Transcript Case 4 (Martin Möckel)

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
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4
7
6
Glossary
Case Details
and Initial Triage
Diagnostic
Results
Author:
Martin Möckel, MD, PhD, FESC, FAHA
Disposition
Decision
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Questions
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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
Martin Möckel, MD, PhD, FESC, FAHA
Professor, Charité–Universitätsmedizin
Berlin, (Berlin; Germany)
• Head, Division of Emergency
Medicine, Campus Virchow and Mitte
• Professor of Medicine, Department of
Cardiology, Campus Virchow
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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
Background
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This is the ER of a university tertiary care
hospital in a large urban center. The ER is 1
of 3 sites which form the division of EM for
adult patients. You are the consultant on duty
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In this respective site there are at least 2
residents and 1 consultant on duty, a full
complement of nurses, and 24/7 immediate
(less than 30 minute) echo capability
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Essentially, this ER handles any type of nontraumatic adult emergency
Echo=echocardiogram; EM=emergency medicine; ER=emergency room
Teaching Points
Discussion and Conclusions
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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
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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:
Martin Möckel, MD, PhD, FESC, FAHA
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Initial Diagnosis
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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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76 year old male who complains of severe
shortness of breath
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Case Details
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Initial Diagnosis
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Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Vital Signs
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BP: 123/77 mmHg
HR: 78 bpm
RR: 19 brpm
Temperature: 36.9°C/98.4°F
O2 sat: 93% room air
BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; HR=heart rate; O2 sat= oxygen saturation;
RR=respiratory rate
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Case Details
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Initial Diagnosis
and Care Plan
Diagnostic
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Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
History of Present Illness
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76 year old male
Severe dyspnea, near syncope this morning
The patient called the ambulance to be
brought to the ED
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Patient has been admitted previously to this
hospital several months ago
The patient has suffered from severe dyspnea
at rest during the past week
Today, the patient almost fainted, prompting
the patient to call the ambulance
Body weight has increased by 5 kg during the
past week
ED=emergency department; NYHA=New York Heart Association
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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
Review of Systems
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Slight cough, no fever
No black or bloody stools
No nausea or vomiting
No back, abdominal or chest pain
No palpitations
Severe shortness of breath
Fatigue
No rash or temperature intolerance
Near syncope
Edema (legs and ankles)
Disposition
Decision
Teaching Points
Discussion and Conclusions
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Case Details
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Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
Past History
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Chronic heart failure
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EF 25 %
Ischemic cardiomyopathy
2 times bypass surgery
several PCI/Stents
last coronary angiography 6 months ago without
interventional options
Primary ICD implantation
Acute renal failure, hyperkalemia
Atrial fibrillation, oral anticoagulation (rivaroxaban)
Stroke
PAD
Myocardial infarction
Arterial hypertension
Abdominal aortic aneurysm
Diabetes mellitus, hyperlipidemia
Parkinson’s disease
Smoker
EF=ejection fraction; ICD=implantable cardioverter-defibrillator: PAD=peripheral artery disease;
PCI=percutaneous coronary intervention
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Initial Diagnosis
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Diagnostic
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Revised Diagnosis
and Care Plan
Disposition
Decision
Allergy History, Medications,
and Social History
Allergies
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None
Social History
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Not known
Current Medications
• Rivaroxaban
• Prasugrel
• Metoprolol
• Ramipril
• Torasemide
• Simvastatin
• Benserazid
• Levodopa
Teaching Points
Discussion and Conclusions
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Case Details
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Initial Diagnosis
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Diagnostic
Results
Revised Diagnosis
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Disposition
Decision
Teaching Points
Discussion and Conclusions
Physical Examination
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Heart:
– no murmurs, but hard to examine due to severe tachypnea
Lungs:
– rales at bilateral lung bases
Abdomen:
– Mild distension, no pain with palpitation
Legs:
– massive edema past knees
+JVD
Glasgow Coma Scale:
– 15
JVD=jugular venous distension
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Clinical Impression
(Initial Diagnosis)
and Differential
Diagnosis
Initial Plan of Care
INITIAL DIAGNOSIS
AND CARE PLAN
Author:
Martin Möckel, MD, PhD, FESC, FAHA
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INITIAL DIAGNOSIS
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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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AHF: known h/o chronic HF (with presence of
severe dyspnea, rales, edema)
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Precipitant unclear
AHF=acute heart failure; HF= heart failure; h/o=history of
?
QUESTION
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INITIAL DIAGNOSIS
AND CARE PLAN
Initial Plan of Care
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Oxygen
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Furosemide 40 mg i.v.
i.v.=intravenous
Disposition
Decision
Teaching Points
Discussion and Conclusions
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Discussion and Conclusions
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Lab Results
ECG
Chest X ray
DIAGNOSTIC RESULTS
Author:
Martin Möckel, MD, PhD, FESC, FAHA
Ancillary Imaging
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ECG
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Performed 10 minutes after admission
Disposition
Decision
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 in I, V5/V6, no ST-changes
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Discussion and Conclusions
Lab Results (Within 60 min)
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Sodium
Potassium
Creatinine
TnT (POCT)*
CK
CRP
WBC
Platelets
Hemoglobin
143 mmol/L
3.8 mmol/L
1.05 mg/dL
10 ng/L
70 U/L
0.8 mg/L
5.67/nL
137/nL
11.3 g/dL
(Reference range)
(131–146 mmol/L)
(3.5–5.1 mmol/L)
(0.7–1.2 mg/dL)
(<30 ng/L)
(<190 U/L)
(<5.0 mg/L)
(3.9–10.5/nL)
(150–370/nL)
(12.5–17.2 g/dL)
*Radiometer AQT90 assay
CK=creatine kinase; CRP=c-reactive protein; POCT=point of care testing; TnT=Troponin T; U/L=upper limit of
normal; WBC = white blood cell count
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Chest X ray (within 60 min)
Disposition
Decision
Teaching Points
Discussion and Conclusions
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Chest X ray:
Interpretation
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Teaching Points
Discussion and Conclusions
Chest X ray: Radiology Interpretation
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Enlarged heart silhouette, signs of sternotomy, ICD device and
leads, pleural effusion both sides, perhaps early infiltration
right lung base
ICD=implantable cardioverter-defibrillator
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DIAGNOSTIC
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Diagnostic
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Ancillary Imaging
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Not performed
Revised Diagnosis
and Care Plan
Disposition
Decision
Teaching Points
Discussion and Conclusions
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Revised Diagnosis
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Disposition
Decision
Teaching Points
Discussion and Conclusions
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Revised Clinical
Impression and
Differential Diagnoses
Next Actions
REVISED DIAGNOSIS
AND CARE PLAN
Author:
Martin Möckel, MD, PhD, FESC, FAHA
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REVISED DIAGNOSIS
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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
Revised Clinical Impression
and Differential Diagnoses
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CRP=c-reactive protein
Clinical impression strongly suggests a diagnosis of
(sub)acute decompensated heart failure on the basis of known
chronic heart failure
Absence of other findings by lab results or chest x ray further
supports diagnosis of AHF
Radiology indicated early stages of infiltration in right lung
base, but CRP was very low at admission
?
QUESTION
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REVISED DIAGNOSIS
AND CARE PLAN
Next Actions
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Re-assessment in the ED: slight improvement of dyspnea with
diuresis, no shock, no critical hypoxemia
Transfer to cardiology ward planned
ED=Emergency Department
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H
DISPOSITION
DECISION
Disposition
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Transferred to normal cardiology ward
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Slow recompensation observed with intensified
diuretic therapy
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No clear precipitant identified. Patient denied any
medication or dietary indiscretion
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On Day 3, an increase of CRP to 29.1 mg/L was
observed
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initiation of i.v. antibiotics (Ceftriaxon)
On Day 6, the patient was transferred to geriatric
rehabilitation
CRP=c-reactive protein; i.v.=intravenous
Teaching Points
Discussion and Conclusions
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Teaching Points
Discussion and Conclusions
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Discussion and
Conclusions
Teaching Points
Local Variation
TEACHING POINTS, DISCUSSION
AND CONCLUSIONS
Author:
Martin Möckel, MD, PhD, FESC, FAHA
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TEACHING POINTS,
DISCUSSION AND
CONCLUSIONS
Case Details
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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
Teaching Points
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This is a ‘typical’ case of AHF – acute on chronic HF
Known chronic HF and history is crucial for diagnosis
A case that teaches:
– new drugs are needed for faster symptom relief
and prognostic improvement
– Earlier identification of infection may have led to
faster recovery. Potentially, antibiotic treatment
should have based on procalcitonin levels and not
“unspecific” CRP only
AHF=acute heart failure; HF=heart failure; CRP=c-reactive protein
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Teaching Points
Discussion and Conclusions
Discussion and Conclusions
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The case has been managed adequately
– upon reflection, this is a potential case for new medical
options
– it can be debated whether initial application of nitrates may
have improved symptoms earlier
Typically these cases are prone to in-hospital complications
(e.g. acute renal failure under diuretic therapy or infection) and
improve clinically over 2–5 days
PCT can also help in these types of cases to “qualify”
moderate CRP increases
The initial dose of furosemide was a standard of 40 mg but
80 mg could have been considered as the patient was already
on chronic diuretic medication; there is no clear evidence on
initial diuretic dose in AHF
AHF=acute heart failure; CRP=c-reactive protein; PCT=procalcitonin
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CONCLUSIONS
Case Details
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Revised Diagnosis
and Care Plan
Disposition
Decision
Local Variation
•
Specific points were:
– standard dose of 40 mg furosemide i.v. initially
– use of CRP and potential use of PCT to detect
bacterial infection early may be unique to this
institution
CRP=c-reactive protein; PCT=procalcitonin
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