What is the initial management for a patient presenting with acute decompensated heart failure (ADHF)?

Initial Management of Acute Decompensated Heart Failure (ADHF)

The initial management of acute decompensated heart failure requires immediate administration of intravenous diuretics, oxygen therapy for patients with SpO2 <90%, and non-invasive ventilation for those with respiratory distress to reduce mortality and improve outcomes. 1

Initial Assessment and Triage

• Determine severity of cardiopulmonary instability based on respiratory rate, dyspnea severity, hemodynamic status, and heart rhythm 1
• Measure vital signs including respiratory rate, oxygen saturation, blood pressure, and heart rate 1
• Assess for signs of congestion: peripheral edema, rales, elevated jugular venous pressure 1
• Obtain ECG to rule out ST-segment elevation myocardial infarction and assess for arrhythmias 1
• Measure plasma natriuretic peptide levels (BNP, NT-proBNP) to confirm diagnosis 1
• Perform chest X-ray to rule out alternative causes of dyspnea 1

Immediate Interventions

Oxygenation and Ventilatory Support

• Administer oxygen therapy when SpO2 <90% 1
• Initiate non-invasive ventilation (NIV) as soon as possible in patients with respiratory distress 1, 2
• Choose appropriate NIV modality:
  • Continuous positive airway pressure (CPAP) is simpler and suitable for pre-hospital settings 1, 2
  • Pressure support ventilation with positive end-expiratory pressure (PS-PEEP) is preferred for patients with acidosis and hypercapnia 1, 2

Pharmacological Management

• For patients with new-onset HF or not on oral diuretics: administer 20-40 mg IV furosemide 1
• For patients on chronic diuretic therapy: give IV bolus at least equivalent to oral dose 1
• Adjust diuretic dosing based on:
  • Volume overload severity 1
  • Response to initial therapy 1
  • Urine output 1
• Blood pressure-guided therapy:
  • SBP >110 mmHg: Consider IV vasodilators with diuretics for symptomatic relief 1
  • SBP <90 mmHg with signs of hypoperfusion: Consider inotropic support (e.g., dobutamine) 1, 3

Monitoring and Follow-up

• Continuously monitor:
  • Oxygen saturation via pulse oximetry 1
  • Vital signs including blood pressure and heart rate 1
  • Respiratory rate and work of breathing 1
  • Urine output and fluid balance 1
• Perform daily measurements of:
  • Body weight 1
  • Renal function and electrolytes 1
• Assess response to initial therapy through:
  • Improvement in subjective symptoms 1
  • Resting heart rate <100 bpm 1
  • Adequate urine output 1
  • Oxygen saturation >95% on room air 1

Disposition Decisions

• Patients with significant dyspnea or hemodynamic instability should be admitted to a high-dependency setting (CCU/ICU) 1
• Criteria for ICU admission include:
  • Respiratory rate >25 breaths/min 1
  • SaO2 <90% 1
  • Use of accessory muscles for breathing 1
  • Systolic BP <90 mmHg 1
  • Need for intubation 1
  • Signs of hypoperfusion (oliguria, altered mental status, lactate >2 mmol/L) 1
• Patients with less severe symptoms may be managed in a regular ward with specialist heart failure knowledge 1

Special Considerations

• For cardiogenic shock (SBP <90 mmHg with signs of hypoperfusion):
  • Transfer to tertiary care center with 24/7 cardiac catheterization and mechanical circulatory support 1
  • Consider vasopressors (preferably norepinephrine) if not responding to inotropes 1
• Avoid routine use of opioids as they may be associated with higher rates of mechanical ventilation and mortality 1
• Continue evidence-based disease-modifying therapies in patients with chronic HFrEF if hemodynamically stable 1