What are the emergency management protocols for acute heart failure (HF)?

From the Guidelines

Heart failure emergencies require immediate medical attention, and the most recent guidelines recommend oxygen therapy, intravenous diuretics, and vasodilators as the cornerstone of treatment. According to the 2019 ACC/AHA guidelines comparison 1, the initial management of acute heart failure (AHF) should focus on early identification of precipitants/causes leading to decompensation. The guidelines recommend a classification based upon “congestive” signs and symptoms (wet or dry), and peripheral perfusion (warm or cold).

Key Recommendations

• Intravenous diuretics, such as furosemide (20-40mg IV), are recommended to improve symptoms 1
• Vasodilators, such as nitroglycerin (starting at 5-10 mcg/min IV and titrating up), can be used in most patients with AHF 1
• Inotropic agents, such as dobutamine (2-20 mcg/kg/min), may be considered in patients with hypotension and/or symptoms of hypoperfusion 1
• Non-invasive positive pressure ventilation might be used for respiratory distress 1
• After stabilization, physicians will adjust long-term medications including ACE inhibitors, beta-blockers, and diuretics 1

Important Considerations

• The use of low-dose dopamine to improve diuresis and preserve renal function is not recommended 1
• Ultrafiltration is not recommended as a routine strategy in AHF, but may be considered in patients with refractory congestion not responding to diuretic agents 1
• Vasopressors, such as noradrenaline, should be reserved for patients with severe hypotension to increase blood pressure and ensure blood supply to vital organs 1

Monitoring and Adjustment

• Patients should be closely monitored for symptoms, urine output, renal function, and electrolytes during treatment 1
• The dose and duration of diuretics and vasodilators should be adjusted according to patients’ symptoms and clinical status 1

From the Research

Heart Failure Emergency

• Acute heart failure (AHF) patients often present to the emergency department with a variety of chief complaints, symptoms, and physical exam findings, making diagnosis challenging 2.
• The initial diagnostic workup for AHF typically includes a thorough history and exam, EKG, chest X-ray, laboratory testing, and point-of-care ultrasonography 2.
• Treatment for AHF is guided by the presenting phenotype, with hypertensive patients treated aggressively with vasodilators and normotensive patients requiring significant diuresis with intravenous loop diuretics 2, 3.
• Patients with hypotensive AHF require careful assessment of intra- and extra-vascular volume status and may need emergent specialty consultation and initial fluid bolus, followed by initiation of inotropic agents with or without vasopressors 3.

Management of Heart Failure

• The management of AHF in the emergency department setting involves tailoring treatments to the appropriate type of heart failure, with a focus on blood pressure and hemodynamic status 3.
• Loop diuretics, such as furosemide, are commonly used to improve haemodynamic parameters and dyspnoea due to congestion, while nitrate derivatives, such as trinitrine, are used to improve certain haemodynamic parameters and reduce blood pressure 4, 5.
• Inotropes, such as dobutamine, may be used in patients with cardiogenic shock, but their use requires continuous monitoring in an intensive care unit due to the risk of ventricular and supraventricular arrhythmias and tachycardia 5.

Oxygen Therapy

• Supplemental oxygen therapy is recommended in patients with acute heart failure and hypoxemia, but its use in normoxemic patients is controversial due to the potential detrimental effects of hyperoxia 6.
• The use of oxygen therapy in patients with acute heart failure should be guided by clinical practice guidelines and individual patient needs, with careful monitoring of oxygen saturation levels and potential adverse effects 6.