ACEP ID:

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 emergency departments (EDs).

Inclusion Criteria

This guideline is intended for adult patients presenting to the ED with suspected acute heart failure syndrome.

Exclusion Criteria

This guideline is not intended for patients presenting with acute ST-elevation myocardial infarction, high-output heart failure, cardiogenic shock, renal failure, valvular emergencies, pregnant patients, or pediatric patients.


Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician’s judgment and patient preferences.

Critical Questions

  • In adult patients presenting to the emergency department with suspected acute heart failure syndrome, is the diagnostic accuracy of point-of-care lung ultrasound sufficient to direct clinical management?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations

    Use point-of-care lung ultrasound as an imaging modality in conjunction with medical history and physical examination to diagnose acute heart failure syndrome when diagnostic uncertainty exists as the accuracy of this diagnostic test is sufficient to direct clinical management.*

    * Use of lung ultrasound requires that the equipment is available, and the physician is proficient in its use.

    Level C Recommendations
    None specified.
    Level A Recommendations
    None specified.
    Level B Recommendations

    Use point-of-care lung ultrasound as an imaging modality in conjunction with medical history and physical examination to diagnose acute heart failure syndrome when diagnostic uncertainty exists as the accuracy of this diagnostic test is sufficient to direct clinical management.*

    * Use of lung ultrasound requires that the equipment is available, and the physician is proficient in its use.

    Level C Recommendations
    None specified.
  • In adult patients presenting to the emergency department with suspected acute heart failure syndrome, is early administration of diuretics safe and effective?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    Although no specific timing of diuretic therapy can be recommended, physicians may consider earlier administration of diuretics when indicated for emergency department patients with acute heart failure syndrome, because it may be associated with reduced length of stay and inhospital mortality (Consensus recommendation).

    Physicians should be confident in the diagnosis of acute heart failure syndrome with volume overload in a patient before the administration of diuretics because treatment with diuretics may cause harm to those with an alternative diagnosis (Consensus recommendation).

    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    Although no specific timing of diuretic therapy can be recommended, physicians may consider earlier administration of diuretics when indicated for emergency department patients with acute heart failure syndrome, because it may be associated with reduced length of stay and inhospital mortality (Consensus recommendation).

    Physicians should be confident in the diagnosis of acute heart failure syndrome with volume overload in a patient before the administration of diuretics because treatment with diuretics may cause harm to those with an alternative diagnosis (Consensus recommendation).

  • In adult patients presenting to the emergency department with suspected acute heart failure syndrome, is vasodilator therapy with high-dose nitroglycerin administration safe and effective?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations

    None specified.

    Level C Recommendations

    Consider using high-dose nitroglycerin as a safe and effective treatment option when administered to patients with acute heart failure syndrome and elevated blood pressure (Consensus recommendation).*

    * Although nitroglycerin infusions of up to 400 mcg/min have been described as “standard dosing,” some may consider a dosage of 200 mcg/min or higher as “high dose.” “High dose” nitroglycerin has also been described as bolus intravenous dosing of 2,000 mcg every 3 to 5 minutes.

    Level A Recommendations
    None specified.
    Level B Recommendations

    None specified.

    Level C Recommendations

    Consider using high-dose nitroglycerin as a safe and effective treatment option when administered to patients with acute heart failure syndrome and elevated blood pressure (Consensus recommendation).*

    * Although nitroglycerin infusions of up to 400 mcg/min have been described as “standard dosing,” some may consider a dosage of 200 mcg/min or higher as “high dose.” “High dose” nitroglycerin has also been described as bolus intravenous dosing of 2,000 mcg every 3 to 5 minutes.

  • In adult patients presenting to the emergency department with symptomatic acute heart failure syndrome, is there a defined group that may be safely discharged home for outpatient follow-up?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    Do not rely on current acute heart failure syndrome risk stratification tools alone to determine which patients may be discharged directly home from the emergency department. 

    Consider using the Ottawa Heart Failure Risk Scale (OHFRS) to help determine which higher-risk patients for adverse outcome should not be discharged home.

    Level C Recommendations

    Consider using the Emergency Heart Failure Mortality Risk Grade for 7-day mortality (EHMRG7) or the STRATIFY decision tool to help determine which higher-risk patients for adverse outcome should not be discharged home.

    Use shared decision-making strategies when determining the appropriate disposition of AHFS patients (Consensus recommendation). 

    Level A Recommendations

    None specified.

    Level B Recommendations

    Do not rely on current acute heart failure syndrome risk stratification tools alone to determine which patients may be discharged directly home from the emergency department. 

    Consider using the Ottawa Heart Failure Risk Scale (OHFRS) to help determine which higher-risk patients for adverse outcome should not be discharged home.

    Level C Recommendations

    Consider using the Emergency Heart Failure Mortality Risk Grade for 7-day mortality (EHMRG7) or the STRATIFY decision tool to help determine which higher-risk patients for adverse outcome should not be discharged home.

    Use shared decision-making strategies when determining the appropriate disposition of AHFS patients (Consensus recommendation). 

Download the Policy

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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