Chouihed Tahar, Manzo-Silberman Stéphane, Peschanski Nicolas, Charpentier Sandrine, Elbaz Meyer, Savary Dominique, Bonnefoy-Cudraz Eric, Laribi Said, Henry Patrick, Girerd Nicolas, Zannad Faiez, El Khoury Carlos
Emergency Department, University Hospital of Nancy, Nancy, France.
INSERM, Centre d'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux, Nancy, France.
Scand J Trauma Resusc Emerg Med. 2016 Sep 17;24(1):112. doi: 10.1186/s13049-016-0300-x.
An appropriate diagnostic process is crucial for managing patients with acute heart failure (AHF) in emergency department (ED). Our study aims to describe the characteristics and therapeutic management of patients admitted to the ED for dyspnea suspected to have AHF, their in-hospital pathway of care and their in-hospital outcome.
Consecutive patients admitted in 26 French ED for dyspnea suspected to be the consequence of AHF, prior to in hospital diagnostic test, were prospectively included at the time of their admission in the DeFSSICA Survey. Clinical characteristics at admission were recorded by the ED physicians. At discharge from ED, patients were categorized as AHF or non-AHF based on the final diagnosis reported in the discharge summary. The completeness of the data was controlled by the local investigator.
From 16/6/2014 to 7/7/2014, 699 patients were included, of whom 537 (77 %) had a final diagnosis of AHF at discharge. Patients with AHF were older (median 83 vs 79 years, p = 0.0007), more likely to have hypertension (71 % vs 57 %, p = 0.002), chronic HF (54 % vs 37 %, p = 0.0004), atrial fibrillation (45 % vs 34 %, p = 0.02) and history of hospitalization for AHF in the previous year (40 % vs 18 %, p < 0.0001) when compared to patients without AHF. Furosemide and oxygen were used in approximately 2/3 of the patients in the ED (respectively 75 and 68 %) whereas nitrates were in 19 % of the patients. Diagnostic methods used to confirm AHF included biochemistry (100 %), pro-B-type natriuretic peptide (90 %), electrocardiography (98 %), chest X-ray (94 %), and echography (15 %) which only 18 % of lung ultrasound. After the ED visit, 13 % of AHF patients were transferred to the intensive care unit, 28 % in cardiology units and 12 % in geriatric units. In-hospital mortality was lower in AHF vs non-AHF patients (5.6 % vs 14 %, p = 0.003).
DeFSSICA, a large French observational survey of acute HF, provides information on HF presentation and the French pathway of care. Patients in DeFSSICA were elderly, with a median age of 83 years. Compared with the French OFICA study, patients in DeFSSICA were more likely to have hypertension (71 % vs 62 %) and atrial fibrillation (45 % vs 38 %). As atrial fibrillation and a rapid heart rate have been closely linked to mortality, detection of atrial fibrillation should be considered systematically.The limited use of nitrates in DeFSSICA may be related to the median SBP of 140 (121-160) mmHg. However, our use of nitrates was similar to those in the EAHFE (20.7 %) and OPTIMIZE-HF (14.3 %) registries. In line with guidelines, the proportions of patients who underwent ECG, biological analysis, or chest X-ray were all >90 % in DeFSSICA. Similarly, BNP or pro-BNP was measured in 93 % of patients, compared with 82 % of patients in the OFICA study. Although BNP may be helpful when the diagnosis of HF is in doubt, ultrasound remains the gold standard. The use of ultrasound in the ED has been reported to accelerate the diagnosis of HF and the initiation of treatment, and shorten the length of stay. In-hospital mortality of HF patients in DeFSSICA was 6.4 %, slightly lower than in the OFICA study (8.2 %). Improved interdisciplinary cooperation has been highlighted as a key factor for the improvement of HF patient care.
DeFSSICA shows that patients admitted for dyspnea suspected to be the consequence of AHF are mostly elderly. The diagnosis of AHF is difficult to ascertain based on clinical presentation in patients with dyspnea. Novel diagnostic techniques such as thoracic ultrasound are warranted to provide the right treatment to the right patients in the ED as early as possible.
恰当的诊断流程对于急诊科（ED）管理急性心力衰竭（AHF）患者至关重要。我们的研究旨在描述因疑似AHF导致呼吸困难而入住ED的患者的特征和治疗管理、他们在医院的护理路径以及住院结局。
在DeFSSICA调查中，对26家法国急诊科收治的、因疑似AHF导致呼吸困难且尚未进行院内诊断检查的连续患者进行前瞻性纳入。急诊科医生记录入院时的临床特征。在ED出院时，根据出院小结中报告的最终诊断将患者分类为AHF或非AHF。数据的完整性由当地研究人员进行核查。
从2014年6月16日至2014年7月7日，共纳入699例患者，其中537例（77%）出院时最终诊断为AHF。与非AHF患者相比，AHF患者年龄更大（中位数83岁对79岁，p = 0.0007），更有可能患有高血压（71%对57%，p = 0.002）、慢性心力衰竭（54%对37%，p = 0.0004）、心房颤动（45%对34%，p = 0.02）以及上一年有AHF住院史（40%对18%，p < 0.0001）。约2/3的ED患者使用了呋塞米和氧气（分别为75%和68%），而使用硝酸盐的患者为19%。用于确诊AHF的诊断方法包括生化检查（100%）、前B型利钠肽（90%）、心电图（98%）、胸部X线（94%）以及超声检查（15%），其中仅18%为肺部超声。ED就诊后，13%的AHF患者被转入重症监护病房，28%转入心内科病房，12%转入老年病科病房。AHF患者的住院死亡率低于非AHF患者（5.6%对14%，p = 0.003）。
DeFSSICA是一项针对急性心力衰竭的大型法国观察性调查，提供了关于心力衰竭表现和法国护理路径的信息。DeFSSICA研究中的患者为老年人，中位年龄为83岁。与法国的OFICA研究相比，DeFSSICA研究中的患者更有可能患有高血压（71%对62%）和心房颤动（45%对38%）。由于心房颤动和快速心率与死亡率密切相关，应系统地考虑检测心房颤动。DeFSSICA中硝酸盐的使用有限可能与中位收缩压为140（121 - 160）mmHg有关。然而，我们硝酸盐的使用与EAHFE（20.7%）和OPTIMIZE - HF（14.3%）登记研究中的使用情况相似。与指南一致，在DeFSSICA中接受心电图、生物学分析或胸部X线检查的患者比例均>90%。同样，93%的患者检测了BNP或前BNP，而在OFICA研究中这一比例为82%。尽管当心力衰竭诊断存疑时BNP可能有所帮助，但超声检查仍然是金标准。据报道，在ED中使用超声可加速心力衰竭的诊断和治疗的启动，并缩短住院时间。DeFSSICA研究中HF患者的住院死亡率为6.4%，略低于OFICA研究（8.2%）。改善多学科合作已被强调为改善HF患者护理的关键因素。
DeFSSICA表明，因疑似AHF导致呼吸困难而入院的患者大多为老年人。基于呼吸困难患者的临床表现难以确定AHF的诊断。需要新的诊断技术，如胸部超声，以便尽早在ED中为合适的患者提供正确的治疗。
