Transcript Acute heart failure triggered by anaemia

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:
Òscar Miró, MD, PhD
Disposition
Decision
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Questions
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Case
Introduction
Case Details
and Initial Triage
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
Òscar Miró, MD, PhD
Emergency Department, Hospital Clínic
(Barcelona, Catalonia: Spain)
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Case
Introduction
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
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This is the ED of an academic tertiary care
hospital in a large urban center. You
completed training as a board-certified internal
medicine physician 5 years ago
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You have 5 residents on duty (of different
medical specialties, but none of emergency
medicine because this specialty is not
recognized in your country), a full complement
of nurses and assistants, and 24/7 immediate
access to image explorations (CT, MR, US)
CT=computer tomography; ED=Emergency Department; MR=magnetic resonance; US=ultrasound
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Introduction
CASE INTRODUCTION
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Background
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Nobody in the ED is skilled in emergency
echo and the ED does not have natriuretic
peptide availability. Essentially, this ED
handles any type of emergency
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You are also in charge of a 16-bed
observation unit, located in the ED, where the
expected maximum length of stay is 24 hours
echo=echocardiogram; ED=Emergency Department
Teaching Points
Discussion and Conclusions
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Initial Diagnosis
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Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
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Past History, Allergy
History, Medications,
and Social History
History of
Present Illness
Chief Complaint
and Vital Signs
Physical
Examination
CASE DETAILS
AND INITIAL TRIAGE
Author:
Òscar Miró, MD, PhD
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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
CASE DETAILS
AND INITIAL TRIAGE
Chief Complaint
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A 79-year old woman presents to the ED
(9.21 am) on her own, complaining of
progressive dyspnea over the last 3 weeks
ED=Emergency Department
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CASE DETAILS
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Case Details
and Initial Triage
Initial Diagnosis
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Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Vital Signs
Upon arrival, vital signs:
• BP: 145/68 mmHg
• HR: 77 bpm (regular rhythm)
• RR: 24 brpm
• Temperature: 36.6 °C / 97.9 °F
• O2 sat: 96% (room air)
BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; HR=heart rate; O2 sat=oxygen saturation;
RR=respiration rate
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CASE DETAILS
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Case Details
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Initial Diagnosis
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Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
History of Present Illness
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The patient started to feel shortness of breath
3 weeks previously upon exertion (while taking
her daily walk on flat streets)
She has progressively shortened the duration
of walks
1 week before coming to the ED, she noticed
that shortness of breath was also present
during routine activity at home
Otherwise, she felt fine when resting and no
changes during sleep were reported
No fever, no chest pain, no changes in her
chronic medication were reported
ED=Emergency Department
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Revised Diagnosis
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Disposition
Decision
Teaching Points
Discussion and Conclusions
CASE DETAILS
AND INITIAL TRIAGE
Past History
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Transient ischemic attack (6 years previous)
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Arterial hypertension
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Heart failure (1 year previous)
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LVEF 39%, left ventricular hypertrophy, no significant
valvular dysfunction
presence of leg edema
shortness of breath on exertion
BNP of 320 nmol/mL
the patient achieved adequate symptom control with
bisoprolol, enalapril and hydrochlorothiazide, and no
changes in treatment have been introduced since then
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BNP=B-type natriuretic peptide; LVEF=left ventricular ejection fraction
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Revised Diagnosis
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Disposition
Decision
Teaching Points
Discussion and Conclusions
Allergy History, Medications,
and Social History
Allergies
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Has no drug allergy
Current Medications
Aspirin
Bisoprolol
Enalapril
Hydrochlorothiazide
Social History
• Does not smoke
• Does not consume
alcohol
• Is functionally independent
• Is intellectually intact
• Is adherent to treatment
• Lives with husband (who is
also independent)
• Exercises daily (30 min walk,
until her recent shortness of
breath 3 weeks previous)
300 mg/day
5 mg/day
20 mg/day
12.5 mg/day
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Disposition
Decision
Physical Examination
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NYHA Class II
General:
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Lung:
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mild cardiac murmur (II/VI) on mitral focus
mild edema until knees
Abdomen:
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rales on both pulmonary bases, clear above
Cardiac:
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well-hydrated, pallid, no jaundice
mild edema until knees
no jugular venous distension
unremarkable
Neurologic:
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unremarkable
NYHA=New York Health Association
Teaching Points
Discussion and Conclusions
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Discussion and Conclusions
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Clinical Impression
(Initial Diagnosis)
and Differential
Diagnosis
Initial Plan of Care
INITIAL DIAGNOSIS
AND CARE PLAN
Author:
Òscar Miró, MD, PhD
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INITIAL DIAGNOSIS
AND CARE PLAN
Case Details
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Initial Diagnosis
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Revised Diagnosis
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Teaching Points
Discussion and Conclusions
Clinical Impression
(Initial Diagnosis)
and Differential Diagnosis
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Acute heart failure (as main diagnosis)
– resident and consultant agreed with this diagnosis
based on previous diagnosis of HF, and on signs
and symptoms found in clinical history
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No other differential diagnosis for dyspnea came up at
this point
– resident and consultant discussed the other main
causes of dyspnea that should always be taken
into account in the ED (ACS, bronchospasm,
pulmonary infection and pulmonary embolism)
and agreed that at this point there were no data
suggesting these
ACS=acute coronary syndrome; ED=Emergency Department; HF=heart failure
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QUESTION
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INITIAL DIAGNOSIS
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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
Initial Plan of Care
(10.11 pm; +0.50 hours after ED arrival)
Treatment
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Oxygen supplementation was discussed but was not
considered necessary based on the absence of
dyspnea on resting and on a O2 sat of 96% in room air
Furosemide 40 mg i.v. (based on clinical diagnosis)
Work-up
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Order X ray
Order ECG
Order laboratory tests including troponin
Gas blood analysis was proposed by resident, but
after discussion with the consultant, it was considered
unnecessary based on pulse oxymetry
ECG=electrocardiogram; ED=Emergency Department; i.v.=intravenous; O2 sat=oxygen saturation
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Lab Results
ECG
Chest X ray
DIAGNOSTIC RESULTS
Author:
Òscar Miró, MD, PhD
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ECG: (10.34 am; +1.13 hours after ED arrival)
ED=Emergency Department
Teaching Points
Discussion and Conclusions
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ECG:
Interpretation
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ECG: Interpretation
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Sinus rhythm, negative T waves from V1 to V3
Teaching Points
Discussion and Conclusions
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and Care Plan
Chest X ray
(10.46 am; +1.25 hours after ED arrival)
ED=Emergency Department
Disposition
Decision
Teaching Points
Discussion and Conclusions
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Chest X ray:
Interpretation
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Discussion and Conclusions
Chest X ray: Radiology Interpretation
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Heart enlargement, pulmonary interstitial edema
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Discussion and Conclusions
Lab Results
(11.06 am; +1.55 hours after ED arrival)
Biochemistry
• Glucose
• Creatinine
• Sodium
• Potassium
• eGFR
• Troponin
101 mg/dL
0.9 mg/dL
136 mmol/L
3.6 mmol/L
79 mL/min/1.73 m2
<0.017 ng/mL
(reference range)
(65–110 mg/dL)
(0.3–1.3mg/dL)
(135–145 mmol/L)
(3.5–5.0 mmol/L)
(>60 mL/min/1.73 m2)
(<0.05 ng/mL)
Hemogram
• Red cell count
• Hemoglobin
• Hematocrit
• Mean corpuscular vol.
• White blood cell count*
• Platelets
2.5 x 1012/L
71 g/L
23%
69 fL
10.9 x 106/L
462 x 109/L
(4–5.2 x 1012/L)
(125–160 g/L)
(37–46%)
(80–100 fL)
(4–10 x 106/L)
(130–400 x 109/L)
*Differential count unremarkable. ED=Emergency Department; eGFR = estimated glomerular filtration rate
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Revised Clinical
Impression and
Differential Diagnoses
Next Actions
REVISED DIAGNOSIS AND
CARE PLAN
Author:
Òscar Miró, MD, PhD
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REVISED DIAGNOSIS
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Case Details
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Revised Diagnosis
and Care Plan
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Teaching Points
Discussion and Conclusions
Revised Clinical Impression
and Differential Diagnoses
• EM consultant and resident concurred:
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complementary explorations support initial diagnosis of AHF
the patient does not need further investigations to confirm this
diagnosis
they need to recheck the clinical history looking for
gastrointestinal blood loss
the patient requires transfusion because anemia is triggering the
current AHF episode (3 months earlier, hematocrit was 34% and
MCV 73 fL)
In this ED, usual practice involves discussion with a cardiologist
as this is the first visit to the ED for shortness of breath
the patient requires discussion with a gastrointestinal specialist in
order to arrange upper and lower gastrointestinal tract tests (in
the search for any potential bleeding gastrointestinal lesion)
AHF=acute heart failure; ED=Emergency Department; EM=emergency medicine;
MCV=mean corpuscular volume
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Initial Diagnosis
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Revised Diagnosis
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Disposition
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Teaching Points
Discussion and Conclusions
Revised Clinical Impression
and Differential Diagnoses (Cont’d)
• Patient is in a stable condition, everything she
requires in the next few days can be provided as an
outpatient if she is observed for 24 hours, shows
good response to treatment, and stable serial
hematocrits.
• Additionally, the EHMRG* tool indicates that she is
in a low risk group for short term mortality
*Emergency Heart Failure Mortality Risk Grade (EHMRG) calculator available at
https://ehmrg.ices.on.ca/#. Classifies patients as ‘low’, ‘intermediate’ or ‘high’ risk for mortality
during the next 7 days post-discharge.
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Teaching Points
Discussion and Conclusions
Risk stratification
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Please note, the EHMRG Risk Score has not been
prospectively validated
Consideration of patients risk for re-hospitalization
should also be considered. This score only looks
at mortality
This score applies only to HF risk-stratification- not
necessarily for someone who may require transfusion
and may have a GI bleed. Clinical judgment is
important
EHMRG=Emergency Heart Failure Mortality Risk Grade
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Teaching Points
Discussion and Conclusions
Next Actions
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i.v.=intravenous
The patient was transferred to the observation unit
2 units of packed blood cells were ordered
Patient had no history of dyspepsia, weight loss or change in
depositional habit
She denied any evidence of upper (hematemesis) or lower (melena)
blood loss
The resident performed a fecatest that was moderately positive. No
melena
Furosemide 40 mg/8 h i.v. plus an additional 20 mg bolus
immediately prior to starting each pack infusion were ordered
Enalapril (20 mg/day) and bisoprolol (5 mg/day) were maintained
Aspirin was stopped
The duty cardiologist and gastroenterologist were contacted
Patient remained in the observation unit (maximum stay allowed:
24 hours) to assess the clinical response and await the specialist’s
expert opinion
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Teaching Points
Discussion and Conclusions
Outcome
Blood transfusion was performed over 4 hours with no
remarkable incidents
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Post-transfusion hematocrit rose to 30%
The cardiologist:
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Considered that the patient had a good performance status, had
adequate home support, and that patient did not need any urgent
intervention
Agreed to see the patient as an outpatient in the cardiology clinic
during the next week for follow up and complete cardiological
studies
The gastroenterologist:
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Agreed that upper and lower intestinal endoscopy is necessary, but
due to the absence of data related to acute bleeding (fecatest+ but
not melena, MCV low since at least 3 months), these procedures
could be performed in the outpatient clinic
Agreed to see the patient the following week to make the
appropriate arrangements
Clinical response was good
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Patient remained without dyspnea at rest
Urine output was 1,100 mL in 14 hours
No remarkable changes in vitals were registered
MCV=mean corpuscular volume
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H
DISPOSITION
DECISION
Final Disposition
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The patient was discharged 16 hours after ED
admission with the following instructions and
adjustments to management:
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enalapril was maintained (20 mg/day)
hydrochlorothiazide was stopped and replaced by
furosemide (40 mg/day)
bisoprolol was maintained (5 mg/day)
omeprazole was added (20 mg/day)
ferrous sulfate was added 2 pills/every morning
(fasting)
aspirin was stopped until a specific diagnosis for
chronic gastrointestinal bleeding was achieved
an appointment for cardiological follow up was
scheduled within 6 days
upper gastrointestinal endoscopy was scheduled
within 5 days
an appointment for gastroenterological follow up
was scheduled within 10 days
warning signs for returning to the ED were given
ED=Emergency Department
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Discussion and
Conclusions
Local Variation
TEACHING POINTS, DISCUSSION
AND CONCLUSIONS
Author:
Òscar Miró, MD, PhD
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Discussion and Conclusions
Discussion and Conclusions
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Anemia can trigger an episode of AHF
Observation units (predicted stays of less than
24 hours) can help to avoid hospital admissions in
low risk AHF patients
Organization of a clear plan for AHF patient
follow-up is crucial if we want to discharge them
directly from the ED
AHF=acute heart failure; ED=Emergency Department
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Local Variation
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Countries with time limitation in the ED stay
(like 4-hour rule or similar) would have had to
admit this patient in-hospital for complete
treatment
In places where outpatient clinics are not able
to provide quick organization of microcytic
anemia study, these kind of patients have to
be admitted to hospital
If patient lives far away from hospital and/or
outpatient clinics, admission is recommended
in order to avoid losses in follow-up
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