emDocs - October 05, 2020 - By Rider I ; Benson S
Reviewed by Lew E; Koyfman A; Long B
"Question: Which heart failure patients need to be admitted, and which patients can be discharged home?
Conclusion: Acute heart failure is a presentation commonly seen in the ED that carries high morbidity and mortality. The emergency physician’s role involves rapid identification, management and disposition of these patients based on clinical presentation, response to therapy and risk of adverse events. Several risk stratification tools can be used to risk stratify patients. A wide majority of AHF patients require admission and all require close follow-up with cardiology and primary care.
Pearls:
- High risk features in AHF are hypotension, elevated BNP, troponin, Cr, and hyponatremia.
- Patients who require continuous infusions, NIPPV, or are initially treatment-resistant generally require ICU admission.
- New onset HF patients should be admitted for a broader workup.
- Patients with OHFRS less than 1 can be discharged.
- Patients with OHFRS above 1 or 2 require admission (at the EP’s discretion regarding which score to use based on comorbidities and follow-up).
- Patients with OHFRS of 1 due to O2 saturation <90% on arrival to ED should be admitted.
- EHFMRG is an externally validated tool to predict a % risk in 7-day mortality for AHF patients.
- Low-risk MEESSI patients carry a <2% mortality and may be appropriate to discharge home from the ED.
- Some patients in AHF will be in the MEESSI higher risk categories with a significant increase in 30-day mortality compared to the low-risk groups.
- Observation units are appropriate for hemodynamically stable patients with good response to therapy who are in very low-risk categories and are reliable to follow-up."