Acute Left Heart Failure in the Emergency Room

Main Article Content

Carlos Jerjes-Sanchez, M.D. Christian Camacho Mondragon, M.D. Victor E. Lozano-Corres, M.D. Rene D Gomez-Gutierrez, M.D. Arturo Vargas, M.D. Mauricio Vazquez Guajardo, M.D. Erasmo de la Peña Almaguer, M.D. Juan Quintanilla, M.D. Vicente Jimenez, M.D. Guillermo Torre-Amione


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.

Keywords: Acute heart failure, biomarkers, dyspnea, cardiogenic pulmonary edema

Article Details

How to Cite
JERJES-SANCHEZ, Carlos et al. Acute Left Heart Failure in the Emergency Room. Medical Research Archives, [S.l.], v. 11, n. 1, jan. 2023. ISSN 2375-1924. Available at: <>. Date accessed: 23 may 2024. doi:
Research Articles


1. Gheorghiade M, Pang PS. Acute Heart Failure Syndromes. J Am Coll Cardiol. 2009;53(7):557-573. doi:10.1016/j.jacc.2008.10.041
2. Tubaro M, European Society of Cardiology, eds. The ESC Textbook of Acute and Intensive Cardiac Care. Oxford University Press; 2014.
3. Filippatos G, Zannad F. An introduction to acute heart failure syndromes: definition and classification. Heart Fail Rev. 2007;12(2):87-90. doi:10.1007/s10741-007-9008-3
4. Jerjes-Sanchez C, Vazquez M. Acute left heart failure in the ER. In: Cardiology in the ER. A Practical Guide. Springer International Publishing; 2019:225-245.
5. Searle J, Frick J, Möckel M. Acute heart failure facts and numbers: acute heart failure populations. ESC Heart Fail. 2016;3(2):65-70. doi:10.1002/ehf2.12092
6. Weintraub NL, Collins SP, Pang PS, 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(19):1975-1996. doi:10.1161/CIR.0b013e3181f9a223
7. Kurmani S, Squire I. Acute Heart Failure: Definition, Classification and Epidemiology. Curr Heart Fail Rep. 2017;14(5):385-392. doi:10.1007/s11897-017-0351-y
8. Hasin T, Zalut T, Hasin Y. Managing the Patient with Heart Failure in the Emergency Department. Eur Heart J. 2018;39(38):3493-3495. doi:10.1093/eurheartj/ehy615
9. Collins S, Storrow AB, Albert NM, 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(1):27-43. doi:10.1016/j.cardfail.2014.07.003
10. McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599-3726. doi:10.1093/eurheartj/ehab368
11. Chioncel O, Parissis J, Mebazaa A, et al. Epidemiology, pathophysiology and contemporary management of cardiogenic shock – a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2020;22(8):1315-1341. doi:10.1002/ejhf.1922
12. Farmakis D, Parissis J, Lekakis J, Filippatos G. Acute Heart Failure: Epidemiology, Risk Factors, and Prevention. Rev Esp Cardiol Engl Ed. 2015;68(3):245-248. doi:10.1016/j.rec.2014.11.004
13. Allen CJ, Cardiology Department, Royal Brompton Hospital, London, UK, Guha K, 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. doi:10.15420/cfr.2015.1.2.69
14. Thibodeau JT, Drazner MH. The Role of the Clinical Examination in Patients With Heart Failure. JACC Heart Fail. 2018;6(7):543-551. doi:10.1016/j.jchf.2018.04.005
15. 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(1):111-115. doi:10.1002/ejhf.610
16. Baran DA, Grines CL, Bailey S, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019. Catheter Cardiovasc Interv. Published online May 19, 2019:ccd.28329. doi:10.1002/ccd.28329
17. Wang CS. Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? JAMA. 2005;294(15):1944. doi:10.1001/jama.294.15.1944
18. Benza RL, Tallaj JA, Felker GM, et al. The impact of arrhythmias in acute heart failure. J Card Fail. 2004;10(4):279-284. doi:10.1016/j.cardfail.2003.12.007
19. Papadimitriou L, Georgiopoulou VV, Kort S, Butler J, Kalogeropoulos AP. Echocardiography in Acute Heart Failure: Current Perspectives. J Card Fail. 2016;22(1):82-94. doi:10.1016/j.cardfail.2015.08.001
20. Maw AM, Hassanin A, Ho PM, et al. Diagnostic Accuracy of Point-of-Care Lung Ultrasonography and Chest Radiography in Adults With Symptoms Suggestive of Acute Decompensated Heart Failure: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(3):e190703. doi:10.1001/jamanetworkopen.2019.0703
21. Platz E, Jhund PS, Girerd N, et al. Expert consensus document: Reporting checklist for quantification of pulmonary congestion by lung ultrasound in heart failure. Eur J Heart Fail. 2019;21(7):844-851. doi:10.1002/ejhf.1499
22. Pivetta E, Goffi A, Lupia E, et al. Lung Ultrasound-Implemented Diagnosis of Acute Decompensated Heart Failure in the ED. Chest. 2015;148(1):202-210. doi:10.1378/chest.14-2608
23. Al Deeb M, Barbic S, Featherstone R, Dankoff J, Barbic D. Point-of-care Ultrasonography for the Diagnosis of Acute Cardiogenic Pulmonary Edema in Patients Presenting With Acute Dyspnea: A Systematic Review and Meta-analysis. Zehtabchi S, ed. Acad Emerg Med. 2014;21(8):843-852. doi:10.1111/acem.12435
24. Martindale JL, Wakai A, Collins SP, et al. Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Carpenter C, ed. Acad Emerg Med. 2016;23(3):223-242. doi:10.1111/acem.12878
25. Bistola V, Polyzogopoulou E, Ikonomidis I, Parissis J. Lung ultrasound for the diagnosis of acute heart failure: time to upgrade current indication? Eur J Heart Fail. 2019;21(6):767-769. doi:10.1002/ejhf.1414
26. Picano E, Scali MC, Ciampi Q, Lichtenstein D. Lung Ultrasound for the Cardiologist. JACC Cardiovasc Imaging. 2018;11(11):1692-1705. doi:10.1016/j.jcmg.2018.06.023
27. Gargani L. Ultrasound of the Lungs. Heart Fail Clin. 2019;15(2):297-303. doi:10.1016/j.hfc.2018.12.010
28. Martindale JL. Resolution of sonographic B-lines as a measure of pulmonary decongestion in acute heart failure. Am J Emerg Med. 2016;34(6):1129-1132. doi:10.1016/j.ajem.2016.03.043
29. Martindale JL, Secko M, Kilpatrick JF, et al. Serial Sonographic Assessment of Pulmonary Edema in Patients With Hypertensive Acute Heart Failure: Serial Lung Sonography in Acute Heart Failure. J Ultrasound Med. 2018;37(2):337-345. doi:10.1002/jum.14336
30. Miglioranza MH, Picano E, Badano LP, et al. Pulmonary congestion evaluated by lung ultrasound predicts decompensation in heart failure outpatients. Int J Cardiol. 2017;240:271-278. doi:10.1016/j.ijcard.2017.02.150
31. Lichtenstein DA. Lung ultrasound for the cardiologist – a basic application: The B-profile of the Bedside Lung Ultrasound in Emergencies protocol for diagnosing haemodynamic pulmonary oedema. Arch Cardiovasc Dis. 2020;113(8-9):489-491. doi:10.1016/j.acvd.2020.05.005
32. Peacock, MD WF. Heart Failure in the Emergency Department. Emerg Med. 2017;49(10):443-460. doi:10.12788/emed.2017.0061
33. Heart Failure Society of America. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail. 2010;16(6):e1-e2. doi:10.1016/j.cardfail.2010.04.004
34. Kuo DC, Peacock WF. Diagnosing and managing acute heart failure in the emergency department. Clin Exp Emerg Med. 2015;2(3):141-149. doi:10.15441/ceem.15.007
35. Quintanilla J, Jerjes-Sanchez C, Perez L, et al. Intermediate- to high-risk pulmonary embolism with normal B-type natriuretic peptide. Am J Emerg Med. 2016;34(12):2463.e1-2463.e3. doi:10.1016/j.ajem.2016.05.070
36. Manautou L, Jerjes-Sanchez C, Meraz M, et al. Myopericarditis with predominantly right ventricular involvement with normal B-type natriuretic peptide and cardiac tamponade as the initial manifestation of systemic lupus erythematosus. Lupus. 2014;23(9):935-938. doi:10.1177/0961203314530486
37. Pang PS, Teerlink JR, Voors AA, 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(7):591-599. doi:10.1016/j.jchf.2016.02.009
38. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: Executive Summary. J Am Coll Cardiol. 2013;62(16):1495-1539. doi:10.1016/j.jacc.2013.05.020
39. Matsue Y, Damman K, Voors AA, et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure. J Am Coll Cardiol. 2017;69(25):3042-3051. doi:10.1016/j.jacc.2017.04.042
40. Mentz RJ, Felker GM, Ahmad T, et al. Learning from recent trials and shaping the future of acute heart failure trials. Am Heart J. 2013;166(4):629-635. doi:10.1016/j.ahj.2013.08.001
41. Felker GM, Lee KL, Bull DA, et al. Diuretic Strategies in Patients with Acute Decompensated Heart Failure. N Engl J Med. 2011;364(9):797-805. doi:10.1056/NEJMoa1005419
42. Jondeau G, Neuder Y, Eicher JC, 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(18):2186-2192. doi:10.1093/eurheartj/ehp323
43. Prandoni P, Lensing AWA, Prins MH, et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med. 2016;375(16):1524-1531. doi:10.1056/NEJMoa1602172
44. Colucci W. Treatment of acute decompensated heart failure: Components of therapy. Published online August 25, 2017.
45. Tsangaris A, Alexy T, Kalra R, et al. Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock. Front Cardiovasc Med. 2021;8:686558. doi:10.3389/fcvm.2021.686558
46. Telukuntla KS, Estep JD. Acute Mechanical Circulatory Support for Cardiogenic Shock. Methodist DeBakey Cardiovasc J. 2020;16(1):27. doi:10.14797/mdcj-16-1-27
47. for The International ECMO Network (ECMONet) and The Extracorporeal Life Support Organization (ELSO), Abrams D, Garan AR, et al. Position paper for the organization of ECMO programs for cardiac failure in adults. Intensive Care Med. 2018;44(6):717-729. doi:10.1007/s00134-018-5064-5
48. Guglin M, Zucker MJ, Bazan VM, et al. Venoarterial ECMO for Adults. J Am Coll Cardiol. 2019;73(6):698-716. doi:10.1016/j.jacc.2018.11.038
49. Lorusso R, Shekar K, MacLaren G, et al. ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients. ASAIO J. 2021;67(8):827-844. doi:10.1097/MAT.0000000000001510
50. El Sibai R, Bachir R, El Sayed M. ECMO use and mortality in adult patients with cardiogenic shock: a retrospective observational study in U.S. hospitals. BMC Emerg Med. 2018;18(1):20. doi:10.1186/s12873-018-0171-8
51. Conrad SA, Grier LR, Scott LK, Green R, Jordan M. Percutaneous Cannulation for Extracorporeal Membrane Oxygenation by Intensivists: A Retrospective Single-Institution Case Series*. Crit Care Med. 2015;43(5):1010-1015. doi:10.1097/CCM.0000000000000883