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With 4.7 million cases and approximately 550,000 new patients each year,1 the U.S. is currently experiencing a heart failure epidemic. Heart failure disproportionably affects the aged. Fewer than 1% of Americans <50 years are stricken, but prevalence doubles each decade until, by age 80 years, nearly 10% carry the diagnosis. It is the leading cause of hospitalization among those >65 years,1 accounts for nearly 1,000,000 hospitalizations annually, and up to 60% of discharged heart failure patients are rehospitalized within 6 months due to recurrent decompensation.2 With predictions that the cohort >65 years will double in the next 30 years, the impact of heart failure is expected to increase. The annual costs of heart failure are roughly double that of any cancer diagnoses in the U.S. and estimated to exceed 27 billion U.S. dollars.2

Acute heart failure syndromes are classified by clinical presentation (Table 57-1).3

Table 57-1 Classification of Acute Heart Failure

Heart failure has a poor prognosis, with an annual death rate of 18.7%.2 Once symptomatic, 2-year mortality is about 35% and over the next 6 years increases to 80% for men and 65% for women.1 Symptom severity predicts outcome. Annual mortality rates are 5% to 10% in mild-moderate heart failure and 30% to 40% in severe heart failure. After the development of pulmonary edema, only 50% survive 1 year. After cardiogenic shock, up to 85% die within 1 week.

Pooled data from multiple acute heart failure registries provide important epidemiologic information pertinent to ED presentations.4 The majority of acute heart failure patients have arterial hypertension (53% to 73%) and ischemic heart disease (46% to 68%): many have diabetes (27% to 42%) and atrial fibrillation (21% to 42%). One quarter to one third of patients with acute heart failure present with new onset of symptoms, most commonly with acute coronary artery syndrome.4

Heart failure may present acutely as a result of acute pump dysfunction from acute myocardial infarction. Mechanistically, loss of a critical mass of myocardium results in immediate symptoms. If there is symptomatic hypotension ...

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