What is the initial management for acute heart failure?

Initial Management of Acute Heart Failure

The initial management of acute heart failure (AHF) should include immediate assessment of respiratory and hemodynamic status, administration of oxygen therapy for SpO₂ <90%, non-invasive ventilation for respiratory distress, and prompt initiation of IV diuretics and/or vasodilators based on blood pressure. 1

Initial Assessment and Monitoring

• Immediately assess for:

  • Respiratory distress: respiratory rate >25/min, SpO₂ <90%, increased work of breathing
  • Hemodynamic instability: blood pressure, heart rate (especially <60 or >120 bpm), arrhythmias
  • Mental status using AVPU scale (Alert, Visual, Pain, Unresponsive) 2, 1

• Implement immediate monitoring:

  • Continuous pulse oximetry
  • Blood pressure monitoring
  • Respiratory rate
  • Continuous ECG
  • Urine output 2, 1

• Essential initial investigations:

  • Plasma natriuretic peptide level (BNP, NT-proBNP)
  • Arterial or venous blood gas (pH, pCO₂, pO₂)
  • Chest X-ray (to rule out alternative causes of dyspnea)
  • ECG (to exclude ST elevation myocardial infarction)
  • Bedside thoracic ultrasound (if expertise available) 2, 1

Immediate Therapeutic Interventions

Oxygen and Ventilatory Support

1. Oxygen therapy: Administer if SpO₂ <90%, targeting SpO₂ 88-92% 1
2. Non-invasive ventilation (NIV): Initiate promptly in patients with respiratory distress to reduce intubation rates 2, 1
   • BiPAP preferred for patients with acidosis and hypercapnia
   • Monitor blood pressure during NIV as it can reduce BP
3. Intubation: Consider if respiratory failure cannot be managed non-invasively 1

Pharmacological Management Based on Blood Pressure

For patients with SBP >110 mmHg:

• IV nitroglycerin: Start at 10-20 μg/min, titrate up to reduce preload and afterload 3, 4
• IV furosemide:
  • For new-onset heart failure: 20-40 mg IV
  • For established heart failure: At least equivalent to oral dose or 1-2.5× oral dose 1

For patients with SBP 90-110 mmHg:

• IV furosemide as above
• Avoid vasodilators 2, 1
• Monitor closely for hypotension

For patients with SBP <90 mmHg (cardiogenic shock):

• Emergent specialty consultation
• Initial fluid bolus: 250-500 mL if no signs of fluid overload 4
• Dobutamine: For inotropic support in cardiac decompensation due to depressed contractility 5, 4
  • Start at 2-3 μg/kg/min, titrate up to 20 μg/kg/min based on response
• Consider norepinephrine if additional blood pressure support is needed 4

Triage and Disposition

• High-risk patients requiring ICU/CCU admission:

  • Respiratory rate >25/min
  • SpO₂ <90% despite supplemental oxygen
  • Use of accessory muscles for breathing
  • Systolic BP <90 mmHg
  • Need for intubation
  • Signs of hypoperfusion (oliguria, cold peripheries, altered mental status, lactate >2 mmol/L) 2

• Intermediate-risk patients: Admit to cardiac monitoring unit or telemetry

• Lower-risk patients: Consider observation unit with discharge criteria:

  • Hemodynamic stability
  • Improved symptoms
  • Resting heart rate <100 bpm
  • No high-risk features (elevated natriuretic peptides, low BP, worsening renal failure, hyponatremia, positive troponin) 2

Post-Stabilization Care

• Perform echocardiography after stabilization (immediately if hemodynamically unstable)
• Maintain systolic BP >90 mmHg, peripheral perfusion, and oxygen saturation >90%
• Continue monitoring clinical parameters
• Adjust oral heart failure medications based on blood pressure, heart rate, renal function, and potassium levels 2, 1

Common Pitfalls to Avoid

• Delayed initiation of NIV in patients with respiratory distress
• Excessive oxygen therapy in patients with COPD (can worsen hypercapnia)
• Routine use of opioids in AHF patients
• Inappropriate use of vasopressors outside of cardiogenic shock
• Premature discharge before achieving hemodynamic stability and euvolemia
• Failure to arrange early follow-up (within 72 hours of discharge) 2, 1

By following this structured approach to the initial management of acute heart failure, clinicians can effectively stabilize patients, relieve symptoms, and improve outcomes while avoiding common pitfalls.