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 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.

Critical Questions

1. 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?
   
   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.
   
   
   
   
2. In adult patients presenting to the emergency department with suspected acute heart failure syndrome, is early administration of diuretics safe and effective?
   
   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 in-hospital 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).
   
   
   
   
3. 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?
   
   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 2000 mcg every 3 to 5 minutes.
   
   
   
   
4. 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?
   
   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).
   
   

Disclaimer
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.