Approach to Acute Heart Failure in the Emergency Department

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.

Serelaxin, recombinant human relaxin-2, for heart failure patients

“…Unfortunately, the treatments of AHF have not make much progress in the last 4 decades. [ 19 ] Serelaxin has been proved to have beneficial clinical and hemodynamic effects without serious adverse effects in many randomized controlled trials.…”

Diagnosis of Acute Heart Failure in the Emergency Department: An Evidence-Based Review

“…Acute heart failure (AHF) is a gradual or rapid decompensation in heart failure (HF) requiring urgent management 1–4. The condition covers a large spectrum of disease, ranging from mild exacerbations with gradual increases in edema to cardiogenic shock.…”

Urapidil, compared to nitroglycerin, has better clinical safety in the treatment of hypertensive patients with acute heart failure: a meta-analysis

“…The preferred treatment of hypertensive patients who have AHF, especially those who have significantly high blood pressure, severe distress and hypertension with AHF, usually involves the use of vasodilators,10,11 which can be found in the guide 12,13. The most commonly used vasodilators are nitroglycerin and other nitrates.…”