What is the initial management for a patient presenting with signs of congestive heart failure, including trouble breathing and edema?

Initial Management of Congestive Heart Failure with Trouble Breathing and Edema

The initial management for a patient presenting with signs of congestive heart failure, including trouble breathing and edema, should include immediate oxygen therapy, non-invasive ventilation if respiratory distress is present, intravenous diuretics, and appropriate monitoring of vital signs and response to treatment. 1

Immediate Assessment and Monitoring

• Establish non-invasive monitoring including pulse oximetry, blood pressure, respiratory rate, and continuous ECG within minutes of patient contact 1
• Monitor dyspnea (using visual analog scale), heart rate and rhythm, urine output, and peripheral perfusion 1
• Position patient upright to reduce work of breathing 1
• Assess severity using respiratory rate (>25/min), SpO2 (<90%), and work of breathing 1

Oxygen Therapy and Ventilatory Support

• Provide oxygen therapy if oxygen saturation <90% or based on clinical judgment 1
• Initiate non-invasive ventilation (NIV) immediately in patients showing respiratory distress 1
• Use continuous positive airway pressure (CPAP) in the pre-hospital setting as it requires minimal training and equipment 1
• Consider pressure-support positive end-expiratory pressure (PS-PEEP) for patients with acidosis and hypercapnia, particularly those with COPD history 1
• Avoid hyperoxia unless specifically indicated 1

Pharmacological Management

• Administer intravenous loop diuretics promptly 1, 2:
  • For new-onset HF or no maintenance diuretic therapy: Furosemide 40 mg IV 1
  • For established HF or patients on chronic oral diuretic therapy: Furosemide bolus at least equivalent to oral dose 1
• Consider vasodilators for patients with normal to high blood pressure (SBP >110 mmHg) 1
• Avoid routine use of opioids as they are associated with higher rates of mechanical ventilation, ICU admission, and death 1
• Avoid sympathomimetics or vasopressors except in patients with persistent hypoperfusion despite adequate filling status 1

Laboratory and Diagnostic Tests

• Measure plasma natriuretic peptide level (BNP, NT-proBNP, or MR-proANP) in all patients with acute dyspnea and suspected AHF 1
• Perform basic laboratory assessments including troponin, BUN (or urea), creatinine, electrolytes, glucose, and complete blood count 1
• Consider chest X-ray to identify pulmonary venous congestion, pleural effusions, and interstitial or alveolar edema, though it may be normal in up to 20% of cases 1
• If expertise is available, consider bedside thoracic ultrasound to visualize interstitial edema and assess cardiac function 1
• Perform immediate echocardiography in patients with cardiogenic shock; in others, it can be performed after stabilization 1

Disposition and Further Management

• Reassess clinical, biological, and psychosocial parameters regularly 1
• Consider admission to intensive care unit/coronary care unit for patients with severe respiratory distress or hemodynamic instability 1
• For stable patients, consider observation unit (<24h) or ward admission (cardiology, internal medicine, geriatrics) 1
• Once stabilized, plan for follow-up with a cardiologist within 1-2 weeks 1

Special Considerations

• For patients with heart failure and atrial fibrillation, consider intravenous cardiac glycosides for rapid control of ventricular rate 1
• Beta-blockers are preferred first-line treatment for ventricular rate control in patients with HF and AF 1
• In patients with preserved ejection fraction (HFpEF), consider other causes of dyspnea and edema, including kidney disease, liver disease, chronic venous insufficiency, or specific cardiomyopathies 1
• For long-term management after stabilization, consider ACE inhibitors (e.g., lisinopril) which have been shown to improve symptoms including edema, rales, paroxysmal nocturnal dyspnea, and jugular venous distention 3, 4

Pitfalls to Avoid

• Do not delay treatment; the "time-to-treatment" concept is important in AHF patients 1
• Avoid routine use of morphine in AHF patients 1
• Do not assume all patients with dyspnea and edema have heart failure; consider non-cardiac mimics 1
• Avoid invasive mechanical ventilation if possible by early use of non-invasive ventilation in appropriate patients 1
• Do not neglect monitoring for electrolyte imbalances during diuretic therapy 1