How do we manage congestive heart failure (CHF) exacerbation in the emergency department (ED)?

Management of CHF Exacerbation in the Emergency Department

The management of congestive heart failure (CHF) exacerbation in the emergency department should follow a systematic approach focusing on rapid assessment, oxygen therapy, ventilatory support, and appropriate medication administration based on the patient's hemodynamic status.

Initial Assessment and Triage

• Patients with significant dyspnea or hemodynamic instability should be immediately triaged to a resuscitation area where emergency interventions can be provided 1
• Initial vital sign monitoring should include pulse oximetry, blood pressure, respiratory rate, and continuous ECG 1
• Severity assessment should evaluate for respiratory distress (RR >25/min, SpO2 <90%, increased work of breathing) and hemodynamic instability (abnormal blood pressure, severe arrhythmias, HR <40 or >130 bpm) 1
• Laboratory tests should include BNP/NT-proBNP, troponin, BUN/urea, creatinine, electrolytes, glucose, and complete blood count 1
• ECG and chest radiography should be performed promptly to rule out alternative diagnoses 1

Oxygen Therapy and Ventilatory Support

• Oxygen therapy should be considered in patients with AHF having SpO2 <90% 1
• Non-invasive ventilation (NIV) is indicated in patients with respiratory distress and should be started as soon as possible to reduce respiratory distress and decrease the rate of endotracheal intubation 1, 2
• For patients with respiratory distress, CPAP is recommended in the prehospital setting as it is simpler than pressure-support positive end-expiratory pressure (PS-PEEP) 1
• In patients with acidosis and hypercapnia, particularly those with COPD history or signs of fatigue, PS-PEEP is preferred upon hospital arrival 1

Medication Management Based on Blood Pressure

For Patients with Normal to High Blood Pressure (SBP >110 mmHg):

• Intravenous vasodilators should be administered along with diuretics as first-line therapy for patients with normal to high blood pressure 1
• Sublingual nitrates may be considered as an initial therapy 1
• Intravenous diuretics (furosemide) should be administered with the following dosing recommendations:
  • For new-onset HF or no maintenance diuretic therapy: 40 mg IV furosemide 1
  • For established HF or chronic oral diuretic therapy: IV furosemide bolus at least equivalent to oral dose 1, 3

For Patients with Low Blood Pressure (SBP <90 mmHg):

• Patients with hypotension and signs of hypoperfusion (oliguria, cold peripheries, altered mental status, lactate >2 mmol/L, metabolic acidosis) should be assessed for cardiogenic shock 1
• In cardiogenic shock, dobutamine may be indicated for inotropic support in the short-term treatment of cardiac decompensation due to depressed contractility 4
• Invasive monitoring with arterial line is needed in cardiogenic shock cases 1

Monitoring During Treatment

• Patients should be continuously monitored for:
  • Dyspnea (using Visual Analog Scale, respiratory rate)
  • Blood pressure, SpO2, heart rate and rhythm
  • Urine output and peripheral perfusion 1
• Renal function and electrolytes should be measured daily 1
• Daily weight and accurate fluid balance charts should be maintained 1

Criteria for Admission vs. Discharge

• Patients requiring ICU/CCU admission include those with:

  • RR >25, SaO2 <90%, use of accessory muscles for breathing
  • Systolic BP <90 mmHg
  • Need for intubation
  • Signs of hypoperfusion (oliguria, cold peripheries, altered mental status, lactate >2 mmol/L, metabolic acidosis) 1

• Indicators of good response to initial therapy that might allow discharge consideration include:

  • Patient-reported subjective improvement
  • Resting HR <100 bpm
  • No hypotension when standing up
  • Adequate urine output
  • Oxygen saturation >95% in room air 1

Common Pitfalls and Caveats

• Hyperoxia should be avoided unless specifically indicated 1
• Inotropes are not recommended unless the patient has symptomatic hypotension or evidence of hypoperfusion due to safety concerns 5
• ECG and blood pressure monitoring are mandatory when using inotropes and vasopressors, as they can cause arrhythmias and myocardial ischemia 5
• Parenteral diuretic therapy should be replaced with oral furosemide as soon as practical 3
• Neither dobutamine nor any other cyclic-AMP-dependent inotrope has been shown in controlled trials to be safe or effective in long-term treatment of CHF 4