What is the treatment approach for acute congestive heart failure (CHF)?

Treatment of Acute Congestive Heart Failure

Acute CHF requires immediate oxygen therapy (target SpO2 94-96%), intravenous vasodilators (nitrates or nitroprusside), and loop diuretics (furosemide IV bolus followed by continuous infusion), with treatment tailored to the patient's blood pressure and hemodynamic profile. 1, 2

Immediate Assessment and Monitoring

Upon presentation, three critical parallel assessments must be made: 1

• Confirm the diagnosis of heart failure versus alternative causes (chronic lung disease, anemia, pulmonary embolism) 1
• Identify precipitants requiring immediate correction (arrhythmia, acute coronary syndrome) 1
• Assess for life-threatening conditions including hypoxemia or hypotension causing organ hypoperfusion 1

Insert an intravenous line immediately and initiate continuous monitoring of vital signs, ECG, and oxygen saturation (SpO2). 1, 2 Blood pressure should be measured every 5 minutes until vasodilator, diuretic, or inotrope dosing is stabilized. 1 An arterial line should be inserted when hemodynamic instability is present. 1, 2

Obtain ECG, chest X-ray, BNP/NT-proBNP, electrolytes, creatinine, and glucose immediately. 1, 2 Echocardiography should be performed as soon as possible unless recently completed. 1, 2

Initial Treatment Algorithm

For Patients WITHOUT Hypotension (SBP ≥85 mmHg)

Oxygen Therapy:

• Administer oxygen via face mask or CPAP targeting SpO2 94-96% 1, 2
• Avoid routine oxygen in non-hypoxemic patients as it causes vasoconstriction and reduces cardiac output 1

Vasodilators (First-Line):

• Initiate intravenous nitrates or nitroprusside immediately as the primary therapy for pulmonary edema, hypertensive crisis, and exacerbated heart failure 1, 2, 3
• These syndromes result from excessive vasoconstriction superimposed on reduced left ventricular functional reserve, creating afterload mismatch 3
• Vasodilators break the vicious cycle of elevated afterload, reduced cardiac output, and elevated left ventricular end-diastolic pressure 3

Diuretics:

• Administer furosemide or other loop diuretic as IV bolus followed by continuous infusion when needed 1, 2
• Most patients obtain rapid symptomatic relief from IV diuretics through immediate venodilator action and subsequent fluid removal 1
• Do not administer diuretics before achieving optimal preload and afterload reduction 4
• Higher doses may be required in patients with renal dysfunction or chronic diuretic use 2
• For resistant peripheral edema, combine loop diuretic with thiazide (e.g., bendroflumethiazide) 1

Morphine:

• Use morphine for relief of physical and psychological distress and to improve hemodynamics 1, 2

For Patients WITH Hypotension (SBP <85 mmHg) or Cardiogenic Shock

Initial Fluid Assessment:

• If no signs of overt fluid overload, administer 200-500 mL crystalloid over 15-30 minutes to determine if hypotension is due to hypovolemia versus cardiac dysfunction 5, 2
• Monitor closely for signs of fluid overload (increased jugular venous pressure, pulmonary crackles) 5

Inotropic Support:

• Dobutamine is the inotrope of choice for patients with low cardiac output who are not on beta-blockers 5, 6, 7
• Dobutamine is indicated for short-term inotropic support in cardiac decompensation due to depressed contractility 6
• Experience with IV dobutamine in controlled trials does not extend beyond 48 hours 6
• Levosimendan or phosphodiesterase inhibitors may be considered in patients not responding to initial treatment 2

Vasopressor Support:

• Norepinephrine is the recommended vasopressor when mean arterial pressure needs pharmacologic support in cardiogenic shock 5, 2, 7
• Target mean arterial pressure (MAP) of 65 mmHg or individualized goal 8
• Administer through large vein, preferably central venous catheter, to minimize extravasation risk 8
• Continuous arterial blood pressure monitoring via arterial line is mandatory 8

Cardiogenic shock results from severe reduction in cardiac power without adequate compensatory increase in peripheral vascular resistance, leading to decreased blood pressure and end-organ perfusion. 3 Treatment should focus on improving cardiac performance (optimizing filling pressure, intra-aortic balloon pump, immediate revascularization) and administering peripheral vasoconstrictors. 3

Non-Invasive Ventilation

Initiate non-invasive positive pressure ventilation (CPAP or BiPAP) as soon as possible in patients with acute pulmonary edema showing respiratory distress. 1, 2, 7 This is a highly effective adjunct that should be combined with nitroglycerin therapy. 7, 9 Monitor closely for acute decompensation requiring intubation. 2, 7

Treatment of Precipitating Factors

Acute Coronary Syndrome:

• Patients with acute coronary syndrome should undergo cardiac catheterization and angiography with consideration for invasive intervention including surgery 1

Arrhythmias:

• Rapid ventricular rate control is critical, particularly in patients with diastolic dysfunction 1
• For atrial fibrillation, consider medical or electrical cardioversion after initial stabilization if paroxysmal 1
• Amiodarone and beta-blockers are effective for rate control and prevention of recurrence 1
• Avoid verapamil and diltiazem in acute atrial fibrillation as they may worsen heart failure 1
• For bradycardia, initially treat with atropine 0.25-0.5 mg IV, repeated as needed 1

Advanced Therapies for Refractory Cases

Mechanical Circulatory Support:

• Consider intra-aortic balloon pump, mechanical ventilation, or circulatory assist devices for refractory acute heart failure 1, 2
• These may serve as temporary measures or as bridge to heart transplantation 1, 2

Ultrafiltration or Dialysis:

• May be prescribed for refractory heart failure unresponsive to diuretics 1, 2

Transfer to Tertiary Center:

• Rapid transfer to tertiary care center with 24/7 cardiac catheterization capability and dedicated ICU with mechanical circulatory support availability is recommended for cardiogenic shock 5

Ongoing Monitoring Requirements

• Monitor blood pressure, heart rate, respiratory rate, temperature, ECG continuously during acute phase 1
• Measure electrolytes, creatinine, and glucose repeatedly; control hypo- or hyperkalemia 1
• Daily weight monitoring and accurate fluid balance recording are essential 2
• Monitor renal function preferably with daily BUN/urea, creatinine, and electrolytes 2
• Assess urine output, mental status, skin temperature, and capillary refill for tissue perfusion 8

Critical Pitfalls to Avoid

• Never delay treatment as early intervention is associated with better outcomes 5
• Avoid excessive fluid administration as it may worsen pulmonary congestion 5
• Do not use vasopressors without adequate fluid challenge unless obvious fluid overload is present 5
• Avoid routine use of inotropes in normotensive patients without evidence of decreased organ perfusion 5, 2
• Do not use oxygen routinely in non-hypoxemic patients as it causes vasoconstriction 1
• Avoid verapamil and diltiazem in acute atrial fibrillation with heart failure 1
• Recognize that inotropes carry safety concerns including risk of arrhythmias and myocardial ischemia, requiring continuous ECG and blood pressure monitoring 2
• Long-term use of cyclic-AMP-dependent inotropes (including dobutamine) has been associated with increased risk of hospitalization and death in controlled trials 6

Specialized Care Requirements

Best outcomes are achieved when patients are treated promptly by expert staff in areas reserved for heart failure patients, with experienced cardiologists and suitably trained personnel. 1 Comparative studies demonstrate shorter hospitalization in patients treated by staff trained in heart failure management. 1