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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.annemergmed.2007.07.007 Byline: Sean Collins (a), Alan B. Storrow (b), J. Douglas Kirk (c), Peter S. Pang (d), Deborah B. Diercks (c), Mihai Gheorghiade (d) Abstract: The majority of heart failure hospitalizations in the United States originate in the emergency department (ED). Current strategies for acute heart failure syndromes have largely been tailored after chronic heart failure guidelines and care. Prospective ED-based acute heart failure syndrome trials are lacking, and current guidelines for disposition are based on either little or no evidence. As a result, the majority of ED acute heart failure syndrome patients are admitted to the hospital. Recent registry data suggest there is a significant amount of heterogeneity in acute heart failure syndrome ED presentations, and diagnostics and therapeutics may need to be individualized to the urgency of the presentation, underlying pathophysiology, and acute hemodynamic characteristics. A paradigm shift is necessary in acute heart failure syndrome guidelines and research: prospective trials need to focus on diagnostic, therapeutic, and risk-stratification algorithms that rely on readily available ED data, focusing on outcomes more proximate to the ED visit (5 days). Intermediate outcomes (30 days) are more dependent on inpatient and outpatient care and patient behavior than ED management decisions. Without these changes, the burden of acute heart failure syndrome care is unlikely to change. This article proposes such a paradigm shift in acute heart failure syndrome care and discusses areas of further research that are necessary to promote this change in approach. Author Affiliation: (a) University of Cincinnati, Department of Emergency Medicine, Cincinnati, OH (b) Vanderbilt University, Nashville, TN (c) University of California-Davis, Sacramento, CA (d) Northwestern University, Chicago, IL. Article History: Received 3 May 2007; Revised 22 June 2007; Revised 26 June 2007; Accepted 9 July 2007 Article Note: (footnote) Supervising editor: Donald M. Yealy, MD, Donald M. Yealy, MD, was the supervising editor of this article. W. Brian Gibler, MD, did not participate in the editorial review or decision to publish this article., Author contributions: SC, AS, and JK conceived the article. All authors contributed substantially to the manuscript. SC takes responsibility for the paper as a whole., Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. SC received research support from Biosignetics and Inovise Medical, Inc., and NIH/NHLBI, received previous honoraria from SCIOS, Inovise Medical, Inc., and PDL Biopharma, and works as a consultant for Abbott-Point-of-Care. ABS received research support from Biosignetics, Abbott Laboratories, Inovise Medical Inc., Inverness Medical Innovations, NIH/NHLBI, and Biosite, Inc., and worked as a consultant for the Medicines Company and Molecular Insights Pharmaceutical. JDK received research support from Biosite and Inovise Medical, Inc., and was a consultant and on the speakers bureau for Biosite. DBD received an honorarium from SCIOS, received research support from Dade-Behring and Inovise. MG received research support from NIH, Otsuk, Sigma Tau, Merck & Company, and SCIOS; MG is a consultant for GlaxoSmithKline, PDL, Errekappa Terapeutici, Medtronic, Debbio Pharm, and receive honoraria from Medtronic, AstraZeneca; SCIOS, GlaxoSmithKline, Otsuka, PDF, Abbott, and Sigma Tau., Earn CME Credit: Continuing Medical Education for this article is available at: www.ACEP-EMedHome.com., Reprints not available from the authors., Publication dates: Available online September 14, 2007.