What is the management of acute cardiac failure?

Management of Acute Cardiac Failure

Immediate treatment should be initiated as early as possible for all acute heart failure (AHF) patients, with therapy based on blood pressure, respiratory status, and degree of congestion using oxygen therapy, non-invasive ventilation, vasodilators, and/or diuretics. 1

Initial Assessment and Triage

Severity Assessment

• Assess for respiratory distress: RR >25/min, SpO2 <90%, increased work of breathing 1
• Evaluate hemodynamic stability: Blood pressure, heart rate (<40 or >130 bpm), arrhythmias 1
• Look for signs of congestion or hypoperfusion 2

Immediate Monitoring

• Implement continuous monitoring within minutes of patient contact 1:
  • Pulse oximetry (SpO2)
  • Blood pressure
  • Respiratory rate
  • Continuous ECG

Essential Initial Testing

• Plasma natriuretic peptide level (BNP, NT-proBNP, or MR-proANP) 1
• Laboratory tests: troponin, BUN/urea, creatinine, electrolytes, glucose, complete blood count 1
• ECG to exclude ST elevation myocardial infarction 1
• Chest X-ray to rule out alternative causes of dyspnea 1
• Consider bedside thoracic ultrasound if expertise available 1

Immediate Management

Positioning and Oxygen Therapy

• Position patient upright to reduce pulmonary congestion 1, 2
• Administer oxygen therapy if SpO2 <90% 1, 2

Respiratory Support

• For respiratory distress, initiate non-invasive ventilation (NIV) immediately 1:
  • CPAP is feasible in pre-hospital setting (simpler than PS-PEEP)
  • Consider PS-PEEP for patients with acidosis and hypercapnia, particularly with COPD history 1

Pharmacological Management Based on Blood Pressure

For SBP >110 mmHg (most common presentation):

• IV vasodilators (first-line) 1, 3:
  • Nitroglycerin IV for treatment of congestive heart failure 3
• IV diuretics (e.g., furosemide) 1:
  • 40 mg IV for new-onset HF or no maintenance diuretic therapy
  • At least equivalent to oral dose for established HF or chronic oral diuretic therapy

For SBP <110 mmHg:

• IV diuretics as first-line therapy 2
• Avoid vasodilators 1
• Monitor closely for signs of hypoperfusion 1

Drugs to Use Cautiously

• Opioids are not recommended routinely (associated with higher rates of mechanical ventilation, ICU admission, and death) 1
• Sympathomimetics or vasopressors should be reserved for patients with persistent hypoperfusion despite adequate filling status 1

Management Based on Clinical Presentation

Cardiogenic Shock

• Focus on improving cardiac performance:
  • Optimize filling pressure
  • Consider intra-aortic balloon pump
  • Immediate revascularization if indicated
  • Administer peripheral vasoconstrictors 4

Pulmonary Edema, Hypertensive Crisis, Exacerbated HF

• Administer strong, fast-acting IV vasodilators (nitrates or nitroprusside) 4
• Target gradual blood pressure reduction, avoiding rapid drops 2

Acute Coronary Syndrome with AHF

• Consider immediate invasive strategy regardless of ECG or biomarker findings 5
• Prioritize time-sensitive therapies for both conditions 5

Ongoing Hospital Management

Monitoring and Reassessment

• Continue monitoring: dyspnea, BP, SpO2, heart rate & rhythm, urine output, peripheral perfusion 1
• Reassess clinical, biological, and psychosocial parameters 1
• Perform echocardiography after stabilization (immediately if hemodynamically unstable) 1

Treatment Objectives

• Improve symptoms
• Maintain SBP >90 mmHg and peripheral perfusion
• Maintain SpO2 >90% 1

Medication Management

• Initiate ACE inhibitors within 24 hours (e.g., lisinopril 5 mg orally) 2
• For atrial fibrillation:
  • Beta-blockers are preferred for rate control
  • Consider cardiac glycosides (digoxin) for rapid ventricular rate control 1, 2

Discharge Planning and Follow-up

Discharge Criteria

• Hemodynamically stable
• Euvolemic
• Established on evidence-based oral medications
• Stable renal function for at least 24 hours 2

Follow-up Recommendations

• Primary care follow-up within 1 week of discharge
• Cardiology follow-up within 1-2 weeks 1, 2
• Enrollment in heart failure disease management program
• Daily weight monitoring and medication adherence education 2

Common Pitfalls to Avoid

• Delaying treatment initiation 2, 6
• Overuse of opioids 1, 2
• Inappropriate use of inotropes 2
• Failure to identify and treat the underlying cause 2, 7
• Neglecting to initiate long-term oral therapies before discharge 2
• Inadequate monitoring during the perioperative period 2
• Inappropriate fluid management 2
• Persistent subclinical congestion after discharge 6