What is the initial management for a patient presenting with Acute Decompensated Heart Failure (ADHF)?

Initial Management of Acute Decompensated Heart Failure (ADHF)

Begin immediate stabilization within minutes of patient contact with oxygen support, IV loop diuretics for congestion, and IV vasodilators if systolic blood pressure >110 mmHg, while establishing continuous monitoring of vital signs. 1

Immediate Assessment and Monitoring (First 5 Minutes)

Establish continuous monitoring immediately including pulse oximetry, blood pressure, respiratory rate, and continuous ECG whether in the ambulance or emergency department. 2, 1 Monitor these parameters every 5 minutes until therapy is stabilized. 3

Assess two critical clinical parameters:

• Perfusion status: Check for narrow pulse pressure, cool extremities, altered mentation, and resting tachycardia 3
• Volume status: Evaluate jugular venous distention, hepatojugular reflux, peripheral edema, and recent weight changes 3

Obtain immediate diagnostic tests:

• ECG to exclude ST-elevation myocardial infarction 2, 3
• Cardiac biomarkers (troponin) to identify acute coronary syndrome 3
• BNP or NT-proBNP to confirm diagnosis in patients with acute dyspnea 3
• Electrolytes, renal function, and arterial blood gases when needed 4

Respiratory Support

Administer oxygen therapy if SpO₂ <90%, targeting SpO₂ 94-96%. 1, 3 For SpO₂ >90%, give oxygen based on clinical judgment for respiratory distress. 2, 1

Initiate non-invasive ventilation (NIV) immediately in patients with acute pulmonary edema showing respiratory distress to decrease work of breathing, reduce intubation rates, and potentially reduce mortality. 1, 3 Use continuous positive airway pressure (CPAP) in pre-hospital settings due to simplicity, while pressure-support positive end-expiratory pressure (PS-PEEP) is preferred in-hospital, particularly for patients with acidosis, hypercapnia, or COPD history. 4

Pharmacological Management Based on Blood Pressure

Normotensive or Hypertensive Patients (SBP >110 mmHg)

Administer IV loop diuretics immediately as first-line therapy for patients with congestion. 1, 3

Dosing for IV loop diuretics:

• New-onset ADHF or diuretic-naive patients: 20-40 mg IV furosemide bolus 3, 4
• Patients on chronic oral diuretics: Give IV bolus at least equivalent to their oral daily dose 2, 3
• Alternative: 10-20 mg IV torasemide 2

Initiate IV vasodilators early in patients with SBP >110 mmHg, as delayed administration is associated with higher mortality. 1, 3 Options include nitroglycerin, nitroprusside, or nesiritide. 3 For hypertensive ADHF, vasodilators are recommended as first-line therapy with close monitoring. 4

Hypotensive Patients (SBP <90 mmHg) or Cardiogenic Shock

Avoid diuretics before adequate perfusion is attained in patients with signs of hypoperfusion. 2

Consider fluid challenge of 250 mL over 10 minutes if clinically indicated. 3, 4

If SBP remains <90 mmHg after fluid challenge, initiate inotropic support with dobutamine, milrinone, or dopamine. 3, 4 However, inotropic agents are not recommended unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns. 2

For vasopressor support, norepinephrine is preferred in patients with cardiogenic shock despite treatment with another inotrope to increase blood pressure and vital organ perfusion. 2

Monitor ECG and blood pressure continuously when using inotropic agents and vasopressors, as they can cause arrhythmia, myocardial ischemia, and in the case of levosimendan and PDE III inhibitors, hypotension. 2 Intra-arterial blood pressure measurement may be considered. 2

Management of Chronic Heart Failure Medications

Continue ACE inhibitors/ARBs and beta-blockers in patients with acutely decompensated chronic heart failure unless hemodynamic instability or contraindications exist. 3, 4

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. 3, 4 Use beta-blockers cautiously if the patient is hypotensive. 2

If beta-blockade is contributing to hypoperfusion, levosimendan is preferable over dobutamine to reverse the effect. 2 However, levosimendan is a vasodilator and not suitable for patients with SBP <85 mmHg or cardiogenic shock unless combined with other inotropes or vasopressors. 2

Medications to AVOID

Avoid routine use of morphine/opiates, as they are associated with higher rates of mechanical ventilation, ICU admission, and death. 3, 4 Opiates may be considered for cautious use only to relieve severe dyspnea and anxiety, but nausea and hypopnea may occur. 2

Do not use parenteral inotropes in normotensive patients without evidence of decreased organ perfusion. 3

Avoid invasive hemodynamic monitoring in normotensive patients with acute decompensated HF and congestion with symptomatic response to diuretics and vasodilators. 3

Strategies for Diuretic Resistance

To enhance diuresis or overcome diuretic resistance, use dual nephron blockade by combining loop diuretics (furosemide or torasemide) with thiazide diuretics or natriuretic doses of mineralocorticoid receptor antagonists (MRAs). 2 This combination requires careful monitoring to avoid hypokalemia, renal dysfunction, and hypovolemia. 2

Diuretics can be administered as intermittent boluses or continuous infusion, with dose and duration adjusted according to symptoms and clinical status. 4

Thromboembolism Prophylaxis

Administer thromboembolism prophylaxis (e.g., low molecular weight heparin) in patients not already anticoagulated and with no contraindication to anticoagulation to reduce the risk of deep venous thrombosis and pulmonary embolism. 2

Triage and Disposition Decisions

Triage to high-dependency setting (ICU/CCU) if patients have:

• 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 3

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

For cardiogenic shock, perform immediate ECG and echocardiography with rapid transfer to a tertiary care center. 3

In-Hospital Monitoring

Daily monitoring should include:

• Daily weights and accurate fluid balance charts 1
• Daily renal function and electrolytes 1, 4
• Continuous assessment of dyspnea, heart rate and rhythm, urine output, and peripheral perfusion 1

Regular monitoring of symptoms, urine output, renal function, and electrolytes is essential during treatment, especially with IV diuretic use. 4

Special Considerations for Acute Coronary Syndrome

Patients with acute coronary syndrome and ADHF should undergo early coronary angiography and revascularization when appropriate. 4 When signs and symptoms of inadequate systemic perfusion are present, urgent cardiac catheterization and revascularization is reasonable where it is likely to prolong meaningful survival. 3

Advanced Therapies for Refractory Cases

For patients with refractory congestion not responding to medical therapy, ultrafiltration is reasonable. 3

Invasive hemodynamic monitoring can be useful for carefully selected patients with persistent symptoms despite empiric adjustment of standard therapies, particularly when fluid status or perfusion remains uncertain. 3

Transition to Chronic Management Before Discharge

Initiate goal-directed medical therapy (GDMT) before discharge with start of SGLT2 inhibitors, ARNi or ACEi, beta-blockers, and MRAs at half dose before discharge. 1 Use an intensive strategy of rapid up-titration during frequent follow-up visits in the first 6 weeks. 1

Beta-blockers should be initiated when the patient is stabilized on an ACEI or ARB, preferably before hospital discharge. 4

Enrollment in a multidisciplinary care management program is recommended to reduce the risk of HF hospitalization and mortality. 4