What is the comprehensive management of a patient with acute decompensated heart failure?

Comprehensive Management of Acute Decompensated Heart Failure

Patients with acute decompensated heart failure should be immediately stabilized with oxygen support and intravenous loop diuretics (20-40 mg furosemide for diuretic-naïve patients, or equivalent to oral dose for those on chronic therapy), while simultaneously monitoring hemodynamics and initiating risk stratification to determine appropriate level of care. 1, 2

Immediate Assessment and Triage

Initial Evaluation

• Obtain ECG and echocardiography immediately upon presentation to assess cardiac structure, function, and identify precipitating causes such as ischemia or arrhythmias 1, 2
• Measure natriuretic peptides (BNP or NT-proBNP) to differentiate ADHF from non-cardiac dyspnea 2
• Monitor vital signs every 5 minutes during initial stabilization, including blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature 1
• Obtain baseline laboratory tests: electrolytes, creatinine, glucose, complete blood count, and markers for infection 1

Risk Stratification and Level of Care

High-risk patients requiring ICU/CCU admission include those with: 1

• Respiratory rate >25 breaths/min
• SaO₂ <90% despite oxygen
• Systolic BP <90 mmHg
• Use of accessory respiratory muscles
• Signs of hypoperfusion (oliguria, cold peripheries, altered mental status, lactate >2 mmol/L, metabolic acidosis)
• Need for intubation or mechanical ventilation

Patients with cardiogenic shock should be rapidly transferred to a tertiary center with 24/7 cardiac catheterization capability and mechanical circulatory support availability 2

Respiratory Support

Oxygen Therapy

• Increase FiO₂ up to 100% as needed based on SpO₂ monitoring, avoiding hyperoxia 1
• Apply non-invasive positive pressure ventilation (CPAP or BiPAP) for patients with respiratory distress, particularly those with hypercapnia or COPD 1
• CPAP is simpler and feasible in pre-hospital settings; transition to PS-PEEP in hospital if acidosis and hypercapnia persist 1

Intubation Considerations

• Use midazolam over propofol for sedation in ADHF patients, as propofol causes more hypotension and cardiodepressive effects 1

Pharmacological Management

Diuretic Therapy (First-Line for Volume Overload)

Initial dosing: 1, 2

• New-onset ADHF or not on oral diuretics: 20-40 mg IV furosemide (or equivalent)
• Chronic diuretic users: IV dose at least equivalent to oral dose

Administration strategy: 1, 2

• Give as intermittent boluses or continuous infusion, adjusting dose and duration based on symptoms and clinical response
• Monitor daily: weight, fluid intake/output, urine output, renal function, and electrolytes 1, 2
• When diuresis is inadequate, intensify by increasing loop diuretic dose or adding a second diuretic (thiazide or spironolactone) 1, 2

Vasodilator Therapy

Indications: 1, 2

• Consider IV vasodilators for symptomatic relief in patients with SBP >90 mmHg without symptomatic hypotension
• Hypertensive ADHF: IV vasodilators should be initial therapy to improve symptoms and reduce congestion

Options: 1

• Nitroglycerin: venodilator and arteriodilator, reduces preload and afterload
• Nitroprusside: potent vasodilator for severely congested patients with hypertension or severe mitral regurgitation (requires intensive monitoring, risk of thiocyanate toxicity with prolonged use in renal insufficiency)
• Nesiritide: reduces LV filling pressure but has variable effects; use conservative dosing without bolus

Monitoring: 1

• Monitor symptoms and blood pressure frequently during IV vasodilator administration

Inotropic Agents (Reserved for Specific Indications)

Inotropes are NOT recommended unless the patient is symptomatically hypotensive or shows signs of hypoperfusion due to safety concerns (increased mortality risk) 1, 2

When indicated (SBP <90 mmHg with hypoperfusion): 1, 2

• Dobutamine: first-line inotrope
• Levosimendan or PDE III inhibitors: may be considered to reverse beta-blockade effects
• Low-dose dopamine: may improve diuresis and preserve renal function alongside loop diuretics 2

Vasopressors: 1

• Norepinephrine (preferred) may be considered in cardiogenic shock despite inotrope therapy to increase blood pressure and vital organ perfusion

Management of Chronic Heart Failure Medications

Beta-blockers: 1, 2

• Continue beta-blockers in most hospitalized patients unless recent initiation/uptitration or marked volume overload
• If temporarily reduced or omitted due to hemodynamic instability, reinitiate before discharge once stable
• For new initiations, start after volume optimization and discontinuation of IV diuretics/vasodilators/inotropes

ACE inhibitors/ARBs/Aldosterone antagonists: 1

• Continue unless worsening azotemia develops; consider temporary reduction or discontinuation until renal function improves
• Continue evidence-based disease-modifying therapies in absence of hemodynamic instability or contraindications 2

Invasive Monitoring and Procedures

Right-Heart Catheterization

Indicated for: 1

• Respiratory distress or impaired perfusion when clinical assessment is inadequate
• Persistent symptoms despite empiric therapy adjustment
• Uncertain fluid status, perfusion, or vascular resistance
• Systolic pressure remains low or symptomatic despite initial therapy
• Worsening renal function with therapy
• Patients requiring parenteral vasoactive agents
• Consideration for mechanical circulatory support or transplantation

NOT recommended: 1

• Routine use in normotensive patients with symptomatic response to diuretics and vasodilators

Coronary Angiography

Reasonable when ischemia may be contributing to HF in patients eligible for revascularization 1

Clinical Phenotype-Specific Management

Congestion with Adequate Blood Pressure

• IV diuretics are the mainstay 2

Hypertensive ADHF

• Vasodilators with close monitoring and low-dose diuretic treatment 2

Cardiogenic Shock

• Fluid challenge if clinically indicated (250-500 mL bolus) 3
• Inotropic therapy if SBP remains <90 mmHg 2
• Consider mechanical circulatory support for potentially reversible causes 2
• Intra-aortic balloon pump and evaluation for mechanical circulatory support devices 2

Advanced Therapies for Refractory Cases

Ultrafiltration

• Consider for obvious volume overload or refractory congestion when diuretics are ineffective 2, 4

Mechanical Circulatory Support

• Consider for biventricular failure patients who cannot be stabilized with medical therapy 2
• Initiate early, prior to end-organ damage development, in candidates for transplantation or destination LVAD 4

Discharge Criteria and Planning

Patients are medically fit for discharge when: 1, 2

• Hemodynamically stable
• Euvolemic
• Established on evidence-based oral medications
• Stable renal function for at least 24 hours

Follow-up: 2

• General practitioner within 1 week of discharge
• Hospital cardiology team within 2 weeks
• Enrollment in multidisciplinary heart failure management program to reduce rehospitalization and mortality

Critical Pitfalls to Avoid

• Avoid NSAIDs and COX-2 inhibitors as they increase risk of HF worsening and hospitalization 2
• Do not routinely discontinue beta-blockers during hospitalization; continuation results in better outcomes 1
• Avoid routine invasive hemodynamic monitoring in stable patients responding to therapy 1
• Do not use inotropes in normotensive patients due to increased mortality risk 1
• Monitor for hypotension with vasodilators, especially nesiritide which has longer half-life 1
• Watch for thiocyanate toxicity with prolonged nitroprusside use, particularly in renal insufficiency 1
• Ensure adequate decongestion before discharge; patients are often discharged with inadequate weight loss and persistent hemodynamic compromise 1