What is the full treatment plan for a patient with Acute Decompensated Heart Failure (ADHF)?

Full Treatment Plan for Acute Decompensated Heart Failure (ADHF)

Initiate IV loop diuretics immediately upon presentation in the emergency department—do not delay—and administer IV vasodilators early in normotensive or hypertensive patients, as delayed vasodilator administration is associated with higher mortality. 1, 2

Immediate Assessment and Stabilization

Respiratory Support

• Administer supplemental oxygen immediately if SpO2 <90%, targeting SpO2 94-96% (90% in COPD patients). 3, 1
• Start non-invasive ventilation (NIV) with PEEP as early as possible in patients with acute cardiogenic pulmonary edema and respiratory distress, as it reduces intubation rates and improves clinical parameters. 3, 1
  • Begin with PEEP of 5-7.5 cmH2O, titrate up to 10 cmH2O based on clinical response. 3
  • NIV with PEEP improves LV function by reducing LV afterload. 3
  • Continue for 30 min/hour until dyspnea and oxygen saturation remain improved without continuous support. 3
• Reserve intubation and mechanical ventilation for patients with inadequate oxygen delivery despite oxygen mask or NIV, or those with progressive respiratory failure/exhaustion evidenced by hypercapnia. 3

Hemodynamic Monitoring

• Measure blood pressure every 5 minutes until vasodilator, diuretic, or inotrope dosing is stabilized. 3
• Monitor continuously: heart rate, respiratory rate, ECG (for arrhythmias and ST segment changes), and pulse oximetry. 3, 1
• Obtain immediate ECG and cardiac biomarkers to identify acute coronary syndrome as a precipitating factor. 1, 2
• Measure BNP or NT-proBNP to confirm diagnosis in patients with acute dyspnea. 1, 2
• Assess perfusion status by checking for narrow pulse pressure, cool extremities, altered mentation, and resting tachycardia. 1, 2
• Determine volume status through jugular venous distention, hepatojugular reflux, peripheral edema, and recent weight changes. 1, 4

Primary Pharmacologic Management

Loop Diuretics (First-Line for Congestion)

• Administer furosemide 20-40 mg IV bolus immediately for new-onset heart failure or patients not on maintenance diuretics. 3, 1, 2
• For patients on chronic oral diuretics, give IV bolus at least equivalent to their oral daily dose. 3, 1
• Place bladder catheter to monitor urinary output and rapidly assess treatment response. 3
• Total furosemide dose should remain <100 mg in the first 6 hours and <240 mg during the first 24 hours. 3
• Consider continuous infusion after initial bolus in patients with evidence of volume overload. 3
• If inadequate response, intensify by: (a) increasing loop diuretic dose, (b) adding thiazide (hydrochlorothiazide 25 mg PO) or aldosterone antagonist (spironolactone 25-50 mg PO), or (c) switching to continuous infusion. 3, 4, 2
• Monitor daily: urine output, symptoms, renal function, and electrolytes (especially potassium). 3, 4, 2

Vasodilators (First-Line for Normotensive/Hypertensive Patients)

• Initiate IV vasodilators (nitroglycerin or nitroprusside) early when systolic blood pressure is >110 mmHg, as delayed administration is associated with higher mortality. 3, 1, 2
• Nitroglycerin: Start at low dose with upward titration to achieve optimal vasodilation (increased cardiac index, decreased pulmonary wedge pressure). 3
  • Can be given as GTN spray 400 mcg (2 puffs) every 5-10 minutes initially, or buccally. 3
  • Titrate IV nitroglycerin to highest hemodynamically tolerable dose. 3
  • Limitation: rapid development of tolerance (effectiveness limited to 16-24 hours). 3
• Nitroprusside: Start at 0.3 mcg/kg/min, titrate every few minutes until desired effect or maximum 10 mcg/kg/min reached. 5
  • May be preferable in patients with congestion and low cardiac output. 6
  • Use only with infusion pump (preferably volumetric), never gravity-regulated apparatus. 5
  • Requires continuous blood pressure monitoring with intra-arterial pressure sensor preferred. 5
  • Avoid administering >500 mcg/kg faster than 2 mcg/kg/min due to cyanide toxicity risk. 5

Management of Chronic Heart Failure Medications

• Continue ACE inhibitors/ARBs unless hemodynamic instability or contraindications exist. 1, 2
• Continue beta-blockers or reduce dose temporarily, but do not stop unless patient has signs of low cardiac output, bradycardia, advanced AV block, or cardiogenic shock. 1, 4, 2

Medications to AVOID or Use with Extreme Caution

Morphine

• Avoid routine use of morphine, as it is associated with higher rates of mechanical ventilation, ICU admission, and death. 1, 2
• If used, administer 2.5-5 mg IV boluses only in patients with severe restlessness, dyspnea, anxiety, or chest pain, with careful respiratory monitoring. 3

Inotropic Agents

• Do NOT use inotropes (dobutamine, milrinone) unless patient is symptomatically hypotensive or hypoperfused, as they are associated with increased mortality risk. 1, 2, 7
• Dobutamine and milrinone have not been shown to be safe or effective in long-term treatment of congestive heart failure; patients with NYHA Class IV symptoms appear at particular risk. 7
• If required for persistent hypoperfusion despite adequate filling pressures, milrinone may be preferable in patients with significant pulmonary venous hypertension. 6

Other Contraindications

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

Special Hemodynamic Scenarios

Cardiogenic Shock (SBP <90 mmHg with Hypoperfusion)

• Obtain immediate ECG and echocardiography. 3, 2
• Rapidly transfer to tertiary care center with 24/7 cardiac catheterization and mechanical circulatory support availability. 2
• Consider fluid challenge (250 mL over 10 minutes) if clinically indicated. 2
• Start inotropic agent if systolic BP remains <90 mmHg after fluid challenge. 3
• Consider intra-aortic balloon pump (IABP) and mechanical circulatory support early. 2

Acute Coronary Syndrome/Ischemia

• Coronary angiography is indicated in cases of ADHF with evidence of ischemia (unstable angina or ACS) in patients without strong contraindications. 3
• Consider revascularization options (PCI/CABG) if technically possible in appropriate patients with acceptable risk profile, as successful reperfusion improves prognosis. 3
• Initiate appropriate medical therapy: IIb/IIIa glycoprotein antagonists, oral antiplatelet agents, and statins. 3

Advanced Monitoring (When Indicated)

Pulmonary Artery Catheter

• PAC insertion is usually unnecessary for diagnosis of ADHF. 3
• Consider PAC in: (a) complex patients with concurrent cardiac and pulmonary disease when echo/Doppler measurements are difficult, or (b) hemodynamically unstable patients not responding to traditional treatments. 3
• Have clear objectives prior to insertion; complication rate increases with duration of use. 3

Titration in Acute Congestive Heart Failure

• When treating acute congestive heart failure, titrate infusion rate guided by invasive hemodynamic monitoring with simultaneous urine output monitoring. 5
• Titrate until: (a) measured cardiac output no longer increasing, (b) systolic blood pressure cannot be further reduced without compromising vital organ perfusion, or (c) maximum recommended infusion rate reached. 5

Criteria for ICU/CCU Admission

• Triage patients with significant dyspnea or hemodynamic instability to locations where immediate resuscitative support is available. 1
• Specific ICU admission criteria: respiratory rate >25 breaths/min, SaO2 <90%, use of accessory muscles for breathing, systolic BP <90 mmHg, need for intubation, signs of hypoperfusion. 1

Discharge Planning and Follow-Up

• Ensure patients are hemodynamically stable, euvolemic, established on evidence-based oral medication, and have stable renal function for at least 24 hours before discharge. 4
• Arrange follow-up with primary care physician within 1 week of discharge. 4
• Schedule cardiology follow-up within 2 weeks of discharge. 4
• Enroll patient in multidisciplinary heart failure disease management program. 4
• Ensure continuation and uptitration of disease-modifying therapies for heart failure with reduced ejection fraction. 4
• Educate patient on lifestyle adjustments and provide adequate secondary prophylaxis to prevent early readmission. 3