Acute heart failure in emergency settings

Acute heart failure (AHF) represents a major cause of emergency medical care worldwide and continues to carry a substantial burden of morbidity and mortality despite advances in chronic heart failure management. Most patients with AHF present to emergency departments (EDs), where the first hours of care are critical to determine prognosis. Of these, some have been previously evaluated and treated by prehospital emergency medical services before ED arrival. This consensus document summarizes the current evidence and provides practical advice to emergency physicians for the diagnosis, treatment, and disposition of patients with AHF in these emergency settings (emergency medical services and ED). It emphasizes the importance of a rapid phenotypic classification into acute decompensated heart failure, acute pulmonary oedema, isolated right ventricular failure, or cardiogenic shock, as a key tool to guide early management and triage decisions. It reviews evidence on prehospital and ED management, including the use of biomarkers, imaging, ventilatory support, diuretic and vasodilator strategies, and early initiation or continuation of guideline-directed medical therapy. It also discusses risk stratification and disposition decisions supported by validated tools. Finally, it identifies major knowledge gaps and future research priorities, including pragmatic trials to assess prehospital interventions, biomarker-guided therapy, and early initiation of disease-modifying treatments. Ultimately, this consensus document is aimed to contribute to the improvement of outcomes in AHF.