title: Management of suspected acute heart failure dyspnea in the emergency department: results from the French prospective multicenter DeFSSICA survey.
abstract: BACKGROUND
  An appropriate diagnostic process is crucial for managing patients with acute heart failure (AHF) in emergency department (ED). Our study aims to describe the characteristics and therapeutic management of patients admitted to the ED for dyspnea suspected to have AHF, their in-hospital pathway of care and their in-hospital outcome.
  
  
  METHODS
  Consecutive patients admitted in 26 French ED for dyspnea suspected to be the consequence of AHF, prior to in hospital diagnostic test, were prospectively included at the time of their admission in the DeFSSICA Survey. Clinical characteristics at admission were recorded by the ED physicians. At discharge from ED, patients were categorized as AHF or non-AHF based on the final diagnosis reported in the discharge summary. The completeness of the data was controlled by the local investigator.
  
  
  RESULTS
  From 16/6/2014 to 7/7/2014, 699 patients were included, of whom 537 (77 %) had a final diagnosis of AHF at discharge. Patients with AHF were older (median 83 vs 79 years, p = 0.0007), more likely to have hypertension (71 % vs 57 %, p = 0.002), chronic HF (54 % vs 37 %, p = 0.0004), atrial fibrillation (45 % vs 34 %, p = 0.02) and history of hospitalization for AHF in the previous year (40 % vs 18 %, p < 0.0001) when compared to patients without AHF. Furosemide and oxygen were used in approximately 2/3 of the patients in the ED (respectively 75 and 68 %) whereas nitrates were in 19 % of the patients. Diagnostic methods used to confirm AHF included biochemistry (100 %), pro-B-type natriuretic peptide (90 %), electrocardiography (98 %), chest X-ray (94 %), and echography (15 %) which only 18 % of lung ultrasound. After the ED visit, 13 % of AHF patients were transferred to the intensive care unit, 28 % in cardiology units and 12 % in geriatric units. In-hospital mortality was lower in AHF vs non-AHF patients (5.6 % vs 14 %, p = 0.003).
  
  
  CONCLUSIONS
  DeFSSICA, a large French observational survey of acute HF, provides information on HF presentation and the French pathway of care. Patients in DeFSSICA were elderly, with a median age of 83 years. Compared with the French OFICA study, patients in DeFSSICA were more likely to have hypertension (71 % vs 62 %) and atrial fibrillation (45 % vs 38 %). As atrial fibrillation and a rapid heart rate have been closely linked to mortality, detection of atrial fibrillation should be considered systematically.The limited use of nitrates in DeFSSICA may be related to the median SBP of 140 (121-160) mmHg. However, our use of nitrates was similar to those in the EAHFE (20.7 %) and OPTIMIZE-HF (14.3 %) registries. In line with guidelines, the proportions of patients who underwent ECG, biological analysis, or chest X-ray were all >90 % in DeFSSICA. Similarly, BNP or pro-BNP was measured in 93 % of patients, compared with 82 % of patients in the OFICA study. Although BNP may be helpful when the diagnosis of HF is in doubt, ultrasound remains the gold standard. The use of ultrasound in the ED has been reported to accelerate the diagnosis of HF and the initiation of treatment, and shorten the length of stay. In-hospital mortality of HF patients in DeFSSICA was 6.4 %, slightly lower than in the OFICA study (8.2 %). Improved interdisciplinary cooperation has been highlighted as a key factor for the improvement of HF patient care.
  
  
  CONCLUSIONS
  DeFSSICA shows that patients admitted for dyspnea suspected to be the consequence of AHF are mostly elderly. The diagnosis of AHF is difficult to ascertain based on clinical presentation in patients with dyspnea. Novel diagnostic techniques such as thoracic ultrasound are warranted to provide the right treatment to the right patients in the ED as early as possible.
authors.affiliation: Emergency Department, University Hospital of Nancy, Nancy, France.|INSERM, Centre d'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux, Nancy, France.|INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France.|INSERM UMR-S 1116, Université Lorraine Nancy I, Nancy, France.
authors.forename: Tahar
authors.initials: T
authors.lastname: Chouihed
authors.affiliation: Department of Cardiology, Lariboisière Hospital, Paris, France.|INSERM UMR-S 942, Université Paris-Diderot, Sorbonne Paris Cité, Paris, France.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Manzo-Silberman
authors.affiliation: Emergency Department, University Hospital of Rouen, Rouen, France.|University of Rouen-Normandy, INSERM UMR-U1096, Rouen, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Peschanski
authors.affiliation: Emergency Department, Rangueil University Hospital, Toulouse, France.|INSERM, U1027, Toulouse, France.|Université Toulouse III - Paul Sabatier, Toulouse, France.
authors.forename: Sandrine
authors.initials: S
authors.lastname: Charpentier
authors.affiliation: Department of Cardiology, Rangueil Hospital, Toulouse, France.
authors.forename: Meyer
authors.initials: M
authors.lastname: Elbaz
authors.affiliation: Emergency Department and Intensive Care Unit, Annecy-Genevois, Metz-Tessy, France.
authors.forename: Dominique
authors.initials: D
authors.lastname: Savary
authors.affiliation: Department of Cardiology, Hôpital Cardiologique de Lyon, Lyon, France.
authors.forename: Eric
authors.initials: E
authors.lastname: Bonnefoy-Cudraz
authors.affiliation: Department of Cardiology, Lariboisière Hospital, Paris, France.|INSERM UMR-S 942, Université Paris-Diderot, Sorbonne Paris Cité, Paris, France.
authors.forename: Said
authors.initials: S
authors.lastname: Laribi
authors.affiliation: INSERM UMR-S 942, Université Paris-Diderot, Sorbonne Paris Cité, Paris, France.|Emergency Medicine Department, University Hospital of Tours, Paris, France.
authors.forename: Patrick
authors.initials: P
authors.lastname: Henry
authors.affiliation: INSERM, Centre d'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux, Nancy, France.|INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Girerd
authors.affiliation: INSERM, Centre d'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux, Nancy, France.|INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France.
authors.forename: Faiez
authors.initials: F
authors.lastname: Zannad
authors.affiliation: Emergency Department and RESCUe Network, Lucien Hussel Hospital, Vienne, France. c.elkhoury@ch-vienne.fr.|Univ. Lyon, Claude Bernard Lyon 1 University, HESPER EA 7425, Lyon, France. c.elkhoury@ch-vienne.fr.
authors.forename: Carlos
authors.identifier: http://orcid.org/0000-0003-2638-8181
authors.initials: C
authors.lastname: El Khoury
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D019468:Disease Management; D004417:Dyspnea / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D004452:Echocardiography; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D005602:France / Q000453:epidemiology; D006333:Heart Failure / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D011446:Prospective Studies; D011795:Surveys and Questionnaires