From the Guidelines
The treatment of acute congestive heart failure (CHF) should prioritize diuretics, such as furosemide, to improve symptoms and exercise capacity, as recommended by the 2016 ESC guidelines 1. The initial management of acute CHF focuses on rapid symptom relief and hemodynamic stabilization.
Key Recommendations
- Diuretics are recommended to improve symptoms and exercise capacity in patients with signs and/or symptoms of congestion 1.
- The initial recommended dose of furosemide should be 20–40 mg i.v. for patients with new-onset AHF or those with chronic, decompensated HF not receiving oral diuretics, and at least equivalent to the oral dose for those on chronic diuretic therapy 2.
- Vasodilators, such as nitroglycerin, should be considered for symptomatic relief in AHF with SBP >90 mmHg 2.
- Inotropic agents, such as dobutamine, may be necessary for severe cases with hypoperfusion, but are not recommended unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 3.
- Non-invasive positive pressure ventilation should be considered for respiratory distress.
Guideline-Directed Medical Therapy
Once stabilized, patients should be transitioned to guideline-directed medical therapy, including:
- ACE inhibitors/ARBs
- Beta-blockers
- Mineralocorticoid receptor antagonists
- SGLT2 inhibitors ### Supportive Measures
- Fluid restriction (1.5-2 L/day)
- Daily weight monitoring
- Sodium restriction (<2-3g/day) The underlying cause of decompensation should be identified and addressed, as this may include arrhythmias, medication non-adherence, dietary indiscretion, or acute coronary syndrome. This approach works by reducing preload and afterload, improving contractility, and optimizing fluid status to enhance cardiac output and reduce pulmonary congestion.
From the FDA Drug Label
INDICATIONS & USAGE Nitroglycerin Injection is indicated for treatment of peri-operative hypertension; for control of congestive heart failure in the setting of acute myocardial infarction; INDICATIONS AND USAGE Dobutamine Injection, USP is indicated when parenteral therapy is necessary for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility resulting either from organic heart disease or from cardiac surgical procedures The current guidelines for the treatment of acute Congestive Heart Failure (CHF) include:
- Nitroglycerin (IV) for control of CHF in the setting of acute myocardial infarction 4
- Dobutamine (IV) for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility resulting from organic heart disease or cardiac surgical procedures 5 Key points:
- Nitroglycerin is used for CHF in the setting of acute myocardial infarction
- Dobutamine is used for short-term inotropic support in cardiac decompensation
From the Research
Current Guidelines for Acute Congestive Heart Failure (CHF) Treatment
The treatment of acute Congestive Heart Failure (CHF) involves a multidisciplinary approach, focusing on the underlying mechanisms of the disease and the clinical scenario of the patient 6. The key therapies for the initial treatment of AHF include:
- Oxygen
- Diuretics
- Vasodilators
Diagnosis and Assessment
Diagnosis of AHF is based on clinical assessment, measurement of natriuretic peptides, and imaging modalities 6. It is essential to rapidly identify the underlying trigger of AHF and assess the severity of AHF, as well as recognize end-organ injuries.
Treatment Approaches
Treatment approaches vary depending on the clinical scenario:
- For patients with mild AHF exacerbations, intravenous diuretics are often used 7.
- For patients with AHF with flash pulmonary edema, nitroglycerin and noninvasive positive pressure ventilation are recommended, with consideration of an angiotensin-converting enzyme inhibitor 7.
- For patients with hypotensive AHF, emergent specialty consultation and an initial fluid bolus of 250-500 mL, followed by initiation of inotropic agents with or without vasopressors, are recommended 7.
- For patients with severe forms of AHF with cardiogenic shock, inotropes are recommended to achieve hemodynamic stability and restore tissue perfusion 6.
Pharmacological Treatment
Pharmacological treatment of AHF aims to stabilize the patient, improve clinical symptoms, and increase long-term survival rates 8. Various pharmacological agents are used to alleviate symptoms and slow the progression of the disease, including:
- Diuretics to improve congestion and decrease filling pressures 9.
- Digitalis to improve hemodynamics and symptomatology by increasing inotropy and slowing resting heart rate in atrial fibrillation 9.
- Vasodilators, such as nitrates, to decrease left ventricular filling pressure and systemic vascular resistance while modestly improving cardiac output 10.
- Angiotensin-converting enzyme inhibitors to slow the progression of CHF and reduce mortality 9, 10.