ED ThErapy for acuTE hEarT failurE - TimE for changE?

The emergency department (ED) accounts for 80% of hospital admissions due to acute heart failure (AHF). Further, because of their multiple comorbidities, approximately 80% of ED patients with AHF are admitted to the hospital, the majority to a telemetry floor. Most of these patients present with worsening chronic heart failure, requiring and benefiting from urgent ED‐based intravenous therapy. A minority of patients present as de novo or end‐stage heart failure patients, where ED‐based therapy is also important, but other factors often determine disposition (etiologic work‐up, bridge to destination therapy, etc). As a direct result, emergency physicians and hospitalists deliver acute therapy to the majority of patients hospitalized with AHF. Improved survival from myo‐ cardial infarction, an aging population, and hospital overcrowding have also resulted in an increased ED burden of acute heart failure management. 5 Accordingly, early management decisions made in the ED will continue to have a significant impact on the acute care of these patients. Chronic heart failure management has improved dramatically over the last decade. While the introduction of beta‐ blockers and ACE‐inhibitors has led to tremendous advances in chronic heart failure management, clinical trial results for novel therapies treating AHF have shown limited success with regard to efficacy and/or safety. Furthermore, these trials tend to enroll a highly select group of patients with systolic dysfunction long after ED presentation, resulting in poor generalizability to the ED population. Recently, AHF registries have highlighted the dichotomy between the patients seen and treated in the ED and hospital and those enrolled in clinical trials (Table 1).