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Heart Failure Syndromes (Acute - Adult)

Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Heart Failure Syndromes (May 2007)

Complete Clinical Policy on Acute Heart Failure Syndromes (PDF)

Scope of Application. This guideline is intended for physicians working in hospital-based emergency departments (EDs).

Inclusion Criteria. This guideline is intended for adult patients presenting to the ED with symptoms or signs suggestive of acute heart failure.

Exclusion Criteria. This guideline is not intended to address the care of those patients presenting with acute ST-elevation myocardial infarction, high-output heart failure, cardiogenic shock, renal failure, valvular emergencies, or the care of pediatric patients.

Critical Questions

1. Does a B-type natriuretic polypeptide (BNP) or NT-ProBNP measurement improve the diagnostic accuracy over standard clinical judgment in the assessment of possible acute heart failure syndromes in the ED?

  • Level A recommendations. None specified.


  • Level B recommendations. The addition of a single BNP or 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 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


  • Level C recommendations. None specified.


2. Is there a role for noninvasive positive-pressure ventilatory support in the ED management of patients with acute heart failure syndromes and respiratory distress?

  • Level A recommendations. None specified.


  • Level B recommendations. 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.


  • Level C recommendations. Consider using bi-level positive airway pressure (BiPAP) as an alternative to CPAP for dyspneic patients with acute heart failure syndrome; however, data about the possible association between BiPAP and myocardial infarction remain unclear.


3. Should vasodilator therapy (eg, nitrates, nesiritide, and ACE inhibitors) be prescribed in the ED management of patients with acute heart failure syndromes?

  • Level A recommendations. None specified.


  • Level B recommendations. Administer intravenous nitrate therapy to patients with acute heart failure syndromes and associated dyspnea.


  • Level C recommendations. (1) 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.
    (2) 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.


4. Should diuretic therapy be prescribed in the ED management of patients with acute heart failure syndromes?

  • Level A recommendations. None specified.


  • Level B recommendations. Treat patients with moderate-to-severe pulmonary edema resulting from acute heart failure with furosemide in combination with nitrate therapy.


  • Level C recommendations. (1) Aggressive diuretic monotherapy is unlikely to prevent the need for endotracheal intubation compared with aggressive nitrate monotherapy.
    (2) 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.


Purpose of ACEP's Clinical Policies

Clinical Findings and Strength of Recommendations