Sax Dana R, Mark Dustin G, Rana Jamal S, Huang Jie, Casey Scott D, Norris Robert P, Tillage Viliami, Reed Mary E
The Permanente Medical Group, Oakland, California, USA.
Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA.
ESC Heart Fail. 2024 Dec;11(6):4432-4436. doi: 10.1002/ehf2.14989. Epub 2024 Jul 25.
Emergency department (ED) providers play an important role in the management of patients with acute heart failure (AHF). We present findings from a pilot study of an electronic decision support that includes personalized risk estimates using the STRIDE-HF risk tool and tailored recommendations for initiating guideline directed medical therapy (GDMT) among appropriate patients.
Among ED patients treated for AHF who were discharged from the ED or the ED-based observation unit in two EDs from 1 January 2023 to 31 July 2023, we assess prescriptions to the four classes of GDMT at two intervals: (1) ED arrival and (2) ED discharge. Specifically, we report active prescriptions for beta-blockers (BBs), renin-angiotensin receptor system inhibitors (RASis), sodium-glucose transport protein 2 inhibitors (SGLT2is) and mineralocorticoid receptor antagonists (MRA) among patients with reduced ejection fraction (HFrEF) and mildly reduced (HFmrEF). Second, we describe rates of 30-day serious adverse events (SAE) (death, cardiopulmonary resuscitation, balloon-pump insertion, intubation, new dialysis, myocardial infarction or coronary revascularization) among patients predicted to be very low risk by STRIDE-HF and discharged home.
Among 234 discharged patients, 55% were female and 76% were non-White. We found 51 (21.8%), 21 (9.0%) and 126 (53.8%) had HFrEF, HFmEF and HFpEF, respectively, while 36 (15.4%) were missing EF, and 51 (22%) were very low risk, 82 (35%) were low risk, 60 (26%) were medium risk and 41 (18%) were high risk. Among HFrEF patients, 68.6%, 66.7%, 25.5% and 19.6% were on a RASi, BB, SGLT2i and MRA, respectively, at ED arrival, while 42.9%, 66.7%, 14.3% and 4.8% of HFmrEF patients were on a RASi, BB, SGLT2i and MRA, respectively. Among patients with HFpEF, only 6 (4.8%) were on an SGLT2i at ED arrival. The most prescribed new medication at ED discharge was an SGLT2i, with a nearly 10% increase in the proportion of patients with an active prescription for SGLT2i at ED discharge among HFrEF and HFmEF patients. We observed no 30-day SAE among the 51 patients predicted to be very low risk and discharged home.
Ongoing treatment with GDMT at ED arrival was sub-optimal. Initiation among appropriate patients at discharge may be feasible and safe.
急诊科医护人员在急性心力衰竭（AHF）患者的管理中发挥着重要作用。我们展示了一项电子决策支持试点研究的结果，该研究包括使用STRIDE-HF风险工具进行个性化风险评估，以及针对合适患者启动指南指导的药物治疗（GDMT）的定制建议。
在2023年1月1日至2023年7月31日期间，从两个急诊科出院或从急诊科观察单元出院的AHF治疗患者中，我们在两个时间点评估四类GDMT的处方情况：（1）急诊科就诊时；（2）急诊科出院时。具体而言，我们报告射血分数降低（HFrEF）和轻度降低（HFmrEF）患者中β受体阻滞剂（BBs）、肾素-血管紧张素受体系统抑制剂（RASis）、钠-葡萄糖转运蛋白2抑制剂（SGLT2is）和盐皮质激素受体拮抗剂（MRA）的有效处方。其次，我们描述STRIDE-HF预测为极低风险并出院回家的患者中30天严重不良事件（SAE）（死亡、心肺复苏、球囊泵置入、插管、新的透析、心肌梗死或冠状动脉血运重建）的发生率。
在234名出院患者中，55%为女性，76%为非白人。我们发现分别有51名（21.8%）、21名（9.0%）和126名（53.8%）患者患有HFrEF、HFmEF和HFpEF，而36名（15.4%）患者射血分数缺失，51名（22%）患者为极低风险，82名（35%）患者为低风险，60名（26%）患者为中度风险，41名（18%）患者为高风险。在HFrEF患者中，急诊科就诊时分别有68.6%、66.7%、25.5%和19.6%的患者使用RASi、BB、SGLT2i和MRA，而HFmrEF患者中分别有42.9%、66.7%、14.3%和4.8%的患者使用RASi、BB、SGLT2i和MRA。在HFpEF患者中，急诊科就诊时只有6名（4.8%）患者使用SGLT2i。急诊科出院时最常开具的新药是SGLT2i，HFrEF和HFmEF患者中SGLT2i有效处方患者的比例在急诊科出院时增加了近10%。在51名预测为极低风险并出院回家的患者中，我们未观察到30天SAE。
急诊科就诊时GDMT的持续治疗未达最佳水平。在合适患者出院时启动治疗可能是可行且安全的。
