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    Acute Heart Failure Syndromes (beta)

    Official guideline from the American College of Emergency Physicians.

    Summary by Eric Steinberg, DO
    Strength
    Level A
    Level B
    Level C

    Diagnosis

    Diagnosis
    1. The addition of a single B-type natriuretic polypeptide (BNP) or N-terminal (NT)-pro hormone BNP (NT-proBNP) measurement can improve the diagnostic accuracy compared to standard clinical judgment alone in the diagnosis of acute heart failure syndrome among patients presenting to the emergency department (ED) with acute dyspnea. Use the following guidelines:

      - BNP <100 pg/mL or NT-proBNP <300 pg/mL acute heart failure syndrome unlikely (Approximate LR- = 0.1).

      - BNP >500 pg/mL or NT-proBNP >1,000 pg/mL acute heart failure syndrome likely (Approximate LR+ = 6).

      BNP conversion: 100 pg/mL=22 pmol/L; NT-proBNP conversion: 300 pg/mL=35 pmol/L

    Intervention

    Non-Invasive Positive-Pressure Ventilatory Support (NIPPV)
    1. Use 5 to 10 mm Hg continuous positive airway pressure (CPAP) by nasal or face mask as therapy for dyspneic patients with acute heart failure syndrome without hypotension or the need for emergent intubation to improve heart rate, respiratory rate, blood pressure, and reduce the need for intubation, and possibly reduce inhospital mortality.
    2. Consider using bi-level positive airway pressure (BiPAP) as an alternative to continuous positive airway pressure (CPAP) for dyspneic patients with acute heart failure syndrome; however, data about the possible association between bi-level positive airway pressure and myocardial infarction remain unclear.
    Vasodilator Therapy
    1. Administer intravenous nitrate therapy to patients with acute heart failure syndromes and associated dyspnea.
    2. Because of the lack of clear superiority of nesiritide over nitrates in acute heart failure syndrome and the current uncertainty regarding its safety, nesiritide generally should not be considered first line therapy for acute heart failure syndromes.
    3. Angiotensin-converting enzyme (ACE) inhibitors may be used in the initial management of acute heart failure syndromes, although patients must be monitored for first dose hypotension.
    Diuretic Therapy
    1. Treat patients with moderate-to-severe pulmonary edema resulting from acute heart failure with furosemide in combination with nitrate therapy.
    2. Aggressive diuretic monotherapy is unlikely to prevent the need for endotracheal intubation compared with aggressive nitrate monotherapy.
    3. Diuretics should be administered judiciously, given the potential association between diuretics, worsening renal function, and the known association between worsening renal function at index hospitalization and long-term mortality.
    What do the icons mean?  
    Research PaperSilvers 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 Med. 2007;49(5):627-69.