Diagnosis of Acute Heart Failure in the Emergency Department

An Evidence-Based Review

Brit Long, MD; Alex Koyfman, MD; Michael Gottlieb, MD


Western J Emerg Med. 2019;20(6):875-884. 

In This Article

Abstract and Introduction


Heart failure is a common presentation to the emergency department (ED), which can be confused with other clinical conditions. This review provides an evidence-based summary of the current ED evaluation of heart failure. Acute heart failure is the gradual or rapid decompensation of heart failure, resulting from either fluid overload or maldistribution. Typical symptoms can include dyspnea, orthopnea, or systemic edema. The physical examination may reveal pulmonary rales, an S3 heart sound, or extremity edema. However, physical examination findings are often not sensitive or specific. ED assessments may include electrocardiogram, complete blood count, basic metabolic profile, liver function tests, troponin, brain natriuretic peptide, and a chest radiograph. While often used, natriuretic peptides do not significantly change ED treatment, mortality, or readmission rates, although they may decrease hospital length of stay and total cost. Chest radiograph findings are not definitive, and several other conditions may mimic radiograph findings. A more reliable modality is point-of-care ultrasound, which can facilitate the diagnosis by assessing for B-lines, cardiac function, and inferior vena cava size. These modalities, combined with clinical assessment and gestalt, are recommended.


Acute heart failure (AHF) is a gradual or rapid decompensation in heart failure (HF) requiring urgent management.[1–4] The condition covers a large spectrum of disease, ranging from mild exacerbations with gradual increases in edema to cardiogenic shock. HF affects close to six million people in the United States (U.S.) and increases in prevalence with age.[6–11] Currently, the emergency department (ED) initiates the evaluation and treatment of over 80% of patients with AHF in the U.S.[12–17] As the population ages, increasing numbers of patients with HF will present to the ED for evaluation and management. However, making the correct diagnosis can be challenging due to the broad differential diagnosis associated with presenting symptoms and variations in patient presentations.

Over one million patients are admitted for HF in the U.S. and Europe annually.[6–11,16–20] In the U.S. population, people have a 20% risk of developing HF by 40 years of age.[21–25] HF is more common in males until the age of 65, at which time males and females are equally affected.[25–28] Patients with HF average at least two hospital admissions per year.[25,29,30] Among patients who are admitted with AHF, over 80% have a prior history of HF, referred to as decompensated heart failure.[20–23] De novo HF is marked by no previous history of HF combined with symptom appearance after an acute event.[3,4,19,23] Mortality in patients with HF can be severe, with up to half of all patients dying within five years of disease diagnosis.[20,21,25] Other studies have found that post-hospitalization mortality rates at 30 days, one year, and five years are 10.4%, 22%, and 42.3%, respectively.[23–27] AHF expenditures approach $39 billion per year, which is expected to almost double by 2030.[31,32]