What is the treatment for exacerbated congestive heart failure with shortness of breath?

Treatment for Exacerbated Congestive Heart Failure with Shortness of Breath

The immediate treatment for exacerbated congestive heart failure with shortness of breath requires oxygen therapy for patients with SpO2 <90%, intravenous diuretics (20-40 mg IV furosemide), and non-invasive positive pressure ventilation for patients with respiratory distress. 1

Initial Assessment and Management

Triage and Monitoring

• Patients with persistent, significant dyspnea or hemodynamic instability should be triaged to a location where immediate resuscitative support can be provided 1
• High-risk patients should receive care in a high-dependency setting (ICU/CCU) 1
• Continuous monitoring of:
  • Transcutaneous arterial oxygen saturation (SpO2)
  • Vital signs
  • Work of breathing
  • Mental status
  • Response to therapy 2

Respiratory Support

1. Oxygen Therapy:

   • Administer oxygen immediately when SpO2 <90% or PaO2 <60 mmHg 1
   • Target saturation of 93-98% in most patients; 88-92% in those with COPD 2
   • Avoid routine oxygen use in non-hypoxemic patients as it causes vasoconstriction and reduces cardiac output 1

2. Non-invasive Positive Pressure Ventilation (NIPPV):

   • Implement CPAP or BiPAP for patients with respiratory distress (respiratory rate >25 breaths/min, SpO2 <90%) 1
   • Start as soon as possible to decrease respiratory distress and reduce need for intubation 1
   • Monitor blood pressure regularly during NIPPV as it can cause hypotension 1
   • BiPAP is especially useful for patients with hypercapnia, typically those with COPD 1

3. Intubation:

   • Indicated when respiratory failure cannot be managed non-invasively:
     • PaO2 <60 mmHg (8.0 kPa)
     • PaCO2 >50 mmHg (6.65 kPa)
     • pH <7.35 1

Pharmacological Management

Diuretics

• Administer IV diuretics promptly for pulmonary congestion 2
• Initial dose:
  • For new-onset heart failure: 20-40 mg IV furosemide (or equivalent) 1
  • For patients on chronic diuretic therapy: at least equivalent to oral dose 1
• Give diuretics either as intermittent boluses or continuous infusion 2
• Adjust dose and duration according to patient's symptoms and clinical status 2
• Monitor urine output, renal function, and electrolytes regularly 2

Vasodilators

• Indicated for left heart backward failure with pulmonary edema 1
• Nitroglycerin is recommended for patients with flash pulmonary edema 3
• Use with caution in hypotensive patients 1

Inotropic Support

• Not recommended unless the patient is symptomatically hypotensive or hypoperfused 2
• Dobutamine is indicated for short-term treatment of cardiac decompensation due to depressed contractility 4
• For hypotensive AHF, dobutamine is the inotrope of choice, with norepinephrine added if blood pressure support is needed 3
• Note: Experience with IV dobutamine in controlled trials does not extend beyond 48 hours 4

Evidence-Based Medications for Chronic Management

When the patient is hemodynamically stable, initiate or continue:

1. ACE Inhibitors:

   • Recommended for symptomatic patients with HFrEF to reduce risk of HF hospitalization and death 1
   • Lisinopril has been shown to reduce signs and symptoms of heart failure including edema, rales, paroxysmal nocturnal dyspnea, and jugular venous distention 5

2. Beta-Blockers:

   • Start with low dose of evidence-based beta-blocker (bisoprolol, metoprolol succinate, or carvedilol) 2
   • Slowly uptitrate, doubling the dose every 1-2 weeks as tolerated 2
   • Monitor heart rate, blood pressure, and signs of worsening heart failure 2

3. Mineralocorticoid Receptor Antagonists (MRAs):

   • Add to therapy for eligible patients 2
   • Monitor renal function and potassium levels 2

4. SGLT2 Inhibitors:

   • Consider adding to standard therapy when appropriate 2

Common Precipitants to Identify and Address

Identify and treat underlying causes of exacerbation:

• Acute coronary syndrome (33% of cases) 6
• Respiratory infections (16%) 6
• Uncontrolled hypertension (15%) 6
• Atrial arrhythmias with rapid ventricular response (8%) 6
• Medication non-compliance (15%) 6
• Dietary non-compliance/sodium excess (6%) 6

Discharge Planning and Follow-up

• Provide comprehensive written discharge instructions covering:
  • Diet (sodium and fluid restrictions)
  • Discharge medications
  • Activity level
  • Follow-up appointments
  • Daily weight monitoring
  • Instructions on what to do if heart failure symptoms worsen 2
• Perform medication reconciliation at discharge 2
• Schedule follow-up appointment within 7-14 days of discharge

Cautions and Pitfalls

• Avoid NSAIDs as they can worsen both heart failure and renal function 2
• Avoid calcium channel blockers for heart failure treatment 2
• Never abruptly discontinue beta-blockers unless absolutely necessary due to risk of rebound ischemia/infarction and arrhythmias 2
• Use non-invasive positive pressure ventilation with caution in hypotensive patients 1
• Avoid inotropic agents unless specifically indicated for hypotension or hypoperfusion 2