Patients with acute heart failure in the emergency department: do they all need to be admitted?

Hospitalization for acute heart failure (AHF) is associated with a high rate of postdischarge mortality and readmissions, as well as high financial costs. Reducing 30-day readmissions after AHF hospitalization is a major national quality goal intended to both improve patient outcomes and reduce costs. Although the decision threshold for the vast majority of hospitalized AHF patients lies in the emergency department (ED), the role of the ED in reducing preventable admissions has largely been ignored. While admissions for AHF also originate from outpatient clinics, the greatest opportunity to reduce inpatient admissions lies with the cohort of patients who present to the ED with AHF. Safe discharge mandates interdisciplinary collaboration, close follow-up, careful scrutiny of psychosocial and socioeconomic factors, and a shared definition of risk stratification. Although additional research is needed, strategies for lower risk patients can and should be initiated to safely discharge AHF patients from the ED.