ABSTRACT
BACKGROUND: Dyspnea is one of the most common emergency department (ED) symptoms, but early diagnosis and treatment are challenging because of multiple potential causes. Impedance cardiography (ICG) is a noninvasive method to measure hemodynamics that may assist in early ED decision making. OBJECTIVES: To determine the rate of change in working diagnosis and initial treatment plan by adding ICG data during the course of ED clinical evaluation of elder patients presenting with dyspnea. METHODS: The authors studied a convenience sample of dyspneic patients 65 years and older who were presenting to the EDs of two urban academic centers. The attending emergency physician was initially blinded to the ICG data, which was collected by research staff not involved in patient care. At initial ED presentation, after history and physical but before central lab or radiograph data were returned, the attending ED physician completed a case report form documenting diagnosis and treatment plan. The physician then was shown the ICG data and the same information was again recorded. Pre- and post-ICG differences were analyzed. RESULTS: Eighty-nine patients were enrolled, with a mean age of 74.8 +/- 7.0 years; 52 (58%) were African American, 42 (47%) were male. Congestive heart failure and chronic obstructive pulmonary disease were the most common final diagnoses, occurring in 43 (48%), and 20 (22%), respectively. ICG data changed the working diagnosis in 12 (13%; 95% CI = 7% to 22%) and medications administered in 35 (39%; 95% CI = 29% to 50%). CONCLUSIONS: Impedance cardiography data result in significant changes in ED physician diagnosis and therapeutic plan during the evaluation of dyspneic patients 65 years and older.
Subject(s)
Cardiography, Impedance , Dyspnea/etiology , Heart Failure/diagnosis , Pulmonary Disease, Chronic Obstructive/diagnosis , Aged , Cardiography, Impedance/methods , Diagnosis, Differential , Electrocardiography , Emergency Medicine , Emergency Service, Hospital , Female , Heart Failure/complications , Hemodynamics , Humans , Male , Prospective Studies , Pulmonary Disease, Chronic Obstructive/complications , Radiography, ThoracicABSTRACT
The authors performed a 6-month review of heart failure patients presenting to a teaching hospital emergency department to determine the rate of positive serum myocardial infarction markers. All patients with an emergency department discharge diagnosis of heart failure were included; those with a creatinine level >2.0 mg/dL were excluded. There were 151 patients who met the entry criteria, with a mean age of 68.6 +/- 13.6 years, and 84 (56%) were men. The mean ejection fraction was 32%, and the mean Framingham score was 3.8 +/- 1.6. Twenty (14%) had positive markers. Troponin T was positive in 17 (11%), and creatine kinase was positive in nine (6%). Both markers were positive in six (4%). Chest pain was absent in 70% of the positive marker group. The authors conclude that elevated cardiac markers are not rare in decompensated heart failure. These pilot data suggest these tests should be routinely obtained on heart failure patients.
Subject(s)
Electrocardiography , Emergency Service, Hospital , Heart Failure/diagnosis , Myocardial Infarction/diagnosis , Adult , Aged , Aged, 80 and over , Biomarkers/blood , Creatine Kinase/blood , Creatine Kinase, MB Form , Data Interpretation, Statistical , Diagnosis, Computer-Assisted , Diagnosis, Differential , Female , Heart Failure/blood , Humans , Incidence , Isoenzymes/blood , Male , Middle Aged , Myocardial Infarction/blood , Retrospective Studies , Stroke Volume/physiology , Troponin T/blood , Ventricular Dysfunction, Left/blood , Ventricular Dysfunction, Left/diagnosisABSTRACT
There is little information on the effectiveness of emergency department (ED) observation unit (OU) heart failure (HF) therapy. The authors' objective was to evaluate outcomes after implementation of an ED-OU treatment protocol for HF exacerbation. Unblinded assessment of the effectiveness of an HF protocol was performed, controlled by outcome for 9 months prior to implementation. This included diagnostic and therapeutic algorithms, cardiology consultation, close monitoring, patient education, and discharge planning. Adverse outcomes were defined as the 90-day rates of ED HF revisits, hospital HF readmissions, or death, as determined by chart review, computer database search, and phone follow-up. One hundred fifty-four patients were enrolled; 50 entered before, and 104 after protocol implementation. Only six (12%) in the preprotocol and one (1%) of the postprotocol group were lost to follow-up. After an OU visit, postprotocol 90-day ED HF revisit rates declined 56% (0.90-0.51; p<0.0000) and the 90-day HF rehospitalization rate decreased 64% (0.77-0.50; p=0.007). The 90-day rates of death and OU HF readmission decreased from 4% to 1% (p=0.096) and 18% to 11% (p=0.099), respectively. An intensive outpatient ED OU HF management protocol safely decreases 90-day rates of emergency department visits and inpatient hospitalizations.
