What is the treatment for acute heart failure?

Treatment for Acute Heart Failure

The cornerstone treatment for acute heart failure includes intravenous diuretics, vasodilators (particularly nitrates), and oxygen therapy, with careful monitoring of symptoms, urine output, renal function, and electrolytes. 1

Initial Assessment and Management

Immediate Interventions

• Oxygen therapy: Administer oxygen if SpO₂ <90% or respiratory distress is present
  • Target SpO₂ 88-92% in patients at risk of hypercapnia 2
  • Consider CPAP for respiratory distress with SpO₂ <90% despite supplemental oxygen 1

Diagnostic Workup

• Obtain plasma natriuretic peptide levels (BNP, NT-proBNP) to differentiate AHF from non-cardiac causes of dyspnea 1
• Perform immediate ECG and echocardiography, especially in suspected cardiogenic shock 1

Pharmacological Management

Diuretics

• First-line therapy for congestion:
  • For diuretic-naïve patients: IV furosemide 20-40 mg 1
  • For patients on chronic diuretic therapy: Initial IV dose at least equivalent to oral dose 1
  • Can be administered as intermittent boluses or continuous infusion 1
  • Consider adding IV acetazolamide to enhance diuresis 1

Vasodilators

• Nitrates are recommended as first-line therapy in patients with adequate blood pressure 1, 3
  • Initial administration: Oral/sublingual nitroglycerin (GTN spray 400 μg, 2 puffs every 5-10 min) 1
  • For severe cases: IV nitroglycerin (20-200 μg/min) or isosorbide dinitrate (1-10 mg/h) 1, 4
  • Titrate to optimal vasodilation while monitoring blood pressure (avoid systolic BP <90-100 mmHg) 1
  • Benefits include reduced preload, afterload, and improved coronary blood flow 3, 4
  • Be cautious of tolerance development with prolonged use (>16-24h) 1

Medications to Avoid

• Do not use inotropic agents unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 1
• Avoid calcium channel blockers (diltiazem, verapamil) as they may worsen heart failure 1
• Avoid thiazolidinediones (glitazones) as they increase risk of heart failure worsening 1
• Avoid NSAIDs and COX-2 inhibitors as they increase risk of heart failure worsening 1

Management of Specific Scenarios

Cardiogenic Shock

• Transfer patients rapidly to a tertiary care center with 24/7 cardiac catheterization capability and ICU/CCU with mechanical circulatory support 1
• Immediate ECG and echocardiography are essential 1

Continuation of Chronic HF Medications

• Continue evidence-based disease-modifying therapies in patients with worsening chronic HFrEF, unless hemodynamically unstable 1
• Consider initiation of ACE inhibitors within 48 hours after stabilization if blood pressure allows 1, 2

Monitoring and Follow-up

• Regular monitoring of symptoms, urine output, renal function, and electrolytes during IV diuretic use 1
• Target diuretic response: Urine sodium >50 mEq/L after 2 hours or urine output >1 liter at 6 hours 1
• Schedule follow-up within 6 weeks after discharge with at least three visits including clinical and laboratory evaluation 1
• Enroll patients in a multidisciplinary care management program to reduce risk of HF hospitalization and mortality 1

Pre-discharge Planning

• Initiate or continue guideline-directed medical therapy before discharge 1, 5
  • ACE inhibitors/ARBs or ARNI (angiotensin receptor-neprilysin inhibitor)
  • Beta-blockers
  • Mineralocorticoid receptor antagonists (MRA)
  • Consider SGLT2 inhibitors (gliflozins) 1
• Ensure patient is hemodynamically stable and euvolemic for at least 24 hours before discharge 2
• Encourage regular aerobic exercise to improve functional capacity and symptoms 1

By following this evidence-based approach to acute heart failure management, focusing on relieving congestion with diuretics and vasodilators while avoiding potentially harmful agents, clinicians can effectively manage this serious condition while reducing the risk of complications and improving outcomes.