What is the treatment for acute decompensated heart failure?

Treatment of Acute Decompensated Heart Failure

The initial management of acute decompensated heart failure (ADHF) should include oxygen therapy, intravenous loop diuretics, and vasodilators, with respiratory support as needed based on the patient's clinical presentation and hemodynamic status. 1, 2

Initial Assessment and Monitoring

• Immediate clinical evaluation including vital signs, ECG, and echocardiography should be performed to assess 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, 3
• Regular monitoring of symptoms, urine output, renal function, and electrolytes is essential during treatment, especially with IV diuretic use 1, 2

Respiratory Support

• Oxygen therapy should be administered when oxygen saturation is <90% to target SpO2 94-96% 1, 2
• Non-invasive ventilation (NIV) should be initiated promptly in patients with respiratory distress 1, 3
• Continuous positive airway pressure (CPAP) is feasible in pre-hospital settings due to simplicity 1, 4
• Pressure-support positive end-expiratory pressure (PS-PEEP) is preferred in hospital for patients with acidosis and hypercapnia, particularly those with COPD history 1, 2

Pharmacological Management

Diuretics

• IV loop diuretics are first-line therapy for patients with volume overload and congestion 1, 5
• Initial recommended dosing for IV loop diuretics is 20-40 mg IV furosemide for new-onset ADHF or patients not on maintenance diuretic therapy 1, 3
• Higher doses may be considered in patients with renal dysfunction or chronic diuretic use 2, 6
• Diuretics can be given as intermittent boluses or continuous infusion, with dose and duration adjusted according to symptoms and clinical status 1, 6

Vasodilators

• IV vasodilators (nitrates, nitroprusside) should be used for symptomatic relief in ADHF with SBP >90 mmHg 1, 7
• Nitroglycerin is indicated for control of congestive heart failure in the setting of acute myocardial infarction 7
• Vasodilators are recommended as first-line therapy with close monitoring for hypertensive ADHF 1, 8

Inotropes

• Short-term IV inotropes (dobutamine, milrinone) may be considered in patients with hypotension (SBP <90 mmHg) and signs of hypoperfusion 1, 9
• Dobutamine is indicated when parenteral therapy is necessary for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility 9
• Experience with intravenous dobutamine in controlled trials does not extend beyond 48 hours 9

Management Based on Clinical Presentation

• For hypertensive ADHF: Vasodilators are recommended as first-line therapy with close monitoring 1, 2
• For normotensive ADHF with congestion: IV diuretics and vasodilators are the mainstay of treatment 1, 5
• For hypotensive ADHF/cardiogenic shock: Consider fluid challenge (250 mL/10 min) if clinically indicated; if SBP remains <90 mmHg, initiate inotropic support 1, 2
• For patients with pulmonary edema: Use morphine cautiously, vasodilators, and diuretics; intubation and mechanical ventilation may be required 2, 4

Special Considerations

• Patients with acute coronary syndrome and ADHF should undergo early coronary angiography and revascularization when appropriate 1, 5
• Avoid routine use of opioids in ADHF patients as they may be associated with increased rates of mechanical ventilation, ICU admission, and mortality 1, 3
• Avoid hyperoxia despite the need for oxygen therapy 1, 2
• Continue evidence-based disease-modifying therapies in patients with chronic HFrEF if hemodynamically stable 1, 3
• Beta-blockers may need dose reduction temporarily or omission in unstable patients with signs of low output 1, 2

Mechanical Circulatory Support

• Patients with refractory ADHF should be considered for additional support, including intra-aortic balloon counterpulsation, mechanical ventilation, or circulatory assist devices 2, 5
• For cardiogenic shock, transfer to tertiary care center with 24/7 cardiac catheterization and mechanical circulatory support capabilities 3, 10

Transition to Chronic Management

• Once stabilized, patients should be transitioned to oral heart failure medications 1, 2
• 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, 10