Actividad Meridiana de “Evidencia Científica”
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Emergency Department Observation of Heart Failure: Preliminary Analysis of Safety and Cost
Emergency-department (ED)-based observation-unit treatment has been shown to reduce inpatient admissions, hospital bedhours, and costs without adversely affecting outcomes for several conditions. A sequential group design study compared riskmatched, acute decompensated heart failure patients admitted directly to the inpatient setting with those admitted to an ED observation unit for up to 23 hours before ED disposition. Outcomes were 30-day readmissions or repeat ED visits for heart failure or 30-day mortality. Estimates of bed-hours and charges between the groups were compared. Sixty-four patients were enrolled with 36 inpatient admissions and 28 observation unit patients. No patients died within 30 days. Observation unit patients had no significant difference in outcomes, a decrease in time from ED triage to discharge, a saving in mean bedhours, and less total charges. This pilot trial provides preliminary data that suggest admitted, low-risk heart failure patients may be safely and cost-effectively managed in an ED-based observation unit. These findings
Alan B. Storrow, MD;1 Sean P. Collins, MD;1 Michael S. Lyons, MD;1 Lynne E. Wagoner, MD;2 W. Brian Gibler, MD;2
Christopher J. Lindsell, PhD1,3
From the Department of Emergency Medicine;1 Department of Internal Medicine, Division of Cardiology;2 and Institute for Health
Policy and Health Services Research;3 University of Cincinnati, Cincinnati, OH
Address for correspondence: Alan B. Storrow, MD, Department of Emergency Medicine, 231 Albert Sabin Way, MSB # 6109,
Cincinnati, OH 45267-0769
E-mail:
Manuscript received July 6, 2004; revised October 4, 2004; accepted October 25, 2004
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- Escrito por Thaismel J. Ojeda R.
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Background
Loop diuretics are an essential component of therapy for patients with acute decompensated
heart failure, but there are few prospective data to guide their use.
Methods
In a prospective, double-blind, randomized trial, we assigned 308 patients with acute
decompensated heart failure to receive furosemide administered intravenously by
means of either a bolus every 12 hours or continuous infusion and at either a low
dose (equivalent to the patient’s previous oral dose) or a high dose (2.5 times the previous
oral dose). The protocol allowed specified dose adjustments after 48 hours. The
coprimary end points were patients’ global assessment of symptoms, quantified as
the area under the curve (AUC) of the score on a visual-analogue scale over the course
of 72 hours, and the change in the serum creatinine level from baseline to 72 hours.
Results
In the comparison of bolus with continuous infusion, there was no significant difference
in patients’ global assessment of symptoms (mean AUC, 4236±1440 and
4373±1404, respectively; P = 0.47) or in the mean change in the creatinine level
(0.05±0.3 mg per deciliter [4.4±26.5 μmol per liter] and 0.07±0.3 mg per deciliter
[6.2±26.5 μmol per liter], respectively; P = 0.45). In the comparison of the high-dose
strategy with the low-dose strategy, there was a nonsignificant trend toward greater
improvement in patients’ global assessment of symptoms in the high-dose group
(mean AUC, 4430±1401 vs. 4171±1436; P = 0.06). There was no significant difference
between these groups in the mean change in the creatinine level (0.08±0.3 mg
per deciliter [7.1±26.5 μmol per liter] with the high-dose strategy and 0.04±0.3 mg per
deciliter [3.5±26.5 μmol per liter] with the low-dose strategy, P = 0.21). The high-dose
strategy was associated with greater diuresis and more favorable outcomes in some
secondary measures but also with transient worsening of renal function.
Conclusions
Among patients with acute decompensated heart failure, there were no significant
differences in patients’ global assessment of symptoms or in the change in renal
function when diuretic therapy was administered by bolus as compared with continuous
infusion or at a high dose as compared with a low dose. (Funded by the
National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT00577135.)