Emergency Department Management of Acute Heart Failure

Acute heart failure represents a sudden or rapid decline in cardiac function, characterised by pulmonary congestion, systemic hypoperfusion and fluid overload. In the emergency department (ED), prompt recognition and early intervention are vital to reduce morbidity and mortality. Initial assessment focuses on airway, breathing and circulation, accompanied by targeted history and examination to distinguish decompensated heart failure from other causes of dyspnoea. Rapid risk stratification integrates clinical variables—blood pressure, heart rate, renal function and biomarkers such as B-type natriuretic peptide—with semi-quantitative triage scales to identify patients at high risk of short-term adverse events. Point-of-care ultrasound and laboratory testing facilitate diagnosis, guide decongestive strategies and inform decisions on non-invasive ventilation. First-line treatment commonly comprises high-dose intravenous diuretics and, where indicated, vasodilators to reduce preload and afterload. Non-invasive positive-pressure ventilation may be employed in cases of respiratory distress, while inotropes or mechanical circulatory support are reserved for refractory hypotension and end-organ hypoperfusion. Dedicated observation areas and short-stay units within the ED can provide extended monitoring and titration of therapy for selected patients, optimising resource utilisation. Disposition decisions—ranging from direct discharge with rapid outpatient follow-up to admission to specialised wards—rely on dynamic risk assessment, response to initial therapy and presence of comorbidities. Advances in triage algorithms, decision-support tools and care pathways aim to streamline patient flow, reduce unnecessary admissions and improve clinical outcomes on a global scale.

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Emergency Department Management of Acute Heart Failure publication trend

The graph below shows the total number of articles in emergency department management of acute heart failure across all publications each year (not limited to Nature Index journals).

Technical terms

Acute heart failure: A rapid onset or worsening of symptoms caused by inadequate cardiac output and fluid overload.

Risk stratification: The process of categorising patients according to the likelihood of adverse outcomes, based on clinical and laboratory data.

Short stay unit (SSU): A designated area within or adjacent to the ED where patients receive observation and treatment without full hospital admission.

Brief intensive observation area (OBI): An ED holding unit staffed by a dedicated team, designed for stabilisation and close monitoring of acute heart failure patients.

Non-invasive ventilation: A method of respiratory support that delivers positive pressure via a mask to improve gas exchange without intubation.

References

1. Admission prioritization of heart failure patients with multiple comorbidities. Frontiers in Digital Health (2024).
2. Emergency department direct discharge compared to short-stay unit admission for selected patients with acute heart failure: analysis of short-term outcomes. Internal and Emergency Medicine (2023).
3. Prediction of Emergent Heart Failure Death by Semi-Quantitative Triage Risk Stratification. PLOS ONE (2011).
4. Considerations for initial therapy in the treatment of acute heart failure. Critical Care (2015).
5. Derivation and Validation of Clinical Prediction Models for Rapid Risk Stratification for Time-Sensitive Management for Acute Heart Failure. Journal of Clinical Medicine (2020).
6. Role of a Brief Intensive Observation Area with a Dedicated Team of Doctors in the Management of Acute Heart Failure Patients: A Retrospective Observational Study. Medicina (2020).