What is the initial management of heart failure in a hospital setting?

Initial Management of Heart Failure in a Hospital Setting

The initial management of acute heart failure (AHF) in a hospital setting should include immediate assessment for respiratory distress, oxygen therapy or non-invasive ventilation as needed, and early administration of intravenous diuretics and vasodilators based on blood pressure status. 1, 2

Initial Assessment and Monitoring

• Rapid triage assessment to determine severity:

  • Respiratory distress: RR >25/min, SpO₂ <90%, increased work of breathing
  • Hemodynamic instability: abnormal blood pressure, severe arrhythmias, HR <40 or >130 bpm
  • Mental status changes

• Continuous monitoring should be established immediately:

  • Pulse oximetry, blood pressure, respiratory rate, continuous ECG
  • Fluid balance monitoring (urine output)
  • Monitor for changes in signs/symptoms suggesting response to treatment 1, 2

• Essential initial investigations:

  • Plasma natriuretic peptide levels
  • Arterial or venous blood gas
  • Chest X-ray
  • ECG
  • Bedside thoracic ultrasound (if expertise available) 2

Immediate Interventions

Oxygen Therapy and Ventilatory Support

1. Oxygen therapy:

   • Administer if SpO₂ <90%
   • Target SpO₂ 88-92% to avoid worsening hypercapnia 2

2. Non-invasive ventilation (NIV):

   • Start immediately in patients with acute pulmonary edema showing respiratory distress
   • CPAP is feasible in pre-hospital setting (simpler than PS-PEEP)
   • Consider BiPAP (PS-PEEP) for patients with acidosis and hypercapnia 1, 2

3. Intubation if respiratory failure cannot be managed non-invasively:

   • Persistent hypoxemia
   • Worsening hypercapnia
   • Acidosis not improving with NIV
   • Deteriorating mental status 2

Pharmacological Management

1. Intravenous diuretics:

   • For new-onset HF or no maintenance diuretic therapy: Furosemide 40 mg IV
   • For established HF or on chronic oral diuretic therapy: Furosemide bolus at least equivalent to oral dose 1
   • Early administration (within 60 minutes of arrival) is associated with lower in-hospital mortality 3

2. Vasodilators:

   • IV nitroglycerin for patients with SBP >110 mmHg
   • Avoid in patients with SBP <110 mmHg 1, 2

3. Rate control for patients with atrial fibrillation:

   • Beta-blockers are preferred first-line treatment
   • IV cardiac glycosides can be considered for rapid ventricular rate control 1, 2

4. Medications to use cautiously:

   • Routine use of opioids is not recommended (associated with higher rates of mechanical ventilation, ICU admission, and death)
   • Limited role for sympathomimetics or vasopressors in AHF without cardiogenic shock 1

Management Based on Risk Stratification

High-Risk Patients

• Require ICU/CCU admission:
  • Respiratory rate >25/min
  • SpO₂ <90% despite supplemental oxygen
  • Signs of hypoperfusion
  • Hemodynamic instability 2

Lower-Risk Patients

• Can be considered for observation unit with discharge criteria:
  • Hemodynamic stability
  • Improved symptoms
  • No high-risk features 2

Transition to Oral Therapy

• ACE inhibitors/ARBs:

  • Initiate within 24-48 hours if blood pressure allows
  • For patients with normotension/hypertension: review/increase dose
  • For patients with hypotension (85-100 mmHg): reduce dose
  • For patients with severe hypotension (<85 mmHg): stop 1
  • For heart failure, lisinopril starting dose is 5 mg once daily when used with diuretics 4

• Beta-blockers:

  • Initiate before hospital discharge if patient is stable
  • Studies show pre-discharge initiation is associated with higher rates of beta-blocker use after discharge 5

Discharge Planning and Follow-up

• Ensure patient is:

  • Hemodynamically stable
  • Euvolemic
  • Established on evidence-based oral medications
  • Has stable renal function for at least 24 hours 2

• Arrange early follow-up:

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

• Consider enrollment in a heart failure disease management program to improve outcomes 2, 5

Common Pitfalls and Caveats

• Delayed treatment: Early administration of IV diuretics (within 60 minutes) is associated with lower mortality 3
• Overuse of opioids: Associated with higher rates of mechanical ventilation, ICU admission, and death 1
• Inappropriate use of vasopressors: Should be reserved for patients with persistent signs of hypoperfusion despite adequate filling status 1
• Failure to initiate evidence-based therapies before discharge: Pre-discharge initiation of beta-blockers and ACE inhibitors improves post-discharge medication adherence and outcomes 5
• Inadequate monitoring: Continuous monitoring of vital signs, urine output, and response to treatment is essential 1, 2

The management of AHF requires a systematic approach with early intervention to improve symptoms, prevent organ damage, and reduce mortality. The European Society of Cardiology guidelines emphasize the importance of rapid assessment, appropriate oxygen therapy or ventilatory support, and early administration of diuretics and vasodilators based on blood pressure status.