What is the management for a patient presenting with acute decompensated heart failure?

Management of Acute Decompensated Heart Failure

The initial management of acute decompensated heart failure (ADHF) should include oxygen therapy, intravenous diuretics, vasodilators, and appropriate monitoring of vital signs, with treatment tailored based on blood pressure and perfusion status. 1

Initial Assessment and Monitoring

• All patients with suspected ADHF should undergo immediate clinical evaluation including ECG and echocardiography to assess systolic and diastolic ventricular function, valvular function, and rule out other cardiac abnormalities 1
• Continuous monitoring of vital signs including pulse oximetry, blood pressure, respiratory rate, and ECG should be instituted within minutes of patient contact 1
• Laboratory tests should include natriuretic peptides (BNP, NT-proBNP), cardiac enzymes, electrolytes, renal function, and arterial blood gases when needed 1
• Regular monitoring of symptoms, urine output, renal function, and electrolytes is essential during treatment, especially with IV diuretic use 1

Respiratory Support

• Oxygen therapy should be administered based on clinical judgment, and routinely if oxygen saturation is <90% 1
• Position patients upright to reduce work of breathing and improve ventilation 1
• Non-invasive ventilation (NIV) should be started promptly in patients with respiratory distress 1
  • Continuous positive airway pressure (CPAP) is feasible in pre-hospital settings due to simplicity 1
  • Pressure-support positive end-expiratory pressure (PS-PEEP) is preferred in hospital for patients with acidosis and hypercapnia, particularly those with COPD history 1
• Intubation and mechanical ventilation should be considered for patients who fail to respond to non-invasive measures 1

Pharmacological Management

Diuretics

• IV loop diuretics are first-line therapy for patients with volume overload 1
• Initial recommended dosing 1:
  • For new-onset ADHF or no maintenance diuretic therapy: 20-40 mg IV furosemide
  • For established HF on chronic oral diuretics: IV dose at least equivalent to oral dose
• Diuretics can be given as intermittent boluses or continuous infusion, with dose and duration adjusted according to symptoms and clinical status 1
• Consider combination with thiazide-type diuretics or spironolactone in resistant cases 1

Vasodilators

• IV vasodilators (nitrates, nitroprusside) should be considered for symptomatic relief in ADHF with SBP >90 mmHg 1
• Vasodilators are particularly indicated in hypertensive ADHF as initial therapy 1
• Frequent monitoring of blood pressure is required during vasodilator administration 1
• Vasodilators are contraindicated in patients with SBP <90 mmHg 1

Inotropes and Vasopressors

• Short-term IV inotropes (dobutamine, milrinone) may be considered in patients with hypotension (SBP <90 mmHg) and signs of hypoperfusion 1, 2, 3
• Dobutamine is indicated for inotropic support in the short-term treatment of cardiac decompensation due to depressed contractility 3
• Milrinone is indicated for short-term IV treatment of patients with ADHF 2
• Inotropic agents are not recommended unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 1
• Vasopressors (preferably norepinephrine) may be considered in cardiogenic shock despite treatment with another inotrope 1

Management Based on Clinical Presentation

Hypertensive ADHF

• Vasodilators are recommended as first-line therapy with close monitoring 1
• Low-dose diuretic treatment in patients with volume overload or pulmonary edema 1

Normotensive ADHF with Congestion

• IV diuretics and vasodilators are the mainstay of treatment 1
• Monitor for hypotension during treatment 1

Hypotensive ADHF/Cardiogenic Shock

• Consider fluid challenge (250 mL/10 min) if clinically indicated 1
• If SBP remains <90 mmHg, initiate inotropic support 1, 3
• If inotropes fail to restore adequate perfusion, consider norepinephrine with extreme caution 1
• Intra-aortic balloon pump (IABP) and mechanical ventilation should be considered 1
• All patients with cardiogenic shock should be rapidly transferred to a tertiary care center with 24/7 cardiac catheterization and ICU/CCU capabilities 1

Continuation of Chronic HF Medications

• In case of worsening chronic HFrEF, attempt to continue evidence-based disease-modifying therapies unless contraindicated or hemodynamically unstable 1
• For patients on beta-blockers, the dose may need to be reduced temporarily or omitted in unstable patients with signs of low output 1
• ACE inhibitors/ARBs may need dose adjustment based on blood pressure and renal function 1

Special Considerations

• Patients with acute coronary syndrome and ADHF should undergo early coronary angiography and revascularization when appropriate 1
• Avoid routine use of opioids in ADHF patients as they may be associated with increased rates of mechanical ventilation, ICU admission, and mortality 1
• Avoid hyperoxia despite the need for oxygen therapy 1
• Patients with right heart failure may not respond to fluid challenges and may require specific management 1

Transition to Chronic Management

• Once stabilized, patients should be transitioned to oral heart failure medications 1
• Beta-blockers should be initiated when the patient is stabilized on an ACEI or ARB, preferably before hospital discharge 1
• Enrollment in a multidisciplinary care management program is recommended to reduce the risk of HF hospitalization and mortality 1