What are the differences in treatment for acute vs chronic heart failure?

Treatment Differences: Acute vs Chronic Heart Failure

Acute heart failure requires immediate hemodynamic stabilization with IV diuretics, oxygen (if hypoxemic), and vasodilators, while chronic heart failure focuses on long-term disease-modifying therapies to prevent progression and reduce mortality. 1, 2

Acute Heart Failure Management

Immediate Priorities

The treatment approach centers on rapid symptom relief and hemodynamic stabilization rather than long-term mortality reduction:

• IV loop diuretics are the cornerstone of acute treatment, administered within 60 minutes of presentation for patients with congestion 1, 3
• Initial furosemide dosing: 40 mg IV for diuretic-naive patients, or a dose equal to or exceeding the chronic oral daily dose for patients already on diuretics 4, 3
• Continuous infusion may be superior to bolus dosing in high-risk patients with severe decompensation, showing better decongestion and freedom from congestion (48% vs 25%) 5
• However, bolus administration (every 12 hours) provides similar clinical relief with lower hypokalaemia risk in less severe cases 6, 7

Respiratory Support

Oxygen and ventilatory support follow specific parameters:

• Administer oxygen only when SpO2 <90%—avoid routine use in non-hypoxemic patients as it causes vasoconstriction and reduces cardiac output 1, 2
• Non-invasive positive pressure ventilation (CPAP or BiPAP) should be initiated immediately in patients with respiratory distress (respiratory rate >25, SpO2 <90%) to reduce intubation rates 1, 4
• CPAP is preferred in pre-hospital settings due to simplicity; PS-PEEP is better for patients with hypercapnia or COPD history 1, 4

Vasodilators

• IV vasodilators (nitroglycerin) are first-line for hypertensive acute heart failure to improve symptoms and reduce congestion 1, 2
• Frequent blood pressure monitoring is essential as vasodilators can cause hypotension 1

Inotropes and Vasopressors (Use Sparingly)

• Inotropic agents are NOT recommended unless the patient is hypotensive (SBP <90 mmHg) or hypoperfused due to safety concerns including increased mortality 1, 3
• Dobutamine is the preferred inotrope when needed 1, 8
• Norepinephrine (preferred over dopamine) may be considered for persistent hypotension despite inotropes 1

Critical Monitoring

• Daily weights, strict fluid balance charts, and daily monitoring of renal function (BUN, creatinine) and electrolytes (potassium, sodium) during IV therapy 1, 4
• Natriuretic peptide measurement before discharge helps predict outcomes—falling levels correlate with lower 6-month mortality 1

Chronic Heart Failure Management

Disease-Modifying Pharmacotherapy

The focus shifts entirely to preventing progression and reducing long-term mortality:

• Quadruple therapy is the foundation for HFrEF: ACE inhibitors (or ARBs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ARNI (sacubitril/valsartan) 2
• These medications reduce mortality and hospitalization through neurohumoral blockade, not acute symptom relief 1
• Diuretics are used for symptom control and congestion management but do not modify disease progression 1

Device Therapy

• Implantable cardioverter-defibrillators (ICDs) reduce sudden cardiac death in patients with LVEF ≤35% despite optimal medical therapy 1, 2
• Cardiac resynchronization therapy (CRT) improves outcomes in symptomatic patients with LVEF ≤35% and QRS ≥130 ms 2

HF with Preserved Ejection Fraction (HFpEF)

• No treatment has convincingly reduced mortality in HFpEF 1
• Management focuses on risk factor control, diuretics for congestion, and emerging evidence for SGLT2 inhibitors and MRAs 2
• Rate-limiting calcium channel blockers (verapamil) may be used—unlike in HFrEF where they are dangerous due to negative inotropy 1

Key Distinctions in Approach

Acute Setting

• Goal: Immediate symptom relief and hemodynamic stabilization
• Timeline: Hours to days
• Setting: Emergency department, ICU/CCU, high-dependency units 1
• Route: Predominantly intravenous medications 1
• Monitoring: Continuous vital signs, invasive monitoring if cardiogenic shock 1

Chronic Setting

• Goal: Prevent disease progression, reduce mortality and hospitalizations
• Timeline: Months to years
• Setting: Outpatient clinics, multidisciplinary HF programs 1, 2
• Route: Oral medications with gradual uptitration 2
• Monitoring: Periodic clinical assessment, daily weights, symptom tracking 2

Transition from Acute to Chronic Management

Discharge criteria require hemodynamic stability for ≥24 hours, euvolemia, establishment on evidence-based oral medications, and stable renal function 1, 3:

• Continue disease-modifying therapies (ACE inhibitors, beta-blockers, MRAs) during acute exacerbation unless contraindicated by hypotension 3
• Follow-up with primary care within 1 week and cardiology within 2 weeks 1, 4
• Enrollment in multidisciplinary disease management programs reduces rehospitalization 2

Common Pitfalls

• Avoid routine morphine use in acute heart failure—associated with higher mechanical ventilation rates, ICU admission, and death 3
• Do not withhold beta-blockers reflexively during acute exacerbations unless severe hypotension or cardiogenic shock is present 1, 3
• Excessive diuretic dosing in acute settings causes renal dysfunction and electrolyte abnormalities without improving outcomes 1, 7
• Inotropes increase mortality when used outside of true hypoperfusion/cardiogenic shock scenarios 1, 3