What is the best treatment approach for a patient with acute decompensated heart failure (ADHF) and a history of cardiovascular disease (CVD)?

Treatment of Acute Decompensated Heart Failure (ADHF)

The cornerstone of ADHF management is immediate intravenous loop diuretics combined with oxygen therapy and vasodilators (if systolic BP >90 mmHg), followed by rapid initiation of guideline-directed medical therapy before discharge. 1

Immediate Assessment and Stabilization

Initial Monitoring Requirements

• Establish continuous monitoring of blood pressure, heart rate, respiratory rate, oxygen saturation, and ECG immediately upon presentation 2
• Insert intravenous line and obtain arterial line if hemodynamically unstable or requiring frequent blood gas sampling 2
• Measure hourly urine output initially, daily weights (target 0.5-1.0 kg loss daily), and daily electrolytes (especially potassium), BUN, and creatinine 1
• Obtain urgent echocardiography within 48 hours to assess ventricular function, valvular abnormalities, and mechanical complications 2

Oxygen and Respiratory Support

• Administer oxygen via face mask or CPAP targeting SpO2 94-96% (>90% in COPD patients) 2, 1
• Non-invasive positive pressure ventilation (NIV) with PEEP should be initiated early in patients with acute cardiogenic pulmonary edema and hypertensive AHF, as it improves clinical parameters, reduces respiratory distress, and may decrease intubation rates 2, 1

Pharmacologic Management

Loop Diuretics (First-Line Therapy)

• Administer IV furosemide as the cornerstone of initial treatment: 20-40 mg IV for diuretic-naïve patients, or at minimum the equivalent of their total daily oral dose for patients on chronic therapy 1
• Diuretics can be given as intermittent boluses or continuous infusion, adjusted according to urine output and symptom relief 1
• Monitor response through hourly urine output (target >0.5 mL/kg/hour), daily weights, and serial assessment of congestion 1, 3

Common Pitfall: High doses of diuretics may lead to hypovolemia and hyponatremia, increasing the likelihood of hypotension when initiating ACE inhibitors or ARBs 1

Vasodilator Therapy

• IV vasodilators (nitrates or nitroprusside) should be considered for symptomatic relief in AHF with SBP >90 mmHg without symptomatic hypotension 2, 1, 3
• In hypertensive AHF, IV vasodilators should be considered as initial therapy to improve symptoms and reduce congestion 1
• Vasodilators are physiologically superior to inotropes as persistently elevated left ventricular filling pressure predicts increased mortality, while measures of systemic perfusion and arterial pressure do not 4

Inotropic Agents (Use with Extreme Caution)

Inotropic agents should only be considered in patients with peripheral hypoperfusion (hypotension with SBP <90 mmHg, decreased renal function) with or without congestion refractory to diuretics and vasodilators at optimal doses 2, 1

• Dobutamine is indicated only for short-term (<48 hours) inotropic support in cardiac decompensation with evidence of hypoperfusion 5
• Critical Warning: Routine use of inotropes increases mortality risk and should be discouraged in patients without hypotension or hypoperfusion 1, 5
• Inotropes increase oxygen demand, calcium loading, and risk of arrhythmias and myocardial ischemia 2

Dopamine Dosing Strategy

• Low doses (<2 mcg/kg/min IV): Acts on dopaminergic receptors, improves renal blood flow and diuresis in patients with renal hypoperfusion 2
• Higher doses (>2 mcg/kg/min IV): Stimulates β-adrenergic receptors, increases contractility and cardiac output 2
• Doses >5 mcg/kg/min: Acts on α-adrenergic receptors, increases peripheral vascular resistance (potentially deleterious by augmenting LV afterload) 2

Adjunctive Therapies

• Morphine may be used cautiously for relief of dyspnea and anxiety, but be aware of potential side effects including respiratory depression 2, 1
• Thromboembolic prophylaxis is recommended in all hospitalized patients not already anticoagulated and without contraindications 1

Management of Diuretic Resistance

• For inadequate response to loop diuretics, consider combination therapy with thiazide-type diuretic or spironolactone 1
• Ultrafiltration or dialysis may be prescribed for refractory heart failure 2

Beta-Blocker Management During ADHF

In patients with overt AHF and more than basal pulmonary rales, β-blockers should be used cautiously 2

• Continue β-blockers during hospitalization unless hemodynamically unstable (SBP <90 mmHg with end-organ dysfunction) or requiring inotropic support 2, 1
• The dose may be reduced if signs of excessive dosage are present (bradycardia, hypotension) 2
• In patients with AMI who stabilize after developing AHF, β-blockers should be initiated early (Class IIa recommendation) 2
• In patients with chronic heart failure, β-blockers should be initiated when the patient has stabilized after the acute episode (usually after 4 days) 2

Coronary Artery Disease Considerations

In acute coronary syndromes complicated by AHF, coronary angiography is indicated and emergency PCI or surgery should be considered at an early stage 2

• In cardiogenic shock caused by acute coronary syndromes, coronary angiography and revascularization should be performed as soon as possible (Class I recommendation, Level A evidence) 2
• Temporary stabilization can be achieved with adequate fluid replacement, intra-aortic balloon counter-pulsation, pharmacological inotropic support, nitrates, and artificial ventilation 2

Guideline-Directed Medical Therapy Before Discharge

Rapid implementation of guideline-directed oral medical therapies (GDMT) before discharge is essential and includes β-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists 2, 1

• ACE inhibitors/ARBs should be continued during hospitalization unless hemodynamically unstable 1
• SGLT2 inhibitors must be part of the therapeutic arsenal and should be initiated before discharge 2
• Avoid excessive diuresis before starting ACE inhibitor treatment 6

Discharge Criteria and Follow-Up

Patients are medically fit for discharge when hemodynamically stable, euvolemic, and established on evidence-based guideline-directed medical therapy 1

• Arrange follow-up within 7-14 days with telephone follow-up within 3 days 1
• A multidisciplinary heart failure team should follow the patient to ensure safe transition of care 2

High-Risk Patients Requiring ICU/CCU

Triage to intensive care if any of the following are present 1:

• Respiratory rate >25 breaths/min
• SaO2 <90%
• Use of accessory muscles for breathing
• Systolic BP <90 mmHg
• Need for intubation
• Signs of hypoperfusion (oliguria, cold peripheries, altered mental status, lactate >2 mmol/L)
• BUN ≥43 mg/dL, systolic BP <115 mmHg, or creatinine ≥2.75 mg/dL