How to manage Acute Decompensated Heart Failure (ADHF)?

Management of Acute Decompensated Heart Failure (ADHF)

The immediate goals in managing ADHF are to improve symptoms, stabilize hemodynamics, restore oxygenation, and limit cardiac and renal damage through a systematic approach of respiratory support, diuretic therapy, and targeted pharmacological interventions based on clinical presentation. 1

Initial Assessment

• Determine severity of cardiopulmonary instability based on respiratory rate, dyspnea severity, hemodynamic status, and heart rhythm 2
• Measure vital signs including respiratory rate, oxygen saturation, blood pressure, and heart rate 2
• Assess for signs of congestion (peripheral edema, rales, elevated jugular venous pressure) 2
• Obtain ECG to rule out ST-elevation myocardial infarction and assess for arrhythmias 2
• Measure plasma natriuretic peptide levels (BNP, NT-proBNP) to confirm diagnosis 2
• Consider echocardiography to assess ventricular function, valvular function, and rule out other cardiac abnormalities 3

Respiratory Support

• Administer oxygen therapy when SpO2 <90% 2, 3
• Initiate non-invasive ventilation (NIV) promptly in patients with respiratory distress 2, 4
• Choose appropriate NIV modality:
  • Continuous positive airway pressure (CPAP) is feasible in pre-hospital settings due to simplicity 3, 4
  • Pressure support ventilation with positive end-expiratory pressure (PS-PEEP) is preferred for patients with acidosis and hypercapnia, particularly those with COPD 3, 4
• NIV improves clinical parameters including respiratory distress and reduces LV afterload 1, 5
• Consider intubation and mechanical ventilation in patients with progressive respiratory failure or exhaustion as assessed by hypercapnia 1

Pharmacological Management Based on Clinical Presentation

Congested Patients (Most Common)

• Administer IV loop diuretics as first-line therapy 2, 3
  • For patients with new-onset HF or not on oral diuretics: 20-40 mg IV furosemide 2, 3
  • For patients already on diuretics: administer at least equivalent of their oral dose intravenously 3
• Adjust diuretic dosing based on volume overload severity, response to initial therapy, and urine output 2, 3
• Consider vasodilators (nitrates, nitroprusside) for symptomatic relief when SBP >90 mmHg 3, 6

Hypertensive ADHF

• Vasodilators are recommended as first-line therapy with close monitoring 3
• IV diuretics should be administered concurrently to address congestion 3

Hypotensive ADHF/Cardiogenic Shock

• Consider fluid challenge (250 mL/10 min) if clinically indicated 3
• If SBP remains <90 mmHg with signs of hypoperfusion, initiate inotropic support 3, 7
• Consider milrinone for patients with significant pulmonary venous hypertension 7, 6
• For cardiogenic shock, consider transfer to tertiary care center with 24/7 cardiac catheterization and mechanical circulatory support capabilities 2, 1

Monitoring During Treatment

• Continuously monitor oxygen saturation, vital signs, respiratory rate, and work of breathing 2, 3
• Monitor urine output and fluid balance 2, 3
• Perform daily measurements of body weight, renal function, and electrolytes 2, 3
• Consider pulmonary artery catheterization in hemodynamically unstable patients not responding to traditional treatments 1
• Consider coronary angiography in cases of ADHF with evidence of ischemia 1, 3

Special Considerations

• Avoid routine use of opioids as they may be associated with higher rates of mechanical ventilation, ICU admission, and mortality 2, 8
• If opioids are considered for severe distress, use with caution (2.5-5 mg IV morphine boluses) and monitor respiratory status closely 8
• For patients with chronic HFrEF, attempt to continue evidence-based disease-modifying therapies unless contraindicated or hemodynamically unstable 3, 9
• Beta-blockers may need dose reduction temporarily in unstable patients with signs of low output 3
• ACE inhibitors/ARBs may need dose adjustment based on blood pressure and renal function 3

Criteria for ICU Admission

• Respiratory rate >25 breaths/min, SaO2 <90%, use of accessory muscles for breathing 2
• Systolic BP <90 mmHg, need for intubation, and signs of hypoperfusion 2
• Need for mechanical circulatory support 1

Criteria for Discharge and Follow-up

• Hemodynamic stability and euvolemia established on evidence-based oral medication 1
• Stable renal function for at least 24 hours before discharge 1
• Follow-up plans must be in place prior to discharge 1:
  • Review by primary care physician within 1 week of discharge 1
  • Cardiology team follow-up within 2 weeks of discharge if feasible 1
  • Enrollment in a multidisciplinary heart failure management program 1, 3

Mechanical Circulatory Support

• Consider for patients who cannot be stabilized with medical therapy 1
• Short-term mechanical support systems (percutaneous cardiac support devices, ECLS, ECMO) may be used in cardiogenic shock 1
• Early treatment with mechanical circulatory support should be considered for patients with progression to cardiogenic shock 1, 6

By following this systematic approach to ADHF management, clinicians can effectively improve symptoms, stabilize hemodynamics, and potentially reduce morbidity and mortality in this high-risk patient population.