What is the initial management for a patient admitted with congestive heart failure?

Initial Management of Acute Decompensated Heart Failure

Patients admitted with congestive heart failure should receive intravenous loop diuretics within 60 minutes of presentation, starting at a dose equal to or exceeding their chronic oral daily dose (or 40 mg furosemide equivalent if diuretic-naïve), with early aggressive decongestion as the primary therapeutic goal. 1, 2

Immediate Assessment and Stabilization

Critical Initial Determinations (First 30-60 Minutes)

Upon admission, rapidly assess these five key parameters 1:

• Volume status and degree of congestion - Look for elevated jugular venous pressure, pulmonary rales, peripheral edema, ascites, and pleural effusions 1
• Adequacy of systemic perfusion - Assess for cool extremities, altered mental status, decreased urine output, and hypotension 1
• Precipitating factors - Identify acute coronary syndrome (obtain ECG and troponin immediately), severe hypertension, arrhythmias (especially atrial fibrillation), infections, pulmonary embolism, renal failure, or medication/dietary non-compliance 1
• New-onset versus chronic heart failure exacerbation 1
• Ejection fraction status - Obtain or review echocardiography 1

Oxygen and Respiratory Support

• Administer supplemental oxygen if SpO2 <90% to relieve hypoxemia-related symptoms, but avoid hyperoxia 1
• Consider non-invasive ventilation (CPAP or BiPAP) immediately for patients with acute pulmonary edema showing respiratory distress, as this reduces intubation rates and may decrease mortality 1
• Continuous positive airway pressure (CPAP) is simpler and feasible even in pre-hospital settings 1

Diuretic Therapy - The Cornerstone of Treatment

Initial Dosing Strategy

Start IV loop diuretics immediately - do not delay beyond 60 minutes, as early intervention improves outcomes 1, 2:

• For diuretic-naïve patients: Start with furosemide 40 mg IV bolus 1, 2, 3
• For patients already on loop diuretics: Give IV dose equal to or exceeding (2-2.5 times) their total daily oral dose 1, 2, 3
• Administer as intermittent boluses rather than continuous infusion initially, as the DOSE trial showed no benefit of continuous infusion 1, 2

Monitoring Diuretic Response (Critical First 6 Hours)

Assess response using these specific targets 2, 3:

• At 2 hours: Check spot urine sodium - should be ≥50-70 mmol/L 2, 3
• At 6 hours: Urine output should be ≥100-150 mL/hour 2, 3
• At 24 hours: Target weight loss of 0.5-1.5 kg or total urine output of 3-5 L 3

Escalation for Inadequate Response

If decongestion targets are not met within 6-24 hours, intensify therapy using 1:

1. Double the loop diuretic dose (up to 400-600 mg furosemide daily, or up to 1000 mg in severe renal dysfunction) 1, 2
2. Add combination diuretic therapy early (within first 24-48 hours) 2, 3:
   • Acetazolamide 500 mg IV once daily - particularly effective if baseline bicarbonate ≥27 mmol/L; use only for first 3 days to prevent metabolic complications 2, 3
   • Thiazide diuretic (metolazone or hydrochlorothiazide) for dual nephron blockade 1
3. Consider continuous furosemide infusion only if bolus escalation and combination therapy fail 1

Monitor closely for: hypotension, electrolyte disturbances (especially hypokalemia), and worsening renal function with daily labs during active diuresis 1

Vasodilator Therapy

For patients with systolic BP >110 mmHg and severe symptomatic fluid overload, add IV vasodilators to diuretics 1:

• IV nitroglycerin or nitroprusside can be beneficial for dyspnea relief and afterload reduction 1
• Do NOT use vasodilators if SBP <110 mmHg 1
• Early vasodilator administration (within first hours) may be associated with lower mortality 1

Management of Hypotension and Hypoperfusion

For patients with SBP <90 mmHg AND signs of hypoperfusion (cool extremities, altered mental status, oliguria) 1:

• Hold diuretics until adequate perfusion is restored 1
• Consider IV inotropes (dobutamine, milrinone, or levosimendan) to maintain systemic perfusion and end-organ function 1
• Levosimendan is preferred over dobutamine if beta-blockade is contributing to hypoperfusion, but avoid if SBP <85 mmHg unless combined with vasopressors 1
• Add vasopressor (norepinephrine) for cardiogenic shock despite inotropic support 1
• Monitor with continuous ECG and arterial line when using inotropes or vasopressors due to arrhythmia and ischemia risk 1

Critical caveat: Do NOT use inotropes routinely in normotensive patients without evidence of hypoperfusion, as they increase mortality 1

Guideline-Directed Medical Therapy (GDMT) Management

Continue Existing GDMT in Most Cases

For patients already on ACE inhibitors/ARBs and beta-blockers 1:

• Continue these medications unless hemodynamic instability (SBP <85 mmHg, HR <50 bpm) or contraindications exist 1
• Beta-blockers can be safely continued during acute heart failure except in cardiogenic shock 1
• Reduce or temporarily hold if severe hypotension, bradycardia, or cardiogenic shock 1

Initiate GDMT Before Discharge

For GDMT-naïve patients with reduced ejection fraction, initiate ACE inhibitors/ARBs and beta-blockers before discharge 1:

• Start beta-blockers only after volume optimization and discontinuation of IV diuretics, vasodilators, and inotropes 1
• Begin at low doses and titrate cautiously, especially in patients who required inotropes 1

Additional Essential Interventions

Thromboembolism Prophylaxis

• Administer low molecular weight heparin to all patients without contraindications or existing anticoagulation to prevent deep venous thrombosis and pulmonary embolism 1

Identify and Treat Acute Coronary Syndrome

• Obtain ECG and cardiac troponin immediately on all admissions 1
• Urgent cardiac catheterization and revascularization is reasonable for patients with acute myocardial ischemia and signs of inadequate perfusion, where it may prolong meaningful survival 1

Daily Monitoring

Monitor these parameters daily during active treatment 1:

• Fluid intake and output (strict measurement)
• Daily weights (same time each day)
• Vital signs including orthostatic blood pressures
• Clinical signs of perfusion and congestion (supine and standing)
• Daily electrolytes, BUN, and creatinine during IV diuretic use or medication titration

Invasive Hemodynamic Monitoring

Consider pulmonary artery catheter placement for carefully selected patients with 1:

• Respiratory distress or impaired perfusion where volume status cannot be determined clinically
• Persistent symptoms despite empiric therapy adjustments
• Persistent hypotension despite initial therapy
• Worsening renal function with therapy
• Need for parenteral vasoactive agents
• Consideration for advanced therapies (mechanical support, transplantation)

Do NOT use routine invasive monitoring in normotensive patients responding to diuretics and vasodilators 1

Discharge Planning

Do not discharge patients who remain congested 2:

• Transition to oral diuretics only after adequate decongestion with careful dose adjustment 1
• Provide comprehensive written discharge instructions emphasizing: diet, medications (with focus on adherence and uptitration), activity level, follow-up appointments, daily weights, and symptom monitoring 1
• Arrange early follow-up within 72 hours of discharge, ideally with heart failure specialist or nurse practitioner 1
• Optimize GDMT before discharge with plan for uptitration within 2 weeks 2