Original article
Epidemiology, pathophysiology, and in-hospital management of pulmonary edema: data from the Romanian Acute Heart Failure Syndromes registry Ovidiu Chioncela, Andrew P. Ambrosyb, Serban Bubeneka, Daniela Filipescua, Dragos Vinereanuc, Antoniu Petrisd, Ruxandra Christodorescue, Cezar Macariea, Mihai Gheorghiadef, Sean P. Collinsg, on behalf of the Romanian Acute Heart Failure Syndromes study investigators Aim The objective of this study was to evaluate the clinical presentation, inpatient management, and in-hospital outcome of patients hospitalized for acute heart failure syndromes (AHFS) and classified as pulmonary edema (PE). Methods The Romanian Acute Heart Failure Syndromes (RO-AHFS) study was a prospective, national, multicenter registry of all consecutive patients admitted with AHFS over a 12-month period. Patients were classified at initial presentation by clinician-investigators into the following clinical profiles: acute decompensated HF, cardiogenic shock, PE, right HF, or hypertensive HF. Results RO-AHFS enrolled 3224 patients and 28.7% (n U 924) were classified as PE. PE patients were more likely to present with pulmonary congestion, tachypnea, tachycardia, and elevated systolic blood pressure and less likely to have peripheral congestion and body weight increases. Mechanical ventilation was required in 8.8% of PE patients. PE patients received higher doses (i.e. 101.4 W 27.1 mg) of IV furosemide for a shorter duration (i.e. 69.3 W 22.3 hours). Vasodilators were given to 73.6% of PE patients. In-hospital all-cause mortality (ACM) in PE patients was 7.4%, and 57% of deaths occurred on day one. Increasing age, concurrent acute coronary syndromes, lifethreatening ventricular arrhythmias, elevated BUN, left bundle branch block, inotrope therapy, and requirement for
Introduction Registry data suggest there is substantial heterogeneity in the clinical characteristics, in-hospital management, and outcomes of patients admitted for acute heart failure syndromes (AHFS).1–11 However, classification by clinical profile at admission may facilitate early decision-making including initial therapy and patient disposition. Pulmonary edema is a manifestation of AHFS characterized by tachypnea, hypoxemia, and reactive hypertension secondary to high sympathetic tone.12 Pulmonary edema is defined by the European Society of Cardiology (ESC) guidelines as severe respiratory distress accompanied by alveolar or interstitial edema verified by chest X-ray and/or with oxygen saturation 90% or 1558-2027 ß 2016 Italian Federation of Cardiology. All rights reserved.
invasive mechanical ventilation were independent risk factors for ACM. Conclusions In this national registry, the PE profile was found to be a high-acuity clinical presentation with distinctive treatment patterns and a poor short-term prognosis. Advances in the management of PE may necessitate both the development of novel targeted therapies as well as systems-based strategies to identify high-risk patients early in their course. J Cardiovasc Med 2016, 17:92–104 Keywords: in-hospital therapies, outcomes, pulmonary edema a Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania, bDivision of Cardiology, Duke University Medical Center, Durham NC, USA, cUniversity Emergency Hospital, University of Medicine and Pharmacy Carol Davila, Bucuresti, dEmergency Hospital ‘Sf. Spiridon’, University of Medicine and Pharmacy Gr.T.Popa, Iasi, eASCAR Timisoara, University of Medicine and Pharmacy, Victor Babes Romania, fCenter for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Illinois and g Department of Emergency Medicine Vanderbilt University - Nashville, Tennessee, USA
Correspondence to Ovidiu Chioncel, MD, PhD, Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti 950474, Romania Tel: +0040 745400498; fax: +0040 213175224; e-mail: [email protected] Received 30 March 2014 Revised 1 July 2014 Accepted 1 July 2014
higher on room air.13 It is the second most common clinical presentation of AHFS, though its reported prevalence and in-hospital mortality may vary considerably by geographic region (Table 1).2,3,5–7,9–11 This may be explained by the absence of a universally accepted formal definition of pulmonary edema, variation in the methodologies employed by hospital-based registries, and differences in patient characteristics at initial presentation. In the Romanian Acute Heart Failure Syndromes (ROAHFS) registry,11 all consecutive patients admitted for a primary diagnosis of heart failure during a 12-month time period were enrolled and classified by phenotypic profile at initial presentation. RO-AHFS provides a unique DOI:10.2459/JCM.0000000000000192
© 2016 Italian Federation of Cardiology. All rights reserved
ACM, all-cause mortality; AHEAD, acute heart failure database; ALARM-HF, acute heart failure global survey of standard treatment; ATTEND, Acute Decompensated Heart Failure Syndromes registry; EFICA, Epide´miologieFrancaise de l’InsuffisanceCardiaqueAigue¨; EHFS II, European Heart Failure Survey II; HF pilot, Heart Failure pilot study; IN-HF, Italian Registry on heart failure outcome; OFICA, French Observational Survey on Acute Heart Failure RO-AHFS ¼ Romanian Acute Heart Failure Syndromes registry.
5.6 7.1 9.1 7.4
–
7.4
7.3
6.4
13.3 18.4 16.2
Pulmonary edemaprevalence (%) Pulmonary edema–ACM (%)
28.7
60
37
38
27
HF pilot10 (2009–2010) N ¼ 1892; 137 sites; periodic consecutive; ACM ¼ 3.8% IN-HF5 (2007–2009) N ¼ 1855; 61 sites; 1y-; ACM ¼ 6.2% AHEAD9 (2006–2009) N ¼ 4153; 7 sites; consecutive; ACM ¼ 12.7% OFICA3 (2009) N ¼ 1468; 170 sites; 1 d survey; ACM ¼ 8.2% ALARM-HF2 (2006–2007) N ¼ 4953; 666 sites; 5–8 pts/site; ACM ¼ 12% ATTEND6 (2007–2011) N ¼ 4842; 53 sites; consecutive; ACM ¼ 6.4% EHFS II7 (2004–2005) N ¼ 3580; 133 sites; 20 pts/site; ACM ¼ 6.7% RO-AHFS11 (2008–2009) N ¼ 3224; 13 sites; 1 y all consecutive; ACM ¼ 7.7%
Table 1 Prevalence and in-hospital mortality rate of patients admitted with pulmonary edema in registries with different enrollment strategies. Study acronyms, methodology, time frame of enrollment, and in-hospital ACM in overall cohorts are presented in the first row
Pulmonary edema in acute heart failure Chioncel et al. 93
opportunity to perform a comprehensive assessment of pulmonary edema during hospitalization. The objectives of the present analysis were to evaluate the clinical presentation, inpatient management, and hospital course of patients admitted for AHFS and classified as having pulmonary edema.
Methods Study overview
The methods and primary results of the RO-AHFS registry have been previously reported.11 Briefly, ROAHFS was a prospective, national, multicenter registry of all consecutive patients admitted for AHFS over the course of 12 months. The registry enrolled 3224 patients at 13 medical centers including six academic and seven community hospitals representative of the geography and available cardiology services in Romania. The study protocol was approved by the Romanian Society of Cardiology and the institutional review board of each participating site and is in compliance with the Declaration of Helsinki. Clinical profiles
A diagnosis of AHFS was made by clinician-investigators at initial presentation and required the presence of signs and symptoms of heart failure, evidence of cardiac dysfunction, and the need for intravenous (i.v.) therapy.13 A training meeting was organized for study investigators to assure consistency in data collection among participating centers. Patients were classified into the following five clinical profiles by clinician-investigators at the time of presentation according to the 2008 ESC guidelines: acute decompensated heart failure (ADHF), cardiogenic shock, pulmonary edema, right heart failure (RHF), and hypertensive heart failure (HTHF).13 The study definition for pulmonary edema included dyspnea at rest with orthopnea, pulmonary rates more than 1/2 of the lung fields, and SaO2 less than 90% on room air. In addition, classification as pulmonary edema required radiographic evidence of pulmonary alveolar edema at the time of admission. Patients presenting with pulmonary edema were further stratified by systolic blood pressure (SBP) (i.e. SBP
Epidemiology, pathophysiology, and in-hospital management of pulmonary edema: data from the Romanian Acute Heart Failure Syndromes registry Ovidiu Chioncela, Andrew P. Ambrosyb, Serban Bubeneka, Daniela Filipescua, Dragos Vinereanuc, Antoniu Petrisd, Ruxandra Christodorescue, Cezar Macariea, Mihai Gheorghiadef, Sean P. Collinsg, on behalf of the Romanian Acute Heart Failure Syndromes study investigators Aim The objective of this study was to evaluate the clinical presentation, inpatient management, and in-hospital outcome of patients hospitalized for acute heart failure syndromes (AHFS) and classified as pulmonary edema (PE). Methods The Romanian Acute Heart Failure Syndromes (RO-AHFS) study was a prospective, national, multicenter registry of all consecutive patients admitted with AHFS over a 12-month period. Patients were classified at initial presentation by clinician-investigators into the following clinical profiles: acute decompensated HF, cardiogenic shock, PE, right HF, or hypertensive HF. Results RO-AHFS enrolled 3224 patients and 28.7% (n U 924) were classified as PE. PE patients were more likely to present with pulmonary congestion, tachypnea, tachycardia, and elevated systolic blood pressure and less likely to have peripheral congestion and body weight increases. Mechanical ventilation was required in 8.8% of PE patients. PE patients received higher doses (i.e. 101.4 W 27.1 mg) of IV furosemide for a shorter duration (i.e. 69.3 W 22.3 hours). Vasodilators were given to 73.6% of PE patients. In-hospital all-cause mortality (ACM) in PE patients was 7.4%, and 57% of deaths occurred on day one. Increasing age, concurrent acute coronary syndromes, lifethreatening ventricular arrhythmias, elevated BUN, left bundle branch block, inotrope therapy, and requirement for
Introduction Registry data suggest there is substantial heterogeneity in the clinical characteristics, in-hospital management, and outcomes of patients admitted for acute heart failure syndromes (AHFS).1–11 However, classification by clinical profile at admission may facilitate early decision-making including initial therapy and patient disposition. Pulmonary edema is a manifestation of AHFS characterized by tachypnea, hypoxemia, and reactive hypertension secondary to high sympathetic tone.12 Pulmonary edema is defined by the European Society of Cardiology (ESC) guidelines as severe respiratory distress accompanied by alveolar or interstitial edema verified by chest X-ray and/or with oxygen saturation 90% or 1558-2027 ß 2016 Italian Federation of Cardiology. All rights reserved.
invasive mechanical ventilation were independent risk factors for ACM. Conclusions In this national registry, the PE profile was found to be a high-acuity clinical presentation with distinctive treatment patterns and a poor short-term prognosis. Advances in the management of PE may necessitate both the development of novel targeted therapies as well as systems-based strategies to identify high-risk patients early in their course. J Cardiovasc Med 2016, 17:92–104 Keywords: in-hospital therapies, outcomes, pulmonary edema a Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania, bDivision of Cardiology, Duke University Medical Center, Durham NC, USA, cUniversity Emergency Hospital, University of Medicine and Pharmacy Carol Davila, Bucuresti, dEmergency Hospital ‘Sf. Spiridon’, University of Medicine and Pharmacy Gr.T.Popa, Iasi, eASCAR Timisoara, University of Medicine and Pharmacy, Victor Babes Romania, fCenter for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Illinois and g Department of Emergency Medicine Vanderbilt University - Nashville, Tennessee, USA
Correspondence to Ovidiu Chioncel, MD, PhD, Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti 950474, Romania Tel: +0040 745400498; fax: +0040 213175224; e-mail: [email protected] Received 30 March 2014 Revised 1 July 2014 Accepted 1 July 2014
higher on room air.13 It is the second most common clinical presentation of AHFS, though its reported prevalence and in-hospital mortality may vary considerably by geographic region (Table 1).2,3,5–7,9–11 This may be explained by the absence of a universally accepted formal definition of pulmonary edema, variation in the methodologies employed by hospital-based registries, and differences in patient characteristics at initial presentation. In the Romanian Acute Heart Failure Syndromes (ROAHFS) registry,11 all consecutive patients admitted for a primary diagnosis of heart failure during a 12-month time period were enrolled and classified by phenotypic profile at initial presentation. RO-AHFS provides a unique DOI:10.2459/JCM.0000000000000192
© 2016 Italian Federation of Cardiology. All rights reserved
ACM, all-cause mortality; AHEAD, acute heart failure database; ALARM-HF, acute heart failure global survey of standard treatment; ATTEND, Acute Decompensated Heart Failure Syndromes registry; EFICA, Epide´miologieFrancaise de l’InsuffisanceCardiaqueAigue¨; EHFS II, European Heart Failure Survey II; HF pilot, Heart Failure pilot study; IN-HF, Italian Registry on heart failure outcome; OFICA, French Observational Survey on Acute Heart Failure RO-AHFS ¼ Romanian Acute Heart Failure Syndromes registry.
5.6 7.1 9.1 7.4
–
7.4
7.3
6.4
13.3 18.4 16.2
Pulmonary edemaprevalence (%) Pulmonary edema–ACM (%)
28.7
60
37
38
27
HF pilot10 (2009–2010) N ¼ 1892; 137 sites; periodic consecutive; ACM ¼ 3.8% IN-HF5 (2007–2009) N ¼ 1855; 61 sites; 1y-; ACM ¼ 6.2% AHEAD9 (2006–2009) N ¼ 4153; 7 sites; consecutive; ACM ¼ 12.7% OFICA3 (2009) N ¼ 1468; 170 sites; 1 d survey; ACM ¼ 8.2% ALARM-HF2 (2006–2007) N ¼ 4953; 666 sites; 5–8 pts/site; ACM ¼ 12% ATTEND6 (2007–2011) N ¼ 4842; 53 sites; consecutive; ACM ¼ 6.4% EHFS II7 (2004–2005) N ¼ 3580; 133 sites; 20 pts/site; ACM ¼ 6.7% RO-AHFS11 (2008–2009) N ¼ 3224; 13 sites; 1 y all consecutive; ACM ¼ 7.7%
Table 1 Prevalence and in-hospital mortality rate of patients admitted with pulmonary edema in registries with different enrollment strategies. Study acronyms, methodology, time frame of enrollment, and in-hospital ACM in overall cohorts are presented in the first row
Pulmonary edema in acute heart failure Chioncel et al. 93
opportunity to perform a comprehensive assessment of pulmonary edema during hospitalization. The objectives of the present analysis were to evaluate the clinical presentation, inpatient management, and hospital course of patients admitted for AHFS and classified as having pulmonary edema.
Methods Study overview
The methods and primary results of the RO-AHFS registry have been previously reported.11 Briefly, ROAHFS was a prospective, national, multicenter registry of all consecutive patients admitted for AHFS over the course of 12 months. The registry enrolled 3224 patients at 13 medical centers including six academic and seven community hospitals representative of the geography and available cardiology services in Romania. The study protocol was approved by the Romanian Society of Cardiology and the institutional review board of each participating site and is in compliance with the Declaration of Helsinki. Clinical profiles
A diagnosis of AHFS was made by clinician-investigators at initial presentation and required the presence of signs and symptoms of heart failure, evidence of cardiac dysfunction, and the need for intravenous (i.v.) therapy.13 A training meeting was organized for study investigators to assure consistency in data collection among participating centers. Patients were classified into the following five clinical profiles by clinician-investigators at the time of presentation according to the 2008 ESC guidelines: acute decompensated heart failure (ADHF), cardiogenic shock, pulmonary edema, right heart failure (RHF), and hypertensive heart failure (HTHF).13 The study definition for pulmonary edema included dyspnea at rest with orthopnea, pulmonary rates more than 1/2 of the lung fields, and SaO2 less than 90% on room air. In addition, classification as pulmonary edema required radiographic evidence of pulmonary alveolar edema at the time of admission. Patients presenting with pulmonary edema were further stratified by systolic blood pressure (SBP) (i.e. SBP
![[Acute heart failure: acute cardiogenic pulmonary edema and cardiogenic shock].](/assets/img/hold.png)
