Management of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature.

BACKGROUND: Acute heart failure (AHF) is a common presentation to the emergency department (ED), with the potential to cause significant morbidity and mortality. It is important to tailor treatments to the appropriate type of heart failure.

OBJECTIVES: This review provides an evidence-based summary of the current ED management of acute heart failure.

DISCUSSION: Heart failure can present along a spectrum, especially in acute exacerbation. Treatment should focus on the underlying disease process, with guidelines focusing primarily on blood pressure and hemodynamic status. Treatment of patients with mild AHF exacerbations often focuses on intravenous diuretics. Patients with AHF with flash pulmonary edema should receive nitroglycerin and noninvasive positive pressure ventilation, with consideration of an angiotensin-converting enzyme inhibitor, while monitoring for hypotension. Patients with hypotensive AHF should receive emergent specialty consultation and an initial fluid bolus of 250-500 mL, followed by initiation of inotropic agents with or without vasopressors. Dobutamine is the inotrope of choice in these patients, with norepinephrine recommended if blood pressure support is needed. If noninvasive positive pressure ventilation is required, providers should monitor closely for acute decompensation. Mechanical circulatory support devices may be considered as a bridge to further therapeutic intervention. High-output heart failure can be managed acutely with vasoconstricting agents, with focus on treating the underlying etiology. Disposition is not always straightforward, and several risk scores may assist in this decision.

CONCLUSION: AHF is a condition that requires rapid assessment and management. Understanding the appropriate management strategy can allow for more targeted treatment and improved outcomes.