What is the acute management of heart failure?

Acute Management of Heart Failure

Initiate treatment immediately upon patient contact with a time-sensitive approach similar to acute coronary syndromes, prioritizing rapid stabilization based on blood pressure and respiratory status. 1, 2

Immediate Assessment and Triage (First Minutes)

Establish continuous monitoring within minutes of patient contact, including pulse oximetry, blood pressure, respiratory rate, and continuous ECG. 1, 2

Assess severity using two critical domains:

Respiratory Distress Indicators 1

• Respiratory rate >25/min
• SpO₂ <90% despite supplemental oxygen
• Increased work of breathing or use of accessory muscles

Hemodynamic Instability Indicators 1

• Heart rate <40 or >130 bpm
• Systolic blood pressure <90 mmHg or severe hypertension
• Severe arrhythmias

If either domain is positive, immediately triage to resuscitation area/CCU/ICU for stabilization and consideration of non-invasive ventilation. 1

Respiratory Support

Administer oxygen therapy based on SpO₂ measurement:

• **If SpO₂ <90%: Start oxygen immediately** to maintain SpO₂ >90% 1, 3, 2
• If SpO₂ 90-94%: Use clinical judgment considering respiratory distress and work of breathing 3
• If SpO₂ ≥94%: Oxygen is NOT routinely recommended in normoxemic patients 3

Critical caveat: For patients with known COPD, target SpO₂ 88-92% to avoid hypercapnia and increased mortality risk. 3

Initiate non-invasive ventilation (CPAP or BiPAP) immediately if:

• Respiratory distress persists despite oxygen therapy 1, 3, 2
• Patient shows signs of acute pulmonary edema 2
• CPAP is simpler for prehospital settings; consider PS-PEEP for patients with acidosis, hypercapnia, or COPD history 2

NIV reduces intubation rates and may reduce mortality. 2

Pharmacological Management: Blood Pressure-Guided Approach

For SBP >110 mmHg (Hypertensive AHF) 1, 2

First-line: IV vasodilators PLUS IV loop diuretics for aggressive blood pressure reduction and decongestion. 2

Vasodilator options:

• Nitroglycerin IV (preferred for flash pulmonary edema) 4
• FDA Warning: Benefits in acute heart failure not established; careful hemodynamic monitoring required due to risk of hypotension and tachycardia 5

Loop diuretic dosing: 2

• New-onset HF or no maintenance diuretic: Furosemide 40 mg IV bolus
• Established HF on chronic oral diuretics: IV bolus at least equivalent to oral maintenance dose

For SBP 90-110 mmHg (Normotensive AHF) 1, 2

First-line: IV loop diuretics alone using the dosing strategy above. 2

For SBP <90 mmHg (Hypotensive AHF/Cardiogenic Shock) 1, 4

This represents cardiogenic shock, defined as: 1

• SBP <90 mmHg for >30 minutes despite adequate filling
• Signs of hypoperfusion: oliguria (<0.5 mL/kg/h for ≥6 hours), cold peripheries, altered mental status, lactate >2 mmol/L, metabolic acidosis, SvO₂ <65%

Immediate management sequence: 1, 4

1. Obtain immediate ECG and echocardiography to identify reversible causes 1
2. Establish invasive arterial line monitoring 1
3. Fluid challenge first: 200-500 mL saline or Ringer's lactate over 15-30 minutes if no overt fluid overload 1, 4
4. If hypotension persists after fluid challenge:
   • Inotrope: Dobutamine (first choice) 1, 4
   • Alternative inotrope: Levosimendan (especially if patient on beta-blockers) 1
5. If vasopressor needed for persistent hypoperfusion:
   • Norepinephrine is recommended over dopamine 1, 4

Immediately transfer to tertiary care center with 24/7 cardiac catheterization and ICU with mechanical circulatory support capability. 1

IABP is NOT routinely recommended in cardiogenic shock. 1

Short-term mechanical circulatory support may be considered in refractory shock depending on age, comorbidities, and neurological function. 1

Additional Immediate Interventions

Position patient upright to reduce work of breathing and improve ventilation. 3, 2

Obtain 12-lead ECG immediately to exclude STEMI and assess for arrhythmias. 1, 2

If acute coronary syndrome identified: Implement immediate invasive strategy with intent to perform revascularization. 2

If rapid arrhythmia present: Correct urgently with medical therapy or electrical cardioversion. 2

Criteria for ICU/CCU Admission 1

Admit to ICU/CCU if ANY of the following present:

• Respiratory rate >25/min
• SpO₂ <90% despite supplemental oxygen
• Use of accessory muscles for breathing
• Systolic BP <90 mmHg
• Need for intubation or already intubated
• Signs of hypoperfusion: oliguria, cold peripheries, altered mental status, lactate >2 mmol/L, metabolic acidosis, SvO₂ <65%
• Heart rate <60 or >120 bpm
• Evidence of right heart failure with hemodynamic compromise

High-risk laboratory parameters suggesting need for ICU: 1

• BUN ≥43 mg/dL
• Creatinine ≥2.75 mg/dL
• Systolic BP <115 mmHg (These predict 22% in-hospital mortality)

In-Hospital Monitoring 2

Continuous monitoring requirements:

• Daily weights and accurate fluid balance charts 2
• Daily renal function and electrolytes 2
• Continuous assessment of dyspnea, heart rate/rhythm, urine output, peripheral perfusion 2
• Standard noninvasive vital signs 2

Resting heart rate <100 bpm should be associated with symptom improvement to indicate good response to therapy. 1

Diuretic Resistance Management 2

If inadequate response to loop diuretics, consider combination therapy:

• Loop diuretic PLUS thiazide-type diuretic, OR
• Loop diuretic PLUS spironolactone

Discharge Criteria 2

Patients are medically fit for discharge when ALL of the following are met:

• Hemodynamically stable and euvolemic
• Established on evidence-based oral medication
• Stable renal function for at least 24 hours before discharge
• Provided with tailored education about self-care

Measure natriuretic peptides before discharge to help with post-discharge planning. 2

Post-Discharge Follow-Up 1, 2

Mandatory follow-up structure:

• Contact with physician or nurse practitioner within 72 hours of discharge 1
• General practitioner visit within 1 week 2
• Cardiology follow-up within 2 weeks 2
• Enrollment in multidisciplinary heart failure disease management program 2

Critical caveat: Patients with de novo (new-onset) AHF need further evaluation and should NOT be discharged from the ED or downgraded too quickly if hospitalized. 1

Common Pitfalls to Avoid

Do not routinely administer oxygen to normoxemic patients (SpO₂ ≥90-94%) as effectiveness is unknown and may be harmful in COPD patients. 3

Do not use oral isosorbide dinitrate in acute settings as effects are difficult to terminate rapidly; FDA warns against use in acute heart failure due to hypotension/tachycardia risk. 6

Do not overlook precipitating factors: Non-compliance with medications is the most common precipitating factor and must be addressed before discharge. 1

Do not delay treatment: The time-to-treatment concept is critical in AHF, similar to acute coronary syndromes. 1