What is the management of acute decompensated heart failure?

From the Guidelines

Management of acute decompensated heart failure requires prompt intervention to improve symptoms and stabilize the patient, with initial treatment focusing on relieving congestion with intravenous loop diuretics, typically furosemide 20-40mg IV, as recommended by the European Society of Cardiology guidelines 1.

Key Considerations

• Initial treatment should focus on relieving congestion with intravenous loop diuretics, with the dose and duration adjusted according to the patient's symptoms and clinical status 1.
• Oxygen should be administered to maintain saturation above 90% 1.
• For patients with severe symptoms, nitroglycerin or nitroprusside may be used to provide rapid preload reduction, while inotropic support with dobutamine or milrinone may be necessary in cases with reduced cardiac output, though these carry increased arrhythmia risk 1.
• Non-invasive positive pressure ventilation should be considered for respiratory distress 1.
• Fluid and sodium restriction (2g sodium/day, 1.5-2L fluid/day) is important, and close monitoring of vital signs, urine output, daily weights, and electrolytes is essential throughout treatment to guide therapy adjustments and prevent complications like electrolyte abnormalities or worsening renal function 1.

Inotropic Agents and Vasopressors

• Inotropic agents are not recommended unless the patient is symptomatically hypotensive or hypoperfused because of safety concerns 1.
• Vasopressors, such as norepinephrine, may be considered in patients with cardiogenic shock, despite treatment with another inotrope, to increase blood pressure and vital organ perfusion 1.

Transition to Oral Medications

• Once stabilized, patients should transition to oral heart failure medications, including ACE inhibitors/ARBs, beta-blockers, and aldosterone antagonists, as appropriate 1.
• The underlying cause of decompensation must be identified and addressed, whether it's medication non-adherence, dietary indiscretion, arrhythmias, or infection 1.

From the FDA Drug Label

Dobutamine Injection, USP is indicated when parenteral therapy is necessary for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility resulting either from organic heart disease or from cardiac surgical procedures Nitroglycerin Injection is indicated for treatment of peri-operative hypertension; for control of congestive heart failure in the setting of acute myocardial infarction; The management of acute decompensated heart failure may involve the use of:

• Dobutamine (IV) 2 for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility
• Nitroglycerin (IV) 3 for control of congestive heart failure in the setting of acute myocardial infarction Key considerations:
• Dobutamine is only recommended for short-term use (up to 48 hours)
• Nitroglycerin is indicated for control of congestive heart failure in the setting of acute myocardial infarction

From the Research

Treatment Goals and Strategies

• The primary goals of treating acute decompensated heart failure are to decrease congestion, afterload, and neurohormonal activation, thereby improving hemodynamics and symptoms, and reducing in-hospital events, re-hospitalizations, and mortality 4.
• Relief of congestion through intravenous loop diuretics is a mainstay of therapy, with ultrafiltration considered in cases where diuretics are not effective 4.
• Beta-blockers should be continued or reduced in dose at admission, but not typically held, while afterload reduction with vasodilators should be instituted at presentation in patients with normotensive or hypertensive heart failure 4.

Noninvasive Ventilation

• Noninvasive ventilation (NIV) is indicated as first-line therapy in acute cardiogenic pulmonary edema (ACPE) and may be considered in stable cardiogenic shock and acute heart failure (AHF) associated with chronic obstructive pulmonary disease (COPD) 5, 6.
• Continuous positive airway pressure (CPAP) and noninvasive pressure support ventilation (NIPSV) are effective modalities of NIV, with CPAP being a simpler technique that may be preferred in low-equipped areas 5, 6.
• High-flow nasal cannula is an alternative for patients who need prolonged ventilation or show poor tolerance to other techniques 5, 6.

Comprehensive Management Approach

• A comprehensive care plan for patients with acute decompensated heart failure should include a brief overview of the pathophysiology, clinical presentation, and evaluation of patients, as well as management goals and treatment guidelines 7.
• The plan should address challenges presented by diuretic resistance and worsening renal function, and provide information on recognition of advanced heart failure, estimation of prognosis, and proactive identification of patients who may benefit from mechanical cardiac devices, transplantation, or palliative care/hospice 7.
• Strategies to address the problem of readmissions, which is an ominous prognostic factor with enormous economic burden, should also be included in the comprehensive management approach 7.

Contemporary Medical Management

• Hospitalizations for acute decompensated heart failure are increasing in the United States, and the prevalence of heart failure is increasing due to an aging population and improvements in therapies for coronary artery disease and sudden cardiac death 8.
• Common in-hospital treatments for acute decompensated heart failure include intravenous diuretics, vasodilators, and inotropic agents, with novel pharmaceutical agents showing promise in simplifying treatment and reducing morbidity associated with the disease 8.