What is the initial step in managing an elderly patient with heart failure, reduced ejection fraction (39%), exertional dyspnea, and orthopnea?

Initial Management of Acute Decompensated Heart Failure with Reduced Ejection Fraction

The correct answer is A: non-invasive ventilation and IV furosemide should be initiated immediately for this patient presenting with acute decompensated heart failure, exertional dyspnea, orthopnea, and reduced ejection fraction (39%). 1

Immediate Management Priorities

Intravenous loop diuretics must be started without delay in the emergency department or outpatient clinic, as early intervention is associated with better outcomes in patients hospitalized with decompensated heart failure. 1 The initial IV dose should equal or exceed the patient's chronic oral daily dose if already on diuretics, or start with an appropriate IV dose if diuretic-naive. 1

Why IV Furosemide is Essential

• Patients with significant fluid overload (evidenced by orthopnea and dyspnea) require intravenous loop diuretics as first-line therapy. 1
• Urine output and signs of congestion should be serially assessed, with diuretic dose titrated accordingly to relieve symptoms and reduce extracellular fluid volume excess. 1
• If diuresis is inadequate, intensify the regimen using higher loop diuretic doses, addition of a second diuretic (metolazone, spironolactone, or IV chlorothiazide), or continuous infusion of loop diuretics. 1

Why Non-Invasive Ventilation May Be Needed

• Invasive hemodynamic monitoring or respiratory support should be performed in patients with respiratory distress or impaired perfusion when adequacy of intracardiac filling pressures cannot be determined from clinical assessment. 1
• Non-invasive ventilation can provide immediate respiratory support while IV diuretics work to reduce pulmonary congestion. 1

Why the Other Options Are Incorrect

Option B (Mechanical Ventilation and IV Fluids) is Wrong

• IV fluids are contraindicated in acute decompensated heart failure with fluid overload. 1 This patient has orthopnea and dyspnea indicating volume overload, not hypovolemia.
• Mechanical ventilation is reserved for severe respiratory failure unresponsive to non-invasive support, not as initial management. 1
• The aggressive fluid resuscitation approach is appropriate for sepsis, not decompensated heart failure. 2

Option C (Oral Furosemide) is Inadequate

• Oral diuretics are insufficient for acute decompensated heart failure requiring hospitalization. 1
• The bioavailability and speed of action of oral diuretics are inadequate in the setting of gut edema and acute congestion. 1
• Transition to oral diuretics should only occur after stabilization with IV therapy, with careful attention to dosing and electrolyte monitoring. 1

Critical Monitoring Parameters

During IV diuretic therapy, monitor the following daily: 1

• Fluid intake and output measurements
• Vital signs including supine and standing blood pressure
• Body weight at the same time each day
• Clinical signs and symptoms of systemic perfusion and congestion
• Daily serum electrolytes, urea nitrogen, and creatinine concentrations

Continuation of Guideline-Directed Medical Therapy

In patients with reduced ejection fraction experiencing symptomatic exacerbation requiring hospitalization, continue chronic maintenance treatment with ACE inhibitors/ARBs and beta-blockers in the absence of hemodynamic instability or contraindications. 1 Do not discontinue these medications unless there is clear evidence of hypoperfusion or specific contraindications. 1

Common Pitfalls to Avoid

• Never delay diuretic initiation waiting for admission to the hospital floor—start in the emergency department immediately. 1
• Avoid using thiazides alone if GFR <30 mL/min unless combined synergistically with loop diuretics. 3
• Do not give IV fluids to patients with clear signs of volume overload (orthopnea, dyspnea). 1
• Monitor for worsening renal function and electrolyte abnormalities, particularly hypokalemia and hypomagnesemia. 1