What is the management approach for acute on chronic congestive heart failure (CHF)?

Management of Acute on Chronic Congestive Heart Failure

The management of acute on chronic heart failure requires prompt administration of intravenous diuretics, oxygen therapy for patients with SpO2 <90%, and consideration of non-invasive ventilation for those with respiratory distress to reduce mortality and improve outcomes. 1

Initial Assessment and Stabilization

• Assess respiratory distress by monitoring respiratory rate, oxygen saturation, work of breathing, and presence of orthopnea 1
• Monitor vital signs including blood pressure, heart rate, respiratory rate, and oxygen saturation to determine severity and guide treatment 2
• Evaluate for signs of congestion including peripheral edema, rales, jugular venous distension, hepatojugular reflux, and ascites 2
• Position patient upright to reduce work of breathing and improve ventilation 1

Respiratory Management

• Administer oxygen therapy when SpO2 <90%, but avoid hyperoxia as it may be harmful 1
• Initiate non-invasive ventilation promptly in patients showing respiratory distress to reduce intubation rates and mortality 1, 3
• Use continuous positive airway pressure (CPAP) in pre-hospital settings due to its simplicity and minimal training requirements 1
• Consider pressure support ventilation with positive end-expiratory pressure (PS-PEEP) for patients with acidosis and hypercapnia, particularly those with COPD history 1
• Monitor response to respiratory support by assessing work of breathing, respiratory rate, and oxygen saturation 1, 2

Pharmacological Management

Diuretics

• Administer intravenous loop diuretics as first-line therapy for congestion 1
• For new-onset heart failure or patients not on maintenance diuretics: administer furosemide 40 mg IV 1
• For established heart failure or patients on chronic oral diuretic therapy: administer IV furosemide bolus at least equivalent to oral dose 1
• Monitor response to diuretics by tracking urine output, symptoms, renal function, and electrolytes 1
• Consider combination therapy with loop diuretic plus thiazide-type diuretic or spironolactone for diuretic resistance 1

Vasodilators

• Consider intravenous vasodilators for symptomatic relief when systolic blood pressure >90 mmHg 1
• Use vasodilators as initial therapy in hypertensive acute heart failure to improve symptoms and reduce congestion 1
• Monitor blood pressure and symptoms frequently during vasodilator administration 1

Inotropes and Vasopressors

• Reserve inotropic agents (dobutamine, milrinone) for patients with hypotension (SBP <90 mmHg) and signs of hypoperfusion 1
• Dobutamine is indicated for short-term treatment of cardiac decompensation due to depressed contractility 4
• Avoid routine use of inotropes in patients without hypotension or hypoperfusion due to safety concerns 1
• Consider norepinephrine as preferred vasopressor for cardiogenic shock despite treatment with inotropes 1

Medications to Use with Caution

• Avoid routine use of opioids as they may increase rates of mechanical ventilation, ICU admission, and mortality 1
• Limit use of sympathomimetics or vasopressors to patients with persistent hypoperfusion despite adequate filling status 1

Rate Control in Atrial Fibrillation

• Consider intravenous cardiac glycosides for rapid ventricular rate control in heart failure with atrial fibrillation 1
• Beta-blockers are the preferred first-line treatment for ventricular rate control in stable patients with heart failure and atrial fibrillation 1

Monitoring and Follow-up

• Weigh patient daily and maintain accurate fluid balance charts 1
• Monitor renal function and electrolytes daily 1
• Measure natriuretic peptides before discharge to guide post-discharge planning 1
• Ensure patients are hemodynamically stable, euvolemic, established on evidence-based oral medication, and have stable renal function for at least 24 hours before discharge 1

Post-Discharge Care

• Arrange follow-up with primary care physician within 1 week of discharge 1
• Schedule cardiology follow-up within 2 weeks of discharge 1
• Enroll patient in a multidisciplinary heart failure disease management program 1
• Ensure continuation and uptitration of disease-modifying therapies for heart failure with reduced ejection fraction 1

Common Pitfalls to Avoid

• Delaying initiation of non-invasive ventilation in patients with respiratory distress 1, 3
• Routine use of opioids for dyspnea management 1
• Using inotropes in patients without hypotension or signs of hypoperfusion 1
• Discharging patients before they are hemodynamically stable and euvolemic 1
• Failing to arrange appropriate follow-up care after discharge 1