CardioPulse
doi:10.1093/eurheartj/ehy615
Managing the Patient with Heart Failure in the
Emergency Department
Heart failure (HF) is a global public health problem affecting an esti-
mated 26 million people worldwide. It is the leading cause of hospital-
ization in the USA and Europe.1,2 Patients hospitalized with HF have a
higher in-hospital3 and post-discharge4 mortality as well as an
increased rate of rehospitalizations.3,4 As many as 77% of these
patients initially present to the emergency department (ED),5 posing
several challenges. These include the need for rapid diagnosis inte-
grated with early delivery of appropriate therapy together with risk
stratification to aid the correct patient disposition.6
Heart failure patients may present to the ED with varying clinical
scenarios, each associated with specific clinical characteristics
(Figure 1). Acute HF, defined as the rapid onset of symptoms and signs
secondary to abnormal cardiac function, may present as acute pulmo-
nary oedema and hypertension (vasoactive), shock, shortness of
breath, or oedema with fluid overload. Cardiac dysfunction can be
related to systolic or diastolic dysfunction, valvular dysfunction, or as
isolated right ventricular dysfunction. While acute HF can present
without previously known cardiac dysfunction, 63%7 to 75%5 have a
diagnosis of HF prior to presentation.
Ancillary conditions or precipitating factors may cause destabilization
of HF. In the OPTIMIZE HF registry, a precipitating factor was identified
in 61.3% of hospitalized HF patients. These include lung infection
(15.3%), ischaemia (14.7%), arrhythmia (13.5%), poorly controlled
hypertension (10.7%), and medication non-compliance (8.9%).8 The
precipitant may dominate the clinical presentation such as with overt
infection or acute coronary syndrome or can be subtle and necessitate
in-depth investigation. Another clinical scenario often neglected by HF
registries is the patient with a history of HF and a seemingly unrelated
ED referral. These are probably common and may be mixed with the
other patients with acute HF. As an example, in the European HF sur-
vey, the principal reason for admission to the hospital was HF in only
40%.2 Little information is available about the implications on the treat-
ment and suggested disposition of these patients.
For the evaluation of the patient with HF, three efforts are required
(Figure 2):
(1) Establishing the diagnosis of HF as the cause for symptoms and ruling
out alternative diagnoses.
(2) Evaluating for precipitating factors.
(3) Risk stratification to aid correct disposition.
The diagnosis of HF in the ED needs to be performed rapidly but
accurately, simultaneously with therapeutic interventions. The ED
physician (consulting a cardiologist as needed) must determine the
aetiology of symptoms in patients with suspected HF based on the ini-
tial history, physical examination, diagnostic studies (laboratory data,
electrocardiogram, and radiography), and the response to empiric
therapy. The most common symptom is dyspnoea but differentiating
pulmonary from cardiac cause may be difficult. As many as 20% of the
patients admitted with HF have chronic lung disease.7 Jugular venous
distention has the best diagnostic value to assess congestion with a
3493
predictive accuracy of about 80%.9 Laboratory evaluation in the
ED usually includes complete blood count, serum electrolytes, blood
urea nitrogen (BUN), creatinine, thyroid function, troponin (T or I)
and brain natriuretic peptide (BNP), or it’s N terminal (NT-proBNP).
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Additional testing such as D-dimer, digoxin blood level, and urinary
toxic screen may be added. Natriuretic peptides (both BNP and
NT-proBNP) are of special interest to aid the diagnosis. Given a
high specificity (above 90%) but modest sensitivity (70–80%), they
are better utilized to rule out the disease.10 Additional testing
includes an electrocardiogram and chest radiograph.11 However,
chest radiography does not show signs of congestion in 18% of
admissions.12
The overall sensitivity of HF diagnosis in the ED is only 65%.13 By
incorporating patients age, NTproBNP as a continuous variable and
pre-test probability for HF, HF ED diagnosis was redirected in 48%
with 95% accuracy.14 New diagnostic tools include lung ultrasound
and ED echocardiography. Identification and quantification of B-lines
with lung ultrasound can aid in ruling in or excluding pulmonary con-
gestion.15 Echocardiography is integral to the diagnosis of HF.16 If
formal echocardiography isn’t available rapidly, focused cardiac ultra-
sound can be performed by ED personal to assess global left
ventricular systolic function, restrictive mitral inflow pattern,17 valve
malfunction, right ventricular dysfunction and inferior vena cava dis-
tension, and may be combined with pulmonary ultrasonography to
improve specificity of HF diagnosis.18
It is important to identify and treat precipitating factors early. The
2016 European Society of Cardiology (ESC) HF Guidelines highlight
coronary disease, hypertension, arrhythmia, mechanical complications,
and pulmonary emboli (acronym CHAMP) as diagnoses which need to
be ruled out early in the evaluation. While coronary artery disease is
common among patients with decompensated HF,19 testing for ischae-
mia in patients with new-onset HF is underutilized.20 Other causes for
decompensation such as bleeding, infection, and thyroid dysfunction
should also be identified promptly and treated.
The treatment of HF in the ED involves simultaneous ‘generic’ HF
treatment and consideration of the precipitating factors. After initial
stabilization current guidelines suggest treatment with diuretics, vaso-
dilators, or inotropes based on clinical haemodynamic profiles (wet vs.
dry and warm vs. cool).16 Evidence base for acute HF treatment is lim-
ited and currently the only Class I recommendation for medical ther-
apy in acute HF is intravenous loop diuretics in patients with fluid
overload (LOE C). In patients without hypotension intravenous vaso-
dilators (such as nitroglycerine) should be considered and may be first
line in those with hypertension (Class IIa LOE B).16
An important aspect of the treatment in the ED, after the diagnosis
and initiation of treatment is the decision on appropriate disposition
(Figure 2). This should be based on the individual patient risk stratifica-
tion. To aid this evaluation, the ED physician can consult the cardiolo-
gist, preferably a HF specialist. Additional valuable information may be
gathered by direct contact with the primary care physician or referring
cardiologist.
3494 CardioPulse

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Figure 1 Clinical scenarios of heart failure presenting in the emergency department.

Admission may be useful in patients with new-onset HF where rapid

diagnostic workup can’t be assured as an outpatient. Current practice
Stabilizaon is that most patients get hospitalized. Indeed, excluding patients in
Hemodynamic
Venlatory support shock or needing ventilatory support, 83.7% of American patients
from the Nationwide Emergency Department Sample (NEDS) data-
Diagnosis
Heart failure; Precipitants base with a primary ED diagnosis of acute HF were hospitalized.21
consultaon
Cardiology

Heart failure treatment Precipitant treatment

Risk straficaon
Low Intermediate High
Observaon
Discharge Hospitalizaon
Outpaent care
Figure 2 Management and triage of heart failure patients in the
emergency department.
Hospitalization in HF can be used for diagnostic workup, improving
symptoms and volume overload, treatment of precipitating factors and
coexisting diagnoses, initiating guideline directed therapy for chronic
HF and tailoring ongoing medical management and social support.
Hospitalization is obviously indicated for patients in shock or need-
ing ventilator support. Additional patients at high risk include those
with HF severity markers (low blood pressure, markedly elevated NP:
BNP >1000 pg/mL or NT-proBNP >5000 pg/mL, low urine output or
otherwise low perfusion, hyponatremia, tachypnoea >32 b.p.m.; end
organ dysfunction (renal dysfunction: BUN >40 mg/dL or creatinine
>3 mg%, elevated troponin, hypoxaemia, mental disturbances) and sig-
nificant associated factors such as new ischaemic changes on the
elcetrocardiogram.11
Other indications for hospitalization include significant co-
morbidities, poor social support, and availability of follow-up.21
Is it mandatory to hospitalize all these patients? Obviously not. But
who can be safely discharged?6 The response to treatment and resolu-
tion of symptoms is important but even patients with no congestion at
discharge have significant rates of rehospitalization and higher mortal-
ity.22,23 Biomarkers may be reassuring at the time of discharge. Brain
natriuretic peptide levels <200 pg/mL had 9% combined HF visits and
mortality24 and a normal high sensitivity troponin at admission was asso-
ciated with no mortality at 180 days.25 Decision tools integrating various
parameters are developed to help risk stratification.26 Pulmonary ultra-
sound was shown to predict upcoming hospitalizations in ambulatory
patients27,28 and low (<15–30) B-line count at discharge was associated
with event-free survival.29,30 When a decision on hospitalization or dis-
charge is not straightforward it may be helpful to observe the patient.
This may give time for risk stratification while administering effective
treatment31 and seems to reduce readmissions.32,33
Integral to the care in the ED is to ensure sufficient ambulatory
follow-up care. A disease directed management programme may facili-
tate this.34 Communication is essential, obtained via improving the
quality of summary notes35 or direct communication with the primary
care physician. Early (within 7 days) follow-up visits are associated with
decreased 30-day readmissions.36 A clinical trial investigating the utility
of a transition of care plan including an early home visit and close out-
patient follow-up after discharge from the ED is currently under
investigation.37
In conclusion, HF is a major cause of hospitalization and most of the
patients are admitted through the ED. It may present with various clini-
cal scenarios. Diagnosis is challenging and should be established quickly
utilizing various available tools. An investigation looking for precipitat-
ing factors should be done simultaneously. Treatment includes early
stabilization based on haemodynamic profiles, together with treating
CardioPulse 3495

Tal Hasin MD
Corresponding author
Jesselson Integrated Heart Center Todd Zalut MD Yonathan Hasin MD
Shaare Zedek Medical Center Department of Emergency Medicine Meuhedet Health Medical Organization
Jerusalem, Israel & Hebrew University Shaare Zedek Medical Center Israel
Medical School Jerusalem, Israel E-mail: yonathanhasin@gmail.com
Tel: +972507558415
Email: hasintal@gmail.com

the precipitating factor if one can be identified. Patient triage and dispo- References
sition is based on the estimated risk, utilizing an observation unit if nec- References are available as supplementary material at European Heart
essary and assuring continued care in the outpatient setting. Journal online.

Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/38/3493/5122816 by guest on 24 October 2018

Conflict of interest: none declared.

doi:10.1093/eurheartj/ehy616

Young Cardiologist Researchers

in Kemerovo
A brief summary of the Forum of Young Cardiologists in
the Russian Research Session “Preventive Cardiology
and Current Cardiovascular Research”, Kemerovo,
2018: the view of a young investigator

The Forum of Young Cardiologists in the Russian Research Session
‘Preventive Cardiology and Current Cardiovascular Research’ has
recently been held in Kemerovo, a capital of the industrial region of
Southwestern Siberia. The Forum was attended by scientists not only
from Russia, but also from the Ukraine and Belarus. The first day of the
Forum coincided with the ‘National Wear Red Day’, which commem-
orates the struggle with heart disease in women, and most of the
organizers and guests of the event came wearing red.
That day included critical discussions on cardiovascular epidemiol-
ogy, important aspects of diagnosis, primary and secondary prevention,
rehabilitation in cardiovascular diseases, and current trends in the
treatment of arterial hypertension as well as case reports, reflecting
the compliance with the guidelines in real clinical practice and various
master classes to improve practical skills.
At the end of the day, conference participants could have been
inspired by the ‘true’ Kuzbass (an alternative name of the