What is the next step in managing a patient with acute heart failure?

Management of Acute Heart Failure

The next step in managing a patient with acute heart failure is to triage the patient based on clinical severity, with high-risk patients requiring immediate ICU/CCU admission and lower-risk patients managed in observation units or regular wards with appropriate monitoring and treatment. 1

Initial Assessment and Risk Stratification

High-Risk Features Requiring ICU/CCU Admission:

• Respiratory rate >25/min
• SpO₂ <90% despite supplemental oxygen
• Use of accessory muscles for breathing
• Systolic BP <90 mmHg
• Signs of hypoperfusion (oliguria, cold peripheries, altered mental status)
• Lactate >2 mmol/L
• Metabolic acidosis
• SvO₂ <65%
• Need for intubation or already intubated 2, 1

Lower-Risk Features (Ward Management):

• Hemodynamic stability
• Improved symptoms with initial therapy
• No signs of respiratory distress
• Adequate urine output
• Normal mental status 2

Immediate Management Interventions

Monitoring:

• Continuous monitoring of vital signs (pulse, respiratory rate, blood pressure)
• Oxygen saturation monitoring
• ECG monitoring
• Daily weight measurements
• Accurate fluid balance charting
• Daily renal function and electrolytes 2, 1

Oxygen and Ventilatory Support:

• Administer oxygen if SpO₂ <90%
• Consider non-invasive ventilation (NIV) for patients with respiratory distress
• BiPAP may be beneficial in patients with acidosis and hypercapnia 1

Pharmacological Management:

1. Diuretics: IV furosemide for patients with fluid overload
2. Vasodilators: Consider IV nitroglycerin for patients with SBP >110 mmHg
3. ACE inhibitors: Initiate within 24 hours when hemodynamically stable
   • For systolic heart failure, start with lisinopril 5 mg once daily (2.5 mg if hyponatremic)
   • Titrate up to maximum of 40 mg once daily as tolerated 1, 3
4. Beta-blockers: First-line for rate control in patients with atrial fibrillation 1

Hospital Care Pathway

For ICU/CCU Admitted Patients:

• Intensive monitoring of hemodynamic parameters
• Management of respiratory failure
• Optimization of cardiac output
• Treatment of precipitating factors
• Transfer to cardiology ward once stabilized 2

For Ward-Managed Patients:

• Daily weight monitoring
• Fluid balance assessment
• Medication optimization
• Identification and treatment of underlying causes 2, 1

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

Post-Discharge Plan:

• Follow-up with general practitioner within 1 week
• Cardiology follow-up within 2 weeks
• Enrollment in a disease management program
• Daily weight monitoring
• Medication adherence education 2, 1

Common Pitfalls to Avoid

1. Excessive fluid removal: May lead to hypotension and worsening renal function
2. Inadequate monitoring: Failure to monitor daily weights and fluid balance
3. Premature discharge: Discharging before achieving euvolemia and hemodynamic stability
4. Delayed follow-up: Not arranging early post-discharge follow-up
5. Overaggressive BP reduction: Decreases below 120 mmHg within 12 hours associated with increased adverse outcomes 4

Special Considerations

• Patients with preserved ejection fraction often present with pulmonary congestion and elevated blood pressure 5, 6
• African American patients have higher rates of hypertensive heart failure and may require more intensive resources 4
• Clinical phenotyping based on perfusion (warm vs. cold) and congestion (wet vs. dry) can help predict outcomes and guide management 7