Initial Management of Acute Decompensated Heart Failure
Begin immediate stabilization with oxygen support, non-invasive ventilation for respiratory distress, IV loop diuretics for congestion, and IV vasodilators for patients with systolic blood pressure >110 mmHg—this time-to-treatment approach mirrors acute coronary syndrome management and should be initiated within minutes of patient contact. 1, 2, 3
Immediate Assessment and Monitoring (First 5 Minutes)
Establish continuous monitoring immediately including pulse oximetry, blood pressure, respiratory rate, and continuous ECG within minutes of patient contact, whether in the ambulance or emergency department. 1, 2, 3
Determine Cardiopulmonary Stability by Assessing Two Critical Domains:
Respiratory distress indicators:
- Respiratory rate >25 breaths/min 1, 3
- SpO₂ <90% despite supplemental oxygen 1, 3
- Use of accessory muscles for breathing 1, 3
Hemodynamic instability indicators:
- Heart rate <40 or >130 bpm 2, 3
- Systolic blood pressure <90 mmHg or severe hypertension 1, 3
- Signs of hypoperfusion: cool extremities, altered mental status, oliguria, narrow pulse pressure 3
Position the patient upright to reduce work of breathing and improve ventilation. 2
Immediate Diagnostic Workup (Concurrent with Treatment)
Obtain ECG immediately to exclude ST elevation myocardial infarction and assess for arrhythmias—this is rarely normal in ADHF but necessary to identify acute coronary syndrome as a precipitant. 1, 3
Measure plasma BNP or NT-proBNP to confirm the diagnosis in patients presenting with acute dyspnea. 1, 3
Order laboratory tests including troponin, electrolytes, BUN, creatinine—high BUN (≥43 mg/dL), low systolic BP (<115 mmHg), and high creatinine (≥2.75 mg/dL) identify high-risk patients with 22% in-hospital mortality who require ICU-level care. 1, 3
Obtain chest X-ray to rule out alternative causes of dyspnea, though it may be normal in nearly 20% of patients. 1
Perform echocardiography as soon as possible unless recently done and results are available—this evaluates preload, afterload, mitral regurgitation, and other complicating disorders. 1
Respiratory Support
Administer oxygen therapy to maintain SpO₂ 94-96% if oxygen saturation is <90%. 1, 3 Oxygen should be given based on clinical judgment for respiratory distress even if SpO₂ is >90%. 1
Initiate non-invasive ventilation (NIV) immediately in patients with acute pulmonary edema showing respiratory distress—this decreases work of breathing, reduces intubation rates, and may reduce mortality. 1, 2, 3
- Use CPAP in the prehospital setting due to its simplicity 2
- Consider pressure-support with PEEP (PS-PEEP) in the hospital particularly for patients with acidosis, hypercapnia, or COPD history 2
Pharmacological Management: The Core of Initial Therapy
For Patients with Congestion (Most Common Presentation)
Administer IV loop diuretics immediately as first-line therapy:
- For diuretic-naive patients or new-onset heart failure: Give furosemide 20-40 mg IV bolus 1, 2, 3
- For patients on chronic oral diuretic therapy: Give IV bolus at least equivalent to (or double) their total daily oral dose 1, 2, 3
- Follow with continuous IV infusion if needed for persistent congestion 1
Monitor diuretic response at 2 and 6 hours:
Consider adding acetazolamide for diuretic resistance. 1
For Patients with Normal to High Blood Pressure (SBP >110 mmHg)
Initiate IV vasodilators early—delayed administration is associated with higher mortality. 3 The choice depends on clinical scenario:
- Preferred for patients with acute coronary syndrome or ongoing ischemia 1
- Start at 5 mcg/min and titrate up by 5 mcg/min every 3-5 minutes 4
- Can increase increments to 10-20 mcg/min if no response at 20 mcg/min 4
IV nitroprusside 1:
- Preferable for patients with severe congestion and low cardiac output 5
- Use with caution in significant hypotension 5
Combine vasodilators with loop diuretics for aggressive blood pressure reduction in hypertensive ADHF. 3
Management of Chronic Heart Failure Medications
Continue ACE inhibitors/ARBs and beta-blockers unless hemodynamic instability or contraindications exist. 3
Beta-blockers should generally not be stopped but may be reduced temporarily if the patient has:
For Hypotensive Patients (SBP <90 mmHg) with Hypoperfusion
Consider fluid challenge first if clinically indicated: give 250 mL over 10 minutes. 3
Start inotropic agents only if systolic BP remains <90 mmHg after fluid challenge or if there are signs of poor tissue perfusion. 3, 5
- FDA-approved for short-term inotropic support in cardiac decompensation 6
- Experience does not extend beyond 48 hours 6
- Associated with increased risk of hospitalization and death in long-term use 6
- FDA-approved for short-term IV treatment of ADHF 7
- May be preferable in patients with significant pulmonary venous hypertension 5
- Requires continuous ECG monitoring with immediate treatment capability for life-threatening ventricular arrhythmias 7
Critical caveat: Inotropes have not been demonstrated to improve outcomes and may be deleterious—limit use to symptomatic hypotension with evidence of poor tissue perfusion. 3, 8, 5
Medications to AVOID
Do NOT routinely use morphine—it is associated with higher rates of mechanical ventilation, ICU admission, and death. 1, 3 The older 2005 guidelines recommended morphine for relief of distress 1, but more recent evidence contradicts this practice. 1, 3
Triage and Disposition Decisions
Criteria for ICU/CCU Admission
Triage to high-dependency setting (ICU/CCU) if any of the following:
- Respiratory rate >25 breaths/min 1, 3
- SaO₂ <90% 1, 3
- Use of accessory muscles for breathing 1, 3
- Systolic BP <90 mmHg 1, 3
- Need for intubation or already intubated 1, 3
- Signs of hypoperfusion: oliguria, cold peripheries, altered mental status, lactate >2 mmol/L, metabolic acidosis, SvO₂ <65% 1
High-risk laboratory findings predicting 22% in-hospital mortality:
Criteria for Potential ED Discharge or Observation Unit
Patients WITHOUT high-risk features could be treated in the ED observation unit where more time is available to evaluate response to initial therapy. 1
Good response to initial therapy includes:
- Resting heart rate <100 bpm with improvement in symptoms 1
- Hemodynamic stability 1
- Resolution of respiratory distress 1
Do NOT discharge patients with de novo AHF—they need further evaluation and should not be downgraded too quickly if hospitalized. 1
Arrange early follow-up with contact within 72 hours of discharge. 1
In-Hospital Monitoring and Goal-Directed Medical Therapy
Daily monitoring includes:
- Daily weights and accurate fluid balance charts 2
- Daily renal function and electrolytes 2
- Continuous assessment of dyspnea, heart rate and rhythm, urine output, and peripheral perfusion 2
Initiate GDMT before discharge:
- Start SGLT2 inhibitors, ARNi or ACEi, beta-blockers, and MRAs at half dose before discharge 1
- Intensive strategy of rapid up-titration during frequent follow-up visits in first 6 weeks reduces risk of HF rehospitalization or death 1
Measure natriuretic peptides before discharge to help with post-discharge planning. 2
Administer IV iron supplementation (ferric carboxymaltose or ferric derisomaltose) in symptomatic patients with iron deficiency to reduce risk of HF hospitalization. 1
Common Pitfalls to Avoid
Do not delay vasodilator therapy in normotensive or hypertensive patients—early initiation is associated with improved outcomes, shorter lengths of stay, and lower mortality. 3, 8
Do not use inotropes liberally—they should be reserved only for hypotensive patients with poor perfusion, as they have not improved outcomes and may cause harm. 3, 5
Do not stop beta-blockers reflexively—they should be continued or dose-reduced but not typically held at admission. 3, 5
Do not discharge patients too quickly—ensure hemodynamic stability, euvolemia, stable renal function for at least 24 hours, and establishment on evidence-based oral medications before discharge. 2