What is the management approach for a patient with congestive heart failure (CHF) exacerbation and heart pauses?

Management of CHF Exacerbation with Heart Pause

For patients experiencing CHF exacerbation with heart pauses, immediate assessment and stabilization are required, followed by optimization of heart failure therapy while addressing the underlying conduction abnormality. 1

Initial Assessment and Stabilization

• Perform immediate assessment with ECG and echocardiography to evaluate the severity of heart failure and characterize the heart pauses 1
• Monitor hemodynamic status with invasive arterial line if there are signs of hypoperfusion (oliguria, cold peripheries, altered mental status, lactate > 2 mmol/L, metabolic acidosis) 1
• Administer fluid challenge (saline or ringer lactate, > 200 mL/15-30 min) if no signs of overt fluid overload are present 1

Management of Heart Failure Component

• Administer intravenous diuretics for patients with signs of fluid overload to alleviate symptoms, improve exercise capacity, and reduce hospitalizations 1
• Consider vasodilators such as intravenous nitroglycerin, nitroprusside, or nesiritide for severely symptomatic fluid overload without systemic hypotension 1
• For patients with low cardiac output and signs of hypoperfusion despite adequate filling:
  • Dobutamine is the preferred inotropic agent (2-3 μg/kg/min without loading dose, titrated up to 15 μg/kg/min) 2
  • Dopamine is an alternative (3-5 μg/kg/min for inotropic effect, >5 μg/kg/min for both inotropic and vasopressor effects) 2

Management of Heart Pause Component

• For patients with symptomatic bradycardia or heart pauses causing hemodynamic instability:
  • Consider temporary pacing if pauses are causing hemodynamic compromise 1
  • Evaluate for permanent pacemaker implantation based on the nature and frequency of pauses 1
  • If patient has HFrEF and requires permanent pacing for high-degree AV block, cardiac resynchronization therapy (CRT) is recommended over right ventricular pacing regardless of NYHA class or QRS width 1

Medication Adjustments

• Review current medications that may contribute to heart pauses:
  • Beta-blockers may need temporary reduction or discontinuation if they are contributing to bradycardia or heart pauses 3
  • Avoid or withdraw medications known to adversely affect heart failure status, including most antiarrhythmic drugs and calcium channel blockers (except amlodipine) 1

Long-term Management

• Once stabilized, optimize guideline-directed medical therapy (GDMT):

  • ACE inhibitor (or ARB if intolerant), mineralocorticoid receptor antagonist (MRA), SGLT2 inhibitor, and beta-blocker (once stabilized) for patients with HFrEF 1
  • SGLT2 inhibitor for patients with HFmrEF or HFpEF 1
  • Sacubitril/valsartan as replacement for ACE-I or ARB in HFrEF patients 1

• Consider device therapy:

  • ICD for patients with symptomatic HF (NYHA class II-III) of ischemic etiology and LVEF ≤35% despite ≥3 months of optimized GDMT 1
  • CRT for patients with symptomatic HF, sinus rhythm, LVEF ≤35% despite GDMT, and QRS duration ≥150 ms with LBBB morphology 1

Monitoring and Follow-up

• Daily weight and accurate fluid balance monitoring during hospitalization 1
• Daily assessment of renal function and electrolytes 1
• Continuous cardiac monitoring with ECG telemetry due to increased risk of arrhythmias, especially when using inotropic agents 2
• Pre-discharge measurement of natriuretic peptides for post-discharge planning 1
• Enrollment in a multidisciplinary HF management program to reduce the risk of HF hospitalization and improve survival 1

Common Pitfalls to Avoid

• Avoid long-term use of infused positive inotropic drugs except as palliation for end-stage disease 1
• Do not abruptly discontinue beta-blockers in patients with coronary artery disease; if necessary, gradually reduce over 1-2 weeks 3
• Avoid routine use of calcium channel blockers in HFrEF patients 1
• Avoid NSAIDs as they can cause sodium and water retention and blunt the effects of diuretics 1
• Recognize and address common precipitants of CHF exacerbation: noncompliance with salt restriction, pulmonary infections, arrhythmias, and inappropriate reductions in HF therapy 4