From the Guidelines
Treatment for acute heart failure in a hospitalized patient involves a multi-step approach. The primary goal is to improve hemodynamics, restore oxygenation, alleviate symptoms, and limit cardiac and renal damage 1.
Immediate Treatment
In the emergency department or intensive care unit, treatment focuses on:
- Improving hemodynamics and organ perfusion
- Restoring oxygenation
- Alleviating symptoms
- Limiting cardiac and renal damage
- Preventing thrombo-embolism
Medications
- Intravenous loop diuretics are recommended for patients with evidence of significant fluid overload 1
- Vasodilators such as intravenous nitroglycerin, nitroprusside, or nesiritide can be beneficial in patients with severely symptomatic fluid overload without systemic hypotension 1
- Inotropic or vasopressor drugs may be necessary for patients with clinical evidence of hypotension associated with hypoperfusion and elevated cardiac filling pressures 1
- Beta-blocker therapy should be initiated at a low dose in stable patients after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents 1
Monitoring and Adjustment
- Invasive hemodynamic monitoring can be useful in guiding therapy for patients with uncertain fluid status, perfusion, or systemic or pulmonary vascular resistances 1
- Careful measurement of fluid intake and output, vital signs, body weight, and clinical signs and symptoms is essential for monitoring the effect of treatment 1
- Diuretic dose should be titrated to relieve symptoms and reduce extracellular fluid volume excess 1
Long-term Management
- Heart failure management programs are recommended for patients with HF recently hospitalized and for other high-risk patients 1
- Comprehensive written discharge instructions should be provided, including information on diet, discharge medications, activity level, follow-up appointments, daily weight monitoring, and what to do if HF symptoms worsen 1
- Post-discharge systems of care should be used to facilitate the transition to effective outpatient care for patients hospitalized with HF 1
From the Research
Treatment Overview
The treatment for acute heart failure in a hospitalized patient involves several aspects, including:
- Diagnosis and prognostication using biomarker evaluation and noninvasive assessment of fluid status 2
- Decongestion strategies, such as pharmaceutical options and ultrafiltration for refractory hypervolemia 2, 3
- Vasoactive therapy to augment cardiac function, although its efficacy is limited 2, 4
- Goal-directed medical therapy initiation, including quadruple therapy with angiotensin receptor-neprilysin inhibitors, mineral receptor antagonists, sodium glucose type 2 (SGLT-2) inhibitors, and beta blockers 2, 5
Pharmacological Treatment
Pharmacological treatment for acute heart failure aims to stabilize the patient, improve clinical symptoms, and increase long-term survival rates 4. Recommended treatment includes:
- Intravenous diuretics to correct volume overload 3
- Oxygen therapy to improve vital organ perfusion 3
- Vasodilators to ameliorate cardiac hemodynamics 3
- Novel agents, such as cardiac myosin activators, are being investigated to improve outcomes in patients with heart failure 5
Management and Monitoring
Effective management of acute heart failure requires:
- Risk stratification of patients to prioritize treatment 6
- Disposition of patients to appropriate areas, such as monitored inpatient beds or emergency department-based observation units 6
- Safe transition of care prior to discharge to prevent heart failure rehospitalization and mortality 2
- Post-discharge close ambulatory monitoring, including remote hemodynamic monitoring, virtual visits, and rehabilitation 2