What is the immediate management of a patient presenting with acute decompensated heart failure?

Immediate Management of Acute Decompensated Heart Failure

Begin intravenous loop diuretics immediately upon presentation—do not delay—as early intervention is associated with better outcomes and reduced mortality. 1, 2, 3

Initial Assessment (First 15 Minutes)

Determine hemodynamic status immediately to guide treatment intensity and location of care:

• Assess for cardiogenic shock: Systolic blood pressure <90 mmHg with signs of hypoperfusion (cool extremities, altered mental status, narrow pulse pressure, oliguria) requires immediate ICU/CCU transfer 2, 3
• Evaluate respiratory status: Respiratory failure or severe dyspnea necessitates transfer to resuscitation bay where advanced airway support is available 2
• Check volume status: Look for jugular venous distention, hepatojugular reflux, peripheral edema, pulmonary crackles 1, 3
• Obtain 12-lead ECG immediately to exclude ST-elevation MI and identify arrhythmias as precipitating factors 4, 2, 3
• Measure cardiac troponin and BNP/NT-proBNP to identify acute coronary syndrome and confirm heart failure diagnosis 4, 2, 3

Primary Pharmacologic Management

Intravenous Loop Diuretics (First-Line Therapy)

Administer within 60 minutes of presentation: 1, 2

• If diuretic-naïve: Furosemide 20-40 mg IV bolus 2, 3
• If already on oral loop diuretics: Give IV dose equal to or greater than chronic oral daily dose 4, 1
• Target urine output: ≥100-150 mL/hour within 6 hours 2
• Limit total dose: Keep <100 mg in first 6 hours and <240 mg in first 24 hours to avoid excessive diuresis and renal dysfunction 2

If inadequate diuresis after initial dose: 4, 1

• Increase loop diuretic dose, OR
• Add thiazide diuretic (metolazone or IV chlorothiazide) for sequential nephron blockade, OR
• Switch to continuous infusion
• Consider ultrafiltration for refractory congestion 4, 1

Vasodilators (For Normotensive/Hypertensive Patients)

Initiate IV vasodilators early in patients with SBP >110 mmHg—delayed administration is associated with higher mortality: 3

• Nitroglycerin: Start 10-20 mcg/min, titrate rapidly for pulmonary edema 4
• Nitroprusside: Preferred in patients with congestion and low cardiac output, particularly with severe hypertension 4, 5
• Avoid routine use in hypotensive patients 3

Management of Chronic Heart Failure Medications

Continue guideline-directed medical therapy unless hemodynamically unstable: 4, 3

• ACE inhibitors/ARBs: Continue unless hypotension (SBP <85 mmHg), hyperkalemia (K+ >5.5 mmol/L), or severe renal impairment (Cr >2.5 mg/dL) 4, 3
• Beta-blockers: Generally continue or reduce dose temporarily—do not stop unless cardiogenic shock, symptomatic bradycardia (<50 bpm), or advanced AV block 4, 3
• Mineralocorticoid receptor antagonists: Stop if hyperkalemia or severe renal dysfunction 4

Initiate beta-blocker therapy at low dose after volume optimization and discontinuation of IV inotropes in newly diagnosed patients 4

Medications to AVOID

• Inotropic agents (dobutamine, milrinone): Use ONLY in patients with symptomatic hypotension or hypoperfusion despite adequate filling pressures—associated with increased mortality risk 3, 6, 5
• Morphine: NOT recommended routinely—associated with higher rates of mechanical ventilation, ICU admission, and death 3
• NSAIDs and COX-2 inhibitors: Contraindicated—increase risk of worsening heart failure and hospitalization 3

Continuous Monitoring Requirements

Monitor the following parameters continuously or daily: 1, 2, 3

• Dyspnea severity, respiratory rate, oxygen saturation (maintain SpO₂ >90%)
• Blood pressure (maintain SBP >90 mmHg), heart rate and rhythm
• Urine output (strict intake/output measurement)
• Daily weights
• Daily laboratory monitoring: Serum electrolytes, creatinine, BUN during IV diuretic therapy 4, 1
• Clinical assessment of congestion (JVP, edema, lung sounds) and perfusion (mental status, extremity temperature)

Special Considerations for Cardiogenic Shock

If SBP <90 mmHg with signs of hypoperfusion: 2, 3

• Immediate transfer to ICU/CCU with continuous hemodynamic monitoring
• Consider fluid challenge (250 mL over 10 minutes) if clinically indicated 3
• Inotropes/vasopressors only when persistent hypoperfusion despite adequate filling pressures 3
• Early consideration of mechanical circulatory support (intra-aortic balloon pump, ventricular assist devices) before end-organ damage develops 3, 5
• Rapid transfer to tertiary center with 24/7 cardiac catheterization and mechanical support capabilities 3

Common Pitfalls to Avoid

• Delaying diuretic administration: Start IV diuretics immediately in the emergency department—every hour of delay worsens outcomes 1, 2
• Stopping beta-blockers unnecessarily: Unless true cardiogenic shock or severe bradycardia, continue at reduced dose 4, 3
• Using inotropes in normotensive patients: Reserve for true hypoperfusion—increases mortality 3, 6
• Inadequate monitoring: Elderly patients require supine AND standing blood pressure measurements due to higher risk of orthostatic hypotension 1
• Excessive diuresis: Monitor for worsening renal function and electrolyte abnormalities with aggressive diuresis 4, 2

Thromboembolism Prophylaxis

Initiate thromboembolism prophylaxis in all hospitalized heart failure patients unless contraindicated 4