Contemporary management of acute heart failure in the emergency department and the potential impact of early diuretic therapy on outcomes.

OBJECTIVE: Acute heart failure (AHF) is one of the most common conditions presenting to the ED and patients often require hospitalisation. Emerging evidence suggests early diagnosis and administration of diuretics are associated with improved patient outcomes. Currently, there is limited literature on the management of AHF in the Australian ED context. METHODS: A retrospective review of consecutive AHF presentations to the ED in a metropolitan hospital. Patient demographics, clinical status and management were assessed including timeliness of diuretics administration and association with outcomes including ED length of stay (LOS) and inpatient mortality using linear regression. RESULTS: One hundred and ninety-one presentations (median age 81 years, 50.8% male) were identified. Common cardiovascular comorbidities were prevalent. Fifty-four patients (28.3%) had ≥1 clinical high-risk feature at presentation. The median time from presentation to furosemide administration was 187 min (interquartile range 97-279 min); only 35 patients received diuretics within 60 min of presentation. Early diuretics was associated with shorter ED LOS (246 min vs 275 min, P = 0.03) and a lower but non-significant inpatient mortality (4.9% vs 6.3%, P = 0.21) and a non-significant increased rate of discharge home from ED (8.6% vs 4.7%, P = 0.15). The likelihood of discharge home was significantly more pronounced in patients receiving early diuretics without clinical high-risk features (16.7% vs 4.3%, P = 0.028). CONCLUSION: Despite symptoms and signs being well recognised at presentation, time to diuretics was relatively long. Early diuretics administration was associated with improved patient outcomes, particularly in clinically more stable patients. Due to the limitations of the study design, results should be interpreted with caution and warrant further research to identify factors that delay timely administration of diuretics.

Syncope, Epilepsy and Ictal Asystole: A Case Series and Narrative Review.

IMPORTANCE: Syncope is a common presentation to emergency departments, and cardiac and neurological aetiologies are the predominant causes. Ictal asystole is a rare cardio-neural phenomenon seen in epilepsy syndromes whereby a seizure causes asystole (≥3 s) leading to syncope. OBSERVATIONS: We present three cases of ictal asystole, together with a narrative review of the literature to assess the prevalence of the condition and review the pathophysiology, diagnosis and management. Our review of the literature has shown that ictal asystole is an unlikely contributor to sudden unexplained death in epilepsy (SUDEP). Pacemaker insertion may limit morbidity from trauma related to syncopal episodes but does not impact mortality. CONCLUSIONS AND RELEVANCE: Patients with ictal asystole should be diagnosed with concurrent electroencephalogram-electrocardiograph (EEG-ECG) monitoring, have their anti-epileptic drugs optimised and be considered for epilepsy surgery if feasible. The use of longer term ECG monitoring may be used as a diagnostic aid if ictal asystole is suspected. If there are ongoing syncopal episodes with associated ictal asystole ≥6 seconds, particularly despite medical therapy, a permanent pacemaker may be considered to reduce morbidity. Current guidelines should be updated to reflect the increasing knowledge of this condition.