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Acute Heart Failure Syndromes

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

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

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

    Recommendations
    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.

    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.

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

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

    Recommendations
    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.

    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.

Download the Policy

PDF Icon AHFS2007.pdf.pdf April 2018

Additional Resources

Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
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 in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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