Acute Heart Failure in the Emergency Department: the SAFE-SIMEU Epidemiological Study

Abstract

Background

Patients with acute heart failure (AHF) have high rates of attendance to emergency departments (EDs), with significant health care costs.

Objectives

We aimed to describe the clinical characteristics of patients attending Italian EDs for AHF and their diagnostic and therapeutic work-up.

Methods

We carried out a retrospective analysis on 2683 cases observed in six Italian EDs for AHF (January 2011 to June 2012).

Results

The median age of patients was 84 years (interquartile range 12), with females accounting for 55.8% of cases (95% confidence interval [CI] 53.5–57.6%). A first episode of AHF was recorded in 55.3% (95% CI 55.4–57.2%). Respiratory disease was the main precipitating factor (approximately 30% of cases), and multiple comorbidities were recorded in > 50% of cases (history of acute coronary syndrome, chronic obstructive pulmonary disease, diabetes, chronic kidney disease, valvular heart disease). The treatment was based on oxygen (69.7%; 67.9–71.5%), diuretics (69.2%; 67.9–71.5%), nitroglycerin (19.7%; 18.3–21.4%), and noninvasive ventilation (15.2%; 13.8–16.6%). Death occurred within 6 h in 2.5% of cases (2.0–3.1%), 6.4% (5.5–7.3%) were referred to the care of their general practitioners within a few hours from ED attendance or after short-term (< 24 h) observation 13.9% (12.6–15.2%); 60.4% (58.5–62.2%) were admitted to the hospital, and 16.8% (15.4–18.3%) were cared for in intensive care units according to disease severity.

Conclusions

Our study reporting the “real-world” clinical activity indicates that subjects attending the Italian EDs for AHF are rather different from those reported in international registries. Subjects are older, with a higher proportion of females, and high prevalence of cardiac and noncardiac comorbidities.

Introduction

Acute heart failure (AHF) is a global public health issue characterized by high mortality and high rates of hospital admissions and re-hospitalizations, with a massive economic burden for national health systems (1). A recent state-of-the-art review reported that the number of patients with AHF exceeds 20 million in Europe and the United States, with an incidence of over 1.5 million cases/year 2, 3, 4. Patients with AHF are a very heterogeneous group in terms of etiology, precipitating factors, comorbidities, and the extent and severity of signs and symptoms at presentation (2).

The majority of studies are derived from inpatient settings; only a few have been obtained in the setting of emergency departments (EDs) 1, 4, 5, 6. Compared with inpatient settings, the ED represents a high-yield area to identify symptomatic patients eligible for enrollment in large AHF trials testing the early treatment phase (7). Exclusion of the ED phase of patient management has been suggested as a possible reason for the lack of success of AHF studies (4).

In clinical practice, AHF mainly affects old subjects, whose management and outcome are dictated by acute and chronic comorbidities 8, 9. Differences are reported in the clinical characteristics at presentation, in the clinical course, treatment, and prognosis 8, 10. In addition, specific health care system configurations are likely to have an impact on the measured incidence rate, due to different methods of data retrieval (9).

Our primary outcome was to investigate the demographic and clinical characteristics at ED presentation, as well as the treatment of subjects with a final diagnosis of AHF treated in a few EDs of Italian general hospitals. The secondary outcome was to analyze the contribution of different comorbidities to recurrent vs. new-onset AHF.