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We’d like to think that we’re getting better at identifying acute heart failure and making good disposition decisions. But the facts are, ED physicians are only about 80% accurate diagnosing acute heart failure, and 30-day mortality outcomes and readmission rates for acute heart failure have been about the same in North America for the last few decades – plus we often send home patients who should be admitted and admit patients who should be sent home. This is because there are many challenges for EM docs when it comes to acute heart failure. First, the diagnosis can be tough, and often is only made once the patient is admitted. There is no one clinical feature that is a slam dunk for the diagnosis, and even combinations of features are not great. There are many flavours of heart failure – diastolic, systolic, right-sided, left-sided, SCAPE, cardiogenic shock - just too complicate things further. Even if we’ve made an accurate diagnosis, the decision of whether to admit or send home can be challenging. We have risk stratification decision scales to help, but are they good enough? Are we using them appropriately? In this podcast, with the help of Dr. Doug Lee, cardiologist and researcher at Sunnybrook Hospital in Toronto and Dr. Clare Atzema, our go to EM Atrial fibrillation expert, an EM doc and researcher also from Sunnybrook Hospital, with a special appearance by Ian Chernoff on the role of PoCUS in the diagnosis and risk stratification of acute heart failure, we’ll dig into how to improve our diagnostic accuracy of acute heart failure in the ED and how to improve our disposition decision making so that just the right number of people are admitted and just the right number of people of sent home safely...

Podcast production, sound design & editing by Anton Helman

Written Summary and blog post by Ryan O'Reilly and Anton Helman August, 2024

Cite this podcast as: Helman, A. Episode 197 Acute Heart Failure Risk Stratification and Disposition. Emergency Medicine Cases. August, 2024. https://emergencymedicinecases.com/acute-heart-failure-risk-stratification-disposition. Accessed November 5, 2024

Résumés EM CasesAccuracy of initial evaluation findings in the diagnosis of acute heart failure

Source: King M, Kingery J, Casey B. Diagnosis and evaluation of heart failure. Am Fam Physician. 2012 Jun 15;85(12):1161-8.

Value of NT-pro-BNP in risk stratification of acute heart failure remains controversial

Based on our in depth review of the world's literature in 2018 in this Journal Jam podcast, and as detailed on First10EM, BNP has limited, if any, value in risk stratification of acute heart failure in the ED. However, a subsequent study and guidelines suggest that NT-pro-BNP is highly accurate at the extremes (NT-pro-BMP <300 highly unlikely acute heart failure and NT-pro-BNP ≥5,000 highly likely acute heart failure). There remains an argument to be made that in patients who obviously do not have acute heart failure clinically or obviously do have heart failure clinically, a BNP is not going to shift your diagnostic certainty significantly, and for the intermediate cases where BNP would be most valuable, it is seldom discerning, and may be misleading.

Cardiology guidelines from Europe and Canada seem to have settled on NT-pro-BNP <300pg/ml as “rule-out” threshold, while implementing an age-adjusted “rule-in” threshold:

* Rule out - <300

* Rule in ("consider admission")

* <50y - >450

* 50-75 - >900