Acute decompensated heart failure: Rapid overview of emergency management

Differential diagnosis: Pulmonary embolism, acute asthma, pneumonia, noncardiogenic pulmonary edema (eg, adult respiratory distress syndrome), pericardial tamponade or constriction

Symptoms and signs

Acute dyspnea, orthopnea, tachypnea, tachycardia, and hypertension are common

Hypotension reflects severe disease, and arrest may be imminent; assess for inadequate peripheral or end-organ perfusion

Accessory muscles are often used to breathe

Diffuse pulmonary crackles are common; wheezing (cardiac asthma) may be present

S3 is a specific sign but may not be audible; elevated jugular venous pressure and/or peripheral edema may be present

Diagnostic studies

Obtain ECG: Look for evidence of ischemia, infarction, arrhythmia (eg, AF), and left ventricular hypertrophy.

Obtain portable chest radiograph: Look for signs of pulmonary edema, cardiomegaly, alternative diagnoses (eg, pneumonia); normal radiograph does not rule out ADHF.

Obtain: Complete blood count; cardiac troponin; electrolytes (Na⁺, K⁺, Cl–, HCO₃^–); BUN and creatinine; arterial blood gas (if severe respiratory distress); liver function tests; BNP or NT-proBNP if diagnosis is uncertain.

Perform bedside echocardiography if the cardiac or valvular function is not known.

Treatment

Monitor oxygen saturation, vital signs, and cardiac rhythm.

Provide supplemental oxygen if hypoxic (SpO₂ <90%), place 2 IV catheters, and position patient upright.

Provide NIV as needed, unless immediate intubation is required or NIV is otherwise contraindicated; have airway management equipment readily available; etomidate is a good induction agent for RSI in ADHF.

Initiate diuretic therapy without delay to relieve congestion/fluid overload:

Give IV loop diuretic furosemide 40 mg IV or torsemide 20 mg IV; or bumetanide 1 mg IV.

Higher doses are needed for patients taking diuretics chronically (eg, twice home dose) and in patients with renal dysfunction.

Search for cause of ADHF (including: acute coronary syndrome, hypertension, arrhythmia, acute aortic or mitral regurgitation, aortic dissection, sepsis, renal failure, anemia, or drugs) and treat appropriately.

Patients with ADHF and AF with rapid ventricular rate often require medication (eg, digoxin) to slow their heart rate.

Direct current cardioversion is indicated for patients with new onset AF and hemodynamic instability or refractory symptoms despite rate control.

Obtain immediate cardiac surgery consultation for acute aortic or mitral regurgitation or ascending aortic dissection.

For patients with adequate end-organ perfusion (eg, normal or elevated blood pressure) and signs of ADHF with fluid overload:

If urgent afterload reduction is required, early vasodilator therapy may be needed: Give nitroprusside* for severe hypertension, or if acute aortic regurgitation or acute mitral regurgitation is present; titrate rapidly to effect (eg, start nitroprusside at 5 to 10 mcg/min and titrate up every 5 minutes as tolerated to a dose range of 5 to 400 mcg/min).

If response to diuretics to treat congestion/fluid overload is inadequate, give vasodilator to reduce preload: Give IV nitroglycerin in addition to diuretic therapy if persistent dyspnea or as a component of therapy in refractory HF and low cardiac output.^¶
Start nitroglycerin* infusion at 5 to 10 mcg/min and titrate every 3 to 5 minutes as needed and tolerated based upon mean arterial blood pressure or SBP to a dose range of 10 to 200 mcg/min.

For patients with known systolic HF (eg, documented low ejection fraction) presenting with signs of severe ADHF and cardiogenic shock, discontinue chronic beta blocker therapy and:

Give an IV inotrope* (eg, dobutamine or milrinone) and/or mechanical support (eg, intraaortic balloon counter pulsation).

For patients with known diastolic HF (ie, preserved systolic function) presenting with signs of severe ADHF and cardiogenic shock:

Treat for possible left ventricular outflow obstruction with a beta blocker, IV fluid (unless pulmonary edema is present), and give an IV vasopressor* (eg, phenylephrine or norepinephrine); do not give an inotrope or vasodilator. Obtain immediate echocardiogram as needed.

Consider possibility of acute mitral or aortic regurgitation, or aortic dissection, and need for emergency surgical intervention. Obtain immediate echocardiogram as needed.

For patients whose cardiac status is unknown but present with signs of severe ADHF (ie, pulmonary edema) and hypotension or signs of shock:

Give an IV inotrope* (eg, dobutamine or milrinone), with or without an IV vasopressor (eg, norepinephrine) and assess need for mechanical support (eg, intraaortic balloon counter pulsation); obtain immediate echocardiogram as needed.

ECG: electrocardiogram; AF: atrial fibrillation; ADHF: acute decompensated heart failure; BUN: blood urea nitrogen; BNP: brain natriuretic peptide; NT-proBNP: N-terminal pro-BNP; IV: intravenous; NIV: noninvasive ventilation; RSI: rapid sequence intubation; SBP: systolic blood pressure.
* Patients receiving vasodilator, vasopressor, or inotrope infusions require continuous noninvasive monitoring of blood pressure, heart rate and function, and oxygen saturation.
¶ Treatment of patients with heart failure with reduced ejection fraction with volume overload unresponsive to diuretics is guided by hemodynamics, which are most commonly imputed from the physical examination with right heart catheterization performed when required for selected cases; refer to accompanying text and separate topic review of management of refractory heart failure.

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Acute decompensated heart failure: Rapid overview of emergency management