Summary
Background
We previously conducted a pilot study that reported the safety of isosorbide dinitrate boluses for elderly emergency patients with acute heart failure syndrome.
Aims
To assess the temporal trend in the rate of elderly patients treated with isosorbide dinitrate, and to evaluate subsequent outcome differences.
Methods
This was a single-centre study. We compared patients aged > 75 years who attended the emergency department with a primary diagnosis of acute pulmonary oedema in the years 2007 and 2014. The primary endpoint was the rate of patients who received isosorbide dinitrate boluses in the emergency department. Secondary endpoints included in-hospital mortality, need for intensive care and length of stay.
Results
We analysed 368 charts, 232 from patients included in 2014 (63%) and 136 in 2007 (37%). The mean age was 85 ± 6 years in both groups. There was a significant rise in the rate of patients treated with isosorbide dinitrate between 2007 and 2014: 97 patients (42%) in 2014 vs. 24 patients (18%) in 2007 ( P < 0.01). Comparing the two periods, we report similar in-hospital mortality rates (8% vs. 11%; P = 0.5), rates of admission to the intensive care unit (13% vs. 17%; P = 0.3) and lengths of stay (10 days in both groups).
Conclusion
We observed a significant rise in the rate of elderly patients treated with isosorbide dinitrate boluses for acute heart failure. However, we did not observe any significant improvement in outcomes.
Résumé
Contexte
Nous avons publié précédemment une étude rapportant la sécurité d’utilisation du dinitrate d’isosorbide (ISDN) chez les patients de plus de 75 ans aux urgences.
Objectifs
Évaluer l’évolution temporelle du taux de patients âgés traités par ISDN aux urgences pour œdème aigu pulmonaire (OAP), et l’impact en terme de pronostic.
Méthodes
Étude monocentrique rétrospective. Nous avons comparé les patients de plus de 75 ans admis aux urgences pour OAP sur les années 2007 et 2014. Le critère de jugement principal était le traitement par bolus intraveineux d’ISDN. Les critères secondaires incluaient la mortalité hospitalière, l’admission en soins intensifs, et la durée d’hospitalisation.
Résultats
Nous avons analysé 368 dossiers – 232 en 2014 (63 %) et 136 en 2007 (37 %). L’âge moyen était de 85 ans (écart-type 6) dans les deux groupes. Il y avait une augmentation significative du taux de patients traités par ISDN en 2014 : 97 patients (42 %) vs 24 (18 %) en 2007. La mortalité hospitalière, l’admission en soins intensifs et la durée d’hospitalisation étaient inchangées entre les deux périodes.
Conclusion
Le taux de patients traités par ISDN a bien augmenté avec le temps, sans que nous n’ayons pu en montrer un impact pronostique.
Background
Acute heart failure (AHF) syndrome represents 5% of all emergency hospitalizations , and is reported to be the most common discharge diagnosis from the emergency department (ED) in elderly patients . Rates of rehospitalization and/or death at 60 days range from 30% to 50% . Acute pulmonary oedema (APE) is characterized by an increase in capillary pulmonary pressures and tissue congestion, and its pharmacological therapy usually includes loop diuretics and nitrates. The value of these treatments lies in their potential to reduce congestion, through either vasodilatation or diuresis, which subsequently helps to decrease systemic vascular resistances and capillary pulmonary pressures. Since the pivotal studies by Cotter et al. , nitrates are recommended for the treatment of APE. The American Heart Association and the European Society of Cardiology (ESC) include the use of nitrates in their guidelines for patients with systolic blood pressure > 110 mmHg . Recently, this treatment has been confirmed as first-line therapy by the ESC and the European Society of Emergency Medicine .
Although recommended by the ESC (grade IIA), nitrates are still insufficiently prescribed, as described in several studies . A very low rate of elderly patients treated with nitrates was also seen in our previous retrospective study conducted in 2007 . Of note, this study reported that isosorbide dinitrate (ISDN) as an intravenous bolus was safe in patients aged > 75 years presenting to the ED with APE.
Since the publication of our 2007 study, we have repeatedly highlighted the need for and safety of use of ISDN boluses for the treatment of elderly patients who present with APE in our ED; this was done by regular training sessions. The principal objective of this study was, therefore, to determine the effect of these training sessions on the use of nitrates by emergency physicians, by establishing the change in the rate of patients treated with ISDN in bolus form between 2007 and 2014. The secondary objective was to describe the evolution of patient status between 2007 and 2014.
Methods
This was a single-centre study. We retrospectively included all patients who presented to our ED with a diagnosis of APE in the year 2007 (the “before” cohort, from our previously published study ) and 2014 (the “after” cohort). Our institution is an academic, urban, 1800-bed hospital, with an ED attendance of approximately 70,000 visits each year. As the study was observational and retrospective, our Institutional Review Board (Comité de Protection des Personnes-Paris Île-de-France VI) waived the need for approval. We followed the recommendations by Kaji et al. for chart abstractions, including training of the abstractors, explicit definition of the inclusion criteria (International Classification of Diseases, Tenth Revision [ICD10] of APE or AHF syndrome) and endpoint (provision of intravenous nitrates), definition of variables, standardized abstraction forms, regular meetings with the principal investigators and abstractors or experts, and chart abstractions only performed by two abstractors who were not blinded to each other’s work, and who were aware of the study hypothesis.
Selection of participants and outcomes
We included patients aged ≥ 75 with cardiogenic APE in the ED with an indication for treatment using nitrates. These patients correspond to clinical scenarios 1 and 2 of the practical recommendations for early in-hospital management of patients with AHF syndrome : patients with a systolic blood pressure > 110 mmHg, signs of pulmonary oedema, no sign of shock and no predominant signs of hypoperfusion. To select these patients, we first electronically retrieved all the files for patients who visited the ED with a primary discharge diagnosis (using ICD10) of “pulmonary oedema” or “acute heart failure” and an age > 74 years. Two abstractors reviewed all charts pertaining to the patients’ ED visit, to select those with a presentation of clinical scenario 1 or 2. Patients with another primary diagnosis and those with incomplete records were excluded, as were patients with a primary diagnosis of AHF and no APE, and patients with hypotension or pulmonary oedema from a cause other than AHF. We also excluded patients with a contraindication for ISDN (e.g. aortic stenosis).
Our primary endpoint was the administration of ISDN in bolus form in the ED. Secondary endpoints include receipt of other treatments within the ED, in-hospital mortality, intensive care unit (ICU) admission and length of hospital stay.
Baseline characteristics, treatment and disposition were collected through our electronic system for medical charts and prescriptions (UrQual; McKesson, San Francisco, CA, USA). Data regarding outcomes were collected in the department or the institution where the patients were admitted or transferred to, through examination of the medical charts or the administrative system, if necessary.
Intervention
After 2007 and the results of our pilot study, we emphasized the need for and safety of ISDN use for elderly patients with APE. We presented the results at a national scientific assembly, and at other faculty courses on emergency and geriatrics.
Every 6 months, our trainees underwent a 30-minute course on APE and its recommended treatment, with particular emphasis on ISDN boluses. Senior emergency physicians repeatedly insisted on this treatment during morning rounds, and our standard of protocols set after 2007 included the use of ISDN in bolus form for patients with APE who presented to our institution: all patients with evidence of cardiogenic pulmonary oedema should be treated with boluses of 3 mg intravenous ISDN, every 5 minutes, as long as their systolic blood pressure remains > 90–100 mmHg.
Statistical analysis
Continuous variables are expressed as means ± standard deviations when normally distributed, and as medians (interquartile ranges [IQRs]) when not. Normality was tested with the Kolgomorov-Smirnov test. Categorical variables are expressed as numbers (percentages). We compared means and medians using Student’s t -test and the Mann-Whitney U test, respectively, and percentages using the Chi 2 test or Fisher’s exact test, when appropriate. The numbers of patients with missing data are reported for each analysed category. A sensitivity analysis was prespecified to include only patients in whom the diagnosis of APE was confirmed during the hospitalization.
To assess the effect of the period, we ran a multivariable logistic regression with prespecified variables that we found clinically relevant and without missing data, namely period, age, history of chronic obstructive pulmonary disorder, history of diabetes, history of hypertension, chronic use of nitrates, chronic use of diuretics, heart rate on arrival, systolic blood pressure and clinical signs of respiratory distress.
A P level of 0.05 was required to rule out the null hypothesis, and all comparisons were two-tailed. Statistical analysis was carried out with NCSS 2007 software (Statistical Solutions Ltd., Cork, Ireland).
Results
In the 2007 cohort, we included 136 patients with APE (from an annual census of 50,497 ED visits). In 2014, 13% of patients were aged > 75 years. From these, 256 files were extracted and 24 patients were excluded (12 with incorrect main diagnosis, five incomplete files and seven patients aged < 75 years), leaving 232 patients in total (from an annual census of 59,507 ED visits).
Baseline characteristics of the population are shown in Table 1 . The mean age of included patients was 85 ± 6 years. Patients included in 2014 had a higher prevalence of co-morbidities and cardiovascular risk factors. Chronic obstructive pulmonary disease (28% vs. 8%; P < 0.01), AHF (69% vs. 40%; P < 0.01) and ischaemic heart disease (38% vs. 28%; P = 0.05) were more prevalent in the 2014 cohort compared with the 2007 cohort. Similarly, diuretics, angiotensin-converting enzyme inhibitors and beta-blockers were more commonly prescribed in 2014 compared with 2007. Physiological variables on admission were similar in both groups, except for the more frequent presence of signs of acute respiratory distress – paradoxical respiration, intercostal indrawing or use of accessory inspiratory muscle (23% in 2014 vs. 13% in 2007; P = 0.02).
| Total ( n = 368) | Year 2014 ( n = 232) | Year 2007 ( n = 136) | P | |
|---|---|---|---|---|
| Age (years) | 85 ± 6 | 85 ± 6 | 85 ± 6 | 0.08 |
| Medical history | ||||
| Smoking | 116 (32) | 77 (33) | 39 (29) | 0.4 |
| Diabetes mellitus | 107 (29) | 81 (35) | 26 (19) | < 0.01 |
| Hypertension | 292 (79) | 201 (87) | 91 (67) | < 0.01 |
| Obesity | 38 (10) | 30 (13) | 8 (6) | 0.03 |
| Chronic pulmonary disease | 77 (20) | 66 (28) | 11 (8) | < 0.01 |
| Asthma | 22 (5) | 11 (5) | 11 (8) | 0.2 |
| Thromboembolic episode | 46 (13) | 36 (16) | 10 (7) | 0.02 |
| Heart failure | 215 (58) | 160 (69) | 55 (40) | < 0.01 |
| Ischaemic heart disease | 126 (34) | 88 (38) | 38 (28) | 0.05 |
| Stroke | 40 (11) | 30 (13) | 10 (7) | 0.1 |
| Dementia | 82 (22) | 73 (32) | 9 (7) | < 0.01 |
| Cancer | 55 (15) | 46 (20) | 9 (7) | < 0.01 |
| Current medication | ||||
| Diuretics | 228 (62) | 159 (69) | 69 (51) | < 0.01 |
| Nitrates | 30 (8) | 16 (7) | 14 (10) | 0.3 |
| ACE inhibitors | 182 (49) | 121 (52) | 61 (45) | 0.2 |
| Calcium channel blockers | 81 (22) | 50 (22) | 31 (23) | 0.8 |
| Amiodarone | 75 (20) | 42 (18) | 33 (24) | 0.2 |
| Digoxin | 21 (5) | 9 (4) | 12 (9) | 0.05 |
| Beta-blockers | 174 (47) | 126 (54) | 48 (35) | < 0.01 |
| Oxygen at home | 20 (5) | 16 (7) | 4 (3) | 0.1 |
| Beta2 agonists | 28 (8) | 18 (8) | 10 (7) | 0.9 |
| Inhaled corticoids | 29 (8) | 22 (10) | 7 (5) | 0.1 |
| Anticoagulants | 162 (44) | 123 (53) | 39 (29) | < 0.01 |
| Vital signs on arrival | ||||
| Heart rate (beats/min) | 85 ± 20 | 84 ± 19 | 88 ± 21 | 0.08 |
| Respiratory rate (breaths/min) | 26 ± 6 | 26 ± 56 | 26 ± 6 | 0.7 |
| Systolic BP (mmHg) | 139 ± 27 | 138 ± 26 | 140 ± 28 | 0.6 |
| Diastolic BP (mmHg) | 77 ± 17 | 77 ± 17 | 78 ± 18 | 0.5 |
| Pulse oximetry (%) | 95 (90–97) | 95 (90–97) | 93 (90–97) | 0.7 |
| Glasgow Coma Score | 15 (15–15) | 15 (15–15) | 15 (15–15) | 0.5 |
| Temperature (°C) | 36.8 (0.7) | 36.7 ± 0.7 | 36.9 ± 0.6 | < 0.01 |
| On examination | ||||
| Signs of right heart failure | 238 (65) | 165 (71) | 73 (54) | < 0.01 |
| Mottling | 16 (4) | 12 (5) | 4 (3) | 0.2 |
| Clinical signs of respiratory distress | 72 (20) | 54 (23) | 18 (13) | 0.02 |
| Abdominal respiration | 37 (10) | 26 (11) | 11 (8) | 0.3 |
| Cyanosis | 19 (5) | 13 (6) | 6 (4) | 0.8 |
| Atrial fibrillation | 115 (31) | 80 (35) | 35 (26) | 0.08 |
| Biology | ||||
| PaCO 2 (mmHg) a | 38 ± 11 | 37 (34–38) | 36 (35–38) | 0.2 |
| PaO 2 (mmHg) a | 68 ± 23 | 73 ± 25 | 61 ± 19 | < 0.01 |
| HCO 3 (mmol/L) a | 24 ± 5 | 24 (22–27) | 24 (21–26) | 0.12 |
| Lactate (mmol/L) b | 1.5 ± 0.8 | 1.5 ± 0.8 | 1.5 ± 0.9 | 0.6 |
| Haemoglobin (g/dL) | 12 ± 1.8 | 11.8 ± 1.8 | 12.4 ± 1.8 | < 0.01 |
| Creatinine (μmol/L) c | 96 (74–124) | 99 (75–127) | 88 (70–119) | 0.1 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
