What is the initial management and medication regimen for a patient with acute decompensated heart failure?

Acute Decompensated Heart Failure: Initial Management Protocol

Immediate Interventions (First 60 Minutes)

Start IV furosemide 20-40 mg slow IV push (over 1-2 minutes) if diuretic-naïve, OR give at least the equivalent of the patient's oral home dose if already on chronic diuretics. 1, 2, 3

Oxygen/Respiratory Support

• Oxygen via face mask or CPAP targeting SpO2 94-96% 1
• Non-invasive positive pressure ventilation (PS-PEEP preferred) if respiratory distress with acidosis/hypercapnia persists 1
• CPAP starting at 5-7.5 cmH2O, titrate up to 10 cmH2O with FiO2 0.40 4

Vasodilator Therapy (If SBP >90 mmHg)

• IV nitroglycerin: Start at 5 mcg/min via infusion pump, titrate by 5 mcg/min increments every 3-5 minutes 5
• Once at 20 mcg/min without response, increase by 10-20 mcg/min increments 5
• Maximum concentration 400 mcg/mL; use non-PVC tubing to avoid drug absorption 5
• Indicated for symptomatic relief in patients without symptomatic hypotension 1

Adjunctive Medications

• Morphine 2.5-5 mg IV bolus for severe dyspnea, restlessness, or anxiety (repeat as needed, monitor respirations) 4
• Antiemetic as needed (nausea common with morphine) 4

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Monitoring Protocol (First 6 Hours)

Immediate Assessment

• Insert bladder catheter to accurately monitor urine output 4, 2
• Check spot urinary sodium at 2 hours: Target ≥50-70 mmol/L 6
• Assess urine output at 6 hours: Target ≥100-150 mL/hour 6

If Inadequate Response at 6 Hours

• Double the furosemide dose (maximum 400-600 mg/day, up to 1000 mg/day in severe renal impairment) 4, 6
• Consider early combination therapy:
  • Acetazolamide 500 mg IV once daily (especially if bicarbonate ≥27 mmol/L, use only first 3 days) 6, OR
  • Hydrochlorothiazide 25 mg PO 4
  • Spironolactone/eplerenone 25-50 mg PO 4

Continuous Monitoring

• Symptoms, urine output, renal function, electrolytes (K+, Na+) 1, 2
• Blood pressure and ECG if using inotropes/vasopressors 1

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Dosing Details by Clinical Scenario

Diuretic-Naïve Patients

• Furosemide 20-40 mg IV slow push 2, 3
• Alternative: Bumetanide 0.5-1 mg IV or Torasemide 10-20 mg IV 4

Patients on Chronic Oral Diuretics

• Give IV dose at least equivalent to oral home dose 1, 2
• Higher outpatient doses (≥120 mg furosemide equivalent) predict worse outcomes and may respond better to bolus strategy rather than continuous infusion 7

Bolus vs. Continuous Infusion

• Either strategy is acceptable - the landmark DOSE trial showed no difference in symptom relief or renal function 8
• However, in high-risk patients (NYHA IV, EF ≤30%, SBP ≤110 mmHg, Na ≤135 mmol/L), continuous infusion achieves better decongestion (48% vs. 25% freedom from congestion, p=0.04) 9
• If using continuous infusion: Add to D5W or NS after adjusting pH >5.5, infuse at ≤4 mg/min 3

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Special Populations & Contraindications

Hypotensive Patients (SBP <90 mmHg)

• Unlikely to respond to diuretics alone 4, 2
• Consider short-term inotropic infusion (dobutamine/milrinone) with extreme caution due to increased mortality risk 1
• Avoid vasodilators 1

Severe Hyponatremia or Acidosis

• Poor diuretic response expected 4, 2
• Acetazolamide particularly useful if bicarbonate elevated 6

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Critical Pitfalls to Avoid

• Do NOT use inotropes in normotensive patients - increases mortality 1
• Do NOT discharge with residual congestion - associated with poor prognosis 6
• Do NOT exceed furosemide 100 mg in first 6 hours or 240 mg in first 24 hours without reassessment 4
• Do NOT mix nitroglycerin with acidic solutions (labetalol, ciprofloxacin, amrinone, milrinone) - causes precipitation 5
• Do NOT forget thromboembolic prophylaxis if not already anticoagulated 1

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Additional Measures

• Continue guideline-directed medical therapy (ACE-I/ARB/ARNI, beta-blockers, MRA) unless contraindicated 1
• Ensure early follow-up within 2 weeks for medication optimization 6