Approach to Acute Heart Failure in the Emergency Department

doi:10.1016/j.pcad.2017.08.008

Progress in Cardiovascular Diseases

Volume 60, Issue 2, September–October 2017, Pages 178-186

https://doi.org/10.1016/j.pcad.2017.08.008 Get rights and content

Abstract

Acute heart failure (AHF) patients rarely present complaining of ‘acute heart failure.’ Rather, they initially present to the emergency department (ED) with a myriad of chief complaints, symptoms, and physical exam findings. Such heterogeneity prompts an initially broad differential diagnosis; securing the correct diagnosis can be challenging. Although AHF may be the ultimate diagnosis, the precipitant of decompensation must also be sought and addressed. For those AHF patients who present in respiratory or circulatory failure requiring immediate stabilization, treatment begins even while the diagnosis is uncertain.

The initial diagnostic workup consists of a thorough history and exam (with a particular focus on the cause of decompensation), an EKG, chest X-ray, laboratory testing, and point-of-care ultrasonography performed by a qualified clinician or technologist. We recommend initial treatment be guided by presenting phenotype. Hypertensive patients, particularly those in severe distress and markedly elevated blood pressure, should be treated aggressively with vasodilators, most commonly nitroglycerin. Normotensive patients generally require significant diuresis with intravenous loop diuretics. A small minority of patients present with hypotension or circulatory collapse. These patients are the most difficult to manage and require careful assessment of intra- and extra-vascular volume status. After stabilization, diagnosis, and management, most ED patients with AHF in the United States (US) are admitted. While this is understandable, it may be unnecessary. Ongoing research to improve diagnosis, initial treatment, risk stratification, and disposition may help ease the tremendous public health burden of AHF.

Section snippets

Stabilization

Occasionally, patients with possible AHF present in extremis or near respiratory failure. In these instances, the diagnostic work up and management occur in parallel. Importantly, the precipitating cause of the patient's dramatic presentation must be simultaneously identified and treated. Arrhythmias, infection, and acute coronary syndromes are just a few potential precipitants. The classical teaching of ensuring “Airway, Breathing, and Circulation” first is worth reiterating.

Obtunded patients

Initial diagnosis and assessment

Fortunately, most AHF patients do not present in extremis. Establishing the diagnosis is the sine qua non of medicine, but is not always easy. It is worth noting the myriad of different patient complaints: Fatigue, dizziness, shortness of breath, chest pain, weakness, exercise intolerance, swelling, and weight gain are all symptoms prompting consideration of AHF as the cause.

The clinical presentation of AHF varies widely, ranging from mildly worsening heart failure, de novo or new onset HF, to

Initial management

Once the diagnosis is made, presenting phenotype and cause of exacerbation guides initial treatment. As mentioned earlier, first assuring respiratory and hemodynamic stability is paramount (see Table 1 for goals of ED management). While addressing the patient's respiratory status, the precipitant of AHF should be sought and treated. For example, rapid atrial fibrillation (AF), ACS, pulmonary embolism, underlying infection or dietary indiscretion can all trigger AHF.⁵⁷ Often the precipitant is

Initial classification

As an initial guide, we recommend grouping patients with suspected AHF by systolic BP (SBP).58., 59. As evidenced by registries, SBP is often high (> 140 mm Hg) at the time of presentation.⁶⁰ We recommend using cutpoints of > 140 mm Hg, 100–140 mm Hg, and < 100 mm Hg to guide initial selection of pharmacologic therapy.58., 59. While there is considerable overlap, simple categorization aids the busy clinician. As such, it is reasonable to assume the predominant pathophysiologic derangement in a patient

Initial therapy

At the present time, no AHF therapy receives a Level I, Class A recommendation from guidelines,1., 2. highlighting the lack of robust evidence from randomized studies. Therapies used today are largely the same as those employed 4 decades ago (Table 2). Rotating tourniquets and phlebotomy are no longer used; whether this represents a major advance is debatable. Importantly, lack of high quality evidence from robust, randomized controlled trials does not equate with ineffectiveness in achieving

The hypotensive AHF patient

Shock due solely to worsening HF rarely occurs relative to other types of AHF.¹⁵ Given its relatively uncommon presentation combined with the complexity of these patients' underlying pathophysiology, precipitant, cardiac structure, function, and resultant hemodynamic status, management can be challenging. Patients with advanced HF may present with alarmingly low SBP. This may, in fact, reflect their baseline SBP. Even when resuscitating shock, a common mistake is attempting to normalize SBP and

Inotropes and vasopressors

Table 3 shows commonly used inotropes and vasoactive agents. Although inotropes and vasopressors improve hemodynamics, to date, none are associated with better clinical outcomes. In fact, available inotropes have been associated with harm, though the evidence base is small and inconsistent.68., 69., 70., 71. In terms of vasopressors, there is a paucity of robust data to strongly recommend one vasopressor over another. Subgroup analysis from a large randomized trial found increased mortality in

The hypertensive patient

Approximately half of patients admitted with AHF present with hypertension (SBP ≥ 140 mm Hg).15., 60. In general, these patients tend to be older, have preserved EF,⁶⁰ and present with a more acute onset of symptoms, often < 24 h. Pulmonary edema in such patients is more likely to be caused by vascular redistribution than by hypervolemia. As such, vasodilators are the mainstay of treatment.

Of the guideline-recommended vasodilator options [nitroglycerin (NTG), nitroprusside, or nesiritide], we

The normotensive patient (SBP 100–140 mm Hg)

AHF patients presenting with SBP ranging from 100 to 140 mm Hg rarely arrive to the ED in extremis.⁶⁰ The prototypical patient reports an indolent course over days or even weeks, and may report significant weight gain. Decongestion with intravenous (IV) loop diuretics is the primary therapy. Bolus or continuous infusion diuretic administration makes no difference.⁸⁰ A randomized trial comparing IV doses of the patient's standard oral dose to larger IV doses (2.5 times the standard oral dose)

Disposition and outcomes

Contrary to commonly held belief, most patients who visit the ED are sent home; only 9.3% of the annual 130 million ED visits in the US result in hospitalization. However, nearly all ED patients with AHF are hospitalized. From 2006 to 2011, the annual US hospitalization rate for AHF patients in the ED has consistently been around 85%.⁸⁶ Given financial penalties tied to excess re-hospitalization, this admission rate warrants scrutiny.

Administrative data analyses suggest up to 50% of patients

Conclusion

The ED management of AHF centers around diagnosis, stabilization, identification of the precipitant of AHF, initial treatment, and risk-stratification. We recommend initial ED treatment be guided by presenting phenotype but treatment largely centers around diuretics and vasodilators. Although currently available therapies improve symptoms, none definitively improve outcomes. Identification of life saving therapies for the early treatment of AHF remains an unmet need, though whether a short-term

Statement of conflict of interest

Benton Hunter has no conflicts of interest.

Osama Abdel Hafez has no conflicts of interest.

Jennifer Martindale has no conflicts of interest.

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Effectiveness and safety of non-invasive ventilation in the management of cardiogenic shock
2024, Revista Portuguesa de Cardiologia
Cardiogenic shock (CS) has long been considered a contraindication for the use of non-invasive ventilation (NIV). The main objective of this study was to analyze the effectiveness, measured as NIV success, in patients with respiratory failure due to CS. As secondary objective, we studied risk factors for NIV failure and compared the outcome of patients treated with NIV versus invasive mechanical ventilation (IMV).
Retrospective study on a prospective database, over a period of 25 years, of all consecutively patients admitted to an intensive care unit, with a diagnosis of CS and treated with NIV. A comparison was made between patients on NIV and patients on IMV using propensity score matching analysis.
Three hundred patients were included, mean age 73.8 years, mean SAPS II 49. The main cause of CS was acute myocardial infarction (AMI): 164 (54.7%). NIV failure occurred in 153 (51%) cases. Independent factors for NIV failure included D/E stages of CS, AMI, NIV related complications, and being transferred from the ward. In the propensity analysis, hospital mortality (OR 1.69, 95% CI 1.09–2.63) and 1 year mortality (OR 1.61, 95% CI 1.04–2.51) was higher in IMV. Mortality was lower with NIV (vs. EIT-IMV) in C stage (10.1% vs. 32.9%; p<0.001) but did not differ in D stage or E stage.
NIV seems to be relatively effective and safe in the treatment of early-stage CS.
O choque cardiogénico (CC) tem sido considerado uma contraindicação para o uso de ventilação não-invasiva (VNI). O principal objetivo deste estudo foi analisar a eficácia, medida como sucesso da VNI, em doentes com insuficiência respiratória devido a CC. Como objetivo secundário, foram estudados os fatores de risco para falência da VNI e foram comparados os resultados de doentes tratados com VNI com doentes submetidos a ventilação mecânica invasiva (VMI).
Análise retrospetiva de uma base de dados prospetiva, durante um período de 25 anos, de todos os doentes consecutivamente internados numa Unidade de Cuidados Intensivos, com diagnóstico de CC e tratados com VNI. Foi feita uma comparação entre doentes sob VNI e doentes sob VMI através de análise de propensão.
Foram incluídos 300 doentes, idade média de 73,8 anos, SAPS II médio de 49. A principal causa de CC foi enfarte agudo do miocárdio (EAM): 164 (54,7%). Verificou-se falência da VNI em 153 (51%) casos. Fatores independentes para falência da VNI incluíram estadios D/E de CC, EAM, complicações relacionadas com a VNI e o doente ter sido transferido de enfermaria. Na análise de propensão, a mortalidade hospitalar (OR 1,69, IC 95% 1,09-2,63) e mortalidade a um ano (OR 1,61, IC 95% 1,04-2,51) foram maiores na VMI. A mortalidade foi menor na VNI (vs. EIT-IMV) no estadio C (10,1% vs. 32,9%; p<0,001), mas não foi diferente nos estadios D ou E.
A VNI parece ser eficaz e segura no tratamento do CC em estadio inicial.
Acute heart failure. Acute pulmonary edema. Diagnostic and therapeutic management in the emergency department
2023, Medicine (Spain)
La insuficiencia cardíaca aguda es un síndrome clínico complejo que engloba diferentes entidades con diversos mecanismos fisiopatológicos y presentaciones clínicas que precisan distintas estrategias terapéuticas. Todas comparten un fallo de la función de bomba cardíaca que deriva en la aparición de síntomas y signos de congestión pulmonar y sistémica, junto con hipoperfusión periférica. Es una entidad con una incidencia creciente asociada a una alta morbimortalidad y un elevado coste sociosanitario.
Existen cuatro presentaciones clínicas fundamentales: descompensación aguda de insuficiencia cardíaca crónica (la más frecuente), edema agudo de pulmón, insuficiencia de ventrículo derecho aislada y shock cardiogénico. Es importante identificar el factor desencadenante, requiriendo un manejo específico y urgente los siguientes: el síndrome coronario agudo, la emergencia hipertensiva, las arritmias con respuesta ventricular rápida o bradicardias/alteraciones graves de la conducción, el tromboembolismo pulmonar y las causas mecánicas agudas. El diagnóstico de sospecha es clínico, confirmándose con diversas pruebas complementarias como electrocardiograma, radiografía de tórax, analítica sanguínea completa con péptidos natriuréticos y ecocardiograma.
El inicio del tratamiento debe ser inmediato ante la sospecha clínica y, según el cuadro de presentación, incluirá: oxigenoterapia, diuréticos, vasodilatadores, inotrópicos, vasopresores o incluso soporte ventilatorio o circulatorio.
Acute heart failure is a complex clinical syndrome. It encompasses different diseases with diverse pathophysiologic mechanisms and clinical presentations that require different therapeutic strategies. What they all have in common is failure in heart pump function that leads to the onset of signs and systems of pulmonary and systemic congestion along with peripheral hypoperfusion. It is a disease with a growing incidence associated with high morbidity and mortality and an elevated social and healthcare cost.
There are four fundamental clinical presentations: acute decompensation of chronic heart failure (the most common), acute pulmonary edema, isolated right ventricular failure, and cardiogenic shock. It is important to identify the triggering factor; the following require specific emergency management: acute coronary syndrome, hypertensive emergency, arrhythmias with rapid ventricular response or bradycardias/severe conduction disorders, pulmonary embolism, and acute mechanical causes. The suspected diagnosis is clinical and confirmed through various additional tests such as an electrocardiogram, chest x-ray, complete blood count with natriuretic peptides, and an echocardiogram.
Treatment must be started immediately if there is clinical suspicion. According to the presenting symptoms, it will include oxygen therapy, diuretics, vasodilators, inotropics, vasopressors, or even ventilatory or circulatory support.
Prehospital ultrasound and cardiological emergencies
2022, Annales de Cardiologie et d'Angeiologie
Les progrès technologiques des deux dernières décennies ont ouvert la voie à l'utilisation préhospitalière de l’échographie. Cette pratique s'est d'abord développée en traumatologie puis dans une multitude d'autres indications dont la cardiologie. Le développement de l’échographie pulmonaire en est certainement l'illustration la plus visible. En premier lieu parce que c'est un examen extracardiaque qui apporte la réponse à une question cardiaque. En second lieu parce que d'un point de vue théorique cette indication d’échographie était une mauvaise indication à l'utilisation des ultrasons en raison de l'air contenu dans le thorax. En troisième lieu parce que cette indication est devenue un « standard de soins » lors de la prise en charge d'un patient dyspnéique – pratique qui s'est largement répandue pendant l’épidémie COVID. Chez le patient insuffisant cardiaque l’échographie a une puissance diagnostique élevée (y compris pour des diagnostics alternatifs) d'autant plus précieuse que la technique est non-invasive, que la réponse est obtenue rapidement, que l'examen peut être renouvelé à l'envi pour suivre l’évolution du patient. Les principales autres indications de l’échographie préhospitalière sont l'arrêt cardiaque pour la recherche d'une cause curable, l'identification d'une activité cardiaque mécanique résiduelle, le monitorage de la perfusion cérébrale ; la douleur thoracique, pour des diagnostics positifs autant que négatifs ; le choc pour la recherche d'une étiologie et le suivi thérapeutique ou encore l'embolie pulmonaire où l’échographie pour la recherche d'une dilatation du ventricule droit est désormais en première ligne dans l'algorithme des recommandations.
Technological advances over the past two decades have paved the way for the prehospital use of ultrasound. This practice was first developed in traumatology and then in a multitude of other indications, including cardiology. The development of pulmonary ultrasound is certainly the most visible illustration of this. Firstly, because it is an extra-cardiac examination that provides the answer to a cardiac question. Secondly because from a theoretical point of view this ultrasound indication was a bad indication for the use of ultrasound due to the air contained in the thorax. Thirdly, because this indication has become a ‘standard of care’ when caring for a patient with dyspnea – a practice that has become widespread during the COVID epidemic. In patients with heart failure, ultrasound has a high diagnostic power (including for alternative diagnoses) which is all the more precise since the technique is non-invasive, the response is obtained quickly, the examination can be repeated at desire to follow the evolution of the patient. The main other indications for prehospital ultrasound are cardiac arrest to search for a curable cause, identification of residual mechanical cardiac activity, monitoring of cerebral perfusion; chest pain, for both positive and negative diagnoses; shock for the search for an etiology and therapeutic follow-up or even pulmonary embolism or ultrasound for the search for dilation of the right ventricle which is now at the forefront of the recommendation algorithm.
Acute heart failure
2019, Medicine (Spain)
La insuficiencia cardíaca aguda (ICA) es un síndrome clínico caracterizado por una disfunción cardíaca estructural o funcional, con un alto impacto en nuestro medio debido a su alta incidencia y morbimortalidad. Una correcta clasificación fisiopatológica del paciente con ICA es clave a la hora de instaurar un tratamiento adecuado y precoz. Las manifestaciones clínicas de la ICA son debidas a mecanismos de congestión e hipoperfusión. Es crucial la detección de cuadros precipitantes de ICA. Los cuadros clínicos más frecuentes son: ICA descompensada o de novo, edema agudo de pulmón (EAP) y shock cardiogénico (SC). La disnea es el síntoma más frecuente en estos pacientes, cuyo diagnóstico diferencial en el paciente con sospecha de ICA incluye tanto patología cardíaca como no cardíaca. El tratamiento en la ICA va dirigido a mantener la estabilidad hemodinámica y una correcta oxigenación tisular. Para ello, contamos con una amplia variedad de fármacos y dispositivos.
Acute heart failure (AHF) is a clinical syndrome characterized by structural or functional cardiac dysfunction associated with significant morbidity and mortality emerging as a major public health problem. Appropriate and early treatment requires a suitable classification of patient with AHF. Clinical manifestations are caused by congestion and hypoperfusion. Identification of the events that trigger AHF is crucial. The most common clinical pictures are: decompensated or de novo AHF, acute lung edema (ALE) and cardiogenic shock (CS). The most frequent symptom is dyspnea; its differential diagnosis in patients suspicious of AHF involves cardiac and no cardiac disorders. The goals of AHF treatment are maintain hemodynamic stability and proper tissue oxygenation (a wide range of drugs and devices are available for this purpose).
Anterior vs lateral symmetric interstitial syndrome in the diagnosis of acute heart failure
2019, International Journal of Cardiology
Citation Excerpt :
Acute heart failure (AHF) is one of the most common reasons for admission to the Emergency Department (ED) and dyspnea is one of its most frequent clinical presentation [1]. For patients with acute respiratory failure, recognition of AHF is sometimes challenging and requires a complete diagnostic workup including history, physical exam, EKG, chest X-ray, laboratory tests and point-of-care ultrasound [2]. The importance of lung and multi-organ ultrasound examination in the diagnosis of AHF has been established [3–5].
Acute dyspnea due to acute heart failure (AHF) is one of the most common reasons for admission to the Emergency Department (ED). The importance of lung ultrasound (LUS) examination in the diagnostic workup of AHF has been widely established. Limited anterior LUS examination for the diagnosis of AHF is controversial. This study compares the accuracy of LUS examination limited to the anterior or lateral lung zones for the diagnosis of AHF and their accuracy among patients with different levels of hypoxemia according to PO₂/FiO₂ ratio evaluation. We analyzed 170 patients admitted to the ED for acute dyspnea, who underwent multi-organ ultrasound examination of lung, heart and inferior vena cava for differential diagnosis. The thorax was examined following a simplified protocol that provides two scans at each side (anterior and lateral) to sample upper and lower lobes and the presence or the absence of interstitial syndrome (IS) was evaluated. The presence of anterior symmetric IS exhibited lower accuracy than lateral symmetric IS in the diagnosis of AHF in the whole population, but its diagnostic accuracy improves in sub-groups of patients with severe and critical hypoxemia.
Acute Heart Failure Risk Stratification in the Emergency Department: Are We There Yet?
2019, Revista Espanola de Cardiologia

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: Statement of Conflict of Interest: see page 184.

¹: Peter Pang is or has been in the last one year a Consultant for: BMS, Novartis, Trevena, scPharmaceuticals, Roche Diagnostics, Relypsa and Research Support: Roche, Novartis, AHA, NIH, PCORI, AHRQ.

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Approach to Acute Heart Failure in the Emergency Department

Abstract

Section snippets

Stabilization

Initial diagnosis and assessment

Initial management

Initial classification

Initial therapy

The hypotensive AHF patient

Inotropes and vasopressors

The hypertensive patient

The normotensive patient (SBP 100–140 mm Hg)

Disposition and outcomes

Conclusion

Statement of conflict of interest

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Am J Cardiol

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Am J Emerg Med

Chest

Am J Emerg Med

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Int J Cardiol

J Crit Care

Ann Emerg Med

JACC Heart Fail

JACC Heart Fail

Am Heart J

J Card Fail

J Am Coll Cardiol

Circulation

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J Card Fail

Ann Emerg Med

J Am Coll Cardiol Heart Fail

Ann Emerg Med

Heart Fail Clin

JACC Heart Fail

Ann Emerg Med

J Card Fail

Eur Heart J

2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Circulation

The growing role of emergency departments in hospital admissions

N Engl J Med

Airway management & assessment of dyspnea in emergency department patients with acute heart failure

Curr Emerg Hosp Med Rep

Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema

Cochrane Database Syst Rev