What is the best course of treatment for a patient with acute decompensated heart failure (HF), an ejection fraction (EF) of 17%, currently taking 20mg of lisinopril (angiotensin-converting enzyme inhibitor) daily, and experiencing shortness of breath?

Management of Acute Decompensated Heart Failure with EF 17% on Lisinopril

For a patient with acute decompensated heart failure, EF 17%, and shortness of breath on 20mg lisinopril daily, immediate treatment should include IV diuretics, oxygen therapy if SpO2 <90%, and consideration of vasodilators, while maintaining ACE inhibitor therapy unless contraindicated by hypotension or worsening renal function.

Initial Assessment and Stabilization

• Immediately assess cardiopulmonary stability:

  • Respiratory rate, oxygen saturation, work of breathing
  • Blood pressure, heart rate, signs of hypoperfusion
  • Heart rhythm and ECG changes 1

• Provide oxygen therapy if SpO2 <90% with target saturation of 93-98% (88-92% if COPD present) 1

• Consider non-invasive positive pressure ventilation for persistent respiratory distress despite oxygen 1

Pharmacological Management

Immediate Interventions

1. IV Loop Diuretics:

   • First-line therapy for congestion 1
   • Initial dose: 20-40mg IV furosemide (or equivalent) for new-onset ADHF, or at least equivalent to current oral dose for chronic diuretic users 1
   • Can be administered as intermittent boluses or continuous infusion 1

2. Vasodilators:

   • Consider IV nitroglycerin, nitroprusside, or nesiritide if systolic BP >100 mmHg 2
   • Particularly beneficial in hypertensive ADHF 1

Maintenance Therapy

1. Continue ACE inhibitor (Lisinopril):

   • Maintain current dose of 20mg daily unless contraindicated by hypotension or worsening renal function 1
   • The ATLAS study showed that higher doses of lisinopril (32.5-35mg daily) resulted in 24% fewer hospitalizations for heart failure compared to lower doses 3

2. Beta-blockers:

   • Continue if already prescribed and patient is hemodynamically stable
   • If not on beta-blocker, initiate after stabilization with low dose of evidence-based agent (bisoprolol, metoprolol succinate, or carvedilol) 1
   • Never abruptly discontinue beta-blockers unless absolutely necessary 1

3. Consider ARNI (sacubitril/valsartan):

   • Superior to ACE inhibitors in reducing cardiovascular death or heart failure hospitalization (HR 0.8; 95% CI, 0.73,0.87) 4
   • Consider switching from lisinopril to sacubitril/valsartan after stabilization

4. Mineralocorticoid Receptor Antagonists (MRAs):

   • Add if not already prescribed, unless contraindicated by renal dysfunction or hyperkalemia 1

5. SGLT2 Inhibitors:

   • Consider adding after stabilization 1

Monitoring and Follow-up

• Continuously monitor:

  • Vital signs and oxygen saturation
  • Urine output
  • Renal function and electrolytes
  • Clinical signs of congestion 1

• Adjust diuretic dose based on:

  • Response to treatment
  • Symptoms
  • Clinical status 1

• For increasing congestion:

  • Double diuretic dose
  • Consider temporary reduction in beta-blocker dose 1

Diagnostic Workup

• ECG: Rule out acute coronary syndrome and assess for arrhythmias
• Chest X-ray: Confirm pulmonary edema and rule out alternative causes
• BNP or NT-proBNP: Confirm heart failure exacerbation
• Troponin: Evaluate for myocardial injury
• Complete blood count, electrolytes, BUN, creatinine: Assess for precipitating factors 1

Common Pitfalls to Avoid

1. Do not discontinue ACE inhibitors or beta-blockers abruptly unless absolutely necessary due to severe hypotension or cardiogenic shock 1

2. Avoid routine use of inotropes unless patient is symptomatically hypotensive or shows signs of hypoperfusion 1

3. Avoid NSAIDs as they can worsen both heart failure and renal function 1

4. Avoid non-dihydropyridine calcium channel blockers (verapamil, diltiazem) as they can worsen heart failure 2, 1

5. Do not delay treatment - early intervention reduces morbidity and mortality 1

Discharge Planning

• Provide comprehensive written discharge instructions covering:

  • Medication regimen with clear instructions
  • Daily weight monitoring
  • Dietary sodium and fluid restrictions
  • Activity recommendations
  • Follow-up appointments
  • Signs/symptoms requiring medical attention 2

• Consider referral to heart failure disease management program 1