-

A
PAGE 2| Introduction To The Current Guidelines For The January/February 2014
Guidelines: Heart Failure Volume 6, Number 1
Evaluation And Management Of Author

PAGE 3| Guest Editor Comment Heart Failure Trevor Lewis, MD, FACEP

T
Medical Director, Emergency Department, Cook County Hospital; Associate
Professor of Emergency Medicine, Rush Medical College, Chicago, IL
his issue of EM Practice Guidelines Update reviews 2
Guest Editor
recently updated guidelines on the evaluation and man-
PAGE 4| Assessment Of The Deborah B. Diercks, MD
Guideline Methodology agement of heart failure (HF). The European Society of Professor and Vice Chair of Research, Department of Emergency Medicine,
University of California, Davis, Davis, CA
Cardiology (ESC) guideline is an update of their 2008 issue and
Editor-In-Chief
provides practical, evidence-based guidelines for the diagnosis Sigrid Hahn, MD, MPH
PAGE 5 | Selected Guideline and treatment of acute and chronic HF. The joint American Col- Associate Professor of Emergency Medicine, Department of Emergency
Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
Recommendations, lege of Cardiology Foundation (ACCF)/American Heart Associa-
Editorial Board
With Discussion tion (AHA) guideline is an update of their 2009 publication that Luke K. Hermann, MD
is primarily focused on chronic HF. The focus of this review is Associate Professor of Emergency Medicine, Director of Quality and Finance,
Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai,
PAGE 12| References on the recommendations most relevant to emergency medicine New York, NY

practice—the assessment and treatment of acute HF. Andy Jagoda, MD, FACEP
Professor and Chair, Department of Emergency Medicine, Icahn School of
Medicine at Mount Sinai, New York, NY

PAGE 13| CME Questions Practice Guideline Impact Eddy S. Lang, MDCM, CCFP (EM), CSPQ
Senior Researcher, Alberta Health Services; Associate Professor, University of
Calgary; Adjunct Professor, McGill University, Montreal, Quebec, Canada
• B-type natriuretic peptide (BNP) or N-terminal pro-B-type natri- Trevor Lewis, MD, FACEP

Editor’s Note: To read more about this publication

uretic peptide (NT-proBNP) measurements are useful to support Medical Director, Emergency Department, Cook County Hospital; Associate
Professor of Emergency Medicine, Rush Medical College, Chicago, IL
and the background and methodologies for practice clinical judgment for the diagnosis of acute HF, especially in the Gregory M. Press, MD, RDMS
guideline development, go to: Emergency Ultrasound Director, Hutt Valley Hospital, Lower Hutt, New Zealand
http://www.ebmedicine.net/introduction setting of clinical uncertainty. Christopher Tainter, MD, RDMS
Critical Care Fellow, Department of Anesthesia, Critical Care, and Pain
• A completely normal electrocardiogram (ECG) indicates that HF Medicine, Massachusetts General Hospital/Harvard Medical School, Boston,
MA
is unlikely. Scott M. Silvers, MD
Chair, Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL
• Patients with acute HF should be treated promptly with intrave- Scott D. Weingart, MD, FCCM
nous (IV) diuretics to reduce morbidity. Associate Professor, Department of Emergency Medicine, Director, Division of
ED Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY

• Vasodilators may be used as an adjunct to diuretic therapy in an

effort to reduce dyspnea, but they do not improve major outcomes. Prior to beginning this activity, see “CME Information”
on page 14.

• Drugs that are potentially harmful in patients with a reduced

ejection fraction include most antiarrhythmic drugs, most calci-
um-channel-blocking drugs (except amlodipine), and nonsteroi-
dal anti-inflammatory drugs (NSAIDs).
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Introduction To The Guidelines: Heart Failure

T
his issue of EM Practice Guidelines Update reviews 2 recently “heart failure with a reduced ejection fraction” (HFrEF), defined as an
published guidelines on the evaluation and management of HF: EF ≤ 40%.4 The ESC uses similar definitions, but considers a reduced
EF to be ≤ 35%.5 EFs of 35% to 50% encompass a gray area, and
1. “ESC Guidelines for the Diagnosis and Treatment of Acute and most likely represent patients with mild systolic dysfunction. There is
Chronic Heart Failure 2012,” published by the European Society of also no standardized terminology to describe acutely or subacutely
Cardiology (ESC), available at: worsened HF, and the terms “acute heart failure,” “acute heart failure
http://eurheartj.oxfordjournals.org/content/33/14/1787.full.pdf syndromes,” and “acutely decompensated heart failure” have been
2. “2013 ACCF/AHA Guideline for the Management of Heart Failure: used by various authors and organizations. The ACCF/AHA suggests
a Report of the American College of Cardiology Foundation/Ameri- that the use of clinical descriptors can help subclassify patients with
can Heart Association Task Force on Practice Guidelines,” pub- acute HF as congested or not (“wet” or “dry”) and/or as being well-
lished by the American Heart Association (AHA), available at: perfused or not (“warm” or “cold”).
http://circ.ahajournals.org/content/early/2013/06/03/
CIR.0b013e31829e8776.full.pdf This issue of EM Practice Guidelines Update will inform the emergency
clinician of the new and updated guidelines in the diagnosis and care
HF is a common condition affecting approximately 1% to 2% of the of patients with HF. Faced with the pressures of managing patients
adult population, with a prevalence of ≥ 10% in patients aged > 70 with acute HF or HF as a comorbidity, reducing admission rates for
years.1 Survival for HF patients has improved, but absolute mortality acute HF, and determining the often subtle presentations of new-onset
rates remain at approximately 50% at 5 years for all-cause HF.2 There HF in the ED, the emergency clinician must be well-versed in the acute
is some evidence that the number of hospitalizations attributed pri- treatment guidelines, chronic treatment regimens, and approaches to
marily to HF is declining; however, there has been an increase in the diagnosis. Many of the recommendations in the full guidelines apply
number of hospitalizations of patients with a diagnosis of chronic HF.3 to the outpatient setting, and only those that are applicable to the care
of the ED patient will be reviewed here. The ACCF/AHA guidelines are
HF is a heterogeneous clinical syndrome caused by structural and more focused on the United States population and much broader in
functional impairment of ventricular filling or ejection of blood, result- their discussion of outpatient management and chronic congestive HF.
ing primarily in dyspnea and fatigue with or without symptoms of The ESC recommendations apply to a more global population, with a
volume overload.4 There is no definitive diagnostic test for HF. As a greater focus on acute care.
result, there is considerable variability in the definitions and terminol-
ogy used to describe HF. The AHA recommends against use of the —Trevor Lewis, MD
term “congestive heart failure,” as fluid overload need not be present,
and prefers the term “heart failure.” The ACCF/AHA guideline writ-
ing committee used the terms “heart failure with a preserved ejection
fraction” (HFpEF), defined as an ejection fraction (EF) ≥ 50%; and

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Guest Editor Comment: Deborah Diercks, MD a randomized controlled trial (RCT) from 2008 did not show positive
For the emergency clinician, an ideal guideline on HF would provide results;6 however, readers should be reminded of the 2013 Cochrane
clear recommendations for decsions regarding ED-based diagnostics, review (which included this RCT) that showed a reduction in mortal-
treatment, and disposition. These 2 recently published guidelines by ity, a reduction in the need for endotracheal intubation, as well as a
the major American and European cardiology societies focus largely reduction in the number of days spent in the intensive care unit without
on the care of chronic HF, but they also provide guidance for patients increasing the risk of having a heart attack during or after treatment.7
presenting with acute HF. The ACCF/AHA HF guideline covers acute
care under the section entitled “The Hospitalized Patient." It does not Overall, the treatment guidelines are relatively consistent with current
explicitly address the ED setting (not surprising, perhaps, as no emer- practices in the ED, so they may provide reassurance to ED clinicians
gency physicians were included on the writing panel). that their current management plan is sufficient. However, these guide-
lines also highlight important regulatory benchmarks that are tracked
The ACCF/AHA continues to suggest categorization of acute HF pa- on HF patients, and these are relevant, as emergency clinicians are
tients by their hemodynamic status and degree of congestion. Diag- taking a more comprehensive role in the management of acute HF
nostic tests (eg, chest x-ray and natriuretic peptide levels) can be used patients. The outcome measures of admission rates and 30-day risk-
to assist in this assessment. For patients with congestion who are standardized HF readmission rates are clearly in the domain of the
hemodynamically stable, the Class I recommendation is to use loop emergency clinician. Currently, there are approximately 700,000 ED
diuretics as part of the initial management (“...to be given in the ED”). visits for acute HF per year in the United States, approximately 80%
Adjuncts to diuretics that are also suggested (with Class IIb recom- of which result in admission.8 Despite this (and perhaps because the
mendations) include low-dose dopamine, ultrafiltration, IV vasodila- ACCF/AHA writing committee did not focus on the ED setting), the
tors (nitroglycerin, nitroprusside, nesiritide), and vasopressin receptor question of risk stratification and potential discharge from the ED is not
antagonists (for patients with severe hyponatremia). Ultrafiltration may addressed.
not be relevant to emergency clinicians outside of specialized health-
care settings, as it requires resources that are limited in the ED setting. The recommendations in the ACCF/AHA guidelines for management of
Surprisingly, the ACCF/AHA guidelines do not address the use of non- acute HF are somewhat difficult to locate within the document; how-
invasive ventilation (NIV). Unlike ultrafiltration, NIV is widely available ever, the ESC guidelines present the information in a clear format. The
and in common use in the ED. best use of the ACCF/AHA guidelines is as a reference for specific is-
sues. For the emergency clinician seeking to practice guideline-based
In contrast to the ACCF/AHA guidelines, the ESC HF guidelines pres- therapy and utilize algorithms, the ESC guidelines are much more
ent more comprehensive and user-friendly recommendations for useful. ■
patients presenting with acute HF. These guidelines present algorithms
for diagnosis and management, and, unlike the ACCF/AHA guidelines
that suggest treatment based on assessment of perfusion and conges-
tion, these guidelines recommend treatment based on blood pressure
and oxygenation in patients with pulmonary congestion. The actual
treatment recommendations differ very little between the guidelines.
The ESC does address NIV, endorsing it with a IIB recommendation
based on class B evidence. In their discussion, they cite concern that

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Assessment Of The Guideline Methodology

A
committee appointed by the ACCF/AHA Task Force on Practice Table 1. Definition Of Classes And Levels Of Evidence Used In American
Guidelines authored the ACCF/AHA guidelines. The definitions Heart Association Recommendations
and levels of recommendations are noted in Table 1. Members
of the ESC Task Force were selected by the ESC to write the guide- Level of Evidence
line in accordance with the ESC Committee for Guidelines Policy. The A Data derived from multiple sources
same definitions for the recommendations were utilized as noted in B Data derived from a single randomized trial or nonrandomized studies
Table 1. C Consensus opinion of experts
Classes of Recommendation
The authors of this issue of EM Practice Guidlines Update, Trevor
Class I Conditions for which there is conflicting evidence for and/or general
Lewis, MD and Editor-in-Chief Sigrid Hahn, MD, MPH graded this agreement that the procedure or treatment is useful and effective
guideline using the Appraisal of Guidelines for Research and Educa- Class II Conditions for which there is conflicting evidence and/or a divergence of
tion (AGREE) II instrument (available at http://www.agreetrust.org/). opinion about the usefulness/efficacy of a procedure or treatment
This instrument is a checklist that allows users to grade a guideline on | PRINT | SUBSCRIBE | WEBSITE
Class IIa The weight of evidence or opinion is in favor of the procedure or treatment
23 items in 6 domains, reflecting the degree to which the guideline de-
Class IIb Usefulness/efficacy is less well established by evidence or opinion
velopers used unbiased, best-practice methodology in developing the
Class III Conditions for which there is evidence and/or general agreement that
guideline and writing the recommendations. The results of the AGREE
the procedure or treatment is not useful/effective and in some cases
instrument are presented in Figure 1, with a percentile calculated and may be harmful
assigned for each domain (maximum score of 100%). The score for
relevance to emergency medicine is not part of the AGREE instrument, Figure 1. AGREE Criteria For Heart Failure Guidelines
but reflects the judgment of the author and editor of this issue
Scope and purpose

—Trevor Lewis, MD; and Sigrid Hahn, MD, MPH Stakeholder involvement

Rigor of development

n ESC
Clarity of presentation
n ACCF/AHA
Applicability

Editorial independence

Overall guideline quality

Relevance to emergency medicine

0 20 40 60 80 100
Abbreviation: AGREE, Appraisal of Percentile Score
Guidelines for Research and Education.

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Selected Guideline Recommendations, With Discussion

T
he recommendations excerpted here are presented as they ap- markers, including cardiac troponin testing, and treated optimally
pear in the original guidelines, including the strength of the as appropriate to the overall condition and prognosis of the patient.
recommendation and the level of evidence. Recommendations (ACCF/AHA, Class I, Level C)
on the same clinical topic from the 2 guidelines are presented side-
by-side to facilitate comparison. However, when there is overlap and Electrocardiogram
no significant discrepancy, only 1 of the 2 guideline recommendations • A 12-lead ECG is recommended to determine heart rhythm, heart
are presented, in the interest of brevity. Disease prevention, nonsurgi- rate, QRS morphology, and QRS duration, and to detect other
cal device implantation, and surgical options are not reviewed, as they relevant abnormalities. This information also assists in planning
have limited relevance to the emergency clinician. treatment and is of prognostic importance. A completely normal
ECG makes systolic HF unlikely. (ESC, Class I, Level C)
Initial Assessment Of Suspected Acute Heart Failure
• Common precipitating factors for acute HF should be considered Chest X-Ray
during initial evaluation, as recognition of these conditions is critical • Patients with suspected or new-onset HF or patients presenting
to guide appropriate therapy. (ACCF/AHA, Class I, Level C) with acute decompensated HF, should undergo a chest x-ray to as-
• Common factors that precipitate acute decompensated HF include: sess heart size and pulmonary congestion and to detect alternative
◦◦ Nonadherence with medication regimen, sodium and/or fluid cardiac, pulmonary, and other diseases that may cause or contrib-
restriction ute to the patient’s symptoms. (ACCF/AHA, Class I, Level C)
◦◦ Acute myocardial ischemia
◦◦ Uncorrected high blood pressure Editorial Comment: Trevor Lewis, MD
◦◦ Atrial fibrillation and other arrhythmias Several points are worth highlighting: (1) Heart failure is very unlikely
◦◦ Recent addition of negative inotropic drugs (eg, verapamil, nife- in patients with a normal ECG; (2) A normal chest x-ray does not
dipine, diltiazem, beta blockers) exclude pulmonary edema and is better for identifying an alternative di-
◦◦ Pulmonary embolus agnosis than for ruling in acute HF; (3) Although ESC does not make a
◦◦ Initiation of drugs that increase salt retention (eg, steroids, thia- formal recommendation about the role of echocardiography in the ED
zolidinediones, NSAIDs) (the recommendations about echocardiography refer to the ambulatory
◦◦ Excessive alcohol or illicit drug use setting), they incorporate echocardiography in their diagnostic algo-
◦◦ Endocrine abnormalities (eg, diabetes mellitus, hyperthyroid- rithm for acute HF. They endorse early echocardiography for patients
ism, hypothyroidism) presenting to the ED with suspected acute HF (immediate echocar-
◦◦ Concurrent infections (eg, pneumonia, viral illnesses) diography is recommended in shocked or severely hemodynamically
◦◦ Additional acute cardiovascular disorders (eg, valve disease compromised patients). Neither organization discusses the role of
endocarditis, myopericarditis, aortic dissection) bedside echocardiography. (See Figure 2, page 6.)
• Acute coronary syndromes (ACS) precipitating acute HF decom-
pensation should be promptly identified by ECG and serum bio-

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Figure 2. European Society Of Cardiology Recommended Diagnostic Testing For Acute Heart Failure

Suspected heart failure of acute onset

• ECG
• Chest x-ray
• BNP/NT-proBNP*

ECG abnormal ECG normal

or and
NT-proBNP ≥ 300 pg/mL† NT-proBNP < 300 pg/mL
or or
BNP ≥ 100 pg/mL† BNP < 100 pg/mL

Echocardiogram Heart failure unlikely‡

If heart failure is confirmed, determine

etiology and start appropriate treatment

*In the acute setting, MR-proANP may also be used (cut-off point < 120 pmol/L; ie, < 120 pmol/L = heart failure unlikely).
†
Other causes of elevated natriuretic peptide levels in the acute setting are an acute coronary syndromes, atrial or ventricular arrhythmias, pulmonary embolism, and severe chronic obstructive pulmonary disease with
elevated right heart pressure, renal failure, and sepsis. Other causes of an elevated natriuretic level in the nonacute setting are: old age (> 75 years), atrial arrhythmias, left ventricular hypertrophy, chronic obstructive
pulmonary disease, and chronic kidney disease.
‡
Treatment may reduce natriuretic peptide concentration, and natriuretic concentrations may not be markedly elevated in patients with HF-PEF.

Abbreviations: BNP, B-type natriuretic peptide; ECG, electrocardiogram; HF-pEF, heart failure with preserved ejection fraction; MR-proANP, midregional pro-atrial natriuretic peptide; NT-proBNP, N-terminal B-type
natriuretic peptide.

EM Practice
EM Practice Guidelines
Guidelines Update
Update ©
© 2011
2014 2 6 www.ebmedicine.net • January/February
ebmedicine.net 2014
• April 2012
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Laboratory Testing Treatment Of Acute Heart Failure Without Shock

• Measurement of BNP or NT-proBNP is useful to support clinical Oxygen
judgment for the diagnosis of acutely decompensated HF, especial- High-flow oxygen is recommended in patients with a capillary oxygen
ly in the setting of uncertainty for the diagnosis. (ACCF/AHA, Class saturation < 90% or PaO2 < 60 mm Hg (8.0 kPa) to correct hypoxemia.
I, Level A; revised from previous guidelines)9 (ESC, Class I, Level C)
• Measurement of BNP or NT-proBNP and/or cardiac troponin is
useful for establishing prognosis or disease severity in acutely Editorial Comment: Trevor Lewis, MD
decompensated HF. (ACCF/AHA, Class I, Level A; revised from Oxygen should not be used routinely in nonhypoxic patients as it
previous guidelines)9 causes vasoconstriction and reduced cardiac output.
• The usefulness of BNP- or NT-proBNP-guided therapy for acutely
decompensated HF is not well established. (ACCF/AHA, Class IIb, Noninvasive Ventilation
Level C, new recommendation) NIV (eg, CPAP) should be considered in dyspneic patients with pulmo-
• Measurement of other clinically available tests (such as biomarkers nary edema and a respiratory rate > 20 breaths/min to improve breath-
of myocardial injury or fibrosis) may be considered for additive risk lessness and reduce hypercapnia and acidosis. NIV can reduce blood
stratification in patients with acutely decompensated HF. (ACCF/ pressure and should not generally be used in patients with a systolic
AHA, Class IIb, Level A, new recommendation) blood pressure (SBP) < 85 mm Hg (and blood pressure should be moni-
• Measurement of natriuretic peptide (BNP, NT-proBNP, or midregional tored regularly when this treatment is used). (ESC, Class IIa, Level B)
pro-atrial natriuretic peptide [MR-proANP]) should be considered to:
◦◦ Exclude alternative causes of dyspnea (if the level is below the Editorial Comment: Trevor Lewis, MD
exclusion cut-point, HF is very unlikely) (ESC, Class IIb, Level C) The use of NIV has become routine in the management of patients
◦◦ Obtain prognostic information (ESC, Class IIb, Level C) presenting to the ED with acute HF. As previously noted, a 2013 Co-
chrane meta-analysis found a reduction in hospital mortality and the
Editorial Comment: Trevor Lewis, MD need for intubation with NIV.7 The ESC guideline authors, however, cite
Routine laboratory testing can help elucidate possible causes of acute an RCT (also included in the meta-analysis) that demonstrated that
HF (such as anemia). The ACCF/AHA guideline newly recommends neither continuous positive airway pressure (CPAP) nor noninvasive
measuring troponin for “additive risk stratification” in acute HF, and com- positive pressure ventilation (NIPPV) reduced mortality or the rate of
ments that the measurement of troponins should be routine in patients endotracheal intubation when compared with standard therapy.6 This
presenting with acute HF. The ESC suggests only that troponins “may appears to be why they describe NIV as an “adjunct” therapy for pa-
be indicated” in the ED patient. The ACCF/AHA has revised its recom- tients who are not improving with pharmacologic therapy or who are in
mendations regarding the use of BNP and provides a strong recommen- severe distress, rather than as a Class I, first-line therapy.
dation in support of the role of BNP in cases of diagnostic uncertainty
(much stronger than the ESC). The ESC guideline emphasizes the abil-
ity of a BNP measurement to exclude acute HF in the ED patient if NT-
proBNP is < 300 pg/mL or BNP is < 100 pg/mL. BNP also has obvious
prognostic value, but no established value in guiding treatment. The role
of BNP in the diagnostic workup of acute HF is shown in the algorithm
from the ESC guideline. (See Figure 2, page 6.)

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Treatment Of Acute Heart Failure Without Shock (Continued) Vasodilators

Diuretics • If symptomatic hypotension is absent, IV nitroglycerin, nitroprus-
• Patients with HF admitted with evidence of significant fluid overload side, or nesiritide may be considered an adjuvant to diuretic ther-
should be promptly treated with IV loop diuretics to reduce morbid- apy for relief of dyspnea in patients admitted with acutely decom-
ity. (ACCF/AHA, Class I, Level B) pensated HF. (ACCF/AHA, Class IIb, Level B)
• If patients are already receiving loop diuretic therapy, the initial • An IV infusion of a nitrate should be considered in patients with
IV dose should equal or exceed their chronic oral daily dose and pulmonary congestion/edema and a SBP > 110 mm Hg who do not
should be given as either intermittent boluses or as a continu- have severe mitral or aortic stenosis, to reduce pulmonary capillary
ous infusion. Urine output and signs and symptoms of conges- wedge pressure and systemic vascular resistance. Nitrates may
tion should be serially assessed, and the diuretic dose should be also relieve dyspnea and congestion. Symptoms and blood pres-
adjusted accordingly to relieve symptoms, reduce volume excess, sure should be monitored frequently during administration of IV
and avoid hypotension. (ACCF/AHA, Class I, Level B; revised from nitrates. (ESC, Class IIa, Level B)
previous guideline)9 • An IV infusion of sodium nitroprusside may be considered in
• An IV loop diuretic is recommended to improve breathlessness and patients with pulmonary congestion/edema and a SBP > 110 mm
relieve congestion. Symptoms, urine output, renal function, and Hg who do not have severe mitral or aortic stenosis, to reduce
electrolytes should be monitored regularly during use of IV diuretics pulmonary capillary wedge pressure and systemic vascular resis-
(ESC, Class I, Level B) tance. Caution is recommended in patients with acute myocardial
• Low-dose dopamine infusion may be considered in addition to loop infarction. Nitroprusside may also relieve dyspnea and congestion.
diuretic therapy to improve diuresis and to better preserve renal Symptoms and blood pressure should be monitored frequently dur-
function and renal blood flow. (ACCF/AHA, Class IIb, Level B) ing administration of IV nitroprusside. (ESC, Class IIa, Level B)

Editorial Comment: Trevor Lewis, MD Editorial Comment: Trevor Lewis, MD

Both guidelines conclude that diuretics are a cornerstone of therapy for Both guideline writing committees conclude that, overall, there are no
acute HF. The AHA guidelines codify what has already been a common data to suggest that IV vasodilators improve major outcomes in the
ED dosing regimen for years, and they recommend starting diuretics patient hospitalized with HF. IV vasodilators may help relieve dyspnea.
in the ED without delay, in an effort to improve outcomes (although The ACCF/AHA guideline also cautions that IV vasodilators should be
their impact on mortality is not well established). The ESC guideline administered with caution in patients with HFpEF, as these patients are
does not specify dosing, noting the lack of good evidence for the use typically more volume sensitive.
of high-dose over low-dose loop diuretics and tradeoffs that include
transiently worsened renal function. The addition of a thiazide diuretic Opiates
is a good option to remember when initial aggressive furosemide dos- An IV opiate (along with an antiemetic) should be considered in par-
ing is inadequate. The weak recommendation to consider dopamine is ticularly anxious, restless, or distressed patients to relieve these
added in this section for reader interest; however, it should be noted symptoms and improve breathlessness. Alertness and ventilatory effort
that this is based on a single study and the guideline authors remarked should be monitored frequently after administration because opiates
that more data are needed. can depress respiration. (ESC, Class IIa, Level C)

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Treatment Of Acute Heart Failure Without Shock (Continued) • An IV infusion of an inotrope (eg, dobutamine) should be consid-
Inotropes And Vasopressors ered in patients with hypotension (SBP < 85 mm Hg) and/or hy-
• Inotropic agents are NOT recommended unless the patient is hy- poperfusion to increase cardiac output, increase blood pressure,
potensive (SBP < 85 mm Hg), hypoperfused, or shocked because and improve peripheral perfusion. The ECG should be monitored
of safety concerns (atrial and ventricular arrhythmias, myocardial continuously because inotropic agents can cause arrhythmias and
ischemia, and death). (ESC, Class III, Level C) myocardial ischemia. (ESC, Class IIa, Level C)
• Use of parenteral inotropic agents in hospitalized patients without • A vasopressor (eg, dopamine or norepinephrine) may be consid-
documented severe systolic dysfunction, low blood pressure, or ered in patients who have cardiogenic shock, despite treatment
impaired perfusion and evidence of significantly depressed cardiac with an inotrope, to increase blood pressure and vital organ perfu-
output, with or without congestion, is potentially harmful. (ACCF/ sion. The ECG should be monitored, as these agents can cause
AHA, Class III, Level B) arrhythmias and/or myocardial ischemia. Intra-arterial blood pres-
sure measurement should be considered. (ESC, Class IIb, Level C)
Editorial Comment: Trevor Lewis, MD • An IV infusion of levosimendan (or a phosphodiesterase inhibitor)
Inotropes or vasopressors are only potentially appropriate in patients may be considered to reverse the effect of beta blockade if beta
with significant hypoperfusion or cardiogenic shock. (See discussion blockade is thought to be contributing to hypoperfusion. The ECG
following.) should be monitored continuously because inotropic agents can
cause arrhythmias and myocardial ischemia, and, as these agents
Treatment Of Acute Heart Failure With Hypotension, are also vasodilators, blood pressure should be monitored care-
Hypoperfusion, Or Shock fully. (ESC, Class IIb, Level C)
Cardioversion
• Electrical cardioversion is recommended if an atrial or ventricular Editorial Comment: Trevor Lewis, MD
arrhythmia is thought to be contributing to the patient’s hemody- Patients with acute HF and shock have severely compromised cir-
namic compromise in order to restore sinus rhythm and improve culatory status, and the use of inotropes and vasopressors requires
the patient’s clinical condition. (ESC, Class I, Level C) an assessment of the tradeoff between potential benefits and risks
(including myocardial ischemia and arrhythmias) in these critically ill
Inotropes And Vasopressors patients. Despite improving hemodynamic status, inotropes have not
• Short-term, continuous IV inotropic support may be reasonable in been shown to improve patient outcomes. Of note, many of the studies
hospitalized patients presenting with documented severe systolic focus on end-stage chronic HF patients, which may not be applicable
dysfunction who present with low blood pressure and significantly to the acute presentation of the ED patient.
depressed cardiac output to maintain systemic perfusion and
preserve end-organ performance (ACCF/AHA, Class IIb, Level B;
revised from previous guideline)9
• Until definitive therapy (eg, coronary revascularization, mechani-
cal circulatory support, heart transplantation) or resolution of the
acute precipitating problem, patients with cardiogenic shock should
receive temporary IV inotropic support to maintain systemic perfu-
sion and preserve end-organ performance. (ACCF/AHA, Class I,
Level C)

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Treatment Of Acute Heart Failure With Hypotension, ST-segment elevated myocardial infarction (NSTEMI) is complicated
Hypoperfusion, Or Shock (Continued) by the fact that patients both with and without coronary artery disease
Mechanical Circulatory Support often have elevated troponin levels in the setting of acute HF.
• Short-term mechanical circulatory support should be considered
(as a “bridge to recovery”) in patients remaining severely hypoper- Treatment Of Acute Heart Failure With An Arrhythmia
fused despite inotropic therapy and with a potentially reversible • Electrical cardioversion is recommended in patients hemodynami-
cause (eg viral myocarditis) or a potentially surgically correctable cally compromised by atrial fibrillation and in whom urgent resto-
cause (eg acute interventricular septal rupture). (ESC, Class IIa, ration of sinus rhythm is required to improve the patient’s clinical
Level C) condition rapidly. (ESC, Class I, Level C)
• Short-term mechanical circulatory support may be considered (as • Patients should be fully anticoagulated (eg, with IV heparin), if not
a ‘bridge to decision’) in patients deteriorating rapidly before a full already anticoagulated and with no contraindication to anticoagula-
diagnostic and clinical evaluation can be made. (ESC, Class IIb, tion, as soon as atrial fibrillation is detected to reduce the risk of
Level C) systemic arterial embolism and stroke. (ESC, Class I, Level A)
• Electrical cardioversion or pharmacological cardioversion with
Treatment Of Acute Heart Failure Due To Acute Coronary amiodarone should be considered in patients when a decision is
Syndromes made to restore sinus rhythm nonurgently (“rhythm control” strat-
• Immediate primary percutaneous coronary intervention (PCI) (or egy). This strategy should only be employed in patients with a first
coronary artery bypass graft [CABG] in selected cases) is recom- episode of atrial fibrillation of < 48 hours’ duration (or in patients
mended if there is an ST elevation or a new left bundle branch with no evidence of left atrial appendage thrombus on transesoph-
block ACS in order to reduce the extent of myocyte necrosis and ageal echocardiogram). (ESC, Class I, Level C)
reduce the risk of premature death. (ESC, Class I, Level A; revised
from previous guideline)10 Editorial Comment: Trevor Lewis, MD
• Alternative to PCI or CABG: IV thrombolytic therapy is recommend- The ACCF/AHA guideline defers to the 2011 ACCF/AHA/HRS Focused
ed if PCI/CABG cannot be performed, or if there is ST-segment Update on the Management of Patients With Atrial Fibrillation guide-
elevation or new left bundle branch block, to reduce the extent of line (available at http://circ.ahajournals.org/content/123/1/104.extract)
myocyte necrosis and reduce the risk of premature death. (ESC, for treatment of patients with HF and arrhythmia. The ESC guideline
Class I, Level A; revised from previous guideline)10 comments on the use of urgent heparin for patients who are not cur-
• Early PCI (or CABG in selected patients) is recommended if there rently anticoagulated. In addition, the guidelines mirror the current
is non-ST elevation ACS in order to reduce the risk of recurrent Advanced Cardiac Life Support (ACLS) recommendations to cardio-
ACS. Urgent revascularization is recommended if the patient is vert the unstable patient. Care must be employed in interpreting what
hemodynamically unstable. (ESC, Class I, Level A; revised from constitutes an "unstable" patient, especially in the setting of unknown
previous guideline)10 duration of AF with the potential for atrial clot. A fully revised atrial
fibrillation guideline, which will include updated recommendations on
Editorial Comment: Trevor Lewis, MD HF with atrial fibrillation, is in development by the ACCF/AHA, with
Management of patients with ST-segment elevated myocardial infarction publication expected in 2014.
(STEMI) and HF is straightforward, as these patients need immediate
cardiac intervention. In contrast, the diagnosis and management of non-

EM Practice Guidelines Update © 2014 10 www.ebmedicine.net • January/February 2014

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Treatments That May Cause Harm Summary Of Guideline-Directed Medical Therapy For The
• Drugs known to adversely affect the clinical status of patients with Emergency Physician: Trevor White, MD
current or prior symptoms of HFrEF are potentially harmful and The ACCF/AHA guideline emphasizes the importance of “guideline-di-
should be avoided or withdrawn whenever possible (eg, most rected medical therapy," and both they and the ESC spend much time
antiarrhythmic drugs, most calcium-channel-blocking drugs [except discussing the appropriate outpatient regimen for the management of
amlodipine], NSAIDs, or thiazolidinediones). (ACCF/AHA, Class III, chronic HF. An understanding of these medications is useful for the
Level B) emergency clinician when managing HF patients in the ED, whether
• Thiazolidinediones (glitazones) should not be used, as they cause they have an acute decompensation or not.
worsening HF and increase the risk of HF hospitalization. (ESC,
Class III, Level A) Both angiotensin-converting enzyme (ACE) inhibitors and beta block-
• Most calcium-channel blockers (with the exception of amlodipine ers have been cornerstones of HFrEF treatment for years. Key trials
and felodipine) should not be used, as they have a negative inotro- have included the Cooperative North Scandinavian Enalapril Survival
pic effect and can cause worsening HF. (ESC, Class III, Level B) Study (CONSENSUS) and Studies of Left Ventricular Dysfunction
• NSAIDs and cyclooxygenase-2 (COX-2) inhibitors should be (SOLVD), which have shown reductions in mortality of 27% and 16%,
avoided, if possible, as they may cause sodium and water reten- respectively, with the use of these drugs.11-13 The primary role of angio-
tion, worsening renal function, and worsening HF. (ESC, Class III, tensin-receptor blockers (ARBs) still appears to be as a substitute for
Level B) patients who are intolerant to ACE inhibitors. The expansion of the role
of mineralocorticoid/aldosterone-receptor antagonists has come from
Editorial Comment: Trevor Lewis, MD recent RCTs, including the Eplerenone in Mild Patients Hospitalization
These recommendations are new in the current guidelines. They pro- and Survival Study in Heart Failure (EMPHASIS-HF), which found that
vide a useful summary of drugs for emergency clinicians to avoid when patients already taking ACE inhibitors and beta blockers had a de-
managing HF. Reviewing a patient’s medication list can provide clues crease in hospitalizations and death.14,15 The bottom line is that the use
to reasons for their decompensation. Commonly prescribed diabetes of ACE inhibitors, beta blockers, and mineralocorticoid/aldosterone-re-
medications, such as pioglitazone (Actos®) and rosiglitazone (Avan- ceptor antagonists is fundamentally important in improving the course
dia®) should be avoided in HF patients. More important for emergency of systolic HF and should, at least, be considered in every patient. The
medicine practice is the avoidance of NSAIDs and COX-2 selective utility of digoxin still remains more of an additive medication after the
inhibitor medications in HF. These are commonly prescribed medica- implementation of other first-line therapies. ■
tions in the ED and often given to this subset of patients.

EM Practice Guidelines Update © 2014 11 www.ebmedicine.net • January/February 2014

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References 9. Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorpo-
1. Mosterd A, Hoes AW. Clinical epidemiology of heart failure. Heart. rated into the ACC/AHA 2005 guidelines for the diagnosis and man-
2007;93(9):1137-1146. (Review) agement of heart failure in adults: a report of the American College
2. Roger VL, Weston SA, Redfield MM, et al. Trends in heart failure of Cardiology Foundation/American Heart Association Task Force
incidence and survival in a community-based population. JAMA. on Practice Guidelines developed in collaboration with the Interna-
2004;292(3):344-350. (Population-based cohort study; 4537 pa- tional Society for Heart and Lung Transplantation. J Am Coll Cardiol.
tients) 2009;53(15):e1-e90. (Guidelines)

3. Blecker S, Paul M, Taksler G, et al. Heart failure-associated hospital- 10. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for
izations in the United States. J Am Coll Cardiol. 2013;61(12):1259- the diagnosis and treatment of acute and chronic heart failure 2008:
1267. (Nationwide inpatient sample) the Task Force for the Diagnosis and Treatment of Acute and Chronic
Heart Failure 2008 of the European Society of Cardiology. Developed
4. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for in collaboration with the Heart Failure Association of the ESC (HFA)
the management of heart failure: a report of the American College of and endorsed by the European Society of Intensive Care Medicine
Cardiology Foundation/American Heart Association Task Force on (ESICM). Eur J Heart Fail. 2008;10(10):933-989. (Guidelines)
Practice Guidelines. Circulation. 2013;128(16):e240-e319. (Guide-
lines) 11. Effects of enalapril on mortality in severe congestive heart failure. Re-
sults of the Cooperative North Scandinavian Enalapril Survival Study
5. McMurray JJ, Adamopoulos S, Anker SD, et al. ESC guidelines for (CONSENSUS). The CONSENSUS Trial Study Group. N Engl J Med.
the diagnosis and treatment of acute and chronic heart failure 2012: 1987;316(23):1429-1435. (Randomized double-blind study; 253
The Task Force for the Diagnosis and Treatment of Acute and Chronic patients)
Heart Failure 2012 of the European Society of Cardiology. Developed
in collaboration with the Heart Failure Association (HFA) of the ESC. 12. Effect of enalapril on mortality and the development of heart failure in
Eur J Heart Fail. 2012;14(8):803-869. (Guidelines) asymptomatic patients with reduced left ventricular ejection fractions.
The SOLVD Investigators. N Engl J Med. 1992;327(10):685-691.
6. Gray A, Goodacre S, Newby DE, et al. Noninvasive ventilation in (Randomized double-blind trial; 4228 patients)
acute cardiogenic pulmonary edema. N Engl J Med. 2008;359(2):142-
151. (Multicenter open prospective randomized controlled trial; 13. Effect of enalapril on survival in patients with reduced left ventricular
1069 patients) ejection fractions and congestive heart failure. The SOLVD Investi-
gators. N Engl J Med. 1991;325(5):293-302. (Randomized double-
7. Vital FM, Ladeira MT, Atallah AN. Non-invasive positive pressure blind trial; 2569 patients)
ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oe-
dema. Cochrane Database Syst Rev. 2013;5:CD005351. (Systematic 14. Zannad F, McMurray JJ, Krum H, et al. Eplerenone in patients
review; 32 blinded or unblinded randomized or quasi-randomised with systolic heart failure and mild symptoms. N Engl J Med.
studies; 2916 participants) 2011;364(1):11-21. (Randomized double-blind trial; 2737 patients)

8. Collins SP, Storrow AB. Moving toward comprehensive acute heart 15. Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldoste-
failure risk assessment in the emergency department: the impor- rone blocker, in patients with left ventricular dysfunction after myocar-
tance of self-care and shared decision making. JACC Heart Fail. dial infarction. N Engl J Med. 2003;348(14):1309-1321. (Randomized
2013;1(4):273-280. (Assessment) trial; 6632 patients)

EM Practice Guidelines Update © 2014 12 www.ebmedicine.net • January/February 2014

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CME Questions
To take the CME test, visit: www.ebmedicine.net/G0114 or scan the QR code below with a smartphone:

1. BNP may be helpful for all of the following clinical scenarios except to:
a. Support a clinical diagnosis in the setting of suspected acute HF
b. Provide prognostic information in patients with acute HF
c. Guide therapy for patients with acute HF
d. Establish disease severity in patients with acute HF

2. The ACCF/AHA guideline gives the strongest recommendation to which of the following treatments for acute HF?
a. IV vasodilators
b. IV diuretics
c. NIV
d. IV opiates

3. Which of the following treatment options is generally contraindicated in the severely hypotensive patient with acute HF?
a. NIV
b. Inotropes
c. Vasopressors
d. Mechanical circulatory support

4. Which of the following classes of medications is generally contraindicated in patients with HFrEF?
a. ACE inhibitors
b. Beta blockers
c. MRAs
d. NSAIDs

EM Practice Guidelines Update © 2014 13 www.ebmedicine.net • January/February 2014

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CME information for EM Practice Guidelines Update

To contact the Editor-In-Chief, email Sigrid Hahn, MD, MPH at: To take the CME test, visit: www.ebmedicine.net/G0114
[email protected] Date of Original Release: January 1, 2014. Date of most recent review: December 15, 2013. Termination
date: January 1, 2017.
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Director of Editorial: Dorothy Whisenhunt Goals: Upon completion of this article, you should be able to: (1) demonstrate medical decision-making
Content Editors: Erica Carver, Lesley Wood based on the strongest clinical evidence, (2) cost-effectively diagnose and treat the most critical ED presen-
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