What is the step-by-step management of acute heart failure?

Step-by-Step Management of Acute Heart Failure

Acute heart failure requires immediate, simultaneous assessment and treatment with a time-critical approach similar to acute coronary syndromes, prioritizing early respiratory support, hemodynamic stabilization, and pharmacologic therapy based on blood pressure status. 1

Step 1: Immediate Cardiopulmonary Stability Assessment (First Minutes)

Determine cardiopulmonary stability immediately by evaluating two critical domains: 2

Respiratory Distress Indicators:

• Respiratory rate >25 breaths/minute 1
• SpO₂ <90% despite supplemental oxygen 1
• Increased work of breathing with orthopnea 2

Hemodynamic Instability Indicators:

• Heart rate <40 or >130 bpm 1
• Systolic blood pressure <90 mmHg or >180 mmHg 2
• Mental status changes using AVPU mnemonic (Alert, Visual, Pain, Unresponsive) as indicator of hypoperfusion 2
• Cold peripheries, altered mentation, oliguria 2

Triage patients with persistent dyspnea or hemodynamic instability immediately to a high-dependency or resuscitation area where emergency interventions can be provided. 1, 3

Step 2: Position and Establish Monitoring (Within Minutes)

• Position patient upright immediately to reduce work of breathing and improve ventilation 1, 3
• Establish continuous monitoring: pulse oximetry, blood pressure, respiratory rate, ECG, and cardiac rhythm 1, 3
• Place on continuous cardiac monitoring 1

Step 3: Respiratory Support (Immediate)

Oxygen Therapy:

• Administer oxygen therapy only when SpO₂ <90% 3
• Avoid hyperoxia as it may be harmful 3
• Target SpO₂ >90% 1

Non-Invasive Ventilation:

Initiate non-invasive ventilation (NIV) as soon as possible in patients with acute pulmonary edema showing respiratory distress - this reduces respiratory distress, decreases intubation rates, and may reduce mortality. 2, 1, 3

• Use CPAP in the prehospital setting because it is simpler than pressure support ventilation, requires minimal training, and does not require a ventilator 2, 3
• Consider pressure support with PEEP (PS-PEEP) for patients with acidosis and hypercapnia, particularly those with COPD history 1

Step 4: Immediate Diagnostic Workup (Concomitant with Treatment)

On arrival in the ED/CCU/ICU, initial clinical examination, investigations and treatment should be started immediately and concomitantly. 2

Essential Immediate Tests:

• ECG immediately to exclude ST elevation myocardial infarction and assess for arrhythmias 2, 3
• Plasma natriuretic peptides (BNP or NT-proBNP or MR-proANP) using point-of-care assay to confirm diagnosis and differentiate from non-cardiac causes of dyspnea 2, 1, 3
• Laboratory tests: troponin, complete blood count, BUN/urea, creatinine, electrolytes, glucose 2, 3
• Chest X-ray to rule out alternative causes of dyspnea (pneumonia, pneumothorax), though it may be normal in nearly 20% of patients 2
• Bedside thoracic ultrasound for signs of interstitial edema (B-lines) and abdominal ultrasound for inferior vena cava diameter if expertise available 2

Echocardiography Timing:

• Immediate echocardiography is mandatory in all patients presenting with cardiogenic shock 2
• In all other patients, perform echocardiography after stabilization, especially with de novo disease 2

Step 5: Pharmacological Management Based on Blood Pressure

For Hypertensive AHF (SBP >140 mmHg - approximately 60-75% of patients):

Initiate aggressive blood pressure reduction with IV vasodilators in combination with loop diuretics. 1

• IV nitroglycerin is indicated for control of congestive heart failure in the setting of acute myocardial infarction 4
• IV vasodilators are indicated in AHF with normal to high blood pressure (SBP >110 mmHg) 1
• Combine with IV loop diuretics for congestion 1

For Normotensive AHF (SBP 90-140 mmHg):

IV loop diuretics are first-line therapy for congestion. 1, 3

Dosing:

• New-onset heart failure or patients not on maintenance diuretics: Furosemide 40 mg IV 1, 3
• Established heart failure on chronic oral diuretics: IV bolus at least equivalent to the oral dose 1, 3
• For diuretic resistance: Consider combination therapy with loop diuretic plus thiazide-type diuretic or spironolactone 1

For Hypotensive AHF/Cardiogenic Shock (SBP <90 mmHg):

Cardiogenic shock is defined as hypotension (SBP <90 mmHg) despite adequate filling status with signs of hypoperfusion: oliguria, cold peripheries, altered mental status, lactate >2 mmol/L, metabolic acidosis, SvO₂ <65%. 2

Management Algorithm:

1. Immediate assessment with ECG and echocardiography required immediately 2
2. Establish invasive monitoring with arterial line 2
3. Fluid challenge first-line: Saline or Ringer's lactate >200 mL over 15-30 minutes if no sign of overt fluid overload 2
4. Inotropic support:
   • Dobutamine may be used to increase cardiac output in patients not on beta-blockers 2
   • Levosimendan may be considered as alternative, especially in chronic HF patients on oral beta-blockade 2
   • Milrinone is indicated for short-term IV treatment of acute decompensated heart failure, but patients must be observed closely with appropriate ECG equipment and facility for immediate treatment of life-threatening ventricular arrhythmias 5
5. Vasopressor support (only if strict need):
   • Norepinephrine is recommended over dopamine when mean arterial pressure needs pharmacologic support in presence of persistent hypoperfusion 2
   • Target MAP ≥65 mmHg 6
   • Administer through large vein, preferably central venous catheter 6
   • Continuous arterial blood pressure monitoring via arterial line mandatory 6
6. Rapid transfer to tertiary care center with 24/7 cardiac catheterization and dedicated ICU with availability of short-term mechanical circulatory support 2
7. IABP is not routinely recommended in cardiogenic shock 2
8. Short-term mechanical circulatory support may be considered in refractory cardiogenic shock depending on patient age, comorbidities, and neurological function 2

Step 6: Management of Specific Precipitants

Recognition of precipitating factors is a critical step for optimal management, with compliance issues listed at the top of most important precipitating factors. 2

• Acute coronary syndrome: Implement immediate invasive strategy with intent to perform revascularization 1, 3
• Rapid arrhythmias: Correct urgently with medical therapy or electrical cardioversion 1, 3
• Atrial fibrillation with rapid ventricular response: Consider IV cardiac glycosides for rapid rate control, though beta-blockers are preferred first-line treatment for rate control in stable patients 1, 3

Step 7: Continuous Monitoring During Hospitalization

Patients require comprehensive monitoring throughout hospitalization: 1

• Daily weights and accurate fluid balance charts 1
• Daily renal function and electrolytes 1
• Standard noninvasive monitoring of pulse, respiratory rate, blood pressure 1
• Continuous assessment of dyspnea, heart rate and rhythm, urine output, peripheral perfusion 1
• Assess urine output to evaluate response to diuretic therapy 1
• Measure natriuretic peptides before discharge to help with post-discharge planning 1

Step 8: Discharge Criteria

Patients are medically fit for discharge when: 1, 3

• Hemodynamically stable and euvolemic 1, 3
• Established on evidence-based oral medication 1, 3
• Stable renal function for at least 24 hours before discharge 2, 1, 3
• Provided with tailored education and advice about self-care 1, 3

Step 9: Post-Discharge Follow-Up Plan

Implement structured follow-up plan before discharge: 1, 3

• Enroll in disease management programs 2, 1, 3
• See general practitioner within 1 week of discharge 2, 1, 3
• See hospital cardiology team within 2 weeks of discharge 2, 1, 3
• Follow-up within multi-professional heart failure service 2, 1, 3
• Ensure continuation and up-titration of disease-modifying therapy for heart failure with reduced ejection fraction if appropriate 2

Critical Pitfalls to Avoid

• Do not delay NIV in respiratory distress - early initiation reduces intubation and mortality 2, 1, 3
• Do not routinely administer oxygen if SpO₂ ≥90% - hyperoxia may be harmful 3
• Do not use vasopressors before adequate fluid challenge in cardiogenic shock unless overt fluid overload present 2
• Do not use dopamine as first-line vasopressor - norepinephrine is preferred 2
• Do not discharge patients before 24 hours of stable renal function on oral medications 2, 1, 3
• Do not perform routine immediate echocardiography except in cardiogenic shock - it can be done after stabilization 2