What is the management of acute heart failure?

Management of Acute Heart Failure

Acute heart failure patients should receive appropriate therapy as early as possible, with immediate initiation of oxygen therapy, non-invasive ventilation for respiratory distress, and medical treatment based on blood pressure and degree of congestion using vasodilators and/or diuretics. 1

Initial Assessment and Triage

Severity Assessment

• Respiratory distress indicators: SpO2 <90%, respiratory rate >25/min, increased work of breathing, orthopnea
• Hemodynamic instability: Low or high blood pressure, severe arrhythmia, heart rate <40 or >130 bpm
• Patients with these signs require immediate transfer to Resuscitation Area/CCU/ICU 1

Immediate Monitoring

• Noninvasive monitoring: pulse oximetry, blood pressure, respiratory rate, continuous ECG
• Dyspnea assessment (using Visual Analogue Scale)
• Heart rate and rhythm, urine output, peripheral perfusion 1

Treatment Algorithm Based on Clinical Presentation

1. Respiratory Management

• Upright positioning for all patients
• Oxygen therapy based on clinical judgment, routinely administered if SpO2 <90%
• Non-invasive ventilation for patients with respiratory distress:
  • CPAP (preferred in pre-hospital setting due to simplicity)
  • PS-PEEP for patients with acidosis and hypercapnia, particularly with COPD history 1
• Intubation if non-invasive measures fail

2. Pharmacological Management Based on Blood Pressure

Normal to High Blood Pressure (SBP >110 mmHg)

• IV vasodilators (first-line therapy)
• IV diuretics:
  • New-onset HF: Furosemide 40 mg IV
  • Established HF: IV bolus at least equivalent to oral maintenance dose 1

Low Blood Pressure (SBP <90 mmHg)

• Avoid vasodilators
• Consider fluid challenge (250-500 mL) if no signs of congestion
• Inotropic support if signs of hypoperfusion persist despite adequate filling status
• Dobutamine is the inotrope of choice; norepinephrine if blood pressure support is needed 2

Atrial Fibrillation with Rapid Ventricular Response

• Beta-blockers are preferred first-line treatment for rate control
• Cardiac glycosides (digoxin) should be considered for rapid ventricular rate control 1
• Caution: Avoid cardiac glycosides in bradycardia, AV-blocks, sick sinus syndrome, WPW syndrome, hypertrophic obstructive cardiomyopathy, hypokalemia, and hypercalcemia 1

Special Scenarios

Acute Heart Failure in Acute Myocardial Infarction

• ACE inhibitors (e.g., lisinopril) should be initiated within 24 hours:
  • Start with 5 mg orally, followed by 5 mg after 24 hours, 10 mg after 48 hours, then 10 mg daily
  • Lower initial dose (2.5 mg) for patients with SBP ≤120 mmHg
  • Continue for at least six weeks 3
• Early revascularization when indicated 1

Cardiogenic Shock

• Immediate specialty consultation
• Optimize filling pressures
• Consider mechanical circulatory support (intra-aortic balloon pump)
• Vasopressors may be necessary 4

Valvular Disease Causing AHF

• Echocardiographic assessment is crucial
• Surgical consultation for severe acute aortic or mitral regurgitation
• Specific management for prosthetic valve thrombosis (thrombolysis vs. surgery) 1

Medications to Use with Caution

• Opioids: Routine use is not recommended as they may be associated with higher rates of mechanical ventilation, ICU admission, and death 1
• Sympathomimetics/vasopressors: Reserve for patients with persistent hypoperfusion despite adequate filling status 1

Nursing Management

• Rapid nursing assessment to optimize triage
• Monitor hemodynamic, respiratory, and mental status at least every four hours
• Track fluid balance and electrolytes
• Immediately communicate significant changes or unsatisfactory treatment responses to physicians 1

Discharge Planning

After stabilization:

• Conduct structured clinical, psychological, and social assessment
• Ensure rapid implementation of guideline-directed oral medical therapies before discharge
• Arrange follow-up with cardiologist within 1-2 weeks 1, 5

Common Pitfalls to Avoid

1. Delaying treatment initiation - the "time-to-treatment" concept is important in AHF
2. Overuse of opioids for dyspnea relief
3. Inappropriate use of inotropes in patients without signs of hypoperfusion
4. Failure to identify and treat the underlying cause or triggering factor
5. Neglecting to initiate long-term oral therapies before discharge 1, 5

By following this structured approach to acute heart failure management, focusing on early intervention, appropriate respiratory support, and tailored pharmacological therapy based on blood pressure, clinicians can improve symptoms, prevent organ damage, and potentially reduce mortality.