What is the recommended acute management for an adult with acute decompensated chronic heart failure?

Acute Management of CHF Exacerbation

Immediately administer intravenous loop diuretics in the emergency department without delay—early administration improves decongestion outcomes and may reduce mortality. 1, 2

Immediate Assessment (First 5-15 Minutes)

Determine hemodynamic profile by assessing:

• Perfusion status: Check for narrow pulse pressure, cool extremities, altered mental status, resting tachycardia, and urine output <15 mL/hour 3, 1, 4
• Volume status: Assess jugular venous distention, hepatojugular reflux, peripheral edema, pulmonary rales, and recent weight gain 3, 1
• Blood pressure: Measure immediately and repeat every 5 minutes until therapy stabilizes 3, 1
• Oxygen saturation: Obtain pulse oximetry; provide supplemental oxygen if SpO2 <90%, targeting 94-96% 1, 4

Obtain diagnostic tests:

• 12-lead ECG and cardiac troponin to identify acute coronary syndrome as precipitating factor 3, 1
• BNP or NT-proBNP if diagnosis uncertain (interpret in clinical context, not as stand-alone test) 3, 1
• Chest radiograph and echocardiography 3
• Serum electrolytes, BUN, creatinine 3, 1

Primary Pharmacologic Management

IV Loop Diuretics (First-Line Therapy)

Dosing strategy:

• For patients already on chronic oral loop diuretics: Initial IV dose must equal or exceed their total daily oral dose 3, 1, 2
• For diuretic-naïve patients: Start with furosemide 20-40 mg IV bolus 1, 2
• Administer in the emergency department immediately—do not wait for laboratory results when fluid overload is clinically evident 3, 1, 2

Administration method:

• Either intermittent bolus (every 12 hours) or continuous infusion—no significant efficacy difference 1, 4
• Target urine output of 100-150 mL/hour in first hour 4

Dose escalation for inadequate response:

1. Double the IV loop diuretic dose for next administration 3, 4
2. Add sequential nephron blockade with metolazone 5-10 mg PO or IV chlorothiazide 3, 4
3. Switch to continuous furosemide infusion if bolus strategy fails 3, 4
4. Consider ultrafiltration for refractory congestion unresponsive to aggressive pharmacologic therapy 3, 1, 4

IV Vasodilators (Adjunctive Therapy)

Indications and timing:

• Administer early in patients with systolic BP >110 mmHg—delayed administration is associated with higher mortality 1, 2
• Use in normotensive or hypertensive patients with severe symptomatic fluid overload 3, 1

Agent selection:

• IV nitroglycerin or nitroprusside 3, 1, 5
• Nesiritide is an alternative but requires conservative dosing without bolus due to hypotension risk 2

Contraindication:

• Do NOT use vasodilators when systolic BP <110 mmHg—risk of precipitous hypotension and cardiogenic shock 4

Management of Chronic Heart Failure Medications

Continue during acute decompensation unless specific contraindications:

ACE inhibitors/ARBs:

• Continue unless hemodynamic instability, serum creatinine rises ≥50% from baseline, or hyperkalemia >5.5 mmol/L develops 1, 2, 4

Beta-blockers:

• Do NOT stop—discontinuation worsens outcomes 1, 2, 4
• May reduce dose by 50% temporarily if patient has signs of low cardiac output, symptomatic bradycardia, high-grade AV block, or cardiogenic shock 1, 2, 4
• Resume full dose once volume optimized and IV inotropes discontinued 2

Respiratory Support

Non-invasive ventilation (NIV):

• Start immediately in patients with acute pulmonary edema showing respiratory distress 1
• CPAP is feasible pre-hospital; pressure-support PEEP preferred in-hospital 1
• Intubate if SpO2 remains <90% despite optimal oxygen/NIV, or if respiratory distress, altered mental status, or inability to protect airway develops 4

Management of Hypotension and Cardiogenic Shock (SBP <90 mmHg with Hypoperfusion)

Immediate actions:

1. Cautious fluid challenge: 250 mL crystalloid over 10-15 minutes ONLY if overt pulmonary edema is absent 1, 4
2. Start IV inotrope: Dobutamine 2.5-5 µg/kg/min, titrate up to 20 µg/kg/min if needed 4, 6
3. Add vasopressor if hypotension persists: Norepinephrine preferred; avoid dopamine due to higher arrhythmia risk 4
4. Hold diuretics temporarily until perfusion restored (SBP ≥90 mmHg, adequate urine output, warm extremities) 2, 4
5. Transfer to ICU with invasive hemodynamic monitoring capability 3, 4
6. Consider mechanical circulatory support (IABP, Impella, ECMO) if shock is refractory 4

Critical caveat:

• Do NOT use inotropes in normotensive patients without evidence of organ hypoperfusion—associated with increased mortality 3, 1, 4, 6

Medications to AVOID

Morphine:

• Do NOT use routinely—associated with higher rates of mechanical ventilation, ICU admission, and death 1, 2

NSAIDs and COX-2 inhibitors:

• Contraindicated—increase risk of heart failure worsening and hospitalization 2

Daily Monitoring Requirements

During active IV diuresis:

• Daily weights at same time on same scale 3, 1, 2
• Strict intake-output charting with hourly urine output 1, 2, 4
• Daily serum electrolytes, BUN, creatinine 3, 1, 2
• Supine and standing blood pressure to detect orthostatic hypotension 2
• Continuous cardiac rhythm monitoring 3, 1
• Assess for signs of worsening perfusion (cool extremities, altered mentation, decreasing urine output) 4

Therapeutic Targets

Decongestion goals:

• Daily weight loss of 0.5-1.5 kg 4
• Resolution of elevated jugular venous pressure, peripheral edema, orthopnea, and pulmonary rales 4
• Continue diuresis until all clinical signs of fluid retention are eliminated, even if mild azotemia or hypotension occurs (provided patient remains asymptomatic without end-organ hypoperfusion) 4

ICU/CCU Admission Criteria

Transfer to intensive care if any of the following:

• Respiratory rate >25 breaths/min or SpO2 <90% 1
• Use of accessory muscles for breathing 1
• Systolic BP <90 mmHg with signs of hypoperfusion 1, 4
• Need for intubation or mechanical ventilation 1, 4
• Cardiogenic shock requiring inotropes or mechanical circulatory support 3, 4
• Refractory congestion despite aggressive diuresis 4

Common Pitfalls to Avoid

Underdosing diuretics:

• Leads to persistent fluid retention and diminishes response to ACE inhibitors/ARBs 4
• Always match or exceed patient's home oral dose when converting to IV 4

Delaying diuretic administration:

• First IV loop diuretic should be given promptly in ED without waiting for laboratory results when fluid overload is evident 3, 1, 2

Routine invasive hemodynamic monitoring:

• Not recommended in normotensive patients with symptomatic response to diuretics and vasodilators 3, 1
• Reserve for carefully selected patients with persistent symptoms despite empiric therapy, uncertain fluid status, worsening renal function, or need for parenteral vasoactive agents 3