What is the management of acute decompensated heart failure (ADHF) in a patient presenting with dyspnea (difficulty breathing)?

Management of Acute Decompensated Heart Failure in a Patient with Dyspnea

The immediate management of acute decompensated heart failure (ADHF) in a patient presenting with difficulty breathing requires rapid assessment of cardiopulmonary stability followed by oxygen therapy, non-invasive ventilation if needed, and prompt administration of diuretics and/or vasodilators based on blood pressure. 1

Initial Assessment and Stabilization

• Determine cardiopulmonary stability by assessing respiratory distress (respiratory rate, work of breathing, oxygen saturation) and hemodynamic status (blood pressure, heart rate, peripheral perfusion) 1
• Establish continuous monitoring including pulse oximetry, blood pressure, respiratory rate, and ECG within minutes of patient contact 1
• Assess mental status using the AVPU (alert, visual, pain, or unresponsive) mnemonic as an indicator of hypoperfusion 1, 2
• Position patient upright to reduce work of breathing and improve ventilation 1
• Administer oxygen therapy if SpO₂ <90% with a target of maintaining SpO₂ >90% 1
• Initiate non-invasive ventilation (NIV) in patients with respiratory distress to improve clinical parameters and reduce work of breathing 1

Immediate Diagnostic Workup

• Obtain ECG to exclude ST elevation myocardial infarction and assess for other cardiac abnormalities 1
• Order laboratory tests including:
  • Cardiac biomarkers (troponin) 1
  • BUN/creatinine, electrolytes 1
  • Complete blood count 1
  • Natriuretic peptides (BNP or NT-proBNP) to confirm diagnosis 1
  • Glucose 1
• Perform chest X-ray to rule out alternative causes of dyspnea (though may be normal in up to 20% of ADHF cases) 1
• Consider bedside thoracic ultrasound for signs of interstitial edema if expertise is available 1

Pharmacological Management

• For patients with normal or high blood pressure (majority of ADHF cases):

  • Administer IV loop diuretic (furosemide) - initial dose should be 2-2.5 times the patient's home dose 1, 3
  • Consider IV vasodilators (nitroglycerin) titrated according to blood pressure 1, 4
  • Consider morphine (2.5-5 mg IV bolus) in early stages, especially with severe dyspnea, restlessness, or anxiety 1

• For patients with low blood pressure (SBP <90 mmHg) or signs of cardiogenic shock:

  • Consider inotropic support with dobutamine for short-term treatment of cardiac decompensation due to depressed contractility 5, 4
  • Avoid high doses of diuretics in hypotensive patients as they are unlikely to respond 1

Monitoring Response to Treatment

• Monitor vital signs continuously: blood pressure, heart rate, respiratory rate, oxygen saturation 1, 2
• Assess urine output to evaluate response to diuretic therapy 1, 3
• A satisfactory diuretic response can be defined as:
  • Urine output >100-150 mL/h in first 6 hours or 3-5 L in 24 hours
  • Change in weight of 0.5-1.5 kg in 24 hours 3
• If congestion persists after maximization of loop diuretic therapy over first 24-48 hours, consider adding an adjunctive diuretic such as a thiazide 3
• If decongestion targets are not met, consider continuous infusion of furosemide 3

Special Considerations and Pitfalls

• Avoid excessive oxygen therapy in patients with COPD (target SpO₂ >90% rather than 95%) 1
• Be cautious with NIV in patients with cardiogenic shock and right ventricular failure 1
• Recognize that troponin may be elevated in ADHF without acute coronary syndrome, making it difficult to exclude ACS unless levels are below the 99th percentile 1
• Immediate echocardiography is mandatory in patients with cardiogenic shock but can be performed after stabilization in other cases 1
• Time-to-treatment concept is important in ADHF - all patients should receive appropriate therapy as early as possible 1
• Inadequate inpatient decongestion is a major contributor to high readmission rates 3

Disposition Planning

• Patients with respiratory failure or hemodynamic compromise should be admitted to a location where immediate respiratory and cardiovascular support can be provided (ICU/CCU) 1
• Stable patients can be managed in observation units or regular wards after initial stabilization 1
• Consider early cardiology consultation, especially for patients with de novo heart failure 1