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New ACEP Policy on Acute Heart Failure

November 17, 2022

Written by Seth Walsh-Blackmore

Spoon Feed
ACEP released acute heart failure syndrome (AHFS) consensus recommendations that cover: diagnosis with lung ultrasound, risk stratification, high-dose nitroglycerin, and early diuretics.

Why does this matter?
The prevalence of heart failure continues to rise, and most AHFS admissions will present via the ED. We need to know the best evidence to care for these patients.

Take these recommendations to heart

Lung ultrasound (LUS) has better diagnostic utility than a standard AHFS workup and is sufficient to diagnose AHFS in conjunction with the history and physical. (Level B) (One class II study, eight Class III studies)

  • LUS alone had sensitivity 93.5%, specificity 95.5%, positive LR 20.9, negative LR 0.07 (vs. 85/89/8.0/0.17 with CXR plus BNP) and decreased time to diagnosis (5 minutes vs. 104.5 minutes) in a large multicenter RCT.1
  • Pooled sensitivity/specificity was 82.5%/83.6%, with heterogeneity, reflecting the impact of operator experience in a large meta-analysis.2

Current AHFS risk stratification tools alone cannot identify patients safe for ED discharge but miss fewer high-risk patients than clinical judgment. The Ottawa Heart Failure Risk Scale (OHFRS) is the preferred tool for this purpose. (Level B, One Class II, One Class III study)

  • OHFRS cutoff of 1 would increase sensitivity for 30-day mortality or 14-day significant adverse event vs. clinical judgment (95.8% vs. 70%). 3
  • EHMRG7 and STRATIFY appear to function similarly to OHFRS but are less practical in application. (Level C, Two Class III studies)

High-dose IV nitroglycerin appears well tolerated in hypertensive AHFS patients. (Level C, one Class III study)

  • In a group 29 hypertensive AHFS patients receiving multiple 2000 mcg nitro boluses plus infusion up to 400 mcg/minute, after failing standard therapy, there was a single episode of hypotension (which was fluid responsive).4

Early ED diuretics, for which there is no consensus definition, should only be considered in confirmed AHFS with volume overload. (Level C, One class III study)

  • Increased time to treatment is associated with a marginal increase in in-hospital mortality (OR 1.01) and length of stay (1.4 hours), with no difference in readmission or 30-day mortality.5

Another Spoonful
A full library of ACEP clinical policies can be found here!

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Heart Failure Syndromes: Approved by ACEP Board of Directors, June 23, 2022. Ann Emerg Med. 2022 Oct;80(4):e31-e59. doi: 10.1016/j.annemergmed.2022.05.027.

Works Cited

  1. Pivetta E, Goffi A, Nazerian P, et al. Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial. Eur J Heart Fail. 2019;21(6):754-766. doi:10.1002/ejhf.1379
  2. McGivery K, Atkinson P, Lewis D, et al. Emergency department ultrasound for the detection of B-lines in the early diagnosis of acute decompensated heart failure: a systematic review and meta-analysis. CJEM. 2018;20(3):343-352. doi:10.1017/cem.2018.27
  3. Collins SP, Pang PS. ACUTE Heart Failure Risk Stratification. Circulation. 2019;139(9):1157-1161. doi:10.1161/CIRCULATIONAHA.118.038472
  4. Levy P, Compton S, Welch R, et al. Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis. Ann Emerg Med. 2007;50(2):144-152. doi:10.1016/j.annemergmed.2007.02.022
  5. Wong YW, Fonarow GC, Mi X, et al. Early intravenous heart failure therapy and outcomes among older patients hospitalized for acute decompensated heart failure: findings from the Acute Decompensated Heart Failure Registry Emergency Module (ADHERE-EM). Am Heart J. 2013;166(2):349-356. doi:10.1016/j.ahj.2013.05.014

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