Nurse‐led ambulatory care supported by non‐invasive haemodynamic assessment after acute heart failure decompensation

Abstract Background Prognosis of patients with acute heart failure (AHF) and different etiologies remains a challenging issue for the Cardiologist. Purpose We aimed to evaluate clinical and echocardiographic indexes and blood tests values of patients admitted to Intensive Care Unit (ICU) for AHF to test their capability to predict events at short-, medium- and long-term follow-up. Methods We retrospectively enrolled 830 patients who entered the ICU of our third-level hospital between 2010 and 2013 for AHF. Exclusion criteria included: active malignances, heart transplantation, patients with left ventricular assist device. We evaluated in each subject: cause of admission, medical history, chest congestion severity at admission, blood tests, echocardiographic parameters and administered drugs during in-hospital stay. Primary endpoints included: mortality rate at 30 days, 6 months and 5 years after dismission, days of ICU stay and cardiology ward stay. Indexes with statistical significance at univariate analysis, were then tested by multivariate analysis. Results The study population (average age 72.2±13 y) had an ejection fraction (EF) 36±12% at ICU admission. Best predictors of prognosis in the populations, after multivariate analysis, resulted to be: renal failure, EF, age, mitral regurgitation (MR) more than mild, use of non-invasive ventilation support during ICU stay, previous stroke or transient ischemic attack (TIA). With these indexes, we created a multi-parametric prognostic score composed by: 0.7*[age >76 years] + 1.4*[plasmatic creatinine >2mg/dl] + 0.8*[non-invasive mechanical ventilation] + 0.9*[previous stroke/TIA] + 0.8*[EF <30%] + + 0.7*[previous hospitalization for AHF] + 0.5*[moderate/severe MR]. According to the score, we stratified the population in 3 tertiles with increasing mortality risk: low if <1.5, medium if 1.5–3, high risk if >3 (Figure 1). At ROC curve analysis, the score showed a greater prognostic accuracy than each parameter (30 days AUC 0.75, 6 months AUC 0.78, 5 years AUC 0.79). Figure 1 Conclusions A combined clinical, humoral and echocardiographic score could represent a new tool in the prognostication of patients with AHF since the admission in ICU.

Download Full-text

Time-pattern of adverse outcomes after an infection-triggered acute heart failure decompensation and the influence of early antibiotic administration and hospitalisation: results of the PAPRICA-3 study

Clinical Research in Cardiology ◽

10.1007/s00392-019-01481-3 ◽

2019 ◽

Vol 109 (1) ◽

pp. 34-45 ◽

Cited By ~ 5

Author(s):

Òscar Miró ◽

Koji Takagi ◽

Étienne Gayat ◽

Víctor Gil ◽

Pere Llorens ◽

...

Keyword(s):

Heart Failure ◽

Acute Heart Failure ◽

Adverse Outcomes ◽

Antibiotic Administration ◽

Time Pattern ◽

Heart Failure Decompensation

Download Full-text

Hemodynamic profiles by non-invasive monitoring of cardiac index and vascular tone in acute heart failure patients in the emergency department: external validation and clinical outcomes

10.1101/2021.11.18.21266430 ◽

2021 ◽

Author(s):

Nicholas Eric Harrison ◽

Sarah Meram ◽

Xiangrui Li ◽

Patrick Medado ◽

Morgan B White ◽

...

Keyword(s):

Heart Failure ◽

Emergency Department ◽

Cardiac Index ◽

Acute Heart Failure ◽

Vascular Tone ◽

Primary Outcome ◽

De Novo ◽

Risk Scores ◽

Secondary Outcome ◽

Non Invasive

Abstract Background Non-invasive finger-cuff monitors measuring cardiac index and vascular tone (SVRI) classify emergency department (ED) patients with acute heart failure (AHF) into three otherwise-indistinguishable subgroups. Our goals were to validate these hemodynamic profiles in an external cohort and assess their association with clinical outcomes. Methods AHF patients (n=257) from five EDs were prospectively enrolled in the validation cohort (VC). Cardiac index and SVRI were measured with a ClearSight finger-cuff monitor (formerly NexFin, Edwards Lifesciences) as in a previous study (derivation cohort, DC, n=127). A control cohort (CC, n=127) of ED patients with sepsis was drawn from the same study as the DC. K-means cluster analysis previously derived two-dimensional (cardiac index and SVRI) hemodynamic profiles in the DC and CC (k=3 profiles each). The VC was subgrouped de novo into three analogous profiles by unsupervised K-means consensus clustering. PERMANOVA tested whether VC profiles 1-3 differed from profiles 1-3 in the DC and CC, by multivariate group composition of cardiac index and vascular tone. Profiles in the VC were compared by a primary outcome of 90-day mortality and a 30-day ranked composite secondary outcome (death, mechanical cardiac support, intubation, new/emergent dialysis, coronary intervention/surgery) as time-to-event (survival analysis) and binary events (odds ratio, OR). Descriptive statistics were used to compare profiles by two validated risk scores for the primary outcome, and one validated score for the secondary outcome. Results The VC had median age 60 years (interquartile range {49-67}), and was 45% (n=116) female. Multivariate profile composition by cardiac index and vascular tone differed significantly between VC profiles 1-3 and CC profiles 1-3 (p=0.001, R2=0.159). A difference was not detected between profiles in the VC vs. the DC (p=0.59, R2=0.016). VC profile 3 had worse 90-day survival than profiles 1 or 2 (HR = 4.8, 95%CI 1.4-17.1). The ranked secondary outcome was more likely in profile 1 (OR = 10.0, 1.2-81.2) and profile 3 (12.8, 1.7-97.9) compared to profile 2. Diabetes prevalence and blood urea nitrogen were lower in the high-risk profile 3 (p<0.05). No significant differences between profiles were observed for other clinical variables or the 3 clinical risk scores. Conclusions Hemodynamic profiles in ED patients with AHF, by non-invasive finger-cuff monitoring of cardiac index and vascular tone, were replicated de novo in an external cohort. Profiles showed significantly different risks of clinically-important adverse patient outcomes.

Download Full-text

PL01: Creation of a risk scoring system for emergency department patients with acute heart failure

CJEM ◽

10.1017/cem.2020.46 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S5-S5

Author(s):

I. Stiell ◽

J. Perry ◽

C. Clement ◽

S. Sibley ◽

A. McRae ◽

...

Keyword(s):

Heart Failure ◽

Emergency Department ◽

Acute Heart Failure ◽

Care Hospital ◽

Invasive Ventilation ◽

Non Invasive ◽

Non Invasive Ventilation ◽

Risk Patients ◽

Risk Scoring ◽

Risk Scale

Introduction: Acute heart failure (AHF) is a common emergency department (ED) presentation and may be associated with poor outcomes. Conversely, many patients rapidly improve with ED treatment and may not need hospital admission. Because there is little evidence to guide disposition decisions by ED and admitting physicians, we sought to create a risk score for predicting short-term serious outcomes (SSO) in patients with AHF. Methods: We conducted prospective cohort studies at 9 tertiary care hospital EDs from 2007 to 2019, and enrolled adult patients who required treatment for AHF. Each patient was assessed for standardized real-time clinical and laboratory variables, as well as for SSO (defined as death within 30 days or intubation, non-invasive ventilation (NIV), myocardial infarction, coronary bypass surgery, or new hemodialysis after admission). The fully pre-specified, logistic regression model with 13 predictors (age, pCO2, and SaO2 were modeled using spline functions with 3 knots and heart rate and creatinine with 5 knots) was fitted to the 10 multiple imputation datasets. Harrell's fast stepdown procedure reduced the number of variables. We calculated the potential impact on sensitivity (95% CI) for SSO and hospital admissions and estimated a sample size of 170 SSOs. Results: The 2,246 patients had mean age 77.4 years, male sex 54.5%, EMS arrival 41.1%, IV NTG 3.1%, ED NIV 5.2%, admission on initial visit 48.6%. Overall there were 174 (7.8%) SSOs including 70 deaths (3.1%). The final risk scale is comprised of five variables (points) and had c-statistic of 0.76 (95% CI: 0.73-0.80): 1.Valvular heart disease (1) 2.ED non-invasive ventilation (2) 3.Creatinine 150-300 (1) ≥300 (2) 4.Troponin 2x-4x URL (1) ≥5x URL (2) 5.Walk test failed (2) The probability of SSO ranged from 2.0% for a total score of 0 to 90.2% for a score of 10, showing good calibration. The model was stable over 1,000 bootstrap samples. Choosing a risk model total point admission threshold of >2 would yield a sensitivity of 80.5% (95% CI 73.9-86.1) for SSO with no change in admissions from current practice (48.6% vs 48.7%). Conclusion: Using a large prospectively collected dataset, we created a concise and sensitive risk scale to assist with admission decisions for patients with AHF in the ED. Implementation of this risk scoring scale should lead to safer and more efficient disposition decisions, with more high-risk patients being admitted and more low-risk patients being discharged.

Download Full-text