What are the initial management and treatment guidelines for acute heart failure?

From the Guidelines

Initial management of acute heart failure requires prompt assessment and intervention to improve oxygenation and reduce cardiac workload, starting with supplemental oxygen and positioning the patient upright, followed by administration of intravenous loop diuretics such as furosemide 20-40mg IV bolus, as recommended by the 2016 ESC guidelines 1. The goal is to reduce fluid overload and improve symptoms.

• Key interventions include:
  • Supplemental oxygen to maintain saturation above 90%
  • Positioning the patient upright to decrease pulmonary congestion
  • Intravenous loop diuretics, such as furosemide, with an initial dose of 20-40mg IV bolus, which can be adjusted based on the patient's symptoms and clinical status 1
  • Nitroglycerin, if the patient has adequate blood pressure, to reduce preload and afterload
  • Non-invasive positive pressure ventilation (CPAP or BiPAP) for patients with severe symptoms or inadequate response to initial therapy
  • Morphine, used cautiously, for severe anxiety and dyspnea
• Continuous monitoring of vital signs, urine output, and oxygen saturation is essential to guide therapy and adjust interventions as needed.
• The underlying cause of heart failure should be identified and treated simultaneously, and guideline-directed oral medical therapies should be implemented before discharge, including beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists, as well as sodium-glucose co-transporter 2 inhibitors, which have been shown to be beneficial in acute heart failure patients 1.
• In patients with hypotension and evidence of hypoperfusion, inotropic agents like dobutamine or vasopressors may be necessary, but their use should be guided by the patient's clinical status and hemodynamic parameters, as recommended by the 2019 ACC/AHA guidelines 1.
• The management of acute heart failure should be tailored to the individual patient's needs, taking into account their medical history, symptoms, and clinical profile, and should involve a multidisciplinary team of healthcare professionals.

From the FDA Drug Label

Dobutamine Hydrochloride in 5% Dextrose Injection is indicated when parenteral therapy is necessary for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility resulting either from organic heart disease or from cardiac surgical procedures Nitroglycerin Injection is indicated for treatment of peri-operative hypertension; for control of congestive heart failure in the setting of acute myocardial infarction; The initial management and treatment guidelines for acute heart failure include:

• Inotropic support: Dobutamine may be used for short-term treatment of patients with cardiac decompensation due to depressed contractility 2
• Vasodilator therapy: Nitroglycerin may be used for control of congestive heart failure in the setting of acute myocardial infarction 3
• Parenteral therapy: Dobutamine Hydrochloride in 5% Dextrose Injection may be administered intravenously through a suitable intravenous catheter or needle, with a recommended dosage of 0.5-1.0 mcg/kg/min, titrated to the patient’s response 2

From the Research

Initial Management of Acute Heart Failure

The initial management of acute heart failure (AHF) involves tailoring treatments to the appropriate type of heart failure, focusing on blood pressure and hemodynamic status 4. Treatment should be guided by the underlying disease process.

Treatment Guidelines

• Patients with mild AHF exacerbations often receive intravenous diuretics 4.
• Patients with AHF and flash pulmonary edema should receive nitroglycerin and noninvasive positive pressure ventilation, with consideration of an angiotensin-converting enzyme inhibitor, while monitoring for hypotension 4.
• Patients with hypotensive AHF should receive emergent specialty consultation and an initial fluid bolus of 250-500 mL, followed by initiation of inotropic agents with or without vasopressors 4.
• Dobutamine is the inotrope of choice in these patients, with norepinephrine recommended if blood pressure support is needed 4.

Use of Intravenous Therapies

The use of intravenous therapies, such as diuretics, nitrates, opioids, inotropes, and vasopressors, as well as non-invasive ventilation (NIV), varies depending on the clinical presentation and systolic blood pressure (SBP) on admission 5.

• Furosemide is the most common treatment in all clinical classes and irrespective of SBP on admission 5.
• Nitrates are given most often in pulmonary oedema and hypertensive AHF 5.
• Inotropes and vasopressors are given most frequently in cardiogenic shock and pulmonary oedema, and their use is inversely related to initial SBP 5.

Loop Diuretics in Acute Decompensated Heart Failure

Loop diuretics are commonly used in acute decompensated heart failure (ADHF), but data supporting their safety and efficacy are limited 6.

• The use of loop diuretics, especially at higher doses, may be associated with increased mortality in patients with heart failure 6.
• The optimal dosing and means of administration (continuous infusion vs. intermittent boluses) of loop diuretics are unclear 6.

Mechanical Circulatory Support

Mechanical circulatory support devices may be considered as a bridge to further therapeutic intervention in patients with AHF 4, 7.

• Early initiation of mechanical circulatory support is recommended in patients with refractory cardiogenic shock 7.