What is the management of acute heart failure?

Acute Heart Failure Management

Immediate Assessment and Triage

Acute heart failure requires immediate stabilization with a time-to-treatment approach similar to acute coronary syndromes, prioritizing early oxygen support, non-invasive ventilation for respiratory distress, and pharmacologic therapy based on blood pressure status. 1

Severity Assessment

Determine cardiopulmonary stability immediately upon patient contact by evaluating two key domains 1:

Respiratory distress indicators:

• Respiratory rate >25/min 1
• SpO₂ <90% despite supplemental oxygen 1
• Increased work of breathing 1

Hemodynamic instability indicators:

• Heart rate <40 or >130 bpm 1
• Systolic blood pressure extremes (low or high) 1
• Severe arrhythmias 1

Patients meeting any of these criteria require immediate triage to resuscitation area/CCU/ICU for vital sign stabilization and potential non-invasive ventilation 1, 2.

Initial Monitoring

Institute noninvasive monitoring within minutes of patient contact, including pulse oximetry, blood pressure, respiratory rate, and continuous ECG 1, 3. This should occur in the ambulance during prehospital care when possible 1.

Respiratory Support

Oxygen Therapy

Administer oxygen therapy based on clinical judgment, with routine administration mandatory only when oxygen saturation falls below 90% 1, 3. Avoid hyperoxia unless specifically indicated 2. The treatment objective is to maintain SpO₂ >90% 1.

Non-Invasive Ventilation

Start non-invasive ventilation (NIV) as soon as possible in patients with acute pulmonary edema showing respiratory distress 1, 3, 4. NIV reduces respiratory distress, decreases intubation rates, and may reduce mortality 1, 4.

Choice of NIV modality:

• CPAP (Continuous Positive Airway Pressure): Preferred in the prehospital setting because it is simpler, requires minimal training, and needs less equipment 1, 3, 2, 4
• PS-PEEP (Pressure Support with Positive End-Expiratory Pressure): Consider for patients with acidosis and hypercapnia, particularly those with COPD history or signs of fatigue 1, 3, 4

Both modalities are effective, but CPAP's simplicity makes it the practical choice in low-equipped areas 4.

Pharmacological Management

Diuretic Therapy

Intravenous loop diuretics are first-line therapy for congestion 1, 3, 2. Initiate medical treatment based on blood pressure and degree of congestion 1.

Dosing recommendations for furosemide 1:

• New-onset HF or no maintenance diuretic: 40 mg IV 1
• Established HF on chronic oral diuretics: IV bolus at least equivalent to oral dose 1

For diuretic resistance, consider combination therapy with loop diuretic plus thiazide-type diuretic or spironolactone 3.

Vasodilator Therapy

Intravenous vasodilators are indicated in AHF with normal to high blood pressure (SBP >110 mmHg) 1, 3, 2. They should be administered in combination with loop diuretics for hypertensive AHF 3. Vasodilators are contraindicated when SBP <110 mmHg 1.

Nitroglycerin IV is FDA-approved for control of congestive heart failure in the setting of acute myocardial infarction 5. Early administration of vasodilators is associated with lower mortality, while delays in administration correlate with higher mortality 1.

Agents to Avoid or Use Cautiously

Morphine: Routine use is not recommended 1. While morphine reduces preload, afterload, and heart rate, it was associated with higher rates of mechanical ventilation, ICU admission, and death in the ADHERE registry 1. Since it has never been shown to improve outcomes and may cause harm, its use should be individualized rather than routine 1.

Inotropes/Vasopressors: There is very limited indication for sympathomimetics or vasopressors in AHF excluding cardiogenic shock 1, 2. Reserve these agents only for patients with persistent signs of hypoperfusion despite adequate filling status 1. Milrinone is FDA-approved for short-term IV treatment of acute decompensated heart failure but requires close monitoring with appropriate electrocardiographic equipment and facilities for immediate treatment of potential life-threatening ventricular arrhythmias 6.

Dobutamine: No evidence supports routine use when pulmonary edema is associated with normal or high systolic blood pressure 1.

Rate Control in Atrial Fibrillation

For patients with HF and atrial fibrillation, consider IV cardiac glycosides for rapid ventricular rate control 1, 3. However, beta-blockers are the preferred first-line treatment for controlling ventricular rate in stable patients with HF and atrial fibrillation 1, 3.

In-Hospital Monitoring

Daily Monitoring Requirements

Patients require comprehensive monitoring throughout hospitalization 1, 3, 2:

• Daily weights and accurate fluid balance charts 1, 3, 2
• Daily renal function and electrolytes (urea, creatinine, electrolytes) 1, 3, 2
• Standard noninvasive monitoring of pulse, respiratory rate, and blood pressure 1, 3
• Continuous assessment of dyspnea, heart rate and rhythm, urine output, and peripheral perfusion 1, 2

Renal function is commonly impaired at admission and may improve or deteriorate with diuresis 1.

Pre-Discharge Assessment

Measure natriuretic peptides before discharge to help with post-discharge planning 1, 3. Patients whose natriuretic peptide concentrations fall during admission have lower cardiovascular mortality and readmission rates at 6 months 1.

Discharge Criteria and Follow-Up

Criteria for Medical Fitness for Discharge

Patients are medically fit for discharge when 1, 3:

• Hemodynamically stable and euvolemic 1, 3
• Established on evidence-based oral medication 1, 3
• Stable renal function for at least 24 hours before discharge 1, 3
• Provided with tailored education and advice about self-care 1, 3

Post-Discharge Follow-Up Structure

Implement a structured follow-up plan before discharge 1, 3:

• Enroll in disease management programs 1, 3
• See general practitioner within 1 week of discharge 1, 3
• See hospital cardiology team within 2 weeks of discharge 1, 3
• Follow-up within a multi-professional heart failure service 1, 3

This structured approach ensures continuation and up-titration of disease-modifying therapy for heart failure with reduced ejection fraction 1.

Management of Precipitating Factors

Identify and treat precipitating factors, as compliance issues rank among the most important causes of AHF 3. Recognition of compliance problems along with other potential precipitating factors is critical for optimal management 1.

Acute Coronary Syndrome

Implement an immediate invasive strategy with intent to perform revascularization for acute coronary syndrome 3.

Arrhythmias

Correct rapid arrhythmias urgently with medical therapy or electrical cardioversion 3.

Common Pitfalls

• Delaying NIV initiation: Start immediately in respiratory distress rather than waiting for worsening 1, 4
• Inadequate diuretic dosing: Use at least equivalent to home oral dose in established HF 1
• Premature discharge: Ensure 24 hours of stability on oral medications before discharge 1, 3
• Lack of follow-up planning: Arrange specific appointments before discharge rather than vague instructions 1, 3
• Using inotropes inappropriately: Reserve only for hypoperfusion despite adequate filling 1, 2