What are the differences in management and treatment between acute decompensated heart failure (ADHF) and chronic heart failure (CHF)?

Management Differences: Acute Decompensated Heart Failure vs Chronic Heart Failure

The fundamental difference is that acute decompensated heart failure (ADHF) requires immediate hemodynamic stabilization with intravenous therapies focused on decongestion and symptom relief, while chronic heart failure (CHF) management centers on oral disease-modifying medications that reduce long-term morbidity and mortality. 1

Acute Decompensated Heart Failure Management

Immediate Diagnostic Approach

• Measure plasma natriuretic peptides (BNP, NT-proBNP, or MR-proANP) upon presentation to differentiate ADHF from non-cardiac causes of acute dyspnea 1
• Obtain immediate ECG and echocardiography if cardiogenic shock is suspected 1

Pharmacotherapy for ADHF

Intravenous Diuretics (First-Line)

• For diuretic-naive patients or those not on chronic diuretics: start with 20-40 mg IV furosemide (or equivalent) 1
• For patients already on chronic oral diuretics: initial IV dose should be at least equivalent to their oral dose 1
• Administer as intermittent boluses or continuous infusion, adjusting based on symptoms and clinical status 1
• Mandatory monitoring: symptoms, urine output, renal function, and electrolytes throughout IV diuretic use 1

Vasodilators

• Consider IV vasodilators for symptomatic relief when systolic blood pressure (SBP) >90 mmHg 1
• In hypertensive ADHF, IV vasodilators should be initial therapy to improve symptoms and reduce congestion 1
• Options include nitroglycerin, nitroprusside, or nesiritide, with choice depending on presence of ischemia, degree of congestion, and renal function 2, 3

Inotropic Agents (Restricted Use)

• Inotropic agents are NOT recommended unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 1
• Reserve dobutamine, dopamine, levosimendan, or phosphodiesterase III inhibitors only for hypotension (SBP <90 mmHg) with signs of peripheral hypoperfusion 1, 4

Critical Management for Cardiogenic Shock

• Rapidly transfer all cardiogenic shock patients to a tertiary care center with 24/7 cardiac catheterization and ICU/CCU with short-term mechanical circulatory support availability 1

Disease-Modifying Therapies During ADHF

This is a critical distinction from traditional acute care:

• In patients with worsening chronic HFrEF, make every attempt to continue evidence-based disease-modifying therapies (ACE inhibitors/ARBs, beta-blockers) in the absence of hemodynamic instability or contraindications 1
• Beta-blocker dose may need temporary reduction but generally should not be stopped unless the patient is clinically unstable with signs of low output 1
• Carvedilol is contraindicated in patients with decompensated heart failure requiring IV inotropic therapy 5

Chronic Heart Failure Management

Oral Disease-Modifying Pharmacotherapy

The cornerstone of CHF management differs fundamentally from ADHF by focusing on long-term mortality and morbidity reduction rather than acute symptom relief:

Beta-Blockers

• Metoprolol reduces 3-month mortality by 36% in post-MI patients and is effective for angina and hypertension 6
• Initiate or uptitrate to target doses in stable patients 1

ACE Inhibitors/ARBs

• Lisinopril attenuates remodeling and reduces morbidity and mortality in heart failure 7
• In combination with digitalis and diuretics, reduces edema, rales, paroxysmal nocturnal dyspnea, and jugular venous distention 7

Device Therapy (CHF-Specific)

• CRT is recommended for symptomatic HF patients in sinus rhythm with QRS ≥150 msec and LBBB morphology with LVEF ≤35% despite optimal medical therapy 1
• CRT also recommended for QRS 130-149 msec with LBBB and LVEF ≤35% 1

Non-Pharmacologic Management (CHF-Specific)

• Regular aerobic exercise is recommended to improve functional capacity, symptoms, and reduce HF hospitalization risk in stable HFrEF patients 1
• Enroll patients in multidisciplinary care management programs to reduce HF hospitalization and mortality 1

Common Pitfalls to Avoid

In ADHF:

• Do not routinely use inotropes—they increase mortality risk and should only be used for symptomatic hypotension/hypoperfusion 1
• Do not discontinue beta-blockers reflexively; only reduce or hold if hemodynamically unstable 1
• Avoid NSAIDs and COX-2 inhibitors as they worsen HF and increase hospitalization risk 1

In CHF:

• Thiazolidinediones (glitazones) are contraindicated—they increase HF worsening and hospitalization 1
• Adaptive servo-ventilation is not recommended in HFrEF with predominant central sleep apnea due to increased mortality 1

Transition from ADHF to CHF:

• Initiate or reinitiate ACE inhibitors/ARBs before hospital discharge 1
• Consider beta-blocker initiation once patient is stabilized on ACE inhibitor/ARB, preferably before discharge 1