What are the pillars for managing acute decompensated heart failure?

Management Pillars for Acute Decompensated Heart Failure

The management of acute decompensated heart failure rests on five core pillars: (1) immediate oxygenation and respiratory support, (2) intravenous loop diuretics for decongestion, (3) vasodilator therapy in normotensive/hypertensive patients, (4) identification and urgent treatment of precipitating causes, and (5) continuous hemodynamic monitoring with appropriate escalation of care. 1, 2

Pillar 1: Oxygenation and Respiratory Support

• Provide supplemental oxygen immediately if SpO2 <90%, targeting SpO2 94-96% using face mask or non-invasive ventilation 1, 2, 3
• Initiate non-invasive positive pressure ventilation (CPAP or PS-PEEP) as soon as possible in patients with acute pulmonary edema showing respiratory distress, as this reduces intubation rates and mortality 2, 3
• CPAP is feasible in pre-hospital settings, while pressure-support positive end-expiratory pressure (PS-PEEP) is preferred in-hospital, particularly for patients with acidosis and hypercapnia 2, 3
• Pulse oximetry should be used continuously on any unstable patient receiving supplemental oxygen 1

Pillar 2: Intravenous Loop Diuretics for Decongestion

• Administer IV furosemide immediately as the cornerstone of initial treatment 1, 2, 3
• For diuretic-naïve patients or those not on maintenance therapy: give 20-40 mg IV bolus 2, 3
• For patients on chronic oral diuretic therapy: give IV bolus at least equivalent to their total daily oral dose 2, 3
• Diuretics can be administered as intermittent boluses or continuous infusion, with the dose adjusted according to symptoms, urine output, and clinical status 1, 3
• Monitor hourly urine output initially, daily weights, and daily electrolytes (especially potassium), BUN, and creatinine during active IV diuresis 2, 3

Pillar 3: Vasodilator Therapy (Blood Pressure Dependent)

• Administer IV vasodilators (nitroglycerin, nitroprusside, or nesiritide) early in patients with systolic blood pressure >110 mmHg, as delayed administration is associated with higher mortality 1, 2, 3, 4
• IV vasodilators should be considered for symptomatic relief in patients with SBP >90 mmHg without symptomatic hypotension 3
• In hypertensive acute heart failure (hypertensive emergency with acute pulmonary edema), aggressive blood pressure reduction of approximately 25% during the first few hours with IV vasodilators combined with loop diuretics is recommended 1
• Blood pressure should be measured regularly (every 5 minutes) until the dosage of vasodilators and diuretics has been stabilized 1, 2

Pillar 4: Identification and Urgent Management of Precipitating Causes

The following precipitants require immediate recognition and urgent intervention 1:

• Acute coronary syndrome: Patients with ACS and AHF represent a very-high-risk group requiring immediate invasive strategy with intent to perform revascularization (within 2 hours), irrespective of ECG or biomarker findings 1
• Rapid arrhythmias or severe bradycardia/conduction disturbances: Electrical cardioversion is recommended if an arrhythmia is contributing to hemodynamic compromise 1
• Hypertensive emergency: Prompt blood pressure reduction should be initiated as soon as possible as the primary therapeutic target 1
• Obtain 12-lead ECG, cardiac troponins, and echocardiography immediately in hemodynamically unstable patients 1
• Coronary angiography is indicated in acute coronary syndromes complicated by AHF, with emergency PCI or surgery considered at an early stage 1

Pillar 5: Continuous Monitoring and Hemodynamic Assessment

• Establish continuous ECG monitoring, pulse oximetry, blood pressure, respiratory rate, and heart rate within minutes of arrival 1, 2
• Monitor vital signs every 5 minutes until therapy is stabilized 1, 2
• 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
• Obtain laboratory assessments including cardiac troponins, BUN/creatinine, electrolytes (sodium, potassium), glucose, complete blood count, liver function tests, and TSH 1
• Measure BNP or NT-proBNP levels to confirm diagnosis in patients presenting with acute dyspnea 1, 2
• Echocardiography is recommended immediately in hemodynamically unstable patients and within 48 hours when cardiac structure and function are unknown or may have changed 1

Critical Management Principles Across All Pillars

Continue guideline-directed medical therapy (ACE inhibitors/ARBs and beta-blockers) unless hemodynamic instability or contraindications exist 2, 3. Beta-blockers should generally not be stopped but may be reduced temporarily if the patient has signs of low cardiac output, bradycardia, advanced AV block, or cardiogenic shock 2.

Avoid routine use of morphine, as it is associated with higher rates of mechanical ventilation, ICU admission, and death 2.

Inotropic agents (dobutamine, milrinone) should NOT be used unless the patient is symptomatically hypotensive (SBP <90 mmHg) or has signs of hypoperfusion, as they increase mortality risk 2, 5. If inotropes are required, dobutamine is indicated only for short-term treatment (experience does not extend beyond 48 hours) 5.

Patients with respiratory distress/failure, hemodynamic compromise, respiratory rate >25 breaths/min, SaO2 <90%, systolic BP <90 mmHg, or signs of hypoperfusion should be triaged immediately to a location where resuscitative support can be provided (CCU/ICU) 1, 2.

Treatment should be delivered by expert staff trained in heart failure management in areas reserved for heart failure patients, as comparative studies show shorter hospitalization times with specialized care 1.