What are the initial management strategies for inpatient treatment of acute heart failure?

Inpatient Management of Acute Heart Failure

The initial management of acute heart failure requires immediate assessment of cardiopulmonary stability, administration of oxygen therapy when SpO₂ <90%, initiation of non-invasive ventilation for respiratory distress, and administration of intravenous loop diuretics as first-line therapy for congestion. 1, 2, 3

Initial Assessment and Stabilization

• Determine cardiopulmonary stability by assessing respiratory distress and hemodynamic status within minutes of patient contact 1
• Position the patient upright to reduce work of breathing and improve ventilation 1
• Establish continuous monitoring including pulse oximetry, blood pressure, respiratory rate, and ECG 1
• Assess mental status using the AVPU mnemonic to identify hypoperfusion 1
• Triage patients with persistent dyspnea or hemodynamic instability to a high-dependency setting (CCU/ICU) 1, 2

Immediate Diagnostic Workup

• Obtain an ECG to exclude ST elevation myocardial infarction and assess for arrhythmias 1, 2
• Measure plasma natriuretic peptide levels (BNP, NT-proBNP) to confirm diagnosis 1, 2
• Order laboratory tests including troponin, electrolytes, renal function, and complete blood count 1
• Perform a chest X-ray to rule out alternative causes of dyspnea 1

Respiratory Support

• Administer oxygen therapy to maintain SpO₂ >90%, but avoid hyperoxia 1, 3
• Initiate non-invasive ventilation (NIV) 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 4, 3
• Consider pressure support ventilation with positive end-expiratory pressure (PS-PEEP) for patients with acidosis and hypercapnia, particularly those with COPD history 4, 3

Pharmacological Management

Diuretic Therapy

• Administer intravenous loop diuretics as first-line therapy for congestion 4, 2, 3
• For new-onset HF or patients not on maintenance diuretics, give furosemide 40 mg IV 4, 2
• For patients on chronic oral diuretic therapy, administer IV bolus at least equivalent to oral dose 4
• Monitor response to diuretics by tracking urine output, symptoms, renal function, and electrolytes 2, 3
• Consider combination therapy with loop diuretic plus thiazide-type diuretic or spironolactone for diuretic resistance 3

Vasodilator Therapy

• Administer intravenous vasodilators in AHF with normal to high blood pressure (SBP >110 mmHg) 4
• Use nitroglycerin IV for treatment of congestive heart failure, especially in the setting of acute myocardial infarction 5
• Consider nitroglycerin particularly for patients with acute cardiogenic pulmonary edema 6
• Be aware that high doses (>120 μg/min) may be required for optimal effect in heart failure patients 7

Management of Atrial Fibrillation

• Consider intravenous cardiac glycosides for rapid ventricular rate control in heart failure with atrial fibrillation 4, 3
• Use beta-blockers as the preferred first-line treatment for ventricular rate control in stable patients with heart failure and atrial fibrillation 4, 3

Medications to Use Cautiously

• Avoid routine use of opioids as they may be associated with higher rates of mechanical ventilation, ICU admission, and mortality 4, 2
• Reserve sympathomimetics or vasopressors for patients with persistent signs of hypoperfusion despite adequate filling status 4
• For cardiogenic shock (SBP <90 mmHg with signs of hypoperfusion), consider transfer to tertiary care center with mechanical circulatory support capabilities 2

Monitoring and Follow-up

• Weigh the patient daily and maintain accurate fluid balance charts 4, 3
• Monitor renal function and electrolytes daily 4, 3
• Continue standard non-invasive monitoring of pulse, respiratory rate, and blood pressure 4
• Measure natriuretic peptides before discharge to help with post-discharge planning 4, 3

Criteria for Discharge

• Ensure patients are hemodynamically stable, euvolemic, established on evidence-based oral medication, and have stable renal function for at least 24 hours before discharge 4, 3
• Provide tailored education and advice about self-care 4
• Arrange follow-up with primary care physician within 1 week of discharge 4, 3
• Schedule cardiology follow-up within 2 weeks of discharge 4, 3
• Enroll patients in a multidisciplinary heart failure disease management program 4, 3

Special Considerations

• For patients with cardiogenic shock, dobutamine is the inotrope of choice, with norepinephrine recommended if blood pressure support is needed 8
• Continue evidence-based disease-modifying therapies in patients with chronic HFrEF if hemodynamically stable 2
• Identify and treat precipitating factors of AHF, as compliance issues are among the most important 4, 6