Abstract 3170: Acute Heart Failure: What Doesn’t Get Admitted May Come Back To Haunt You
Background: Previous epidemiologic studies of acute heart failure (AHF) have involved patients admitted to hospital therefore failing to account for an unknown proportion of pts discharged directly from the emergency department (ED). We evaluated discharge vs. admission rates of AHF pts as well as changes in evidence-based medication (EBM) prescriptions and whether their outcomes, including mortality, differed from those who were admitted.
Methods: A population-based cohort was analyzed including all pts ≥65 years presenting to Alberta EDs with a most responsible diagnosis of heart failure (ICD9-CM 428.x) between 1998 and 2001. Pts were either discharged from the ED (DCED) or admitted to hospital (HOSP). Data includes procedures (angiogram, PCI, CABG, echo, nuclear, exercise tests, pacemakers), EBMs (ACE inhibitors, beta-blockers, spironolactone) and socioeconomic data, repeat ED (re-ED) visits, inpatient admissions (hosp and re-hosp) and death. Results: Of 4652 AHF pts evaluated in the ED, 29% were DCED whereas 71% were direct hospital admissions. Gender (52% female) and median household income ($44,648) were similar, but the DCED were younger (median age 79 vs. 80, p<0.003), had fewer comorbidities (DM, HTN, CAD, pulmonary and renal, all p<0.001), and had fewer procedures within 90 days (all p<0.0001). The DCED had a higher prior ACE (55%) and BB (31%) use than the HOSP group (51%, 29% respectively, p<0.05). Whereas EBM use increased for the DCED (ACE 61%, BB 33%, spiro 9%) over the subsequent 30 days, it substantially increased in HOSP (ACE 67%, BB 34%, spiro 14%, [p<0.001]). Clinical outcomes are in the Table⇓.
Conclusions: These novel data indicate that nearly 1/3rd of AHF pts are direct ED discharges. Whereas they have a lower initial mortality, a “catch-up” to admitted pts occurs in the first year and 3/4 present to the ED and 41% are hospitalized. Risk assessment and treatment strategies are needed in the ED for AHF and are an opportunity for improving care.