Misconceptions in acute heart failure diagnosis and Management in the Emergency Department

Brit Long, Alex Koyfman, Eric J Chin
American Journal of Emergency Medicine 2018, 36 (9): 1666-1673

INTRODUCTION: Acute heart failure (AHF) accounts for a significant number of emergency department (ED) visits, and the disease may present along a spectrum with a variety of syndromes.

OBJECTIVE: This review evaluates several misconceptions concerning heart failure evaluation and management in the ED, followed by several pearls.

DISCUSSION: AHF is a heterogeneous syndrome with a variety of presentations. Physicians often rely on natriuretic peptides, but the evidence behind their use is controversial, and these should not be used in isolation. Chest radiograph is often considered the most reliable imaging test, but bedside ultrasound (US) provides a more sensitive and specific evaluation for AHF. Diuretics are a foundation of AHF management, but in pulmonary edema, these medications should only be provided after vasodilator administration, such as nitroglycerin. Nitroglycerin administered in high doses for pulmonary edema is safe and effective in reducing the need for intensive care unit admission. Though classically dopamine is the first vasopressor utilized in patients with hypotensive cardiogenic shock, norepinephrine is associated with improved outcomes and lower mortality. Disposition is complex in patients with AHF, and risk stratification tools in conjunction with other assessments allow physicians to discharge patients safely with follow up.

CONCLUSION: A variety of misconceptions surround the evaluation and management of heart failure including clinical assessment, natriuretic peptide use, chest radiograph and US use, nitroglycerin and diuretics, vasopressor choice, and disposition. This review evaluates these misconceptions while providing physicians with updates in evaluation and management of AHF.

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James French

There is no one size fits all approach to heart failure. Sometimes nitrates first, sometimes diuretics first , sometimes rate control, sometimes paCO2 in right sided heart failure. It depends on the dominant point of disruption of the expanded blood pressure equation when considering both ventricles and both vascular beds. Learn echo and lung ultrasound. Forget BNP (the CRP of AHF) look at the EKG. Synthesize these results with the history and clinical exam. Make a paradigm for the specific patient and then decide how you will test it.


Bill Anderson

Diuretics were always a bit dubious in a group of patients largely with normal fluid balance. Now we understand better.


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