Acute Left Heart Failure in the ER

Abstract

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.