Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Heart Failure Syndromes

Publication Date: June 23, 2022
Last Updated: July 25, 2022

Summary of Recommendations

Use point-of-care lung ultrasound as an imaging modality in conjunction with medical history and physical examination to diagnose acute heart failure syndrome when diagnostic uncertainty exists as the accuracy of this diagnostic test is sufficient to direct clinical management. (B)
Use of lung ultrasound requires that the equipment is available, and the physician is proficient in its use.
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Although no specific timing of diuretic therapy can be recommended, physicians may consider earlier administration of diuretics when indicated for emergency department patients with acute heart failure syndrome, because it may be associated with reduced length of stay and inhospital mortality. (C)
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Physicians should be confident in the diagnosis of acute heart failure syndrome with volume overload in a patient before the administration of diuretics because treatment with diuretics may cause harm to those with an alternative diagnosis. (C)
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Consider using high-dose nitroglycerin as a safe and effective treatment option when administered to patients with acute heart failure syndrome and elevated blood pressure. (C)
Although nitroglycerin infusions of up to 400 mcg/min have been described as “standard dosing,” some may consider a dosage of 200 mcg/min or higher as “high dose.” “High dose” nitroglycerin has also been described as bolus intravenous dosing of 2,000 mcg every 3 to 5 minutes.
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Do not rely on current acute heart failure syndrome risk stratification tools alone to determine which patients may be discharged directly home from the emergency department. (B)
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Consider using the Ottawa Heart Failure Risk Scale (OHFRS) to help determine which higher-risk patients for adverse outcome should not be discharged home. (B)
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Consider using the Emergency Heart Failure Mortality Risk Grade for 7-day mortality (EHMRG7) or the STRATIFY decision tool to help determine which higher-risk patients for adverse outcome should not be discharged home. (C)
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Use shared decisionmaking strategies when determining the appropriate disposition of AHFS patients. (C)
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Recommendation Grading

Overview

Title

Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Heart Failure Syndromes

Authoring Organization

Publication Month/Year

June 23, 2022

Last Updated Month/Year

February 13, 2024

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives

This clinical policy from the American College of Emergency Physicians is a revision of the 2007 Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Heart Failure Syndromes. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients presenting to the emergency department with suspected acute heart failure syndrome, is the diagnostic accuracy of point-of-care lung ultrasound sufficient to direct clinical management? (2) In adult patients presenting to the emergency department with suspected acute heart failure syndrome, is early administration of diuretics safe and effective? (3) In adult patients presenting to the emergency department with suspected acute heart failure syndrome, is vasodilator therapy with high-dose nitroglycerin administration safe and effective? (4) In adult patients presenting to the emergency department with symptomatic acute heart failure syndrome, is there a defined group that may be discharged directly home for outpatient follow-up? Evidence was graded, and recommendations were made on the basis of the strength of the available data.

Target Patient Population

This guideline is intended for adult patients presenting to the ED with suspected acute heart failure syndrome

Target Provider Population

This guideline is intended for physicians working in emergency departments (EDs)

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Emergency care, Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D006333 - Heart Failure, D004630 - Emergencies

Keywords

heart failure, acute heart failure

Source Citation

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.

Methodology

Number of Source Documents
37
Literature Search Start Date
January 1, 2007
Literature Search End Date
June 29, 2020