title: Presenting phenotypes of acute heart failure patients in the ED: Identification and implications.
abstract: BACKGROUND
  There is little known about the baseline hemodynamic (HD) profiles (beyond pulse/blood pressure) of patients presenting to the Emergency department (ED) with acute heart failure (AHF). Assessing these baseline parameters could help differentiate underlying HD phenotypes which could be used to develop specific phenotypic specific approaches to patient care.
  
  
  METHODS
  Patients with suspected AHF were enrolled in the PREMIUM (Prognostic Hemodynamic Profiling in the Acutely Ill Emergency Department Patient) multinational registry and continuous HD monitoring was initiated on ED presentation using noninvasive finger cuff technology (Nexfin, BMEYE, Edwards Lifesciences, Irvine, California). Individuals with clinically suspected and later confirmed AHF were included in this analysis and initial 15minute averages for available HD parameters were calculated. K-means clustering was performed to identify out of 23 HD variables a set that provided the greatest level of inter-cluster discrimination and intra-cluster cohesions.
  
  
  RESULTS
  A total of 127 patients had confirmed AHF. The final model, using mean normalized patient baseline HD values was able to differentiate these individuals into 3 distinct phenotypes. Cluster 1: normal cardiac index (CCI) and systemic vascular resistance index (SVRI); cluster 2: very low CI and markedly increased SVRI: and cluster 3: low CI and an elevated SVRI. These clusters were not differentiated using clinically available ED information.
  
  
  CONCLUSIONS
  Three distinct clusters were defined using novel noninvasive presenting HD monitoring technology in this cohort of ED AHF patients. Further studies are needed to determine whether phenotypic specific therapies based on these clusters can improve outcomes.
authors.affiliation: Department of Emergency Medicine, Henry Ford Health System, Detroit, MI, USA. Electronic address: rnowak1@hfhs.org.
authors.forename: Richard M
authors.initials: RM
authors.lastname: Nowak
authors.affiliation: Department of Biostatistics, Wayne State University, Detroit, MI, USA. Electronic address: bpreed@med.wayne.edu.
authors.forename: Brian P
authors.initials: BP
authors.lastname: Reed
authors.affiliation: Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza, Rome, Italy. Electronic address: Salvatore.Disomma@uniroma1.it.
authors.forename: Salvatore
authors.initials: S
authors.lastname: DiSomma
authors.affiliation: Section of Acute Medicine, Department of Internal Medicine, VU Medical Center, Amsterdam, Netherlands. Electronic address: P.Nanayakkara@vumc.nl.
authors.forename: Prabath
authors.initials: P
authors.lastname: Nanayakkara
authors.affiliation: Department of Emergency Medicine, Henry Ford Health System, Detroit, MI, USA. Electronic address: mmoyer1@hfhs.org.
authors.forename: Michele
authors.initials: M
authors.lastname: Moyer
authors.affiliation: Department of Biostatistics, Wayne State University, Detroit, MI, USA. Electronic address: smillis@med.wayne.edu.
authors.forename: Scott
authors.initials: S
authors.lastname: Millis
authors.affiliation: Departments of Emergency Medicine and Physiology and Cardiovascular Research Institute, Wayne State University, Detroit, MI, USA. Electronic address: plevy@med.wayne.edu.
authors.forename: Phillip
authors.initials: P
authors.lastname: Levy
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D001794:Blood Pressure / Q000502:physiology; D016000:Cluster Analysis; D004636:Emergency Service, Hospital; D005260:Female; D006333:Heart Failure / Q000503:physiopathology*; D006339:Heart Rate / Q000502:physiology; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic; D010641:Phenotype; D011446:Prospective Studies; D012042:Registries; D014655:Vascular Resistance / Q000502:physiology
keywords: Acute heart failure; Emergency Department; Hemodynamic phenotypes