Observation Unit Management of HF, Afib, DVT. Associate Professor University of Cincinnati Department of Emergency Medicine October 22, 2010

Transcription

1 Observation Unit Management of HF, Afib, DVT Sean Collins, MD, MSc Associate Professor University of Cincinnati Department of Emergency Medicine October 22, 2010

2 Overview Touch on some clinical issues for background Focus on bread and butter OU Related Literature Inclusion/Exclusion Criteria Protocol Synopsis

3 Acute Heart Failure in the OU

4 HF Disposition Decision Making Guidelines from ACC/AHA, HFSA and ACEP are vague They suggest hospitalization ti for high-riskh i No guidance for non-high-risk Non-high-risk = low-risk

5 Current Disposition Decisions ED Patient with AHF 85% 10% 5% Hospital Admission OU Home

6 Why are most admitted? Complex disease- Diabetes, HTN, COPD Number of reasons s for disease worsening Medication/dietary noncompliance Worsening underlying disease Ischemia/MI Evidence base for ED discharge lacking Enter the Observation Unit

7 The Observation Unit for AHFS A place for concurrent treatment and risk assessment: Treatment: blood pressure control and diuresis Risk Assessment: Echocardiogram if needed Stress test and serial cardiac markers Feasible in those with no significant active co-morbidities Difficult to also treat high blood sugar, COPD exacerbation, pneumonia, etc. Follow-up is key

8 What AHFS patients can go to an OU?

9 A consensus statement based on most recent evidence Examined diagnosis, treatment, risk-stratification Recommended patients for OU management based on clinical variables

10 No high-risk Criteria to be OU Eligible

11 Secondary analysis of prosp. collected AHFS database (1000 patients) Excluded SBP < 100 mmhg ECG changes, TnT > 0.1, TnI > 0.3 BUN > 40, Cr > 3 Na2+ < 135

12 Results 25 events (12.4%) in low-risk cohort 1 death 16/25 HF readmission 47 events (14.8%) in high-risk 5.7% (18) deaths

13 OU HF Protocol Synopsis Therapy consists of several angles: Target BP IV/PO/topical vasodilators Target congestion diuretics Restart home medications Re-evaluate and replace electrolytes Evaluation: ECHO if not done recently or suspicion of change in cardiac function Serial markers +/- stress testing Arrange follow-up and fill medications

14 Looked at hypothetical case of 60-YO male (no high-risk features) Admission i vs OU management vs ED d/c Previous data for risk of events CMS for cost data ED OU management - $44,249/QALY Collins AJEM 2009; 27:

15 Other Institutions

16 What s Missing? A randomized trial Naysayers s of OU point to cherry picking Comparing apples to apples? Similar idea in chest pain patients

17 Current Disposition Decisions ED Patient with AHF 85% 10% 5% Hospital Admission OU Home

18 Future Dispositions a win ED Patient with AHF 75% 20% 5% Hospital Admission OU Home

19 Acute HF Inclusion/Exclusion Criteria

20 OU HF Protocol Serial cardiac markers +/- ECHO over 1 year or clinical ca suspicion Stress test? Resume home medicns- ½tofullβ β blocker BP control and diurese Repeat electrolytes and re-evaluate

21 Discharge Criteria

22 Atrial Fibrillation

23 Overview What this lecture will discuss: Pharmacologic options for rate control Electrical and chemical cardioversion Disposition Options Observation Unit Management What this lecture will not discuss: Diagnosis A Fib Differential- PE, thyroid, etc Zebras- WPW In depth long-term rate vs rhythm control- AFFIRM/RACE

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25 Stable A Fib

26 A Fib Rate Control: Evidence? Literature is not stellar Rate control o Diltiazem most successfulu 1 Dilt 90% - 3º Dig and Amio 74% - 6º and 7º Similar findings in Meta Analysis 2 No real comparison with β-blockers Other Considerations COPD No β Blockers Acute HF Dig? 1-Siu JJJ; 2-Parris Emer Med J 2009;26:

27 A Fib Rhythm Control: Evidence? Up to 50% convert spontaneously < 24º Symptoms < 48 hours, stable Most studies have not studied isolated A Fib in younger patients Electrical generally more successful 1,2,3 Chemical 50-70% Electrical 80-90% Higher Joules = higher success Few adverse events (5%) which require interventions 1-Burton Ann Emerg Med 2004; 44(1); 2-Michael Ann Emerg Med 1999;33(4);3-GEFAUR- Ann Emerg Med 2005;46(5)

28 Anticoagulation Acute risk: < 48 hours sx = <1% risk of TE during cardioversion 1 CHADS 2 risk of long-term TE events 1- Weigner - Ann Int Med 1997;126(8)

29 Ross MA, Davis B, Dresselhouse A. The role of an emergency department observation unit in a clinical pathway for atrial fibrillation. Crit Path in Cardio. 2004;3:8-12. Design - descriptive Population - ED acute AF patients t in 2002 Outcome -LOS Admitted AAF patients (n=412) IP LOS = 3.54 days (85 hr) EDOU AAF patients (n=74) Discharged EDOU LOS = 14.9 hr Admitted EDOU LOS = 12.6 hr

30 Koenig BO, Ross MA, Jackson RE. An emergency department observation unit protocol for acute-onset atrial fibrillation is feasible. Ann Emerg Med Apr; 39(4): Design - Descriptive case series Population - 67 ED patients with acute a-fib that failed initial ED therapy 73% received ED med for cardioversion Serial markers, rate control, heparin discretionary 12 hours electrical cardioversion 18 hours and no conversion = admit 1 hour in SR with VSS = discharge Follow-up by chart review

31 Koenig BO, Ross MA, Jackson RE. An emergency department observation unit protocol for acute-onset atrial fibrillation is feasible. Ann Emerg Med Apr; 39(4): Outcomes: Conversion to SR = 82% (76% without EC) Discharge home = 81% LOS = 11.8hr (home) / 17.7hr (admit) Complications of AAF = 7.5% 7-day recidivism = 4.5% Conclusion: RCT is needed d

32 Ann Emerg Med 2008;52(4)

33 Methods 18 or older with AF < 48 hours Excluded: BP < 90/50 P > 130 after rate control attempts Class IV HF, active angina, ACS in last 4 weeks, CVA/TIA in last 3 months CVA/TIA in last 3 months Rate control with CCB or Beta-blocker Primary endpt- SR restoration F/U arranged within 3 DAYS All patients f/u at 6 months- stroke, death, etc

34 Results 153 patients randomized over 39 months Median LOS- 12 hours in OU vs 25 hours in hospitalized OU group 64/75 (85%) to sinus rhythm 24 spontaneously Hospital group 57/78 (73%) 34 spontaneously

35 Results 6-month events OU group- 8 patients (10%) with recurrent Afib Hospital group- 8 patients (10%) with recurrent Afib and 1 with MI

36 Paroxysmal AF Summary 1) Rate control: Dilt > Dig/Amio 2) Rhythm control: <48 hours of symptoms - minimal comorbidities consider OU Up to 50% spontaneously convert Cardioversion: Ibutilide/Procainamide/Electricity D/C after 2 hours observation- good followup >48 hours and/or comorbidities rate control Likely admit Could anticoagulate and manage as outpt

37 Atrial Fibrillation OU Inclusion Criteria* Stable Blood pressure, heart rate under 100 for one hour after treatment No chest pain when rate controlled No evidence of acute or recent comorbidities: MI, CHF, PE, sepsis, CVA Onset < 48 hours Cardiologist agrees with plan *Koenig- Ann Emerg Med (4)

38 Atrial Fibrillation OU Exclusion Criteria Unstable vitals, heart rate not controlled with medications Ongoing ischemic chest pain Chronic atrial fibrillation, >48 hours or unknown Cardiologist chooses inpatient admission *Koenig- Ann Emerg Med (4)

39 EDOU Interventions - Atrial Fibrillation Cardiac and ST segment monitoring ASA, Heparin discretionary Medication control: Cardizem, beta blockers CPK MB, troponin I at 0, 4, 8 hours (Ross 3, 6, 9) U/a, TSH, BNP, pulse ox 2-D echo?? NPO for possible cardioversion- electrical preferred *Koenig- Ann Emerg Med (4), Decker Ann Emerg Med 2008;52(4)

40 DVTintheOU

41 ACEP Clinical policy: Critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism Epidemiology ~ 600,000 hospitalization/ year with DVT ~ 300,000 people die from pulmonary embolus each year Approximately 1 in 20 people will develop a DVT over their lifetime

42 Virchow s Triad Venous Stasis Vessel Wall Injury Hypercoagulable State Varying degrees of each

43 Risk Factors Increased age Hormone o replacement epace e therapy or oral contraceptives Cancer and cancer therapy Heart Failure COPD Major surgery, trauma, pregnancy Immobility Inherited or acquired clotting disorders Smoking

44 Levine M, et al A Comparison Of Low-Molecular-Weight Heparin Administered Primarily At Home With Unfractionated Heparin Administered In The Hospital For Proximal Deep Vein Thrombosis. New Eng J of Med, Vol 334, 2001 No11, p 677. Design - Prospective randomized intervention Population Canadian patients with proximal DVT Therapy LMWH outpatient (though admit initially if needed) UFH & hospitalized - then bridge to coumadin at day 2 Outcomes measured over 90 days: Recurrent thromboembolism b Major bleeding

45 Levine M, Gent M, Hirsh J, et al A Comparison Of Low-Molecular-Weight Heparin Administered Primarily At Home With Unfractionated Heparin Administered In The Hospital For Proximal Deep Vein Thrombosis. New Eng J of Med, Vol 334 No11, 2001 p 677.

46 Levine M, Gent M, Hirsh J, et al A Comparison Of Low-Molecular-Weight Heparin Administered Primarily At Home With Unfractionated Heparin Administered In The Hospital For Proximal Deep Vein Thrombosis. New Eng J of Med, Vol 334 No11, 2001,p 677.

47 Levine M, et al A Comparison Of Low-Molecular-Weight Heparin Administered Primarily At Home With Unfractionated Heparin Administered In The Hospital For Proximal Deep Vein Thrombosis. New Eng J of Med, Vol 334 No11, 2001, p 677.

48 Study Conclusions Treatment for 5+/- days with either heparin 120/247 LMWH were e d/c home primarily Equally efficacious Similar findings in another outpt study- 4.4% vs 5.9% - 2 LMWH regimens 1 Forms a foundation for OU management 1-Wells- Arch Int Med 2005;165:

49 Exclusion Criteria DVT Clinical evidence of PE, although some centers are accepting stable PE History of bleeding disorder, thrombocytopenia High risk of bleeding complications Recent intracranial or spinal surgery Recent epidural or lumbar puncture Recent major trauma

50 EDOU Exclusion Criteria DVT History of prosthetic heart valve Social inability to use enoxaparin Active cancer, history of brain tumor or AV Malformation Allergies to pork products, heparin, or Lovenox Patient < 18 years of age Pregnancy Weight > 150 kg (330 lbs) Creatinine clearance, 30 ml/min

51 EDOU Interventions DVT Send PT, PTT, INR if not done in ED BUN, Creatinine, e, Creatinine e Clearance a Hypercoagulation profile, Protein C & S, Factor V Leiden genotype, Antithrombin 3 antibody, Antiphospholipid/anticardiolipin antibody, homocysteine, Prothrombin genotyping

52 EDOU Interventions DVT Nurse gives first dose of enoxaparin, 1mg/kg q 12 hours Warfarin dose given 4 hours after enoxaparin, 7.5mg or 5 mg based on weight and age Pharmacy/Anticoagulant Medical service Consulted Patient education including video on enoxaparin Patient demonstrates second dose administration of enoxaparin

53 EDOU Interventions DVT Monitor pulse oximetry CBC, PT, INR q 12 hours

54 Disposition Stable patient Stable hemoglobin ob No signs of PE, respiratory distress Discharge medication prescriptions confirmed and given for enoxaparin times 5 days with refill, and warfarin 2.5 mg # 30 AMS service/ physician follow-up confirmed PT, INR, CBC daily for follow-up

55 Cincinnati Outpt Treatment Protocol

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57 DVT Conclusions DVT and PE a continuum Amenable abe to treatment e t in OU or as outpatient Largely driven by social factors: follow-up, fill medicn, give themselves a shot

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