Management of acute heart failure syndromes in ED: ACEP recommendations

USA: The American College of Emergency Physicians has issued a clinical policy that addresses critical issues in the evaluation and management of adult patients presenting to the emergency department with acute heart failure syndromes (AHFS). 

 A systematic review of the literature was conducted by a writing subcommittee to derive evidence-based recommendations to answer some critical questions. A systematic literature search was performed for each question, evidence was graded and synthesized, and recommendations were formulated on the basis of the strength of the available data. The recommendations are featured in the Annals of Emergency Medicine. 

For patient management, the authors recommend the use of point-of-care lung ultrasound as an imaging modality in conjunction with a medical history and physical examination for the diagnosis of acute heart failure syndrome in cases where diagnostic uncertainty exists. (Level B recommendation).

The authors recommend that physicians may consider earlier administration of diuretics when indicated for emergency department patients with acute heart failure syndrome as it may be linked with reduced in-hospital mortality and length of stay (consensus recommendation). 

The document further recommends that before diuretics administration physicians should be confident in the diagnosis of acute heart failure syndrome with volume overload in a patient because diuretics treatment may harm those with an alternative diagnosis (consensus recommendation).

High-dose nitroglycerin should be considered a safe and effective treatment option when given to patients with acute heart failure syndrome and elevated blood pressure (consensus recommendation).

The authors recommend against relying alone on current acute heart failure syndrome risk stratification tools for determining which patients may be discharged directly home from the emergency department. 

"The Ottawa Heart Failure Risk Scale (OHFRS) should be considered for determining which higher-risk patients for adverse outcomes should not be discharged home," the document stated. "The Emergency Heart Failure Mortality Risk Grade should be considered for 7-day mortality or the STRATIFY decision tool to help determine which higher-risk patients for the adverse outcome should not be discharged home."

For determining the appropriate disposition of AHFS patients, the authors recommend the use of shared decision-making strategies. 

The authors summarized the document, "in patients presenting with acute dyspnea and the possible AHFS diagnosis, evidence supports POCUS use to improve diagnostic accuracy and help direct management. The presence of B-lines on bedside ultrasound is an independent predictor of AHFS."

"Bedside, when combined with historical information and physical examination findings, outperforms chest radiograph and laboratory testing, including natriuretic peptides."

Reference:

American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Acute Heart Failure Syndromes. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Heart Failure Syndromes: Approved by ACEP Board of Directors, June 23, 2022. Ann Emerg Med. 2022 Oct;80(4):e31-e59. doi: 10.1016/j.annemergmed.2022.05.027. PMID: 36153055.