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Emergency Department Management of Acute Heart Failure: Research Challenges and Opportunities

Executive Summary

This working group was organized by the National Heart, Lung, and Blood Institute (NHLBI) to address the challenges of managing acute heart failure syndrome (AHFS) in the emergency department (ED). The purpose of the meeting was to provide an interdisciplinary forum on promising and novel life saving AHFS therapies in the ED and to provide clinical research recommendations to the NHLBI regarding research directions that will best address the most critical areas in ED AHFS management. The working group provided the unique opportunity to bring together experts from both cardiology and emergency medicine. The workshop was held at the Cloister Conference Center, NIH, Bethesda, MD, on August 20-21, 2009.

Management of AHF in ED Setting: A Unique Opportunity to Improve Care and Survival

The participants agreed that there is a critical need for evidence-based management of AHFS in the ED setting. Most of the existing therapies for AHFS have not been tested rigorously or prospectively and most current therapies are used based on the experience and the opinions of experts (Level of Evidence C). In addition, most new therapies and technologies have not fulfilled the expectations to significantly improve either acute or long-term survival.

Two major management concepts were discussed: 1) the need for the early identification of patients who are at low vs. higher risk, allowing direct discharge from the ED for those at low risk and direct admission from the ED for those at high risk who do not respond to therapy; and, 2) the need for better understanding of early injury to both the heart and other organs, the contribution of this injury to the pathophysiology of AHFS, and the impact it may have on potential response to therapy in the ED setting.

Future therapeutic interventions are likely to come from the frontiers of molecular medicine, basic cardiovascular sciences, pharmacology, epidemiology, new diagnostic techniques, and technological advances. However, these therapies need to be tested using appropriate study designs with a special focus on timing, route of administration and co-administration of other drugs. The new approach to AHFS management will require integration and close collaboration among diverse clinical disciplines, including emergency medicine, cardiology, and critical care, as well as basic sciences and biotechnology. The working group believed that close multi-disciplinary collaboration would improve the understanding of early AHFS physiology and facilitate research that would lead to more evidence-based practices in the ED.

Recommendations

To advance AHFS management and improve morbidity and mortality the group recommended the following specific actions:

  1. Design and Conduct Clinical Trials Based in the ED:
    New studies in this field should include testing of both existing and new interventions in the ED setting. The following research priorities were recommended: 1) biomarker use for optimization of early diagnosis and management, 2) early use of digoxin, 3) early aggressive vs. more conservative volume management, 4) initial vs. delayed neurohormonal system manipulation, and 5) ED disposition and discharge strategies. Studies should include women and racial and ethnic minorities.
  2. Improved Methodologies for Early Detection and Monitoring of AHFS:
    New studies should evaluate biotechnology that acquires and monitors "real time" physiologic data that may be used to guide AHFS interventions. The development of new technologies will likely require collaborations between basic and translational scientists, as well as partnerships between academia and industry.
  3. Expand Translational and Applied AHFS Focused Research and Biotechnology:
    New research initiatives, including collaborative and integrated research projects, should focus on of cellular, organ, and systems injury in AHFS. Special interest areas include: 1) cellular energy and related variations in gene expression, induction, and regulation in AHFS with a focus on early management opportunities; and 2) the role of the vasculature in AHFS, including responsiveness to vasomodulating agents in the ED setting.

Publication Plans

The proceedings of the workshop will be submitted for publication in a peer-reviewed journal.

NHLBI Contacts

George Sopko, MD, MPH
Division of Cardiovascular Sciences
E-mail: sopkog@nhlbi.nih.gov; telephone: 301-435-0504

Monica Shah, MD, MHS, MSJ
Division of Cardiovascular Sciences
E-mail: shahmr@nhlbi.nih.gov; telephone: 301-435-0504

Working Group Members

Chairs

  • Eugene Braunwald, MD, Brigham and Women’s Hospital
  • Frank Peacock, MD, Cleveland Clinic Foundation

Members

  • William Abraham, MD, Ohio State University
  • Nancy Albert, PhD, RN, Cleveland Clinic Foundation
  • John Burnett, MD, Mayo Clinic
  • Robert Christenson, PhD, University of Maryland
  • Sean Collins, MD, University of Cincinnati
  • Deborah Diercks, MD, University of California, Davis Health System
  • G. Michael Felker, MD, Duke University Medical Center
  • Gregg Fonarow, MD, University of California, Los Angeles Medical Center
  • Mihai Gheorghiade, MD, Northwestern University
  • Brian Hiestand, MD, University of Ohio
  • Arthur Kellerman, MD, MPH, Emory University
  • Douglas Kirk, MD, University of California, Davis Medical Center
  • Phil Levy, MD, Detroit Receiving Hospital
  • Alan Maisel, MD, University of California, San Diego, VAMC
  • Barry Massie, MD, University of California, San Francisco, VAMC
  • Christopher O’Connor, MD, Duke University Medical Center
  • Peter Pang, MD, Northwestern University
  • Lynne Stevenson, MD, Brigham and Women’s Hospital
  • Alan Storrow, MD, Vanderbilt Medical Center
  • John Teerlink, MD, University of California, San Francisco, VAMC
  • Myron Waclawiw, PhD, NHLBI

Last Updated: February 2010

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