Transcript Case 5 (Peter S. Pang)

Managing Acute Heart Failure in the Emergency Department
Patient Case Study
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Initial Diagnosis
and Care Plan
Case Introduction
1
Revised Diagnosis
and Care Plan
3
2
Teaching Points
Discussion and Conclusions
5
4
7
6
Glossary
Case Details
and Initial Triage
Diagnostic
Results
Author:
Peter S. Pang,
MD, MS, FACEP, FAAEM FAHA, FACC
Disposition
Decision
?
Questions
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Case
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Case Details
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Initial Diagnosis
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Diagnostic
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Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
CASE INTRODUCTION
Peter S. Pang, MD, MSc, FACEP
FAAEM, FAHA, FACC
Indiana University School of Medicine
(Indianapolis, IN; USA)
•
Associate Professor, Emergency
Medicine
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Associate Director, Clinical Research
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Case
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CASE INTRODUCTION
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Background
•
It is 2 am. You are the only physician immediately
available for the entire hospital in this small,
50 bed hospital located approximately 300 km
from the nearest tertiary referral medical center.
You are board certified in emergency medicine
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Although the hospital is small, you have a full
complement of nurses and you are skilled in
bedside ultrasound. This is the only hospital
within a 150 km radius
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There is no point of care (POC) testing
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There is no formal echo available within 6 hours
echo=echocardiogram
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Initial Diagnosis
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Diagnostic
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Revised Diagnosis
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Disposition
Decision
Teaching Points
Discussion and Conclusions
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Past History, Allergy
History, Medications,
and Social History
History of Present Illness
and Review of systems
Chief Complaint
and Vital Signs
Physical
Examination
CASE DETAILS
AND INITIAL TRIAGE
Author:
Peter S. Pang,
MD, MS, FACEP, FAAEM FAHA, FACC
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Initial Diagnosis
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Diagnostic
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Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Chief Complaint
“I can’t breathe” (states the patient)
•
Mode of arrival: EMS
• Paramedics report a 71 year old female
who called 911 at 1.15 am c/o shortness of
breath and palpitations. Unclear duration
• Vitals per EMS: BP 110/71 mmHg,
HR 140 bpm, RR 35 brpm, O2 sat 93%
room air
• The paramedics report crackles but no
wheezing. They administered oxygen via
facemask and brought her in. Meds are in
the grocery bag
BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; c/o=complaining of;
EMS= emergency medical services; HR=heart rate; O2 sat=oxygen saturation; RR=respiratory rate
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Decision
Teaching Points
Discussion and Conclusions
Vital Signs (in ER)
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BP: 115/74 mmHg
HR: 141 bpm
RR: 33 brpm
Temperature: 37.3°C/99.2°F (oral)
O2 sat: 98% 2 L NC
BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; ER=emergency room; HR=heart rate;
NC=nasal cannula; O2 sat=oxygen saturation; RR=respiration rate
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Initial Diagnosis
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Revised Diagnosis
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Disposition
Decision
Teaching Points
Discussion and Conclusions
History of Present Illness
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For the last 3 days, patient reports feeling
increasingly short of breath, especially with
exertion
She denies chest pain or pressure and denies
any past h/o MI. She denies any history of HF
She does report sleeping on 2 extra pillows at
night and that perhaps her shoes feel ‘tight’
Only rest makes her feel better, though she
feels her heart is ‘pounding’
HF=heart failure; h/o=history of; MI=myocardial infarction
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Decision
Review of Systems
•
No:
– cough or fever
– black or bloody stools
– nausea or vomiting
– back, chest or abdominal pain
– rash or hot/cold intolerance
•
Patient has:
– fatigue
– palpitations and shortness of breath
Teaching Points
Discussion and Conclusions
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Discussion and Conclusions
Past History
Past Medical History
• Hypertension
• Type II diabetes mellitus
Past Surgical History
• Appendectomy
• Cholecystectomy
• Hysterectomy
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Decision
Allergy History, Medications,
and Social History
Allergies
•
NKDA
Social History
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No cigarettes
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No illicit drugs
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Alcohol only on
weekends (6 pack)
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Lives alone
NKDA=no known drug allergy; q.d.=once daily
Current Medications
Hydrochlorothiazide 25 mg q.d.
Teaching Points
Discussion and Conclusions
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Teaching Points
Discussion and Conclusions
Physical Examination (Focused Exam)
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Appears in moderate distress
CV: tachycardic, irregular, “irregularly irregular”, no murmurs, gallops, rubs
(though it is loud in the ER and hard to hear)
Neck veins: + JVD
Lungs: rales 1/3 way up lung fields, no wheezing, equal and symmetric
Abdomen: Soft, not tender and not distended. No hepatomegaly
Skin: diaphoretic, 1+ pitting edema bilaterally, no calf tenderness
Some considerations…
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Patient is short of breath with an irregularly irregular tachycardia
She has no past history of a dysrhythmia or heart failure or known coronary
artery disease. However, absence of these does not rule them out
She has no fever, making pneumonia less likely.
There is no reported recent travel, h/o VTE, surgery, tobacco or hormone
replacement therapy
There is no leg edema or swelling reported
CV=cardiovascular; ER=emergency room; h/o=history of; JVD=jugular venous distension; VTE=venous thromboembolism
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Clinical Impression
(Initial Diagnosis)
and Differential
Diagnosis
Initial Plan of Care
INITIAL DIAGNOSIS
AND CARE PLAN
Author:
Peter S. Pang,
MD, MS, FACEP, FAAEM FAHA, FACC
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Clinical Impression
•
New onset HF secondary to atrial fibrillation
with rapid ventricular response
Other considerations:
• Pneumonia
• Pulmonary embolism
• Acute coronary syndrome
• Pericardial effusion/tamponade
HF=heart failure
Teaching Points
Discussion and Conclusions
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Revised Diagnosis
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Teaching Points
Discussion and Conclusions
Initial Plan of Care
Treatment
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i.v., O2, cardiac monitor, rhythm strip, ECG,
portable CXR
Work-up
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CBC, chem-7, Mg, troponin (not hs), BNP
BNP=B-type natriuretic peptide; CBC=complete blood count; CXR=chest X ray; ECG=electrocardiogram;
hs=high sensitivity; i.v.=intravenous
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Initial Treatment
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You order diltiazem 20 mg, slow i.v. push.
However, you are concerned about the
relatively long half-life and potential for
systolic depression, especially if the patient
has a reduced EF. Since she has no recent
echo in her past history, you do a bedside US
You weren’t trained to determine EF and the
patient is increasingly dyspneic lying flat.
However, the heart has good function
qualitatively
You go ahead with diltiazem 20 mg as well as
furosemide 20 mg i.v. push
echo=echocardiogram; EF=ejection fraction; i.v.-intravenous; US=ultrasound
Teaching Points
Discussion and Conclusions
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Diagnostic
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Discussion and Conclusions
Lab Results
ECG
Chest X ray
DIAGNOSTIC RESULTS
Author:
Peter S. Pang,
MD, MS, FACEP, FAAEM FAHA, FACC
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(Rhythm Strip <5 min)
• No clear p waves, irregular. Rate ~140-150 bpm
More
bpm=beats per minute
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ECG
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ECG:
Interpretation
(<10 min from Arrival)
?
QUESTION
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ECG: interpretation
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No clear p waves
Irregular rhythm
Narrow complex
Interpretation: AF with RVR
AF=atrial fibrillation; RVR=rapid ventricular response
Disposition
Decision
Teaching Points
Discussion and Conclusions
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ECG:
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Lab Results* (or Point of Care Testing
Results)
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Na
K
BUN
Creatinine
Troponin I#
BNP ‡
133 mEq/L
4.6 mEq/L
24 mg/dL
1.1 mg/dL
0.10 ng/mL (100 pg/mL)
751 pg/mL
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Lab results:
Reference
Ranges
(elevated)
(elevated)
*Other labs are within normal reference ranges.
#Abnormal Troponin I value >0.05 ng/mL, however NSTEMI criteria is >0.5 ng/mL. Abbott POC iStat assay. Reportable range
0.0 to 50.0 ng/mL. Upper 99% reference limit is 0.08 ng/mL.
‡Abbott POC iStat assay. Upper 95% reference range is 50 pg/mL. Reportable range is 15 to 5,000 pg/mL
BUN=blood urea nitrogen; BNP=B-type natriuretic peptide; NSTEMI=Non ST-segment elevation myocardial infarction
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Chest X ray
Diagnostic
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Discussion and Conclusions
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Chest X ray:
Interpretation
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Chest X ray: Radiology Interpretation
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Mild cardiomegaly, cephalization, vascular
congestion, interstitial edema, blunting of the left
costal margin
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Revised Clinical
Impression
Next Actions
REVISED DIAGNOSIS
AND CARE PLAN
Author:
Peter S. Pang,
MD, MS, FACEP, FAAEM FAHA, FACC
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Revised Clinical Impression
•
New onset AHF secondary to AF with RVR
AF=atrial fibrillation; AHF=acute heart failure; RVR=rapid ventricular response
Teaching Points
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Clinical Thinking…
Treatment
• ECG demonstrates AF with RVR
• Exam, lab work and CXR consistent with acute heart failure
• Troponin is mildly elevated but does not meet NSTEMI
threshold. In addition, ACS is less likely by history; though this
remains on the differential
• Infectious process might be obscured on CXR. However, no
fever at this time
ACS=acute coronary syndrome; AF=atrial fibrillation; CXR=chest X ray; ECG=electrocardiogram; NSTEMI= Non
ST-segment elevation myocardial infarction; RVR=rapid ventricular response
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Discussion and Conclusions
Patient Re-evaluation
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HR has slowed after diltiazem to high 90 – low 100’s (bpm)
BP 121/86 mmHg
Patient has diuresed multiple times, but no exact I/O
Patient looks better and reports feeling better
BP=blood pressure; HR=heart rate; I/O=input/output
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Next Steps (<3 hours)
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Repeat ECG shows AF with HR in the high 90’s (bpm)
You order a diltiazem 5 mg/hr i.v. drip
You also order diltiazem 30 mg p.o.
You hold on further i.v. loop diuretic given brisk diuresis and plan
to monitor frequently.
• You consider anticoagulation. CHA2DS2-VASC score is
4 (moderate to high risk), counting her current AHF as history of
HF. As you plan to admit the patient, you defer to the inpatient
team
AF=atrial fibrillation; AHF=acute heart failure; ECG=electrocardiogram; HF=heart failure; HR=heart rate;
i.v.=intravenous; p.o.=by mouth
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H
DISPOSITION
DECISION
Disposition
•
Admission to telemetry ward
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As this is new onset AHF as well as new onset AF
with RVR that was symptomatic, patient will require
an in-depth evaluation for potential causes, as well as
education for anti-coagulation and heart failure selfmanagement
•
As patient reports palpitations, but the exact timing is
unknown to the patient, assume >48 hours
AF=atrial fibrillation; AHF=acute heart failure; RVR=rapid ventricular response
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Discussion and
Conclusions
Teaching Points
Local Variation
TEACHING POINTS, DISCUSSION
AND CONCLUSIONS
Author:
Peter S. Pang,
MD, MS, FACEP, FAAEM FAHA, FACC
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Teaching Points
Why not cardiovert?
• In someone with HF, one could consider this
an emergent indication for cardioversion.
However, the patient is hemodynamically
stable and duration of symptoms is unknown
with certainty. This increases her risk for
embolic stroke
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HF=heart failure
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Teaching Points (Cont’d)
What about other drugs such as digoxin or -blocker
to control her rate?
• Neither would be absolutely contraindicated. Similar to
non-dihydropyridine calcium channel blockers such as
diltiazem, strong opinions may emerge re: choice of drug
• There is no robust data on the pharmacological rate
control management of AF with RVR and AHF in the
ED setting
• As this patient has presumed HFpEF, you chose
diltiazem in part due to comfort and knowledge of the
drug
• If the patient had a reduced EF, digoxin or amiodarone
would be more in line with guideline recommendations
AF=atrial fibrillation; AHF=acute heart failure; ED=Emergency Department; EF=ejection fraction; HFpEF=heart
failure preserved ejection fraction; RVR=rapid ventricular response
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Discussion and Conclusions
• Patient has AF with RVR and new onset AHF. It is most likely
that AF is the driver of the AHF. Managing the AF will improve
the AHF symptomatology. However, AHF still requires treatment
• Overall, the case is well managed. Whether or not to cardiovert
depends on the history and duration of symptoms, with less
stroke risk, the closer cardioversion occurs to the onset of
symptoms (but always <48 hours per guidelines)
• As new onset AHF, in general, patient should be admitted for
further diagnostic and therapeutic management. In addition,
education will be key for this patient with new diagnoses
AF=atrial fibrillation; AHF=acute heart failure; RVR=rapid ventricular response
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Local Variation
•
Formal (as opposed to bedside point of care)
echocardiography in the ED for new onset
AHF or even decompensation, is uncommon
AHF=acute heart failure; ED=Emergency Department
Teaching Points
Discussion and Conclusions
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
US terminology. A basic metabolic panel
including Na, K, Cl−, HCO3− or CO2, blood
urea nitrogen, creatinine and glucose
GP
General practitioner. UK terminology.
The equivalent role in the US would be family
physician
Community heart failure team
UK terminology. A specialist community
heart failure nursing service working in
partnership with Hospital Trusts
R/O
Ruled out
Consultant
UK terminology. The equivalent role in the
US would be an attending/staff physician
C/O
Complaining of
Stat
statim (Latin) referring to speed
Specialist
UK terminology. See consultant
DIAGNOSTIC
RESULTS
Lab results: Reference Ranges1,2
Hematology
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D-Dimer
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Hematocrit
Male
Female
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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%
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BNP, blood
<100 pg/mL
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BUN
8–20 mg/dL
(2.9–7.1 mmol/L)
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CRP
0.0–0.8 mg/dL
(0.0–8.0 mg/L)
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Ca, serum
9–10.5 mg/dL
(2.2–2.6 mmol/L)
41%–51%
36%–47%
Hemoglobin, blood
Male
14–17 g/dL
(140–170 g/L)
Female
12–16 g/dL
(120–160 g/L)
Platelets
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<500 μg/L (0.5 mg/L)
150,000–350,000/µL
(150–350 x 109/L)
Blood, plasma and serum chemistry
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Albumin, serum
3.5–5.5 g/dL
(35–55 g/L)
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ALT
0–35 units/L*
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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
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DIAGNOSTIC
RESULTS
Lab results: Reference Ranges1,2
Blood, plasma and serum chemistry
(cont’d)
•
Creatinine, serum
0.7–1.3 mg/dL
(61.9–115 µmol/L)
•
Electrolytes, serum
Na
136–145 meq/L
(136–145 mmol/L)
K
3.5–5.0 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)
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Glucose, plasma*
70–100 mg/dL
(3.9–5.6 mmol/L)
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Lactic acid, venous blood
6-16 mg/dL
(0.67-1.8 mmol/L)
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Urea nitrogen, blood
8–20 mg/dL
(2.9–7.1 mmol/L)
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Uric acid, serum
2.5–8 mg/dL
(0.15–0.47 mmol/L)
Urine
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GFR, normal
Male
Female
130 mL/min/1.73 m2
120 mL/min/1.73 m2
1. American College of Physicians, Laboratory Reference Values; 2. McMurray et al. Eur Heart J 2012:33;1787–1847
GFR=glomerular filtration rate. *Fasting.