Acute Heart Failure in the Emergency Settings: Clinical Presentations, Diagnosis and Therapeutic Management

Heart failure (HF) is a common disease, with incidence increasing in all developed countries, and with an appalling impact on mortality. Acute dyspnea is the main symptom of congestive HF decompensation and the diagnosis of acute heart failure (AcHF) remains difficult in an emergency setting. Indeed, a better understanding of the pathophysiological mechanisms, made the concept of a single clinical entity evolve toward the notion of acute HF syndrome (AcHFS) integrating several frameworks of HF, from the decompensation of a congestive HF to the acute respiratory distress due to acute cardiogenic pulmonary edema (cAPE), and even cardiogenic shock. In order to make a diagnosis when faced with these different forms of acute decompensations, the emergency physician needs complementary work-up in order to determine the etiology of the acute episode of HF. Although the electrocardiogram and the chest X-ray are still essential, the use of cardiac biomarkers, most importantly natriuretic peptides, has become an integral part of the tools needed to develop the right diagnostic approach. In addition, the progressive generalization of clinical point-of-care ultrasound has improved diagnostic ability and given an opportunity to quicken therapeutic management. Thus, the modern concept of ``Timeto-therapy'' makes sense in the emergency setting where the optimized use of different drug treatments must be associated with the oxygen delivery supports often necessary for the management of acute dyspnea. This article proposes a review of the literature and current recommendations to ensure optimal management of SICA (Syndrome d'Insuffisance Cardiaque Aigue) in an emergency setting, from the out-of-hospital field to the bedside within the emergency department.