Recommendations on Pre- and Early Hospital Management of Acute Heart Failure | Ten Points to Remember

Mebazaa A, Yilmaz MB, Levy P, et al.
Recommendations on Pre-Hospital and Early Hospital Management of Acute Heart Failure: A Consensus Paper From the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine – Short Version. Eur Heart J 2015;May 21:[Epub ahead of print].

The following are 10 points to remember from this consensus paper on recommendations for pre- and early hospital management of acute heart failure (AHF):

  1. AHF is rapid onset of, or acute worsening of, symptoms and signs of HF, associated with elevated plasma levels of natriuretic peptides. And the majority of the patients with AHF present with normal or high blood pressure and with symptoms and/or signs of congestion rather than low cardiac output.
  2. As with patients with acute myocardial infarction, the “time-to-treatment” concept may be important in patients with AHF; therefore, in the prehospital setting, medical treatment should be initiated based on blood pressure and/or the degree of congestion using vasodilators and/or diuretics (such as furosemide). Oxygen therapy should be given based on clinical judgment unless oxygen saturation is <90%, in which case, oxygen therapy should be routinely administered.
  3. Upon initial evaluation of suspected AHF (excluding patients with cardiogenic shock), the key first step is determination of the severity of cardiopulmonary instability based on the level of dyspnea (New York Heart Association class), hemodynamic status (blood pressure), heart rate and rhythm, and signs/symptoms of hypoperfusion (cool extremities, narrow pulse pressure, mental status).
  4. The next step should include a search for congestion including peripheral edema, audible crackles (especially in the absence of fever), and elevated jugular venous pressure.
  5. Upon presentation to the emergency department or coronary care unit/intensive care unit (ICU), a point-care-of-assay of plasma natriuretic peptide level (B-type natriuretic peptide, N-terminal proBNP, or mid-regional pro-atrial natriuretic peptide [MR- proANP] MR-proANP) should be done in all patients with acute dyspnea and suspected AHF, to help in the differentiation of AHF from noncardiac causes of acute dyspnea. Also, cardiac troponin, blood urea nitrogen (or urea), creatinine, electrolytes, glucose, and complete blood count should be performed on all patients.
  6. Intravenous furosemide can be considered in all AHF patients on initial presentation and when systolic blood pressure is normal to high (>110 mm Hg); intravenous vasodilator therapy might be given for symptomatic relief as an initial therapy (alternatively, sublingual nitrates may be administered).
  7. Clinical condition can change dramatically within a few hours of arrival to the emergency room. Hence, clinical response to initial treatment is an important indicator of likely discharge from the emergency room. Factors favoring early discharge include patient-reported subjective improvement, resting heart rate <100 bpm, no hypotension when standing up, adequate urine output, oxygen saturation <95% in room air, and no or moderate worsening of renal function (when chronic renal disease might be present).
  8. Patients with significant shortness of breath or hemodynamic instability should be triaged to a hospital floor where immediate resuscitative support can be provided if needed. The criteria for triage at admission to ICU include respiratory rate >25 breaths/minute, oxygen saturation <90%, use of accessory muscles for breathing, systolic blood pressure <90 mm Hg, need for intubation (or already intubated), or signs of hypoperfusion (oliguria, cold peripheries, altered mental status, lactate >2 mmol/L, metabolic acidosis, and mixed venous oxygen saturation [SvO2] <65%).
  9. Cardiogenic shock is defined as hypotension (systolic blood pressure <90 mm Hg) despite adequate filling status and signs of hypoperfusion (oliguria, cold peripheries, altered mental status, lactate >2 mmol/L, metabolic acidosis, SvO2 <65%). Management of cardiogenic shock includes invasive monitoring with an arterial line, intravenous fluid challenge with normal saline or ringer lactate, use of inotropes such as dobutamine or levosimendan, use of norepinephrine in preference to dopamine to maintain systolic blood pressure when indicated, and careful consideration before using intra-aortic balloon pump or mechanical circulatory support.
  10. There are several gaps in knowledge in the management of AHF including the utility of biomarkers in risk stratification and to guide therapy, which are the most important signs of severity, and which are the best measures of efficacy.

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