title: Early changes in clinical characteristics after emergency department therapy for acute heart failure syndromes: identifying patients who do not respond to standard therapy.
abstract: Clinical trials for acute heart failure syndromes (AHFS) have traditionally enrolled patients well after emergency department (ED) presentation. We hypothesized a large proportion of patients would undergo changes in clinical profiles during the first 24 h of hospitalization, and these changes would be associated with adverse events. We evaluated a prospective cohort of patients with clinical data available at ED presentation and 12-24 h after ED treatment for AHFS. Patients were categorized into distinct clinical profiles at these time points based on (1) systolic blood pressure: a-hypertensive (>160 mmHg); b-normotensive (100-159 mmHg); or c-hypotensive (<100 mmHg); (2) moderate-to-severe renal dysfunction (GFR ≤ 60 ml/min/1.73 m(2)); and (3) presence of troponin positivity. A composite outcome of 30-day cardiovascular events was determined by phone follow-up. In the 370 patients still hospitalized with data available at the 12-24 h time point, 196 (53.0%) had changed their clinical profiles, with 117 (59.7%) improving and 79 (40.3%) worsening. The composite 30-day event rate was 16.9%. Patients whose clinical profile started and stayed abnormal had a significantly greater proportion of events than those who started and stayed normal (26.1% vs. 11.3%; P = 0.03). Patients with abnormal clinical profiles at presentation that remain abnormal throughout the first 12-24 h of hospitalization are at increased risk of 30-day adverse events. Future clinical trials may need to consider targeting these patients, as they may be the most likely to benefit from experimental therapy.
authors.affiliation: Department of Emergency Medicine, Vanderbilt University, Nashville, TN 47232, USA. sean.collins@vanderbilt.edu
authors.forename: Sean P
authors.initials: SP
authors.lastname: Collins
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Lindsell
authors.forename: Alan B
authors.initials: AB
authors.lastname: Storrow
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Fermann
authors.forename: Phillip D
authors.initials: PD
authors.lastname: Levy
authors.forename: Peter S
authors.initials: PS
authors.lastname: Pang
authors.forename: Neal
authors.initials: N
authors.lastname: Weintraub
authors.forename: W
authors.initials: W
authors.lastname: Frank Peacock
authors.forename: Douglas B
authors.initials: DB
authors.lastname: Sawyer
authors.forename: Mihai
authors.initials: M
authors.lastname: Gheorghiade
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001794:Blood Pressure; D015331:Cohort Studies; D004636:Emergency Service, Hospital; D005260:Female; D006333:Heart Failure / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D006973:Hypertension / Q000150:complications; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D016896:Treatment Outcome