What is the initial assessment and treatment plan for an inpatient with acute systolic heart failure?

Assessment and Management of Inpatient Acute Systolic Heart Failure

Initial Assessment

The initial assessment of acute systolic heart failure should include immediate evaluation of cardiopulmonary stability, hemodynamic status, and heart rhythm to determine the severity and guide urgent interventions. 1

• Assess for respiratory distress: respiratory rate, oxygen saturation, work of breathing, and ability to tolerate supine position 1
• Monitor vital signs: blood pressure, heart rate, rhythm, and signs of hypoperfusion (cool extremities, narrow pulse pressure, altered mental status) 1
• Evaluate for congestion: peripheral edema, pulmonary rales, elevated jugular venous pressure 1
• Obtain objective measurements: transcutaneous oxygen saturation (SpO2), ECG, and laboratory tests including BNP/NT-proBNP 2
• Consider arterial blood gas analysis in patients with severe respiratory distress or previous COPD 1

Immediate Management

• Administer oxygen therapy if SpO2 <90% to correct hypoxemia 1
• Initiate non-invasive positive pressure ventilation (CPAP, BiPAP) in patients with respiratory distress (respiratory rate >25 breaths/min, SpO2 <90%) to reduce work of breathing and avoid endotracheal intubation 1
• Consider intubation if respiratory failure cannot be managed non-invasively (PaO2 <60 mmHg, PaCO2 >50 mmHg, pH <7.35) 1
• Administer intravenous loop diuretics promptly - early treatment (within 60 minutes) is associated with lower in-hospital mortality 3
  • For new-onset HF: furosemide 40 mg IV bolus 1
  • For chronic HF on oral therapy: IV bolus at least equivalent to oral dose 1

Pharmacological Management

• Administer intravenous diuretics as the cornerstone of treatment for congestion and volume overload 1, 2

  • Tailor dose based on prior diuretic use and renal function 1, 4
  • For resistant edema, consider combination therapy with loop diuretic plus thiazide or metolazone 1
  • Monitor urine output, renal function, and electrolytes daily 1

• Consider vasodilators (nitrates) when systolic BP >110 mmHg for symptomatic relief 1

  • Avoid in patients with hypotension (SBP <90 mmHg) or significant valvular stenosis 1

• Consider morphine in early stages for patients with severe dyspnea, anxiety, or chest pain 1

  • Use cautiously (2.5-5 mg IV bolus) and monitor for respiratory depression 1
  • Avoid in patients with hypotension, bradycardia, advanced AV block, or CO2 retention 1

• For cardiogenic shock (SBP <90 mmHg with signs of hypoperfusion):

  • Consider inotropic support (dobutamine) if vital organ perfusion is compromised 1, 2
  • Add vasopressors (norepinephrine preferred) if blood pressure support is needed 2, 5
  • Consider mechanical circulatory support for refractory cases 2, 6

Monitoring and Follow-up Care

• Weigh patient daily and maintain accurate fluid balance charts 1
• Monitor renal function and electrolytes daily 1, 2
• Measure pre-discharge natriuretic peptides to guide post-discharge planning 1
• Address common complications:
  • Hypokalemia/hypomagnesemia: provide appropriate supplementation 1
  • Hyponatremia: consider fluid restriction in volume overloaded patients 1
  • Worsening renal function: assess volume status and avoid nephrotoxic agents 1

Disposition Criteria

• Triage patients with significant dyspnea or hemodynamic instability to a high-dependency setting (ICU/CCU) 1
• Consider ICU/CCU admission for patients with:
  • Respiratory rate >25, SpO2 <90%, use of accessory muscles
  • Systolic BP <90 mmHg
  • Need for intubation or signs of hypoperfusion
  • Lactate >2 mmol/L, metabolic acidosis, SvO2 <65% 1

Common Pitfalls and Caveats

• Avoid excessive diuresis leading to hypovolemia, hypotension, and worsening renal function 1
• Monitor blood pressure closely when using vasodilators, especially in patients with borderline blood pressure 1
• Inotropes should be used cautiously due to potential for increased mortality, arrhythmias, and myocardial ischemia 1, 2
• Avoid calcium channel blockers in patients with systolic heart failure due to negative inotropic effects 1, 7
• Avoid hyperoxia unless specifically indicated 2
• Early treatment with IV loop diuretics (within 60 minutes) is associated with lower in-hospital mortality - don't delay treatment 3