> Heart Failure

Acute Heart Failure Syndromes

Official guideline from the American College of Emergency Physicians.

summary by Eric Steinberg, DO, MEHP

Diagnosis

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.*

*Use of lung ultrasound requires that the equipment is available, and the physician is proficient in its use.

Level B

Intervention

Diuretic Therapy

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 in-hospital mortality (consensus recommendation).

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 (consensus recommendation).

Level C

Vasodilator Therapy

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 (consensus recommendation).*

*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.

Level C

Disposition

Risk Stratification

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.

Consider using the Ottawa Heart Failure Risk Scale (OHFRS) to help determine which higher-risk patients for adverse outcome should not be discharged home.

Level B

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.

Use shared decision-making strategies when determining the appropriate disposition of AHFS patients (consensus recommendation).

Level C

What do the icons mean?

Level A

Generally accepted principles for patient management that reflect a high degree of clinical certainty (ie, based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues).

Level B

Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (ie, based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies).

Level C

Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances where consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.

Literature

Original/Primary Reference

Silvers SM, Howell JM, Kosowsky JM, et al. American College of Emergency Physicians. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Heart Failure Syndromes. Ann Emerg M

Calc Function

Diagnosis

Intervention

Disposition