Acute Left Heart Failure in the ER

  • Carlos Jerjes-SánchezEmail author
  • Mauricio Vázquez Guajardo


Acute heart failure can be defined as new onset or worsening heart failure signs and symptoms requiring urgent therapy. It affects over 5 million Americans and 15 million Europeans. It should be considered in patients presenting to the emergency room with dyspnea and peripheral and/or pulmonary congestion with or without a prior history of heart failure. It is estimated that in patients over 65 years of age that present with the breathlessness of exertion, one in every six will have unrecognized heart failure. Diagnostic workup requires the knowledge of normal and abnormal variants of each specific study and a careful interpretation of results. A chest X-ray may present with atypical features like unilateral and lobar pulmonary edema in patients with pre-existing COPD and minimal edema during the transition of interstitial edema into alveolar edema. Echocardiography is integral for the diagnosis of acute heart failure. In cases associated with respiratory distress, routine arterial blood gas is not needed and restricted to patients in whom oxygenation cannot be readily assessed by pulse oximetry. Routine invasive hemodynamic evaluation with a pulmonary artery catheter is not indicated for the diagnosis of acute HF. In the ER early treatment with intravenous loop diuretics reduces in-hospital mortality. While diuretics remain the mainstay of therapy, depending on the patient’s profile and the precipitant factor, other targets like surgery, thrombolysis, preload, and afterload reduction or inotropic support gain importance and can be implemented. This chapter focuses mainly on diagnosis and therapeutic approach of left heart failure.


Acute heart failure Venous congestion Dyspnea Acute cardiogenic pulmonary edema Diuretics Vasodilators Inotropes 


  1. 1.
    Gheorghiade M, Pang PS. Acute heart failure syndromes. J Am Coll Cardiol. 2009;53:557–73.CrossRefGoogle Scholar
  2. 2.
    Tubaro M, European Society of Cardiology, editors. The ESC textbook of acute and intensive cardiac care. Oxford: Oxford University Press; 2014.Google Scholar
  3. 3.
    Filippatos G, Zannad F. An introduction to acute heart failure syndromes: definition and classification. Heart Fail Rev. 2007;12:87–90.CrossRefGoogle Scholar
  4. 4.
    Searle J, Frick J, Möckel M. Acute heart failure facts and numbers: acute heart failure populations. ESC Heart Fail. 2016;3:65–70.CrossRefGoogle Scholar
  5. 5.
    Hasin T, Zalut T, Hasin Y. Managing the patient with heart failure in the emergency department. Eur Heart J. 2018;39:3493–5.CrossRefGoogle Scholar
  6. 6.
    Collins S, Storrow AB, Albert NM, Butler J, Ezekowitz J, Felker GM, et al. Early management of patients with acute heart failure: state of the art and future directions. A consensus document from the Society for Academic Emergency Medicine/Heart Failure Society of America Acute Heart Failure Working Group. J Card Fail. 2015;21:27–43.CrossRefGoogle Scholar
  7. 7.
    Weintraub NL, Collins SP, Pang PS, Levy PD, Anderson AS, Arslanian-Engoren C, et al. Acute heart failure syndromes: emergency department presentation, treatment, and disposition: current approaches and future aims: a scientific statement from the American Heart Association. Circulation. 2010;122:1975–96.CrossRefGoogle Scholar
  8. 8.
    Kurmani S, Squire I. Acute heart failure: definition, classification and epidemiology. Curr Heart Fail Rep. 2017;14:385–92.CrossRefGoogle Scholar
  9. 9.
    Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37:2129–200.CrossRefGoogle Scholar
  10. 10.
    Arrigo M, Parissis JT, Akiyama E, Mebazaa A. Understanding acute heart failure: pathophysiology and diagnosis. Eur Heart J Suppl. 2016;18:G11–8.CrossRefGoogle Scholar
  11. 11.
    Mentz RJ, O’Connor CM. Pathophysiology and clinical evaluation of acute heart failure. Nat Rev Cardiol. 2016;13:28–35.CrossRefGoogle Scholar
  12. 12.
    Ponikowski P, Jankowska EA. Pathogenesis and clinical presentation of acute heart failure. Rev Esp Cardiol (Engl Ed). 2015;68:331–7.CrossRefGoogle Scholar
  13. 13.
    Farmakis D, Parissis J, Lekakis J, Filippatos G. Acute heart failure: epidemiology, risk factors, and prevention. Rev Esp Cardiol (Engl Ed). 2015;68:245–8.CrossRefGoogle Scholar
  14. 14.
    Allen CJ, Sharma R, et al. How to improve time to diagnosis in acute heart failure — clinical signs and chest X-ray. Card Fail Rev. 2015;1(2):69–74.CrossRefGoogle Scholar
  15. 15.
    Thibodeau JT, Drazner MH. The role of the clinical examination in patients with heart failure. JACC Heart Fail. 2018;6:543–51.CrossRefGoogle Scholar
  16. 16.
    Baeza-Trinidad R, Mosquera-Lozano JD, El Bikri L. Assessment of bendopnea impact on decompensated heart failure: assessment of bendopnea impact on decompensated HF. Eur J Heart Fail. 2017;19:111–5.CrossRefGoogle Scholar
  17. 17.
    Wang CS. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005;294:1944.CrossRefGoogle Scholar
  18. 18.
    Benza RL, Tallaj JA, Felker GM, Zabel KM, Kao W, Bourge RC, et al. The impact of arrhythmias in acute heart failure. J Card Fail. 2004;10:279–84.CrossRefGoogle Scholar
  19. 19.
    Papadimitriou L, Georgiopoulou VV, Kort S, Butler J, Kalogeropoulos AP. Echocardiography in acute heart failure: current perspectives. J Card Fail. 2016;22:82–94.CrossRefGoogle Scholar
  20. 20.
    Peacock MDWF. Heart failure in the emergency department. Emerg Med. 2017;49:443–60.CrossRefGoogle Scholar
  21. 21.
    Kuo DC, Peacock WF. Diagnosing and managing acute heart failure in the emergency department. Clin Exp Emerg Med. 2015;2:141–9.CrossRefGoogle Scholar
  22. 22.
    Heart Failure Society of America. HFSA 2010 comprehensive heart failure practice guideline. J Card Fail. 2010;16:e1–2.CrossRefGoogle Scholar
  23. 23.
    Quintanilla J, Jerjes-Sanchez C, Perez L, Valdes F, Jimenez V, Trevino AR, et al. Intermediate- to high-risk pulmonary embolism with normal B-type natriuretic peptide. Am J Emerg Med. 2016;34:2463.e1–3.CrossRefGoogle Scholar
  24. 24.
    Pang PS, Teerlink JR, Voors AA, Ponikowski P, Greenberg BH, Filippatos G, et al. Use of high-sensitivity troponin T to identify patients with acute heart failure at lower risk for adverse outcomes. JACC Heart Fail. 2016;4:591–9.CrossRefGoogle Scholar
  25. 25.
    Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, et al. 2013 ACCF/AHA guideline for the Management of Heart Failure: executive summary. J Am Coll Cardiol. 2013;62:1495–539.CrossRefGoogle Scholar
  26. 26.
    Velazquez EJ, Morrow DA, DeVore AD, Duffy CI, Ambrosy AP, McCague K, et al. Angiotensin–Neprilysin inhibition in acute decompensated heart failure. N Engl J Med [Internet] 2018 [cited 2018 Nov 14]. Available from: CrossRefGoogle Scholar
  27. 27.
    Matsue Y, Damman K, Voors AA, Kagiyama N, Yamaguchi T, Kuroda S, et al. Time-to-furosemide treatment and mortality in patients hospitalized with acute heart failure. J Am Coll Cardiol. 2017;69:3042–51.CrossRefGoogle Scholar
  28. 28.
    Mentz RJ, Kjeldsen K, Rossi GP, Voors AA, Cleland JGF, Anker SD, et al. Decongestion in acute heart failure: decongestion in heart failure. Eur J Heart Fail. 2014;16:471–82.CrossRefGoogle Scholar
  29. 29.
    Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med. 2011;364:797–805.CrossRefGoogle Scholar
  30. 30.
    Jondeau G, Neuder Y, Eicher J-C, Jourdain P, Fauveau E, Galinier M, et al. B-CONVINCED: Beta-blocker CONtinuation Vs. INterruption in patients with congestive heart failure hospitalizED for a decompensation episode. Eur Heart J. 2009;30:2186–92.CrossRefGoogle Scholar
  31. 31.
    Prins KW, Neill JM, Tyler JO, Eckman PM, Duval S. Effects of beta-blocker withdrawal in acute decompensated heart failure. JACC Heart Fail. 2015;3:647–53.CrossRefGoogle Scholar
  32. 32.

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Instituto de Cardiología y Medicina Vascular, TecSalud, Escuela de Medicina y Ciencias de la Salud, Tecnológico de MonterreySan Pedro Garza GarcíaMéxico
  2. 2.Centro de Investigación Biomédica del Hospital Zambrano Hellion, TecSalud, Escuela de Medicina, Tecnológico de MonterreySan Pedro Garza GarcíaMéxico

Personalised recommendations