Immediate Management of Acute Heart Failure
The immediate management of acute heart failure requires rapid assessment of cardiopulmonary stability, prompt oxygen therapy for patients with SpO₂ <90%, early initiation of non-invasive ventilation for respiratory distress, and targeted pharmacological therapy based on blood pressure and clinical presentation. 1
Initial Assessment and Stabilization
- Determine cardiopulmonary stability by assessing respiratory distress (respiratory rate >25/min, SpO₂ <90%, increased work of breathing) and hemodynamic status (blood pressure, heart rhythm) 2, 3
- Position patient upright to reduce work of breathing 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, unresponsive) mnemonic as an indicator of hypoperfusion 1, 2
- Administer oxygen therapy if SpO₂ <90% with a target of maintaining SpO₂ >90% 1
- Initiate non-invasive ventilation (CPAP or BiPAP) in patients with respiratory distress to improve clinical parameters and reduce the rate of mechanical endotracheal intubation 1
Immediate Diagnostic Workup
- Obtain ECG to exclude ST elevation myocardial infarction and assess for arrhythmias 1, 3
- Measure plasma natriuretic peptide levels (BNP, NT-proBNP) to confirm diagnosis 1, 3
- Order laboratory tests including cardiac troponin, BUN/creatinine, electrolytes, complete blood count, and glucose 1
- Perform chest X-ray to rule out alternative causes of dyspnea 1
- Consider bedside thoracic ultrasound for signs of interstitial edema if expertise is available 1, 2
Pharmacological Management Based on Clinical Presentation
For Hypertensive Acute Heart Failure (Most Common Presentation)
- Administer IV vasodilators (nitroglycerin) for rapid blood pressure reduction (target 25% reduction in first few hours) 1, 4, 5
- Start IV loop diuretics (furosemide 40mg IV for new-onset HF or at least equivalent to oral dose for chronic HF patients) 1, 3
- Consider non-invasive ventilation to reduce work of breathing 1
For Normotensive Acute Heart Failure
- Administer IV loop diuretics as first-line therapy 1, 6
- Consider low-dose vasodilators if systolic BP >100 mmHg 5, 7
- Monitor closely for hypotension 3, 7
For Hypotensive Acute Heart Failure/Cardiogenic Shock
- Obtain immediate specialty consultation 1, 3
- Consider initial fluid bolus of 250-500 mL if no signs of congestion 6
- Initiate inotropic support with dobutamine for patients with cardiac decompensation due to depressed contractility 8, 6
- Consider mechanical circulatory support for refractory cases 6
For Acute Heart Failure Due to Arrhythmias
- Correct severe rhythm disturbances urgently with medical therapy, electrical cardioversion, or temporary pacing 1
- Electrical cardioversion is recommended if arrhythmia is contributing to hemodynamic compromise 1
Monitoring Response to Treatment
- Monitor vital signs continuously, including blood pressure, heart rate, respiratory rate, and oxygen saturation 1, 2
- Assess urine output to evaluate response to diuretic therapy 1, 3
- Monitor for electrolyte imbalances, especially with aggressive diuresis 1, 2
- Reassess symptoms and signs of congestion regularly 1, 3
Common Pitfalls and Considerations
- Avoid excessive oxygen therapy in patients with COPD, targeting SpO₂ >90% rather than 95% 1, 2
- Be cautious with NIV in patients with cardiogenic shock and right ventricular failure 1, 2
- Recognize that troponin may be elevated in acute heart failure without acute coronary syndrome 1, 2
- Avoid routine use of opioids as they may increase the need for mechanical ventilation 3, 7
- Nitrate tolerance may develop with prolonged use, requiring dose adjustments 5, 7