Characterizing Missed Cases of Acute Decompensated Heart Failure Across an Integrated Health System

Acute decompensated heart failure (ADHF) is a leading cause of emergency department (ED) visits and hospitalizations. Diagnosis remains challenging due to nonspecific symptoms, overlapping clinical presentations, and diagnostic limitations. Missed or delayed ADHF diagnosis delays initiation of guideline-directed therapy and increases mortality. We aimed to characterize missed ED cases of ADHF to better understand disposition patterns, and understand elements associated with misdiagnosis.

We conducted a retrospective descriptive analysis of all adult ED visits (≥18 years) with chief complaints suggestive of ADHF during 2023-2024 at a large integrated health system with 9 EDs and over 500,000 annual visits. Patients receiving an ADHF diagnosis (ICD-10 I50.x) in the ED, observation, or inpatient hospitalization were included. For discharged patients, we examined 72-hour return visits. Missed ED diagnosis was defined as patients having a chief complaint concerning for ADHF or received an ADHF diagnosis in the ED who were discharged and returned within 72 hours with subsequent admission for ADHF, admitted patients who received a diagnosis other than ADHF in from the ED but has a primary diagnosis of ADHF on hospital discharge. The primary outcome was concordance between ED and hospital discharge diagnoses of ADHF, with final hospital discharge diagnosis as the gold standard.

Of 10,099 visits (1.2% of all ED visits) meeting inclusion criteria, 537 were discharged, and 9,260 were admitted. In total, 1,980 (19.6%) had ADHF misdiagnoses: 1,881 (18.6%) received no ADHF diagnosis in the ED despite subsequent hospital diagnosis, 4,675 (46.3%) received an ED ADHF diagnosis, but no diuretics were administered in the ED. Among patients discharged from the ED 99 (5.0%) were initially discharged from the ED with return ADHF admission within 72 hours.

Missed ADHF diagnoses among admitted patients were surprisingly common (19.6%), though inappropriate ED discharges were rare. These findings reveal a significant quality gap in ED ADHF recognition and suggest interventions to improve diagnostic accuracy could enhance timely, guideline-directed treatment.