What is the initial treatment for a congestive heart failure (CHF) exacerbation in the emergency room?

Emergency Department Treatment of CHF Exacerbation

Immediately initiate IV loop diuretics (furosemide 40-80 mg IV bolus if diuretic-naïve, or at least equal to the patient's chronic oral daily dose) within 60 minutes of presentation, combined with continuous monitoring and supplemental oxygen if SpO₂ <90%. 1

Immediate Stabilization (First 15 Minutes)

Assess Cardiopulmonary Stability

• Determine if the patient has respiratory failure or hemodynamic compromise as the critical first step – these patients require immediate transfer to a resuscitation bay where advanced respiratory and cardiovascular support is available. 2
• Use the AVPU mnemonic (Alert, Visual, Pain, Unresponsive) to assess mental status as an indicator of hypoperfusion. 2
• Identify cardiogenic shock (SBP <90 mmHg with signs of hypoperfusion) immediately, as these patients require ICU/CCU transfer and consideration of pulmonary artery catheter-guided therapy. 1

Establish Monitoring

• Institute continuous noninvasive monitoring within minutes: pulse oximetry, blood pressure, respiratory rate, heart rate, and continuous ECG. 2, 1
• Begin strict monitoring of urine output from the start. 2, 1

Respiratory Support

• **Administer supplemental oxygen if SpO₂ <90%** (target >90%, or 88-92% if COPD present). 2, 1
• Initiate non-invasive ventilation (CPAP or BiPAP) immediately if respiratory rate >25/min or SpO₂ <90% despite oxygen – this reduces work of breathing and decreases need for intubation. 2, 3, 1

Pharmacologic Treatment (Within 60 Minutes)

Loop Diuretics (Primary Treatment)

• Administer IV furosemide 40-80 mg IV bolus if diuretic-naïve, OR at least equal to the patient's chronic oral daily dose if already on diuretics, within 60 minutes of presentation. 1
• Target urine output ≥100-150 mL/hour within 6 hours and urinary sodium ≥50-70 mmol/L within 2 hours. 1
• If inadequate response, consider continuous IV furosemide infusion after loading dose, or add thiazide diuretic (hydrochlorothiazide 25 mg PO) or aldosterone antagonist. 1
• Keep total furosemide dose <100 mg in first 6 hours and <240 mg in first 24 hours to avoid excessive diuresis and renal dysfunction. 1

Vasodilators (Adjunctive for Hypertensive Patients)

• IV nitroglycerin (start 20 mcg/min, titrate up to 200 mcg/min) or isosorbide dinitrate (1-10 mg/hour) can be used as adjunct to diuretics in patients with adequate blood pressure and congestion. 1
• Avoid vasodilators if SBP <110 mmHg. 1
• Most AHF patients present with normal or high blood pressure (60-77% have SBP >140 mmHg), making vasodilators particularly relevant. 2

Symptom Relief

• Morphine 3 mg IV boluses (repeat as needed) can be used if severe dyspnea and anxiety present, though use with caution. 1

Diagnostic Workup (Concurrent with Treatment)

Immediate Tests

• 12-lead ECG immediately to exclude ST-elevation MI and identify arrhythmias. 2, 1
• Cardiac troponin to identify acute coronary syndrome as precipitant. 1
• BNP or NT-proBNP to confirm diagnosis and assess severity. 1
• Basic metabolic panel (electrolytes, creatinine, BUN, glucose). 1
• Complete blood count. 1
• Chest X-ray to assess pulmonary congestion and rule out alternative causes (pneumonia, pneumothorax), recognizing it may be normal in up to 20% of AHF cases. 2, 1

Bedside Ultrasound (If Expertise Available)

• Thoracic ultrasound for B-lines (indicating pulmonary edema) and pleural effusions – may be more informative than chest X-ray and saves time. 2
• Abdominal ultrasound for inferior vena cava diameter to assess volume status. 2

Echocardiography Timing

• Immediate echocardiography is mandatory only in patients presenting with cardiogenic shock or hemodynamic instability. 2
• In all other patients, perform echocardiography after stabilization, especially with de novo disease. 2

Treatment Objectives

Primary goals are to improve symptoms, maintain SBP >90 mmHg with adequate peripheral perfusion, and maintain SpO₂ >90%. 2

Critical Pitfalls to Avoid

• Never delay diuretic therapy beyond 60 minutes – time-to-treatment is critical in AHF, similar to acute coronary syndromes. 2, 1
• Do not discontinue guideline-directed medical therapy (GDMT) for mild renal function decrease or asymptomatic blood pressure reduction. 1
• Avoid inotropes (dobutamine) in normotensive patients – they are indicated only for cardiac decompensation with depressed contractility and have not been shown safe or effective in long-term CHF treatment. 1, 4
• Do not abruptly stop beta-blockers during acute exacerbation. 1
• Avoid NSAIDs or COX-2 inhibitors as they worsen renal function and fluid retention. 1

Ongoing Monitoring

• Monitor dyspnea (visual analog scale), respiratory rate, blood pressure, SpO₂, heart rate and rhythm, urine output, and peripheral perfusion continuously. 2, 1
• Daily weights, strict intake/output, and clinical assessment of congestion and perfusion. 1
• Daily electrolytes, creatinine, and BUN during IV diuretic therapy. 1
• Initiate pharmacologic VTE prophylaxis in all hospitalized CHF patients unless contraindicated. 1

Special Considerations

• If significant pleural effusion (>500 mL), consider thoracentesis to reduce diuretic requirements and oxygen therapy duration. 1
• Patients with cardiogenic shock require pulmonary artery catheter-guided therapy to optimize hemodynamics. 1