Acute dyspnoea in the emergency department

Abstract

Acute dyspnoea is a very common symptom in the acute cardiac care setting. In contrast to current beliefs, acute dyspnoea, as the leading symptom in the emergency department, is associated with about twice the mortality risk, compared to acute chest pain. Rapid and accurate identification of the cause of dyspnoea is critical to the initiation of specific and effective treatment. In most patients, a rapid and accurate diagnosis in the emergency department can be achieved by a combination of vital signs, including pulse oximetry, detailed patient history, physical examination, blood tests (including natriuretic peptides—BNP, NT-proBNP, or MR-proANP), venous blood gases, and C-reactive protein in all patients, and D-dimers in selected patients, electrocardiograms, chest X-ray, and more recently also lung ultrasound. It is key to remember that the prevalence of acute heart failure in unselected patients with acute dyspnoea is about 50%. Therefore, a high awareness for the presence of acute heart failure is mandatory. Acute heart failure, pneumonia, obstructive pulmonary diseases (chronic obstructive pulmonary disease and asthma), pulmonary embolism, and anxiety disorders represent more than 90% of all cases with acute dyspnoea in the emergency department. In about 10–15%, two acute causes (e.g. acute heart failure and pneumonia) may be present and require combined treatment. Transthoracic echocardiography should be immediately performed in all patients with acute dyspnoea and shock, and in those patients in whom the diagnosis remains uncertain, even after initial work-up.