What is the initial treatment for acute congestive heart failure (CHF)?

Initial Treatment for Acute Congestive Heart Failure

The initial treatment for acute congestive heart failure should include intravenous diuretics (specifically furosemide 20-40 mg IV for diuretic-naïve patients or at least equivalent to oral dose for those on chronic therapy), oxygen therapy, and vasodilators for patients with adequate blood pressure. 1, 2

First-Line Interventions

Oxygen Therapy

• Provide oxygen therapy with face mask or CPAP (target SpO2 94-96%) 1
• Non-invasive positive pressure ventilation reduces respiratory distress and may decrease intubation and mortality rates in patients with respiratory distress 1
• Continue non-invasive ventilation upon hospital arrival if respiratory distress persists, preferably PS-PEEP for patients with acidosis and hypercapnia 1

Diuretic Therapy

• Administer IV furosemide as the cornerstone of initial treatment 1, 2
  • For diuretic-naïve patients: 20-40 mg IV furosemide 2
  • For patients on chronic diuretic therapy: Initial IV dose should be at least equivalent to their oral dose 2
• Early administration of IV diuretics (within 60 minutes of ED arrival) is associated with lower in-hospital mortality 3
• Diuretics can be given either as intermittent boluses or continuous infusion, with dose and duration adjusted according to symptoms and clinical status 1

Vasodilator Therapy

• IV vasodilators should be considered for symptomatic relief in AHF with SBP >90 mmHg (without symptomatic hypotension) 1
• In hypertensive AHF, IV vasodilators should be considered as initial therapy to improve symptoms and reduce congestion 1
• Monitor symptoms and blood pressure frequently during administration of IV vasodilators 1

Special Considerations Based on Clinical Presentation

For Patients with Hypotension (SBP <90 mmHg)

• Short-term IV infusion of inotropic agents (dobutamine, dopamine, levosimendan, PDE III inhibitors) may be considered for patients with hypotension and signs of hypoperfusion 1
• Dobutamine is indicated for inotropic support in short-term treatment of cardiac decompensation due to depressed contractility 4
• Milrinone is indicated for short-term IV treatment of acute decompensated heart failure 5
• Inotropic agents are NOT recommended unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 1

For Patients with Severe Dyspnea

• Consider cautious use of opiates (such as morphine) to relieve dyspnea and anxiety, but be aware of potential side effects like nausea and hypoventilation 1

Monitoring Requirements

• Regular monitoring of symptoms, urine output, renal function, and electrolytes during IV diuretic therapy 1, 2
• Monitor ECG and blood pressure when using inotropic agents and vasopressors due to risk of arrhythmias, myocardial ischemia, and hypotension 1
• Consider bladder catheterization to accurately monitor urinary output and rapidly assess treatment response 2

Additional Measures

• Thromboembolic prophylaxis (e.g., LMWH) is recommended in patients not already anticoagulated and with no contraindication to anticoagulation 1
• For diuretic resistance, consider combination therapy with loop diuretic plus either thiazide-type diuretic or spironolactone 1
• Consider low-dose dopamine infusion in patients with resistance to loop diuretics 6

Common Pitfalls to Avoid

• Delaying diuretic administration beyond 60 minutes of ED arrival is associated with higher in-hospital mortality 3
• Patients with hypotension, severe hyponatremia, or acidosis may respond poorly to diuretic treatment 2
• High doses of diuretics may lead to hypovolemia, hyponatremia, and increase the likelihood of hypotension when initiating ACE inhibitors or ARBs 2
• Using inotropic agents in patients without hypotension or hypoperfusion increases mortality risk 1