Emergency Management of Acute Dyspnea Suspected of Heart Failure: a Diagnosis and Therapeutic Challenge

Introduction: Acute dyspnea is caused by several etiologies that include acute heart failure (AHF). Early management of acute coronary syndrome is one of the cornerstones to improve prognosis. Dsypnea has become a new diagnostic and therapeutic challenge. This review presents the management of acute dyspnea with suspected AHF. Prehospital management: The mortality is twice the rate in dyspneic patients for whom an adverse diagnosis or treatment is delivered in prehospital setting. Guidelines suggest a relationship between early diagnosis, appropriate treatment and prognosis, introducing the concept of ``time-to-therapy''. Emergency department management: Chest X-ray and biological testing are available in the emergency department. The B-type natriuretic peptide (BNP) allows a better diagnosis performance but its value may be influenced by various factors. Importantly, false low values can be found in very acute pulmonary edemas. Several tools are available to diagnose the etiology of dyspnea including fast clinical echography with a lung ultrasound, a quick four-cavity exploration and venous ultrasound. Therapeutic management: The concept of ``time-to-therapy'' seems to have an impact in AHF management. Oxygen therapy or non-invasive ventilation is recommended as soon as possible. Treatment is represented by vasodilators and diuretics. Every first AHF event must be hospitalized, even without gravity signs and patients with an organ failure should be admitted in the intensive care unit. Conclusion: The lung ultrasound combined with BNP is a suitable tool for dyspneic patients. The therapeutic issue is based on a shorter ``time-to-therapy''. The prognosis improvement of the AHF patient will involve the implementation of an efficient pathway that begins in the prehospital setting.