- Email: [email protected]
Decision Algorithms are Needed in Acute Heart Failure in the Emergency Department
Journal of Cardiac Failure Vol. 19 No. 2 2013
Letters to the Editor Javier Jacob, PhD, MD* Pere Llorens, PhD, MD Oscar Miro, PhD, MD Pablo Herrero, PhD, MD Francisco Javier Martın-Sanchez, PhD, MD * Emergency Department Hospital Universitari de Bellvitge, IDIBELL Barcelona, Spain
Decision Algorithms are Needed in Acute Heart Failure in the Emergency Department
To the Editor: We read the article by Pang et al1 with interest. The authors present a decision algorithm based on income B-type natriuretic peptide (BNP) in the emergency department (ED). Our study group analyzed the data of the EAHFE (Emergency Acute Heart Failure Epidemiology) Spanish multicenter registry, the methodology of which has been described elsewhere,2 and the PICASU (natriuretic peptides in acute heart failure in the emergency department) 1 study, including 662 patients consulting to the emergency department for acute heart failure, regarding elevated N-terminal (NT) proBNP values as a prognostic factor and found that they were clearly associated with hospital and 30-day mortality, with results showing a moderate, but statistically significant, discriminative power for inhospital (area under the receiver operating characteristic curve [AUC] 0.75; P ! .001) and 30-day (AUC 0 , 71, P ! .001) mortality, and null for readmissions (AUC 0.50; P 5 .92).3 However, our working group, comparing in 2,423 patients the hospitals that measure NT-proBNP in the ED with those which do not (the PICASU-2 study presents 840 patients without and 1,583 with determination of BNP in ED), these significant differences in hospital and 30-day mortality disappeared. We therefore concluded that the utility of NT-proBNP in the ED is questionable.4 The algorithm of Pang et al also considers the value of troponin. The TROPICA (Troponin in Acute Heart Failure) study by our group evaluated the prognostic value of troponin in the ED, including 806 patients in whom troponin results were available, with 250 being positive (31.0%). The investigative team made a consensus to consider troponin values as positive when troponin T was O0.04 mg/L or when troponin I was O0.1 mg/L. The global in-hospital mortality was 9.2%, 30-day mortality was 10.4%, and 30-day rehospitalization was 21.3%. The troponin positive patients showed a greater mortality in hospital (hazard ratio [HR] 3.85, 95% confidence interval [CI] 2.33e6.34) and at 30 days (HR 3.07, 95% CI 1.98e4.78) but not greater readmissions at 30 days (HR 0.88, 95% CI 0.62e1.26).5 The emergency services appreciate decision algorithms in patients with acute heart failure, as demanded in some consensus,6 to help decision making in these patients to be the most useful.
Disclosures None.
References 1. Pang PS, Jesse R, Collins SP, Maisel A. Patients with acute heart failure in the emergency department: do they all need to be admitted? J Cardiac Fail 2012;18:900e3. 2. Jacob Rodrıguez J, Herrero Puente P, Martın-Sanchez FJ, Llorens P, Perello R, et al. EAHFE (Epidemiology Acute Heart Failure Miro O, Emergency) study: analysis of the patients with echocardiography performed prior to an emergency visit due to an episode of acute heart failure. Rev Clin Esp 2011;211:329e37. 3. Jacob J, Llorens P, Martın-Sanchez FJ, Herrero P, Alvarez A, PerezDura MJ, et al. Prognostic value of emergency department testing for N-terminal fragment of brain natriuretic peptide in patients with acute heart failure: the PICASU-1 study. Emergencias 2011;23:183e92. 4. Miro O, Jacob J, Martın-Sanchez FJ, Herrero P, Pavon J, PerezDura MJ, et al. Prognostic implications of emergency department determination of B-type natriuretic peptide in patients with acute heart failure: the PICASU-2 study. Emergencias 2011;23:437e46. 5. Jacob J, Martın-Sanchez FJ, Herrero P, Miro O, Llorens P; ICA-SEMES Group. Prognostic value of troponin in patients with acute heart failure attended in Spanish emergency departments: TROPICA study (Troponin in Acute Heart Failure). Med Clin (Barc). http://dx.doi.org/10.1016/ j.medcli.2012.06.029 6. Llorens P, Miro O, Martın Sanchez FJ, Herrero P, Jacob J, Gil V, et al. Guidelines for emergency management of acute heart failure: consensus of the Acute Heart Failure Working Group of the Spanish Society of Emergency Medicine (AHF-SEMES) in 2011. Emergencias 2011;23: 119e39. http://dx.doi.org/10.1016/j.cardfail.2012.12.002
Reply to: Decision Algorithms are Needed in Acute Heart Failure in the Emergency Department
We thank Dr Jacob and colleagues for their interest in our proposal to improve outcomes while reducing costs for lower-risk acute heart failure (AHF) patients in the emergency department (ED). Our commentary was intended to stimulate further work in this area of unmet need. The 147
Letters to the Editor Javier Jacob, PhD, MD* Pere Llorens, PhD, MD Oscar Miro, PhD, MD Pablo Herrero, PhD, MD Francisco Javier Martın-Sanchez, PhD, MD * Emergency Department Hospital Universitari de Bellvitge, IDIBELL Barcelona, Spain
Decision Algorithms are Needed in Acute Heart Failure in the Emergency Department
To the Editor: We read the article by Pang et al1 with interest. The authors present a decision algorithm based on income B-type natriuretic peptide (BNP) in the emergency department (ED). Our study group analyzed the data of the EAHFE (Emergency Acute Heart Failure Epidemiology) Spanish multicenter registry, the methodology of which has been described elsewhere,2 and the PICASU (natriuretic peptides in acute heart failure in the emergency department) 1 study, including 662 patients consulting to the emergency department for acute heart failure, regarding elevated N-terminal (NT) proBNP values as a prognostic factor and found that they were clearly associated with hospital and 30-day mortality, with results showing a moderate, but statistically significant, discriminative power for inhospital (area under the receiver operating characteristic curve [AUC] 0.75; P ! .001) and 30-day (AUC 0 , 71, P ! .001) mortality, and null for readmissions (AUC 0.50; P 5 .92).3 However, our working group, comparing in 2,423 patients the hospitals that measure NT-proBNP in the ED with those which do not (the PICASU-2 study presents 840 patients without and 1,583 with determination of BNP in ED), these significant differences in hospital and 30-day mortality disappeared. We therefore concluded that the utility of NT-proBNP in the ED is questionable.4 The algorithm of Pang et al also considers the value of troponin. The TROPICA (Troponin in Acute Heart Failure) study by our group evaluated the prognostic value of troponin in the ED, including 806 patients in whom troponin results were available, with 250 being positive (31.0%). The investigative team made a consensus to consider troponin values as positive when troponin T was O0.04 mg/L or when troponin I was O0.1 mg/L. The global in-hospital mortality was 9.2%, 30-day mortality was 10.4%, and 30-day rehospitalization was 21.3%. The troponin positive patients showed a greater mortality in hospital (hazard ratio [HR] 3.85, 95% confidence interval [CI] 2.33e6.34) and at 30 days (HR 3.07, 95% CI 1.98e4.78) but not greater readmissions at 30 days (HR 0.88, 95% CI 0.62e1.26).5 The emergency services appreciate decision algorithms in patients with acute heart failure, as demanded in some consensus,6 to help decision making in these patients to be the most useful.
Disclosures None.
References 1. Pang PS, Jesse R, Collins SP, Maisel A. Patients with acute heart failure in the emergency department: do they all need to be admitted? J Cardiac Fail 2012;18:900e3. 2. Jacob Rodrıguez J, Herrero Puente P, Martın-Sanchez FJ, Llorens P, Perello R, et al. EAHFE (Epidemiology Acute Heart Failure Miro O, Emergency) study: analysis of the patients with echocardiography performed prior to an emergency visit due to an episode of acute heart failure. Rev Clin Esp 2011;211:329e37. 3. Jacob J, Llorens P, Martın-Sanchez FJ, Herrero P, Alvarez A, PerezDura MJ, et al. Prognostic value of emergency department testing for N-terminal fragment of brain natriuretic peptide in patients with acute heart failure: the PICASU-1 study. Emergencias 2011;23:183e92. 4. Miro O, Jacob J, Martın-Sanchez FJ, Herrero P, Pavon J, PerezDura MJ, et al. Prognostic implications of emergency department determination of B-type natriuretic peptide in patients with acute heart failure: the PICASU-2 study. Emergencias 2011;23:437e46. 5. Jacob J, Martın-Sanchez FJ, Herrero P, Miro O, Llorens P; ICA-SEMES Group. Prognostic value of troponin in patients with acute heart failure attended in Spanish emergency departments: TROPICA study (Troponin in Acute Heart Failure). Med Clin (Barc). http://dx.doi.org/10.1016/ j.medcli.2012.06.029 6. Llorens P, Miro O, Martın Sanchez FJ, Herrero P, Jacob J, Gil V, et al. Guidelines for emergency management of acute heart failure: consensus of the Acute Heart Failure Working Group of the Spanish Society of Emergency Medicine (AHF-SEMES) in 2011. Emergencias 2011;23: 119e39. http://dx.doi.org/10.1016/j.cardfail.2012.12.002
Reply to: Decision Algorithms are Needed in Acute Heart Failure in the Emergency Department
We thank Dr Jacob and colleagues for their interest in our proposal to improve outcomes while reducing costs for lower-risk acute heart failure (AHF) patients in the emergency department (ED). Our commentary was intended to stimulate further work in this area of unmet need. The 147