What is the management of Acute Decompensated Heart Failure (ADHF) in biventricular cardiomyopathy?

Management of Acute Decompensated Heart Failure in Biventricular Cardiomyopathy

The management of acute decompensated heart failure (ADHF) in biventricular cardiomyopathy requires immediate intravenous diuretic therapy, careful hemodynamic monitoring, and continuation of evidence-based disease-modifying therapies when hemodynamically stable. 1

Initial Assessment and Monitoring

• Immediate ECG and echocardiography are recommended in all patients with suspected ADHF to assess cardiac structure and function, particularly in biventricular involvement 1
• Measurement of plasma natriuretic peptide levels (BNP, NT-proBNP, or MR-proANP) is recommended upon presentation to help differentiate ADHF from non-cardiac causes of dyspnea 1
• Regular monitoring of symptoms, urine output, renal function, and electrolytes is essential during intravenous diuretic therapy 1
• Patients with cardiogenic shock should be rapidly transferred to a tertiary care center with 24/7 cardiac catheterization capability and ICU/CCU with availability of mechanical circulatory support 1

Pharmacological Management

Diuretic Therapy

• For new-onset ADHF or those with chronic decompensated HF not receiving oral diuretics, the initial recommended dose is 20-40 mg IV furosemide (or equivalent) 1, 2
• For patients on chronic diuretic therapy, the initial IV dose should be at least equivalent to their oral dose 1
• Diuretics can be administered either as intermittent boluses or continuous infusion, with dose and duration adjusted according to the patient's symptoms and clinical status 1, 3
• When diuresis is inadequate, intensify the diuretic regimen by:
  • Increasing doses of intravenous loop diuretics 1
  • Adding a second diuretic (e.g., thiazide) 1
• Target measures for adequate response include:
  • Spot urinary sodium ≥50-70 mmol/L after 2 hours 2
  • Urine output ≥100-150 mL/hour after 6 hours 2
• A UNa:UFurosemide ratio <2 mmol/mg or UNa <50 mmol indicates poor natriuretic response and is associated with worse outcomes 4

Vasodilators and Inotropes

• Intravenous nitroglycerin, nitroprusside, or nesiritide may be considered as adjuncts to diuretic therapy for stable patients with ADHF 1
• Inotropic agents are not recommended unless the patient is symptomatically hypotensive or shows signs of hypoperfusion, due to safety concerns 1
• For patients requiring inotropic support, milrinone is indicated for short-term intravenous treatment of ADHF, particularly in biventricular failure where both right and left ventricular support is needed 5
• Low-dose dopamine infusion may be considered alongside loop diuretic therapy to improve diuresis and better preserve renal function 1

Management of Specific ADHF Presentations

• For congestion with adequate blood pressure: IV diuretics are the mainstay of therapy 1
• For hypertensive ADHF: vasodilators with close monitoring and low-dose diuretic treatment 1
• For cardiogenic shock: fluid challenge if clinically indicated (250 mL/10 min) followed by inotropic therapy if SBP remains <90 mmHg; consider mechanical circulatory support for potentially reversible causes 1
• For right heart failure: inotropic agents when there are signs of organ hypoperfusion; mechanical ventilation should be avoided 1

Continuation of Chronic HF Medications

• In patients with worsening of chronic HFrEF, every attempt should be made to continue evidence-based, disease-modifying therapies (ACEIs/ARBs, beta-blockers, MRAs) in the absence of hemodynamic instability or contraindications 1
• If beta-blocker therapy needs to be temporarily reduced or omitted due to hemodynamic instability, it should be reinitiated before discharge once the patient is stable 1
• Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents 1

Advanced Therapies for Refractory Cases

• Ultrafiltration may be considered for patients with obvious volume overload or refractory congestion 1
• For patients with biventricular failure who cannot be stabilized with medical therapy, mechanical circulatory support systems should be considered 1
• For cardiogenic shock, consider intra-aortic balloon pump (IABP) and evaluation for mechanical circulatory support devices 1

Discharge Planning and Follow-up

• Patients are medically fit for discharge when hemodynamically stable, euvolemic, established on evidence-based oral medication, and with stable renal function for at least 24 hours 1
• Follow-up with a general practitioner within 1 week of discharge and with the hospital cardiology team within 2 weeks is recommended 1
• Enrollment in a multidisciplinary heart failure management program is recommended to reduce the risk of HF hospitalization and mortality 1

Common Pitfalls and Caveats

• Delaying diuretic therapy beyond 60 minutes from presentation can worsen outcomes; door-to-diuretic time should not exceed 60 minutes 2
• Residual congestion at discharge is associated with poor prognosis; ensure adequate decongestion before discharge 2, 4
• Monitoring for electrolyte abnormalities is crucial, as hypokalaemia occurs in approximately 19% of patients receiving IV diuretics, with higher incidence in continuous infusion (36.3%) versus bolus administration (8.3-13.5%) 3
• Worsening renal function occurs in about 15.6% of patients during diuretic therapy and requires close monitoring 3
• NSAIDs and COX-2 inhibitors should be avoided as they increase the risk of HF worsening and hospitalization 1