High-risk acute heart failure patients in ward. should they be admitted in intensive care unit? report from a second level hospital
I Sanz Ortega, I A Cantolla Aguirre, J Ruiz Donate, J Gonzalez Ruiz, R Candina Urizar, A Larumbe Kareaga, G Zugazabeitia Irazabal, A Salcedo ArrutiAbstract
Background
High-risk heart failure (HF) patients include those with severe respiratory distress, acute coronary syndromes (ACS) and ventricular tachycardia (VT) and are seldom admitted in Intensive Care Units (ICU) for treatment and/or monitoring (reperfusion, mechanical ventilation). Low blood pressure (BP) (normally defined as systolic BP (sBP) <90 mmHg but also a mean BP (mBP) <60 mmHg) it is usually considered as "preshock" generating admission in ICU.
AIMS
To investigate safety of managing selected high-risk HF patients in cardiology ward.
Methods
We analyzed ward patients attended during eight non-consecutive months by the same consultant cardiologist with congestion without signs of hypoperfusion with either low BP (sBP <90 mmHg) and/or respiratory distress who were considered to be managed safely in ward. We reported characteristics, including lowest value of BP. ICU admission or death defined poor outcomes.
Results
21 patients experienced 23 events (2 patients admitted twice). 26.1% were women with mean age 79.5 years (SD: 8.7)). 13% of cases were admitted from clinic,3.8 from ICU and the rest from Emergency Department (ED). 73.9% were considered candidates for critical care unit in case of instability. Mean systolic BP was 93.1 mmHg (SD: 21), mean diastolic BP was 54.2 mmHg (SD: 11) and mean mBP was 67.2 mmHg (SD: 12.8). 43.4% experienced instability in ward (30% women, all but one admitted from ED (1 patient from clinic). 13% of cases experienced respiratory distress (1/3 with sBP<90 mmHg and 2/3 with sBP≥140). 13% died. 40% of total patients experienced inestabilitation (1/3 with respiratory distress), 16.7% admitted in ICU and 33.3% dying on ward. None with ACS experienced inestabilitation and all ICU admissions were discharged alive from hospital. 65.2% had low sBP (13.3% of them with respiratory distress). They had a mean sBP of 82.3 mmHg (SD: 5.9); mean dBP: 50.3 (SD: 8.5) and mean mBP: 61 (SD: 6.7). Among them 40% of cases had mBP<60 mmHg, 50% with poor outcome (1 ICU admission and 2 deaths). Maximun mBP of these cases 57 mmHg. This shown in picture 1. Characteristics are detailed in picture 2. Comparing sBP (threshold 90 mmHg) to mBP (threshold 60 mmHg) among those without respiratory distress, mBP had better sensibility (S) (0.69 vs 0.29) and negative predictive value (NPV) (38% vs 20%) with a bit worse specificity (Sp) (0.75 vs 1) and positive predictive value (PPV) (92% vs 100%). Calculated for those among them with sBP below 90 mmHg, mBP (threshold 60 mmHg) had a good S (0.73), Sp (1), PPV (100%) and NPV (50%)
Conclusions
In selected patients mBP measurement (cut-off 60 mmHg) seems to discriminate better than sBP (threshold 90 mmHg) those who will experience poor outcomes, especially among those with sBP<90 mmHg, so it could be a good screening method for prophylactic ICU admission. This could be cost-effective with similar mortality than usual management based on sBP.mBP and stabilityFor image description, please refer to the figure legend and surrounding text.Patients´charactersiticsFor image description, please refer to the figure legend and surrounding text.