1) Remember to look for the triggers of acute CHF exacerbations. Common causes include non compliance with heart failure medications and infections.  NSAIDs and non dihydropyridine calcium channel blockers (diltiazem, verapamil) are medications that may trigger CHF. Ischemia and arrhythmia are also considerations.

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2) BNP is useful as a rule out test.  There are some limitations.  BNP can be falsely lowered in settings such as obesity and flash pulmonary edema. It will be elevated in cases of LV dysfunction (without CHF), renal failure, age, high output states.  A BNP of < 100 largely excludes CHF as a cause of dyspnea.

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3) Remember that many patients with CHF with reduced ejection fraction tend to be hypotensive. Also, most CHF exacerbations present with findings of congestion without hypoperfusion. Cardiogenic shock is a less common emergency department presentation. Usually if the blood pressure is low but the patient appears clinically well and perfused, they are not in cardiogenic shock.

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4) Bedside ultrasound can be useful in diagnosing CHF. Look for:

a) SVC distension, dilated and non collapsing IVC, B-lines and pleural effusions on the lung scan.

b) Assess for overall left ventricular ejection fraction and contractility

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5) Be aware of new drugs for CHF and their side effects. Entresto is used for patients with reduced EF and causes presyncope, hyperkalemia and renal failure. Ivabradine is sometimes used in patients with reduced EF and can cause vision changes and bradycardia. SGLT-2 inhibitors have data in CHF with both reduced and preserved EF. They can cause UTIs, AKI and euglycemic DKA.