What is the management of acute heart failure?

Management of Acute Heart Failure

Immediate Assessment and Stabilization

Upon patient contact, immediately assess cardiopulmonary stability by evaluating respiratory distress (respiratory rate >25/min, SpO₂ <90%, increased work of breathing) and hemodynamic instability (heart rate <40 or >130 bpm, systolic blood pressure extremes, severe arrhythmias), then position the patient upright to reduce work of breathing. 1

• Establish continuous monitoring within minutes including pulse oximetry, blood pressure, respiratory rate, and ECG 1, 2
• Triage patients with persistent dyspnea or hemodynamic instability to a high-dependency or resuscitation area where emergency interventions can be provided 1, 2
• Assess mental status using the AVPU mnemonic (Alert, Voice, Pain, Unresponsive) as altered mental status indicates hypoperfusion 1

Diagnostic Workup

• Obtain an ECG immediately to exclude ST elevation myocardial infarction and assess for arrhythmias 1
• Measure plasma natriuretic peptides (BNP/NT-proBNP) to confirm diagnosis 1, 2
• Order laboratory tests including troponin, complete blood count, renal function, and electrolytes 1, 2
• Perform chest X-ray to rule out alternative causes of dyspnea 1

Respiratory Support

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

• Administer oxygen therapy only when SpO₂ <90%, but avoid hyperoxia as it may be harmful 1, 4
• Use continuous positive airway pressure (CPAP) in the prehospital setting because it is simpler than pressure support ventilation, requires minimal training, and does not require a ventilator 5, 1, 3
• Switch to pressure support ventilation with positive end-expiratory pressure (PS-PEEP) upon hospital arrival if the patient still shows respiratory distress, particularly in those with acidosis, hypercapnia, or COPD history 5, 1, 4

Pharmacological Management Based on Blood Pressure

Hypertensive AHF (SBP >110 mmHg)

Initiate aggressive blood pressure reduction with IV vasodilators in combination with loop diuretics as first-line therapy for patients with normal to high blood pressure. 1, 2

• IV nitroglycerin is indicated for control of congestive heart failure in the setting of acute myocardial infarction 6
• Intravenous vasodilators are not indicated when SBP <110 mmHg 5

Normotensive AHF

Administer IV loop diuretics as first-line therapy for congestion. 1, 4

• For new-onset heart failure or patients not on maintenance diuretics: furosemide 40 mg IV 5, 1, 4
• For established heart failure on chronic oral diuretics: IV bolus at least equivalent to oral dose 5, 1, 4
• Monitor response by tracking urine output, symptoms, renal function, and electrolytes 4
• Consider combination therapy with loop diuretic plus thiazide-type diuretic or spironolactone for diuretic resistance 1, 4

Hypotensive AHF and Cardiogenic Shock

Administer an initial fluid bolus of 250-500 mL, followed by initiation of inotropic agents with or without vasopressors, with dobutamine as the inotrope of choice and norepinephrine if blood pressure support is needed. 7

• Dobutamine is indicated for short-term inotropic support in cardiac decompensation due to depressed contractility, but experience in controlled trials does not extend beyond 48 hours 8
• Critical caveat: Dobutamine and other cyclic-AMP-dependent inotropes have not been shown to be safe or effective in long-term treatment of congestive heart failure, and are associated with increased risk of hospitalization and death in controlled trials. 8
• Reserve sympathomimetics or vasopressors for patients with persistent signs of hypoperfusion despite adequate filling status; there is no role for vasopressors if SBP >110 mmHg 5
• Obtain emergent specialty consultation for hypotensive AHF 7

Management of Specific Precipitants

• Implement immediate invasive strategy with intent to perform revascularization for acute coronary syndrome 1
• Correct rapid arrhythmias urgently with medical therapy or electrical cardioversion 1
• For heart failure with atrial fibrillation: consider IV cardiac glycosides for rapid ventricular rate control, but beta-blockers are the preferred first-line treatment for rate control in stable patients 5, 1, 4

Drugs to Use Cautiously or Avoid

Routine use of opioids in AHF patients is not recommended, as morphine use was associated with higher rates of mechanical ventilation, ICU admission, and death in the ADHERE registry, despite never being shown to improve outcomes. 5

• There is no evidence that dobutamine should be given when pulmonary edema is associated with normal or high systolic blood pressure 5
• Inotropes are not recommended unless the patient has symptomatic hypotension or evidence of hypoperfusion 2

In-Hospital Monitoring

• Weigh the patient daily and maintain accurate fluid balance charts 1, 4
• Monitor renal function and electrolytes daily 1, 2, 4
• Continue standard non-invasive monitoring of pulse, respiratory rate, and blood pressure 1
• Continuously assess dyspnea, heart rate and rhythm, urine output, and peripheral perfusion 1
• Measure natriuretic peptides before discharge to help with post-discharge planning 1, 4

Discharge Criteria

Patients are medically fit for discharge when they are hemodynamically stable, euvolemic, established on evidence-based oral medication, and have stable renal function for at least 24 hours before discharge. 1, 4

• Provide tailored education and advice about self-care 1, 4
• Ensure continuation and uptitration of disease-modifying therapies for heart failure with reduced ejection fraction 4

Post-Discharge Follow-Up

• Arrange follow-up with primary care physician within 1 week of discharge 1, 4
• Schedule cardiology follow-up within 2 weeks of discharge 1, 4
• Enroll patients in a multidisciplinary heart failure disease management program 1, 4

Common Pitfalls

• Avoid hyperoxia: Only administer oxygen when SpO₂ <90%, as hyperoxia may be harmful 1, 4
• Monitor NIV closely: If non-invasive positive pressure ventilation is required, monitor closely for acute decompensation 7
• Identify precipitants: Compliance issues are among the most important precipitating factors of AHF and must be addressed 1