What is the initial treatment for acute decompensated heart failure?

From the Guidelines

The initial treatment for acute decompensated heart failure should focus on intravenous loop diuretics, typically furosemide at 20-40mg IV (or equivalent to the patient's oral dose), to reduce fluid overload and relieve symptoms. This approach is supported by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure, which recommend diuretics as the cornerstone of treatment for patients with acute heart failure and signs of fluid overload and congestion 1.

Key Considerations

• The initial recommended dose of furosemide should be 20–40 mg i.v. for patients with new-onset AHF or those with chronic, decompensated HF not receiving oral diuretics, and at least equivalent to the oral dose for those on chronic diuretic therapy 1.
• Diuretics should be given either as intermittent boluses or a continuous infusion, with the dose and duration adjusted according to the patient's symptoms and clinical status 1.
• Supplemental oxygen should be provided to maintain oxygen saturation above 92%, and non-invasive positive pressure ventilation may be necessary for patients with significant respiratory distress.
• Vasodilators such as nitroglycerin can be added for patients with normal or elevated blood pressure to reduce preload and afterload, but should be used cautiously in patients with hypotension 1.
• Inotropic agents like dobutamine or milrinone may be required in cases of cardiogenic shock or poor response to initial therapy, but are not recommended unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 1.

Monitoring and Adjustments

• Continuous monitoring of vital signs, urine output, and electrolytes is essential, as aggressive diuresis can lead to electrolyte abnormalities, particularly hypokalemia and hypomagnesemia.
• The goal is to relieve congestion while maintaining adequate perfusion to vital organs, and identifying and addressing the underlying cause of decompensation is crucial for preventing recurrence.

From the FDA Drug Label

Milrinone lactate injection is indicated for the short-term intravenous treatment of patients with acute decompensated heart failure. The initial treatment for acute decompensated heart failure is intravenous milrinone.

• The treatment should be administered in a setting where close monitoring and appropriate electrocardiographic equipment are available.
• Facilities for immediate treatment of potential cardiac events should also be available 2. Key points to consider when using milrinone include:
• Dose-related and plasma concentration-related increases in cardiac output and decreases in pulmonary capillary wedge pressure and vascular resistance 2.
• Improvements in hemodynamic function within 5 to 15 minutes of initiation of therapy 2.

From the Research

Initial Treatment for Acute Decompensated Heart Failure

The initial treatment for acute decompensated heart failure involves several key strategies:

• Relief of congestion through intravenous loop diuretics, which is a mainstay of therapy 3
• Use of ultrafiltration in cases where diuretics are not effective to achieve euvolemia 3
• Continuation or reduction in dose of beta-blockers at admission, but not typically holding them 3
• Institution of afterload reduction with vasodilators, such as nitroglycerin, nitroprusside, or nesiritide, in patients with normotensive or hypertensive heart failure 3, 4
• Limitation of intravenous inotropes/inodilators, such as dobutamine and milrinone, to hypotensive patients with evidence of poor tissue perfusion 3, 4

Choice of Particular Agents

The choice of a particular agent depends on patient characteristics, such as:

• Presence of ischemia
• Degree of congestion
• Renal function 3, 4
• For example, nitroprusside may be preferable in patients with congestion and low cardiac output, but with caution in patients with significant hypotension 3
• Milrinone may be preferable in patients who have significant pulmonary venous hypertension 3

Recent Advancements and Investigational Agents

Recent studies have reviewed the current recommendations and most recent advancements in the pharmacological treatment of acute decompensated heart failure 5, 6, 7

• New vasoactive agents, such as Nesiritide, Tolvaptan, and Levosimedan, could offer improved hemodynamics and congestive relief to patients in acute pulmonary edema 5
• Early initiation of therapy, such as nesiritide, in the emergency department may lead to improved outcomes, including shorter lengths of stay and lower mortality rates 6