Beyond Pulmonary Edema: Diagnostic, Risk Stratification, and Treatment Challenges of Acute Heart Failure Management in the Emergency Department

Bridging the gap between evidence and practice in acute decompensated heart failure management

“…Sublingual or topical nitrates are recommended as a first step, and initial diuretic use should be minimal to avoid intravascular volume depletion leading to renal dysfunction. 20 In contrast, patients presenting with SBP between 90 mm Hg and 140 mm Hg are more likely to have some degree of systolic dysfunction, leading to a gradual worsening of their heart failure symptoms and total body fluid overload over a period of weeks. 20 These patients require aggressive diuresis.…”

“…12,23 These patients tend to be older and to have diastolic rather than systolic dysfunction. 12,20,23 Symptoms typically have been present for only a short period of time (24-48 hours) and are more often due to maldistribution of fluid producing pulmonary edema than total body fluid overload. Consequently, initial treatment should focus on aggressive BP control to relieve this edema.…”

“…3,4 Also, these patients may require IV vasodilators and/or IV diuretics to treat pulmonary edema once blood pressure (BP) and cardiac output have been stabilized. 2,3,20 For patients with ADHF who present with symptoms of congestion, but not respiratory failure or cardiogenic shock, the initial therapeutic decision is governed by their BP. Approximately 50% of patients with ADHF will have an SBP > 140 mm Hg.…”

“…One must first consider whether there is evidence of respiratory failure or impending respiratory failure. 20 If so, patients should receive immediate ventilatory support via continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or endotracheal intubation, depending on the degree of respiratory impairment. 3,5 In prospective controlled evaluations, patients with acute respiratory failure secondary to pulmonary edema who were randomized to treatment with CPAP demonstrated significant improvement in cardiopulmonary indices 21,22 and significant reductions in need for endotracheal intubation 21 and short-term mortality 22 when compared with similar patients who received standard therapy without CPAP.…”

Clinical and Research Considerations for Patients With Hypertensive Acute Heart Failure: A Consensus Statement from the Society of Academic Emergency Medicine and the Heart Failure Society of America Acute Heart Failure Working Group

“…[44][45][46] While there is no randomized trial evidence evaluating initial treatment strategies for patients with AHF based on hemodynamics, systolic blood pressure plays a central role in AHF as a predictor of morbidity and mortality.…”