What is the initial management of acute decompensated heart failure?

Initial Management of Acute Decompensated Heart Failure

Begin immediate IV loop diuretics and oxygen therapy upon presentation, add IV vasodilators if systolic blood pressure is >110 mmHg, and continue guideline-directed medical therapy unless the patient is hemodynamically unstable. 1, 2

Immediate Assessment and Monitoring

Upon arrival, establish the following baseline parameters:

• Measure oxygen saturation with pulse oximetry and provide supplemental oxygen if SpO2 <90%, targeting SpO2 94-96% 3, 1
• Obtain immediate ECG and cardiac biomarkers to identify acute coronary syndrome as a precipitating factor 1
• Measure BNP or NT-proBNP levels to confirm the diagnosis in patients presenting with acute dyspnea 1, 2
• Monitor vital signs continuously, particularly heart rate, respiratory rate, and blood pressure every 5 minutes until therapy is stabilized 3, 1
• Assess perfusion status by checking for narrow pulse pressure, cool extremities, altered mentation, and resting tachycardia 2
• Determine volume status through jugular venous distention, hepatojugular reflux, peripheral edema, and recent weight changes 2

Primary Pharmacologic Management

Diuretic Therapy (First-Line)

Administer IV loop diuretics immediately—do not delay treatment. 2

• For new-onset heart failure or patients not on maintenance diuretics: Give furosemide 20-40 mg IV bolus 3, 1, 2
• For patients on chronic oral diuretic therapy: Give IV bolus at least equivalent to their oral daily dose 3, 1, 2
• Administer as intermittent boluses or continuous infusion, titrating based on symptoms and clinical response 2
• If inadequate response: (a) increase loop diuretic dose, (b) add a second diuretic (thiazide), or (c) switch to continuous infusion 2
• Monitor urine output, renal function (BUN, creatinine), and electrolytes daily during IV diuretic therapy 1, 2

Vasodilator Therapy (Early Initiation)

Initiate IV vasodilators early in normotensive or hypertensive patients, as delayed administration is associated with higher mortality. 2

• Indicated when systolic blood pressure is >110 mmHg 3, 1, 2
• Contraindicated when systolic blood pressure is <110 mmHg 3, 1
• Options include nitroglycerin or nitroprusside 3, 2
• Nitroglycerin reduces LV and RV filling pressures and afterload, with rapid onset and short half-life allowing easy titration 4
• Benefits include fast optimization of arterial oxygenation, lower rates of mechanical ventilation, and improved survival 4

Respiratory Support

Start non-invasive ventilation (NIV) as soon as possible in patients with acute pulmonary edema showing respiratory distress. 3, 1

• Continuous positive airway pressure (CPAP) is feasible in the pre-hospital setting because it is simpler and requires minimal training 3
• Pressure-support positive end-expiratory pressure (PS-PEEP) is preferred in the hospital for patients with acidosis, hypercapnia, or history of COPD 3
• NIV decreases respiratory distress and may reduce the need for mechanical endotracheal intubation 1

Management of Chronic Heart Failure Medications

Continue Evidence-Based Therapies

Continue ACE inhibitors/ARBs and beta-blockers in patients with acutely decompensated chronic heart failure unless hemodynamic instability or contraindications exist. 1, 2

• Beta-blockers should generally not be stopped—may reduce dose temporarily but continue unless patient has signs of low cardiac output, bradycardia (<50 bpm), advanced AV block, or cardiogenic shock 3, 2
• ACE inhibitors/ARBs should be reviewed and reduced or stopped only if: systolic BP <85 mmHg, creatinine >2.5 mg/dL, eGFR <30, or potassium >5.5 mEq/L 3
• Mineralocorticoid receptor antagonists (MRAs) should be stopped if: systolic BP <85 mmHg, potassium >5.5 mEq/L, creatinine >2.5 mg/dL, or eGFR <30 3

Medications to AVOID or Use with Extreme Caution

Morphine

Routine use of morphine is NOT recommended. 3, 2

• Associated with higher rates of mechanical ventilation, ICU admission, and death in the ADHERE registry 3, 2
• Has never been shown to improve outcomes and may be associated with harm 3
• Decision should be individualized only for severe pain or anxiety, not for routine dyspnea management 3

Inotropic Agents

Inotropic agents (dobutamine, milrinone) are NOT recommended unless the patient is symptomatically hypotensive or hypoperfused. 1, 2

• Safety concerns include increased mortality risk 2
• No role for inotropes when pulmonary edema is associated with normal or high systolic blood pressure 3
• Reserved only for persistent signs of hypoperfusion despite adequate filling status 3, 2

NSAIDs and COX-2 Inhibitors

NSAIDs and COX-2 inhibitors are contraindicated—they increase risk of heart failure worsening and hospitalization. 1, 2

Special Hemodynamic Scenarios

Cardiogenic Shock (SBP <90 mmHg with Hypoperfusion)

Immediate ECG and echocardiography are required, with rapid transfer to a tertiary care center with 24/7 cardiac catheterization and mechanical circulatory support capability. 1, 2

• Consider fluid challenge (250 mL over 10 minutes) if clinically indicated 3, 2
• If systolic BP remains <90 mmHg after fluid challenge, start an inotropic agent 3
• If inotrope fails to restore systolic BP and signs of organ hypoperfusion persist, add norepinephrine with extreme caution 3
• Consider intra-aortic balloon pump (IABP) and mechanical circulatory support early 3, 2
• Intubation and mechanical ventilation should be considered 3

Hypertensive Heart Failure

Vasodilators are the primary treatment with close monitoring, using low-dose diuretics only in patients with volume overload or pulmonary edema. 3

Right Heart Failure

Fluid challenge is usually ineffective, mechanical ventilation should be avoided, and inotropic agents are required when there are signs of organ hypoperfusion. 3

• Suspect pulmonary embolism and right ventricular MI 3

Atrial Fibrillation with Rapid Ventricular Response

Beta-blockers are the preferred first-line treatment to control ventricular rate in patients with heart failure and atrial fibrillation. 3

• IV cardiac glycosides should be considered for rapid control of ventricular rate as an alternative 3

Criteria for ICU/CCU Admission

Triage patients with significant dyspnea or hemodynamic instability to a location where immediate resuscitative support can be provided. 1

Specific criteria for ICU admission include: 1

• Respiratory rate >25 breaths/min
• SaO2 <90%
• Use of accessory muscles for breathing
• Systolic BP <90 mmHg
• Need for intubation
• Signs of hypoperfusion

Common Pitfalls to Avoid

• Do not delay IV diuretic administration—start immediately in the emergency department 2
• Do not use vasodilators if systolic BP <110 mmHg—risk of precipitating cardiogenic shock 3, 1
• Do not routinely discontinue beta-blockers—this is associated with worse outcomes 2
• Do not use inotropes in normotensive or hypertensive patients—reserve only for hypoperfusion 1, 2
• Do not give morphine routinely—associated with increased mortality 3, 2