Heart failure clinics
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The emergency department evaluation and management of patients who have potential acute heart failure syndromes (AHFS) has remained a significant challenge for decades. The emergency physician's diagnostic tools for heart failure have remained limited, and the complexity of the syndrome itself has led to risk-averse practice styles with extremely high admission rates. ⋯ Familiarity with these approaches is essential for improved care for patients who have heart failure and for resource use. This article reviews the available literature and describes patient features that need to be accounted for in disposition decision-making.
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Heart failure clinics · Jan 2009
ReviewPharmacologic stabilization and management of acute heart failure syndromes in the emergency department.
Effective use of diuretics, vasodilators, and inotropes to stabilize acute heart failure (AHF) relies on matching the most appropriately tailored therapy to specific clinical profiles. Some of the drugs may be harmful, and therefore the emphasis should be on patient safety and the attempt to minimize the deleterious effects of these therapies. To date, successful treatment has been limited because no agent has been shown to reduce postdischarge mortality or readmission rates, and patients frequently remain symptomatic after treatment. Ongoing research is needed to further examine these agents and to develop novel therapies to address the unmet needs of the patient who has AHF.
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The evolution of prehospital treatment of decompensated congestive heart failure has in some ways come full circle: rather than emphasizing a battery of new pharmacotherapies, out-of-hospital providers have a renewed focus on aggressive use of nitrates, optimization of airway support, and rapid transport. The use of furosemide and morphine has become de-emphasized, and a flurry of research activity and excitement revolves around the use of noninvasive positive-pressure ventilation. Further research will clarify the role of bronchodilators and angiotensin-converting enzyme inhibitors in the prehospital setting.
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As more patients have pacemakers and internal cardioverter defibrillators implanted, and live longer with these and other life-extending therapies, the utility of these devices and the potential for malfunction become meaningful to physicians. This article presents a basic understanding of the reasons for implantation, how the devices function, and what to do to help improve patient care if a problem occurs.
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Heart failure clinics · Jan 2009
ReviewSpecial cases in acute heart failure syndromes: atrial fibrillation and wide complex tachycardia.
Hospitalization for acute heart failure syndromes (AHFS) results in substantial in-hospital and postdischarge morbidity and mortality. Management of AHFS presents significant challenges, given the heterogeneity of the patient population and the differing etiologies underlying why patients present with acute decompensation. ⋯ Compounding this challenge is the paucity of evidence on which to base early management. General principles for the management of atrial fibrillation and wide complex tachycardia in the setting of emergency department AHFS are discussed.