heart Association
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CASE DETAILS
AND INITIAL TRIAGE Physical Examination
• Visibly short of breath, tachypneic
• Chest auscultation: harsh breath sounds throughout
and bilateral rales halfway up both lung fields
• Heart auscultation: tachycardia with arrhythmic heart
activity; III and IV heart sounds; systolic murmur on
centrum cordis
• Jugular vein distension
• Hepatojugular reflux
• Severe peripheral edema
• Otherwise unremarkable exam
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Clinical Impression
(Initial Diagnosis)
Initial Plan of Care
and Differential
Diagnosis

INITIAL DIAGNOSIS
AND CARE PLAN

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

INITIAL DIAGNOSIS
AND CARE PLAN
Differential Diagnosis
• Acute atrial fibrillation with rapid ventricular
response (a common reason for ADHF)
• Acute decompensated heart failure
• Acute kidney failure (AKI is a common finding
in patients with ADHF)
• Cardiorenal syndrome type 1 due to onset of
atrial fibrillation episode

ADHF=acute decompensated heart failure; AKI=acute kidney injury

Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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INITIAL DIAGNOSIS Initial Plan of Care

AND CARE PLAN

Diagnostic Plans
• Vein cannulation
• Laboratory tests including BNP and Troponin I
• Blood gas analysis
• ECG (12 leads and continuous cardiac monitoring)
• Ultrasound of heart, lungs and inferior vena cava
Point of care bedside ultrasound
• Chest X ray

Therapeutic Plans
• Diuretics (furosemide) i.v.
• Oxygen
• Rate control drugs for atrial fibrillation
BNP=B-type natriuretic peptide; ECG=electrocardiogram; i.v.=intravenous
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Lab Results Chest X ray

DIAGNOSTIC RESULTS
ECG Ancillary Imaging

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

ECG
DIAGNOSTIC
RESULTS

• Performed within 10 minutes

• Demonstrates the absence of p waves,
narrow complex, and an irregular rhythm. No
new ischemic changes compared with an old
ECG. Diagnosis of atrial fibrillation with rapid
ventricular response

ECG=electrocardiogram
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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Lab Results (or Point of Care Testing

DIAGNOSTIC
RESULTS

results)
Lab results were obtained within 1 hour from admission, while
results of point of care blood gas analysis and biomarkers were
obtained within 15 minutes
Lab Test Results:
(reference range) (reference range)
• Hb: 13.2 g/dL (12–16 g/dL) Blood Gas Analysis:
• PLT: 310 x103/L (140–400 x103/L) • pH: 7.57 (7.35–7.45)
• pCO2: 29 mmHg (35–45 mmHg)
• WBC: 9.01 x103/ L (4.3–10.8 x103/L)
• pO2: 64 mmHg (80–100 mmHg)
• Creatinine:1.5 mg/dL (0.7–1.2 mg/dL)
• HCO3‾: 26.6 mmol/L (22–26 mmol/L)
• BUN: 33 mg/dL (5–25 mg/dL)
• Lactates: 1.6 mmol/L (<2 mmol/L)
• eGFR: 50 mL/min • SO2: 95%
• TnI*: 0.02 ng/mL (0–0.05 ng/mL)
• Glucose: 323 mg/dL (70–100 mg/dL)
• Digoxin: <0.4 ng/mL (0.5–2 ng/mL)
• BNP : #
744 pg/mL (<100 pg/mL)
• Albumin: 3.6 g/dL (3.5–5.5 g/dL)

*Abbott Diagnostic Assay; #Abbott Diagnostic Assay.

BNP=B-type natriuretic peptide; BUN=blood urea nitrogen; eGFR=estimated glomerular filtration rate;
Hb=hemoglobin; PLT=platelets; TnI=troponin I; WBC=white blood cell
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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Chest X ray
DIAGNOSTIC
RESULTS
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Chest X ray:
Interpretation

? QUESTION
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Chest X ray: Radiology Interpretation

DIAGNOSTIC
RESULTS

Obtained within 1 hour from admission

Findings
• Cardiomegaly, interstitial and alveolar edema consistent with
pulmonary congestion
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Ancillary Imaging: Interpretation

DIAGNOSTIC
RESULTS

An echocardiogram was performed at ED presentation

Findings
• LVEF: 10%
• LA: (33.3 cm2)
• LV: dilated
• Mild mitral insufficiency
• PAP: 14.98 mmHg
• No pericardial effusion
• IVC: 2.29 cm

ED=emergency department; IVC=inferior vena cava; LA=left atrium; LV=left ventricle; LVEF=left ventricular
ejection fraction; PAP=pulmonary artery pressure
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Revised Clinical
Impression and Next actions
Differential Diagnoses

REVISED DIAGNOSIS AND

CARE PLAN

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

REVISED DIAGNOSIS
AND CARE PLAN
Clinical Impression
• Acute decompensated heart failure due to atrial
fibrillation
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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REVISED DIAGNOSIS
AND CARE PLAN
Next Actions
Therapeutic action in ED:
• Digoxin: 0.75 mg i.v.
• Enoxaparin: 6,000 U
(LMWH)
• Furosemide: 40 mg/b.i.d. i.v.

ED=Emergency Department; i.v.=intravenous; LMWH=low-molecular-weight heparin

Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
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DISPOSITION
DECISION
Re-assessment and Disposition
• Reduction of heart rate, with decrease of
severity of dyspnea and notable diuresis
• As symptoms improve, heart rate may also
improve (HR 95 bpm after 40 min)
• Patient was admitted to the Emergency
Medicine ward (acute medicine) for
continuous monitoring of vital parameters
until clinical stabilization (4 days)
• At discharge, an LVEF of 24% was recorded
bpm=beats per minute; HR=heart rate; LVEF=left ventricular ejection fraction
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Discussion and
Teaching Points
Conclusions

TEACHING POINTS, DISCUSSION

AND CONCLUSIONS

Author:
Salvatore Di Somma, MD, PhD
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

TEACHING POINTS,
DISCUSSION AND
Teaching Points
CONCLUSIONS
• AHF patients are very complex because they
present with many comorbidities
• Atrial fibrillation was the suspected cause of
decompensation, especially as the patient
had no past history of AF and poor systolic
function
• Although creatinine was normal
approximately one month ago (according to
review of past labs), cardiorenal syndrome
type 1 due to AKI in AHF was found to be
present at admission, as reflected by an
increase >0.3 mg/dL in creatinine value from
baseline and decreased urinary output
AHF=acute heart failure; AKI=acute kidney injury
Home Case Case Details Initial Diagnosis Diagnostic Revised Diagnosis Disposition Teaching Points
Introduction and Initial Triage and Care Plan Results and Care Plan Decision Discussion and Conclusions

TEACHING POINTS,
DISCUSSION AND
Discussion and Conclusions
CONCLUSIONS
• As a rapid ventricular rate is the likely precipitant for
this case, rate control is an important goal. However,
careful choice of agent is required to avoid harmful
effects of decreased inotropy as patient has poor
stroke volume at baseline.
• Oxygen supply
• Diuretic in order to reduce congestion. Treating the
heart failure will likely reduce sympathetic drive and
improve the heart rate
BP=blood pressure
 Glossary of terms
Acute Medicine
Also known as emergency medicine ward
CHA2DS2-VASC
A clinical prediction rule for estimation of
stroke risk in patients with atrial fibrillation
EHMRG
Emergency 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

CHEM7 GP
US terminology. A basic metabolic panel General practitioner. UK terminology.
including Na, K, Cl−, HCO3− or CO2, blood The equivalent role in the US would be family
urea nitrogen, creatinine and glucose physician

Community heart failure team R/O

UK terminology. A specialist community Ruled out
heart failure nursing service working in
partnership with Hospital Trusts Stat
statim (Latin) referring to speed
Consultant
UK terminology. The equivalent role in the Specialist
US would be an attending/staff physician UK terminology. See consultant

C/O
Complaining of