What is the treatment prescription for a patient in the Intensive Care Unit (ICU) with acute decompensated heart failure?

Treatment Prescription for Acute Decompensated Heart Failure in the ICU

For a patient with acute decompensated heart failure in the ICU, initiate IV furosemide 20-40 mg bolus (or equivalent to home oral dose if on chronic diuretics), add IV vasodilators if systolic blood pressure ≥110 mmHg, start non-invasive ventilation immediately if respiratory distress is present, and continue evidence-based oral therapies unless hemodynamically unstable. 1

Immediate Respiratory Support

Non-invasive ventilation (NIV) should be started immediately in patients showing respiratory distress with acute pulmonary edema. 1

• Begin with CPAP at 5-7.5 cmH₂O PEEP, titrate up to 10 cmH₂O based on clinical response, with FiO₂ 0.40 1
• CPAP is simpler and requires minimal training, making it feasible even in pre-hospital settings 1
• If acidosis, hypercapnia, or signs of fatigue develop (especially with COPD history), switch to pressure-support PEEP (PS-PEEP) 1
• Continue NIV for approximately 30 minutes per hour until dyspnea and oxygen saturation improve without continuous support 1
• Avoid hyperoxia unless contraindicated 1

Diuretic Therapy - First-Line Treatment

IV loop diuretics are the cornerstone of acute decompensated heart failure management for volume overload. 1, 2

Initial Dosing Algorithm:

• New-onset heart failure or no maintenance diuretics: Start with furosemide 20-40 mg IV bolus 1, 3
• Established heart failure on chronic oral diuretics: Initial IV dose should be at least equivalent to the oral dose 1, 3
• With concurrent AKI: Consider reducing dose by 25-50% if AKI is significant 3

Administration Method:

Either intermittent boluses every 12 hours OR continuous infusion are equally effective - choose based on institutional preference and monitoring capability. 1, 4

• The DOSE trial found no significant difference in symptom improvement between bolus (AUC 4236±1440) versus continuous infusion (AUC 4373±1404, p=0.47) 4
• Total furosemide dose should remain <100 mg in first 6 hours and <240 mg in first 24 hours 1

Monitoring Requirements:

• Place bladder catheter to accurately track urine output hourly 1, 3
• Monitor renal function daily and electrolytes every 12-24 hours 1, 3
• Assess symptoms, urine output, and clinical status frequently 1

Dose Escalation:

• If inadequate response after 2 hours, increase dose by 20 mg 3
• If diuretic resistance develops, add thiazide diuretics (hydrochlorothiazide 25 mg PO) or aldosterone antagonists (spironolactone/eplerenone 25-50 mg PO) for dual nephron blockade 1, 3
• Low-dose combinations are more effective with fewer side effects than high-dose single agents 1

Critical Cautions:

• Patients with SBP <90 mmHg, severe hyponatremia, or acidosis are unlikely to respond to diuretics 1, 3
• High doses may worsen renal function, especially with pre-existing AKI 3
• Avoid NSAIDs as they reduce diuretic efficacy and worsen heart failure 1, 3

Vasodilator Therapy - Second-Line Agent

IV vasodilators should be added early in patients with SBP ≥110 mmHg and are contraindicated if SBP <110 mmHg. 1, 5

• Vasodilators reduce mortality when used early; delays in administration increase mortality 1
• Nitroglycerin IV is indicated for control of congestive heart failure in acute myocardial infarction and peri-operative hypertension 5
• Nitroprusside may be preferable in patients with high arterial blood pressure and low cardiac output, though data are limited 1
• Vasodilators may reduce the need for high-dose diuretic therapy 1
• If worsening renal function occurs, reduce diuretic dose by 50% and add vasodilator therapy if blood pressure allows 3

Management of Chronic Oral Therapies

Continue evidence-based disease-modifying therapies (ACE-I/ARB, beta-blockers, MRA) unless hemodynamic instability or contraindications exist. 1

Blood Pressure-Based Algorithm (First 48 Hours): 1

ACE-I/ARB:

• SBP ≥85 mmHg: Review/increase dose
• SBP 85-100 mmHg: Reduce or stop
• SBP <85 mmHg: Stop

Beta-blockers:

• Heart rate ≥60 bpm: No change (preferred first-line for rate control in atrial fibrillation) 1
• Heart rate 50-60 bpm: Reduce dose
• Heart rate <50 bpm: Stop
• SBP 85-100 mmHg: Reduce or stop
• SBP <85 mmHg: Stop

MRA (Mineralocorticoid Receptor Antagonists):

• Potassium ≤3.5 mEq/dL: Review/increase
• Potassium >5.5 mEq/dL: Stop
• Creatinine >2.5 or eGFR <30: Stop

Diuretics:

• Increase dose with congestion
• Reduce if hypotension develops (SBP 85-100 mmHg)
• Stop if SBP <85 mmHg

Drugs to AVOID

Routine use of morphine is NOT recommended despite older guidelines suggesting consideration. 1

• The ADHERE registry showed morphine use was associated with higher rates of mechanical ventilation, ICU admission, and death 1
• Morphine has never been shown to improve outcomes and may cause harm 1
• If used, decision must be highly individualized; older 2008 guidelines suggested 2.5-5 mg IV boluses for severe restlessness/dyspnea, but this is no longer routine practice 1

Inotropic agents (dobutamine, milrinone) are NOT recommended unless the patient is symptomatically hypotensive or hypoperfused. 1

• No role for vasopressors if SBP >110 mmHg 1
• No evidence that dobutamine should be given when pulmonary edema is associated with normal or high systolic blood pressure 1
• Reserve sympathomimetics/vasopressors only for persistent signs of hypoperfusion despite adequate filling status, excluding cardiogenic shock 1

Rate Control in Atrial Fibrillation

Beta-blockers are the preferred first-line treatment for ventricular rate control in heart failure with atrial fibrillation. 1

• IV cardiac glycosides should be considered for rapid rate control as an alternative 1

When to Escalate Care

If the following occur, consider ultrafiltration, hemodialysis, or mechanical circulatory support: 3

• Oliguria persists despite dose escalation 3
• Hypotension develops 3
• Severe diuretic resistance 3
• Cardiogenic shock: Transfer immediately to tertiary care center with 24/7 cardiac catheterization and ICU/CCU with mechanical circulatory support availability 1

Key Pitfalls to Avoid

• Do not stop beta-blockers reflexively - continue unless heart rate <50 bpm or severe hypotension 1
• Do not use morphine routinely - associated with worse outcomes 1
• Do not give inotropes for normal/high blood pressure pulmonary edema - no evidence of benefit 1
• Do not use vasodilators if SBP <110 mmHg - contraindicated 1
• Do not combine NSAIDs with diuretics - reduces efficacy and worsens heart failure 1, 3
• Do not delay NIV in respiratory distress - start immediately 1