Acute Left Heart Failure in the ER

Acute heart failure (AHF), a rapid or gradual onset of symptoms and/or signs of heart failure severe enough for the patient to seek urgent medical attention, represents a significant and growing healthcare burden. With a prevalence of approximately 1%–2% of the adult population, over 5 million Americans and 15 million Europeans, with a yearly incidence of 550,000, rising ≥ 10% among the elderly. Despite therapeutic advances in chronic heart failure, the prognosis of AHF is poor, with in-hospital mortality ranging from ~2% in hypertensive AHF up to 40-60% in patients with cardiogenic shock, which is a life-threatening state characterized by tissue hypoperfusion resulting in severe multi-organ dysfunction and death. Although no current therapeutic approach has improved mortality in this patient population, incorporating standardized, multidisciplinary shock teams may change. In addition, correct and expedited identification and management of AHF can be challenging due to the heterogenicity of its clinical presentation, precipitant factors, and comorbid conditions. Thus, clinicians involved in patient care should perform a structured diagnostic work-up, starting with high clinical suspicion, followed by key diagnostic tests, including biomarkers, lung ultrasonography, and echocardiography, allowing recognition of the different clinical and hemodynamic profiles and providing guidance to perform further tests and therapeutic interventions. This review discusses the healthcare burden of acute heart failure, highlights the importance of its expedited recognition, and details a proposed diagnostic work-up and individualized management approach in the emergency department. We also perform a concise review of current international guideline recommendations. Future research directions are also provided.