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Treatment of Acute Decompensation of Heart Failure

Initial stabilization:

• Assess the airway
• Position the patient upright at an angle of 45 degrees, with legs dangling off the bedside
• Check pulse oximetry
• If hypoxemia is present (Sa02 < 90% or Pa02 <60 mmHg), administer oxygen with/without noninvasive ventilation
• Avoid IV morphine (may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms)
• Ensure continuous cardiac monitoring
• Secure intravenous access with 18 gauge canula
• Monitor vitals signs
• Monitor fluid intake and urine output

Assess congestion and perfusion:

❑ Congestion at rest (dry vs. wet)
"Wet" suggested by orthopnea, ↑JVP, rales, S3, pedal edema

❑ Low perfusion at rest (warm vs. cold)
"Cold" suggested by narrow pulse pressure, cool extremities, hypotension

• Warm and dry
• Warm and wet
• Cold and dry
• Cold and wet

Admit for in-hospital treatment if:

• Hypotension and/or cardiogenic shock
• Poor end-organ perfusion (worsening renal function, cold clammy extremities, altered mental status)
• Hypoxemia (Sa02 <90%)
• Atrial fibrillation with a rapid ventricular response resulting in hypotension
• Presence of an underlying condition, such as acute coronary syndrome

Identify precipitating factor and treat accordingly:

• Myocardial infarction
• Myocarditis
• Renal failure
• Hypertensive crisis
• Non adherence to medications
• Worsening aortic stenosis
• Drugs (NSAIDS, thiazides, calcium channel blocker, beta blockers)
• Toxins (alcohol, anthracyclines)
• Atrial fibrillation

Rate control of atrial fibrillation is the mainstay of arrhythmia therapy. Avoid the use of drugs with negative inotropic effects such as beta blockers and non-dihydropyridine calcium channel blockers e.g., verapamil in the treatment of acute decompensated systolic heart failure

Consider cardioversion if the patient is in cardiogenic shock or if new onset atrial fibrillation is the clear precipitant of the hemodynamic decompensation

• COPD
• PE
• Anemia
• Thyroid abnormalities
• Systemic infection

Treat congestion and optimize volume status:
Diuretics

• IV loop diuretics as intermittent boluses or continuous infusion (I-B)
• Already on loop diuretics: IV dose >= home PO dose (I-B)
• Serial assessment of fluid intake and output, vital signs, body weight (measured every day at the same time) and symptoms
• Adjust dose according to volume status (I-B)
• Daily electrolytes, BUN, creatinine (I-C)
• Persistent symptoms: Increase dose of IV loop diuretics (I-B) OR Add a second diuretics, such as thiazide (I-B)
• Consider low dose dopamine infusion for improved diuresis and renal blood flow (IIb-B)
• Consider renal replacement therapy/Ultrafiltration in obvious volume overload (IIb-B)

Venodilators

• Consider IV nitroglycerin, nitroprusside, or nesiritide as add-on to diuretics to relieve dyspnea (IIb-A)

Treat low perfusion:

• Inotropes

VTE prevention:

• Anticoagulation in the absence of contraindications (I-B)

Chronic medical therapy:

• Chronic HFrEF and hemodynamically stable: continue medical therapy
• Initiate beat blockers at a low dose in stable patients following optimization of volume status and D/C IV diuretics and inotropes (I-B)

Management of hyponatremia:

• Water restriction
• Optimization of chronic home medications
• Persistent hyponatremia and risk of cognitive impairment: vasopressin antagonist for short term (hypervolemic)