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AHA Scientific Statement

Acute Heart Failure Syndromes: Emergency Department Presentation, Treatment, and Disposition: Current Approaches and Future Aims A Scientific Statement From the American Heart Association

Neal L. Weintraub, MD, Chair; Sean P. Collins, MD, MSc, Co-Chair; Peter S. Pang, MD; Phillip D. Levy, MD, MPH; Allen S. Anderson, MD; Cynthia Arslanian-Engoren, PhD, RN, FAHA; W. Brian Gibler, MD, FAHA; James K. McCord, MD; Mark B. Parshall, PhD, RN; Gary S. Francis, MD, FAHA; Mihai Gheorghiade, MD; on behalf of the American Heart Association Council on Clinical Cardiology and Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation

ith a prevalence of 5 800 000 (2% of the entire populace) in 2009 and an estimated yearly incidence of 550 000, the burden of heart failure (HF) in the United States is tremendous.1 Although HF is largely a condition defined by chronic debility, virtually all patients experi- ence, at some point, acute symptoms that trigger a visit to the emergency department (ED). These symptoms may vary in severity but, for the most part, they necessitate early intervention, often with intravenous medication and, less frequently, respiratory support. As shown by com- bined data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), this is a common occurrence; there are nearly 658 000 annual ED encounters primarily for acute HF in the United States—a figure that represents almost 20% of the total HF-specific ambulatory care delivered each year.2 W

It is noteworthy that few settings other than the ED can offer open access to treatment or provide the level and intensity of care required to effectively manage the acute phase of decompensation, also referred to as episodes of acute heart failure syndromes (AHFS). Nearly 80% of those treated for AHFS in the ED are ultimately admitted to the hospital and, accordingly, the ED serves as the

principal portal of entry for hospitalized AHFS patients.34 The ED therefore plays a unique role in the continuum of AHFS treatment, functioning for most patients as the initial point of definitive healthcare contact, the location where primary stabilization is achieved, and the site where disposition decisions are generally made.4 Whereas the ED is a pivotal place for the vast majority of hospitalized patients with acute HF, the evidence base on which this foundation of acute care is built is astonishingly thin. The purpose of this scientific statement, therefore, is to de- scribe current standard practice for HF clinicians, to highlight the knowledge gaps that are present, and to serve as a call to action for ED-based research as a future endeavor for those with a vested interest in AHFS care. The need for improvement in our approach to AHFS management was recognized in the recently published 2009 Focused Update to the 2005 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for the Diagnosis and Management of Heart Failure in Adults. For the first time recommendations relevant to the hospitalized AHFS patient were included.5 Developed using guideline methodology standardized by the ACC/AHA (Table 1),6 these recommendations repre- sent an important step forward in the ongoing effort to

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on August 11, 2010. A copy of the statement is available at http://www.americanheart.org/presenter.jhtml?identifier3003999 by selecting either the “topic list” link or the “chronological list” link (No. KB-0104). To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.

The American Heart Association requests that this document be cited as follows: Weintraub NL, Collins SP, Pang PS, Levy PD, Anderson AS, Arslanian-Engoren C, Gibler WB, McCord JK, Parshall MB, Francis GS, Gheorghiade M; on behalf of the American Heart Association Council on Clinical Cardiology and Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. 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;122:1975–1996.

Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://www.americanheart.org/presenter.jhtml?identifier3023366.

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.americanheart.org/presenter.jhtml?

identifier4431. A link to the “Permission Request Form” appears on the right side of the page. (Circulation. 2010;122:1975-1996.) © 2010 American Heart Association, Inc.

Circulation is available at http://circ.ahajournals.org

DOI: 10.1161/CIR.0b013e3181f9a223

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