What is the management of acute heart failure?

Management of Acute Heart Failure

The management of acute heart failure requires immediate assessment for respiratory distress, hemodynamic stability, and mental status, followed by prompt initiation of appropriate oxygen therapy, non-invasive ventilation for respiratory distress, IV diuretics for congestion, and vasodilators for patients with adequate blood pressure, while avoiding routine use of opioids and inappropriate inotropes. 1

Initial Assessment and Monitoring

• Immediately assess for:

  • Respiratory distress: respiratory rate >25/min, oxygen saturation <90%, increased work of breathing
  • Hemodynamic stability: blood pressure, heart rate (<40 or >130 bpm), arrhythmias
  • Mental status using the AVPU scale 1

• Implement continuous monitoring within minutes:

  • Pulse oximetry
  • Blood pressure
  • Respiratory rate
  • Continuous ECG 1

• Essential laboratory tests:

  • Arterial or venous blood gas to confirm hypercapnia (PaCO2 >45 mmHg) and assess acidosis
  • Plasma natriuretic peptide level (BNP, NT-proBNP, or MR-proANP)
  • Chest X-ray (should not delay treatment in severe cases) 1

Oxygen Therapy and Respiratory Support

• Target SpO2 of 88-92% to avoid worsening hypercapnia

• Use controlled oxygen delivery devices (Venturi masks or nasal cannulas) with careful titration 1

• For respiratory distress, initiate non-invasive ventilation (NIV) immediately:

  • Consider CPAP for pulmonary edema
  • Use BiPAP (PS-PEEP) for patients with acidosis and hypercapnia, particularly those with COPD history
  • Monitor blood pressure and other parameters closely during NIV 1

Pharmacological Management

1. Diuretics:

   • Administer IV furosemide to patients with fluid overload
   • Dose depends on previous diuretic therapy
   • Monitor urine output, renal function, and electrolytes 1

2. Vasodilators:

   • Consider in patients with systolic BP >110 mmHg
   • Avoid in patients with systolic BP <110 mmHg 1
   • Particularly useful when AHF is precipitated by hypertension 2

3. Rate Control for Atrial Fibrillation:

   • Beta-blockers are first-line for rate control
   • IV cardiac glycosides are an alternative for rapid ventricular rate control 1

4. ACE Inhibitors:

   • Initiate within 24 hours (e.g., lisinopril 5 mg orally)
   • Continue for at least six weeks 1

5. Inotropes:

   • Reserved for hypotensive AHF with evidence of hypoperfusion
   • Milrinone is indicated for short-term IV treatment of acute decompensated heart failure
   • Patients receiving milrinone should have continuous cardiac monitoring 3
   • Dobutamine is the inotrope of choice in hypotensive patients 4
   • Norepinephrine recommended if additional blood pressure support is needed 4

Common Pitfalls to Avoid

• Do not routinely use:

  • Opioids
  • Sympathomimetics
  • Vasopressors (except in cardiogenic shock) 1

• Avoid excessive oxygen therapy in patients with COPD and other causes of acute hypercapnic respiratory failure 1

• Do not delay initiation of NIV in appropriate patients 1

• Avoid inappropriate use of inotropes when pulmonary edema is associated with normal or high systolic blood pressure 1

• Always document an action plan in case of NIV failure 1

• Do not proceed with elective procedures until cardiac condition is stabilized 1

Post-Stabilization Care

• Continue monitoring:

  • Dyspnea
  • Blood pressure
  • Oxygen saturation
  • Heart rate and rhythm
  • Urine output
  • Peripheral perfusion 1

• Perform echocardiography after stabilization (immediately if hemodynamically unstable) 1

• Maintain:

  • Systolic blood pressure >90 mmHg
  • Adequate peripheral perfusion
  • Oxygen saturation >90% 1

• Consider early revascularization when indicated 1

Discharge Planning

• Ensure patient is:

  • Hemodynamically stable
  • Euvolemic
  • Established on evidence-based oral medications
  • Has stable renal function for at least 24 hours 1

• Schedule:

  • Primary care follow-up within 1 week of discharge
  • Cardiology follow-up within 1-2 weeks 1

• Provide education on:

  • Daily weight monitoring
  • Medication adherence
  • Heart failure disease management program enrollment 1

Special Considerations: Cardiogenic Shock

• For refractory cardiogenic shock:
  • Consider mechanical circulatory support early
  • Initiate before onset of renal or liver failure
  • Transfer to a tertiary care center for patients requiring percutaneous coronary intervention or mechanical circulatory support 5