Heart Failure Reviews, 9, 187193, 2004

C 2005 Springer Science + Business Media, Inc.

Emergency Department Management of Patients

with Acute Decompensated Heart Failure
W. Franklin Peacock IV, MD 1 and Charles L.
Emerman, MD 2
1 Department of Emergency Medicine, The Cleveland Clinic
Foundation, Cleveland, Ohio, USA; 2 Department of Emergency
Medicine, Case Western Reserve University, Cleveland, Ohio,
USA

Abstract. The Acute Decompensated HEart Failure NaR

) confirms that the management
tional REgistry (ADHERE

of decompensated heart failure is an emergency department (ED) problem, as more than 75% of patients admitted
to the hospital with heart failure arrive through the ED.
This emphasizes the need for collaboration among emergency medicine, cardiology, nephrology, and hospitalists in
the management of acute decompensated heart failure. Such
collaboration is important for several reasons, including the
enhancement of patient care. It is also known that most hospitals lose money on heart failure admissions. Strategies
that can be employed to limit hospital losses on heart failure include reducing admissions from the ED; decreasing the
length of hospital stay; increasing the use of the observation
unit; reducing re-admissions, particularly through the first
30 days; and reducing the use of high-resource areas such
as the intensive care unit (ICU). This article will focus on
initiatives that can be implemented in the ED to help with
these strategies. In particular, we will discuss early initiation of therapy and its ability to improve length of stay, reduce re-admissions, and reduce ICU admissions. Use of the
observation unit for the management of heart failure will
also be discussed as a way of decreasing admissions from
the ED.
Key Words. cost containment, emergency department,
heart failure, nesiritide, observation unit

Introduction
The Acute Decompensated HEart Failure Na

R
tional REgistry (ADHERE ) verifies that heart
failure is an emergency department (ED) problem,
as more than 75% of patients discharged after an
admission for acute decompensated heart failure
(ADHF) were admitted through the ED [1]. This
has led to a growing interest among emergency
physicians in the management of these patients.
The ADHERE registry provides an indicator of the
current ED management of heart failure in the
United States.
ADHERE is a registry whose entry criteria require a hospital discharge with a primary diagnosis of ADHF [2]. Because of limitations in the
registry, data have not been collected on patients
discharged from the ED or observation units.

What is apparent from the registry, however, is

that among patients who are discharged with a
diagnosis of heart failure, the initial admission diagnosis was heart failure in about 80% of cases.
The remaining 20% who were admitted with a diagnosis other than ADHF, but after additional hospitalization and investigation, were determined to
have ADHF, constitute the ED diagnostic error
rate. Of the 20% ultimately found to have heart
failure, but admitted with an alternative diagnosis, about half are admitted with another cardiac
diagnosis, and the other half are admitted with a
noncardiac diagnosis.

Diagnosis
There has been substantial investigation into the
use of B-type natriuretic peptide (BNP) as a diagnostic test to improve the accuracy of ED diagnosis. Since BNP became available, there has been
and dramatic increase in its use. At the onset of
the ADHERE registry in late 2001, the BNP test
was used infrequently. The most recent data from
ADHERE indicate that more than half of patients
admitted to the hospital with ADHF undergo a
BNP diagnostic test at some time during their hospitalization [1]. See Figure 1 for an algorithm on
the use of BNP as a diagnostic tool for ADHF [3].

Therapy: Diuretics
Diuretics have been a mainstay of treatment for
patients with ADHF for decades. Most patients
receive intravenous diuretics initially in the ED,

Supported by an unrestricted educational grant from Scios Inc.

Address for correspondence: W. Franklin Peacock IV, MD, Department of Emergency Medicine, Desk E19, The Cleveland
Clinic, 9500 Euclid Avenue, Cleveland, Ohio 44195. Tel.: 216445-4546; E-mail: Peacocw@ccf.org
187

188

Peacock and Emerman

Fig. 1. Diagnosis and treatment of patients presenting with acute dyspnea. BNP = B-type natriuretic peptide; BP = blood pressure;
BUN = blood urea nitrogen; CKD = chronic kidney disease; COPD = chronic obstructive pulmonary disease; CrCl = creatinine
clearance; ECG = electrocardiogram; HF = heart failure; SCr = serum creatinine. Adapted with permission from Maisel et al. [3].
c MedReviews, LLC. Reprinted with permission of MedReviews, LLC. Maisel A. B-Type Natriuretic Peptide
(Copyright
)
Measurements in Diagnosing Congestive Heart Failure in the Dyspneic Emergency Department Patient. Rev Cardiovasc Med.
2002;3(suppl 4):S10S17. Reviews in Cardiovascular Medicine is a copyrighted publication of MedReviews, LLC. All rights
reserved.

and about 3% of patients receive them in the ambulance on the way to the hospital. Interestingly,
data from the ADHERE registry of over 150,000
patients report that another 10% of patients do
not receive any intravenous diuretics at any point
during their hospital stay. When analyzing these
cohorts, patients who do receive intravenous diuretics and those who do not are relatively well
matched with respect to a variety of characteristics, including age, ejection fraction, gender, and
other markers of severity of heart failure [4]. However, when comparing outcomes between those
that receive intravenous diuretics to those who do
not, the no diuretic patients have a shorter length
of stay in both the ICU and the hospital overall,
and a lower mortality rate. This is true even when
the data are adjusted for risk factors known to affect outcomes in heart failure.
This fact is consistent with other information known about the effects of loop diuretics.
For example, loop diuretics activate the reninaldosterone-angiotensin system [5], and when
given intravenously to heart failure patients,
furosemide produces an initial increase in pulmonary capillary wedge pressure, mean arterial

pressure, and systemic vascular resistance [6].

Data recently presented at the American College
of Cardiology indicate that patients who receive
chronic outpatient diuretic therapy have a higher
mortality rate than those who do not receive such
therapy [7]; this is particularly true for patients
with chronic renal insufficiency. Finally, data from
the Studies of Left Ventricular Dysfunction trial
indicate a higher mortality rate for patients taking nonpotassium-sparing diuretics [8]. Thus the
data from ADHERE raise provocative questions
about the aggressive use of intravenous diuretics as the mainstay of treatment for patients with
ADHF.

Vasoactive Therapy
The ADHERE database indicates that about
one third of patients receive vasoactive infusion
agents at some point during their hospitalization. This includes patients who receive inotropic
agents such as dobutamine, dopamine, or milrinone, as well as those who receive drugs with vasoactive properties (e.g., nitroglycerin, nitroprusside, and nesiritide). Over the last 5 years, the

Emergency Department Management Heart Failure

use of inotropes for the management of ADHF

has been markedly decreasing [1]. This is consistent with data from the Outcomes of a Prospective
Trial of Intravenous Milrinone for Exacerbations
of Chronic Heart Failure (OPTIME-CHF) and the
Prospective Randomized Evaluation of Cardiac
Ectopy with Dobutamine or Natrecor Therapy
(PRECEDENT) trials. The OPTIME study looked
at the routine use of milrinone for patients with
ADHF [9] and found that milrinone produced no
improvement in outcomes but did result in an increase in adverse side effects, particularly sustained hypertension. Furthermore, those patients
with ischemic cardiomyopathy had a significant
increase in mortality rate and incidence of myocardial infarction.
The PRECEDENT trial compared the arrhythmogenic effects of dobutamine with nesiritide [10].
Data from this study, combined with those from
another trial, indicated an increase in the longterm mortality rate for those patients exposed to
short-term dobutamine therapy [11]. Data from
ADHERE show that on a risk-adjusted basis, both
dobutamine and milrinone are associated with a
significant increase in mortality rate when compared with nesiritide [12]. Patients who receive
dobutamine have double the mortality rate of
those who receive nesiritide or nitroglycerin; and
the mortality rate in patients receiving milrinone
is about 50% higher.
Certain factors predict whether patients will
receive vasoactive infusion agents at some point
during hospitalization. Many of these factors are
known when the patient presents to the ED, which
provides an opportunity for the emergency physician to identify those who may benefit from aggressive therapy [13]. An ejection fraction <40%
doubles the likelihood that the patient will receive vasoactive infusion agents at some point
during hospitalization. Additional conditions that
predict the use of vasoactive infusion agents include serum sodium level <135 mmol/L, chronic
renal insufficiency, and the presence of pulmonary
edema on either clinical examination or chest
radiograph.
If vasoactive infusion agents are administered
in the ED, the time to initiation of therapy is obviously shortened. Those who have ED infusion
therapy will receive it within a median of 2 hours
from arrival to initiation of treatment; by comparison, when therapy is delayed until after admission
to an inpatient unit, the median time to therapy is
about 20 hours [13]. This delay is associated with
adverse outcomes. Compared to patients who undergo initiation of vasoactive therapy on the inpatient unit, those who receive it in the ED have
a decreased overall length of hospital stay, a decreased length of stay in the ICU, and a decrease
in the in-hospital mortality rate [13].

189

It is important to recognize that registry data

can show association but does not necessarily indicate cause and effect. For example, the preceding
association between early initiation of vasoactive
therapy and better outcomes could be explained
by the possibility that emergency physicians selectively start vasoactive agents on patients who
arent critically ill, or that patients who undergo
initiation of vasoactive therapy in the inpatient
unit have had a catastrophic deterioration. While
these explanations may have occurred, it is unlikely that these reasons explain the outcomes in
the more than 7,000 patients included in this analysis. More probably these data suggest that early
initiation of aggressive vasoactive therapy in appropriate patients leads to improved outcomes.
When this question is subjected to multivariate
analysis, adjusting for those factors known to affect outcome in patients with heart failure (e.g.,
low ejection fraction, decreased renal function, diabetes, the presence of pulmonary edema, older
age, high serum sodium level), data from ADHERE show that the early initiation of aggressive
vasoactive therapy is associated with a decreased
in-hospital mortality rate and a decreased length
of stay in either the hospital or the ICU [13].
Another analysis suggests that the early use
of vasodilator therapy in general, and nesiritide
therapy specifically, is associated with improved
outcomes when this therapy is initiated in the ED
[14]. In this study, the baseline clinical characteristics in patients who received ED nesiritide was
similar to that of patients who received nesiritide
in an inpatient unit. When risk adjustment analysis was performed for those factors known to affect
heart failure outcomes, the administration of nesiritide in the ED was associated with a decreased
length of stay in both the ICU and the hospital
overall [14]. In addition, patients were more likely
to be discharged to home rather than to an extended care facility.
These data showing the influence of ED treatment on outcome demonstrate the importance of
collaboration among emergency physicians, cardiologists, and hospitalists. Although untested,
these data suggest that protocols to identify patients who may benefit from aggressive therapy
may lead to improved outcomes in patients with
ADHF.

Heart Failure and the ED

Observation Unit
When faced with a patient with ADHF, emergency
physicians historically have had only two options:
admission to the hospital or discharge home. Because acute dyspnea is a particularly distressing
symptom for the patient, and because ADHF can

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Peacock and Emerman

be the result of a number of serious but protean

underlying pathologic abnormalities, most heart
failure patients presenting to the ED are hospitalized for evaluation and treatment [15]. Unfortunately, inpatient care of individuals with ADHF
is expensive, accounting for an estimated 50% of
the $34 billion spent annually in the United States
for this diagnosis [16].
Most commonly heart failure patients present
to the ED with congestive symptoms, most frequently manifested by dyspnea. The need to relieve circulatory congestion is the primary ratelimiting step preventing the discharge of the
ADHF patient. Although a select cohort of patients will respond to therapy in as little as 12
to 24 hours, this is not a reasonable length of stay
for most EDs. Therefore, the high frequency of admission in heart failure patients is also a function
of the limited evaluation time in todays crowded
and busy EDs.

tients who have improved adequately may then be

discharged, and those who require a longer treatment course may be admitted and converted to a
DRG admission without penalty. The APC-to-DRG
conversion is a once per visit, one-way event; DRG
admissions may not be converted to an APC, and
patients initially admitted under a DRG code may
not be reverted to an APC code [1820].
Because of the opportunity for treatment without admission, many EDs and hospitals are increasing their use of the APC system. Importantly,
the APC system does not require a designated unit
within the hospital; that is, it is a virtual unit. Any
bed in the hospital may be used as an observation
bed. However, because the success of this system is
predicated on expeditious disposition, a dedicated
staff may be more facile at ensuring that the many
complicated aspects of care required for heart failure patients occur in a timely fashion.

Clinical Aspects of the Observation Unit

Economic Aspects of the Observation Unit
Because of the extensive costs associated with hospital admissions, the Centers for Medicaid and
Medicare Studies (CMS) has created remuneration strategies as an incentive for hospital systems
to provide care in the less expensive outpatient environment [17]. Specifically, this organization has
developed observation payment codes for a limited
number of diagnoses so that patients with these
diagnoses may be kept for an extended evaluation
and treatment period, without being considered
in the usual Diagnosis-Related Group (DRG). The
DRG system is designed for longer term, higher
acuity admissions, and as such, provides specific
rules and remuneration penalties that do not exist
in the observation system.
By CMS rules, observation status is reimbursed
via the Ambulatory Patient Code (APC) system.
Within the APC system, patients are eligible for
this code if they have received treatment for less
than 48 hours, although reimbursement stops at
24 hours. The APC system is designed to encourage preferential use compared with the DRG
system. Whereas the DRG system is based on a
lump sum payment from which the hospital must
draw all its costs, the APC system provides passthrough reimbursement for specific treatments
and diagnostic testing in addition to the base payment for an APC admission [18,19].
The rules for observation codes require that a
patient be admitted initially on observation status for at least 8 hours and receive a chest radiograph, electrocardiogram (ECG), and pulse oximetry measurement. Because reimbursement ceases
at 24 hours, most institutions require a disposition
decision at 24 hours. At the time of disposition, pa-

Although care in an observation unit is a viable

reimbursement strategy, the clinical aspects of
such a short-stay admission in the treatment of
heart failure are also valuable. In one retrospective study of short-stay management of patients
with ADHF, those managed in an ED observation
unit had lower 30 day re-admission rates than
those managed on an inpatient hospital floor for
a similar length of time [20]. These results most
likely carried a selection bias resulting from admitting the least sick patients to the ED observation unit and placing those with a higher severity
of illness into the inpatient environment. However, selecting for observation those who require
less intensive care and a shorter treatment time
is precisely the mission of the observation unit.
Recently, newer data have attempted to characterize the appropriate observation unit population as those patients most likely to be able to
be discharged after only 24 hours of treatment
for heart failure. In a study by Diercks et al lowrisk patients were defined as those who were discharged within 24 hours and sustained no adverse events in the subsequent 30 days (adverse
events were defined as death, myocardial infarction, or hospital re-admission) [21]. In 499 patients, univariate analysis identified patients with
a low risk of adverse outcome as those who had
an initial systolic blood pressure >160 mm Hg, no
ischemic changes on ECG, and negative cardiac
markers of ischemia. In a multivariate analysis,
the independent predictors of low risk were systolic blood pressure >160 mm Hg (odds ratio [OR],
1.8; 95% confidence interval [CI], 1.152.7) and
normal troponin-I (OR, 14.7; 95% CI, 1.9105).
These results suggest the type of patients who may
be considered for observation unit treatment.

Emergency Department Management Heart Failure

Other studies have examined factors that predict which heart failure patients will fail observation unit treatment and require hospitalization despite 24 hours of aggressive therapy. In
a retrospective analysis of 385 observation unit
patients, Burkhardt et al. noted that 26.5% of
ADHF observation unit patients could not be discharged home within 24 hours and were subsequently admitted for inpatient care [22]. Interestingly, the presence of pulmonary edema on chest
radiograph was not associated with the requirement for inpatient admission, but a blood urea nitrogen >30 mg/dL was predictive of a patient who
was more likely to fail observation unit therapy.
Although there are some data to guide physicians in selecting patients for the observation
unit, very few studies have specifically evaluated
the observation unit population. Tables 1 and 2
show management entry and exclusion criteria designed to assist in identifying appropriate candidates for observation unit admission and treatment [17,19,20].
Once a cohort of patients with a high probability
of ADHF and a reasonable likelihood of successful management are identified, treatment protocols may be designed to improve outcomes. Data
on specific protocol-driven therapies and diagTable 1. Observation unit admission criteria for patients with
acute decompensated heart failure [17,19,20]
History

Physical examination

Chest radiograph

Laboratory

Orthopnea, dyspnea on exertion,

paroxysmal nocturnal dyspnea,
shortness of breath, swelling of
legs/abdomen, weight gain
Jugular venous distention,
hepatojugular reflux, presence of
an S3 /S4 heart sound, inspiratory
rales, peripheral edema
Cardiomegaly, pulmonary vascular
congestion, Kerley B lines,
pulmonary edema, pleural effusion
B-type natriuretic peptide
>100 pg/Ml

*Must have at least one from each category.

Table 2. Observation unit exclusion criteria for patients with

acute decompensated heart failure [17,19,20]

Chronic renal failure requiring dialysis

Temperature >38.5 C
Chest radiograph showing pulmonary infiltrates
Peak flow <50% of predicted, with wheezing
Clinically significant arrhythmia
Requirement for an intravenous vasoactive medication
other than nesiritide
Electrocardiogram showing evidence of acute myocardial
infarction or ischemia
Abnormal cardiac markers

191

nostic interventions have demonstrated marked

improvement in re-visit and re-admission rates
following an observation unit admission [20].
These protocols should include diuretic algorithms
based on net volume output, administration of
angiotensin-converting enzyme inhibitors, use of
intravenous vasoactive agents, patient education,
and outpatient tracking. In one study of 154 ADHF
patients in an observation unit [20,23], implementation of a diagnosis-and-treatment algorithm resulted in a 44% decrease in 90-day re-visit rates,
a 36% decrease in heart failure re-hospitalization
rates, and an annualized savings of $89,321 (1997
dollars) [23]. Even when protocol-driven observation unit management failed and inpatient admission was requiredas occurred in 23% of patients after protocol implementationthere was
benefit for the patient. Heart failure patients who
required admission despite 24 hours of protocoldriven observation unit care experienced a decrease in their mean length of stay from 4.4 days
to 3.6 days (P = .008), inclusive of the observation
unit stay [20].
Use of the observation unit also resulted in an
alteration in the inpatient heart failure population. When protocol-driven heart failure management was used at the Cleveland Clinic, the acuity
of the inpatient heart failure population (as measured by the number of billable procedures per
heart failure patient) increased by 11%. Thus use
of the observation unit provides better matching
between clinical needs and hospital resources [20].
In the recent past, patients who required intravenous vasoactive agents were excluded from
observation unit admission [20]. This was a multifactorial proscription that occurred during the
era of vasoactive agents that had small therapeutic indexes and required frequent titration and
close hemodynamic monitoring (often with invasive monitoring); it was reinforced by the impression that patients who were sufficiently ill to
justify the use of such agents could not be discharged within the 24-hour time frame. The US
Food and Drug Administration approval of nesiritide presents a new opportunity for observation
unit treatment of patients with ADHF.
The Prospective Randomized Outcomes Study
of Acutely Decompensated Congestive Heart Failure Treated Initially in Outpatients with Natrecor (PROACTION) trial specifically evaluated
the safety and efficacy of nesiritide for use in the
observation unit treatment of patients with ADHF
[24]. This was a multicenter, blinded, randomized,
controlled trial of 237 ADHF patients admitted to
an ED observation unit. Patients were randomly
assigned to receive either standard therapy with
placebo or at least 12 hours of blinded nesiritide treatment combined with standard therapy.
From a safety perspective, the results of this trial

192

Peacock and Emerman

demonstrated that there were no differences between the two groups in mortality at 7 or 30 days.
Symptomatic hypotension occurred in three nesiritide patients between 3 and 15 hours after the
start of study drug, but resolved with termination
of the medication, and no further treatment was
required.
From an efficacy point of view, 30-day heart
failure re-admissions decreased by 21%, and by
29% in those who were more seriously ill (New
York Heart Association Class III/IV) (P = .057).
If patients failed observation unit management
and required subsequent inpatient hospitalization, blinded study drug was continued in the inpatient unit. Subsequent 30-day hospitalizations
in these patients decreased by 57%, and if rehospitalization occurred in the next 30 days, the
length of stay decreased by 45% (from a mean of
8.3 days in patients who did not receive nesiritide
treatment to 4.6 days in those who did).
When total inpatient hospital days were examined in the month after the index observation unit admission, those who received standard
therapy were hospitalized an average of 6.5 days,
compared with 2.5 days for the nesiritide cohort
(P = .032). When a cost analysis was performed,
there was no cost difference between the nesiritide and standard therapy groups.
The PROACTION data were also examined
to determine the safety of nesiritide in ED patients, who by definition are a cohort of potentially hemodynamically unstable patients [25].
Among patients whose initial systolic blood pressure was <100 mm Hg, those receiving nesiritide experienced a 1.24% decline in systolic blood
pressure, whereas those receiving standard care
experienced a 17% increase. Conversely, among
patients whose initial systolic blood pressure exceeded 140 mm Hg, those who received nesiritide
had a decline of 18%, compared with only 5.3% in
those who received standard therapy. Thus nesiritide plus standard therapy had a more beneficial
effect on blood pressure than did standard therapy
alone.

Table 3. Observation unit discharge guidelines [17,19,20]

Patient reports subjective improvement.
Patient is ambulatory, without suffering lengthy orthostasis.
Resting heart rate <100 beats/min, systolic blood pressure
>80 mm Hg.
Total urine output >1 L, and >30 mL/hr or 0.5 mL/kg/hr.
Room air O2 saturation >90% (unless on home O2 ).
No evidence of creatine kinase MB or troponin elevation.
No evidence of ischemic chest pain or clinically significant
arrhythmia.
Stable electrolyte profile.

As noted earlier, disposition becomes necessary

after 24 hours of observation unit therapy. Currently there are very little prospectively derived
data to guide the physician in this decision, but
published criteria suggest that clinical improvement, as manifested by stable vital signs, net urine
output in excess of 1 L, and the ability to perform
the required activities of daily living are the therapeutic goals that suggest success. Table 3 presents
suggested guidelines to assist physicians in selecting the appropriate candidates for discharge home
[17,19,20].

Conclusion
It is only recently that the importance of an aggressive approach to the ED management of decompensated heart failure has been recognized. As
such, we now understand that in selected patients,
failure to implement more than diuretic monotherapy may be associated with a higher risk for adverse clinical events. Furthermore, the standard
heart failure admission is now characterized by
a greater range of choices. This includes observation unit management for selected patients, which
has been demonstrated to provide improved clinical outcomes at lower costs than standard inpatient admission.

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