How should I treat an elderly woman presenting with acute decompensated heart failure, BNP >35,000 pg/mL, peripheral edema of the arms and legs, and dyspnea?

Management of Severe Acute Decompensated Heart Failure

This elderly woman requires immediate hospital admission to a resuscitation area/CCU/ICU for aggressive decongestion therapy with IV loop diuretics, respiratory support with non-invasive ventilation if she has respiratory distress, and continuous hemodynamic monitoring. 1

Immediate Triage and Stabilization

Admit immediately to a high-acuity setting (resuscitation area, CCU, or ICU) given the markedly elevated proBNP >35,000 pg/mL, which indicates severe cardiac decompensation and life-threatening congestion. 1

Initial Assessment Within Minutes

• Establish continuous monitoring: pulse oximetry, blood pressure, respiratory rate, continuous ECG, and mental status assessment. 1, 2
• Position the patient upright to reduce work of breathing and improve ventilation. 2, 3
• Assess respiratory distress indicators: respiratory rate >25/min, SpO₂ <90% on oxygen, or increased work of breathing warrant immediate respiratory support. 1, 3
• Evaluate hemodynamic stability: check for heart rate <40 or >130 bpm, blood pressure extremes, and severe arrhythmias. 1, 3

Respiratory Support

Initiate non-invasive ventilation (NIV) immediately if the patient shows respiratory distress, as this reduces intubation rates, decreases respiratory distress, and may reduce mortality. 2, 3

• Administer oxygen therapy to maintain SpO₂ >90%, but avoid hyperoxia as it may be harmful. 1, 2
• Use CPAP in the initial setting as it is simpler than pressure support ventilation and requires minimal training. 2, 3

Pharmacological Management

Loop Diuretics (First-Line Therapy)

Administer IV furosemide as the cornerstone of treatment for this severe congestion. 1, 2, 3

Dosing strategy:

• If she is not on chronic diuretics: give furosemide 40 mg IV bolus. 2, 3
• If she is on chronic oral diuretics: give an IV bolus at least equivalent to (or higher than) her oral dose. 2, 3
• For this severity (proBNP >35,000), consider starting with higher doses given the massive fluid overload.

Monitor response closely:

• Track urine output hourly to assess diuretic response. 3
• If inadequate response, consider combination therapy with a thiazide-type diuretic (such as metolazone) or spironolactone for diuretic resistance. 3, 4

Vasodilators (If Blood Pressure Permits)

Add IV vasodilators if systolic blood pressure >110 mmHg, as most elderly women with acute heart failure present with normal or elevated blood pressure. 1, 3, 5

• IV nitroglycerin or other vasodilators combined with loop diuretics can provide aggressive blood pressure reduction and improve pulmonary congestion. 1

Diagnostic Workup (Performed Simultaneously)

Obtain immediately:

• 12-lead ECG to exclude ST-elevation myocardial infarction and assess for arrhythmias (acute coronary syndrome occurs in 13-14% of decompensations). 1, 6
• Chest X-ray to assess pulmonary congestion severity and exclude alternative causes. 1, 3
• Laboratory tests: cardiac troponin, complete blood count, renal function (BUN/creatinine), electrolytes (sodium, potassium), glucose, liver function tests, and TSH. 1
• Echocardiography within 48 hours (immediately if hemodynamically unstable) to assess cardiac structure and function. 1

Identify and Treat Precipitants

Common precipitants requiring urgent management:

• Acute coronary syndrome: If troponin elevated or ECG changes present, implement immediate invasive strategy with intent to revascularize. 1, 2
• Rapid arrhythmias: Correct urgently with medical therapy or electrical cardioversion if contributing to hemodynamic compromise. 1, 2
• Medication non-compliance: The most common precipitant (42-47% of cases), particularly important in elderly patients. 6
• Uncontrolled hypertension: Particularly common in women and requires aggressive blood pressure reduction. 6
• Infection (pneumonia/sepsis): Check for fever, leukocytosis, and infiltrates on chest X-ray. 6

Continuous Monitoring During Hospitalization

Monitor daily:

• Daily weights and accurate fluid balance charts. 3
• Daily renal function and electrolytes (watch for worsening renal function and hypokalemia from aggressive diuresis). 3
• Continuous assessment of dyspnea, heart rate and rhythm, urine output, and peripheral perfusion. 1, 3

Critical Pitfalls to Avoid

• Do not routinely catheterize unless specific indication for strict urine output monitoring. 1
• Avoid hyperoxia: Only give oxygen if SpO₂ <90%. 1, 2
• Monitor for cardiorenal syndrome: Up to 1 in 4 patients have right-left mismatch in filling pressures, which can hinder effective decongestion. 6
• Avoid inotropes (such as dobutamine) unless the patient is hypotensive or in cardiogenic shock, as they have not improved outcomes and may be deleterious. 7, 8

Discharge Criteria

Patient is medically fit for discharge when:

• Hemodynamically stable and euvolemic (resolution of peripheral edema). 2, 3
• Established on evidence-based oral medications. 2, 3
• Stable renal function for at least 24 hours before discharge. 2, 3
• Provided with tailored self-care education. 2, 3

Arrange follow-up:

• Primary care physician within 1 week of discharge. 2, 3
• Cardiology follow-up within 2 weeks of discharge. 2, 3
• Enrollment in multidisciplinary heart failure disease management program. 3