Acute heart failure care and beyond

Acute heart failure (AHF) is the major focus of this issue as the editors felt that this is a topic of high importance and relevance to the readers of Acute Cardiac Care. The comprehensive recommendations of the Acute Heart Failure Committee by the Society of Chest Pain Centers are provided by Peacock and Fonarow [1]. The report is presented in six chapters (Preamble, Diagnosis, Risk stratification, Treatment, Discharge criteria, and Patient education) covering almost all aspects of AHF.

In the Preamble, we are provided with statistical data on the impact of Heart failure as a leading cause of morbidity and mortality. In the USA, five million patients bear the diagnosis of heart failure and are responsible for 12–15 million physician office visits per year and 6.5 million hospital days. Heart failure accounts for 3.6% of the total national hospital bill and 5.8% of all Medicare charges. Heart failure is a major problem worldwide with major medical, social, and economical implications on our health care systems.

In the second part, the Diagnosis of AHF is presented. The definitive diagnosis of AHF in the acute care setting can be difficult. The diagnosis should be done rapidly, simultaneously initiating appropriate interventions. The challenge of an acute emergency response, often with limited anamnestic data may be rapidly changing with access to a global electronic medical record system.

Risk stratification is dealt with in the third section. A methodology for unique stratifications with respect to short and long-term risks for the patients is important for patient management.

Treatment has been traditionally focused toward managing the transient acute event, characterized by systolic cardiac dysfunction, low cardiac output, and fluid overload. Short-term strategies targeted at rapidly alleviating fluid congestion (diuretics and vasodilators) became standard care often without adequate evidence. These clinical therapeutic regimes have been challenged by recent data that have shown that the AHF population is not a homogeneous group of patients, but rather multiple types of heart failure patients with various forms of acute decompensation. Tailored therapy for these various categories is presented.

Discharge criteria are of major importance. The decision to discharge a patient from an observation unit or an emergency department is based upon the overall assessment that the patient has clinically improved and can be managed in the outpatient setting. Yet, it is known that over 50% of these patients are discharged with AHF symptoms. Therefore, care must be taken to avoid premature discharge of patients with AHF. The presented recommendations are meant to balance the need for adequate symptom relief and acceptable readmission rates with the requirements for a cost-effective management strategy.

Finally, Patient education is needed to maximize patient's compliance and adherence to the prescribed medical regimen. In fact, over 70% of hospitalizations in the USA have been attributed to either failure to follow medication regimens, failure to follow dietary limitations, or failure to seek care with worsening symptoms. These patients are at increased risk for readmission, with rates between 36 and 75%, and for increased mortality rates.

At the later part of this issue, two additional papers deal with related problems. Our ability to ramp up our measurements of ventricular function automatically by using Multi Detector Computed Tomography (MDCT) data is provided by Ghersin et al. [2] who compared Left Ventricle (LV) angiography to MDCT data. Accurate, clinically relevant results for left ventricular volumes and Left Ventricular Ejection Fraction (LVEF) are readily obtained from MDCT data.

In the final paper, the issue of paramedic perception of their role in prehospital thrombolysis (PHT) in acute myocardial infarction is discussed [3]. In the UK, PHT is provided to around 17% of ST Elevation Myocardial Infarction (STEMI) patients, with the treatment provided largely with paramedics rather than physicians.

While the views between paramedics vary, the vast majority of them view PHT as a positive step to providing evidence-based patient care.

Please enjoy reading this unique issue and keep it as a working document in your clinical setting. This six-chapter comprehensive review and recommendation is a must-read for any practitioner who deals with cardiac patients in the acute, subacute, and chronic settings.