Should a patient presenting with signs of heart failure be managed in the emergency department rather than in an internal‑medicine/outpatient setting?

Acute Heart Failure Requires Immediate Emergency Department Management

Yes, patients presenting with signs of acute heart failure must be treated in the emergency department immediately—this is a life-threatening condition requiring urgent medical attention and hospital admission, not an outpatient internal medicine issue. 1

Why the ER is Essential

Acute heart failure is defined as a life-threatening condition requiring immediate medical attention. 1 The European Society of Cardiology explicitly states that approximately 80% of patients hospitalized for heart failure are admitted through the ED, making emergency management the standard of care. 1

Time-to-Treatment is Critical

• Similar to acute coronary syndromes, the "time-to-treatment" concept is crucial in acute heart failure—all patients should receive appropriate therapy as early as possible. 1
• Treatment should ideally begin in the pre-hospital setting (ambulance) and continue immediately upon ED arrival. 1
• IV diuretics must be administered within 60 minutes of presentation, as early treatment directly impacts outcomes. 2, 3

Immediate ED Triage Algorithm

Step 1: Assess Cardiopulmonary Stability

The critical first step is determining if respiratory failure or hemodynamic compromise exists—these patients require immediate resuscitation bay transfer. 2, 4

Severity criteria requiring ICU/CCU:

• Respiratory distress: RR >25/min, SpO₂ <90% on oxygen, or increased work of breathing 1
• Hemodynamic instability: SBP <90 mmHg, severe arrhythmia, HR <40 or >130 bpm 1
• Altered mental status using AVPU assessment (indicates hypoperfusion) 2

Step 2: Initiate Monitoring and Treatment Simultaneously

Upon ED arrival, clinical examination, investigations, and treatment must start immediately and concomitantly. 1

Required monitoring:

• Continuous pulse oximetry, blood pressure, respiratory rate, ECG 1
• Dyspnea assessment, heart rate/rhythm, urine output, peripheral perfusion 1

Immediate ED Interventions

Respiratory Support

• Oxygen therapy if SpO₂ <90% (avoid routine use in non-hypoxemic patients as it causes vasoconstriction) 3
• Non-invasive ventilation (CPAP or BiPAP) for respiratory distress to reduce intubation rates 3, 4

Pharmacologic Treatment

• IV furosemide 40-80 mg bolus if diuretic-naïve, OR dose equal to/exceeding chronic oral daily dose within 60 minutes 2, 3
• Target urine output ≥100-150 mL/hour within 6 hours 2
• Keep total furosemide <100 mg in first 6 hours, <240 mg in first 24 hours 2

Diagnostic Workup

• 12-lead ECG immediately to exclude ST-elevation MI and identify arrhythmias 2, 3
• Cardiac troponin to identify acute coronary syndrome 2, 3
• BNP or NT-proBNP to confirm diagnosis 2, 3

Treatment Objectives in the ER

Primary goals are improving symptoms, maintaining SBP >90 mmHg with adequate peripheral perfusion, and maintaining SpO₂ >90%. 2, 4

Disposition After Initial ED Stabilization

After initial ED management and stabilization (typically within 2 hours), patients may be:

• Admitted to ICU/CCU if requiring intubation, cardiogenic shock, or persistent respiratory distress 3, 4
• Admitted to cardiology/internal medicine ward if stabilized 1
• Observed in ED observation unit (<24 hours) if rapidly improving 1

Follow-up with cardiologist within 1-2 weeks is recommended for discharged patients. 1

Critical Pitfall to Avoid

Never delay treatment by sending these patients to outpatient internal medicine—delaying diuretic therapy beyond 60 minutes of presentation worsens outcomes. 3 The ED provides the necessary infrastructure for immediate monitoring, respiratory support, and rapid medication administration that cannot be replicated in an outpatient setting.