title: Arrival by ambulance in acute heart failure: insights into the mode of presentation from Acute Studies of Nesiritide in Decompensated Heart Failure (ASCEND-HF).
abstract: OBJECTIVE
  Limited data exist assessing the relationship between ambulance versus self-presentation and outcomes in patients with acute heart failure (AHF).
  
  
  METHODS
  Clinical trial sites in North America.
  
  
  METHODS
  1068 patients enrolled in the Acute Studies of Nesiritide in Decompensated Heart Failure (ASCEND-HF) trial.
  
  
  METHODS
  The association between ambulance use and dyspnoea improvement, 30-day mortality or HF rehospitalisation and 180-day mortality.
  
  
  RESULTS
  Of the 1068 patients in the substudy, 832 (78%) self-presented (SP) and 236 (22%) patients presented via ambulance. Patients presenting via ambulance were older, more likely to be female, have a higher ejection fraction but similar natriuretic peptide levels as patients who SP. Patients presenting by ambulance (compared with SP) trended towards more dyspnoea improvement at 6 (p=0.09) and 24 h (p=0.10). The co-primary end point (30-day mortality or HF rehospitalisation) was similar between groups (ambulance 12.2% vs SP 11.4%, p=0.74). Patients who presented by ambulance had a higher 30-day and 180-day mortality rate than those who SP (30-day: 4.3% vs 2.2%, p=0.08; 180-day: 15.1% vs 10.3%, p=0.04). After adjustment for baseline characteristics, patients arriving by ambulance (compared with SP) had a 2-fold high risk of 30-day mortality (OR 2.12, 95% CI 0.94 to 4.79), but no relationship to the composite of 30-day mortality/HF rehospitalisation (OR 1.01, 95% CI 0.63 to 1.63).
  
  
  CONCLUSIONS
  Among patients with AHF, 30-day and 180-day mortality is 1.5-2 times higher for those with presenting via ambulance compared with patients who self-present. Understanding patient-related and system-related factors of ambulance use for patients with AHF is important.
  
  
  BACKGROUND
  NCT00475852.
authors.affiliation: Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.
authors.forename: Justin A
authors.initials: JA
authors.lastname: Ezekowitz
authors.affiliation: Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.
authors.forename: Mohua
authors.initials: M
authors.lastname: Podder
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina, USA.
authors.forename: Adrian F
authors.initials: AF
authors.lastname: Hernandez
authors.affiliation: Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.
authors.forename: Paul W
authors.initials: PW
authors.lastname: Armstrong
authors.affiliation: Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Randall C
authors.initials: RC
authors.lastname: Starling
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina, USA.
authors.forename: Christopher M
authors.initials: CM
authors.lastname: O'Connor
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina, USA.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Califf
mesh_terms: D000208:Acute Disease; D000368:Aged; D000552:Ambulances; D018450:Disease Progression; D004305:Dose-Response Relationship, Drug; D004417:Dyspnea / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D004632:Emergency Medical Services / Q000706:statistics & numerical data; D005260:Female; D006333:Heart Failure / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain / Q000627:therapeutic use; D009656:North America / Q000453:epidemiology; D010359:Patient Readmission; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D020097:Natriuretic Peptide, Brain
keywords: ambulance; mode of presentation