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Is Hospital Admission for Heart Failure Really Necessary?: The Role of the Emergency Department and Observation Unit in Preventing Hospitalization and Rehospitalization

https://doi.org/10.1016/j.jacc.2012.08.1022Get rights and content
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Approximately 800,000 times a year, an emergency physician admits a patient with symptomatic heart failure (HF). Yet only a minority of emergency department patients with HF are severely ill as a result of pulmonary edema, myocardial ischemia, or cardiogenic shock. The majority of patients are not in need of an acute intervention beyond decongestion, and few patients during hospitalization undergo invasive diagnostic testing or therapeutic procedures that require intense monitoring. Although hospitalization is clearly an inflection point, marking a threshold that independently predicts a worse outcome, the exact impact of hospitalization on post-discharge events has not been well elucidated. Thus, large subsets of patients with HF are hospitalized without a clear need for time-sensitive therapies or procedures. The authors estimate that up to 50% of emergency department patients with HF could be safely discharged after a brief period of observation, thus avoiding unnecessary admissions and minimizing readmissions. Observation unit management may be beneficial for low-risk and intermediate-risk patients with HF as continued treatment, and more precise risk stratification may ensue, avoiding inpatient admission. Whether observation unit management is comparable with or superior to the current approach must be determined in a randomized clinical trial. Critical end points include time to symptom resolution and discharge, post-discharge event rates, and a cost-effective analysis of each management strategy. It is the authors' strong assertion that now is the time for such a trial and that the results will be critically important if we are to effectively influence hospitalizations for HF in the near future.

Key Words

emergency department
heart failure
hospitalization
observation unit

Abbreviations and Acronyms

ED
emergency department
HF
heart failure
OU
observation unit

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This work was supported in part by grant K23HL085387 from the National Heart, Lung, and Blood Institute. Dr. Collins is a consultant for Trevena, Radiometer, The Medicines Company, and Novartis; and has received research support from the National Institutes of Health, Medtronic, Novartis, and Abbott Point of Care. Dr. Pang is a consultant for Novartis, Otsuka, Trevena, and Palatin Technologies; has received research support from Abbott and Alere; and has received honoraria from Alere, Beckman Coulter, Momentum Research, Nile Therapeutics, and MyLife. Dr. Fonarow has received research support from Medtronic, Novartis, and Gambro. Dr. Gheorgiade has received support from Abbott Laboratories, Astellas, AstraZeneca, Bayer Schering Pharma AG, Cardiorentis Ltd., CorThera, Cytokinetics, CytoPherx, Inc., DebioPharm S.A., Errekappa Terapeutici, GlaxoSmithKline, Ikaria, Intersection Medical, Inc, Johnson & Johnson, Medtronic, Merck & Co., Inc., Novartis Pharma AG, Ono Pharmaceuticals USA, Otsuka Pharmaceuticals, Palatin Technologies, Pericor Therapeutics, Protein Design Laboratories, sanofi-aventis, Sigma Tau, Solvay Pharmaceuticals, Sticares InterACT, Takeda Pharmaceuticals North America, Inc., and Trevena Therapeutics; and has received significant (>$10,000) support from Bayer Schering Pharma AG, DebioPharm S.A., Medtronic, Novartis Pharma AG, Otsuka Pharmaceuticals, Sigma Tau, Solvay Pharmaceuticals, Sticares InterACT, and Takeda Pharmaceuticals North America, Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.