2022 ACEP Acute Heart Failure Syndrome (AHFS) Guideline Update

Author: Daniel Morrad, PGY-4

Patients who present to the emergency department (ED) with symptomatic AHFS are not only associated with high morbidity and mortality, but these cases alone account for over 650,000 visits to the ED in the United States annually. Over 80% of these patients will be admitted to the hospital with more than one-third requiring readmission or ultimate death following their initial visit to the ED.1 AHFS also place a heavy financial burden on the US healthcare system with a cost near $40 billion annually.2 The prevalence of heart failure continues to rise in the United States and, while survival after receiving the diagnosis of heart failure has improved since 2012, the fatality rate after requiring hospitalization remains high.3

Given the complexity of AHFS, including diagnosis, management, and sometimes questionable dispositions following ED stabilization, the American College of Emergency Physicians revised the 2007 “Clinical Policy: Critical Issues in the Evaluation of Adult Patients Presenting to the Emergency Department with Acute Heart Failure Syndromes.” The revision sought to update guidelines by evaluating the accuracy of point-of-care lung ultrasound in AHFS, early administration of diuretics, the use of vasodilator therapy, and if discharging a patient is a suitable disposition for low-risk cases.


Level ALevel BLevel C
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
Figure 1: ACEP Definitions for Findings and Strength of Recommendations

Lung Ultrasound Utilization:

Current evidence supports the utilization of POCUS to improve diagnostic accuracy and guide management in patients being evaluated in the ED with acute dyspnea and possible AHFS. B-lines are an independent predictor of AHFS. Bedside ultrasound, when combined with patient history and physical examination outperforms chest radiography and laboratory testing, including natriuretic peptides.

Level B Recommendation

Early ED Diuretic Administration:

No specific timing of diuretic therapy can be recommended. Physicians may consider earlier administration of diuretics when indicated for ED patients with acute heart failure syndrome, because it may be associated with reduced length of stay and in-hospital mortality (consensus recommendation).

Physicians should be confident in the diagnosis of acute heart failure syndrome with volume overload in a patient before the administration of diuretics because treatment with diuretics may cause harm to those with an alternative diagnosis (consensus recommendation).

Level C Recommendation

High-dose Vasodilator Use:

Consider using high-dose nitroglycerin as a safe and effective treatment option when administered to patients with acute heart failure syndrome and elevated blood pressure. Evidence also shows possible clinical outcome improvement with the use of bilevel positive airway pressure, endotracheal intubation, and ICU admission.

Level C Recommendation

Disposition of AHFS Patients from ED:

Do not rely on current acute heart failure syndrome risk stratification tools alone to determine which patients may be discharged directly home from the ED. Consider using the Ottawa Heart Failure Risk Scale (OHFRS) to help determine which higher-risk patients for adverse outcomes should not be discharged home.

Level B Recommendation

Consider using the Emergency Heart Failure Mortality Risk Grade for 7-day mortality (EHMRG7) or the STRATIFY decision tool to help determine which higher-risk patients for adverse outcomes should not be discharged home. Use shared decision-making strategies when determining the appropriate disposition of AHFS patients.

Level C Recommendation

For more information about the AHFS Guideline Update, please click here for the full update.


1.) Peacock WF, Cannon CM, Singer AJ, Hiestand BC. Considerations for initial therapy in the treatment of acute heart failure. Crit Care. 2015;19(399). doi:10.1186/s13054-015-1114-3.

2.) Peacock WF. Congestive Heart Failure and Acute Pulmonary Edema. In: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Seventh Edition. ; 2011:405-415.

3.) Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139:e56-e528.


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